Table of Contents
- Preface
- Basic Plan
- Purpose
- Objectives
- Scope
- Limitations
- Concept of Operations
- Decision Making Structure
- Planning Assumptions
- Legal Authority
- Pandemic Severity and Timelines & Triggers
- Ethical Framework
- Vulnerable Populations
- Continuity of Operations
- Technical Chapters
- Communications
- Epidemiological Surveillance
- Community Mitigation Interventions (CMIs)
- Infection Control
- Clinical Issues
- Healthcare Planning
- Asset Distribution (Antivirals & PPE)
- Vaccine Distribution
- Laboratory
- Poultry Worker Health
- Care of the Deceased
- Flu Centers
- Regional Coordination
- Appendices
1: Background on Intervals, Triggers, Actions / 26
2: Risk Communication Guidelines / 31
3: CMI Background Information / 31
4: Asset Distribution Background Information / 32
5: Vaccination Background Information / 32
6: Flu Center Plan Template / 36
- Record of Plan Changes
A. Preface
An influenza pandemic will place extraordinary and sustained demands on the public health and medical care systems as well as providers of essential services in LakeCounty.
To prepare for the next pandemic, an event considered by many experts to be inevitable, Lake County in cooperation with various state and local organizations has developed the Lake CountyPandemic Influenza Incident Specific Appendix to the Lake CountyAll-Hazard Response Plan. This plan was developed in cooperation with local hospitals, clinics, emergency medical services (EMS), emergency management (EM), the Minnesota Department of Health (MDH), and other community agencies/partners. This cooperation is to enhance the plan as well as develop robust and comprehensive plans for other kinds of emergencies that may impact Lake County.
Emergency preparation is a continuum and planning efforts will always be evolving. As new information arises and lessons are learned the Lake County Pandemic InfluenzaIncident Specific Appendix will be updated as necessary.
B. Basic Plan
- Purpose
The purpose of the Lake County Pandemic Influenza Incident Specific Annexis to provide a coordinated and comprehensive local response to an influenza pandemic in order to reduce morbidity, mortality, and social disruption and to help ensure a continuation of governmental functions.
- Objectives
The Lake CountyPandemic Influenza Incident Specific Appendixhas five primary objectives:
- Maximize the protection of life and property in Lake County.
- Insure that the response effort be organized under National Incident Management System (NIMS).
- Delineate roles and responsibilities for other local governmental and non-governmental agencies participating in the response.
- Assure that the Lake County Pandemic Influenza Incident Specific Appendix is coordinated and consistent with MDH Pandemic Influenza Plan and the plan of other counties in the state.
- Assure that the Lake County Pandemic Influenza Incident Specific Annex is coordinated with the pandemic influenza response activities identified in the Lake CountyEmergency Operations Plan.
- Scope
The Pandemic Influenza Plan focuses on emergency response that is unique to pandemic influenza and therefore serves as anIncident Specific Appendixto the all-hazard Lake County Emergency Operations Plan.
In Minnesota, Pandemic Influenza Plans consist of three parts:
- The Basic Plan: an overviewof the assumptions, concept of operations, legal authority, ethical framework, and key pandemic influenza functions. The Basic Plan is divided into the Preface and Concept of Operations. It also includes sections on Pandemic Phases and Stages.
- Technical Chapters: information that is unique to health departments’ response to an influenza pandemic, provide response information organized by subject or task, address response actions that are specific to pandemic influenza and are a supplement to the All Hazards Functional Annexes
- Appendices:supplements including pandemic influenza specific resources and background information.
- Limitations
Emergency preparedness is a continuum, since planning efforts evolve as new information becomes available. The Regional Pandemic Influenza Plan will be updated when necessary. (A record of plan changes is located at the end of this document.)
C. Concept of Operations
1. Decision Making Structure
The Lake CountyEmergency Operations Plan and the Lake CountyPandemic Influenza incident specific appendixare both organized under the National Incident Management System (NIMS).Details of command structure are provided in the basic plan section of the Lake County Emergency Operations Plan. At the trigger point when Lake County outpatient clinics are overwhelmed (due to patient load or lack of adequate staff), the Lake County Emergency Operations Center (EOC) will be activated to coordinate and support the implementation of this plan.
2. Planning Assumptions
Pandemic influenza is a unique public health emergency, in thata pandemic will likely have devastating effects on the health and wellbeing of the American public.
Influenza is caused by viruses that infect the respiratory tract. Influenza symptoms include rapid onset of fever, chills, sore throat, runny nose, headache, non-productive cough, and body aches. Influenza is a highly contagious illness and can be spread easily from one person to another. It is spread through contact with small droplets and aerosols from the nose and throat of an infected person during coughing and sneezing.
Influenza viruses are unique in their ability to cause sudden infection in all age groups on a global scale. The importance of influenza viruses as biological threats is due to a number of factors, including a high degree of transmissibility, the presence of a vast reservoir of novel (new) variants, and the unusual properties of the viral genome.
Two types of influenza viruses cause disease in humans: type A and type B. Influenza A viruses are composed of two major antigenic structures essential to vaccines and immunity: hemagglutinin (H) and neuraminidase (N). The structure of these two components defines the virus subtype.
A minor change in the structure caused by a mutation (antigenic drift) results in the emergence of a new strain within a subtype. Mutations (antigenic drifts) can occur in both type A and B influenza viruses. A major change in the structure caused by genetic recombination (antigenic shift) results in the emergence of a novel subtype (i.e., one that has never before occurred in humans or adaptive mutation of an avian virus) most commonly associated with influenza pandemics. This shift only occurs with influenza type A viruses.
Influenza A viruses are unique because they can infect both humans and animals thereby causing more severe illness. Antigenic shifts in influenza A viruses have been the cause of the last three pandemics: 1918, 1957, and 1968.
The well-known “Spanish flu” of 1918 was responsible for more than 20 million deaths worldwide, primarily among young adults. Mortality rates associated with the more recent pandemics of 1957 (A/Asia [H2N2]) and 1968 (A/Hong Kong [H3N2]) were reduced, in part, by antibiotic therapy for secondary bacterial infections and more aggressive supportive care. However, both the 1957 and 1968 pandemics were associated with high rates of morbidity and social disruption.
The Centers for Disease Control and Prevention (CDC) uses data from previous pandemics to provide estimatesof the impact of pandemic flu. The estimates range from a moderate pandemic (based upon 1958 and 1968) to a severe pandemic (based upon 1918) outbreak. CDC models provide the following estimates.
In the United States:
- 90million people will be infected (30% of population)
- 45million people will require outpatient care (50% of ill)
- 1-10 million people will be hospitalized (1-11% of ill)
- Between 200,000 and 2 million people will die (.25-2% of ill)
In Minnesota:
- 1.5million people will be infected
- 700,000 people will require outpatient care
- 15,000 to 150,000 people will be hospitalized
- Between 3,600 and 33,000 people will die
In Lake County (population 11,080)
- 3300 people will be infected
- 1600 people will require outpatient care
- 30 to 350 people will be hospitalized
- Between 8 and 70 people will die
Effective preventive and therapeutic measures – including vaccines and antiviral agents – will likely be in short supply, as may some antibiotics to treat secondary infections. Healthcare workers and other first responders will likely be at even higher risk of exposure and illness than the general population, further impeding the care of ill persons. Widespread illness in the community will also increase the likelihood of sudden and potentially significant shortages of various personnel who provide other essential community services.
Pandemic influenza is considered to be a relatively high probability event - even inevitable - by many experts. Yet no one knows when the next pandemic will occur and there may be very little warning. Most experts believe that we will have one to six months between the identification of a novel influenza virus that results in human-to-human transmission and the time that widespread outbreaks begin to occur in the United States. Outbreaks are expected to occur simultaneously throughout much of the nation and the world thus preventing relocation of human and material resources.
The effect of influenza on individual communities will be relatively prolonged – six to eight weeks – when compared to the minutes-to-days observed in most other natural disasters. Should a pandemic occur, every community would have to rely primarily on its own resources as it combats the pandemic.
The following planning assumptions are generalized for pandemics. Because the Novel H1N1 Virus is currently circulating around the globe in 2009, more specific planning assumptions may be added to this plan as time passes.
- Susceptibility to the pandemic influenza virus will be universal.
- Efficient and sustained person-to-person transmission of a novel influenza virus signals an imminent pandemic.
- The clinical disease attack rate will likely be 30% or higher in the overall population. Illness rates will be highest among school-aged children (about 40%) and decline with age. Among working adults, an average of 20% will become ill during a community outbreak.
- Some persons will become infected but not develop clinically significant symptoms. Minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection.
- Of those who become ill with influenza, 50% will seek outpatient medical care; however, if antiviral drugs are effective, this proportion may be higher in the next pandemic.
- The number of hospitalizations and deaths will depend on the virulence of the pandemic virus. Estimates differ about 10-fold between more and less severe scenarios. Planning should include the more severe scenario.
- Risk groups for severe and fatal infection cannot be predicted with certainty but are likely to include infants, the elderly, pregnant women, and persons with chronic medical conditions.
- Rates of absenteeism will depend on the severity of the pandemic.
- In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members, and fear of infection may reach 40% during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak.
- Certain public health measures (closing schools, quarantining household contacts of infected individuals, “snow days”) are likely to increase rates of absenteeism.
- The typical incubation period (interval between infection and onset of symptoms) for influenza is approximately 2 days.
- Persons who become ill may shed virus and can transmit infection for up to 1 day before the onset of illness. Viral shedding and the risk of transmission will be greatest during the first 2 days of illness. Children usually shed the greatest amount of virus and therefore are likely to post the greatest risk for transmission.
- On average, infected persons will transmit infection to approximately two other people.
- In an affected community, a pandemic outbreak will last about 6 to 8 weeks.
- Multiple waves (periods during which community outbreaks occur across the country) of illness could occur with each wave lasting 2-3 months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty.
- When the influenza pandemic first reaches the state of increased and sustained transmission in the general population, there will be no vaccine against the specific strain of influenza for 4-6 months.
An influenza pandemic can:
- Occur at any time.
- Require significant communications and information sharing across jurisdictions and between the public and private sectors.
- Involve multiple geographic areas.
- Impact critical infrastructures.
- Overwhelm the capabilities of local and tribal governments.
- Require short-notice asset coordination and response timelines.
- Require prolonged, sustained incident management operations and support activities
There are a few additional planning assumptions that are specific to Minnesota regional response planning.Minnesota’s regions plan and prepare for health emergencies regionally under the guidance and direction of the MDH. During any health emergency, the MDH district office response teams will work as liaisons with local public health departments to communicate local needs and state direction.
- Legal Authority
As the lead public health agency in the state, the MDH is responsible for protecting, maintaining, and improving the health of all Minnesotans. There is a strong state-local partnership where the MDH provides leadership and direction to front-line public health and private healthcare entities. Lake County Public Health will take the lead technical role, under the guidance of MDH, in Lake County. Lake CountyEmergency Management will be the lead coordinating agency in a pandemic influenza outbreak, and will work closely with Public Health in preparation and response to the flu.
Chapter 12 of Minnesota Statutes grants the Governor and Homeland Security and Emergency Management (HSEM) overall responsibility of preparing for and responding to emergencies and disasters. Chapter 12 directs the Governor and HSEM to develop and maintain a comprehensive state emergency operations plan, known as the Minnesota Emergency Operations Plan (MOEP).
Furthermore, Minnesota Statutes, including Minnesota Chapter 12 (Minnesota Emergency Management Act) Minnesota Chapter 144 (General Duties of the Commissioner of Health), Minnesota Chapter 145A (Powers and Duties of a Community Health Board) and Chapter 157 outline the authorities of local public health agencies and grant the Commissioner of Health broad authority to protect, maintain, and improve the health of the public. In a pandemic, the Commissioner of Health may delegate responsibility to Lake County Public Health to protect the health of the jurisdiction’s residents and visitors.
- Pandemic Severity and Pandemic Timelines and Triggers
Since 2007, the HHS and Centers for Disease Control and Prevention (CDC) have been using the pandemic Severity Index (PSI) to categorize the response needed to a pandemic flu outbreak.
The CDC (Director) will designate the PSI with five categories of increasing severity based on the estimated case fatality ratio (this ratio reflects the percent of people with disease who have died from the disease). A category five pandemic would be a severe pandemic. This category will be determined early and revised as needed throughout the pandemic. Additionally, other epidemiologic features that may be used to determine pandemic severity (when available) are: total illness rate, age-specific illness and mortality rates, the reproductive number, intergeneration time, and incubation period.
Figure 1: Pandemic Severity Index
Table 3: Pandemic Severity Index
Characteristics / Pandemic Severity Index (PSI)Category 1 / Category 2 / Category 3 / Category 4 / Category 5
Case Fatality Ratio
(percentage) / <0.1 / 0.1 - <0.5 / 0.5 - <1.0 / 1.0 - <2.0 / 2.0
Excess Death Rate
(per 100,000) / <30 / 30 - <150 / 150 - <300 / 300 - <600 / 600
Illness Rate (percentage of population) / 20 - 40 / 20 - 40 / 20 - 40 / 20 - 40 / 20 - 40
Potential Number of Deaths
(based on 2006 U.S. population) / <90,000 / 90,000 - <450,000 / 450,000 - <900,000 / 90,000 - <1.8 million / 1.8 million
20th Century U.S. Experience / Seasonal Influenza
(illness rate 5 – 20%) / 1957, 1968 / None / None / 1918 Pandemic
Intervals, Triggers, and Actions (ITA)
In 2008, the CDC released an interim guidance document on the use of Intervals, Triggers, and Actions in CDC Pandemic Influenza Planning”. The ITA guidance introduces a conceptual framework to guide pandemic influenza preparedness and response activities at the national, state and local level. This framework will facilitate better coordinated and timelier strategies at all levels, while acknowledging the heterogeneity of conditions affecting different U.S. communities during the progression of a pandemic. (For more background on Pandemic planning phases, see Appendix A.)
Minnesota Intervals, Triggers, and Actions
MDH intends to use the interval triggers in Table 4 for pandemic influenza response actions, though available epidemiologic data, (e.g. illness rates, age-specific morbidity and mortality rates, reproductive number, intergeneration time, and incubation period) will inform timing of response actions in an influenza pandemic.
MDH is modifying the CDC interval onset definitions in order to (1) take a slightly more aggressive approach to the timing of community mitigation response actions, and (2) move away from laboratory specimen definitions (proportion of specimens from patients with influenza-like illness who are positive for the pandemic strain) since the volume of laboratory testing in a pandemic will be insufficient to assess pandemic progression and deceleration in the state.
Table 4: Minnesota Trigger Definitions
Interval / Minnesota TriggerInvestigation / Identification of human case of potential novel influenza A infection in the state
OR…Identification of animal case of influenza A subtypes with potential implications for human health within the state
Recognition / Confirmation of human cases of novel influenza A and demonstration of efficient and sustained human to human transmission anywhere in the world (Minnesota is using CDC’s national trigger definition instead of the state trigger definition where “recognition” occurs in the state only if the first recognition that a pandemic has emerged occurs in that state).
Initiation / A laboratory confirmed case of pandemic influenza detected in Minnesota or its contiguous states (North Dakota, South Dakota, Iowa, and Wisconsin) (CDC does not include contiguous states in its trigger definition).
Acceleration / One or two laboratory-confirmed cases in Minnesota that are not epidemiologically linked to any previous case
OR… Number of cases exceed the resources necessary for case/contact-based control measures
OR… A significant exposure has occurred in a setting where a large number of individuals cannot be identified for case/contact-based control measures
OR… There are indications that case/contact-based control measures are not effective (CDC uses the first two criteria as triggers).
Peak / Widespread transmission with a level, but high number of new cases and resources exceeded in most areas of Minnesota (CDC trigger focuses on proportion of laboratory confirmed cases for specimens from patients with ILI, or “regional” activity per current CDC surveillance criteria or health care surge capacity exceeded).
Deceleration / Number of new cases drops from peak level for at least two consecutive weeks
(CDC trigger focuses on proportion of laboratory confirmed cases for specimens from patients with ILI and health care system is below surge capacity).
Resolution / Cases without an identified household exposure are “sporadic” per CDC influenza surveillance criteria. MDH will determine that the state has met the trigger (cases without an identified household exposure are “sporadic”) through case-based reporting which will be re-instituted once the number of new hospitalized cases drops to 10% of cases occurring at the pandemic peak.
(CDC trigger is laboratory confirmed cases are occurring sporadically or the health care system is approaching pre-pandemic levels).
- Ethical Framework
Lake County and MDH accept the ethical framework developed by the Minnesota Pandemic Ethics Project of the Minnesota Center for Health Care Ethics and the University of Minnesota Center for Bioethics. This project’s purpose is to propose ethical frameworks and procedures for ethically rationing scarce health resources, including antiviral medications, N95 respirators, surgical masks, vaccines, and mechanical ventilators, in a severe pandemic. These ethical frameworks are based upon four elements: ethical commitments, principles, goals, and strategies, and may be summarized as follows.