The Canadian Pandemic Influenza Plan for the Health Sector

• As per Preparedness Section
  • Ensure links to veterinary counterparts are in place as part of general pandemic preparedness
  • Routine human influenza surveillance

• Disseminate available surveillance information from countries experiencing animal cases and/or outbreaks to public health stakeholders

• Provide updates on ongoing risk assessment for pandemic influenza potential

• If animal outbreaks are occurring:
  • Provide general travel health information pertaining to safe food handling, respiratory etiquette

• As per Preparedness Section

• Develop/maintain response plans

• Explore need to stockpile (e.g. syringes, other medical supplies)

• Identify how essential services will be maintained during a pandemic

• Practice emergency plans

• Train staff that may be re-assigned during a pandemic

• As per Human Health Issues Related to Avian Influenza in Canada document; Rapid sharing of information among animal and human health professionals

• Provide updates on ongoing risk assessment for pandemic influenza potential and make recommendations for increased vigilance for surveillance and public health action

• Continue as per Phase 1.0 actions and;

• Ensure that response network is ready to respond

• Provide technical information liaison

• Report situation to PSEPC (daily report)

• Share PHAC/HC info with regional officers

• Facilitate sharing of information between animal and human health authorities

• As per Phase 1.0 with messages reflecting the increased risk to human health

• Design and seek agreement on a common strategy for the communication of epidemiological data (nationally and with WHO internationally)

• As per Phase 1.1 with increased communications/liaison with other government departments

• As per Human Health Issues Related to Avian Influenza in Canada document

• All measures would reflect the increased risk associated with this novel virus

• As per Phase 2.0

• Verify epidemiological data and current risk assessment from official sources (WHO, Ministries of Health)
• Review and confirm that all inter-pandemic surveillance activities (via FluWatch) are operating optimally

• Convey current international risk assessment in Canadian context
• Provide information and national recommendations to F/P/T stakeholders

• Promote use of annual influenza vaccine
• Promote pneumococcal vaccination to "high-risk" and age-specific target groups to reduce the incidence and severity of secondary bacterial pneumonia

• Collaborate on international vaccine development initiatives, including the development and testing of prototype vaccine strains as needed.

• Review pandemic vaccine infrastructure readiness with domestic manufacturer

• Assess and/or re-assess availability of antiviral medications

• Review recommended priority groups and plans for antiviral use based on available epidemiological data
  - Consider adequacy of stockpiled quantities in light of estimated sizes of the respective priority groups in your jurisdiction

• Review and modify if necessary, contingency plans for storage, distribution and administration of antiviral drugs through public health and other providers to nationally defined priority groups

• Communicate antivirals strategy as part of pandemic educational materials (including which priority groups will likely be covered, current supply and any shortfalls)

• Ensure staff are trained and infrastructure is in place to track who is receiving the drugs for the purpose of treatment and prophylaxis

• Ensuring at least one laboratory within the P/T has the capability to isolate and subtype influenza virus, and if not establish anticipatory "back-up" process

• Ensure that estimates of health care personnel capacity are current (i.e., estimated number of health care workers (HCWs) by type (physician, nurses, respiratory therapists, radiology technicians, etc), and by work setting (hospital, community, LTCF, para
  • Identify if possible HCWs by type of work that they usually do

• As per Annex M (Public Health Measures)
• Review and update educational materials on all aspects of influenza for health care professionals, travellers, other special audiences and the general public

• As per Annex K (Communications)

• Provide case count to PSEPC

• Notify P/T's emergency service managers (ESS+CHEMD)

• Coordinate international consultations (WHO/CDC)

• Alert P/T's

• Inform CMOH

• Investigation of sporadic cases, including collection of detailed epidemiologic data, contact tracing, and public health monitoring
• Ensure that enhanced surveillance is in place across Canada for rapid detection of potential spread

• Review/Revise standard reports for dissemination of epidemiological data within Canada
• Establish and convey current risk assessment to national and international surveillance partners
• Dissemination of epidemiological data, as needed
• If occurring in conjunction with an animal outbreak in Canada – refer to Human Health Issues Related to Avian Influenza in Canada document for more details

• Immunize close contacts of cases with annual influenza vaccine if available as per Annex M (Public Health Measures)

• Conduct initial availability assessment of supplies (e.g. syringes, adrenalin, sharps disposal units), equipment and locations potentially required for a vaccine-based response (i.e., mass clinics)

• Develop list of currently qualified vaccinators and sources of potential vaccinators

• Review educational materials re. Administration of vaccines and adapt/update as needed

• Ensure that any legal issues that may impede rollout of a mass immunization program are addressed

• Ensure domestic vaccine manufactures are alerted and participating in international efforts

• Use neuraminidase inhibitors for treatment of cases as per Annex M (Public Health Measures)
• Perform an inventory assessment (drugs, formulations, and expiry dates)
• Test stockpiled antivirals for potency if necessary (i.e., if past expiry date)

• Laboratory testing as per Annex C (Laboratory Procedures)

• Review protocols and guidelines for prioritization of laboratory services during times of high service demand and staff and supply shortages

• Ensure that any legal and insurance issues that may impede recruitment and use of active and retired health care workers and volunteers have been addressed with P/T licensing bodies

• Prepare and/or update communications defining the extent of care that health care workers and volunteers can perform according to P/T laws and union agreements

• Manage cases and contacts as per recommendations in Annex M (Public Health Measures)
  • Isolation of cases
  • Surveillance of contacts

• Review staffing requirements for implementation of a pandemic response including mass immunization clinics, control measures, and public education

• Consider delaying introduction of public health programs that may not be adequately resourced if situation evolves into a pandemic or other alternatives such as contracting out

• Preparation of educational material for public

• As per Annex K (Communications)

• As per Phase 3.0 and;

• Report to International Health Regulations as required

• Assess risk and disseminate information to and with stakeholders

• Review NESS availability

• Review medical personnel availability

• Review federal legislative authorities

• Aquire (when available) and disseminate any laboratory testing materials (i.e., reagents)

• Verify epidemiological data and current risk assessment from official sources

• Enhance current surveillance activities based on circumstances

• Review and/or revise case definitions, minimum data sets, and data collection forms

• Implement border-based surveillance (depending on origin of cases) coordinated by CEPR, as per Annex M (Public Health Measures)
  • Include notifications to ill and well travellers

• Initiate ramped up surveillance activities to detect and monitor increased morbidity and mortality

• Review and/or revise standard reports for dissemination of epidemiological data within Canada

• Ongoing involvement in vaccine development initiatives

• Review and modify if necessary, contingency plans for storage, distribution and administration of influenza vaccine through public health and other providers to nationally defined high-priority target groups (See Annex J for use of non-traditional sites and workers)

• Ensure staff are trained and infrastructure is in place to record immunizations, including requirements for a two-dose immunization program (i.e. re-call and record-keeping procedures)

• Review estimates of the number of people within the P/T who fall within each of the priority groups for vaccination (i.e., high risk groups, health care workers, responders, specific age groups) and access strategies

• Ongoing promotion of current annual influenza vaccine for NACI recommended groups and for travellers (as per CATMAT recommendations)

• Perform an inventory assesment of available supplies

• Review recommended priority groups and plans for antiviral use based on available epidemiological data

• Review and modify if necessary, contingency plans for storage, distribution and administration of antiviral drugs through public health and other providers to nationally defined high-priority target groups

• Review estimates of the number of people within the P/T who fall within each of the priority groups for receipt of antiviral drugs (i.e., high risk groups, health care workers, responders, specific age groups) and access strategies

• Ensure staff are trained and infrastructure is in place to track who is receiving the drugs for the purpose of treatment and prophylaxis

• Implement/Review infection control precautions for case management

• Review national recommendations for clinical management of cases and modify if necessary

• Anticipate and plan to mobilize human and financial resources

• Review and update local and P/T data on the number & type of health care facilities, and capacity: hospital beds, ICU beds, swing beds, LTC beds with enhanced level of care, emergency department, ventilatory capacity, oxygen supply, antibiotic supply

• Conduct availability assessment of medications, supplies and equipment potentially needed for the response

• Review, modify, and distribute P/T guidelines (or national guidelines) for prioritizing health care needs and service delivery, accessing resources and implementing infection control measures during a pandemic

• Disseminate information on medical supply stockpiles and potential need for, and sources of, additional supplies

• Review, modify, and distribute detailed regional and facility-level plans for providing health services during a pandemic, including the type of care to be delivered at non-traditional health care settings and the triage across sites; human resource, mate

• Disseminate strategy for collecting and monitoring data on health care service use and demands

• Review national recommendations as per Annex M (Public Health Measures) for public health management of cases and other control measures and modify if necessary

• Ensure adequate resources are available to implement recommended public health measures including isolation of cases

• Prepare and revise (if necessary) educational and guidance materials for public health partners (specifically provincial/territorial and local health departments who will be on the front lines with respect to prevention and control measures), the general

• As per Annex K (Communications)

• For Phase 4.0 -actions as per Phase 3.1 and;

• Prepare to respond to GOARN request for participation

• Anticipate and plan to mobilize human and financial resources

• Disseminate information on medical supply stockpiles and potential need for sources of additional supplies

• Alert voluntary organisations

• For Phase 5.0 -actions as per Phase 4.2

• Collection and dissemination of epidemiological and clinical data for cases occurring in Canada
• Review and if necessary, revise case definitions, minimum data sets, and data collection forms

• Ongoing involvement in vaccine development, testing and production initiatives

• Review and modify if necessary, plans for vaccine security (i.e., during, transport, storage and clinic administration)

• If a potentially effective vaccine is available:

• Follow national recommendations for use of the available vaccine

• Implement streamlined VAAE surveillance, in collaboration with PHAC

• Arrange for direct shipping of vaccine to health districts

• Treat cases and provide prophylaxis for contacts of cases, based on local epidemiology and available supplies as per Annex M (Public Health Measures)

• Ensure prompt mobilization of antivirals supplies allocated for early containment

• Ensure that stakeholders are aware of how to report adverse drug reactions if antivirals are being used

• As per Phase 3.1 and;

• Evaluate infection control and occupational health recommendations and practices and revise as necessary

• Ensure adequate resources are available to implement recommended public health measures including isolation of cases

• Establish current level of risk to guide public health actions (e.g. transmission characteristics associated with secondary cases)

• Manage cases and contacts as per recommendations in Annex M (Public Health Measures)
  • Isolate cases
  • Quarantine or activity restriction of contacts
  • Update educational material (with Communications staff)

• Review staffing requirements for implementation of a pandemic response including mass immunization clinics, control measures, and public education

• Consider delaying introduction of public health programs that may not be adequately resourced if situation evolves into a pandemic or other alternatives such as contracting out

• As per Annex K (Communications)

• For Phase 4.1 -actions as per Phase 4.0

• For Phase 5.1 -as per Phase 4.2 and;
  • Prepare dedicated team as necessary

• Refer to actions from phase 4.1, 5.1

• Revise case definitions based on observed clinical presentation of cases

• Implement any special studies identified for these phases

• Ongoing involvement in vaccine development, testing, and production initiatives

• Review recommended priority groups for immunization based on available epidemiological data

• Review and modify if necessary, plans for vaccine security (i.e., during, transport, storage and clinic administration)

• As per Phases 4.1 and 5.1, if a potentially effective vaccine is available

• Follow national recommendations for use of the available vaccine

• Implement streamlined VAAE surveillance, in collaboration with PHAC

• Arrange for direct shipping of vaccine to health districts

• As per Phases 4.1 and 5.1

• Treat cases and provide prophylaxis for contacts of cases, based on local epidemiology and available supplies as per Annex M (Public Health Measures)

• Ensure prompt mobilization of antivirals supplies allocated for early containment

• Ensure that stakeholders are aware of how to report adverse drug reactions if antivirals are being used

• Evaluate infection control and occupational health recommendations and practices and revise as necessary

• Ensure protocols and guidelines for prioritization of laboratory services during times of high service demand and staff and supply shortages have been distributed

• Review and implement mechanisms for coordinating patient transport and tracking/managing beds (e.g. central bed registries, call centre and centralized ambulance dispatch)

• Manage cases and contacts as per recommendations in Annex M (Public Health Measures)
  
  • Isolate cases
  • Quarantine or activity restriction of contacts

• Evaluate interventions and revise recommendations as necessary

• Integrate national recommendations for isolation into practice at the local level

• Implement use of mandatory isolation orders if necessary

• Review and, if necessary, update and disseminate national recommendations regarding containment strategies (i.e., cancellation of public gatherings, school closures) as per Annex M (Public Health Measures)

• Monitor and track compliance with containment recommendations

• Develop or update educational materials for the public and health care providers as the situation evolves

• As per Annex K (Communications)

• For Phase 4.2 -actions as per Phase 4.0

• Consider sending a Liaison Officer to CDC (and vice versa)

• Implement use of mandatory isolation orders if necessary in federal jurisdictions

• For Phase 5.2 -actions as per Phase 5.1

• Verify international epidemiological data and current risk assessment from official sources

• Revise case definitions based on international assessment of observed clinical presentation of cases

• Distribute data collection forms and database transmission instructions and protocols if not done previously

• Follow any new recommendations regarding a switch-over to aggregate reporting of data

• Review protocols for special studies and prepare dedicated teams as necessary to ensure prompt activation of the studies when appropriate

• Ongoing involvement in vaccine development, testing and production initiatives

• Review and if necessary revise recommended priority groups for immunization based on available epidemiological data

• Review and if necessary revise recommended priority groups for immunization based on available epidemiological data

• Modify or refine of nationally defined priority target groups depending on local circumstances

• Modify or refine other aspect of the federal guidelines, as needed for P/T and local application

• Review and modify if necessary, plans for vaccine security (i.e., during, transport, storage and clinic administration)

• When vaccine is available

• National coordination on vaccine purchase

• Activate immunization clinic capability

• Implement streamlined VAAE surveillance, in collaboration with PHAC

• Arrange for direct shipping of vaccine to health districts

• Communicate with bordering jurisdictions (other P/Ts and the U.S.) to facilitate awareness of the vaccine distribution plan and coordination and collaboration on efforts as much as possible

• Review and if necessary revise national recommendations on antiviral use based on available epidemiological data

• Evaluate infection control and occupational health recommendations and practices and revise as necessary

• Review protocols and guidelines for prioritization of laboratory services during times of high service demand and staff and supply shortages

• Review mechanisms for coordinating patient transport and tracking/managing beds e.g. central bed registries, call centre and centralized ambulance dispatch

• Contact and prepare sources of additional HCWs and volunteers i.e., Emergency Measures Organizations and NGOs (Red Cross, St. John ambulance)

• Acquire extra supplies needed to provide medical care in non-traditional sites

• As per Phases 4.0 and 5.0

• Review national recommendations as per Annex M (Public Health Measures) for public health management of cases and other control measures and modify if necessary

• Ensure adequate resources are available to implement recommended public health measures including isolation of cases

• Prepare and if necessary revise educational and guidance materials for public health partners (specifically, P/T and local health departments who will be on the front lines with respect to prevention and control measures), the general public; Some documents for the public should emphasize infection control in homes, schools, places of work

• As per Annex K (Communications)

• As per Phase 5.1
  
  • Ensure NESS resources are ready to be deployed
  • Contact and prepare sources of additional HCWs and volunteers (NGO's)

• 6.1: Confirm that clinical spectrum of disease (based on feedback from local level experts), is consistent with what is being observed internationally (revise case definitions if necessary)

• 6.2: When indicators suggest activity appears to be decreasing (i.e., end of a pandemic wave)

• Determine ongoing surveillance needs for both documentation of end of first wave and detection of any new cases or outbreaks

• As per Phase 6.0 (i.e., if not completed prior to Phase 6.1 or 6.2)
  
  • Ongoing involvement in vaccine development,testing and production initiatives

• Review and if necessary revise recommended priority groups for immunization based on available epidemiological data

• Modify or refine other aspect of the federal guidelines, as needed for P/T and local application

• Review and modify if necessary, plans for vaccine security (i.e., during, transport, storage and clinic administration)

• As per Phase 6.0, when vaccine is available

• National coordination on vaccine purchase

• Activate immunization clinic capability

• Implement streamlined AEFI surveillance, in collaboration with PHAC

• Arrange for direct shipping of vaccine to health districts

• Communicate with bordering jurisdictions (other P/Ts and the U.S.) to facilitate awareness of the vaccine distribution plan and coordination and collaboration on efforts as much as possible

• If not previously completed in Phase 6.0, review and if necessary revise national recommendations on antiviral use based on available epidemiological data

• Based on local epidemiology and available supplies, administer antiviral treatment and prophylaxis according to national priority groups

• Communicate with bordering jurisdictions to facilitate awareness of any antiviral distribution plans

• If antivirals are being used, ensure that stakeholders are aware of how to report adverse drug reactions

• Monitor for drug resistance

Mostly Phase 6.2 actions:

• Implement protocols and guidelines for prioritization of laboratory services during times of high service demand and staff and supply shortages

• Implement mechanisms for coordinating patient transport and tracking/managing beds e.g. central bed registries, call centre and centralized ambulance dispatch

• Access sources of additional HCWs and volunteers i.e., Emergency Measures Organizations and NGOs (Red Cross, St. John ambulance)

• Acquire extra supplies needed to provide medical care in non-traditional sites and open non-traditional sites as needed

• Coordinate clinical care and health services activities with bordering jurisdictions to avoid migration to centres of perceived enhanced services

• Monitor capacity of mortuary and burial services as well as need for social and psychological services for families of victims; Implement and establish alternative sites for provision of services as necessary

• Track national stocks of medications as well as necessary medical equipment and supplies, including ventilators, oxygen, etc. Consider strategies to mitigate shortfalls

• Assess status of stocks, impact of first wave, reorder supplies and ensure circulation of staff to avoid burnout, across all health care services (including mortuary)

• Case and contact management as per Annex M (Public Health Measures) for Phase 6.1 and 6.2

• Discontinue quarantine strategy if previously implemented

• Shift-focus to self-care and self-monitoring as case numbers increase, with concurrent increase in public education messaging

• Implement national recommendations regarding control strategies (i.e., cancellation of public gatherings, school closures)

• As per Annex K (Communications)

• For Phase 6.1 as per Phase 6.0 and;

• Consider declaring Public Welfare Emergency (as per Emergencies Act)

• Track National stocks. Consider strategies to mitigate shortfalls

• Discontinue border strategies

• Conduct prediction analysis

• Define clinical spectrum of disease

• Review mass facilities plan

• Review distribution policy of resources allocation

• Assign medical and other resources

• Access sources of additional HCW`s and volunteers

• For Phase 6.2 as per Phase 6.1 and;

• Monitor and adjust

• Advise and assist P/T's on establishment and operations of non-traditional health care sites and clinics

• Deploy HERT strategically for maximum benefit

• Continue consultation with health sector partners

• Planning for illness in the response team

• Plan for emergency financial resources

• Promote optimal use of emergency resources

• Assess increased demand on health care system

• Resume routine ongoing laboratory and disease surveillance

• Provide recommendations for routine prevention and control including recommendations for vaccines

If vaccine was available and administered in earlier phase(s)

• Expand vaccine programs to cover population not yet immunized

• Summarize and report coverage data (with one and/or two doses) and AEFI data

• Examine vaccine efficacy

• Review and if necessary revise guidelines and/or protocols used during the mass campaigns

• Perform inventory assessment and ongoing monitoring of antiviral availability

• Evaluate effectiveness of strategic antiviral use (in Canada and/or based on international reports)

• Summarize and report antiviral resistance data

• Summarize and report adverse drug reaction data

• Provide recommendations for the strategic use of antivirals during a pandemic based on lessons learned within Canada and internationally

• Review and activate aftercare and recovery plans and guidelines

• Review and revise (if necessary) clinical management guidelines

• Review and revise (if necessary) infection control guidelines

• Review and revise (if necessary) guidelines for management of mass fatalities (if applicable)

• Close or reduce use of "alternate care" and "over-flow sites"

• Restock laboratory supplies and resume routine laboratory services

• Develop projections for future laboratory requirements (i.e., human and physical resources including test kits, etc.)

• Summarize, evaluate and report on the use of social and psychological services for families of victims

• Track national stocks of medications as well as necessary medical equipment and supplies, including ventilators, oxygen, etc. Consider strategies to mitigate shortfalls in next wave or pandemic

• Review and revise (if necessary) public health management guidelines

• Document and report lessons learned

• Update educational materials

• Resume routine public health activities and programs

• Promote immunization for influenza and other secondary infections observed during the pandemic (if appropriate and applicable)

• Disseminate all revised guidelines to appropriate stakeholders

• Evaluate the effectiveness of public health measures (e.g., closure of schools or other institutions etc.)

• Provide recommendations for routine prevention and control including recommendations for any control measures other than vaccines and antivirals

• Provide lessons learned for ourselves and the public and prepare for the next emerging infectious disease

• As per Annex K (Communications)

• Assess lessons learned

• Assess impact

• Update plans

• Restock supplies and equipment

• Implement recovery measures as required

• Update educational materials