1.  Logistics  Command & Control  Communication  PPE  Personnel SARS – Lessons Learned

2. SARS – Lessons Learned Logistics  Stockpile What if SARS had hit in the USA? Where do you store it? How do you rotate stock with a shelf life?  Delivery Don’t count on “Just in Time” If you need it at 03:00 on Sunday, who will ship it to your staff?

3.  Protect your Command and Control Function Back up three-deep  We need centralized decision making  EMS must be at the table  Get financial commitments from those who fund your service SARS – Lessons Learned Command and Control

4.  Common Message, Common Speaker  Media Who creates the message? Who approves content? Politics Reality vs. public fear SARS – Lessons Learned Communication

5.  Speak to your staff daily!  Use technology E-mail Phone (Dialogix) Have them call in (1-800 numbers) One on one from management Postings in stations Mail Podcast SARS – Lessons Learned Communication

6.  Be honest, even if it’s unpleasant  It’s impossible to give them too much information  Provide “real-time” fact-based information  Consider the rumour mill  Balance between need to know and confidentiality SARS – Lessons Learned Communication

7.  Who is the authority? CDC Provincial/State MOH Public Health WHO Wikipedia Bob’s School of Hair Design and Epidemiology SARS – Lessons Learned Communication

8.  Talk to the neighbours Your staff may live and work there too  Build national links  Other agencies may not be as open with information SARS – Lessons Learned Communication

9.  Allow them to vent  Debrief afterwards  Be visible, but if you can’t, explain why SARS – Lessons Learned Communication

10.  How much is “enough?” Surgical mask N95 PAPR  It isn’t designed for the EMS environment Temperature extremes Rain and snow Stairs MVC SARS – Lessons Learned PPE

11.  Immunizations reduce illness Are your people up to date? Influenza kills >36,000 yearly  Workers Compensation vs. ill benefit  Plan for loss of staff Illness Quarantine Family responsibilities Other employers Fear-driven SARS – Lessons Learned Personnel

12.  Ensure that people are paid while on quarantine or ill  If staff suffer financial loss, they won’t stay isolated “I’m not sick. I won’t pass it on.”  EAP is critical SARS – Lessons Learned Personnel

13.  Is your family ready?  Are your workers involved in planning?  Are your plans similar to your neighbours?  Others have good ideas Ask them and steal without compunction SARS – Lessons Learned Personnel - Points to Ponder

14.  How will you get around?  What will you eat?  What if the power goes off?  Will your prescription last?  What about your elderly relatives?  Who is watching the children?  What about Fluffy? SARS – Lessons Learned Personnel-Have you Thought About?

15.  Start planning now  Pester your politicians  Seek community involvement Faith groups Service clubs  Develop a family plan SARS – Lessons Learned Next Steps

16.  www.pandemicflu.gov www.pandemicflu.gov  www.fluwikie.com www.fluwikie.com  www.promedmail.org www.promedmail.org  www.who.int/csr/don/en www.who.int/csr/don/en  www.toronto.ca/health/pandemicflu www.toronto.ca/health/pandemicflu SARS – Lessons Learned Resources

17. gwright4@toronto.ca

18. Department of Health Pandemic (H1N1) 2009 (Human Swine Influenza) Victorian response Dr Rosemary Lester Assistant Director, Health Protection, Communicable Disease Prevention and Control Unit and Deputy Chief Health Officer Department of Health, Victoria

19. Decision making for managing a pandemic Australian government National Pandemic Emergency Committee CMO expert advisory group Australian Health Protection Committee Communicable Diseases Network Australia State and territory governments

20. Plans

21. Framework for management Australian Health Management Plan for Pandemic Influenza (AHMPPI) –Alert –Delay – border control –Contain – aggressively contain spread –Sustain – maintain contain efforts if feasible plus broader measures (modified Sustain) –Control – vaccinate (Protect) –Recover Victorian Health Management Plan for Pandemic Influenza –Mirrors AHMPPI Whole of government plans

22. Summary of H1N1 pandemic in Australia 2009 In Australia there were over 37,000 laboratory confirmed cases with 189 deaths as at 6 November 2009 Victoria had 3069 laboratory confirmed cases, 513 hospitalisations, 118 ICU admissions and 26 deaths Victoria saw the earliest community transmission; other states were delayed in community transmission being established by 2-3 weeks behind Victoria We believe that the virus was imported into Victoria earlier and spread through community in mild form Comprehensive testing strategy in Victoria found this community transmission early Activity in all jurisdictions peaked and decreased by late July

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

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

25. Geographic distribution of cases in the Delay and Contain phases

26. Epidemic curve, Australia Source: Australian Influenza Surveillance Summary Report, Australian Government Department of Health and Ageing

27. Delay phase Emphasis on delaying disease entry into Australia i.e. border surveillance, quarantine and isolation Positive pratique for all incoming international flights, new health declaration cards for incoming travellers Active surveillance undertaken at the border for ill passengers on all flights Thermal scanners at airports Border surveillance nurses to support AQIS at the airport Activated public health emergency operations centre undertaking testing authorisation, manage isolation of cases and quarantine of contacts, distribution of antiviral treatment and prophylaxis, contact tracing and school management

28. Delay phase Case definition for testing: –ILI within 7 days of travel to Mexico, USA or Canada, or within 7 days of close contact with a confirmed or probable case –All approved tests sent to VIDRL for urgent processing Suspected cases couriered Tamiflu (if within 48 hours of onset) and asked to isolate themselves information sent out regularly to hospitals, GPs and laboratories New website launched (27,000 hits/day at peak) Regular media releases and press conferences

29. Contain phase Once disease in Australia – declared 22 May Test all suspected cases Case definition for testing –As for Delay –Tests on all suspected cases sent to VIDRL for urgent testing Tests from community cases positive for influenza A at other laboratories sent to VIDRL for typing Treat and isolate laboratory confirmed cases; prophylaxis and quarantine for all close contacts By the end of Contain, 978 cases had undergone full contact tracing Class or school closure where confirmed cases –by 3/6, 88 schools had undergone full or selective class closure

30. Modified Sustain phase Once community transmission established; declared 3 June (Victoria only) No testing of all suspected cases; concentrate on moderate/severe cases and use sentinel surveillance system to monitor epidemiology Use clinical case definition for cases Treat all cases meeting the clinical case definition with anti-virals; prophylaxis for close household contacts; isolation of cases for 3 days No quarantine for close contacts; no routine school closures

31. Modified Sustain phase Concentrate on vulnerable settings, eg special developmental schools, hospitals, aged care facilities Investigation and early intervention with treatment of cases and possible quarantine of vulnerable contacts “modified” to emphasise that more severe measures such as continued quarantine of contacts, school closures and cancellation of mass gatherings would not be undertaken

33. Protect Phase On 23 June, Victoria implemented the PROTECT phase: Reduce transmission by emphasising personal hygiene measures; do not attend work/school if sick Identifying the vulnerable, in whom H1N1 Influenza 09 may have severe outcomes –Chronic medical conditions –Morbid obesity –Pregnant women –Indigenous people Close clinical assessment of those identified as vulnerable and early commencement of antiviral treatment Encourage voluntary home isolation of cases No treatment for mild cases No quarantine for contacts unless vulnerable setting Investigation and management of cases in “closed” facilities or high risk settings, eg special developmental schools, health care facilities

34. Why move to ‘Protect’ The new phase recognises that the infection with pandemic H1N1 2009 is not as severe as originally envisaged when the AHMPPI was written “Disease is mild in most cases, severe in some and moderate overall.” PROTECT sits alongside CONTAIN and SUSTAIN phases with a greater focus on the vulnerable or people in whom the disease may be severe PROTECT is a measured, reasonable and proportionate health response to the risk that the virus poses to the Australian community

35. Other Victorian Actions Flu diversion clinics opened at several sites in the metropolitan area to reduce pressure on emergency departments Distribution of antivirals via designated community pharmacies negotiated through Pharmacy Guild Gazetting of –Division 1 Registered Nurses as prescribers for treatment and prophylaxis –Pharmacists as prescribers for prophylaxis of household contacts on written advice from GP’s Communications –Regular communications to stakeholders – GPs, ID physicians, hospitals, public (call centre and website)

36. Other Victorian Actions Utilised public health reference laboratory (Victorian Infectious Diseases Reference Laboratory) Utilised existing state stockpile of antivirals and personal protective equipment (PPE), further review and purchase of additional antiviral medication Accessed the National Medical Stockpile for supplemental antiviral stock and PPE Regular briefing of senior ministers and whole of government Continued regular press briefings – minister and Acting Chief Health Officer Notification management via call centre

37. Vaccination program H1N1 vaccination program commenced 30 September Whole population encouraged to be vaccinated; special emphasis on those at risk of severe outcomes, eg pregnant women, obese persons, those with chronic medical conditions Challenges – multi dose vials, perceptions of a mild disease 1.7 million doses distributed in Victoria to end February 2010

38. Snap shot figures Total cases 2009:= 3089 Hospitalised:= 513 ICU:= 118 Deaths:= 26 Total confirmed cases contacted:> 1,000 Total contacts of cases indentified:> 5,800 Total schools affected:= 112 schools impacted with 88 undergoing full or selective class closure Total courses of Tamiflu distributed:> 20,000 by DH > 26,000 by Community Pharmacies Flu reference lab tests :> 17,000 Calls taken in call centre for the period 1 May to 23 June: > 26,000 Website:> 27,000 hits/day at peak Total DH personnel involved throughout response: > 200

39. Lessons learnt The importance of written plans! The importance of clear arrangements for laboratory testing, contact tracing and anti-viral provision The need for communication to be clear and consistent while events are changing rapidly Further clarify roles and responsibilities of committees involved and the communication channels Clarify expectations on use of national stockpile and pathways of patients in primary care Ensure jurisdictional flexibility to account for differing epidemiology in different geographic locations Ensure right balance struck between use of public health reference laboratory, and when to move out to routine laboratories to avoid overload

40. Acknowledgements Rodney Moran, Julian Meagher, James Fielding, Joy Gregory, Kleete Simpson, Lynne Brown, Jan Bowman, Noel Cleaves, Rodney Dedman, Vikki Sinnott, Jo Donelly, Michael Ackland, Bram Alexander and all the staff of CDPCU Mike Catton, Heath Kelly and all the staff of VIDRL All the public health medical officers who assisted in the Emergency Operations Centre All the staff who worked in the Emergency Operations Centre on contact tracing and call management