Logistics Command & Control Communication PPE Personnel

SARS – Lessons Learned

SARS – Lessons LearnedLogistics

Stockpile• What if SARS had hit in the USA?• Where do you store it?• How do you rotate stock with a shelf life?

Delivery• Don’t count on “Just in Time”• If you need it at 03:00 on Sunday, who will ship

it to your staff?

Protect your Command and Control Function• Back up three-deep

We need centralized decision making EMS must be at the table Get financial commitments from those who

fund your service

SARS – Lessons LearnedCommand and Control

Common Message, Common Speaker Media

• Who creates the message?• Who approves content?• Politics• Reality vs. public fear

SARS – Lessons LearnedCommunication

Speak to your staff daily! Use technology

• E-mail• Phone (Dialogix)• Have them call in (1-800 numbers)• One on one from management• Postings in stations• Mail• Podcast

SARS – Lessons LearnedCommunication

Be honest, even if it’s unpleasant It’s impossible to give them too much

information Provide “real-time” fact-based information Consider the rumour mill Balance between need to know and

confidentiality

SARS – Lessons LearnedCommunication

Who is the authority?• CDC • Provincial/State MOH• Public Health• WHO• Wikipedia• Bob’s School of Hair Design and Epidemiology

SARS – Lessons LearnedCommunication

Talk to the neighbours• Your staff may live and work there too

Build national links Other agencies may not be as open with

information

SARS – Lessons LearnedCommunication

Allow them to vent Debrief afterwards Be visible, but if you can’t, explain why

SARS – Lessons LearnedCommunication

How much is “enough?”• Surgical mask• N95• PAPR

It isn’t designed for the EMS environment• Temperature extremes• Rain and snow• Stairs• MVC

SARS – Lessons LearnedPPE

Immunizations reduce illness• Are your people up to date?• Influenza kills >36,000 yearly

Workers Compensation vs. ill benefit Plan for loss of staff

• Illness• Quarantine• Family responsibilities• Other employers• Fear-driven

SARS – Lessons LearnedPersonnel

Ensure that people are paid while on quarantine or ill

If staff suffer financial loss, they won’t stay isolated• “I’m not sick. I won’t pass it on.”

EAP is critical

SARS – Lessons LearnedPersonnel

Is your family ready? Are your workers involved in planning? Are your plans similar to your neighbours? Others have good ideas

• Ask them and steal without compunction

SARS – Lessons LearnedPersonnel - Points to Ponder

How will you get around? What will you eat? What if the power goes off? Will your prescription last? What about your elderly relatives? Who is watching the children? What about Fluffy?

SARS – Lessons LearnedPersonnel-Have you Thought About?

Start planning now Pester your politicians Seek community involvement

• Faith groups• Service clubs

Develop a family plan

SARS – Lessons LearnedNext Steps

www.pandemicflu.gov www.fluwikie.com www.promedmail.org www.who.int/csr/don/en www.toronto.ca/health/pandemicflu

SARS – Lessons LearnedResources

gwright4@toronto.ca

Department of Health

Pandemic (H1N1) 2009 (Human Swine Influenza)Pandemic (H1N1) 2009 (Human Swine Influenza)Victorian responseVictorian response

Dr Rosemary LesterAssistant Director, Health Protection,

Communicable Disease Prevention and Control Unit and

Deputy Chief Health OfficerDepartment of Health, Victoria

Decision making for managing a Decision making for managing a pandemicpandemic

• Australian government • National Pandemic

Emergency Committee• CMO expert advisory group• Australian Health Protection

Committee• Communicable Diseases

Network Australia• State and territory

governments

PlansPlans

Commonwealth Government Action Plan for Influenza Pandemic

State and Territory emergency

management plans

State and Territory influenza pandemic

plans (including health plans)

Commonwealth Disaster Response Plan

Other Commonwealth plans

Other State and Territory plans

National Action Plan for Human Influenza Pandemic

Australian Health Management Plan for Pandemic Influenza

· Australian Veterinary Emergency Plan

· National Response Plan for Mass Casualty Incidents Involving Australians Overseas

· National Food Chain Continuity Plan — Pandemic

· Other national plans

Commonwealth State/Territory NationalKey: While local government plays an important role in disaster preparedness, response and recovery, specific regional plans are not included in this diagram.

Framework for managementFramework for management

• Australian Health Management Plan for Pandemic Influenza (AHMPPI)– Alert– Delay – border control– Contain – aggressively contain spread– Sustain – maintain contain efforts if feasible plus broader

measures (modified Sustain)– Control – vaccinate (Protect)– Recover

• Victorian Health Management Plan for Pandemic Influenza– Mirrors AHMPPI

• Whole of government plans

Summary of H1N1 pandemic in Summary of H1N1 pandemic in Australia 2009Australia 2009

• In Australia there were over 37,000 laboratory confirmed cases with 189 deaths as at 6 November 2009

• Victoria had 3069 laboratory confirmed cases, 513 hospitalisations, 118 ICU admissions and 26 deaths

• Victoria saw the earliest community transmission; other states were delayed in community transmission being established by 2-3 weeks behind Victoria

• We believe that the virus was imported into Victoria earlier and spread through community in mild form

• Comprehensive testing strategy in Victoria found this community transmission early

• Activity in all jurisdictions peaked and decreased by late July

Notified cases of all confirmed influenza and pandemic Notified cases of all confirmed influenza and pandemic H1N1 by week, Victoria, 2009H1N1 by week, Victoria, 2009

0

200

400

600

800

1000

1200

7/0

1/2

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14/0

1/2

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21/0

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28/0

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4/0

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11/0

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18/0

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25/0

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4/0

3/2

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11/0

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18/0

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25/0

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1/0

4/2

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8/0

4/2

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15/0

4/2

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22/0

4/2

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29/0

4/2

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6/0

5/2

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13/0

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20/0

5/2

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27/0

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3/0

6/2

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10/0

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17/0

6/2

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24/0

6/2

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1/0

7/2

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8/0

7/2

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15/0

7/2

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22/0

7/2

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29/0

7/2

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5/0

8/2

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12/0

8/2

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19/0

8/2

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26/0

8/2

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2/0

9/2

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9/0

9/2

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16/0

9/2

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23/0

9/2

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30/0

9/2

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7/1

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14/1

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21/1

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28/1

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11/1

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18/1

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25/1

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Influenza - All

Influenza A pandemic H1N1

23 June - Protect phase

3rd June - Modified sustain phase

22 May-Contain phase

20 May - First case of H1N1 notified

28 April - Delay phase

Notified cases of pandemic H1N1 by age group and Notified cases of pandemic H1N1 by age group and sex, delay and contain phases, Victoria, 2009sex, delay and contain phases, Victoria, 2009

0

20

40

60

80

100

120

140

160

180

200

0-4

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4

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9

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40-4

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50-5

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55-5

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65-6

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85+

Age group (years)

Num

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ases

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40

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Male

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Geographic distribution of cases in the Geographic distribution of cases in the DelayDelay and and ContainContain phases phases

Epidemic curve, AustraliaEpidemic curve, Australia

Source: Australian Influenza Surveillance Summary Report, Australian Government Department of Health and Ageing

Delay phaseDelay phase

• Emphasis on delaying disease entry into Australia i.e. border surveillance, quarantine and isolation

• Positive pratique for all incoming international flights, new health declaration cards for incoming travellers

• Active surveillance undertaken at the border for ill passengers on all flights

• Thermal scanners at airports • Border surveillance nurses to support AQIS at the airport • Activated public health emergency operations centre

undertaking testing authorisation, manage isolation of cases and quarantine of contacts, distribution of antiviral treatment and prophylaxis, contact tracing and school management

Delay phaseDelay phase

• Case definition for testing:– ILI within 7 days of travel to Mexico, USA or Canada, or within

7 days of close contact with a confirmed or probable case– All approved tests sent to VIDRL for urgent processing

• Suspected cases couriered Tamiflu (if within 48 hours of onset) and asked to isolate themselves

• information sent out regularly to hospitals, GPs and laboratories

• New website launched (27,000 hits/day at peak)• Regular media releases and press conferences

Contain phaseContain phase

• Once disease in Australia – declared 22 May• Test all suspected cases• Case definition for testing

– As for Delay– Tests on all suspected cases sent to VIDRL for urgent testing

• Tests from community cases positive for influenza A at other laboratories sent to VIDRL for typing

• Treat and isolate laboratory confirmed cases; prophylaxis and quarantine for all close contacts

• By the end of Contain, 978 cases had undergone full contact tracing

• Class or school closure where confirmed cases– by 3/6, 88 schools had undergone full or selective class

closure

Modified Sustain phaseModified Sustain phase

• Once community transmission established; declared 3 June (Victoria only)

• No testing of all suspected cases; concentrate on moderate/severe cases and use sentinel surveillance system to monitor epidemiology

• Use clinical case definition for cases • Treat all cases meeting the clinical case definition with

anti-virals; prophylaxis for close household contacts; isolation of cases for 3 days

• No quarantine for close contacts; no routine school closures

Modified Sustain phaseModified Sustain phase

• Concentrate on vulnerable settings, eg special developmental schools, hospitals, aged care facilities

• Investigation and early intervention with treatment of cases and possible quarantine of vulnerable contacts

• “modified” to emphasise that more severe measures such as continued quarantine of contacts, school closures and cancellation of mass gatherings would not be undertaken

Protect PhaseProtect Phase• On 23 June, Victoria implemented the PROTECT phase:• Reduce transmission by emphasising personal hygiene

measures; do not attend work/school if sick• Identifying the vulnerable, in whom H1N1 Influenza 09 may

have severe outcomes – Chronic medical conditions– Morbid obesity– Pregnant women– Indigenous people

• Close clinical assessment of those identified as vulnerable and early commencement of antiviral treatment

• Encourage voluntary home isolation of cases • No treatment for mild cases• No quarantine for contacts unless vulnerable setting• Investigation and management of cases in “closed” facilities or

high risk settings, eg special developmental schools, health care facilities

Why move to ‘Protect’Why move to ‘Protect’

• The new phase recognises that the infection with pandemic H1N1 2009 is not as severe as originally envisaged when the AHMPPI was written

• “Disease is mild in most cases, severe in some and moderate overall.”

• PROTECT sits alongside CONTAIN and SUSTAIN phases with a greater focus on the vulnerable or people in whom the disease may be severe

• PROTECT is a measured, reasonable and proportionate health response to the risk that the virus poses to the Australian community

Other Victorian Actions Other Victorian Actions

• Flu diversion clinics opened at several sites in the metropolitan area to reduce pressure on emergency departments

• Distribution of antivirals via designated community pharmacies negotiated through Pharmacy Guild

• Gazetting of – Division 1 Registered Nurses as prescribers for treatment and

prophylaxis– Pharmacists as prescribers for prophylaxis of household

contacts on written advice from GP’s

• Communications– Regular communications to stakeholders – GPs, ID

physicians, hospitals, public (call centre and website)

Other Victorian Actions Other Victorian Actions

• Utilised public health reference laboratory (Victorian Infectious Diseases Reference Laboratory)

• Utilised existing state stockpile of antivirals and personal protective equipment (PPE), further review and purchase of additional antiviral medication

• Accessed the National Medical Stockpile for supplemental antiviral stock and PPE

• Regular briefing of senior ministers and whole of government

• Continued regular press briefings – minister and Acting Chief Health Officer

• Notification management via call centre

Vaccination programVaccination program

• H1N1 vaccination program commenced 30 September• Whole population encouraged to be vaccinated; special

emphasis on those at risk of severe outcomes, eg pregnant women, obese persons, those with chronic medical conditions

• Challenges – multi dose vials, perceptions of a mild disease

• 1.7 million doses distributed in Victoria to end February 2010

Snap shot figuresSnap shot figuresTotal cases 2009: = 3089

Hospitalised: = 513

ICU: = 118

Deaths: = 26

Total confirmed cases contacted: > 1,000

Total contacts of cases indentified: > 5,800

Total schools affected: = 112 schools impacted with 88 undergoing full or selective class closure

Total courses of Tamiflu distributed: > 20,000 by DH> 26,000 by Community Pharmacies

Flu reference lab tests : > 17,000

Calls taken in call centre for the period 1 May to 23 June:

> 26,000

Website: > 27,000 hits/day at peak

Total DH personnel involved throughout response:

> 200

Lessons learntLessons learnt

• The importance of written plans!• The importance of clear arrangements for laboratory

testing, contact tracing and anti-viral provision• The need for communication to be clear and consistent

while events are changing rapidly• Further clarify roles and responsibilities of committees

involved and the communication channels• Clarify expectations on use of national stockpile and

pathways of patients in primary care• Ensure jurisdictional flexibility to account for differing

epidemiology in different geographic locations• Ensure right balance struck between use of public health

reference laboratory, and when to move out to routine laboratories to avoid overload

AcknowledgementsAcknowledgements

• Rodney Moran, Julian Meagher, James Fielding, Joy Gregory, Kleete Simpson, Lynne Brown, Jan Bowman, Noel Cleaves, Rodney Dedman, Vikki Sinnott, Jo Donelly, Michael Ackland, Bram Alexander and all the staff of CDPCU

• Mike Catton, Heath Kelly and all the staff of VIDRL• All the public health medical officers who assisted in the

Emergency Operations Centre• All the staff who worked in the Emergency Operations

Centre on contact tracing and call management