Victorian health management plan for pandemic influenza. July 2007

Victorian health management plan for pandemic influenza July 2007

Victorian health management plan for pandemic influenza Published by the Communicable Disease Control Unit, Rural and Regional Health and Aged Care Services, Victorian Department of Human Services, 2007. State of Victoria 2007 This publication is copyright, however, whole or part thereof may be reproduced in the interests of public health provided that acknowledgement is made. This publication is available at the Internet address: http://www.health.vic.gov.au/ideas Acknowledgements We would like to thank all the members of the Victorian Influenza Pandemic Planning Steering Committee and sub committees. Their generosity in giving up their time and expertise is greatly appreciated.

Victorian health management plan for pandemic influenza Chief Health Officer s foreword The threat of a pandemic has been in the news for some time, mainly because of the spread of avian influenza (bird flu) in parts of Asia, Africa and Europe. The greatest challenge involved in planning for a pandemic is that it is impossible to predict when it will occur and how virulent it will be. The best thing we can do is be prepared. The Victorian Government has developed a number of plans and will lead the State s response to a human pandemic. This plan aims to provide an effective health response framework to minimise the morbidity and mortality associated with an influenza pandemic and its impact on the Victorian community, health care system and the economy. This plan builds upon the foundation established by the Victorian influenza pandemic plan (November 2005) and plans developed by the Australian Government Department of Health and Ageing and the Australian Government Department of Industry, Tourism and Resources. The plan focuses on the containment of the virus and supporting and maintaining critical services. Containment means that, in the early stages of a pandemic, intensive efforts will concentrate on containing the virus to allow time for a pandemic influenza vaccine to be produced. Containment strategies may include reducing traveler numbers to Australia, social distancing and infection control measures, short-term home quarantine for those exposed to the virus and the targeted use of antivirals. Maintenance means that if the pandemic becomes widespread, efforts will concentrate on maintaining health and other services to keep society functioning until a pandemic vaccine becomes available or the pandemic abates. Public confidence in decision making processes at all stages of a pandemic is vital. The Victorian Government has been working closely with a range of government agencies at Commonwealth and local government levels, as well as professional, community and industry stakeholders, to ensure that organisations are prepared and that agreed processes are in place. While the Victorian Government has developed a number of plans and will lead the State s response to a pandemic, we need organisations and individuals to be properly prepared for this threat. I urge you to read this plan and ensure that you have plans in place to protect yourself and your organisation. Dr John Carnie Chief Health Officer, Victoria

ii Victorian health management plan for pandemic influenza

Victorian health management plan for pandemic influenza iii Contents Chief Health Officer s foreword Executive summary Section A: Introduction and background 1 1. Aim and objectives 3 1.1 Aim 3 1.2 Objectives 3 2. Background 4 2.1 Disease description 4 2.2 Transmission 4 2.3 Infectious agents 5 2.4 Emergence of new strains and sub-types 5 Section B: Planning and preparedness 7 3. Planning and preparedness 9 3.1 Likely impact of an influenza pandemic in Victoria 9 3.2 Influenza pandemic planning at national and global levels 9 3.3 Influenza pandemic planning in the context of emergency management planning for Victoria 10 3.4 Communication 11 3.5 Clinical management 12 3.6 Influenza pandemic planning for other agencies 13 3.7 Surge capacity and business continuity 13 3.8 Training and testing of the plan 15 3.9 Review of the plan 15 i iv Section D: Appendices 43 Appendix 1 The impact of a pandemic 45 Appendix 2 Surveillance 46 Appendix 3 Hospitals and health services 49 Appendix 4 Mass fatality planning 58 Appendix 5 Community support and recovery issues 60 Appendix 6 Infection control 64 Appendix 7 Communication 70 Appendix 8 Mass vaccination guide 71 Appendix 9 Antivirals 83 Appendix 10 Isolation and quarantine arrangements 91 Appendix 11 Primary health care 95 Appendix 12 Ethical considerations 106 Appendix 13 Roles and responsibilities 108 Appendix 14 Key actions by Australian phases 112 List of abbreviations 122 Bibliography 124 Section C: Victorian influenza pandemic action plan 17 4. Victorian influenza pandemic action plan 19 4.1 Pandemic phases 20 4.2 Victoria s approach to pandemic response 20 4.4 Response at different phases 21

iv Victorian health management plan for pandemic influenza Executive summary An influenza pandemic occurs when a new viral strain appears which has had a significant antigenic shift to produce a sub-type for which there is little or no immunity in the population, and which is readily transferred between humans to produce infection in a high proportion of those exposed. Influenza pandemics are associated with high morbidity and significant mortality, and involve massive social and economic disruption. Three pandemics occurred in the twentieth century: in 1918, 1957 and 1968. Recent outbreaks of severe acute respiratory syndrome (SARS) and avian influenza overseas have brought the issues of pandemic preparedness to the forefront, as the possibility of a pandemic is real. While it is impossible to predict when a pandemic might occur, Victoria needs to be prepared. Planning and preparedness is the best way to mitigate the potentially serious consequences of an influenza pandemic. It is important that effective strategies for control be activated as early as possible in response to all potential pandemic threats 1. Early warning of unusual or unexpected influenza cases will rely upon a timely, reliable and effective animal and human influenza surveillance system. Influenza vaccines and antiviral drugs are essential components of a comprehensive pandemic response. Immunisation with a suitable vaccine during a pandemic will be a critical component of response strategies aimed at reducing resulting morbidity and mortality and social and economic disruption. Manufacture of the appropriate vaccine must be implemented as early as possible. As it will be impossible to vaccinate everyone at once during an influenza pandemic, priority groups must be identified in advance and quantified. Distribution of vaccines must be well planned and target the priority groups. Antiviral drugs play two principal roles in the management of influenza: prophylaxis, aimed at decreasing the likelihood of developing influenza; and treatment, aimed at reducing 1 Communicable Diseases Network Australia New Zealand 1999, A framework for an Australian influenza pandemic plan. Commonwealth Department of Health and Aged Care. Version 1. Canberra, Commonwealth Department of Health and Aged Care. Technical Report Series No. 4. the severity and duration of influenza. The indications for the use of antiviral medication should be clear and health professionals well acquainted with them. Distribution of antivirals must be well planned and target the priority groups. Primary health care (general practice, community pharmacy, community nurses, community health centres, and dental practice settings) will play an important role in providing information to the general public during all stages of a pandemic. All health services will need to develop a process for identifying, separating, triaging and admitting people with influenza to prevent cross-infection. The Department of Human Services will implement a Designated Hospital Model, which will include the implementation of influenza clinics when patient numbers increase, to minimise impacts on hospital emergency departments and general practice (GP) clinics. Effective communication during the various stages of a pandemic will be vital to minimise the impact on the social and economic infrastructure. Education of the community is a preventive measure that can be used to limit or slow the spread of an influenza pandemic throughout the pandemic phases. The Whole of Victorian Government Communication Strategy aims to maximise stakeholder engagement and existing networks. It targets a distinct but diverse group of key influencers who will channel the appropriate messages and planning actions through to their respective sectors. These key influencers include government departments, the health sector, local government, emergency services, infrastructure services, community services and business associations. This plan builds on the foundation established by the Victorian influenza pandemic plan (November 2005) and plans developed by the Australian Government Department of Health and Ageing and the Australian Government Department of Industry, Tourism and Resources. The change in the name of this plan from the Victorian influenza pandemic plan to the Victorian health management plan for pandemic influenza, is a step towards national consistency given the Australian Government Department of Health and Ageing plan is titled the Australian health management plan for pandemic influenza.

Section A: Introduction and background Victorian health management plan for pandemic influenza 1

Victorian health management plan for pandemic influenza

Victorian health management plan for pandemic influenza 3 1. Aim and objectives 1.1 Aim The aim of this plan is to provide an effective health response framework to minimise the morbidity and mortality associated with an influenza pandemic and its impacts on the Victorian community, health care system and economy. 1.2 Objectives To identify and detail the planning and preparedness activities needed to reduce the impact of an influenza pandemic in Victoria, including: a surveillance system that is able to detect emerging threats timely implementation of activities in the various phases of a pandemic rapid characterisation of a new virus sub-type and early detection, notification and response early containment through disease control measures limitation of morbidity and mortality maintenance of social functioning provision to the public, health care workers, the media and other service providers of timely, accurate information about the pandemic. To ensure intersectoral collaboration in the planning for, and implementation of, the Victorian health management plan for pandemic influenza. To detail the arrangements that will be put in place and actions that will be taken in the event of an influenza pandemic in Victoria. To detail the roles and responsibilities of the agencies involved.

4 Victorian health management plan for pandemic influenza 2. Background 2.1. Disease description Influenza is an acute respiratory disease caused principally by influenza type A or B viruses. Symptoms usually include fever, cough, lethargy, headache, muscle pain and sore throat. Infections in children, particularly type B and A (H1N1), may also be associated with gastrointestinal symptoms such as nausea, vomiting and diarrhoea. Clinical features in babies and children may result in fever alone, fever and cough, croup, poor feeding or features suggestive of meningitis. One of the earliest indicators of the influenza pandemics in Melbourne in 1957 and 1968 was an increased incidence of croup. The incubation period for influenza is usually one to three days. Adults have been shown to shed the influenza virus from one day before developing symptoms to up to seven days after the onset of the illness. Young children can shed the influenza virus for longer than seven days. Generally, shedding peaks early in the illness, typically within a day of symptom onset. 2 The influenza virus remains infectious in aerosols for hours, viability being facilitated by low relative humidity, and potentially remains infectious on hard surfaces for one to two days. Most symptoms resolve within two to seven days although the cough may persist longer. Complications of influenza include middle ear infection, primary viral pneumonia, secondary bacterial pneumonia, a range of rare nonpulmonary complications, and exacerbations of underlying chronic health conditions. Reye s syndrome is a rare complication of influenza involving central nervous system disturbance, coma and death in 10 40 per cent of affected persons. It is associated with infections in children, infections with H1N1 strains and with the use of aspirin or other salicylates to treat influenza symptoms. Aspirin and other salicylates should not be given to children with fever due to influenza or an influenza-like illness. 2.2. Transmission Transmission of human influenza virus is mainly by droplet transmission. This occurs when droplets from the cough or sneeze of an infected person are propelled through the air (generally up to 1 metre) and land on the mouth, nose or eye of a nearby person 3. Influenza can also be spread by contact transmission. This occurs when a person touches respiratory droplets that are either on another person or an object and then touches their own mouth, nose or eyes (or someone else s mouth, nose or eyes) before washing their hands. In some situations, airborne transmission may result from medical procedures that produce very fine droplets (called fine droplet nuclei) that are released into the air and breathed in 4. These procedures include: intubation taking respiratory samples performing suctioning use of a nebuliser. Personal protective equipment Summary of personal protective equipment (PPE) use: To help protect oneself (for example, health care workers, poultry cullers), wear a full gown (or coveralls), gloves, eye shield and mask (P2 or surgical mask depending on activity). See Table 1 Summary of PPE for health care settings. To minimise the risk of infecting others, infected persons should wear a surgical mask. For detailed information on infection control, see Appendix 6. 2 Centres for Disease Control and Prevention, Key facts about the flu, http://www.cdc.gov/flu/keyfacts.htm 3 World Health Organization 2005, Practical guidelines for infection control in health care facilities, http://www.wpro.who.int/sars 4 World Health Organization 2004, WHO interim guidelines on clinical management of humans infected by influenza A (H5N1) www.who. int/csr

Victorian health management plan for pandemic influenza 2.3. Infectious agents Three types of influenza are recognised types A, B, and C although most human infections involve either type A or B. Type C, causes a common cold-like syndrome. Influenza viruses are named according to type, sub-type and antigenic characterisation. Only Type A viruses are sub-typed. Influenza A is the more important epidemiologically and is associated with pandemics. Within influenza A there are: 15 distinct forms of hemagglutinin (HA) designated as H1-H15 nine distinct forms of neuraminidase (NA) designated as N1-N9. HA and NA are viral surface proteins (referred to as antigens) recognised by the body s immune system and are involved in viral replication: HA is responsible for attachment to cell receptors following which infection occurs and then virus replication. NA digests the cell receptor allowing the newly synthesised virus to escape from the cell surface. There may often be more than one type/strain of influenza circulating, however, one strain will usually dominate in a given season/location. 2.4. Emergence of new strains and sub-types Influenza viruses undergo two types of antigenic change antigenic drift and antigenic shift. Antigenic drift Antigenic drift refers to small antigenic changes in the HA and NA surface antigens due to the high rate of mutation in the virus ribonucleic acid. This is an ongoing process, which results in new epidemic strains of influenza A and B virus. These minor antigenic changes often result in localised outbreaks or regional epidemics. Epidemics of influenza usually occur between late autumn and early spring and last for up to two months in individual regions but may also occur progressively across the country. Populations with high susceptibility to epidemic strains of influenza include the elderly, the chronically ill and children. Antigenic shift Antigenic shift refers to major change in the HA and NA surface antigens of influenza A, resulting in the evolution of pandemic strains. This may involve the process of genetic re-assortment between human and avian influenza viruses possibly taking place in animal populations. These events occur at widely spaced intervals of many decades. The majority of the pandemics of the 20th Century seem to have arisen in Southern China. Novel influenza A strains arising through antigenic shift are usually associated with pandemics, that is, rapid worldwide spread and a high incidence of infection and disease. However, the H3N2 strain arising in 1968 was an exception to this; the mildness of this pandemic is thought to result, in part, from protection against severe disease conferred by the pandemic of 1957. If the human population has not been exposed to the new sub-type, or has not been exposed to a similar sub-type for many years, it will be highly susceptible. An influenza pandemic is defined as a worldwide epidemic. Research has identified three prerequisites for the start of a pandemic 5. 1. A novel virus sub-type must emerge to which the general population will have no or little immunity. 2. The new virus must be able to replicate in humans and cause serious illness. 3. The new virus must be efficiently transmitted from human to human. Pandemics, as opposed to epidemics, occur globally at unpredictable intervals, are trans-seasonal, and can last for up to two to three years. 5 World Health Organization 2005, Avian influenza: assessing the pandemic threat, Pre-publication.

Victorian health management plan for pandemic influenza Previous pandemics have started abruptly without warning, swept through populations with ferocious velocity, and left considerable damage in their wake. They could not be stopped, but peaked rapidly and then subsided almost as abruptly as they began. Recovery was, however, impeded by the tendency of many pandemics to recur in second and sometimes third waves, often causing more severe disease. Subsequent waves often began simultaneously in several different parts of the world, intensifying the abrupt disruptions at the global level. 6 During the 20th century there were three recognised influenza pandemics (Spanish influenza 1918 19; Asian influenza 1957 58; and Hong Kong influenza 1968). All three pandemics were associated with increased mortality rates in Australia. The influenza pandemic of 1918 19 was unprecedented in terms of loss of human life. The illness was notorious for its rapid onset and progression to respiratory failure and death, and it is estimated that between 20 and 40 million people died worldwide, with the highest numbers of deaths among those aged between 20 and 40 years. By the end of 1919, 11,500 people in Australia had died of influenza, with 60 per cent of deaths in people aged 20 to 45 years. In these same age groups the male rates were 1.5 to twofold higher than in females. The Asian influenza of 1957 58 had infection rates reported to range between 20 to 70 per cent, but case fatality rates were low, ranging from one in 2000 to one in 10,000 infections. In Australia, mortality rates were two- to five-fold greater than in non-pandemic years. Age-specific mortality rates showed that those aged over 65 years were most affected. The Hong Kong influenza of 1968 had mortality rates similar in magnitude to those caused by the Asian influenza. Age-specific mortality rates were highest for those over the age of 65 years. Infection rates were around 25 to 30 per cent. The differences in past pandemics show the need for flexible contingency plans capable of responding efficiently to a pandemic threat. 6 World Health Organization 2005, Avian influenza: assessing the pandemic threat, Pre-publication.

Section B: Planning and preparedness Victorian health management plan for pandemic influenza 7

Victorian health management plan for pandemic influenza

Victorian health management plan for pandemic influenza 3. Planning and preparedness Planning and preparedness are essential to minimise the effect of an influenza pandemic on the Victorian community. This chapter outlines planning and preparedness that has occurred for pandemic influenza that is relevant to the State of Victoria and briefly describes planning at the local and national levels. 3.1. Likely impact of an influenza pandemic in Victoria Influenza pandemics have commonly been associated with attack rates of 25 30 per cent of the population. However, attack rates of up to 70 per cent have occurred in some communities. Mortality, hospitalisations and staff absenteeism rates have increased substantially during pandemics. In the 1957 influenza pandemic in the United Kingdom, the recorded staff absentee rates in some organisations were between five and 30 per cent. Estimates of morbidity and mortality in Victoria Estimating the potential impacts of an influenza pandemic is difficult given we are unable to predict the virulence and infectivity of the particular strain involved, as well as the epidemiology of the specific strain and the rapidity and effectiveness of the response. In the absence of actual data on the specific strain, it is possible to model various pandemic scenarios given a series of predetermined assumptions and limitations. If a pandemic with an attack rate of 30 per cent (that is, 30 per cent of the population affected) were to occur in Victoria, and there was no pandemic vaccine or treatment available over a 6 8 week period, it could lead to: 2,265 10,145 deaths 6,236 24,323 hospitalisations 602,229 713,513 outpatient visits 7. 3.2. Influenza pandemic planning at national and global levels National planning In June 1999, the Influenza Pandemic Planning Committee (IPPC), a subcommittee of the Communicable Diseases Network of Australia (CDNA) developed A framework for an Australian influenza pandemic plan. This provided a strategic framework for the detection and management of pandemic influenza in Australia. Following publication of the framework, IPPC developed the Australian action plan for pandemic influenza 2003, which provided direction for the development of actions at Federal, state and territory, and local levels. The aim of the action plan was to increase awareness of national pandemic preparedness during the inter-pandemic period. The action plan indicated that the states and territories should prepare their own action plans. The action plan also provided guidance to health service providers and other agencies whose services are likely to be of critical importance during an influenza pandemic. One of the recommendations of the action plan was to establish the National Influenza Pandemic Action Committee (NIPAC). The role of NIPAC is to assist the Australian Government in progressing pandemic preparedness by providing expert advice on policy issues in the inter-pandemic period. In June 2005, the Australian Government Department of Health and Ageing (DoHA) released the Australian management plan for pandemic influenza. This document provides a detailed guide for the Australian response to a pandemic influenza threat. The plan targets the wide range of people who will be involved in planning and responding to an influenza pandemic: health planners, public health and clinical care providers, border workers, state and territory health departments, essential service providers and those in the media and communications. 7 These estimates are based largely on the work of Meltzer et al.

10 Victorian health management plan for pandemic influenza In May 2006, DoHA released an updated Australian health management plan for pandemic influenza, which builds on the 2005 plan and is a detailed national health action plan to guide Australia s response to pandemic influenza. It is designed to be accessible to a broad range of people and describes how pandemics occur, what the government is doing to prepare for a pandemic, what the government will do if it happens and what individuals, organisations and health practitioners can do to prepare. It is supported by a range of technical annexes that provide detailed information on issues such as infection control and clinical care. Additional annexes will be released regularly. It will be updated as new clinical evidence or other management strategies are developed. Global planning In April 1999, the World Health Organization (WHO) published the document, Influenza pandemic plan: the role of the WHO and guidelines for national and regional planning. The document was prepared to assist medical and public health leaders with their response to future threats of pandemic influenza. The document outlines the roles and responsibilities of WHO and national health authorities and pandemic planning committees. It defines the preparedness levels and phases of an influenza pandemic, and the various actions that will be undertaken by WHO and other health authorities in these periods. In May 2005, the WHO developed the WHO global influenza pandemic plan The role of the WHO and recommendations for national measures before and during pandemics. This plan updates, significantly revises and replaces the 1999 plan. 3.3. Influenza pandemic planning in the context of emergency management planning for Victoria While planning and preparation for illness/epidemics is part of the normal business activities of the Department of Human Services, the occurrence of an influenza pandemic will most likely constitute an emergency under the Emergency Management Act 1986. The Emergency management manual Victoria details the emergency roles and responsibilities of agencies in relation to the prevention, mitigation, risk reduction, response and recovery components of emergencies. The Department of Human Services, through the Public Health Branch, is the designated control agency for human illnesses/epidemics. Public health response The department s Public health emergency management arrangements (PHEMA) outlines the policies, procedures and emergency management arrangements for public health emergencies, including infectious disease incidents. The Victorian health management plan for pandemic influenza is a sub-plan of the PHEMA. Under the PHEMA, responsibility for controlling infectious disease emergencies, such as pandemic influenza, lies with the Communicable Diseases Control Unit of the Department of Human Services, with the Chief Health Officer (CHO) as the ultimate authorities. The Victorian health management plan for pandemic influenza also sits under the strategic framework of the Victorian human influenza pandemic plan (April 2007). Additional emergency management arrangements will also be put in place by the department to ensure clarity about the command and control of resources in responding to the incident, and that there is adequate communication within the department, the government, external agencies and the community. The National Medical Stockpile (NMS) was established by the Australian Government in 2002, initially as a national strategic reserve of essential vaccines, antibiotics, antiviral drugs, chemical and radiological antidotes. The NMS supplements existing medical stocks kept in the Australian health system and provides rapid access to large quantities of medications that may not be regularly used. The process to activate the NMS deployment plan is through application to DoHA. Each state/territory requesting agency has developed distribution plans, including details of security measures and arrangements for dispensing. Further details of this planning are included in Appendix 8 Mass vaccination guide and Appendix 9 Antivirals. Incident category classification The Department of Human Services emergency response arrangements will be put into place according to the scale/severity of the incident. The scope of an influenza pandemic will result in immediate classification as a high level incident, due to the need to manage issues

Victorian health management plan for pandemic influenza 11 across regions, statewide media interest, the need for a community call centre and management of whole of government interests. High level incidents activate the State Level Emergency Management Plan. The Executive Director, Operations, will command departmental statewide emergency management operations. The CHO will assume the role of Incident Controller, which may be delegated to an appropriate senior Public Health manager. The Emergency Coordination Centre will be activated to manage the department s response and recovery operations. Appropriate staff will be sourced to act as liaison officers representing response and recovery interests, assess and monitor the incident and its impacts, provide information and advice to senior management and Ministers, and maintain liaison with the State Government through the Central Government Response Committee. Coordination across and between governments The Australian Health Protection Committee (AHPC), formerly the Australian Health Disaster Management Policy Committee, is the key policy and coordinating body that plans for and responds to public health emergencies, communicable disease threats and environmental threats to public health. The AHPC reports to Health Ministers through the Australian Health Ministers Advisory Council. Membership of the committee, which is chaired by the Commonwealth Government, includes the Chief Medical Officer (CMO), the CHOs of the states and territories, the Chairs of each of the three sub-committees (Communicable Diseases Network of Australia (CDNA), Public Health Laboratory Network (PHLN) and the Environmental Health Committee), representatives of key government organisations involved in emergency management and response, and clinical experts and others to be co-opted as necessary. The AHPC is the key group responsible for high level, cross-jurisdictional collaboration in public health protection management planning, response, preparedness and recovery in relation to public health emergencies arising from either natural events or terrorist attack. The committee meets regularly and can be called together at short notice to respond to emergencies. The AHPC will be expected to meet in the development of a pandemic overseas and will meet urgently and regularly if a pandemic spreads to Australia. In a pandemic, the DoHA will provide advice to other agencies to trigger well-established emergency response arrangements. The CMO has a particular role to play as the key adviser to the Commonwealth Government on the development of a pandemic and on declaring the phases of the pandemic in line with the WHO model. The CMO is also the government s chief adviser on human quarantine, and has extensive powers under the Quarantine Act 1908, including the ability to restrict the movement of people in and out of Australia and within Australia to protect human health. Through the Council of Australian Governments, governments at all levels have recognised that the potentially broad-ranging social and economic impacts of a pandemic require a response from the whole of government, not just the health portfolio. In July 2006, the Council of Australian Governments issued a National Action Plan for a Human Influenza Pandemic, outlining how governments at all levels will cooperate in response to a pandemic. 3.4 Communication Effective communication during the various stages of a pandemic is vital to enable business and the community to minimise the impact on the social and economic infrastructure. Education of the community is a preventive measure that is used to limit or slow the spread of an influenza pandemic and is applicable throughout the pandemic stages. Communication strategy The Victorian Government has developed a Whole of Victorian Government Communication Strategy that maximises stakeholder engagement and use of existing networks. It targets a distinct but diverse group of key influencers who will channel the appropriate messages and planning actions through to their respective sectors. These key influencers include government departments, the health sector, local government, emergency services, infrastructure services, community services and business associations.

12 Victorian health management plan for pandemic influenza Research undertaken in Victoria has shown that these audiences require relevant and practical information that will empower them to develop their own pandemic plans and which is embedded in rational communications that are related to running their organisations as effectively as possible. There will be limited direct communication to the community during the preparedness phase, consistent with the research recommendations and the Australian Government s approach. Communication guiding principles Informed by research. Reach all Victorians by leveraging the reach and resources of key influencers. Accurate, consistent messages. Use existing communication channels and protocols wherever possible. Credible, trusted sources. Align with national plans. Communication objectives Mobilise key influencers across Victoria to prepare for a possible human influenza pandemic. Encourage all Victorians to take basic precautionary measures. Inform Victorians that the Victorian Government is leading the preparations for an influenza pandemic in this state. In most cases, where available, the CHO will be the spokesperson for the department. If unavailable, an appropriate senior Public Health manager may be appointed to this role. All media communication will occur through the Department of Human Services Media Unit, which will work with the Department of Premier and Cabinet to ensure a consistent, whole of government message. Advice on public messages will be communicated to the Department of Premier and Cabinet through the Media Unit, based on expert advice from Public Health Branch staff and the Emergency Operations Centre. A community call centre will be established to provide a central contact point for members of the public to obtain personal health and safety advice. The statewide Nurse on Call service may also act as an information outlet for concerned members of the community. DoHA has an information hotline for the general public that provides national information, as opposed to the local information provided by the community call centre. The DoHA information hotline number is 1800 004 599. The department s Health Service Coordination Centre (HSCC) is activated in an event that has a major impact on hospital capacity or demand, such as a mass casualty incident when the State Health Emergency Response Plan (Health Displan) requires coordination of health services to aid casualty management. The HSCC will provide coordination and a single contact point for health services. Further information about the HSCC can be found in Appendix 3 Hospitals and health services. 3.5 Clinical management All health services need to develop a process for identifying, separating, triaging and admitting people with influenza-like illness to prevent cross-infection. General practitioners (GPs) will also need to consider workload management and triage. To prevent the spread of pandemic influenza infection within hospitals, the department will implement a designated hospital model. This model includes the implementation of influenza clinics as patient numbers increase, to contain the transmission of influenza and to reduce the workload on hospital emergency departments and GP clinics. In the containment phase (the phases are detailed in Part 4 Victorian influenza pandemic action plan), confirmed cases will be treated with antivirals and close contacts, including health care workers, will be given antivirals as post-exposure prophylaxis. In the pandemic phase, antivirals will most likely be used as pre-exposure prophylaxis, to maintain health services. Decisions on this will need to be made at the time of a pandemic, based on availability of antivirals.

Victorian health management plan for pandemic influenza 13 Measures to increase social distance Measures to increase social distance, such as closure of schools and higher education centres and discouraging mass gatherings, will be considered during a pandemic. Closure of schools, child care, university and workplaces Infectious diseases can spread rapidly in schools, universities, child care centres and workplaces due to the close proximity of large numbers of people. It is not clear whether school children are responsible for a disproportionate amount of the disease transmission of pandemic influenza. Data on the effectiveness of school closures is limited. 8 Currently no data or analysis exists for recommending illness thresholds or rates of change that should lead to considering closing or reopening schools. Results of modelling suggest that closing schools does reduce the attack rate in children, and will reduce the overall attack rate effectively if school children were found to have a much higher risk of infection than adults. Mass gatherings Mass gatherings have the capacity to spread influenza among participants. Events that may need to be cancelled or closed include concerts or large sporting events. Other places of large gatherings that may also need to be closed or attendance staggered include venues such as casinos, cinemas, nightclubs and places of worship. 3.6. Influenza pandemic planning for other agencies The Department of Human Services has prepared this plan for Victoria. However, individual agencies (including government agencies and essential services) are responsible for ensuring that their own business continuity plans make provision for maintaining high priority activities, critical supply chain, staff and infrastructure in the face of predicted increased absentee rates associated with pandemic influenza. Health care providers (including hospitals and general practice) need to ensure that they have contingency plans to deal with an influenza pandemic. General practice, hospitals and primary health care will be at the forefront of the response to a pandemic, with increased clinical workloads and a need to strengthen and maintain infection control to reduce the chance of cross-infection of pandemic influenza from cases to patients and other staff. At the same time, all agencies and providers will be under pressure from staff absenteeism. Local government should also undertake influenza pandemic planning through their Municipal Emergency Management Committees, and all relevant emergency management stakeholders. The plans need to be interdependent. 3.7. Surge capacity and business continuity The very nature of an influenza pandemic will be unlike any other modern disaster and will create new challenges for business continuity planners. Business will need to rethink their existing continuity response strategies to cope with such an event. All agencies potentially affected by an influenza pandemic should consider their surge capacity/business continuity needs and plan accordingly. It is estimated that businesses should plan for 30 50 per cent staff absenteeism at the peak of a pandemic. Staff absence can be expected for many reasons including: illness/incapacity voluntary or involuntary home quarantine staying home to care for ill family members staying home to look after children (as schools/child care centres may be closed) feeling safer at home fulfilling other voluntary roles in the community. 8 WHO Writing Group 2006. Nonpharmaceutical interventions for pandemic influenza, national and community measures. Emerging infectious diseases 12, 88-94.

14 Victorian health management plan for pandemic influenza A pandemic may have other impacts on businesses, for example: shortages of supplies/inputs to produce goods and services the movement of people/goods may be delayed/ restricted by quarantine and isolation measures within Australia and overseas availability of services from key suppliers demand for services demand for some services may increase (for example, Internet access), while demand for others may fall (for example, certain types of travel) fuel and energy supplies may be disrupted to some locations at times temporary closure of venues/events financial implications. Workforce issues All agencies may be affected by staff absence. This will occur at a time when, for some agencies, the workload may be greater than normal. Key issues that agencies should consider include: establishing minimal staffing levels the need for staff to work in areas they are not formally trained in using volunteers, retired or trainee staff accommodation for staff in between shifts, if transport home is disrupted or not advised staff immunisation policy (for normal seasonal influenza vaccine) stockpiling of appropriate PPE and training on how to use PPE psychological support for staff. Particular issues for staff with occupational exposures to pandemic influenza and other essential workers who may be provided with antivirals and PPE include: availability of PPE and antivirals monitoring of staff for illness and adverse reactions to antiviral medications implementing rotations of staff on antivirals recorded dosing of antivirals. In June 2006, the Australian Government Department of Industry, Tourism and Resources released Being prepared for a human influenza pandemic A business continuity guide for Australian businesses and Being prepared for an influenza pandemic A kit for small businesses. The aim of these guides is to assist businesses in their own pandemic planning. Department of Human Services The department has identified key issues in surge capacity/business continuity needs including: Staffing issues associated with an influenza pandemic existing levels of technical and administrative staff will be decreased by an increased staff absenteeism associated with an influenza pandemic. Initially: there will be an increased demand for additional staff to be involved in the investigation and control functions of an influenza pandemic staff will be needed to backfill positions/programs vacated by staff who are involved in the response to the pandemic staff may be required for manning industry and community call centres. Contingency planning and other processes to deal with these issues include the following: The department s Business Continuity Plan identifies contingency arrangements that are in place to support the continuity of critical business activities in the event that normal processes are interrupted. This approach analyses the department s dependency on key resources and services. Contingency arrangements that provide alternative access to these critical resources enable the department to respond to an incident regardless of type or cause, including incidents resulting in high levels of staff absenteeism (such as an influenza pandemic).

Victorian health management plan for pandemic influenza 15 Staff will be seconded to the incident investigation and control team from other programs within the Communicable Disease Control Unit (CDCU). The department has identified staff with medical and nursing backgrounds, and other associated health professionals. These staff may be seconded to assist the department s response to the influenza pandemic, to backfill in the CDCU performing other essential functions or to staff the community and industry call centres. 3.8. Training and testing of the plan To maximise effectiveness of the plan, staff will require adequate training and the plan will require regular testing. 3.9. Review of the plan Due to the changing nature of influenza and changes within state and Federal planning, this document will be reviewed on an ongoing basis.

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Section C: Victorian influenza pandemic action plan Victorian health management plan for pandemic influenza 17

18 Victorian health management plan for pandemic influenza

Victorian health management plan for pandemic influenza 19 4. Victorian influenza pandemic action plan Table 4.1: Pandemic phases Period Inter-pandemic Pandemic alert Global phase 1 2 3 4 5 Pandemic 6 AUS 0 Australian phase Overseas 1 AUS 1 Overseas 2 AUS 2 Overseas 3 AUS 3 Overseas 4 AUS 4 Overseas 5 AUS 5 Overseas 6 AUS 6a AUS 6b AUS 6c AUS 6d Description of phase No circulating animal influenza sub-types in Australia that have caused human disease Animal infection overseas: the risk of human infection or disease is considered low Animal infection in Australia: the risk of human infection or disease is considered low Animal infection overseas: substantial risk of human disease Animal infection in Australia: substantial risk of human disease Human infection overseas with new sub-type/s but no human to human spread or, at most, rare instances of spread to a close contact Human infection in Australia with new sub-type/s but no human to human spread or, at most, rare instances of spread to a close contact Human infection overseas: small cluster/s consistent with limited human to human transmission, spread highly localised, suggesting the virus is not well adapted to humans Human infection in Australia: small cluster/s consistent with limited human to human transmission, spread highly localised, suggesting the virus is not well adapted to humans 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) 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) Pandemic overseas: increased and sustained transmission in general population Pandemic in Australia: localised (one area of country) Pandemic in Australia: widespread Pandemic in Australia: subsiding Pandemic in Australia: next wave

20 Victorian health management plan for pandemic influenza 4.1 Pandemic phases The phases of this plan are aligned with the stages used in the Australian health management plan for pandemic influenza (May 2006) and the World Health Organization (WHO) phases used in the WHO global influenza preparedness plan (March 2005). Two phases may be referred to simultaneously, for example, one phase for what is occurring overseas and one phase for Australia. The phases are intended to guide actions rather than be a strict categorisation of the events. 4.2 Victoria s approach to pandemic response 4.3 Determination of phases The determination of global phases, including upscaling and downscaling, will be made by the Director-General of the WHO. The Australian phases will be designated by the Australian Government Department of Health and Ageing (DoHA), in particular the Chief Medical Officer (CMO), with advice from an expert advisory group. Victoria will take guidance from DoHA, as well as determining its own actions, by direction of its Chief Health Officer (CHO). Three major strategies are used within Victoria to respond to a pandemic threat. The aim of the strategies is to minimise the morbidity and mortality associated with the pandemic. They are: Preparedness Containment Maintenance of social function This refers to the readiness of arrangements to ensure that Victoria is well prepared. This refers to delaying transmission for as long as possible by border control measures, widespread adoption of good hygiene and infection control practices, isolation of cases, quarantine of contacts, and use of antiviral medication. When community transmission is established, containment is no longer feasible. Pre-exposure prophylaxis for priority groups will be important to maintain societal functioning.

Victorian health management plan for pandemic influenza 21 4.4 Response at different phases Phase: Australia 0 Inter-pandemic period Status: Goal: No circulating animal influenza sub-types in Australia that have caused human disease Preparedness Department of Human Services Maintain the Victorian health management plan for pandemic influenza. Representation on National Influenza Pandemic Committee (NIPAC), Communicable Disease Network of Australia (CDNA) and Australian Health Protection Committee (AHPC). Vaccines/antivirals/PPE Encourage high coverage of influenza and pneumococcal immunisation in identified high-risk groups using current vaccines (these risk groups are outlined in Appendix 8). Maintain supplies of antivirals and have distribution protocols. Maintain appropriate supplies of personal protective equipment (PPE). Surveillance Participate in national surveillance of influenza and ensure appropriate application of CDNA case definition for laboratory confirmed influenza. Maintain laboratory capacity for influenza surveillance. Monitor trends in deaths from all causes. Support routine inter-pandemic surveillance human surveillance. Sentinel surveillance for influenza-like illness includes: sentinel general practitioners throughout Victoria the Melbourne Metropolitan Locum Service. These occur during the influenza season May October, to be extended in 2007 from February November. Notification by laboratories and practitioners of laboratory confirmed influenza to the Communicable Disease Control Unit (CDCU). Communication Department of Human Services to keep a watching brief on overseas and interstate activity and liaise with other jurisdictions, including the DoHA. Ongoing engagement of stakeholders to ensure key groups are aware of developments and adequately prepared. Maintain communication strategy and supplementary material/website. Community support and recovery Department of Human Services branches and regions Work with local government authorities to assist with influenza pandemic planning. Work with health care providers to assist with influenza pandemic planning. Facilitate influenza pandemic planning within the regions and program areas. Local government Undertake influenza pandemic planning. Make provisions for business continuity in the face of increased absenteeism and demand on services. Promote vaccination for influenza and pneumococcal vaccine for the identified high-risk groups. Department of Primary Industries Animal surveillance: Notification by owners, veterinarians and laboratory staff of avian, swine and equine influenza to an Inspector of Livestock, Department of Primary Industries (DPI).

22 Victorian health management plan for pandemic influenza Hospitals Create or update existing emergency and disaster plans to include contingencies for an influenza pandemic, including business continuity issues. Ensure access to current public health advice, guidelines and protocols. Attain high coverage of staff immunisation, particularly for seasonal influenza. Ongoing education of staff about infection control protocols. Ensure all hospitals and emergency departments have sufficient stocks of PPE for 14 days (see Appendix 6) and staff are trained in their use. Notify laboratory confirmed influenza to the CDCU on 1300 651 160. General practice and Divisions of General Practice Notify laboratory confirmed influenza to the CDCU on 1300 651 160. Community pharmacy Strengthen pandemic preparedness. Prepare business continuity plan. Health promotion and communication role to their communities including: education on influenza transmission risks information on vaccines and antiviral prophylaxis awareness of avian influenza when travelling. Community nursing Update existing emergency and disaster plans, including business continuity. Prepare for later stages of a pandemic including a central call point for staff and clients, triage checklist and reporting mechanisms to collect client data. Identify current PPE stock at all sites and determine possible further requirements. Promote/supply seasonal influenza immunisation to all staff to attain high coverage of immunisation within the service annually. Promote pneumococcal immunisation to high-risk groups. Provide ongoing education to all staff regarding infection control protocols for influenza. Ensure access to public health advice, guidelines/ protocols. Ambulance services Plan for influenza pandemic, including business continuity planning. Maintain liaison with the Department of Human Services. Attain high coverage of staff immunisation, particularly for influenza. Provide ongoing education of staff about infection control procedures, including PPE. Consider stockpiling masks and other personal protective and cleaning supplies. Laboratories Notify laboratory confirmed influenza to the CDCU on 1300 651 160. Agencies (Examples include Victoria Police, Victorian State Emergency Service, Fire Services and any other agencies) Create or update existing emergency and disaster plans to include contingencies for an influenza pandemic, including business continuity issues. Attain high coverage of staff immunisation for health care workers, particularly for influenza. Ongoing education of staff about infection control procedures and basic hygiene practices.

Victorian health management plan for pandemic influenza 23 Phase: Overseas 1 and Overseas 2 Animal infection overseas Status: Goal: No human or animal cases in Australia Containment Department of Human Services As per phase 0. Community support and recovery As per phase 0. Border control Upon entering Australia, if a person fills out the Incoming passenger card and declares that they have visited a rural area or been in contact with, or near, farm animals outside Australia in the past 30 days, an Australian Quarantine and Inspections Services (AQIS) officer will assess the situation and contact the Chief Quarantine Medical Officer for advice if necessary. Any returning traveller who has had close contact with poultry, poultry farms, or poultry products (for example, in food markets) in an affected area 9 should be advised that if they develop symptoms of an influenza-like illness they should inform their doctor of their symptoms and the fact that they had contact overseas so that they may be isolated and properly tested. Department of Primary Industries Routine inter-pandemic surveillance with the addition of the following: Chief Veterinary Officer (CVO) of DPI to: provide advice on recommending changes to border security measures at airports for high risk countries (passengers and baggage checks for high risk items) (AQIS responsibility) provide advice on recommending that import quarantine protocols for live birds (few are permitted in) and poultry products be amended (AQIS responsibility) renew communication with the poultry industry stressing the need for biosecurity on farms enhance passive surveillance, including the investigation of unexplained morbidity/mortality in commercial poultry flocks, pigs or horses an example of this would be putting avian influenza on the differential diagnosis list for poultry disease outbreaks and taking diagnostic opportunities as they present to rule out highly pathogenic avian influenza as the cause of disease and mortality incidents in poultry. Hospitals As per phase 0 plus: notify any suspected case to the Department of Human Services immediately on 1300 651 160. General practice and Divisions of General Practice As per phase 0 plus: notify any suspected case to the Department of Human Services immediately on 1300 651 160. Community pharmacy As per phase 0. Community nursing As per phase 0. Ambulance services As per phase 0. Laboratories As per phase 0. Agencies As per phase 0. 9 An affected area is defined as a country currently or recently experiencing avian influenza in poultry. Information on affected areas can be found at the website of the World Organization for Animal Health (OIE) at http://oie.int/eng/en_index.htm

24 Victorian health management plan for pandemic influenza Phase: Australia 1 and Australia 2 Animal infection in Australia Status: Goal: No confirmed human cases in Australia Containment Department of Human Services As per phase overseas 1 with the addition of: Communication Liaise with DPI/DoHA on suitable industry/public communication. Media announcements from the Federal Government. Community support and recovery As per phase overseas 1 with the addition of: Local government Community support: provide support to individuals/communities quarantined/isolated in homes/institutions. Department of Primary Industries Surveillance As per phase overseas 1, with the addition of: DPI activation of emergency animal disease response arrangements based on the relevant AUSVETPLAN response plan. Australian Veterinary Emergency Plan (AUSVETPLAN) is a series of technical response plans that describe the proposed Australian approach to an emergency animal disease incursion. There is an AUSVETPLAN disease strategy for highly pathogenic avian influenza (for further information on animal influenza policy see Appendix 2 Surveillance). Prophylaxis Poultry cullers antivirals to be given for at least seven days after the last contact with an infected bird and vaccination with current vaccine (to prevent possible dual infection and reassortment). Hospitals As per phase overseas 1, with the addition of: Prophylaxis Asymptomatic person who had direct contact with an infected animal in an affected area antivirals for seven days after the last contact. General practice and Divisions of General Practice As per phase overseas 1, with the addition of: Prophylaxis Asymptomatic person who had direct contact with an infected animal in an affected area antivirals for seven days after the last contact. Community pharmacy As per phase overseas 1. Community nursing As per phase overseas 1. Ambulance services As per phase overseas 1. Laboratories As per phase overseas 1. Agencies As per phase overseas 1. Prevention Poultry cullers: Appropriate PPE use (see Appendix 6). Education on infection control and staff health monitoring.

Victorian health management plan for pandemic influenza 25 Phase: Overseas 3 Human cases overseas Status: Goal: No transmission between humans or, at most, rare instances of spread to close contacts Containment Department of Human Services Surveillance/investigation of suspected cases Issue a health industry alert (to GPs, GPDV, hospitals, laboratories, ambulance services, Nurse on Call, community pharmacy). Include information about the overseas situation, case definition, management of cases, infection control procedures, laboratory procedures and where to get further information. Health alerts can be found at: http://www.health.vic.gov. au/ideas/diseases/avian.htm GPs and hospital medical staff will be advised in the health industry alert to report any suspected cases in return travellers to the department immediately on 1300 651 160. If the person meets the case definition, the department will: Advise that the person should be isolated, and nose and throat swabs collected for testing at VIDRL. The examining medical practitioner should wear full PPE. A list of avian influenza affected areas is given on the International Office for Epizootic Diseases (OIE) website. Updates for doctors will be provided on the department websites and health alerts will also be distributed. Provide any cases and subsequent contacts with antivirals. Confirmed cases: Antivirals, within 48 hours of symptom onset/ according to manufacturer s instructions duration five days. Isolation until asymptomatic (adults at least seven days and children 21 days). Contacts of confirmed cases (asymptomatic) this could incude border workers, health care workers (HCWs) or any other people identified through contact tracing. Antivirals for seven days after last contact. Education and monitoring educational material will be given to any asymptomatic people who have had infected animal or human contact. Human contacts at this stage will be advised to stay at home and the department will contact them daily to monitor their health. Communication Department of Human Services to: issue a health industry alert (see above) issue media statements as necessary facilitate workshops for GPs, local government, emergency services personnel, hospitals, community support groups and department regional offices to discuss pandemic planning. Community support and recovery As per phase Australia 2. Border surveillance Provide medical advice to AQIS regarding return travellers from affected countries. Department of Primary Industries As per phase overseas 1 and 2 with the addition of: Preparedness CVO of DPI to: provide information to veterinarians on avian influenza, to assist them in dealing with clients and answering inquiries from members of the public. provide agricultural notes, which contain basic management advice for commercial poultry farms, poultry fanciers, owners of backyard flocks and bird exhibitors on how to help prevent avian influenza. update the DPI website to include: avian influenza information sheet and frequently asked questions.

26 Victorian health management plan for pandemic influenza Hospitals Department of Human Services to issue health industry alert (see above). As part of maintaining vigilance, clinicians will need to look for cases in accordance with case definition set by the department (contained in the health industry alert). All suspected cases need to be reported immediately to Department of Human Services on 1300 651 160. Depending on clinical merit, all suspected cases to be admitted to a hospital pending laboratory testing and isolated in a negative pressure room, observing infection control procedures. If possible, antiviral medication should be commenced within 48 hours of symptom onset in confirmed cases. General practice and Divisions of General Practice As per phase overseas 1 with the addition of: Make one person responsible for coordinating pandemic planning in the practice. Report all suspected cases immediately contact Department of Human Services on 1300 651 160. Train doctors and nurses on symptoms, signs and epidemiology of H5N1 influenza. Prepare a triage plan for suspected cases of H5N1 influenza. Buy PPE and learn how to use it. Start thinking about the possible impacts on practice functioning and how you might respond. For further details, refer to Preparing for an influenza pandemic, An information kit and workplan for general practice available at: http://www.health.vic.gov.au/ pandemicinfluenza/general_practice.htm Community nursing As per phase overseas 2, with the addition of: Re-assess PPE stock at each centre and re-order supplies if necessary. Develop monitoring mechanism to ensure appropriate stock available at each site. Provide a list of infected areas overseas and animals involved to all sites and update as required. Provide written instructions to all staff for monitoring influenza-like illness, signs and symptoms, reporting requirements, and documentation of outcomes, including specific instructions below. Provide access to community information released by the department for staff to give to clients if influenzalike illness suspected. Commence surveillance and document all suspected contacts. Report all suspected cases to the department immediately on 1300 651 160. Institute triage and management plans for possible cases (see Appendix 11) in consultation with the department. Ambulance services As per phase Australia 1. Laboratories As per phase Australia 1. Agencies As per phase Australia 1. Community pharmacy As per phase overseas 2.

Victorian health management plan for pandemic influenza 27 Phase: Australia 3 Human cases in Australia Status: Goal: No human-to-human spread or at most rare instances of spread to a close contact. Containment Department of Human Services Surveillance Liaise with CDNA on a daily basis. Review the case definition and surveillance guidelines for influenza. Improved case/cluster detection: Case detection in general practice all GPs should be advised to be alert for patients presenting with an illness consistent with the case definition, that is, an agreed symptom cluster and exposure history. GPs should be encouraged to be aware of recommended infection control precautions related to a potential case. Hospital case detection all hospital staff should be advised to be alert for patients presenting with an illness consistent with the case definition, that is, an agreed symptom cluster and exposure history. Hospital staff, and in particular staff in the emergency department, should be aware of recommended infection control precautions related to a potential case. Case detection of unexplained deaths the Coroner and hospitals should be requested to report deaths due to unexplained respiratory illness to the Department of Human Services. Case detection in other institutions Department of Human Services will alert representatives from educational authorities (preschool, primary, secondary and tertiary schools), communication, child care, prisons, police, emergency services, utilities (water/gas/electricity/sewerage) and transport (bus/train/tram/taxi) to notify clusters of respiratory illness for further investigation. Similar alerts could be considered for other major employers. Rumour surveillance involves case finding by monitoring media reports. Media monitoring agencies provide daily summary reports of relevant publications and broadcasts to the Department of Human Services Media Unit. Reports related to influenza or respiratory illness should be forwarded to the CDCU for review and possible investigation. It will be expected that Department of Human Services and DoHA will have an open dialogue regarding the veracity of media reports. Contact tracing the contacts of all confirmed cases should be traced and put under surveillance. Contacts should remain in quarantine at home and provided with antivirals for seven days. Notification CDCU should be immediately notified of all suspected and confirmed cases, including those detected as part of rumour surveillance by telephone on 1300 651 160. Border surveillance as per phase Overseas 3. Surveillance communication with DoHA CDCU will provide DoHA with daily (or more frequently if required) updates of suspected and confirmed cases. It is expected that DoHA will communicate with WHO. Collate data on cases and effectiveness of antivirals. Communication Produce media statements as necessary. Provide regular updates provided to health care workers and the public. Possibly activate a national information campaign using print and online media (timing to be determined at the federal level). Public health measures Make recommendations on public health measures as appropriate, in consultation with DoHA/CDNA and provide advice to the Victorian Central Government Response Committee in order for them to make a decision at the time. The issues taken into account will include: morbidity and mortality by age group

28 Victorian health management plan for pandemic influenza levels of absenteeism by different groups (health care workers, essential services staff etc) the virulence and level of infectivity of the novel virus. The following measures will be considered. Measures to increase social distance: voluntary home confinement of symptomatic persons (if not isolated in hospitals) closure of schools (including child care, preschools, primary, secondary and higher education) in conjunction with other measures to reduce mixing of children population-wide measures to reduce the mixing of adults (for example, discourage mass gatherings). Measures to decrease the interval between symptom onset and isolation: public campaign to encourage prompt self-diagnosis urge entire population in affected areas to check for fever daily. Reinforce basic hygiene measures for members of the public: provide advice on handwashing provide advice on cough etiquette provide advice on household disinfection of potentially contaminated surfaces. Measures for persons entering an infected area within Australia: provide advice on avoiding contact with high-risk environments appropriate PPE use recommendation to defer non-essential travel from/ to affected areas. Community support and recovery As per phase Australia 2, with the addition of: Mobilise the preparation to activate community support centres. Management (treatment) Confirmed cases: Antivirals, within 48 hours of symptom onset/according to manufacturer s instructions duration five days. Isolation until asymptomatic (adults at least seven days and children 21 days). Prophylaxis (post-exposure) Border workers antivirals for seven days after last contact. Health care workers working with confirmed human cases antivirals for seven days after last contact. Contacts of confirmed cases (asymptomatic): antivirals for seven days after last contact education and monitoring educational material will be given to any asymptomatic person who has had infected animal or human contact. Human contacts at this stage will be advised to stay at home and the department will contact them daily to monitor their health. Hospitals Influenza streams patients with suspected pandemic influenza may present to any health services in a variety of ways. Health services need to develop a process for identifying, separating, triaging and admitting people with influenza-like illness to prevent cross-infection. This may involve setting up a separate area to triage flu and non-flu patients. Depending on clinical merit, admit suspected cases to a designated hospital pending laboratory testing, and isolate in a negative pressure room, observing infection control procedures. Decide to transfer patients to a designated hospital on a case-by-case basis in consultation with Department of Human Services. Health Service Coordination Centre (HSCC) will advise hospitals where to access antiviral stocks for health care workers, patients and contacts.

Victorian health management plan for pandemic influenza 29 Liaise with Department of Human Services regarding media queries. Report all suspected cases to the department immediately on 1300 651 160. Department of Human Services will organise testing and contact tracing. Provide post-exposure prophylaxis for hospital staff who have contact with a confirmed human case. General practice and Divisions of General Practice As per phase overseas 3 with the addition of: train doctors and nurses to think Could it be flu? use PPE with possible pandemic patients update triage plan for suspected cases for the front desk decide how you will handle home visit requests devise a strategy to identify contacts draw up a practice business survival plan for these stages. Community pharmacy Provide up-to-date information on the current state of the virus, both overseas and in Australia. Provide information on ways to avoid transmission of the virus including personal hygiene, masks and gloves etc. Train staff on staying safe and infection control. Manage possible cases who present to pharmacy: referral points for assessment to the local hospital or GP as appropriate with prior warning to allow for use of infection control. Provide extra supplies of medicines to institutions such as nursing homes via Webster packs. Consider increasing stock holding of analgesics and antibiotics in case of supply chain issues. Community nursing As per phase overseas 3, with the addition of: Implement agency business continuity management plan. Monitor admissions, investigate possible separation of non-critical clients and possible prioritising of current clients for those who could be discharged if required to create capacity Access daily Department of Human Services update, implement specific instructions and keep staff informed. Discuss liaison role with designated influenza hospitals Reinforce infection control standard and additional precautions to all staff. PPE must be used for care of a person with suspected or actual influenza (pandemic or avian). Staff exposed to confirmed cases will be provided with post-exposure prophylaxis by the Department of Human Services. Provide access to community information released by Department of Human Services for staff to give to all clients. Request additional resources through the HSCC. Commence telephone triage questions to be asked before accepting admissions or for existing clients signs and symptoms of influenza etc. Further discussion with Department of Human Services and patient s GP will be required to discuss triage information. Carry PPE car kit in all cars and restock daily. Discussion to be held regarding designated hospital requirements and coordination of referrals (in order of priority) for admission to community nurse agencies, such as Royal District Nursing Service, though a central point. It is not expected that community nurses will assess or provide investigation of suspected cases. Anticipate demand for influenza related items such as thermometers. Consider activation of business continuity plans.

30 Victorian health management plan for pandemic influenza Ambulance services Institute the Ambulance Emergency Response Plan. Remind staff of the relevant provisions of the infection control policies. Department of Human Services to provide postexposure prophylaxis (antivirals) for exposed staff. In consultation with Department of Human Services, triage cases requiring hospitalisation and refer to a designated hospital. Provide information on self-management to patients not requiring transfer to hospital. Laboratories Specialist laboratories (VIDRL) Case testing a testing algorithm will be used as previously established. This will include testing for the novel influenza virus and testing for plausible alternative aetiological agents. Test and type specimens from all suspected cases for the potential new pandemic influenza strain as per the VIDRL testing protocol. Plan for an increased number of tests. Routine laboratories (public and private) Transfer any referred specimens to VIDRL for analysis. Agencies As per phase Australia 0 with the activation of plans as appropriate. Phase: Australia 4 and Australia 5 Human cases in Australia Status: Goal: Transmission between humans (from small to larger clusters) Containment Department of Human Services Surveillance As per phase Australia 3 with the addition of: Continue count of cases and contacts. Communication As per phase Australia 3 with: An escalation of communications. Community support and recovery During a pandemic, hospitals and GPs will experience a high demand of patients, therefore not all patients will be admitted into a hospital. Elective surgery may be cancelled and patients sent home. Cases and contacts will need to be isolated and quarantined. All these actions will result in large numbers of people both well and unwell at home. The level of support required will differ according to individual requirements. Community support will need to be managed locally and with regional support/coordination. One way of providing for the coordination of community support is using existing emergency management arrangements such as activating a community support centre. Further details on the community support centre and its relationship with regional coordination centres will be detailed in the Community Support and Recovery sub plan (to be released in mid-2007). Treatment/prevention Suspected cases Admit all suspected cases to a designated hospital pending laboratory testing and isolate in a negative pressure room, observing infection control procedures.

Victorian health management plan for pandemic influenza 31 Decide to transfer to a designated hospital on a caseby-case basis in consultation with the Department of Human Services. Report any suspected cases to Department of Human Services immediately on 1300 651 160. Confirmed cases Antivirals, within 48 hours of symptoms onset/ according to manufacturer s instructions duration five days. Public health measures As per phase Australia 3. Hospitals As per phase Australia 3 with the addition of: HSCC will be activated. The HSCC and website will be the official mechanism of contact between the department and health services. Key roles of the HSCC in a pandemic include: assessing the impact on Victoria s health system early identification of critical health resource issues monitoring the business continuity capability of health facilities supporting health services on incident management policy matters and priority considerations including service reduction, continuity and standard of care provisions number of influenza patients (in emergency department, admitted, treated and discharged, deceased) number of elective admissions postponed. Hospitals to consider establishing influenza clinics at designated hospitals. The decision to activate an influenza clinic will be made by the HSCC in consultation with the designated hospital. Not all influenza clinics will necessarily be activated concurrently as decisions will depend on epidemiology and patient presentation across the State. General practice and Divisions of General Practice As per phase Australia 3. Community pharmacy As per phase Australia 3. Community nursing As per phase Australia 3. Ambulance services As per phase Australia 3. Laboratories As per phase Australia 3. Agencies As per phase Australia 3. implementing statewide health policies and standards providing centralised reporting and information dissemination structures for the health sector enabling the prioritisation and maximisation of available health resources. Health services will be required to provide situation reports detailing issues such as, but not limited to: total beds occupied total beds vacant

32 Victorian health management plan for pandemic influenza Phase: Overseas 4 and Overseas 5 Human cases overseas Status: Goal: Transmission between humans Containment Department of Human Services Surveillance Review surveillance case definition a case definition for human cases infected with a novel influenza virus will be established by CDNA based on advice from WHO and adopted by the department. Laboratory testing a laboratory testing protocol for the novel influenza virus in both humans and animals will be based on advice from Public Health Laboratory Network (PHLN). This will include testing for other infections that may have a similar clinical presentation. Case notification notify all suspected human cases to the department immediately on 1300 651 160. Communication As per phases Australia 4 and 5. Treatment/prevention As per phases Australia 4 and 5 with the addition of: Border workers antivirals for seven days after last contact with any confirmed cases. Health care workers working with confirmed human cases from overseas antivirals for seven days after last contact. Asymptomatic person with contact in the previous week with a suspected or confirmed case overseas during the infectious period antivirals for seven days after last contact. Public health measures As per Aus Phases 4 and 5 with the addition of: Isolation, quarantine and border control methods DoHA will coordinate a health alert (information leaflets and signage) advising returning travellers of the situation overseas. Returning passengers will also be provided with information on symptoms and advised to contact a doctor or hospital if they develop these symptoms up to two weeks after returning. Advice will include the importance of advising the doctor or hospital that they have returned from an overseas affected area, so that the facility can arrange for a mask to be worn when arriving at the facility to minimise the potential spread to others. GPs who have to examine any suspected cases should wear full PPE. Depending on clinical need, cases may be admitted to a designated hospital, pending laboratory testing. Patients should be kept in a negative pressure room. Confirmed cases should be commenced on antiviral medication as soon as possible and continued for five days. All household contacts should be quarantined at home and given antiviral prophylaxis for seven days. Cases and contacts should be provided with adequate information on infection control, addressing such measures as cough etiquette and cleaning of potentially contaminated surfaces. (Refer to Fact Sheet 2 Information for the general public looking after yourself in a pandemic.) Overseas travel will be discouraged. All incoming passengers will be checked for fever using thermal scanners. Any incoming passengers with fever or other respiratory symptoms will be assessed by health staff at airports/seaports. Consideration may also be given in this phase to mandatory quarantine of incoming passengers from affected areas if there are symptomatic passengers on board. Department of Primary Industries Prevention Poultry cullers, if dealing with possible animal cases: Appropriate PPE use. Education and staff health monitoring.

Victorian health management plan for pandemic influenza 33 Hospitals As per phase Australia 4 and 5. General practice and Divisions of General Practice As per phase Australia 4 and 5. Community pharmacy As per phase Australia 4 and 5. Community nursing As per phase Australia 4 and 5. Ambulance services Advise staff of the relevant provisions of the infection control policies in terms of minimising spread. Provide antivirals for staff exposed to any confirmed cases for seven days after the last contact. Laboratories Laboratory testing protocol for novel influenza virus based on advice from PHLN. Agencies As per phase Australia 4 and 5. Phase: Australia 6a Pandemic in Australia (one area of the country) Status: Goal: Transmission between humans Containment Maintaining essential services Department of Human Services Surveillance Review surveillance determine whether to continue the elements of routine surveillance. Collate data on cases and effectiveness of antivirals. Monitor hospital admissions a designated representative at designated hospitals or all hospitals, depending on response strategies, will report daily to the department on admitted cases of suspected and confirmed pandemic influenza. Monitor deaths: deaths in hospitalised patients a designated representative at all hospitals should report daily to the department on deaths due to suspected and confirmed pandemic influenza deaths in non-hospitalised patients a designated representative from the Coroner s office should report daily to the department on deaths due to suspected and confirmed pandemic influenza. Monitoring health workforce absenteeism (through the HSCC): Absenteeism among hospital staff a designated representative from each hospital/health service will report daily to the department on hospital workforce absenteeism, total and by employment category, if possible. Absenteeism among general practice staff general practice staff will be asked to report workforce levels when ordering antivirals/ppe through the department (for further details see Appendix 11).

34 Victorian health management plan for pandemic influenza Absenteeism among ambulance staff designated representatives from Metropolitan Ambulance Services and Rural Ambulance Victoria should report daily to the department on absenteeism, including total numbers and by employment category, if possible. Absenteeism among community nursing staff a designated representative from the Royal District Nursing Services should report daily to the department on absenteeism, total and by employment category, if possible. Absenteeism among pharmacists a designated representative from the Pharmacy Guild should report regularly to the department on absenteeism, if possible. A range of other surveillance activities will be considered at the time. Other surveillance issues that the department of Human Services may consider implementing are: How recovered cases, who are presumably immune to the novel virus, can be identified by occupation, for example, health care workers or workers in designated essential services, facilitating the development of a resource of presumed immune workers. Vaccine Mobilise to immunise priority groups against pandemic influenza (as soon as vaccine is developed). GPs to vaccinate staff within their practice. Hospitals to identify their high-risk workers and vaccinate staff within their hospital. Local government immunisation teams to vaccinate firstly the identified priority groups within the community then, as vaccine rolls out, vaccinate the remainder of the population. Once mass vaccinations have been completed using Mass Vaccination Centres (MVCs), GPs could assist with mop up for people who are unable to attend MVCs. For community groups unable to attend MVCs (that is, patients in aged care, disability or prison facilities), it is intended that their existing health care provider will provide the vaccine Collate data on vaccine effectiveness. Contacts Provide advice on the disease, its signs and symptoms, and control measures. Advise self-monitoring for signs and symptoms of the disease and reporting if ill. Voluntary home quarantine of healthy contacts. Provide clinical evaluation of symptomatic contacts. Advise contacts to defer travel to unaffected areas. Public health measures As per phases Australia 4 and 5. Communication Inform health services of the response requirements for their agency at all stages of the pandemic. Coordinate the response for public health management of possible/confirmed cases of influenza through the Public Health Branch. Disseminate information to general public on influenza including methods of transmission, risks and risk avoidance including personal protective measures (tailored to the target population) through: media briefings distribution of fact sheets ensuring public access to the Department of Human Services website and other sources for information. Disseminate information to health professionals on disease, infection control, testing, recommended actions etc. Coordinate all media queries through the Department of Human Services Media Unit. Activate a second national information campaign to encourage appropriate disease containment practices. Conduct other communication activities as per phases Australia 4 and 5.

Victorian health management plan for pandemic influenza 35 Community support and recovery State recovery arrangements Activate the state recovery arrangements. The State Emergency Recovery Unit will coordinate and facilitate recovery at the state level. Service provision will, as far as possible, be devolved to local government with resources support, if necessary, from the State Government. This will include: convene the State Emergency Recovery Planning Committee to determine recovery issues, including assessment of the need for temporary accommodation, material assistance, financial assistance and personal support. Economic, environmental and infrastructure impacts will also be assessed. convene the State Personal Support Network to assess need for bereavement support services contact Centrelink to advise on income support issues in consultation with the Federal Government. Community support and recovery Department of Human Services regions Provide assistance to the Department of Human Services Public Health, CDCU as necessary. Provide assistance to local government to help deliver response activities. Coordinate a response at a Department of Human Services regional level. Provide information at a Department of Human Services regional level. Collate regional data to inform a statewide response (data on immunisation, persons/services affected). Coordinate community support and recovery activities across the region. Local government Information/resources Work in conjunction with regions and the Department of Human Services to disseminate information. Provide resources, as available, and needed by the community and response agencies. Establish the Municipal Emergency Coordination Centre (MECC) facilities and staffing. Conduct a post-impact assessment gather and process information (to be determined). Community support Provide support to individuals/communities quarantined/isolated in homes/institutions. Provide and/or coordinate volunteer helpers. Provide personal support services, for example, counselling, advocacy. Provide and staff recovery information centres. Convene Municipal/Community Recovery Committees. Vaccine Store and deliver vaccine. Provide MVCs according to recommendations by the Department of Human Services. Treatment/prevention containment Cases (suspected or confirmed): Educate and monitor give educational material to suspected cases. Cases will have daily communication with the Department of Human Services, if possible, depending on numbers involved. Provide antivirals, if available, within 48 hours of symptom onset/according to manufacturer s instructions) for confirmed cases duration five days. Isolate suspected cases until diagnosis is excluded, or until patient is no longer symptomatic and at least seven days for adults and 21 days for children. Prophylaxis Border workers and health care workers working with suspected or confirmed human cases antivirals for as long as contact continues and seven days after last contact.

36 Victorian health management plan for pandemic influenza Contact in the last week with a confirmed case during the infectious period antivirals for seven days after last contact. Control of health care workers Provide immunisation with pandemic vaccine to all health care workers including investigation teams and staff working in influenza wards as soon as vaccine is available. Provide antiviral prophylaxis as above. Use appropriate PPE during assessment and care. After exposure to possible case of pandemic influenza, do not work if symptoms of respiratory illness. Selfmonitor for signs and symptoms of disease and report if ill. Self-isolate until assessed. Treatment/prevention maintenance of essential services Switch health care workers to pre-exposure prophylaxis. Amount of antivirals used for treatment will depend on the results of the treatment trial and availability. Hospitals As per phase Australia 4 with the addition of: All hospitals to have contingencies for triaging increasing numbers of pandemic influenza patients. Consider cessation of elective surgery and early discharge of patients. General practice and Divisions of General Practice Brief doctors, nurses and non-clinical staff on the pandemic phase. Talk about reducing risk and staying well. Implement practice business survival plan. Consider workload management of pandemic influenza and other patients. Community pharmacy As per phase Australia 3, with the addition of: Role of official pharmacy bodies: Victorian Pharmacy Guild and Victorian Pharmaceutical Society will provide a leadership role to profession through the work of their community pharmacy planning taskforce. Act as a conduit for information to and from pharmacists and government Organise and support a committee of regional facilitators to ensure continuity of supply of essential medicines Engage with wholesalers to help support continuity in the supply chain. Community nursing As per phase Australia 3 with the addition of: Prioritise current clients for those who could be discharged if required to create capacity. Report sick leave figures daily to the Department of Human Services through HSCC. Ambulance services Reassess the Ambulance Emergency Response Plan level of activation. Specifically review all non-essential activities to maximise ongoing response capacity. Continue post exposure prophylaxis (antivirals) for exposed staff. Undertake transport of possible influenza cases in consultation with DHS. Liaise with DHS in regards to actions with non emergency requests (pre planned and routine clinic transports). Know how to order additional supplies of PPE.

Victorian health management plan for pandemic influenza 37 Laboratories Specialist laboratories (VIDRL) Containment Test and type specimens from all possible cases for the pandemic influenza strain as per the VIDRL testing protocol. Maintenance Test and type specimens from a random sample of cases as agreed with the Department of Human Services. Routine laboratories (public and private) Transfer any referred specimens to VIDRL for analysis. Agencies As per phase Australia 3. Phase: Australia 6b Pandemic in Australia widespread Status: Goal: Transmission between humans Maintaining essential services Department of Human Services Surveillance As per phase Australia 6a. Vaccine Upon availability of vaccine, vaccinate priority groups by local government teams (except health care workers). Department of Human Services will source and distribute the vaccine. Hospital pharmacies will act as the liaison points for vaccination of hospital staff. GPs will vaccinate staff within their practice. Once the identified priority groups have been vaccinated and further vaccine is available, the general population will be vaccinated. Public health measures Same as per phase Australia 6a, with the addition of: Review current public health measures and consider whether further public health measures are required. Communication Liaise with DoHA regarding antiviral stockpiles and vaccine. Direct all media queries to the Department of Human Services Media Unit. As per phases Australia 4, 5 and 6

38 Victorian health management plan for pandemic influenza Increased mortality In the event that funeral directors are unable to handle the increased number of deceased persons and funerals, it will be the responsibility of the Department of Human Services, with support from the Victorian Institute of Forensic Medicine (VIFM) to make appropriate arrangements for the ongoing storage of bodies prior to burial/cremation, through the use of temporary refrigerated containers. Hospitals As per phase Australia 6a. General practice and Divisions of General Practice As per phase Australia 6a. Community pharmacy As per phase Australia 6a. Community nursing As per phase Australia 6a. Laboratories As per phase Australia 6a. Agencies As per phase Australia 6a. A: Services coping (low numbers) Hospitals As per phase Australia 6a, with the addition of: Treatment Confirmed case priority may need to be given to those deemed at highest risk of severe outcome. Suspected case depending on availability of supplies, provide antivirals. Those at high risk of serious morbidity and mortality will depend on the epidemiology of the causative virus. Prophylaxis Pre-exposure prophylaxis for health care workers, depending on availability. Contacts As per phase Australia 6a. Control of health care workers As per phase Australia 6a. Treatment/prophylaxis/contacts and control of health care workers to be maintained throughout phase Australia 6. General practice and Divisions of General Practice As per phase Australia 6a. Community pharmacy As per phase Australia 6a. Community nursing As per phase Australia 6a. Ambulance service As per phase Australia 6a. Laboratories It may not be possible to test all suspected cases because of the large increase in numbers. Random testing to be implemented in consultation with the Department of Human Services. B: Services full capacity Hospitals As per A: Services coping. General practice and Divisions of General Practice As per phase Australia 6a. Ambulance services Reassess the Ambulance Emergency Response Plan level of activation. Reduce all non-essential activities to maximise ongoing response capacity as provided for under the Ambulance Emergency Response Plan. As per Phase Australia 6a. Consider infield triage to deliver to selected sites based on severity as provided for under the Ambulance Emergency Response Plan and in conjunction with the Department of Human Services.

Victorian health management plan for pandemic influenza 39 Liaise with the department in regards to actions with non-emergency requests (pre planned and routine clinic transports). Laboratories As per phase Australia 6a. C: Services overwhelmed Increased mortality Crematoria will need to look at surge capacity within their facilities. Community support and recovery As per phase Australia 6a. Hospitals As per A: Services full capacity General practice and Divisions of General Practice As per phase Australia 6a. Ambulance services As per B: Services full capacity. Laboratories Cease testing (unless specifically requested for any reason), clinical diagnosis should suffice. Phase 6c Pandemic in Australia subsided Status: Goal: Pandemic subsided Maintaining vigilance Department of Human Services Evaluate actions to date. Undertake stock inventory and resupply. Document and collate financial issues. Debrief staff. Surveillance Return to routine surveillance. Maintain vigilance. Vaccines and pharmaceuticals Collate data on cases and effectiveness of vaccines and antivirals. Hospitals Undertake stock inventory and resupply. Document financial issues. Debrief staff (psychological and operational). Make counselling and support services available. Community pharmacy Assess overall service. Debrief staff. Provide staff counselling. Restock PPE. Update pandemic plan. Identify probable immune staff. Document financial issues. General practice and Divisions of General Practice Undertake stock inventory and resupply. Document financial issues. Staff/Division of General Practice debrief (psychological and operational).

40 Victorian health management plan for pandemic influenza Laboratories Undertake stock inventory and resupply. Document financial issues. Debrief staff (psychological and operational). Ambulance services Ambulance service to regain continuity of service provision. Phase 6d Pandemic in Australia next wave Status: Next wave Goal: Maintaining essential services Same measures as implemented in phase Australia 6a. Undertake stock inventory and resupply. Document financial issues. Debrief staff (psychological and operational).

Victorian health management plan for pandemic influenza 41 End of pandemic Status: Goal: End of pandemic Return to normal activities Evaluation and reporting Phase out quarantine measures, travel restrictions and public health measures. Summarise impact of pandemic, collate data, and update the Victorian health management influenza plan for pandemic influenza. Community nursing Assess overall service. Debrief staff. Counsel staff. Update pandemic plan. Document financial issues. Re-stock resources used during the pandemic. Debrief major services involved. Evaluate plan and actions taken. Revise plan and amend where necessary. Recovery Government departments tasked to assess impacts on community, small business and industries, including the tourism industry. Convene meetings of Central Government Response Committee and State Emergency Recovery Committee to endorse ongoing support. Develop recovery strategy to promote community cohesiveness, support individuals and promote economic recovery. Liaise with Australian Government on issues around business and income support. Conduct memorial services as determined by the impact. Provide community information on bereavement support services. Communication Evaluate performance and review media strategies.

42 Victorian health management plan for pandemic influenza

Section D: Appendices Victorian health management plan for pandemic influenza 43

44 Victorian health management plan for pandemic influenza

Victorian health management plan for pandemic influenza 45 Appendix 1. The impact of a pandemic Modelling the potential impacts of influenza pandemics is problematic and involves a high degree of uncertainty. Factors such as the virulence and infectivity of the next pandemic strain and an undetermined epidemiology in human populations limit our abilities to characterise the next pandemic with any accuracy. It is, however, possible to model various pandemic scenarios given a series of pre-determined assumptions and limitations. This allows us to review our capacity in light of a variety of possible outcomes, and to estimate the likely efficacy of our interventions. Attempting to directly relate the results of the modelling, particularly the numbers of cases (deaths, hospitalisations etc.) to the occurrence of a real pandemic would be inaccurate and misleading. In the event of a pandemic, epidemiological information as it comes available may be entered into the scenarios for more real-time modelling of the morbidity, mortality and transmission dynamics of the disease. Meltzer morbidity and mortality modelling The Meltzer model 10 was designed to compute a series of pandemic scenarios with the objective to determine the economic benefits of influenza immunisation. It has been used more recently to obtain static point estimates on the range of potential excess hospitalisations, outpatient visits and deaths that may occur given specific population and pandemic characteristics. It is estimated that an attack rate of 30 per cent excess outpatient visits in Victoria could vary from 602,229 to 713,513; excess hospitalisations could vary from 6,236 to 24,323; and excess deaths could vary from 2,265 to 10,145. 10 Meltzer M.I., Cox N.J., and Fukuda, K. 1999, The economic impact of pandemic influenza in the Unites States: Implications for setting priorities for intervention.

46 Victorian health management plan for pandemic influenza Appendix 2. Surveillance An effective surveillance system is a vital component of pandemic preparedness and response, integrating data on disease occurrence with virological and clinical data. A sensitive early warning system is needed to identify the first human cases related to the emergence of a potential pandemic influenza strain and signal the first instances of human-to-human transmission. It is critical to signal the transition from limited human-to-human transmission to the efficient and sustainable transmission that marks the start of a pandemic. 1. Australia In Australia, influenza surveillance is based on several schemes collecting a range of data that can be used to measure influenza activity. In all jurisdictions except South Australia, laboratory confirmed influenza is a notifiable disease under state and territory legislation. In 2006, six sentinel general practitioner schemes contributed reports of influenza-like illness (ILI): the Australian Sentinel Practice Research Network (ASPREN), Tropical Influenza Surveillance from the Northern Territory, and sentinel general practice schemes in Queensland, New South Wales, Victoria and Western Australia. ASPREN and the Northern Territory Tropical Influenza Surveillance Scheme report ILI rates throughout the year, while the other sentinel surveillance schemes report from May to October each year. The national case definition of ILI is: presentation with fever, cough and fatigue. All sentinel surveillance systems, including ASPREN, used the national case definition for ILI in 2005. From autumn to spring, the results of each of the schemes are published on the Communicable Disease Australia website as the National Influenza Surveillance Scheme. Annual reports on influenza are published in Communicable Diseases Intelligence each year. These reports include a summary and review of sentinel surveillance data, absenteeism data from a major national employer and influenza typing from the WHO Collaborating Centre for Influenza Reference and Research (WHOCC). 2. Victoria Human surveillance In Victoria, influenza surveillance consists of notification of laboratory confirmed influenza from pathology laboratories as well as reports from general practices conducting sentinel surveillance for ILI. In 2006, sentinel surveillance for ILI included reports from: sentinel GPs in metropolitan Melbourne and regional Victoria Melbourne Metropolitan Locum Service (MMLS) The Department of Human Services also receives strain typing data from the WHOCC for Reference and Research on Influenza. Laboratories and medical practitioners are responsible for notification of laboratory confirmed influenza. The Department of Human Services collects and collates, analyses, interprets and reports the data. The Victorian Infectious Diseases Reference Laboratory (VIDRL) coordinates sentinel general practice surveillance and sentinel surveillance from the MMLS with laboratory support. Animal surveillance Surveillance for animal influenza in Victoria is the responsibility of the Department of Primary Industries (DPI). Avian, swine and equine influenza are notifiable exotic diseases under the Livestock Disease Control Act 1994. Any person (including owners, veterinarians and laboratory staff) who knows or suspects that one of these diseases is present must notify an Inspector of Livestock immediately by the quickest means of communication available. Diagnostic opportunities to rule out influenza in horses, pigs and poultry are regularly undertaken using syndromebased diagnostic sampling. A wild bird surveillance program is in place. Testing is undertaken at the DPI laboratory at Attwood and the Australian Animal Health Laboratory (AAHL) at Geelong. Nationally agreed procedures for surveillance during disease outbreaks of animal influenza and for proof

Victorian health management plan for pandemic influenza 47 of freedom following an outbreak are included in AUSVETPLAN Disease Strategies. In Australia, the potential for cross-species transmission from domestic poultry and pigs to humans and subsequent reassortment of animal and human viruses in co-infected individuals is extremely low, due to Australia s freedom from influenza viruses of pigs, domestic poultry and horses, and the high standards of animal husbandry and public health. 3. Laboratory issues Laboratory investigation Respiratory tract samples collected within one week after onset of illness, preferably within the first three days, are suitable for influenza virus detection. Combined nose and throat swabs, nasopharyngeal swabs, nasopharyngeal aspirates (NPA) and nasal washes may all be used for influenza detection. Staff collecting samples should follow all recommended infection control precautions, particularly for aerosol producing procedures such as NPA or nasal washes. If initial respiratory samples are positive for a novel strain a second specimen should be collected and re-tested. An acute-phase serum specimen (7 10 ml of whole blood) should be taken soon after onset of clinical symptoms and not later than seven days after onset. A convalescentphase serum specimen should be collected 14 days after the onset of symptoms. Convalescent samples should be collected even when acute samples have not been, as they may still assist in diagnosing or excluding infection. Diagnostic testing 11 In the event of a pandemic strain entering Victoria, there will be a need to rapidly and accurately identify the influenza type (as influenza A or B) and to sub-type influenza A virus haemagglutinin to determine whether it is the pandemic strain. While many laboratories can provide identification of influenza, only a limited number can provide the diagnostic capacity required for pandemic influenza. VIDRL is a WHO National Influenza Centre (NIC) and is able to provide services for identification of pandemic strains. The WHOCC for Reference and Research on Influenza in Melbourne conducts detailed genetic and antigenic analysis of strains. It provides diagnostic support and will be responsible for final confirmation of pandemic strains. In the phase before the pandemic strain enters Australia, or if activity is detected within Australia but not in Victoria, it is important that tests with high sensitivity and specificity are used to ensure accurate identification. Viral culture and nucleic acid detection by polymerase chain reaction (PCR) are the preferred methods. During the phase prior to the entry of the pandemic strain into Australia, all patients with suspected pandemic influenza should have a suitable nucleic acid determination and cell culture performed. In all cases, any sample that tests positive for influenza from a patient with suspected pandemic influenza must be referred for viral culture and must be referred urgently to the WHOCC via the NIC. Testing should be undertaken for other significant viral and bacterial infections that may cause a similar illness, or that might occur as a secondary complication of influenza infection. Once pandemic influenza has entered Australia, the necessity for highly accurate testing will diminish. Other tests that have been shown to detect the pandemic strain, even if suboptimal, will have an important role in reducing the demand on reference laboratories. Where it is an area of known high pandemic activity, diagnostic testing will usually not be needed at all. During the late phases of the pandemic, there shall be a return to the routine use of highly accurate testing so that the end of the pandemic can be confidently identified. 11 This section is adopted from the Australian Government Department of Health and Ageing, Australian management plan for pandemic influenza (June 2005)

48 Victorian health management plan for pandemic influenza Table A2.1: Summary of surveillance objectives according to pandemic phases Period Phase Surveillance objectives Inter-pandemic Aus 0 1. Human standard surveillance/animal surveillance as needed O/s 1 Aus 1 O/s 2 Aus 2 To facilitate the early detection of seasonal influenza virus circulation To monitor the pattern of influenza in the community To monitor strains of influenza virus circulating in Victoria To facilitate the collection of influenza virus isolates that may be suitable for future vaccine strains To monitor trends in deaths from all causes 2. Human surveillance with extra animal surveillance As (1) above with the addition of: To monitor influenza infection or potential infection in birds and animals in Victoria Pandemic alert O/s 3 3. Heightened awareness transmission of animal influenza to humans Aus 3 O/s 4 Aus 4 O/s 5 Aus 5 Pandemic O/s 6 As per 5 Aus 6a Aus 6b Aus 6c As per 4 Aus 6d As per 5 As for (1) and (2) above with the addition of: To facilitate early detection of human infection with an animal influenza virus 4. Heightened awareness Human to human transmission As for (1) (and (3) if potential pandemic influenza strain is of animal origin) above with the addition of: To facilitate the early detection of potential pandemic strain influenza in Victoria 5. Pandemic influenza To monitor the hospital admissions and mortality of confirmed and suspected pandemic influenza in Victoria To monitor the geographic spread of the pandemic within Victoria To monitor the Intensive Care Unit (ICU) bed usage To monitor absenteeism in the health workforce To liaise with other organisations that are monitoring their respective workforces

Victorian health management plan for pandemic influenza 49 Appendix 3 Hospitals and health services 1. Introduction Purpose of document This appendix provides information for hospitals and health services about pandemic influenza planning and preparedness. Scope of document It contains information and concepts that are specific for pandemic influenza and is not intended to be a standalone document. This appendix should be considered along with health service planning for mass casualty events, for example, code brown and hospital surge plans. This appendix is based on the best available evidence, assumptions and estimates currently available and may have to be modified if the epidemiology of the outbreak is significantly different than anticipated. 2. Epidemiology An influenza pandemic occurs when a new viral strain appears for which there is little or no immunity in the population and which is readily transferred between humans to produce infection in a high proportion of people exposed. The potential result is very significant morbidity and mortality and associated large-scale social and economic disruption. Assumptions Influenza pandemics have commonly been associated with attack rates of 25 30 per cent of the population. However, attack rates of up to 70 per cent have occurred in some communities. Mortality, hospitalisations and staff absenteeism rates have increased substantially during pandemics. In the 1957 influenza pandemic in the United Kingdom (UK), the recorded staff absentee rates in some organisations were between 5 and 30 per cent. If a pandemic with an attack rate of 30 per cent (that is, 30 per cent of the population affected) were to occur in Victoria and there was no pandemic vaccine or treatment available over a 6 8 week period, it could lead to: 2,265 10,145 deaths 6,236 24,323 hospitalisations; 602,229 713,513 outpatient visits Estimating the potential impacts of an influenza pandemic is difficult given we are unable to predict the virulence and infectivity of the particular strain involved, as well as the epidemiology of the specific strain and the rapidity and effectiveness of the response. In the absence of actual data on the specific strain, it is possible to model various pandemic scenarios, given a series of pre-determined assumptions and limitations, such as those listed below, to facilitate planning efforts: Susceptibility to the pandemic influenza virus will be universal. Efficient and sustained person-to-person transmission signals an imminent pandemic. The clinical disease attack rate could be 30 50 per cent in the overall population during the pandemic. Rates of serious illness, hospitalisation and deaths will depend on the virulence of the pandemic virus and the ability to minimise the spread and capacity to treat those affected. Rates of absenteeism will depend on the severity of the infection. In a severe pandemic, absenteeism attributable to illness, the need to care for unwell family members, and fear of infection may reach 40 per cent during the peak weeks, with lower rates of absenteeism during the weeks before and after the peak. Certain public health measures (for example, closing schools, quarantining household contacts of infected individuals) are likely to increase rates of absenteeism. Persons who become ill may transmit the infection for up to 24 hours before the onset of symptoms. However viral shedding and the risk of transmission will be greatest during the first two days of symptons but may continue for up to seven days in adults and 21 days in children. Multiple waves (periods during which community outbreaks occur across the country) of illness are likely to occur.

50 Victorian health management plan for pandemic influenza In the event of a pandemic, up to six months production time will be required before sufficient vaccine will become available. A pandemic may have serious impacts on the normal functioning of society, with possible disruption of food supply, utilities including power, water, transport and communications as well as effects on the functioning of businesses, service industries and the economy. Transmission Transmission of human influenza virus is mainly by droplet transmission. This occurs when droplets from the cough or sneeze of an infected person are propelled through the air (generally up to 1 metre) and land on the mouth, nose or eye of a nearby person. Influenza can also be spread by contact transmission. This occurs when a person touches respiratory droplets that are either on another person or an object and then touches their own mouth, nose or eyes (or someone else s mouth, nose or eyes) before washing their hands. In some situations, airborne transmission may result from procedures that produce very fine droplets (called fine droplet nuclei) that are released into the air and breathed in. These procedures include: intubation taking respiratory samples performing suctioning use of a nebuliser. Incubation period The incubation period for influenza can range from 1 7 days, but is usually 2 3 days. Infectious period Adults have been known to shed the virus from one day before developing symptoms to up to seven days after the onset of the illness. Young children can shed the virus for up to 21 days. Case definition Clinical and surveillance case definitions will vary according to the phases of a pandemic and will need to be updated as more is learnt about the transmission characteristics and severity of disease associated with the particular strain. Case definitions will be sent to health care professionals in the form of a Health Industry Alert by the Department of Human Services. Contact definition (pandemic influenza) A person who has had close contact (within 1 metre) with an infectious case or who has spent more than 15 minutes in a confined space (such as an enclosed room) with an infectious person. 3. Victoria s health services Influenza streams Patients with suspected pandemic influenza may present to any health service in a variety of ways. Health services need to develop a process for separating, triaging and admitting people with influenza-like illness to prevent cross-infection. This may involve setting up a separate area, such as an influenza triage or influenza clinic. Designated hospitals To prevent the spread of pandemic influenza infection within hospitals, the Department of Human Services will implement a Designated Hospital Model. This model includes the implementation of influenza clinics as patient numbers increase, to minimise impacts on hospital emergency departments and GP clinics. The Department of Human Services has identified 16 designated hospitals in Victoria (Table A2.2). They have been designated based on: location isolation facilities (for example, negative pressure rooms) infectious diseases expertise.

Victorian health management plan for pandemic influenza 51 The decision to transfer suspected cases to a designated hospital will be made by the Department of Human Services in consultation with the health service. The clinical condition or other considerations may preclude patient transfer. Table A2.2: Designated hospitals Bayside Health, The Alfred Commercial Road Prahran VIC Austin Health, Austin Hospital Studley Road Heidelberg VIC Ballarat Health Services, Base Hospital Drummond Street North Ballarat VIC Bendigo Health, Bendigo Hospital Campus Lucan Street Bendigo VIC Eastern Health, Box Hill Hospital Nelson Road Box Hill VIC Peninsula Health, Frankston Hospital Hastings Road Frankston VIC Barwon Health, Geelong Hospital Ryrie Street Geelong VIC Goulburn Valley Health Graham Street Shepparton VIC Latrobe Regional Hospital Princess Highway Traralgon West VIC Southern Health Monash Medical Centre, Clayton Campus Clayton Road Clayton VIC Northeast Health Wangaratta Green Street Wangaratta VIC Northern Health, The Northern Hospital Cooper Street Epping VIC The Royal Children s Hospital Flemington Road Parkville VIC Melbourne Health The Royal Melbourne Hospital Grattan Street Parkville VIC St. Vincent s Health, St. Vincent s Hospital Princes Street Fitzroy VIC Western Health, Western Hospital Gordon Street Footscray VIC Management by phases Three major phases will be used within Victoria to respond to a pandemic threat. The aim of the phases is to minimise the morbidity and mortality associated with the pandemic. They are: Preparedness Containment Maintenance Health services response by phases: Preparedness The readiness of arrangements to ensure that Victoria is well prepared. Delaying transmission for as long as possible by border control measures, widespread adoption of good hygiene and infection control practices, isolation of cases, quarantine of contacts, and use of antiviral medication. When community transmission is established, containment is no longer feasible. Pre-exposure prophylaxis for priority groups will be important to maintain societal functioning. Develop influenza and business continuity plans. Stockpile personal protective equipment (PPE) and ensure that staff are trained in their use. Attain high coverage of staff immunisation for influenza. Train staff on epidemiology, signs and symptoms for pandemic influenza. Educate staff on infection control protocols and hand hygiene. Prepare triage plan for suspected cases. Containment Update triage plan and case definitions. Report all suspected cases immediately to the Department of Human Services, Communicable Diseases on 1300 651 160.

52 Victorian health management plan for pandemic influenza In the early containment phase, manage suspected cases in an appropriate clinical setting until testing has been conducted. This may or may not be a designated hospital. Refer confirmed cases to designated hospitals if diagnosing hospital cannot produce appropriate clinical or infective control requirements. Health care workers to wear PPE for suspected cases. Isolate cases in single rooms (negative pressure rooms if available). Maintain a list of contacts patients, contacts, staff. Activate the Health Services Coordination Centre. Activate influenza clinics at designated hospitals. Department of Human Services will advise hospitals where to access antiviral stocks for staff, patients and contacts. Maintenance Cohort patients. As much as possible, patients who can manage their symptoms will be managed at home. Consider workload management of staff high levels of absenteeism. Need to manage essential supplies with suppliers due to possible shortages. Educate staff on risks and ways to stay well. Surge capacity An influenza pandemic will lead to a massive demand for hospitals and other health services. All health services should consider their surge capacity/business continuity needs and plan accordingly. It is estimated that businesses should plan for 30 50 per cent staff absenteeism at the peak of a pandemic. Staff absence can be expected for many reasons including: illness some employees may need to stay at home to care for ill family members others may need to stay at home to look after children (as schools/child care centres may be closed) staff may refuse to attend work from fear of contracting pandemic influenza at work. A pandemic may have other impacts on businesses, for example: shortages of supplies to produced goods and services movement of people/goods may be delayed/restricted by quarantine and isolation measures within Australia and overseas availability of services from other suppliers may be impacted demand for services may be impacted demand for some services may increase (Internet access is a possible example); while demand for others may fall (certain types of travel may reduce) fuel and energy supplies may be disrupted to some locations at times temporary closure of schools, public transport, public venues and events financial implications. Health Services Coordination Centre The HSCC is activated in the event of an extraordinary event, which has a major impact on hospital capacity or demand, such as major/mass casualty incident when the State Health Emergency Response Plan (Health Displan) requires coordination of health services to aid casualty management. The HSCC is a function of the Department of Human Services Emergency Coordination Centre, which coordinates all department interests in emergencies and has links with central government and emergency services. It is anticipated that the HSCC will be activated when Victoria has its first confirmed influenza pandemic case, and will provide coordination and a single contact point for health services and rural regions. Key roles of the HSCC in a pandemic include: assessing the impact on Victoria s health system early identification of critical health resource issues

Victorian health management plan for pandemic influenza 53 monitoring the business continuity capability of health facilities supporting health services on incident management policy matters and priority considerations including service reduction, continuity and standard of care provisions implementing statewide health policies and standards providing centralised reporting and information dissemination structures for the health sector enabling the prioritisation and maximisation of available health resources. Health services will be required to provide the HSCC with situation reports detailing: current status any impacts or service failure being experienced patient numbers available beds consumables staff sick leave. A series of standard reporting templates, which detail the information required, will be available at http://www.dhs. vic.gov.au/emergency/hs_pass.htm The HSCC will post health sector bulletins as required on http://www.dhs.vic.gov.au/emergency/hs_pass. htm These will include information on the extent of the incident, any disruption to services, the likely duration until resolution or on the status and needs of Health Services during the pandemic. 4. Workforce issues All agencies may be affected by staff absence because of illness or isolation of suspected cases, the need to take time off to care for others, or fear of contracting pandemic influenza. This will occur at a time when, for some agencies, the workload may be greater than normal. Staff will be at risk of pandemic influenza through both community and health care related exposure. Such exposure can be minimised by applying rigorous infection control procedures, especially hand hygiene (hand washing, use of alcohol-based products) and the appropriate use of PPE (see Appendix 6). In the early phases of an outbreak, it is likely that schools, child care centres and other large public facilities will be closed to minimise the spread of the pandemic virus. To manage potential staff shortages and the large number of expected cases, health services need to consider and review their business continuity arrangements. Factors to consider include: surge capacity maintaining core business elective surgery, outpatient services (dialysis, haematology, oncology) establishing minimal staffing levels the need for staff to work in areas they are not formally trained supplies of consumables such as hand wash, alcohol rub, linen, P2 and surgical masks, gloves and gowns stockpiling of PPE maintaining critical services such as cleaning, food, linen and waste using volunteers, retired or trainee staff staff immunisation policy accommodation for staff who are unable to go home or when transport services are disrupted communication with staff payment of staff psychological and other personal support for staff human resources How will staff who refuse to attend work be managed. Absenteeism caused by staff concerns is best managed by education. An ongoing education program for staff in infection control procedures is an essential element for pandemic influenza preparedness. Health services should identify priority groups for this purpose, including emergency department staff, staff identified for influenza clinic teams, ancillary staff, and staff working on wards that may become influenza wards during a pandemic.

54 Victorian health management plan for pandemic influenza All staff should be screened for influenza-like symptoms before they commence work. Symptomatic people should be sent home and advised not to return for the duration of the infectious period. Health services should maintain accurate records of health care workers who have attended patients with suspected or confirmed influenza. The number of staff caring for the patient should be minimised. Health care workers who care for pandemic influenza patients should not care for other patients. Decisions regarding this issue will need to be made in light of local workforce availability. Health care workers at high risk for complications from pandemic influenza (such as chronic medical conditions, pregnant, immunocompromised) should not provide direct patient care to pandemic influenza patients. Visitor and worker restrictions Restrict visitors to patients with influenza. Exclude visitors with symptoms of respiratory infection from visiting patients. Exclude health care personnel with symptoms of respiratory infection from work for the duration of illness. 5. Guidance for health services Influenza streams Patients with suspected pandemic influenza may present to any health service in a variety of ways. All health services need to develop a process for separating, triaging and admitting people with influenza-like illness to prevent cross-infection. Suspected pandemic patients should be triaged to a separate waiting and assessment area, either within the emergency department or to a designated influenza area. Signage should clearly direct patients with respiratory symptoms to report to reception immediately on arrival. If a patient with suspected pandemic influenza infection presents to hospital: avoid unnecessary contact with other patients and staff apply an alcohol based solution to their hands place a surgical mask on the patient place patient in a suitable separate area place the patient in a negative pressure room (if available) or in a room with a door that is well ventilated and easily cleaned all staff must use PPE when attending the patient. If a suspected case is only identified once in an emergency department or waiting area, then a record is to be kept of people (staff, patients and visitors) who may have been in contact with the suspected case. The Department of Human Services, Public Health, should be contacted to organise appropriate testing of suspected influenza patients. Call: 1300 651 160. The Department of Human Services will advise health services when individual testing of suspected cases is no longer required. Patient placement and care When a person attends with influenza-like illness, the objective is to prevent transmission to attending health care staff and other patients. Strategies for achieving this include: isolate patient immediately in single room (preferably negative pressure room if available); keep the door of the room closed; restrict the patient s movement; if the patient must leave the room, then they should wear a surgical mask use disposable equipment wherever possible and dispose of appropriately limit admission of influenza patients to those who cannot be cared for at home.

Victorian health management plan for pandemic influenza 55 The order of priority for patient room placement is: 1. negative pressure isolation room 2. single room 3. area designated for cohorting of pandemic patients. Designated hospitals Designated hospitals will be implemented to prevent the spread of pandemic influenza and provide specialised care, such as: high level infection control practices specialised infectious diseases support negative pressure isolation facilities. While patient numbers are low, confirmed cases of pandemic influenza may be referred to designated hospitals for treatment and admission. As patient numbers increase and the demand for negative pressure isolation rooms exceeds capacity, influenza clinics will be established at designated hospitals. Influenza clinics Influenza clinics will be established at designated hospitals. The decision to activate an influenza clinic will be made by the HSCC in consultation with the designated hospital. Not all influenza clinics will necessarily be activated concurrently as decisions will depend on epidemiology and patient presentations across the state. Influenza clinics are intended to reduce the load of suspected cases in GP waiting rooms and hospital emergency departments as well as provide an assessment area that is separate from other patient areas. Influenza clinics should: be able to assess and manage large numbers of people be easily accessible provide patients with a surgical mask to wear have unilateral flow through the clinic have access to the emergency department or health facility if admission is required have access to x-ray and pathology services be supported by appropriate clinical and ancillary staff provide patients with written advice on the management of their condition if discharged home. Other health facilities may want to establish influenza clinics to enable triaging and processing people with influenza-like illness to prevent cross-infection. Air handling Airborne precautions are designed to reduce the risk of airborne transmission of infectious agents. Airborne transmission occurs by dissemination of small (less than 5 micrometres in size) droplets containing infectious agents that may remain suspended in the air for long periods of time. There is no evidence that influenza can occur across long distances (for example, through ventilation systems) or through prolonged residence in air; however, precautions should be taken when performing aerosolgenerating procedures. Procedures that are associated with aerosol generation include endotracheal intubation, bronchoscopy, nebuliser treatment and airway suctioning and sputum induction. Strategies for minimising risks during these procedures include: limiting aerosol-generating procedures limiting health care workers in the room during the procedure performing the procedure in an negative pressure room if available; or perform procedure in a private room away from other patients keeping the door closed all staff to wear personal protective equipment (PPE) including a P2 mask. Transfer of patients People suspected of pandemic influenza will be treated at the health service they attend and will only be transferred to another facility if their condition warrants medical care that is not available at that health service.

56 Victorian health management plan for pandemic influenza The decision to transfer pandemic influenza patients to other facilities will be made by the Department of Human Services in consultation with the health services. Influenza wards Patients with pandemic influenza will quickly fill available isolation rooms. Where possible, health services should identify wards to allow the cohorting of patients with influenza. Suspected cases should be separated from confirmed cases. Access to these wards should be restricted to: patients necessary personnel minimal visitors. Out of hospital care Hospital care will be prioritised on the bases of clinical need. Most people will manage their illness at home. When sending a patient home from a health service, consideration needs to be given to: patient follow-up assistance with activities of daily living education about infection control measures to reduce the spread of virus to other household members or visitors. Patients who require medical assistance will need to access existing medical arrangements (for people requiring in-home support see Local government below). The department s fact sheet (Pandemic influenza (flu) Information for the general public looking after yourself in a pandemic, provides guidance for households to plan and prepare for a pandemic. Local government During a human influenza pandemic, local government will provide a range of in-home support services through community support centres including, but not limited to: provision of meals personal support financial assistance material aid volunteer assistance community advice and information. The community support centres will not provide medical assistance. Health care services will need to be accessed through existing medical arrangements. Further information and referral mechanisms can be found in the Community and Support Recovery Sub Plan (to be published mid-2007). 6. Antivirals See Appendix 9 for detailed information. 7. Pandemic vaccination See Appendix 8 for detailed information 8. Stockpile information The Australian Government has established the National Medical Stockpile (NMS) in response to Australia s elevated security threat level. The NMS is a national strategic reserve of essential vaccines, antibiotics, antiviral drugs, chemical and radiological antidotes and PPE. In the event of an influenza pandemic and following exhaustion of existing state resources, the Chief Health Officer or other senior government official will make a request to the Commonwealth Chief Medical Officer for the release of products from the NMS. Once approved by the Chief Medical Officer, required components of the NMS will be delivered to Victoria but will remain the property of the Australian Government until after it is administered/used. The HSCC will coordinate requests for supplies and distribution. 9. Consumables National and state stockpiles of PPE, antivirals and medical supplies have been, and are continuing to be, developed. Health services should have contingencies for an increased demand for PPE prior to the mobilisation of these stockpiles. Therefore, all health services should: income support

Victorian health management plan for pandemic influenza 57 evaluate current stocks of essential supplies, including those necessary for hand hygiene, PPE, antibiotics and appropriate antivirals develop a rotating stockpile of such consumables stockpile sufficient masks for 14 days. Preliminary work has suggested that, for each suspected case attending the emergency department, up to 20 sets of PPE will be used. 10. Infection control guidance for hospitals See Appendix 6 for detailed information. Further infection control information can be found in The interim infection control guidelines for pandemic influenza in healthcare and community settings (June 2006), Annex to: Australian health management plan for pandemic influenza: http://www.health.gov.au/internet/wcms/ publishing.nsf/content/ohp-pandemic-ahmppi.htm 11. Cleaning and disinfection Cleaning and disinfection of environmental surfaces are important components of routine infection control in health care facilities. Clean environmental surfaces with a neutral detergent followed by a disinfectant solution (section 4.2.7 Environmental cleaning and disinfection for further detail) http://www.health.gov.au/internet/wcms/ publishing.nsf/content/ohp-pandemic-infect-controlgl-toc.htm Use dedicated or single use/disposable cleaning equipment wherever possible. Launder non-disposable equipment, including mop heads, after use. When cleaning a patient s room, wear appropriate PPE, including a surgical mask. 12. Care of the deceased It is reasonable to assume that if the patient died of pandemic influenza during the infectious period, infectious virus may be present in respiratory tract tissues beyond death. An infectious risk may be posed if the respiratory secretions or fluids were aerosolised. Health care workers should: adhere to standard precautions wear a surgical mask when moving the body of the deceased, place a surgical mask over the patient s nose and mouth to prevent inhalation of residual air that may be expelled from the lungs when the body is moved. Family members should: in general be allowed to view the body be educated about hand hygiene be advised not to kiss the deceased. See Chapter 8 in the Interim infection control guidelines for pandemic influenza in healthcare and community settings (June 2006) http://www.health.gov.au/internet/wcms/ publishing.nsf/content/ohp-pandemic-ahmppi.htm for further detailed information on post mortem care. 13. Resources Australian Government Department of Health and Ageing, Australian health management plan for pandemic influenza, available at: http://www.health.gov.au/internet/wcms/publishing. nsf/content/ohp-pandemic-ahmppi.htm Australian Government Department of Health and Ageing, Interim infection control guidelines for pandemic influenza in healthcare and community settings (June 2006), Annex to Australian health management plan for pandemic influenza, available at: http://www.health.gov.au/internet/wcms/publishing. nsf/content/ohp-pandemic-infect-control-gl-toc.htm Australian Government Department of Health and Ageing, Interim national pandemic influenza clinical guidelines (June 2006), Annex to Australian health management plan for pandemic influenza, available at: http://www.health.gov.au/internet/wcms/publishing. nsf/content/ohp-pandemic-clin-care-gl-toc.htm

58 Victorian health management plan for pandemic influenza Appendix 4. Mass fatality planning 1. Planning considerations During a pandemic, existing mortuary services will undoubtedly experience an increased workload, potentially over and above their capacity. Within any locality, the number of total deaths (including influenza and all other causes) occurring during a 6 8 week pandemic wave is estimated to be similar to that which typically occurs over six months in the inter-pandemic period. 12 In order to develop guidelines or adjust existing plans to suit the pandemic situation, the following persons need to be involved in mass fatality planning: the State Coroner s Office of Victoria, Victorian Institute of Forensic Medicine (VIFM) the Australian Funeral Directors Association (AFDA) and the Independent Funeral Directors Association (IFDA) Victorian Cemeteries and Crematoria Association of Victoria representatives of religious and ethnic groups. Existing plans may include provisions for mass fatalities but should be reviewed to determine if these plans are appropriate for the relatively long period of increased demand which may occur in a pandemic, as compared to the short response period required for most disaster plans. Since it is expected that most fatal influenza cases will seek medical services prior to death, hospitals, nursing homes and other institutions must plan for more rapid processing of deceased persons. To deal with the increase in fatalities, some municipalities may need to establish temporary mortuary facilities. Plans should be based on the capacity of existing facilities compared to the projected demand. 2. Mortuary/crematoria capacity It is estimated that the Victorian public and private mortuary providers have the capacity to hold approximately 2,000 13 bodies in refrigeration throughout mortuaries in Victoria. Further capacity in holding rooms and refrigerated vehicles could increase this capacity by approximately 500. The daily normal graves capacity in Victoria is 368 and daily normal cremations capacity is 227. Victorian Institute of Forensic Medicine (VIFM) VIFM is tasked with conducting investigations of reportable deaths under the Coroners Act 1985. The current mortuary capacity of the VIFM is 180 deceased. In event of a major disaster, the mortuary capacity can be increased to 250 deceased. The VIFM has contingency plans in place for the storage of additional deceased in refrigerated pan-tecs containers to be placed at various locations in the CBD of Melbourne (close to the VIFM). Each container will be a fully organised temporary cool store with all necessary equipment. There are sufficient supplies of body bags, safety equipment, plastic overalls, boots, respirators, single-use gloves, white coveralls and identification tags on hand for emergency situations. In the event of a major disaster, the VIFM has arrangements in place for the immediate provision of additional supplies. The average turn-around time for bodies held in mortuaries before burial is 72 hours (that includes the time taken for a routine post-mortem to be completed where necessary). Cemeteries/crematoria in Victoria There are 550 public cemeteries and nine crematoria, which contain 21 cremator units in Victoria. 12 Health Canada, The Canadian Influenza Pandemic Plan, Annex I Guidelines for the management of mass fatalities during an influenza pandemic, 2004. 13 Estimate based on information provided by the Australian Funeral Directors Association, the Independent Australian Funeral Directors Association and the Victorian Institute of Forensic Medicine, July 2004.

Victorian health management plan for pandemic influenza 59 The current weekly cremation capacity is 2,776. Consideration of increasing services will need to be made at the time of the pandemic, with the following assumptions: no interruption to natural or LP gas supply no cremator malfunctions availability of operational staff or modern assisted operation. 3. Social/religious considerations A number of religious and ethnic groups have special requirements about how bodies are managed after death, and such needs must be considered as part of pandemic planning. As an example, Aboriginal/Torres Strait Islanders, Jews, Hindus, Muslims all have specific requirements for the treatment of bodies and funerals. Religious leaders should be involved in planning for funeral management, bereavement counselling and communications, particularly in ethnic communities with large numbers of people who do not speak English. During a pandemic it may not be possible for these religious considerations to be met, due to overriding public health measures. 4. Care of the deceased Infection control Infection control policies and procedures (guidelines) used in the funeral industry are no different to those used in the health care settings 14. Post-mortem If the patient died during the infectious period, the lungs may still contain the virus. There is less risk to employees from aerosols (airborne or droplet transmission) from the lungs of the deceased than from the living. During any procedures on the cadaver s lungs, full PPE should be worn, and care should be taken to minimise the production of aerosols by: avoiding the use of power saws conducting procedures under water if there is a chance of aerosolation avoiding splashing when removing lung tissue. Mortuary care Mortuary or funeral home staff should be informed that the deceased had pandemic influenza and that standard precautions are all that is required in the event of exposure to the body. Embalming and the hygienic preparation of the deceased (cleaning, tidying of hair, shaving) may be conducted as routine. Further details on post-mortem care are in the Interim infection control guidelines for pandemic influenza in healthcare and community settings (June 2006) Annex to the Australian health management plan for pandemic influenza available at: http://www.health.gov.au/ internet/wcms/publishing.nsf/content/ohp-pandemicinfect-control-gl-toc.htm Standard precautions should be taken when caring for deceased pandemic influenza cases. Standard precautions are work practices required for the basic level of infection control (see Appendix 6). 14 Australian Worker s Union (Vic), Department of Human Services, Australian Funeral Directors Association. Draft infection control guidelines for the funeral industry, February 2003.

60 Victorian health management plan for pandemic influenza Appendix 5. Community support and recovery issues 1. Roles/responsibilities of Department of Human Services regions and local government Local government Councils play a critical role in Victoria s emergency management system. Councils have emergency management responsibilities because they are the closest level of government to their communities and have access to specialised local knowledge of their districts. People also naturally seek help from their local council and emergency management agencies during emergencies and the recovery process. Table A5.1: Role and responsibilities of local government Issue Planning/ preparedness Response/ recovery Roles/responsibility Undertake influenza pandemic planning Make provision for business continuity in face of increased absenteeism Promote vaccination for influenza and pneumococcal vaccine for the identified high-risk groups Information/resources Work in conjunction with regions and Public Health Group to disseminate information (including warnings) Provide resources as available and needed by the community and response agencies Establish Municipal Emergency Coordination Centre (MECC) facilities and staffing Post-impact assessment gather and process information (to be determined) Community support Provide support to individuals/communities quarantined/isolated in homes/institutions Provide and/or coordinate volunteer helpers Provide personal support services, for example, counselling, advocacy Provide and staff recovery/information centre(s) Convene municipal/community recovery committees Vaccine Store and deliver vaccine Provide immunisation services according to recommendations by Department of Human Services Other Identify temporary mortuary facilities that could be used if required

Victorian health management plan for pandemic influenza 61 Department of Human Services regions One of the operational activities of regions is emergency management/incident response. In conjunction with the Public Health Branch, regions aim to improve the capacity to manage public health incidents and emergencies in accordance with the Public health emergency management plan: undertake risk assessments and risk evaluations as part of the preparedness or response to potential or actual emergency events according to agreed protocols with the Public Health Group develop a control structure in the region provide support to local government public health emergency management planning process review regional public health emergency management plans in line with public health policy in consultation with key stakeholders within the region and the state use regional (and/or divisional) emergency management committees to maximise emergency service organisations knowledge and understanding of public health issues. Table A5.2 Roles and responsibilities of Department of Human Services regions Issue Planning/preparedness Response/recovery Roles/responsibility Facilitate planning arrangements Work with local government authorities to assist with influenza pandemic planning Work with health care facilities to assist with influenza pandemic planning Facilitate influenza pandemic planning within the region (program areas, for example, Disability Services/Community Residential Units/Supported Residential Units Make provision for business continuity within regions in face of increased absenteeism Provide assistance to Department of Human Services, Public Health, CDCU as required Provide assistance to local government to help deliver response activities Coordinate response at a regional level Provide information at a regional level Collate regional data to inform a statewide response (data on immunisation, persons/ services affected) Coordinate community support and recovery activities across the region Convene Regional Emergency Recovery Committee

62 Victorian health management plan for pandemic influenza 2. Recovery The State Emergency Recovery Arrangements will be activated upon notification of a pandemic. The State emergency recovery arrangements are the agreed statewide arrangements that are jointly owned by all levels of government, together with the agencies and organisations that participate in supporting the recovery of people affected by emergencies. The arrangements have been developed in accordance with the directions of the Emergency Management Act 1986 and are part of the Emergency Management Manual Victoria. They have been developed to ensure adequate arrangements are in place to assist those who are affected by emergencies. The Department of Human Services has been nominated by the Coordinator-in-chief as the coordination agency for recovery. The Secretary of the Department has appointed the Executive Director, Operations as the State Recovery Coordinator. The Emergency Management Act 1986 states that recovery is the assisting of persons and communities affected by emergencies to achieve a proper and effective level of functioning. Recovery from emergencies is a developmental process of assisting individuals and communities affected to manage the re-establishment of those elements of society necessary for their wellbeing. The process involves cooperation between all levels of government, non-government organisations, community agencies and the private sector in consideration of the following. Social, health and community environment Social health and community impacts refer to the impact that an emergency may have on the health and wellbeing of individuals and the community fabric. This area includes individual and community needs including but not limited to: material assistance financial assistance personal support health and medical services community development. Recovery planning at municipal, regional and state levels should address each of these aspects. Built environment This area refers to the impact an emergency may have on physical infrastructure. Infrastructure assists individuals and communities in the management of their daily lives, but also forms an important role of community identity. It is essential that the lead agency engage with the affected community to understand the community s restoration priorities, and to keep the community informed of recovery progress. Built environment impacts include, but are not limited to: electricity gas water telecommunications transport roads essential services such as schools, hospitals, emergency services, shops.

Victorian health management plan for pandemic influenza 63 Restoration of critical infrastructure must be undertaken with an awareness of the needs of vulnerable individuals and communities. Recovery planning at municipal, regional and state levels should address each of these aspects and provide for the engagement of agencies that can assist with the recovery. Economic environment This area refers to the economic impact that an emergency may have on individuals and communities in an affected geographical area. This area may include, but is not limited to: tourism industry small business primary producers. Recovery planning at municipal, regional and state levels should address each of these aspects. There are various levels of recovery management and planning, which refers to the administrative arrangements that are developed to ensure recovery activities are managed at the most appropriate level. The levels of recovery management are: municipal regional state national (Australian Government). The Department of Human Services will coordinate and facilitate recovery at the state level. Service provision will, as far as possible, be devolved to local government with resources support, if necessary, from the State Government.

64 Victorian health management plan for pandemic influenza Appendix 6. Infection control This appendix provides a summary of the information available in the Annex to the Australian health management plan for pandemic influenza Interim infection control guidelines for pandemic influenza in healthcare and community settings (June 2006) http://www.health. gov.au/internet/wcms/publishing.nsf/content/ohppandemic-infect-control-gl-toc.htm 1. Characteristics of influenza infection The management of infectious cases of pandemic influenza and their contacts is determined by the mode of transmission, the incubation period, and the infectious period. Transmission Droplet transmission when droplets from the cough or sneeze of an infected person are propelled through the air (up to 1 metre) and land on the mouth, nose or eye of a nearby person. Contact transmission when a person touches respiratory droplets that are either on another person or an object and then touches their own mouth, nose or eyes. Airborne transmission resulting from procedures that produce fine droplets and among crowded populations in enclosed spaces. Influenza and air-conditioning units There is no scientific evidence that influenza can be spread through ventilation systems or through prolonged residence in air. Proper ventilation can be expected to reduce the concentration of airborne organisms in enclosed spaces. Environmental factors and virus survivability The transmission of influenza virus is affected by the relative humidity of the room and by diminished ventilation (which enhances transmission). Ultraviolet irradiation has also been shown indirectly to potentially reduce airborne transmission of influenza. Survival of the influenza virus Influenza A and B viruses have been shown to survive on hard, non-porous surfaces for 24 48 hours, on cloth, paper and tissue for less than 8 12 hours and on hands for five minutes. Incubation period Human influenza usually has a short incubation period of one to three days. The incubation period for avian H5N1 influenza may be longer, most cases have occurred within two to four days of exposure, although the range has been up to eight days. For the purposes of these guidelines, the incubation period for any newly emerging influenza virus will be assumed to be up to seven days and will be adjusted in light of further epidemiological investigation. Infectious period Adults have been known to shed the virus from one day before developing symptoms to up to seven days after the onset of the illness. Young children can shed the virus for up to 21 days. The risk is greatest during the period that the patient is symptomatic (for example, coughing and sneezing). These periods will need to be reviewed in the light of information that becomes available regarding any new influenza sub-type. Case definition Clinical and surveillance case definitions will vary according to the phases of a pandemic and will need to be updated as more is learnt about the transmission characteristics and severity of disease associated with the particular strain. Case definitions will be sent to health care professionals in the form of a Health Industry Alert by the Department of Human Services. Contact definition A contact of pandemic influenza is a person who had close contact (within 1 metre) contact with an infectious case or who has spent more than 15 minutes in a confined space (such as an enclosed room) with an infectious person.

Victorian health management plan for pandemic influenza 65 3. Infection control principles and practices This section outlines the infection control precautions applicable in health care and other special settings. Detailed information on standard and additional precautions are in the Australian Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting which are available at: http://www.health.gov.au/internet/wcms/publishing. nsf/content/icg-guidelines-index.htm Principles Limit contact between infected and non-infected persons: isolate infected persons (for example, confine patients to a defined area as appropriate for the health care setting) limit contact to a small number of health care workers and close family and friends promote spatial separation in common areas (for example, sit or stand as far away as possible, at least 1 metre, from potentially infected persons) to limit contact between symptomatic and asymptomatic persons. Protect persons caring for influenza patients in health care and other special settings from contact with the pandemic influenza virus. Persons who must be in close patient contact should wear appropriate PPE. Contain infectious respiratory secretions: promote use of surgical masks by symptomatic persons in common areas (for example, in waiting rooms) or when being transported (for example, by ambulance) instruct patients who have flu-like symptoms to use respiratory hygiene/cough etiquette. Respiratory hygiene/cough etiquette To contain respiratory secretions, all persons with signs and symptoms of a respiratory infection, regardless of presumed cause, should be instructed to: cover their nose/mouth when coughing or sneezing use tissues to contain respiratory secretions dispose of tissues in the nearest waste receptacle after use perform hand hygiene after contact with respiratory secretions and contaminated objects/materials. Health care facilities should ensure the availability of materials for adhering to respiratory hygiene/cough etiquette in waiting areas for patients and visitors: provide tissues and no-touch receptacles for used tissue disposal provide conveniently located dispensers of alcoholbased hand rub provide soap and disposable towels for handwashing where sinks are available. During periods of increased respiratory infection in the community, persons who are coughing should be offered a surgical mask to contain respiratory secretions. Coughing persons should be encouraged to sit as far away as possible (at least 1 metre) from others in common waiting areas. Some facilities may wish to institute this recommendation year-round. Practices When caring for patients with pandemic influenza, health care personnel should be vigilant to avoid: touching their eyes, nose or mouth with contaminated hands (gloved or ungloved). Careful placement of PPE before patient contact will help avoid the risk of selfcontamination whilst making PPE adjustments. Careful removal of PPE is also important. contaminating environmental surfaces that are not directly related to patient care (such as door knobs, light switches).

66 Victorian health management plan for pandemic influenza Personal protective equipment (PPE) National medical stockpile (NMS) The NMS contains various items for use during a pandemic and is intended to supplement existing stocks kept in the Australian health system. The PPE contained within the NMS includes: dedicated PPE for staff at international air and sea ports undertaking border screening medical equipment (including P2 and surgical masks) antiviral medication equipment for mass vaccination. The NMS is being expanded to include: intravenous antibiotics additional PPE supplies additional stocks of antiviral medication. Use of PPE during a pandemic 15 PPE is used to protect the wearer from contact with the pandemic influenza virus. During the early phases of a pandemic when the transmission characteristics of the newly emergent virus are not fully understood, immunity to the virus is absent and a vaccine is not available, adherence to appropriate PPE is recommended for all contacts with avian or pandemic influenza patients. In the later phases, recommendations will be updated in light of increasing knowledge about the virus, availability of PPE and availability of antivirals and vaccines. PPE includes: P2 (N95) mask disposable gloves protective eyewear (goggles/visor/shield) long-sleeved cuffed gown cap (in high-risk situations where there may be increased aerosols) plastic apron (if splashing of blood, body fluids, excretions or secretions is anticipated). Appropriate PPE should be worn by: all people who provide direct patient care (for example, doctors, nurses, radiographers, physiotherapists, border health care workers) all supporting staff including medical aides and cleaning staff when working in a room when an avian or pandemic influenza patient is being cared for all laboratory workers handling specimens from a patient being investigated for pandemic or avian influenza all sterilizing services workers handling equipment that requires decontamination and has come from a patient with pandemic or avian influenza family members or visitors (a surgical mask may suffice if they are directed not to get closer than 1 metre to the patient except if they are the parent of a child who is ill). 15 Excerpt from the Australian Government Department of Health and Ageing, Interim Infection Control Guidelines for Pandemic Influenza in Healthcare and Community Settings, June 2006 Annex to the Australian health management plan for pandemic influenza.

Victorian health management plan for pandemic influenza 67 Table A6.1 Summary of PPE for health care settings Entering patient room but no close patient contact Close patient contact (<1 metre) P2 mask No Yes Yes, or PAPR Surgical mask Yes Only if P2 unavailable N/A Gown No* Yes Yes Gloves No* Yes, if body fluid exposure anticipated Eyewear No No Yes Cap No No Yes Apron No Yes, if splashing possible and impermeable gown not available Aerosol generating procedure being performed Yes Yes, if impermeable gown not available * Note: Any cleaners who have to enter the room of an infectious patient should wear a gown and gloves, in addition to a surgical mask. This is because cleaning activities are likely to bring their hands and clothes into contact with potentially contaminated surfaces. They should also be advised to maintain a distance of at least 1 metre from the patient if possible. Administration of PPE It is recommended that all hospitals and general practices purchase appropriate PPE in advance of a pandemic. Staff should also all be trained in the appropriate use of PPE. Containment During the containment phase, it will be important to adhere to stringent infection control, including the appropriate use of PPE (refer to summary above). The Department of Human Services will coordinate the distribution of PPE to general practices and hospitals when their own stocks are exhausted. Maintenance During the maintenance phase, it will be important to adhere to stringent infection control (where possible), including the appropriate use of PPE (refer to summary above). The Department of Human Services will continue to coordinate the distribution of PPE to general practices and hospitals until stocks are exhausted. Types of PPE Masks or respirators Masks that are commonly used by health care workers include P2 (N95) disposable respirators and surgical masks. Surgical masks do not protect the wearer from pathogens that are transmitted via the airborne route, but are used to protect the wearer from contact or droplet contamination of the nasal or oral mucosa. P2 (N95) masks provide a facial fit to the wearer that ensures inhaled and exhaled air travels through the filter medium. If a good facial seal cannot be achieved (for example, the intended wearer has a beard or long moustache), an alternative respirator such as a powered air-purifying respirator (PAPR) should be used, provided the wearer is trained in its use. If a PAPR is unavailable, the worker should consider removing their facial hair. Exhalation valves are available on some models of the P2 (N95) masks to increase the wearers comfort and reduce the build-up of moisture from exhaled breath in the filter medium. These masks should never be worn by suspected or confirmed pandemic influenza patients.

68 Victorian health management plan for pandemic influenza Respirators, including P2 (N95) masks, should be used within the context of a respiratory protection program that includes fit-testing, fit-checking and training. A fit check should be carried out each time a respirator is worn. P2 (N95) masks are essential when aerosol generating procedures are being performed (such as intubation, suctioning, chest physiotherapy, bronchoscopy or nebulisation). They may provide an increased level of safety in other close contact situations. Therefore: It is recommended that all health care workers who have to be in close (within 1 metre) contact of a pandemic influenza patient, for example undertaking procedures relating to examination or treatment of the patient, should wear a P2 (N95) mask or other appropriate high filtration device. If a P2 (N95) mask is not available a surgical mask should be worn. If P2 (N95) masks are in short supply at any stage of a pandemic, they should be prioritised for use by health care workers undertaking aerosol generating procedures. The mask should be applied before entering the patient s room. A mask should be worn once and then discarded. If pandemic influenza patients are cohorted in a common area or in several rooms on a nursing unit, and multiple patients must be visited over a short time, it may be practical to wear one mask for the duration of the activity. Change a mask when it becomes moist. The mask should never be reapplied after it has been removed. Do not leave masks dangling around the neck. Upon touching or discarding a used mask, perform hand hygiene. Gloves Gloves do not replace the need for hand hygiene. Gloves should be worn in accordance with standard precautions, that is, when contact with respiratory secretions or other body fluids is anticipated (for example, during provision of oral care, handling soiled tissues). They are not necessary when performing other tasks such as changing bed linen unless the linen is visibly soiled, provided hand hygiene is performed afterwards. Gloves should always be replaced between different patient contacts. Always perform hand hygiene after glove removal. Gowns Gowns should be worn when attending to pandemic influenza patients. A disposable gown made of synthetic fibre or a washable cloth gown may be used. The gown should cover the wearer s clothing. Gowns are essential when soiling of clothes is anticipated (for example, during invasive procedures or suctioning, nebulisation, bronchoscopy, chest physiotherapy or intubation). In such circumstances, a long-sleeved, cuffed and fluid repellent gown is recommended. If gowns are in short supply, consider establishing priorities for their use, such as if soiling of clothes with a patient s blood or body fluids is anticipated, such as during intubation or when holding a patient close to the body (for example, a paediatric patient). Gowns should be worn only once and then placed in waste or laundry receptacle, as appropriate, and hand hygiene performed. Protective eyewear (goggles/visor/shield) In general, wearing goggles or a face shield for routine contact with patients with pandemic influenza is not necessary, unless sprays or splatter of infectious material is likely, especially if the patient is not wearing a surgical mask at the time.

Victorian health management plan for pandemic influenza 69 Protective eyewear should be worn during aerosol generating procedures. PPE for aerosol generating procedures During procedures that may generate aerosols, the use of full PPE is essential. Full PPE consists of: a properly fitted P2 (N95) mask or PAPR a disposable fluid-repellent, long-sleeved gown a plastic apron if splashing of blood, body fluids, excretions or secretions is anticipated and a fluid repellent gown is not available gloves protective eyewear disposable theatre-type cap. The Centers for Disease Control and Prevention (USA) defines aerosol generating procedures as those that stimulate coughing and promote the generation of aerosols such as aerosolised or nebulised medication administration, diagnostic sputum induction, bronschoscopy, airway suctioning, endotracheal intubation, positive pressure ventilation via face masks and high frequency oscillatory ventilation. Cleaning and disinfection Cleaning and disinfection of environmental surfaces are important components of routine infection control in health care facilities. Cleaning of environmental surfaces with a neutral detergent followed by a disinfectant solution is recommended. When cleaning areas where pandemic influenza patients have been cared for, to prevent generation of dust particles, wet dusting rather than dry dusting should be used, and vacuum cleaners should be fitted with HEPA filters Dedicated or single-use/disposable cleaning equipment should be used wherever possible. Non-disposable equipment, including mop-heads, should be laundered after use. If possible, cleaning staff should be allocated to specific areas and not moved between influenza and non-influenza areas. They must be trained in the correct methods of wearing PPE and the precautions to be taken when cleaning cohorted areas. Cleaning and disinfection of patient-occupied rooms The person cleaning the room should wear appropriate PPE including a surgical mask, gown and gloves. The gloves used should be in accordance with facility policies for environmental cleaning. Keep areas around the patient free of unnecessary supplies and equipment to facilitate daily cleaning. Give special attention to frequently touched surfaces (for example, bedrails, bedside and over-bed tables, TV controls, call buttons, telephones, lavatory surfaces including safety/pull-up bars, door knobs, commodes) in addition to floors and other horizontal surfaces. Cleaning and disinfection after patient discharge or transfer The door to the patient s room should be kept closed until the room is cleaned and windows should be kept open if possible. Once a patient has left the room, the main source of infection (respiratory secretions) has been removed. However, there may be residual respiratory secretions on environmental surfaces Clean and disinfect all surfaces that were in contact with the patient or might have become contaminated during patient care. No special treatment is necessary for window curtains, ceilings and walls unless there is evidence of visible soiling. If bed curtains are used in a single room, they should be washed and changed following patient discharge. If a multi-bed room is being used to cohort avian or pandemic influenza patients, the bed curtains need not be changed, provided they are not visibly soiled, until the room is no longer being used for cohorting of avian or pandemic influenza patients.

70 Victorian health management plan for pandemic influenza Appendix 7. Communication Communication strategies are an essential component of managing any infectious disease outbreak and will be essential in the event of a pandemic. Effective communication during the preparedness, response, and recovery phases is vital to minimise the impact upon the social and economic infrastructure of Victoria. A whole of Victorian Government communication strategy has been developed to guide the communication efforts across government in preparing for and responding to a human influenza pandemic. The communication strategy maximises stakeholder engagement and existing networks by targeting a distinct but diverse group of key influencers who will channel the appropriate messages and planning actions through to their respective sectors. These key influencers include government departments, the health sector, local government, emergency services, infrastructure services, community services and business associations. Research has shown that these audiences require relevant and practical information that will empower them to develop their own pandemic plans. This information needs to be embedded in rational communications that are related to running their organisations as effectively as possible. There will be limited direct communication to the community during the preparedness stage, which is consistent with the research recommendations and the Australian Government s approach. An overview of the whole of Victorian Government communication strategy is available online at: www.health. vic.gov.au/pandemicinfluenza The website also features links to fact sheets and planning resources for pandemic influenza related material. The Victorian strategy supports and is consistent with the Australian Government s communication strategy which is available at: http://www.health.gov.au/internet/wcms/ publishing.nsf/content/ohp-pandemic-commstrat.htm

Victorian health management plan for pandemic influenza 71 Appendix 8. Mass vaccination guide 1. Introduction Pandemic vaccine A vaccine that gives good protection against pandemic influenza can only be developed after that virus strain appears. The Australian Government has contracts in place with vaccine manufactures to expedite the development and supply of a vaccine as soon as the pandemic strain emerges, as well as priority provision of any vaccine developed to Australia. This could, however, take several months. National medical stockpile (NMS) The NMS was established by the Australian Government and contains items for use in a health emergency. The stockpile components for pandemic influenza include equipment for vaccination (50 million vaccination kits) and personal protection, antiviral medication and antibiotics. The Department of Human Services will source and distribute the vaccine and equipment required for vaccination from the NMS by the Chief Health Officer (CHO) obtaining authorisation from the Chief Medical Officer (Department of Health and Ageing). Arrangements for storage and distribution are currently being negotiated. The pandemic vaccine will be provided free of charge and payment formula per encounter for local government will be implemented by the department. Vaccination strategy/priority groups The vaccine will be made available first to people at high risk of exposure to the virus (frontline health care workers) and people most vulnerable to severe illness from infection, then rolled out to the rest of the community. Priority group rationale is detailed later in this Appendix. It is intended that: GPs will vaccinate staff within their practice hospitals will identify their high-risk workers and vaccinate staff within their hospital as well as high-risk patients local government immunisation teams will vaccinate the identified priority groups within the community then, as vaccine rolls out, vaccinate the remainder of the population once mass vaccinations have been completed using Mass Vaccination Centres (MVCs), GPs could assist with mop up for persons who are unable to attend MVCs for community groups unable to attend MVCs, it is intended that their existing health care provider will provide the vaccine. These groups include: inmates of corrections system facilities (jails, prisons, juvenile detention) patients in nursing homes and other long-term care institutions immobile patients who receive care at home through community health care service providers. Rationale for the strategy In Victoria, it is recognised that the most effective way to deliver mass immunisation is through existing local government structures with GPs providing support with mop up services. Given the expected pressure on primary health services during a pandemic, directing the majority of the community to MVCs will release pressure on local health services and enable them to continue to manage the ill. It is also likely that two doses of vaccine will be required and that any developed vaccine will be in multi-dose vials. Purpose of this guide This guide has been developed to provide guidance to all organisations undertaking vaccination during a pandemic with pandemic vaccine as well as for those setting up MVCs. It provides some guidance on how these clinics could be established. All providers who will be used for delivering vaccines during a pandemic should include the provision of this service in their business continuity plan. This guide should be read in conjunction with the Guidelines for immunisation practice in local governments (Department of Human Services, 2006), which is available at: http://www.health.vic.gov.au/immunisation/general/ guidelines_local_gov

72 Victorian health management plan for pandemic influenza 2. Background Influenza vaccines have been available for over 60 years. Extensive experience during this long period has demonstrated their safety and efficacy. In populations at risk of severe complications, vaccination is known to reduce hospital admissions and deaths. Vaccination is thus the cornerstone of influenza prevention. As influenza viruses are constantly evolving, vaccine is produced each year with a composition based on the most relevant strains of virus identified through a global surveillance system 16. Modern influenza vaccinations achieve immunity in up to 70 per cent of those immunised (less in older people). Immunity is typically produced after a period of two to three weeks following a single vaccine dose when the viruses contained are similar to ones to which the vaccinees have had past experience. A second dose will be required for pandemic vaccine. Currently only inactivated vaccines produced in embryonated eggs are available throughout the world. By definition, a pandemic strain of influenza is a new strain of virus. Existing stocks of influenza vaccine will be ineffective against the pandemic strain when it emerges. Influenza vaccines registered in Australia are currently distributed as single dose product pre-dispensed in disposable syringes. In the event of a pandemic it is likely that even if antigen production can be increased, the availability of suitable syringes will become limiting, and that the pandemic vaccine will be available only in a multi-dose preparation. The DoHA will procure sufficient equipment for vaccination of the Australian population. In the pandemic situation, it is likely that only limited quantities of vaccine specific for the new strain will be available prior to the first wave of infection. The amount of antigen in each vaccine dose is currently the subject of trials. Two doses will be necessary for optimal protection, due to the novel nature of the pandemic strain. High rates of compliance for the second dose must be achieved. Limited vaccine supplies must be allocated and distributed to those considered to benefit most from the vaccination. 16 World Health Organization Department of Communicable Disease Surveillance and Response, WHO Guidelines on the Use of Vaccines and Antivirals during Influenza Pandemics, 2004. This benefit needs to be considered from the perspective of the population as a whole. Allocation of priority groups for vaccination will be done in conjunction with the decision-making structures nationally, that is, the National Influenza Pandemic Action Committee, Australian Health Protection Committee and the advisory committee to the Chief Medical Officer. Routine vaccination in the inter-pandemic period Seasonal influenza vaccine Influenza vaccine is strongly recommended and free for: everyone aged 65 years or older Aboriginal and Torres Strait Islander people aged between 15 and 49 years with health risks Aboriginal and Torres Strait Islander people aged 50 years and over public hospital outpatients (in the hospital setting) and inpatients at high risk for complications of influenza. Influenza vaccine is also strongly recommended for people over six months of age with: Chronic heart disorders Diabetes and kidney disorders Asthma and chronic respiratory disorders Suppressed immune system due to illness or treatment. It is also recommended for people who: live in a nursing home or hostel work in a hospital, long-term care facility or nursing home live or care for someone who has chronic illness or is aged. Influenza immunisation is also recommended for: severe asthmatics children on long-term Aspirin therapy pregnant women workers travellers in groups.

Victorian health management plan for pandemic influenza 73 Influenza vaccine should be administered to any person who wishes to reduce the likelihood of becoming ill with influenza. Influenza vaccine can be given to children as young as six months of age. Children under two years of age with medical risk factors are at greatest risk of severe influenza illness. Pneumococcal vaccine The following groups are eligible for free pneumococcal vaccine: everyone aged 65 years and older public hospital outpatients (in the hospital setting) and inpatients at high risk for pneumococcal disease Aboriginal and Torres Strait Islanders aged between 15 and 49 years with health risks and those aged 50 years and older all children born since 1 January 2005. Pneumococcal vaccine is also recommended for: people aged five years and over with serious health problems, such as heart or lung disease, diabetes or kidney disease people aged five years and over with illnesses that reduce immunity to infections, such as leukaemia or HIV or who are being treated with drugs that suppress the immune system transplant recipients or people with a damaged (or no) spleen people aged over five years with a CSF leak Victoria aims for high levels of immunisation coverage against influenza and pneumococcal disease in the community during the inter-pandemic period. Influenza vaccination coverage in those aged 65 and over was 82 per cent in 2004, and for pneumococcal immunisation coverage in this age group was 62 per cent 17. Both influenza and pneumococcal vaccination coverage in those aged 64 and under in other high risk groups are poor. The emergence of antibiotic-resistant strains of S. pneumoniae and the difficulties in implementing a mass pneumococcal vaccination program amidst an influenza pandemic, support the importance of high coverage with pneumococcal vaccine in the at risk population prior to a pandemic. Pneumococcal vaccination may reduce complications of secondary pneumococcal infection in cases of pandemic influenza. GPs and other doctors and health care workers can have a great influence on a person s decision about vaccination. Health care professionals have been shown to benefit from influenza vaccination, in reduction of reported days of work absence and febrile respiratory illness as well as reduced transmission of influenza from health worker to patients. Health care workers are a group that can be readily accessed and targeted for routine annual influenza vaccination. During the lead up to a pandemic, when the seasonal vaccine is still in production, it will have an important role to play in preventing simultaneous infection with the seasonal influenza strain and a novel influenza strain. There is the small possibility that if a person is infected with both of these viruses at the same time, the viruses could share genetic material to produce a new highly transmissible virus that poses the threat of a pandemic 18. tobacco smokers. Local government has historically played an important role in delivering immunisation services to the Victorian public and currently participates in providing immunisation to their constituents with the emphasis on childhood and school immunisations. In recent years, GPs have become an important partner in providing vaccines, particularly to those under five years old and adult immunisations. 17 Australian Institute of Health and Welfare, 2004 Adult Vaccination Survey, March 2005 18 World Health Organization Western Pacific Region, WHO interim recommendations for the protection of persons involved in the mass slaughter of animals potentially affected with highly pathogenic avian influenza viruses, 26 January 2004.

74 Victorian health management plan for pandemic influenza The seasonal influenza vaccine does not protect against the H5N1 strain of influenza. It is possible that a vaccine using the H5N1 strain of influenza may give partial protection if that strain changes and spreads more easily among humans. Prototypes of an H5N1 vaccine are being developed by several manufacturers around the world, including Australia s domestic manufacturer, CSL Limited. The Australian Government is committed to buying a substantial amount of H5N1 vaccine as soon as it is proven safe and effective. 3. Session structure and management Example of a successful mass vaccination session Portland, meningococcal C outbreak (December 2002) Two mass immunisation sessions took place over two days. In short, one person was vaccinated every 13 seconds over six hours on the first day and three hours on the second day (2,600 people). There were 12 administration staff and eight vaccinators (four GPs) 19. Mass vaccination centres (MVCs) The aim of MVCs is to have rapid throughput to deliver pandemic vaccine (two doses) to all Victorians, to undertake data collection and ensure the wellbeing of the public. If initially targeting school aged children in primary schools (if appropriate and schools are still open), a package of information for parents, including a consent form signed and returned by parents will be needed for a two-dose course. Consent can be given for two doses with initial information. Venues and timing of session Depending on numbers of people requiring vaccination, an appropriate venue will need to be identified in advance. An appropriate venue will include consideration of the following: venues already being used for immunisation sessions size appropriate signage accessibility (for the public and emergency vehicles, close to public transport) facilities (car parking, toilets, handwashing facilities). Session timing will be up to councils and depend on when they have the equipment and staff. The timing and venue will also need to consider other services so that no clash occurs. The public will be advised to return to the same venue for their second dose and they will be given a reminder in writing. Staffing Staff at the MVC will be vaccinated prior to any mass vaccination sessions. Core staff required to operate a centre include: medical (nursing staff to administer vaccine) administrative (including staff to undertake data entry) security environmental health officers and other staff as considered appropriate to manage numbers of clients. It may be useful to have staff in the MVC wear fluorescent vests to be easily identified. It may be useful to train extra staff members on the computer system used to manage data (ImPS). The Department of Human Services is in the process of exploring legal options to enable additional nurses to vaccinate, a process of coordinating nurses and exploring who can draw up the vaccine. 19 Personal communication, Greg Andrews, Glenelg Shire, November 2006.

Victorian health management plan for pandemic influenza 75 Operational flow Registration When members of the public enter a MVC, they will need to register their details at a registration desk. They will be asked to show their Medicare card as a unique identifier as well as proof of age to ascertain that they are within the priority group. Information They will then go to an information area where they will be provided with information about the vaccination in a group session. Information will include: what is in the vaccine what are the risks/benefits what are the contraindications possible side effects and where to seek treatment for such side effects the elements of informed consent. They will then be asked to proceed to the next area if they consent. Presentation of sick people If sick people attend a MVC, they will need to be assessed on their clinical status and referred to their health care provider. They should be provided with a surgical mask if influenza is the suspected illness. If a person collapses at a MVC, they should be assessed or treated according to medical protocol. If people present with fever, they should not receive the vaccine. Their temperature should be checked by thermometer and they should be referred to their GP. Vaccination Patients will receive their vaccination from an approved health professional. In most cases vaccine will be administered into either the arm or thigh as appropriate for age. Following vaccination, clients should remain on the premises under observation for 15 minutes. Exit review This is the final station, where clients can: be told the time and date for return for their second dose in writing (it may also be possible to record their mobile phone number as a recall reminder through SMS text messages) have any remaining questions answered Be checked by staff to ensure that each patient exits with their information sheets (including possible reactions and who to contact). Communication Public communication will advise of the identified priority groups and location of sessions. It should also advise about adverse reactions and contraindications. Local government will need to work with local media to communicate and identify their priority groups. The Department of Human Services will provide advice about the continuance of routine vaccination programs (suspending primary and secondary programs) closer to the time. Prioritisation Vaccination of front line priority groups (such as essential services, at risk groups) will be based on the epidemiology of the pandemic, that is, those age groups most affected will be targeted first. When designating priority groups, broader considerations will need to be undertaken (for example, if infants are a priority group, vaccinate parents). Depending on the success of containment efforts, it may be possible to develop and produce enough vaccine to protect the entire Australian population before it spreads to Australia. If vaccine doses are available in the containment phase, the vaccine will be used to further support the containment effort and protect Australians by reducing the spread of disease. The Department of Human Services will source and distribute the vaccine (see Vaccine storage and distribution below).

76 Victorian health management plan for pandemic influenza Resources Equipment All vaccine related equipment will be provided to local government by the department (out of the NMS). Additional fridges will not be required for storage, rather the department will arrange for more frequent deliveries of the vaccine. The Department of Human Services will have in place an inventory management system and local governments will need a similar system to keep track of equipment. Personal protective equipment As mentioned earlier, staff at the MVC will be vaccinated prior to the MVC. This means that PPE (masks) will not be required by staff beyond that normally required for vaccine programs. A supply of surgical masks should be available at sessions for sick people who attend. Infection control The following precautions should be taken when drawing up the vaccine from the multi-dose vials: A new sterile disposable syringe must be used for each draw-up. A new sterile disposable needle for injection should be used to administer the vaccine One sterile disposable drawing up needle is used for a multi-dose vial. On opening, all vaccine doses are withdrawn immediately. 4. Logistics of maintaining stock and vaccines Vaccines It is essential that improved vaccine tracking mechanisms are implemented during a pandemic. The department s Immunisation Program currently performs such procedures in Victoria, but increased monitoring of vaccine administration will be required to ensure that priority group order is being observed and an appointment for a second dose is arranged. Vaccine cold chain, whereby vaccines must be transported and stored at 2 8 degrees Celsius, is as important in this scenario as in the routine program. Ordering vaccines The pandemic vaccine will be provided free of charge by the Australian Government. The department has existing arrangements to store, deliver and order vaccines. These existing arrangements will be used during a pandemic. Enquiries regarding orders should be referred to The Department of Human Services on 1300 882 008. 5. Pre-immunisation procedures It is recommended that prior to any vaccination, the person giving the vaccination review the vaccination history of the client, determine the client s suitability for vaccination, and obtain the client s consent for vaccination. Review vaccination history The vaccinee will need to be asked if they have been vaccinated before, to ascertain whether they are to receive their first or second vaccination. Determine suitability for vaccination It is recommended that a clinical assessment is conducted to ensure that the vaccinee is medically well enough for the vaccination and has no contraindications to any specific vaccine. The pre-immunisation checklist appears on the immunisation consent form. A specific pre-immunisation checklist will be designed for pandemic influenza vaccine. Obtain valid consent Consent for vaccination will be undertaken by the usual process that is, written and/or verbal information will be provided on the benefits and risks of immunisation (in a number of languages if possible) and either verbal or written consent obtained. If verbal consent is obtained, a note in the documentation should state that the consent process has been undertaken. If available, interpreters will be of assistance in the consent process.

Victorian health management plan for pandemic influenza 77 Information resources Information resources will be provided by the Department of Human Services and include: Immunisation consent form (including a preimmunisation checklist) pro forma Record of treatment pro forma Report of suspected adverse reaction to drugs and vaccines pro forma posters common reactions fact sheets on risk and benefit, vaccine content (in various languages). 6. Vaccine administration As vaccines are classified as schedule 4 drugs, they must be administered by a medical practitioner or an accredited immunisation nurse who is employed by an organisation that employs or contracts a medical practitioner. Legislative options for exempting the requirement to be an accredited immunisation nurse as opposed to a registered nurse are currently being explored. As GPs will be fully engaged in providing care for those ill with influenza, we do not envisage they will be engaged in the immunisation process in the first instance. This decision would be reviewed in the light of the incidence of disease at the time when the majority of the vaccine became available. They will be provided with information on the timing and location of immunisation sessions in their locality to which they could direct their patients. Similarly, pharmacists will be provided with information. The Department of Human Services will provide the vaccine in batches according to the storage facilities available. The frequency and duration of clinics must be bolstered considerably when the pandemic is imminent to provide maximum benefit to the community. This will require considerable scaling up of the local government immunisation workforce, which is the subject of further negotiation. As approximately 1,500 nurses have passed through the immunisation accreditation course at La Trobe University, identification of this workforce will be undertaken to bolster the available workforce. Identification of the eligible population will be best undertaken by the use of the Medicare database, which contains approximately 98 per cent of the Australian population. Use of the Medicare number as the identification number also has precedent in immunisation programs, due to its use as the number in the childhood program. Presentation of the Medicare card will be required as proof of identity and eligibility. Security arrangements will be necessary to prevent unauthorised access to vaccine and to maintain order at sessions. Announcements of the locations of immunisation sessions could be done by local press release, to fully inform the public.

78 Victorian health management plan for pandemic influenza Priority group rationale The goals in vaccine use for the priority groups are as follows: Group: Goal: Group: Goal: Group: Goal: Group: Goal: Essential services personnel, including health care workers Maintain essential services The purpose of vaccinating these individuals will be to allow them to continue to provide services, including health care, to those in need. Groups at high risk of severe morbidity and mortality Prevent and reduce deaths and hospital admissions In the inter-pandemic period, those who have underlying disease or are older are most likely to experience severe morbidity and mortality. In a pandemic, previously healthy individuals are more likely to experience a severe outcome than they would in an ordinary outbreak. However, it is still individuals in the high risk group who have the greatest risk of hospitalisation and death. Groups in which the virus spreads rapidly Prevent or reduce spread This group includes children. Persons without risk factors for complications Prevent or reduce morbidity This is the largest group and will include healthy adults and children. The main goal in vaccinating this group will be twofold: to reduce demand for medical services and to allow individuals to continue normal daily activities. This is particularly important for working adults. Simultaneous absence of large numbers of individuals from their site of employment could produce major disruption even in non-essential personnel. Information from countries where the pandemic first strikes will assist in determining which groups are most at risk. The priority list must be modified in the light of this information. Documentation/forms Information sheets will be provided for medical personnel at the vaccination centres. These will outline the strategy and priority groups for pandemic influenza and pneumococcal vaccination. ImPS 2.5 or the existing local government database will be used for documentation and to produce data on numbers vaccinated. As there is no policy excluding non-residents and expatriates, they will be able to be vaccinated. Immunisation providers will be provided with: vaccine an order form for doses of the influenza vaccine a consent form for vaccination pre-vaccination checklist adverse event following immunisation form time, date and venue for second dose (in writing). Forms and information sheets for the public will need to be available in different languages. Documentation instructions A record of vaccine brand name, batch number and date will be entered onto the local government software with the vaccinee s name, address, date of birth and Medicare number. These records will be transmitted to the Department of Human Services or a central national database (to be decided). The vaccinee will be given a record of the vaccine and date administered, and date the next dose is due (if applicable).

Victorian health management plan for pandemic influenza 79 Vaccine security Security at MVCs may be required to maintain order and ensure vaccine security. Local governments should have a system in place to engage security personnel should they be required. These arrangements should be developed in consultation with Victoria Police. To reduce the risk of mass theft of vaccines while stored on local council property, vaccines will be provided on a regular basis rather than bulk amounts upfront. Those storing vaccines should, however, review their security arrangements to reduce the risks of break-ins or internal theft. If private security is required, the State Government, where appropriate, will reimburse the costs involved. 7. Post immunisation procedures Observation post-immunisation Following vaccination, vaccinees should remain on the premises under observation for 15 minutes. Common reactions Providers should ensure that vaccinees and/or their parents/guardians receive take-home written information on common reactions to immunisations and what to do. Adverse events following immunisation Public communication surrounding adverse reactions will be important during a pandemic (to prevent reports of sore arms and mild fever). If a suspected adverse reaction to the vaccine occurs, then a Report of Suspected Adverse Reaction to Drugs and Vaccines should be filled out by the vaccinee s GP. These reports are then directed to the Adverse Drug Reactions Advisory Committee (ADRAC). 8. Vaccination records including privacy Data collection and storage Systematic recording of those who have been immunised will be essential for evaluation of age-specific coverage rates and identification of those who have received a first dose in order to receive a second dose. ImPS can produce a report on: brand/batch number venue/school year level in school age range. Vaccinees will be asked to contact their GP if an adverse event occurs after immunisation. Documentation Record vaccination information in Child Health Record and clinical records (ImPS 2.5). Vaccination data should be forwarded to the Department of Human Services or a central national database in accordance with protocol (to be decided). Vaccinees and/or parents/guardians should be informed in writing of the time the next vaccination is due, which should be noted in the patient records.

80 Victorian health management plan for pandemic influenza Immunisation consent form (pro forma only) Pre-immunisation checklist What to tell your doctor or nurse before immunisation The conditions listed below do not necessarily mean that immunisation cannot be given. Before the immunisation, tell the doctor or nurse if any of the following apply to the person to be immunised: is unwell on the day of immunisation (temperature over 38.5 C) has had a severe reaction to any vaccine has a severe allergy to any vaccine component (for example, eggs) is pregnant. Before any immunisation takes place, the doctor or nurse must ask you if: Consent I acknowledge that I have received and understood the information on the risks and benefits of this vaccine and consent to be treated. My relationship to the person receiving the vaccine is: Self Parent Guardian Signature: Date: Print name: Family name Given name(s) Address you have read this information you understand this information Suburb Telephone Postcode you need more information to decide whether or not to proceed. Home Work The information you provide on this consent form is for the sole purpose of monitoring immunisation programs by the State and Australian Governments. The data will be kept confidential and identifying information will not be disclosed for any other purpose. You can access your information by contacting your immunisation provider. Sex Vaccine given Batch number Female Male Date received Administered by

Victorian health management plan for pandemic influenza 81 Record of administration (pro forma only) Use ImPS where possible. This might be useful for a small rural council if ImPS is not available Vaccine brand name: Location: Date: Name Medicare no. Batch Address Telephone 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

82 Victorian health management plan for pandemic influenza Report of suspected adverse reaction to drugs and vaccines (pro forma only) Patient identifier* Birth date / / Sex Female Male Weight (kg) All drug therapy/vaccines prior to reaction (please use trade names) Daily dosage (Dose no for vaccines) Date begun Date stopped Reason for use suspected drug other drugs Onset of reaction Description of adverse reaction / / Outcome: Recovered Date of recovery: / / Not yet recovered Unknown Fatal Date of death: / / Sequelae: No Yes If yes, describe: Severity: Life threatening Hospitalised Required a visit to the doctor Treatment (of reaction): Comments (for example, relevant history, allergies, previous exposure to this drug): Reporting doctor, pharmacist, etcetera: Name: Address: Signature: Date: Fax this information to the Department of Human Services on 1300 768 088

Victorian health management plan for pandemic influenza 83 Appendix 9. Antivirals Introduction Influenza is spread by droplets, direct and indirect contact, but may also be spread by airborne transmission, particularly in enclosed spaces. Prevention of influenza infection primarily relies on appropriate use of infection control strategies such as hand hygiene, respiratory hygiene, social distancing and personal protective equipment (PPE). Antivirals are a class of medicines that have some effectiveness in preventing and treating influenza, and may also show these properties against a pandemic strain of influenza. Antivirals do not prevent contact with the virus, but minimise the risk and severity of infection. The Australian Government Department of Health and Ageing (DoHA) has developed the Australian health management plan for pandemic influenza, which includes an appendix on clinical guidelines. These guidelines provide details on the assessment and management of avian and pandemic influenza cases including specific details on the use of antivirals. This appendix provides an overview of preparedness initiatives at a state and national level, provides guidance on the proper use of antivirals, and outlines the strategies Victoria will use in the event of a pandemic of influenza. It is important to note that as new evidence is gathered (both medical and scientific) and additional supplies of consumables are secured, strategies outlined below may vary. Therefore this guide is a living document. Antiviral medications National medical stockpile (NMS) The NMS was established by the Commonwealth Government and contains items for use in a health emergency. The stockpile components for pandemic influenza include equipment for vaccination and personal protection, antiviral medication and antibiotics. The NMS intends to supplement existing medical stocks kept in the Australian health system and provides rapid access to large quantities of medications that may not be regularly used. The process to activate the NMS deployment plan needs to be undertaken through DoHA and the Victorian CHO. Arrangements for storage and distribution within Victoria are being negotiated. Use of antivirals during a pandemic The use of antivirals will depend on the phase of a pandemic in Australia and will be carefully monitored. In general, antiviral medication can be used for: treatment, with one course of medication prevention of infection after exposure (post-exposure prophylaxis), with one course of medication continuous prevention of infection (pre-exposure prophylaxis), where one course provides 10 days of protection. Antivirals are indicated for use up to 12 weeks. Given there are different antiviral medications available in Australia, they should always be taken in accordance with product instructions. Containment phase During the containment phase of a pandemic, the health response will be directed at identifying new infections and preventing further spread. During this period, antivirals will be used to: treat new cases of pandemic influenza provide post-exposure prophylaxis to contacts of new cases of influenza protect individuals seeking (contact tracing) and managing new cases and contacts. The rationale for using antivirals in post-exposure prophylaxis is that there is evidence that the neuraminidase inhibitors, oseltamivir and zanamivir, can reduce seasonal influenza infections among household contacts of infected people by about 60 80 per cent. Treating symptomatic cases with antivirals reduces symptoms and can lower virus load, therefore should theoretically reduce transmission. Mathematical modelling of the spread of influenza indicates that the combination of treatment of new cases and prophylaxis of contacts is effective at delaying the peak of a pandemic.

84 Victorian health management plan for pandemic influenza This is designed to prevent the spread and buy time for developing a vaccine. Containment interventions require that cases be identified early in the course of the illness, and a rapid response is put into place to prevent transmission. Maintenance During the maintenance phase of a pandemic the health response will be directed to maintaining effective social functioning while managing the pandemic. In this period, antivirals will be used to: provide continuous prophylaxis for health care workers at continuous high risk of infection, for example, workers directly caring for pandemic influenza cases provide post-exposure prophylaxis for health and safety workers at medium risk of exposure to the virus. There is evidence that the neuraminidase inhibitors can reduce the rate of influenza infections among people exposed to seasonal influenza epidemics by about 40 60 per cent when given as pre-exposure prophylaxis. The reason that health care workers will be targeted is that they are clearly at high risk of infection, keeping them functional may reduce adverse outcomes in others, and they are in a position to spread infection widely if they themselves contract influenza. Post-exposure prophylaxis is offered to people at lower risk of infection because the evidence is that it is effective and more people can be covered with intermittent use of postexposure courses than with continuous use of antivirals. The use of PPE (e.g. masks, gowns and gloves), handwashing and other hygiene measures will also be important. It is estimated that continuous pre-exposure prophylaxis will be required for 12 weeks for an individual, which is approximately eight ten-day treatment courses of oseltamivir. Prioritisation The designation of antiviral priority groups will need to be reassessed both in containment and maintenance phases frequently in relation to: location of cases rate of transmission attack rates in different ages groups clinical severity in different age groups potential strategies for control depletion of antiviral stockpile. Administration of antivirals Containment During the containment phase, the department will distribute antivirals to the priority groups (new cases, contacts, and those seeking and managing new cases and contacts) through public health staff, supplemented in some cases by hospital staff. Maintenance During the maintenance phase, when antivirals are used for prophylaxis (continuous and post-exposure) of health care workers, hospitals will act as liaison points. GPs will be supplied with antivirals through the department s distribution contractor. Types of antivirals Detailed information on antivirals can be found in the Australian health management plan for pandemic influenza, interim national pandemic influenza clinical guidelines (June 2006). There are currently three antiviral medicines that can shorten the course of infection if given early in the disease (treatment) and provide short-term protection against influenza (prophylaxis). These are amantadine, oseltamivir and zanamivir.

Victorian health management plan for pandemic influenza 85 Table A9.1 Antiviral medications Drug class Neuraminidase inhibitor Neuraminidase inhibitor M2 channel inhibitor Generic name (brand name) Indication Dose, duration and route of transmission Oseltamivir (Tamiflu) Treatment Age > one yr Prophylaxis Age > 13 yrs Prophylaxis Age < 13 yrs Zanamivir (Relenza) Treatment Age > five years Amantadine (Symmetral) Prophylaxis Age > five yrs Prophylaxis Age > five yrs 2mg/kg (up to 75mg) twice daily for 5 days 75mg once daily for 10 days (may continue to 42 days if necessary) 2mg/kg (up to 75mg) once daily for 10 days. 10mg twice daily for 5 days 10mg once daily for 10 days (may continue to 28 days if necessary in adults) 5 9 years: 5mg/kg/day in 2 divided doses, up to 150 mg/day for 10 days 10 64 years: 100mg twice daily for 10 days 65 years and over: 100mg once daily for 10 days Oseltamivir stocks represent the largest component of the antiviral component of the stockpile due to its ease of administration when compared to zanamivir, particularly in mass pre-exposure prophylaxis settings, and its sideeffect profile and resistance propensity when compared to amantadine. Antiviral treatment Adverse events Each type of antiviral has different side-effects which, in general, are neither serious nor life-threatening. Indications for antiviral treatment Depending upon their availability within the context of pandemic requirements, and provided they can be administered within 48 hours of symptom onset, the indication for antiviral treatment is patients fitting the clinical or laboratory case definition of pandemic influenza. The product information for the antiviral medication should also be reviewed. Onset, dose and duration of antiviral treatment The neuraminidase inhibitor class of antivirals is recommended for treatment of human H5N1 infections because of the high frequency of M2 channel inhibitor resistance in human isolates of the virus. As the antivirals for seasonal influenza are only effective if commenced in the first 48 hours, generally they should not be used if they are to be commenced after this time. The earlier treatment can be initiated within the 48 hours the better the patient s outcome is likely to be. Only consider treatment onset beyond 48 hours if: the patient is severely ill and hospitalised and there is clinical evidence of primary viral pneumonia or the person is immunosuppressed. This should be done in conjunction with an infectious diseases physician clinical data emerges that treatment after this period is efficacious. The recommended dose and duration of antivirals is outlined in Table A9.1.

86 Victorian health management plan for pandemic influenza Antiviral resistance The efficacy of the antivirals and the development of clinical resistance in the pandemic virus needs to be monitored for both treatment and prophylaxis. Despite recent case reports of oseltamivir resistance emerging in patients treated for influenza A H5N1 infection with the currently recommended regimen of oseltamivir therapy, there is no current evidence to support the use of higher doses, longer durations of therapy or combination therapy. However, this issue will be closely followed and the recommendation adjusted accordingly in light of new data related to clinical efficacy and patterns of resistance. Persistent detection of virus may be a marker of the emergence of resistance. Based on experience with human influenza, use of neuraminidase inhibitors and amantadine to treat clinical cases will not affect the development of an immune response to the infecting influenza strain. Antiviral prophylaxis Indication for antiviral post-exposure prophylaxis The index case should ideally meet the laboratory case definition before commencing contacts on antivirals, to minimise wastage of limited resources. However, in the early phases, if an aggressive approach is being recommended by public health authorities to contain the spread of the virus, antiviral therapy may be commenced prior to laboratory confirmation of the index case and then ceased if the diagnosis is excluded. Onset and duration of post-exposure antiviral prophylaxis Post-exposure prophylaxis should be commenced as soon as possible but no later than the incubation period. Prophylaxis should be continued for 10 days. In a setting of ongoing exposure (for example, household), the first exposure should be regarded as 24 hours before the onset of symptoms in the index case. Therefore, postexposure prophylaxis should be commenced within six days of the index case first developing symptoms. If the exposure was an isolated event, post-exposure prophylaxis should be commenced within seven days of the exposure (based on an upper limit of an incubation period of seven days). If a contact develops clinical features of influenza while on prophylaxis, then full therapeutic doses should be administered. Long-term prophylaxis Long-term prophylaxis for seasonal influenza (for example, for occupational exposure or high risk) has been used for 4 6 weeks; the safety, tolerability and efficacy of longerterm prophylaxis are unknown. During a pandemic, it may be necessary to provide long-term prophylaxis to those at frequent high risk of exposure or in particular occupations. Logistical plan Scope This plan is intended to cover an event where it is necessary to provide antiviral prophylaxis to a large group of people in Victoria during an influenza pandemic. Antiviral administration Front line priority groups In the early phases, the Department of Human Services will distribute antivirals to contacts of cases through public health staff, supplemented in some cases by regional department or hospital staff. In later phases, when antivirals are used for mass prophylaxis of health care workers, hospitals will act as liaison points. GPs will be supplied with antivirals through the Department of Human Services. The department will coordinate the distribution of antivirals to these groups via a distribution contractor. In the initial stages, as only the designated priority groups will receive antivirals, a system will need to be put in place to ensure only those designated receive medication.

Victorian health management plan for pandemic influenza 87 Antiviral security Wherever antivirals are stored, security will need to be in place in order to reduce the risk of theft. Distribution of antivirals In the early phases when there are limited numbers affected, the department will organise the distribution of antivirals to cases and their contacts. In later phases, distribution to health care workers will occur through both hospital administration and/or general practices. Distribution to other occupational groups will be dictated by the priority afforded these groups and the availability of antivirals and if necessary will be distributed through existing occupational health and safety medical providers. Report of adverse reactions If a suspected adverse reaction to drugs (influenza antivirals) occurs then a report of suspected adverse reaction to drugs and vaccines form should be filled out. These reports are usually directed to the Adverse Drug Reactions Advisory Committee (ADRAC). In the case of a pandemic, these reports may be made directly to the department (to be further advised). Consent form and checklists Once the person has read the information sheet (which will be available at the time) and indicated that they have understood its contents, answered the questions on the appropriate checklist and given the opportunity to ask questions, they are asked if they consent to the treatment being offered. If they agree, they are asked to sign the consent form. This form will forwarded to the Department of Human Services. Batched forms should be mailed to GPO Box 4057 Melbourne 3000. Information sheets will be required for staff and patients. Record of treatment Generic forms for consent and record of treatment will need to be amended to suit the drug being used. Record of treatment sheets should be completed at each site. A new sheet should be commenced each day and if there is a new batch number. This form will forwarded to the Department of Human Services. Batched forms should be mailed to GPO Box 4057 Melbourne 3000.

88 Victorian health management plan for pandemic influenza Antiviral consent form (pro forma only) Pre-antiviral checklist (pro forma only) What to tell your doctor or nurse before treatment The conditions listed below do not necessarily mean that treatment cannot be given. Before the treatment, tell the doctor or nurse if any of the following apply to the person to be treated: has had a severe reaction to any medication is suffering from renal disease is pregnant is breastfeeding. Before any treatment takes place, the doctor or nurse must ask you if: you have read this information Consent I acknowledge that I have received and understood the information on the risks and benefits of this vaccine and consent to be treated. My relationship to the person receiving the vaccine is: Self Parent Guardian Signature: Date: Print name: Family name Given name(s) Address you understand this information you need more information to decide whether or not to proceed. Suburb Telephone Postcode The information you provide on this consent form is for the sole purpose of monitoring immunisation programs by the State and Australian Governments. The data will be kept confidential and identifying information will not be disclosed for any other purpose. You can access your information by contacting your immunisation provider. Home Sex Vaccine given Female Male Work Batch number Date received Administered by NOT FOR FURTHER CIRCULATION

Victorian health management plan for pandemic influenza 89 Record of treatment (pro forma only) Antiviral type and brand: Location: Date: Name Medicare no. Batch Address Telephone 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. NOT FOR FURTHER CIRCULATION

90 Victorian health management plan for pandemic influenza Report of suspected adverse reaction to antivirals (pro forma only) Patient identifier* Birth date / / Sex Female Male Weight (kg) All drug therapy/vaccines prior to reaction (please use trade names) Daily dosage (Dose no for vaccines) Date begun Date stopped Reason for use suspected drug other drugs Onset of reaction Description of adverse reaction / / Outcome: Recovered Date of recovery: / / Not yet recovered Unknown Fatal Date of death: / / Sequelae: No Yes If yes, describe: Severity: Life threatening Hospitalised Required a visit to the doctor Treatment (of reaction): Comments (for example, relevant history, allergies, previous exposure to this drug): Reporting doctor, pharmacist, etcetera: Name: Address: Signature: Date: Fax this information to the Department of Human Services on 1300 768 088

Victorian health management plan for pandemic influenza 91 Appendix 10. Isolation and quarantine arrangements * Please note that containment measures within this appendix should only be used as a guide and may change at the time depending on State/Commonwealth discussions and best available evidence. Isolation and quarantine To contain the spread of infectious diseases, public health authorities rely on many strategies. Two of these strategies are isolation and quarantine. Both are common practices in public health, and both aim to control exposure to infected or potentially infected persons or exposing noninfected people. Both may be undertaken voluntarily or compelled by public health authorities. The two strategies differ in that isolation applies to persons who are known to have an illness, and quarantine applies to those who have been exposed to an illness but who may or may not become ill. 1 Whether a suspected case is picked up at the border or in the community (GP clinic, hospital or other facility), it is important that the Department of Human Services is contacted and that the case is isolated. Initially, depending on clinical needs, suspected cases may be transferred to a hospital that has negative pressure facilities and appropriate infection control procedures should be followed. The Department of Human Services will arrange urgent testing to confirm or reject the diagnosis. If unwell, contacts will be clinically assessed by their GP or the nearest emergency department and appropriate tests taken under the guidance of the department. Applicable antiviral treatment (for example, Tamiflu) will be provided to positive cases and contacts by the department. Border Travel advisories Travel advisories can reduce the numbers of people travelling to or from affected areas. This can reduce the number of infected persons returning from such areas and, therefore, the spread of the virus in Australia. Travel advisories are provided by the Department of Foreign Affairs and Trade (DFAT) at http://www.dfat.gov. au/travel/ Border protection measures The objectives of border control will include the following. When transmission is occurring overseas To identify infected persons (cases) entering Australia and institute appropriate control measures. To provide information to persons entering Australia who may be incubating disease after contact with infected animals or infectious cases so that appropriate surveillance and control measures may be implemented. To provide information to travellers leaving Australia and travelling to areas of transmission so that appropriate preventive and control measures can be implemented. When transmission is occurring in Australia To identify an infected person departing the country and institute appropriate control measures. To provide information to departing persons who may be incubating disease after contact with infected animals or infectious cases so that appropriate surveillance and control measures may be instituted. Guidelines for border control (air and sea ports) screening and evaluation are contained within the Interim infection control guidelines for pandemic influenza in healthcare and community settings (June 2006). This includes: international procedures for border nurse referrals actions by the border nurse border nurse assessment summary. Health information cards will also be produced and distributed by DoHA. Quarantine The aim of quarantine is to ensure that people who are well, who may be incubating the disease, are identified rapidly as suspect cases if illness develops and the disease is able to be contained.

92 Victorian health management plan for pandemic influenza Legal powers Responsibility for human quarantine is exercised by the Minister for Health and Ageing through the Quarantine Act 1908. The Minister is able to delegate to the Director for Human Quarantine (DHQ), who is the Australian Government Chief Medical Officer (CMO). The human diseases that are currently subject to quarantine controls in Australia are cholera, plague, rabies, smallpox, SARS, Highly Pathogenic Avian Influenza in Humans (HPAIH), viral haemorrhagic fever and yellow fever. The management of human quarantine is undertaken by the Department of Health and Ageing (DoHA), Australian Quarantine and Inspection Services (AQIS), and state/ territory health authorities. As appropriate, the Chief Quarantine Officers (CQO) may issue public health orders for isolation/quarantine of cases/contacts as per the legislation (State/ Commonwealth). Public health orders are designed to limit the risk of transmission. Roles and responsibilities The DoHA has primary responsibility for human quarantine activities in Australia. The purpose of these activities is to allow for the identification, surveillance and management of persons who have been potentially exposed to, or have symptoms of, a disease that could require quarantine. The DHQ (CMO) has overall responsibility for human quarantine policy and for providing directions to the CQO for human quarantine in each state/territory. The day-to-day delivery of human quarantine activities is the responsibility of AQIS and state/territory health authorities, with administrative support being provided by DoHA officers. In Victoria, the Chief Quarantine Medical Officer is delegated to the Assistant Director, CDCU. This position provides 24/7 medical assistance to AQIS officers in accordance with existing protocols and memorandums of understanding. Quarantine at Melbourne Airport avian influenza proposed passenger management protocol The AQIS provides quarantine services at all international air and sea ports in Victoria. Quarantine officers are not expected to diagnose diseases in passengers but need to assess ill passengers with support of medical advice, where appropriate, so that decisions can be made for any immediate action to protect Australia s population. Through a formal agreement with the Commonwealth Government, the Department of Human Services provides a Chief Quarantine Medical Officer as a contact point for AQIS officers if they have concerns about the health of a particular person entering the country. AQIS officers have a matrix-based checklist that is applied should a passenger or crew member declare an illness or observation of arriving passengers triggers some concern. The checklist is designed to help the AQIS officer obtain the most helpful information and establish a record of the patient s situation. In the case of influenza, some of the prescribed symptoms (for example, high temperature, persistent coughing) could apply to mild influenza or to influenza of serious concern. However, those exhibiting mild influenza with little differentiation from a common cold, such as runny nose and sore throat, will not be assessed as a quarantine risk. The department, through the Chief Quarantine Medical Officer, will be liaising with DoHA and AQIS at Melbourne Airport to enable sea and air port passenger surveillance programs to be implemented rapidly, if necessary, in accordance to the Australian health management plan for pandemic influenza and our own state plan. This may include the deployment of health nurses and thermal imaging equipment (infrared temperature monitoring device) at the airport (and sea ports as necessary) to monitor the health of incoming international passengers. If required, departmental medical staff will be used initially to support AQIS staff. The Department of Human Services has also had discussions with a nursing agency to be able at short notice, to deploy nurses to work at the airport. The discussions with AQIS have included the ability to speed up security procedures for agency nurses to enable access to restricted areas.

Victorian health management plan for pandemic influenza 93 Current situation Pandemic alert, Overseas 3 (current situation) A person arrives from overseas and is showing respiratory symptoms, after a brief discussion with a AQIS official they indicated that they have just returned from an avian influenza affected area (that has either animal or human cases) and had bird contact. Suggested actions: Case Take passenger to the established medical room. Provide passenger with a surgical mask. The AQIS officer (and/or other officers present) should wear a P2 mask while in the room. Contact the Chief Quarantine Officer (Medical) using standard contact protocols. Following over the phone assessment, if it is decided the passenger requires hospitalisation, make arrangements to transfer the passenger to the Royal Melbourne Hospital. Notify ambulance staff of the risks and ask them to implement their staff protection protocols. Forward pathology specimens to VIDRL, which can have a result within approximately six hours. Department of Human Services will provide applicable antiviral treatment (for example, Tamiflu) to positive cases. Contacts If the case turns out to be positive, the department will determine, on a case-by-case basis, who the close contacts are and organise appropriate prophylaxis. Human cases overseas (pandemic alert, overseas 4) A plane returns from an influenza affected area (where there is human to human transmission) and a passenger on the flight is symptomatic. Passengers/crew on all flights from an avian influenza affected area will be provided with a Health Declaration Card. The card will serve as a Health Alert Notice and provide AQIS with health information about them and their contact details. Suggested actions: Case Follow as outlined above in Pandemic alert, Overseas 3 If a larger room is required, divert operations to tarmac level medical room. Contacts All passengers and crew should be streamed off the plane via the tarmac (to minimise mixing with other flights) to a holding area (large room at tarmac level), which has adequate seating facilities, toilet facilities, access to food and beverage (vending machines or provided) and access to medical care if required. Customs procedures could take place here. Suitable transport home will be arranged for persons to be self quarantined for seven days. If they do not have homes (travellers), the Department of Human Services will organise suitable accommodation, for example, hotel facilities. A list of contacts should be compiled if the person turns out to be positive. If the case turns out to be positive, antiviral treatment (Tamiflu) will be provided to contacts as prophylaxis. Human cases overseas Pandemic alert overseas 4 A plane returns from an influenza affected area (where there is human to human transmission) and no one on the flight is symptomatic. Suggested actions to consider (in consultation with CQO): The whole planeload of people should be streamed off the plane via the tarmac (to minimise mixing with other flights) to a holding area (large room) that has adequate seating facilities, toilet facilities, access to food and beverage (machines or provided) and access to medical care if required. Customs procedures could take place here. Suitable transport home will be arranged for persons to be self quarantined for seven days. If they do not have homes (travellers), the Department of Human Services will organise suitable accommodation.

94 Victorian health management plan for pandemic influenza Human case overseas Pandemic alert overseas 5 Suggested actions: Department of Human Services coordinates medical staff 24/7 at the airport Thermal imaging is undertaken for all flights. People meeting the case definition are triaged to designated hospitals (if hospitalisation is required) assessment clinics or home quarantine. Community Containment Victorian GPs and hospital medical officers have received a series of health alerts for avian influenza, the most recent in June 2006, outlining strategies on how to maintain vigilance for highly pathogenic avian influenza in the background of ongoing overseas human cases of avian influenza. The alerts outline when to suspect avian influenza. They provide infection control procedures and ask that any suspected cases be reported to the department immediately. Cases Upon notification to the Department of Human Services (CDCU) of a suspected case that meets the case definition, CDCU will assist in case management. In the early stages, all suspected cases will be transferred to a designated hospital with negative pressure facilities. If the case is confirmed, he/she will be treated with antiviral medication as will their contacts. Contacts Contacts will be placed in quarantine (usually in their home) and provided with counselling and information about pandemic influenza, its control and preventative therapies in a fact sheet (Pandemic influenza (flu) Information for people who may have been exposed to pandemic influenza and are isolated). The CDCU will ensure that contacts are followed up on a daily basis for seven days after the last contact to determine whether symptoms of pandemic influenza have developed, and to ensure that the contact is observing quarantine restrictions and is taking any antiviral medication. If symptoms develop, the CDCU will arrange medical assessment in a designated hospital with negative pressure facilities, with appropriate infection control precautions. Contacts asked to self quarantine for seven days will be provided with: a thermometer an information sheet contact number for the Department of Human Services officer who will contact them daily a letter for their GP or emergency department They will also be asked to contact their GP (if they have one) as a courtesy to keep them informed. Unless they are unwell, the GP does not need to see them immediately, but can provide information and support through this time. All health care workers should use PPE when assessing unwell contacts and when taking initial swabs. Where cases or contacts refuse to comply with quarantine or isolation voluntarily, legislative mechanisms may be required to ensure compliance. Maintenance Clinical staff in hospitals and general practices will manage patients and determine the best place for care for them. The CDCU will ensure that fact sheets are provided to patients and their families. Individual follow up of contacts by CDCU will not be feasible, but the principles of quarantine will be encouraged at the population level. Education on disease prevention and control will be delivered via mass media and via the clinician caring for the case.

Victorian health management plan for pandemic influenza 95 Appendix 11. Primary health care Introduction Primary health care, including general practice, pharmacy, community nursing and community health centres, will be in the front line of Victoria s response for human pandemic influenza. Many of the issues that these services may face during a pandemic are common to all health and community services and are covered extensively in other sections of this plan and in the Primary Care Annexe to the Australian health management plan for influenza to be released in the near future. However, some issues and approaches are more specific to the Victoria primary health care sector and this appendix aims to provide further clarification of these. To avoid duplication, those covered extensively elsewhere in this plan have not been included in this appendix. The need for a planning process Primary health care services may be the first to see suspected pandemic influenza in humans and are likely to bear the brunt of the demand for assessment, advice and support during a pandemic. Every general practice, community agency, community health centre and pharmacy needs a pandemic influenza plan as planning is likely to mitigate the operational impact of a pandemic and increase the safety of staff and patients/ clients. Coordination of this planning by a member of the management team, director or owner will allow timely and appropriate plans to be developed, staff trained and protocols reviewed. Planning tools specific for general practice are contained in Preparing for an influenza pandemic, an information kit and workplan for general practice were sent to all Victorian general practices in January 2007 and available at www. health.vic.gov.au/pandemicinfluenza The different phases and response strategies as a pandemic develops are set out earlier in this plan as Australia/ Overseas phases 0 6 but can be summarised as: Preparation aiming to keep out a potential pandemic strain Containment aiming to stamp out any outbreaks Maintenance aiming to help practices and services ride out the pandemic Recovery. Indigenous Australians The particular needs and concerns of Aboriginal and Torres Straits Islanders should be recognised in the plans of every primary health care practice/service. Primary health care services that focus on Indigenous Australians will need to consult widely with the communities that they service to help protect cultural sensitivities, as much as is practicable, while maintaining infection control standards. Culturally and linguistically diverse Victoria Victoria has a diverse population drawn from many different cultures and language backgrounds. As part of preparing Victoria to respond to a pandemic, the government will have available various translated materials and will use community radio to send messages throughout the community. Primary health care services may want to use this information or develop their own material based on their known specific client needs, or adapt their plans for their specific patient/client population. It is important, however, to maintain consistency of local plans within the infection control and other public health principles set out in the Victorian plan. Other relevant areas for primary healthcare covered elsewhere in the plan Vaccination is covered in Appendix 8. Primary health care providers may be involved in mop up vaccination activities after mass vaccination by local government, and vaccination of hospital staff by hospitals. Training will be provided for these primary health care workers. Clinical guidelines for GPs and remote area nurses are covered in Interim national pandemic influenza clinical guidelines to the Australian health management plan for pandemic influenza.

96 Victorian health management plan for pandemic influenza Roles and responsibilities for different providers, nongovernment organisations, such as Divisions of General Practice, and government are covered in Appendix 13 Roles and responsibilities. Individual providers will be faced with difficult decisions for the care of many sick people in a time of scarcity of resources while maintaining their professional standards as far as reasonably practicable. Services will need to devise appropriate triage plans to help prioritise the delivery of care. Ethical issues relevant to priority setting are covered in Appendix 12 Ethical considerations. Consumer education is covered in Appendix 7 Communication. Planning for a pandemic Key components of planning for a pandemic by all parts of primary health care are: Heightened surveillance: increased awareness of possibility of novel influenza strains in returned travellers rapid communication with the Department of Human Services Clinical training epidemiology and surveillance advice and referral Safety Risk of infection and communication Staff working with patients with pandemic influenza need to be conscious of the risk of exposure to the virus. They need the prior opportunity to understand the possible risks and how they can minimise their risk of exposure. Practices/services must allow staff to make informed choices about working in a potentially risky environment with plenty of notice to consider their responses. When the outbreak of a potential pandemic flu arrives, it will be too late to respond rationally and staff may react out of fear or ignorance. Staff may want to opt out of work in this area or may want to stay at home. It is, however, important to emphasise the duty of care that health care workers have, in that they have voluntarily accepted to work in an area with known risks (see Appendix 12). Some staff may volunteer for flu work elsewhere. Infection control Infection control, including personal protective equipment (PPE) use, is covered more extensively in Appendix 6. Primary health care services should buy sufficient sets of PPE for appropriate use with suspected cases of avian influenza or pandemic strain influenza. Once a pandemic starts, the Department of Human Services will distribute PPE supplies from the National Medical Stockpile. These stocks are not unlimited and policies on their delivery will be determined according to national and state priorities. infection control triage management of cases and contacts Communication Business continuity Preparation for later stages. Certain principles apply to all areas.

Victorian health management plan for pandemic influenza 97 Guidelines for appropriate use of PPE are contained in Appendix 6 and should be followed to allow safer working for staff within finite resources. Different approaches to infection control will be taken depending on the phase of the pandemic, clinical setting and patient, for example: person with suspected influenza at home well household contact of someone with confirmed influenza confirmed case undergoing aerosol generating procedure Occupational health and safety legislation states that: An employer must, so far as is reasonably practicable, provide and maintain for employees of the employer a working environment that is safe and without risks to health. It also states that: If it is not reasonably practicable to eliminate risks to health and safety, (an employer must aim) to reduce those risks so far as is reasonably practicable. routine well patient/client without influenza. Table A11.1 Summary of PPE for community health care settings for suspected or actual cases of influenza In same room but no close patient contact Close clinical contact (<1 metre for >15 minutes) P2 mask No Yes Yes Surgical mask Yes Only if P2 unavailable N/A Gown No Yes if possible Yes Gloves No Yes, if body fluid exposure anticipated Eyewear No No Yes Cap No No Yes Apron No Yes, if splashing possible and impermeable gown not available Aerosol generating procedure being performed Yes Yes, if impermeable gown not available

98 Victorian health management plan for pandemic influenza PPE stockpiles and subsequent supply Pharmacy: each pharmacy will need masks to allow use by pharmacy staff in close contact, within 1 metre, of a person with suspected influenza for a prolonged period of time (>15 minutes). Masks do not have to be worn continuously. General practice: it is recommended that all practices should have on hand at least two boxes of 50 P2/N95 masks from their usual medical supplies wholesaler and some gowns and eye wear for high exposure procedures. These can be useful for the assessment of patients with other communicable diseases, such as measles and seasonal influenza, as well as providing a small stockpile for the start of an influenza pandemic. Community nursing: each community nurse will need a stockpile of sufficient PPE to allow safe working in the first two weeks of a pandemic. Fifty N95/P2 masks for each clinical nurse car likely to visit people with pandemic influenza is a reasonable start to a stockpile as well as some eyewear, gloves and gowns for high exposure prone procedures. Once the Department of Human Services starts to distribute PPE from the National Medical Stockpile, ordering will be via the departments fax number 1300 768 088. A specific pandemic PPE ordering form will be used which will also ask practices and clinics to provide clinical workload, workforce availability and disease information to assist in planning, surveillance and reporting. Business continuity Concerns and anxieties about infection in patients and staff are likely to occur at the same time as public health measures, such as social distancing, are implemented. Absenteeism of staff will put pressure on rosters, practice management and finances. Developing business survival or continuity plans now covering the possible impacts on practice/service functioning and potential responses will help maintain your service. Planning should incorporate absence of staff and the also the possibility of intermittent interruption of supply of power, water, and other utilities. Some practices/services may consider collaborating or decide to share resources with local colleagues to be able to continue functioning. Divisions of General Practice and regional department offices might provide a role in brokering such collaborations but the success of such ventures will rely on local providers talking to each other, exploring options and discussing practicalities, prior to a pandemic. Businesses that supply and service practices/services are likely to be under pressure as well. Wholesalers need pandemic business continuity plans as well and individual practice/service business continuity plans should include confirmation that suppliers have planned for a pandemic. Further information on general business continuity planning can be downloaded from www.industry.gov.au/ pandemicbusinesscontinuity Pre-and post-exposure prophylaxis Protocols for pre- and post-exposure prophylaxis for health care workers at high risk of exposure to pandemic influenza during their work are detailed in Appendix 9. These are, based on the Australian health management plan for pandemic influenza Appendix 1. Planning should not, however, be based solely on receiving prophylaxis as these will be in limited supply. Other minimisation strategies need to be considered and documented.

Victorian health management plan for pandemic influenza 99 Table A11.2 Criteria for allocation for antivirals beyond the containment phase Work requirement Risk exposure to the virus Antiviral category Health and safety Health and safety Continuous high risk of exposure to infected people or another source of the virus Medium risk of close contact exposure to infected people or another source of the virus 1 continuous prophylaxis 2 single course post- exposure (or possible exposure) prophylaxis Source: Australian health management plan for pandemic influenza page 51 Patient education Post signs that promote cough etiquette and respiratory hygiene in common areas (for example, waiting areas and toilets) where they can serve as reminders to all persons in the practice/service. See www.health.vic.gov.au/ pandemicinfluenza/prof_res.htm#general Staff wellbeing Anxiety and fear may lead to patients becoming demanding and aggressive. Training staff to deal with these behaviours may reduce the risk of verbal or physical violence. Many patients will want to see their doctor and may try to claim special favours from staff. Staff may feel scared, ill or vulnerable. Support and time off to help staff through this difficult work will be vital. Municipal emergency management plans will be activated and extra security may be needed for primary health care services. Vaccination Vaccinate staff and high-risk patients for seasonal flu to reduce co-infection with two different types of virus, which may increase the chances of a mutated virus emerging. Vaccinate at risk patients with pneumococcal vaccination. Pneumococcal pneumonia is one of the common complications of influenza so it is important to achieve high coverage in at risk groups. See www.health.vic.gov. au/immunisation When a vaccine for a pandemic strain becomes available, the department will coordinate distribution. The vaccine will be made available first to people at high risk of exposure to the virus (front line health care workers) and people most vulnerable to severe illness from infection, then rolled out to the rest of the community. Local government will provide this through mass vaccination sessions (see Appendix 8). Once mass vaccination has been completed using mass vaccination sessions, GPs could assist with mop up for persons who were unable to attend mass vaccination sessions. When primary health care providers and their staff are eligible for vaccine, this will be ordered from the department (see Appendix 8). The roles of government and communication Once pandemic cases start to appear, the Victorian Government will update general practice, pharmacy and community nursing regularly through a range of channels including health alerts for GPs, information to GP Divisions, the RACGP, the Pharmaceutical Society and the Pharmacy Guild, and organisations such as the Royal District Nursing Service. Once cases are widespread throughout the community, the best source of up-to-date information will be through the web pages of the Chief Medical Officer (Australian Government) and the CHO of Victoria: www.health.gov.au and www.health.vic.gov.au/pandemicinfluenza

100 Victorian health management plan for pandemic influenza The Department of Human Services also intends to use ABC local radio 774 Melbourne to provide updates, GP Divisions, the Pharmacy Guild and Australian Practice Nurses Association (APNA), as well as professional member associations. The government will advise primary health care providers on any changes to regulations and legislation necessary to help control and manage the pandemic as new evidence and data emerges. Testing and updating plans Plans need testing for refinement and improvement, so primary health care services and practices should perform a dry run using a hypothetical patient. Regular updates of plans will be needed as new data on the clinical and epidemiological nature of a pandemic strain virus emerges. Occupation specific recommendations Pharmacy Preparedness phases Aus 0 2 Pharmacy will need to strengthen pandemic preparedness including preparing business continuity plans. Pharmacy has a vital health promotion and communication role to their communities, including education on influenza transmission risks, information on vaccines and antiviral prophylaxis, and awareness of avian influenza when travelling. Containment phases Aus 3 5 Many concerned members of the public may seek information from their pharmacy at this time to differentiate between seasonal flu and pandemic flu, transmission risks and what they should do. Pharmacy focus in this phase includes: providing up-to-date information on the state of the virus, both overseas and in Australia providing information on ways to avoid transmission of the virus, including personal hygiene, use of masks and gloves etc staff training on staying safe and infection control managing possible cases who present to pharmacy referral points for assessment to the local hospital or GP, as appropriate, with prior warning to allow for use of infection control at the receiving point providing extra supplies of medicines to institutions such as nursing homes via Webster packs increasing stock holding of analgesics and antibiotics in case of supply chain disruptions anticipating demand for influenza related items such as thermometers activating business continuity plans. Notification of cases is not required. Pandemic phases Role of official pharmacy bodies The Victorian Pharmacy Guild and the Victorian Pharmaceutical Society will provide a leadership role to the profession through the work of their community pharmacy planning taskforce. This includes: acting as a conduit for information to and from pharmacists and government organising and supporting a committee of regional facilitators to ensure continuity of supply of essential medicines engaging with wholesalers to help support continuity in the supply chain. The role of community pharmacies will continue as above with the possible addition of roles during the maintenance phase, which depends on changes to Federal and state legislation on scheduling of pharmaceuticals. This may include: resupplying prescription medications without a doctor s prescription for people with long-term medical problems such as hypertension.

Victorian health management plan for pandemic influenza 101 General practice Issues for planning in general practice will be relevant to other direct providers of primary health care, including bush nurses and community health centres. Preparedness phases Aus 0 2 Clinical Clinical staff need training in: signs, symptoms and epidemiology of influenza investigation what to do with a suspected case how to notify the department managing contacts using PPE. Clinicians need to take a travel/work history from all patients with fever or influenza-like illness. The department provides regular health alerts to GPs on communicable diseases. Any suspected cases of H5N1 influenza must be notified immediately to the department on 1300 651 160. Triage plans Triage plans for patients with suspected H5N1 influenza or avian influenza help prevent mixing with non-flu patients. If patients/clients mention a risk of H5N1 or avian influenza when they call for appointments, such as travel to affected areas and influenza-like illness, practices/ services need to: have a triage plan ready for front-desk staff to follow try to see these patients at home if at all possible decide how, who, where and when they will handle home visit requests have a home visit bag prepared with PPE and receipts/ Medicare forms, for example. If seen at the clinic, avoid unnecessary contact with other patients and staff: ask suspected H5N1 influenza patients to wait in their car outside or in a suitably-covered or separated area provide surgical masks for all those with respiratory symptoms choose a specific consulting or treatment room to see the patient; the room should be well-ventilated and easily cleaned after the consultation (note: transmission through air-conditioning systems is not likely) use PPE when seeing the patient and put it in the infectious waste bin after each patient call the department on 1300 651 160 for advice on management and access to laboratory testing. If a suspected case is only identified once in the consulting room: ask the practice/service manager or clinic nurse to record who may have been in the waiting room with the suspected case (despite minimal risk of human-tohuman transmission, contacts may require isolation and prophylaxis, which can be organised and supplied by the department) practices/services do not need to inform possible contacts immediately, but they do need to know their names and contact numbers, as a minimum clinical staff should wear PPE and give the patient a surgical mask to put on get instructions from the department on 1300 651 160. Cleaning and disinfection Follow the standard cleaning procedures for control of potentially infectious materials as outlined in the Australian Government infection control guidelines for the prevention of transmission of infectious diseases in the health care setting at http://www.health.gov.au/internet/wcms/ publishing.nsf/content/icg-guidelines-index.htm

102 Victorian health management plan for pandemic influenza Containment phases Aus 3 5 Clinical GPs and other primary health care providers are likely to see a surge of many potential cases, contacts and worried people. GPs need to ask every unwell patient about recent (in the last 10 days) travel to at risk areas and think Could it be influenza?. The department will provide health alerts updating GPs. Notification and referral pathways During the early containment phases, all suspected cases of pandemic influenza will be admitted to designated hospitals (see Appendix 3). Primary care practitioners, including GPs, will need to contact the CDCU to notify all suspected cases and seek direction for referral. Home visits If GPs are asked to assess suspected cases, it will be best, if practical, for the patient to be assessed at home. GPs will need to consider whether they are willing and able to do home visits and to which areas. Home visit bags should include PPE as well as infectious waste bags. Triage plans To avoid contact between suspected cases and other patients, GPs should implement a new triage plan, such as: see people at home if possible if seen at a practice/service, options include asking a suspected case to: wait in separate area or in their car come at a different time to other patients wear a mask and sit at least 1 metre from other patients wait in a separate consulting or treatment room. During the consultation, GPs should wear PPE and ask the patient/client to wear a surgical mask. Pandemic phases Clinical Mildly sick patients or terminally ill patients with pandemic influenza are likely to stay at home once hospitals are overwhelmed. GPs will also be faced with an increased workload from out-of-hospital care of patients with chronic diseases such as diabetes, asthma, hypertension and ischaemic heart disease, as well as the additional challenges associated with these patients infected with pandemic influenza. To manage this increased workload, telephone triage may help direct sick patients to appropriate care and also reduce lower priority visits by well patients for repeat prescriptions or routine check-ups. Sick patients At first, sick patients requiring admission on clinical grounds will be sent via influenza streams or clinics based in hospitals. Algorithms for assessment of clinical severity are attached to Appendix 3 and also in the Interim national pandemic influenza clinical guidelines at www.health. gov.au/internet/wcms/publishing.nsf/content/ohppandemic-clin-care-gl-toc.htm Once demand for inpatient care exceeds capacity, referral pathways may change with admission only of patients who may benefit from hospital care and the opening of intermediate care facilities for post-acute or step-down care (see Appendix 3). Management of non-influenza patients Practices/services may try to reduce non-urgent visits for workload management and to reduce the chance of susceptible people having contact with sick pandemic influenza patients. Safety Staying well: clinical staff: consider doctors roster for influenza patients if enough staff antiviral prophylaxis as provided by the department use PPE when seeing a possible influenza patient

Victorian health management plan for pandemic influenza 103 after exposure to a possible case of pandemic influenza, self-monitor for signs and symptoms of disease should not to work if they have influenza-like symptoms; they should self-isolate until assessed. PPE should be worn for all close contact (within 1 metre) for a prolonged time (15 minutes or more) with possible influenza patients. In the midst of a pandemic, masks may be worn for more than one patient/client in a row, until filters become clogged. Gloves for examination of all patients and handwashing with standard hand hygiene preparations or soap and water will remain very important. Practices and pharmacies may need to review security. People may become demanding or aggressive and extra help for security may be needed from local police. Palliative care General practices may have increased demand for palliative care for terminally ill people, including home visits. The emotional and psychological needs of carers may require attention and management including specialist bereavement counselling services. Waste control The amount of infectious waste will increase (from use of PPE), so more frequent collections of waste will be needed. Waste from patients being cared for at home will need double bagging and transport back to the clinic for disposal. Community nursing Introduction Community nursing agencies, including the Royal District Nursing Service and Bush Nursing Centres, will be important components of the primary health care response. Existing patients/clients may require additional care and new patients/clients may be referred from hospitals and general practice. Preparedness phases Aus 0 2 Key tasks in this phase include: Update existing emergency and disaster plans business continuity management review identify critical staff and functions review current client essential classification scale Investigate central call point for staff and clients for use in later phases Develop triage checklist to be used at central call point and in the field access required from intranet. Surveillance develop reporting mechanisms to collect client data related to pandemic influenza/ influenza-like illness encourage staff to report possible/confirmed diagnosis of influenza to infection control staff if available. Infection control identify current PPE stock at all sites and determine possible further requirements promote/supply influenza immunisation to staff and high-risk patients/clients to attain high coverage of immunisation within the service annually (January to March) promote pneumococcal immunization, targeting highrisk groups (conditions/diseases) provide ongoing education to all staff regarding infection control protocols and specifically influenza including complications and personal protective measures. Communication ensure access to public health advice, guidelines/ protocols (Department of Human Services and DoHA) and relevant websites continue to update the Influenza Pandemic Plan with new public health advice, and address issues relevant to level of alert

104 Victorian health management plan for pandemic influenza provide list of infected overseas areas/animals involved to all sites and update as required provide written instructions to all staff for monitoring influenza-like illness, signs and symptoms, reporting requirements and documentation of outcomes, including specific instructions below provide access to community information released by the department for staff to give to clients if influenzalike illness suspected. Containment phases Aus 3 5 As before plus: Business continuity management plan implementation monitor admissions, investigate possible separation of non critical clients introduce template for sick leave notification to include total number, individual sites and employment category with instructions for completing; notification of staff absenteeism will be required for the department daily telephone reporting to centre for those working from home to receive any updated information and to report possible illness. Communications daily Department of Human Services update to be accessed and specific instructions implemented RDNS central call point for staff queries to be activated notify all staff consider multiple mediums, such as email, centre managers, SMS messaging provide written instructions to all staff for monitoring influenza-like illness; signs and symptoms, reporting requirements and documentation of outcomes develop/update call priority list of telephone numbers for department hotlines health care workers and public and for internal contacts discussion with liaison nurses on the designated hospital requirements and coordination of referrals (in order of priority) for admission to RDNS though a central point. Infection control circulate instructions for the implementation/ stocking of PPE car kits; provide written checklist reinforce infection control standard and additional precautions to all staff direct requests for additional resources through the HSCC ensure PPE car kit is carried in all cars and restocked daily if used. Checklist to be completed at the beginning and end of each day. Pandemic phases As previously plus: Business continuity management and associated plans implemented for pandemic phase prioritise current clients for those who could be discharged if required to create capacity correlate sick leave notification daily and send to the department daily through the HSSC. Infection control possible vaccination of staff with pandemic influenza vaccine if available. Communications circulate updated influenza information to all staff detection, protection and notification (refer Department of Human Services fact sheets) including specific instructions to be given below reinforce protocol for the deceased as per policy telephone triage commenced questions to be asked before accepting admissions or for existing clients signs and symptoms of influenza etc. Further discussion with department and client s GP will be required to collect triage information.

Victorian health management plan for pandemic influenza 105 Dental practice settings Infection control is the same as for other medical settings as outlined above and detailed in Appendix 6. During all phases of a pandemic, suspected and confirmed pandemic influenza patients should not undergo elective consultation and dental procedures during the infectious and symptomatic period. Contacts should not undergo elective consultation and dental procedures until the incubation period has passed. If urgent surgery is required, strict adherence to infection control procedures including the correct use of PPE is recommended. These patients should be referred to a designated dental clinic where possible. Further detail in relation to dental practice settings is available in the Interim infection control guidelines for pandemic influenza in healthcare and community settings (June 2006), Annex to: Australian health management plan for pandemic influenza: http://www.health.gov.au/ internet/wcms/publishing.nsf/content/ohp-pandemicahmppi.htm

106 Victorian health management plan for pandemic influenza Appendix 12. Ethical considerations When a pandemic occurs, many people, ranging from government to health care workers, will face a range of difficult decisions that will affect people s freedoms and their chance of survival. There will be choices about the level of risk health care workers should face while caring for the sick, the imposition of restrictive measures such as quarantine, the allocation of limited resources such as medicines (antivirals and vaccine) and the use of travel restrictions and other measures to contain the spread of disease. The report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group Stand on Guard for Thee Ethical considerations in preparedness planning for pandemic influenza (November 2005) contains an ethical guide for pandemic planning which can be used both in advance of and during a pandemic. The guide is composed of 15 ethical values, of which 10 are substantive values and five are procedural values that are important in any democratic society. An ethical guide for pandemic planning Ten substantive values to guide ethical decision-making for a pandemic Value Individual liberty Description In a pandemic, restrictions to individual liberty may be necessary to protect the public from serious harm. Restrictions to individual liberty should: be proportional, necessary and relevant employ the least restrictive means be applied equitably. Protection of the public from harm To protect the public from harm, health care organisations and public health authorities may be required to take actions that impinge on individual liberty. Decision makers should: weigh the imperative for compliance provide reasons for public health measures to encourage compliance establish mechanisms to review decisions. Proportionality Privacy Duty to provide Reciprocity Restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk or critical needs of the community. Individuals have a right to privacy in health care. In a pandemic, it may be necessary to override this right to protect the public from serious harm. Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Health care workers will face significant challenges related to resource allocation, scope of practice, professional liability and workplace conditions. Reciprocity required that society support those who face a disproportionate burden in protecting the public good, and take steps to minimise burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients and their families.

Victorian health management plan for pandemic influenza 107 Value Equity Trust Solidarity Stewardship Description All patients have an equal claim to receive the health care they need under normal conditions. During a pandemic, difficult decisions will need to be made about which health services to maintain and which to defer. Depending on the severity of a pandemic, this could limit not only elective surgery, but also the provision of emergency or necessary services. Trust is an essential component of the relationships among clinicians and patients, staff and their organisations. Decision makers will be confronted with the challenge of maintaining stakeholder trust while simultaneously implementing various control measures during a pandemic. Trust is enhanced by upholding such process values as transparency. A pandemic can challenge conventional ideas of national sovereignty, security or territoriality. It also requires solidarity within and among health care institutions. It calls for collaborative approaches that set aside traditional values of self-interest or territoriality among health care professionals, services or institutions. Those entrusted with governance roles should be guided by the notion of stewardship. Inherent in stewardship are the notions of trust, ethical behaviour and good decision making. This implies that decisions regarding resources are intended to achieve the best patient health and public health outcomes given the unique circumstances of the pandemic. Five procedural values to guide ethical decision making for a pandemic Procedural value Reasonable Open and transparent Inclusive Responsive Accountable Description Decisions should be based on reasons (that is, evidence, principles and values) that stakeholders can agree are relevant to meeting health needs in a pandemic. The decisions should be made by people who are credible and accountable. The process by which decisions are made must be open to scrutiny, and the basis upon which decisions are made should be publicly accessible. Decisions should be made explicitly with stakeholder views in mind, and there should be opportunities to engage stakeholders in the decision making process. There should be opportunities to review decisions as new information emerges throughout the pandemic. There should be mechanisms to address disputes and complaints. There should be mechanisms in place to ensure that decision makers are answerable for their actions and inactions. Defence of actions and inactions should be grounded in the other ethical values proposed above.

108 Victorian health management plan for pandemic influenza Appendix 13. Roles and responsibilities Community pharmacy As pharmacies are currently a recognised source of health information they will have a significant responsibility in the event of an influenza pandemic to provide accurate advice and information to the public. During the inter-pandemic period, the role of pharmacy is largely a health information and triage role, providing education in areas such as possibility of an influenza pandemic, avoiding exposure to influenza virus, and promoting basic hygiene practices (cough etiquette/hand hygiene). During the pandemic alert period, pharmacy may be a first point of contact for people requiring further information. They can provide all the same health promotion messages with the addition of up-to-date information on the current status of transmission of the virus both overseas and in Australia, provision of advice as to how to reduce the transmission of the virus, and what to do if you are unwell. The role of pharmacy during the pandemic phase will be further explored. Consideration will to be given to the continuity of supplies of medicines to people with chronic illness in the community and residential aged care facilities. GPs are likely to be overloaded and prescriptions for chronic illness may become a low priority. Community nursing Community nursing agencies, including the Royal District Nursing Service (RDNS) and Bush Nursing Centres, will be important components of the primary health care response. Existing clients may require additional care and new clients may be referred from hospitals and general practice. Hospitals In the inter-pandemic phase Aus 3 and the containment phases Aus 4 5, all confirmed cases of avian/pandemic influenza will be referred to designated hospitals (if diagnosing hospital cannot provide appropriate clinical or infection control requirements), which will provide isolation in negative pressure rooms. During the containment phase, all hospitals will need to implement mechanisms for infection control and workload management appropriate to their facilities and staffing levels. Some hospitals may decide to set up flu/fever clinics/streams for assessment of suspected cases and triage within the hospital close to the emergency department. Hospitals should be aware that human resources will be stretched throughout the health sector and may need to staff these clinical areas from other disciplines within the hospital. In the pandemic phase, all hospitals will need to manage their clinical workload with available resources. Sick patients may require intubation and ventilation. When hospitals start to be overwhelmed, milder cases may be managed at home. Hospitals, general practice and community sectors will need to strengthen communication channels with each other to allow cross-referral of patients for health care and community support. General practice General practices may be first to see suspected pandemic strain influenza in humans and will be important in the provision of: 1. Clinical assessment: a. referral of suspected cases in the early containment phase b. care of confirmed cases in the pandemic or maintenance phase. 2. Information, support and reassurance to concerned people. 3. Clinical management of people with chronic diseases usually managed through hospitals. 4. Home care (if practical) for mildly ill or even terminally ill pandemic patients in the maintenance phase. 5. Referral of people requiring social support to local councils and appropriate agencies. Department of Human Services The Department of Human Services is the lead agency responsible for the control of incidents involving human illnesses and epidemics, including a human influenza pandemic, and for the coordination of the recovery from emergencies.

Victorian health management plan for pandemic influenza 109 As control agency, the department will provide overall direction and ensure that adequate planning and logistics are in place to support the operations for responding to a human influenza pandemic. The department will also ensure that agencies are able to support the response in accordance with the needs of the situation. 1. Incident controller: the Chief Health Officer (CHO) The CHO has overall responsibility for the emergency response operations for a human influenza pandemic. The CHO incident controller responsibilities during a human influenza pandemic may include: establishing control facilities assessing emergency cause and impacts establishing appropriate incident control system structure including relevant agencies developing an incident action plan establishing liaison with emergency services organisations and other support agencies providing briefings to emergency managers allocating tasks to emergency managers ensuring safety of personnel involved in responding to a pandemic preparing reports on situation management managing media requirements managing risks associated with incident control reviewing progress of incident control activities. 2. State emergency recovery coordination The department s Executive Director, Operations, is the State Emergency Recovery Coordinator and is responsible for the coordination of emergency recovery activities as specified in the Emergency Management Act. At a regional level, recovery coordination is the responsibility of department s regional directors. Recovery responsibilities include: coordinating recovery planning and management at state and regional levels supporting other agencies in logistics, plant and transport and other services assisting with provision of temporary accommodation coordinating personal support services and material aid supporting councils and community recovery committees in recovery planning and managing recovery activities administering personal hardship grants and subsidies to employ municipal community development officers coordinating the supply function for recovery activities providing advice, information and assistance to affected individuals, communities and municipal councils. State emergency response coordination The State Emergency Response Coordinator is the Chief Commissioner of Police. The role of the State Emergency Response Coordinator is to ensure that the activities of the agencies that have roles or responsibilities in responding to emergencies are coordinated. The responsibilities of emergency response coordinators are detailed in the Emergency management manual Victoria and include: ensuring appropriate control and support agencies are in attendance or have been notified and are responding to an emergency ensuring effective control has been established in response to an emergency ensuring effective coordination of resources and services arranging for the provision of resources requested by control and support agencies ensuring consideration has been given to alerting the public to existing and potential dangers arising from a serious emergency direct or through the media. Government departments and agencies All State Government departments and agencies are responsible for the following.

110 Victorian health management plan for pandemic influenza 1. Supporting the maintenance of society during a pandemic by: ensuring that appropriate plans and processes are in place to enable the continuity of their services that will be essential in the event of a pandemic assisting and supporting non-government essential service providers within their portfolios with pandemic planning. 2. Supporting the control of the spread of the influenza virus by: ensuring that appropriate strategies are in place to inform staff and associated stakeholders and agencies of actions to be taken in the event of a pandemic creatively using existing networks to further communicate public health messages. Local government Local government is the closest level of government to the community and is often the first point of contact for assistance, advice and information. It is therefore expected that local government will provide a level of leadership during a pandemic and establish partnerships with respective service providers within its community. This role can be best described under four distinct areas: community support and recovery, public health, business continuity and essential services. 1. Community support and recovery Local government has a pivotal role in assisting individuals and communities in the recovery phase of an emergency. The Emergency management manual Victoria outlines the key activities carried out by local government in close conjunction with, or with direct support by, government departments. During a pandemic these may include: providing information services to affected communities using, for example, information lines, newsletters, community meetings and websites providing and staffing of recovery/information centre(s) forming and leading Municipal/Community Recovery Committees post-impact assessment gathering and processing of information environmental health management including food and sanitation safety, vector control etc. providing and managing community development services providing and/or coordinating volunteer helpers providing personal support services, such as counselling, advocacy, in home support providing/coordinating temporary accommodation organising, managing or assisting with public appeals. 2. Public health Local government performs important public health roles during their normal day-to-day business. During a human influenza pandemic this role may be escalated to include: conducting extraordinary vaccination sessions (mass vaccination sessions) distributing public information and advice assessing the impact of the pandemic in their municipality and assisting the State Government to develop and implement strategies to maintain public health. 3. Business continuity Business continuity will be an essential part of local government s role in preparing for and responding to an influenza pandemic and should complement and support other activities that they will be performing during a pandemic. Local government planning will need to take into account activities that are specific to an influenza pandemic as well as its own essential services in an environment of increased absenteeism and demand on services. The comprehensive Business continuity guide developed by the Federal Government will assist local government undertake this planning.

Victorian health management plan for pandemic influenza 111 4. Essential services A human influenza pandemic will have an enormous impact on the service delivery of local essential services which subsequently will have a great impact on communities. During a pandemic, local government will need to ensure important community support services are maintained, such as Home and Community Care programs, maternal and child health services, waste management and other regulatory services. Communities In the event of a human influenza pandemic, it will be important for individuals and communities to work together to achieve common goals for maintaining wellbeing. Individuals and communities will have a critical role in assisting to minimise the spread of a human influenza pandemic by observing and practising basic hygiene measures. These include: The specific strategies required to support the plans will need to address: extended loss of personnel extended impact on critical supply chains. These should be included as pandemic specific in their business continuity plans, in addition to an all hazards approach. In addition, organisations should expand the focus of their business continuity planning to include the planning undertaken by providers or suppliers that could impact their organisation. This would include situations where extended unavailability of staff impacts any service on which the organisation relies, or where one of their critical services is delivered by a third party or outsourced. regular handwashing with soap and water covering your mouth when coughing or sneezing the careful disposal of used tissues. During a pandemic, the Department of Human Services will provide information about how communities can contribute to protecting themselves and others. Individuals and communities will be asked to cooperate with a number of social distancing initiatives to reduce the population s risk of exposure to a pandemic virus, such as reducing non-essential social interactions and minimising attendance at mass gatherings. Businesses and essential services A human influenza pandemic will see significant levels of staff absenteeism. This will affect the ability of most industries and businesses to maintain and deliver services to the community. To minimise the impact of a pandemic, organisations will need to identify their most critical services and personnel and ensure that business continuity plans and pandemic management strategies are in place to enable the delivery of critical services.

112 Victorian health management plan for pandemic influenza Appendix 14: Key actions by Australian phases Department of Human Services (DHS) Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Surveillance Maintaining vigilance, Issue Health Industry Alert: reporting of suspected cases immediately to DHS Surveillance Liaise with CDNA daily Review case definition Improve case cluster detection: in general practice, hospitals and other institutions of unexplained deaths Rumour surveillance The contacts of all confirmed cases should be traced and put under surveillance, contacts to remain in quarantine at home and provided with antivirals for 7 days Notify all suspected and confirmed cases immediately to DHS Discourage overseas travel to affected areas Health Alert for return travellers Surveillance As per Aus 3 with the addition of: Check all incoming passengers for fever using thermal scanners Continue count of cases and contacts Surveillance Review surveillance activities Monitor hospital admissions Monitor deaths in hospitalised and nonhospitalised patients Monitor health workforce absenteeism Consider a range of other surveillance activities at the time Consider how recovered cases can be identified by occupation, facilitating the development of a resource of presumed immune workers Evaluate action to date Undertake stock inventory and resupply Document and collate financial issues Debrief staff Surveillance Return to routine surveillance Maintain vigilance Surveillance As per 6A

Victorian health management plan for pandemic influenza 113 Antivirals Provided by DHS from the NMS Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Collate data on cases and effectiveness of antivirals As per Overseas 3 with the addition of: Collate data on cases and effectiveness of antivirals Collate data on cases and effectiveness of antivirals Collate data on cases and effectiveness of antivirals As per 6A Treatment Confirmed cases commence antivirals within 48 hours of symptom onset Prophylaxis Contacts (includes household and health care workers (HCWs)) of confirmed cases for 7 days Prophylaxis Border workers antivirals for 7 days after last contact HCWs working with confirmed human cases antivirals for 7 days after last contact Treatment (containment) Confirmed cases commence antivirals, if available, within 48 hours of symptom onset Prophylaxis Border workers antivirals for 7 days after last contact Treatment Confirmed cases priority may need to be given to those deemed at highest risk of severe outcome Prophylaxis Will depend on availability, preexposure prophylaxis for HCWs HCWs working with confirmed human cases antivirals for as long as contact continues and 7 days after last contact Treatment (maintenance of essential services) As per Aus 6A Treatment (maintenance of essential services) HCWs will be switched to preexposure prophylaxis Amount of antivirals used for treatment will depend on the results of the treatment trial

114 Victorian health management plan for pandemic influenza Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Vaccine Encourage high coverage of influenza and pneumococcal immunisation in identified highrisk groups using current vaccines Mobilisation to immunise priority groups against pandemic influenza (as soon as vaccine is developed) It is intended that GPs will vaccinate staff within their practice Hospitals to identify their high-risk workers and vaccinate staff within their hospital, and highrisk patients Local government immunisation teams will vaccinate firstly the identified priority group within the community then, as vaccine rolls out, vaccinate the remainder of the population Once mass vaccinations have been completed using MVCs, GPs to assist with mop up For community groups unable to attend MVCs, existing health care providers to provide vaccine Collate data on cases and effectiveness of vaccines Upon availability of the vaccine, priority groups will be vaccinated by local government teams using MVCs DHS will source and distribute the vaccine Hospital pharmacies will act as the liaison points for vaccination of hospital staff GPs will vaccinate staff within their practice Once the identified priority groups have been vaccinated and further vaccine is available, the general population will be vaccinated Collate data on cases and effectiveness of vaccines Collate data on cases and effectiveness of vaccines

Victorian health management plan for pandemic influenza 115 Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Public Health measures As above Make recommendations based on the epidemiology of the disease at the time. Measures to include: social distancing disease awareness basic hygiene As per 6A including assessing current public health measures and consider whether further measures are required As per 6A DPI Maintain up to date website on avian influenza and provide information to veterinarians and poultry industry DPI activity in accordance with AUSVET plan

116 Victorian health management plan for pandemic influenza Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Hospitals Report any suspected cases immediately to DHS Depending on clinical merit, transfer patient to hospital and place in isolation and use appropriate infection control Commence antivirals within 48 hours of symptom onset in confirmed cases Influenza streams, patients with suspected pandemic influenza may present to any health services in a variety of ways. Health services need to develop a process for identifying, separating, triaging and admitting people with influenza like illness to prevent cross-infection. This may involve setting up a separate area to triage flu and nonflu patients Depending on clinical need, suspected cases to be admitted to a designated hospital Patient will be assessed in a separate room (NPR if available), observing infection control procedures Decision to transfer patients to a designated hospital will be made on a caseby-case basis in consultation with DHS HSCC to advise hospitals where to access antiviral stocks for HCWs, patients and contacts Hospitals to liaise with DHS regarding media queries All suspected cases to be reported immediately to DHS to organise testing and contact tracing As per Aus 3 with the addition of: Activate the DHS HSCC as the official mechanism of contact between DHS and health services Hospitals to consider establishing influenza clinics at designated hospitals. The decision to activate an influenza clinic will be made by the HSCC in consultation with the designated hospital. Not all influenza clinics will necessarily be activated concurrently as decisions will depend on epidemiology and patient presentation across the State As per phase 4 with the addition of: All hospitals to have contingencies for triaging increasing numbers of pandemic influenza patients Consider cessation of elective surgery and early discharge of patients As per Phase 6a, including the addition of: Treatment Confirmed cases priority may need to be given to those deemed at highest risk of severe outcome Suspected cases depending on availability of supplies, provide antivirals Those at high risk of serious morbidity and mortality will depend on the epidemiology of the causative virus Prophylaxis Will depend on availability, priority groups to minimise social disruption HCWs and essential service workers Stock inventory and resupply Document financial issues Staff debrief (psychological and operational) Counselling and support services available As per 6A

Victorian health management plan for pandemic influenza 117 General practice and Divisions Community pharmacy Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Make one person responsible for coordinating pandemic planning in the practice Report all suspected cases immediately to DHS Train doctors and nurses on symptoms, signs and epidemiology of H5N1 influenza Prepare a triage plan for suspected cases Buy PPE and learn how to use it Start thinking about the possible impacts on practice functioning and how you might respond Train doctors and nurses to think Could it be flu? Use PPE with possible cases Update triage plan for suspected cases for the front desk Decide how you will handle home visit requests Devise a strategy to identify contacts Draw up a practice business survival plan for these stages Know how to order additional supplies of PPE Brief doctors, nurses and non-clinical staff on the pandemic phase Talk about reducing risks and staying well Implement practice business survival plan Consider workload management of flu and non-flu patients Stock inventory and resupply Document financial issues Staff debrief (psychological and operational) Counselling and support services available As per 6A Strengthen pandemic preparedness Prepare business continuity plan Health promotion and communication role to their communities, including education on influenza transmission risks information on vaccines and antiviral prophylaxis awareness of avian influenza when travelling Provide up to date information on the current state of the virus, both overseas and in Australia Provide information on ways to avoid transmission of the virus including personal hygiene, masks and gloves etc Train staff on staying safe and infection control Manage possible cases who present to pharmacy: referral points for assessment to the local hospital or GP as appropriate with prior warning to allow for use of infection control notification of cases is not required Provide extra supplies of medicines to institutions such as nursing homes via Webster packs Consider increasing stock holding of analgesics, antibiotics in case of supply chain issues Anticipate demand for influenza related items such as thermometers Activate business continuity plans As per Aus 3-5 with the addition of: Role of official pharmacy bodies Victorian Pharmacy Guild and Victorian Pharmaceutical Society provide a leadership role to profession through the work of their community pharmacy planning taskforce Act as a conduit for information to and from pharmacists and government Organise and support a committee of regional facilitators to ensure continuity of supply of essential medicines Engage with wholesalers to help support continuity in the supply chain Stock inventory and resupply Document financial issues Staff debrief (psychological and operational) Counselling and support services available As per 6A

118 Victorian health management plan for pandemic influenza Community nursing Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Update existing emergency and disaster plans including business continuity Prepare for later stages of a pandemic including central call point for staff and clients, triage checklist and reporting mechanisms to collect client data Re-assess PPE stock at each centre and reorder supplies if necessary Develop monitoring mechanism to ensure appropriate stock available at each site Promote/supply seasonal influenza immunisation to all staff to attain high coverage of immunisation within the service annually Promote Pneumococcal Immunisation to high-risk groups Provide ongoing education to all staff regarding infection control protocols for influenza Encourage staff to report possible/ confirmed diagnosis of influenza to CDCU Ensure access to public health advice, guidelines/ protocols (DHS and DoHA) and relevant websites Report all suspected cases immediately to DHS on 1300 651 160 Institute triage and management plans for possible cases (see Appendix 11 Primary health care) in consultation with DHS As per OS 3 with the addition of: Implement agency business continuity management plan Monitor admissions, investigate possible separation of non critical clients. Possible prioritising of current clients for those who could be discharged if required to create capacity Access daily DHS update, implement specific instructions and keep staff informed Discuss liaison role with designated influenza hospitals Reinforce infection control standard and additional precautions to all staff. PPE must be used for care of a person with suspected or actual avian influenza. Staff exposed to confirmed cases will be provided with post-exposure prophylaxis per standard HCW protocols Provide access to community information released by DHS for staff to give to all clients Requests for additional resources will be through the HSCC Telephone triage commenced questions to be asked before accepting admissions or for existing clients, signs and symptoms of influenza etc). Further discussion with DHS and patient s GP will be required to discuss triage information DHS will provide pre-exposure prophylaxis for clinical staff at greater risk of exposure to pandemic influenza due to their occupation, subject to supply and protocols of the National Medical Stockpile PPE car kit must be carried in all cars and restocked daily Discussion to be held with liaison regarding designated hospital requirements and coordination of referrals (in order of priority) for admission to community nurse agencies, such as RDNS, though a central point Note: it is not expected that community nurses will be assessing, or provide investigation of suspected cases As per Aus 3-5 with the addition of: Prioritise current clients for those who could be discharged if required to create capacity Report sick leave figures daily to DHS through HSCC Stock inventory and resupply Document financial issues Staff debrief (psychological and operational) Counselling and support services available As per 6A

Victorian health management plan for pandemic influenza 119 Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Laboratories Notification of laboratory influenza to DHS VIDRL Test and type specimens from all suspected cases Plan for increased number of testing Test for the pandemic virus and for plausible alternative aetiological agents Test and type specimens from all possible cases for the pandemic influenza strain as per the VIDRL testing protocol Routine laboratories Transfer any referred specimens to VIDRL for analysis VIDRL Containment Test and type specimens from a random sample as agreed with DHS Routine laboratories Transfer any referred specimens to VIDRL for analysis VIDRL It may not be possible to test all suspected cases because of the large increase in numbers Routine laboratories Transfer any referred specimens to VIDRL for analysis Stock inventory and resupply Document financial issues Staff debrief (psychological and operational) As per 6A Ambulance Services Maintain liaison with DHS Attain high coverage of staff immunisation, particularly for influenza Ongoing education of staff about infection control procedures Plan for influenza pandemic plus business continuity Institute the Ambulance Emergency Response Plan Remind staff of relevant provisions of the infection control policies Provide antivirals (from NMS) for exposed staff In consultation with DHS, triage cases requiring hospitalisation and refer to appropriate facility. Information on self-management will be provided to patients not requiring transfer to hospital Provide information on self-management to patients not requiring transfer to hospital Re-assess the Ambulance Emergency Response Plan level of activation Specifically review all non-essential activities to maximise ongoing capacity Continue antivirals for exposed staff Undertake transport of possible influenza cases in consultation with DHS Liaise with DHS in regard to actions with non-emergency requests (pre-planned and routine clinic transports) Ambulance Service to regain continuity of service provision Stock inventory and resupply Document financial issues Staff debrief (psychological and operational) As per 6A

120 Victorian health management plan for pandemic influenza Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d Communication DHS to Issue Health Industry Alerts as necessary Media statements as necessary DHS to facilitate workshops for GPs, local government, emergency services personnel, community support groups and DHS Regional Offices to discuss pandemic planning Media statements as necessary Regular updates provided to healthcare workers and to the public Possible activation of a national information campaign using print and online media As per Australia 3 with an escalation of communications At all stages of the Pandemic, health services will be informed of the response requirements for their agency Public health will coordinate response for public health management of possible/ confirmed cases of influenza Disseminate information to general public on influenza - tailored to the target population through media briefings, the distribution of fact sheets and ensuring public access to the DHS website and other sources of information Disseminate information to health professionals on disease, infection control, testing, recommended actions etc Activation of a second national information campaign to encourage appropriate disease containment practices As per 6A As per 6A As per 6A

Victorian health management plan for pandemic influenza 121 Community support and recovery Current situation (OS 3) Aus 3 Aus 4 Aus 5 Aus 6a Aus 6b Aus 6c Aus 6d DHS regions and branches Facilitate influenza pandemic planning within the DHS regions and program areas Work with local government to assist with influenza pandemic planning Work with health care providers to assist with influenza pandemic planning Local government Undertake pandemic planning Make provisions for business continuity in the face of increased absenteeism and demand on services Promote vaccination for influenza and pneumococcal vaccine for identified high-risk groups Mobilise the preparation to activate Community Support Centres Activate Community Support Centres DHS regions Provide assistance to DHS Public Health, Communicable Disease Section as necessary Provide assistance to local government to help deliver response activities Coordinate a response at a DHS regional level Provision of information at a DHS regional level Collation of regional data to inform statewide response Coordinate community support and recovery activities across the region Local government Information/resources Community support Vaccination Stock inventory and resupply Document financial issues Staff debrief (psychological and operational) As per 6A

122 Victorian health management plan for pandemic influenza List of abbreviations AAHL ADRAC AFDA AHPC AHDMPC AI AMA AQIS AUSVETPLAN CDCU CDNA CGRC CHO CAD CMO CQMO CVO DECC DERC DHS DoHA DOI DOJ DPI ECC ED EI EMA EMMV GPDV GP/GPs Australian Animal Health Laboratory Adverse Drug Reactions Advisory Committee Australian Funeral Directors Association Australian Health Protection Committee (formerly known as the AHDMPC) Australian Health Disaster Management Policy Committee avian influenza Australian Medical Association Australian Quarantine and Inspection Service Australian Veterinary Emergency Plan Communicable Diseases Control Unit (of the Department of Human Services) Communicable Diseases Network of Australia Central Government Response Committee Chief Health Officer chronic airways disease Chief Medical Officer Chief Quarantine Medical Officer Chief Veterinary Officer Departmental Emergency Coordination Centre Divisional Emergency Response Coordinator Department of Human Services Australian Government Department of Health and Ageing Department of Infrastructure Department of Justice Department of Primary Industries Emergency Coordination Centre (hospital) emergency department equine influenza Emergency Management Australia Emergency Management Manual Victoria General Practice Divisions Victoria general practice/general practitioners

Victorian health management plan for pandemic influenza 123 HCW HPAI HSCC IFDA IPPC MECC MOH NEMRN NHMRC NIC NIPAC NIR NMS NPRs OIE PCR PHEMA PPE RACGP RDNS RERPC SARS SECC SERO SI VHMPPI VIDRL VIFM WHO WHOCC health care worker highly pathogenic avian influenza Health Service Coordination Centre Independent Funeral Directors Association Influenza Pandemic Planning Committee Municipal Emergency Coordination Centre Medical Officer of Health National Emergency Media Response Network National Health and Medical Research Council National Influenza Centre National Influenza Pandemic Action Committee National Incident Room National Medical Stockpile negative pressure rooms International Office for Epizootic Diseases polymerase chain reaction Public Health Emergency Management Arrangements personal protective equipment Royal Australian College of General Practitioners Royal District Nursing Service Regional Emergency Recovery Planning Committee severe acute respiratory syndrome Security and Emergency Committee of Cabinet State Emergency Response Officer swine influenza Victorian health management plan for pandemic influenza Victorian Infectious Diseases Reference Laboratory Victorian Institute of Forensic Medicine World Health Organization World Health Organization Collaborating Centre

124 Victorian health management plan for pandemic influenza Bibliography Anderson, T., Hart, G.K., Kainer, M. and Moon, K., 1999, Influenza pandemic planing for intensive care, Australian and New Zealand Intensive Care Society, ANZICS Research Centre for Critical Care Resources, Melbourne. Australian Government Department of Health and Ageing, 2002, Australian action plan for pandemic influenza, Canberra. Australian Government Department of Industry, Tourism and Resources, 2006, Being prepared for human influenza pandemic A business continuity guide for Australian businesses, and A kit for small businesses, Canberra. Australian Government Department of Health and Ageing, 2006, Australian health management plan for pandemic influenza, Canberra. Centers for Disease Control and Prevention, 2001, Pandemic influenza: A planning guide for state and local officials (Draft 2.1), National Vaccine Program Office, USA. Centers for Disease Control and Prevention, 2004, Fact sheet on isolation and quarantine, USA. Department of Health, 1997, Multiphase contingency plan for pandemic influenza, Department of Health, London. Influenza pandemic preparedness action plan for the United States: 2002 update, Clinical infectious diseases, 35:590 596 Tam, T.W.S., 1999, Preparing for influenza epidemics and pandemics in the new millenium, Canadian journal of public health, 90 (5):293 294. Treanor, J. et al. 2000, Efficacy and safety of the oral neuraminidase inhibitor oseltamivir in treating acute influenza: A randomised controlled trial, The journal of the American Medical Association, 283 (8): 1016 1024. World Health Organization 1999, Influenza pandemic plan. The role of WHO and guidelines for national and regional planning, World Health Organization, Geneva, Switzerland. Zambon, M. and Joseph, C.A., 2001, The PHLS plan for pandemic of influenza, PHLS Respiratory Viruses PHLS Respiratory Viruses Influenza Forum, London. Influenza Pandemic Planning Committee, 1999, A framework for an Australian influenza pandemic plan, Communicable Diseases Network Australian and New Zealand, Commonwealth Department of Health and Aged Care, Canberra. Influenza Pandemic Planning Committee, 2002, Australian action plan for pandemic influenza, Communicable Diseases Network Australia, Department of Health and Ageing, Canberra. Kelly, H. and Catton, M., 1999, Influenza surveillance in Victoria, Victorian Influenza Immunisation Committee, Melbourne. Melzer M.I., Cox, N.J., Fukuda, K., 1999, The economic impact of pandemic influenza in the US: Priorities for intervention, Emerging infectious diseases, 5. Nicholson K.G. et al 2000, Efficacy and Safety of oseltamivir in treatment of acute influenza: a randomised controlled trial, The lancet Vol 355, No 9218: 1845 1850. Schoch-Spana, M., 2000, Implication of pandemic influenza for bioterrorism response, Clinical infectious diseases, 31: 1409 1413. Strikas, R. A., Wallace, G.S. and Myers, M.G., 2002,

Victorian health management plan for pandemic influenza

For more information visit: www.health.vic.gov.au/pandemicinfluenza Working together to protect our communities Authorised by the Victorian Government, 50 Lonsdale Street Melbourne. June 2007.