Pandemic Influenza and Highly Infectious Respiratory Disease Response Plan for Boone County Missouri

 
Pandemic Influenza and
     Highly Infectious
    Respiratory Disease
      Response Plan
for Boone County Missouri

                   Prepared by:
      Columbia/Boone County Health Department

                 November 28, 2006
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
Plan

TABLE OF CONTENTS
Acronym Reference…………………………………………………………………………3
Executive Summary ................................................................................................... 4
Purpose and Goals ................................................................................................... 5
Organization and Scope..............................................................................................5
Situation and Assumptions…………………………………………………………………6
Impact Estimate of Pandemic .................................................................................... 9
Coordinated Responsibilities ................................................................................... 10
Command and Control…………………………………………………………………… 15
Avian Influenza…………………………………………………………………………….18
Surveillance and Epidemiological Investigation ....................................................... 19
Community Based Containment Measures............................................................. 24
Vaccine and Antiviral Management: Inventory and Storage ................................... 33
Vaccine Management: Distribution and Administration.......................................... 33
Communication …………………………………………………………………….……...40
Healthcare Systems……………………………………………………………………….42
Mortuary Services and Mass Fatality Management ………………….……………….45
Workforce Management and Support………………………………….………………..46
Maintenance of Essential Services ......................................................................... 48
Attachment List
      1:ICS Org Chart……………………………………………………………………………1
      2: Contact Information…………………………………………………………..………...2
      3: Avian Influenza Call Decision Tree……………………………………………..…….4
      4: Issues That Will Require Real-time Guidance During a Pandemic………..………7
      5: Interim CDC Recommendations………………………………………….…..………..8
      6: DHSS Health Update: 6.20.06 Avian Flu Testing Guidance……………..…………9
      7: CDC Human Influenza A(H5) Case Screening and Report Form………..………..13
      8: Surveillance Forms…………………………………………………………..……..…..19
      9: Investigation…………………………………………………………………………......21
      10: Public Information Messages………………………………………..…………...….22
      11: Household Flu Preparedness Checklist………………..…………………………..23
      12: Home Isolation Checklist………………………………………………………….….24
      13: Rehydration Fluids……………………………………………………………….…….26
      14: Possible Protective Measures……………………………………..…………..……..29
      15: Community Containment Legal Authority………………………….……….……….29
      16: Continuity of Operations Issues…………………………………………….………..35
      17: Mental Health Handout Materials……………………………………………………37

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
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ACRONYM REFERENCE
ACIP – Advisory Committee on Immunization Practices
CBCHD – Columbia/Boone County Health Department
CDC – Centers for Disease Control and Prevention
DHSS – Missouri Department of Health and Senior Services
EMS – Emergency Medical Systems
EOC – Emergency Operations Center
EOP – Emergency Operations Plan
HAN – Health Alert Network
HEICS – Hospital Emergency Incident Command System
HHS – United States Department of Health and Human Services
ICS – Incident Command Structure/System
ILI – Influenza-Like Illness
JIC – Joint Information Center
LPHA – Local Public Health Agency
MDA – Missouri Department of Agriculture
MDC-Missouri Department of Conservation
MICA – Missouri Information for Community Assessments
MOU – Memorandum of Understanding
MSPHL –Missouri State Public Health Laboratory
NIMS – National Incident Management System
NVAC – National Vaccine Advisory Committee
PIO – Public Information Officer
POD – Point of Dispensing
SARS – Severe Acute Respiratory Syndrome
SNS – Strategic National Stockpile
PHERP – Public Health Emergency Response Plan
PPE – Personal Protective Equipment
USDA/APHIS/VS- United States Department of Agriculture/Animal and Plant Health
    Inspection Service/Veterinary Services
USDA/APHIS/WS- United States Department of Agriculture/Animal and Plant Health
    Inspection Service/Wildlife Services
VAERS – Vaccine Adverse Event Reporting System
VIS – Vaccine Information Sheet
WHO – World Health Organization

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
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EXECUTIVE SUMMARY

Influenza causes seasonal epidemics of disease resulting in an average of 36,000
deaths each year. An influenza pandemic – or global epidemic – occurs when there
is a major change in the influenza virus so that most or all of the world’s population
has never been exposed or immunized previously and is, thus, vulnerable to the
virus. Three pandemics occurred during the 20th century, the most severe of which,
in 1918, caused over 500,000 U.S. deaths and more than 20 million deaths
worldwide. Influenza pandemics have a greater potential to cause rapid increases in
death and illness than virtually any other naturally occurring infectious disease.

Throughout this document, the term Pandemic Influenza will be used to differentiate
between seasonal influenza and a pandemic of influenza. This Pandemic Influenza
and Highly Infectious Respiratory Disease Response Plan describes a coordinated
strategy by the Columbia/Boone County Health Department (CBCHD) and its
community partners to prepare for and respond to an influenza pandemic or similar
highly infectious respiratory disease. It is based on the framework recommended by
the World Health Organization for national pandemic plans and the United States
Department of Health and Human Service’s Pandemic Influenza Plan. The response
outlined is divided into phases, starting with work to be done before a pandemic
happens, followed by an escalating step-by-step response as a pandemic evolves.

There are two main components in the response plan:

   1. Pre-Vaccine/Community Based Containment: A vaccine that is protective
      against a new pandemic influenza strain can only be produced once that
      strain is known. This means that the vaccine manufacturing and testing
      process may require as long as 6-8 months before vaccine becomes widely
      available.

       The following three strategies addressed in the plan will slow the spread of
       influenza prior to the vaccine’s arrival:
           a. Public Information and Education on respiratory etiquette and hand
              hygiene, as well as the use of masks.
           b. Disease control measures such as isolation of cases, effective
              quarantine of contacts, limits on non-essential travel, cancellation of
              school and mass gatherings.
           c. Antiviral drugs if and when they are available.

   2. Vaccine Management: A tiered approach to immunization is planned,
      immunizing portions of the population in stages as vaccine supplies become
      available. The need to keep health and other essential services running will
      require that vaccine distribution be prioritized. Health care workers and other
      essential service workers may need to take precedence over some of the risk
      groups traditionally immunized during normal flu season years. Vaccine
      Inventory, Storage, Distribution and Administration are covered in the Public
      Health Emergency Response Plan.

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
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PURPOSE AND GOALS OF THE PLAN
This pandemic response plan aims to develop a coordinated countywide strategy
through shared responsibility. It has three main purposes:
    1. Serve as a planning guide for the CBCHD and other government departments
       to prepare for and respond to a pandemic.
    2. Provide guidance and tools to the many partners in the community who will
       be involved in preparing for and responding to a pandemic.
    3. Guide activities to educate and prepare the general public regarding this
       public health threat.

Ultimately, when the plan is implemented, the intention is to minimize the impact of
the pandemic in Boone County and to protect the public’s health by achieving these
goals:
       1. Limit the number of illnesses and deaths.
       2. Preserve continuity of essential government functions.
       3. Minimize social disruption.
       4. Minimize economic losses.

Any CBCHD response will follow the Centers for Disease Control and Prevention
(CDC), the United States Department of Health and Human Services (HHS) and
Missouri Department of Health and Senior Services (DHSS) guidance for pandemic
influenza response.

ORGANIZATION AND SCOPE

Scope of the Plan and its Relationship to Other Plans

The Response Plan should be read and understood prior to a pandemic situation. It
is a dynamic document that will be updated to reflect new developments in the
understanding of the disease agent, its spread, treatment and prevention. The plan
will also incorporate changes in response roles and improvements in response
capability developed through ongoing planning efforts.

Columbia/Boone County Emergency Management Agency is responsible for the
Columbia/Boone County Emergency Operations Plan (EOP), an all-hazards
disaster plan for Columbia and Boone County. Within this plan, the CBCHD is
responsible for the Health and Medical Annex, Annex M, which outlines the Health
and Medical response. The Pandemic Influenza and Highly Infectious Respiratory
Disease Response Plan presented here will be integrated as Appendix to the                        Comment [c1]: Will this be an
                                                                                                  Appendix to Annex M or an Annex to our
Columbia/Boone County Public Health Emergency Response Plan and work                              PHERP
concurrently with other Annexes in an all-hazards approach. As such, the elements
of this Plan are based on the existing emergency response capabilities, overall
Incident Command System (ICS), the National Incident Management System
(NIMS), legal authorities and basic responsibilities identified in the Columbia/Boone
County Basic Plan and Annex M.

In addition to the County Emergency Operations Plan, the Columbia/Boone County
Health Department maintains a Public Health Emergency Response Plan
(PHERP) with operational guidelines on the public health response to a public health

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
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emergency. This Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan will reference both the County EOP and the PHERP. The Director of
the Columbia/Boone County Health Department has the authority to declare a public
health emergency and is responsible for the activation of this plan.

SITUATIONS AND ASSUMPTIONS

Situation

Influenza is a highly contagious viral disease. Epidemics of influenza affecting
hundreds of thousands of people occur nearly every year. The ability for influenza
viruses to make slight structural changes over time is known as “antigenic drift”.
This results in the annual appearance of different strains that circulate among the
human population. Vaccines are developed to match the strains expected to
circulate each year.

In contrast to the gradual “antigenic drift” process, the influenza virus can also
change structure suddenly and dramatically. This process occurs infrequently and is
known as “antigenic shift”. “Antigenic shift” results in a new or “novel” influenza virus
that is so different from ordinary strains that very few people, if any, are immune.
The potential for a pandemic exists if the new virus has the ability to spread easily
from person to person and can cause serious illness.            It is important to note,
however, that the influenza virus does not need to be novel to cause large-scale
epidemics.

The World Health Organization (WHO) has defined phases of a pandemic to assist
with planning and response activities. For purposes of consistency, comparability
and coordination of national, state and local responses, identification and declaration
of the following phases will be done at the national level:

PANDEMIC PHASES                                     PUBLIC HEALTH GOALS
                                INTER-PANDEMIC PERIOD
Phase 1. No new influenza virus subtypes have
been detected in humans. An influenza virus Strengthen pandemic preparedness at
subtype that has caused human infection may all levels.
be present in animals. If present in animals, the
risk of human infection or disease is considered
to be low.

Phase 2. No new influenza virus subtypes have
been detected in humans.            However, a Minimize the risk of transmission to
circulating animal influenza virus subtype poses humans; detect and report such
a substantial risk of human disease              transmission rapidly if it occurs.

                                PANDEMIC ALERT PERIOD

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
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Phase 3.      Human infection(s) with a new Ensure rapid characterization of the new
subtype but no human-to-human spread or at virus subtype and early detection,
most rare instances of spread to a close contact notification and response to additional
                                                 cases.
Phase 4. Small cluster(s) with limited human-to- Contain the new virus within limited foci
human transmission but spread is highly or delay spread to gain time to
localized, suggesting that the virus is not well implement preparedness measures,
adapted to humans.                               including vaccine development.

Phase 5. Larger cluster(s) but human-to-human Maximize efforts to contain or delay
spread still localized, suggesting that the virus is spread to possible avert a pandemic,
becoming increasingly better adapted to humans and to gain time to implement response
but may not yet be fully transmissible measures.
(substantial pandemic risk).
                                     PANDEMIC PERIOD
Phase 6. Pandemic phase: increased and
sustained transmission in the general population Minimize the impacts of the pandemic.

Columbia/Boone County response will follow the WHO Operational Time Frames.
As Operational Time Frames escalate, the Director of CBCHD will activate an
Incident Command System (ICS) to coordinate all response activities. CBCHD will
operate under ICS throughout the event and collaborate with other similar structures
at the local, state, and federal levels. The Emergency Operations Center may or
may not be activated, depending on the severity of the event.

Assumptions

Due to the uncertainty about the timing, trajectory and ultimate impact of a pandemic
influenza in Boone County, the following assumptions underlie the contents of this
preparedness and response plan. These assumptions include potential scenarios
and impacts in the context of Boone County:

   1. An influenza pandemic will result in the rapid spread of infection with
      outbreaks throughout the world. Communities across the state and the
      country may be impacted simultaneously. Boone County will not be able to
      rely on timely or effective mutual aid resources, State or Federal assistance to
      support local response efforts.
   2. An influenza pandemic may occur in waves of 6 to 8 weeks and last for 12 to
      24 months.
   3. Residents may be requested to stay in their homes for a significant period
      during an influenza pandemic; thus, residents will need public information,
      education and tools so they are prepared to take responsibility for basic
      needs (food, water, prescription medications, over-the-counter medications,
      etc.). Antiviral medications will be in extremely short supply. Administration of
      local supplies of antiviral medications will be prioritized by the
      Columbia/Boone County Health Department.
   4. A vaccine for the pandemic influenza strain will likely not be available for 6 to
      8 months following the emergence of a novel virus.

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
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   5. The number of ill people requiring outpatient medical care and hospitalization
       will overwhelm the local health care system. The normal amount and level of
       hospital care may not be available.
   6. Hospitals and clinics will have to modify their operational structure to respond
       to high patient volumes and maintain functionality of critical systems.
   7. The health care system will have to respond to increased demands for
       service while the medical workforce experiences 25-35% absenteeism due to
       illness or caring for ill family members. Demand for inpatient beds and
       assisted ventilators could increase by ten-fold or more and patients will need
       to be prioritized for services.
   8. There will be tremendous demand for urgent care services.
   9. Infection control measures specific to management of influenza patients will
       need to be developed and implemented at health care facilities, out-patient
       care settings and long term care facilities.
   10. The health system will need to develop alternative care sites to relieve
       demand at hospitals.
   11. Emergency Medical Service responders will face extremely high call volumes,
       and may face 25% - 35% reduction in available staff.
   12. The number of fatalities will overwhelm the resources of the Medical
       Examiner’s Office, morgues and funeral homes.
   13. The demand for home care and social services will increase dramatically.
   14. There will likely be significant disruption of public and privately owned critical
       infrastructure including transportation, commerce, utilities, public safety and
       communications.
   15. Strategies aimed at reducing the spread of infection such as closing schools,
       community centers, and other public gathering points and canceling public
       events will likely be implemented during a pandemic.
   16. Risk Communication will be critically important during all phases of planning
       and implementation of a Pandemic Influenza Response. The general public,
       health care system, response agencies, and elected leaders will need
       continuous updates on the status of the pandemic outbreak, impacts on
       critical services, the steps being taken to address the incident, and steps the
       public can take to protect themselves.

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease Response
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IMPACT ESTIMATE OF A PANDEMIC ON BOONE COUNTY

Potential Impact of a 1918-like “major pandemic” Pandemic – U. S. and
Boone County
                   Population      Clinically    Outpatient     Hospitalized   Deaths
                                   Ill           Care           (11% of ill)   (2.1%)
                                   (30%)         (50% of ill)
U.S.               297.7 million   90 million    45 million     9.9 million    1.9 million

Missouri           6 million       1.8 million   900,000        198,000        37,980
Boone County       141,367         42,410        21,205         4,665          895
Boone Co. +        169,067         50,720        25,360         5,579          1,070
college students

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
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Boone Co. +        661,107       198,332         99,166          21,817               4,185
college students
+ regional draw
to healthcare
service1

*
FluSurge Estimates of a mild pandemic (similar to 1957 and 1968 pandemics)

Population                         Hospitalized (15-35%)                  Deaths (15-35%)
Boone County                       358-835                                87-203
Boone Co. + college                425-992                                103-241
students
Boone Co. + college                1833-4278                              458-1068
students + regional
draw to healthcare
service1
1
  Estimation of regional draw from Boone Hospital Center discharge data to include a 25 county area
around Boone County.
*FluSurge is a Center for Disease Control computer program for estimating pandemic flu impacts on a
community. The program utilizes projections based on the 1957 and 1968 pandemics.

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
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COORDINATED RESPONSIBILITIES FOR PREPAREDNESS AND
RESPONSE
The Columbia/Boone County Health Department is the lead agency involved in planning
and preparing for pandemic influenza and responding to the pandemic when it occurs as
it relates largely to medical/health issues. Implementation of this plan will enable the
Public Health Department to fulfill its significant roles and responsibilities for a
coordinated strategy aimed at protecting the public’s health and minimizing the impact of
the pandemic influenza in Boone County.

Businesses
Local businesses, in order to protect their businesses’ viability, employees, clients and
customers during a pandemic, should plan for continuity of operations in the event that
infrastructure and other services are disrupted. Disruption of services and supplies may
be due to high absenteeism among their own employees and customers and/or
absenteeism in outside partners, services or other organizations. Business plans should
address how to continue to function due to a lack of utilities, supplies, deliveries and
staff. Two important aspects, where applicable, will be to address providing essential
products to the public (e.g., food, water and pharmacy merchandise) and planning for
the potential suspension of business services that involve public assembly (e.g.,
entertainment venues, hotels, restaurants, etc.). Local businesses will play a key role in
protecting the health and safety of their employees and customers by instituting
protocols to limit the spread of disease in the workplace (i.e., “no work while sick” and
infection control practices, such as covering coughs and washing hands). Local
businesses may be asked to provide resources for the pandemic influenza response
(i.e., vacant space for alternate care centers, critical supply provision, etc.).

Centers for Disease Control and Prevention (CDC)
The CDC is responsible for national and international disease surveillance,
communicating direction and information from the Federal government to the State and
local public health agencies, investigating pandemic outbreaks, and overall monitoring
the impact of a pandemic. The CDC acts as the national liaison to the World Health
Organization (WHO).

Chamber of Commerce: Facilitate the delivery of education to local businesses.

City and County Government
City and county governments should have continuity of operations plans that consider
the likelihood of an influenza pandemic; take steps to limit the spread of influenza within
their jurisdictions (i.e., “no work while sick” and personal hygiene practices); and
cooperate with CBCHD to provide resources for the pandemic influenza response (e.g.,
vacant space for alternate care centers, critical services provision, etc.). In addition, City
and County government will be involved in monitoring the state of the pandemic and
supporting the CBCHD Director in establishing necessary disease containment
measures. City and County government also plays a leadership role in the pandemic
influenza response as part of its Office of Emergency Management, which will provide
and coordinate logistical support (in coordination with cities). City and county
governments have a direct role in providing fire services and law enforcement in
response to an influenza pandemic. Finally, all City and County employees may be
called upon to serve as Disaster Service Workers during the pandemic.

City and County Legal/Court System
City of Columbia and Boone County Counselors are responsible for assisting the Public
Health Director to develop and refine Public Health orders for disease containment. The
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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
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Court System ensures that citizens are afforded their due process as they are asked to
comply with such orders. City and County Counsel will assist in reviewing and resolving
any legal issues that arise related to workplace, occupational health, labor relations and
overall medical response activities.

Colleges and Universities
Colleges and universities will need to incorporate some of the responsibilities of
businesses, schools, and city government. Depending on their size, they may need to
secure space for alternate care centers and/or mass prophylaxis sites, address how to
provide services to students isolated in dormitories, and make academic plans should
the university/college need to be closed for several months. Colleges and universities
should have continuity of business plans that consider the likelihood of a influenza
pandemic; take steps to limit the spread of influenza within their institution (i.e., “no work
while sick” and “no school while sick” policies and personal hygiene practices); and
cooperate with CBCHD to provide resources for the pandemic influenza response (e.g.,
vacant space for alternate care centers, critical supply provision, etc.).

Columbia/Boone County Emergency Management Agency
The Columbia/Boone County Emergency Management Agency will have the following
responsibilities, consistent with the Emergency Operations Plan.
   1. Coordinate all other areas of resource requests.
   2. Coordinate the formation of a Joint Information Center, as needed.
   3. Coordinate activation of the Emergency Operations Center, as needed.
   4. Coordinate the formation and staffing of a Volunteer Reception Center, as
      needed.
   5. Coordinate meeting the essential needs of residents who are asked to shelter in
      place.
   6. Monitor and report on the state of readiness of critical partners (e.g., cities,
      schools, businesses, as well as local, state and federal governments).

Columbia/Boone County Health Department (CBCHD)
The CBCHD has a lead role in mobilizing partners in the county to prepare for and
respond to pandemic influenza. To this end, the CBCHD will:
   1. Facilitate countywide pandemic planning and preparedness efforts.
   2. Coordinate the community’s emergency public health response.
   3. Educate the public and health care, response partners, businesses, community-
       based organizations and elected leaders about influenza and preventive
       measures.
   4. Conduct county-wide surveillance to track the spread of the disease and its
       impact on the community.
   5. Propose a declaration of Public Health Emergency when appropriate.
   6. Implement disease containment strategies.
   7. Facilitate the health care system’s planning and response efforts for medical
       surge capacity including mass casualty and mass fatality incidents.
   8. Coordinate mass vaccination and antiviral dispensing.
   9. Provide effective communications to the public, the media, elected officials,
       health care providers, law enforcement, first responders, and business and
       community leaders throughout public health emergencies.
   10. Monitor and report on the state of readiness of critical partners (e.g., cities,
       schools, businesses, healthcare, as well as local, state and federal
       governments).

Community-based and Faith-based Organizations

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
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Community-based and faith-based organizations will be responsible for their own
continuity of operations planning in the event of an influenza pandemic. Additionally,
these organizations play a key role in providing support services to individuals,
neighborhoods and their customer/client base during a pandemic and may be called
upon for assistance within their communities as appropriate.

Emergency Medical Systems (EMS)/Pre-Hospital Responders
EMS will be responsible for prioritizing and providing patient transport, planning for surge
capacity needs due to increased demand for service combined with increased employee
absenteeism, and preparing responders for effective infection control. EMS will need to
plan for and train personnel in personal protective equipment and other disease and
infection control measures.

Environmental Health
Environmental Health will support the delivery of messages regarding infection control,
especially in food establishments. Environmental Health will assist in the planning for
disposal of infectious waste. Environmental Health/Animal Control will also be the
coordinator for local animal disaster issues, to include the presence of Avian Influenza in
the bird population in Boone County.

Fire Services
As critical first responders, City and County Fire Departments will need to plan for
increases in employee absenteeism due to the pandemic influenza and an increase in
demand for services. Fire Services will need to plan for and train personnel in personal
protective equipment and other disease and infection control measures. Fire Services
should have continuity of business plans that consider the likelihood of an influenza
pandemic; take steps to limit the spread of influenza within their jurisdictions (i.e., “no
work while sick” and personal hygiene practices); and cooperate with CBCHD to provide
resources for the pandemic influenza response.

Individual Citizens
Individuals and families, in order to protect themselves and limit the spread of the
disease, will need to take responsibility for staying informed about the risk for pandemic
influenza and take appropriate common-sense actions such as practicing good hygiene
and preparing their own pandemic influenza emergency kits. Individuals and families
should also become familiar with isolation, quarantine and social distance measures
they may be required to take during a pandemic. Households will need to make
contingency plans for scenarios such as closure of daycare and school facilities.

Law Enforcement
The main responsibilities of law enforcement will be to provide security and assist in the
enforcement of Public Health Orders as necessary. Security issues will be likely at
hospitals, alternate care centers, closures of venues, etc. Law Enforcement will need to
plan for and train personnel in personal protective equipment and other disease and
infection control measures. Law enforcement should have continuity of operations plans
that consider the likelihood of an influenza pandemic; take steps to limit the spread of
influenza within their workplace (i.e., “no work while sick” and personal hygiene
practices); and cooperate with CBCHD to provide resources for the pandemic influenza
response.

Local Healthcare System Partners (Hospitals, Clinics, Providers)

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
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Healthcare partners will be instrumental in detecting influenza, limiting the spread of
disease, and providing treatment to affected individuals. To this end, local healthcare
system partners should:
           1. Develop a pandemic influenza plan that details surge capacity addressing
               staffing, bed capacity and stockpiling of food, water, fuel, and patient care
               equipment and supplies.
           2. In the event of a pandemic, conduct enhanced surveillance among
               patients, staff and visitors.
           3. Comply with public health requests for detecting, preventing and reporting
               cases of pandemic influenza.
           4. Implement appropriate infection control measures.
           5. Develop and provide education and training to healthcare staff on
               recommendations for pandemic influenza.
           6. Comply with admission and triage guidelines provided by the CDC or
               CBCHD.
           7. Comply with Occupational Health Guidelines provided by CBCHD for
               healthcare staff.
           8. Cooperate with CBCHD by providing estimates of quantities of vaccine for
               healthcare staff and patients and develop a vaccination plan for own
               facility.
           9. Plan for additional site security for own facility.
           10. Develop plan for Care of the Deceased and cooperate in fatality
               management with guidance from the County Medical Examiner.
           11. Participate in a Pandemic Influenza Health Care Sub-committee
               established by the CBCHD to maximize the health care system’s ability to
               provide medical care during a pandemic. Specific responsibilities of the
               Health Care Sub-committee include:
                   a. Identify and prioritize response issues affecting the county-wide
                         health system during a pandemic.
                   b. Develop mechanisms to efficiently share information and
                         resources between health system partners.
                   c. Identify and communicate policy level recommendations regarding
                         the operations of the local health system to the Public Health
                         Director for action.

Local Veterinarians: Local veterinarians participate with the Missouri Department of
Agriculture by conducting routine surveillance for disease in animals.                         Comment [WIC2]: Leave in or take
                                                                                               out. Most are covered in a vague way in
                                                                                               the general sections.
Medical Examiner
The Medical Examiner will be responsible for planning for the disposition of an increased
number of deceased persons, consistent with the Mass Fatality Plan.

Mental Health
Mental health professionals have a key role in planning for psychosocial services for
responders and the community at-large. During a pandemic, mental health professionals
will likely experience high levels of service demand, coupled with high employee
absenteeism. The Mental Health Sub-committee will develop and implement a plan to
address the psychosocial needs of health care workers, Disaster Service Workers,
Columbia and Boone County employees, and the community at large. This will require
planning for maintaining essential workers and increasing staffing capacity as
necessary.

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Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
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Missouri Department of Conservation: The Department of Conservation participates
in the state surveillance plan for wild birds that could be infected with the Avian Influenza
virus (H5N1).

Missouri Department of Health and Senior Services (DHSS)
The DHSS coordinates planning and preparedness efforts, surveillance activities, and
disease containment strategies at the state level and across multiple counties and
regions within the state. Additionally, the DHSS is responsible for operating a bio-safety
level 3 laboratory, coordinating the receipt and distribution of pandemic information,
distributing antiviral medicines and vaccines from the Strategic National Stockpile to
local health departments, and informing the public on the course of the pandemic and
preventive measures.

News Media
The news media have a primary role in providing public education during the alert
period, as well as timely and accurate public information throughout the pandemic
period. News media organizations will need to consider planning for their continued
operations during a pandemic, addressing the issue of high absenteeism at all levels of
their organization. With guidance from the CBCHD, news media organizations may want
to provide personal protective equipment to reporters, camera operators and any other
personnel expected to work in a public and potentially contagious setting.

Red Cross: Local Red Cross volunteers can provide mental health and nurse
volunteers, logistical support, pre-event education on business continuity planning, and
event education on home care.

Schools (Including Preschools, Child Care Centers, Family Day Care Providers)
All school districts will need to take steps to limit the spread of influenza within the
school (i.e., “no work while sick” for employees, “no school while sick” for students, and
personal hygiene practices). Schools should have contingency options if schools are
closed as part of a social distancing strategy (e.g., home schooling lesson plans for
parents; catch-up school calendars, etc.). Schools may need to be closed for as long as
several months.

UM Extension: The UM Extension Office will assist with the dissemination of
coordinated public information messages.

U.S. Department of Health and Human Services (HHS)
The responsibility of HHS is to provide overall guidance on pandemic influenza planning
within the United States and coordinate the national response to an influenza pandemic.

World Health Organization (WHO)
WHO is responsible for monitoring global pandemic conditions and providing information
updates. WHO facilitates enhanced global pandemic preparedness, surveillance,
vaccine development and health response. WHO is the organization responsible for
declaring a global pandemic phase and adjusting phases based on current outbreak
conditions.

                                                                                          15
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan

COMMAND AND CONTROL

Refer to the PHERP, Command and Control Chapter, for details on command
and control to include response structure, job action sheets, procedures, and
forms.

Operational Time Frames
A. Inter-pandemic Period (Phases 1 and 2)

   1. Columbia/Boone County Health Department (CBCHD) will take the lead in               Comment [WIC3]: Specific titles or
                                                                                          just CBCHD?
       planning the public health response to influenza for Columbia/Boone
       County and will involve key stakeholders in the planning process.
   2. The Regional Epidemiologist within CBCHD will coordinate surveillance
       and epidemiological investigation activities, including implementing
       ongoing influenza surveillance, planning for epidemiological investigation
       and coordinating specimen testing with the Missouri State Public Health
       Laboratory (MSPHL).
   3. The CBCHD will define and quantify local priority population groups to
       receive vaccine or antiviral medications in case of a vaccine shortage.
   4. The CBCHD will coordinate planning for the procurement of vaccines,
       antivirals and supplies.
   5. The CBCHD will coordinate planning for the distribution of vaccines,
       antivirals and supplies.
   6. The CBCHD will coordinate activities related to planning for the public
       health response to an identification of avian influenza in the animal
       population.
   7. The CBCHD Regional Public Information Officer (PIO), in coordination
       with the DHSS PIO, will coordinate communications activities for a public
       health response.
   8. The CBCHD Regional Response Planner will review and update the
       Response Plan on an annual basis.
   9. The CBCHD will coordinate emergency response planning with DHSS and
       other area jurisdictions.
   10. The Public Information Officer, in coordination with the Columbia/Boone
       County Emergency Management Director, will provide information to
       businesses on methodology outlined by CDC and HHS to decrease the
       spread of infection during pandemic influenza and maintain essential
       services.

B. Pandemic Alert Period (Phases 3 through 5)

   If the novel virus appears first elsewhere:
   1. The Director of the CBCHD will ensure ongoing communication with local
        and state counterparts.
   2. The Planning Section will monitor the HAN, the EMSystem, surveillance
        data, and other channels of information and will provide ongoing
        assessments of the situation to the Director of the CBCHD and other
        relevant CBCHD personnel.

                                                                                     16
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan

   3. The Disease Prevention and Control Branch will increase local
      surveillance activities to detect the presence of the novel virus in Boone
      County.
   4. The Director will alert the health community through all available means
      such as HAN, EMSystem, and infection control professionals. Area
      hospitals and health care providers will be advised to inquire about recent
      travel to affected areas by patients presenting with severe respiratory
      illness and to consider implementing infection control measures.                    Comment [WIC4]: What is that?
   5. The CBCHD Logistics Section, in coordination with Columbia/Boone                    Comment [WIC5]: Logistics or
                                                                                          CMRCB?
      County Emergency Operations Center (EOC), will confirm the availability
      of local medical resources to include; hospital beds, medical supplies,
      medical staffing, and antivirals.

   If the novel virus appears first in Boone County:
   1. The Director will activate the Public Health Emergency Response Plan,
        Pandemic Influenza Appendix. (see Attachment for ICS structure)
   2. The Director of CBCHD will initiate communication with local and state
        counterparts and determine any changes to interim guidance needed.
        (See Attachment for Interim Guidance that will need to be obtained)
   3. The Environmental Health Manager will coordinate any animal disease
        response with local veterinarians, Animal Control, DHSS, Missouri
        Department of Agriculture, United States Department of Agriculture,
        Missouri Department of Conservation, and the Columbia/Boone County
        Emergency Management Agency.
   4. The Disease Prevention and Control Branch will initiate the appropriate
        clinical, epidemiological investigation. A thorough investigation of the
        initial case(s) will be conducted, including contact tracing of members of
        households, schools, and workplaces. (Attachment)
   5. The Regional Epidemiologist will assure enhanced surveillance is initiated
        in order to detect additional persons with similar illness. (Attachment)
   6. The CBCHD Director will issue a novel virus alert to the health community
        through all available means including the Health Alert Network (HAN),
        EMSystem, and infection control professionals. The Director will provide
        an advisory to area hospitals and health care providers to implement
        appropriate infection control measures.                                           Comment [WIC6]: Should this really
                                                                                          say effective?
   7. The Lab Unit will coordinate with area hospitals, physicians and clinics to
        ensure that appropriate laboratory samples are collected and tested to
        ensure rapid diagnostic confirmation.
   8. The Community Medical Resource Coordination Branch, in coordination                 Comment [WIC7]: Or Logistics?
        with Columbia/Boone County Emergency Operations Center (EOC), will
        confirm the availability of resources to support a public health response to
        include; hospital beds, medical supplies, medical staffing, and antivirals.
   9. In the event vaccines are available, the Logistics Section will notify pre-
        determined sites to inform them about the possibility of utilizing their
        locations as mass vaccination sites, in accordance with agreements
        currently in place.
   10. The Regional PIO in coordination with the DHSS and city and county
        communications staff will develop and disseminate appropriate

                                                                                     17
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan

        information to the public. (See attachment for message templates that
        have been developed by phase)

C. Pandemic Period (Phase 6)

   1. The Director of the CBCHD will activate an Incident Command Structure
      to:
      • Continue and increase surveillance and tracking activities
      • Determine the need for and scope of mass vaccination activities
      • Coordinate delivery of vaccine and/or antivirals with DHSS
      • Carry out mass vaccination activities in accordance with the
           Columbia/Boone County Public Health Emergency Response
           Plan, Mass Prophylaxis Section
      • Develop and disseminate appropriate information to the public
      • Ensure ongoing communication with local, state and federal authorities
   2. The Director of the CBCHD, as the Public Health Authority, will consider
      implementing disease containment measures, quarantine and isolation
      measures for Columbia/Boone County as appropriate to control the
      spread of influenza. These control measures will be particularly important
      as the first line of defense prior to the widespread availability of vaccine.
   3. The Director of the CBCHD will review procedures conducted during the
      first pandemic wave and continue response activities as appropriate
      during the second wave.

D. Post-pandemic Period

      DEMOBILIZE AS NEEDED
   1. The Director of the CBCHD will convene relevant parties to debrief from
      response activities.
   2. The Director of the CBCHD will communicate the status of the response to
      appropriate local, state and federal authorities.
   3. The CBCHD Regional Response Planner(s) will review and update the
      CBCHD Pandemic Influenza Response Plan based on lessons learned
      from response activities.

                                                                                     18
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan

AVIAN INFLUENZA
The bird population routinely becomes ill from influenza viruses. These viruses
can be of low pathogenicity and make few birds sick or they can be highly
pathogenic and make many birds very sick. The current virus that is causing
alarm is H5N1, a highly pathogenic strain, that if it mutates to become easily
transmissible between people, could lead to an Influenza Pandemic in the human
population. This H5N1 strain is not currently found in poultry in the United
States. For this reason, it is vital that the presence of the H5N1 strain in birds be
detected when it arrives in any county, the appropriate notifications made, and
surveillance be enhanced to detect the virus in the human population.

Operational Time Frames
A. Inter-Pandemic Period (Phases 1 and 2)

   •   The Missouri Department of Conservation (MDC), Missouri Department of
       Agriculture (MDA), USDA/APHIS and local veterinarians will monitor the             Comment [WIC8]: Dbl check this
                                                                                          w/Dr. Pues email.
       bird population for the presence of Avian Influenza.
   •   DHSS will educate local veterinarians through the MO Veterinary Medical
       Association.
   •   The Animal Control and Environmental Health Divisions will field calls
       regarding the presence of Avian Influenza in the birds in Boone County.
       Calls will be referred to the appropriate state agency according to the
       Missouri Dead/Sick Bird Call Decision Tree provided by DHSS.
       (Attachment) The Dead Bird Reporting Form will be used to record
       information related to the dead bird.
   •   Testing of dead birds will be done by DHSS, MDC, and MDA/USDA.
   •   The MDA and USDA/VS will coordinate any control measures for
       domestic poultry found to have Avian Influenza. MDC and USDA/WS will
       coordinate any control measures for wild birds. The CBCHD has
       quarantine authority if it is necessary to temporarily quarantine the
       infected animals until the MDA has issued a quarantine or disposal orders.

   Upon finding a positive case of Avian Influenza in birds in Boone County
   • The CBCHD will issue a Health Alert to Boone County veterinarians
     informing them of the presence of Avian Influenza in Boone County.
   • The CBCHD will issue a Health Alert to healthcare providers and
     laboratories informing them of the presence of Avian Influenza in birds in
     the county and signs and symptoms to be aware of in people who may
     have been in contact with infected birds. Providers and laboratories will
     be asked to notify the CBCHD of anyone who becomes ill with the
     symptoms.
   • Education on Avian Influenza and signs and symptoms to be aware of can
     be distributed to poultry owners through local feed stores and the
     Extension Office.
   • The Environmental Health Manager will coordinate any needed local
     response including consultation on the disposal of the infected
     poultry/animals and disinfection of the affected farms.

                                                                                     19
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan

   •   The CBCHD will coordinate local information released to the public
       regarding the presence of positive birds in Boone County and impact on
       Boone County citizens.

SURVEILLANCE AND EPIDEMIOLOGICAL INVESTIGATION

During a pandemic, early identification of the initial outbreak will be key to
activating other aspects of the plan in a timely fashion to best contain the spread
of the disease. This may be accomplished in many different ways-from
computer-based, real-time syndromic surveillance systems to hospital,
laboratory, and mortality surveillance to diseases reporting conducted by astute
clinicians.

The epidemiological investigation will provide vital information about both the
potential spread of the disease, with contact tracing identifying the most high-risk
individuals who may require quarantine.

The goals of surveillance are to:
   • Rapidly detect the introduction and early cases of a novel and pandemic
      virus.
   • Track the virus’ introduction into local areas.
   • Monitor the changes in the virus, including the development of anti-viral
      resistance.
   • Serve as an early warning system to detect increases in influenza-like (ILI)
      illness in the community.
   • Monitor the pandemic’s impact on health (e.g. by tracking outpatient visits,
      hospitalizations, and deaths).
   • Track trends in influenza disease activity and identify populations that are
      severely affected.

National Surveillance Capabilities
There are six national surveillance components:
   • Virologic surveillance – Each week, approximately 75 U.S. collaborating
      laboratories that are part of the WHO Influenza Surveillance Network and
      50 National Respiratory and Enteric Virus Surveillance System
      laboratories report the number of clinical specimens tested for influenza
      and the number of positive results by virus type and subtype.
   • Outpatient ILI surveillance (Sentinel Provider Network) – Approximately
      2,300 sentinel health care providers/clinics located in 50 states regularly
      report the number of patient visits for ILI by age group and the total
      number of patient visits each week.
   • Hospitalization surveillance – hospitalizations associated with laboratory-
      confirmed influenza in children are monitored in 12 metropolitan areas
      through two surveillance networks that report patient-level data to CDC
      every 2 weeks.
   • Mortality surveillance – The Vital Statistics Offices of 122 U.S. cities report
      each week the percentage of total deaths that may be influenza-related.
                                                                                     20
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan

   •   State-level influenza activity assessments - state and territorial
       epidemiologists assess influenza activity levels in their respective areas
       each week and report it as “widespread,” “regional,” “local,” “sporadic” or
       “no activity.”
   •   Veterinary surveillance – the CDC in collaboration with state health
       departments will assist the U.S. Department of Agriculture (USDA) and
       state veterinary laboratories in monitoring influenza strains among poultry
       and swine.

Missouri Surveillance Capabilities
At the state level, the Missouri Department of Health and Senior Services
(DHSS) coordinates the following surveillance activities:
   • Annual passive surveillance of laboratory-based influenza testing through
      sentinel provider sites.
   • Select health care providers and sentinel surveillance sites report the
      number of patients they see with influenza-like illness each week.
   • Suspected influenza outbreaks in schools, hospitals, daycare facilities,
      nursing homes and other group institutions are reportable by law to the
      local public health agency.
   • Reporting of state influenza activity level in a timely manner.
   • Communication with all partners about the heightened need for timely and
      complete surveillance data.

Additionally, the DHSS Influenza Surveillance Coordinator will be responsible for:
   • Maintaining the current influenza Sentinel Provider Network
   • Overseeing ongoing surveillance enhancements
   • Promoting year-round influenza surveillance
   • Collaborating with the CDC Influenza Branch

CBCHD Surveillance Capabilities
The PHERP, Surveillance Section includes details on the CBCHD plans for
surveillance response. Refer to the PHERP, Liaison Section for details in
sending Health Alerts and EMSystem messages.

In addition to the federal and state surveillance activities, CBCHD will establish
and coordinate the following local surveillance activities during the appropriate
operational time frame:

Disease surveillance includes:
   • Enhanced surveillance by healthcare providers:
         o Sending alerts to healthcare providers detailing the clinical
            presentation and exposure history of interest. Healthcare providers
            will be asked to report if they evaluate a patient with the suspected
            illness.
   • Surveillance for Influenza-like-illness (defined as temperature greater than
      100.4 and at least one upper respiratory symptom (cough, rhinorrhea, or
      pharyngitis). Tracks general trends in the scope and magnitude of ILI.
   • Monitoring of 911 calls and hospitalizations.
                                                                                     21
Columbia/Boone County Pandemic Influenza and Highly Infectious Respiratory Disease
Response Plan

   •   Surveillance of influenza deaths via the Vital Records Registrar.

Operational Time Frames

A. Inter-pandemic Period (Phases 1 and 2)

   1. CBCHD will collaborate with hospitals physicians, and clinics within
      Columbia/Boone County to count positive rapid influenza tests and
      influenza viral cultures on a weekly basis. This will be done year round.
   2. The DHSS electronically monitors local hospitals to count emergency
      room visits and hospital admissions on an ongoing basis.
   3. CBCHD will collaborate with school districts within Columbia/Boone
      County to count reports of Influenza-like-illness (ILI) complaints to the
      school nurse or counts of school absentees with reported ILI.
   4. CBCHD will maintain a syndromic surveillance system, which will include
      a representative number of sites for the county reporting ILI complaints to
      the CBCHD.
   5. CBCHD will monitor 911 calls via the Firstwatch Electronic Surveillance
      System for ILI Illness.
   6. CBCHD will monitor the Retail Drug Sale Surveillance system for
      increased levels of sales of over the counter cold and flu medications.

B. Pandemic Alert Period (Phases 3 through 5)

If the novel virus appears first elsewhere: (Phase 3 or 4)
     1. CBCHD will monitor the HAN, CDC’s Epi-X, EMSystem, Firstwatch and
        other appropriate sources for information and situation updates.
     2. CBCHD will ensure that all influenza surveillance activities are underway,
        enhancing activities as needed based on information from HAN alerts,
        Epi-X alerts, local surveillance activities, and communication from local,
        state and federal partners, and other sources.
     3. CBCHD will monitor and institute recommendations from CDC/DHSS for
        any additional surveillance activities that should be undertaken given the
        specific circumstances.
     4. Using all available means including HAN, EMSystem, and ICPs, CBCHD
        will notify area hospitals, physicians, emergency rooms and urgent care
        centers, requesting that they increase laboratory diagnosis of influenza for
        persons presenting with ILI, especially those with recent travel history to
        regions where the pandemic strain of influenza is circulating or those with
        unusual or severe symptoms and to report positive tests to the CBCHD.
        CBCHD will provide instructions for the safe handling of potential novel
        influenza virus specimens. (Attachment)
     5. CBCHD will assess the completeness and timeliness of reports from all
        participating sentinel providers. CBCHD will collaborate with these
        partners to assure complete and timely reporting.

If the novel virus appears first in Boone County: (Phases 3 through 5)
     1. Clinicians will be asked to report to CBCHD any information on a
        suspected human case of novel strain infection.
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