` GUAM PANDEMIC INFLUENZA PLAN PANDEMIC PLANNING GET INFORMED / BE PREPARED (REVISED JULY 2008) CONTRIBUTING AGENCIES AND ACKNOWLEDGMENTS PANDEMIC PLANNING TASK FORCE MEMBERS EXECUTIVE ORDER 2006-11 Arthur U. San Agustin, MHR Florencio “Larry” Lizama, MD Charles H. Ada III Leo Espia PeterJohn D. Camacho, MPH Wilfred Aflague Deborah Alicto Lillian Perez-Posadas Yvonne Damian Katrina Rosario-Sanchez Mary C. Torres William Kando Annie Unpingco Reina Sanchez Paul Bassler Thomas Poole, DVM Ben Pangelinan John Roberto Francis Fejerang John Leon Guerrero Gerard Bautista Herman Paulino John Benavente Lucy Perez Karri T. Perez, PhD Karri T. Perez, PhD Capt. Leon Ryan Capt. Fred Chargualaf Assistant Fire Chief Tony Rabon John P. Santos Ignacio Santos Gerry Cruz James Pettite John Blas Richard Rennie Dave Peredo Lt. Col. Diron Cruz Major Ambrosio Constantino Acting Director, Department of Public Health and Social Services (Appointed Co-Chair) Community Representative (Appointed Co-Chair) Guam Homeland Security/Office of Civil Defense Guam Memorial Hospital Authority Guam Visitors Bureau Department of Mental Health & Substance Abuse Department of Agriculture Customs and Quarantine Agency Guam International Airport Authority Port Authority of Guam Consolidated Commission on Utilities Guam Telephone Authority Society for Human Resources Management Guam Police Department Guam Fire Department Guam Public School System Mayors Council of Guam Guam Hotel & Restaurant Association American Red Cross – Guam Chapter Guam Army National Guard Major Nicanor Legaspi 1st Lt. Joseph Connelley 1st Lt. Ricky Flores 2nd Lt. Gary Tanaka 2nd Lt Sean Cripps Capt. Raymond Perez Geoffrey Galgo, MD Nicole Nededog Tom Berkemeyer Dan Luces Jennifer Artero Chief Gary Yestingsmeier Lt. Daron Patton BM1 Charles Lynch Jimmy Lumibao Guam Air National Guard Guam Medical Society Guam Chamber of Commerce Continental Airlines U.S. Naval Hospital U.S. Coast Guard EXECUTIVE ORDER 2008-04 J. Peter Roberto, A.C.S.W. Doris Crisostomo Dennis Santo Tomas, COL (USA/RET) Ray Shinohara Edward J. Cruz Lesley Leon Guerrero Jonathan Lujan PeterJohn D. Camacho, MPH William Kando Deborah Alicto Yvonne Damian Glenda Pangelinan Michael Poblete Danny Matanane Mary C. Torres Rolando Delfin John Leon Guerrero Gerard Bautista Rufo Lujan, Jr. Johnric Mendiola John Crisostomo Joyce N. Sayama Lucia Perez Herman Paulino Capt. Leon Ryan Bradley Hokanson Acting Director, DPHSS (Appointed Co-Chair) Office of the Governor (Appointed Co-Chair) Guam Homeland Security/Office of Civil Defense (Appointed Co-Chair) Guam Memorial Hospital Authority Guam Visitors Bureau Department of Agriculture Guam International Airport Authority Customs and Quarantine Agency Guam Power Authority Guam Power Authority GTA Teleguam, LLC Port Authority of Guam Guam Police Department Fire Chief David Quifunas Peredo Assistant Fire Chief Anthony Perez Rabon Fire Captain John Peter Santos Firefighter I Angel Borja Llagas, Jr. Bruce Williams Dr. Maria Salomon Ruth Leon Guerrero Ken Borja John Blas Gene Tennessen Bruce Perez Lt. Col. John Howerton Capt. Joseph I. Cruz Reina Leddy Lillian Perez-Posadas Lt. Steven Clifford LCDR Amy Wirts Guam Fire Department Guam Public School System University of Guam Department of Labor Department of Administration Mayors Council of Guam Office of Senator Frank T. Ishizaki American Red Cross – Guam Chapter Guam Army National Guard Guam Chamber of Commerce Continental Airlines U.S. Naval Hospital U.S. Coast Guard DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES (DPHSS) INTERNAL PANDEMIC INFLUENZA PLANNING COMMITTEE Arthur U. San Agustin, MHR Division of Public Health: Suzanne A. Sison, DDS Gil S. Suguitan, MPA Cynthia L. Naval, MS Josephine T. O’Mallan Annette L. Aguon Lourdes A. Duguies, MPH Cecilia T.T. Arciaga Claire M. Baradi Roselie V. Zabala, MSW William Brandshagen Zenaida Lebita, RPh Eugene S.N. Santos Linda Unpingco-DeNorcey, MPH Margarita B. Gay, RN, MN Marlene M. Carbullido, RN Margaret L. Bell Janet B. Cruz MaryLou M. Loualhati Annakutty Mathew, MD Division of Public Welfare: Diana B. Calvo, MS Acting Director, DPHSS Acting Chief Public Health Officer Emergency Preparedness and Response Program Emergency Preparedness and Response Program Bureau of Communicable Disease Control (BCDC) BCDC, Immunization Program BCDC, Foreign Quarantine/Enteric Diseases BCDC, TB/Hansen Disease Program BCDC, Laboratory Bureau of Professional Support Services (BPSS) BPSS, Medical Social Services BPSS, Pharmacy BPSS, Health Education Bureau of Primary Care Services (BPCS) Bureau of Family Health and Nursing Services (BFHNS) BFHNS BFHNS Health Professional Licensing Office Emergency Medical Services Medical Director Chief Human Services Administrator Lydia Diaz Tenorio Bureau of Social Services Administration Division of Environmental Health: Masatomo T. Nadeau, MS Marilou O. Bumagat Environmental Health Specialist Administrator Environmental Health Specialist III Division of Senior Citizens: Charlene D. San Nicolas Cerina Y. Mariano Transportation Program Services Program Administration Unit PAST DPHSS MEMBERS: Division of Public Health: Ronald G. Balajadia Severino M. David Janice L.S. Yatar Bureau of Communicable Disease Control Bureau of Professional Support Services Bureau of Family Health and Nursing Services CONSULTANTS: Robert L. Haddock, DVM, MPH Vasiti Uluiviti Michael O’Leary, MD, MPH Peter A. Judicpa Epidemiologist, DPHSS Regional Laboratory Coordinator, Pacific Islands Health Officers Association (PIHOA) Epidemiologist, U.S. Centers for Disease Control and Prevention Public Health Advisor, U.S. Centers for Disease Control and Prevention TABLE OF CONTENTS Introduction .......................................................................................................................i Purpose ..............................................................................................................................ii Policies ..............................................................................................................................iii Background .......................................................................................................................iii Assumptions ......................................................................................................................iv Responsibilities .................................................................................................................v-ix Concept of Operations .......................................................................................................ix Emergency Management Plan ...........................................................................................ix Pandemic Phase Chart .......................................................................................................x Statutory Authority ............................................................................................................xi Command and Control ......................................................................................................xii-xv Attachment: Command and Control ......................................................................................................A Chapter 1: Section 1.0 Section 2.0 Section 3.0 Section 4.0 Emergency and Community Health Outreach Plan Introduction .................................................................................................1-1 Goal .............................................................................................................1-1 ECHO Objectives ........................................................................................1-1 Response Activities .....................................................................................1-2 Section 5.0 Partner Agencies..........................................................................................1-2 Section 6.0 Personnel Needs ..........................................................................................1-3 Section 7.0 Facility, Equipment and Material Needs .....................................................1-3 Pandemic Phases ...............................................................................................................1-4-5 Attachments: ECHO Intervention Strategy Matrix .................................................................................1-A Pandemic Flu Pamphlet .....................................................................................................1-B-1-2 Checklist for Individuals and Families ..............................................................................1-C-1-2 Cover your Cough Flier .....................................................................................................1-D Cover your Cough for Healthcare .....................................................................................1-E Be a Germ Stopper Flier ....................................................................................................1-F Chapter 2: Surveillance Activities Section 1.0 Introduction .................................................................................................2-1 Section 2.0 Section 3.0 Objectives ....................................................................................................2-1 Surveillance for Human Infection ...............................................................2-1 Section 3.1 Components of Surveillance .......................................................................2-2 Section 3.2 Enhanced Surveillance Activities ................................................................2-3 Section 3.3 Criteria for Assessing and Reporting ..........................................................2-4-8 Pandemic Phases ...............................................................................................................2-9-23 Attachments: Pandemic Influenza Case Screening and Report Form .....................................................2-A1-6 Contact Record Form ........................................................................................................2-B1-2 Pandemic Influenza Health Surveillance Form .................................................................2-C Chapter 3: Section 1.0 Section 2.0 Section 3.0 Section 4.0 Laboratory Response Plan Introduction ................................................................................................3-1 Functions ....................................................................................................3-1 Laboratory Test Requests ...........................................................................3-1 Specimen Collection and Submission ........................................................3-2 Section 5.0 Section 6.0 Section 7.0 Section 8.0 Specimen Receipt at GPHL ........................................................................3-5 Preliminary Influenza Testing at GPHL.....................................................3-5 Confirmatory Influenza Testing at HSLD ..................................................3-6 Shipping of Specimens to HSLD ...............................................................3-7 Section 9.0 Section 10.0 Section 11.0 Section 12.0 Section 13.0 Section 14.0 Documentation and Reporting of Laboratory Test Results ........................3-8 Procurement and Inventory of Laboratory Supplies ..................................3-9 Continuity of Laboratory Operations During an Outbreak ........................3-9 Safety Precautions in the Laboratory .........................................................3-9 Contact Information ...................................................................................3-10 References ..................................................................................................3-10 Pandemic Phases ...............................................................................................................3-11 Attachments: In-House Specimen Testing Algorithm for Influenza at GPHL........................................3-A Algorithm for Surveillance and Testing at GIAA/PAG ....................................................3-B Influenza Specimen Laboratory Submission Form (GPHL) .............................................3-C-1-2 Specimen Requirements for Detection of Influenza A and B (GPHL) .............................3-D-1-2 Influenza GIAA/PAG Specimen Submission Form ..........................................................3-E Consent for Diagnostic Evaluation....................................................................................3-F Patient Information Sheet: Rapid Influenza Testing ........................................................3-G-1-2 Appendix H: Respiratory Specimen Laboratory Submission Form (Hawaii) .................3-H ii Appendix G: Specimen Requirements for Influenza A (Flu A), Influenza B (Flu B), Adenovirus, Detection and Identification by real-time Taqman Reverse Transcriptase (RT) Polymerase Chain Reaction (PCR) (Hawaii) .....................................3-I-1-3 State Laboratory Submission Form-Airport (Hawaii).......................................................3-J Contact Information for GPHL .........................................................................................3-K-1-2 Chapter 4: Section 1.0 Section 2.0 Section 3.0 Isolation and Quarantine Introduction .................................................................................................4-1 Definitions ...................................................................................................4-1-2 Assumptions and Planning Principles .........................................................4-2-3 Section 4.0 Section 4.1 Self-Quarantine and General Public Health Containment Measures ..........4-3 Underlying Principles ..................................................................................4-3-5 Section 5.0 Section 5.1 Section 5.2 Section 5.3 Isolation Concept of Operations ..................................................................4-5 Authority .....................................................................................................4-5-6 Notification and Communication ................................................................4-6 Enforcement ................................................................................................4-6 Section 5.4 Section 5.5 Section 6.0 Section 6.1 Levels of Isolation .......................................................................................4-6-7 Isolation Facility Requirements...................................................................4-7-8 Quarantine Concept of Operations ..............................................................4-8-9 Authority .....................................................................................................4-9 Section 6.2 Section 6.3 Section 6.4 Section 6.5 Section 6.6 Section 6.7 DPHSS Due Process Plan............................................................................4-9 Enforcement ................................................................................................4-9 Key Requirements for Quarantine ...............................................................4-9 Types of Quarantine ....................................................................................4-9-11 Support Services ..........................................................................................4-11 Determination of Need for Isolation and Quarantine ..................................4-11 Section 6.8 Section 6.9 Section 7.0 Initiation of Requests for Voluntary Compliance .......................................4-11-13 Other Community Based Containment Measures .......................................4-13-16 Travel Related Containment Measures .......................................................4-16-20 Pandemic Phases ...............................................................................................................4-21-33 Attachments: Graded Implementation of Social Distancing Measures ...................................................4-A Voluntary Home Isolation Agreement ..............................................................................4-B-1-3 Voluntary Home Quarantine Agreement ..........................................................................4-C-1-3 Isolation and Quarantine Sites ...........................................................................................4-D-1-2 Contact Daily Temperature Log Tracking Form ...............................................................4-E iii Chapter 5: Emergency Medical Services Section 1.0 Introduction .................................................................................................5-1 Section 2.0 Section 3.0 Emergency Medical Services ......................................................................5-1-4 Specific Pre-Hospital Care EMS Guidance.................................................5-4 Chapter 6: Section 1.0 Section 2.0 Section 3.0 Section 4.0 Antiviral Distribution Plan Introduction .................................................................................................6-1 Establishing Priority Groups .......................................................................6-2 Critical Assumptions ...................................................................................6-3 Strategies for Antiviral Use in Pandemic Influenza – Treatment and Section 5.0 Prophylaxis ..................................................................................................6-3 Distributing Antivirals to Priority Groups...................................................6-5 Section 6.0 Section 7.0 Section 8.0 Section 9.0 Points of Distribution ..................................................................................6-5 Legal Preparedness ......................................................................................6-6 Training .......................................................................................................6-6 Contingency Plan for Investigational Drug Use..........................................6-6 Section 10.0 Activation ...................................................................................................6-6 Pandemic Phases ...............................................................................................................6-7-9 Attachments: Recommended Daily Dosage of Antivirals for Treatment/Prophylaxis ...........................6-A Priority Group Chart ..........................................................................................................6-B Chapter 7: Section 1.0 Section 2.0 Section 3.0 Vaccine Delivery Introduction .................................................................................................7-1 Assumptions ................................................................................................7-2 Interpandemic Infrastructure .......................................................................7-2-3 Section 4.0 Section 4.1 Section 4.2 Pandemic Vaccine Supply and Distribution ................................................7-3 Ordering and Distribution ...........................................................................7-3 DPHSS Activities ........................................................................................7-4 Section 4.3 Potential Partners for Vaccine Administration Only ...................................7-4-5 Section 4.4 Potential Mass Vaccination Clinic Sites .....................................................7-5 Section 5.0 Priority Groups for Vaccination ..................................................................7-6 Pandemic Phases ...............................................................................................................7-7-14 Attachments: Guam Vaccine Delivery Plan for Pandemic Influenza .....................................................7-A-1-68 Potential Partners ...............................................................................................................7-B iv Chapter 8: Medical Surge Section 1.0 Introduction .................................................................................................8-1 Section 2.0 Section 2.1 Section 2.2 Section 3.0 Surge Capacity Response Strategies ...........................................................8-1-3 GMHA Threshold........................................................................................8-4-5 GMHA Cohort Plan.....................................................................................8-5-6 Pandemic Influenza Phone Triage Protocol ................................................8-6-8 Section 4.0 Section 4.1 Section 4.2 Section 4.3 NRCHC Outpatient Triage and Treatment Site ..........................................8-8-10 Staffing Surge Capacity...............................................................................8-10-12 Staff Reduction ............................................................................................8-12-14 GMHA Minimum Personnel .......................................................................8-14-15 Section 5.0 Post Pandemic Period ..................................................................................8-15-16 Attachments: Clinical Guidelines Flow Chart for Avian Influenza without Local Transmission ..........8-A-1-3 Health Emergency Assistance Line and Triage HUB .......................................................8-B Recommended MOA/MOU ..............................................................................................8-C GMHA Appendix 15A ......................................................................................................8-D NRCHC Access Flow Chart ..............................................................................................8-E Clinical Guidelines Flow Chart for Avian Influenza with Local Transmission................8-F-1-3 GMHA Facility Access Flow Chart ..................................................................................8-G Infection Control Plan .......................................................................................................8-H-1-18 Chapter 9: Section 1.0 Section 2.0 Section 3.0 Section 4.0 Psychosocial Introduction .................................................................................................9-1 Scope of Operations ....................................................................................9-1 Situation and Assumptions ..........................................................................9-1-2 Concept of Operations .................................................................................9-2-4 Section 5.0 Activation and Implementation ...................................................................9-4 Pandemic Phases ...............................................................................................................9-5-8 Attachments: Special Needs Registration Instructions ............................................................................9-A-1-2 Special Needs Registration Form ......................................................................................9-B Dispatching Procedures for Individual and Family Support Team ...................................9-C-1-4 Tracking Card/Dispatch Information ................................................................................9-D Psychosocial Detailing Sheet for Pandemic Response......................................................9-E-1-3 v Chapter 10: Mass Fatality Management Section 1.0 Introduction .................................................................................................10-1 Section 1.1 Section 1.2 Section 2.0 Section 2.1 Guam Laws Governing Human Remains ....................................................10-2 Islan Guahan Emergency Health Powers Act .............................................10-3 Mass Fatality Management Plan .................................................................10-4 General Plan ................................................................................................10-4 Section 2.2 Section 2.3 Section 2.4 Section 2.5 Preparations for Funeral Directors and Crematoriums of Guam ................10-5 Office of the Chief Medical Examiner and Autopsies ................................10-6 Plan for Temporary Morgues ......................................................................10-6 Plan for Temporary Mortuary .....................................................................10-7 Section 2.6 Section 3.0 Capacity and Access to Temporary Holding Facility .................................10-7 Additional Technical and Logistical Considerations ..................................10-7 Section 3.1 Section 3.2 Section 3.3 Section 3.4 Death Registration .......................................................................................10-8 Infection Control .........................................................................................10-8 Transportation of Human Remains .............................................................10-9 Supply Management of Mortuary Operation ..............................................10-9 Section 3.5 Section 3.6 Section 3.7 Section 3.8 Land and Sea Burials ...................................................................................10-9 Crematoriums ..............................................................................................10-10 Transshipment of Corpse Off-Island ...........................................................10-10 Assistance from Disaster Mortuary Operational Response Team...............10-11 Section 3.9 Communications ..........................................................................................10-11 Section 3.10 Facility Resources .......................................................................................10-11 Section 3.11 Employee Assistance Program ....................................................................10-12 Section 4.0 Religious and Cultural Considerations ........................................................10-13 Section 5.0 Activation and Implementation ...................................................................10-13 Section 5.1 – 5.6 Pandemic Phases .................................................................................10-14-21 Section 6.0 Section 6.1 Section 6.2 Standard Operating Procedures of the Corpse Processing Center ..............10-23 CPC Operations ...........................................................................................10-23 Processing of Dead Bodies ..........................................................................10-24 Section 6.3 Section 6.4 Section 6.5 Section 6.6 Deaths Occurring Outside the Hospital .......................................................10-28 Office of Vital Statistics, DPHSS................................................................10-28 Mass Embalming and Casketing of Dead Bodies .......................................10-29 Transport of Embalmed Bodies ...................................................................10-30 Section 6.7 Section 6.8 Funeral Home Operation .............................................................................10-30 Cemetery Operation ....................................................................................10-31 vi Attachments: Algorithm for Normal Management of Corpse .................................................................10-A Limiting Factors and Possible Solutions for Corpse Processing .......................................10-B-1-2 List of Guam Funeral Homes and Morticians ...................................................................10-C List of Required Materials and Possible Vendors .............................................................10-D-1-9 Recommended Specifications for Wooden Casket ...........................................................10-E List of Guam Cemeteries ...................................................................................................10-F Memorandum of Agreement between the Department of Public Health and Social Services, Department of Public Works, Department of Parks and Recreation, Office of the Chief Medical Examiner, and Office of Homeland Security/Office Of Civil Defense ................................................................................................................10-G-1-11 Corpse Transportation Form .............................................................................................10-H Corpse Processing Form ....................................................................................................10-I-1-3 Corpse Processing Log Sheet ............................................................................................10-J Certificate of Death ...........................................................................................................10-K-1-2 Flow Chart of Corpse Processing Center (CPC) ...............................................................10-L Draft Press Release: (Activation of the Corpse Processing Center and the Delivery of Deceased) .....................................................................10-M Algorithm for Management of Decedent at the Corpse Processing Center (CPC) ...........10-N Burial-Transit Permit .........................................................................................................10-O Floor Plan for CPC at the Dededo Sports Complex ..........................................................10-P Draft Press Release: (Expansion of CPC for Temporary Mortuary Services) .................10-Q Contact Numbers ...............................................................................................................10-R Chapter 11: Critical Infrastructure/Key Resources Section 1.0 Introduction .................................................................................................11-1 Section 2.0 Section 3.0 Guam Emergency Response Plan (GERP)..................................................11-1 Guam All-Hazards Catastrophic Incident CONOP .....................................11-2 APPENDIX List of Acronyms ...............................................................................................................A-1-4 List of Supporting local authorities, response plans, protocols and SOPs………………A-1-5 vii INTRODUCTION. The Guam Department of Public Health and Social Services (DPHSS) is the primary government agency responsible for leading, coordinating and directing all emergency planning and response activities in the event of a declared public health emergency, such as an influenza pandemic. In May 2006, the Governor of Guam’s Executive Order 200611 specifically created the Guam Pandemic Planning Task Force and charged the DPHSS with coordinating the development of a comprehensive pandemic influenza response plan for the Territory. The following Guam Pandemic Influenza Plan (hereafter referred to as the Plan) is a result of the collaboration of key stakeholders and emergency response entities represented on the task force. Membership on the task force included local and federal government agencies; the military; private businesses; and non-profit and faith-based organizations. Task force members’ input to the overall development of the Plan was solicited through the various task force subcommittees and general meetings. Critical planning data was collected from non-task force partners through several pandemic-scenario tabletop exercises and/or drills. The Plan itself is organized into eleven major chapters intended to efficiently respond to an influenza pandemic as outlined below: 1. Emergency and Community Health Outreach 2. Surveillance Activities 3. Laboratory Response 4. Isolation and Quarantine 5. Emergency Medical Services 6. Antiviral Distribution 7. Vaccine Delivery 8. Medical Surge 9. Psychosocial 10. Mass Fatality Management The Plan represents an evolutionary process that is recommended to be periodically reviewed and updated as new information and guidelines from the World Health Organization (WHO) or the U.S. Centers for Disease Control and Prevention (CDC) become available to ensure that the local assumptions, resources, priorities, and plans are consistent with current knowledge and changing infrastructure. It is also anticipated that in the event of a pandemic, the judgments of the public health leadership, based on the epidemiology of the current virus, and the extent of its spread within the population of Guam and the region, may alter or override anticipated strategies and plans. Guam completed its Initial Plan and submitted it to the US Government on April 15, 2007 for analysis and review. USG feedback was then provided via official memorandums in November 2007 to the Chief of Staff of the Governor of Guam and the territory’s Public Health authority. Guam Pandemic Plan Task Force – Executive Order 2008-04 This feedback included Guam’s comparison to the States by critical review areas as well as a specific gap analysis and recommendations for improvement. In response, the Governor of Guam reconvened the Guam Pandemic Influenza Task Force and on April 16, 2008, issued Executive Order 2008-04, identifying the Department of Public Health and Social Services and the Guam Homeland Security/Office of Civil Defense as co-leads in this round of pandemic planning. As part of the USG’s efforts to update the National Implementation Strategy for Pandemic Influenza, all States and territories were provided assistance through the “Federal Guidance to assist States in Improving State-level Pandemic Influenza Operating Plans” and required to submit an update to pandemic plans, specifically addressing the following critical operating objectives by July 9, 2008. Operating Readiness (Exercises) COOP/COG PH COOP Food Supply Agriculture Emergency Uniform Military Services Transportation Surveillance/Lab Ports of Entry Community Mitigation School Closures Countermeasures Mass Vaccination Healthcare Mass Casualties Communication Workers Foreign Missions EMS/911 Public Safety Answering Points Law Enforcement Define Critical Infrastructure/Key Resources (CI/KR) Partnerships Implement National Infrastructure Protection Plan CI/KR Information-sharing CI/KR Leveraging Activities CI/KR Public/Private integration Scarce Resources To accomplish this enormous task, the Guam Pandemic Plan Task Force embarked on a series of task force meetings and pandemic-related exercises to gather critical data for further planning development. Within the months of April through June 2008, task force planning meetings were held every Wednesday and pandemic exercises that included: Public Health Continuity of Operation Plan (COOP) tabletop exercise, March 2008 Laboratory and Surveillance tabletop exercise, May 2008 Community containment tabletop exercise, June 2008 Updates to the Plan were accomplished and all existing legislation, emergency response plans and protocols were identified that supported the execution of Guam’s Pandemic Influenza Plan. A separate chapter was developed to include Guam’s established response protocols for critical infrastructure protection & key resources management – Chapter 11, Critical Infrastructure & Key Resources. On July 8, 2008, Guam submitted its revised Pandemic Influenza Plan and the supporting response plans above to the US Government for final review. Through timely communication, education, training, exercises, procurement and stockpiling of necessary materials, the Plan will strive to reduce the morbidity and mortality of Guam’s residents and to minimize the pandemic’s overall economic and societal impact to the island. PURPOSE. The purpose of this Plan is to provide guidance for the Territory of Guam in preparing for and responding to an influenza pandemic or other infectious ii disease outbreak. If confronted with an influenza pandemic, the priorities of the Territory will be to assure the continuation and delivery of essential services while providing assistance to meet the emergency needs of the population. The Plan describes disease surveillance and detection in human populations; health care; emergency medical services; vaccine and antiviral delivery; community education campaigns and risk communication activities; community containment measures; medical surge contingencies; and mass fatality management, establishing the framework and guidelines for ensuring that the preservation of human life and the sustainment of critical infrastructure and key resources are given the highest priority. POLICIES: A. The priorities of this Plan are to reduce the loss of life, reduce illness or injury, maintain vital services, and reduce economic loss and societal impact. B. This Plan will be made available to the general populace for their information and preparedness planning. C. All non-governmental organizations and private entities are encouraged to use the Plan for their information, preparation and development of their respective Continuity of Operations Plan (COOP). D. All Government of Guam agency directors shall have a working knowledge of this Plan and their identified roles. E. Territorial resources will be utilized to the greatest extent possible before requesting assistance from federal sources. F. This Plan will be coordinated with the National Response Plan (NRP) and the National Incident Management System (NIMS). BACKGROUND. Influenza viruses are unique in their ability to cause infection in all age groups on a global scale. In addition to the highly transmissible nature of influenza, the virus can change its antigenic structure, resulting in novel sub-types that have never occurred in humans before. Major shifts in the viral sub-types are associated with influenza pandemics. The 1918 influenza pandemic caused more than 20 million deaths worldwide and caused the death of approximately 5% of Guam’s population (this would be equivalent to approximately 8,400 deaths on Guam today). The pandemics of 1957 and 1968 resulted in lower mortality rates due in part to antibiotic therapy for secondary bacterial infections and more aggressive supportive care. They both, however, were associated with high rates of morbidity and social disruption. Pandemic influenza is a unique public health emergency and community disaster. It is considered a highly probable and inevitable event that no one can predict when it will occur. Most experts agree there will be at least one to six months between identification of a novel virus and widespread outbreaks in the United States. Outbreaks will occur simultaneously throughout the United States and the effect on individual communities may last from six to eight weeks or more. Depending on where the pandemic starts, Guam may be affected sooner or later than the continental United States. By definition, a pandemic is defined as a global event with three qualifying conditions needing to be met: (1) sustained human to iii human transmission, (2) no immunity within the population, and (3) no available vaccine. In reality, a pandemic is a local crisis worldwide. It can happen in every state and every city and every town at almost the same time. Pandemic influenza has the potential of affecting all elements of society. A large number of cases will add a burden to hospitals and other health care systems already stressed with the normal day to day crisis. Mortality is usually markedly increased. Health and medical personnel as well as other infrastructure workers (i.e. law enforcement, fire, public works) will not be immune. The effects on our community could be staggering. ASSUMPTIONS: For planning purposes, the following assumptions are made: A. Susceptibility to the pandemic influenza virus will be universal. B. Efficient and sustained human to human transmission signals an imminent pandemic. C. The clinical disease attack rate will likely be 30% or higher in the overall population during the pandemic. Illness rates will be highest among school-aged children (about 40%) and decline with age. Among working adults, an average of 20% will become ill during a community outbreak. Some persons will become infected but not develop clinically significant symptoms. Asymptomatic or minimally symptomatic individuals can transmit infection and develop immunity to subsequent infection. D. Of those who become ill with influenza, 50% will seek outpatient medical care. With the availability of effective antiviral drugs for treatment, this proportion may be higher in the next pandemic. E. The number of hospitalizations and deaths will depend on the virulence of the pandemic virus. Estimates differ about 10-fold between more and less severe scenarios. Two scenarios are presented based on extrapolation of past pandemic experiences. Planning should include the more severe scenario. Risk groups for severe and fatal infection cannot be predicted with certainty but are likely to include infants, the elderly, pregnant women, and persons with chronic medical conditions. F. Rates of absenteeism will depend on the severity of the pandemic. In a severe pandemic, absenteeism attributable to illness, the need to care for ill family members and fear of infection may reach 40% during the peak weeks of a community outbreak, with lower rates of absenteeism during the weeks before and after the peak. Certain public health measures (closing schools, quarantining household contacts of infected individuals, “typhoon days”) are likely to increase rates of absenteeism. G. The typical incubation period (interval between infection and onset of symptoms) for influenza is approximately 2 days. H. Persons who become ill may shed virus and can transmit infection for up to one day before the onset of illness. Viral shedding and the risk of transmission will be greatest during the first 2 days of illness. Children usually shed the greatest amount of virus and therefore are likely to post the greatest risk for transmission. iv I. On the average, infected persons will transmit infection to approximately two other people. J. In an infected community, a pandemic outbreak will last about 6 to 8 weeks. K. Multiple waves (periods during which community outbreaks occur across the country) of illness could occur with each wave lasting 2-3 months. Historically, the largest waves have occurred in the fall and winter, but the seasonality of a pandemic cannot be predicted with certainty. In addition to the above assumptions, it is felt there may be as little as one to six months warning before outbreaks begin in the U.S. and Guam, if the pandemic emerges in another country. The pandemic may occur during time periods not normally associated with our usual influenza season, and the pandemic strain may attack categories of people at different rates than those that normally occur during typical influenza seasons. RESPONSIBILITIES: Specific preparation and response activities of each of the various Government of Guam and partner agencies are outlined below. Each Government of Guam agency shall have a COOP to include: 1. Lines of succession; 2. Scaling back of routine operations; 3. Identifying and maintaining essential operations; 4. Procurement and stockpiling of materials and supplies for essential operations; 5. Identifying mission essential and nonessential personnel by position and task. Government agencies should also be prepared to provide a personnel inventory by essential and non-essential categories to the Emergency Operations Center (EOC) at the Guam Homeland Security/Office of Civil Defense (GHS/OCD). Government of Guam personnel that do not serve a primary response role or who are not identified by their agencies as mission essential may, at the direction of the Incident Commander (IC) at the EOC, be activated to provide support to other agencies. The following represents key government and non-governmental agencies and their primary responsibilities during a pandemic response. A. DEPARTMENT OF AGRICULTURE (DoAg) will: 1. Put forth a coordinated plan ensuring the animal agricultural businesses are prepared to respond to emerging zoonotic viral strains. 2. Continue to keep abreast of developments of zoonotic viral strains that appear and are reported in the agricultural community. 3. Conduct educational campaigns in response to increased reports concerns of animal to human transmission of diseases. 4. Conduct surveillance activities of closely monitored livestock. 5. Conduct prevention activities to educate the community on procedures and measures to safeguard their livestock and pets. 6. Ensure laboratory activities to conduct confirmation testing are in place either off or on island. B. DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES (DPHSS) will: 1. Continue to facilitate meetings of the Pandemic Planning Task Force to coordinate pandemic planning efforts between different segments of the community. v 2. Conduct surveillance and detection activities as outlined in the Plan. 3. Upon determination of an imminent threat of an illness or health condition, seek an Executive Order from the Governor of Guam declaring a public health emergency to activate territorial resources for response as described in the Emergency Health Powers Act (Guam Public Law 26-173) and the Guam Pandemic Influenza Plan. 4. Assume, unless otherwise directed, the role of IC at the EOC and provide leadership to other agencies and resources in the management of a public health emergency. 5. Activate the Department Operations Center (DOC) to provide command and control of all public health response activities as well supporting requests for assistance from the IC at the EOC. C. GUAM VISITORS BUREAU (GVB) will: 1. Put forth a coordinated plan that ensures the visitor industry is prepared to address tourist related concerns such as returning to their country of origin or unable to return to their country of origin. The coordination of this plan will involve the Guam Hotel and Restaurant Association (GHRA), tour agents, travel agents, airlines, and consulate offices, as needed. 2. Coordinate efforts to meet the basic needs (food, water, shelter, communication, medications) of all tourists unable to return to their country of origin. 3. Coordinate hotel resources to have all remaining tourists transferred into a single hotel to minimize the number of employees required to staff this operation thereby minimizing the need for the unnecessary use of resources. 4. Coordinate efforts to address the safe disposal or repatriation of human remains. 5. Coordinate with the Guam Chamber of Commerce, GHRA, Guam Economic Development and Commerce Authority (GEDCA) and other stakeholders for the development of a plan to address the revival of the economy. D. GUAM POLICE DEPARTMENT (GPD) will: 1. Coordinate all law enforcement agencies that will fall under the purview of the Chief of Police. 2. Implement a coordinated plan to ensure sufficiency of resources for law enforcement activities. E. GUAM MEMORIAL HOSPITAL AUTHORITY (GMHA) will: 1. Put forth a coordinated plan to address and implement home health care and medical surge capacity to include coordination with other government agencies, Guam National Guard (GNG), Guam Medical Society (GMS), Guam Nurses Association (GNA) and private health clinics. 2. Maintain and activate the Emergency System for Advanced Registration of Volunteer Healthcare Professionals (ESARVHP) as necessary. F. GUAM FIRE DEPARTMENT (GFD) will: 1. Put forth a coordinated plan to ensure sufficiency of resources for vi pre-hospital emergency medical services. 2. Support the efforts of the DPHSS in mass vaccination activities. 3. Act as a point of contact for psychosocial support. G. GUAM PUBLIC SCHOOL SYSTEM (GPSS) will: 1. Put forth a coordinated plan for the use of their facilities as quarantine/isolation sites and medical surge overflow sites. 2. Provide social work, counseling and nursing personnel support in accordance with the Plan. J. GUAM INTERNATIONAL AIRPORT AUTHORITY (GIAA) will: 1. Put forth a coordinated plan with airline companies through the Airport Operations Committee (AOC) to support enhanced pandemic surveillance, isolation and quarantine efforts. 2. In accordance with 42 CFR 71, identify an on-site isolation room. 3. Coordinate with DPHSS for implementation of the Plan for the isolation and quarantine of affected crew and arriving passengers. H. CONSOLIDATED COMMISSION ON UTILITIES (CCU) will: 1. Put forth a coordinated plan to ensure adequate and continuous services for all utilities. 2. Include in their coordinated plan, a priority restoration list to support the various pandemic response activities in the event of utility outages. 3. Develop a plan to defer consumer payments for the duration of the emergency and, for a reasonable period afterward, to allow for recovery and re-employment, in consideration of potential unemployment or furloughs. I. MAYORS COUNCIL OF GUAM (MCG) will: 1. Put forth a coordinated plan to liaise and support pandemic response efforts within their community, to include use of village resources as outlined in the Emergency Health Powers Act (Guam Public Law 26173). 2. Assist in identifying persons in their community who are isolated or atrisk. K. PORT AUTHORITY OF GUAM (PAG) will: 1. Put forth a coordinated plan with shipping companies to support enhanced pandemic surveillance, isolation and quarantine efforts. 2. In accordance with 42 CFR 71, identify an on-site isolation room. 3. Coordinate with DPHSS for the implementation of the Plan for the isolation and quarantine of affected arriving crew and passengers. 4. Coordinate with shipping companies for the use of refrigerated containers as temporary morgues. L. GUAM CUSTOMS AND QUARANTINE AGENCY (CQA) will: 1. Put forth a coordinated plan to support enhanced pandemic surveillance, isolation and quarantine efforts. 2. Coordinate with DPHSS for implementation of the Plan for the isolation and quarantine of affected crew and arriving passengers. vii M. DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE (DMHSA) will: 1. Put forth a coordinated plan to ensure their consumers are provided with adequate and continuous services, to include medication supplies and distribution. 2. Ensure adequate staffing for continuity of services. 3. Receive referrals from the Plan’s Psychosocial Individual and Family Support (IFS) Team and provide services for individuals in need of greater psychosocial intervention. 4. Provide social work and counseling support to the DPHSS Psychosocial Support Team in accordance with the Plan. N. GUAM HOMELAND SECURITY/ OFFICE OF CIVIL DEFENSE (GHS/OCD) will: 1. Activate and operate the Territory’s EOC. 2. Facilitate the coordination and provision of resources identified by IC and as needed by public health and safety authorities to cope with the emergency. O. AMERICAN RED CROSS will coordinate with the IC at the EOC for the implementation of their emergency response functions as outlined in the NRP. P. GUAM CHAMBER OF COMMERCE will: 1. Coordinate with GVB and the Small Business Administration (SBA) for the education and support of the business industry in the development of a pandemic response plan. 2. Be solicited for their assistance and participation in coordinating pandemic response activities for the business community. 3. Coordinate with the GHRA, GEDCA, GVB, and other stakeholders for the development of a plan to address the revival of the economy. 4. Coordinate for the pandemic education and awareness of their employees and consumers. Q. GUAM HOTEL AND RESTAURANT ASSOCIATION (GHRA) will: 1. Coordinate with the Guam Chamber of Commerce, GEDCA, GVB and other stakeholders for the development of a plan to address the revival of the economy. 2. Put forth a coordinated plan to ensure adequate staffing and resources for continuity of services. 3. Coordinate for the pandemic education and awareness of their employees and consumers. R. GUAM NATIONAL GUARD (GNG) will, once activated by the Governor, respond to and support all Requests for Assistance (RFA) from the EOC. S. U.S. AIR FORCE will: 1. Continue to provide health and medical services to their active-duty military members, their dependents and other authorized personnel. 2. Follow Department of Defense (DoD) protocols for influenza pandemic response. 3. Support the local civilian government’s pandemic response efforts, as appropriately authorized by regulations, policies or agreements. viii T. U.S. NAVY will: 1. Continue to provide health and medical services to their active-duty military members, their dependents and other authorized personnel. 2. Follow DoD protocols for influenza pandemic response. 3. Support the local civilian government’s pandemic response efforts, as appropriately authorized by regulations, policies or agreements. DPHSS and the Pandemic Planning Task Force will continue to review and coordinate the planning and response efforts among its members along with key stakeholders necessary to effectively mobilize pandemic response activities. As identified, the roles of other agencies and organizations may be included in the future. CONCEPT OF OPERATIONS. The Department of Health and Human Services’ (DHHS) Five Primary Objectives: 1. 2. 3. 4. 5. Monitoring disease spread to support rapid response. Developing vaccines and vaccine production capacity. Stockpiling antivirals and other countermeasures. Coordinating federal, state and local preparation. Enhancing outreach and communications planning. The DPHSS Director shall assume command for directing the response to the influenza pandemic. At the point where resources outside DPHSS are needed or the provision of essential community services are being affected as a result of the pandemic, the DPHSS Director with the guidance and assistance of the Pandemic Influenza Committee (PIC) will recommend to the Governor for the activation of the EOC. The EOC shall be utilized to track missions, acquire resources, document costs, and coordinate response activities among the major territorial agencies/organizations. The general methods of operation shall be undertaken as provided in this Plan and the Guam Emergency Response Plan (GERP). In responding to the influenza pandemic, the DPHSS will have lead responsibility and the OCD (the State Emergency Management Agency) will have a support role. If emergency powers are needed, the DPHSS Director, in consultation with the PIC, shall draft a Governor’s Executive Order declaring that a state of public health emergency exists and specifying the emergency powers necessary or appropriate to cope with the emergency. If it appears that significant expenditures will be required to respond to this emergency, the DPHSS Director and the GHS Advisor will jointly recommend, and the Governor will request, a presidential disaster declaration. If granted, this declaration may make federal funding and resources available. In addition to public health, the general strategy of the plan is to protect the infrastructure to ensure the health and medical community, as well as government and private business, will continue to function. This decision will require the allocation and redirection of scarce resources where needed to maintain the optimal functioning and health of society. EMERGENCY MANAGEMENT PLAN: The GHS/OCD prepares and maintains a comprehensive GERP which provides for an emergency management system that includes a broad range of preparedness, response, recovery, and mitigation responsibilities for a variety of emergency or ix disaster scenarios. The Plan will be included into the GERP. The OCD coordinates with local and federal elected officials and liaises with agency heads and cabinet officers, providing a key link with the Governor and key staff. When an emergency or a disaster overwhelms local governmental resources, assistance may be requested from federal resources through the OCD. Response Activity Coordinators (RACs) are typically recalled to the EOC in response to an emergency or disaster. The RAC consists of representatives from core Government of Guam agencies, voluntary organizations, and the military organizations on island. The EOC, in almost all disasters, maintains direction and control while serving as the central clearinghouse for disaster-related information and requests for assistance from local government, private businesses and community members at large. After the island or an area within the island has been impacted by a major disaster, the Government of Guam continues to provide support to local communities through response and recovery operations. In the case of presidential declared disasters, the federal and local governments jointly coordinate recovery efforts from a Disaster Field Office. PANDEMIC PHASE CHART. Pandemic planning is divided into several phases, from early identification of a novel virus to resolution of pandemic cycling. These phases are determined and announced by CDC in collaboration with the WHO. The Guam Pandemic Influenza Plan follows the same phase guidelines, prescribing necessary activities and identifying responsible parties by pandemic phase. These declared and defined phases will help ensure a consistent and coordinated response by national, state, and local agencies in the event of an influenza pandemic event. The intent is for all activities listed in this document to be initiated during the assigned pandemic phase. Some activities will, of course, continue during subsequent phases. The pandemic phase table is based on the phases outlined in WHO’s “Global Influenza Preparedness Plan”, Geneva, Switzerland, 2005. WHO PANDEMIC PHASES PERIOD DEFINITION PHASE 1 Interpandemic Period No indication of any new virus types. PHASE 2 Interpandemic Period New virus type detected in animals but not in humans. PHASE 3 Pandemic Alert Period New influenza strain in a human but no (or rare) human-to-human spread. PHASE 4 Pandemic Alert Period Small cluster(s) with transmission anywhere. PHASE 5 Pandemic Alert Period Larger cluster(s) of human-to-human transmission but still localized to a single country/region. PHASE 6 Pandemic Period Increased and sustained human-to-human transmission in the general population. PostPandemic Period Pandemic transmission over, likely 2-3 years after onset; immunity to new virus type is widespread in the population. limited human-to-human x STATUTORY AUTHORITY: Statute: Agency: Authority: Chapter 68. Title 42 Federal Government provides authority to declare and respond to emergencies and provide assistance to protect public health; implemented by the Federal Emergency Management Agency Statute: Agency: Authority: Section 361(b) of the Public Health Service Act (42 U.S.C. 264 (b)) Federal Government control of communicable diseases as determined by the Secretary of Health, in consultation with the Surgeon General Statute: Agency: Authority: 10 GCA, Chapter 19, Emergency Health Powers Act, Article 4, Section 19401 Governor allows Governor to declare a state of Public Health Emergency Statute: 10 GCA, Chapter 3, Article 3, Disease Control, and Chapter 19, Emergency Health Powers Act, Article 3, Section 19301 Department of Public Health and Social Services authorizes the department to administer and enforce laws and rules relating to control of communicable diseases Agency: Authority: Statute: Agency: Authority: 10 GCA, Chapter 19, Emergency Health Powers Act, Article 5 Department of Public Health and Social Services special powers during a State of Public Health Emergency: Management of Property Statute: Agency: Authority: 10 GCA, Chapter 19, Emergency Health Powers Act, Article 6 Department of Public Health and Social Services special powers during a State of Public Health Emergency: protection of persons, including isolation and quarantine Statute: Agency: Authority: 10 GCA, Chapter 19, Emergency Health Powers Act, Article 7 Department of Public Health and Social Services public information regarding Public Health Emergency Statute: Agency: Authority: 10 GCA, Chapter 19, Emergency Health Powers Act, Article 8 Department of Public Health and Social Services conditions to address financing and expenses during a Public Health Emergency Response xi COMMAND AND CONTROL SECTION 1.0 INTRODUCTION This section defines the command and control of operations in response to a pandemic influenza, including: ƒ Authority for the required actions. ƒ How the overall response follows an Incident Command System (ICS) that is compliant with the NIMS. ƒ Role of the DPHSS as the lead agency in the island’s public health response to an influenza pandemic. ƒ Roles and responsibilities of DPHSS partner agencies at the federal and local levels. ƒ DPHSS personnel who will act as liaisons with the Command and Control Function. SECTION 2.0 AUTHORITY A. The cornerstone of Guam’s ability to respond to emergencies and disasters is the GERP. This Plan: ƒ ƒ Provides guidance in preparing for and reacting to threats from natural and man-induced emergencies and disasters, including Terrorism and Weapons of Mass Destruction, and war-related threats. Provides a mechanism for government-wide coordination and integrity, especially in aspects of authority, responsibility administrative capabilities. and B. The Governor is responsible for the direction and control over all emergency management activities on Guam. The Governor will designate the DPHSS Director or his/her designee as the lead public health authority on the island who will be responsible for officially activating the Plan. (10 GCA Health & Safety Div. 1 – Public Health; Chapter 19 Emergency Health Powers) C. DPHSS is the overall authority in charge of coordinating with GMHA for the medical response during a public health emergency, in collaboration with the OCD/EOC. D. At the point where resources outside the DPHSS are needed, or the basic infrastructure of Guam is being affected as a result of the pandemic, the assistance of agencies’ support shall be sought. SECTION 3.0 DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES A. DPHSS has overall responsibility and authority for management of any public health emergency in the island, including a pandemic influenza. B. During a pandemic, DPHSS will establish a DOC, which will communicate with the EOC to manage the pandemic and requests for resources. The DOC will be located at the Division Guam Pandemic Influenza Plan Command and Control xii of Senior Citizens (DSC) Conference Room in Mangilao. requirements for the implementation of the Plan. 1. The Division of Public Health within DPHSS will manage the overall pandemic response effort until such time that the DOC is activated. G. DPHSS Public Information Officer (PIO) – Risk Communications 2. The DPHSS DOC will coordinate, when activated and as appropriate, all public health support requirements for the response effort. C. Based on decisions made previously for preparedness plans, current information and any existing or new national guidelines, DOC will establish indications for use and prioritize preventive medications or vaccines to be dispensed, if available. D. DPHSS leadership will designate personnel required to provide support to DPHSS DOC activities and liaise with other partner response agencies. E. DPHSS DOC Incident Commander 1. The DOC IC will collaborate with the OCD Director at the EOC on health and medical matters related to the pandemic. 2. The DOC IC will support the activities of the Community Health Centers. F. Liaison Officer - Civil Defense Coordinator (RAC – Response Activity Coordinator) will coordinate reciprocal updates between DPHSS and OCD/EOC regarding ongoing response activities and will identify DPHSS resource 1. Responsible for coordinating all public information messages, coordinating with the news media, and will be the point of contact for media interview and information requests. 2. Responsible for implementing the DPHSS Risk Communications Plan. 3. Will either lead or assist with monitoring the flow of real-time information from and among the different response partners in a Joint Information Center (JIC) setting established at EOC. H. Planning Chief will head the planning section and will be responsible for the planning and delegation of roles and responsibilities for multi-agency support to effectively manage the pandemic flu response effort. I. Operations Chief 1. Will head the operations section which includes the following branches: Utilities/Infrastructure Management; Law Enforcement; Emergency Medical Services (EMS); Public Health/Medical; Public School System. 2. Responsible for coordination of all response activities as identified by the IC. Guam Pandemic Influenza Plan Command and Control xii J. Logistics Chief 1. Responsible for ensuring the availability and distribution of adequate supplies, facilities, ground support, and communications and information technology hardware and software. 2. Oversees the services requested of and provided by various government response agencies as directed and authorized by the EOC. 3. Responsible for the staging area for emergency response personnel and equipment/vehicles. SECTION 4.0 FEDERAL PARTNERS A. The availability of federal, military, and related support during a response to an influenza pandemic in Guam will not be certain until the time of the event and will depend on a federal decision to approve allocation of resources during a response in support of Guam’s effort. B. Request for federal assistance will be through the Governor. A DPHSS DOC request will be communicated through the DPHSS Liaison Officer/RAC. SECTION 5.0 LOCAL PARTNERS K. Finance Chief 1. Responsible for coordinating all human resources support for all personnel assigned to the response effort. 2. Responsible for tracking labor costs such as payroll or contractors, if applicable. 3. Responsible for logging all expenditures to substantiate claims for possible future Federal funding reimbursement. 4. Responsible for tracking and processing all requisitions and purchase orders relating to response activities. 5. Oversees volunteer management and resources. A. Request for local assistance will be through the EOC. A DPHSS DOC request will be communicated through the DPHSS Liaison Officer/RAC. B. Support from other agencies and the Governor will mirror what is outlined in the Guam Emergency Response Plan. C. Among local partners include: the GNG, Office of the Attorney General (AG), Department of Administration (DoA) to include General Services Agency (GSA), GPSS, Department of Public Works (DPW), GFD, GPD, CQA, and MCG. D. Request for local businesses assistance will be through the EOC. A DPHSS DOC request will be communicated through the DPHSS Liaison Officer/RAC. Guam Pandemic Influenza Plan Command and Control xiii SECTION 6.0 PANDEMIC PHASE RESPONSE A. Phases 1-3, all government agencies are developing preparedness and response plans for a pandemic influenza under the umbrella of DPHSS. An island-wide Pandemic Influenza Plan will be developed to incorporate all plans. The Plan will be periodically exercised, reviewed and revised according to WHO/CDC pandemic updates. B. Phases 4-5, all government agencies and key stakeholders are in stand-by mode in anticipation of an emergency declaration by the Governor. C. Phase 6, The DPHSS Director or his/her designee as the IC and as the lead Public Health Authority (PHA) on the island will be responsible for officially activating the Plan. (10 GCA Health & Safety Div. 1 – Public Health; Chapter 19 Emergency Health Powers). Guam Pandemic Influenza Plan Command and Control xiv Command and Control Algorithm Guam Pandemic Influenza Plan Public Health Incident Commander Liaison Response Activity Coordinator (RAC) Pandemic Influenza Committee Finance Officer Documentation Officer Health and Safety Officer Logistics Officer Operations and Planning Information System Environmental Epi/Surveillance PIO/Risk Communications Lab EMS Clinical/ Medical Attachment Command and Control A CHAPTER 1 EMERGENCY AND COMMUNTIY HEALTH OUTREACH PLAN SECTION 1.0 INTRODUCTION The Guam Emergency and Community Health Outreach (ECHO) Plan will utilize the following strategy in the different phases of pandemic influenza preparedness to promote and increase awareness of the potential impact of pandemic influenza on Guam as well as increase levels of prepandemic preparedness. Team ECHO, located in the Health Education Section, DPHSS, is responsible for the implementation of the ECHO Plan as directed by the DPHSS Director and later as part of the JIC. The ECHO Plan currently implements and will continue to apply an Intervention Strategy Matrix. See Attachment 1-A SECTION 2.0 GOAL During the project period, approximately 126,000, or 80%, of Guam’s population shall have attended a pandemic influenza orientation or received pandemic influenza information on how to develop and implement an individual and family emergency preparedness plan. SECTION 3.0 ECHO OBJECTIVES Conduct presentations at each of the 19 village mayor’s offices. The first presentation was done in July 2006 at a MCG meeting in which eight mayors attended. An Isolation and Quarantine Tabletop Exercise was conducted in August 2006 in which three mayors participated. The remaining 11 mayors will be requested to have presentations at their offices either for the general village population and/or their office staff. Maintain a directory of locations where presentations were conducted including points of contact (liaisons). Presentations will be conducted beginning with the 14 agencies listed in the Governor’s Executive Order 2006-11 and continue on to other Government of Guam agencies, boards and commissions. Prepare and transmit a letter informing all Government of Guam agencies, per the most updated Government of Guam Protocol Listing, of the importance of Pandemic Influenza Awareness/Preparedness and how to request and schedule a presentation(s) with DPHSS. Prepare and transmit a flyer informing the general public of the importance of Pandemic Influenza Awareness and Preparedness on how to request and schedule a presentation(s). Encourage agencies and other organizations to economically distribute copies of the pandemic influenza materials to their respective staff participating in presentations. Notify organizations of the opportunity to utilize pandemic influenza Computer-Based Training (CBT) curriculum at the worksite. Pandemic influenza inserts were provided with employee payroll check stubs at the Courts of Guam and Guam Legislature. Subsequent presentations were conducted at the Courts thereafter. Notify organizations that DPHSS can provide materials, which can be used for producing copies for internal distribution, thus minimize DPHSS printing costs. Provide CBT curriculum to organizations to train/cross-train new employees in workplaces. Conduct pandemic influenza presentations to at least five faith-based umbrella organizations (e.g. Ministerial Association of Guam, the Archdiocese of Agana (includes groups like Parish Councils, Christian Mothers of Guam), Knights of Columbus, and Catholic Daughters of the Americas). Collaborate with the JIC through the OCD to include the ECHO Plan as part of the development of an overall emergency preparedness campaign for Guam. Request OCD network to have brochures, pamphlets translated. Collaborate with the American Red CrossGuam Chapter to identify related preparedness materials that can be reproduced and included with existing pandemic influenza resources. Team ECHO will develop at least two brochures, pamphlets, or flyers on pandemic influenza that are low literacy, culturally sensitive, and age appropriate. Continue to review and collect various types of pandemic influenza materials as additional resources. Collaborate with the Guam Risk Communication Coordinator to determine if the Guam Pandemic Influenza materials need updating. Team ECHO will prepare and concurrently submit to the Governor’s Pandemic Planning Task Force for approval. Transmit pandemic influenza materials to OCD for possible translation and pilot test newly developed materials. Submit for inclusion onto Government of Guam website. DPHSS Conduct presentations with three umbrella industries, specifically financial, telecommunication and retail. Conduct pandemic influenza presentations with at least six professional organizations like the Guam Chamber of Commerce, the Guam Federation of Teachers, GHRA, GMS, and the Guam Dental Society. SECTION 4.0 RESPONSE ACTIVITIES ƒ Direct communication dissemination from DPHSS to print, broadcast or other media. ƒ Disseminate information to educate the general public on the risks of disease exposure and an effective public response. ƒ Direct all communication dissemination through the JIC. SECTION 5.0 PARTNER AGENCIES All broadcast and print media organizations as requested or required by Federal law (i.e. Federal Communications Commission); the Crisis Hotline, local telephone help lines, and other appropriate partners. Every group and organization that have been given presentations to are requested to have Guam Pandemic Influenza Plan 1-2 a liaison. This individual will train and provide materials to any new members in their organizations to maintain 100% trained personnel and continuity of awareness, information, and preparedness. Liaisons will be requested to report all sessions conducted thereafter. The number of web information downloads will also be tracked through partners which host our program link. or 2-way radios, digital broadcast radios, and accessible cable television, color copiers, paper shredder, maps and charts, easel pads stand, large chalkboards or dry erase boards, audio-visual equipment, teleconferencing equipment, and supplies. ƒ Pandemic Influenza Brochure (Local) (See Attachment 1-B) SECTION 6.0 PERSONNEL NEEDS ƒ Individuals and Families Planning Checklist with statement to increase CDC two-week stockpiling to three-six months (See Attachment 1-C) ƒ “Cover Your Cough” Green (See Attachment 1-D) ƒ “Cover Your Cough” Red (See Attachment 1-E) ƒ “Be a Germ Stopper” (See Attachment 1-F) ƒ Pandemic Influenza Presentation Evaluation Form (See Attachment 1-G) The ECHO Plan identifies the utilization of the DPHSS health educators (Health Education Section, Women Infants Children (WIC) Program, STD/HIV Prevention Program, Diabetes and Tobacco Prevention and Control Programs, Maternal and Child Health Program, Breast and Cervical Cancer Early Detection Program, etc.) as required. Additionally, GPSS health and physical education teachers are another viable resource group to be trained as personnel who can participate and assist in educating school students and the general public. Another potential group can be the UOG Health, Physical Education, Recreation and Dance (HPERD) students. SECTION 7.0 FACILITY, EQUIPMENT, AND MATERIAL NEEDS Team ECHO requires a facility with sufficient workspace, cooking appliances, power, water, and toilet/shower access for several staff as assigned The availability of high or low technology equipment (eg. personal protective equipment (PPE), facsimile machines, computers with printers, cellular telephones Guam Pandemic Influenza Plan 1-3 PANDEMIC PHASES WHO PHASE 1: INTERPANDEMIC PERIOD ƒ DPHSS … Purchase or print the Individual and Family Pandemic Influenza Awareness and Planning Materials identifying potential impact on Guam and develop a system for rapid communication dissemination. … Develop and begin to conduct pandemic influenza awareness presentations at the different Government of Guam agencies and other organizations as scheduled. Presentations directly or indirectly commenced at the offices of the 19 village mayors and at the offices of task force members identified in Governor’s Executive Order 2006-11. WHO PHASE 2: INTERPANDEMIC PERIOD ƒ DPHSS … Prepare lists (i.e., Questions & Answers on Pandemic Influenza) for general public as required. … Continue preparations, and coordination for presentations on Pandemic Influenza. Develop print and broadcast templates for public information releases. WHO PHASE 3: INTERPANDEMIC PERIOD ƒ DPHSS … Prepare lists (i.e., Questions & Answers on Pandemic Influenza) for general public as required. … Continue presentations, preparation for/coordination of presentations on pandemic influenza. In addition DPHSS will develop templates for public information releases (print and broadcast). WHO PHASE 4: PANDEMIC ALERT PERIOD ƒ DPHSS … Coordinate with local agency or organization liaisons to conduct additional presentations as needed. … Continue presentations and enhancement of public education on hygiene etiquette (coughing, hand-washing, etc.). Guam Pandemic Influenza Plan 1-4 WHO PHASE 5: PANDEMIC ALERT PERIOD ƒ DPHSS … Communicate with JIC for more targeted/frequent information updates to public on the disease. Guidance on self-care for those sick at home. Preparation of updated crowd avoidance and school closure advisories. … Continue development and issuances of travel advisories (local or global) and special needs advisories. WHO PHASE 6: PANDEMIC PERIOD ƒ DPHSS … Enhance communication(s) with the JIC for more targeted and frequent information updates to the general public on the disease and precautions to minimize additional pandemic influenza waves on-island. … Provide enhanced dissemination of guidance on the care or self-care of those sick at home and crowd avoidance advisories. Also DPHSS will continue the development and issuances of travel advisories (local or global) to include special needs advisories as required or recommended to minimize the export of disease to other islands in Micronesia or beyond. Guam Pandemic Influenza Plan 1-5 Emergency and Community Health Outreach (ECHO) Plan Intervention Strategy Matrix I Ecological Level/Strategy Individual/Family Awareness and Behavioral Changes Theories Precaution Adoption Process Model Health Belief Model Educational Session/Meetings/Conferences/Interactive Outreaches/Health Fairs/Displays-Kiosks II Community Awareness and Environmental Changes Communication Theory Media Advocacy Campaigns Advocating Changes to Organization Policy Interpersonal Health Intervention (Down-N-Dirty) Social Cognitive Theory National Cancer Institute, US DHHS, “Theory at a Glance, A Guide for Health Promotion Practice”, Spring 2005. Attachment 1-A && & & % % ! ! 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You should know both the magnitude of what can happen during a pandemic outbreak and what actions you can take to help lessen the impact of an in?uenza pandemic on you and your family. This checklist will help you gather the information and resources you may need in case of a ?u pandemic. 1. To plan for a pandemic: Store a supply of water and food. During a pandemic, if you cannot get to a store, or if stores are out of supplies, it will be important for you to have extra supplies on hand. This can be useful in other types of emergencies, such as power outages and disasters. CI Ask your doctor and insurance company if you can get an extra supply of your regular prescription drugs. Have any nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, ?uids with electrolytes, and vitamins. CI Talk with family members and loved ones about how they would be cared for if they got sick, or what will be needed to care for them in your home. CI Volunteer with local groups to prepare and assist with emergency response. CI Get involved in your community as it works to prepare for an in?uenza pandemic. 2. To limit the spread of germs and prevent infection: Teach your children to wash hands frequently with soap and water, and model the current behavior. CI Teach your children to cover coughs and sneezes with tissues, and be sure to model that behavior. CI Teach your children to stay away from others as much as possible if they are sick. Stay home from work and school if sick. Ilia a Willi/A Attachment 1-C-1 A Guide for Individuals and Families 3. Items to have on hand for an extended stay at home: Examples of food and non-perishables Examples of medical, health, and emergency supplies Ready?to-eat canned meats fruits, vegetables and soups Protein or fruit bars Dry cereal or granola Peanut butter or nuts Dried Fruit Crackers Cannedjuices Bottled water Cl Canned orjarred baby food and formula Pet food Prescribed medical supplies such as glucose and blood-pressure monitoring equipment Soap and water, or alcohol?based hand wash Medicines for fever, such as acetaminophen or ibuprofen Thermometer Anti?diarreal medication Vitamins Fluids with electrolytes Cleansing agent/soap Cl Flashlight CI Batteries Portable radio Manual can opener Garbage bags Tissues, toilet paper, disposable diapers A Guide for Individuals and Families SERVIC 8.9.0 - 0 Bl: lorlndivillualsafamilies BE 4 of A1184 You can prepare for an in?uenza pandemic now. You should know both the magnitude of what can happen during a pandemic outbreak and what actions you can take to help lessen the impact of an in?uenza pandemic on you and your family. This checklist will help you gather the information and resources you may need in case of a ?u pandemic. 1. To plan for a pandemic: Store a supply of water and food. During a pandemic, if you cannot get to a store, or if stores are out of supplies, it will be important for you to have extra supplies on hand. This can be useful in other types of emergencies, such as power outages and disasters. CI Ask your doctor and insurance company if you can get an extra supply of your regular prescription drugs. Have any nonprescription drugs and other health supplies on hand, including pain relievers, stomach remedies, cough and cold medicines, ?uids with electrolytes, and vitamins. CI Talk with family members and loved ones about how they would be cared for if they got sick, or what will be needed to care for them in your home. CI Volunteer with local groups to prepare and assist with emergency response. CI Get involved in your community as it works to prepare for an in?uenza pandemic. 2. To limit the spread of germs and prevent infection: Teach your children to wash hands frequently with soap and water, and model the current behavior. CI Teach your children to cover coughs and sneezes with tissues, and be sure to model that behavior. CI Teach your children to stay away from others as much as possible if they are sick. Stay home from work and school if sick. Ilia a Willi/A A Guide for Individuals and Families 3. Items to have on hand for an extended stay at home: Examples of food and non-perishables Examples of medical, health, and emergency supplies Ready?to-eat canned meats fruits, vegetables and soups Protein or fruit bars Dry cereal or granola Peanut butter or nuts Dried Fruit Crackers Cannedjuices Bottled water Cl Canned orjarred baby food and formula Pet food Prescribed medical supplies such as glucose and blood-pressure monitoring equipment Soap and water, or alcohol?based hand wash Medicines for fever, such as acetaminophen or ibuprofen Thermometer Anti?diarreal medication Vitamins Fluids with electrolytes Cleansing agent/soap Cl Flashlight CI Batteries Portable radio Manual can opener Garbage bags Tissues, toilet paper, disposable diapers Attachment 1-C-2 A Guide for Individuals and Families SCHOOLS, DAYCARE CENTERS, MAYOR OFFICE, HOMES *XDP 'HSDUWPHQW RI 3XEOLF +HDOWK 6RFLDO 6HUYLFHV ',9,6,21 352*5$0 6(&7,21 1$0( &217$&7 180%(56 :(%6,7( ,1)250$7,21 ',6&/$,0(5 ,) $33/,&$%/( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Attachment 1-D FOR HOSPITALS, PRIVATE CLINIC, NURSING HOMES *XDP 'HSDUWPHQW RI 3XEOLF +HDOWK 6RFLDO 6HUYLFHV ',9,6,21 352*5$0 6(&7,21 1$0( &217$&7 180%(56 :(%6,7( ,1)250$7,21 ',6&/$,0(5 ,) $33/,&$%/( BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Attachment 1-E *XDP 'HSDUWPHQW RI 3XEOLF +HDOWK 6RFLDO 6HUYLFHV ',9,6,21 352*5$0 6(&7,21 1$0( &217$&7 180%(5 :(%6,7( ,1)250$7,21 BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Attachment 1-F CHAPTER 2 SURVEILLANCE RESPONSE PLAN SECTION 1.0 INTRODUCTION Established local and statewide surveillance systems are fundamental for detecting influenza activity, identifying circulating strains, and monitoring the burden of morbidity and mortality. For this plan, the term ‘Novel Virus Strain’ or ‘Novel Influenza’ includes avian or animal influenza strains that can affect humans (like the H5N1 strain), and new or re-emergent human influenza strain that can cause cases or clusters of human disease. This definition includes the H5N1 strain currently circulating in Asia and Europe, even though this strain does not appear to be capable of causing a pandemic at this time. A few of the activities in this section may also apply to some situations when there are concerns about human influenza-like illness cases epidemiologically associated with birds infected with other highly pathogenic avian influenza (HPAI) or low pathogenic strains or other animals with influenza (e.g., dogs, horses, pigs) even though transmission to humans has been infrequently or never documented previously. SECTION 2.0 OBJECTIVES ƒ Ensure early detection of cases and clusters of respiratory infections that might signal the presence of a novel influenza virus. ƒ If a novel strain of influenza is confirmed, ensure prompt and complete identification and reporting of potential cases to facilitate control and management of local outbreaks. ƒ Once a pandemic has been confirmed, monitor: Changes in the circulating virus, including development of antiviral resistance. … Impact on human health by conducting an ongoing assessment of the morbidity and mortality. … SECTION 3.0 SURVEILLANCE FOR HUMAN INFECTION The level of surveillance will depend on the global, regional, and local epidemiology of an influenza pandemic. Surveillance activities will be utilized within the framework of the pandemic phases (see section of plan that outlines the phases) as developed by the WHO. In addition, actions may be different if infections caused by a novel influenza virus occur in the United States or a neighbor country and depending on whether person-to-person spread is slow, limited or widespread. In conjunction with recommendations from other public health partners, such as the CDC or WHO, DPHSS will provide updated guidance to medical providers on an ongoing basis. Activities outlined below will be contingent on local, national, and international influenza activity at the time. The DPHSS Director is responsible for the overall direction and control of healthrelated personnel and resources committed to the control of an influenza pandemic, including surveillance and related activities. National Surveillance - In the US, national influenza surveillance is coordinated by the CDC, with state and county health departments assuming responsibility for virologic, mortality and morbidity components. These activities consist of: ƒ WHO Collaborating Laboratory Surveillance – approximately 70 labs report the number and type of influenza viruses isolated each week, as well as submits representative and unusual viral specimens to CDC for antigenic analysis. ƒ 121 Cities Influenza and Pneumonia Mortality System – Vital Statistics Offices of 121 US cities report on a weekly basis the percentage of total deaths caused by influenza and pneumonia. ƒ Sentinel Physicians Influenza-LikeIllness (ILI) Surveillance System – a voluntary national network of physicians and clinics that report number of patients presenting with ILI and total number of patient visits by age group each week. International Surveillance - These activities are coordinated at CDC by WHO Collaborating Center for Influenza Reference and Research. WHO’s Global Influenza Network includes approximately 110 national laboratories in over 80 countries and four international reference centers. The CDC maintains frequent communication with this network concerning the numbers and types/subtypes of influenza viruses isolated, including the extent of influenza-like disease occurring at the time of virus isolation. Coordinator is the Territorial Epidemiologist or designee. The Current on-going activities include: 1. A sentinel syndromic surveillance network system that reports daily and weekly Acute Respiratory Distress Syndrome (ARDS), the number of patients seen at the GMHA-ER, and the number of patients admitted to GMHAER with the diagnosis of ARDS. 2. Voluntary reporting through the DPHSS of ARDS outbreaks in institutional settings, such as long-term care facilities, schools and prisons. As part of the regional laboratory network, Guam Public Health Laboratory (GPHL) has the capacity to perform rapid testing for Influenza A and B. SECTION 3.1 COMPONENTS OF SURVEILLANCE Hospital/Healthcare Facility Surveillance Nosocomial Outbreak Reporting Acute care and long-term care facilities are required throughout the year to report any increased incidence in respiratory illness, including suspected and confirmed influenza outbreaks, to the Territorial Epidemiologist or his designee. Guam Surveillance - Routine surveillance activities on Guam are also part of the national monitoring system (items 1 and 2 below). The local Influenza Surveillance Guam Pandemic Influenza Plan 2-2 ASSESSMENT GUAM. OF INFLUENZA ACTIVITY ON Territorial Epidemiologist’s Report: Current influenza activity level throughout the island is assessed weekly. Both the local and regional influenza activity is shared with the healthcare providers (including DoD partners), Medical Examiners, and Office of Vital Statistics by means of the weekly G.E.N. or by faxed Health Alerts, as appropriate, Activity Level No Activity Sporadic Local ILI Activity/Out breaks Low ILI activity Laboratory Data And ILI activity increased above mean And Increased ILI in one village. And No Labconfirmed cases. Isolated Labconfirmed case. Recent (within the past three weeks) lab evidence of influenza in region with increased ILI in more than one region. *Regions include North, Central and South ** Institution means a school, government agency, business, etc. MORTALITY SURVEILLANCE Surveillance for Influenza and Pneumonia Deaths As part of DPHSS surveillance system for pneumonia and influenza deaths, the DPHSS Office of Vital Statistics (OVS) provides the Territorial Epidemiologist or his designee weekly reports of the total number of deaths and those with influenza or pneumonia listed as a contributing cause of death. Death Certificates All death certificates with either (1) influenza listed as the immediate cause of death, (2) death due to or as a consequence of influenza, or (3) influenza listed as a significant condition contributing to death but not the immediate cause of death are forwarded weekly to the Territorial Epidemiologist or his designee for review. SECTION 3.2 ENHANCED SURVEILLANCE ACTIVITIES Regional Increased ILI in > two villages in a single region.* And Widespread Increased ILI and/or institutional* * outbreaks (ILI OR lab confirmed) And Recent (within the past three weeks) lab confirmed influenza in the affected villages Recent (within the past three weeks) labconfirmed influenza in the island Surveillance activities will be modified based on the phase and level of influenza activity. Following is a list of enhanced influenza surveillance activities that could be initiated as needed throughout the phases of the pandemic. Outpatient Surveillance ƒ Implement provider influenza case reporting as necessary during the Pandemic Alert and Pandemic Phases prior to the Guam Pandemic Influenza Plan 2-3 novel influenza strain being identified on Guam. During the pandemic period after the virus has been identified on Guam providers may be asked to report cases of pandemic influenza with an unusual clinical presentation. It is not expected that provider individual case reporting will be a primary method for surveillance during the Pandemic Period. ƒ Implement enhanced disease surveillance at ports of entry to Guam (GIAA and PAG), if an influenza pandemic begins outside the United States. Hospital/Healthcare Facility Surveillance ƒ Modify influenza hospitalization data reporting as necessary. Data collected and frequency of reporting can be adjusted as indicated to monitor the pandemic and ensure recommended surveillance and control measures are appropriate. It is anticipated that during widespread pandemic influenza activity, hospitalization data will be the primary surveillance method used to assess severity of illness. ƒ DPHSS will collaborate and coordinate with GMHA in doing active hospital based surveillance, which may include specimen collection and virologic testing from a subset of patients. Territorial Epidemiologists Report Current influenza activity level throughout the island will continue to be assessed weekly. This weekly data assessment is shared with healthcare providers through the weekly Guam Epidemiology Newsletters (G.E.N.) or by means of Health Alert FAX as appropriate. Mortality Surveillance ƒ Expand reporting of influenza-associated deaths beyond the pediatric age group as needed based on the analysis of the current epidemiologic data and/or CDC case definitions. ƒ Provide mortality data to CDC as needed to help guide national response measures. ƒ Participate in national and international surveillance activities as indicated. SECTION 3.3 CRITERIA FOR ASSESSING AND REPORTING POSSIBLE PANDEMIC INFLUENZA CASES DPHSS will develop and distribute to healthcare providers the current CDC/WHO recommendations for enhanced surveillance, case reporting, and laboratory testing. The criteria listed below are based on the current information known about the novel H5N1 influenza virus. These criteria may need to be modified throughout the pandemic phases according to the circulating virus and the known epidemiology of the infection at that time. It is anticipated that individual case reporting will not be feasible once pandemic influenza has been confirmed on Guam. Surveillance during the pandemic period will focus on data collection mechanisms to assess morbidity and mortality. Select individual case investigations may need to be conducted to guide prevention and control recommendations. Medical Provider Activities Providers should question all patients who present to health care settings with fever and respiratory symptoms regarding possible travel and occupational exposure to Guam Pandemic Influenza Plan 2-4 Influenza A (H5N1) or other novel influenza virus. Criteria for Assessing a Possible Novel Influenza Case Worked on a farm or in a live poultry market or process or handle poultry infected with known or suspected avian influenza viruses. … Work in a laboratory that contains live animal, bird, or novel human influenza viruses. … Clinical Criteria ƒ Severe illness: Hospitalized with severe illness, including pneumonia or ARDS ƒ Healthcare worker in direct contact with suspected or confirmed novel influenza case. … Mild Illness: Criteria for Reporting Fever (temperature > 38° C or > 100.4° F); and … One or more of the following: sore throat, cough, or dyspnea. … Epidemiologic Criteria ƒ Travel Risk (Report cases within 10 days of symptom onset) Visited or lived in an area affected by HPAI A outbreaks in domestic poultry or where a human case of novel influenza has been confirmed. … ƒ During the Interpandemic and Pandemic Alert Periods and No Evidence of HPAI or Other Novel Influenza Virus on Guam, patients meeting the following clinical and epidemiologic criteria should be reported immediately to the Territorial Epidemiologist or designee: Severe illness AND, within 10 days of onset, either travel to an affected area (even if no direct contact with poultry or suspected or confirmed human cases) or occupational risk. … Mild illness AND, within 10 days of onset, one or more of the following: direct contact with ill poultry in an affected area, close contact with a suspected or confirmed human case of novel influenza, or occupational risk. … Had direct contact with poultry, in an area affected by HPAI A. Direct contact with poultry is defined as touching well, sick, or dead birds, poultry feces or contaminated surfaces, or consuming uncooked poultry. … Had close contact (within three feet) with a person with confirmed or suspected novel influenza. … ƒ Occupational Risk (Report cases with occupational risk within 10 days of symptom onset) ƒ During the Interpandemic and Pandemic Alert Periods and Documented HPAI or Other Novel Influenza Virus in animals on Guam, patients meeting the following clinical and epidemiologic criteria should be reported immediately to the local health department: … Severe or mild illness. Guam Pandemic Influenza Plan 2-5 AND Reside in or travel within 10 days of onset to a locally affected area. … AND Direct contact with ill poultry or other implicated animal in an affected area OR close contact with a suspected or confirmed human case of novel influenza OR occupational risk. ƒ During the Pandemic Period and No Documented Pandemic Influenza Virus on Guam, patients meeting the following clinical and epidemiologic criteria should be reported immediately to the local health department: investigate any unusual cases reported by medical providers. ƒ During the Pandemic Alert Period healthcare providers should immediately report any patient meeting the surveillance and reporting criteria for novel influenza to the Territorial Epidemiologist at: … … Work: Home: Mobile: ƒ 671.735.7298/7305 671.472.2780 671.888.3740 Territorial Epidemiologist will immediately notify Centers for Disease Control (www.cdc.gov.) via email on the novel influenza cases once the laboratory results has been received. Severe or mild illness. AND Within 10 days of onset travel to a locally affected area (even if no direct contact with poultry or suspect or confirmed human cases) OR occupational risk. … Once an influenza pandemic has begun, it is expected that it would only be a brief period of time before the virus is identified on Guam. Therefore it is anticipated that the period for individual case reporting of suspect cases during the pandemic will be brief. ƒ During the Pandemic Period and Documented Pandemic Influenza Virus on Guam, patients meeting the mild illness clinical criteria will be classified as a suspected pandemic influenza case. However, individual case reporting will likely be suspended. DPHSS will Guam Pandemic Influenza Plan 2-6 If unable to reach the Territorial Epidemiologist or designee, the following should be contacted in the following order: Title CONTACT INFORMATION Work Home Mobile Administrator, Bureau of Communicable Disease Control 671.735.7142 671.789.4396 671.888.9276 CDC Coordinator III, Supervisor FQ/Enteric Control Program 671.735.7154 671.632.1236 671.888.3770 Chief Public Health Officer 671.735.7305 671.477.6161 671.888.7277 Director, Department of Public Health and Social Services 671.735.7101 671.653.6190 671.888.4261 Guam Pandemic Influenza Plan 2-7 DPHSS Surveillance and Control Activities during Periods of Individual Case Reporting ƒ Receive reports from healthcare providers of potential human novel influenza cases to determine if the patient meets the surveillance criteria using the Pandemic Influenza Case Screening and Report Form (Attachment A). ƒ Assess case information to determine if there is increased likelihood of a novel influenza infection: Interpandemic Alert Periods … Respiratory etiquette; hygiene and cough Droplet precautions when entering patient’s room; and Pandemic • Direct contact with a case of suspected or confirmed human novel influenza. ƒ If the patient meets the surveillance and reporting criteria for a novel influenza virus infection, review appropriate infection control precautions with the medical provider. … and • Direct contact with poultry (well, sick, or dead), consumption of uncooked poultry, or direct exposure to environmental contamination with poultry feces in affected area. Pandemic Period and No Documented Pandemic Influenza Virus in Guam … … Standard precautions to include gloves and gowns when indicated. … These precautions should be continued for a minimum of five days. Home isolation may be employed early during an influenza pandemic, as outlined in Chapter 4 Isolation and Quarantine Response Plan, to slow the spread of influenza in communities. • Close contact in an affected area with an ill person or birds and/or animals suspected or confirmed to have novel influenza virus infection. ƒ Report immediately by telephone to the Territorial Epidemiologist or designee an ill person who meets the novel influenza surveillance criteria based on the period of the pandemic. ƒ Patients meeting the current surveillance case definition, or those with an influenza infection with an unusual clinical presentation should be interviewed using the DPHSS Pandemic Influenza Case Screening and Report Form to determine possible risk factors and mode of transmission. When indicated, use the Contact Record Form to identify close contacts (Attachment B). Guam Pandemic Influenza Plan 2-8 PANDEMIC PHASES WHO PHASE 1: INTERPANDEMIC PERIOD ƒ United States Department of Agriculture-Animal Plant Health Inspection Services (USDA-APHIS) Embargo on importation of birds and unprocessed bird products from all countries with H5NI in domestic poultry for states and territories. … ƒ Department of Agriculture (DoAg) … The Territorial Veterinarian will, on a continuing basis, accumulate information relative to the presence of diseases in other countries, the mainland United States, and Guam, and shall activate the appropriate Emergency Response Level (ERL) to alleviate the threat. … Implementation of ERL I ERL 1 will commence when an emerging animal disease or an emerging threat to animal agriculture, including threats that may affect human health, has been identified in the mainland United States, or Asian countries but has not been identified on Guam. In the event of an ERL 1, the office of the Territorial Veterinarian may: Notify the Office of the Governor, DoAg Director, GHS/OCD Advisor and DPHSS Director of a potentially serious animal disease threat. … Notify appropriate industry groups and animal agriculture businesses of the presence of the emerging animal disease threat and request their support to keep infected and exposed animals or commodities out of the island. … Identify operational support needs and coordinate with GHS/OCD to provide operational and logistical support beyond DoAg resources. … … As appropriate, impose animal movement restrictions by emergency order. Notify the Federal Animal Health emergency response team and keep personnel apprised of any changing events. … … ƒ Implement public information plan. DPHSS … Routine collection of morbidity data from health care providers, including military providers. Guam Pandemic Influenza Plan 2-9 … Routine laboratory surveillance of ILI to determine circulating virus types. … Weekly summary of syndromic surveillance data from the GMHA-Emergency Room (ER) Patient Log and GMHA pneumonia case discharges. … Routine collection of animal morbidity and mortality data by Territorial Veterinarian. … Routine inspection by CQA at ports of entry (GIAA and PAG). … Territorial Epidemiologist will notify healthcare providers of the need for enhanced surveillance testing and reporting recommendations by means of the weekly publication of the Guam Epidemiology Newsletter (G.E.N.) or by the Health Alert FAX as appropriate. ƒ GMHA Infection Control Nurse will review the weekly summary of syndromic surveillance data from the GMHA-ER patient log done by Territorial Epidemiologist or designee. … … Microbiology Department will log all influenza test results done per normal lab protocol and monitored for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse. … Infection Control Nurse will do a weekly review of medical records of patients discharged from the hospital with documentation of pneumonia. … Pandemic Influenza Multi-disciplinary Planning Committee will periodically review and revise the Surveillance Plan as appropriate. ƒ ƒ CQA … Routine examination of documents for imported poultry from the United States. … Routine surveillance for ill passengers and prompt notification of the DPHSS. Airlines … Direct surveillance of passengers for obvious symptoms of influenza. For this purpose the signs and symptoms may be as follows: • A temperature of >380C (1000F) or greater, accompanied by one of the following: cough, sore throat, body aches and vomiting. WHO PHASE 2: INTER PANDEMIC PERIOD ƒ USDA-APHIS Guam Pandemic Influenza Plan 2-10 Continue embargo on importation of birds and unprocessed bird products from all countries with H5NI in domestic poultry for states and territories. … ƒ DoAg Implementation of ERL 2 will commence when an emerging disease has been confirmed, or a highly likely case has been discovered on Guam, or exposed animals have been imported into the island. … … In the event ERL 2 is activated, the Office of the Territorial Veterinarian will : • Accomplish objectives as listed for ERL 1 • Notify response agencies and groups under Section V of the Guam Agriculture Emergency Response Plan that were not notified under ERL 1. These may include: DOA, GSA, AG, GPD; the UOG Cooperative Extension Service, and volunteer and industry group as appropriate. • Request disease control assistance from the USDA-APHIS, Emergency Response Staff, and request activation of a disease control task force. • As appropriate declare an animal disease emergency and coordinate with GHS/OCD to request an emergency proclamation by the Governor. ƒ DPHSS … Routine collection of morbidity data from health care providers. … Weekly summary of syndromic surveillance data from GMHA-ER Patient Log. Routine collection of animal morbidity and mortality data by Territorial Veterinarian, and laboratory testing of specimens from unusual mortalities among reservoir species. … … Routine laboratory surveillance of ILI. Coordinate with the DPHSS Risk Communication Coordinator and Health Education Section to provide education and recommendations to health care facilities, health care providers, and the general public regarding the prevention, detection, and control of influenza. … Territorial Epidemiologist will notify healthcare providers of the need for enhanced surveillance testing and reporting recommendations by means of the weekly publication of the Guam Epidemiology Newsletter (G.E.N.) or by the Health Alert FAX as appropriate. … Guam Pandemic Influenza Plan 2-11 ƒ GMHA Infection Control Nurse will continue to review the weekly summary of syndromic surveillance data from the GMHA-ER patient log done by the Territorial Epidemiologist or designee. … Microbiology Department will continue to log all influenza test results done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse. … Infection Control Nurse will do a weekly review of medical records of patients discharged from the hospital with documentation of pneumonia. … Pandemic Influenza Multi-disciplinary Planning Committee will periodically review and revise the Surveillance Plan as appropriate. … ƒ CQA … Routine examination of documents for imported poultry. Routine surveillance for ill passengers (questions are asked before passengers disembark). … … ƒ Routine inspection by CQA staff at the ports of entry (GIAA and PAG). Airlines … Direct surveillance of passengers for obvious symptoms of influenza. WHO PHASE 3: PANDEMIC ALERT PERIOD ƒ USDA-APHIS Continue embargo on importation of birds and unprocessed bird products from all countries with H5NI in domestic poultry for states and territories. … ƒ DoAg … Continue enhanced surveillance on migrating waterfowl. Inspection of dead birds found throughout the island. … Continue implementation of ERL 1 and ERL 2. … Request continued disease control assistance from the USDA-APHIS, Emergency Response Staff, and request activation of a disease control task force. Guam Pandemic Influenza Plan 2-12 ƒ DPHSS … Continue routine collection of morbidity data. Weekly summary of syndromic surveillance data from GMHA-ER Patient Log. Continue routine collection of animal morbidity and mortality data by the Territorial Veterinarian, and laboratory testing of specimens from unusual mortalities among reservoir species. … … Coordinate with CQA and airlines to provide current health information to travelers who visit countries where avian or animal influenza strains that can infect humans (e.g. avian influenza A [H5N1]) with pandemic potential have been reported. … … May initiate airport arrival visual screening, distribution of pandemic influenza health alert notices and collection of Health Surveillance forms (Attachment C), as per CDC guidance. … Activation of DPHSS Epi Response Team (ERT) at GIAA or PAG if passenger/crew meet criteria for suspect Avian Influenza (see Chapter 3, Laboratory Response Plan Attachment B). … Continue coordination with the DPHSS Communications and Education to provide education and recommendations to health care facilities, health care providers, and the general public regarding the prevention, detection, and control of influenza. Territorial Epidemiologist will notify healthcare providers of the need for enhanced surveillance testing and reporting recommendations by means of the weekly publication of the Guam Epidemiology Newsletter (G.E.N.) or by the Health Alert FAX as appropriate. … … ƒ Continue routine laboratory surveillance for ILI. GMHA … Infection Control Nurse will continue to review the weekly summary of syndromic surveillance data from the GMHA-ED patient log done by the Territorial Epidemiologist or designee. … Microbiology Department will continue to log all influenza test results done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse. … Infection Control Nurse will continue weekly review of patients discharged from hospital with medical records documentation of pneumonia. Guam Pandemic Influenza Plan 2-13 Pandemic Influenza Multi-disciplinary Planning Committee will periodically review and revise the Surveillance Plan as appropriate. … ƒ CQA … ƒ Continue surveillance activities from previous Phases. Airlines … Pilot-in-command and flight crew to immediately report ill passenger(s) or crew members suspected of having communicable diseases to the GIAA Control Tower. Make an initial assessment of the situation and communicate pertinent information to the GIAA Control Tower. … Refer to their respective Medical Consultants ill domestic and international travelers who do not meet Foreign Quarantine regulations “ill” clinical criteria. … … GIAA Control Tower upon notification of the pilot-in-command of an “ill” passenger or crew is responsible for informing the CQA. … If patient meets the criteria of a Suspect Avian Influenza: • CQA will call DPHSS Bureau of Communicable Disease Control (BCDC) Administrator or designee at Warn Line at 888-9276. • BCDC Administrator will activate the DPHSS ERT by calling 888-0321. • ERT will respond within 30 minutes of notification by CQA. • Upon the recommendation of the ERT and the Medical Advisor, the DPHSS Director or designee may enforce isolation and quarantine control measures as deemed appropriate. • Institute Health Surveillance Form for all incoming passengers (air and sea) and crew, as recommended by DPHSS ERT and CQA (Attachment C). WHO PHASE 4: PANDEMIC ALERT PERIOD ƒ USDA-APHIS Continue embargo on importation of birds and unprocessed bird products from all countries with H5NI in domestic poultry for states and territories. … ƒ DoAg Guam Pandemic Influenza Plan 2-14 Continue enhanced surveillance on migrating waterfowl. Inspection of dead birds found throughout the island. … … Continue implementation of ERL 1 and ERL 2. Request continued disease control assistance from the USDA-APHIS, Emergency Response Staff, and request activation of a disease control task force. … ƒ DPHSS … Continue routine collection of morbidity data from health care providers. … Weekly summary of syndromic surveillance data from GMHA-ER Patient Log. Enhanced reporting of surveillance data to Territorial Epidemiologist or designee by assigning personnel to assist in the daily collection and review of absenteeism data from: … • Schools • Childcare Centers and Pre-Schools • Private clinics of their healthcare workers • Government of Guam departments and agencies • Facilities catering to senior citizens population (Senior Citizen Centers, Adult Day Care, St. Dominic’s, etc.). • Front line employees of high risk groups (i.e., airline employees, CQA, U.S. Customs and Border Protection (CBP), flight crews). Inform physicians of procedures and begin laboratory testing for suspect local cases meeting CDC/WHO case definition. … … Continue to coordinate with CQA to enhance surveillance at ports of entry including investigation of illness among travelers returning from affected areas and implementing isolation and quarantine measures as needed. … Continue routine laboratory surveillance for ILI. DPHSS Director or designee shall convene a meeting with key government and nongovernment stakeholders and partners to discuss enhanced surveillance and possible containment measures. … Guam Pandemic Influenza Plan 2-15 ƒ GMHA … Infection Control Nurse will do daily review of patients admitted to the hospital with the diagnosis of pneumonia. … Microbiology Department will log all influenza test results done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse. … Infection Control Nurse will review log kept by Microbiology, of patients meeting the criteria for avian influenza A testing (see Criteria for Testing for Avian Influenza A (H5N1), Attachment 5). … Cases meeting the case definition for testing shall be reported by the clinician as a suspect Class I disease within 24 hours (See Reporting to DPHSS of Suspected / Actual Cases, See Attachment 16). Infection Control Nurse will do daily review of GMHA-ER log for influenza and ILI at this phase under the Clinical Guidelines Plan. Total number of cases will be reported by Infection Control to the Territorial Epidemiologist or designee for surveillance purposes. … Infection Control Nurse will work with the Territorial Epidemiologist or designee to be added to the Health Alert Network (HAN). The notification system shall take place as follows: … • When a HAN fax arrives during regular hours, the Infection Control Department immediately notifies the Medical Director’s office and confirms that he or she has received it. • When a HAN fax arrives during off-hours, the Communication Center shall immediately notify the Medical Director and confirms that he or she has received it. The Medical Director contacts the Administrator to alert him when appropriate. … MIS shall send out an automatic alert in the sign-in set up to inform all departments regarding heightened surveillance levels, encouraging consistent reporting of cases to the Infection Control Department will also be encouraged. … Infection Control will review Employee Health log of employees screened for Epidemiological Criteria (see GMHA Employee Health Plan.) Pandemic Influenza Multi-disciplinary Planning Committee will periodically review and revise the Surveillance Plan as needed. … ƒ CQA Guam Pandemic Influenza Plan 2-16 … ƒ Continue surveillance activities from previous Phases. Airlines Continue surveillance activities from previous Phases. WHO PHASE 5: PANDEMIC ALERT PERIOD … ƒ USDA-APHIS Continue embargo on importation of birds and unprocessed bird products from all countries with H5NI in domestic poultry for states and territories. … ƒ DoAg … Continue enhanced surveillance on migrating waterfowl. Inspection of dead birds found throughout the island. … Continue implementation of ERL 1 and ERL 2. Request continued disease control assistance from the USDA-APHIS, Emergency Response Staff, and request activation of a disease control task force. … ƒ DPHSS … Continue to collect individual case reports of influenza from health care providers. Continue to inform physicians of procedures and continue laboratory testing for suspect local cases meeting CDC/WHO case definition. … … Continue enhanced surveillance through the daily collection and review of absenteeism data from: • Schools • Childcare Centers and Pre-Schools • Private clinics of their healthcare workers • Government of Guam departments and agencies • Facilities catering to senior citizens population (Senior Citizen Centers, Adult Day Care, St. Dominic’s, etc.) • Front line employees of high risk groups (i.e., airline employees, CQA, CBP, flight crews). Guam Pandemic Influenza Plan 2-17 … Continue enhanced surveillance at ports of entry in coordination with CQA. Intensified laboratory surveillance of ILI, particularly for those with history of travel. GMHA … ƒ Infection Control Nurse will continue daily review of patients admitted to the hospital with a diagnosis of pneumonia. … … Microbiology Department will log all routine influenza test results done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse. … Infection Control Nurse will continue to review log kept by Microbiology, of patients meeting the criteria for Avian Influenza A testing. See Criteria for Testing for Avian Influenza A (H5N1), See Attachment 5. • Cases meeting the case definition for testing shall be reported by the clinician as a suspect Class I disease within 24 hours (See Reporting to DPHSS of Suspected / Actual Cases, See Attachment 16). Infection Control Nurse will continue to review the GMHA-ER log for influenza and ILI. Total number of cases will be reported by Infection Control to the Territorial Epidemiologist or designee for Surveillance purposes. … … MIS will continue daily monitoring of the following areas: • Numbers of individuals treated for influenza. • Numbers of employees treated for influenza. • Numbers of all hospital admissions for influenza. MIS shall send out an automatic alert in the sign-in set up to inform all departments regarding heightened surveillance levels. Consistent reporting of cases to the Infection Control Department will also be encouraged. … Infection Control will review Employee Health log of employees screened for Epidemiological Criteria (see Employee Health Plan.). Infection Control will report cases to the Territorial Epidemiologist or designee. … … Infection Control Nurse will continue to monitor the HAN. The notification system shall take place as outlined in Phase 4. Guam Pandemic Influenza Plan 2-18 • When a HAN fax arrives during regular hours, the Infection Control Department immediately notifies the Medical Director’s office and confirms that he or she has received it. • When a HAN fax arrives during off-hours, the Communication Center shall immediately notify the Medical Director and confirms that he or she has received it. The Medical Director contacts the Administrator to alert him when appropriate. • Infection Control will update this notification system as needed. Pandemic Influenza Multi-disciplinary Planning Committee will periodically review and revise the Surveillance Plan as needed. … ƒ CQA … ƒ Continue surveillance activities from previous Phases. Airlines … Continue surveillance activities from previous Phases. WHO PHASE 6: PANDEMIC PHASE ƒ USDA-APHIS Continue embargo on importation of birds and unprocessed bird products from all countries with H5NI in domestic poultry for states and territories. … ƒ DoAg … Continue enhanced surveillance in migrating waterfowl. Inspection of dead birds found throughout the island. … Continue implementation of ERL 1 and ERL 2. … Request continued disease control assistance from the USDA-APHIS, Emergency Response Staff, and request activation of a disease control task force. ƒ DPHSS Continue enhanced surveillance activities, collection and review of data from health care providers. … … Daily review of syndromic surveillance data from GMHA-ER Patient Log by the Territorial Epidemiologist. Guam Pandemic Influenza Plan 2-19 Health care providers may be asked to report case of pandemic influenza with an unusual clinical presentation. … Closely monitor data from CDC/WHO regarding the cases of pandemic influenza in the other countries as well as tracking disease spread. … … OVS begins to report influenza deaths. … Using CDC/WHO definition of the pandemic illness, make it a reportable disease. Continue to inform physicians of procedures and continue laboratory testing for suspect local cases meeting CDC/WHO case definition. … … In coordination with CQA, initiate airport surveillance for fevers, apparent illness (passengers transported to hospital), and distribute “yellow arrival advisories” (based on Severe Acute Respiratory Syndrome (SARS) advisory) to passengers on flights from affected countries with direct flights to Guam. Continue enhanced surveillance through the daily collection and review of absenteeism data from: … • Schools • Childcare Centers and Pre-Schools • Private clinics of their healthcare workers • Government of Guam departments and agencies • Facilities catering to senior citizens population (Senior Citizen Centers, Adult Day Care, St. Dominic’s, etc.). • Front line employees of high risk groups (i.e., airline employees, CQA, CBP, flight crews). Investigate initial cases and outbreaks and implement interventions to decrease spread of disease. … … Most lab testing discontinued when local transmission is confirmed. Initiate “crowd avoidance” advisories and discourage gatherings with possible closure of schools, etc. Trigger points: • 2 standard deviations in GMHA-ER ARDS census, and absenteeism data. … Guam Pandemic Influenza Plan 2-20 In coordination with the DPHSS Risk Communications Coordinator and JIC, issuance of advisory on voluntary home isolation of sick persons and encouraging employers/supervisors to send ill employees home. … In coordination with CQA, continue intensified joint airport surveillance for fevers, apparent illness (transported to hospital), and distribution of “yellow arrival advisories”. … … ƒ Continue to enhance surveillance to detect further pandemic waves. GMHA … Infection Control Nurse will continue daily review of patients admitted to the hospital with a diagnosis of pneumonia. … During widespread pandemic influenza activity, hospitalization data will be the primary surveillance method used to assess severity of illness. Microbiology Department will log all influenza test results done per normal lab protocol and monitor for any significant changes in the number of cases. The microbiologist on duty will report significant changes to the Infection Control Nurse. … NOTE: Routine laboratory confirmation of clinical diagnosis will be unnecessary as pandemic activity becomes widespread in the community. Therefore surveillance activities related to positive influenza tests may be stopped. … Infection Control Nurse will review log kept by Microbiology of patients meeting the criteria for Avian Influenza A testing (See Criteria for Testing for Avian Influenza A (H5N1), Attachment 5). • Cases meeting the case definition for testing shall be reported by the clinician as a suspect Class I Disease within 24 hours (See Reporting to DPHSS of Suspected / Actual Cases, Attachment 16). Infection Control Nurse will continue to review the GMHA-ER log on ILI. Total number of cases will be reported by the Infection Control Department to the Territorial Epidemiologist for surveillance purposes. … … MIS will continue daily electronic monitoring of the following areas: • Numbers of individuals treated for influenza. • Numbers of employees treated for influenza. • Numbers of all hospital admissions for influenza. Guam Pandemic Influenza Plan 2-21 MIS shall send out an automatic alert in the sign-in set up to inform all departments regarding heightened surveillance levels encouraging consistent reporting of cases to the Infection Control Department will also be encouraged. … Infection Control will review Employee Health log of employees screened for Epidemiological Criteria (see Employee Health Plan.). The Infection Control Department will report cases to the Territorial Epidemiologist. … … Infection Control Nurse will continue to monitor the HAN for significant changes. Pandemic Influenza Multi-disciplinary Planning Committee will periodically review and revise the Surveillance Plan as needed. … Infection Control Nurse will continue hospital surveillance for pandemic influenza in incoming and already admitted patients. … ƒ CQA … ƒ Continue enhanced surveillance activities from previous Phases. Airlines … Continue enhanced surveillance activities from previous Phases. WHO POST PANDEMIC PERIOD ƒ USDA-APHIS … ƒ DoAg … ƒ Revert to inter pandemic surveillance and control activities. DPHSS … ƒ Revert to inter pandemic surveillance and control activities. Revert to inter pandemic surveillance and control activities. GMHA … Infection Control Nurse will continue surveillance activity in anticipation of a secondwave of influenza cases. … MIS will gather electronic numbers and reports to the Infection Control Nurse and Territorial Epidemiologist for the following: Guam Pandemic Influenza Plan 2-22 • Total number of patients treated for influenza. • Total number of employees treated for influenza. • Total numbers of all mortality cases from influenza and/or complications of influenza. • Total numbers of all hospital admissions for influenza. Pandemic Influenza Multi-disciplinary Committee in conjunction with the Executive Management Council shall conduct an evaluation of how the surveillance plan worked. … … ƒ CQA … ƒ Repeat Phases 4-6 as appropriate. Revert to inter pandemic surveillance and control activities. Airlines … Revert to inter pandemic surveillance and control activities. Guam Pandemic Influenza Plan 2-23 PANDEMIC INFLUENZA CASE SCREENING AND REPORT FORM DPHSS ID: 1. Reported By Date Reported: ___ / ___/ ___ (mm/dd/yy) Case ID: Last Name: First Name: Affiliation: Email: Phone: Fax: 2. Patient Information Last Name: Gender: ; Male ; First Name: Female Date of Birth: ___ / ___/ ___ Race: (Check one) ; Chamorro ; Palauan ; Filipino ; Caucasian ; Black ; Chuukese ; Korean ; Japanese ; Vietnamese ; Chinese Resident Address: ; Yapese ; Pohnpeian ; Yapese ; Kosraean ; Indonesian ; Thai ; Other (specify): __________________ ______________________________ Village Zip Code Telephone Number: ______________________________ House #/Apt/#Street Cell/Pager Number: 3. Signs and Symptoms Date of fever onset: ___ / ___/ ___ Date of illness onset: ___ /___ /___ (Temperature ≥ 100.4°° F or ≥ 38.0°° C, or feverish if not measured) What symptoms and signs did the patient have during the course of illness? (Check all that apply) ; Fever ≥ 100.4° F (38.0° C) ; Shortness of breath ; Runny nose/Congestion ; Feverish (temp. not taken) ; Sore Throat ; Vomiting ; Cough ; Conjunctivitis ; Lethargy ; Headache ; Muscle aches ; Other (specify):_______________ ; Diarrhea Attachment 2-A-1 Was the patient evaluated by a health care provider or admitted for medical care? ; Yes If admitted: ; No ; Unknown Date of Admission: ___ /___ / ___ Date of Discharge: ___ / ___ / ___ Was a chest X-ray or chest CAT scan performed? ; Yes* ; No ; Unknown If yes*, did the patient have radiographic evidence of pneumonia or respiratory distress syndrome (RDS)? ; Yes ; No ; Unknown Did the patient require a mechanical ventilation (intubated)? ; Yes ; No ; Unknown 5. Epidemiologic Risk Factors In the 10 days prior to illness onset, did the patient travel to any of the countries listed in the table below? ; Yes* ; No ** ; Unknown If yes*, please fill in arrival and departure dates for all countries that apply. If no**, skip to section 6. Country Arrival Date Departure Country Date ; Indonesia ; Thailand ; Cambodia ; Mainland China ; Vietnam ; Turkey ; Iraq ; Egypt ; Djibouti ; Other (specify): ______________ Arrival Date Departure Date In the 10 days prior to illness onset, while in the countries listed above: Did the patient come within 3 feet of any live poultry or domesticated birds (e.g. visited a poultry farm, a household raising poultry, or a bird market? ; Yes* ; No ; Unknown If Yes* Attachment 2-A-2 Did patient touch any recently butchered poultry? ; Yes ; No ; Unknown Did the patient visit or stay in the same household with anyone with pneumonia or severe flu-like illness? ; Yes ; No ; Unknown Did the patient visit or stay in the same household with a suspected human influenza A(H5) case? ; Yes ; No ; Unknown Did the patient visit or stay in the same household with a known human influenza A (H5) case? ; Yes ; No ; Unknown 6. Exposure for Non Travelers For patients whom did not travel outside the U.S., in the 10 days prior to illness onset, did the patient visit or stay in the same household with a traveler returning from one of the countries listed above who developed pneumonia or severe flu-like illness? ; Yes* ; No ; Unknown If Yes*, was the contact a confirmed or suspected H5 case patient? ; Yes* ; No If yes*: DPHSS ID: ; Unknown CDC ID: 7. Influenza Vaccination Did the patient receive any influenza vaccine during the current season (before illness)? ; Yes ; No ; Unknown If yes, please specify influenza vaccine received before onset of illness: ; Trivalent inactivated influenza vaccine (injected) ; Live-attenuated influenza vaccine (nasal spray) If yes, how many doses did the patient receive during the current season (before illness)? Attachment 2-A-3 ; 1 dose ; 2 doses If yes, specify influenza vaccination dates: Dose 1: ___ / ___ / ___ ; < 14 days prior to illness ; ≥ 14 days prior to illness Dose 2: ___ / ___ / ___ ; < 14 days prior to illness ; ≥ 14 days prior to illness Did the patient ever receive influenza vaccination in a previous season? ; Yes ; No ; Unknown 8. Laboratory Test Results Specimen 1: ; NP swab ; OP swab ; Broncheoalveolar lavage specimen (BAL) ; NP aspirate Date Collected: ___ / ___ / ___ ; Other ____________________ Test Type: ; RT-PCR ; Viral Culture ; DFA/IFA ; Rapid Antigen Test* Result: ; Influenza A ; Influenza B ; Influenza (type unk) ; Negative ; Pending *Name of Rapid Test:____________________ ; Indeterminate Specimen 2: ; NP swab Date Collected: ; OP swab ; Broncheoalveolar lavage specimen (BAL) ; NP aspirate ___ / ___ / ___ ; Other ____________________ Test Type: ; RT-PCR ; DFA/IFA ; Viral Culture ; Rapid Antigen Test* *Name of Rapid Test:____________________ Specimen 3: ; NP swab ; OP swab ; Broncheoalveolar lavage specimen (BAL) ; NP aspirate Result: ; Influenza A ; Influenza B ; Influenza (type unk) ; Negative ; Pending ; Indeterminate Date Collected: ___ / ___ / ___ Attachment 2-A-4 ; Other ____________________ Test Type: ; RT-PCR ; Viral Culture ; DFA/IFA ; Rapid Antigen Test* *Name of Rapid Test:____________________ Result: ; Influenza A ; Influenza B ; Influenza (type unk) ; Negative ; Pending ; Indeterminate 9. List specimens sent to the CDC Select a SOURCE* from the following list for each specimen: serum (acute), serum (convalescent), NP swab, NP aspirate, broncheoalveolar lavage specimen (BAL), OP swab, tracheal aspirate, or tissue Specimen 1: ; Clinical Material ; Extracted RNA ; Virus Isolate Specimen 2: ; Clinical Material ; Extracted RNA ; Virus Isolate Specimen 3: ; Clinical Material ; Extracted RNA ; Virus Isolate Source*: _______________ Collected: ___ / ___ / ___ Date Sent: ___ / ___ / ___ Source*: Collected: ___ / ___ / ___ _______________ Date Sent: ___ / ___ / ___ Source*: Collected: ___ / ___ / ___ _______________ Date Sent: ___ / ___ / ___ Carrier: Tracking #: 10. Close Contacts Name Address Phone (s) Nature of Contact Attachment 2-A-5 11. Death Information Date of Death: ___ / ___ / ___ Was an autopsy performed? ; Yes ; No ; Unknown Location of death: ; Home ; GMHA-ER ; Inpatient ; ICU ; other (specify): ________ 12. Case Notes Attachment 2-A-6 CONTACT RECORD FORM Index DPHSS Case ID: Contact Case ID: Contact Information Last Name: Gender: ; Male ; First Name: Female Date of Birth: ___ / ___/ ___ Race: (Check one) ; Chamorro ; Filipino ; Palauan ; Korean ; Caucasian ; Black ; Chuukese ; Japanese ; Vietnamese ; Chinese _________________________________ Village Zip Code ; Yapese ; Pohnpei ; Yapese ; Indonesian ; Thai ; Other (specify): Employment Address: __________________________________ ; Kosraen __________________ Resident Address: _________________________________ House #/Apt/#Street __________________________________ Home Telephone Number: _____________ Cellular Phone Number: _______________ Work Telephone Number: _____________ Underlying Medical Conditions: _________ _____________________________ For Female; Pregnant?: ; Yes* ; No If Yes*, how many months?: __________ _____________________________ EDC: ___ / ___ / ___ Exposure History 1st Exposure: ___ / ___ / ___ 2nd Exposure: ___ / ___ / ___ Frequency/Duration: Frequency Ongoing: ; Yes ; No Type of exposure: Exposure timing: Outcome Date notified: ___ / ___ / ___ Symptoms present? ; Yes* ; No If Yes*, date of onset: ___ / ___ / ___ Symptom type:_________________________ Attachment 2-B-1 Date of resolution: ___ / ___ / ___ Medical exam? ; Yes* ; No Start of Quarantine: ___ / ___ / ___ If yes*, date of exam: ___ / ___ / ___ End of Quarantine: ___ / ___ / ___ Administrative Data Staff Completing Form: If New Case Enter DPHSS Case ID: Notes: Attachment 2-B-2 GOVERNMENT OF GUAM Felix P. Camacho GOVERNOR DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES (DIPATTAMENTON SALUT PUPBLEKO YAN SETBISION SUSIAT) Post Office Box 2816, Hagatña, Guam 96932 123 Chalan Kareta, Route 10 Arthur U. San Agustin, MHR ACTING DIRECTOR Mangilao, Guam 96923 Michael W. Cruz JPeter Roberto, ACSW LIEUTENANT GOVERNOR DEPUTY DIRECTOR PANDEMIC INFLUENZA HEALTH SURVEILLANCE FORM Last Name: ______________________ First Name: ______________ Date of Birth: ___/___/___ Gender: M ___ F ___ PASSPORT NO. ______________________ AIRLINE/FLIGHT NO. ________ Today’s Date:___/___/___ NATIONALITY _______________________________ SEAT(S) NO. ____________ Transit: ___ Yes ___ No NUMBER OF PERSONS COVERED BY THIS REPORT (IMMEDIATE FAMILY ONLY): PURPOSE OF VISIT: Tourist ___ Returning Resident ___ LOCATION OF STAY WHILE ON GUAM Residence/Hotel Other ___ (Specify):___________________________ Telephone Date (MM/DD/YY) ___/___/___To ___/___/___ DATE OF DEPARTURE FROM GUAM: ___/___/___ DESTINATION: ___________________________ Permanent Home Address: ________ Telephone: Email address: Occupation: Employer: Work Telephone: Additional Contact Information: Emergency Contact Person: Telephone: Medical Insurance (name and contact information): _______ CONTACT INFORMATION FOR THE NEXT 14 DAYS Destination/Date Address Telephone In which of the following countries have you spent time in the last 10 days: Indonesia ___Yes ___ No Thailand ___Yes ___ No Cambodia ___ Yes ___ No Mainland China ___ Yes ___ No Vietnam ___ Yes ___ No Turkey Iraq Egypt __ Yes ___ No ___ Yes ___ No ___ Yes ___ No Have you had fever or cough in the last 3-5 days? ___ Yes ___ No Azerbaijan ___ Yes ___ No Djibouti ___ Yes ___ No Other Countries: Attachment 2-C CHAPTER 3 LABORATORY RESPONSE PLAN SECTION 1.0 INTRODUCTION DPHSS plays a significant role in the response to outbreaks and surveillance of influenza-like illness including suspect cases of avian influenza. This protocol describes the procedures for initial processing and submission of human specimens to GPHL, the testing capabilities for influenza at GPHL and the procedure for referral of specimens for confirmatory testing at the Hawaii State Laboratory Division (HSLD). SECTION 2.0 FUNCTIONS OF GPHL is also anticipated that GPHL will receive specimens for preliminary testing from the following laboratories: • GMHA • U.S. Naval Hospital (USNH) Andersen Air Force Base Clinic (AAFB Clinic) • Diagnostic Laboratory Services, Inc. (DLS) [Satellites located at the ITC Building, TakeCare, Pacific Medical Center (PMC), Sagua Managu and The Doctors Clinic/The Family Practice (TDC)] • Guam Seventh-Day Adventist Clinic (SDA) • ƒ Outbreak Investigation … Guam ERT is comprised of the Territorial Epidemiologist, Medical Director, BCDC, GPHL, and Bureau of Family Health and Nursing Services (BFHNS). ERT is responsible for the surveillance and epi-investigation of diseases of public health significance at ports of entry on Guam in collaboration with CQA. ƒ Suspect Cases of Avian Influenza or Other Novel Virus … GPHL will conduct preliminary testing and send specimens to HSLD for confirmatory testing on patients highly suspected of infection with avian influenza. Apart from the public health clinics: Southern Region Community Health Center (SRCHC), Northern Region Community Health Center (NRCHC) and Central Public Health, it LabTech Diagnostics (Satellites located at Guam Medical Plaza, Guam Adult & Pediatric Clinic, Good Samaritan Clinic, American Medical Center) • SECTION 3.0 LABORATORY TEST REQUESTS ƒ Effective communication with GPHL staff should be established when a laboratory or clinician intends to request for preliminary testing at GPHL. ƒ Laboratory Test Requests for GPHL o Refer to Attachment 3-A. Test requests initiated at GIAA/ PAG … Test requests forwarded by other laboratories/clinics on Guam (Inhouse) … The ERT physician/clinician and the laboratory technician will complete the following forms: • The physician/clinician and if applicable, the laboratory technician will complete and submit the laboratory submission form, Attachment 3-C with the specimen. • Attachment 3-E (in duplicate for HSLD & GPHL) o The laboratory supervisor/ designee of the requesting hospital laboratory, private clinic, or medical center will contact by phone, and email the following individuals at GPHL, to request testing for influenza. • o Attachment copy) o Position Administrator, BCDC Microbiologist b II Medical c Technologist I Laboratory d Supervisor PIHOA e Regional Lab Coordinator a Phone 671-735-7142 888 9276 671-735-7355 888-5222 671-735-7158 671-735-7355 888-5223 671-735-7158 671-735-7355 671-735-7158 671-734-3338 898-1852 Individuals (a) and (b) are the primary contacts to notify for requests. (patient Attachment 3-J (in duplicate for HSLD & GPHL) Refer to Attachment 3-K for detailed information. 1° 3-G o • o Mobile phone Attachment 3-F Refer to Attachment 3-B SECTION 4.0 SPECIMEN COLLECTION AND SUBMISSION ƒ Collection Sites Specimens for influenza testing may be collected from any of the following locations: … SRCHC (During a pandemic, workforce will be redirected to NRCHC) • • NRCHC • GMHA • USNH • AAFB Clinic • DLS o Persons (c), (d) and (e) will be respectively contacted when the primary contacts are unavailable or unreachable. o Guam Pandemic Influenza Plan 3-2 ƒ • SDA Clinic • LabTech The virus is best detected in specimens containing infected cells and secretions. • GIAA/PAG (GPHL only) … Collection Personnel All required specimens for laboratory testing will be collected by the physician/clinician of the requesting facility/institution. … ƒ Required Specimens A variety of specimens are suitable for the diagnosis of virus infections of the upper respiratory tract; however, specimen requirements for testing at GPHL are outlined in Attachment 3-D. … … Specimens for the direct detection of viral antigens or nucleic acids and virus isolation in cell cultures should be taken preferably during the first three days after onset of clinical symptoms. Use only Dacron swabs with a plastic or wire shaft. Swabs with wooden shafts, cotton-tips or calcium alginate will not be accepted. … All specimens must be clearly labeled with the patient name, patient identification number, type of specimen and date/time of collection. … All specimens must be delivered to GPHL as soon as possible or within 2 hours of collection for specimens at room temperature, (15-30°C) or 8 hours for refrigerated specimens (2-8°C) if a rapid test is not performed by submitting facility. All specimens must be delivered refrigerated. … The requesting laboratory will submit three nasopharyngeal swabs if no prior test has been performed on the specimen. • The requesting laboratory will submit two nasopharyngeal swabs if a screening test has been performed on the specimen. • For the port of entry initiated specimens, the ERT physician/ clinician may collect two nasopharyngeal swabs for testing. • ƒ Method and Timing of Specimen Collection Respiratory virus diagnosis depends on the collection of high-quality specimens, their rapid transport to the laboratory and appropriate storage before laboratory testing. … Specimens collected at the ports of entry will be packed on site and shipped out on the next flight to Honolulu, Hawaii. … Acceptable respiratory specimens, for patients who do not have a history of travel to an area where the H5N1 avian influenza virus is endemic and are not suspected to be infected with a novel influenza virus, include: … • Nasopharyngeal swabs A Dacron swab is inserted into the nostril, back to the Guam Pandemic Influenza Plan 3-3 alternate nostrils until a total of 10-15 mL of washing fluid has been used. GPHL may dilute approximately 3 mL of washing fluid 1:2 in viral transport medium. nasopharynx and left in place for a few seconds. It is slowly withdrawn with a rotating motion. A new swab should be used for the other nostril. The tip of the swab is placed into a vial of viral transport medium, sterile normal saline, or plain sterile sheath/container and the shaft cut. • Using only sterile Dacron swabs with a plastic/wire shaft, swab both tonsillar and posterior areas, avoiding the tongue. A new swab should be used for the other nostril. Place the swab in a vial of viral transport medium, sterile normal saline, or plain sterile sheath/container and break shaft. Nasopharyngeal aspirates (recommended for pediatric patients) • Nasopharyngeal secretions are aspirated through a catheter connected to a mucus trap and fitted to a vacuum source. The catheter is inserted into the nostril parallel to the palate. The vacuum is applied and the catheter is slowly withdrawn with a rotating motion. Mucus from the other nostril is collected with the same catheter in a similar manner. After mucus has been collected from both nostrils, the catheter is flushed with 3 mL of transport medium/normal saline. The patient sits in a comfortable position with the head slightly tilted backward and is advised to keep the pharynx closed by saying “K” while the washing fluid (usually normal saline) is applied to the nostril. With a transfer pipette, 1-1.5 mL of washing fluid is instilled into one nostril at a time. The patient then tilts the head forward and lets the washing fluid flow into a specimen cup or a Petri dish. The process is repeated with Oropharyngeal swabs Acceptable specimens for patients who have a history of travel to an area where the avian influenza virus is endemic or are suspected to be infected with a novel influenza virus: … Note: Specimens should consist of nasopharyngeal or oropharyngeal swabs contained in a vial of viral transport medium, sterile normal saline, or plain sterile sheath /container. While it appears that lower respiratory tract secretions may have a higher viral load than upper respiratory secretions in patients infected with a strain of avian influenza virus or other novel virus, collecting these samples may present a risk to health care providers. If appropriate personal protective equipment is not available, lower respiratory tract secretions should NOT be collected and sample collection should be restricted to nasopharyngeal and Guam Pandemic Influenza Plan 3-4 oropharyngeal swabs as directed above. ƒ Criteria for Specimen Rejection … Samples with insufficient volume … Dry swabs The specimens shall be labeled with the patient name, patient identification number, type of specimen and date/ time of collection. … Specimens will be wrapped in absorbent material (e.g. paper towel). … All specimens will be transported in a clean, plastic, transparent, sealable bag. … Specimen received in a container that is leaking … Samples not collected in a proper container or special handling instructions are not followed … … Expired transport media Samples not received at 2-8°C or packed with cold packs due to the potential for false-negative results Swabs with calcium wooden shafts, or cotton-tips The form will be packed in such a way to prevent contamination by the specimen. … … … The specimen will be forwarded with Attachment 3-C when delivered to GPHL. … alginate, … Incomplete submission form (e.g., no date of onset, travel history, if appropriate, etc.). Improperly labeled samples or specimen label does not match the submission form. If patient meets CDC Avian Influenza-Enhanced Surveillance Case definition, testing will be performed, but results will not be released until clarification can be made. … ƒ Specimen Transport from Requesting Laboratory to GPHL To prevent the deterioration of the specimens by heat, specimens must be transported with ice packs to GPHL to keep samples at 2-8oC. … SECTION 5.0 SPECIMEN RECEIPT AT GPHL ƒ All incoming specimens for influenza testing at GPHL will be accessioned by the receiving laboratory technician. ƒ The specimen will be logged into the GPHL Patient Accessioning Log. ƒ The specimen will be assigned a laboratory accession number. the … The requesting facility/institution will be responsible for the transport and delivery of the specimens to GPHL for influenza testing in a timely manner. ƒ The specimen will be referred to the Microbiologist II or alternate who will log it into the GPHL Influenza Register. Guam Pandemic Influenza Plan 3-5 SECTION 6.0 PRELIMINARY INFLUENZA TESTING GPHL Results may be available as early as 5 hours from time of receipt. • AT Selection of Specimens Preliminary Testing at GPHL … ƒ Two methods will be utilized for influenza testing at GPHL. for Only specimens meeting the criteria (high risk groups and/or outbreak occurrences) and case definition set by the CDC/WHO listed below will be tested. • Rapid detection testing for influenza using the QuickVue£ £ Influenza A+B Test, QuickVue£ £ Influenza Test or equivalent. … Principle of test: This assay is a preliminary test for Type A and Type B influenza. By no means can results from this assay be directly used to confirm H5N1 strain of Influenza (Avian Influenza). It will primarily be used to investigate whether Influenza Type A (under which Avian Influenza is categorized) is present. • • Test Duration: ~ 25 minutes Results may be available within 25 minutes from time of receipt. • … Immunofluorescence Assay (IFA) Principle of test: Influenza A and Influenza B viruses are detected by an indirect immunofluorescence technique. Monoclonal antibodies specific to each virus, bind to the antigen expressed in the cytoplasm of infected cells. Fluorescein labeled mouse anti-IgG in the conjugate binds to these antibodies and the cells exhibit fluorescence upon microscopy. • • CDC Avian Influenza-Enhanced Surveillance Case Definition Clinical criteria: T>100.4ºF AND one or more of the following: cough, sore throat, SOB AND Epi criteria: History of close contact with domestic poultry (including ducks, geese, or chickens) or a known or suspected human case of influenza A (H5N1) in an affected country within 10 days of symptoms onset. Specimens of patients who have a history of travel to an area where the avian influenza virus is endemic or are suspected to be infected with a novel influenza virus. • Refer to http://www.oie.int/eng/en_index.htm http://www.cdc.gov/flu/avian/ http://www.pandemicflu.gov/ • Test Duration: ~ 4-5 hours. Guam Pandemic Influenza Plan 3-6 SECTION 7.0 CONFIRMATORY INFLUENZA TESTING HSLD ƒ Real Time TaqMan Transcriptase-Polymerase Reaction (rti-RT-PCR) Assay CDC Enhanced Definition • AT Reverse Chain Avian InfluenzaSurveillance Case Clinical criteria: T>100.4ºF AND one or more of the following: cough, sore throat, SOB Principle of test: The rti-RT-PCR assay is used to detect respiratory virus pathogens that may be associated with a clinical presentation indistinguishable from Severe Acute Respiratory Syndrome (SARS) Corona-virus. The rti-RT-PCR assay is a confirmatory test for the detection and identification of Influenza A (Flu A), Influenza B (Flu B), and Adenovirus. … … Test Duration: ~ 6-8 hours Epi criteria: History of close contact with domestic poultry (including ducks, geese, or chickens) or a known or suspected human case of influenza A (H5N1) in an affected country within 10 days of symptoms onset. Specimens of patients who have a history of travel to an area where the avian influenza virus is endemic or are suspected to be infected with a novel influenza virus. • Results may be available as early as 6 hours from the time of receipt at HSLD. … … The clinical sensitivity and specificity of this assay for both influenza A and B are 100%. Subtyping will be performed on all Influenza A positive isolates. All specimens that are unable to be subtyped by culture or rtiRT-PCR will be referred to CDC’s Strain Surveillance Laboratory in Atlanta, Georgia for further analysis and confirmation. ƒ Selection of Specimens Confirmatory Testing at HSLD AND for Refer to http://www.oie.int/eng/en_index.htm http://www.cdc.gov/flu/avian/ http://www.pandemicflu.gov/ • ƒ Specimens testing positive with the QuickVue£ or equivalent rapid test and IFA that fit the case definition. ƒ Specimens producing an indeterminate test result for IFA that fit the case definition. Only specimens meeting the criteria (high risk groups and/or outbreak occurrences) and case definition set by the CDC/WHO listed below will be tested. … Guam Pandemic Influenza Plan 3-7 SECTION 8.0 SHIPPING OF SPECIMENS TO HSLD affecting humans’ using the IATA packing instruction 602. ƒ Import permit will be issued by HSLD. … ƒ Specimen Packing … GPHL will be responsible for packing and shipping specimens from Guam to HSLD for confirmatory influenza testing using GPHL Shipping Protocol. Packing and preparation of shipping documents are the responsibility of GPHL staff who are current certified shippers. All copies of these documents will be filed for reference. … ƒ … It is essential that influenza virus specimens are sent to HSLD as soon as possible after collection. If shipped within two days of collection, ship with cold packs to keep sample at 4°C. DO NOT use wet ice. Shipping Communications The shipper at GPHL will be responsible for the immediate notification of the intended shipment to the Consignee (HSLD). … For specimens collected at GIAA /PAG, GPHL will also notify the following parties of the shipment in transport: … … If shipping is delayed >2 days, then the specimens should be frozen at -70°C and shipped on dry ice. • Packing and shipping of influenza specimens will comply with Continental Micronesia Airlines or TNT Express Worldwide/Ambyth Logistics operator variations and current edition of the International Air Transport Association (IATA) Dangerous Goods Regulations (DGR). Refer to: Continental Micronesia Airlines … Influenza specimens collected at GIAA/PAG will be transported to Honolulu via Continental Micronesia flights. They will be packed and shipped as ‘Infectious substances, Quarantine PIHOA Regional Coordinator Laboratory In the event a shipment goes astray, the Federal Aviation Administration (FAA), Continental Micronesia Airlines or other agencies will be notified as applicable. … And US DOT 49 CFR Parts 171-180: … U.S. Honolulu Station (HQS) • (www.iata.org) (http://hazmat.dot.gov/regs/rules.htm). • ƒ Payment of Shipments DPHSS will be responsible for funding the costs of shipment to Honolulu through TNT Express Worldwide/Ambyth Logistics courier. … Guam Pandemic Influenza Plan 3-8 OF IFA report only (for specimens with prior testing at the requesting facility). ƒ All preliminary and confirmatory laboratory tests will be recorded in the GPHL Influenza Register daily or upon availability. Rapid detection test and IFA test results will be marked as ‘Preliminary’ on the laboratory report. SECTION 9.0 DOCUMENTATION AND REPORTING LABORATORY TEST RESULTS • ƒ Copies of all laboratory reports will be filed at GPHL. ƒ GPHL will be responsible for communicating all laboratory test results of preliminary and/or confirmatory tests to the requesting laboratory/physician/ clinician as outlined in Attachment 3-A and Attachment 3-B. ƒ GPHL will deliver all laboratory test results to the requesting facility via telephone, fax, email and/or hand delivery (for requests from within Central Public Health (Mangilao). ƒ All positive results will be reported immediately to the 24 hour point of contact authorized to receive results at the requesting institution. ƒ HSLD will convey all confirmatory test results to GPHL through telephone, fax and/or electronically. • Reports on confirmatory conducted at HSLD … • … Reports on preliminary conducted at GPHL tests Rapid detection test and IFA reports (for specimens without any prior testing). • rti-RT-PCR only This result will be marked as ‘Final’ on the laboratory report. • SECTION 10.0 PROCUREMENT AND INVENTORY LABORATORY SUPPLIES OF ƒ Any facility requesting influenza testing at GPHL will be responsible for procuring and maintaining inventory for following laboratory supplies: Dacron swabs (for collection of nasopharyngeal/oropharyngeal specimens) … Sterile specimen containers (for collection of nasopharyngeal aspirates) … … ƒ It should be noted that two or three levels of reporting will be available for each sample. tests Clean, sealable biohazard bags PPE (i.e. gowns, examination gloves, respirators/masks, face shields) … ƒ GPHL medium. will supply viral transport ƒ The Attachment 3-C will be available on-line. Hard-copies may be obtained at GPHL. Guam Pandemic Influenza Plan 3-9 SECTION 11.0 CONTINUITY OF LABORATORY OPERATIONS DURING AN OUTBREAK ƒ Refer to DPHSS COOP. SECTION 12.0 SAFETY PRECAUTIONS LABORATORY ƒ The following activities involving untreated specimens should be performed in a BSL-2 facility AND in a Class II biological safety cabinet using standard BSL-2 practices: Any procedure or process that cannot be conducted within a biological safety cabinet requires the use of appropriate combinations of PPE (e.g. respirators/ masks and face shields) and physical containment devices (centrifuge safety cups or sealed rotors). Centrifugation should always be carried out using aerosol-sealed centrifuge cups and rotors that are loaded and unloaded in a biological safety cabinet. … IN THE ƒ Refer to current edition of Biosafety in Microbiological and Biomedical Laboratories or http://www.cdc.gov/OD/ohs/biosfty/bmbl4/b mbl4toc.htm ƒ The following should be performed with standard Biosafety Level 2 (BSL-2) practices: … Collection of respiratory specimens Aliquoting, agitation, diluting or other manipulation of specimens that may cause aerosols. … Perform rapid detection testing. … … Decontamination of primary container for packing specimens for transport to HSLD for additional testing. Work surfaces should be decontaminated upon completion of work with appropriate disinfectants and all biohazardous waste autoclaved. … ƒ The following should be performed in BSL-2 facilities with standard BSL-2 practices: Laboratory workers should wear PPEs, including disposable gloves and solid front gowns with cuffed sleeves. Work surfaces should be decontaminated upon completion of work with appropriate disinfectants and all biohazardous waste autoclaved. … SECTION 13.0 CONTACT INFORMATION … Routine staining and microscopic analysis of fixed smears (IFA) ƒ Any changes to the contact information must be conveyed to the BCDC Administrator and GPHL. … ƒ Refer to Attachment 3-K. Work surfaces should be decontaminated upon completion of work with appropriate disinfectants and all biohazardous waste autoclaved. … Guam Pandemic Influenza Plan 3-10 SECTION 14.0 REFERENCES Association. October 19, http://www.iata.org/index.htm 2006. ƒ Collecting, Preserving and Shipping Specimens for the Diagnosis of Avian Influenza A (H5N1) Virus Infection. Guide for Field Operations. World Health Organization. (October 2006). Retrieved November 09, 2006 from http://www.who.int/csr/resources/publicatio ns/surveillance/WHO_CDS_EPR_ARO_20 06_1.pdf ƒ PHMSA Pipeline and Hazardous Materials Safety Administration. 2005. PHMSA Pipeline and Hazardous Materials Safety Administration. October 19, 2006. http://hazmat.dot.gov/regs/rules.htm ƒ The State of Hawai`I Pandemic Influenza Preparedness & Response Plan. Version 05.2. Hawai’I State Department of Health. (December 2005). Retrieved October 19, 2006 from http://www.hawaii.gov/health/family-childhealth/contagious-disease/pandemicflu/fluplan.pdf ƒ Laboratory Diagnostic Procedures for Influenza. (September 26, 2006). CDC /NCID Retrieved September 29, 2006 from http://www.cdc.gov/ncidod/diseases/flu/flu_ dx_table.htm ƒ Richmond, Jonathan Y., and Robert W. McKinney, eds. Biosafety in Microbiology and Biomedical Laboratories. 4th ed. Washington: Us Government Printing Office, 1999. OR ƒ Biosafety in Microbiology and Biomedical Laboratories. 4th ed. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and National Institutes of Health. Retrieved October 19, 2006 from http://www.cdc.gov/OD/ohs/biosfty/bmbl4/b mbl4toc.htm ƒ International Air Transport Association. 1997-2007. International Air Transport Guam Pandemic Influenza Plan 3-11 PANDEMIC PHASES WHO PHASE 1: INTERPANDEMIC PERIOD ƒ DPHSS … Continue with routine laboratory services. … Maintain inventory of laboratory supplies and equipment. Establish guidelines for collection and transport of human specimens for the laboratory diagnosis of pandemic influenza infection. … Establish guidelines to notify physicians of laboratory testing and criteria for submitting specimens. … Purchase at least four rapid detection test kits for Influenza A and B (i.e. QuickVue£ Influenza A+B Test -25 tests per kit) and maintain one kit at all times. … … ƒ Establish a list of reference laboratories for the confirmation of H5N1 strain. GMHA … Continue with routine laboratory services. Microbiology Department will log all routine influenza test results done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse or designee. … ƒ USNH … ƒ AAFB CLINIC … ƒ USNH will follow DoD protocols in handling pandemic influenza. AAFB Clinic will follow DoD protocols in handling pandemic influenza. DLS, SDA and LAB TECH DIAGNOSTICS … These laboratories will follow directives from DPHSS. WHO PHASE 2: INTERPANDEMIC PERIOD Guam Pandemic Influenza Plan 3-12 ƒ DPHSS … Continue with routine laboratory services. … Review inventory of laboratory supplies and procure as needed. … Local physicians notified of available laboratory testing and criteria for submitting specimens. Laboratory testing for Influenza A and B of human patients with symptoms of the flu and history of contact to infected animals. … If positive for Influenza A, specimen will be sent to HSLD, CDC, or closest available laboratory for confirmatory pandemic influenza testing. … … ƒ Monitor for significant increase in cases for influenza. GMHA … Continue with routine laboratory services. Microbiology Department will log all routine influenza test results done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse or designee. … ƒ USNH … ƒ AAFB CLINIC … ƒ USNH will follow DoD protocols in handling pandemic influenza. AAFB Clinic will follow DoD protocols in handling pandemic influenza. DLS, SDA and LAB TECH DIAGNOSTICS … These laboratories will follow directives from DPHSS. WHO PHASE 3: PANDEMIC ALERT PERIOD ƒ DPHSS … Continue with routine laboratory services. … Review inventory of laboratory supplies and procure as needed. Guam Pandemic Influenza Plan 3-13 Laboratory testing for Influenza A and B of human patients with symptoms of the flu and history of contact to infected animals/travel to country/region where strain detected. … If positive for Influenza A, specimen will be sent to HSLD, CDC, or closest available laboratory for confirmatory pandemic influenza testing. … … ƒ Monitor for significant increase in cases for influenza. GMHA Laboratory Administrator or designee will evaluate the supply and usage of Rapid Influenza A and B tests (i.e. QuickVue£ Influenza A+B Test) to determine supply needs during a 6-8 week period. … Laboratory Director, Laboratory Administrator and Microbiology Supervisor will work with GPHL to address surge capacity issues during an influenza pandemic. … Laboratory Administrator or designee will assess current routine lab supplies and resources needs to last for a 6-8 week period in preparation for a pending influenza pandemic. See Laboratory Collection, Processing, and Referral of Specimens to DPHSS, See Appendix 4. … Microbiology Department will continue surveillance of all routine influenza tests done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse or designee. The surveillance log will specifically identify the following: … … • Total number of respiratory specimens tested • Number testing positive for influenza by type (or subtype if known) and age group Laboratory personnel will continue to conduct routine testing. Laboratory Administrator will start planning with DPHSS the specimen requirements and transport flow in the event that GMHA is directed to refer specimens. See Laboratory Collection, Processing, and Referral of Specimens to DPHSS, See Appendix 4. … … ƒ USNH … ƒ Laboratory Director shall update Laboratory Plan as needed. USNH will follow DoD protocols in handling pandemic influenza. AAFB CLINIC … AAFB Clinic will follow DoD protocols in handling pandemic influenza. Guam Pandemic Influenza Plan 3-14 ƒ DLS, SDA and LAB TECH DIAGNOSTICS … These laboratories will follow directives from DPHSS. WHO PHASE 4: PANDEMIC ALERT PERIOD ƒ DPHSS … Continue with routine laboratory services. … Review inventory of laboratory supplies and procure as needed. … Continue laboratory testing for local cases meeting CDC/WHO case definition. If positive for Influenza A, specimen will be sent to HSLD, CDC, or closest available laboratory for confirmatory pandemic influenza testing. … … ƒ Monitor for significant increase in cases for influenza. GMHA Laboratory Administrator or designee will continue to evaluate the supply and usage of Rapid Influenza A and B tests (i.e. QuickVue£ A+B Test) to determine supply needs during a 6-8 week period. … Laboratory Director, Laboratory Administrator and Microbiology Supervisor will continue to work with GPHL to address surge capacity issues during an influenza pandemic. … … Laboratory Administrator or designee will continue to monitor supply and equipment needs. Microbiology Department will continue surveillance of all routine influenza tests done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse or designee. The surveillance log will specifically identify the following: … … • Total number of respiratory specimens tested • Number testing positive for influenza by type (or subtype if known) and age group Laboratory personnel will continue to conduct routine testing. If a specimen is sent to laboratory that is referenced as meeting the criteria for testing as a novel influenza strain, then the following actions need to be taken: … Guam Pandemic Influenza Plan 3-15 • Microbiology will implement processes for processing and referral of specimens to DPHSS. See Laboratory Collection, Processing, and Referral of Specimens to DPHSS, See Appendix 4. • Microbiology will contact the Microbiologist II at DPHSS or alternative for additional instructions or updates for specimen referral. • Microbiology staff will log the case in the Influenza Log book and report the case to Infection Control. Laboratory Director in conjunction with Laboratory Administrator will update Laboratory Plan as needed. … ƒ USNH … ƒ AAFB CLINIC … ƒ USNH will follow DoD protocols in handling pandemic influenza. AAFB Clinic will follow DoD protocols in handling pandemic influenza. DLS, SDA and LAB TECH DIAGNOSTICS … These laboratories will follow directives from DPHSS. WHO PHASE 5: PANDEMIC ALERT PERIOD ƒ DPHSS … Continue with routine laboratory services. … Review inventory of laboratory supplies and procure as needed. … Continue laboratory testing for local cases meeting CDC/WHO case definition. If positive for Influenza A, specimen will be sent to HSLD, CDC, or closest available laboratory for confirmatory pandemic influenza testing. … … ƒ Monitor for significant increase in cases for influenza. GMHA Laboratory Administrator or designee will ensure the continuous availability of Rapid Influenza A and B tests based on determined supply needs for a 6-8 week period. … Guam Pandemic Influenza Plan 3-16 Laboratory Director, Laboratory Administrator and Microbiology Supervisor will continue to work with GPHL to address surge capacity issues and referral of lab specimens during an influenza pandemic. … … Laboratory Administrator or designee will continue to monitor supply and equipment needs. Microbiology Department will continue surveillance of all routine influenza tests done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse or designee. The surveillance log will specifically identify the following: … … • Total number of respiratory specimens tested • Number testing positive for influenza by type (or subtype if known) and age group Laboratory personnel will continue to conduct routine testing. If a specimen is sent to laboratory that is referenced as meeting the criteria for testing as a novel influenza strain, then the following actions need to be taken: … • Microbiology will implement processes for processing and referral of specimens to DPHSS. See Laboratory Collection, Processing, and Referral of Specimens to DPHSS, See Appendix 4. • Microbiology will contact the Microbiologist II at DPHSS or alternative for additional instructions or updates for specimen referral. • Microbiology staff will log the case in the Influenza Log book and report the case to Infection Control. Laboratory Director in conjunction with Laboratory Administrator will update Laboratory Plan as needed. … ƒ USNH … ƒ AAFB CLINIC … ƒ USNH will follow DoD protocols in handling pandemic influenza. AAFB Clinic will follow DoD protocols in handling pandemic influenza. DLS, SDA and LAB TECH DIAGNOSTICS … These laboratories will follow directives from DPHSS. Guam Pandemic Influenza Plan 3-17 WHO PHASE 6: PANDEMIC PERIOD ƒ DPHSS Routine laboratory services may halt. Only routine laboratory services deemed essential may continue. … … Review inventory of laboratory supplies and procure as needed. Continue laboratory testing for local cases meeting CDC/WHO case definition until local case is confirmed positive. … If positive for Influenza A, specimen will be sent to HSLD, CDC, or closest available laboratory for confirmatory pandemic influenza testing. … … Criteria for submitting specimens may be altered to avoid laboratory overload. … Most testing discontinued when local transmission is confirmed. Review results of laboratory testing; changes made in criteria for submitting specimens if necessary. … At end of first wave, discontinue laboratory testing once activity in initially affected regions/countries has stopped, decrease in cases or is absent. Test only specimens from patients with appropriate travel history, new syndrome, etc. … … ƒ Upon second outbreak (3-9 months after first wave), repeat Phases 4-6 as appropriate. GMHA Laboratory Administrator or designee will ensure the continuous availability of Rapid Influenza A and B tests based on determined supply needs for a 6-8 week period. … Laboratory Director, Laboratory Administrator and Microbiology Supervisor will continue to work with GPHL to address surge capacity issues and referral of lab specimens during an influenza pandemic. … … Laboratory Administrator or designee will continue to monitor supply and equipment needs. Microbiology Department will continue surveillance of all routine influenza tests done per normal lab protocol and monitor for any significant increase in cases. The microbiologist on duty will report significant changes to the Infection Control Nurse or designee. The surveillance log will specifically identify the following: … • Total number of respiratory specimens tested Guam Pandemic Influenza Plan 3-18 • … Number testing positive for influenza by type (or subtype if known) and age group. Laboratory personnel will continue to conduct routine testing. If a specimen is sent to laboratory that is referenced as meeting the criteria for testing as a novel influenza strain, then the following actions need to be taken: … • Microbiology will implement processes for processing and referral of specimens to DPHSS. See Laboratory Collection, Processing, and Referral of Specimens to DPHSS, See Appendix 4. • Microbiology will contact the Microbiologist II at DPHSS or alternative for additional instructions or updates for specimen referral. • Microbiology staff will log the case in the Influenza Log book and report the case to Infection Control. • NOTE: Laboratory Administrator will continually check for updates in recommendations from DPHSS for routine laboratory confirmation of clinical diagnoses. Routine laboratory confirmation of clinical diagnosis of pandemic flu will be unnecessary as pandemic activity becomes widespread in the community. CDC will continue to work with the DPHSS laboratory to conduct virologic surveillance to monitor antigenic changes and antiviral resistance in the pandemic virus strains throughout the Pandemic Period. Laboratory Director in conjunction with Laboratory Administrator will update Laboratory Plan as needed. … ƒ USNH … ƒ AAFB CLINIC … ƒ USNH will follow DoD protocols in handling pandemic influenza. AAFB Clinic will follow DoD protocols in handling pandemic influenza. DLS, SDA and LAB TECH DIAGNOSTICS … These laboratories will follow directives from DPHSS. WHO POST PANDEMIC PHASE ƒ DPHSS, USNH, AAFB CLINIC, DLS, SDA and LAB TECH DIAGNOSTICS … Revert to Interpandemic Period. Guam Pandemic Influenza Plan 3-19 In-house Specimen Testing Algorithm for Influenza at GPHL No prior test performed on specimen by submitting healthcare facility GPHL performs QuickVue Flu A + B rapid detection test on specimen Rapid detection test NEGATIVE for Flu A/B or POSITIVE for Flu B Results Does patient meet CDC/WHO Avian Flu case definition? Yes Results Rapid testing performed on specimen by submitting healthcare facility Rapid detection test POSITIVE for Flu A GPHL performs IFA staining test NEGATIVE for Flu A/B POSITIVE for Flu B POSITIVE for Flu A No Notify result to requesting laboratory Refer to Naval Hospital for confirmatory testing, if available. GPHL to submit results back to requesting laboratory GPHL to notify preliminary results to requesting lab, BCDC Administrator, and Territorial Epidemiologist GPHL to ship specimen to Hawaii State Laboratory for RT-PCR testing Attachment 3-A Algorithm for Surveillance and Testing at GIAA/PAG CDC Avian Influenza- Enhanced Surveillance Case definition Aircraft/Vessel reports incoming ill passenger to GIAA Control Tower/Harbor Master. OR GIAA Control Tower/Harbor Master reports incoming ill passenger to Guam Customs and Quarantine Agency (CQA). Clinical criteria: T>100.4ºF AND one or more of the following: cough, sore throat, SOB AND Epi criteria: History of close contact with domestic poultry (including ducks, geese, or chickens) or a known or suspected human case of influenza A (H5N1) in an affected country within 10 days of symptoms onset. Guam DPHSS Epi Response Team (ERT) is called and evaluates the patient. If CQA is not yet involved, ERT will notify CQA immediately. CQA and ERT will follow federal guidelines for Quarantinable Diseases. Yes CQA protocol will: • Confirm origin, review symptoms. • Liaise with ERT for instructions. • Possibly detain passengers. • Collect detailed contact information from passengers • Hand out Health Alert Card if appropriate. • Airline carrier may be notified to hold plane. Patient Consent Does patient meet CDC Quarantine Station suspect Avian Flu criteria? No No ERT will release patient from treatment. ERT will release patient from treatment. Yes ERT will: • Provide information sheet. • Complete Hawaii State Lab Submission Form. • Nurse/Clinician will collect 2 nasopharyngeal swabs. • Notify HSLD of specimen referral. • Package and Deliver shipment to Continental Cargo for immediate transport to HSLD. Does ill passenger meet clinical criteria for influenza testing? Fever or history of fever ”100ºF with at least one of the following symptoms: • Headache • Muscle aches • Sore throat • Cough • Chills • malaise (tiredness) • Vomiting CQA or ERT will respond by isolating passenger at GIAA if appropriate. • CQA will enforce travel restrictions in accordance with CDC and ERT protocol. • DPHSS/ERT will provide assistance as necessary. • Specimen goes to HSLD for confirmatory testing (RT-PCR). • Results available within 6-8 hours of specimen arrival at HSLD. • HSLD will forward results to GPHL. No Yes Patient treatment & specimen collection are terminated. CQA will continue to follow federal guidelines for Quarantinable Diseases Patient Consent GPHL will distribute results according to written protocol. DPHSS will adhere to CDC guidelines for reporting any confirmed cases. CQA=Guam Customs & Quarantine Agency ERT=Guam DPHSS Epi-Response Team GPHL=Guam Public Health Laboratory HSLD=Hawaii State Laboratory Division DPHSS=Guam Department of Public Health & Social Services ERT will: • Provide information sheet. • Complete Hawaii State Lab Submission Form. • Nurse/Clinician will collect 2 nasopharyngeal swabs. • Perform rapid detection test for influenza. • Notify HSLD of specimen referral. • Package and deliver shipment to Continental Cargo for immediate transport to HSLD. • Review influenza management recommendations on information sheet with all patients. • Recommend hygienic practices to decrease spread of germs. • No travel restrictions will be enforced. • Specimen goes to HSLD for confirmatory testing (RT-PCR). • Results available within 6-8 hours of specimen arrival at HSLD, if performed. • Culture isolation reports available approximately 14 day after arrival at HSLD. • HSLD will forward results to GPHL. Attachment 3-B Government of Guam Department of Public Health & Social Services Post Office Box 2816, Hagatña, Guam 96932 123 Chalan Kareta, Route 10 Mangilao, Guam 96932 GPHL ACCESSION NUMBER DATE RECEIVED BY GPHL Influenza Specimen Laboratory Submission Form USE FOR RESPIRATORY SPECIMENS COLLECTED FOR INFLUENZA SURVEILLANCE ONLY PLEASE NOTE THAT ALL ITEMS WITH AN ASTERISK (*) ARE REQUIRED PATIENT IDENTIFICATION NAME AND ADDRESS OF PHYSICIAN/SCHOOL/FACILITY:* (SUBMITTER) FIRST NAME & MIDDLE INITIAL* LAST NAME* ADDRESS* CONTACT PERSON LABORATORY PERFORMING INFLUENZA RAPID TESTING CITY* ZIP* COUNTRY (IF NOT U.S.A.)* STATUS* DATEOF BIRTH: (MM/DD/YY)* CONTACT PERSON CLINICAL DIAGNOSIS Guam Resident ,1)/8(1=$ SEX:* Male RACE:* Tourist CATEGORY OF AGENT SUSPECTED 9,586 Female HOSPITALIZATION REQUIRED?* LABORATORY EXAMINATION REQUEST Yes SPECIFIC AGENT SUSPECTED HOSPITAL ADMISSION DATE: (MM/DD/YY) No DATE OF ONSET:* (MM/DD/YY) CHART NUMBER:* ,1)/8(1=$ 9,586 SPECIMEN INFORMATION TYPE OF SPECIMEN* DATE COLLECTED* (MM/DD/YY) PATIENT CLINICAL INFORMATION 1. CLINICAL SIGNS AND SYMPTOMS THROAT SWAB FEVER NASOPHARYNGEAL SWAB COUGH SORE THROAT MALAISE BODY ACHES CHILLS DIARRHEA PNEUMONIA OR ARDS OTHER NASAL ASPIRATE SPUTUM OTHER, (Specify) °C/°F) (Maximum Temp 2. LIST ANY TRAVELLING WITHIN THE 10-DAY PERIOD PRIOR TO ONSET OF ILLNESS (Place and Date) SCREENING TEST* TEST METHOD NOT DONE RESULTS TEST DATE SPECIMEN REF NUMBER QUICKVUE INFLUENZA QUICKVUE INFLUENZA A+B 3. PATIENT EVER RECEIVED INFLUENZA VACCINE?* YES NO DATE OF LAST VACCINATION:* (MM/DD/YY) DIRECTIGEN FLU A DIRECTIGEN FLU B IFA MANUFACTURER NAME: LOT NUMBER: OTHER (Specify) 4. ANTIVIRAL THERAPY DO NOT WRITE BELOW THIS LINE DEPARTMENT OF PUBLIC HEALTH USE ONLY NAME OF MEDICATION DOSAGE DATE 5. OTHER INFORMATION: DATE REPORTED: SEE REVERSE FOR AVIAN INFLUENZA TESTING CRITERIA Attachment 3-C-1 Testing for avian influenza A (H5N1) is indicated for hospitalized patients with: • Radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established, AND • History of travel within 10 days of symptom onset to a country with documented H5N1 Avian Influenza in poultry and/or humans (for a regularly updated listing of H5N1affected countries, see the OIE website and the WHO website). Testing for avian influenza A (H5N1) should be considered on a case-by-case basis in consultation with state and local health departments for hospitalized or ambulatory patients with: • Documented temperature of >38°C (>100.4°F), AND • One or more of the following: cough, sore throat, shortness of breath, AND • History of contact with poultry (e.g., visited a poultry farm, a household raising poultry, or a bird market) or a known or suspected human case of Influenza A (H5N1) in an H5N1 affected country within 10 days of symptom onset. Attachment 3-C-2 Specimen Requirements for Detection of Influenza A and B (GPHL) Methodology: QuickVue£ Influenza/Influenza A+B test; Immunofluorescence staining (IFA); real-time TaqMan Reverse Transcriptase Polymerase Chain Reaction (rti-RT-PCR) Performed: The QuickVue£ Influenza/Influenza A+B test is a rapid, in vitro immunoassay membrane test for the direct and qualitative detection of influenza A and B viral antigens from respiratory specimens of symptomatic patients. It is a differentiated test, and therefore influenza A viral antigens can be distinguished from influenza B viral antigens in a single test. The test is to be used as an aid in the diagnosis of influenza A and B viral infections. The Immunofluorescence staining test kit is intended for the detection of Influenza A and B virus in infected cells by means of indirect Immunofluorescence technique using monoclonal antibodies specific to each of the viruses. Real time TaqMan RT-PCR is used to detect respiratory virus pathogens that may be associated with a clinical presentation indistinguishable from Severe Acute Respiratory Syndrome (SARS) Coronavirus. Only specimens meeting the criteria (high risk groups and/or outbreak occurrences) and case definition set by the CDC/WHO/Bureau of Communicable Disease Control (BCDC) at the Guam Department of Public Health and Social Services (DPHSS) will be tested. See reverse side of submission form. Turn-AroundTime: Preliminary report(s) should be available 30 minutes for the rapid test and 4-6 hours for the IFA from the time the specimen was received at the Guam Public Health Laboratory (GPHL). Positive specimens will be forwarded to the Hawaii State Laboratory Division (HSLD) for PCR for confirmatory testing. PCR reports(s) may be available 6–8 hours from the time the specimen was received at HSLD. Specimen required: Respiratory specimens including, nasopharyngeal (NP) swabs/aspirates/washes and oropharyngeal swabs. Bronchoalveolar lavage is also acceptable. Specimen Collection: If SWABS are submitted and if no prior test has been performed, supply THREE separate specimens of the same sample type. If a rapid/screening test has already been performed, submit TWO separatespecimens of the same sample type. Use only Dacron swabs with plastic/wire shafts. Swabs with wooden shafts, cotton-tipped, or with calcium alginate will be rejected. For Nasopharyngeal swabs- Insert swab into the nostril parallel to the palate and leave in place for a few seconds to absorb secretions. For Oropharyngeal swabs- Both tonsils and the posterior pharynx are swabbed vigorously. For NP wash/aspirate- Have the patient sit with the head tilted slightly backward. Instill 1-1.5 mL of nonbacteriostatic saline (pH 7.0) into one nostril. Flush a plastic catheter or tubing with 2-3 mL of saline. Insert the tubing into the nostril parallel to the palate. Aspirate NP secretions. Repeat this procedure with each nostril. Collect NP wash or aspirate in sterile vials. Label each specimen with a unique identifier, type of specimen and date of collection. NP aspirates are the specimen of choice for the detection of respiratory viruses and recommended for pediatric patients. Note: Respiratory specimens should be collected as soon as possible in the course of illness. Recovery of viruses diminishes markedly >72 hours after onset of symptoms. Specimen storage, packing and transport: Specimen packing and transport: Test Transport Medium Rapid test IFA PCR None, direct None, direct None, VTM Room Temp 2 hrs < 3 hrs - Storage/Stability 2 - 8°C 8 hrs 72 hrs 72 hrs - 20°C 7 days Ship specimens with cold packs (2 - 8°C). If necessary, specimens may be stored at 2 - 8°C up to 72 hours from time of collection. Fresh specimens are preferable to frozen, as decreased sensitivity may result. Avoid multiple freeze-thaw cycles. Follow instructions on the U.S. Department of Transportation (U.S.DOT) Hazardous Materials Regulations for transporting diagnostic specimens and the packing instructions from the current edition of the International Air Transport Association (IATA) Dangerous Goods Regulations. Attachment 3-D-1 Specimen submission: The submitting facility must notify BT Microbiologist II or alternate of GPHL at (671)735-7355/158 or (671)888-5222 (emergency) prior to the submission of specimens. Note: It is the responsibility of the submitter to track the arrival of specimens and the Influenza Specimen Laboratory Submission forms at GPHL to ensure that these specimens are received by the Laboratory staff. Rejection Criteria: • • • • • • • • • • Stability: All specimens must be refrigerated at 2-8°C immediately after collection. If the specimen cannot be transported to GPHL within 48 hours after collection, it should be kept refrigerated at 2-8°C. Submission Form: Influenza Specimen Laboratory Submission Form Specimen quantity is insufficient to perform the tests; Dry swabs Specimen received in a container that is leaking; Specimen is not collected in a proper container or special handling instruction is not followed; Transport media is expired; Specimen is not received at 2 - 8°C/packed on cold packs; Swabs with calcium alginate, wooded shafts, cotton-tipped; Unlabeled specimens; Illegible/Incomplete Submission forms (e.g., no date of onset, travel history, if appropriate, etc.); Specimen label does not match the submission form. • Each specimen submitted must have a completed Submission Form, with the patient name, patient identification number, type of specimen, date/time of collection, submitter, date of onset, travel history, date shipped/sent to GPHL, test(s) requested and other pertinent information. • Illegible submission forms that are not consistent with the specimen submitted will be rejected and requesting facility will be asked to re-submit. • Submission forms will not be in direct contact with the specimen(s). Normal Value: N/A Result Notification: Laboratory reports will be forwarded to the submitting facility, territory epidemiologist, and the BCDC Administrator by electronic reporting system or via FAX. Any other request for copies of laboratory reports, apart from that stipulated above will not be accepted. Testing performed at: Preliminary Testing: Guam Public Health Laboratory (GPHL) Government of Guam Department of Public Health & Social Services 123 Chalan Kareta, Route 10 Mangilao, Guam 96923 Contact: Claire M. Baradi, BT Microbiologist II, GPHL (671) 735-7355/158; (671) 888-5222 (emergency) (671) 735-7158 FAX claire.baradi@dphss.guam.gov Confirmatory Testing: Bioterrorism Response Laboratory (BTRL) Hawaii State Laboratory Division (HSLD) Department of Health 2725 Waimano Home Road Pearl City, Hawaii 96782 Joy S. Villanueva, Chemical Terrorism Medical Technologist I, GPHL (alternate) (671) 735-7153/355; (671) 888-5223 (emergency) (671) 735-7158 FAX joy.villanueva@dphss.guam.gov Josephine T. O’Mallan, BCDC Administrator, Guam Department of Public Health & Social Services (671) 735-7142; (671) 888-9276 (emergency) ; (671) 734-2103 (fax) josephine.omallan@dphss.guam.gov Rebecca H. Sciulli, M.S., M.T. (AMT), Hawaii State Laboratory Division (BTRL/HSLD) (808) 453-5993; (808)368-3373; (808) 363-3373 (emergency) rebecca.sciulli@doh.hawaii.gov Attachment 3-D-2 GOVERNMENT OF GUAM INFLUENZA GIAA/PAG SPECIMEN SUBMISSION FORM DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES (DIPATTAMENTON SALUT PUPBLEKO YAN SETBISION SUSIAT) Post Office Box 2816, Hagatña, Guam 96932 123 Chalan Kareta, Route 10 Mangilao, Guam 96923 FOR RESPIRATORY SPECIMENS COLLECTED FOR INFLUENZA SURVEILLANCE ONLY ACCESSION NUMBER: TIME/DATE SUBMITTED: LAB NUMBER: PATIENT IDENTIFICATION FIRST NAME & MIDDLE INITIAL: CITIZENSHIP: U.S. Citizen? Ƒ YES Ƒ NO LAST NAME: SEX: DATE OF BIRTH: COUNTRY OF CITIZENSHIP: (MM/DD/YY) PERMANENT MAILING ADDRESS STREET ADDRESS: PHONE NUMBER: CITY: ZIP CODE: STATE/PROVINCE: Ƒ MALE Ƒ FEMALE COUNTRY: LOCAL CONTACT INFORMATION LOCAL ADDRESS/LOCATION: PROVIDE HOTEL NAME /LOCATION WHEN APPLICABLE (i.e. The Guam Hotel Resort, Guam) TRAVEL INFORMATION LIST ALL TRAVEL WITHIN THE 14 DAY PERIOD PRIOR TO ONSET OF ILLNESS (PLACES & DATES) CITIES: DATES: AIRCRAFT/VESSEL: AIRCRAFT/VESSEL NUMBER: ORIGIN OF AIRCRAFT/VESSEL: EXPECTED DATE OF DEPARTURE FROM GUAM: CLINICAL SIGNS/SYMPTOMS CHECK ALL THAT APPLY: Ƒ FEVER (Maximum temp. _______°F) Ƒ COUGH Ƒ SORE THROAT Ƒ MALAISE Ƒ OTHER Ƒ HEADACHE Ƒ MUSCLE ACHE Ƒ CHILLS Ƒ DIAHRREA Ƒ VOMITING DATE OF ONSET OF SYMPTOMS: (MM/DD/YY) DATE OF RECENT INFLUENZA VACCINATION: (MM/DD/YY) DOES PASSENGER MEET SUSPECT AVIAN INFLURNZA CRITERIA? SPECIMEN INFORMATION DATE OF SPECIMEN COLLECTION: (MM/DD/YY) TITLE: YES Ƒ NO TYPE OF SPECIMEN: Ƒ NASOPHARYNGEAL SWAB Ƒ OTHER (Specify): AM/PM PROVIDER SIGNATURE: Ƒ SCREENING TEST: QUICKVUE INF A+B (Results -Circle One) A+ B+ NEG INVALID NOT DONE OTHER (Specify): RESULTS: DO NOT WRITE BELOW THIS LINE DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES USE ONLY DATE OF REPORT: Attachment 3-E GOVERNMENT OF GUAM Felix P. Camacho GOVERNOR DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES (DIPATTAMENTON SALUT PUPBLEKO YAN SETBISION SUSIAT) Post Office Box 2816, Hagatña, Guam 96932 123 Chalan Kareta, Route 10 Mangilao, Guam 96923 Michael W. Cruz, MD LIEUTENANT GOVERNOR Arthur U. San Agustin, MHR ACTING DIRECTOR JPeter Roberto, ACSW ACTING DEPUTY DIRECTOR CONSENT FOR DIAGNOSTIC EVALUATION CONSENT TO DIAGNOSTIC EVALUATION: I authorize and consent to the Guam Public Health Laboratory to collect and submit specimens to the Hawaii Department of Health for diagnostic evaluation of influenza. RELEASE OF INFORMATION I understand that my health information including possible exposure history may be disclosed to the Hawaii Department of Health and the Guam Department of Public Health and Social Services for the purposes of conducting public health surveillance and response. I certify that I have read this Consent and that I am the patient or the patient's appointed representative, and I accept and agree to be bound by the Consent, a Copy of which will be made available upon request. X______________________________________________ Date:________________ Time: ____:____a.m./p.m. SIGNATURE OF PATIENT or SIGNATURE OF PATIENT’S REPRESENTATIVE _____________________________________________ RELATIONSHIP TO PATIENT INFORMED REFUSAL TO DIAGNOSTIC EVALUATION: I refuse to consent to the Guam Public Health Laboratory to collect and submit specimens to the Hawaii Department of Health for diagnostic evaluation of influenza offered to me at no charge. I understand that if I refuse the services offered as indicated above, I am doing so against the recommendation of the public health authority in the State of Hawaii and the Territory of Guam. I understand that my refusal may inhibit proper diagnosis and treatment which could result in a worsening of my (patient’s) condition. X______________________________________________ Date:________________ Time: ____:____a.m./p.m. SIGNATURE OF PATIENT or SIGNATURE OF PATIENT’S REPRESENTATIVE _____________________________________________ RELATIONSHIP TO PATIENT Attachment 3-F GOVERNMENT OF GUAM Felix P. Camacho GOVERNOR DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES (DIPATTAMENTON SALUT PUPBLEKO YAN SETBISION SUSIAT) Post Office Box 2816, Hagatña, Guam 96932 123 Chalan Kareta, Route 10 Mangilao, Guam 96923 Michael W. Cruz, MD LIEUTENANT GOVERNOR Arthur U. San Agustin, MHR ACTING DIRECTOR JPeter Roberto, ACSW ACTING DEPUTY DIRECTOR Patient Information Sheet: Rapid Influenza Testing Dear Sir/Madam: Because you are ill with symptoms that suggest influenza, the Department of Public Health & Social Services offered a rapid flu test called “QuickVue® Influenza A + B test” free of charge. Your test results are as follows: 1. Date of test: _________________________________ 2. QuickVue® Influenza A + B test result: (GPHL to circle one) POSITIVE NEGATIVE INDETERMINATE 3. If the test result was positive for influenza, the strain was type: (GPHL to circle one) A B If your rapid test result was POSITIVE and you are concerned about your health, you should seek further medical attention. The Department of Public Health & Social Services can provide you with a list of clinics if so desired. The results of the rapid flu test can show whether you may be infected with influenza, and if so, by which type of influenza (A or B). While the rapid influenza test is not 100% conclusive, it is a licensed test widely used in medical care in the U.S. If you have further questions regarding the QuickVue® Influenza A + B test or your test results, please contact the Bureau of Communicable Disease Control Administrator at 671-735-7142/888 9276 or DPHSS Microbiologist at 671-735-7355/888-5222. What You Should Know If You Have the Flu How should the flu be treated? • • • • Get plenty of rest Drink plenty of liquids Avoid using alcohol and tobacco You may take over-the-counter medications to relieve the symptoms of flu but never give aspirin to children or teenagers who have flu-like symptoms – and particularly fever – without first speaking to your doctor. If you are at high risk for complications of the flu, consult your health-care provider. Your doctor may recommend use of an antiviral medication (see later section) to help treat the flu. Persons at high risk for complications include the following: • persons aged >65 years; • residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions; • adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma; Attachment 3-G-1 • • • • adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]); children & adolescents (aged 6 months-18 years) who are receiving long-term aspirin therapy and therefore might be at risk for experiencing Reye syndrome after influenza infection; women who will be pregnant during the influenza season; and children aged 6--23 months. A. Antiviral Medications Four antiviral drugs (amantadine, rimantadine, zanamavir, and oseltamivir) are approved for treatment of the flu. These are prescription medications, and a doctor should be consulted before the drugs are used. Antiviral treatment lasts for 5 days and must be started within 2 days of illness so if you get flu-like symptoms, seek medical care early. Look Out for Warning Signs that the Illness is Worsening There are some “emergency warning signs” that require urgent medical attention. In children, emergency warning signs that need urgent medical attention include: • Fast breathing or trouble breathing • Bluish skin color • Not drinking enough fluids • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with fever and worse cough • Fever with a rash In adults, emergency warning signs that need urgent medical attention include: • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting Seek medical care immediately (call your doctor or go to an emergency room) if you or someone you know is experiencing any of the signs above. When you arrive, tell the reception staff that you think you have the flu. You may be asked to wear a mask and/or sit in a separate area to protect others from getting sick. Stop the Spread of Germs that Make You and Others Sick! Serious respiratory illnesses like influenza are spread by: • Coughing or sneezing • Unclean hands To help stop the spread of germs, Avoid close contact. Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too. Stay home when you are sick. If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness. Cover your mouth and nose. Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick. Note: You may be asked to put on a surgical mask to protect others. The above are excerpts from: Key Facts About the Flu: How to Prevent the Flu and What To Do If You Get Sick. 10, 2004. CDC Website. http://www.cdc.gov/flu/keyfacts.htm November Attachment 3-G-2 HAWAII Hum Hun rH 34 Appendix H: Sp eeimen Lab mater}; Submission Form '1 Lh'l ER ME USE FUR SPEGMENS BBL 3 ATE IZIF Fun INFLUENZA - - I EATE HE: It ?73 LANCE DEAR. gem: EIEE "Hrr new; mm I RE mun i?wp LABOR-HWY PEHFICI IHFLUE RAFD TET MGHILLIWIA in?; ?mm um?. Imam-WI LL: m. Imam uni-enema a: near suapeeta: MEGA-DH mm? ON Hu; [Inpu?umH Htuum-Luer l?ldl'l' mint-n 3=E:ll' S- seem-mm mum: 'm enumm" WHUE CULI UFIE :l mueummum 51w :1 mm Hill-?! IZIF IZIH [mut?lb 1 seam?: 1e31- E51- H514 Ell! ll? H1 in I'll! II II If." i BI I?m-bf HOT 3 DHE i .1. (IF HEALTH IJIE mt? DATE FEFCHT: EH Ell]!- hum-Rm- luul. uni-gm ?In ?at?23 Urea Em: UNI: 5 5ND it?llme FEVER _?IhIrurn tarp Fl mum: RE ?4 F5 HERE-H EITHER ItiT ?11' TIIUEL I. ME- 1d 7410'? l'l and DIET: ennem even: RECEIVE n; mam. menu?" Um [_Hn (II I. 1F I HHE: WMER: _rl EIF {51:11:11,- Ll? m: mug: admristererj: I-H Pandemic In?uenza Preparedness S: Reapanse Plan Willi] Attachment hith I [iffy-:31? NT Appendix G: Specimen Requirements for In?uenza A {Flu A), In?uenza (Flu Adenovirus, Detection and Identification by real?time Taqman Reverse Transcriptase (RT) Polymerase Chain Reaction Methodology: Performed: Turn-Around?Time: Specimen required: Specimen Collection: Real time Toghlan RT-PCR Real time Togl?clan RT-PCR is used to detect respiratory virus pathogens that may be associated with a clinical presentation indistinguishable from Severe Acute Respiratory Coronavirus. lClinly specimens meeting the criteria (high risk groups and-"or outbreak occurrences} and case de?nition set by the Disease Investigation Branch (DIE) of the Disease and lControl Division of the Department of Health will be tested. Preliminary report?s} will be available 6-3 hours from the time the specimen was received at the ET Response Laboratory. Positive specimens will be forwarded to the Virology Section for confinnatory testing. Respiratory specimens including bronchoalveolar lavage- tracheal aspirates, sputum, nasopharyngeal or oropliaryngeal aspirates or washes- and HP or DP swabs- Use only Dacron tip swabs with an aluminum or plastic shaft. Calcilun alginate swabs or cotton swabs with wooden sticlts are tmacceptable because they may cause PCR inhibition and may contain substances that inactivate or may be toxic to some viruses. For FF swabs- Insert swab into the nostril parallel to the palate and leave in place for a few seconds to absorb secretions. For HP swabs- swab both posterior pharynx and tonsillar areas- avoiding the tongue- Place swabs immediately into sterile vials containing 2 ml of viral transport media. Break the shaft and tighten the cap of the vial. Label each specimen with a unique identi?er, type of specimen and date of collection. Kote: Duly swabs in viral transport media (TTEI) will be accepted. HI Pandemic In?uenza Preparedness d: Response Plan $35.1 Attachment 3?1?1 [Mr-1.21s? Specimen storage. packing and transport: Specimen submission: Unacceptable conditions: Appendix G: Specimen Requirements for Testing For KP wash-"aspirate? Have the patient sit with the head tilted backward. Instill 1-1.5. ml. of non- bacteriostatic saline {pH into one nostril. Flush a plastic catheter or tubing with 2?3 ml of saline. Insert the tubing into the nostril parallel to the palate. Aspirate NP secretions- Repeat this procedure with each nostril. Collect wash or aspirate in sterile vials. Label each specimen with a unique identi?er. type of specimen and date of collection. NP aspirates are the specimen ofchofce for the detection ofrespt'mtory viruses. Kote: Respiratory specimens should be collected as soon as possible in the course of illness. Recovery of viruses diminishes markedly :52 hours after onset of Ship specimens with cold packs to keep the sample at 4GC. Follow instructions on the US- Department of Transportation Hazardous Materials Regulations for transporting diagnostic specimens and the packing instructions from the current edition of the International Air Transport Association Dangerous IGoods Regulations. The Epidemiology Specialist of the DIE must notify Rebecca H. Sciulli of the Eioterrorism Response Laboratoryr at or 453?59913 prior to the submission of specimens. Kote: It is the responsibility of the submitter to track the arrival of the specimens along with Form 81.3 at the State Laboratories Division to ensure that these specimens are received by the ET Response Laboratory staff. Specimen is received in a container that is leaking: Specimen is not collected in a proper container or special handling instruction is not followed; transport media is expired; Swabs with cotton tips; calcium alginate, and swabs with wooden shafts; Specimen is not received at 45C or packed in blue ice; Specimen quantity is insufficient to perform the tests:_ Unlabeled specimens; l-lI Pandemic In?uenza Preparedness dc Response Plan Attachment 3?1?2 Pm {?ll-HI HIMHI Stability: Requisition Form: Normal Result Noti?cation: Test performed at: Contact: Appendix G: Specimen Requirements. for Iesting Incomplete requisition fonn (sag, no date of onset, travel history. if appropriate. are); Specimen label does not match the requisition- All specimens must be re?igerated at 2?831: immediately after collection. If the specimen cannot be transported to the State Laboratories Division within 43 hours after collection. it should be kept frozen at JUCC [for PCR detection]- State Laboratories Division Requisition Form $1.55 Each specimen submitted must have a completed Form with the patientis unique identifier, submitter= specimen site."specimen type= date of onset, travel history= date of collection, date sliipped:'sent to the test[s} requested and other pertinent information. Illegible Form 31.3 or forms that are not consistent with the specimen submitted will be rejected and requesting facility will be asked to re-submit. Requisition forms shall be placed in a separate bag and shall not be packed with the specimen[s]. Laboratory reports will be forwarded to the submitter (Epidemiological Specialist at the Disease Investigation Branch Disease Dutbrealc Control Division or submitting laboratory} by electronic reporting system or via FAX. Any other request for copies of laboratory reports by submitters other than DUCD or the submitting laboratory will not be accepted and laboratory reports will only be released to DUCD or the submitting laboratory. Bioterrorisin (ET) Response Laboratory State Laboratories Division Department of Health 27?25 ?Naimano Home Road Pearl City. Hawaii SENSE Rebecca H. Sciulli. M.S., MI. 453-5991} fit?'22 Pandemic In?uenza Preparedness d: Response Plan 1.335.] Attachment 3?1?3 nm?hu? Emn?k. m?im Om Impral Hwnm. 3 p20 10: ?mhmr 9.3.. 134%: ruvmja a. Drum mmnmEmU album Ermombqomg. mom: mom mnmeamzm noFQOm mom mcmf..m__._.pznm 025. Em 2 1153.5 2 Emma aim m. EJE. Ema 235m {mm I 0.91m O_u mmxu Fm. 20 Errm . . nmaprm ummabzmza 3252a. ET. 0.2. 00 2.39.04 5 mm. mg .540 DE. 10.2w: viam E6 r??bjO? 5.1m: ?emu IE: 9.: Fri?m Ozghdoz ?pmm?m? Gm mxtm??mu Dram Gm Dm??macmm 02mm. Om .PZD DhAmmH" 02.2mm? 0.94m? ELL 2.7 Khan? ?mman. $3.03 nEz?nbr Emzm ha: maag?qogm Eur UPAM D_u .UmeA D_n miau?ugm 2:333? I ?IFrm. whim 0.94m Om mm?mrj. 02.1mm? 00mm Emma. bib: _z_u_ucmZN.P {mm 20 mun?whim: Ew?mghd?zu D_n ?Orrm?jDZH Milan?2.4.? H1303. Es Es ?mumnq? Amm? m. hr+ m+ 3mm ?Au?m 02 my 2mm. no :54 EM um mml?? Ins. Umu??dimzd Om :mm 02?.4. nm?u?m n?qm Om "Emma? amnum?Sm ?53mm ?an?an; >?orBoE wL Contact Information for GPHL GPHL Name a. Josephine T. O’Mallan b. Joy S. Villanueva c. Mary Jean J. Jacar d. Vasiti Uluiviti Position Phone Administrator, BCDC Medical Technologist I Laboratory Supervisor PIHOA Regional Lab Coordinator 671-735-7142 671-735-7355 671-735-7355 671-734-3338 Mobile phone 888 9276 888-5223 898-1852 Email josephine.omallan@dphss.guam.gov joy.villanueva@dphss.guam.gov mjjjac@yahoo.com rlcpihoa@yahoo.com Southern Regional Community Health Center -Inarajan (During a pandemic, workforce will be redirected to NRCHC) Name Eugene Rosario Position Laboratory Technician III Phone 671-828-7546 Mobile phone - Email - Northern Regional Community Health Center (Dededo) Name Evelyn Nededog Theresa Carbon Position Microbiologist III Laboratory Technician II Phone 671-635-7415 671-635-7415 Mobile phone 888-7873 - Email - Guam Memorial Hospital Authority Name GMHA Switchboard*1° Glendalyn Pangalinan* 2° Position Fe A. Bactad Laboratory Assistant Administrator Microbiology Supervisor Dr. Philip Dauterman Medical Director Phone 647-2554, 2 671-647-2555 671-647-2283 671-647-2555 671-647-2181 671-647-2555 671-647-2284 Mobile phone 727-1863 - Email glenda.pangelinan@gmha.org drp_dauterman@yahoo.com U.S. Naval Hospital Guam Name LT Steven Clifford* Position Laboratory Officer Phone 671-344-9753 Mobile phone 777-9125 678-6550 Email steven.clifford@med.navy.mil Andersen Air Force Base Clinic Name Capt. Devona Luna Capt. William Lujan Position Laboratory Officer Public Health Officer Phone 671-366-6581 671-366-4147 Mobile phone - Email devona.luna@andersen.af.mil william.lujan@andersen.af.mil Diagnostic Laboratory Services, Guam Name Position Cynthia Henson *1° Laboratory Manager Mary Jean J. Jacar *2° Laboratory Supervisor Phone 671-646-5770 671-646-5771 671-646-5770 671-646-5771 Mobile phone 678-7767 chenson@dlslab.com 678-7768 mjacar@dlslab.com Email Guam Seventh-Day Adventist Clinic Name Position Lee H. Meadows, MD* 1° Influenza Control Officer Catherine D. Taitano 2° Frances Mantanona Eddie Abaya Infection Control Officer Administrator Laboratory Supervisor Phone 671-646-8881-5 x 620 671-646-8881 x 620 671-646-8881 x 111 671-646-8881 x 680 Mobile phone 7770694* - Email lmeadows@guamsda.com ctaitano@guamsda.com fmantanona@guamsda.com eabaya@guamsda.com Attachment 3-K-1 LabTech Diagnostics Name Evelina McDonald Velma Tabares Florencia A. Nocon Position Laboratory Manager General Laboratory Supervisor Microbiologist Phone 671-646-4678 671-646-4678 671-646-4678 Mobile phone - Email labtech@guamcell.net labtech@guamcell.net labtech@guamcell.net Hawaii State Laboratory Division (HSLD) Name Rebecca H. Sciulli, M.S., M.T. (AMT)* 1° Remedios B. Gose 2° Position Phone BT Microbiologist & Coordinator 808-453-5993 808 368-3373 808-453-5985 BT Senior Microbiologist Mobile phone 363-3373 rebecca.sciulli@doh.hawaii.gov - remedios.gose@doh.hawaii.gov Email Continental Micronesia, Inc. (CMI) Name Pacific Operations Control Center GUM (POCC )* 1° Thomas Berkemeyer* 2° Vince Borja* 3° Leo Tkel* 4° Ray Cruz* 5° Lance Hoppai Edwin Moriwaki Robbi Crisostomo Brian Wessling Jeff Moken Position Phone 24 hour Primary Contact 671-645-8473 Director, Safety & Security GUM Manager, Safety & Security GUM Manager, GSE GUM Training Coordinator, GUM Manager, Cargo Operations HNL Supervisor, Cargo Operation HNL Manager, Cargo Operation GUM Senior Director, Operations GUM Manager HNL 671-645-8525 671-645-8522 671-645-8851 671-645-8726 808-275-0447 808-275-0449 671-645-8793 671-645-8838 808-351-3112 Mobile phone 687-5934 687-2414 687-2726 371-7049 687-4071 687-4909 Email thomas.berkemeyer@coair.com vince.borja@coair.com leo.tkel@coair.com ray.cruz@coair.com lhoppai@coair.com edwin.moriwaki@coair.com robbi.crisostomo@coair.com brian.wessling@coair.com jeff.moken@coair.com CDC Honolulu Quarantine Station Name CDR. William L. Jackson, MD, PhD, MSPH, DNWC Position Quarantine Medical Officer Phone 808-861-8530 808-861-8475 Mobile phone 404-917-9085 Email bwf3@cdc.gov Federal Aviation Authority (FAA) Name Robert (Jeff) Coppock Velma Fish Anthony Tepedino Position Special Agent Phone 808-861-8483 808-861-8485 808-861-8484 Mobile phone 630-0247 630-5913 630-0246 Email jeff.coppock@faa.gov velma.fish@faa.gov anthony.tepedino@faa.gov TNT Express Worldwide/Ambyth Logistics, Guam Name Position Eric James* 1° Manager of Operations Leiana Rabon* 2° Station Manager Lori San Nicolas 3° Sales Executive Phone 671-646-3723 671-646-3729 671-646-3723 671-646-3729 671-646-3723 671-646-3729 Mobile phone 898-1378 eric.james@ambyth.guam.net 898-1750 leiana.rabon@ambyth.guam.net 898-7351 lori.sannicolas@ambyth.guam.net Email *24 hour point of contact Attachment 3-K-2 CHAPTER 4 ISOLATION AND QUARANTINE RESPONSE PLAN SECTION 1.0 INTRODUCTION The initial response to a novel strain of influenza will aim at containing the virus at its source. Thorough case isolation and quarantine of contacts in the area where the novel strain emerges may slow the spread of a pandemic. Travel restrictions to and from areas of viral transmission may help slow viral spread to other parts of the world. When the virus moves beyond its initial range and is introduced into the United States, early efforts will likely include isolation and quarantine of newly arrived cases and their contacts. But as transmission becomes more widespread in the United States, quarantine becomes less effective and may not be used as a primary public health intervention. Slowing initial viral spread will allow greater time to manufacture and distribute influenza antiviral medications and to develop, manufacture, distribute, and administer influenza vaccine. Epidemiologic investigations of early influenza cases may reveal features of the novel strain that will be relevant to what efforts have the greatest potential in slowing viral spread. The goals of Travel-Related Disease Control and Community Prevention are to slow the initial spread of pandemic influenza; to describe steps that individuals can take to reduce their risk of becoming infected and their risk of spreading infection to others; and steps that the community as a whole can take. The containment measures of isolation and quarantine aim to reduce the risk of transmission of pandemic influenza virus by decreasing the probability of contact between infected and uninfected individuals and decreasing the probability that contact will result in infection. These measures can be applied at the individual or community level and can be directed towards persons who are ill and persons who are well. Individual measures include isolation of ill patients (those with symptoms), quarantine and symptom monitoring of well persons who have had contact with ill persons, hand and respiratory hygiene, and use of PPE such as masks and gloves. Community measures include social distancing such as restricting mass gatherings, closing schools, and limiting domestic and international travel. SECTION 2.0 DEFINITIONS ƒ ISOLATION is the separation of ill persons with contagious disease from those who are healthy and the restriction of their movement or activities to stop the spread of that illness. Ƒ Isolation typically applies to an individual. Ƒ People in isolation may be cared for in hospitals, in their homes, or in designated isolation facility. ƒ QUARANTINE is the separation and restriction of movement of persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious. Ƒ Applied to an individual or groups in the community and may be implemented in individual homes or designated quarantine facility. Ƒ Its main purpose is to stop the spread of infectious disease. Ƒ Involves identifying what constitutes an exposure and who is considered a close contact to determine when a person is to be quarantined. is acting as the Public Health Authority (PHA). ƒ At the same time, there may be a very limited supply of available antiviral drugs, thus, public health measures of isolation, quarantine, and general public health containment may be necessary to slow the spread of pandemic influenza virus. ƒ COMMUNITY-BASED CONTROL MEASURES aim to decrease the risk of disease transmission by limiting social interactions such as cancellation of public events, limiting public transportation, and restriction of movements of segments of the community; and preventing inadvertent exposures in public or common daily measures such as fever monitoring before entering a place of congregation such as schools, use of masks, or community-wide quarantine. These measures can be used to delay spread of the disease and allow more time for development and production of vaccines and antiviral drugs. ƒ SECTION 3.0 ASSUMPTIONS AND PLANNING PRINCIPLES ƒ Isolation and quarantine, whether for an individual, a group, or a community, is best implemented on a voluntary basis. ƒ At the initial detection of the pandemic virus, the vaccine will be unavailable for an undetermined and prolonged length of time. ƒ Isolation and quarantine planning efforts must incorporate and address the unique needs and circumstances of vulnerable populations including the homeless, limited English proficiency populations, persons with special medical needs, etc. ƒ All policies and procedures to assure the care of Protected Health Information (PHI) apply. Policies and procedures recognize that DPHSS may make necessary disclosures to protect public health when it Quarantine involves isolation as well. ƒ Several difficulties may be encountered in controlling exposure to pandemic influenza including our current mobile society, short incubation period of the virus, and the period of communicability that begins prior to onset of symptoms. ƒ The Government of Guam has the primary responsibility for the implementation of isolation and quarantine measures within the island while Federal law has authority to prevent interstate and international travel and importation. ƒ During a pandemic, DPHSS in conjunction with CDC will most likely recommend voluntary home quarantine when possible, wherein exposed persons check themselves for fever and report early symptoms to public health staff. This will likely occur when a large portion of the population becomes ill and a shortage of personnel to monitor and enforce mandatory containment measures occurs. ƒ Compliance with self-quarantine and home quarantine recommendations provided by DPHSS and the CDC is greater when those in quarantine will be more accessible Guam Pandemic Influenza Plan 4-2 to receive necessary supplies and healthcare, not discriminatory, and are clear and reasonable. ƒ Personal hygiene measures such as hand washing and recommendations for use of PPE such as masks will likely also be included in recommendations to the community to help limit transmission. ƒ The legal authority and duty to enforce isolation and quarantine orders is vested to the DPHSS Director as contained in 10GCA Chapter 3, Article 3, § 3310 and Public Law 26-173 known as the “Islan Guahan Emergency Health Powers Act”. ƒ DPHSS and law enforcement responders involved in enforcement of quarantine orders will be provided appropriate PPE and related training by their respective agencies as recommended by the CDC and WHO. ƒ By law, all isolation and quarantine orders must include the length of time for the isolation and quarantine periods and specify places or areas to or in which they are restricted in their movements. ƒ The DPHSS Director is responsible for determining and justifying the isolation and quarantine time periods. SECTION 4.0 SELF-QUARANTINE AND GENERAL PUBLIC HEALTH CONTAINMENT MEASURES A critical aspect to the successful implementation of self-quarantine and public health containment measures is full public support and understanding; focusing on the accuracy and timeliness of communication and collaboration with the general public in the community. SECTION 4.1 UNDERLYING PRINCIPLES Attending to the medical, legal, social, psychological, financial, and logistical challenges facing isolated or quarantined persons are keys to the successful application of containment measures for those who have needs that they cannot meet on their own. Essential services and supplies for persons in isolation and quarantine include: ƒ Food and water ƒ Utilities (electricity, water, sewage, garbage collection, telephone, heating or air conditioning, internet, etc.) ƒ Shelter (NOTE: identify facilities for the isolation or quarantine of the homeless, travelers and others whose own homes/ households may be inappropriate) ƒ Medications, medical supplies, medical consultation and care ƒ Access to legal representation ƒ Mental health and psychological support services ƒ Faith-based services ƒ Other supportive services (such as childcare, laundry, banking, essential shopping, etc) ƒ Social amenities (e.g. television, radio, internet access, reading materials) ƒ Transportation ƒ Financial support Guam Pandemic Influenza Plan 4-3 Persons who do not require hospitalization for medical reasons will be isolated in their homes whenever possible. Personal residences are generally the preferred settings for quarantine. Isolation and quarantine are optimally performed with the consent and cooperation of the patient. However pursuant to 10GCA Chapter 3, Article 3, § 3310 and Public Law 26-173 known as the “Islan Guahan Emergency Health Powers Act”, the PHA or the Superior Court may issue an emergency detention order placing a person or group of persons into detention for purposes of isolation or quarantine. ƒ Support transition to isolation and quarantine site (home or facility) as needed. ƒ Deliver and explain educational materials in appropriate languages and literacy levels. ƒ Deliver and explain essential medical supplies. ƒ Monitor and evaluate isolated or quarantined individuals daily by phone for health status as well as support needs and compliance with orders; coordinate and follow-up on delivery of goods and services as needs arise. DPHSS will assure the following: ƒ Coordinate necessary medical care and follow-up with the appropriate medical provider. ƒ In concert with healthcare providers, identify and evaluate status of cases, identify and monitor contacts of patients, and determine whether to quarantine contacts if indicated. ƒ Coordinate with local providers for medications and medical supplies. ƒ Coordinate with community-based partners (i.e. American Red Cross, Salvation Army, Catholic Social Service) to establish the infrastructure to deliver essential goods and services to persons in isolation and quarantine. ƒ Coordinate with the AG and Superior Court of Guam to issue legally binding isolation and quarantine orders. ƒ Assess the home environment to determine its suitability for isolation or quarantine. ƒ Identify and activate facilities to house persons for whom isolation or quarantine is indicated but who do not have access to an appropriate home setting. ƒ Coordinate transfer to persons needing acute care. hospital of ƒ Provide interpreter services to isolated or quarantined persons, if needed. ƒ Ensure access to legal representation. ƒ Monitor the course and extent of the outbreak and evaluate the need for community containment measures. ƒ Coordinate with GPD and other law enforcement agencies for the support necessary to enforce isolation and quarantine orders issued; notify the AG of suspected non-compliance. ƒ Provide training and PPE’s for law enforcement and other first responders, as needed. Guam Pandemic Influenza Plan 4-4 ƒ Provide training for community providers as needed, including training in incident command and infection control. ƒ Arrange for childcare or senior information and assistance for elderly care, if needed. ƒ Identify potential resources to support response partners. ƒ Arrange transportation if needed to access medical treatment or other critical services. ƒ Coordinate with Department of Integrated Services for Individuals with Disabilities (DISID) for the continuity of services for people with disabilities and special case-management needs. ƒ Document the needs of isolated and quarantined persons and document whether these needs were met. ƒ Coordinate risk communications and public information in concert with the JIC, partner PIOs, and the media. ƒ Coordinate with the American Red Cross, the other social service providers, and businesses to provide food, shelter, and clothing on an emergency basis. ƒ Coordinate public utilities to ensure the ongoing provision of basic utilities (water, electricity, garbage collection, and heating or air-conditioning) to residences of persons who are isolated or quarantined. ƒ Coordinate other social service organizations and local businesses to provide basic supplies (clothing, food, and laundry services) to individuals who are isolated or quarantined. ƒ Coordinate with GTA to access telephone services for individuals who are isolated or quarantined, if needed. ƒ Provide access to mental health and other psychological support. Coordinate with DMHSA, if needed. ƒ Coordinate with local social service providers to ensure faith-based services and social amenities, e.g. television, radio, Internet access, and reading materials. SECTION 5.0 ISOLATION – CONCEPT OF OPERATIONS The primary purpose for isolation is to separate an ill and/or contagious person from the healthy population in the community. It is easier to understand, accept, and implement isolation rather than quarantine. Isolation facilities include homes, hospitals, and/or alternate sites in the community such as skilled nursing facility, hotels, or tents. SECTION 5.1 AUTHORITY Pursuant to the provisions of 10GCA Chapter 3, Article 3, §3310, DPHSS Director has authority to impose isolation of any person who has or is reasonably suspected of having any communicable disease or any disease dangerous to the public health. DPHSS Director will have primary authority for implementation of the Plan, including recommendations and request for isolation and quarantine, with guidance from the Territorial Epidemiologist and the Medical Advisor. Guam Pandemic Influenza Plan 4-5 As the pandemic threat escalates and becomes a civil defense emergency requiring resources outside of the control of the DPHSS Director, the Governor, OCD, and GHS will become involved. SECTION 5.2 NOTIFICATION AND COMMUNICATION Notification and communication of isolation and quarantine requirements will follow existing protocols. ƒ If the on-site visit confirms noncompliance by the absence of the quarantined person, pursuant to 10GCA, law enforcement has the authority to locate and confine individuals in violation of the quarantine order, using reasonable force. ƒ Ensure collection of accurate data for each quarantined person, including demographics, as well as the following: Ƒ Relationship to the case-patient DPHSS will reach clinicians through the Office of Epidemiology & Research email system and broadcast fax used for health notifications. Ƒ Nature and time of exposure Multiple media sources, such as television, radio, newspapers, and DPHSS website, will be used to send announcements to the public. Ƒ Any underlying medical conditions Ƒ Whether contact is vaccinated, on antiviral prophylaxis, or using PPE Ƒ Number of days in quarantine Ƒ Symptom log SECTION 5.3 ENFORCEMENT ƒ Based on the current available data, the recommended duration of quarantine for influenza is generally ten days from the time of exposure. This will be adjusted based on available information during a pandemic. ƒ BCDC or emergency response staff conducts at least two randomly timed phone calls to the quarantined person on a daily basis to monitor for development of symptoms such as fever, respiratory symptoms, etc. ƒ If phone calls fail to reach the quarantined person, a DPHSS response team staff trained in the use of appropriate PPE and related equipment, makes an on-site visit to the quarantined individual to ensure compliance or to confirm non-compliance. Ƒ Compliance with quarantine SECTION 5.4 LEVELS OF ISOLATION ƒ The first patients presenting on Guam with the novel influenza virus will be most likely isolated in isolation rooms at GMHA or USNH. ƒ When hospital isolation beds have reached capacity and influenza cases continue to increase, the next level of isolation may be in mobile acute care modules established near the hospitals and staffed by hospital personnel to provide surge capacity or as indicated in the GMHA Pandemic Plan. ƒ The third level of isolation will take place in cohort facilities, such as skilled Guam Pandemic Influenza Plan 4-6 nursing facility, that will provide living quarters for a group of people who are all ill with the novel influenza virus or as indicated in the GMHA Pandemic Plan. ƒ As the number of influenza cases increases and infection becomes widespread, DPHSS will more likely recommend to the public to isolate themselves and remain at home after becoming ill, thus, they will be less likely to be exposed to other infections and be less likely to infect others. Voluntary home isolation is ideal for infected persons who are not sick enough to be hospitalized but still have access to sufficient care and basic needs at home. SECTION 5.5 ISOLATION FACILITY REQUIREMENTS ƒ GMHA has isolation beds/rooms that conform to guidelines from the CDC and the Healthcare Infection Control Practices Advisory Committee. community health centers, senior citizen centers, apartments, dormitories, and hotels (see Attachment F). Temporary structures for community isolation facilities include trailers, barracks, or tents. ƒ The following features must be considered when selecting a site and facility: Ƒ Size of facility and rooms. Ƒ Ability to provide strict standard and droplet isolation precautions. Ƒ Bathroom with commode and sink, including showers. Ƒ Provision of infection control facilities for hospital or clinical staff, such as gowning/de-gowning areas, changing rooms, shower facilities, and widely available handwashing basins or waterless hand sanitizers. ƒ Facilities with negative pressure capacity are desirable if the novel virus possesses characteristics that require airborne precautions. Ƒ Easy & controlled access to facility, including handicap accessibility. ƒ A community-based facility for isolation will be required when home, hospital, or health care facility are not sufficient to accommodate persons requiring isolation. Ƒ Food and laundry service. Ƒ Such facility will be useful during large outbreaks in the community. Ƒ Basic security. Ƒ Functioning telephone to allow patients contact with family and friends. Ƒ Waste and sewage disposal system. Ƒ Procedures to monitor health of staff. Ƒ Potential community sites for isolation are identified and will be evaluated during pre-pandemic preparedness planning stages. ƒ For home-isolation, these additional recommendations must be made to both ill persons and their family members: Ƒ Existing structures for community isolation facilities include schools, Ƒ Separate the ill person who must stay at home while he is most likely Guam Pandemic Influenza Plan 4-7 infectious to others, (usually for five days after onset of his symptoms). Complete pandemic influenza case report form, Attachment 2-A, if not yet completed and voluntary isolation agreement, Attachment 4-B. Ƒ Restrict visitors to the home. Ƒ The patient must follow cough etiquette such as covering the mouth and nose when coughing or sneezing; disposing used tissues immediately after use; and washing hands after using tissues. Ƒ Household members must limit contact with the patient and designating one person as primary care provider, preferably someone who does not have any underlying condition which may predispose that person to an increased risk of getting a severe influenza disease. Complete contact record form, Attachment 2-B, if not yet completed. Ƒ All household members must carefully wash hands or use alcoholbased rub after any contact with the patient, his linens, any tissues, or towels and handkerchiefs. Ƒ Ill patients and caregiver must wear masks during interactions to decrease the spread of infection. In unavoidable circumstances, any person entering home of suspected influenza patients should wear mask within three feet from the ill patient and should wash hands after each contact and before leaving the home. Ƒ Soiled dishes and eating utensils must be washed in a dishwasher or by hand with warm water and soap. Separation of eating utensils for use by patient with pandemic influenza should be considered. Ƒ Laundry can be washed in a standard washing machine with warm water and detergent. When handling soiled laundry, care must be used to avoid contamination; avoid “hugging” the laundry and wash hands with soap and water or alcohol-based rub afterwards. Ƒ Household members must monitor themselves for development of influenza symptoms and to contact a telephone hotline or medical care provider if symptoms occur. SECTION 6.0 QUARANTINE – CONCEPT OF OPERATIONS Quarantine is the separation and restriction of movement or activities of persons who are not ill but who are suspected to have been exposed to infection to prevent or reduce influenza transmission through monitoring their health and providing medical care and infection control precautions as soon as symptoms are detected. It is a more complex measure than isolation as it involves some serious issues concerning public health, public health law, and public policy. It is resource and labor intensive, taxing the reserves of virtually every area within the government such as health care, public health, social service, and law enforcement. Quarantine should not be used as a means to immediately stop the spread of disease, but rather as one of many tools to reduce the likelihood that new cases will arise from individuals who are not aware that they may be infected. When quarantine is required, public health officials will inform the public of the threat to their health, communicate the known risks, Guam Pandemic Influenza Plan 4-8 provide full information for the need for public action, and describe how the government will support individuals whose movement is restricted. It must be emphasized to the general public that quarantine is only temporarily restricting personal movement and is a collective action implemented for the common good. SECTION 6.1 AUTHORITY Same as that provided for Isolation needs described in Section 5.1. SECTION 6.2 DPHSS DUE PROCESS PLAN P.L. 26-173 §19605 specifies the procedures for isolation and quarantine. DPHSS legal counsel at the AG’s office will finalize templates for written directives or quarantine orders. Draft samples are ongoing. SECTION 6.3 ENFORCEMENT – Refer to Section 5.3. SECTION 6.4 KEY REQUIREMENTS FOR QUARANTINE Regardless of location or type of quarantine, every effort must be made to provide those in quarantine with the following minimum set of basic capabilities: ƒ Quarantined individuals must have access to public health and healthcare personnel whether through telephone hotlines, two-way radio, email, or personal care. The form of interaction must be consistent with the level of healthcare required. ƒ They must have access to public information and educational resources to assist them in making informed decisions and take educated actions to protect their own health and the health of their families. This may also be in the form of emails, websites set up specifically to meet this need, hotlines, two-way radio, public access TV, or mailings. ƒ Communication with relatives and friends must be made available through telephone, email, two-way radio, or video conferencing capability, if in-person visits are not advised. ƒ Individuals in quarantine must be monitored for symptoms, whether by a public health or response professional, family members, or by themselves. Monitoring must be efficient and effective enough to identify the key symptoms immediately, using form in Attachment 4-E. ƒ Quarantine enforcement guidelines must be established, disseminated, and maintained. ƒ Upon identification, authorities must provide transportation for those who show symptoms to isolation facilities. Such transportation capabilities are important to ensure the greatest medical care of the symptomatic individuals and are critical for minimizing potential exposure of nonsymptomatic individuals in quarantine. SECTION 6.5 TYPES OF QUARANTINE DPHSS may choose from any of the following types of quarantine to implement based on the nature and scale of the pandemic, characteristics of the public at risk, susceptibility of the population, Guam Pandemic Influenza Plan 4-9 geographic distribution of the influenzainfected persons, availability of resources, and legal authorities in place. ƒ Voluntary home quarantine will be the primary strategy wherein the exposed or potentially exposed persons remain at home during the incubation period, possibly ten days with pandemic influenza. ƒ Facility quarantine or alternative quarantine sites will be used for those contacts unwilling or unable to maintain home quarantine, e.g. senior citizen centers, schools, gymnasiums, motels, or hotels. The movement of exposed or potentially exposed persons is restricted to the facility for the duration of the quarantine. Advantages of facility quarantine include consolidation and centralization of efforts, and provide options for those who may not want home quarantine and wish to minimize risk to their household members. However, the prospect of being placed in close proximity to potentially infected persons or simply being away from home or family may cause psychological distress and pose a challenge to public health officials seeking to encourage voluntary compliance. ƒ Community quarantine applies when all persons in a specific area or region where a high community-wide case count has been identified or where there is a potential for widespread exposure are quarantined. It is implemented by arranging a perimeter of a controlled access area around the region of concern, sometimes known as cordon sanitaire. This type of quarantine is the most difficult to implement and enforce. It may involve a legally enforceable action and travel restriction into or out of an area circumscribed by a real or virtual “sanitary barrier” or “cordon sanitaire” except to authorized persons, such as public health or healthcare workers. Alternative quarantine identified based on considerations: sites the will be following Ƒ Scope of pandemic Ƒ Size of facility, room, and site – adequate rooms for each contact Ƒ Controlled security access and adequate Ƒ On-site showers ƒ Work quarantine may also be considered as was used in Toronto, Canada during the SARS epidemic of 2003. It mainly applies to health care workers and other emergency response personnel where outbreak control requires employee to continue working but are required to use the prescribed PPE. When not working, they must remain in home or facility quarantine and authorities would need to arrange for safe transportation to limit contacts with others, enforce strict and frequent monitoring of symptoms. Ƒ Food service delivery Ƒ Laundry service Ƒ Telephone service to allow patients contact with family and friends Ƒ Waste disposal procedures Ƒ Staff to monitor contacts at least daily for fever and respiratory symptoms Ƒ Transportation for medical evaluation for persons who will develop Guam Pandemic Influenza Plan 4-10 symptoms Quarantine sites to be considered include all schools used as typhoon shelters, senior citizen centers, village gymnasium/sports complex, apartments, and hotels (see Attachment 4-D). Each hotel is encouraged to identify a designated area or wing in their facility to be used for the quarantine of susceptible guests exposed to a suspect or ill person with pandemic influenza. SECTION 6.6 SUPPORT SERVICES ƒ During quarantine, movement to the area of quarantine will be restricted. ƒ Ensure that mental health and psychological support services are provided when necessary. ƒ Available law enforcement personnel to maintain security at borders and enforce restriction of movement within the quarantine areas. SECTION 6.7 DETERMINATION OF NEED FOR ISOLATION OR QUARANTINE ƒ The DPHSS Director will authorize the use of isolation and/or quarantine as strategies to control pandemic influenza based on the advice of the Medical Advisor, Territorial Epidemiologist, CPHO and BCDC Administrator. ƒ Once the DPHSS EOC is activated, the IC, Medical Advisor, Territorial Epidemiologist and Clinical Team will determine whether an isolation or quarantine facility should be activated. ƒ DPHSS will seek voluntary compliance with requests for isolation and quarantine, unless the Medical Advisor advises the DPHSS Director that the following conditions are present, making it necessary to immediately initiate involuntary detention for the purposes of isolation or quarantine: Ƒ There is reason to believe that the individual or group is, or is suspected to be, infected with, exposed to, or contaminated with pandemic influenza that could spread to or contaminate others if remedial action is not taken. Ƒ There is reason to believe that the individual or group would pose a serious and imminent risk to the health and safety of others if not isolated or quarantined. Ƒ Seeking voluntary compliance would create a risk of serious harm. SECTION 6.8 INITIATION OF REQUESTS FOR VOLUNTARY COMPLIANCE WITH ISOLATION OR QUARANTINE ERT will: ƒ Initiate contact with the individual or group suspected of being infected or exposed. ƒ Determine whether interpretation services are needed to facilitate communication with the person; if so, coordinate with interpreter resource listing, as needed. ƒ Enter cases and contact(s) in a database and document information related to cases including dates and times of all verbal and written communications. Guam Pandemic Influenza Plan 4-11 ƒ Verbally communicate the following information to the individual or group. Ƒ Explain the circumstances regarding the infection or exposure, the nature and characteristics of the illness, and the potential for infection of others. Provide written material when available. Ƒ Request that the individual or group isolate or quarantine themselves and have the isolation (see Attachment 4-B) or quarantine agreement signed (see Attachment 4-C). Ƒ Explain the process for isolation and quarantine, what is expected of each individual, how DPHSS will support their needs, and how long they must remain under isolation or quarantine. Ƒ If necessary, explain that the DPHSS Director/Medical Advisor has authority to issue an emergency detention order or petition the court ex parte for an order authorizing involuntary detention if the individual or group does not comply with the request for isolation or quarantine. ƒ If an individual is a patient in a hospital, make contact with hospital staff as well as the patient to ensure hospital-based isolation and appropriate infection control measures are practiced, if indicated. ƒ Complete a written request for voluntary compliance with isolation or quarantine instructions, including the location and dates of isolation or quarantine, suspected disease, medical basis for isolation or quarantine, and relevant patient information. Provide copies to the Clinical Team and AG. ƒ Make a reasonable effort to obtain the cooperation and compliance of the individual or group with the request for isolation or quarantine. ƒ Document efforts on a standardized form and enter into a database. ƒ Alert the DPHSS Director/Medical Advisor and the AG about situations where a person or group indicates unwillingness to comply. ƒ Recommend whether detention should be initiated. involuntary ƒ Cooperate with the epi-investigation team regarding the issuance of requests for voluntary compliance with isolation or quarantine instructions. ƒ Contact the identified individual to evaluate the suitability of their residence for isolation or quarantine; determine whether evaluation can be implemented using a telephone questionnaire or if an in-person review is necessary. ƒ Immediately deliver an information packet to the individual placed in isolation or quarantine. Provide appropriate instructions and training, if needed, regarding the packet contents, public health expectations and infection control measures (note: patients isolated within health care facilities will be provided similar packet). ƒ Activate the isolation and quarantine response teams to support the needs of isolated and quarantined persons including the following: Ƒ Develop a schedule of daily check-in calls with each individual under isolation or quarantine. Guam Pandemic Influenza Plan 4-12 Ƒ Verify that the individual is at a specified location and monitor their health status. Ƒ Continue conducting daily check-in calls with each individual until they are released from isolation or quarantine. Ƒ Record information gathered during check-in calls on a standardized form and input information into a database. Ƒ Respond to irregularities such as changes in health status and failure to respond to call(s) (e.g., request law enforcement or PH staff drive by; make contact with patient’s health care provider, personal contacts or employer, etc.). NOTE: If repeated attempts to locate individuals who are subject to isolation or quarantine are unsuccessful (via telephone calls or site visits), coordinate with DPHSS IC, AG or designee and Medical Director regarding the need to pursue involuntary detention. SECTION 6.9 OTHER COMMUNITY-BASED CONTAINMENT MEASURES If disease transmission in the community is significant and sustained, community-based containment measures or nonpharmaceutical interventions will be implemented (see Attachment 4-A). Community-based containment measures are grouped into two broad categories: ƒ Measures that affect groups of exposed or at-risk individuals ƒ Measures that apply the use of specific sites or buildings sometimes known as “focused measures to increase social distance” include cancellation of events and closure of buildings or restricting access to certain sites or buildings. Following are examples: Ƒ Cancellation of public events like concerts, sports events, political rallies, holiday celebrations, movies, and plays, as well as smaller social activities like weddings or religious services. The great challenge for this kind of restriction is that humans are inherently social beings. By depriving persons of certain social interactions in the midst of a public health crisis in which they may feel isolated and afraid, public officials may aggravate an already stressful situation. To promote mental health, compliance with the restrictive measures, and as much “normalcy” as possible, every effort will be made to arrange for alternative means of entertainment, social, religious, or political gatherings. These might include use of radio/public TV broadcasts, video web casts, internetbased “community square” chat rooms and teleconferences to provide alternative means for groups to congregate, to experience “live” entertainment, or participate in religious services. These “quality of life” activities will be supplemented with access to mental health counselors or other support, as needed. Ƒ Closure of recreational facilities like community swimming pools, youth clubs, gymnasium, and senior citizen centers. Ƒ Group Quarantine (i.e. home, facility, work, or community quarantine) Guam Pandemic Influenza Plan 4-13 ƒ Measures that affect communities that include both exposed and non-exposed individuals. Such measures must be considered at the following circumstances: • Perform hand hygiene after contact with respiratory secretions and contaminated objects or materials Ƒ There is moderate to extensive transmission in the area Ƒ During the pandemic, persons at high-risk for complications of influenza will be advised to avoid public gatherings such as movies, religious services, or public meetings and avoid going to public areas such as supermarkets, stores, malls, or pharmacies. The use of other persons for shopping or home delivery service is encouraged. Use of surgical-type masks by healthcare workers taking care of ill patients is recommended to prevent splashes and droplets of potentially infectious material from coughs and sneezes from reaching the mucous membranes of healthcare workers’ nose or mouth. The benefit of wearing masks by well individuals in public settings has not been established and is not recommended as a public health measure at this time. Ƒ Many cases cannot be traced to contact with an earlier case or known exposure Ƒ Cases are increasing among contacts of influenza patients Ƒ There is a significant delay between the onset of symptoms and isolation of cases because of the large number of ill persons ƒ As community outbreaks of pandemic influenza occur, the general public must avoid close contact with ill individuals and the following measures may decrease the overall magnitude of the outbreak: Ƒ Promotion of community-wide infection control measures such as respiratory hygiene/cough etiquette. Throughout the pandemic, DPHSS will encourage all persons with signs and symptoms of a respiratory infection, regardless of presumed cause, to do the following: • Cover the nose and/or mouth when coughing or sneezing • Use tissues to contain respiratory secretions • Dispose of tissues in the nearest waste receptacle after use Ƒ Individuals may choose to wear a mask as part of their individual protection strategies that include cough etiquette, hand hygiene, and avoidance of public gatherings. Mask use is most important for individuals who are at high risk for complications of influenza and those who are unable to avoid close contact with others or those who must travel for essential reasons such as seeking medical care or attending religious services. Public education will be provided on how to use and dispose of masks appropriately. In addition, it must be emphasized that mask use is not a substitute for social distancing or other personal protection measures. Supply Guam Pandemic Influenza Plan 4-14 issues will be considered so that mask use in communities does not limit availability for healthcare settings where importance and effectiveness of this issue has been documented. Ƒ Asking everyone to stay home is acceptable to most people, and is relatively easy to implement. “Stay Home Days” may be declared by the DPHSS Director, for an initial 10-day period, with final decisions on duration based on an epidemiologic and social assessment of the situation. Such a declaration would be an official public health recommendation, but would not be legally enforceable. Local public health authorities will consider recommendations to the public for acquisition and storage of necessary provisions including type and quantity of supplies needed during “Stay Home Days”. “Stay Home Days” can effectively reduce transmission without explicit activity restrictions such as in quarantine. Consideration will be given to personnel who maintain primary functions in the community such as law enforcement personnel, transportation workers and utility workers (electricity, water, gas, telephone, garbage disposal/sanitation). Compliance might be enhanced by “self isolation” or selfshielding behavior (i.e. many people may stay home even in the absence of an official “Stay Home Days” Declaration) as in voluntary sheltering or sometimes known as “sheltering-in-place”. It is done when individuals, acting out of self-interest, limit their own social interactions for the purpose of protecting their health. Ƒ Closure of office buildings, museums, libraries, shopping malls and schools have significant impact on the community and workforce, thus careful consideration will be focused on their potential effectiveness, how they can most effectively be implemented, and how to maintain critical supplies and infrastructure while limiting community interaction. ƒ Although data are limited, school closures may be effective in decreasing spread of influenza and reducing the overall magnitude of disease in the community. Risk of infection and illness among children is likely to be decreased which would be particularly important if the pandemic strain causes significant morbidity and mortality among children. Results of mathematical modeling also suggest a reduction of overall disease, especially when schools are closed early in the outbreak. During a Pandemic Period, parents will be encouraged to consider child care arrangements that do not result in large gatherings of children outside the school setting. Ƒ Restrictions on travel have been shown to reduce geographic spread, as well as total and local incidence during a disease outbreak. Restrictions may be placed on some or all modes of transportation – air, water, and land – and may include a range of increasingly stringent limitations including issuance of travel warnings, closure of high-risk stops, limiting schedules or canceling travel routes altogether. The effectiveness of such measures will depend on many factors, most notably by total travel intensity of a community, behavior of travelers and disease pathology. Although individual car travel naturally poses lower risk for community transmission, it could Guam Pandemic Influenza Plan 4-15 potentially facilitate the spread of disease to other locations. Thus, traffic restrictions may be considered to reduce flow between villages and limiting only to passage of response and emergency vehicles and other essential transportation. Ƒ Enhanced screening for sick individuals in public places may help detect and separate infected persons. Such screenings may take place passively or as a requirement for access into public or private buildings, businesses or public events. Checkpoints or screenings may also be set up in key transportation hubs such as airports or seaports. A good example is temperature screening and visual screening of incoming or outgoing travelers. Ƒ Scaling back community containment measures. The decision to discontinue community-level measures will balance the need to lift individual movement restrictions against community health and safety. Premature removal of containment strategies can increase the risk of additional transmission. Decisions will be based on evidence of improving local/regional control such as: • Consistent decrease in number of confirmed cases. the • Reduction in the number of probable and known cases. • Effective protective countermeasures are in place (e.g. high coverage with a pandemic influenza vaccine) • General recommendations are to withdraw the most stringent or disruptive measures first. SECTION 7.0 TRAVEL-RELATED CONTAINMENT MEASURES The 2003 Severe Acute Respiratory Syndrome (SARS) pandemic demonstrated how quickly human respiratory viruses can spread, especially in a world of modern air travel. Disease spread will likely be even faster during an influenza pandemic because a typical influenza virus has a shorter average incubation period and is more efficiently transmitted from person to person. It will not be possible to identify and isolate all arriving infected or ill passengers and quarantine their fellow passengers because some persons infected with influenza will still be in the incubation period, be shedding virus asymptomatically, or have mild symptoms. Moreover, if an ill passenger is identified after leaving the airport, it might not be possible to identify all contacts within the incubation period for pandemic influenza. Nevertheless, depending on the situation, these activities might slow spread early in a pandemic, allowing additional time for implementation of other response measures such as vaccination. The recommendations on travel-related containment strategies range from distribution of travel health alert notices, to isolation and quarantine of new arrivals, to restriction or cancellation of nonessential travel. These strategies will be implemented in coordination with CDC quarantine stations located at 18 U.S. ports of entry, primarily HQS which has jurisdiction for Guam Pandemic Influenza Plan 4-16 Guam, CBP, Transportation Security Administration (TSA), CQA, and the airlines. The recommendations for the Interpandemic and Pandemic Alert Periods focus on preparedness planning and on management of arriving ill passengers on international flights or cruise ships. The recommendations for the Pandemic Period focus on travel-related measures to decrease spread into, out of, and within the United States. ƒ Recommendations for the Interpandemic and Pandemic Alert periods Ƒ Prepare for implementation of travelrelated containment measures. If a pandemic begins outside of Guam, early application of travel-related control measures such as identification and isolation of ill travelers and quarantine of close contacts might slow the introduction of the virus. • Engaging community partners including CQA officers, first responders (GFD, GPD), TSA, CBP, GMHA and EMS personnel, GIAA, PAG, political leaders, GVB, businesses, and other related agencies to plan for managing travelrelated disease risks. • Collaborate with partners plan for mobilizing and deploying public health staff and other emergency workers. • Conduct walk-through exercises or drills at ports of entry • Ensure that healthcare workers and emergency responders are trained in the use of PPE. • Develop Memorandum of Agreement (MOA) with GMHA to isolate, evaluate, and manage suspected influenza patients and if applicable, with EMS that can help perform on-site assessments of ill passengers and transport them to the hospital for evaluation. • Protocols for managing ill travelers at GIAA and PAG will include provisions for the following: o Meeting flights reported ill passenger. with a o Establishing notification procedures and communication links among organizations involved in the response. o Reporting potential cases to CDC. o Providing a medical assessment of the ill traveler and referral for evaluation and care. o Separating the ill traveler from other passengers during the initial medical assessment. o Transporting the ill traveler to GMHA. o Identifying other ill passengers and separating them from passengers who are sick. • Transporting and quarantining contacts, if necessary. • Enforcing isolation and quarantine, if necessary, when ill Guam Pandemic Influenza Plan 4-17 travelers and their contacts are uncooperative. • CDC is working with partners in the travel industry to ensure that airplane and cruise personnel are familiar with the following: ż case definitions (symptoms, travel history) for Avian Influenza A (H5N1) and other novel influenza strains of public health concern as they arise; additional and updated case definitions will be provided as necessary. ż actions to take and persons to contact at their home offices, local quarantine station, or CDC if they are concerned about a sick passenger who might have novel influenza. ƒ Quarantine preparedness at GIAA and PAG Ƒ GIAA, DPHSS and local government leaders, in consultation with CDC, will identify quarantine facilities for housing passengers, crew, and emergency workers who may have been exposed to an ill traveler. These facilities should be equipped for: • Temporary quarantine (a few days), until the results of diagnostic tests become available. • Long-term quarantine (up to 10 days) if a diagnosis of pandemic influenza is confirmed. ƒ DPHSS and community partners should plan for the provision of goods and services to persons in quarantine. ƒ Legal preparedness – ensure legal authorities in place and develop protocols, if necessary, for the following: Ƒ Requirements for pre-departure screening of international and domestic travelers. Ƒ Requirements for arrival screening and/or quarantine of international and domestic travelers. Ƒ Prohibitions on travel by ill persons and their contacts. Ƒ Restrictions on use of mass transit systems. Ƒ Cancellation of nonessential travel. Ƒ Enforcement of travel restrictions, in collaboration with federal &/or local law enforcement officers. ƒ Health Information for Travelers – CDC’s Travelers’ Health website (www.cdc.gov/travel/) will provide up-todate travel notices for international travelers to countries affected by novel influenza viruses. This information will be provided to all representatives of airlines operating on Guam, CQA, GIAA, CBP, and TSA. Additional travel health precautions or warnings will be issued to inbound and outbound travelers if avian influenza spreads internationally and causes additional cases of human influenza. Evaluation of travel-related cases of infection with novel strains of influenza. Guam Pandemic Influenza Plan 4-18 ƒ During the Pandemic Alert Period, travel-related cases of infection might be detected after entry into Guam or reported during transit by airline or cruise ship personnel prior to arrival of an ill passenger. Ƒ Managing ill passengers • Follow protocols for management of arriving ill passengers who meet the clinical and epidemiologic criteria for infection with a novel strain of influenza (see also algorithm in Chapter 3, Attachment B). • If an ill passenger with a suspected case of novel influenza is reported aboard an arriving airplane or cruise ship, airline pilot or captain will inform GIAA Tower or Harbor Master who will notify CQA, DPHSS official or designated health officer who will do the following: ż Notify all partners, including the HQS and CDC. ż Request information on the ill passenger’s symptoms and travel exposure history to make an initial assessment if the illness meets the current clinical and epidemiologic criteria for avian influenza (H5N1) or is suspicious for a novel influenza strain. ż DPHSS ERT shall meet the airplane or ship to further evaluate the ill traveler. ż Provide the crew with guidance on infection control procedures, if needed (e.g. separate the ill passenger as much as possible from other passengers; provide ill passenger with a mask or tissues to cover coughs and sneezes). Ƒ If the designated DPHSS officials meet the airplane or ship and perform an initial medical evaluation of the ill traveler, the passengers and crew will be informed of the situation and will not be allowed to disembark until evaluation is complete. Ƒ If DPHSS officials determine that the ill passenger meets the clinical and epidemiologic criteria for infection with a novel influenza strain, the patient will be sent by ambulance to GMHA, using appropriate infection control procedures for transit and patient isolation. Ƒ Managing travel contacts DPHSS officials, in consultation with HQS and CDC, will decide how to manage travel contacts of an ill traveler on a case-by-case basis, taking into consideration the following factors: • Likelihood that the suspected case is due to a novel influenza strain (based on symptoms and travel history, if laboratory results are not available). • Likelihood that the causative virus is transmitted from person to person with a moderate or high efficiency (as in later phases of Pandemic Alert Period). Guam Pandemic Influenza Plan 4-19 • Feasibility of tracing and monitoring travel contacts, as well as the patient’s family members, workmates, schoolmates, and healthcare providers. • Management of contacts include passive or active monitoring without activity restrictions; quarantine at home or in a designated facility and/or; antiviral prophylaxis or treatment. Guam Pandemic Influenza Plan 4-20 PANDEMIC PHASES WHO PHASE 1: INTERPANDEMIC PERIOD ƒ DPHSS Ƒ Review and collect existing laws and regulations pertaining to isolation and quarantine applicable to pandemic influenza response. Ƒ Monitor current recommendations and collaborate with other partners in reviewing and updating plans for isolation and quarantine measures. Ƒ Identify resources available to educate the public on proper handwashing, cough and sneeze etiquette, as well as, on appropriate use of masks and other protective measures when in self-quarantine. ƒ GMHA Ƒ Routine isolation activities for seasonal influenza and other infectious diseases. Ƒ Continue with routine infection control activities for patients and staff. Ƒ Enhanced dissemination of health education materials such as posters and brochures on handwashing and cough etiquette for patients and staff. Ƒ Encourage physicians to promote compliance to handwashing and cough etiquette of patients and staff at their respective clinics. ƒ CQA Ƒ Routine examination of airline and vessel declaration forms. Ƒ Routine reporting to DPHSS and isolation of ill passenger or crew at ports of entry. ƒ GIAA Ƒ Routine support to CQA/DPHSS for identification and isolation of ill passenger or crew. ƒ PAG Ƒ Routine examination of vessel declaration forms. Ƒ Routine reporting to CQA/DPHSS and isolation of ill vessel crew or passenger at Commercial Port. Guam Pandemic Influenza Plan 4-21 ƒ Airlines Ƒ Routine screening and reporting to CQA/DPHSS of ill passenger or crew. Ƒ Routine isolation of ill passenger or crew. WHO PHASE 2: INTERPANDEMIC PERIOD ƒ DPHSS Ƒ Monitor current recommendations and collaborate with other partners in reviewing and updating plans for isolation and quarantine measures. Ƒ If funds are available, print educational materials (i.e. posters on proper handwashing, and cough and sneeze etiquette). Ƒ Ensure that DPHSS and all partner agencies including first responders, epi investigators, healthcare and law enforcement personnel have adequate PPE’s. ƒ GMHA Ƒ Routine isolation activities for seasonal influenza and other infectious diseases. Ƒ Continue with routine infection control activities for patients and staff. Ƒ Enhanced dissemination of health education materials such as posters and brochures on handwashing and cough etiquette for patients and staff. Ƒ Encourage physicians to promote compliance to handwashing and cough etiquette among patients and staff at their respective clinics. Ƒ Maintain adequate inventory of PPE’s for staff and patients. ƒ CQA Ƒ Routine examination of airline and vessel declaration forms. Ƒ Routine reporting to DPHSS and isolation of ill passenger or crew at ports of entry. ƒ GIAA Ƒ Routine support to CQA/DPHSS for identification and isolation of ill passenger or crew. Ƒ Designation of quarantine room at the airport (current location is to leave plane on tarmac; discussions are ongoing for permanent room). Guam Pandemic Influenza Plan 4-22 ƒ PAG Ƒ Routine examination of vessel declaration forms. Ƒ Routine reporting to CQA/DPHSS and isolation of ill vessel crew or passenger at Commercial Port. ƒ Airlines Ƒ Routine screening and reporting to CQA/DPHSS of ill passenger or crew. Ƒ Routine isolation of ill passenger or crew. WHO PHASE 3: PANDEMIC ALERT PERIOD ƒ DPHSS Ƒ Ensure that DPHSS and all partner agencies including first responders, epi investigators, healthcare and law enforcement personnel have adequate PPE’s. Ƒ Monitor current recommendations and collaborate with other partners in reviewing and updating plans for isolation and quarantine measures. Ƒ Coordinate with DPHSS Communication and Education in educating the public on proper handwashing, cough and sneezing etiquette, and if necessary, on appropriate use of masks and other protective measures such as when in self-quarantine. Ƒ Identify list of possible sites, facilities, equipment, and other resources that may be used for isolation and quarantine purposes, both at ports of entry and in the community. Ƒ Identify necessary support services and supplies in the event of activation of isolation and/or quarantine plans. Ƒ Identify methods and other measures to facilitate and encourage self-quarantine should such become necessary. ƒ GMHA Ƒ Continue preparedness activities from Phases 1 and 2. Ƒ Exercise emergency response plan related to isolation activities. ƒ CQA Guam Pandemic Influenza Plan 4-23 Ƒ Continue preparedness activities from Phases 1 and 2. Ƒ Distribution of generic health alert cards at ports of entry. Ƒ Enhanced awareness among staff on current procedures in handling suspect or ill passengers and crew at ports of entry. Ƒ Disseminate health promotion and education materials to staff. Ƒ Maintain adequate inventory of PPE’s for staff, including fit-testing for masks. Ƒ Continue to disseminate to staff CDC and WHO updates and recommendations on pandemic influenza provided by DPHSS. Ƒ Develop pandemic response plan. ƒ GIAA Ƒ Routine support to CQA/DPHSS for identification and isolation of ill passenger or crew. Ƒ Designation of quarantine room at the airport (current location is to leave plane on tarmac; discussions are ongoing for permanent room). Ƒ Dissemination of health promotion and infection control education materials to staff and vendors. Ƒ Develop pandemic response plan ƒ PAG Ƒ Continue preparedness activities from Phase 1 and 2. Ƒ Dissemination of health promotion and infection control education materials to staff. Ƒ Develop pandemic response plan to include identifying an Isolation and Quarantine facility at the port. ƒ Airlines Ƒ Continue preparedness activities from Phases 1 and 2. Ƒ Develop pandemic/communicable disease emergency response plan, if none in place. Ƒ Enhanced awareness among staff on current procedures in handling suspect or ill passengers or crew at airports. Guam Pandemic Influenza Plan 4-24 Ƒ Dissemination of health promotion and infection control education materials to staff. Ƒ Continue to disseminate to staff CDC and WHO updates and recommendations on pandemic influenza provided by DPHSS. ƒ CBP Ƒ Routine examination of travel/immigration documents and visual inspection of arriving passengers and crew at ports of entry. Ƒ Maintain inventory of PPE’s of staff. Each CBP Officer is provided a pandemic kit (1 box of N-95 mask, 1 box of gloves, and 2 packs of hand sanitizer). Ƒ Develop pandemic response plan applicable to Guam (CBP has a national pandemic response plan already in place. ƒ MCG Ƒ Inventory and identify resources of each village related to the provisions of the Emergency Health Powers Act §19202(13). Ƒ Develop pandemic response plan applicable for each village. ƒ GPD Ƒ Develop law enforcement pandemic response plan. Ƒ Identify teams (2-3 staff/team) to support pandemic activities (i.e. security, escort) at isolation and quarantine sites in the northern, central and southern regions. ƒ GFD Ƒ Routine triage and transport of ill passenger or crew. Ƒ Maintain adequate inventory of PPE supplies for staff. ƒ GPSS Ƒ Continue educating staff, students and parents on the signs and symptoms of influenza versus common cold, importance of good hygiene practices and the importance of staying home when sick. Ƒ Confirm school’s role in local isolation and quarantine response plan, i.e. support services. Guam Pandemic Influenza Plan 4-25 Ƒ Inventory and identify possible isolation and quarantine sites. WHO PHASE 4: PANDEMIC ALERT PERIOD ƒ DPHSS Ƒ Regular consult with CDC and WHO to monitor current situation and recommendations. Ƒ May activate isolation and quarantine plan at anytime based on occurrence of highly suspicious case who meets the criteria. Ƒ Enhanced coordination with partners to isolate probable case and quarantine contacts. Ƒ May recommend local residents defer non-essential travel to areas impacted by H5N1/ pandemic influenza, as per CDC and WHO guidance. Ƒ Recommend local residents avoid close contact with other persons to the extent possible; may close schools or suspend group gatherings in consultation with CDC and WHO. Ƒ Coordinate through GPD and OCD to ensure necessary security and enforcement when needed. Ƒ May initiate airport arrival visual screening, distribution of pandemic influenza health alert notices and collection of Health Surveillance Forms (see Attachment 2-C), as per CDC guidance. ƒ GMHA Ƒ Continue activities from Phases 1, 2 and 3. Ƒ Implement pandemic response plan related to isolation activities as indicated in the GMHA Clinical Guidelines Plan. Ƒ Individual patient isolation precautions for possible novel strain of influenza. ƒ CQA Ƒ Continue activities from Phases 1, 2 and 3. Ƒ Continue screening at ports of entry, including more thorough visual examination of passenger or crew possibly ill with pandemic influenza. Ƒ Assist DPHSS in the distribution of pandemic influenza health alert notices and collection of Health Surveillance Forms (see Attachment 2-C) when required, as per CDC guidance. Guam Pandemic Influenza Plan 4-26 ƒ GIAA Ƒ Continue activities from Phases 1, 2 and 3. Ƒ Designation of a permanent isolation and quarantine room at the airport. ƒ PAG Ƒ Continue activities from Phases 1, 2 and 3. Ƒ Ensure a designated quarantine facility at the port. ƒ Airlines Ƒ Continue activities from Phases 1, 2 and 3. Ƒ Enhanced visual and verbal screening of passengers both at departure and arrival areas. ƒ CBP Ƒ Continue activities from Phases 1, 2 and 3. Ƒ If required, assist in distributing pandemic influenza health alert notices, especially to transiting passengers at the airport ƒ MCG Ƒ Maintain facilities and resources of each village related to the provisions of the Emergency Health Powers Act §19202(13). Ƒ Provide manpower support services to DPHSS, if isolation and quarantine facilities are needed through OCD-GHS. ƒ GPD Ƒ Enhanced readiness for emergency response to provide security support for isolation and quarantine activities. ƒ GFD, GIAA/Aircraft Rescue and Fire Fighting Unit (ARFF) Ƒ Enhanced readiness for emergency response to support isolation and quarantine activities. ƒ GPSS Guam Pandemic Influenza Plan 4-27 Ƒ Continue activities from Phases 1, 2 and 3. Ƒ Enhanced readiness for emergency response (i.e. implementation of non-pharmaceutical interventions or community-based containment measures such as school closure, cancellation of large gatherings), when required as recommended by CDC and WHO. ƒ GHS/OCD, DMHSA, American Red Cross, Guam Army National Guard (GUARNG) Ƒ Enhanced readiness for emergency response to support isolation and quarantine activities. ƒ Consulate Offices and GVB Ƒ If possible, provide language interpretation support services. WHO PHASE 5: PANDEMIC ALERT PERIOD ƒ DPHSS Ƒ Regular consult with CDC and WHO to monitor current situation and recommendations. Ƒ May activate isolation and quarantine plan at anytime based on occurrence of highly suspicious case who meets the criteria. Ƒ Enhanced coordination with partners to isolate probable case and quarantine contacts. Ƒ May recommend local residents defer non-essential travel to areas impacted by H5N1/ pandemic influenza, as per CDC and WHO guidance. Ƒ Recommend that local residents avoid close contact with other persons as much as possible; may close schools or suspend group gatherings in consultation with CDC and WHO. Ƒ Coordinate through GPD and OCD to ensure necessary security and enforcement when needed. Ƒ May initiate airport arrival visual screening, distribution of pandemic influenza health alert notices and collection of Health Surveillance Forms, as per CDC guidance. ƒ GMHA Ƒ Continue activities from Phases 1, 2, 3 and 4. Ƒ Implement pandemic response plan related to isolation activities as indicated in the GMHA Clinical Guidelines Plan. Guam Pandemic Influenza Plan 4-28 Ƒ Individual patient isolation precautions for possible novel strain of influenza. ƒ CQA Ƒ Continue activities from Phases 1, 2, 3 and 4. Ƒ Continue screening at ports of entry, including more thorough visual examination of passenger or crew possibly ill with pandemic influenza. Ƒ Assist DPHSS in distribution of pandemic influenza health alert notices and collection of Health Surveillance Forms when required as per CDC guidance. ƒ GIAA Ƒ Continue activities from Phases 1, 2, 3 and 4. Ƒ Designation of a permanent isolation and quarantine room at the airport. ƒ PAG Ƒ Continue activities from Phases 1, 2, 3 and 4. Ƒ Ensure a designated quarantine facility at the port. ƒ Airlines Ƒ Continue activities from Phases 1, 2, 3 and 4. Ƒ Enhanced visual and verbal screening of passengers both at departure and arrival areas. ƒ CBP Ƒ Continue activities from Phases 1, 2, 3 and 4. Ƒ If required, assist in distributing pandemic influenza health alert notices, especially to transiting passengers at the airport. ƒ MCG Ƒ Maintain facilities and resources of each village related to the provisions of the Emergency Health Powers Act §19202(13). ƒ Ƒ Provide manpower support services to DPHSS, if isolation and quarantine facilities are needed through GHS/OCD. GPD Guam Pandemic Influenza Plan 4-29 Ƒ Enhanced readiness for emergency response to provide security support for isolation and quarantine activities. ƒ GFD, GIAA, ARFF Ƒ Enhanced readiness for emergency response to support isolation and quarantine activities. ƒ GPSS Ƒ Continue activities from Phases 1, 2, 3 and 4. Ƒ Enhanced readiness for emergency response i.e. implementation of non-pharmaceutical interventions such as school closure, cancellation of large gatherings, when required as recommended by CDC and WHO. ƒ GHS/OCD, DMHSA, American Red Cross, GUARNG Ƒ Enhanced readiness for emergency response to support isolation and quarantine activities. ƒ Consulate Offices and GVB Ƒ If possible, provide language interpretation support services. WHO PHASE 6: PANDEMIC PERIOD ƒ DPHSS Ƒ Activate plans and support for isolation according to CDC/WHO recommendations and as necessary to limit spread of infection from ill individuals. Ƒ Activate plans and support for quarantine according to CDC/WHO recommendations and as necessary to limit potential transmission from exposed healthy individuals. Ƒ Continue to monitor current recommendations and collaborate with other partners in implementing isolation and quarantine measures. Ƒ Continue to coordinate with CQA and CBP to ensure isolation and quarantine procedures are in place at ports of entry. Ƒ In coordination with the DPHSS Communications Office and JIC, issuance of advisory on voluntary home isolation of sick persons and encouraging employers/supervisors to send ill employees home. Ƒ Activate community-based control measures as needed. Guam Pandemic Influenza Plan 4-30 Ƒ Continue to coordinate through GPD and OCD to ensure potential necessary security and enforcement. ƒ GMHA Ƒ Admission limited to influenza patients to those with severe complications of influenza who cannot be cared for outside the hospital setting. Ƒ Patients admitted to either a single-patient room or an area designated for cohorting of patients with influenza. Ƒ Designed units or areas of a facility should be used for cohorting patients with pandemic influenza. During a pandemic, other respiratory viruses (e.g., non-pandemic influenza, respiratory syncytial virus, parainfluenza virus) may be circulating concurrently in a community. Therefore, to prevent cross-transmission of respiratory viruses, whenever possible assign only patients with confirmed pandemic influenza to the same room. At the height of a pandemic, laboratory testing to confirm pandemic influenza is likely to be limited, in which case cohorting should be based on having symptoms consistent with pandemic influenza. Ƒ Personnel (clinical and non-clinical) assigned to cohorted patient care units for pandemic influenza patients should not “float” or otherwise be assigned to other patient care areas. The number of personnel entering the cohorted area should be limited to those necessary for patient care and support. Ƒ Personnel assigned to cohorted patient care units should be aware that patients with pandemic influenza may be concurrently infected or colonized with other pathogenic organisms (e.g. Staphylococcus aureus, Clostridium difficile) and should adhere to infection control practices (e.g., hand hygiene, changing gloves between patient contact) used routinely, and as part of standard precautions, to prevent nosocomial transmission. Ƒ Because of the high patient volume anticipated during a pandemic, cohorting should be implemented early in the course of a local outbreak. Ƒ The Command Post will identify the trigger points during the pandemic phases for determining implementation of the cohort plan. Cohort units will be opened in the following order: • • • • The first cohort unit will be the Pediatrics Department (4th floor B Wing). The second cohort unit will be the New Surgical Unit (4th floor A Wing) The third cohort unit will be Medical Surgical Unit (3rd floor A Wing) The fourth cohort unit will be the Old Surgical Unit (3rd floor A Wing) NOTE: The Command Post will determine the threshold for preparation by OCD of the GMHA Overflow Site (see GMHA Overflow Plan, Appendix 40). Guam Pandemic Influenza Plan 4-31 Ƒ The Nursing Supervisor on duty will coordinate transport of existing inpatients from the identified cohort unit to a non-influenza patient care area before transport of pandemic influenza patients to that unit. If rooms are not available, the Nursing Supervisor will work with Command Post to assist with implementation of the Patient Rapid Discharge Plan, See GMHA Appendix 17. If staff are not available to assist with transporting patients, the Nursing Supervisor on duty will work with Command Post to identify additional assistance. Admission limited to influenza patients to those with severe complications of influenza who cannot be cared for outside the hospital setting. Ƒ Infection Control practices for cohorting should be followed by all personnel. Infection Control Plan, See GMHA Appendix 2. See Ƒ The Command Post must be sought for assistance in identifying security needed for a patient who may need to be isolated against his/her will. Implement Isolation/Quarantine Law as needed. ƒ CQA, CBP, GIAA, ARFF, Airlines, PAG Ƒ Continue activities from Phases 4 and 5, if travel remains. ƒ MCG, GFD, GPSS, GHS/OCD, Consulate Offices, GVB, GHRA, American Red Cross, DMHSA, GPD, GUARNG Ƒ Provide support activities at isolation and quarantine facilities as needed WHO POST PANDEMIC PERIOD ƒ DPHSS Ƒ Revert to interpandemic isolation and quarantine activities. Ƒ Recovery, evaluation, and preparation activities for subsequent waves. Ƒ Repeat phases 4-6 as appropriate. ƒ GMHA Ƒ Revert to interpandemic isolation and quarantine activities. Ƒ Repeat phases 4-6 as appropriate. ƒ CQA, CBP, GIAA, ARFF, Airlines, PAG Ƒ Revert to interpandemic isolation and quarantine activities. Guam Pandemic Influenza Plan 4-32 Ƒ Repeat phases 4-6 as appropriate. ƒ MCG, GPD, GFD, GPSS, GHS/OCD, Consulate Offices, GVB, GHRA, American Red Cross, DMHSA, GPD, GUARNG Ƒ Revert to interpandemic isolation and quarantine activities. Ƒ Repeat phases 4-6 as appropriate. Guam Pandemic Influenza Plan 4-33 GUAM DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES GRADED IMPLEMENTATION OF SOCIAL DISTANCING MEASURES Level of PanFlu Activity Possible DPHSS Response Actions on Guam (response measures implemented by decision makers will be based Phase on specific health circumstances) 3 Novel influenza virus infecting humans Preparedness planning with partners abroad; no human-to-human Business continuity planning transmission; no cases in the U.S. Educate response partners Continue public education campaign Stockpile antiviral medications and essential supplies 4 Limited human-to-human transmission Isolation of all cases of novel influenza virus abroad; small Quarantine of close contacts number of local cases may begin Recommend local residents defer travel to countries or areas of the appearing, however all are either U.S. impacted by the novel virus, as per CDC guidance imported or have clear epidemiologic links to other cases. 4 Limited human-to-human transmission Isolation of all cases of novel influenza virus on Guam; a Quarantine of close contacts small number of cases appear without Recommend local residents defer travel to countries or areas of the clear epidemiologic links to other cases U.S. impacted by the novel virus, as per CDC guidance and/or increased occurrence of Recommend local residents avoid close contact with other persons influenza among close contacts to the extent possible by curtailing travel and non-essential contact with other persons 5 Sustained novel influenza virus Isolation of all cases transmission on Guam with a large Close public and private schools(K-12) and daycare centers number of cases identified Limit social interaction at college/university and libraries Government and businesses prepare to implement emergency staffing plans 5 Rate of infection continues to increase Close theaters, stadiums, and community centers following school and childcare center Cancel all large public gatherings including houses of worship closures and social distancing in Recommend mass transit be used only for essential travel. government agencies and businesses. 6 Sustained novel influenza activity on Guam with widespread community Suspend all government operations that are not dedicated to the pandemic response or critical continuity operations impact. Attachment 4-A Voluntary Home Isolation Agreement I have been informed that I have been diagnosed as a suspect or probable case of pandemic influenza, a communicable disease dangerous to the public health, and that unless precautions are taken, others may contract this infection from me. The Department of Public Health and Social Services (DPHSS) Director, is required to protect the public from the danger of such communicable diseases as contained in 10GCA Chapter 3, Article 3, § 3310 and Public Law 26173 known as the “Islan Guahan Emergency Health Powers Act”. In order to prevent the spread of this virus the DPHSS has provided me with the following information, advised me of the need to comply with the following instructions and I hereby agree to the following: Ƒ I shall remain in home isolation for a period of ___ days without fever, respiratory symptoms (such as cough, shortness of breath, or difficulty breathing) or sore throat. Ƒ I shall be isolated at the following location which shall hereinafter be referred to as “home”: Street address:________________________________________________________ Village: __________________ State: ________________ Zip: _________________ Telephone: ____________________ Ƒ I have been educated about the disease, the reasons for isolation in the home, and the length of time I can expect to be confined to the home. Ƒ I shall limit all activities and interaction with all other persons living outside the home. I shall not go to work, school, a house of worship, stores or other public areas. Ƒ I shall not leave the home for any reason unless first authorized to do so by DPHSS. Ƒ I understand that only those persons authorized by the DPHSS may enter my home during the period of my isolation. Those who enter the home without prior authorization from the DPHSS may be subject to isolation or quarantine themselves. I agree to notify relatives and friends that they shall not visit the home until further notice. Ƒ I shall use a separate bed and, if possible, a separate bedroom. Ƒ I shall wear a surgical mask when in the same room with non-infected persons. If I cannot wear a surgical mask, others in the same room will be asked to wear a surgical mask. Ƒ If I am not masked I shall cover my nose and mouth with a disposable tissue when coughing or sneezing. Ƒ Household waste, including surgical masks and disposable tissues soiled with respiratory secretions, blood, or other body fluids will be disposed of as normal household waste. Attachment 4-B-1 Ƒ I will wash my hands with soap and water after all contact with respiratory secretions from coughing or sneezing, blood, and other body fluids (e.g. urine, feces, wound drainage, etc.). I will educate and encourage other members of my household to do the same. Ƒ All members of my household will wear gloves on hands when they have contact with my respiratory secretions (lung or nasal), blood, and other body fluids (e.g. urine, feces, wound drainage, etc.). Alcohol based hand hygiene products may be substituted for hand washing with soap and water after removing the gloves, IF the hands are not visibly soiled with respiratory secretions, blood, or other body fluids. Gloves shall not be reused and shall be discarded immediately after removal. Ƒ My eating and drinking utensils will be washed with hot water and a household dishwashing detergent. Ƒ Environmental surfaces (e.g. countertops, tables, sinks, etc.) in the kitchen, bathroom, and my bedroom will be cleaned and disinfected with a household disinfectant, such as household bleach or Lysol®, while wearing gloves, at least daily and when soiled with the respiratory secretions, blood, and other body fluids. Ƒ My bed linens, towels, and personal clothing shall not be shared with other members of the household. Clothes and linens will be washed in hot soapy water. Ƒ The DPHSS will be contacted if members of the household develop influenza symptoms (e.g. fever, cough, respiratory symptoms, etc.) for guidance in seeking medical evaluation. Ƒ I will obtain or request the DPHSS to provide me and members of my household with surgical masks, gloves, and other items necessary to prevent the spread of influenza (i.e. alcohol-based hand wash). Ƒ I will arrange or request the DPHSS to arrange for the delivery of necessary items to my home, including but not limited to food, medication, clothing, and supplies during the period of isolation. Ƒ I agree to adhere to any additional recommendations and instructions from the DPHSS that may be listed below: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I, or my legal guardian, may contact the following DPHSS representative to seek relief from, clarification of, or further explanation of the conditions contained in, any part of this agreement. _____________________________ (Name of DPHSS contact person) _______________________ (Daytime telephone #) Attachment 4-B-2 The provisions of this agreement have been explained to me by the DPHSS representative and I fully understand that my failure to follow these guidelines or to voluntarily remain in isolation may result in my being placed in involuntary isolation, or committed to a facility where I may be isolated against my wishes. _________________________________ (Print name of influenza case/contact) __________________________ (Signature) Date: ______________ I, the caretaker/head of household, acknowledge that the DPHSS representative has explained the provisions of this agreement to me as well as the patient in isolation. I fully understand that my failure to follow these guidelines may result in my exposure to influenza and in my being placed in involuntary isolation, or committed to a facility where I may be isolated against my wishes. ________________________________ (Print name of caretaker/head of household) __________________________ (Signature) Date: ____________ ________________________________ (Print name of DPHSS representative) __________________________ (Signature Date: ______________ Attachment 4-B-3 Voluntary Home Quarantine Agreement I have been informed that I have been determined to be a contact of a suspect or probable case of pandemic influenza, a communicable disease dangerous to the public health, and that unless precautions are taken, I could potentially infect others. In order to prevent the spread of this virus, the Department of Public Health and Social Services, pursuant to 10GCA Chapter 3, Article 3, § 3310 and Public Law 26-173 known as the “Islan Guahan Emergency Health Powers Act”, has provided me with the following information, and I hereby agree to the following: Ƒ I shall remain in quarantine for 10 days after the date of exposure and will immediately notify the DPHSS should I develop influenza symptoms, including but not limited to, a temperature equal or greater than 100.4° F., and/or symptoms of a respiratory infection such as cough, shortness of breath or difficulty breathing, and/or sore throat. Ƒ The DPHSS has determined that the date of my exposure was ___________ and I shall be released from quarantine on or about __________, provided I do not develop influenza symptoms as noted above. Ƒ I shall be quarantined at the following location, which shall be referred to as “home”: Street address:________________________________________________________ Village: __________________ State: ________________ Zip: _________________ Telephone: ____________________ Ƒ I have been educated about the disease, the reasons for my quarantine, and the length of time I can expect to be restricted from certain activities. Ƒ I shall limit all activities and interaction with all other persons living outside the home. Ƒ I understand that only those persons authorized by the DPHSS may enter my home during the quarantine period. Those who enter the home without prior authorization from the DPHSS may be subject to isolation or quarantine themselves. I agree to notify relatives and friends that they shall not visit the home until further notice. Ƒ I shall cover my nose and mouth with a disposable tissue when coughing or sneezing. Ƒ Household waste, including surgical masks and disposable tissues soiled with respiratory secretions, blood, or other body fluids will be disposed of as normal household waste. Ƒ I will wash my hands with soap and water after all contact with respiratory secretions from coughing or sneezing, blood, and other body fluids (e.g. urine, feces, wound drainage, etc.). I will educate and encourage other members of my household to do the same. Ƒ I shall not share food or beverages with members of the household and my eating and Attachment 4-C-1 drinking utensils will be washed with hot water and a household dishwashing detergent. Ƒ Environmental surfaces (e.g. countertops, tables, sinks, etc.) in the kitchen, bathroom, and my bedroom will be cleaned and disinfected with a household disinfectant, such as household bleach or Lysol®, while wearing gloves, at least daily and when soiled with the respiratory secretions, blood, and other body fluids. Ƒ If requested by DPHSS, I agree to monitor my temperature two times a day and report this information to DPHSS as requested. The number I must call to report this information is __________________. Ƒ The DPHSS will be contacted if members of the household develop influenza symptoms (e.g. fever, cough, respiratory symptoms, etc.) for guidance in seeking medical evaluation. Ƒ I understand that if I develop fever or respiratory symptoms I must adhere to the following provisions: • I shall use a separate bed and, if possible, a separate bedroom. • I shall wear a surgical mask when in the same room with non-infected persons. If I cannot wear a surgical mask, others in the same room will be asked to wear a surgical mask. • My bed linens, towels, and personal clothing shall not be shared with other members of the household. Clothes and linens will be washed in hot soapy water. • All members of my household will wear gloves on hands when they have contact with my respiratory secretions (lung or nasal), blood, and all other body fluids (e.g. urine, feces, wound drainage, etc.). Alcohol-based hand hygiene products may be substituted for hand washing with soap and water after removing the gloves, IF the hands are not visibly soiled with respiratory secretions, blood, or other body fluids. Gloves shall not be reused and shall be discarded immediately after removal. • I will obtain or request the DPHSS to provide me and members of my household with surgical masks, gloves, and other items necessary to prevent the spread of influenza (i.e. alcohol-based hand wash). Ƒ I understand that I will arrange or request the DPHSS to arrange for the delivery of necessary items to my home, including but not limited to food, medication, clothing, and supplies during the quarantine period if I am not authorized to leave the quarantine location in order to obtain these items myself. Ƒ I understand that during the quarantine period, if authorized, I may only leave the home to go to __________________ (work/pharmacy, etc.). I shall not go to a house of worship, out-ofhome day cares, stores/malls, restaurants, movies, sporting events, or other public areas or events. Attachment 4-C-2 Ƒ I understand that if I am authorized to leave the home I shall avoid close contact (within 3 feet) with others to the best of my ability. This includes, but is not limited to, avoiding the use of public transportation and confining myself to my office as much as possible when I’m at work (if applicable). Ƒ I agree to adhere to any additional recommendations and instructions from the DPHSS that may be listed below: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I, or my legal guardian, may contact the following DPHSS representative to seek relief from, clarification of, or further explanation of the conditions contained in, any part of this agreement. _____________________________ (Name of DPHSS contact person) _______________________ (Daytime telephone #) The provisions of this agreement have been explained to me by the DPHSS representative and I fully understand that my failure to follow these guidelines or to voluntarily remain in quarantine will result in my being placed in involuntary quarantine, or committed to a facility where I may be quarantined against my wishes. _________________________________ (Print name of influenza case/contact) __________________________ (Signature) Date: ______________ I, the caretaker/head of household, acknowledge that the DPHSS representative has explained the provisions of this agreement to me as well as the patient in quarantine. I fully understand that my failure to follow these guidelines may result in my exposure to influenza and in my being placed in involuntary quarantine, or committed to a facility where I may be quarantined against my wishes. ________________________________ (Print name of caretaker/head of household) ___________________________________ (Signature) Date: ____________ ________________________________ (Print name of DPHSS representative) ____________________________________ (Signature and Date) Attachment 4-C-3 ISOLATION & QUARANTINE SITES GPD SUPPORT FUNCTION Activity: Location: Requirement: Precinct Assigned: Pending GPD approval/confirmation Primary Sites: (GPSS Consult) Northern Region Security of the Benavente Middle School* Provide Security for the Dededo Precinct (DPC) facility (24 hrs) Simon Sanchez High School facility or Tamuning/Tumon (TTPC) Central Region George Washington High School* Hagatna Precinct (HPC) Agueda Johnston Middle School Southern Region Southern High School Agat Precinct Command (APC) Inarajan Middle School* Secondary Sites: (Mayors’ Council of Guam Consult) Northern Region Security of the Astumbo Gymnasium* Dededo Precinct (DPC) facility (24 hrs) Yigo Gymnasium or Tamuning/Tumon (TTPC) Central Region Tamuning Gymnasium* Tamuning/Tumon (TTPC) Agana Heights Gymnasium Hagatna Precinct (HPC) Southern Region Agat Gymnasium Agat Precinct Command (APC) Yona Gymnasium Talofofo Gymnasium* Attachment 4-D-1 Back-up Sites: (DSC Consult) Northern Region Security of the facility (24 hrs) Dededo Precinct (DPC) Dededo Senior Citizen Center* or Tamuning/Tumon (TTPC Astumbo SCC Yigo SCC Central Region Tamuning/Tumon (TTPC) Tamuning SCC Hagatna Precinct (HPC) Mangilao SCC* Sinajana SCC Agana Heights SCC Southern Region Yona/Talofofo SCC Agat Precinct Command (APC) Inarajan SCC* Merizo SCC Agat SCC Santa Rita SCC Provide escort as Provide escort for non- needed compliant persons to Isolation/Quarantine site * Isolation Sites 01-31-07 Attachment 4-D-2 CONTACT DAILY TEMPERATURE LOG TRACKING FORM NAME:_____________________________ Date Morning Evening Temperature Temperature Date of Birth:_______________ Cough Shortness of breath ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No ; Yes ; No Telephone No.: Other symptoms (describe) Unable to Locate Name & Initial of Person Who Conducted Follow-up Attachment 4-E CHAPTER 5 EMERGENCY MEDICAL SERVICES SECTION 1.0 INTRODUCTION The Plan assumes that an influenza pandemic will increase the need for EMS activity. EMS activity will be impacted by an increased number of persons requesting care, expansion in triage activity and especially the opening of alternative treatment centers and inter-facility patient transfer. With only one civilian hospital that provides direct patient care, effective infection control will be critical to preserving EMS capacity and slowing the spread of influenza in the community. Therefore, GFD must reinforce infection control practices including promoting annual influenza vaccination and the proper use of personal protective equipment (PPE). ƒ Develop an internal plan to immunize all pre-hospital personnel and essential ancillary staff in a short period of time, should a vaccine be made available for a novel influenza virus causing a pandemic. Levels of priority staff need to be established as vaccine availability may be limited. ƒ Develop an internal plan to provide antiviral medications for prophylaxis and/or treatment of all pre-hospital personnel and essential ancillary staff should antivirals be made available for a novel influenza virus causing a pandemic. Levels of priority staff need to be established as antiviral availability may be limited. ƒ Develop an Infection Control Plan that addresses the following: A plan for implementing Respiratory Hygiene/Cough Etiquette for patients with possible respiratory illness. … Communication will also be a key factor both in preparation for and in response during a pandemic. The GFD must ensure that they have strong communication links to GFD RAC at the OCD-EOC as delineated in the GERP. SECTION 2.0 EMERGENCY MEDICAL SERVICES INTERPANDEMIC PERIOD (PHASES 1-2) AND PANDEMIC ALERT PERIOD (PHASES 3-4): A plan for the distribution of masks to symptomatic patients who are able to wear them (adult and pediatric sizes should be available), providing facial issues and receptacles for their disposal, and hand hygiene materials (i.e. hand sanitizers) in EMS and medical transport vehicles. … Implementation of Respiratory Hygiene/Cough Etiquette to be exercised when seasonal influenza and other respiratory viruses (e.g. respiratory syncytial virus, parainfluenza virus) are circulating in the communities. … GFD will: ƒ Promote routine annual influenza vaccination to include seasonal flu vaccinations to all pre-hospital personnel with the department. Develop standard operating procedure requiring EMS personnel to use Standard and Droplet Precautions with symptomatic patients. … Establish fit testing and skill training on all respiratory types used to prevent exposures. … resources or using vehicles other than those designed for emergency or medical transport (e.g. school buses). ƒ Develop a occupational health and continuity of operations plans that includes the following: A liberal/non-punitive sick leave policy for managing EMS and fire personnel who have symptoms of, or documented illness with, pandemic influenza. … ƒ Reinforce infection control education and training of EMS personnel as described in Department’s Employee Health and Infection Control policies and procedures. ƒ Develop an education and training plan on pandemic influenza to insure that all EMS personnel understand the implications of and control measures for, pandemic influenza and the current organization and community response plans. … • Handling of staff who become ill at work. • When personnel may return to work after recovering from pandemic influenza. ƒ Develop a plan for triage and management of patients during a pandemic that includes the following: • When personnel who are symptomatic but well enough to work will be permitted to continue working. A system for phone triage of patients calling 911 that includes pre-established criteria and coordination protocols to determine who needs emergency transport. … A plan for coordination with receiving facilities such as alternative treatment sites, GMHA-ER, clinics, to manage the transportation of large number of patients during the height of the pandemic. … A standard operating procedure for transporting multiple patients with pandemic influenza during a single ambulance run. Policies and procedures that address: • Personnel who need to care for their ill family members. A system for evaluating symptomatic personnel before reporting for duty that has been tested during a pandemic. … ƒ Develop a plan to address surge capacity concerns during a pandemic that includes the following: … The plan considers the possible necessity of sharing transportation … The minimum number and categories of personnel necessary to sustain EMS and non-emergent (medical) transport services on a day-to-day basis have been determined. … Guam Pandemic Influenza Plan 5-2 Anticipated consumable resources needs (e.g. N-95 respirators, masks, gloves, and hand hygiene products) have been estimated. … A primary plan and contingency plan to address supply shortages have been developed. critically ill patients to and between medical facilities or mass care sites. PANDEMIC ALERT PERIOD PHASE 5 AND PANDEMIC PERIOD (PHASE 6) … Designate Assistant Chief EMS/Rescue Bureau to receive further pandemic influenza updates from DPHSS during a public health emergency. … GFD will: ƒ Identify agency resources that may be or become limited during a pandemic. Communicate with Assistant Chief EMS/Rescue Bureau with regards to the following needs: … Staffing … Medical Supplies DPHSS will: ƒ Collaborate with the GFD to develop a plan to immunize all pre-hospital personnel and essential ancillary staff in a short period of time, should a vaccine be made available for a novel influenza virus causing a pandemic. Levels of priority staff need to be established as vaccine availability may be limited. ƒ Develop a plan to provide antiviral medications for prophylaxis and/or treatment of all pre-hospital personnel and essential ancillary staff should antivirals be made available for a novel influenza virus causing a pandemic. Levels of priority staff need to be established, as antiviral availability may be limited. ƒ Collaborate with the GFD to offer and coordinate infection control education and training of EMS personnel relative to a pandemic. ƒ Coordinate and collaborate with the EMS Medical Director and GFD Assistant Chief EMS/Rescue Bureau to identify alternate means for transporting non- PPE (e.g. N95 Respirators, gowns, masks, etc.) … … Emergency Response Vehicles ƒ Monitor/identify critical gaps relative to the ability to provide emergency medical services with the Assistant Chief EMS/Rescue Bureau and EMS Medical Director and report these critical gaps to the EOC via the GFD RAC. ƒ Implement a plan to provide antiviral medications for prophylaxis and/or treatment of all pre-hospital personnel, essential ancillary staff and inpatients should antivirals be made available for a novel influenza virus causing a pandemic. Levels of priority staff and patients need to be established, as antiviral availability may be limited. DPHSS will: ƒ Coordinate/collaborate with first responder agencies (such as GPD; CQA; PAG Police; GIAA Police; etc) and the GFD Guam Pandemic Influenza Plan 5-3 Assistant Chief EMS/Rescue Bureau through the EOC as the influenza pandemic evolves. ƒ Collaborate with the Assistant Chief EMS/Rescue Bureau on identified gaps with the GFD RAC at the EOC. ƒ Collaborate with the Assistant Chief of EMS/Rescue Bureau and the EMS Medical Director regularly as the pandemic unfolds. ƒ Monitor status through the EOC. of EMS when pandemic community. influenza is in the ƒ If possible, place a procedure or surgical mask on the patient to contain droplets expelled during coughing. If this is not possible (i.e., would further compromise respiratory status, difficult for the patient to wear), have the patient cover the mouth/nose with tissue when coughing, or use the most practical alternative to contain respiratory secretions. resources ƒ Assist in mobilization and allocation of requested resources through the EOC. ƒ Monitor for critical gaps in ability to provide emergency medical services. ƒ Provide regular updates to the EMS Medical Director for EMS staff on the current status of the pandemic. ƒ Oxygen delivery with a non-rebreather face mask can be used to provide oxygen support during transport. If needed, positivepressure ventilation should be performed using a resuscitation bag-valve mask. ƒ Unless medically necessary to support life, aerosol-generating procedures (e.g. mechanical ventilation) should be avoided during pre-hospital care. SECTION 3.0 SPECIFIC PRE-HOSPITAL CARE EMERGENCY MEDICAL SERVICES GUIDANCE ƒ Optimize the vehicle’s ventilation to increase the volume of air exchange during transport. When possible, use vehicles that have separate driver and patient compartments that can provide separate ventilation to each area. Patients with severe pandemic influenza or disease complications are likely to require emergency transport to the hospital. The following information is designed to protect EMS personnel during transport. ƒ Notify the receiving facility that a patient with possible pandemic influenza is being transported. ƒ Screen patients requiring emergency transport for symptoms of influenza. ƒ Follow standard operating procedures for routine cleaning of the emergency vehicle and reusable patient care equipment. ƒ Follow standard and droplet precautions when transporting symptomatic patients. ƒ Consider routine use of surgical or procedure masks for all patient transport Guam Pandemic Influenza Plan 5-4 CHAPTER 6 ANTIVIRAL DISTRIBUTION PLAN SECTION 1.0 INTRODUCTION not interfere with antibody response to inactivated vaccines. Appropriate use of antiviral agents during a pandemic may reduce morbidity and mortality, minimize social disruption, reduce economic impacts, and diminish the overwhelming demands that will be placed on the health care system. Antivirals might also be used during the Pandemic Alert Period to contain small disease clusters and potentially slow the spread of novel influenza viruses. Drugs that have been shown to be effective against influenza viruses include the Adamantines (Amantadanes® and Rimantadine®) and the Neuraminidase inhibitors (Tamuiflu® and Relenza®). Treatment with Neuraminidase inhibitors (Tamiflu® and Relenza®) have been shown to decrease severe complications from influenza such as pneumonia and bronchitis and reduce hospitalization. These drugs have been useful for the management of interpandemic (i.e. seasonal) influenza. During a pandemic, the demand for antivirals is likely to surpass the supplies available in the stockpiles. A large and uncoordinated demand for antivirals early in a pandemic could rapidly deplete national and local supplies. Planning for the optimal use of antiviral stocks is therefore essential. During an influenza pandemic, DPHSS will need to play a central role in ensuring that limited supplies of antivirals will be distributed efficiently to where there is the greatest need and benefit. In addition, DPHSS will have to play a key role in giving guidance to healthcare providers about the use of antivirals (i.e. prophylaxis and treatment). The use of antiviral prophylaxis has been up to 70% - 90% effective in preventing symptomatic influenza infection caused by susceptible strains, if prophylaxis is begun before exposure to the influenza. Treatment earlier after the onset of the disease is most effective in decreasing the risk of complications and shortening the duration of the illness. Generally treatment should be given within 48 hours after the onset of symptoms. These interventions are important when vaccines are unavailable and for those in whom vaccination may be medically contraindicated. It is estimated that a pandemic vaccine is unlikely to be available until four to six months into the pandemic. The protection afforded by antiviral medications is virtually immediate and does The role of DPHSS: ƒ Procurement of antiviral drugs for local stockpiles; ƒ Distribution of antiviral drugs to priority groups through Points of Distribution (POD); ƒ Data collection to monitor drug use, drug related adverse events, and drug resistance; ƒ Legal preparedness; ƒ Training of health care providers; and ƒ Dissemination of information. In February 2007, DPHSS informed the DHHS that its antiviral allocation of 17,176 (at 25% subsidy) would consist of 90% Tamiflu® and 10% Relenza®. Due to space constraints, management logistics, and challenges with rotating stock, DPHSS will only be able to maintain a limited stockpile of antiviral medications. DPHSS is responsible for coordinating and managing the Guam antiviral stockpile. The VAPPC membership consists of: ƒ Office of the Governor/Lt. Governor or designee ƒ DPHSS See Attachment A. SECTION 2.0 ESTABLISHING PRIORITY GROUPS In situations where there are limited supplies of antivirals for influenza, the antivirals should go to individuals who have the greatest need and are most likely to benefit from them. … Territorial Epidemiologist … Office of EMS Public Health Preparedness Program … … Recommendations for priority groups for antiviral prophylaxis and treatment were provided by DHHS. This guidance for priority groups will most likely change depending on the epidemiological data (i.e. type of pandemic virus, drug supply, resistance pattern, etc). The highest priority should be the treatment of high-risk individuals who are hospitalized due to pandemic influenza illness. The next would be (1) the treatment of healthcare workers with direct patient contact and EMS providers, and (2) the treatment of pandemic health responders, public safety workers, essential utility workers, and key government decision makers. Only when there is an adequate supply of antivirals, will it be possible to provide treatment for low-risk outpatients and prophylaxis for high-risk outpatients and other high-risk healthcare workers who have no direct patient contact. During the interpandemic and pandemic alert periods, DPHSS will coordinate and collaborate with the healthcare providers and form a standing committee - Vaccine and Antiviral Prioritization Policy Committee (VAPPC) to establish and refine “priority groups”. Emergency Guam Immunization Program ƒ Community Physicians comprising the following specialties: … Emergency Medicine … Critical Care … Infectious Disease … Internal Medicine/Family Medicine … Pediatrics ƒ GMS Representative ƒ GMHA Representative ƒ Guam Pharmacological Representative Association The VAPPC will define how a priority group will apply on a local level and will define who should be included in the groups of public safety workers, essential service providers, and key government decision makers. The VAPPC will provide the rationale for establishing the priority groups so that the reasons for prioritization can be communicated to the community. Guam Pandemic Influenza Plan 6-2 In addition, the VAPPC will determine the projected use of antivirals during a pandemic on Guam using, DHHS recommendations (i.e. treatment and prophylaxis). During an influenza pandemic, the VAPPC will modify these priority groups as needed based on the availability of antiviral drugs, the characteristics of the causative virus (i.e. drug susceptibilities, initial geographic distribution, fatality rate, age-specific morbidity and mortality rates), and the effectiveness of implemented strategies. See Attachment B. SECTION 3.0 CRITICAL ASSUMPTIONS Assumptions regarding groups at highest risk during a pandemic and impacts on the healthcare system and other critical infrastructure are the same as those underlying the vaccine priority recommendations. Additional assumptions specific for antiviral drugs include: ƒ Treating earlier after the onset of disease is more effective in decreasing the risk of complications and shortening the illness duration. Generally, treatment should be given within the first 48 hours. ƒ Treatment with neuraminidase inhibitors have been shown to reduce hospitalizations and to decrease severe complications from influenza such as pneumonia and bronchitis. ƒ Antiviral resistance to the Adamantanes (Amantadine® and Rimantadine®) may limit their use during a pandemic. ƒ The primary source of antiviral drugs for a pandemic response will be the supply of antiviral drugs that have been stockpiled. ƒ Assumptions for the amount of antiviral drugs needed for defined priority groups are based on the population in those groups. It is assumed that 35% of persons in the priority groups will have influenza-like illness and 75% will present within the first 48 hours and be eligible for treatment. For persons admitted to the hospital, the VAPPC would assume that 80% would be treated. ƒ For antiviral drugs, the number of priority groups that can be covered would be known at the start of the pandemic based on the amount of drug that is stockpiled, unlike vaccines, where each tier would be protected in turn as more are produced. Some flexibility could be provided as more antivirals become available. SECTION 4.0 STRATEGIES FOR ANTIVIRAL USE IN PANDEMIC INFLUENZA – TREATMENT AND PROPHYLAXIS Treatment: Planning considerations include: ƒ Effectiveness of antivirals against a new pandemic influenza virus cannot be predicted. ƒ Early treatment may reduce the risk of hospitalization by 50%. ƒ Early treatment is a more effective use of antivirals than widespread prophylaxis. ƒ Because prophylaxis for approximately six weeks would require at least four times the number of doses as a five day treatment course, huge antiviral stockpiles would be required to permit prophylaxis of more than a small proportion of the population. ƒ Reserve Tamiflu® and Relenza® for treatment whenever possible because Guam Pandemic Influenza Plan 6-3 supplies will be limited. of essential utility services. Treatment Strategies: Strategies for Antiviral Use in Pandemic Influenza Prophylaxis: Optimal use of limited stocks of antiviral drugs will vary depending upon the phase of the pandemic. ƒ Target antiviral therapy to influenza patients admitted to the hospital, who present within 48 hours, of the onset of symptoms. ƒ Modify priority groups for treatment based on current information on drug supplies, susceptibilities, fatality rates, agespecific mortality rates, and effectiveness of implemented strategies. ƒ Targeting prophylaxis to priority groups throughout the first wave of the pandemic. ƒ Using post-exposure generally for 10 days. prophylaxis ƒ Control small, well-defined disease clusters such as outbreaks in nursing homes or other institutions. ƒ Protect individuals with a well known recent exposure to pandemic virus (i.e. household contact of pandemic influenza patients). Prophylaxis: Planning considerations include: ƒ Limited supplies. ƒ Increased risk of side effects with prolonged use. ƒ Potential emergence of drug resistant variants of the pandemic strain. ƒ Post-exposure prophylaxis might be useful in attempts to control small well defined clusters (i.e. institutional outbreaks). ƒ The number of people who receive treatment with Tamiflu® should be limited primarily to ensure that supplies are available to treat persons at highest risk of serious morbidity and mortality. ƒ If sufficient supplies are available, prophylaxis should be used only during the periods of pandemic to protect health care workers, public safety, and other providers ƒ Modify priority groups for prophylaxis based on up-to-date information. ƒ Consider post exposure prophylaxis to protect key personnel. The National Vaccine Advisory Committee (NVAC) and the Advisory Committee on Immunization Practices (ACIP) recommendations for prioritization of vaccine and antiviral drugs can be found at http://www.hhs.gov/pandemicflu/plan/pdf/A PPD.pdf. Strategies for Combined Treatment and Prophylaxis: During a pandemic, combined antiviral treatment for ill persons and targeted post exposure prophylaxis of contact would be considered in small disease clusters (i.e. households or institutions). The administration of Tamiflu® does not interfere with the development of antibodies to influenza virus after the administration of Guam Pandemic Influenza Plan 6-4 the inactivated vaccine. Therefore persons receiving prophylaxis can continue to receive Tamiflu® during the period between the vaccination and the development of immunity. Whether Tamiflu® can interfere with immune response elicited by the live attenuated vaccine is unknown. Pediatric Use: None of the currently available antivirals are FDA approved for use among children younger than one year of age. The decision by an individual physician to treat children under one year of age with an antiviral must be made on a case by case basis with full consideration of potential risks and benefits. Tamiflu® is available as an oral suspension for use in children; however supplies are limited. SECTION 5.0 DISTRIBUTING ANTIVIRALS GROUPS ƒ Explore how to implement standing orders if they are needed for treatment of certain priority groups (i.e. hospitalized patients and health care workers). ƒ Review and update pre-existing plans for the transport, receipt, storage, security, tracking, and delivery of: Antiviral stocks for use in treatment to hospitals, clinics, nursing homes, alternate care facilities, and other health care institutions. … Antiviral stocks for use in postexposure prophylaxis (i.e. for direct contacts of infected patients). … Antiviral stocks for use in prophylaxis even when there is no known direct pandemic influenza exposure (i.e. pandemic health responders, public safety workers, essential utility workers, and key government decision makers). … TO PRIORITY The distribution of antivirals will depend on the amounts of antivirals available on Guam, the priority groups that are to be targeted as recommended by the VAPPC, and the locations of greatest need. In order to equitably and effectively distribute antivirals to priority groups during an influenza pandemic, DPHSS must rapidly direct their flow to the appropriate priority groups. During the interpandemic period (Phases 1 – 2) and pandemic alert periods (Phases 3 – 5) DPHSS will: ƒ Work with stakeholders to develop a system to assess and track antiviral stocks. ƒ ƒ Establish the legal authority to have standing orders for antivirals. Establish the VAPPC. ƒ Work with private health clinics to plan for and exercise the distribution of antiviral drugs based on priorities and needs. During a pandemic, requests for antivirals will be handled through an ICS. … Providers will request antivirals through the EOC and the distribution will be guided by the VAPPC’s recommendation for priority groups. … SECTION 6.0 POINTS OF DISTRIBUTION With the recent expansion of the NRCHC, Bureau of Primary Care Services (BPCS), it was agreed that NRCHC would store and serve as the main antiviral distribution site for Guam’s initial antiviral inventory of 17,176 courses. In February 2007, Guam Guam Pandemic Influenza Plan 6-5 requested for an additional 50,000 courses of antiviral medication from the DHHS. Additional points of distribution for antivirals would include the GMHA and major private clinics. SECTION 7.0 LEGAL PREPAREDNESS DPHSS needs to establish legal authority to have standing orders for antivirals at the health department level. During a pandemic there may be a need for the DPHSS Medical Director to issue blanket prescriptions for dispensing and distributing antivirals. The DPHSS Medical Director would need the authority to do so in a way that is consistent with Guam’s prescription laws. In addition, there needs to be clarification as to whether adverse side effects of antivirals, when taken for prophylaxis by essential workers, would be covered by the Workmen’s Compensation Law. SECTION 8.0 TRAINING To assist healthcare providers in identifying and managing pandemic influenza, the “Clinician Fact Sheet” for healthcare providers will be posted on the DPHSS website. In addition, DPHSS will involve the VAPPC and it’s stakeholders in conducting exercises on how to distribute the antiviral drugs on priority needs. follows: ƒ Role of antivirals in responding to pandemic influenza. ƒ Need to prioritize limited antiviral supplies for treatment and prophylaxis. ƒ Importance of appropriate use (i.e. using the drug for a full number of days recommended to minimize the development of drug resistance). SECTION 9.0 CONTINGENCY PLAN FOR INVESTIGATIONAL DRUG USE Unlicensed antiviral drugs may be available under the Food and Drug Administration’s (FDA) Investigational Drug (IND) provision during an influenza pandemic. The FDA regulations permit the use of a national or “Central Institutional Review Board (IRB)” for IND medications and would likely be used in such a situation. Alternative to IND, the US DHHS may utilize the drug product under emergency use authorization procedures as described in the FDA draft guidance “Emergency Use Authorization of Medical Products”. SECTION 10.0 ACTIVATION The actual activation of the Plan will begin when Phase IV is declared. DPHSS will also implement an educational plan for the general public which is as Guam Pandemic Influenza Plan 6-6 PANDEMIC PHASES WHO PHASE 1: INTERPANDEMIC PERIOD ƒ DPHSS Focus on preparedness planning for the rapid distribution and use of antivirals and education of the healthcare providers about antiviral use in the phase of a pandemic. … Keep abreast of the development, evaluation, production, and availability of antiviral agents n the U.S. … … Ensure that mechanisms are in place for the acquisition and procurement of antiviral agents. … Coordinate and collaborate with healthcare providers and form a standing committee, the VAPPC, to establish and refine priority groups. … Convene the VAPPC consisting of medical professionals and allied health practitioners. Develop a strategic plan for the storage, management, use and rapid distribution of antiviral drugs, in accordance with CDC guidelines. … … ƒ Identify existing storage capabilities through DPHSS. VAPPC Throughout the pandemic period, education of healthcare providers will continue and be facilitated by the VAPPC. DPHSS’s recommendations for the optimal use of antivirals will be updated throughout the course of the influenza pandemic to reflect new epidemiological data, laboratory results, and the availability of an effective pandemic influenza vaccine. … … Establish a list of priority populations involved in the pandemic response activities, maintenance of critical services, and health infrastructure for antiviral prophylaxis. WHO PHASE 2: INTERPANDEMIC PERIOD ƒ DPHSS … In collaboration with the VAPPC, will develop a communication plan to explain the rationale for the target group for antiviral treatment or prophylaxis. Identify POC and POD that would be needed to administer the antiviral drugs (i.e. hospital, private clinics, community health centers, nursing home). … Guam Pandemic Influenza Plan 6-7 … ƒ Initiate order of antiviral agents for stockpile, if available. VAPPC Establish a list of priority populations involved in the pandemic response activities, maintenance of critical services, and health infrastructure for antiviral prophylaxis. … Review the current information on the use, effectiveness, safety, and the development of drug resistance of antiviral agents. … Review modifications, if any, to interim recommendations on antiviral prophylaxis in selected groups or circumstances. … WHO PHASE 3: PANDEMIC ALERT PERIOD ƒ DPHSS … Follow-up procurement of antiviral drugs. … Develop a tracking system to monitor the use, efficacy, and adverse events of antiviral drugs. Develop a standing order for antiviral distribution to the priority groups for treatment or prophylaxis. … DPHSS will establish legal authority to have standing orders for antivirals at the health department level. … … ƒ Continue to assess status of available antiviral agents and strategies for use. VAPPC Accelerate training on the appropriate use of antiviral drugs among public health staff and health care partners. … WHO PHASE 4: PANDEMIC ALERT PERIOD ƒ DPHSS … … Receive, store, and stage at the designated site. Work with other government agencies, and non-governmental organizations (NGO) to ensure effective public health communication. Guam Pandemic Influenza Plan 6-8 ƒ VAPPC … Review and revise, as needed, priority groups and strategies for antiviral drug use. … Monitor current information on the antiviral resistance of the pandemic strain. … Maintain updates of treatment guidelines, as recommended by the CDC. WHO PHASE 5: PANDEMIC ALERT PERIOD ƒ DPHSS Prepare for the rapid distribution of antiviral drugs through pre-identified POC and POD sites. … … Handle request for antivirals through IC/EOC. … Maintain inventory of antiviral drugs. … Maintain a registry of individuals in priority population receiving antiviral drugs. … Monitor adverse events in persons receiving antiviral drugs. WHO PHASE 6: PANDEMIC PERIOD ƒ DPHSS … Distribute antiviral drugs through pre-identified POC and POD sites. … Monitor drug distribution and use, assess whether antiviral drugs are effectively being targeted to priority groups, and determine whether there is equitable distribution among them. ƒ VAPPC Modify priority groups based on the availability of antivirals, characteristics of the causative virus, and effectiveness of the implemented strategy. … Guam Pandemic Influenza Plan 6-9 Recommended Daily Dosage of Antivirals for Treatment/Prophylaxis Source: Prevention & Control of Influenza Recommendation of the Advisory Committee on Immunization Practices, July 2005 Antiviral Agent Zanamivir (Relenza®) Treatment* Influenza A/B 1-6 Years 7-9 Years NA 10 mg twice daily x 5 dys 10 mg twice daily x 5 dys 10 mg twice daily x 5 dys Prophylaxis Influenza A/B NA 10 mg twice daily x 5 dys 10 mg once daily x 1028 days 10 mg once daily x 10-28 days 10 mg once daily x 10-28 days 10 mg once daily x 10-28 days Dose varies by child weight NA Dose varies by child weight NA 75 mg twice daily x 5 days 75 mg twice daily x 5 days Oseltamivir (Tamiflu®) Treatment* Influenza A/B Dose varies by child weight 10-12 Years 13-64 Years 65 & Older Prophylaxis NA 75 mg/day x 75 mg/day x Influenza A/B 4-6 weeks 4-6 weeks *Treatment with Tamiflu/Relenza for influenza should be started within 48-hours after the onset of symptoms. Attachment 6-A Priority Group Chart Source: U.S. Department of Health and Human Services Group Patients admitted to hospital Population Strategy Treatment Healthcare workers w/ direct patient contact and EMS. Treatment High risk outpatients – immunocompromised persons and pregnant women Pandemic health responders, public safety workers, and key government decision makers Increased risk outpatients – young children 12-23 months old, persons > 65 years old and persons with underlying medical conditions Outbreak response in nursing homes and other residential settings Healthcare workers (HCW) in ER, ICU, dialysis centers, and EMS providers Essential utility workers and HCW without direct patient contact Other outpatients Treatment Highest risk outpatients Other HCW with direct patient contact Rationale Consistent with medical practices and ethics to treat those with serious illness and who are most likely to die. Healthcare service required for quality medical care. There is little surge capacity among healthcare sector personnel to meet increased demand. Groups at greatest risk of hospitalization and death; immunocompromised cannot be protected by the vaccine. Treatment Groups are critical for an effective public health response to a pandemic. Treatment Groups are at high risk for hospitalization and death. Post Exposure Prophylaxis Prophylaxis Treatment Treatment Prophylaxis Prophylaxis Treatment of patients and prophylaxis of contacts are effective in stopping outbreaks; vaccination priorities do not include nursing home residents. These groups are critical to an effective healthcare response and have limited surge capacity. Prophylaxis will best prevent absenteeism. Essential infrastructure groups that have impact on maintaining health. Includes others who develop influenza and do not fall within the above groups. Prevents illness in the highest risk groups for hospitalization and death. Prevention would best reduce absenteeism and preserve optimal function. Attachment 6-B Attachment CHAPTER 7 MASS VACCINATION RESPONSE PLAN SECTION 1.0 INTRODUCTION The annual distribution and administration of vaccine for each predicted strain of influenza is an “institutionalized” process involving both the public and private sectors. For this annual vaccination effort, the vaccine type is predicted by CDC approximately 18 months before the anticipated influenza season. Three U.S. and one English manufacturer produce approximately 100 million doses over a six to eight month production period, with the supply ready for distribution during October and through the influenza immunization period of October through February. Except for some children under eight years of age, effective immunization is generally achieved with a single dose of vaccine. Approximately 90 percent of the vaccine is administered by the private sector and is directed toward high-risk individuals as defined by the Advisory Committee on Immunization Practice (ACIP). The next pandemic influenza will pose a number of threats to this existing vaccine delivery and immunization process. Critical factors that will affect the current system of vaccine distribution include the following: ƒ The time period for the identification, production, and distribution of vaccine to prevent influenza will be greatly shortened, placing considerable burdens on all existing processes and procedures. ƒ Because time frames may be shortened, significant shortages and delays in vaccine availability will likely occur. ƒ In all likelihood, the target population for vaccination coverage will be extended well beyond the typical high-risk populations, with a potential goal of vaccinating the entire population. ƒ The influenza virus encountered during a pandemic will represent a new strain, with new hemagglutinin and/or neuraminidase antigens. Thus, to maximize vaccine efficacy, a second dose of vaccine given approximately 30 days after the initial administration may be necessary. As a result of these concerns and considerations, local public health providers must develop a strategic plan for the management of vaccine delivery and administration during a pandemic. That plan must ensure that the distribution and allocation of available vaccine is completed in an organized and coordinated manner in order to maximize the public’s health and safety. The resources of local and the federal governments are utilized in sequential order to ensure a rapid and efficient response. Each level of government, upon requesting assistance from the next level of government, must ensure that local requirements have exceeded local resources before requesting assistance from the next higher level. SECTION 2.0 ASSUMPTIONS When considering the challenges that must be addressed to ensure a smooth and efficient distribution of available vaccine, Guam has accepted CDC guidance and has based its plan for making vaccine available on the following assumptions: ƒ Supply Based on guidelines issued by the CDC, it is understood that in the event of a pandemic, the total vaccine supply will be under the control of the federal government. This suggests that Guam will be assigned an “allotment” of vaccine and that all distribution efforts will be based on that allocation. ƒ Distribution Activity Actual distribution activities cannot begin until the CDC, in cooperation with manufacturers, can offer an expected date for delivery of vaccine. ƒ Shortages The vaccine allotment may not be adequate to meet Guam’s entire need for vaccine. That is, vaccine shortages are expected. These shortages may be so extensive that the vaccine supply would not be adequate to protect all individuals even identified as having a critical role in managing the crisis. ƒ Costs Guam will need to absorb the “up-front” costs associated with the purchase, delivery, and administration of vaccine. The CDC anticipates that national resources may be able to offset costs, although the exact level and nature of such resources is not yet determined. Federal resource assistance may include such items as federal contracts for the purchase of vaccine, grants, or reimbursement activities to subsidize the costs associated with vaccine distribution. However, at a minimum, the territory should expect to absorb the costs associated with the redirection of personnel and should expect to use other financial resources to meet immunization objectives. ƒ Liability Any activity related to liability issues and concerns that may be associated with instances of adverse reactions to vaccine administration will be the responsibility of the Federal Government. For inclusion in this federal liability coverage, the medical provider must ensure there is adequate and accurate documentation regarding the vaccine administration process and be able to identify vaccine recipients. ƒ Centralized Control Activity to properly manage the distribution and allocation of available vaccine will begin as soon as is reasonably possible. However, excessively short implementation periods, limited supply, or the emergence of a highly incapacitated infrastructure may require Guam’s executive leadership to issue a state of emergency. An Executive Order from the Governor will be needed for the deployment and use of personnel, supplies, equipment, materials, and facilities: this intervention would facilitate access to and use of expanded resources to meet vaccination objectives. SECTION 3.0 INTERPANDEMIC INFRASTRUCTURE As a base for disaster planning associated with vaccine delivery issues, Guam intends Guam Pandemic Influenza Plan 7-2 to rely to a large extent on the strength of its current distribution system, which is based in the DPHSS Immunization Program. The infrastructure is currently used to efficiently distribute childhood vaccines. This distribution system has the policies, procedures, and processes that can be adapted to assist the territory in its pandemic vaccine distribution goals and objectives. Specifically, the current distribution system includes: ƒ DPHSS Immunization Program for management of an island wide distribution system. ƒ Adequate coolers and back-up power for proper storage of vaccine. ƒ Adequate supplies vaccine as necessary. ƒ Established protocols communication. for repackaging and lines of ƒ An existing communications infrastructure, which includes phone and fax accessibility for the community. ƒ An existing computer system for tracking inventory receipt and distribution. ƒ Trained professional and support staff, who are capable of preparing vaccine orders. ƒ Experience with providing rapid, accurate service with the ability to complete vaccine orders within the same day. SECTION 4.0 PANDEMIC VACCINE SUPPLY AND DISTRIBUTION Guam had 154,805 residents in the year 2000. Guam’s estimated population in 2005 is 168,564. If faced with a novel influenza virus, current estimates suggest that Guam could need over 110,000 doses of vaccine for the civilian population (including tourists) and 30,000 for the military population, with adequate lead-time, to fully immunize its population. This number may vary by season due to tourists and other visitors. However, due to anticipated shortages and delays in acquiring vaccine, the actual distribution will, in most likelihood, be substantially less than the amount needed for full population immunization. SECTION 4.1 ORDERING AND DISTRIBUTION Assuming that the need will exceed vaccine availability, Guam will submit its order to the CDC for the maximum allocation of vaccine. The CDC will assume responsibility for ensuring that the manufacturer ships the vaccine to DPHSS Immunization Program, who in turn will be responsible for ordering the vaccines and distributing them to other sites. The DPHSS (Immunization Program, Central Pharmacy and Laboratory, Community Health Centers (CHCs) and BFHNS) estimate they would be able to store 104,000 (10 dose vial) doses of influenza if other vaccines and biologicals currently in storage were temporarily relocated. Guam Pandemic Influenza Plan 7-3 SECTION 4.2 DPHSS ACTIVITIES The local vaccine storage site will be based at the DPHSS central facility in Mangilao. The DPHSS Immunization Program has the experience and resources to properly store and secure vaccine as well as track its receipt and redistribution (Attachment A). DPHSS will be required to: ƒ Educate the local community in advance of a pandemic. ƒ Identify the maximum amount of vaccine that can be accepted under emergency conditions for short-term storage. ƒ Augment standard procedures to assure the biological safety and physical security of the vaccine within the health department. ƒ Identify the community partners who will work with the heath department to administer vaccine to targeted populations. ƒ Adhere to procedures to accurately document the receipt and redistribution of vaccine. This documentation should, at a minimum, indicate the amount and date the vaccine is received, as well as the amount, date, and method of redistribution to the identified community partner. ƒ Modify as necessary the system for notifying community partners. Notice will include timing for the local availability of vaccine for delivery. ƒ Assure that the redistribution of vaccine will occur prior to receiving the next capacity shipment so that no vaccine is lost because of storage shortages. The DPHSS Immunization Program will continue shipments of vaccine to designated distribution sites. Shipments may occur weekly to monthly depending on vaccine supply and usage. If additional staff is needed to manage excessively large shipments or to continue vaccine management and shipping activity for extended hours or over non-traditional workdays, staff from DPHSS will be detailed. These staff, regardless of primary duties and authority, will be responsive to Immunization Program staff responsible for vaccine distribution and management. Other DPHSS staff participating in the Guam Strategic National Stockpile Program will be activated to assist with operations as well. SECTION 4.3 POTENTIAL PARTNERS ADMINISTRATION ONLY FOR VACCINE Depending upon the extent of the event and the need for vaccinators, volunteers will be called up in a tiered manner, first calling upon licensed health care professionals, and then going down the list, as need dictates (Attachment B). The recruitment of community partners will depend on the resources available to the community. In addition, the actual coordination with community partners may be further refined based on the populations that are targeted for actual disease management during a pandemic. In working with community partners that will administer vaccine during a pandemic, Guam Pandemic Influenza Plan 7-4 DPHSS must ensure that these partners understand their roles and the expectations associated with this partnership. Specifically, the community partner must be prepared to accept and store their allotment of vaccine and must ensure that vaccine administration is properly documented for accountability purposes, and in the event that reimbursement becomes available. Finally, the personnel resources devoted by community partners should be considered a public health contribution to the community, rather than a costreimbursable or profit-making activity. … University of Guam Field House ƒ Southern Region … Inarajan Social Hall Southern High gymnasium/cafeteria … School Mass Immunization Clinics are meant to accommodate a large-scale vaccination activity. The sites should be chosen accordingly. Following are criteria for site selection: During an influenza pandemic, clinics and organizations that believe they are not receiving their fair share of vaccine will be directed to contact the DPHSS. That office will assume responsibility for managing calls and requests from the community to consider amendments to the allocation and distribution sites. ƒ Large floor space facility SECTION 4.4 POTENTIAL MASS VACCINATION CLINIC SITES ƒ Adequate sanitary facilities (bathrooms and sinks) DPHSS is responsible for planning and implementing Mass Vaccination Clinic Sites to administer vaccine to large numbers of people in a short period of time (Attachment A). The following facilities are potential sites for the Mass Vaccination Clinics: ƒ Access to one or two private rooms for staff conferencing and storage ƒ Access to power (electrical outlets) ƒ Access to telephones ƒ Accessible to physically disabled persons (Required by Title II of the Americans Disability Act) ƒ Access to telephones ƒ Consider auditoriums, conference halls, open-area buildings ƒ Northern Region ƒ Able to maintain security of area … Yigo gymnasium … Astumbo gymnasium ƒ Computer lines (in some instances, may not be required. ƒ Central Region Guam Pandemic Influenza Plan 7-5 SECTION 5.0 PRIORITY GROUPS FOR VACCINATION DURING THE PANDEMIC Establishing Target Recipient Groups ƒ In view of the likely vaccine shortage, the vaccine will be prioritized based on national recommendations and refined to meet the specific needs of Guam. (Attachment A). General Considerations ƒ Both the public and private sector will be mobilized to administer whatever vaccine is available. The actual organization of the vaccination program, in both the public and private sectors, will have to be customized for the community and target group and will depend on the extent and availability of the available infrastructure and resources. Success of the pandemic vaccination program will be determined in large part by public confidence in the benefits of influenza vaccination and the strength of the plan. Guam Pandemic Influenza Plan 7-6 PANDEMIC PHASES WHO PHASE 1: INTERPANDEMIC PERIOD ƒ DPHSS Maintain a system for distribution of vaccines through the DPHSS Immunization Program. … Develop a strategic plan through the DPHSS Immunization Program, NRCHC, SRCHC, and Vaccines for Children (VFC) Providers for the management of vaccine delivery and administration during an influenza pandemic. … Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies through the DPHSS Immunization Program. … Identify existing vaccine storage capability through the DPHSS Immunization Program and CHCs. … Identify partners, such as CHCs and GMHA, which will assist with short-term emergency storage needs. … … Identify partners in the community that can assist with mass immunizations. Promote increased influenza and pneumococcal vaccine coverage levels in traditional high-risk groups through local associations with assistance from DPHSS Immunization Program and Health Education. … Encourage the GMS and other physicians and healthcare professionals, associations and organizations to promote increased influenza and pneumococcal vaccine coverage levels in high-risk groups. … Ensure that adverse events following vaccination are reported through the DPHSS Immunization Program and the Vaccine Adverse Events Reporting System (VAERS). … ƒ GMHA … Develop or update recall list of essential and nonessential personnel. Develop a plan for management of pandemic strain vaccine delivery, administration during an influenza pandemic and monitoring for adverse reaction. … Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies. … … Encourage physicians to promote increased influenza and pneumococcal vaccine Guam Pandemic Influenza Plan 7-7 coverage levels in high risk groups. Pharmacy will identify existing securable storage capabilities and evaluate needs for additional storage space. … ƒ GFD … Develop or update recall list of essential and nonessential personnel. … Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies. … Need to address the protocol on emergency cases to GMHA ER via Ambulance. ƒ GPD … Develop or update recall list of essential and nonessential personnel. … Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies. … Law enforcement plan regarding security and delivery of vaccines ƒ GPSS … Develop specific pandemic response procedures and add to existing emergency plans. … Maintain a database of school health counselors (nurses). … Train their school health counselors on “Pandemic Mass Administration.” … Ensure all students are up-to-date with immunizations. … Conduct routine inventories of first aid and medical supplies. ƒ OCD … Maintain a registry of all the agencies’ databases pertaining to voluntary emergency recall. ƒ DMHSA … Develop or update recall list of essential and nonessential personnel. … Identify the essential employees with direct patient care, employees with minimal direct Guam Pandemic Influenza Plan 7-8 patient care, and non-essential employees with no direct patient care, for initial influenza vaccine. Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies … ƒ MCG … Identify high risk populations in their villages. … Develop a Plan on assisting DPHSS with vaccine delivery and setup on the assign Mass Vaccination sites. … Develop a plan for prioritized administration of influenza vaccines in the event of limited. ƒ Department of Corrections (DepCor) … Develop or update recall list of essential and nonessential personnel. Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies. … … Identify high risk populations ƒ Department of Integrated Services for Individuals with Disabilities (DISID) … Develop and maintain a registry of all the agencies’ databases pertaining to persons with disabilities. (Catholic Social Services, Guma Mami, Public Guardian). Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies. … ƒ University of Guam (UOG) … Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies. ƒ Guam Community College (GCC) … Identify volunteers among Allied Health Program (Nursing). … Develop a plan for prioritized administration of influenza vaccine in the event of inadequate supplies. Guam Pandemic Influenza Plan 7-9 ƒ CQA, Department of Youth Affairs (DYA), and Private Medical Clinics … Develop a plan for prioritized administration of influenza vaccines in the event of limited. ƒ Guam Army National Guard (GUARNG) … Develop a plan for prioritized administration of influenza vaccines in the event of limited. Develop a plan on assisting DPHSS with security, vaccine delivery and setup of the designated Mass Immunization sites. … ƒ Guam Power Authority (GPA), Guam Waterworks Authority (GWA) and GTA … Develop a plan for prioritized administration of influenza vaccines in the event of limited. … Assess infrastructure capacity and needs at potential sites for Mass Immunization Clinics. ƒ Guam Medical Society (GMS) … Educate members on pandemic influenza planning and business continuity plan. … Develop a plan for prioritized administration of influenza vaccines in the event of limited. ƒ Guam Nurses Association (GNA) … Maintain a database of volunteers. … Develop a plan for prioritized administration of influenza vaccines in the event of limited. WHO PHASE 2: INTERPANDEMIC PERIOD ƒ DPHSS … Continue preparedness stage as listed in Phase I. … Develop vaccine administration training module. ƒ GMHA, GFD, GPD, GPSS, OCD, DMHSA, MCG, DepCor, DISID, UOG, GCC, CQA, DYA, Private Medical Clinics, GUARNG,GPA, GWA, GTA, GMS, and GNA … Continue preparedness stage as listed in Phase I. Guam Pandemic Influenza Plan 7-10 WHO PHASE 3: PANDEMIC ALERT PERIOD ƒ DPHSS … Continue preparedness stage, including exercising of mass immunization plan. … Developed a guideline for vaccine management and distribution system. … Developed a list of priority groups for vaccination (see Attachment A). … Identified existing vaccine storage capacity. Identified community partners that will assist with mass immunizations (clinic sites and vaccine administrators). … Continue to promote increased seasonal influenza and pneumococcal vaccine coverage in high-risk groups with the assistance of healthcare providers. … … Monitor reports received through the VAERS. … Follow progress in development of effective vaccine for new virus. ƒ GMHA … Continue preparedness stage. … Exercise mass immunization plan. … Plan to increase security. ƒ GFD … Continue preparedness stage. … Periodic email Pandemic Precaution Information to fire personnel. ƒ GPD … Continue preparedness stage. … Develop Memorandum of Understanding (MOU) with other security agencies. … Periodic email Pandemic Precaution Information to police personnel. Guam Pandemic Influenza Plan 7-11 ƒ GPSS, OCD, DMHSA, MCG, DepCor, DISID, UOG, GCC, CQA, DYA, Private Medical Clinics, GUARNG,GPA, GWA, GTA, GMS, and GNA … Continue preparedness stage. WHO PHASE 4: PANDEMIC ALERT PERIOD ƒ DPHSS … Follow progress in development of effective vaccine for new virus. Develop Memorandum of Agreements (MOA) with community partners that will assist with mass immunization. … Implement vaccine administration training module via UOG- School of Nursing, Social Work and Health Sciences. … ƒ GMHA, GFD, GPD, GPSS, OCD, DMHSA, MCG, DepCor, DISID, UOG, GCC, CQA, DYA, Private Medical Clinics, GUARNG,GPA, GWA, GTA, GMS, and GNA … Continue preparedness stage. Each agency will submit an updated list of essential personnel for antiviral and vaccine delivery to DPHSS on a quarterly basis. … WHO PHASE 5: PANDEMIC ALERT PERIOD ƒ DPHSS … Prepare DPHSS Immunization Program for quick distribution of the vaccine, once available. … Determine other possible community vaccine distribution sites. ƒ GMHA, GFD, GPD, GPSS, OCD, DMHSA, MCG, DepCor, DISID, UOG, GCC, CQA, DYA, Private Medical Clinics, GUARNG,GPA, GWA, GTA, GMS, and GNA … Continue preparedness stage. … Each agency will submit an updated list of essential personnel for antiviral and vaccine delivery to DPHSS on a quarterly basis. Guam Pandemic Influenza Plan 7-12 WHO PHASE 6: PANDEMIC PERIOD ƒ DPHSS … Begin distribution of pandemic vaccine, if available, and immunization of target groups. … Deliver vaccine to CHC’s, VFC Providers and the other community sites or have them pick-up vaccine at DPHSS Immunization Program. Begin active coordination through the DPHSS Immunization Program and CHCs with local partners to establish massive immunization efforts directed at high priority target groups. … … Assess vaccine coverage, effectiveness of targeting to priority groups, and efficiency of distribution and administration; determine number of persons who remain unprotected. Modify distribution system (DPHSS Immunization Program) as needed to ensure optimal coverage. … … ƒ Monitor continued administration of vaccine to persons not previously protected. GMHA … Pharmacy will collaborate with DPHSS for availability of pandemic strain vaccine. … When vaccines are available: Employee Health will coordinate the initiation of the GMHA Antiviral/Vaccine Administration Plan. • Employee Health Nurse will ensure distribution based on priority, See Prioritization Listing for Antiviral and Vaccine Deliver. • Place vaccines in the designated secured storage area identified by Pharmacy (to be inserted upon completion). • Nurses assigned to the vaccine distribution site will ensure documentation, monitoring, and surveillance of adverse events based on Pandemic Influenza Post Vaccination Worksheet and Adverse Events Monitoring, See Attachment 24. • VAPPC will update Priority Listing for Vaccine Distribution and contingent plan as needed. … … Submit an updated list of essential personnel for antiviral and vaccine delivery to DPHSS on a monthly basis. Guam Pandemic Influenza Plan 7-13 ƒ GPSS … Closure of schools as directed by DPHSS Director or School Superintendent. Prepare schools for possible use for mass immunization sites, children shelters, quarantine sites and other emergency needs. … Collaborate with local agencies in make school facilities available in local response efforts, as previously identified. … … Institute rigorous cleaning policies and practices to reduce the spread of a flu virus. Submit an updated list of essential personnel for antiviral and vaccine delivery to DPHSS on a monthly basis. … ƒ GFD, GPD, OCD, DMHSA, MCG, DepCor, DISID, UOG, GCC, CQA, DYA, Private Medical Clinics, GUARNG,GPA, GWA, GTA, GMS, and GNA Each agency will submit an updated list of essential personnel for antiviral and vaccine delivery to DPHSS on a monthly basis. … WHO POSTPANDEMIC PERIOD ƒ DPHSS … Assess supply status and any imminent needs. … Prepare report assessing vaccine delivery response. Guam Pandemic Influenza Plan 7-14 APPENDIX J GUAM VACCINE DELIVERY PLAN FOR PANDEMIC INFLUENZA DIVISION OF PUBLIC HEALTH DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES ACKNOWLEDGEMENT Department of Public Health and Social Services (DPHSS) Vaccine Delivery Subcommittee Suzanne A. Sison, DDS Gil Suguitan Margarita Gay Marylou Lualhati Marlene Carbullido Annette L. Aguon Michelle S. Leon Guerrero Rita Oliva Grace C. Quiambao Acting Chief Public Health Officer Biotterrorism Preparedness and Response Program Bureau of Family Health and Nursing Services Office of Emergency Medical Services Bureau of Family Health and Nursing Services Bureau of Communicable Disease Control Bureau of Communicable Disease Control Bureau of Communicable Disease Control Bureau of Communicable Disease Control HOSPITAL EMPLOYEE DISPENSING / VACCINATION CENTER GUIDELINES, COUNTY OF LOS ANGELES DEPARTMENT OF HEALTH SERVICES PUBLIC HEALTH PANDEMIC INFLUENZA PREPAREDNESS & RESPONSE PLAN HAWAII STATE DEPARTMENT OF HEALTH VACCINE DELIVERY PLAN Statement of Purpose……………………………………………………… 3 General Information………………………………………………………. 4 Annex A: Annex B: Annex C: Annex C-1: Annex C-2: Annex C-3: Annex C-4: Annex D: Annex E: Annex E-1: Annex F: Annex G: Annex H: Annex H-1: Annex I: Annex I-1: Annex I-2: Annex I-3: Annex J: Potential Vaccine Distribution Sites Priority Groups for Influenza Immunization Clinic Procedures Floor Plan- Fully Staffed Clinic Fully Staffed Clinic Description Floor Plan- Limited Staffed Clinic Limited Staffed Clinic Description Vaccination Timeline Storage and Handling of Vaccine Security Considerations Physician Certification Form Vaccine Administration Vaccine Accountability Vaccine Usage Report Emergency Procedures Protocol for Management of Anaphylactic Reactions Vaccine Adverse Event Reporting System Needle Stick Injuries Post Vaccination Clinics STATEMENT OF PURPOSE This document is intended as a guideline for Department of Public Health and Social Services (DPHSS) emergency planning efforts for the use of preventative therapy in the form of vaccination of targeted priority groups in preparation for or in response to a health emergency due to pandemic influenza. During a large-scale disaster, public and private healthcare leaders and local and federal governments may be forced to make many difficult decisions. Working together in the planning process will ensure that those decisions are based on an understanding of the capabilities and limitations of those involved. This planning guide should be modified to fit your structure, function, patient population, and staffing numbers, and should be integrated into your existing emergency management plan. This plan is easily modifiable for antibiotic prophylaxis or vaccination. As information related to recognizing, diagnosing, treating, and preventing pandemic influenza is updated at the federal and local level, DPHSS will revise existing response plans accordingly. DPHSS will monitor such changes and notify staff accordingly. The goals of these guidelines are: • To assist DPHSS in preparing as a response to a probable or confirmed case of pandemic influenza virus with the potential to cause widespread death or disability. • To reduce the incidence and transmission of pandemic influenza to targeted priority groups and the community. • To rapidly provide preventative therapy to exposed staff in the form vaccination. • To prevent interruption in medical care for patients during large-scale public health emergencies. • To integrate personal health and public health emergency response plans. GENERAL INFORMATION A. INTRODUCTION This plan provides guidelines for managing vaccine and conducting rapid vaccination activities. Vaccination may be recommended in either the context of bioterrorism readiness (pre-event) or as a response to a bioterrorism event (post-event) or large-scale epidemic of a naturally occurring infectious diseases (such as Pandemic Influenza). B. ACTIVATION OF VACCINE DELIVERY PLAN The Immunization Program will notify the Director of DPHSS upon receipt of viable pandemic influenza vaccine. The DPHSS Director will activate the vaccine delivery plan as required to address the emergency. C. MAJOR RESPONSE ACTIVITIES 1. Vaccine Delivery „ Transportation, storage and handling of vaccines „ Distribution of vaccines to community partners, modify as needed (See Annex A) 2. Coordinate logistics for pre-designated sites for Mass Immunization Clinic (MIC) 3. Vaccine Administration „ Activate DPHSS and community partners designated to assist with mass immunization activities. 4. Vaccine Accountability „ Monitor and assess vaccine usage, coverage and effectiveness. D. PRIORITY GROUPS FOR PANDEMIC INFLUENZA VACCINE Because the supply of pandemic influenza vaccine is likely to be far less than that required to protect the susceptible population, targeting available supply to defined priority groups will be critical to optimally reduce morbidity and mortality as well as decrease social and economic disruption. Any available pandemic influenza vaccine should be distributed in an equitable and consistent manner to be pre-defined priority groups. (See Annex B) Any further prioritization, extension, or other modification of these recommendations for the benefit of the people of Guam will be addressed by the Vaccine and Anti-viral Prioritization Policy Committee, which will forward recommendations to the Director of DPHSS. E. PARTNER AGENCIES DPHSS will coordinate with various partner agencies to ensure the major response activities are met. 1. Guam Homeland Security/Office of Civil Defense (GHS/OCD)- activate and coordinate with government of Guam agencies on needed resources; maintain registry of all agencies’ database pertaining to voluntary emergency recall. 2. Guam Police Department (GPD)- Security for vaccine transportation, vaccine storage, and MIC sites 3. Guam Army National Guard (GUARNG)- assist GPD for security detail 4. Assist with vaccine administration during MIC Guam Public School System (GPSS)- School Health Counselors University of Guam/School of Nursing (UOG)- Instructors, Student Nurses Guam Community College/Allied Health Program (GCC)- Nursing Instructors, Medical Assistant Students and Student Nurses Guam Nurses Association (GNA) RNs Volunteer Healthcare providers (PA, certified midwives, dentists, veterinarians, military personnel, etc.) 5. Mayors Council of Guam- coordinate use of designated village facility for MIC sites; provide logistic support; identify high risk populations in their villages 6. Utilities- ensure uninterrupted service at DPHSS facilities and designated MIC sites Guam Power Authority (GPA) Guam Waterworks Authority (GWA) GTA 7. Food and water (distribution and preparation) during MIC American Red Cross Salvation Army 8. Provide vaccination to identified priority groups Guam Memorial Hospital (GMH) Designated Private Medical Clinics F. MASS IMMUNIZATION CLINIC PROCESS The MIC vaccination model provides vaccinations to staff. The vaccination model provides vaccinations at a rate of 125 people per hour, a total of 1500 people per day. The MIC process model description and flow diagram is included in Annex A. G. DOCUMENTATION DPHSS has a formal system for documenting the MIC process and the vaccination administered. Documentations (e.g. procedure logs, consent forms) will be maintained by DPHSS in their files. DPHSS will provide forms to be used for inventory, control, medical screening, and vaccine information. All documentation must be maintained for entry into the DPHSS Pandemic Influenza Database. Examples of documentation are located in Annexes C-J H. SCALING BACK AND DEACTIVATION OF VACCINE DELIVERY PLAN DPHSS will scale back its vaccine activities upon 10% absenteeism of vaccine administrators OR limited stock of pandemic influenza vaccine available. DPHSS will deactivate the vaccine delivery plan upon depletion of pandemic influenza vaccine ANNEX A Potential Point of Distribution Sites SCENARIO I: LIMITED DOSES OF PANDEMIC INFLUENZA VACCINE A. Department of Public Health and Social Services- Immunization Program B. Guam Memorial Hospital SCENARIO II: ADEQUATE DOSES OF PANDEMIC INFLUENZA VACCINE A. Department of Public Health and Social Services 1. Bureau of Family Health and Nursing Services ƒ Region I ƒ Region II ƒ Region III 2. Bureau of Primary Care Services ƒ NRCHC ƒ SRCHC B. Guam Memorial Hospital C. U.S. Military Installations (If only DPHSS to receive all of vaccine allotment) 1. Naval Hospital 2. Anderson Air Force Base Medical Clinic D. Private Medical Clinics* 1. FHP 2. PMC Isla Health System 3. SDA Clinic 4. TDC *Criteria: Large clientele, multiple medical providers, back-up generator, and security guard E. Long Term Care Facilities 1. GMH- Skilled Nursing Unit 2. St. Dominic’s Senior Care Home ANNEX B Priority Groups for Pandemic Influenza Vaccine Source: U.S. Department of Health & Human Services Pandemic Influenza Plan Appendix D: NVAC/ACIP Recommendations for Prioritization of Pandemic Influenza Vaccine and NVAC Recommendations on Pandemic Antiviral Drug Use Vaccine Priority Group Recommendations* TierSubtierPopulation 1 A x x B x x x C x x x D x x Rationale Vaccine and antiviral manufacturers and x others essential to manufacturing and critical support (~40,000) Medical workers and public health x workers who are involved in direct patient contact, other support services essential for direct patient care, and vaccinators (8-9 million) Need to assure maximum production of vaccine and antiviral drugs Healthcare workers are required for quality medical care (studies show outcome is associated with staff-to-patient ratios). There is little surge capacity among healthcare sector personnel to meet increased demand Persons > 65 years with 1 or more x influenza high-risk conditions, not including essential hypertension (approximately 18.2 million) Persons 6 months to 64 years with 2 or more influenza high-risk conditions, not including essential hypertension (approximately 6.9 million) Persons 6 months or older with history of hospitalization for pneumonia or influenza or other influenza high-risk condition in the past year (740,000) These groups are at high risk of hospitalization and death. Excludes elderly in nursing homes and those who are immunocompromised and would not likely be protected by vaccination Pregnant women (approximately 3.0 x million) Household contacts of severely immunocompromised persons who would not be vaccinated due to likely poor response to vaccine (1.95 million with x transplants, AIDS, and incident cancer x 1.4 household contacts per person = 2.7 million persons) Household contacts of children <6 month olds (5.0 million) In past pandemics and for annual influenza, pregnant women have been at high risk; vaccination will also protect the infant who cannot receive vaccine. Vaccination of household contacts of immunocompromised and young infants will decrease risk of exposure and infection among those who cannot be directly protected by vaccination Public health emergency response workers critical to pandemic response (assumed one-third of estimated public health workforce=150,000) Key government leaders Critical to implement pandemic response such as providing vaccinations and managing/monitoring response activities Preserving decision-making capacity also critical for managing and implementing a response x x 2 A x x Healthy 65 years and older (17.7 million) x 6 months to 64 years with 1 high-risk Groups that are also at increased risk but not as high risk as x B x x x x x 3 x x 4 x condition (35.8 million) 6-23 months old, healthy (5.6 million) population in Tier 1B Other public health emergency x responders (300,000 = remaining twothirds of public health work force) Public safety workers including police, fire, 911 dispatchers, and correctional facility staff (2.99 million) Utility workers essential for maintenance of power, water, and sewage system functioning (364,000) Transportation workers transporting fuel, water, food, and medical supplies as well as public ground public transportation (3.8 million) Telecommunications/IT for essential network operations and maintenance (1.08 million) Includes critical infrastructure groups that have impact on maintaining health (e.g., public safety or transportation of medical supplies and food); implementing a pandemic response; and on maintaining societal functions Other key government health decisionmakers (estimated number not yet determined) Funeral directors/embalmers (62,000) x Other important societal groups for a pandemic response but of lower priority Healthy persons 2-64 years not included x in above categories (179.3 million) All persons not included in other groups based on objective to vaccinate all those who want protection *The committee focused its deliberations on the U.S. civilian population. ACIP and NVAC recognize that Department of Defense needs should be highly prioritized. DoD Health Affairs indicates that 1.5 million service members would require immunization to continue current combat operations and preserve critical components of the military medical system. Should the military be called upon to support civil authorities domestically, immunization of a greater proportion of the total force will become necessary. These factors should be considered in the designation of a proportion of the initial vaccine supply for the military. Other groups also were not explicitly considered in these deliberations on prioritization. These include American citizens living overseas, non-citizens in the U.S., and other groups providing national security services such as the border patrol and customs service. ANNEX-C1 Immunization Clinic Procedures This policy will be instituted in the event of a large scale natural disaster or terrorist event is anticipated. Staffing patterns have been developed with the intention of reducing the number of licensed personnel needed to run a center. It is anticipated that most licensed medical personnel will be caring for the sick and/or injured people. Clinic procedures provided are broken into two sections: x Fully staffed clinics x Limited staffed clinics In general, the same staffing pattern can be used with numbers of staff adjusted to the size needed by the clinic. In smaller immunization clinics, one person may be able to do several jobs. All clinic personnel must be immunized. Any personnel with symptoms/signs of influenza or other communicable illness must not be allowed to work in the clinic. ANNEX C-2 Fully Staffed Clinic Description Station 1: Triage Type of staff: 1 EMT/2 Nurse Aide/ 1 Clerical/ 2 Security Total staff per 8 hour shift: Physical Requirements: 6 Able to stand (sit) for at least 8 hours. Able to interview patients for at least 8 hours. Able to wear N-95 mask and gloves. x x x x Station 1 should be located before the entrance to the clinic. Desk and chairs (for volunteers working at the station) should be situated in a way to allow control of patient flow into the clinic, but without obstructing the doorway. Post the “Triage” sign, identifying the station, in a location that is clearly visible to incoming persons. Tape the Station 1 procedure card on the desk where it is visible to the clinic staff working at the station. Forms/Supplies: x N-95 masks x Surgical Mask (for ill patients) x Thermometers /covers x Antiseptic hand gel x Disposable gloves x Pens x Tape x Declination/Refusal to Vaccinate Forms x Trash bag x “Station 1:Triage” sign identifying station x Vaccine Information Statements (V.I.S.) x Numbers for patients x Laptops (2) w/Pandemic Flu database x Station 1 procedure card x Expandable Folder to hold V.I.S. x Paper towels Ɣ Table covers Ɣ Biohazard bags Ɣ I-Connect Radio/Phone Ɣ Alcohol preps Ɣ Extension Cord w/multiple outlets Station 1: Triage Procedures: 1. All personnel in this station should use mask and gloves. 2. Security 1A & 1B will: x Maintain order in the line x Answer questions x Announce eligibility for flu vaccine and have shot record ready, if available. x Identify physically disabled patients (e.g. wheel chair, a walker, on oxygen) and discreetly guide him/her to the front of triage line. 3. Clerk will: x Document the temperature taken by the NA or EMT. x If cleared by EMT/NA issue number card to patient. 4. EMT and NA’s will: x Ask patient for shot record, if available. Review record to see if current flu vaccine was given. x Conduct temperature check on all potential patients. x Screen all potential patients for the following: o Do you have any flu like symptoms? o Are you sick today or have been sick in the last 2-3 days? Station 1: Triage Screening EMT and/or NA 1) Ask patient: Are you sick now, or have you been sick in the last 2-3 days? YES 2) Take patients temperature. Patient reports he/she is or has been sick OR Temp • 102°F Clerk is to give patient their number card with temperature reading and VIS. Patient is instructed to hold on to the card. Refer to Station 2, he/she will be told what to do with it. Station 2: EVALUATION Station NO Patient denies he/she is or has been sick OR Temp ” 102°F Clerk to provide patient with number card, w/temperature and V.I.S. Security 1B: Check all patients number card to ensure they have been seen by Station 1. Guide patients to clinic entrance to Waiting Area for Station 3. If patient is cleared by Station 2, Security 1B to: x Verify clearance “cleared by” at the bottom of referral form and patient has his/her number card w/temperature indicated . If either is missing, refer pt. back to Station 2 for missing item. x Mark referral form with highlighter to indicate they have been screened for the above info. x Direct patient to Station 3. Note 1: Should there be a physically disabled patient (e.g. on a wheelchair, on a walker, or on oxygen) Security 1B should alert security 3A by radio of incoming patient. This patient will be utilizing the express lane in the clinic. Note 2: If patient refuses vaccination at this point have patient sign a “Declination of Influenza Vaccination” do not issue a number card. Give white copy to the patient, and file the yellow copy in refusal folder. Station 2: Evaluation Type of staff: Physician or Nurse/ 1 Security Total staff per 8 hour shift: Physical Requirements: 1 Able to stand (sit) for at least 8 hours Able to interview patients for at least 8 hours Able to wear N-95 mask and gloves. x x x x x x Station 2 should be located in a confined area with minimal traffic flow, in a separate area from the main vaccination clinic. Desk and chairs should be set-up at “entrance” of Station 2 for clinic personnel checking in patients. Privacy Screens and chairs should be set-up for patients awaiting evaluation. Cots should be set-up for moderately ill patients. Post the “Evaluation” sign, identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 2 procedure card on the desk where it is visible to the clinic staff working at the station. Forms/Supplies: x N-95 masks x Surgical Masks (for ill patients) x Gloves x Blood pressure cuff x Biohazard bags x Pulse oximeter x Tongue Depressor x Alcohol based hand cleansing gel x Thermometer and disposable covers x Stethoscope x I-Connect Radio Phones x Privacy Screens x Antiseptic wipes x Paper towels x Alcohol preps x Pens x Evaluation/Referral Form(to be revised) x Station 2: Procedure card x Table covers x Expandable Folder labeled “Station 2: Referrals” for collection of Evaluation/Referral Form x Declination/Refusal to Vaccinate Form x “Station 2: Evaluation” sign identifying station x Masking Tape x Clipboards x Trash bag Station 2: Evaluation Procedures: 1. Patients seen at this station are sent by Station 1. All personnel at his station must wear gloves and mask. 2. Take vital signs, recheck temperature and perform a brief history. Record this information on the Medical Evaluation/Referral form. (See “Cold or Flu Chart”) 3. Patient refusal for vaccination. Should the patient refuse vaccination at this point or at any point in this process have the patient sign a “Declination of Influenza Vaccination” Collect the number card and place it in the box . Give patient the white copy. File the yellow copy in the refusal folder. 4. Screening of Patients: a) Moderately Ill Patients x Complete a Medical Evaluation/Referral form. (see sample) x Refer patient to their primary care provider/doctor, or to the hospital emergency room for further evaluation as appropriate. At the bottom of the referral form indicate where the pt was “Transferred to”. x Collect the number card from the patient and place it in the box and give the patient the white copy of the referral form and file yellow copy in the folder marked “Referral” x Direct patient to exit. x Security in this station will radio Security in Station 3 informing him/her that this number has been deferred. b) Well Patients and/or those with mild illness (not Influenza) x Complete a Medical Evaluation/Referral form (see sample) x At the bottom of the referral form indicate “Cleared by”. x Give the patient the white copy of the referral form. Instruct pt. to hold onto their form & number card. Direct patient to Security (1B) behind station 1. (Entrance of the clinic) x File Yellow copy in the folder marked “Referral”. Security: x Should there be a physically disable patient (e.g. On a wheelchair, on a walker, or on oxygen) Security should alert security 3A by radio of the incoming patient this patient will be utilizing the express lane in the clinic. x Monitor Exit for no entry. x Directs patient(s) to the exit. x Will I-Connect Security Guard 3B for any deferred patients and patients who are pending medical evaluation. Station 3: Processing Type of staff: 1 Health Educator/ 18 Clerical/ 3 Security/2 Social Workers Total staff per 8 hour shift: Physical Requirements: 24 Able to stand (sit) for at least 8 hours x x x x x x Station 3 should be located at the entrance to the clinic in an area (room) that can accommodate a group of people. Set up chairs at the “entrance” to Station 3 for the “waiting area”. Set up Health Ed. equipment and materials to be displayed. If space allows, set up tables and chairs “inside” Station 3 where patients can complete and sign the consent form. If space is not available for tables, set up chairs and have clipboards available to provide hard, writing surfaces. Post the “Waiting Area” and “Check In/Forms Completion” signs identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 3 procedure card(s) on the desk where it is visible to the clinic staff working at the station. Forms/Supplies: x Pandemic Influenza Vaccine Screening/Consent Form x Immunization shot records (child and adult) x 2 I-Connect Radio Phones (1 for Security B and designated clerk) x Pens x Clipboards x Paper clips x Numbers checklist x Bullhorn x Trash bag x Table covers x TV w/ DVD/VCR or LCD Projector and Laptop x Health Education Influenza Video/DVD x “Waiting Area” & “Check In/Forms Completion” signs identifying station x Masking Tape x Station 3 procedure cards x Declination/Refusal to Vaccinate Form x 2 Refusal box/container Station 3: Processing Procedures: 1. Health Educator will provide information through the use of videos, printed materials, and answer any questions patients may have. 2. Designated security personnel: x 3A will remind patient to hold onto their number card and direct patient to seating area. x 3B will: o Call patients by numerical order and check off each number on the number check list. o Indicate the letter “D” next to the number that was deferred when informed by security in Station 2. x 3C will: o Direct pt. to the next available processor. o Direct physically disabled (when indicated) to express lane. 3. Patient “Refusal for Vaccination” If the patient refuses vaccination at this point, have the patient sign a “Declination of Influenza Vaccination” form. Collect the number card and place it in the box . Give the white copy to the patient. File the yellow form in Refusal folder. 4. Clerks are to: x Inform the patient that they will be completing the immunization consent form in this station. x Ask the patient for their number card and write the following information on the top of the consent form in the designated spaces: 1. Patient Number 2. Patient Temperature (copy from the number card) 5. Instruct the patient to complete the following section of the consent form: x Information about the patient x Screening questions (#1 thru #8) x Print their name, sign and date at the bottom of the form. Note: If the patient verbalizes needing assistance in completing the form the clerk can assist the patient. 6. Once the patient completes the consent form, the clerk will: x Fill out the “vaccine section” of the form (Follow the information as written on the sample consent form). x Sign on the Witness signature section. x Prepare the shot record (Write the patient name and date of birth). x Clip the shot record to the completed consent form give forms to pt. and refer him/her to Station 4: Forms Review. Note: Alert Clinic Manager for patients who require interpretation assistance with completing the Screening/Consent Form and/or in need Psychosocial counseling. There will be a social worker in this station. Station 4: Review Type of staff: 4 Support staff/ 2 Nurse Aide/ 1 Security Total staff per 8 hour shift: Physical Requirements: 6 Able to sit for at least 8 hours Able to interview patients for at least 8 hours x x x Station 4 to be located right after Station 3. Post the “Review” sign identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 4 procedure card(s) on the desks where it is visible to the clinic staff working at the station. Forms/Supplies: x Processors Guide to Screening Questionnaire Form x Red and Black Pens x Immunization Protocol/ Standing Order x Guide to Contraindications x I-Connect Radio Phone x Station 4 procedure card x “Station 4: Review” sign identifying station x Tape x Post it pads x Trash bag x Table covers Procedures: 1. Security will direct patient to the next available reviewer. 2. Support Staff/Nurse Aide will: x Review immunization consent form to ensure that all sections of the form is completed including the signatures. Should any information be missing on the consent form such as processors signature ask patient to bring forms back to the clerk who processed him/her for completion of form. x If “No” contraindications/precautions remain after interviewing the patient: o Check the box “Vaccinate” and initial with red ink. o Refer patient to Station 6: Vaccination. o For physically disable pt. refer to express lane in Station 6. x Patient with boxes marked “Yes” consult the Processors Guide to Screening Questions or Guide to Contraindications to Vaccinations o If any contraindications/precautions remain after interviewing the patient or if patient has questions not covered in the education materials refer patient to Station 5: Medical Screening. 3. Security will direct patient towards the next available reviewer. Station 5: Medical Screening Type of staff: Physician or Nurse Total staff per 8 hour shift: Physical Requirements: 1 Able to sit for at least 8 hours Able to interview patients for at least 8 hours x x x x Station 5 may have multiple stations to allow for privacy during medical screening. If multiple rooms not available, space screening stations as far apart as possible to allow for privacy during medical screening. Post the “Medical Screening” sign identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 5 procedure card(s) on the desks where it is visible to the clinic staff working at the station. Forms/Supplies: x Doctor’s Orders/Progress Notes x Assessment Sheet x Red and Black Pens x “Medical Screening” sign identifying station x Contraindication Guidelines x I Connect Radio Phone x Referral Forms x Declination/Refusal to Vaccinate x Expandable Folder labeled “Station 5: Do Not Vaccinate/Referral Forms” x Tape x Table covers x Trash bags x Station 5 procedure cards Station 5: Medical Screening Procedures: 1. Answer any medical questions the patient may have. 2. Review the patient’s screening form for any contraindications and/or precautions. x If no contraindications/precautions exist. Screener should: o Mark the box “Vaccinate” (located in the upper right corner of the consent form) and initial in red ink. (See Sample Form) o Refer patient to Station 6: Vaccination Note: If the patient is physically disabled (e.g wheelchair, walker, on oxygen) direct to Station 6: Vaccination express lane. x If any contraindication/precautions remain after interviewing the patient or patient is unsure of questions/responses, screener should: o Mark the box “DO NOT VACCINATE” (located in the upper right corner of the consent form) and initial in red ink. o Refer patient to their primary care provider/doctor, or to the hospital emergency room for further evaluation as appropriate. At the bottom of the referral form indicate where the pt. was “Transferred to”. o Keep the immunization consent form and provide the patient the white copy of the referral form and attach yellow copy to the consent form. o Place forms in folder labeled: Station 5: Do Not Vaccinate/Referral Forms. o Direct patient to “Exit”. 3. Patient refusal for vaccination/or to respond to screening questions: Collect the Immunization Consent form from the patient. Have patient sign a “Declination of Influenza Vaccination”. Give the patient the white copy and attach the yellow copy to the consent form and file it in the “Refusal folder”. Station 6: Vaccination Type of staff: 13 Nurse/13 NA or clerical/ 3 Security/ 2 Vaccine Runner Total staff per 8 hour shift: Physical Requirements: 26=13/13 Able to stand (sit) for at least 8 hours Able to administer vaccines to patients for at least 8 hours x x x Set up tables (for vaccination supplies) and chairs (for patients) at Station 6 Post the “Vaccination” sign identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 6 procedure card on the desk where each clinic staff working at the station is situated Forms/Supplies: x Gloves x Pandemic influenza vaccine x Small Coolers with frozen ice packs and insulation material x Alcohol prep pads x 1 cc Syringe 27 ½ (tuberculin tip) x 23G1, 25G1, 25G5/8 x Band Aids x Sharps container x Biohazard bags x 2- I Connect Radio Phones (1-Secuirty/1-Designated Staff) x Antiseptic spray for clean-up/Lysol wipes x Guam DPHSS stamps x Stamp pads x Paper towels x Alcohol based hand gel x Pens x Table covers x Trash bag x Tape (to post signs) x Station 6 procedure cards x “Vaccination” sign identifying station x Standing Orders x Expandable Folder labeled “Station 6: Completed Consent Forms” x Handheld flags Station 6: Vaccination Procedures: 1. Security : x 6A & B will direct patients to the next available vaccination station. Must be alert and ready to respond should they be call upon by the Nurse. x 6C will be located by the exit: o Will direct patients coming from Station 6 and/or 7 to the Exit. o Monitor “EXIT” ensuring no one else enters the clinic that is not authorized. 2. Vaccine Supply Runner: x Must be alert and ready to restock vaccines or other supplies needed at the stations. Runner must ensure that the coolers with the vaccines are kept closed at all times. Runner to remind nurses to: Close the lids of the coolers and put vaccine vials back in the cooler when not in used. 3. Clerk/NA: x Clerk/NA shall not leave their station. x If they are in need of supplies, the Nurse in Charge (NIC), or security. The NA/Clerk will use hand held color coded flags to signal. The following are the color codes: ƒ Red: Security ƒ Green: Next Patient ƒ Blue: NIC ƒ Yellow: Supplies (indicate which one) x Clerk /NA to review consent form for any contraindication/precautions. Check top right corner of the form to ensure the box “Vaccinate” is checked and initialed. x Review consent forms for signature and confirm with patient if he/she is still willing to be vaccinated. o Should the patient refuse vaccination at this point have patient sign a “Declination of Influenza Vaccination” staple this form, the consent form and shot record together and place in refusal folder. o For patients who will receive their vaccination: ƒ Fill in the date of vaccination and site of vaccination instructed by nurse, on the consent form (see Sample). ƒ Fill in the date of vaccination and stamp “Guam DPHSS” in patient shot record. ƒ Give the nurse the consent form and shot record. Station 6: Vaccination 4. The Nurse will: x Answer any remaining questions. x Vaccinate the patient. x Initials both the consent form and shot record. x Give the patient the shot record. x File the consent form in the folder labeled “Station 6: Completed Consent Forms” x If patient states he/she is feeling ill after immunization, refer to Station 7: Post Vaccination/Observation, otherwise, clerk to direct patient to “Exit” Station 7: Post Vaccination/Observation (if needed) Type of staff: 1 Nurse Aide Total staff per 8 hour shift: Physical Requirements: x x x x x x x 1 Able to stand (sit) for at least 8 hours Station 7 should be located in an area that is near the vaccination area Set up table and chairs in Station 7 for clinic staff Set up table for first aid supplies Avoid hazardous areas if oxygen is to be kept at the first aid station Post “First Aid” and “Observation” sign where it is clearly visible Post the “Exit” sign where patients will leave the clinic premises, but where traffic flow is controlled to prevent unauthorized individuals from entering the clinic. Tape the Station 7 procedure card on the desk where it is visible to clinic staff working at the station Forms/Supplies: x Diphenhydramine 50mg ampules Ɣ Stretcher x Syringe 1ml 27G ½ Ɣ Table covers x Needles: 22G1 Ɣ Alcohol prep pads x Epi Pen and Junior Epi Pen Ɣ Oxygen (if available) x External defibrillator (if available) Ɣ Pens x Adult/Pediatric airway Ɣ Evaluation/Referral Forms x Stethoscope Ɣ First aid kit x Ammonia inhalants Ɣ Emesis basin x Protocol for Allergic Reaction Ɣ Flashlight x Thermometers and disposable covers Ɣ Station 7 procedure card x Ambubag with mask for both adult and pediatric patients x Blood pressure cuff for both adult and pediatric patients x Vaccine Adverse Event Recording System (VAERS) forms x “Post Vaccination Observation,” and “Exit” signs x Expandable Folder labeled “Station 7: VAERS” and “Station 7: Referrals” Procedures: 1. Consult with clinic physician for any injuries/incidents which occur during the vaccination clinic. 2. Observe patient post-vaccination. 3. Refer to Protocol for Allergic Reactions for acute adverse reaction post-vaccination. 4. Complete the Evaluation/Referral form for any acute adverse reaction post-vaccination. x Refer patient to their primary care provider, to a hospital emergency room, or to a predesignated area for further evaluation as needed. o White copy of medical Evaluation/Referral form to accompany the patient. o Yellow copy of the Medical Evaluation/Referral form stay in Station 8. 5. Complete VARES form if needed (see instruction at the back of the form, for line 13a, see sample to copy information as written). 6. Ensure patient has VIS and shot record. 7. Direct patient to exit. Limited Staff Clinic Flecr Plane Annex C-S Line Security uppity Statuar- clinic Ctiant Waiting Anna i Security Secu rity Clinic Manager Security Security Stetien 4: Forms. Reviey.- [multiple static-ins} "fee hcteaf?'f Security Security Vaccinatien [multiple etetiene} I Nic .1 Security Runner Feet ens-rater [if'tee-rieci1?1?.312umemnn an, ANNEX C-4 Limited Staffed Clinic Description Station 1: Triage Type of staff: 1 EMT/2 Nurse Aide/ 1 Clerical/ 2 Security Total staff per 8 hour shift: Physical Requirements: x x x x 5 Able to stand (sit) for at least 8 hours Able to interview patients for at least 8 hours. Able to wear N-95 mask and gloves. Station 1 should be located before the entrance to the clinic Desk and chairs (for volunteers working at the station) should be situated in a way to allow control of patient flow into the clinic, but without obstructing the doorway Post the “Triage” sign, identifying the station, in a location that is clearly visible to incoming persons Tape the Station 1 procedure card on the desk where it is visible to the clinic staff working at the station Forms/Supplies: x N-95 masks x Surgical Mask (for ill patients) x Thermometers /covers x Antiseptic hand gel x Disposable gloves x Pens x Tape x Declination/Refusal to Vaccinate Forms x Trash bag x “Triage” sign identifying station x Vaccine Information Statements (V.I.S.) x Numbers for patients x Laptops (2) w/Pandemic Flu database x Station 1 procedure card x Expandable Folder to hold V.I.S. x Paper towels Ɣ Table covers Ɣ Biohazard bags Ɣ I-Connect Radio/Phone Ɣ Alcohol preps Ɣ Extension Cord w/multiple outlets Station 1: Triage Procedures: 1. All personnel in this station should use mask and gloves. 2. Security 1A & 1B will: x Maintain order in the line x Answer questions x Announces eligibility for flu vaccine and have shot record ready, if available. x Identify physically disable patients (e.g on wheel chair, a walker, on oxygen) and discreetly guide him/her to the front of triage line. 3. Clerk will: x Document the temperature taken by the NA or EMT. x If cleared by EMT/NA issue number card to patient. 4. EMT and NA’s will: x Ask patient for shot record, if available. Review record to see if current flu vaccine was given. x Conduct temperature check on all potential patients. x Screen all potential patients for the following: o Do you have any flu like symptoms? o Are you sick today or have been sick in the last 2-3 days? Station 1: Triage Screening EMT and/or NA 1) Ask patient: Are you sick now, or have you been sick in the last 2-3 days? YES 2) Take patients temperature. Patient reports he/she is or has been sick OR Temp • 101°F Clerk is to give patient their number card with temperature reading and VIS. Patient is instructed to hold on to the card. Refer to Station 2, he/she will be told what to do with it. Station 2: EVALUATION Station NO Patient denies he/she is or has been sick OR Temp ” 101°F Clerk to provide patient with number card, w/temperature and V.I.S. Security 1B: Check all patients number card to ensure they have been seen by Station 1. Guide patients to clinic entrance to Waiting Area for Station 3. If patient is cleared by Station 2, Security 1B to: x Verify clearance “cleared by” at the bottom of referral form and patient has his/her number card w/temperature indicated . If either is missing, refer pt. back to Station 2 for missing item. x Mark referral form with highlighter to indicate they have been screened for the above info. x Direct patient to Station 3. Note 1: Should there be a physically disabled patient (e.g. on a wheelchair, on a walker, or on oxygen) Security 1B should alert security 3A by radio of incoming patient. This patient will be utilizing the express lane in the clinic. Note 2: If patient refuses vaccination at this point have patient sign a “Declination of Influenza Vaccination” do not issue a number card. Give white copy to the patient, and file the yellow copy in refusal folder. Station 2: Evaluation Type of staff: Physician or Nurse/ 1 Security Total staff per 8 hour shift: Physical Requirements: x x x x x x 1 Able to stand (sit) for at least 8 hours Able to interview patients for at least 8 hours Able to wear N-95 mask and gloves. Station 2 should be located in a confined area with minimal traffic flow, in a separate area from the main vaccination clinic. Desk and chairs should be set-up at “entrance” of Station 2 for clinic personnel checking in patients. Privacy Screens and chairs should be set-up for patients awaiting evaluation. Cots should be set-up for moderately ill patients. Post the “Evaluation” sign, identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 2 procedure card on the desk where it is visible to the clinic staff working at the station. Forms/Supplies: x N-95 masks x Surgical Masks (for ill patients) x Gloves x Blood pressure cuff x Biohazard bags x Pulse oximeter x Tongue Depressor x Alcohol based hand cleansing gel x Thermometer and disposable covers x Stethoscope x I-Connect Radio Phones x Privacy Screens x Antiseptic wipes x Paper towels x Alcohol preps x Pens x Evaluation/Referral Form(to be revised) x Station 2: Procedure card x Table covers x Expandable Folder labeled “Station 2: Referrals” for collection of Evaluation/Referral Form x Declination/Refusal to Vaccinate Form x “Station 2: Evaluation” sign identifying station x Masking Tape x Clipboards x Trash bag Station 2: Medical Evaluation Procedures: 1. Patients seen at this station are sent by Station 1. All personnel at his station must wear gloves and mask. 2. Take vital signs, recheck temperature and perform a brief history. Record this information on the Medical Evaluation/Referral form. (See Cold or Flu Chart) 3. Patient refusal for vaccination. Should the patient refuse vaccination at this point or at any point in this process have the patient sign a “Declination of Influenza Vaccination” Collect the number card and place it in the box . Give patient the white copy. File the yellow copy in the refusal folder. 4. Screening of Patients: a) Moderately Ill Patients x Complete a Medical Evaluation/Referral form. (see sample) x Refer patient to their primary care provider/doctor, or to the hospital emergency room for further evaluation as appropriate. At the bottom of the referral form indicate where the pt was “Transferred to”. x Collect the number card from the patient and place it in the box and give the patient the white copy of the referral form and file yellow copy in the folder marked “Referral” x Direct patient to exit. x Security in this station will radio Security in Station 3 informing him/her that this number has been deferred. b) Well Patients and/or those with mild illness (not Influenza) x Complete a Medical Evaluation/Referral form (see sample) x At the bottom of the referral form indicate “Cleared by”. x Give the patient the white copy of the referral form. Instruct pt. to hold onto their form & number card. Direct patient to Security (1B) behind station 1. (Entrance of the clinic) x File Yellow copy in the folder marked “Referral”. Security: x Should there be a physically disable patient (e.g. On a wheelchair, on a walker, or on oxygen) Security should alert security 3A by radio of the incoming patient this patient will be utilizing the express lane in the clinic. x Monitor Exit for no entry. x Directs patient(s) to the exit. x Will I-Connect Security Guard 3B for any deferred patients and patients who are pending medical evaluation. Station 3: Processing Type of staff:1 Health Educator/ 6 Clerical/ 3 Security Total staff per 8 hour shift: Physical Requirements: x x x x x x 10 Able to stand (sit) for at least 8 hours Station 3 should be located at the entrance to the clinic in an area (room) that can accommodate a group of people. Set up chairs at the “entrance” to Station 3 for the “waiting area”. Set up Health Ed. equipment and materials to be displayed. If space allows, set up tables and chairs “inside” Station 3 where patients can complete and sign the consent form. If space is not available for tables, set up chairs and have clipboards available to provide hard, writing surfaces. Post the “Waiting Area” and “Check In/Forms Completion” signs identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 3 procedure card(s) on the desk where it is visible to the clinic staff working at the station. Forms/Supplies: x Pandemic Influenza Vaccine Screening/Consent Form x Immunization shot records (child and adult) x 2- I Connect Radio Phone (1 for Security B and designated clerk) x Pens x Clipboards x Paper clips x Numbers checklist x Bullhorn x Trash bag x Table covers x TV w/ DVD/VCR or LCD Projector and Laptop x Health Education Influenza Video/DVD x “Waiting Area” & “Check In/Forms Completion” signs identifying station x Masking Tape x Station 3 procedure cards x Declination/Refusal to Vaccinate Form x 2 Refusal box/container x Hand Flags “Next” patient Station 3: Processing Procedures: 1. Health Educator will provide information through the use of videos, printed materials, and answer any questions patients may have. 2. Designated security personnel: x 3A will remind patient to hold onto their number card and direct patient to seating area. x 3B will: o Call patients by numerical order and check off each number on the number check list. o Indicate the letter “D” next to the number that was deferred when informed by security in Station 2. x 3C will: o Direct pt. to the next available processor. o Direct physically disabled (when indicated) to express lane. 3. Support Staff : x Staff to be stationed in between tables. x Staff to flag security for patient(s) x Ask the patient for their number card and write the following information on the top of the consent form in the designated spaces: 1. Patient Number 2. Patient Temperature (copy from the number card) x Staff to pass out consent form and instruct the patient to complete the following sections on the consent form: o Information about the patient o Screening questions (#1 thru #8) o Print their name, sign and date at the bottom of the form. x Patient(s) to fill out consent form. x To answer any questions patients may have regarding the consent form. 4. Once the patient completes the consent form, staff to direct to Station 4: Station 4: Review Type of staff: 4 Support staff/ 2 Nurse Aide/ 2 Security Total staff per 8 hour shift: Physical Requirements: 7 Able to sit for at least 8 hours Able to interview patients for at least 8 hours x x x Station 4 to be located right after Station 3. Post the “Review” sign identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 4 procedure card(s) on the desks where it is visible to the clinic staff working at the station. Forms/Supplies: x Processors Guide to Screening Questionnaire Form x Red and Black Pens x Immunization Protocol/ Standing Order x Guide to Contraindications x I Connect Radio Phone x Station 4 procedure card x “Station 4: Review” sign identifying station x Tape x Post it pads x Trash bag x Table covers Procedures: 1. Security will direct patient to the next available reviewer. 2. Support Staff/Nurse Aide will: x Review immunization consent form to ensure that all sections of the form is completed including the signatures. Should any information be missing on the consent form such as processors signature ask patient to bring forms back to the clerk who processed him/her for completion of form. x If “No” contraindications/precautions remain after interviewing the patient: o Check the box “Vaccinate” and initial with red ink. o Refer patient to Station 6: Vaccination. o For physically disable pt. refer to express lane in Station 6. x Patient with boxes marked “Yes” consult the Processors Guide to Screening Questions or Guide to Contraindications to Vaccinations o If any contraindications/precautions remain after interviewing the patient or if patient has questions not covered in the education materials refer patient to Station 5: Medical Screening. 3. Security will direct patient towards the next available reviewer. Station 5: Medical Screening Type of staff: Physician or Nurse Total staff per 8 hour shift: Physical Requirements: 1 Able to sit for at least 8 hours Able to interview patients for at least 8 hours x x x x Station 5 may have multiple stations to allow for privacy during medical screening. If multiple rooms not available, space screening stations as far apart as possible to allow for privacy during medical screening. Post the “Medical Screening” sign identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 5 procedure card(s) on the desks where it is visible to the clinic staff working at the station. Forms/Supplies: x Doctor’s Orders/Progress Notes x Assessment Sheet x Red and Black Pens x “Medical Screening” sign identifying station x Contraindication Guidelines x I Connect Radio Phone x Referral Forms x Declination/Refusal to Vaccinate x Expandable Folder labeled “Station 5: Do Not Vaccinate/Referral Forms” x Tape x Table covers x Trash bags x Station 5 procedure cards Station 5: Medical Screening Procedures: 1. Answer any medical questions the patient may have. 2. Review the patient’s screening form for any contraindications and/or precautions. x If no contraindications/precautions exist. Screener should: o Mark the box “Vaccinate” (located in the upper right corner of the consent form) and initial in red ink. (See Sample Form) o Refer patient to Station 6: Vaccination Note: If the patient is physically disabled (e.g wheelchair, walker, on oxygen) direct to Station 6: Vaccination express lane. x If any contraindication/precautions remain after interviewing the patient or patient is unsure of questions/responses, screener should: o Mark the box “DO NOT VACCINATE” (located in the upper right corner of the consent form) and initial in red ink. o Refer patient to their primary care provider/doctor, or to the hospital emergency room for further evaluation as appropriate. At the bottom of the referral form indicate where the pt. was “Transferred to”. o Keep the immunization consent form and provide the patient the white copy of the referral form and attach yellow copy to the consent form. o Place forms in folder labeled: Station 5: Do Not Vaccinate/Referral Forms. o Direct patient to “Exit”. 3. Patient refusal for vaccination/or to respond to screening questions: Collect the Immunization Consent form from the patient. Have patient sign a “Declination of Influenza Vaccination”. Give the patient the white copy and attach the yellow copy to the consent form and file it in the “Refusal folder”. Station 6: Vaccination Type of staff: Total staff per 8 hour shift: Physical Requirements: x x x Nurse/ NA or clerical/ 3 Security/1 Vaccine Runner (This number is dependant upon availability of nurses, and if there is more than one clinic operating simultaneously. For every 2 nurses, there is 1 NA or clerk). Able to stand (sit) for at least 8 hours Able to administer vaccines to patients for at least 8 hours. Set up tables (for vaccination supplies) and chairs (for patients) at Station 6 Post the “Vaccination” sign identifying the station, in a location that is clearly visible to incoming patients. Tape the Station 6 procedure card on the desk where each clinic staff working at the station is situated Forms/Supplies: x Gloves x Pandemic influenza vaccine x Small Coolers with frozen ice packs and insulation material x Alcohol prep pads x 1 cc Syringe 27 ½ (tuberculin tip) x 23G1, 25G1, 25G5/8 x Band Aids x Sharps container x Biohazard bags x 2- I Connect Radio Phones (1-Secuirty/1-Designated Staff) x Antiseptic spray for clean-up/Lysol wipes x Guam DPHSS stamps x Stamp pads x Paper towels x Alcohol based hand gel x Pens x Table covers x Trash bag x Tape (to post signs) x Station 6 procedure cards x “Vaccination” sign identifying station x Standing Orders x Expandable Folder labeled “Station 6: Completed Consent Forms” x Handheld flags Station 6: Vaccination Procedures: 1. Security : x 6A & B will direct patients to the next available vaccination station. Must be alert and ready to respond should they be call upon by the Nurse. x 6C will be located by the exit: o Will direct patients coming from Station 6 and/or 7 to the Exit. o Monitor “EXIT” ensuring no one else enters the clinic that is not authorized. 2. Vaccine Supply Runner: x Must be alert and ready to restock vaccines or other supplies needed at the stations. Runner must ensure that the coolers with the vaccines are kept closed at all times. Runner to remind nurses to: Close the lids of the coolers and put vaccine vials back in the cooler when not in used. 3. Clerk/NA: x Clerk/NA shall not leave their station. x If they are in need of supplies, the Nurse in Charge (NIC), or security. The NA/Clerk will use hand held color coded flags to signal. The following are the color codes: ƒ Red: Security ƒ Green: Next Patient ƒ Blue: NIC ƒ Yellow: Supplies (indicate which one) x Clerk /NA to review consent form for any contraindication/precautions. Check top right corner of the form to ensure the box “Vaccinate” is checked and initialed. x Review consent forms for signature and confirm with patient if he/she is still willing to be vaccinated. o Should the patient refuse vaccination at this point have patient sign a “Declination of Influenza Vaccination” staple this form, the consent form and shot record together and place in refusal folder. o For patients who will receive their vaccination: ƒ Fill in the date of vaccination and site of vaccination instructed by nurse, on the consent form (see Sample). ƒ Fill in the date of vaccination and stamp “Guam DPHSS” in patient shot record. ƒ Give the nurse the consent form and shot record. Station 6: Vaccination 4. The Nurse will: x Answer any remaining questions. x Vaccinate the patient. x Initials both the consent form and shot record. x Give the patient the shot record. x File the consent form in the folder labeled “Station 6: Completed Consent Forms” x If patient states he/she is feeling ill after immunization, refer to Station 7: Post Vaccination/Observation, otherwise, clerk to direct patient to “Exit” Station 7: Post Vaccination/Observation (if needed) Type of staff: 1 Nurse Aide Total staff per 8 hour shift: Physical Requirements: x x x x x x x 1 Able to stand (sit) for at least 8 hours Station 7 should be located in an area that is near the vaccination area Set up table and chairs in Station 7 for clinic staff Set up table for first aid supplies Avoid hazardous areas if oxygen is to be kept at the first aid station Post “First Aid” and “Observation” sign where it is clearly visible Post the “Exit” sign where patients will leave the clinic premises, but where traffic flow is controlled to prevent unauthorized individuals from entering the clinic. Tape the Station 7 procedure card on the desk where it is visible to clinic staff working at the station Forms/Supplies: x Diphenhydramine 50mg ampules Ɣ Stretcher x Syringe 1ml 27G ½ Ɣ Table covers x Needles: 22G1 Ɣ Alcohol prep pads x Epi Pen and Junior Epi Pen Ɣ Oxygen (if available) x External defibrillator (if available) Ɣ Pens x Adult/Pediatric airway Ɣ Evaluation/Referral Forms x Stethoscope Ɣ First aid kit x Ammonia inhalants Ɣ Emesis basin x Protocol for Allergic Reaction Ɣ Flashlight x Thermometers and disposable covers Ɣ Station 7 procedure card x Ambubag with mask for both adult and pediatric patients x Blood pressure cuff for both adult and pediatric patients x Vaccine Adverse Event Recording System (VAERS) forms x “Post Vaccination Observation,” and “Exit” signs x Expandable Folder labeled “Station 7: VAERS” and “Station 7: Referrals” Procedures: 1. Consult with clinic physician for any injuries/incidents which occur during the vaccination clinic. 2. Observe patient post-vaccination. 3. Refer to Protocol for Allergic Reactions for acute adverse reaction post-vaccination. 4. Complete the Evaluation/Referral form for any acute adverse reaction post-vaccination. x Refer patient to their primary care provider, to a hospital emergency room, or to a predesignated area for further evaluation as needed. o White copy of medical Evaluation/Referral form to accompany the patient. o Yellow copy of the Medical Evaluation/Referral form stay in Station 8. 5. Complete VARES form if needed (see instruction at the back of the form, for line 13a, see sample to copy information as written). 6. Ensure patient has VIS and shot record. 7. Direct patient to exit. ANNEX D Vaccination Timeline Clinic staffing for vaccination clinics is based on three 4-hour shifts. Vaccination clinics will be operational 12 hours a day. The vaccination staffing model is based on the ability to vaccinate 125 people per hour and a total of 1500 people per day. ANNEX E Storage and Handling of Vaccine The brand of vaccine to be used may not be known beforehand, therefore, review the manufacturer’s insert for the storage and handling instructions for the specific vaccine received. Based on the current seasonal influenza vaccine, the storage and handling requirements are listed below: Vaccine Manufacturer Doses per Vial Storage Requirements Fluzone Sanofi Pasteur 10 35°to 46°F (2°to 8°C) Fluvirin Chiron 10 35°to 46°F (2°to 8°C) Receiving Vaccine Shipments Arrange for vaccine deliveries to be made only when the vaccine coordinator or backup person is on duty. All staff members who accept vaccine deliveries must be aware of the importance of maintaining the cold chain and of the need to immediately notify the vaccine coordinator or backup person of the arrival of the vaccine shipment so that it can be handled and stored appropriately. Providers Picking Up Vaccine Shipments When picking up vaccines: x Providers are responsible to bring their own supply of insulated coolers and frozen ice packs for transport. o Use properly insulated containers/coolers to transport. One may use the shipping containers the vaccines arrived in from the manufacturers or hard-sided plastic insulated containers or Styrofoam coolers with at least 2 inch thick walls. o Pack enough refrigerated/frozen packs to maintain the cold chain. DO NOT use loose or bagged ice. o Provide insulating barrier (e.g. bubble wrap, crumpled brown packing paper, newspaper). x Do not place vaccine in the trunk of the vehicle. The temperature inside the trunk cannot be regulated and could become too hot or too cold for the vaccine. x Deliver the vaccine directly to the facility and unpack and store it at recommended temperatures upon arrival. Checking the Condition of a Shipment When you receive your vaccine shipment: x Immediately examine the shipping container and its contents for any signs of physical damage. x Crosscheck the contents with the Physicians Request Form to be sure the amounts match. x Check the vaccine expiration dates to ensure that you have not received any vaccine that is already expired. x Examine the vaccine for heat or cold damage: o Check that inactivated vaccines are cold but not frozen. o Refrigerated packs should still be cold. Frozen packs can be melted but the package should still be cold. Vaccines should not be in direct contact with refrigerated/frozen packs. There should be an insulating barrier between the vaccine and the refrigerated/frozen packs, such as crumpled brown packing paper, bubble wrap, or some other barrier. If there are any discrepancies with the Physicians Request Form or concerns about the shipment, immediately notify the primary vaccine coordinator (or the backup person), mark the vaccine as “DO NOT USE,” store them under proper conditions apart from other vaccine supplies and call the Guam DPHSS Immunization Program for further guidance. Storing and Documenting Vaccine Shipments Upon Arrival After the vaccine shipment has been checked: x Immediately store the vaccine at the recommended temperatures. x Do not leave the shipment unattended. The vaccines inside the cooler might warm to inappropriate temperatures and become unstable. Packing Vaccine for Transport to Off-Site Clinics The following are general guidelines for packing vaccine: x Use properly insulated containers/coolers to transport. One may use the shipping containers the vaccines arrived in from the manufacturers or hard-sided plastic insulated containers or Styrofoam coolers with at least 2 inch thick walls. x Place cold packs on the bottom of the container. x Cover with insulation barrier (vaccine should not come in direct contact with the cold packs. A layer of toweling is not sufficient as a barrier.) x Place vaccine(s) on top of barrier (pack vaccines in their original packing. Do not remove vaccines vials from boxes). x x Place another layer of barrier on top of vaccine(s) and then additional refrigerated/frozen packs. A thermometer should be placed in container next to vaccine(s), it should not come in contact with refrigerated/frozen packs. Monitoring Temperatures During Off-Site Clinics If vaccine must be maintained in an insulated cooler during an off-site clinic: x Keep the cooler closed as much as possible. x A thermometer must be kept in the cooler with the vaccines, to ensure that the cold chain is not broken. x Vaccine temperatures to be checked and recorded HOURLY. x Replace ice packs as necessary to maintain temperature between 35° to 46°F or place vaccine(s) in a secure temperature monitored refrigerator at the outreach site. ANNEX E-1 Security Considerations Provision of appropriate security should be made for the following: 1. Vaccine storage sites (clinic and non-clinic) to include security personnel and locked, limited access areas for vaccine storage. 2. Backup power sources (generators) should be identified for all sites where vaccine is stored (vaccination clinics and storage sites). 3. Vaccination clinic sites: security personnel for crowd control, traffic movement, clinic personnel safety, and related security issues. 4. Vaccine transportation to storage sited and dispensing clinics. ANNEX F-1 DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES GOVERNMENT OF GUAM P.O. BOX 2816 HAGTNA, GUAM 96932 PHYSICIAN CERTIFICATION FORM PANDEMIC INFLUENZA VACCINE I certify that in administering the influenza (flu) vaccine I receive from the Department of Public Health and Social Services (DPHSS) for use in my private practice: 1. I will follow the “Public Health Order” signed into law XXX 2. I will administer the PANDEMIC INFLUENZA VACCINE to the following HIGH RISK PATIENTS ONLY (depending on available supplies, DPHSS may further limit administration if necessary): i. ii. iii. iv. v. vi. Health care providers and their support staff; Persons > 65 years with 1 or more influenza high-risk conditions, not including essential hypertension; Persons 6 months to 64 years with 2 or more influenza high-risk conditions, not including essential hypertension; Persons 6 months or older with history of hospitalization for pneumonia or influenza or other influenza high-risk condition in the past year; Pregnant women beyond their first trimester; Household contacts of severely immunocompromised persons who would not be vaccinated due to likely poor response to vaccine; 3. I will provide to each patient (parent or guardian) receiving such flu vaccine information materials or literature in accordance with the National Childhood Vaccine Injury Act. 4. I will not charge a fee for any flu vaccine provided to me by the DPHSS. 5. I will return any flu vaccine TWO MONTHS BEFORE expiration date to DPHSS. 6. I will adopt or develop a tickler system to identify immunized patients and recall them, one month later, to receive their second dose of flu vaccine (if available). 7. I will provide DPHSS, on a daily basis, a list of patients who received the flu vaccine. 8. I will exercise individualized medical judgment in the administration of all such flu vaccine. 9. I will immediately report all cases of reactions to the flu vaccine received from the DPHSS by completing the “Vaccine Adverse Event Reporting System” form provided by the Bureau of Communicable Disease Control, Immunization Section, Department of Public Health and Social Services. ________________________________ Name of Clinic/Physician’s Name Flu vaccine #of Doses ________________________________ Physician’s Signature/Date FOR PHARMACY USE ONLY LOT # EXPIRATION DATE Influenza Brand: Other Specify: ________________________________ Received By/Date ________________________________ Distributed By/Date This form must be used when picking up the flu vaccine. ALL CLINICS MUST PROVIDE A COOLER WITH FROZEN ICE PACKS. For questions, please call the Bureau of Communicable Disease Control, Immunization Program at 735-7143/48 or Fax 734-1475. ANNEX G. Vaccine Administration Appropriate vaccine administration is critical to vaccine effectiveness. The recommended site, route and dosage for each vaccine is based on clinical trials, practical experience and theoretical considerations. The following information provides general guidelines for administration of vaccines fur those who administer vaccines, as well as those in training, education and supervisory positions. This information should be used in conjunction with professional standards for medication administration, vaccine manufacturers' product guidelines, Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) General Recommendations on Immunization, the American Academy of Pediatrics' (AAP) Report or the Committee on Infectious Diseases Red Book and state/agency-related policies and procedures. Preparation ¾ Patient Preparation - Patients should be prepared for vaccination with consideration for their age and stage of development. Parents/guardians and patients should be encouraged to take an active role before, during and after the administration of vaccine. Parents/guardians who elect not to directly participate during vaccine administration can wait in a nearby area. ƒ Screening - All patients should be screened for contraindications and precautions for each scheduled vaccine. Many state immunization programs and other organizations have developed and make available standardized screening tools. ƒ Vaccine Safety & Risk Communication - Parents/guardians and patients are exposed through the media to information about vaccines, some of which is inaccurate or misleading. Health-care providers should be prepared to discuss the benefits and risks of vaccines using Vaccine Information Statement (VIS) and other reliable resources. ƒ Atraumatic Care - Vaccine safety issues and the need for multiple injections have increased the concerns and anxiety associated with immunizations. Health-care providers need to display confidence and establish an environment that promotes a sense of security and trust fur the patient and family, utilizing a variety of techniques to minimize the stress and discomfort associated with receiving injections. This is particularly important when administering vaccines to children . x Positioning & Comforting Restraint - The health-care provider must accommodate fur the patient's comfort, safety, age, activity level, and the site of administration when considering patient positioning and restraint. For a child, the parent/guardian should be encouraged to hold the child during administration. if the parent is uncomfortable, another person may assist or the patient may be positioned safely on an examination table. ¾ Infection Control - Health-care providers should follow Standard Precautions to minimize the risks of spreading disease during vaccine administration. ƒ Handwashing - The single, most eftective disease prevention activity is good handwashing. Hands should be washed thoroughly with soap and water or cleansed with an alcohol-based waterless antiseptic between patients, before vaccine preparation or any time hands become soilcd, c.g. diapcring, cleaning excreta, etc. ƒ Gloving - Gloves are not mandatOl)' for vaccine administration unless there is potential for exposure to blood or body tluids or the provider has open lesions on the hands. It is important to remember that gloves cannot prevent needle stick injuries. ƒ Needle Stic!19 yrs.: 1.0 mL IM Vastus lateralis: for infants (& toddlers lacking adequate deltoid mass); Deltoid: for toddlers, children & adults 22–25g, 1–2" Hepatitis B (HepB) <19 yrs.: 0.5 mL* >20 yrs.: 1.0 mL IM Vastus lateralis: for infants (& toddlers lacking adequate deltoid mass); Deltoid: for toddlers, children & adults 22–25g, 1–2" 0.5 mL Intranasal spray 6-35 mos: 0.25 mL >3 yrs.: 0.5 mL IM Vastus lateralis: for infants (& toddlers lacking adequate deltoid mass); Deltoid: for toddlers, children & adults 22–25g, 1–2" Measles, mumps, rubella (MMR) 0.5 mL SC Anterolateral fat of thigh: for young children Posterolateral fat of upper arm: for children & adults 23–25g, 5/8" Meningococcal (Men) 0.5 mL SC Anterolateral fat of thigh: for young children Posterolateral fat of upper arm: for children & adults 23–25g, 5/8" Pneumococcal conjugate (PCV) 0.5 mL IM Vastus lateralis: for infants (& toddlers lacking adequate deltoid mass); Deltoid: for toddlers & children 22–25g, 1–2" IM Deltoid 22–25g, 1–2" Pneumococcal polysaccharide (PPV) 0.5 mL SC Anterolateral fat of thigh: for young children Posterolateral fat of upper arm: for children & adults 23–25g, 5/8" IM Vastus lateralis: for infants (& toddlers lacking adequate deltoid mass); Deltoid: for toddlers, children & adults 22–25g, 1-2" SC Anterolateral fat of thigh: for infants & young children Posterolateral fat of upper arm: for children & adults 23–25g, 5/8" SC Anterolateral fat of thigh: for young children Posterolateral fat of upper arm: for children & adults 23–25g, 5/8" Influenza, live attenuated (LAIV) Influenza, trivalent inactivated (TIV) Polio, inactivated (IPV) Varicella (Var) Administer 0.25 mL dose into each nostril while patient is in an upright position NA 0.5 mL 0.5 mL ® *Persons 11 through 15 years of age may be given Recombivax HB (Merck) 1.0 mL (adult formulation) on a 2–dose schedule. Combination Vaccines DTaP+HepB+IPV (Pediarix™) DTaP+Hib (Trihibit™) Hib+HepB (Comvax™) HepA+HepB (Twinrix®) 0.5 mL IM Vastus lateralis: for infants (& toddlers lacking adequate deltoid mass); Deltoid: for toddlers & children 22–25g, 1–2" >18 yrs.: 1.0 mL IM Deltoid 22–25g, 1–2" Please note: Always refer to the package insert included with each biologic for complete vaccine administration information. The Advisory Committee on Immunization Practices (ACIP) statement for the particular vaccine should be reviewed as well. www.immunize.org/catg.d/p3085.pdf • Item #P3085 (11/03) Immunization Action Coalition • 1573 Selby Avenue • St. Paul, MN 55104 • (651) 647-9009 • www.immunize.org I Subcutaneous (SC) injections are administered into the fatty tissue found below the dermis and above muscle tissue. -- Lynne Larson, 0 Site - SC tissue can be thund allover the body. The usual SC sites for vaccine administration are the thigh and the upper outer triceps of the arm. If necessary, the upper outer triceps area can be used to administer SC injections to infants. Lynne Larson, I Needle Gauge Length SHE-inch, 23- to 25?gauge needle I Technique Following appropriate site assessmentfselection, prep the injection site with an alcohol wipe. Using a circular motion, wipe from the center out and allow to dry. 0/ To avoid reaching the muscle, the fatty tissue is pinched up, the needle is inserted at a 45 degree angle and the vaccine is injected into the tissue. Withdraw the needle and apply light pressure to the injection site for several seconds with a dry cotton ballfgauzc. I Intramuscular (1M) injections are administered into muscle tissue below the dermis and SC tissue. Lynne Larson, Site - Although there are several injection sites on the body, the recommended TM sites for vaccine administration are the vastus lateralis muscle {anterolateral thigh) and the deltoid muscle (upper arm). The site depends on the age of the individual and the degree of muscle development. lateraiis Femoral artery and vein Lynne Larson, The vastus Iateralis musde of the upper thigh used for intramuscular injections. Greater Irnchanter of Pemur Vastus lateralis {muddle Lateral femoral conder The vaslus lateralis site of the right thigh. used for an intramuscular Injection. The deltcid muscle site is most commonly used in older children and adults. The deltoid muscle can be used in toddlers if the muscle mass is adequate. The buttock should never be used to administer vaccines. --. i . . . Deltoid muscle - Site of i" eiv 7' Injection Lynne Larson, Needle Gauge 22? to 25~gaugc needle 0 Needle Length - The needle length must be adequate to reach the muscle and is based on the size of the individual. Following are the typical for various ages. Infant - 78- to 1-inch Toddler older children - WS- to lf4?inch Adults - l-to L?s-inch I Technique - Following appropriate site assessment/selection, prep the injection site with an alcohol wipe. Using a circular motion, wipe from the center out and allow to dry. To avoid injection into SC tissue, the skin ofthe selected vaccine administration site can be spread taut between the thumb and forefinger, isolating the muscle. Another technique, acceptable mostly for pediatric and geriatric patients, is to grasp the tissue and ?bunch up? the muscle. Insert the needle fully into the muscle at a 90 degree angle and inject the vaccine into the tissue. Withdraw the needle and apply light pressure to the injection site for several Seconds with a dry cotton ball/gauze. Aspiration Aspiration is the process of pulling back on the plunger ofthe syringe prior to injection to ensure that the medication is not injected into a blood vessel. Although this practice is advocated by some experts, there is no research data documented to support the need for this procedure. Ifblood appears following aspiration, the needle should be withdrawn, a new site selected and the entire administration process restarted. Multiple Vaccinations - When administering multiple vaccines, NEVER mix vaccines in the same syringe unless approved for mixing by the Food and Drug Administration (FDA). If more than one vaccine must be administered in the same limb, the injection sites should be separated by 1-2 inches so that any 10cal reactions can be differentiated. Vaccine doses range from 0.5 to 1 mL.. The recommended maximum volume of medication for an site, varies among references and depends on the muscle mass ofthe individual. l-lowever, administering two IM vaccines into the same muscle would not exceed any suggested volume ranges for either the vastus lateralis or the deltoid muscle in any age group. The option to also administer a SC vaccine into the same limb, if necessary, is acceptable since a different tissue site is involved. I Nonstandard Administration - Deviation from the recommended route, site and dosage ofvaccine is strongly discouraged and can result in inadequate protection. In situations where nonstandard administration has occurred, refer to the ACIP General Recommendation on Immunization, MMWR 2002; 51 for speci?c guidance. Special Situations - Bleeding Disorders Individuals with a bleeding disorder or who are receiving anticoagulation therapy may develop hematomas in NW injection sites. Prior to administration oflM vaccines the patient or family should be instructed about the risk of hematoma formation from the injection. Additionally, a physician familiar with the patient?s bleeding disorder or therapy should be consulted regarding the safety of administration by this route. If the patient periodically receives hemophilia replacement factor or other similar therapy, 1M vaccine administration should ideally be scheduled shortly after replacement therapy. A 23- gauge or finer needle should be used and firm pressure applied to the site for at least two minutes. The site should not be rubbed or massaged. Latex Allergy - Administration ofa vaccine supplied in a vial or syringe that contains natural rubber (refer to product infonnation} should not be administered to an individual with a history ofa severe (anaphylactic) allergy to latex, unless the benefit of vaccination clearly outweighs the risk of an allergic reaction. These situations are rare. Medical consultation and direction should be sought regarding vaccination. A local or contact sensitivity to latex is not a contraindication to vaCCination. Limited Sites - Sometimes vaccination sites may be limited in an individual because of amputation, injury, orthopedic device or cast, etc. It may be necessary to consult the patient?s primary health-care provider to develop an individualized immunization schedule. I Syncopal or vasovagal response (?fainting?) may occur during vaccine administration, especially with adolescents and adults. Because individuals may fall and sustain injury as a result, the provider may consider having the patient sit during A syncopal or vasovagal response is not an allergic reaction, however, the provider should observe and administer supportive care until the patient is recovered. ¾ Anaphylaxis (a life-threatening acute allergic reaction) - Each facility that administers vaccines should have a protocol, procedures and equipment to provide initial care for suspected anaphylaxis; Facility staff should be prepared to recognize and respond appropriately to this type of emergency situation. All staff should maintain current CPR certification. Emergency protocols, procedures and equipment/supplies should be reviewed periodicaJly. For detailed information on medical management, refer to the ACIP General Recommendations on Immunization and AAP Red Book. Although both fainting and allergic reactions are rare, some experts suggest observing patients for, 15-20 minutes following vaccine administration. EPI PROTOCOL Documentation - All vaccine administration should be fully documented in the patient's pem1anent medical record to include: 1. Date of administration 2. Name or common abbreviation of vaccine 3. Vaccine lot number 4. Vaccine manufacturer 5. Administration site 6. Vaccine Information Statement (VIS) edition date (found either in the lower left or lower right corner of the VIS). 7. Name and address of vaccine administrator (This should be the address where the record is kept. If immunizations are given in a shopping mall, for example, the address would be the clinic where the permanent record will reside). Facilities that administer vaccines are encouraged to participate in state/local vaccine registries. The patient or parent should be provided with an immunization record that includes the vaccines administered with dates of administration. EMERGENCY MEDICAL PROTOCOL FOR MANAGEMENT OF ANAPHYLACTIC REACTIONS 1. Vaccines to be administered: Diphtheria, Tetanus, Pertussis (DTaP/Td/Tdap), Measles, Mumps, Rubella ( MMR), Varicella, Haemophilus Influenza type b (Hib), Human Papillomavirus (HPV),Hepatitis A, Hepatitis B, Inactivate Poliovirus, Meningococcal (MCV4), Influenza, Pneumococcal 7-valent Conjugate (Prevnar), 23-valent Pneumococcal Polysaccharide. 2. For any allergic reaction to the above vaccines follow procedures below. Signs and Symptoms of Anaphylactic Reaction Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips, face or throat); bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse. Treatment a. If itching and swelling are confined to the injection site where the vaccination was given, observe patient closely for the development of generalized symptoms. b. If symptoms are generalized, activate the Emergency Medical System (EMS) call 911 and notify the on call physician (if available) This should be done by a second person, while the primary nurse assesses the air way, breathing, circulation, and level of consciousness of the patient. c. Administer aqueous epinephrine 1:1000 dilution intramuscularly; (See chart below) d. Monitor the patient closely until EMS arrives, Perform Cardiopulmonary resuscitation (CPR), if necessary, and maintain airway, Keep patient in supine position (flat on back) unless he or she is having breathing difficulty. If breathing is difficult, patient’s head may be elevated, provided blood pressure and pulse every 5 minutes. e. If EMS has not arrived and symptoms are still present, repeat dose of epinephrine every 10-20 min for up to 3 doses, depending on patient’s response. f. Using a referral form record all vital signs, medications administered to patient, including the time, dosage, response, and name of the medical personnel who administered the medication, and other relevant clinical information. g. Patient should be endorsed to EMS personnel once they arrive at the scene. h. Give white copy of the referral form to EMS Personnel. i. The medical personnel who assisted the patient should complete a Vaccine Adverse Reaction form (VARES) and provide a copy to the Department of Public Health and Social Services (DPHSS), Immunization Program for reporting. Dosage and Administration Epinephrine Dose 1 mg/mL injectable Age Group Weight in lbs (1:1000 dilution) intramuscular 1-6 months 9-15 lbs 0.05mg (0.05ml) 7-18 months 15-24 lbs 0.1 mg (0.1 ml) 19-36 months 24-31 lbs 0.15 mg (0.15 ml) 37-48 months 31-37 lbs 0.15 mg (0.15 ml) 49-59 months 37-42 lbs 0.2 mg (0.2 ml) 5-7 years old 42-51 lbs 0.2 mg (0.2 ml) 8-10 years old 51-77 lbs 0.3 mg (0.3 ml) 11-12 years old 77-99 lbs 0.4 mg (0.4 ml) 13 years & older 99+ lbs 0.5 mg (0.5 ml) *Dosing by body weight is preferred Children The standard dose is 0.01 mg/kg body weight, up to 0.3 mg maximum single dose in children. Adolescents/Adults The dosage range from 0.3 mL to 0.5 mL,with maximum single dose of 0.5 mL. ______________________________________ ROBERT LEON GUERRERO, M.D. Guam Immunization Medical Advisor _____________ DATE ______________________________________ ANNAKUTTY MATHEW, M.D. Guam Public Health Medical Director ______________ DATE Concurred by: ___________________________________ ARTHUR U. SAN AGUSTIN, MHR Acting _______________ DATE ANNEX H Vaccine Accountability Procedure At the completion of each clinic session, a vaccine accountability form (vaccine usage) is to be completed (see Annex H-1). Usage Reports Usage reports are used to record vaccine doses that were administered, wasted, spoiled, expired, or transferred. Each time a dose of vaccine is used, it should be marked on a tally sheet that is placed on the outside of the storage unit door or in some other convenient location. The Immunization Program requires vaccine doses administered and inventory on hand reports to be submitted by the provider. The provider is responsible for: a. Completing all sections on the Vaccine Usage Report: x x x x Age-Dose Table Inventory Table Age-Insurance Table Waste-Expired Table b. Cross check Ending Inventory indicated on the usage report by conducting a Visual Inventory. c. Sign off on the usage report certifying the information provided is true and accurate: - For Private Providers: A Physician or Medical Director - For Guam DPHSS centers: A “clinic supervisor” d. Submit or fax a completed report by the end of business day the following day. Counting Stock An actual count of the number of doses of vaccine in stock is an important component of inventory management and is the responsibility of the vaccine coordinator or designee. Vaccine should be counted at the completion of each clinic session and before ordering vaccine. This will ensure there are enough supplies to meet the needs of the practice and is useful for checking the accuracy of the running balance of doses in the usage report. When counting vaccine doses: x Review the expiration dates of all stock, looking for short-dated vaccine that must be used quickly and for expired vaccine that should not be administered. o If you have vaccine that will expire within two (2) months that cannot be administered during this time period, return it to the Immunization Program. In some cases, this short-dated vaccine can be moved to another clinic where it may be used before it expires. o Remove expired vaccine from the refrigerator or freezer, label “DO NOT USE”, fill out wastage form and return to the Immunization Program for proper disposal. x If the count of vaccine doses is different from the running balance on the usage report, count the stock again and recalculate the running balance to find the error. x If a discrepancy remains, contact the Immunization Program for further guidance. Inventory Accounting Inventory accounting is important for vaccine quality management. Proper inventory management means knowing the following: x what quantities of vaccine have been received; x what quantities of vaccine have been administered, wasted, or spoiled; x which vaccines are currently in stock; x which vaccine vials should be used first; x which vaccine vials are expired and must not be administered; x how many vaccine vials are in excess supply and may be returned for possible credit; and x which vaccine need to be ordered. ANNEX . DEPARTMENT OF PUBLIC HEALTH SOCIAL SERVICES PANDEMIC INFLUENZA 1VACCINE USAGE REPORT Name Of Clinic: Tel. Fax NO: Contact Person: Month Year: Vaccine AGE IN YEARS DOSE <7-8 9-14 15-18 19-24 25-49? 50-64 65+ 1 FLU 2 Total VACCINE INVENTORY VACCINE BEGINNING VACCINE RECEIVED VACCINES USED DOSES WASTED ENDING INVENTORY INVENTORY (DOSES) FROM (DOSES) (DOSES) Flu FILL IN THE INSURANCE STATUS FOR THOS IMMUNIZED WITH VACCINES <1 YEAR OLD 1-2 YEARS OLD 3-6 YEARS OLD 7-18 YEARS OLD 19-49 YEARS OLD 50-64 YEARS OLD 65+ YEARS OLD MEDICARE M.I.P. MEDICAID NO INSURANCE PRIVATE INSURED ANNEX I Emergency Procedures Emergency procedures should be consistent with those normally carried out by the facility (see Annex I-1). In addition to those procedures, complete a Vaccine Adverse Events Reporting Systems (VAERS) form (see Annex I-2). Felix P. Camacho GOVERNOR Michael W. sz, MD. LIEUTENANT GOVERNOR GOVERNMENT OF GUAM DEPARTMENT OF PUBLIC HEALTH SOCIAL SERVICES (DIPATTAMENTON SALUT PUPBLEKO YAN SETBISION SUSIAT) Post Of?ce Box 2816, Hagat?a, Guam 96932 ?23 Chalan Kareta, Route 10 Mangilao, Guam 96923 Arthur U. San Agustin, MHR ACTING DIRECTOR James H. Underwood DEPUTY DTRECTOR EMERGENCY MEDICAL PROTOCOL FOR MANAGEMENT OF 1. ANAPHYLACTIC REACTIONS Vaccines to be administered: Diphtheria, Tetanus, Pertussis Measles, Mumps, Rubella MMR), Varicella, Haemophilus In?uenza type (Hib), Human Papillomavirus (HPV),Hepatitis A, Hepatitis B, Inactivated Poliovirus, Meningococcal (MCV4), In?uenza, Pneumococcal 7-valent Conjugate (Prevnar), 23-valentPneumococca1 Polysaccharide. 2. For any allergic reaction to the above vaccines follow procedures below. Signs and of Aaphylactic Reaction Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips, face or throat); bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse. Treatment If itching and swelling are con?ned to the injection site where the vaccination was given, observe patient closely for the development of generalized If are generalized, activate the Emergency Medical System (EMS) call 911 and notify the on call physician (if available) This should be done by a second person, while the primary nurse assesses the air way, breathing, circulation, and level of consciousness of the patient. Administer aqueous epinephrine 1:1000 dilution subcutaneous or intramuscular. (See chart below) Monitor the patient closely until EMS arrives, perform cardiopulmonary resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine position (?at on back) unless he or she is having breathing dif?culty. If breathing is dif?cult, patient?s head may be elevated, provided blood pressure is adequate. Monitor blood pressure and pulse every 5 minutes. If EMS has not arrived and are still present, repeat dose of epinephrine every 10-20 min for up to 3 doses, depending on patient?s response. Using a referral form record all vital signs, medications administered to patient, including the time, dosage, response, and name of the medical personnel who administered the medication, and other relevant clinical information. Patient should be endorsed to EMS personnel once they arrive at the scene. Give white copy of the referral form to EMS Personnel. Tel. No; (6H) 735-?399 I 0 Fax: (oil) 734-59?) i. The medical personnel who assisted the patient should complete a Vaccine Adverse Reaction Event form (VARES), attach the yellow copy of the referral form and provide a copy to the Department of Public Health and Social Services Immunization Program for reporting. Dosage and Administration Epinephrine Dose Age Group Weight in 1 3:32:36 subcumucous/intramuscular 1-6 months 9-15 0.05mg (0.05m1) 7?18 months 15-24 0.1 mg (0.1 ml) 19-36 months 24-31 0.15 mg (0.15 ml) 37-48 months 31-37 0.15 mg (0.15 ml) 49-59 months 3142 0.2 mg (0.2 ml) 5-7 years old 42?51 0.2 mg (0.2 ml) 8-liLyears old 51-77 0.3 mg (0.3 ml) 11-12 years old 77-99 0.4 mg (0.4 ml) 13 years older 99+ 0.5 mg (0.5 ml) *Dosing by body weight is preferred Children The standard dose is 0.01 mg/kg body weight, up to 0.3 mg maximum single dose in children. AdolescentslAdults The dosage range ?'om 0.3 mL to 0.5 mL,with maximum single dose of 0.5 mL. Muff MM ROBERT LEON GUERRERO, MD. Guam Immunization Medical Advisor Mr ANNAKUTTY MATHEW, MD. Guam Public Health Medical Director Concurred by: .. ARTHUR AGUSTIN, MHR Acting 210260?? DA 0%05207} DA ?9 AT ANNEX I ?2 . VACCINE ADVERSE EVENT REPORTING SYSTEM 24 Hour Toll-tree information line 1-800-822-7967 VAERS Patient identity kept confidential are Patient Name: Vaccine administered by (Name): Form compieted by (Name): Lam Fm? M?l? Responsible Rotation to Cl Vaccine Provider PatienttParent Physician Patient 3 Manufacturer ?3 Other Address Facility Namei?Address Address (if different from patient or provider) City State Zip City State Zip City State Zip Teiephone no. i Telephone no. i Teiephone no. i 1. State 2. County where administered Date of birth Patient age 5. Sex 6. Date form compieted mm at yy bl mr'n dd yy Ill Describe adverse eventts) signs, time course) and treatment, it any Check. all appropriate: Patient died (date Lite threatening illness d? 2 Required emergency moanoctor visit Ci Required hospitalization days) Resulted in protongation of hospitalization i] Resulted in permanent disability El None of the above apatient recovered YES a No a UNKNOWN of vaccination EJMverse eventunset . a: 12. Relevant diagnostic data mm dd AM mm tie yy Time PM Time PM Enter all vaccines given on date listed in no. 10 No- Previous Vaccine (type) Manufacturer Lot number RoutetSite closes a. b. c. d. 14. Any other vaccinations within 4 weeks of date listed in no. 10 No. Previous Date Vaccine (type) Manufacturer Lot number RoutetSite doses given a. b. 15. Vaccinated at: Private doctor's officethospital 2 Public health ciinicr?hospital Military ciinicthospital 3 Othertunknown 16. Vaccine purchased with: 3 Private funds 3 Military funds 2 Public funds Other medications 3 Other tunltnown 13. illness at time of vaccination (specify) 19. Pro-existing physician-diagnosed allergies. birth defects. medical conditions {specify} 20. Have you reported 2 No 3 To health department OW term 5W this adverse event 22. Birth weight 23. No. of brothers and Sisters previously? I To doctor I To manufacturer lb. 02. 2t . Adverse event following prior vaccination {check an applicable. sparsity} Only Wm WM cranium-mm project ?Wise Onsai TYPE 9059 24. Mfr. imm. proj. repair no. 25. Date received by mtr. term. pm}. Event Age Vaccine in series - I In patient In brother 26. 3'5 day report? 27. Report type or sister I Yes I No 3 initial 2 Follow-Up Health care orovrders and manufacturers are recurred by law I42 USC {Jonas-25: to repon reactlons i0 tracer-BS In the Vaccine "1 us Table. Reports for reactions to other vaccines are voiontary except when required as a condition of Immunization grant awards. WW {Additional pages may be attached if more space is needed.) Use a separate form for each patient. Complete the form to the best of your abilities. Items are considered essential and should be completed whenever possible. Pmentstuardians may need to consult the facility where the vaccine was administered for some of the information (such as manufacturer. lot number or laboratory data.) Flefer to the Vaccine injury Table (WT) for events mandated for reporting bylaw. Reporting for other serious events felt to be related but not on the VIT is encouraged. Health care providers other than the vaccine administrator (VA) treating a patient for a suspected adverse event should notify the VA and provide the information about the adverse event to allow the VA to complete the form to meet the was legal responsibility. i These data will be used to increase understanding of adverse events following vaccination and will become part of CDC Privacy Act System 09-20-0136. ?Epidemiologic Studies and Surveillance of Disease Problems". Information identifying the person who i received the vaccine or that person's legal representative will not be made available to the public. but may be available to the vaccines i or legal representative. INSTRUCTIONS form Completed By: To be used by vaccine manufacturersrdistributors. vaccine administrators. andror the person completing the form on behalf of the patient or the health professional who administered the vaccine. tam 7: Describe the suspected adverse event. Such things as temperature. local and general signs and time course. duration of diagnosis, treatment and recovery should be noted. tern 9: Check if the patient's health condition is the same as it was prior to the vaccine. if the patient has not returned to the ore-vaccination state of health. or if the patient's condition is not known. :em to: Give dates and times as specifically as you can remember. If you do not know the exact time, please and 1 1 indicate or when possible if this information is known. If more than one adverse event, give the onset date and time for the most serious event. :em 12: include "negative" or ?normal? results of any relevant tests performed as well as abnormal findings. :em 13: List ONLY those vaccines given on the day listed in Item 10. :em 14: List ANY OTHER vaccines the patient received within four weeks of the date listed in Item 10. :em 16: This section refers to how the person who gave the vaccine purchased it. not to the patient's insurance. :em 17: List any prescription or non-prescription medications the Patient was taking when the vaccineis) was given. :em 18: List any short term illnesses the patient had on the date the vaccinels) was given cold. flu, ear infection). em 19: List any ore-existing physician?diagnosed allergies. birth defects. medical conditions {including developmental andmr neurologic disorders) the patient has. em 21: List any suspected adverse events the patient. orlhe patient's brothers or sisters, may have had to previous vaccinations. lfmore than one brother or sister. or ifthe patienthas reacted to more than one prior vaccine. use additional pagesto explain completely. For the onset age of a patient. provide the age in months if less than two years old. em 25: This space is for manufacturers use only. ANNEX I-3 Needle Stick Injuries Follow current DPHSS policy on referral of staff for medical evaluation that sustains a needle stick injury while administering the pandemic influenza vaccine. ANNEX J Post Vaccination Clinic Activities The clinic manager will: x Insure that all medical waste is disposed of properly. x Insure that all forms and documentation paperwork is collected, and vaccine accountability is forwarded to the DPHSS Immunization Program. The nurse-in-charge will: x Insure that all unused vaccine is placed into insulated containers with cool packs and returned to DPHSS Immunization Program. POTENTIAL PARTNERS FOR VACCINE ADMINISTRATION ONLY Group 1: A. School Health Counselors 1) Guam Public School System 2) Guam Community College 3) University of Guam B. Department of Mental Health and Substance Abuse Nursing Staff (RN and LPN) C. Military Personnel 1) Physicians 2) Nurses (RN and LPN) D. Physician Assistants E. Certified Midwives F. Emergency Medical Technician- Intermediate G. Guam Nurses Association (including retired nurses) H. UOG- College of Nursing and Health Sciences (CNHS) 1) Nursing Instructors 2) Senior Nursing Students I. Certified Medical Assistants Group 2: (If additional vaccinators are needed) A. Dentists B. Veterinarians C. Military Personnel 1) Corpsmen 2) Immunization Technicians 3) Allergy Technicians D. Laboratory Technicians E. Phlebotomist F. UOG-CNHS Junior Nursing Students G. Dental Hygienist H. GCC Medical Assistant Students- Second Year (successfully completed Pharmacology Course) Attachment 7-B CHAPTER 8 MEDICAL SURGE RESPONSE PLAN SECTION 1.0 INTRODUCTION existing healthcare facilities as well as home care entities. In the event of a pandemic influenza, tens of thousands of patients will likely overwhelm the resources of the community’s healthcare system. In this scenario, it will be necessary to allocate scarce medical resources in a manner that is different from usual circumstances, but appropriate to the situation. Making optimal decisions concerning allocation of scarce resources could make a big difference in the degree to which healthcare systems continue to function; ultimately it could mean saving many thousand of lives. SECTION 2.0 SURGE CAPACITY RESPONSE STRATEGIES One of the major challenges the hospital would face during a pandemic is surge capacity because of the fact that it is already full, or near capacity for emergencies, trauma cases, etc. The impact of a pandemic influenza of any significant magnitude will overwhelm and indeed may render the hospital and other healthcare facilities inoperable. This situation will necessitate the establishment of alternate care sites for the provision of care that normally would be provided in an in-patient facility, including acute, sub acute, and chronic care. As the number of people presenting for treatment increases, so will the number of patients requiring hospitalization, especially for those in high-risk groups. Strategies involve critical issues such as patient flow, bed capacity, overcrowding, the diversion of medical facilities (overflow sites/alternate care sites), transfer of equipment, contribution and replenishment of medical and pharmaceutical supplies, security, and medical waste disposal. GMHA and DPHSS in conjunction with private healthcare/home care facilities shall expand their capacity in anticipation of the increased demand for medical care during the pandemic as follows (Attachment A): ƒ DPHSS will: Activate the Health Emergency Assistance Line and Triage Hub (HEALTH) to ensure patients are directed to the appropriate triage/treatment sites (Phase 6). … Set-up NRCHC as External Triage Screening Site (Site outside NRCHC building) (Phase 6). … The overall goal of hospital and acute care response to a pandemic is to maximize care across the greatest number of people, while meeting at least minimal obligations for care to all who are in need. Advance planning is critical to the establishment and operation of alternate care sites; this planning must be coordinated with Set-up NRCHC as Outpatient Treatment Site (Site inside NRCHC building) (Phase 6). … … Set-up Mass Care Site (Phase 6). ƒ GMHA will: … Set up GMHA External Triage Screening Site (ER Parking Lot) (Phase 4 & 5). Activate GMHA Overflow Sites (Alternate Sites) (refer to GMHA Pandemic Flu Plan Appendix 49) (Phase 6). … Expedite hospital discharge to alleviate bed occupancy in accordance with GMHA’s “Patient Rapid Discharge Plan” (GMHA Pandemic Flu Plan Appendix 17) (Phase 5). … … Update JIC daily on surge capacity (Phase 6). Update JIC daily on personnel availability (Phase 6). … … GMHA will network with DPHSS Risk Communication Coordinator to ensure that the public is aware of the cancellation of non-emergency surgeries and elective procedures (Phase 6). GMHA BED CAPACITY UNIT/DEPARTMENT New Surgical (4th floor) Old Surgical (3rd floor) Medical Surgical Medical Telemetry PCU ICU/CCU Pediatrics PICU NICU Intermediate Newborn OB Skilled Nursing Facility TOTAL TOTAL BED CAPACITY 33 16 28 20 6 10 22 3 4 10 20 60 232 Guam Pandemic Influenza Plan 8-2 GMHA BED SURGE CAPACITY Resource Bed Capacity Acute Care (adult & 172 pediatrics ER Annex Inpatient Hemodialysis Rehab Treatment L&D Observation Skilled Nursing 60 * Renovate shell space behind ICU Daily Staffed Beds 80% occupancy rate Surge Bed 38 8 6 50% occupancy rate Existing Surge Additional Surge 4 3 30 89 40 TOTAL 129 *The shell space behind the ICU unit is currently under construction. GMHA AIRBORNE INFECTION ISOLATION CAPACITY Department Rooms Beds Emergency Room 1 1 Intensive Care Unit 1 1 OR Recovery 1 1 OB Nursery 2 2 Medical Surgical 4(2 with anterooms) 4 Medical Telemetry 1 1 Surgical 2 2 Pediatrics 1 1 Outpatient Hemodialysis 1 1 ER Annex 1 *8 Medical Telemetry 1 private, 5 semi *11 Pediatrics 1 private, 6 semi *13 Skilled Nursing 15 30 Pediatrics 8 private, 1 triple 11 ICU/CCU Shell Space 40 **40 * New Isolation Beds provided by Health Resource Services Administration Funds ** Isolation Rooms that are currently being constructed Guam Pandemic Influenza Plan 8-3 SECTION 2.1 GMHA THRESHOLD … Pros: • • • • • Once GMHA has met its 232 bed capacity and its 21 surge beds (not including the shell space behind ICU), GMHA will implement its Overflow Plan, whereby the JFK, Tamuning, and Saint Anthony Gymnasiums have been identified as “Overflow Sites (alternate care sites).” • Access control Easy mobilization Large facility Close proximity to GMHA Availability of cafeteria (cooking) facility Availability of generator and air conditioning units Areas identified as GMHA overflow sites are as follows (in order of priority for use): PROCEDURE: (Process for Activating Overflow Sites via OCD) ƒ JFK Gymnasium (ample square footage, availability of power, water, utilities, restroom facilities, generator power hookup, etc) ƒ … Pros: • Ease of visibility of all patients minimizes some of the safety issues and minimizes the burden on the shortage of healthcare providers • Close proximity to the hospital. • Parking space is abundant. • Mobilization can be controlled because of the gates. GMHA will: Contact the HEALTH when trigger/threshold has been met for overflow. … Will make endorsements to the HEALTH in coordination with the OCD regarding patients who need to be transported to the overflow site. OCD will make arrangements for the transport of patients to the overflow sites. … GMHA Overflow Site Manager will monitor the site capacity. … ƒ Tamuning Gymnasium … Pros: • Same as JFK except parking space is limited and control of access is more difficult because of the limited space external to the building ƒ Saint Anthony School Gymnasium (Upon completion of MOU) In the event that the GMHA Overflow Site resources are depleted and additional resources are needed at the Overflow Sites, the Overflow Care Site Manager shall contact both the GMHA Command Post and the HEALTH to make arrangements with EOC for the immediate transport of the needed resources to GMHA. … Implement the ESAR-VHP to identify, assign, and activate credentialed volunteers to assist in the medical capacity of GMHA overflow sites. The first draft of the policy and … Guam Pandemic Influenza Plan 8-4 procedures for deploying and tracking volunteer healthcare providers using the ESAR-VHP System requirements was developed in January 2007. GMHA and Health Professional Licensing Office (HPLO) staff are finalizing the ESARVHP System policies and procedures and upon its completion, it would be incorporated into the Plan. ƒ OHS/OCD will: Activate their personnel listing of registered volunteers to assist in the medical capacity of GMHA Overflow Sites. … Ensure continued supply of water and power and communication capabilities at the overflow sites. … implementation of the cohort plan. Cohort units will be opened in the following order: ƒ The first cohort unit will be the Pediatrics Department (4th floor B Wing). ƒ The second cohort unit will be the New Surgical Unit (4th floor A Wing). ƒ The third cohort unit will be Medical Surgical Unit (3rd floor A Wing). ƒ The fourth cohort unit will be the Old Surgical Unit (3rd floor A Wing). ƒ NOTE: GMHA Command Post will determine the threshold for preparation of the GMHA overflow site (see GMHA Pandemic Overflow Plan Appendix 40). The Nursing Supervisor on duty will coordinate transport of existing inpatients from the identified cohort unit to a non-influenza patient care area before transport of pandemic influenza patients to that unit. If rooms are unavailable, the Nursing Supervisor will work with GMHA Command Post to assist with implementation of the Patient Rapid Discharge Plan, GMHA Pandemic Plan Appendix 17. If staff is unavailable to assist with transporting patients, the Nursing Supervisor on duty will work with GMHA Command Post to identify additional assistance. … ƒ HEALTH will: In coordination with OCD will arrange for the mobilization of the following resources to GMHA overflow sites: … • Medical supplies and equipment (to include ventilators and oxygen supply). • Patient needs (such as cots, chairs, etc). • Food and beverages as needed for patients and staff. SECTION 2.2 GMHA COHORT PLAN • Infection Control practices for cohorting should be followed by all personnel (see GMHA Pandemic Infection Control Plan, Appendix 2). PROCEDURE: GMHA Command Post will identify the trigger points during the pandemic phases for determining Guam Pandemic Influenza Plan 8-5 The GMHA Command Post must be sought for assistance in identifying security needed for a patient who may … need to be isolated against his/her will. Implement Isolation/Quarantine Law as needed. SECTION 3.0 PANDEMIC INFLUENZA PHONE TRIAGE PROTOCOL All individuals calling the Outpatient Triage/Treatment Sites shall be assessed of the following Clinical and Epidemiological criteria: Clinical Criteria Ask the individual if they have any of the following symptoms: - Temperature> 100.4 F - Cough, - Sore throat, - Dyspnea or short of breath If the individual has any of the above symptoms, ask the following: Epidemiological Criteria Within the last 10 days of symptoms, did you have: • A history of recent (within the last 10 days) travel to an affected area? and have you had at least one of the following exposures: • Direct contact with poultry or poultry products? • Close contact with a person with suspected or confirmed Pandemic Flu? • Close contact with a person who died, or was hospitalized due to severe respiratory illness? • Are you working at a place where there is a particular risk for pandemic influenza? If yes to both criteria Initiate Standard and Droplet Precaution instruction to the individual. Advice individual to go to the Outpatient Triage Site for further screening. If the individual is experiencing shortness of breath and/or chest pain, have him/her seek immediate medical attention by calling 911. If no to any, reassess if suspicious If yes to clinical criteria and no to epidemiological criteria, Advise the individual to seek treatment at either the NRCHC or private health clinic outpatient triage/treatment sites. Guam Pandemic Influenza Plan 8-6 HEALTH EMERGENCY ASSISTANCE LINE AND TRIAGE HUB ƒ EOC shall ensure continued supply of water and power and communication capabilities at HEALTH. PROCEDURE: ƒ HEALTH shall be activated upon confirmation of epidemic H5N1 locally (Attachment B). ƒ HEALTH is located at the HPLO Legacy Square. It is manned by one nurse practitioner (head) and a nurse from DPHSS, four social workers, four community volunteers, and assisted by OCD for the coordination of transportation and security needs. ƒ Need eight to ten phones, two fax machines, five computers, three tables, and ten chairs would be set up at HEALTH. ƒ Nurses at HEALTH would be answering calls from patients who are inquiring whether or not they have flu-like illness. The nurses would screen calls in accordance with the “Pandemic Influenza Phone Triage Protocol”. ƒ Those in need of medical care/intervention will be directed to the respective healthcare facilities (i.e., NRCHC, SDA, TDC, PMC, Take Care, etc) for triaging and disposition as to home, home care, or GMHA for critical care. ƒ Patients who present themselves to HEALTH will be provided transportation to the respective triage/treatment site. Transportation will also be provided from patients’ home to the respective triage/treatment site for those in need by coordinating with the OCD. ƒ HEALTH staff would assess resources needed at the triage/treatment sites, GMHA, and its overflow sites. Once the patient to staff ratio thresholds have been exceeded for all of the aforementioned sites, HEALTH staff shall request for personnel, supplies, and equipment to the IC and such request shall be forwarded to the EOC. The EOC Director may request the EOC Administration and Finance Section to effectuate emergency procurement of personnel, supplies, and equipment through GSA. Additionally, the EOC Director shall assess and identify the availability of personnel, equipment, and supplies within the Government of Guam, the military, private health clinics, and community based and non-profit organizations. Moreover, EOC may request for the Governor of Guam to appeal to key stakeholders in the private sector to mobilize personnel, supplies, equipment, and other resources to assist in responding to island-wide emergency. These key stakeholders include: private pharmacies, insurance companies, diagnostic lab services, radiological services, private clinics, Marianas Gas Cooperation, and private home healthcare agencies. The EOC in coordination with HEALTH shall mobilize additional staff and other resources as needed. Private entities providing personnel and other resources may be compensated as delineated through the Governor of Guam’s Executive Order (the government would be prepared to enter into formal agreements with private entities to compensate personnel and reimbursement for services rendered during the pandemic influenza period). See Executive Order 2006-11. Guam Pandemic Influenza Plan 8-7 * MOA/MOU between the Government of Guam and the aforementioned key stakeholders to be in place so that Guam would be in the state of readiness (Attachment C). ƒ Once all local resources have been depleted, HEALTH staff in conjunction with the EOC shall inform the IC of the needed medical resources and equipment so that Governor of Guam can make an official request to CDC to mobilize the Strategic National Stockpile (SNS) for Guam. Upon the receipt of the stockpile, the DPHSS SNS Coordinator or his/her designee shall distribute the stockpile in accordance with the protocol for distribution. ƒ The Governor of Guam will also request for assistance from Disaster Medical Assistance Team (DMAT) when island resources have been depleted. ƒ Given the limited number of supplies and equipment, resources must be ethically distributed within the healthcare coalition. Physicians assign patients to the appropriate level of care (see matrix below). Levels of Care Status Level 1 Critical Care Level 2 Unstable Level 3 Serious Level 4 Stable Level 5 Stable Level 6 Stable Needs ICU respirator IV, Cardiac Medications, oxygen Regular Hospital Bed Skilled Nursing Home Health No Home Healthcare In all areas of care, there will be demands for resources that may be considered lifesustaining. At any given point, the demand may exceed the availability of the resources (e.g. ventilators, oxygen supply, etc). As such, there may be a point in time when there is only one critical resource that is being demanded by two or more physicians to sustain the life of their patients. In an event such as this, the following chain of demand shall be followed as specified in “GMHA’s Pandemic Plan for the Ethical Distribution of Scarce Resources” (Attachment D: of GMHA Pandemic Plan Appendix 15A). SECTION 4.0 NRCHC OUTPATIENT TREATMENT SITE TRIAGE AND The NRCHC under the auspices of the BPCS has been identified as one of the Outpatient Triage/Treatment Sites, which will remain open 12 hours per day and depending on the availability of staffing, it may operate 24 hours/seven days a week. ƒ Pros: Over 40% of the population resides at the Northern area of the island. … NRCHC has 16 examination rooms in addition to having an isolation room, and decontamination area. … Laboratory capabilities available on site. … NRCHC has a 230 KW generator in place in the event of power outages. … NRCHC has a large capacity for the storage of SNS. … Guam Pandemic Influenza Plan 8-8 Easy mobilization because of large parking space and facility’s compliance with ADA requirements. … NRCHC is within close proximity to GMHA for transport of patients. … PROCEDURE (Attachment E): ƒ BPCS will prepare and open the NRCHC Outpatient Triage/Treatment Site when Guam is in Phase 6. ƒ Triage screening will be provided in the parking lot outside the building and via telephone to determine who needs a medical evaluation. ƒ Patients who have been screened, yet do not need further medical evaluation will be sent home. However, those with flu like or non-flu-like illness who need further evaluation and/or medical intervention will be seen by the physician (Attachment F). ƒ The NRCHC site will have a designated area for patients with flu-like illness (i.e., NRCHC New Clinic Addition) and another area for those patients with non-flu-like illness (i.e., NRCHC Old Wing) as delineated in the “NRCHC Access Flow Chart” (Appendix E of the BPCS Pandemic Influenza Plan). ƒ Subsequent to the medical evaluation, patients needing medical intervention will be given appropriate instructions for treatment either self-care at home, or home healthcare services. ƒ Only patients requiring critical care will be referred from NRCHC to GMHA or GMHA’s overflow site (Attachment D). The NRCHC staff will endorse patients requiring hospital admission via Hospital Nursing Supervisor (647-2426/647-2555-57). ƒ The NRCHC Physician will prepare a written referral for hospitalization and endorse this document to the transport personnel, who in turn will deliver it to GMHA Receiving Personnel (Attachment G). ƒ Hospital Nursing Supervisor will identify the designated space for direct patient admission (space may be a direct admission to the hospital facility or the Overflow Site). ƒ NRCHC Clinic Manager will monitor site capacity. In the event that NRCHC has reached its patient to staff ratio threshold, the NRCHC Clinic Nurse Manager shall notify the BPCS Administrator (the CHC’s Pandemic Influenza Response Coordinator) or his/her designee who in turn shall contact the Emergency Assistance Line and Triage Hub. The Emergency Assistance Line and Triage Hub would coordinate with EOC to direct patients to other triage/treatment sites, which can accommodate additional people. ƒ In the event that NRCHC resources (i.e., supplies, equipment, etc.) are depleted and additional resources are needed, the NRCHC Clinic Manager shall notify the BPCS Administrator who in turn would contact HEALTH to request EOC to mobilize resources. ƒ EOC/OCD following: shall arrange for the Mobilization of the following resources to the NRCHC Outpatient Triage/ Treatment Site: … Guam Pandemic Influenza Plan 8-9 • Medical supplies and equipment (oxygen supply) as needed. • Appropriate physicians, etc) • staff ƒ ƒ ƒ 5 Medical Record Clerks 2 Security guard 2 Custodians (nurses, Maximum Triage Patient Threshold: 250 patients per 12 hr shift. Patient needs (chairs, etc) • Food, beverages, toiletries as needed for patients and staff. • Mobilization of the portable water tanks in the event of a water outage. Transportation of those in need to another triage/treatment site once NRCHC’s threshold has been met. … SECTION 4.1 STAFFING SURGE CAPACITY NRCHC MINIMUM PERSONNEL During a pandemic-influenza period, the NRCHC shall open 12 hours per day. However, depending on the availability of additional staff, the center may open 24 hours per day/seven days a week. The BPCS staff would be activated to work at the NRCHC Outpatient Triage/Treatment Care Site. The minimum number of personnel must be maintained at the NRCHC Outpatient Triage/Treatment Site in order to ensure continuity of staffing surge for patient care. NRCHC External Triage Site (Site is located at the parking lot of the NRCHC building) Staff needs per 12 Hr shift: ƒ 2 RNs ƒ 1 LPN ƒ 1 NA NRCHC External Triage Site Supply and Equipment Needs: ƒ Mobile desk and chairs ƒ Computer with Patient Registration Capabilities and access to AS400 ƒ Printer ƒ Copier Papers ƒ Pens ƒ Clipboards ƒ Influenza Screening Forms ƒ Thermometers ƒ Thermometer probes ƒ Alcohol pads ƒ Biohazard Containers ƒ Trash Cans ƒ Masks ƒ Ammonia ƒ Face Shields ƒ Gloves ƒ Gowns ƒ Tissues ƒ Hand Sanitizers ƒ Toilet Tissues ƒ Drapes ƒ Roll Sheets ƒ Paper Towels ƒ Paper cups ƒ Emesis Basin ƒ Gel lubricant for rectal thermometers ƒ Blood Pressure Cuffs ƒ Disposable Blood Pressure Cuff cover ƒ Pulse Oximeters ƒ Oxygen tanks (22 cubic ft). ƒ Stretcher ƒ Wheelchair ƒ Portable Toilets ƒ Portable Water Dispensers ƒ Fans Guam Pandemic Influenza Plan 8-10 ƒ ƒ Xerox Machine Communication link such as radio or cellular phone. Set-Up Two canopies will be set-up at the NRCHC External Triage Site (NRCHC parking lot) during an influenza pandemic. In the event that additional tents or other resources are needed, the BPCS Administrator shall notify the Incident Commander (DPHSS Director) so that coordination can be made with HEALTH and OCD in providing needed resources to the NRCHC External Triage Site. NRCHC Old Waiting Room Area (Area inside NRCHC building where Patients with Non-ILI are stationed): Staff Needs per 12 hour shift: ƒ 1 Physician ƒ 1.5 RNs ƒ 0.5 LPNs ƒ 3 Nurse Aides ƒ 3 Medical record clerks ƒ 2 Security guards ƒ 2 Custodians NRCHC Old Waiting Area Maximum Patient Threshold: 55 patients per 12 hr shift. Pharmacy and Lab Stations ƒ 1 Pharmacist ƒ 2 Pharmacy Technicians ƒ 1 Lab Technician NRCHC New Clinic Addition Waiting Room (Area inside NRCHC building where Patients with ILI will be stationed). Staff Need per 12Hour Shift: ƒ 1 Physician ƒ 2 RNs ƒ ƒ ƒ ƒ ƒ 1 LPNs 1 Nurse Aide 2 Medical record clerks 2 Security guards 2 Custodians NRCHC New Clinic Addition Maximum Patient Threshold: 45 patients per 12 hr shift. NRCHC Clinic Area (Area inside building) Supply and Equipment Needs: ƒ Influenza Screening Form ƒ Thermometer ƒ Tongue blades ƒ Tylenol ƒ Thermometer probes ƒ Alcohol hand rub ƒ Biohazard Container ƒ Trash Cans ƒ Masks ƒ Gloves ƒ Gowns ƒ Tissues ƒ Naso- Pharyngeal Swab ƒ drapes ƒ blankets ƒ Blood Pressure Cuffs ƒ Hand Sanitizers ƒ Toilet Tissues ƒ Paper Towels ƒ Gel lubricant for rectal thermometers ƒ Portable Water Dispensers ƒ Communication Link such as radio or cellular phone. Work-Practice: ƒ Staff assigned to this area should wear a mask and should follow standard precautions. ƒ Hand hygiene should be practiced regularly. Guam Pandemic Influenza Plan 8-11 ƒ Supplies used for obtaining patient information should be disinfected using an EPA approved disinfectant. ƒ Patients being referred or transported to GMHA should be using a mask. ƒ Implement Infection Control Measures (Attachment H). SECTION 4.2 20% STAFF REDUCTION During a pandemic, healthcare workers and other first responders may be at higher risk of exposure and illness than the general population, further straining the healthcare system. Thus, in the event of a 20% reduction of staff capacity, personnel required for NRCHC clinic operation is as follows: NRCHC Triage (Outside the building) STAFF NRCHC RNs 0 LPNs 2 NAs 1 Med Record Clerk 4 Guards 1 Custodians 1 GRAND TOTAL 9 12 Hr TOTAL 0 2 1 4 1 1 9 NRCHC Triage Maximum Patient Threshold: 75 patient’s per 12 hr shift Guam Pandemic Influenza Plan 8-12 NRCHC Old Wing (Site for Non-ILI) STAFF Old Wing Physicians 1 RNs 2 LPNs 0 NAs 1 Med Record Clerk 2 Security 1 Custodian 1 GRAND TOTAL 8 12 Hr 1 2 0 1 2 1 1 8 NRCHC Old Wing Maximum Patient Threshold: 50 patients per 12 hr shift NRCHC Pharmacy and Lab Stations STAFF Lab Technician 1 Pharmacist 0 Pharm Technician 0 GRAND TOTAL 1 1 0 0 1 NRCHC New Clinic Addition (Site for Influenza Like Illness) STAFF Physicians RNs LPNs NAs Med record Clerk Security Custodian GRAND TOTAL New Clinic 1.4 2.4 0 2 2 1 1 9.8 12 Hr 1.4 2.4 0 2 2 1 1 9.8 NRCHC New Clinic Addition Maximum Patient Threshold: 50 patients per 12 hr. shift In the event that the percentage of staff reduction goes higher than 20%, the BPCS Administrator (CHC’s Pandemic Influenza Response Coordinator) shall notify HEALTH regarding the staffing crisis and request for assistance from the Emergency Operations Center to mobilize personnel. Guam Pandemic Influenza Plan 8-13 SECTION 4.3 GMHA MINIMUM PERSONNEL Station 1: ER External Triage Site (This external site will be necessary until a barrier is set up in the internal ER Registration area (i.e. plexi-glass) Staff Needs: ƒ 1 Nurse ƒ 1 Registration clerk ƒ 1 Security guard Equipment and Supply Needs: ƒ Mobile desk and chairs ƒ Computer with Patient Registration Capabilities and access to AS400 ƒ Pens ƒ Clipboards ƒ Case Definition Screening Forms ƒ Thermometer ƒ Alcohol hand rub ƒ Communication link such as radio or cellular phone. ƒ Patients being admitted to the ER Annex should be referred or transported using a mask. ƒ See Infection Control Plan (Attachment H). ER Annex and Tent Station Staff Needs: ƒ 1 Physician ƒ 2 Nurses ƒ 1 Nurse aide ƒ 1Ward clerk ƒ 1 Designated laboratory technician ƒ 1 Designated respiratory technician ƒ 1 Designated radiology technician Equipment and Supply Needs: ƒ Computer and printer with AS400 access (Order Communication) ƒ Pharmaceuticals ƒ Crash cart with medications and supplies Work Practice: ƒ Staff assigned to this area should wear a mask and should follow standard precautions. ƒ Medical supplies ƒ Visitors should be restricted. Visitors accompanying the sick individual should be screened for avian/novel influenza. Their contact information should be obtained for reporting to DPHSS. Work Practice: ƒ Staff should initiate Droplet Precautions. ƒ Hand hygiene should be practiced regularly. ƒ Supplies used for obtaining patient information should be disinfected using an EPA approved disinfectant. ƒ Communication link such as telephone, radio, or cellular phone. Standard and ƒ Hand Hygiene should be practiced regularly. ƒ Avoid procedures that generate aerosols if possible (nebulized medications, intubation, bronchoscopy, ventilation using high-frequency oscillation). ƒ Visitors should be restricted. Guam Pandemic Influenza Plan 8-14 ƒ Avoid transportation as much as possible. Transporter is to follow standard and droplet precautions. If transportation is necessary, patient should be masked appropriately. ƒ See Infection Control Plan (Attachment H). Current Situation: Two canopies would be set-up at the external triage site. If additional resources are needed, GMHA Command Post will inform the Incident Command system. GMHA Staffing: ƒ GMHA shall be responsible for determination of the ideal minimum staffing for the numbers of patients with pandemic influenza (refer to GMHA’s Pandemic Plan Appendix 32-33). This is with consideration that the numbers of patients may vary depending on the community situation. ƒ EOC shall identify and allocate staff to the Overflow Sites. ƒ The Guam Pandemic Planning Task Force shall coordinate with the HPLO (Board of Medical Examiners, Board of Nursing Examiners, Board of Allied Health Professionals, etc) to implement a plan for “Relaxation of Licensing Standards”, which will allow non-licensed personnel with educational background to perform duties of a licensed personnel (e.g, a graduate nurse to perform duties of a registered nurse) to assist GMHA’s staffing needs. GMHA EQUIPMENT AND SUPPLY NEEDS ƒ ƒ ƒ PPE Medical supplies and equipment Respiratory supplies and equipment ƒ ƒ ƒ ƒ Oxygen Ventilators Antibiotics General Medications For the detailed listing of the breakdown of supplies and equipment, refer to GMHA’s Pandemic Plan Appendix 45. SECTION 5.0 POSTPANDEMIC PERIOD Surveillance Surveillance activities will continue for both DPHSS, BPCS and GMHA by gathering numbers and reports, which will be shared with the Territorial Epidemiologist in the form of: ƒ Total number of patients treated for influenza ƒ Total number of employees treated for influenza ƒ Total number of all mortality cases from influenza and/or complications of influenza ƒ Total number of admissions related to influenza and/or complications of influenza. Deactivation of HEALTH: Staff shall await instructions from the DPHSS Director to deactivate HEALTH (when Guam is clear of epidemic). HEALTH staff shall assess resources (i.e., personnel, supplies, equipment, and other inventory) to determine readiness of Outpatient Triage/Treatment Sites, GMHA, and its overflow sites to revert to normal operations. Guam Pandemic Influenza Plan 8-15 Clinical Guidelines: NRCHC will resume pre-pandemic clinical care. All Outpatient Triage/Treatment Sites (private health clinics) will resume prepandemic clinical care. Facility: NRCHC will resume primary healthcare, acute outpatient care, and preventive services in accordance with pre-pandemic practices. Private Health Clinics (SDA, TDC, Take Care, PMC, etc) will resume acute outpatient care, urgent care, and emergency care services in accordance with prepandemic practices. GMHA will resume in-patient care, urgent care, non-emergency surgeries, and other elective procedures in accordance with prepandemic practices. Capacity: NRCHC, private health clinics, and GMHA will resume pre-pandemic operations (i.e., staffing, clinical practices, survey and replenishment of supplies and equipment, etc.) Guam Pandemic Influenza Plan 8-16 CLINICAL GUIDELINES FLOW CHART FOR AVIAN INFLUENZA/NOVEL INFLUENZA WITHOUT LOCAL TRANSMISSION Initiate at Phase 4 through Phase 6 Clinical Criteria An illness with all of the following: - Temperature > 100.4 °F and - Cough, sore throat, or dyspnea, and - Requiring hospitalization, or not hospitalized with epidemiological link1 If no to any, treat as clinically indicated, but reevaluate if suspicious And Epidemiological Criteria The clinician should ask the patient about the following within 10 days of symptom onset - History of recent (within last 10 days) travel to an affected area2 and at least one of the following: • Direct contact with poultry or poultry products3, or • Close contact with a person with suspected or confirmed Pandemic Flu4, or • Close contact with a person who died or was hospitalized due to If yes to either criterion Novel influenza culture positive - Continue Standard and Droplet Precautions5 - Continue antivirals10 - Do not cohort with seasonal influenza patients - Treat complications, such Footnotes to Appendix as secondary bacterial 14: pneumonia, as indicated13 - Provide clinical updates to health department If no to both criteria, treat as clinically indicated, but reevaluate if suspicious - Initiate Standard and Droplet Precautions5 - Treat as clinically indicated6 - Notify DPHSS about the case7 - Initiate general work-up as clinically indicated8 - Collect and send specimens to DPHSS9 - Begin empiric antiviral treatment, if available10 - Help identify contacts, including healthcare workers11 All influenza testing negative12 - - - Continue infection control precautions, as clinically appropriate5 Treat complications, such as secondary bacterial pneumonia, as indicated13 Consider discontinuing antivirals, if Seasonal influenza culture positive - Continue Standard and Droplet Precautions5 - Continue antivirals for a minimum of 5 days10 - Treat complications, such as secondary bacterial pneumonia, as indicated13 appropriate10 Attachment 8-A-1 GMHA Pan Flu Plan DRAFT Revision #5, February 2007 Page 62 of 137 Footnotes to Appendix 14: 1. Further evaluation and diagnostic testing should also be considered for outpatients with strong epidemiological risk factors and mild or moderate illness. 2. Updated information on areas where novel influenza virus transmission is suspected or documented is available on the WHO website (http://www.who.int/csr/disease/avian_influenza/country/en/index.html). 3. For persons who live in or visit affected areas, close contact includes touching live poultry (well-appearing, sick or dead) or touching or consuming uncooked poultry products, including blood. For animal or market workers, it includes touching surfaces contaminated with bird feces. In recent years, most instances of human infection with a novel influenza A virus having pandemic potential, including influenza A (H5N1), are thought to have occurred through direct transmission from domestic poultry. A small number of cases are also thought to have occurred through limited person-to-person transmission or consumption of uncooked poultry products. Transmission of novel influenza viruses from other infected animal populations or by contact with fecal contaminated surfaces remains a possibility. These guidelines will be updated as needed if alternate sources of novel influenza viruses are suspected or confirmed. 4. Close contact includes direct physical contact, or approach within 3 feet of a person with suspected or confirmed novel influenza. 5. Standard and Droplet Precautions (see Infection Control Plan, See Appendix 2) 6. Hospitalization should be based on all clinical factors, including the potential for infectiousness and the ability to practice adequate infection control. If hospitalization is not clinically warranted, and treatment and infection control is feasible in the home, the patient may be managed as an outpatient. The patient and his or her household should be provided with Home Quarantine and Self-Help information, See Appendix 43. The patient and close contacts should be monitored for illness by local public health department staff. 7. Guidance on how to report suspected cases of novel influenza: See Reporting to DPHSS of Suspected / Actual Cases, See Appendix 16. 8. The general work-up should be guided by clinical indications. Depending on the clinical presentation and the patient¶s underlying health status, initial diagnostic testing might include: - Pulse oximetry - Chest radiograph - Complete blood count (CBC) with differential - Blood cultures - Sputum (in adults), tracheal aspirate, pleural effusion aspirate (if pleural effusion is present) Gram stain and culture - Antibiotic susceptibility testing (encouraged for all bacterial isolates) - Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or swabs for common viral respiratory pathogens, such as influenza A and B, adenovirus, parainfluenza viruses, and respiratory syncytial virus, particularly in children - In adults with radiographic evidence of pneumonia, Legionella and pneumococcal urinary antigen testing GMHA Pan Flu Plan DRAFT Revision #5, February 2007 Page 63 of 137 If clinicians have access to rapid and reliable testing (e.g., PCR) for M. pneumoniae and C. pneumoniae, adults and children <5 yrs. with radiographic pneumonia should be tested. - Comprehensive serum chemistry panel, if metabolic derangement or other end-organ involvement, such as liver or renal failure, is suspected. 9. Guidelines for novel influenza virus testing as per DPHSS / CDC. All of the following respiratory specimens should be collected for novel influenza A virus testing: nasopharyngeal swab; nasal swab, wash, or aspirate; throat swab; and tracheal aspirate (for intubated patients), stored at 4° C (39°F) in viral transport media; and acute and convalescent serum samples. See WHO Guidelines for the Collection of Human Specimens for Laboratory Diagnosis of Avian Influenza Infections, See Appendix 7. 10. Strategies for the use of antiviral drugs are provided in the Antiviral Agents Plan. 11. Guidelines for the management of employee exposures are provided in the Employee Health Plan. 12. Given the unknown sensitivity of tests for novel influenza viruses, interpretation of negative results should be tailored to the individual patient in consultation with the state health department. Novel influenza directed management might need to be continued, depending on the strength of clinical and epidemiological suspicion. Antiviral therapy and isolation precautions for novel influenza may be discontinued on the basis of an alternative diagnosis. The following criteria may be considered for this evaluation: ‡ Absence of strong epidemiological link to known cases of novel influenza ‡ Alternative diagnosis confirmed using a test with a high positive-predictive value ‡ Clinical manifestations explained by the alternative diagnosis - Further evaluation and diagnostic testing should also be considered for outpatients with strong epidemiological risk factors and mild or moderate illness. Updated information on areas where novel influenza virus transmission is suspected or documented is available on the WHO website: http://www.who.int/csr/disease/avian_influenza/country/en/index.html For persons who live in or visit affected areas, close contact includes touching live poultry (wellappearing, sick or dead) or touching or consuming uncooked poultry products, including blood. For animal or market workers, it includes touching surfaces contaminated with bird feces. In recent years, most instances of human infection with a novel influenza A virus having pandemic potential, including influenza A (H5N1), are thought to have occurred through direct transmission from domestic poultry. A small number of cases are also thought to have occurred through limited person-to-person transmission or consumption of uncooked poultry products. Transmission of novel influenza viruses from other infected animal populations or by contact with fecal contaminated surfaces remains a possibility. These guidelines will be updated as needed if alternate sources of novel influenza viruses are suspected or confirmed. Close contact includes direct physical contact, or approach within 3 feet of a person with suspected or confirmed novel influenza. Standard and Droplet Precautions (see Infection Control Plan, Appendix 2) Hospitalization should be based on all clinical factors, including the potential for infectiousness and the ability to practice adequate infection control. If hospitalization is not clinically warranted, and treatment and infection control is feasible in the home, the patient may be managed as an outpatient. The patient and his or her household should be provided with Home Quarantine and Self-Help information, (See GMHA Pandemic Plan Appendix 43). The patient and close contacts should be monitored for illness by local public health department staff. Guidance on how to report suspected cases of novel influenza: (See Reporting to DPHSS of Suspected / Actual Cases, GMHA Pandemic Plan Appendix 16). The general work-up should be guided by clinical indications. Depending on the clinical presentation and the patient’s underlying health status, initial diagnostic testing might include: ƒ ƒ ƒ ƒ ƒ ƒ Pulse oximetry Chest radiograph Complete blood count (CBC) with differential Blood cultures Sputum (in adults), tracheal aspirate, pleural effusion aspirate (if pleural effusion is present) Gram stain and culture Antibiotic susceptibility testing (encouraged for all bacterial isolates) Attachment 8-A-2 ƒ Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or swabs for common viral respiratory pathogens, such as influenza A and B, adenovirus, parainfluenza viruses, and respiratory syncytial virus, particularly in children In adults with radiographic evidence of pneumonia, Legionella and pneumococcal urinary antigen testing If clinicians have access to rapid and reliable testing (e.g., PCR) for M. pneumoniae and C. pneumoniae, adults and children <5 yrs. with radiographic pneumonia should be tested. Comprehensive serum chemistry panel, if metabolic derangement or other end-organ involvement, such as liver or renal failure, is suspected. Guidelines for novel influenza virus testing as per DPHSS/CDC All of the following respiratory specimens should be collected for novel influenza A virus testing: nasopharyngeal swab; nasal swab, wash, or aspirate; throat swab; and tracheal aspirate (for intubated patients), stored at 4° C (39°F) in viral transport media; and acute and convalescent serum samples. (See WHO Guidelines for the Collection of Human Specimens for Laboratory Diagnosis of Avian Influenza Infections, and GMHA Pandemic Plan Appendix 7). Strategies for the use of antiviral drugs are provided in the Antiviral Agents Plan. Guidelines for the management of employee exposures are provided in the Employee Health Plan. Given the unknown sensitivity of tests for novel influenza viruses, interpretation of negative results should be tailored to the individual patient in consultation with the Guam Department of Public Health & Social Services. Novel influenza directed management might need to be continued, depending on the strength of clinical and epidemiological suspicion. Antiviral therapy and isolation precautions for novel influenza may be discontinued on the basis of an alternative diagnosis. The following criteria may be considered for this evaluation: • Absence of strong epidemiological link to known cases of novel influenza • Alternative diagnosis confirmed using a test with a high positive-predictive value • Clinical manifestations explained by the alternative diagnosis Attachment 8-A-3 HEALTH EMERGENCY ASSISTANCE LINE AND TRIAGE HUB (HEALTH) The Health Emergency Assistance Line and Triage Hub (HEALTH) is located at the Health Professional Licensing Office (HPLO) Legacy Square and manned by the Department of Public Health and Social Services. This area will be an initial point of phone contact for any person seeking medical advice and care. All calls will be directed to the phone hotline, coordinated by the nurses of the Bureau of Family Health and Nursing Services, social workers, and community volunteers. Those in need of medical care/intervention will be directed to the respective health care facilities (i.e., NRCHC, SDA, TDC, PMC, Take Care, etc) for triaging. Those in need of critical care will be referred to GMHA. Home Quarantine and Self Help PMC 75 Patients (25 patients from Triage) NRCHC 350 patients (250 from Triage) Take Care 200 (100 from Triage) SDA 150 (50 patients (from Triage) TDC 75 (25 Patients from Triage) GMHA THOSE NEEDING CRITICAL CARE Attachment 8-B The following is a list of recommended Memoranda of Agreement or Understanding needed to ensure that medical surge emergency response roles and responsibilities are clearly defined among the various partners. ƒ GMHA: Memorandum to refer critically ill patients to GMH and patients with acute care to GMH Overflow Site(s). ƒ Private Health Clinics: Memorandum for patient cross referrals & for the provision of personnel, supplies, equipment, and other resources. ƒ DMHSA: Memorandum for the provision of Mental Health and counseling services (grievance for the loss of loved one(s). ƒ Home Health Care Agencies: Memorandum for the provision of home health services. ƒ Private Pharmacies: Memorandum to provide medications. ƒ Laboratory Services: Memorandum for the provision of laboratory screening/testing services. ƒ Radiological Services: Memorandum for radiological services (X-ray, MRI, etc). ƒ Marianas Gas Corporation: Memorandum for the procurement of Oxygen. ƒ Insurance Companies: Memorandum for reimbursement of medical and ancillary services. Attachment 8-C APPENDIX 15 A: GMHA ETHICAL DISTRIBUTION (SCARCE RESOURCES) In all areas of care there will be demands for resources that may be considered lifesustaining. At any given point the demand may exceed the availability of the resource (for example ventilators, oxygen supply). As such, there may be a point in time when there is only one critical resource that is being demanded by two or more physicians to sustain the life of their patients. In an event such as this, the following chain of command shall be followed. Level 1: Critical Care Patients To include: ICU/CCU, PCU, NICU, PICU Level 2: Unstable Monitored Patients To include: Telemetry, Medical, M/S Level 3: Regular/Routine Patients Vital Life-Sustaining Resource demanded by two or more clinicians GMHA Command Post is notified of the need for the scarce resource Vital Resource available outside of the hospital? YES GMHA Command Post will make arrangements with EOC / OCD for immediate transport of the resource to GMHA NO Unit Director in consultation with the Medical Director is informed of the Demands and makes the final decision. Attachment 8-D NRCHC ACCESS FLOW CHART (CHC PATIENT) *Northern Region Community Health Center Outpatient Triage/Treatment Site NRCHC External Triage screening (2) RNs, (1) LPN, (1) NA, *(5) Medical Record Clerks, (2) Security Guards, (2) Custodians *Medical Record Clerks are cross-trained for triaging purposes Clinical Criteria Met? YES Meet Epidemiology Criteria NO NO Send patients home with Self-Care Instructions YES If yes to either Clinical or Epidemiology Criterion NRCHC New Clinic Addition Waiting Room Area (Area for patients with Influenza Like Illness Patient Evaluated by CHC Physician NRCHC Old Clinic Waiting Room (Area for Patients with NonInfluenza Like-Illness) Patient Evaluated by CHC Physician Refer to GMHA Refer to GMHA YES OCD Transport Patient to GMHA or Cohort Unit NO D/C Home Mass Care Site YES OCD Transport Patient to GMHA or Cohort Unit NO Mass Care Site D/C Home Attachment 8-E CLINICAL GUIDELINES FLOW CHART FOR AVIAN INFLUENZA/NOVEL INFLUENZA WITH LOCAL TRANSMISSION Initiate at Phase 6 Illness with both of the following: - Temperature >100.4 ° F, and - Cough, sore throat or dyspnea No Yes - No If no to either, treat as clinically indicated, reevaluate if suspicious1 Initiate Standard and Droplet precautions2 Test for pandemic influenza virus in a subset of Requires hospitalization?4 Yes Admit to cohort or single room5 Initiate work-up as clinically indicated6 - Treat complications, such as secondary bacterial pneumonia, as clinically indicated7 - Follow current antiviral treatment strategies8 - Notify Guam Department of Public Health & Social Services9 - No - Give instructions to return if worsens Give instructions for home isolation and care10 Arrange home health care or other follow-up (if needed) Follow current antiviral treatment strategies8 Provide other supportive therapy as needed Attachment 8-F-1 Clinical Guidelines Flow Chart for Avian Influenza/Novel Influenza with Local Transmission 1. Antiviral therapy and isolation precautions for pandemic influenza should be discontinued on the basis of an alternative diagnosis only when both the following criteria are met: a. Alternative diagnosis confirmed using a test with a high positive-predictive value, AND b. Clinical manifestations entirely explained by the alternative diagnosis 2. Standard and Droplet Precautions (See Infection Control Plan, Attachment A). 3. Update plans and guidance from the DPHSS on laboratory testing during the Pandemic Period. Generally, specimens should include respiratory samples (e.g., nasopharyngeal wash/aspirate; nasopharyngeal, nasal or oropharyngeal swabs, or tracheal aspirates) stored at 4°C in viral transport media. (See WHO Guidelines for the Collection of Human Specimens for Laboratory Diagnosis of Avian Influenza Infections, GMHA Pandemic Plan Appendix 7). Routine laboratory confirmation of clinical diagnoses will be unnecessary as pandemic activity becomes widespread in the community. CDC will continue to work with the DPHSS laboratory to conduct virologic surveillance to monitor antigenic changes and antiviral resistance in the pandemic virus strains throughout the Pandemic Period. The decision to hospitalize should be based on a clinical assessment of the patient and the availability of hospital beds and personnel. Guidelines on cohorting can be found in the Infection Control Plan and Surge Capacity Plan. Laboratory confirmation of influenza infection is recommended, when possible, before cohorting patients. The general work-up should be guided by clinical indications. Depending on the clinical presentation and the patient’s underlying health status, initial diagnostic testing might include: ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ Pulse oximetry Chest radiograph Complete blood count (CBC) with differential Blood cultures Sputum (in adults) or tracheal aspirate Gram stain and culture Antibiotic susceptibility testing (encouraged for all bacterial isolates) Multivalent immunofluorescent antibody testing of nasopharyngeal aspirates or swabs for common viral respiratory pathogens, such as influenza A and B, adenovirus, parainfluenza viruses, and respiratory syncytial virus, particularly in children. In adults with radiographic evidence of pneumonia, Legionella and pneumococcal urinary antigen testing. If clinicians have access to rapid and reliable testing (e.g., PCR) for M. pneumoniae and C. pneumoniae, adults and children <5 yrs. with radiographic pneumonia should be tested. Attachment 8-F-2 ƒ Comprehensive serum chemistry panel, if metabolic derangement or other end-organ involvement, such as liver or renal failure, is suspected. Strategies for the use of antiviral drugs are provided in GMHA Pandemic Antiviral Agents Plan. Guidance on the reporting of pandemic influenza cases is provided in (See Reporting to DPHSS of Suspected /Actual Cases, GMHA Pandemic Plan Appendix 16). Patients with mild disease should be provided with standardized instructions on home management of fever and dehydration, pain relief, and recognition of deterioration in status. Patients should also receive information on infection control measures to follow at home. (See Home Quarantine and Self-Help Information, GMHA Pandemic Plan Appendix 43). Patients cared for at home should be separated from other household members as much as possible. All household members should carefully follow recommendations for hand hygiene, and tissues used by the ill patient should be placed in a bag and disposed of with other household waste. Infection within the household may be minimized if a primary caregiver is designated; ideally, someone who does not have an underlying condition that places them at increased risk of severe influenza disease. Although no studies have assessed the use of masks at home to decrease the spread of infection, using a surgical or procedure mask by the patient or caregiver during interactions may be beneficial. Separation of eating utensils for use by a patient with influenza is not necessary, as long as they are washed with warm water and soap. Attachment 8-F-3 GMHA FACILITY ACCESS FLOW CHART External triage screening (1) Clerk (1) Security Guard (1) Nurse Clinical Criteria Met ? YES NO Meet Epidemiology Criteria NO ER Department Routine ER Staff YES Admit to Hospital Note: If ER Annex is full, patients will be placed in Tent Station for ER Annex Overflow YES ER Annex and Tent Station (2) Nurses, (1) Nurse Aid, (1) Ward Clerk, (1) Physician, (1) Security Guard (1) designated laboratory technician (1) designated Respiratory technician (1) designated Radiology Technician Non InfluenzaLike Illness Unit NO D/C Home Admit to Hospital YES Private Room, Cohort Unit, or ICU NO D/C Home **Pandemic Flu Task Force will identify Outpatient Triage/Treatment sites for patients to seek non-critical care. Only patients requiring critical care will be referred from these sites to GMHA or GMHA’s overflow facility. The processes for referral of these patients shall include adequate endorsement. Attachment 8-G INFECTION CONTROL PLAN PURPOSE: The purpose of this plan is to provide guidance to health care and public health partners on basic principles of infection control for limiting the spread of pandemic influenza. OVERVIEW: Infection control principles apply in any setting where persons with pandemic influenza might seek and receive health care services (e.g. hospitals, emergency departments, out-patient facilities, residential care facilities, home). Recommendations for Infection Control are generally applicable throughout the different pandemic phases. In some cases, recommendations may be modified as the situation progresses from limited cases to widespread community illness. Outbreaks of influenza can be prevented or controlled through a set of well established strategies that include: ƒ Early detection of influenza cases in clinical facilities. ƒ Implementation of mandatory pandemic containment procedures in all clinical health care settings. Use of appropriate barrier precautions during patient care, as recommended for Standard and Droplet Precautions (See Box 1). … … Isolation of infectious patients in private rooms or cohort units. Administrative measures, such as restricting visitors, educating patients and staff, and cohorting healthcare workers assigned to an outbreak unit. … ƒ Implementation of prophylactic measures. Provide clinicians and staff who may be exposed to patients with pandemic flu within the clinical setting with antivirals in accordance with Guam’s Antiviral Distribution Plan. … Use antivirals to treat ill persons and, if recommended, as prophylaxis in accordance with Guam’s Antiviral Distribution Plan. … Immunize providers and staff in accordance with Guam’s Vaccination Delivery Plan. … … Vaccinate patients in accordance with Guam’s Vaccination Delivery Plan. The primary infection control measures recommended in this plan will be updated, as necessary, based on the observed characteristics of the pandemic influenza virus. Attachment 8-H-1 BASIC INFECTION CONTROL ƒ Basic infection control principles for preventing the spread of pandemic influenza in the health care settings are as follows: … Limit contact between infected and non-infected persons (*2) Isolate infected persons (i.e., confine patients to a defined area as appropriate for the healthcare setting). … Limit contact between nonessential personnel and other persons (e.g., social visitors) and patients who are ill with pandemic influenza. … Promote spatial separation in common areas (i.e., sit or stand as far away as possible—at least 3 feet—from potentially infectious persons) to limit contact between symptomatic and non-symptomatic persons. … Protect persons caring for influenza patients in healthcare settings from contact with the pandemic influenza virus. … … Persons who must be in contact should: Wear a surgical or procedure mask (*3) for close contact with infectious patients. • Use contact and airborne precautions, including the use of N95 respirators, when appropriate. • … • Wear gloves (gown if necessary) for contact with respiratory secretions. • Perform hand hygiene after contact with infectious patients. Contain infectious respiratory secretions: Instruct persons who have “flu-like” symptoms (see below) to practice respiratory hygiene/cough etiquette (See Box 2). Post Visual Alert signs as reminders of Respiratory Hygiene/Cough Etiquette. • Promote use of masks (*4) by symptomatic persons in common areas (e.g., waiting rooms in physician offices or emergency departments) or when being transported (e.g., in emergency vehicles). • … During the early stages of a pandemic, laboratory-confirmation of influenza infection is recommended when possible. Attachment 8-H-2 Surgical masks come in two basic types: one type is affixed to the head with two ties, conforms to the face with the aid of a flexible adjustment for the nose bridge, and may be flat/pleated or duck-billed in shape; the second type of surgical mask is premolded, adheres to the head with a single elastic and has a flexible adjustment for the nose bridge. Procedure masks are flat/pleated and affix to the head with ear loops. All masks have some degree of fluid resistance but those approved as surgical masks must meet specified standards for protection from penetration of blood and body fluids. … Coughing persons may wear either a surgical or procedure mask. However, only procedure masks come in both adult and pediatric sizes. … ƒ Symptoms of influenza include fever, headache, myalgia, prostration, coryza, sore throat, and cough. Otitis Media, nausea, and vomiting are also commonly reported among children. Typical influenza (or “flu-like”) symptoms, such as fever, may not always be present in elderly patients, young children, patients in long-term care facilities, or persons with underlying chronic illnesses. ƒ Management of infectious patients … Respiratory hygiene/cough etiquette Respiratory hygiene/cough etiquette has been promoted as a strategy to contain respiratory viruses at the source and to limit their spread in areas where infectious patients might be awaiting medical care (e.g., emergency department). The impact of covering sneezes and coughs and/or placing a mask on a coughing patient on the containment of respiratory secretions or on the transmission of respiratory infections has not been systematically studied. In theory, however, any measure that limits the dispersal of respiratory droplets should reduce the opportunity for transmission. Masking may be difficult in some settings, e.g., pediatrics, in which case the emphasis will be on cough hygiene. … The elements of respiratory hygiene/cough etiquette include: Education of healthcare facility staff, patients, and visitors on the importance of containing respiratory secretions to help prevent the transmission of influenza and other respiratory viruses; • Post signs in languages appropriate to the populations served with instructions to patients and accompanying family members or friends to immediately report symptoms of a respiratory infection as directed; • Source control measures (e.g., covering the mouth/nose with a tissue when coughing and disposing of used tissues; using masks on the coughing person when they can be tolerated and are appropriate); • Attachment 8-H-3 • Hand hygiene after contact with respiratory secretions; and Spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. • ƒ Droplet precautions and placement Patients with known or suspected pandemic influenza should be placed on droplet precautions for a minimum of 5 days from the onset of symptoms. Because immunocompromised patients may shed virus for longer periods, they may be placed on droplet precautions for the duration of their illness. Healthcare personnel should wear appropriate PPE. If the pandemic virus is associated with diarrhea, contact precautions (i.e., gowns and gloves for all patient contact) should be added. ƒ Infection control practices for healthcare personnel Infection control practices for pandemic influenza are the same as for other human influenza viruses and primarily involve the application of standard and droplet precautions during patient care. During a pandemic, conditions that could affect infection control may include shortages of antiviral drugs, decreased efficacy of the vaccine, increased virulence of the influenza strain, shortages of single-patient rooms, and shortages of personal protective equipments. These issues may necessitate changes in the standard recommended infection control practices for influenza. CDC will provide updated infection control guidance as circumstances dictate. ƒ Personal protective equipment PPE for standard and droplet precautions PPE is used to prevent direct contact with the pandemic influenza virus. PPE that may be used to provide care includes surgical or procedure masks, as recommended for droplet precautions, and gloves and gowns, as recommended for standard precautions (See Box 1). Additional precautions may be indicated during the performance of aerosol-generating procedures (see below). Information on the selection and use of PPE is provided at www.cdc.gov/ncidod/hip/isolat/isolat.htm/. … Masks (surgical or procedure) Wear a mask when entering a patient’s room. A mask should be worn once and then discarded. If pandemic influenza patients are cohorted in a common area or in several rooms on a nursing unit, and multiple patients must be visited over a short time, it may be practical to wear one mask for the duration of the activity; however, other PPE (e.g., gloves, gown) must be removed between patients and hand hygiene performed. • • Change masks when they become moist. Attachment 8-H-4 … • Do not leave masks dangling around the neck. • Upon touching or discarding a used mask, perform hand hygiene. Gloves A single pair of patient care gloves should be worn for contact with blood and body fluids, including during hand contact with respiratory secretions (e.g., providing oral care, handling soiled tissues). Gloves made of latex, vinyl, nitrile, or other synthetic materials are appropriate for this purpose; if possible, latex-free gloves should be available for healthcare workers who have latex allergy. • • Gloves should fit comfortably on the wearer’s hands. Remove and dispose of gloves after use on a patient; do not wash gloves for subsequent reuse. • • Perform hand hygiene after glove removal. If gloves are in short supply (i.e., the demand during a pandemic could exceed the supply), priorities for glove use might need to be established. In this circumstance, reserve gloves for situations where there is a likelihood of extensive patient or environmental contact with blood or body fluids, including during suctioning. • Use other barriers (e.g., disposable paper towels, paper napkins) when there is only limited contact with a patient’s respiratory secretions (e.g., to handle used tissues). Hand hygiene should be strongly reinforced in this situation. • … Gowns Wear an isolation gown, if soiling of personal clothes or uniform with a patient’s blood or body fluids, including respiratory secretions, is anticipated. Most patient interactions do not necessitate the use of gowns. However, procedures such as intubation and activities that involve holding the patient close (e.g., in pediatric settings) are examples of when a gown may be needed when caring for pandemic influenza patients. • A disposable gown made of synthetic fiber or a washable cloth gown may be used. • Ensure that gowns are of the appropriate size to fully cover the area to be protected. • Attachment 8-H-5 Gowns should be worn only once and then placed in a waste or laundry receptacle, as appropriate, and hand hygiene performed. • If gowns are in short supply (i.e., the demand during a pandemic could exceed the supply) priorities for their use may need to be established. In this circumstance, reinforcing the situations in which they are needed can reduce the volume used. Alternatively, other coverings (e.g., patient gowns) could be used. It is doubtful that disposable aprons would provide the desired protection in the circumstances where gowns are needed to prevent contact with influenza virus, and therefore should be avoided. There are no data upon which to base a recommendation for reusing an isolation gown on the same patient. To avoid possible contamination, it is prudent to limit this practice. • … Goggles or face shield In general, wearing goggles or a face shield for routine contact with patients with pandemic influenza is not necessary. If sprays or splatter of infectious material is likely, goggles or a face shield should be worn as recommended for standard precautions. Additional information related to the use of eye protection for infection control can be found at http://www.cdc.gov/niosh/topics/eye/eye-infectious.html. PPE for special circumstances … PPE for aerosol-generating procedures During procedures that may generate increased small-particle aerosols of respiratory secretions (e.g., endotracheal intubation, nebulizer treatment, bronchoscopy, suctioning), healthcare personnel should wear gloves, gown, face/eye protection, and a N95 respirator or other appropriate particulate respirator. Respirators should be used within the context of a respiratory protection program that includes fit-testing, medical clearance, and training. If possible, and when practical, use of an airborne isolation room may be considered when conducting aerosol-generating procedures. … PPE for managing pandemic influenza with increased transmissibility The addition of airborne precautions, including respiratory protection (an N95 filtering face piece respirator or other appropriate particulate respirator), may be considered for strains of influenza exhibiting increased transmissibility, during initial stages of an outbreak of an emerging or novel strain of influenza, and as determined by other factors such as vaccination/immune status of personnel and availability of antivirals. As the epidemiologic characteristics of the pandemic virus are more clearly defined, CDC will provide updated infection control guidance, as needed. Attachment 8-H-6 … Precautions for early stages of a pandemic Early in a pandemic, it may not be clear that a patient with severe respiratory illness has pandemic influenza. Therefore precautions consistent with all possible etiologies, including a newly emerging infectious agent, should be implemented. This may involve the combined use of airborne and contact precautions, in addition to standard precautions, until a diagnosis is established. ƒ Caring for patients with pandemic influenza … Healthcare personnel should be particularly vigilant to avoid: Touching their eyes, nose or mouth with contaminated hands (gloved or ungloved). Careful placement of PPE before patient contact will help avoid the need to make PPE adjustments and risk self-contamination during use. Careful removal of PPE is also important. (See also: http://www.cdc.gov/ncidod/hip/ppe/default.htm.) • Contaminating environmental surfaces that are not directly related to patient care. (e.g., door knobs, light switches). • ƒ Hand Hygiene: Hand hygiene has frequently been cited as the single most important practice to reduce the transmission of infectious agents in healthcare settings (see http://www.cdc.gov/handhygiene/pressrelease.htm) and is an essential element of standard precautions. The term “hand hygiene” includes both hand washing with either plain or antimicrobial soap and water and use of alcohol-based products (gels, rinses, foams) containing an emollient that do not require the use of water. … If hands are visibly soiled or contaminated with respiratory secretions, wash hands with soap (either non-antimicrobial or antimicrobial) and water. … In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of the skin, and convenience. … Always perform hand hygiene between patient contacts and after removing PPE. … Ensure that resources to facilitate hand washing (i.e., sinks with warm and cold running water, plain or antimicrobial soap, disposable paper towels) and hand disinfection (i.e., alcohol-based products) are readily accessible in areas in which patient care is provided. For additional guidance on hand hygiene See http://www.cdc.gov/handhygiene/. Attachment 8-H-7 ƒ Disposal of solid waste Standard precautions are recommended for disposal of solid waste (medical and nonmedical) that might be contaminated with a pandemic influenza virus: ƒ … Contain and dispose of contaminated medical waste in accordance with facilityspecific procedures and/or local or state regulations for handling and disposal of medical waste, including used needles and other sharps, and non-medical waste. … Discard as routine waste used patient-care supplies that are not likely to be contaminated (e.g., paper wrappers). … Wear disposable gloves when handling waste. Perform hand hygiene after removal of gloves. Linen and laundry Standard precautions are recommended for linen and laundry that might be contaminated with respiratory secretions from patients with pandemic influenza: ƒ … Place soiled linen directly into a laundry bag in the patient’s room. Contain linen in a manner that prevents the linen bag from opening or bursting during transport and while in the soiled linen holding area. … Wear gloves and gown when directly handling soiled linen and laundry (e.g., bedding, towels, personal clothing) as per standard precautions. Do not shake or otherwise handle soiled linen and laundry in a manner that might create an opportunity for disease transmission or contamination of the environment. … Wear gloves for transporting bagged linen and laundry. … Perform hand hygiene after removing gloves that have been in contact with soiled linen and laundry. … Wash and dry linen according to routine standards and procedures (www.cdc.gov/ncidod/hip/enviro/guide.htm). Dishes and eating utensils Standard precautions are recommended for handling dishes and eating utensils used by a patient with known or possible pandemic influenza: … Wash reusable dishes and utensils in a dishwasher with recommended water temperature (www.cdc.gov/ncidod/hip/enviro/guide.htm). Attachment 8-H-8 ƒ … Disposable dishes and utensils (e.g., used in an alternative care site set-up for large numbers of patients) should be discarded with other general waste. … Wear gloves when handling patient trays, dishes, and utensils. Patient-care equipment Follow standard practices for handling and reprocessing used patient-care equipment, including medical devices: … Wear gloves when handling and transporting used patient-care equipment. … Wipe heavily soiled equipment with an EPA-approved hospital disinfectant before removing it from the patient’s room. Follow current recommendations for cleaning and disinfection or sterilization of reusable patient-care equipment. Wipe external surfaces of portable equipment for performing x-rays and other procedures in the patient’s room with an EPA-approved hospital disinfectant upon removal from the patient’s room. … ƒ Environmental cleaning and disinfection Cleaning and disinfection of environmental surfaces are important components of routine infection control in healthcare facilities. Environmental cleaning and disinfection for pandemic influenza follow the same general principles used in healthcare settings. … Cleaning and disinfection of patient-occupied rooms (See: www.cdc.gov/ncidod/hip/enviro/Enviro_guide_03.pdf) Wear gloves in accordance with facility policies for environmental cleaning and wear a surgical or procedure mask in accordance with droplet precautions. Gowns are not necessary for routine cleaning of an influenza patient’s room. • Keep areas around the patient free of unnecessary supplies and equipment to facilitate daily cleaning. • Use any EPA-registered hospital detergent-disinfectant. Follow manufacturer’s recommendations for use-dilution (i.e., concentration), contact time, and care in handling. • Follow facility procedures for regular cleaning of patient-occupied rooms. Give special attention to frequently touched surfaces (e.g., bedrails, bedside and over-bed tables, TV controls, call buttons, telephones, lavatory surfaces including safety/pull-up bars, doorknobs, commodes, ventilator surfaces) in addition to floors and other horizontal surfaces. • Attachment 8-H-9 Clean and disinfect spills of blood and body fluids in accordance with current recommendations for Standard Precautions. • … Cleaning and disinfection after patient discharge or transfer Follow standard facility procedures for post-discharge cleaning of an isolation room. • Clean and disinfect all surfaces that were in contact with the patient or might have become contaminated during patient care. No special treatment is necessary for window curtains, ceilings, and walls unless there is evidence of visible soiling. • Do not spray (i.e., fog) occupied or unoccupied rooms with disinfectant. This is a potentially dangerous practice that has no proven disease control benefit. • ƒ Postmortem care Follow standard facility practices for care of the deceased. Practices should include standard precautions for contact with blood and body fluids. ƒ Laboratory specimens and practices Follow standard facility and laboratory practices for the collection, handling, and processing of laboratory specimens. ƒ Detection of persons entering the facility who may have pandemic influenza … Post visual alerts (in appropriate languages) at the entrance to Outpatient Triage/Treatment Sites and GMHA facility (e.g., emergency department) instructing persons with respiratory symptoms (e.g., patients, persons who accompany them) to: • Inform reception and healthcare personnel when they first register for care, and • … Practice respiratory hygiene/cough etiquette Triage patients calling for appointments for influenza symptoms: • Discourage unnecessary visits. Instruct symptomatic patients on infection control measures to limit transmission in the home and when traveling for necessary medical appointments. • … As the scope of the pandemic escalates locally, consider setting up a separate triage area for persons presenting with symptoms of respiratory infection. Attachment 8-H-10 Because not every patient presenting with symptoms will have pandemic influenza, infection control measures will be important in preventing further spread. … During the peak of a pandemic, the GMHA Emergency Room and outpatient triage/treatment sites may be overwhelmed with patients seeking care. The Health Emergency Assistance Line and Triage Hub will serve as a means for managing patient flow and directing them to the appropriate health care facilities for triaging, including deferral of patients who do not require emergency care. … Designate separate waiting areas for patients with influenza-like symptoms. If this is not feasible, the waiting area should be set up to enable patients with respiratory symptoms to sit as far away as possible (at least 3 feet) from other patients. ƒ “Source control” measures to limit dissemination of influenza virus from respiratory secretions … Post signs that promote respiratory hygiene/cough etiquette in common areas (e.g., elevators, waiting areas, cafeterias, lavatories) where they can serve as reminders to all persons in the healthcare facility. Signs should instruct persons to: 1. Cover the nose/mouth when coughing or sneezing. 2. Use tissues to contain respiratory secretions. 3. Dispose of tissues in the nearest waste receptacle after use. 4. Perform hand hygiene after contact with respiratory secretions. … Facilitate adherence to respiratory hygiene/cough etiquette by ensuring the availability of materials in waiting areas for patients and visitors. … Provide tissues and no-touch receptacles (e.g., waste containers with pedaloperated lid or uncovered waste container) for used tissue disposal. … Provide conveniently located dispensers of alcohol-based hand rub. … Provide soap and disposable towels for hand washing where sinks are available. … Promote the use of masks and spatial separation by persons with symptoms of influenza. … Offer and encourage the use of either procedure masks (i.e., with ear loops) or surgical masks (i.e., with ties or elastic) by symptomatic persons to limit dispersal of respiratory droplets. … Encourage coughing persons to sit as far away as possible (at least 3 feet) from other persons in common waiting areas. Attachment 8-H-11 ƒ Hospitalization of Pandemic Influenza Patients … Patient placement Limit admission of influenza patients to those with severe complications of influenza who cannot be cared for outside the hospital setting. • Admit patients to either a single-patient room or an area designated for cohorting of patients with influenza. • … Cohorting Designated units or areas of a facility should be used for cohorting patients with pandemic influenza.6 During a pandemic, other respiratory viruses (e.g., nonpandemic influenza, respiratory syncytial virus, parainfluenza virus) may be circulating concurrently in a community. Therefore, to prevent cross-transmission of respiratory viruses, whenever possible assign only patients with confirmed pandemic influenza to the same room. At the height of a pandemic, laboratory testing to confirm pandemic influenza is likely to be limited, in which case cohorting should be based on having symptoms consistent with pandemic influenza. • Personnel (clinical and non-clinical) assigned to cohorted patient care units for pandemic influenza patients should not “float” or otherwise be assigned to other patient care areas. The number of personnel entering the cohorted area should be limited to those necessary for patient care and support. • Personnel assigned to cohorted patient care units should be aware that patients with pandemic influenza may be concurrently infected or colonized with other pathogenic organisms (e.g., Staphylococcus aureus, Clostridium difficile) and should adhere to infection control practices (e.g., hand hygiene, changing gloves between patient contact) used routinely, and as part of standard precautions, to prevent nosocomial transmission. • Because of the high patient volume anticipated during a pandemic, cohorting should be implemented early in the course of a local outbreak. • … Patient transport Limit patient movement and transport outside the isolation area to medically necessary purposes only. • Consider having portable x-ray equipment available in areas designated for cohorting influenza patients. • Attachment 8-H-12 If transport or movement is necessary, ensure that the patient wears a surgical or procedure mask. If a mask cannot be tolerated (e.g., due to the patient’s age or deteriorating respiratory status), apply the most practical measures to contain respiratory secretions. Patients should perform hand hygiene before leaving the room. • … Visitors Screen visitors for signs and symptoms of influenza before entry into the facility and exclude persons who are symptomatic. • Family members who accompany patients with influenza-like illness to the hospital are assumed to have been exposed to influenza and should wear masks. • Limit visitors to persons who are necessary for the patient’s emotional wellbeing and care. • Instruct visitors to wear surgical or procedure masks while in the patient’s room. • • ƒ Instruct visitors on hand-hygiene practices. Control of Nosocomial Pandemic Influenza Transmission … Once patients with pandemic influenza are admitted to the hospital, nosocomial surveillance should be heightened for evidence of transmission to other patients and healthcare personnel. (Once pandemic influenza is firmly established in a community this may not be feasible or necessary.) … If limited nosocomial transmission is detected (e.g., has occurred on one or two patient care units), appropriate control measures should be implemented. These may include: • Cohorting of patients and staff on affected units Restriction of new admissions (except for other pandemic influenza patients) to the affected unit(s) • Restriction of visitors to the affected unit(s) to those who are essential for patient care and support • … If widespread nosocomial transmission occurs, controls may need to be implemented hospital wide and might include: • Restricting all nonessential persons Attachment 8-H-13 Stopping admissions not related to pandemic influenza and stopping elective surgeries • ƒ Monitoring Patients for Pandemic Influenza and Instituting Appropriate Control Measures Despite aggressive efforts to prevent the introduction of pandemic influenza virus, persons in the early stages of pandemic influenza could introduce it to the facility. Early detection of the presence of pandemic influenza is critical for ensuring timely implementation of infection control measures. … Early in the progress of a pandemic in the region, increase resident surveillance for influenza-like symptoms. Notify state or local health department officials if a case(s) is suspected. … If symptoms of pandemic influenza are apparent, implement droplet precautions for the patient, pending confirmation of pandemic influenza virus infection. Patients and roommates should not be separated or moved out of their rooms unless medically necessary. Once a patient has been diagnosed with pandemic influenza, roommates should be treated as exposed cohorts. … Cohort residents and staff on units with known or suspected cases of pandemic influenza. … Limit movement within the facility (e.g., temporarily close the dining room and serve meals on nursing units, cancel social and recreational activities). Attachment 8-H-14 RECOMMENDATIONS FOR APPLICATION OF STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS IN ALL HEALTHCARE SETTINGS Component Recommendations STANDARD PRECAUTIONS Hand hygiene Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items; after removing gloves; and between patient contacts. Hand hygiene includes both handwashing with either plain or antimicrobial soap and water or use of alcoholbased products (gels, rinses, foams) that contain an emollient and do not require the use of water. In the absence of visible soiling of hands, approved alcoholbased products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity. Personal protective equipment (PPE) • Gloves • For touching blood, body fluids, secretions, excretions, and contaminated items; for touching mucous membranes and non intact skin • Gown • During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated Face/eye protection (e.g., surgical or • During procedures and patient care activities likely to procedure mask and goggles or a face generate splash or spray of blood, body fluids, secretions, shield) excretions Avoid touching eyes, nose, mouth, or exposed skin with Safe Work Practices contaminated hands (gloved or ungloved); avoid touching surfaces with contaminated gloves and other PPE that are not directly related to patient care (e.g., door knobs, keys, light switches). • Patient Resuscitation Avoid unnecessary mouth-to-mouth contact; use mouthpiece, resuscitation bag, or other ventilation devices to prevent contact with mouth and oral secretions. Attachment 8-H-15 Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visible contaminated; perform hand hygiene after handling equipment. Soiled Linen and Laundry Handle in a manner that prevents transfer of microorganisms to oneself, others, and to environmental surfaces; wear gloves (gown if necessary) when handling and transporting soiled linen and laundry; and perform hand hygiene. Needles and Other Sharps Use devices with safety features when available; do not recap, bend, break or hand-manipulate used needles; if recapping is necessary, use a one-handed scoop technique; place used sharps in a puncture-resistant container. Environmental cleaning and disinfection Use EPA-registered hospital detergent-disinfectant; follow standard facility procedures for cleaning and disinfection of environmental surfaces; emphasize cleaning/disinfection of frequently touched surfaces (e.g., bed rails, phones, door knobs, lavatory surfaces) Disposal of Solid Waste Contain and dispose of solid waste (medical and nonmedical) in accordance with facility procedures and/or state regulations; wear gloves when handling waste containers; perform hand hygiene. Respiratory hygiene/cough etiquette Source control measures for persons with symptoms of a respiratory infection; implement at first point of encounter (e.g., triage/reception areas) within a healthcare setting. Cover the mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacles; perform hand hygiene after contact with respiratory secretions; wear a mask (procedure or surgical) if tolerated; sit or stand as far away as possible (more than 3 feet) from persons who are not ill. Attachment 8-H-16 DROPLET PRECAUTIONS Patient Placement Place patients with influenza in a private room or cohort with other patients with influenza/ *Keep door closed or slightly ajar; maintain room assignments of patients in nursing homes and other residential settings; and apply droplet precautions to all persons in the room. *During the early stages of a pandemic, infection with influenza should be laboratory-confirmed, if possible. Personal protective Equipment Wear a surgical or procedure mask for entry into patient room; wear other PPE as recommended for standard precautions. Patient transport Limit patient movement outside of room for medically necessary purposes; have patient wear a procedure or surgical mask when outside the room. Other Follow standard precautions and facility procedures for handling linen and laundry and dishes and eating utensils, and for cleaning/disinfection of environmental surfaces and patient care equipment, disposal of solid waste, and postmortem care. AEROSOL-GENERATING PROCEDURES During procedures that may generate small particles of respiratory secretions (e.g., endotracheal intubation, bronchoscopy, nebulizer treatment, suctioning), healthcare personnel should wear gloves, gown, face/eye protection, and a fit-tested N95 respirator or other appropriate particulate respirator. Attachment 8-H-17 RESPIRATORY HYGIENE/COUGH ETIQUETTE To contain respiratory secretions, all persons with signs and symptoms of a respiratory infection, regardless of presumed cause, should be instructed to: • Cover the nose/mouth when coughing or sneezing. • Use tissues to contain respiratory secretions. • Dispose of tissues in the nearest waste receptacle after use. • Perform hand hygiene after contact with respiratory secretions and contaminated objects/materials. See Visual Alert Posters Environmental Services should ensure the availability of materials for adhering to respiratory hygiene/cough etiquette in waiting areas for patients and visitors: • Provide tissues and no-touch receptacles for used tissue disposal. • Provide conveniently located dispensers of alcohol-based hand rub. • Provide soap and disposable towels for handwashing where sinks are available. Masking and separation of persons with symptoms of respiratory infection during periods of increased respiratory infection in the community should be pursued. Persons who are coughing should be offered either a procedure mask (i.e., with ear loops) or a surgical mask (i.e., with ties) to contain respiratory secretions. Coughing persons should be encouraged to sit as far away as possible (at least 3 feet) from others in common waiting areas. Attachment 8-H-18 CHAPTER 9 PSYCHOSOCIAL RESPONSE PLAN SECTION 1.0 INTRODUCTION the island’s emergency response could save lives and prevent substantial economic loss. The purpose of the psychosocial response plan is to address how the Government of Guam will respond to situations concerning the psychological health and well being of the population of Guam as they relate to pandemic influenza. The Governor of Guam in conjunction with the DPHSS Director and GHS are jointly responsible for periodically reviewing and updating this component to ensure that information contained within the document is consistent with current knowledge and changing infrastructure. While this plan serves as a guide specifically for influenza intervention activities during a pandemic, the judgment of public health leadership based on knowledge of the specific virus may alter the plan. Priorities established during an influenza pandemic will be to assure the continuation and delivery of essential services while providing assistance to meet the emergency needs of the population. ƒ During a pandemic or other disaster, the delivery of critical services within the community will be severely impacted because of widespread illness, absenteeism and death. SECTION 2.0 SCOPE OF OPERATIONS The scope of operations applies to all victims of any disaster as well as personnel assigned to emergency oriented missions within the Territory of Guam. All public and private agencies, as they relate to the plan, will operate within the established incident command structure. SECTION 3.0 SITUATION AND ASSUMPTIONS ƒ An influenza pandemic or other disaster will present a massive test of the emergency preparedness system. Advance planning for ƒ Guam’s healthcare and mental health systems will be strained to the breaking point by staff attrition and increased demand for services. First responders, healthcare workers and others will be at higher risk of viral exposure, stress related illness and anxiety than the general population, further straining the healthcare system. ƒ Extraordinary numbers of casualties within the community will cause sudden and significant shortages of personnel (approximately 40%) in areas providing critical public services and support. ƒ An effective response to an influenza pandemic will require the coordinated efforts of a wide variety of organizations, private as well as public. ƒ Disasters, by their nature, produce the need for a coordinated psychosocial approach and intervention. Responding to the impact of disasters, for all people involved, is an integral part of a comprehensive and effective disaster response plan and recovery strategy. Hence a Psychosocial Response Plan should be available for all individuals. ƒ Due to the additional stress related to caring for high numbers of casualties, disaster responders, including medical personnel, are at high risk for developing trauma-related disorders. Certain members of the workforce may be at increased risk of viral infection or stress related illness. (Those workers at increased risk of infection are especially vulnerable due to a real or perceived increased risk of becoming infected themselves and transmitting infection to their friends and families.) Healthcare organizations, in addition to assuring access to PPE, vaccination and prophylactic treatments for first responders, and their immediate family members, will also need to direct attention to addressing the stress-related effects of the disaster response on these individuals. Hence, there is a particular need for sensitivity to the personal concerns and obligations of workers who may be separated from their families and loved ones for long hours and even days. ƒ During an influenza pandemic, there may be short and/or long-term effects on the mental health of individuals because of direct exposure to sick and dying loved ones, and on the population as a whole. ƒ The particular mental health needs of special needs populations such as tourists, residents from other cultures, homeless people, and persons who are homebound or with special health care requirements also need to be considered. Along with additional pandemic-related mental health needs of the community, providing care for those with pre-existing mental illness will need to continue to be addressed. ƒ Provision, distribution and training in the use of specialized safety equipment, such as PPEs (masks, gloves, eye protection, hand sanitizers and other protective equipment) for members of the Psychosocial Support Team will be the responsibility of the DPHSS. ƒ To reduce any stigma associated with the term “psychosocial” the Psychosocial Response Team will be called the “Individual and Family Support Team” or IFS Team. SECTION 4.0 CONCEPT OF OPERATIONS The psychosocial support response will be formed into a comprehensive network including social workers, school guidance counselors, other mental health providers and volunteers from various agencies and organizations public and private. This network will be referred to as the Psychosocial Planning Committee. The focus of the Psychosocial Response Plan will be to mitigate the impact that a mass casualty incident may have on the population of Guam. This will be accomplished by coordinating the activities of public/private agencies and organizations, such as the Guam Association of Individual, Marriage and Family Therapists (GAIMFT), the Guam National Association of Social Workers (GNASW), American Red Cross, faith-based organizations, and others. Additionally, the involvement of the Social Work and Psychology Departments of the University of Guam are essential to the plan. Available resources may limit implementation of the Psychosocial Response Plan. Due to the expected high demand for emotional support and counseling, resources may quickly be exhausted; therefore there may be a need for the Government of Guam to request additional assistance from the Federal Government, such as the Federal Emergency Management Agency (FEMA), the National Disaster Medical System (NDMS), CDC or other Federal agencies. In particular the NDMS may provide specialized support from the following: Medical Support Unit, Guam Pandemic Influenza Plan 9-2 Mental Health and Stress Management teams, Disaster Medical Assistance Team, the Disaster Mortuary Operation Response Team and the Veterinary Medical Assistance Team. The Psychosocial Response Plan will provide psychosocial support for members of law enforcement, fire department and others during their daily “end of shift” debriefings. A minimum of two members of the Psychosocial Team will be dispatched to the debriefing sites or other locations to provide emotional support, assistance, evaluation, and referral as required. The IFS will need to: ƒ Conduct an island-wide resource inventory to determine the availability and numbers of qualified psychosocial support team members to staff the debriefing centers, corpse processing centers, senior citizens centers, community shelters and other sites, which may require psychosocial support. The priority of services for the IFS shall be in the following order: first responders, Corpse Processing Centers (CPC), isolation and quarantine sites, triage sites, medical treatment locations, the influenza hot line and other locations as required. ƒ Assess the mental health needs of the community especially for: first responders, healthcare providers, special needs populations, individuals and families undergoing isolation or quarantine, survivors, members of the IFS Team, and others. ƒ Provide guidance and coordination for the Guam Pandemic Response by promoting psychological first aid and resilience programs for victims and families as well as coordinating with IC to ensure that Critical Incident Stress Management is available for first responders and healthcare workers. ƒ Assist the Government of Guam in providing community partners with literature and educational materials on the human response to disaster, stress reduction, workforce resiliency programs and self-help information, in support of the DPHSS. ƒ Coordinate with the designated Public Information Officer (PIO), Risk Communications and GHS in providing accurate non-inflammatory information to the public that will address the fear and other psychological reactions to an influenza pandemic via media (TV, radio, newspaper). ƒ In conjunction with GTA assist in the development of a specific Pandemic Information Phone System that will provide a means for the public to seek telephonic assistance regarding pandemic issues. Provide information and education via phone for the community. Ƒ Assure that the concerns of mental health consumers are addressed. Ƒ Provide languages. Ƒ information in other ƒ Develop a comprehensive psychosocial methodology for providing support services to help workers manage emotional stress during the response to an influenza pandemic and to resolve related personal, professional and family issues. ƒ Train first responders on how to: Provide limited emotional support and assistance to victims to help them Ƒ Guam Pandemic Influenza Plan 9-3 manage the psychological trauma associated with the impact that the emergency or disaster may cause. Make appropriate referrals for continuing psychosocial services for individuals and families requiring further assistance or evaluation through workshops specific to first responders (such as law enforcement). Ƒ various phases of pandemic influenza may be blurred or occur in a matter of hours, underscoring the need for flexibility. The Psychosocial Response Plan is outlined for each phase. ƒ Create a plan for providing continuity of operations due to increased workload and staff losses during a pandemic. Anticipate that approximately 40% of staff will be unavailable due to the pandemic. Ƒ May need to recruit and train additional non-professional volunteers from the community (retired social workers or private citizens who have received specialized training). Ƒ ƒ As funding permits, provide periodic training to psychosocial support staff and volunteers. Ƒ Coordinate with the American Red Cross and the CDC for members of the Psychosocial Team to attend specialized Disaster Mental Health Training. Ƒ Follow up/refresher training. SECTION 5.0 ACTIVATION AND IMPLEMENTATION It is expected that an influenza pandemic will occur in the phases listed below. In actual practice, the distinction between the Guam Pandemic Influenza Plan 9-4 PANDEMIC PHASES WHO PHASES 1 AND 2: INTERPANDEMIC PERIOD ƒ DPHSS … Identify private and public sector partners who may be willing to participate in the process of planning for a Psychosocial Response to a possible pandemic on Guam and incorporate them into a Psychosocial Planning Committee. … Foster further coordination and participation among private and public sector partners in the planning process. Work within the participating agencies and organizations to develop overall contingency plans for a large-scale public health disaster such as an influenza pandemic. … Provide further planning and guidance to responding partners and the community on preparing individual response plans to address the psychosocial impact that a pandemic may cause. … ƒ DPHSS and DMHSA Review the suitability of existing pamphlets and brochures on stress, anxiety, and disaster management for use by the public during a pandemic. … In conjunction with the DPHSS Education Team, develop a Workforce Resilience Program for first responders … ƒ Psychosocial Planning Committee … Develop a Resource Directory for psychosocial support staff. … Hold regular meetings with the psychosocial support partners to further update and develop the plan to include recent developments and additional research. … Identify major gaps in the current ability of the Psychosocial Response Plan to effectively respond to an influenza pandemic and explore possible avenues for addressing and resolving them ƒ DPHSS, DISID with the UOG Social Work Department … Coordinate with the MCG to develop of a comprehensive village-by-village demographic profile indicating the requirements and physical location of persons with special needs (Attachment A). Guam Pandemic Influenza Plan 9-5 ƒ DPHSS and GTA Coordinate with Risk Communications and GTA for development of a community hotline to include a updating of the contact listing for members of the Psychosocial Team. … WHO PHASE 3: PANDEMIC ALERT PERIOD ƒ DPHSS … Designate an official member of the psychosocial support staff as the contact person to receive updates. … ƒ Develop and update the training syllabus for psychosocial support staff. Psychosocial Planning Committee … Develop an assessment tool to evaluate the Psychosocial Response Plan. WHO PHASE 4: PANDEMIC ALERT PERIOD ƒ DPHSS and DMHSA … Update the Resource Directory for the psychosocial support staff. Monitor bulletins from CDC, WHO, Health Alert Network (HAN), and others regarding clinical updates as appropriate. … ƒ Psychosocial Planning Committee … Review the pandemic influenza response and contingency plans for psychosocial support, update as required. WHO PHASE 5: PANDEMIC ALERT PERIOD ƒ DPHSS and DMHSA … Coordinate with the designated PIO, Risk Communications and the JIC in notifying the public and community partners of the potential for an influenza pandemic occurring on Guam. … Monitor bulletins from CDC, WHO, HAN, and others regarding clinical updates as appropriate. Guam Pandemic Influenza Plan 9-6 ƒ Psychosocial Planning Committee Continue to review the pandemic influenza response and contingency plans for a largescale public health disaster. … Advise first responders that members of the psychosocial team will be available to provide emotional support interviews during their respective debriefings. … ƒ DISID and DPHSS Coordinate with the village mayors through the MCG for updated demographic profiles for each village (Attachment B). … WHO PHASE 6: PANDEMIC PERIOD ƒ DPHSS … Activate psychosocial support staff at pre-designated sites. Ensure that the partner agency contacts are available to receive updates from psychosocial support staff. … … Coordinate the deployment and detailing of available psychosocial support staff during the pandemic outbreak, including private, public, and volunteers (Attachment C, D, and E). ƒ DMHSA with the Psychosocial Planning Committee … Plan and conduct formal debriefings or emotional support interviews for Psychosocial Team Members. … Reassess and revise the plan as required. Monitor bulletins from CDC, WHO, HAN, and others regarding clinical updates as they become available. … Assess the effectiveness of the Psychosocial Response Plan using the previously developed assessment tool. … WHO PHASE 6: PANDEMIC PERIOD ƒ DPHSS … Continue all activities listed under pandemic phase. … Review, evaluate and modify the plan as needed. Guam Pandemic Influenza Plan 9-7 … Continue to monitor manpower resources and staffing needs. WHO POST PANDEMIC PERIOD ƒ DMHSA … ƒ Assess state and local capacity to resume normal behavioral health functions. Psychosocial Planning Committee … Modify the pandemic influenza response and contingency plans based on lessons learned. Guam Pandemic Influenza Plan 9-8 SPECIAL NEEDS REGISTRATION INSTRUCTIONS ASSUMPTIONS In the event of a major long-term disaster such as a pandemic, persons with special needs may require assistance specific to their condition. With the exception of the Special Needs Identification Project (SNIP), there is no consolidated listing of persons with special needs exists. During disasters, in the absence of extraordinary circumstances, family members and caretakers will continue to provide support to household members with special needs. During long-term disasters, such as a pandemic, some persons with special needs, such as those who are technology dependent, may require assistance from EMS or other government resources. As there is no centralized listing identifying Guam’s Special Needs Population, during times of emergency, it may prove to be exceedingly difficult to locate or provide assistance to them. Additionally without foreknowledge of the needs and requirements of persons with special needs, it would be very difficult for the Government to efficiently provide the required services. To address this question, a simple confidential voluntary registration program is proposed which would be maintained by the village mayors. DPHSS, GHS, OCD, and EMS are the only ones allowed to have access to the data for contingency planning purposes before, during and after disaster situation. REGISTRATION FOR PERSONS WITH SPECIAL NEEDS The University of Hawaii (UH), in cooperation with UOG will be conducting a door-to-door Tsunami and Typhoon Survey on Guam and on other islands in the Pacific Rim. UH has tentatively agreed to assist the DPHSS by distributing the Special Needs Registration Forms. (Attachment B) METHODOLOGY If during the course of distributing the UH survey, canvassers encounter a family with a special needs person(s) they will provide them with a copy(s) of the Special Needs Registration Form and a pre-addressed envelope. The family is asked to complete the form, one for each person with special needs in the home and mail it to the EMS Section at DPHSS. Attachment 9-A-1 When received by the EMS office the data concerning the requirements of persons with special needs will be analyzed and placed in a database. The EMS office will then collate the registration forms by village, place them in binders and distribute them to the appropriate village mayors. The mayor’s offices will be responsible for maintaining the special needs registry, for registering new individuals and for periodically updating the registry. To the greatest extent possible, when advance warning about an impending disaster (such as a typhoon or pandemic) is available, the EMS office will collect the most current information from the mayors, update the database, and provide the information to GHS/OCD, EOC, EMS personnel and others authorized to receive the data. It is not the purpose of the Special Needs Registry to devise a mechanism for the Government of Guam to take over or supplant the duties and responsibilities of families and caretakers of persons with special needs. The data in the Registry will be utilized for contingency planning to meet unexpected demands on the Emergency Health Care System. ƒ ƒ ƒ ƒ The number of homebound patients requiring oxygen. The number of oxygen canisters the Government of Guam has to stockpile in case the oxygen plan fails during a disaster. The number of technology-dependent patients requiring emergency power to back up line. The number of generators the Government of Guam has to provide if necessary. DEFINITIONS Person With Special Needs Any person, adult or child who because of age, illness or infirmity requires extensive assistance with their daily needs or who is dependent on technology for survival. Attachment 9-A-2 SPECIAL NEEDS REGISTRATION FORM SPECIAL NEEDS REGISTRATION A member of my household or I wish to register as a person with special needs. So that in the event of a disaster (Typhoon, Tsunami, Pandemic or other emergency) the appropriate authorities will be aware of my special needs and requirements. I understand that the registration of Persons with Special Needs is strictly voluntary; and I may choose not to answer any or all of the questions. The information I provide will be used to develop plans to contact, and if need be, to evacuate or otherwise care for persons with special needs. This information will be kept strictly confidential, but as the need arises can be shared with any of the following organizations: The Village Mayor, Emergency Medical Services, Guam Homeland Security/Office of Civil Defense, and the Governors Pandemic Planning Taskforce. Patient Information Date of Registration: Patient’s Name: Street Address: Mailing Address: Caretaker Name: Diagnosis 1: Diagnosis 3: Prescription Medications: Rx 3: Rx4: Attending Physician Name: Contact number: Please Check All that Apply … Difficulty Walking … Bed Ridden … Technologically Dependant Serial Number: Sex : M / F Age: DOB: / / Contact Numbers: (H) (C) (Other) Contact Number: (H) (C) (Other) Diagnosis 2: Diagnosis 4: Rx 1: Rx 2: Primary Language: _____________________________ … … … … …Oxygen …Tank …Concentrator … … … TDY/Communications Device … … On Medication … … Self Harm Precautions … Restraints … Never … … Occasionally … Frequently Print Name: ___________________ Signature: Physical Disability Wheel Chair Bound Other Respirator Air Conditioner Other: Mental Disability Attendant required … Full Time … Part Time Map to my home (Please use the back of this form) Date: / / Attachment 9-B Dispatching Procedures for Individual and Family Support Team Assumptions: That all members of the IFS Team will receive at least minimal specialized training (such as those available through the American Red Cross and/ or the CDC) to provide psychosocial support to first responders, healthcare workers, survivors, and to the community. That a comprehensive listing of IFS Team members will be available. That adequate communications, telephonic, wireless, Internet or radio will be available for use by members of IFS Team at the EOC or Department of Public Health Command Center and at each of the sites where members of the IFS Team are expected to be assigned. This may require the issuance of wireless communications devices to the IFS Team Leaders. Documentation, such as identification cards / badges or insignia as a member of the IFS Team will be provided by higher authority (DPHSS or GHS). That training in the use of PPE for members of the IFS Team will be conducted by the DPHSS. That PPE will be available and distributed to IFS Team members at a location to be identified. Check in Procedures: Members assigned to the IFS Team will check in with the designated Shift Leader at the Pandemic Influenza Command Operations Center EOC or DPHSS Command Center. Upon check in, each team member will receive a short situation briefing from the Team Leader and fill out an IFS Tracking Card (Attachment 1). The Team Member will then be placed in a standby status until assigned. The members tracking card will be placed in a folder labeled “STANDBY POOL” until dispatched. Dispatching Members of the IFS Team: When IFS Team are requested by the Incident Commander, the IFS Team Shift Leader will review the personnel available in the STANDBY POOL and appropriately dispatch them to the site as quickly as possible. A minimum of two members of the IFS Team will be dispatched to each site: a Site Leader and a Team Member, depending on availability, additional Team Members will be assigned as required. As the number of psychosocial professionals and trained volunteer members is finite, not all sites requesting services may be able to be consistently accommodated. Attachment 9-C-1 Priority of coverage will be towards the provision of services to first responders, healthcare workers, the CPC, quarantine / isolation sites, triage sites, treatment sites, and hotline duty. Additionally, participating members of the IFS Team will be required to rest for a minimum of 12 hours after each shift. Each shift will begin and end at the dispatching center with a situation briefing / de-briefing conducted by the Shift Leader. During this briefing / de-briefing process the shift leader will assess each team member for signs and symptoms of stress related injury or other problems. Members judged to be suffering from a stress related or other difficulties will be referred to Mental Health or another provider for assessment and treatment. The on and off going Shift Leaders will responsible to brief / de-brief and assess each other. The IFS Team shall operate three shifts around the clock each shift shall be for 9 hours each including time for in-briefing and out-briefing at the point of dispatch (see attachment). A standing requirement for IFS Team support will be the 24 hr hotline to address psychosocial questions and issues from the public. When IFS Team assets are in short supply this function can be temporarily covered by the Shift Leader or by the Assistant Shift Leader. Duties and Assignments SHIFT LEADER: The Shift Leader will be responsible for the daily administration of the IFS Team and will be required to maintain a close liaison with the Operations and Planning Chiefs for accurate and timely awareness of the pandemic situation. Additionally the Shift Leader will: ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ Conduct on and off shift briefing for all team members. Collate the reports from each Site Leader for inclusion into the End of Shift report. Assign and dispatch team members as required. Maintain accurate assignment tracking information for all team members. At the end of each shift be prepared to provide a written End of Shift Report of IFS Team activities to the Incident Commander. Maintain the IFS Team tracking card system and detailing log (attachment). Assign the senior or most experienced member as the Site Leader. Maintain an awareness of the mental health status of all personnel at the EOC and make referrals as required. Maintain a confidential contact list of individuals referred to Mental Health for further care and evaluation. This will aid the Team in identifying problems at the sites and to check for patient patterns. ASSISTANT SHIFT LEADER: The Assistant Shift Leader will be responsible to assist the Shift Leader in all aspects of the daily administration of the IFS Team. Additionally the Assistant Shift Leader will be prepared to take over the duties of the Shift Leader should the need arise. Attachment 9-C-2 SITE LEADERS: Will be responsible to conduct psychosocial support activities at each assigned location, additionally they will be required to: ƒ Maintain an activity log which will reflect (attachment): Briefly describe any significant events that may have occurred at the assigned location during the shift. … Number of client contacts assisted during the shift. … Number of referrals made to Mental Health. … Confidential listing of the identification of persons referred (for IFS Team use only). … Comments on the amount of stress, anxiety or tension the workers at each site may be experiencing. Maintain contact with the Shift Leader. … ƒ TEAM MEMBERS: The Team Member will assist the Site Leader in the operations at the assigned location and be prepared to take over the duties of the Site Leader should the need arise. Briefing – De-Briefing Sites (Law Enforcement / Fire / First Responders): At the beginning and end of each shift, the senior first responder usually conducts briefings for their personnel. During these meetings, an IFS Team will be available to provide supportive counseling, evaluation and referral as required. The Team should be prepared to make short presentations on identifying and counteracting the symptoms of work related stress. Additionally they will closely observe the first responders for signs and symptoms of stress. The Team will also be available for one on one counseling as required. Healthcare Workers (HCW): Physicians, nurses and other members of the healthcare field are susceptible to work related illness especially when faced with a mass casualty, mass death situation. Although each health care facility participating in the pandemic response should have at least two members of the IFS Team providing support for them, any additional support specifically for healthcare workers will have to be arranged with the Shift Leader through the EOC. Corpse Processing Center (CPC): Assignment to the CPC for members of the IFS Team will be challenging and difficult. Team members will have to be especially careful to help each other in avoiding stress related illness. The primary duties of the IFS Team members will be to assist family members and survivors in the grieving process; additionally they may be tasked to provide guidance in the administrative protocols of the CPC. To the greatest extent possible team members assigned to the CPC will be individuals with experience in dealing with the grieving process (eg. faith based organizations). IFS Team members assigned to the CPC must be cautioned not to inject any particular religious belief or dogma into their grief counseling. Any additional specialized training in CPC management protocols or administration for members of the IFS Team will be the responsibility of the CPC administrator. Quarantine / Isolation Sites: IFS TEAM members detailed to quarantine and isolation sites should be aware that they might be dealing with angry individuals being held against their will. Therefore, the IFS Team will Attachment 9-C-3 have to maintain a calm cautious and professional approach when working with quarantined or isolated persons. Upon entering the quarantine or isolation site, the IFS Team should report to the site manager for any special instruction about the persons interned on the site. At no time should members of IFS Team place themselves in harm’s way. Triage Sites: Duty at the triage sites will be challenging and fast paced. Team members will be required to provide emotional support to the sick, dying and also to staff members. IFS Team members should be prepared to diplomatically explain triage protocol to concerned family members; this will be especially true when the patient's treatment is delayed. Additionally the team members may be tasked with notifying the next of kin in the event of a death at the site. Treatment Sites: Duty at the treatment sites, although, not as fast paced as triage will be equally challenging. Team members will be required to provide emotional support to the sick, dying, family members and to the medical staff. In the event of a death at the treatment site, the task of notifying next of kin may fall to the IFS Team. Immunization / Dispensing Sites: It is anticipated that availability of a vaccine specifically for pandemic influenza will not be available until several months after the pandemic has been established, therefore the presence of IFS Team members at the immunization sites will probably not be required. Attachment 9-C-4 Front Individual and Family Support Team Tracking Card Name: ____________________ Title: ________ Check in Date: ____/____/_____ … Leader … Member … Alternate … Student … Volunteer … Other: ____________________ Back DISPATCH INFORMATION I Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ II Contact Information Home: _____ - ________ Wk: _____ - ________ Cell: _____ - ________ Other: _____ - _______ Email: __________ @ ____________ Address: Home: __________________________________ Village: ________________ Zip: ____________ Work: __________________________________ Village: ________________ Zip: ____________ Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ III Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ Emergency Response Training: … ARC … CERT …CDC … Other:_________ Emergency Contact Information Name: _________________________________ Relationship: … Spouse … Parent … Sibling … Other: _____________________ Contact Numbers: Home: _____ - ________ Wk: _____ - ________ Cell: _____ - ________ Other: _____ - ________ Email: __________ @ ____________ Address Home: _________________________________ Village: _________________ Zip: __________ Dispatch Code 1. EOC 2. GMHA 3. CPC 4. Triage 5. Treatment Sites A: Northern B: Central C: Southern 6. Quarantine Site 7. Isolation Site 8. Mass Care Site 9. De-Briefing Cent A GPD B GFD C Other 10. Hotline 11. R and R 12. Sick Leave Home 13. Sick Leave Hospital 14: Other: _______________ Comments: _____________________________________________ IV Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ VI Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ VII Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ VIII Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ IX Date: ___ /___ / _____ Time: _____:_____ Location: Code: ____ Location:_________ Comments: __________________________ ____________________________________ Attachment 9-D Psychosocial Detailing Sheet for Pandemic Response Shift 1 (07:00 – 16:00) Entrance Briefing 07:00-07:30 Exit Briefing 15:30-16:00 Shift Leader: ______________________________ LOCATIONS Contact Number: _____________________________ TEAM LEADER TEAM MEMBER Date: ___________ ALTERNATE EOC GMHA Corpse Processing Center Triage TREATMENT SITES Northern Clinic Central Clinic Southern Clinic Quarantine Site Isolation Site GPD DE-BRIEFING CENTERS Site P-1 Site P-2 Site P-3 Site P-4 GFD DE-BRIEFING CENTER Site F-1 Tamuning Site F-2 Piti Site F-3 Dededo Site F-4 HQ Hotline Duty Revised 1/12/07 Attachment 9-E -1 Psychosocial Detailing Sheet for Pandemic Response Shift 2 (15:00 – 24:00) Entrance Briefing 15:00-15:30 Exit Briefing 23:30-24:00 Shift Leader: ______________________________ LOCATIONS EOC GMHA Corpse Processing Center Contact Number: _____________________________ TEAM LEADER TEAM MEMBER Date: ___________ ALTERNATE Triage TREATMENT SITES Northern Clinic Central Clinic Southern Clinic Quarantine Site Isolation Site GPD DE-BRIEFING CENTERS Site P-1 Site P-2 Site P-3 Site P-4 GFD DE-BRIEFING CENTER Site F-1 Tamuning Site F-2 Piti Site F-3 Dededo Site F-4 HQ Hotline Duty Revised 1/12/07 Attachment 9-E -2 Psychosocial Detailing Sheet for Pandemic Response Shift 3 (23:00 – 08:00) Entrance Briefing 23:00-23:30 Exit Briefing 07:30-08:00 Shift Leader: ______________________________ LOCATIONS EOC GMHA Corpse Processing Center Contact Number: _____________________________ Date: ______________ TEAM LEADER TEAM MEMBER ALTERNATE Triage TREATMENT SITES Northern Clinic Central Clinic Southern Clinic Quarantine Site Isolation Site GPD DE-BRIEFING CENTERS Site P-1 Site P-2 Site P-3 Site P-4 GFD DE-BRIEFING CENTER Site F-1 Tamuning Site F-2 Piti Site F-3 Dededo Site F-4 HQ Hotline Duty Revised 1/12/07 Attachment 9-E -3 CHAPTER 10 MASS FATALITY MANAGEMENT SECTION 1.0 INTRODUCTION During a pandemic, Guam will be prepared to manage additional deaths due to influenza, over and above the number of fatalities currently expected during the interpandemic period. The total number of fatalities, including influenza and all other causes, occurring during a six to eight week pandemic wave is estimated to be similar to that which typically occurs over six months in the inter-pandemic period that is approximately 350 people in Guam. This would equate to about six to eight deaths a day during a pandemic wave. This is based on WHO estimate. As provided for in Public Law 26-173, §19504 Safe Disposal of Human Remains, (a) Adopt Measures, the Government of Guam views the content of this document as the enforceable measures to provide for the safe disposal of human remains as may be reasonable and necessary to respond to a public health emergency. Such measures may include, but are not limited to, the embalming, burial, cremation, internment, disinterment, transportation, and disposal of human remains. Therefore, the content of this plan, “Guam Mass Fatality Management Plan” equivalent to the Fatality Management Plan guidelines issued by DHHS, unless otherwise directed by PHA during a health emergency shall be the measures to enforce, operate and respond to a mass fatality in line with the aforementioned section of Guam law. The following assumptions are made with regard to mass fatality management for pandemic influenza: ƒ In a worst-case scenario, Guam may expect deaths of approximately 8,400 individuals based on 5% fatality of the entire island population similar to the 1918 Pandemic. Assuming all such deaths was to occur over two pandemic waves, each lasting six to eight weeks; Guam might be tasked to manage 75-100 bodies every day during each wave ƒ Most victims will have sought medical care and have been identified before dying in the hospital; however, many others may die in their homes. ƒ There will be an increase in the number of official pronouncement and certification of death by authorized individuals. ƒ There will be an increase in the number of body bags needed to wrap the greater number of dead bodies in and outside of the hospital. ƒ There will be mobilization of equipment (i.e. vehicles, stretchers) and personnel needed to transport dead bodies from the sites of death to the morgue or an alternate site for the processing of human remains. ƒ GMHA, OCME, and USNH will not have the capacity to store the anticipated increase of human remains in and outside the hospital. ƒ Guam mortuaries will not have the resources to conduct mass fatality operations, for administering, embalming, cremating, storing, and burying of corpses, as they will lose staff to illness, caring for ill family members, death, and refusing to work. ƒ OVS will be unable to issue death certificates as quickly as they occur, requiring detailed documentation and close coordination with morgue and funeral response activities. ƒ Mutual aid resources will be needed to support local hospital, OCME, OVS, and funeral homes. ƒ Federal assistance will be sought; however, Guam cannot be assured that necessary support will be provided in a timely manner. ƒ The Government of Guam will take the lead role in the management of mass fatality for all individuals on Guam regardless of citizenship. This plan will guide DPHSS to respond to large-scale fatalities due to pandemic influenza. The plan was developed with the review and comments of the Guam Mass Fatality Subcommittee, which is comprised of OCME, participating Guam funeral directors, OVS, GMHA, USNH, AAFB, as well as members of the Guam Pandemic Planning Task Force. DPHSS Division of Environmental Health (DEH), or other designated entity as determined by the DPHSS Director or PHA, will take the lead role in the operations of the CPC, which shall be the centralized site for the processing of decedents when morgue and mortuary operations become overwhelmed due to the pandemic. The Dededo Sports Complex has been identified as the CPC. Whoever is assigned such task shall be identified as the “CPC Manager”. This response effort will be supported by DSC, Department of Parks and Recreation (DPR), DPW, and the Guam National Guard (GNG), as appropriate. SECTION 1.1 GUAM LAWS GOVERNING HUMAN REMAINS Title 10 GCA, Chapter 3 and its rules and regulations, Chapters 4a and 30 shall govern the embalming, cremation, transport, burial, and record keeping of dead bodies in Guam: ƒ All human remains not embalmed shall be buried or cremated within 24 hours after death, unless kept under adequate refrigeration. To the extent possible, religious, cultural, family and individual beliefs of the deceased person or that person’s family shall be considered when disposing of human remains. ƒ DPHSS shall issue a burial permit before a human body is buried; deposited in a crypt, mausoleum or vault; cremated; or otherwise disposed of. ƒ DPHSS shall arrange for the burial or other disposition of unclaimed dead bodies. ƒ In the interest of protecting the health of the public, DPHSS in its discretion may order such form of burial or disposition of a dead human body, as it deems necessary. ƒ No person shall transport any dead human body of any person who died from, or while having, any communicable disease specified in Subchapter D, within Guam without the approval of DPHSS. ƒ DEH in concert with the DPHSS Director shall approve the establishment of all cemetery, crypt, mausoleum, vault, or crematory. ƒ Every person in charge of a cemetery, crypt, mausoleum, vault, or crematory shall keep complete records of all dead human bodies interred, disinterred, removed, or cremated. ƒ Only one body shall be buried in each grave, unless approved by DPHSS. Guam Pandemic Influenza Plan 10-2 ƒ Graves shall not be less than six feet in depth below the surface and shall not be less than one foot in width and length than the coffin; however, when vaults are used, it shall not be less than 18 inches in depth below surface. ƒ The Governor of Guam is authorized to set aside from public lands such amount thereof as he may deem necessary for the establishment of a public cemetery. SECTION 1.2 ISLAN GUAHAN EMERGENCY HEALTH POWERS ACT The management of human remains is further governed by Title 10 GCA, Chapter 19 (Emergency Health Powers Act) during a declaration of public health emergency by the Governor. Under such state of emergency: ƒ The Governor of Guam may suspend any Government of Guam regulatory statutes, orders, and rules and regulations that would prevent, hinder, or delay necessary action to respond to the public health emergency, and seek the aid of the Federal Government in accordance with any emergency compact. ƒ DPHSS shall coordinate all matters pertaining to the public health emergency response of Guam, including the safe disposal of dead bodies. ƒ DPHSS may take measures to safely dispose of dead bodies, which includes, but not limited to, their embalming, burial, cremation, interment, disinterment, transportation, and disposal. ƒ DPHSS shall require any business or facility authorized to embalm, bury, cremate, inter, disinter, transport, and dispose of human remains under the laws of Guam to accept any human remains or provide the use of its business or facility, if such actions are reasonable and necessary to respond to the public health emergency as a condition of licensure, authorization, or ability to continue doing business on Guam as such a business or facility. The use of business or facility may include transferring the management and supervision of such business or facility to public health authority for a limited or unlimited period of time, but shall not exceed the termination of the declaration of state of public health emergency. ƒ DPHSS shall procure, by condemnation or otherwise, any business or facility authorized to embalm, bury, cremate, inter disinter, transport and dispose of human remains under the laws of Guam as may be reasonable and necessary to respond to the public health emergency, with the right to take immediate possession thereof. ƒ DPHSS shall ensure that every human remains prior to disposal shall be clearly labeled with all available information to identify the decedent and the circumstances of death. Any human remains of a deceased person with a contagious disease shall have an external, clearly visible tag indicating that the human remains are infected and, if known, the contagious disease. ƒ DPHSS shall ensure that every person in charge of disposing of any human remains shall maintain a written or electronic record of each human remains and all available information to identify the decedent and the circumstances of death and disposal. If human remains cannot be identified prior to disposal, a qualified person shall, to the extent possible, take fingerprints and Guam Pandemic Influenza Plan 10-3 photographs of the human remains, obtain, identifying dental information, and collect a DNA specimen. All information gathered under this paragraph shall be promptly forwarded to the public health agency. ƒ The Government of Guam shall pay just compensation to the owner of any facilities or materials lawfully taken by DPHSS or public health authority for temporary or permanent use during a public health emergency. Compensation shall not be provided for facilities or materials that are closed, evacuated, decontaminated or destroyed when there is reasonable cause to believe they may endanger public health pursuant to §19501. SECTION 2.0 MASS FATALITY MANAGEMENT PLAN To identify planning needs for the management of mass fatality during a pandemic, the subcommittee first examined each step in the management of a corpse under normal circumstances during interpandemic phase, which is presented in an algorithm in Attachment 10-A. Then members identified the limiting factors within each significant steps, along with the solutions (or planning) required to address the increase in number of human remains over a short period of time, Attachment 10B. It is not the intent of DPHSS to dictate or interfere with the normal operation of funeral homes, cemeteries, mortuaries, hospitals, and morgues. Service providers are expected to prepare its own internal plan to counter the anticipated increase in demand for their services during a pandemic. Only when such services cannot be or will not be provided by the service providers, and upon activation should DPHSS implement the necessary actions in the management of mass fatalities in accordance to this plan. As reflected in the plan, mass burials or mass cremations is not recommended and will be considered in the most extreme circumstance. SECTION 2.1 GENERAL PLAN In developing this plan, which shall be known as the “Guam Mass Fatality Management Plan” referred to as the “Mass Fatality Plan”, DPHSS involved the representatives from the following entities: ƒ Medical Examiner from OCME; ƒ Local funeral directors; ƒ Territorial Registrar at OVS; ƒ Planner from GMHA; ƒ Preventive Medicine of USNH; ƒ Public Health Element of AAFB; and ƒ Members of the Guam Pandemic Planning Task Force, Executive Order 200611. The Mass Fatality Plan continues to be reviewed by DEH, and was tested through a table-top exercise on July 19, 2006. The Mass Fatality Plan’s viability will truly be tested only upon its actual implementation. Unlike other disaster response and recovery efforts which are generally shorter in time span, a pandemic influenza is anticipated to be of a long duration with increasing and consistent demand on resources. Since it is expected that most fatal influenza cases will seek medical services prior to death, hospitals, nursing homes, and other institutions must be capable of rapidly processing corpses. These institutions must develop their own internal plans for a pandemic influenza and work with DPHSS Guam Pandemic Influenza Plan 10-4 and OCME to ensure they have access to additional supplies (e.g., body bags) and can expedite the steps, including the completion of required documents necessary for efficient corpse management during a pandemic. In order to deal with the increase in fatalities, it may be necessary for funeral homes to establish their own temporary holding facility for corpses needing embalming, cremation, or burial. If funeral directors are unable or unwilling to handle the increased number of corpses, DPHSS will be responsible for initiating and implementing appropriate measures, including the institution of powers granted under the Islan Guahan Emergency Health Powers Act. The Government of Guam may partner with privately owned and operated providers related to this response effort to augment their manpower and equipment to support the continuation of their operations should their resources be exhausted or overwhelmed. Prior to activating this partnership, a determination of need shall be made by the DEH Administrator who will provide a status report to the DPHSS Director who will present the need to PHA (in the event the DPHSS Director is not appointed as the PHA) at EOC for further disposition. In addition, private entities as well as volunteers will be utilized to the greatest extent practicable. SECTION 2.2 PREPARATIONS FOR FUNERAL DIRECTORS AND CREMATORIUMS OF GUAM There are six funeral homes in Guam with five morticians (Attachment 10-C); however, two morticians are military personnel and it would be expected their services may be limited to military activities during a pandemic. The funeral home industry should plan to manage a projected six months of work within a six to eight week period during a pandemic. All funeral directors are expected to develop their own internal plans for addressing the increase in number of corpses during a pandemic. Such plan should include the procurement and storage of supplies (e.g., fluids, body bags, and caskets); contingency plan for what would happen if they were incapacitated or overwhelmed; and the need for additional human resources for their operations to include, but not limited to, embalming, cremating, and digging graves. Crematoriums will also need to look at the surge capacity within their facilities. Crematoriums should be able to handle at least one body every four hours and should plan to operate on a 24 hours basis to cope with the increased demand. This may be an alternative manner of managing the increased number of corpses during a pandemic. SECTION 2.3 OFFICE OF THE CHIEF MEDICAL EXAMINER AND AUTOPSIES OCME is responsible for the autopsies and certifications of death of individuals dying at home, from foul play, and under nonhospital care. OCME has the ability to store nine bodies in its morgue facility and acts as a repository to accept the overflow of dead bodies from GMHA when its own morgue exceeds its capacity of twelve. Thus, OCME and the GMHA combined can accommodate the temporary storage of 21 corpses. The morgue of the USNH can manage 24 dead bodies at maximum capacity. The majority of deaths during a pandemic would not require autopsies since autopsies are not indicated for the confirmation of influenza as the cause of death. However, for the purpose of public health surveillance (e.g., confirmation of the first cases at the Guam Pandemic Influenza Plan 10-5 start of the pandemic), respiratory tract specimens or lung tissue for culture or direct antigen testing could be collected postmortem. Serological testing is not optimal but could be performed if 8-10 mL of blood can be collected from a subclavian puncture post-mortem. In accordance with 10GCA §19602, a Medical Examination and Testing may be performed. During a pandemic, DPHSS will seek ongoing consultation of the Chief Medical Examiner for any proposed changes to the regular practices pertaining to the management of corpses as it relates to autopsy requirements. In cases where the death is reportable to OCME, the usual protocols shall prevail based on Guam law. When the Mass Fatality Plan is activated and implemented, the necessary public announcements will be made to educate and inform the public on when a body will and will not be autopsied. The JIC EOC shall be responsible with issuing public advisories related to this effort. SECTION 2.4 PLAN FOR TEMPORARY MORGUES DEH will take the lead in the effort to identify vendors of refrigeration containers and cold storage facilities as additional temporary cold storage facilities will be required during a pandemic for the storage of corpses. Arrangements will be made for establishing temporary morgues based on availability of resource requirements. The resource requirements (e.g., body bags and refrigeration containers) and supply management for temporary morgues will also be addressed. If the body will not be cremated, expedited embalming process will be necessary considering that bodies will likely be stored for an extended period of time. A temporary morgue must be maintained ideally at 36 0F to 40 0F (2.2 - 4.4 0C); however, if a temporary morgue cannot reach such temperature range, 40 0F to 45 0F (4.4 - 7.2 0C) is acceptable. The types of temporary cold storage to be considered will include refrigerated containers and vehicles, and cold storage lockers. An ice skating rink is another alternative for housing decedents. Without stacking the bodies, a refrigerated 40-ft container can generally hold 20-25 bodies without shelving. To increase storage capacity, temporary wooden shelves can be constructed of sufficient strength to double the capacity to 40-50 bodies. Shelves should be constructed in such a way that allows for safe movement and removal of bodies (i.e., storage of bodies above waist height is not recommended). Containers and trucks with markings of a supermarket chain or other companies will be avoided to the greatest extent practicable since the use of such trucks for the storage of corpses may result in negative implications for continuity of business. Furthermore, utilization of local businesses for the storage of human remains will be considered as a last resort. Dry ice (carbon dioxide frozen at -78.5 0C) may also be utilized for storage of corpses; however, cost and availability may prohibit its extended use. When using such method, groups of 20 bodies are surrounded by a low wall of dry ice (about 1.5 ft high) and covered with a plastic sheet, tarpaulin, or tent. Dry ice should never be placed on top of bodies, even when wrapped, since it may damage the body. About 22 lbs. (10 kg) of dry ice per body, per day is usually needed, pending on outside temperature. Because dry ice produces carbon dioxide when it sublimates (“melts”), its use should only occur in a well-ventilated room or building. Ice should be avoided since large quantities are needed and melting ice may produce contaminated wastewater that may also damage the corpses. Guam Pandemic Influenza Plan 10-6 SECTION 2.5 PLAN FOR TEMPORARY MORTUARY The mass processing of dead bodies at a centralized location, which will be operated by the Government of Guam with the possible assistance from DoD or other designated entities, will occur when local funeral homes are unable or unwilling to meet the demands of embalming, cremating, casketing, and/or burying dead bodies. Within this temporary mortuary facility, bodies will be documented, embalmed (or transported to a crematorium if still possible), dressed, casketed, and arranged for their final disposition. However, certain step or steps may be modified, limited, or ceased altogether depending on resources or time constraints. In a worst-case scenario when the temporary mortuary becomes overwhelmed with a large number of corpses and resources are severely strained to meet the demand, corpses will be immediately casketed or bagged and then buried at a designated site and manner determined by DPHSS. Psychosocial and possibly religious and cultural support to the families of the deceased may be provided at the temporary mortuary facility. These support personnel will assist the family in coping with the death of their loved ones and assist the temporary morgue in the dissemination of pertinent information. They will further assist the morticians of the facility by collecting articles of clothing the family wishes to dress the deceased when a temporary mortuary becomes operational for the mass embalming of dead bodies. SECTION 2.6 CAPACITY AND ACCESS TO TEMPORARY HOLDING FACILITY A temporary dry holding facility may be required for embalmed remains if burials cannot be performed within a reasonable time. Such holding site may be situated in or near the designated temporary mortuary; however, it should ideally be close to the cemetery as reasonably possible. Furthermore, the temporary holding facility needs to be secured with necessary degree of security to prevent unauthorized access. SECTION 3.0 ADDITIONAL TECHNICAL AND LOGISTICAL CONSIDERATIONS The temporary morgue and mortuary operations of the CPC will require the implementation of supporting technical and logistic activities for the facility’s processing of decedents. These essential activities in the management of dead bodies include the issuance of death certificates, implementation of infection control measures, transporting and disposing of decedents, procurement and storage of materials and supplies, seeking of federal assistance, acquisition and activation of necessary communication, and the selection of alternate CPC in the event the Dededo Sports Complex becomes unavailable. SECTION 3.1 DEATH REGISTRATION In Guam, the pronouncement of death is primarily the responsibility of a licensed medical doctor, but it may be performed by a licensed nurse practitioner for a terminally ill patient who dies under his/her care at a hospice. The Chief Medical Examiner is the only one who can issue certification of death, unless the person dies of natural causes at a hospital and who has been admitted for more than 24 hours. In such a case, the decedent’s doctor may certify the Guam Pandemic Influenza Plan 10-7 death. During a pandemic, authorization to perform certification of death will be expanded to include authorized licensed medical physicians as determined by the Chief Medical Examiner. OCME must create and retain a current list of such authorized licensed medical physicians. All deaths occurring in Guam require the filing of the original “Certificate of Death” form with OVS to be officially acknowledged and documented. The form is commonly identified and called a death certificate. Blank death certificates are provided to GMHA, USNH, and OCME by OVS. GMHA, USNH, or OCME representative types relevant information about the deceased on the certificate before it is submitted to Vital Statistics. It is on this form that pronouncement and certification of deaths are formalized through the signature(s) of applicable practitioner(s). Original death certificates are filed and maintained by OVS. Certified copy(ies) of the death certificate is issued to families and/or funeral homes. Such certified “Certificate of Death” is printed on specialized safety paper and embossed with the seal of the Territorial Registrar. During a pandemic situation, with an increased number of deaths, a body collection plan will be implemented to ensure there is no unnecessary delay in moving a body to the morgue. If the person’s death does not meet any of the criteria for needing to be autopsied or further examined by the Chief Medical Examiner, then the body will be moved to a holding area soon after the pronouncement of death by a designated physician. Funeral directors will be prohibited from collecting a body from the community or an institution until there is a completed certificate of death filed with OVS. In the event of a pandemic with numerous deaths, it will be necessary for the DPHSS Director to implement a plan allowing the completion and issuance of death certificates in a timely and efficient manner. SECTION 3.2 INFECTION CONTROL WHO’s “Influenza A (H5N1): Interim Infection Control Guidelines for Health Care Facilities” indicates that embalming may be performed routinely. Thus, special infection control measures are not required for the handling of persons who died from influenza. Funeral homes are recommended to implement universal precautions for embalming of all dead bodies. In the event that infection control recommendations change for the handling of corpses, funeral homes, morticians, and others working in the field will be notified by DPHSS as soon as changes occur. Designated personnel tasked to transport and process dead bodies, exclusive of embalmers, will be provided appropriate personal protection equipment, personal hygiene and sanitizing supplies. It is the responsibility of DPHSS to place restrictions on the type and size of public gatherings if this seems necessary to reduce the spread of disease. This may apply to funerals and religious services. If families are permitted to view the body, they should be provided disposable gloves and masks. Families requesting cremation of their deceased relative are much less likely to request a visitation, thus reducing the risk of spreading influenza through public gatherings. SECTION 3.3 TRANSPORTATION OF HUMAN REMAINS No special vehicle, driver license, or permit is needed for transportation of a corpse in Guam, provided the deceased did not die of the plague, smallpox, cholera, yellow fever, Guam Pandemic Influenza Plan 10-8 typhus fever, typhoid fever, or anthrax. Therefore, there will be no restrictions of families transporting bodies of family members who die of influenza. DPHSS will coordinate and utilize its own resources of Government of Guam agencies’ personnel and vehicles in the event family members or another entity cannot perform the collection and transportation of a corpse. SECTION 3.4 SUPPLY MANAGEMENT OF MORTUARY OPERATION DPHSS is recommending to funeral directors that they not order excessive amounts of supplies, such as embalming fluids, body bags, etc., but that they have enough on hand in a rotating inventory to handle the first wave of the pandemic; that is enough for six months of normal operation. Fluids can be stored for years, but body bags and other supplies have a limited shelf life. Cremations generally require fewer supplies since embalming is not required. A list of current suppliers is provided in Attachment 10-D. Families having multiple deaths are unlikely to be able to afford multiple higher-end products or funeral arrangements. Funeral homes could quickly run out of lower-cost items (e.g., inexpensive caskets such as cloth and some wooden caskets) and should be prepared to provide alternatives. DPHSS will allow the use of durable body bags, cardboard cremation caskets, and other materials that will prevent the leakage of fluids in place of standard commercial caskets when necessary. To assist families and private enterprises address a potential shortage of caskets, DPHSS recommends specifications for the construction of wooden caskets as illustrated in Attachment 10-E. SECTION 3.5 LAND AND SEA BURIALS All burials of corpses in Guam require “Burial-Transit Permit”, aka Disposition Permit, from OVS. For burials at sea, approval must also be obtained from the Guam Environmental Protection Agency (GEPA). This alternative burial will require sea-going vessels of appropriate specifications to handle large number of bodies. Guam has a total of fifteen known cemeteries. Two are public cemeteries while the remaining thirteen are owned by various families, religious denominations, and commercial entities (Attachment 10-F). Vicente Limtiaco Cemetery (Tiguac) in Nimitz Hill and Veteran’s Cemetery in Piti are the two public cemeteries. Limtiaco Cemetery accepts the burial of any dead body for a fee, but Veteran’s Cemetery is limited to only veterans and their dependent spouse. Both public cemeteries are under the authority of DPR; however, the operation of the Veteran’s Cemetery is in the process of being transferred to the U.S. Veteran’s Administration. Thus, Vicente Limtiaco Cemetery is the only cemetery readily available for use by the Government of Guam for burying human remains. Limtiaco Cemetery is approximately 30 acres in total land size; however, only a third of the area is usable for burials. About nine acres are currently occupied with ~3000 bodies and only 120 grave sites available. An alternate site for burial must be identified and prepared if death toll (~8,000) equaling to that of the pandemic of 1918 is assumed. According to DPR, another location for the use of a public cemetery has yet to be finalized. SECTION 3.6 CREMATORIUMS There are two crematoriums on Guam, one Guam Pandemic Influenza Plan 10-9 in Yona at Our Lady of Peace and the other in Sinajana at Ada’s Funeral Home. Each crematorium is capable of cremating one body every 4 hours for total of 6 bodies in a 24-hour period. However, as discussed on July 19, 2006 with the operators of the crematoriums during a Table Top Exercise, a total of 10 corpses can be cremated at the two facilities when operating continuously. Standard cremation involves the use of corrugated cardboard casket to hold the body as it is cremated. This disposable casket is used to retain leakage of bodily and embalming fluids. If necessary, the cardboard caskets may be replaced with body bags that do not contain chlorides and carbons, which pollute the air and damage the cremation chamber. The continuous operation of the furnace will require necessary maintenance and the availability of LP gas to run the furnace. Crematorium operators must include the procurement and storage of these and other supplies and materials in their own pandemic plan. SECTION 3.7 TRANSSHIPMENT OF CORPSE OFF-ISLAND DPHSS does not anticipate restricting the transshipment of dead bodies for off-island burials, provided such bodies have been effectively embalmed. In all likelihood, such restriction or limitation may come from the airlines as availability of space and flights are expected to decrease. Family members who wish to have their loved ones buried off-island, but unable to do so during the period of pandemic, may consider having the bodies buried in Guam in a sound casket. These bodies may later be exhumed for transport off-island, assuming no mass burials were conducted. Additionally, the Government of Japan has an international rescue team that can be activated to transport remains from Guam to Japan if authorized to land on Guam at either GIAA or AAFB. The Government of Guam, EOC would need to request this aid from the Government of Japan. However, approval depends on the situation and is to be handled on a case by case basis. Reference, Japan Consulate Representative shared this possible resource during the July 19, 2006 Table Top Exercise on Mass Fatality. SECTION 3.8 ASSISTANCE FROM DISASTER MORTUARY OPERATIONAL RESPONSE TEAM (DMORT) When the capacity of local jurisdiction to manage mass fatalities is exceeded and the CPC is activated, DPHSS will coordinate with EOC for DoD via DHHS to assist in providing mortuary services; establishing temporary morgue facilities; and processing, preparing, and the proper disposition of dead bodies through the Emergency Support Function #8 (ESF #8). Under ESF #8, Disaster Mortuary Operational Response Team (DMORT) may be activated, which consists of voluntary staff of private citizens with expertise in mass fatalities that are activated in the event of disaster, such as public health emergency. Guam cannot solely rely on the aid of DMORT and other off-island entities during a pandemic to address mass fatality when an entire nation will be seeking similar assistance from DHHS. An alternative to DMORT assistance is to request support from DoD forces stationed on the island. This request for military assistance will be made through EOC under the direction of PHA. DPHSS will seek their assistance to improve the department’s capability to implement this plan for the management of mass fatalities. Guam Pandemic Influenza Plan 10-10 SECTION 3.9 COMMUNICATIONS The necessary communication devices for the operation of the CPC, and its personnel, will consist of the following: ƒ Standard land-lines, inclusive of TTY, facsimile and hotline; ƒ Internet connectivity; ƒ Push-To-Talk iConnect radios equipped with cellular capability; and ƒ DSC’s mobile two-way radios and handheld radios. The Government of Guam agencies that will take a primary role in this response operation will be required to provide a periodic updates of their iConnect numbers, two way radio frequency and handheld radio frequency. The quarterly updates will be transmitted to DEH to update accordingly to be prepared for a recall upon activation. DSC will include in their contract for radio services, the provision to relocate their radio antenna to the CPC (Dededo Sports Complex) or other location as directed by DSC. The quarterly reporting will be shortened and requested by DEH once Guam is in WHO Phase 5. Upon notification to activate the CPC, a request will be made to the GTA to install the necessary communication lines. In addition, the antenna of DSC’s mobile twoway radios will be relocated from the office of DSC to the CPC (Dededo Sports Complex). Additional support for telecommunications will be coordinated through EOC. SECTION 3.10 FACILITY RESOURCES The following considerations were taken into account when selecting the Dededo Sports Complex and the same consideration should be taken into account if an alternate site is to be chosen. ƒ Size of the facility to conduct the full processing of dead bodies, which include administrative processing, embalming, dressing, casketing, and temporary storage of corpses for burials. ƒ Structural capability (plumbing, electrical, ventilation, and telecommunication needs; protection from weather, including typhoons; etc.). ƒ Location (accessibility by government vehicles and personnel; proximity to other facilities, such as the hospital, Temporary Refrigeration Morgue (TRM), and cemetery; psychosocial effects to nearby residents; etc.). ƒ Security to control access and prevent unauthorized entry. To ensure proper facility resources is afforded the personnel and public accessing the CPC, several key operational and logistical requirements would be needed. For example, ƒ Acquisition, installation, refueling and maintenance of a generator in case of loss of power; ƒ Acquisition and delivery of “water buffalo” or other water storage tank/container to ensure adequate water supply; ƒ Installation of exterior lighting around the perimeter of the facility; ƒ Acquisition of portable chemical toilets with service provision for use by the general public; Guam Pandemic Influenza Plan 10-11 ƒ Acquisition and erection of exterior canopy for public protection against the natural elements; ƒ Acquisition of large industrial fans for proper air circulation within the CPC; ƒ Procurement of three photocopying machines with facsimile, scanning and printing from network system for the CPC; ƒ Procurement of laundry services for the CPC to include a provision of personnel to have their clothing laundered; ƒ Procurement of copy paper; ƒ Procurement of three meals beverages per eight hour shift; and and ƒ Other items will be identified by the lead entity, DEH and forwarded to DPHSS Director for transmittal to EOC for proper procurement of other supplies and materials necessary for the operations of the CPC. SECTION 3.11 EMPLOYEE ASSISTANCE PROGRAM In the event it becomes compulsory for personnel to remain on the premises and are not able to return home for rest due to the overwhelming and urgent need to remain on location, provisions for personnel will be provided to assist with their basic personal needs. A shower area will be provided with proper hygienic items for showering. Laundry services for the CPC personnel will be provided for those who remain on site for more than a single shift of eight hours. Duty meals and beverages will also be provided. In addition, web cam and phone connectivity will be afforded for personnel to communicate with their families while on rest status. No employee will be allowed to work more than 12 consecutive hours per shift. Each rest period will be for no more than eight hours. The sleep plan will be implemented by the DEH Administrator. Psychosocial support for personnel will be provided through the psychosocial component of Guam’s plan in response to a pandemic. SECTION 4.0 RELIGIOUS AND CULTURAL CONSIDERATIONS A number of religious and ethnic groups have specific directives about how bodies are managed after death, and such needs are considered as a part of the management of mass fatalities. As a result of these special requirements, the assistance of Catholic Church and other common religious groups on Guam may be sought in the implementation of the Mass Fatality Plan. SECTION 5.0 ACTIVATION AND IMPLEMENTATION The actual implementation of the Mass Fatality Plan will begin when morgue space at GMHA becomes unavailable, which will likely occur in Phase 6 of the pandemic phase, and the CPC is already activated. The TRMs will be positioned at the CPC. At the CPC, all procedures in the processing of dead bodies will be performed in a centralized site operated by the Government of Guam and any other designated entity. Bodies will continue to be documented, embalmed (or transported to a crematorium if still possible), dressed, casketed, and arranged for final disposition. The CPC will modify, limit, or cease certain step or steps depending on available resources or time constraints. For example, intravenous embalming may be replaced or performed in conjunction with external (topical) embalming if embalming fluids become scarce or the need to quickly embalm corpses become necessary. In a worst-case scenario when the CPC is overwhelmed with a large number of remains that cannot be Guam Pandemic Influenza Plan 10-12 processed, bodies will be immediately casketed or bagged without the normal embalming and then buried at a site and manner determined by the CPC. The CPC may provide psychosocial, religious and cultural support to the families of the deceased at the facility. These support personnel will assist the family in coping with the death of their loved ones and assist in the dissemination of information. The Mass Fatality Plan will require periodic updating of relevant operational information such as contact numbers, verifying the continual usability of the designated sites of operations, updating inventory and/or distribution of supplies, procuring materials, identifying and training applicable personnel, and leasing of equipment. It is the intent of this plan to manage dead bodies as it is currently practiced during an interpandemic phase as best as possible. As resources become limited or unavailable, the Mass Fatality Plan will initiate actions to restrict, or cease altogether, certain activities normally performed in the handling and disposition of corpses Guam Pandemic Influenza Plan 10-13 SECTION 5.1 WHO PHASE 1: INTERPANDEMIC PERIOD A. Review and revise, as necessary, the multi-agency MOA between Government of Guam (DPR, DPW, and DPHSS) and GHS/OCD for coordination and support in response to mass fatality as a result of a influenza pandemic. Refer to Attachment 10-G. B. DPR, DPW, and DPHSS shall submit an annual report to GHS/OCD on the following: 1. 2. 3. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of personnel of heavy machinery operators and maintenance personnel from the Highway Safety Division c. Listing of fleet of functional buses under Bus Operations Division d. Listing of personnel from Bus Operations Division e. Listing of personnel from Transportation Maintenance Division DPR: a. Listing of functional heavy machinery for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of departmental personnel c. Identify alternate public burial site d. Provide update as to status of the public burial site for use DPHSS: a. Listing of DEH personnel to be assigned to this effort b. Listing of individuals to perform emergency embalming c. Listing of DSC personnel to be assigned to this effort d. Listing of vehicle fleet under DSC Transportation Services Program e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities OHS/OCD shall compile the reports and provide the report to the DPHSS Director who shall transmit a copy to DEH Administrator. C. The DPHSS Director shall coordinate within his/her department for administrative and support staff to be detailed periodically to OVS to be trained in completing the various certificates issued through this office with emphasis on Certificates of Death and BurialTransit Permits. D. OVS shall ensure sufficient number of Certificates of Death forms is in stock and shall consider an alternate form in the event of an influenza pandemic. The DPHSS Chief Public Health Officer (CPHO) shall ensure this provision is complied with. E. DEH Administrator shall identify and request for the procurement of equipment DPHSS Guam Pandemic Influenza Plan 10-14 should acquire for mass fatality operations as part of the department’s state of readiness in response to a public health emergency, such as influenza pandemic. DEH Administrator shall identify within DPHSS three laptops, 10 compatible digital cameras, three external 1GB external drives, three printers, facsimile machine and activation of cellular phone with unlimited service plan are available. F. The forms for the operation of the CPC shall be printed through a contractor as forms are to be printed in triplicates or quadruplicates. The forms to be used in the operation of the CPC are as follows and shall be maintained on three flash drives and on the hard drive of three laptops by DEH Administrator as a back up: 1. 2. 3. 4. Corpse Transportation Form (CT Form). Refer to Attachment 10-H. Corpse Processing Form (CP Form). Refer to Attachment 10-I. Corpse Processing Log Sheet. Refer to Attachment 10-J. Certificate of Death. Refer to Attachment 10-K. G. The “TRM Kits” for the Temporary Refrigeration Morgue Teams are packaged. The TRM Kits will be prepared and maintained by DEH. Each kit will include, but may not be limited to: 1. 2. 3. 4. 5. 6. Key or combination to open the designated TRM and/or TRV’s Corpse Processing Forms (CP Form) and Corpse Processing Log Sheets Certificates of Death Contact numbers of applicable personnel and facilities Pens, pencils, permanent markers, and paper Personal protection equipment (masks, gloves, boots, hand-sanitizers, and other personal protection and hygiene supplies) 7. Disinfecting solution, spray, and/or wipes H. The “CTT Kits” for Corpse Transportation Team (CTT) are created. The CTT Kits will be prepared and maintained by DEH. Each kit will include, but may not be limited to: 1. 2. 3. 4. 5. 6. 7. 8. 9. Personal protection equipment (masks, gloves, boots, overalls, hand-sanitizers, etc.) Corpse Transportation Forms (CT Form) Corpse Processing Forms (CP Form) Blank photocopies of Certificates of Death Pens, pencils, and permanent markers Street maps of Guam Body bags Clipboards Disinfecting solution, spray, and/or wipes I. The “TRM Kits” for the Temporary Refrigeration Morgue Teams and the “CTT Kits” for the Corpse Transportation Team are to be examined every two years, or as necessary, to ensure readiness for use. Guam Pandemic Influenza Plan 10-15 J. DEH Administrator shall review the corpse processing steps at the CPC (Attachment 10-L) and identify individuals to be assigned to perform internal and/or external embalming of dead bodies when necessary to supplement the current and active certified morticians. SECTION 5.2 WHO PHASE 2: INTERPANDEMIC PERIOD A. DPR, DPW, and DPHSS submit a semi-annual report to GHS/OCD on the following: 1. 2. 3. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of personnel of heavy machinery operators and maintenance personnel from the Highway Safety Division c. Listing of fleet of functional buses under Bus Operations Division d. Listing of personnel from Bus Operations Division e. Listing of personnel from Transportation Maintenance Division DPR: a. Listing of functional heavy machinery for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of departmental personnel c. Identify alternate public burial site d. Provide update as to status of the public burial site for use DPHSS: e. Listing of DEH personnel to be assigned to this effort f. Listing of individuals to perform emergency embalming g. Listing of DSC personnel to be assigned to this effort h. Listing of vehicle fleet under DSC Transportation Services Program i. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities OHS/OCD shall compile the reports and provide the report to the DPHSS Director who shall transmit a copy to the DEH Administrator. B. DPR shall take the necessary steps to finalize the alternate land site for public burial purposes. SECTION 5.3 WHO PHASE 3: PANDEMIC ALERT PERIOD A. DPR, DPW, and DPHSS shall submit a quarterly report to GHS/OCD on the following: 1. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land; Guam Pandemic Influenza Plan 10-16 2. 3. digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of personnel of heavy machinery operators and maintenance personnel from the Highway Safety Division c. Listing of fleet of functional buses under Bus Operations Division d. Listing of personnel from Bus Operations Division e. Listing of personnel from Transportation Maintenance Division DPR: a. Listing of functional heavy machinery for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of departmental personnel c. Identify alternate public burial site d. Provide update as to status of the public burial site for use DPHSS: a. Listing of DEH personnel to be assigned to this effort b. Listing of individuals to perform emergency embalming c. Listing of DSC personnel to be assigned to this effort d. Listing of vehicle fleet under DSC Transportation Services Program e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities OHS/OCD shall compile the reports and provide the report to the DPHSS Director who shall transmit a copy to the DEH Administrator. B. The flow chart of the CPC operation, identifying areas for administrative processing, corpse processing and storage, and transporting of corpses at a minimum, is reviewed and revised every January of each year, as necessary by the DEH Administrator. DEH Administrator shall transmit changes to the operation to the affected external entities and internal divisions of DPHSS. C. The Chief Medical Examiner will identify and train licensed medical doctors who can assist OCME to pronounce and certify deaths outside hospital settings. D. Each TRM Team will be comprised of two individuals. Each team will be scheduled to work an eight hour shift, unless otherwise directed. The number of teams assembled will be determined by the DEH Administrator. The source of personnel for the teams shall be from the primary government entities and volunteers identified to operate the TRM. Teams will be identified by position title from the quarterly reports received from GHS/OCD via the DPHSS Director to DEH Administrator. E. Each CTT will be comprised of three individuals, a driver and two assistants. Each team will be scheduled to work an eight hour shift, unless otherwise directed. The number of teams assembled will be determined by the DEH Administrator. The source of personnel for the teams shall be from the primary government entities and volunteers identified to transport corpses. Teams will be identified by position title from the quarterly reports received from Guam Pandemic Influenza Plan 10-17 GHS/OCD via the DPHSS Director to DEH Administrator. F. The DEH Administrator shall conduct a training course on the management of mass fatality operations with primary government entities and volunteers within 60 days of entering Phase 3 as guided by WHO. The course shall include TRM Team, CTT, and Customer Service Representatives in their respective duties and responsibilities in preparation for their possible activation. At a minimum, they will be instructed on completing applicable forms; operating laptop, printer, and digital camera; and fingerprinting corpses. Additional training shall be conducted as the need is identified. SECTION 5.4 WHO PHASE 4: PANDEMIC ALERT PERIOD A. DPR, DPW, and DPHSS shall submit a monthly report to GHS/OCD on the following: 1. 2. 3. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of personnel of heavy machinery operators and maintenance personnel from the Highway Safety Division c. Listing of fleet of functional buses under Bus Operations Division d. Listing of personnel from Bus Operations Division e. Listing of personnel from Transportation Maintenance Division DPR: a. Listing of functional heavy machinery for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of departmental personnel c. Identify alternate public burial site d. Provide update as to status of the public burial site for use DPHSS: a. Listing of DEH personnel to be assigned to this effort b. Listing of individuals to perform emergency embalming c. Listing of DSC personnel to be assigned to this effort d. Listing of vehicle fleet under DSC Transportation Services Program e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities OHS/OCD shall compile the reports and provide the report to the DPHSS Director who shall transmit a copy to the DEH Administrator. B. The DEH Administrator shall convene a meeting of all primary government entities to dialogue on the state of preparedness in comparison to the flow chart of the CPC operation identifying areas for administrative processing, embalming, dressing and casketing of corpses, temporary storage, transporting of corpses and personnel assignments. Guam Pandemic Influenza Plan 10-18 C. The Chief Medical Examiner shall transmit the list of trained licensed medical doctors who will assist OCME to pronounce and certify deaths outside hospital settings to GHS/OHS who in turn shall transmit the list to the DPHSS Director. The DPHSS Director shall provide a copy of the list to the DEH Administrator. D. The DEH Administrator shall conduct a training course on the management of mass fatality operations with primary government entities and volunteers within 45 days of entering Phase 4 as guided by WHO. The course shall include TRM, CTT, and CSR teams in their respective duties and responsibilities in preparation for their possible activation. At a minimum, they will be instructed on completing applicable forms; operating laptop, printer, and digital camera; and fingerprinting corpses. Additional training shall be conducted as the need is identified in this phase since it is unknown how long each phase will last. SECTION 5.5 WHO PHASE 5: PANDEMIC ALERT PERIOD A. DPR, DPW, and DPHSS shall submit a weekly report to GHS/OCD on the following: 1. 2. 3. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of personnel of heavy machinery operators and maintenance personnel from the Highway Safety Division c. Listing of fleet of functional buses under Bus Operations Division d. Listing of personnel from Bus Operations Division e. Listing of personnel from Transportation Maintenance Division DPR: a. Listing of functional heavy machinery for clearing and grading of land; digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers) b. Listing of departmental personnel c. Identify alternate public burial site d. Provide update as to status of the public burial site for use DPHSS: a. Listing of DEH personnel to be assigned to this effort b. Listing of individuals to perform emergency embalming c. Listing of DSC personnel to be assigned to this effort d. Listing of vehicle fleet under DSC Transportation Services Program e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities OHS/OCD shall compile the reports and provide the report to the DPHSS Director who shall transmit a copy to the DEH Administrator. B. The DEH Administrator shall convene a meeting of all primary government entities to Guam Pandemic Influenza Plan 10-19 dialogue on the state of preparedness in comparison to the flow chart of the CPC operation identifying areas for administrative processing, embalming, dressing and casketing of corpses, temporary storage, transporting of corpses and personnel assignments. C. Upon completion of “B” above, each government entity shall provide written notice to their personnel of their anticipated assignment to the CPC. In addition, the GHS/OCD shall transmit a memorandum to each affected employee to further formalize the intent of the plan. This memorandum will further identify and acknowledge their duties and responsibilities in the event the Mass Fatality Plan is implemented. D. The Chief Medical Examiner shall transmit an updated list of trained licensed medical doctors who will assist OCME to pronounce and certify deaths outside hospital settings to GHS/OHS who in turn shall transmit the list to the DPHSS Director. The DPHSS Director shall provide a copy of the list to the DEH Administrator. E. The DEH Administrator shall conduct a training course on the management of mass fatality operations with primary government entities and volunteers within 30 days of entering Phase 5 as guided by WHO. The course shall include TRM, CTT, and CSR teams in their respective duties and responsibilities in preparation for their possible activation. At a minimum, they will be instructed on completing applicable forms; operating laptop, printer, and digital camera; and fingerprinting corpses. Additional training shall be conducted as the need is identified in this phase since it is unknown how each phase will last. SECTION 5.6 WHO PHASE 6: PANDEMIC PERIOD A. GMHA shall notify EOC when morgue space at GMHA approaches maximum capacity and the need for additional space is anticipated. Morgue space at OCME will not be used to house deceased patients of GMHA. It is to be used for storing bodies requiring autopsy; however, this facility may be temporarily used to assist GMHA when absolutely necessary and the operation of OCME is not compromised. B. Upon notification by DPHSS RAC, CPC shall be activated for full operations within 72 hours. DEH will lead this operation and shall convene a meeting of all personnel identified to assist within three hours of activation. 1. All identified personnel shall report to the CPC (Dededo Sports Complex) upon being notified of their activation. 2. The CPC Manager shall convene a meeting of key agencies and stakeholders to prepare for the opening of the CPC. 3. The CPC Manager shall conduct on-site training of all personnel assigned to the CPC. 4. The CPC Manager shall identify a CPC Fiscal Manager to collaborate with DPHSS RAC Guam Pandemic Influenza Plan 10-20 in the coordination of the delivery of the TRM and initiate other procurement activities necessary for the full operations of the CPC. The CPC Fiscal Manager shall report directly to the CPC Manager. 5. The CPC Manager shall assess operations and determine when the Employee Assistance Program (EAP) shall be activated. The activation of this component of the CPC shall require personnel to work longer hours and remain on site. The EAP shall provide personnel support in the form of sleeping quarters, shower stalls, laundry, nourishment and telecommunications for personnel and their family, at a minimum. The CPC Manager may designate staff to implement the EAP. 6. The CPC Manager shall notify the psychosocial component of the operations and request they be prepared to staff the site upon receiving confirmation from him/her. C. The CPC Manager shall notify EOC once the CPC is ready to provide mortuary services. D. Upon notification from the CPC Manager is received, template(s) for public service announcements of telephone hotlines for the pickup and transport of dead bodies to the CPC is reviewed and revised, as necessary. Refer to Attachment 10-M. Once finalized, the announcement(s) is released to the public through the JIC, EOC with a copy faxed to the CPC to ensure coordination of services and to officially notify the CPC Manager that the public is now aware of their services. E. The CPC Manager or his designee shall telephonically notify the directors of island funeral homes once the CPC begins accepting dead bodies. They will be provided instructions for retrieving bodies from the CPC for funeral services. F. DPR, DPW, and DPHSS shall submit a daily report to the CPC Manager on the status of their heavy machinery for clearing of land and digging of graves, operators of such equipment, status of their fleet of vehicles, and an updated roster of bus drivers, as applicable. G. Federal assistance is sought from DHHS through EOC for the activation of DMORT to Guam. Guam Pandemic Influenza Plan 10-21 SECTION 6.0 STANDARD OPERATING PROCEDURES OF THE CORPSE PROCESSING CENTER All dead bodies delivered to the CPC by CTT or family members will be documented for the purposes of accountability and the issuance of death certificates, and then stored at the facility for their eventual disposition. CTT will provide transportation of dead bodies to and from the CPC. Depending on the origin and cause of death, the decedent may be examined, photographed, tagged, and fingerprinted. When the facility’s operation expands to provide mortuary services, the bodies may be embalmed; however, the CPC will modify, limit, or cease certain step or steps depending on available resources or time constraints. SECTION 6.1 CORPSE PROCESSING CENTER OPERATIONS A. The operation of the CPC shall be led by the CPC Manager, as designated by DPHSS Director or PHA. B. The TRM are manned and operated by the TRM Teams at the CPC. The TRM Teams are to document the receipt and release of all dead bodies at the temporary facility through the utilization of Certificate of Death, CP Form, Corpse Transportation Form (CT Form) and the Corpse Processing Log Sheet. C. Eight separate areas will be established in the CPC (refer to Attachment 10-L): 1. 2. 3. 4. 5. 6. 7. 8. Corpse Delivery Site, Intake Room, Examination Room, Psychosocial Room, TRM, Embalming Room Dressing and Casketing Room, and the Temporary Holding Room The security of the site will be maintained by designated personnel as determined by EOC. The Intake Room is to be occupied by the TRM Teams to interview family members and process documents. The bodies will be examined in the Examination Room by the medical examiner. Psychosocial Room will be used by designated social workers or other crisis workers of the helping profession to console and assist family members. The TRMs will store dead bodies while awaiting final disposition by funeral homes or medical examiner. D. The TRM Team using their assigned laptop and printer will key in and print all handwritten Certificates of Death of decedents that are prepared and delivered to the CPC by CTT that did not originate from GMHA, USNH, or OCME. The handwritten Certificate of Death prepared by CTT is “provisional” until such time the TRM Team transfers the information onto an official death certificate. Guam Pandemic Influenza Plan 10-22 E. Information necessary to complete the official Certificate of Death at the CPC by the TRM Team is obtained from the “provisional” death certificate prepared by CTT Team, or from family members who delivers the deceased to the CPC. Once the formal certificate is printed, it is forwarded to the medical examiner to officially pronounce and certify the death of the deceased. If suspicious death is suspected, the medical examiner will annul the printed certificate, by writing the word “VOID” in large letters across the form. The certificate is returned to the TRM Team, whether signed or voided, for transmittance to OVS. F. The corpses under suspect shall be transported to OCME for further disposition. G. CP Form is used to collect general information of the deceased and includes “Identification Placard”, “Toe Tag”, and “Fingerprint Card” that can be detached from the form along then perforated lines. The form, with the exception of the detachable attachments, comes in triplicate. The TRM Team will retain the original with the first copy going to OVS and the second copy to the family of the deceased. Each CP Form and its attachments are serialized. Identification Placard, Toe Tag, and Fingerprinting Card, which are also serialized, are used to document the identity of deceased through photograph and physical examination. H. CTT must complete the CP Form, Identification Placard, Toe Tag, and Fingerprint Card at the site where the body is collected. CTT must then place the Toe Tag on the toes of the right foot of the body and insert the Identification Placard inside the body bag with the body. If right foot is not available, then it is placed on the left foot. Fingers are to be used if toes are unavailable. I. CT Form is used by CTT to document the pick up and delivery of dead bodies. Corpse Processing Log Sheet is used to centralize the information of all dead bodies received and released by the TRM Team at the CPC. J. Bodies are processed in the order they are received in a “First-In, First Out” (FIFO) method. The medical examiner may prioritize the embalming of a particular body because of its advanced stage of decomposition. SECTION 6.2 PROCESSING OF DEAD BODIES A. Algorithm for the processing of dead bodies delivered to the CPC is presented in Attachment 10-N, and further detailed below: 1. Dead Body delivered to the CPC by family: a. Intake Room (1) The photo identification cards of the deceased and family member are examined to confirm identities. Guam Pandemic Influenza Plan 10-23 (2) The TRM Team completes the CP Form and the second copy of the form is provided to the family. (3) The name of deceased is written on the Identification Placard, Toe Tag, and Fingerprint Card on the CP Form. They are detached from the CP Form and provided to the medical examiner. (4) The Certificate of Death is completed with the assistance of family member and forwarded to the medical examiner for signature. After signed or voided by the medical examiner, the death certificate is stapled to the first copy of the CP Form to be forwarded to OVS. These documents must be filed in a secured location. (5) The original CP Form is stapled to the Fingerprint Card that is returned from the medical examiner and filed with the TRM Team and stored in a secured location. (6) The information of the deceased are recorded in the Corpse Processing Log Sheet. b. Examination Room (1) The body is placed on a gurney with assistance of available CTT or the TRM Team and wheeled into the Examination Room. (2) The toe tag is received from the TRM Team and placed on any of the digits of the right foot. If right foot is not available, then it is placed on the left foot. Fingers are to be used if toes are unavailable. (3) The Serialized Identification Placard is received from the TRM Team and placed on the chest of the deceased. A single photograph of the head and placard is taken. The medical examiner or designee ensures the serial number of the placard is visible in the photograph. (4) The body is examined to rule out foul play, fingerprinted, and bagged with the assistance of CTT or the TRM Team. The Identification Placard is placed inside the body bag. Corresponding serial number is written clearly in large print on the outside of the body bag near the foot of the bag. The date and cause of death are also written on the outside of the body bag. (5) The Fingerprint Card is returned to the TRM Team which will be attached to the original CP Form for filing in a secured location. (6) The body is wheeled out by CTT to the TRM for storage. 2. The dead body delivered by CTT that did not originate from hospital or coroner: a. Intake Room Guam Pandemic Influenza Plan 10-24 (1) The TRM Team will receive the completed CP Form, Fingerprint Card, and provisional Certificate of Death from CTT. (2) The TRM Team formalizes “Provisional” Certificate of Death received from CTT. The information is transferred into the computer and printed on to the official Certificate of Death. The certificate is then forwarded to the medical examiner for signature. (3) The Fingerprint Card is stapled together with the original CP Form and CT Form and filed by the TRM Team in a secured location. (4) The signed or voided Certificate of Death received from the medical examiner is stapled to the first copy of the CP Form for transmittal to OVS and filed in a secured location. (5) The information of the deceased is recorded in the Corpse Processing Log Sheet. b. Examination Room (1) The body is placed on a gurney with assistance of available TRM Team and wheeled into the Examination Room. (2) The number and name on the Identification Placard and the Toe Tag on the body is compared with the original CP Form received from CTT for the confirmation of identity. (3) The Identification Placard included with the dead body is placed on the chest of the deceased. The medical examiner or designee ensures the serial number of the placard is visible in the photograph. (4) The body is examined to rule out foul play. (5) The body is then bagged with the assistance of the TRM Team or CTT. The Identification Placard is placed inside the body bag. Corresponding serial number is written clearly in large print on the outside of the body bag near the foot of the bag. The date and cause of death are also written on the outside of the body bag. (6) CTT or the TRM Team will wheel out the body to the TRM for storage. 3. The dead body delivered by CTT from hospital or coroner: a. Intake Room Guam Pandemic Influenza Plan 10-25 (1) The completed CP Form, Fingerprint Card, and Certificate of Death are received by the TRM Team from CTT. (2) The original Certificate of Death is forwarded to the medical examiner for pronouncement of death, if not done so already by the attending physician. (3) The completed Fingerprint Card is stapled together with the original CP Form and CT Form and filed by the TRM Team in a secured location. (4) The signed Certificate of Death received from the medical examiner is stapled to the first copy of the CP Form that is transmitted to OVS and filed in a secured location. (5) The information of the deceased is recorded in the Corpse Processing Log Sheet. b. Examination Room (1) The body is placed on gurney with assistance of available TRM Team and wheeled into the Examination Room. (2) The identification Placard and Toe Tag inside the body bag is compared to the death certificate for confirmation of identity. (3) A photograph of the decedent is taken with Identification Placard placed on the chest of the deceased. The medical examiner or designee ensures the serial number of the placard is visible in the photograph. (4) The body is examined to rule out foul play. (5) The body is then re-bagged with the assistance of the TRM Team or CTT. The Identification Placard is placed back inside the body bag. Corresponding serial number is written clearly in large print on the outside of the body bag near the foot of the bag. The date and cause of death are also written on the outside of the body bag. (6) The CTT or the TRM Team will wheel out the body to the TRM for storage. B. The bodies examined by the medical examiner deemed suspicious as to the cause of death are transported to OCME for autopsy by CTT. C. All operational documents are filed in a secured location. D. The digital camera used to photograph bodies of deceased by the medical examiner is given to the TRM Team when its memory card is full. The camera is returned to the medical examiner after the TRM Team downloads the images into the hard drive of the laptop. The Guam Pandemic Influenza Plan 10-26 TRM Team creates backup file of the photographs by copying images into flash drive(s). Files are labeled and organized by the dates when the photographs were taken. E. The original Certificates of Death and corresponding copies of CP Forms are picked up by OVS for the processing and issuance of certified Certificates of Death and Disposition Permits to families. SECTION 6.3 DEATHS OCCURRING OUTSIDE THE HOSPITAL A. Individuals who die from influenza or other natural causes outside GMHA or USNH may be delivered directly to the morgue. Such transportation may be conducted by family members of the deceased or CTT may be contacted to pick up and transport the dead. This will not be applicable to suspicious death or foul play which will require the action and involvement of GPD and OCME or his designee. B. DPHSS will establish a telephone hotline for the public to call if they wish to have their dead family member(s) picked up by CTT for transport to the CPC. The hotline number will be disseminated to the public through public announcements issued by the JIC. The hotline and other public announcements will provide instructions on when, where, and how the dead bodies are to be delivered if performed by family members, refer to Attachment 10-M. 1. CTT personnel picking up dead bodies are to complete the CT Form, “Provisional” death certificate and the CP Form through the assistance of family member and photo identification card of the deceased. 2. CTT detaches the Toe Tag and Identification Placard from CP Form when the form is completed. The Toe Tag is attached to any of the digits of the right foot. If right foot is not available, then it is placed on the left foot. Fingers are to be used if toes are unavailable and then the body is bagged. The Identification Placard is inserted inside the body bag. The serial number of CP Form, possible cause of death and date are written on the outside of the body bag at the foot of the deceased. 3. A second copy of the completed CP Form is provided to family of the deceased. 4. Suspicious death is reported to GPD by CTT and the body is not collected. SECTION 6.4 OFFICE OF VITAL STATISTICS, DPHSS A. OVS will continue to operate from DPHSS central facility in Mangilao. The office will operate 24/7 when necessary, as determined by the DPHSS Director. B. Funeral homes are not permitted to pick up the Certificates of Death at GMHA, USNH, OCME, or the CPC when the Mass Fatality Plan is implemented. Instead, OVS will be Guam Pandemic Influenza Plan 10-27 responsible for picking up the Certificates of Death at the CPC. The frequency of visit by OVS to pick up these documents will be based on need, as determined by the Territorial Registrar in coordination with the TRM Team. C. The Territorial Registrar is to request for the activation of support staff to assist in the processing of Certificates of Death and Burial-Transit Permits when the need arises. Upon notification, designated personnel from DPHSS are to report to the Territorial Registrar to assist OVS. Work schedule for all personnel assigned to OVS is managed by the Territorial Registrar. D. OVS is tasked to contact applicable funeral home(s) selected by the family, as indicated in CP Form, when the death certificate is processed. Burial-Transit Permit (Attachment 10-O) is also prepared and released to the funeral home if the location of the burial/cremation is confirmed. OVS will contact the alternate funeral home if the selected primary provider is unable or unwilling to provide mortuary services. For whatever reason, if the alternate funeral home indicated in the CP Form is also unavailable to accept the body, OVS is to contact other mortuary providers. E. Family of a deceased person that cannot, or will not, seek the service of a funeral home will be required to release the corpse to DPHSS for proper disposition. DPHSS will determine such disposition and prepare the Burial-Transit Permit. F. OVS is to immediately notify DPHSS CPHO when funeral homes are collectively unable to accept decedents in a timely manner because of overwhelming number of deaths and limited resources. The DPHSS CPHO shall advise the DPHSS Director of this for further disposition. SECTION 6.5 MASS EMBALMING AND CASKETING OF DEAD BODIES A. The CPC is activated for mass embalming and casketing when the CPC Manager receives notification from EOC. B. DPHSS expands the operation of the CPC (Dededo Sports Complex) for mass embalming and casketing by establishing the facility in accordance to the floor plan and layout provided in Attachment 10-P. 1. Assistance will be requested from EOC to assist in the mobilization and establishment of resources for the activation of the CPC to perform mass embalming and casketing. 2. Upon direction from the public health authority, personnel to perform emergency embalming are contacted by DEH and instructed to report to the CPC. 3. Through collaboration with the JIC, DPHSS will issue public announcements (Attachment 10-Q) informing the public and funeral homes of the activation of the CPC Guam Pandemic Influenza Plan 10-28 for mass embalming and casketing of deceased. C. The embalming of the deceased will occur in the Embalming Room after the body is received from the Examination Room. 1. The Embalming Room is supervised by a licensed mortician, if possible. If none is available, then the CPC Manager shall assign one. 2. Bodies are embalmed intravenously and/or externally. F. The casketing of dead bodies will occur in the Dressing and Casketing Room after the body is received from the Embalming Room. 1. The Dressing and Casketing Room is supervised by a licensed mortician, if possible. If none is available, then the CPC Manager shall assign one. 2. The psychosocial group assigned to the CPC will assist the morticians of the facility by collecting articles of clothing the family wishes to dress the deceased when a temporary mortuary becomes operational for the mass embalming of dead bodies. G. Temporary Holding Room operated by CTT will be utilized as the temporary storage site of embalmed bodies awaiting transport to their final disposition site. SECTION 6.6 TRANSPORT OF EMBALMED BODIES CTT transports the embalmed bodies to the cemetery after receiving the Burial-Transit Permit from OVS. CT Form is used by CTT for recording deliveries to cemeteries. The form is submitted to the TRM Team upon returning to the CPC for recordation purposes. SECTION 6.7 FUNERAL HOME OPERATION A. Funeral homes will not be permitted to pick up the Certificates of Death from the hospital or the CPC for hand delivery to OVS once the Mass Fatality Plan is activated. OVS will instead retrieve the death certificates and contact the funeral homes when these certificates are processed and ready for release to the funeral homes. B. It is the responsibility of a funeral home to notify and educate individuals and family members with whom they have existing funeral contracts regarding the CP Form to ensure the families indicate the appropriate service provider in the form. C. A funeral home is to retrieve the Certificate of Death when contacted by OVS. If site of burial or cremation is already determined, the information is to be provided to OVS. Guam Pandemic Influenza Plan 10-29 D. A funeral home that accepts a body that was not accepted by primary and alternate providers listed in CP Form must contact the family of the deceased and notify them of the change. E. If the family of the deceased so wishes, funeral homes at a minimum are required to casket a body in a wooden casket that meets the specifications provided in Attachment 10-E. F. A funeral home that is no longer capable of continuing operation, or meet public demand, will notify OVS of the situation. SECTION 6.8 CEMETERY OPERATION A. Public cemetery is to be utilized for the burying of all deceased individuals that are not cremated or buried elsewhere. The DPHSS Director or the PHA shall activate individuals identified as emergency grave diggers in the event DPR is unable to provide personnel to perform such functions. As indicated in the Mass Fatality Plan, DPW and other identified entities will assist in this effort to include additional manpower and equipment resources. B. Through activation of the Emergency Health Powers Act and as indicated in the Executive Order issued by the Governor of Guam, when burial spaces become limited at the public cemetery, multiple family members may be buried in a single grave. Minimum distance between each grave may be shortened if necessary to maximize burial space. C. Mass burial will be implemented only when absolutely necessary, and if implemented, DPHSS in collaboration with DPR and DPW will make every reasonable effort to create and retain records of those buried under such condition and the locations of such burial site(s). Guam Pandemic Influenza Plan 10-30 8 Issuance of Death Certificate and Burial Permit Person authorized to perform task Casket 9 Funeral Services Availability of authorized person On-call system 24/7 Availability of caskets and urns Contact suppliers to determine lead time for casket and urn manufacturing and plan for rotating 6 month inventory Cremation urn Funeral Director Appropriate location Availability of location for service Determine capacity to provide service and and visitation identify additional sites Suitable vehicle and driver Availability of human and physical resources 10 Transportation to burial site or temporary holding facility 11 Temporary holding Access to and space of Capacity accessibility of temporary facility facility holding facility Grave digger 12 13 14 Availability of grave diggers Land Burial Identify alternate vehicles for transport, and consider using volunteer drivers Exand capacity by increasing sites in number and/or size Identify sources of additional workers to dig Space in cemetery Availability of space in cemetaries Identify available space to create cemetery Sea burial permit Availability of person authorized to issue burial permit Suitable sea-going vessel and captain Availability of sea-going vessels Determine capacity to provide service and and captains to perform the service identify additional vessels and captains Plan expedited burial permit processing Sea Burial Shipped or Flown Off-island Suitable airplane and Determine capacity to provide service and Availability of air flights or seasea-going vessel to identify alternative non-traditional means going vessels to perform the service transport of transport ATTACHMENT 11-2 (Page 2 of 2) LIST OF GUAM CEMETERIES Cemeteries Caustino (East Agana) Contact Name NOT IDENTIFIED Contact Number Space Available Ground Crypts Remarks NOT Unknown Unknown Baptist Church Cemetery IDENTIFIED Len Mayer (T): 734-9835 Guam Memorial Park, Inc. (Barrigada) 1500 20-30 Private, Commercial Cemetery Sheryl Simpkins Limtiaco Cemetery "Tiguac" (Nimitz Hill) Richard Richard (T): 475-6288 120 0 Public Cemetery; handled by the Department of Parks & Recreation New cemetery identified in Mangilao pending approval Martinez (Anigua) NOT IDENTIFIED NOT Private, Family Cemetery (Anigua Unknown Unknown behind KFC) IDENTIFIED Mt. Carmel Cemetery (Agat) Tony Babauta (T): 565-2758 Our Lady of Peace (Windward Hills) Perez (Yigo) 300 Joyce San (T): 633-8426/30 Nicolas, Funeral Director (C): 687-8437 NOT IDENTIFIED 0 1500 Private, Commercial Cemetery NOT Unknown Unknown Private, Family Cemetery IDENTIFIED Julie Materne (T): 477-9329 0 Janet Flores (T): 477-9745 50 Sherry Chargualaf (T): 828-8312 Juan Cruz (T): 828-8016 SDA Cemetery (Umatac) NOT IDENTIFIED NOT IDENTIFIED St. Joseph Cemetery (Inarajan) Ed Crisostomo (T): 828-2147/8 Inarajan Pigo Cemetery (Asan) 558 Frank Santos Rest Haven (Ipan) San Dimas Cemetery (Merizo) Crypts handled by Mayor's Office 0 41 Veteran's Cemetery (Piti) Mary Sanchez Umatac Mayor's Office Ground burial handled by San Dimas Catholic Church Located next to existing cemetery, but has not been used in years; overgrown with vegetation 0 Public Cemetery; handled by Inarajan Catholic Church 200 (T): 477-9329 0 76 Catholic Cemetery handled by the Archdiocese of Guam (T): 828-8258 0 60 Umatac Mayor's Office 300 Only for War Veteran's and their spouses; handled by the Department of Parks & Recreation - A number of crypts have structural damage, no number given. Julie Materne Umatac Cemetery (Umatac) Catholic Cemetery handled by the Archdiocese of Guam Private - handled by SDA Church (next to Ipan Public Beach) Frank Santos Togcha Cemetery (Yona) Catholic Cemetery handled by the Archdiocese of Guam Richard Richard (T): 475-6288 ANNEX 6 15 RECOMMENDED SPECIFICATIONS FOR WOODEN CASKET 25 ” ¾” Thk. Exterior Plywood D EN 17” 25 TO P 74 ” ” SI DE 17” 74 ” Ex ¾ ter ” T ior hk Pl . yw oo BO SI DE 74 ” TT O d M 17” D EN ¾” rope or strap 25 2” x 2” Bottom plate on four sides (Secure with finishing nails) ATTACHMENT 11-5 ” MEMORANDUM OF AGREEMENT BETWEEN THE DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES, DEPARTMENT OF PUBLIC WORKS, DEPARTMENT OF PARKS AND RECREATION, OFFICE OF CHIEF MEDICAL EXAMINER, AND OFFICE OF HOMELAND SECURITY/OFFICE OF CIVIL DEFENSE The purpose of this Memorandum of Agreement (MoA) is to establish a formal working relationship between the Department of Public Health and Social Services (DPHSS), Department of Public Works (DPW), Department of Parks and Recreation (DPR), Office of the Chief Medical Examiner (OCME), and Guam Homeland Security/Office of Civil Defense (GHS/OCD). This MoA is specific to the implementation of the “Guam Mass Fatality Management Plan for Pandemic Influenza” hereinafter referred to as the “Plan”. WITNESSETH WHEREAS, P.L. 26-173, “Islan Guahan Emergency Health Powers Act”, requires DPHSS to develop a comprehensive plan to provide for a coordinated, appropriate response in the event of a public health emergency, which includes the safe disposition of human remains; WHEREAS, Executive Order 2006-11, “Relative to the Protection of the Island in the Event of Pandemic and to the Creation of a Pandemic Planning Task Force”, directed DPHSS to co-chair the Pandemic Planning Task Force to develop a guide in preparing for and responding to a pandemic influenza; WHEREAS, during an influenza pandemic, Guam will have to be prepared to manage additional deaths over and above the number of fatalities from all causes currently expected during the interpandemic period; WHEREAS, in a worst-case scenario, Guam may expect deaths of approximately 8,400 individuals based on 5% fatality of the entire population similar to the 1918 Pandemic with the assumption that all such deaths are to occur over two pandemic waves, each lasting 6 to 8 weeks, that will result in the deaths of 75-100 individuals each day; WHEREAS, most influenza victims will have sought medical care and have been identified before dying in the hospital; however, many others will die in homes; WHEREAS, there will be an increase in (1) the demand of body bags to wrap the greater number of dead bodies in and outside of the hospital, (2) number of official pronouncement and certification of death by authorized individuals, and (3) the need of additional vehicles, stretchers, and applicable personnel to transport dead bodies from the sites of death to the morgue; WHEREAS, the Guam Memorial Hospital Authority, Office of Chief Medical ATTACHMENT 7 (1 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 2 of 11 Examiner, U.S. Naval Hospital, Guam and island mortuaries will not have the capacity to store the anticipated increase of human remains in and outside their facilities; WHEREAS, Guam mortuaries will not have the resources to conduct mass fatality operations, including administration, embalming, cremation, storage, and burial of corpses, and they will lose staff to illness, family illness, death, and refusal to work; WHEREAS, Federal assistance will be sought, but Guam cannot be assured that necessary support can or will be provided in timely manner; WHEREAS, part of the pandemic influenza response plan developed by DPHSS is for the management of mass fatality through the implementation of the “Mass Fatality Management Plan for Pandemic Influenza”; WHEREAS, the Dededo Sports Complex has been identified as the “Corpse Processing Center” (CPC) where all temporary processing and storage of human remains will be performed when normal morgue and mortuary services become unavailable during a pandemic. WHEREAS, the Plan is divided into several phases, which are determined and announced by the World Health Organization, that prescribes necessary activities and the identification of responsible parties to ensure a consistent and coordinated response by involved entities to manage mass fatalities in the event of an influenza pandemic event; and WHEREAS, all parties agree to the provisions contained below. NOW, THEREFORE, DPHSS, DPW, DPR, OCME, and GHS/OCD in consideration of mutual covenants hereafter set forth, agree to conduct the following during each specific phase: I. WHO PHASE 1: Interpandemic Period A. DPHSS shall lead in the review and revision, as necessary, of the Mass Fatality Management Plan through coordination with DPW, DPR, OCME, and GHS/OCD. B. The Director of DPHSS shall coordinate within his/her department for administrative and support staff to be detailed periodically to the Office of Vital Statistics of DPHSS to be trained in completing the various certificates issued through this office with emphasis on Certificates of Death and Burial-Transit Permits. C. DPHSS shall ensure sufficient number of Certificates of Death forms is in stock and shall consider an alternate form in the event of an influenza pandemic. D. DPHSS shall identify and request for the procurement of equipment that DPHSS should acquire for mass fatality operations as part of the Department’s state of readiness in ATTACHMENT 7 (2 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 3 of 11 response to influenza pandemic. DPHSS shall identify all necessary equipment required for the operation of CPC, including the activation of cellular phone with unlimited service plan. E. DPHSS shall arrange for the printing of all applicable forms for the operation of the CPC, and prepare “TRM Kits” and “CTT Kits”, which shall be examined every two years, or as necessary, to ensure readiness for use. F. DPHSS shall review the corpse processing steps at the CPC and identify individuals to be assigned to perform internal and/or external embalming of dead bodies when necessary to supplement the current and active certified morticians. G. DPHSS, DPR, DPW, and OCME shall submit an annual report to GHS/OCD on the following: 1. DPHSS: a. Listing of Division of Environmental Health (DEH), DPHSS personnel assigned in the implementation of the Plan; b. Listing of individuals to perform emergency embalmment; c. Listing of Division of Senior Citizen (DSC), DPHSS personnel assigned in the implementation of the Plan; d. Listing of vehicle fleet under the DSC Transportation Services Program; and e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities 2. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of personnel of heavy machinery operators and maintenance personnel and Highway Safety Division; c. Listing of fleet of functional buses under Bus Operations Division; d. Listing of personnel from Bus Operations Division; and e. Listing of personnel from Transportation Maintenance Division 3. DPR: a. Listing of functional heavy machinery for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of departmental personnel; c. Identify alternate public burial site; and d. Provide update as to status of the public burial site for use. 4. GHS/OCD: a. Coordinate in the request and collection of annual reports from DPHSS, DPW, ATTACHMENT 7 (3 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 4 of 11 and DPR; and b. Compile the information into a single report and transmit copy to the Administrator of the Division of Environmental Health, DPHSS. II. WHO PHASE 2: Interpandemic Period A. DPR shall take the necessary steps to finalize the alternate land site for public burial purposes. B. DPR, DPW, and DPHSS shall submit a semi-annual report to GHS/OCD on the following: 1. DPHSS: a. Listing of Division of Environmental Health (DEH), DPHSS personnel assigned in the implementation of the Plan; b. Listing of individuals to perform emergency embalmment; c. Listing of Division of Senior Citizen (DSC), DPHSS personnel assigned in the implementation of the Plan; d. Listing of vehicle fleet under the DSC Transportation Services Program; and e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities 2. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of personnel of heavy machinery operators and maintenance personnel and Highway Safety Division; c. Listing of fleet of functional buses under Bus Operations Division; d. Listing of personnel from Bus Operations Division; and e. Listing of personnel from Transportation Maintenance Division 3. DPR: a. Listing of functional heavy machinery for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of departmental personnel; c. Identify alternate public burial site; and d. Provide update as to status of the public burial site for use. 4. GHS/OCD: a. Coordinate in the request and collection of annual reports from DPHSS, DPW, and DPR; and b. Compile the information into a single report and transmit copy to the Administrator of the Division of Environmental Health, DPHSS. ATTACHMENT 7 (4 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 5 of 11 III. WHO PHASE 3: Pandemic Alert Period A. The flow chart of CPC operation, identifying areas for administrative processing, corpse processing and storage, and transporting of corpses at a minimum, are reviewed and revised every January of each year, as necessary by DPHSS. DPHSS shall transmit changes to the operation to the affected external entities and internal divisions of DPHSS. B. DPHSS shall identify multiple TRM Teams and CTT from a list of individuals and their position titles from the quarterly reports prepared by GHS/OCD and transmitted to DPHSS. The work schedule and number of teams shall be determined by DPHSS. C. DPHSS shall conduct a training course on the management of mass fatality operations with primary government entities and volunteers within 60 days of entering Phase 3 as guided by WHO. At a minimum, they will be instructed on completing applicable forms; operating laptop, printer, and digital camera; and fingerprinting corpses. Additional training shall be conducted as the need is identified. D. The Chief Medical Examiner of OCME will identify and train licensed medical doctors who can assist him/her to pronounce and certify deaths outside hospital settings. E. DPR, DPW, and DPHSS shall submit a quarterly report to GHS/OCD on the following: 1. DPHSS: a. Listing of Division of Environmental Health (DEH), DPHSS personnel assigned in the implementation of the Plan; b. Listing of individuals to perform emergency embalmment; c. Listing of Division of Senior Citizen (DSC), DPHSS personnel assigned in the implementation of the Plan; d. Listing of vehicle fleet under the DSC Transportation Services Program; and e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities 2. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of personnel of heavy machinery operators and maintenance personnel and Highway Safety Division; c. Listing of fleet of functional buses under Bus Operations Division; d. Listing of personnel from Bus Operations Division; and e. Listing of personnel from Transportation Maintenance Division 3. DPR: a. Listing of functional heavy machinery for clearing and grading of land, and ATTACHMENT 7 (5 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 6 of 11 digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of departmental personnel; c. Identify alternate public burial site; and d. Provide update as to status of the public burial site for use. 4. GHS/OCD: a. Coordinate in the request and collection of annual reports from DPHSS, DPW, and DPR; and b. Compile the information into a single report and transmit copy to the Administrator of the Division of Environmental Health, DPHSS. IV. WHO PHASE 4: Pandemic Alert Period A. DPHSS shall convene a meeting of all primary government entities to dialogue on the state of preparedness in comparison to the flow chart of the CPC operation identifying areas for administrative processing, embalming, dressing and casketing of corpses, temporary storage, transporting of corpses and personnel assignments. B. DPHSS shall conduct a training course on the management of mass fatality operations with primary government entities and volunteers within 45 days of entering Phase 4 as guided by WHO. At a minimum, they will be instructed on completing applicable forms; operating laptop, printer, and digital camera; and fingerprinting corpses. Additional training shall be conducted as the need is identified in this phase since it is unknown how long each phase will last. C. The Chief Medical Examiner of OCME shall transmit the list of trained licensed medical doctors who will assist him/her to pronounce and certify deaths outside hospital settings to GHS/OHS who in turn shall transmit the list to DPHSS. D. DPR, DPW, and DPHSS shall submit a monthly report to GHS/OCD on the following: 1. DPHSS: a. Listing of Division of Environmental Health (DEH), DPHSS personnel assigned in the implementation of the Plan; b. Listing of individuals to perform emergency embalmment; c. Listing of Division of Senior Citizen (DSC), DPHSS personnel assigned in the implementation of the Plan; d. Listing of vehicle fleet under the DSC Transportation Services Program; and e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities 2. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land, ATTACHMENT 7 (6 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 7 of 11 and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of personnel of heavy machinery operators and maintenance personnel and Highway Safety Division; c. Listing of fleet of functional buses under Bus Operations Division; d. Listing of personnel from Bus Operations Division; and e. Listing of personnel from Transportation Maintenance Division 3. DPR: a. Listing of functional heavy machinery for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of departmental personnel; c. Identify alternate public burial site; and d. Provide update as to status of the public burial site for use. 4. GHS/OCD: a. Coordinate in the request and collection of annual reports from DPHSS, DPW, and DPR; and b. Compile the information into a single report and transmit copy to the Administrator of the Division of Environmental Health, DPHSS. V. WHO PHASE 5: Pandemic Alert Period A. DPHSS shall convene a meeting of all primary government entities to dialogue on the state of preparedness in comparison to the flow chart of the CPC operation identifying areas for administrative processing, embalming, dressing and casketing of corpses, temporary storage, transporting of corpses and personnel assignments. B. DPHSS shall conduct a training course on the management of mass fatality operations with primary government entities and volunteers within 30 days of entering Phase 5 as guided by WHO. At a minimum, they will be instructed on completing applicable forms; operating laptop, printer, and digital camera; and fingerprinting corpses. Additional training shall be conducted as the need is identified in this phase since it is unknown how each phase will last. C. The Chief Medical Examiner of OCME shall transmit an updated list of trained licensed medical doctors who will assist him/her to pronounce and certify deaths outside hospital settings to GHS/OHS who in turn shall transmit the list to DPHSS. D. Upon completion of B above, each government entity shall provide written notice to their personnel of their anticipated assignment to the CPC. In addition, GHS/OCD shall transmit a memorandum to each affected employee to further formalize the intent of the plan to identify and acknowledge their duties and responsibilities in the event the Plan is ATTACHMENT 7 (7 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 8 of 11 E. DPR, DPW, and DPHSS shall submit a weekly report to GHS/OCD on the following: 1. DPHSS: a. Listing of Division of Environmental Health (DEH), DPHSS personnel assigned in the implementation of the Plan; b. Listing of individuals to perform emergency embalmment; c. Listing of Division of Senior Citizen (DSC), DPHSS personnel assigned in the implementation of the Plan; d. Listing of vehicle fleet under the DSC Transportation Services Program; and e. Listing of inventory and equipment for operations of the CPC to include refrigeration facilities 2. DPW: a. Listing of functional heavy machinery necessary for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of personnel of heavy machinery operators and maintenance personnel and Highway Safety Division; c. Listing of fleet of functional buses under Bus Operations Division; d. Listing of personnel from Bus Operations Division; and e. Listing of personnel from Transportation Maintenance Division 3. DPR: a. Listing of functional heavy machinery for clearing and grading of land, and digging of graves and for mass excavation (i.e., back hoes, excavators, bull dozers); b. Listing of departmental personnel; c. Identify alternate public burial site; and d. Provide update as to status of the public burial site for use. 4. GHS/OCD: a. Coordinate in the request and collection of annual reports from DPHSS, DPW, and DPR; and b. Compile the information into a single report and transmit copy to the Administrator of the Division of Environmental Health, DPHSS. VI. WHO PHASE 6: Pandemic Period A. Upon notification from the Emergency Operation Center that morgue space at the Guam Memorial Hospital Authority is approaching maximum capacity, DPHSS shall activate the CPC for full operations within 72 hours. The Administrator of the Division of Environmental Health of DPHSS shall be identified as the CPC Manager and lead this operation and shall convene a meeting of all personnel identified to assist within three ATTACHMENT 7 (8 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 9 of 11 hours of activation. 1. All identified personnel from DPHSS, DPW, DPR, and OCME shall report to the Dededo Sports Complex upon being notified of their activation. 2. The CPC Manager shall convene a meeting of key agencies and stakeholders to prepare for the opening of the CPC. 3. The CPC Manager shall conduct on-site training of all personnel assigned to the CPC. 4. The CPC Manager shall identify a CPC Fiscal Manager to collaborate with the DPHSS RAC in the coordination of the delivery of the Temporary Refrigeration Morgue (TRM) and initiate other procurement activities necessary for the full operations of the CPC. The CPC Fiscal Manager shall report directly to the CPC Manager. 5. The CPC Manager shall assess operations and determine when the Employee Assistance Program (EAP) shall be activated and may designate staff to implement this component. The activation of this component of the CPC shall require personnel to work longer hours and remain on site. The EAP shall provide personnel support in the form of sleeping quarters, shower stalls, laundry, nourishment and telecommunications for personnel and their family, at a minimum. 6. The CPC Manager shall notify the psychosocial component of the operations and request they be prepared to staff the site upon receiving confirmation from him/her. C. The CPC Manager shall notify the EOC once the CPC is ready to provide mortuary services. D. The CPC Manager or his designee shall telephonically notify the directors of island funeral homes once CPC begins accepting dead bodies. They will be provided instructions for retrieving bodies from CPC for funeral services. E. DPR, DPW, and the Division of Senior Citizens of DPHSS shall submit a daily report to CPC Manager on the status of their heavy machinery for clearing of land and digging of graves, operators of such equipment, status of their fleet of vehicles, and an updated roster of bus drivers, as applicable. This Agreement shall be effective on the date approved by the Governor of Guam. It is mutually agreed that: ATTACHMENT 7 (9 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 10 of 11 A. Either of the parties hereto, may, by written notice to the other, terminate this Agreement in whole or in part at any time, either for convenience or default. B. Upon completion of the project, all supplies and equipment furnished for the implementation of the Plan will be returned to the respective agencies. IN WITNESS WHEREOF, the parties have entered into this Agreement on the dates indicated by their respective names. AS APPROVED TO FORM: DEPARTMENT OF PUBLIC HEALTH AND SOCIAL SERVICES: DEPARTMENT OF PUBLIC WORKS: ____________________________________ ARTHUR U. SAN AGUSTIN, MHR Acting Director ____________________________________ LAWRENCE ?. PEREZ Director Date: Date: DEPARTMENT OF PARKS AND RECREATION: OFFICE OF CHIEF MEDICAL EXAMINER: ____________________________________ TOMMY ?. MORRISON Director ____________________________________ AURELIO ESPINOLA, M.D. Chief Medical Examiner Date: Date: OFFICE OF CHIEF MEDICAL EXAMINER: GUAM HOMELAND SECURITY/OFFICE OF CIVIL DEFENSE: ____________________________________ AURELIO ESPINOLA, M.D. Chief Medical Examiner ____________________________________ LT. GOVERNOR MICHAEL W. CRUZ, M.D. Acting Director Date: ATTACHMENT 7 (10 of 11) Pandemic Influenza: Mass Fatality Management Plan Memorandum of Agreement (FY 2008) Between the DPH&SS, DPW, DPR, OCME, OHS/OCD Page 11 of 11 Date: APPROVED AS TO LEGALITY AND FORM: ____________________________________ ALICIA G. LIMTIACO, ESQ. Attorney General of Guam ____________________________________ FELIX P. CAMACHO Governor of Guam Date: Date: ATTACHMENT 7 (11 of 11) CORPSE PROCESSING LOG SHEET SERIAL NUMBER NAME (LAST, FIRST) SEX PROCESSED IN PROCESSED OUT COMMENT? (¥) Transported In Transported Out (If yes, see below) Method (¥) Date CTT Family Other Method (¥) Initial Date CTT Family Other Disposition (¥) Funeral Home Coroner Cemetery Other Initial Yes No COMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ATTACHMENT 11-10 INSTRUCTIONS FOR SELECTED ITEMS item Place of Death lithe death was pronounced in a hospital. check the box Indicatingthe decedent's status at the institution Iinpatient, emergency roomioutpatient. or dead on arrival Ii death was pronounced elsewhere. check the b0): indicating whether pronouncement occurred at a nursing home. residence. or other iocation. 1? other is Checked. Where d?aih was legal?! such as a physician's of?ce. the place where the accident occurred. or at work. Items 13-e-t. Residence at Decadent . Residence oi the decedent is the place where he or she actually resided. This is not necessarily the same as "home State.? or ?legal rosidence." N'ever enter a temporary residence such as one used during a visit. business trip. or a vacation, Place of residence during a tour of military duty or during attendance at college is not considered as temporary and should be considered as the place of residence. Ila decedent had been iiving in a Iacility where an individual usually resides for a long period of time. such as a group home. mental institution. nursing home, penitentiary. or hospital lor the chronical- ly ill. report the location oi that facility in items 13a through t3t. lithe decedent was an iniant who never resided at home. the place oi residence is that of the parentisi or legal guardian. Do not use an acute care hospital's location as the place oi residence for any intent. items 23 end 31 Medical Certification The PRONDUNCING is the person who determines that the decedent is legally dead but who was not in charge of the patient's care for the illness or condition which resulted in death. Items 233 through 23c are to be completed only when the physician responsible [or completing the medical of cause of death [Item is not available at time of death to certiiy cause of death. The pronouncing physician is responsible Ior completing only items 23 through 26. The CERTIFYING PHYSICIAN is the person who determines the cause ol death {item 27]. This box should be checked only in those cases when the person who is completing the medical certification of cause oi death is not the person who pronounced death Iltem 23L The certifying physician is responsible for completing items through 32. The PHDNOUNCENG CERTIFYING PHYSICIAN box should be checked when the same person is responsible [or completing Items 24 through 32. that is. when the same physician has both pronounced death'end certified the cause of death. if this box is checked. items 23a through 23c should be left blank. - The MEDICAL EXAMINERICORDNER box should be checked when investigation is required by the Post Mortem Examination Act and the cause of death is campieted by a medical examiner or coroner. The Medical ExaminerrCoroner is responsible for completing items 24 through 32. Item Cause at Death The cause oi death means the disease. abnormality. iniury. or poisoning that caused the death. not the mode of dying. such as cardiac or respiratory arrest. shock. or heart lailure. In Part i. the immediate cause oi death is reported on line Ial. Antecedent conditions, it any. which gave rise to the cause are reported on lines lb]. lot. and Id]. The underlying cause. should be reported on the last line used In Part E. No entry is necessary on lines Ib}. lcl. and Idl it the immediate cause at death on line [at dascribes completely the train at events. ONLY ONE CAUSE SHOULD BE ENTERED ON A LINE. Additional lines may be added if necessary. Provide the best estimate of the interval between the onset oi each condition and death. Do not leave the interval blank: if unknown. so specify. In Part II. enter other important diseases or conditions that may have contributed to death but did not result in the underlying cause of death given in Part I. See examples below. (?21 PART I. Enter the diuasos. inruriac. or complications that caused the death. Do not enter the mode of dying. such as cardiac or respiratory ?P?fo?imlls JMHWII arrest. Ihocii. or hem llilurc. List only one cause on each line. I 5.1mm." om" mg cause IFinal 1 Death disease at sundown I I resulting In duthl CONSEQUENCE SEE INSTRUCTIONS on omen SIDE . . . b' - I Sequentially list conditions, an? .0 immdm, cue to ion as a conscoueuct on: 1 cause. Enter I CAUSE [Disease or iniury c_ that initiated events DUE TO AS A CONSEQUENCE I resulting in death} LAST 1 a. PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I 2!l- W55 AN AUTOPST 23h. WEHE AVAILABLE PRIOR TO m, a. no, COMPLETION or cause OF {Yes or no! Yes 29. MANNER OF DEATH 30.. DATE OF INJURY TIME OF 301:. AT and. DESCRIBE HOW OCCURRED {Montreolw?foarl (Yes or no; [3 Nat: Pending Accident Invnuw?m sumac Baum My be 30.. 0F horns. farm. streal. IICIOW. 01"? 301'. LOCATION [Street and Number or Rural Route Number. City or Town. Stltal . uI trig. etc. poor . Humid? PART I. Enter the dice-tn. injuriel. or complications that caused the death. Do not enter the mode of dying. such to: cardiac or respiratory I arrest. shock. or hurt torture. Lilt only one cause on each line. Between Onset and IHHEDKATE cause lFinaI I Death disease or condition I resulting in deathCONSEOUENCE I SEE INSTRUCTIONS I on omen sroc Smuentraiiy list condrtiorts. i, ham .0 .mmdim TD ion as A couscoucuce OFI: 1 cause. Enter CAUSE IDIsease or injury a I that initiated events DUE TO IUH AS A CONSEQUENEE OFI: I reenlling rn dallhl LAST I 2m WAS MI AUTOPSY 23b. WERE Autoesv FINDENGS PERFORMED: AVAILABLE PRIOR to or: cause PART H. Other sronriicant conditions contributing to death but not resulting in the underlying cause given In Part I J'Yes or no! OF We: or not 29. MANNER OF DEATH 300. DATE OF INJURY 30b, TIME OF 301:. INJURY AT 30d. DESCRIBE How INJURY OCCURRED iMonth.Dcy. You} I?Yes or not Nature: Pending investigation Accident 0 Suicide [3 Could not be Homicide Determined 30.. PLACE OF home. larm. street. Iactory. ollrce {Street and Number or Hutl'l Route Numb-er. City or Town. State] building. etc. 15pm:in . HI I Hull? ILUI Vt?li?llud GOVERNMENT OF GUAM U.S. STANDARD CERTIFICATE OF DEATH FILE NUMBER PERMANENT BLACK INK (1. NAME . 2. SEX 3. DATE OF DEATH fMonrh Day Year} FOR - - INSTRUCTIONS .SEE OTHER SIDE 4_ EQUAL SECURITY NUMaen B,"de 5b. UNDER 3 YEAR UNDER 1 DAY 5. DATE or BIRTH iMonrh. ?2in and Stan: or ?w "Augauug Wears) Months Days How; Minnie; Dav, Yearl Foreign Country! . B. WAS DECEDENT EVER IN US. 9a. PLACE OF DEATH (Check oniy one; see instructions on other side) ARMED OTHER- !Yes or no! Inpatient CI ERiOulpatient DOA Nursing Home CI Residence Other {Specify} 9b. FACILITY NAME if! not institution. give street and number! CITY. TOWN. OR LOCATION OF DEATH so. COUNTY OF DEATH 10. MARITAL STATUSnMarried. 11. SURVIVING SPOUSE 12o. USUAL OCCUPATION 12h. KIND OF BUSINESSIINOUSTRY Never Married. Widowed. wife. give maiden name! {Give kind of work dune during most of working fife. Divorced (Specify! Do not use retired.)I .. tu 3 13a. RESIDENCE -STATE COUNTY 13:. CITY. TOWN. OR LOCATION 13d. STREET AND NUMBER 3 130. INSIDE CITY 131'. ZIP CODE I 14. WAS DECEDENT OF HISPANIC 15. RACEwAmerican Indian. 15. EDUCATION ?0 ?3 ISpecif-f No or Yes?If yes. specin Cuban. Black. White, etc. (Specify oniy highest grade compr?credl (Yes or no! Mexrcan. Pucrto Rican. etc.I CI No CI Yes {Specri'yi Elementalwsecondaw {042? college or 5 Speedy. - 17. NAME 18. NAME (H'rsr,Mr'ddie,Maiden Surname} 19o. INFO NAME 19b. MAILING ADDRESS (Street and Number or Hora! Route Number. City or Town. State, Zr}: Code! 20:. METHOD OF DISPOSITION 20b. PLACE OF DISPOSITION {Name of cemetery. cremotory. or 20:. or Town. State other piece) a Burial Cremation Removal from State Donation Other (Speedy) 21s. SIGNATURE OF FUNERAL SERVICE LICENSEE OR 21h. LICENSE NUMBER 22. NAME. AND ADDRESS OF FACILITY PERSON ACTING AS SUCH Licensee} SEE DEFINITION on omen SIDE Complete items 23a?: only 233. To the but of my knowledge. death occurred at the time. data. and place stated. 23b. LICENSE NUMBER 23c. DATE SIGNED I when certilying physician is IMOMEDW. Yeari - not available at time of death to certil't,r cause of death. Signature and Tide ITEMS 24-26 MUST BE COMPLETED BY 24. TIME OF DEATH 25. DATE PRONOUNCED DEAD (Martino-itchy} 26. WAS CASE REFERRED TO MEDICAL PERSON WHO .r {yes or no} monounces DEATH 27. PART I. Enter the diseases. inluries. or complications that caused the death. Do not enter the mode of dying. such as cardiac or respiratory I Approximate arrest. shock. or heart failure. List only one cause on each line. - Interval Between a Onset and Death IMMEDIATE CAUSE IFrnai 1 disease or condition CONSEQUENCE on: NSTRUCTIONS I SIDE Sequentially list conditions. if an? leadmg Immedlam DUE TO IOR AS A CONSEQUENCE DFI: cause. Enter UNDERLYING CAUSE {Disease or inple c_ I that initiated BVBHIS DUE TO IOR AS A CDNSEOUENCE I resulting in death} LAST I d. I PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I. 285. WAS AN AUTOPSY 28b. WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO (yes a, no} COMPLETION OF CAUSE OF (Yes or no! 29. MANNER OF DEATH 30:. DATE OF INJURY TIME OF 30:. INJURY AT 30d. DESCRIBE HOW INJURY OCCURRED . {Month?an lire-tr)I INJURY I Yes or no) [3 Natural 8 Pending Atcidml Investtgatlon I Sugcide [j Coma not be 30?. PLACE OF home. farm. street. factory. oflice 301. LOCATION {Street and Number or Rural Route Number. City or Town. Statel building. etc. {Specify} . Homicide Determined I Isle-25:52? a CERTIFYING PHYSICIAN (Physician certifying cause of death when another physician has pronounced death and compieted item 23! one} To the but of my knowledge. death occurred due to the console] and manner its stated. PRONOUNCING AND CERTIFYING PHYSICIAN {Physician 'borl'r pronouncing death and certifying to cause of deant To the bolt 0! my knowledge. death occurred at the time. date. and place. and doc to the camels] and manner as stated. MEDICAL EXAMINERICORONER On the basis of ottomlnatlon andior Introstigatlon. In my opinion. death occurred at the time. data. and place, and due to the causal!) and manner as stated. 31h. SIGNATURE AND TITLE OF CERTIFIER 31c. LICENSE NUMBER 31d. DATE SIGNED rMonrh.Day.Year) 32. NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH 33. SIGNATURE 34. DRTE FILED iMonrh.Day.Yeari 9 HEV.II89 . FLOW-CHART OF CORPSE PROCESSING CENTER (CPC) Corpse Delivery Site Body accompanied by Corpse Transportation Team (CTT) or Family Exit Psycho-Social Room Family Intake Room Body Examination Room Body Temporary Refrigeration Morgue (TRM) Released to Funeral Home or Medical Examiner for Disposition PARTIAL ACTIVATION OF CPC WITH ONLY MORGUE OPERATION Temporary Refrigeration Morgue (TRM) Embalming Room Dressing & Casketing Room Temporary Holding Room Released to CTT ATTACHMENT 12 EXPANDED ACTIVATION OF CPC WITH TEMPORARY MORTUARY SERVICES DRAFT PRESS RELEASE #__________________ ACTIVATION OF THE CORPSE PROCESSING CENTER AND THE DELIVERY OF DECEASED The Governor of Guam and the Director of the Department of Public Health and Social Services (DPHSS) would like to inform the public that to expand the current morgue operations of the Guam Memorial Hospital Authority (GMHA) a Corpse Processing Center (CPC) has been activated. The center is located at (Insert location) and will act as a temporary morgue site for deceased individuals in preparation for their final disposition. Furthermore, the public is advised to contact (Insert Applicable Entity) at (Insert Telephone Number) to report family members who have died from influenza or other natural causes at home. This telephone number will be in operation 24 hours a day, 7 days a week. Upon notification of such death, a team from (Insert Applicable Entity) will arrive at the residence to gather and transport the deceased to the CPC. In preparation (Insert Applicable Entity) requests that a current photo identification of the deceased and the next of kin for the decedent be available when the transportation team arrives. The transportation team will interview the next of kin to obtain information of the decedent to complete the death certificate. As an alternative, if they so wish, families may deliver their deceased loved one(s) directly to the CPC located at (Insert location). The deceased should be wrapped in a plastic sheet when delivered. If a plastic sheet is unavailable, bed sheets or blankets may be substituted. The deceased’s next of kin must accompany the remains and have current photo identification along with a photo identification of the deceased. (Insert Applicable Entity) is requesting that families not deliver remains to the CPC if they are too decomposed. They should instead contact the transportation team. Individuals passing away from influenza will not require an autopsy. An autopsy will only be performed in cases of suspicious or unknown causes. Theses cases will be referred to the Guam Police Department. For further information, please call (Insert Telephone Number). The public’s understanding and cooperation under such extreme difficulties is greatly appreciated. ARTHUR U. SAN AGUSTIN, MHR Acting ALGORITHM FOR MANAGEMENT OF DECEDENT AT THE CORPSE PROCESSING CENTER (CPC) From Hospital by CTT Photo ID of Family& Deceased Examined by TRM Team TRM Team receives CD and gives to ME PsychoPsycho-Social Team CD signed by ME and returned to TRM Team. CD stapled to copy of CP Form for Vital Family and Body escorted for processing Toe tagged body unloaded from bus onto gurney Family CD and CP Form (incl. attachments) completed. Copy of CP Form given to Family Body Taken to Exam Room to be examined, photographed, tagged, and fingerprinted Attachments from CP Form and CD given to ME Foul Play Suspected? CD signed/voided by ME and returned to TRM Team. CD stapled to copy of CP Form for Vital Original CP & CT Forms stapled to Fingerprint Card and filed with TRM CP Form and Fingerprint Card stapled and filed with TRM Picked up by Funeral Home Log Sheet filled, and all forms placed in secure location CD and CP Form meant for Vital picked up by Vital CD filed with Vital for official recordation CD = Certificate of Death ME = Medical Examiner Vital = Office of Vital Statistics TRM = Temporary Refrigeration Morgue CTT = Corpse Transportation Team CP = Corpse Processing DP = Disposition Permit Log Sheet = Corpse Processing Log Sheet DP processed by Vital and makes certified copy of CD Log Sheet filled, and all forms placed in secure location YES Guam Police Department notified Serial No. on ID Placard written and dated on body bag Placed in Temporary Refrigeration Morgue Picked up by Funeral Home Forms CD signed/voided by ME and returned to TRM Team. CD stapled to copy of CP Form for Vital Foul Play Suspected? Original CP & CT Forms stapled to Fingerprint Card and filed with TRM NO NO Body and ID Placard placed in body bag YES TRM Team prints Official CD and gives to ME Taken to Exam Room to be examined, photographed, tagged, and Fingerprinted Forms Placed in Temporary Refrigeration Morgue Buried, Cremated, or Sent Off-Island Family Body Body Serial No. on ID Placard written and dated on body bag Completed provisional CD and CP Form By Family Completed CD and CP Form Toe tagged body unloaded from bus onto gurney From Non-Hospital setting by CTT Body Delivered to CPC Body and ID Placard placed in body bag Notation made on CP Form and Log Sheet filled Body sent to ME morgue for autopsy Body and ID Placard placed in body bag Serial No. on ID Placard written and dated on body bag Placed in Temporary Refrigeration Morgue Picked up by Funeral Home Funeral Home contacted by Vital Log Sheet filled, and all forms placed in secure location CD and CP Form meant for Vital picked up by Vital Official CD filed with Vital for official recordation DP processed by Vital and makes certified copy of CD Funeral Home contacted by Vital Buried, Cremated, or Sent Off-Island Funeral Home picks up DP and certified CD Buried, Cremated, or Sent Off-Island Funeral Home picks up DP and certified CD ATTACHMENT 14 ?mm Date inucd Nn_ Name Date a: non-I- Age Place of Burial Removaf Dal: Cremation Burial I sea I: DESTI nmar?l?' DEPT. OF PUBLIC HEALTH 5: SOCIAL. SERVICES GOVERNMENT OF GUAM 833151-71 PERMIT NO. Dh?t OF "All 0" DICIABKD IFIISTI tn: Incl: Ac: FLACE o: oznu on row?: Icauurn C'Tl'fll FLACK 0' DISPUSITIOH HF OI EIKHQIORYI Muhod cl dismal Burial seal: Date Burial Date Cremation Emmi Date on Town; LOT NO Nun? of Il?hh?lhmen' mans: A ca?i?ule a! dull: having been filed. perminion is hereby given to dispel: of Phil body OF IIGIITIAI (CITY OH SI XEINNV A .d I. iid'ed of ?Els?" CHANGI OF above mud on [duh] Datlnatlon Carrier Signature (handl Ing authority) DATE Wham no disignabd pawn in in charge of a cumin-1. {be {uch divoch Ihould sign hate. The pm signing ii reapon?hlo [or ralmning Hui) permil viihEn ll) dayu lo right!? of HR aw" i" ?d OFFICE OF VITAL STATISTICS FLOOR PLAN FOR CPC AT THE DEDEDO SPORTS COMPLEX REFRIGERATION CONTAINER STORAGE ROOM PUMP ROOM TEMPORARY HOLDING ROOM CONFERENCE ROOM MECHANICAL ROOM ELECTRICAL ROOM LADIES TOILET & LOCKER ROOM DRESSING & CASKETING ROOM PSYCHOSOCIAL ROOM EMPLOYEE’S LOUNGE UTILITY ROOM ADDITIONAL SPACE AVAILABLE FOR EXPANSION OF OPERATION LADIES RESTROOM MEN’S TOILET & LOCKER ROOM STORAGE MEN’S RESTROOM EMBALMING ROOM INTAKE ROOM STORAGE ROOM EXAM ROOM FAMILY EXIT OFFICE STORAGE ROOM BODY LEGENDS: ENTRANCE ATTACHMENT 16 SECURITY FENCE LINE FENCE GATE STANCHION WALL PARTITION ROLL—UP DOOR DRAFT PRESS RELEASE #__________________ EXPANSION OF CPC FOR TEMPORARY MORTUARY SERVICES The Governor of Guam and the Director of the Department of Public Health and Social Services (DPHSS) would like to inform the public that the operation of the Corpse Processing Center (CPC) has been expanded to include temporary mortuary services. This is made necessary to augment the services of the local funeral homes. Any deceased individual delivered to the CPC by the transportation team that can not be processed by a funeral home will be embalmed, dressed, and casketed at the CPC. DPHSS will make every reasonable attempt to contact family members if mortuary services of their loved ones occur at the CPC. Should the transportation team of the CPC transports the deceased, it is requested that the families provide them with the clothing they wish the deceased to wear for his/her burial. Please do not include any jewelry, valuables, or other accessories. The clothing should be placed in a plastic bag and clearly labeled with the name of the deceased. If the family is delivering the deceased directly to the CPC, it is recommended that the appropriate clothing accompany the deceased. Furthermore, the public is advised that if standard caskets are not available, alternative casketing may be utilized. Families may supply their own caskets or improvised wooden coffins. DPHSS recommends that these meet the attached specifications. The Governor of Guam and the Director of Public Health and Social Services wishes to assure the public that the all human remains will be handled with dignity and care. However, the public should be cautioned that in extreme circumstances CPC may modify, limit, or cease certain steps or procedures. For further information, please call (Insert Telephone Number). The public’s understanding and cooperation under such extreme difficulties are greatly appreciated. ARTHUR U. SAN AGUSTIN, MHR Acting CONTACT NUMBERS GOVERNMENT OF GUAM Director’s Office, DPHSS (T) 735-7399 (F) 734-5910 Office of Homeland Security/Office of Civil Defense (T) 475-9600 (F) 477-3727 Division of Environmental Health, DPHSS (T) 735-7221/7216/7222 (F) 734-5556 Division of Senior Citizens, DPHSS (T) 735-7382 (F) 735-7416 Office of Vital Statistics, DPHSS (T) 735- 7280/7263/7185 (F) 734-5910 Guam Memorial Hospital Authority (T) 647-2330/2552/2939 (F) 649-5508 Office of the Chief Medical Examiner (T) 646-9363/647-2369 (F) 646-8860 Department of Public Works (T) 646-3131 (F) 649-6178 Department of Parks and Recreation (T) 475-6296 (F) 477-0997 U.S. DEPARTMENT OF DEFENSE Preventive Medicine, U.S. Navy Hospital Guam (T) 333-2313 (F) 339-1126 36th Public Health Element, Andersen Air Force Base (T) 366-4147 (F) 366-8069 ATTACHMENT 18 ALGORITHM FOR NORMAL MANAGEMENT OF CORPSE PERSON DIES Outside institutional facility Foul play Suspected ? YES GPD & CME notified CME pronounces death Body wrapped & placed on stretcher Transported to hospital via ambulance Stored in morgue Skilled Nursing Facility St. Dominic Senior Where? Home Care NO GMH/USNH, Guam GPD & ambulance notified NO YES GPD & CME notified Transported to hospital via ambulance Body wrapped & placed on stretcher Transported to viewing room Transported to hospital via ambulance Transported to morgue CME certifies death CME certifies death Attending physician pronounces death YES Stored in morgue Autopsy performed CME certifies death Hospital Stay <24 Hours? CME certifies death NO Body wrapped & placed on stretcher Transported to hospital via ambulance CME pronounces death Attending ER physician pronounces death Attending physician pronounces death Body wrapped & placed on stretcher Transported to viewing room Transported to hospital via ambulance Transported to morgue Transported to morgue Transported to morgue Stored in morgue Stored in morgue Stored in morgue Autopsy performed Attending Physician certifies death CME certifies death CME certifies death Transported to morgue Stored in morgue GPD & CME notified GPD & CME notified NO Transported to viewing room YES Foul play suspected ? NO CME pronounces death Attending ER physician pronounces death Stored in morgue Foul play Suspected ? Foul play suspected ? Body wrapped & place on stretcher Autopsy performed Release to family or funeral home Inside institutional facility “PROCESS FOR CORPSE MANGEMENT STEPS” Embalmment Disposition Of body? Send off-island Step 1 Sea burial Step 2 Embalm body Cremation Death certificate & burial permit issued Funeral services Send Off-island Burial permit issued by Vital Statistics Sea burial Sea Burial permit issued by GEPA Cremation Flown or shipped off-island Release to family or funeral home Funeral service possibly (before or after cremation) Buried on land Step 4 Step 5 Release to family Transported to burial site Step 3 Death certificate issued to funeral home by Vital Statistics Step 6 Step 7a Step 7b Release to family or funeral home Step 8 Step 9 Steps 10 & 11 Buried at sea Step 12 Step 13 Body cremated Step 14 ATTACHMENT 11-1 CHAPTER 11 CRITICAL INFRASTRUCTURE/KEY RESOURCES SECTION 1.0 INTRODUCTION In keeping with the All-Hazards concept and the management of critical infrastructure and key resources, Guam’s response to a pandemic influenza outbreak will require a unified coordination of all the island’s resources as well as the seamless integration of federal assistance into a collaborative response effort. To meet this massive undertaking Guam relies on two major response plans. • • Guam Emergency Response Plan (GERP) Guam All-Hazards Catastrophic Incident CONOP with Annexes SECTION 2.0 GUAM EMERGENCY RESPONSE PLAN (GERP) The federal statute governing emergency situations in all States and Territories is Public Law 93-288, as amended. This act is also known as the “Robert T. Stafford Disaster Relief and Emergency Assistance Act”, as amended. Just as each state and territory is tasked with responsibility of developing a State Emergency Operations Plan, the Federal Government is April, 1992 promulgated the Federal Response Plan. This Plan facilitates the delivery of all types of federal response assistance to the states and territories to assist them in dealing and recovering from the consequences of significant disasters. In 1999, the Office of Office of Civil Defense was merged with the Department of Military Affairs under Public Law 24-298. The Department of Military Affairs will be the primary government agency responsible for all response and recovery activities. The Office of Civil Defense will remain the primary agency responsible for maintaining the Government of Emergency Response Plan and coordinating the response to all natural and man made emergencies and disasters. On August 16, 2001, by virtue of Executive Order No. 2001-22, the Guam Emergency Response Plan (GERP), replacing the Territorial Emergency Plan, was implemented as a basis for recovery and emergency response for the island of Guam. The GERP is the current plan in use by the Government of Guam to prepare for, mitigate, respond to and recover from an emergency/disaster situation. It is the duty of GovGuam officials and agencies to provide responsible leadership during emergency conditions and to develop plans and procedures necessary to protect lives, property and island resources. These officials must ensure continuity and cooperation in responding to the Government’s needs during various phases of the emergency utilizing the Unified Command System concept of operation. These officials and agencies are responsible for carrying out their duties and responsibilities as delineated in this Guam Emergency Response Plan. Through their development of plans and procedures, responsible officials will be completely familiar with their emergency management roles in disaster mitigation, preparedness, response and recovery. The GERP (Basic) delineates the objective of the Plan to provide protection for the citizens of Guam utilizing the National Incident Management System to best utilize the Government’s limited resources in mitigating, preparing for, responding to and recovering from the various emergencies or disasters affect this island and its residents. It also establishes a Unified Command System concept of operation for implementing a fully coordinated response through in-depth planning and mutually supported emergency operations management. Functional Annexes 1. There are fourteen (14) Functional Annexes addressing a number of response functions required in all emergencies that range from the initial response to an emergency or disaster, to managing all resources necessary in the response and recovery effort. 2. Identifies the activities to be performed with all pre-identified departments/agencies with responsibility under the specific function. 3. Provides the provisions made to coordinate and communicate amongst agencies to include federal response agencies that may be involved in the emergency response. Hazard Specific Appendix 1. There are currently eleven (11) Hazard Specific Appendices which were identified to potentially affect our island jurisdiction. The Hazard Specific Appendices are developed to support the Functional Annexes and provide greater detail as to the response and recovery operations. 2. Provides unique and regulatory response planning details that apply to the particular hazard, as it is focused on the special planning needs generated by the hazard. Guam’s Pandemic Influenza Plan will be included as a Hazard Specific Appendix – Pandemic Response. SECTION 3.0 GUAM ALL-HAZARDS CATASTROPHIC INCIDENT CONOP WITH ANNEXES This document establishes the Concept of the Operations (CONOP) for the joint response of local and territorial entities in concert with the federal government, military, private non-profit organizations (PNP), non-governmental organizations (NGO), volunteer agencies (VOLAG) and all agencies encompassed within that response. The purpose of this document is to describe the integration of Federal resources into the Territory –led response to a catastrophic incident in order to achieve unity of effort. Territory/Federal integration described herein will be undertaken in accordance with the principles of the National Incident Management System (NIMS) and the National Response Framework (NRF). Existing Territory systems and authorities will be maintained. In particular, this does not supersede the concept that all requests for Federal assistance are made through the Territory. Guam Pandemic Influenza Plan 11-2 The Area of Operation (AO) for this CONOP is the Island of Guam. The Area of Interest (AI) for this CONOP is the greater Pacific Rim, Pacific Ocean, western coast of the Mainland United States and any specific location that would provide support to response efforts in Guam. This CONOP will be implemented in the event of a catastrophic incident affecting Guam. This includes but is not limited to any incident, including terrorism, which results in extraordinary levels of mass casualties, damage or disruption severely affecting the population, infrastructure, environment, economy, national morale and/or government functions. The CONOP is not a plan for a response to a specific incident. As appropriate, the Federal Emergency Management Agency (FEMA) and Guam Homeland Security/Office of Civil Defense (HS/OCD) will develop incident-, hazard- and function-specific CONPLANs and annexes to address specific hazards. Additionally, the CONOP only addresses joint Territory/Federal operations within Guam; it only addresses national level actions by FEMA and the U.S. Department of Homeland Security (DHS) as they impact operations in Guam. The CONOP applies to the threat, response and recovery periods of an incident. Although it recognizes procedures for preparedness or prevention, and mitigation, it does not specifically address them. Additionally, the CONOP does not address the establishment of joint Territory/Federal transitional or long-term recovery operations. The audience for the CONOP includes Territory, Federal, local, and regional leaders, as well as representatives of volunteer, non-governmental and private sector organizations with responsibility for response to, and recovery from, catastrophic incidents in Guam. Such organizations will be expected to participate in the joint Territory/Federal organization. The Regional Administrator for FEMA Region IX and the Governor of Guam will direct the activation of the CONOP, depending on the specific circumstances of the incident. The CONOP will not impede Federal, Territory, and local entities from carrying out their specific authorities in accordance with applicable laws, regulations, executive orders, and directives. Threat The CONOP identifies a full threat spectrum that includes: Pandemic and Epidemic - Guam serves as a major tourist hub for Asia, receiving nearly 1 million visitors annually. It is also unique, as it is the only American Territory in Asia. These factors put Guam at particular risk from the effects from Pandemic Influenza. It is the closest American Territory to China, Vietnam, Indonesia and Thailand, where confirmed cases of Bird Flu have been documented in both humans and poultry. Mission The mission of Guam Homeland Security/Office of Civil Defense is to coordinate and facilitate all Government of Guam, Military, and Federal Liaison Response Agencies, Non-Governmental Organizations and their resources in mitigating, preparing, responding, and recovering from any and all types of emergencies in order to protect the lives, Guam Pandemic Influenza Plan 11-3 environment, and property of the island of Guam. Guam HS/OCD coordinates all territorial response and the integration of all resources provided and managed by the government of Guam. Concept of Operation The successful joint Territorial/Federal response will be achieved by the accomplishment of decisive tasks that support the response. These tasks will be accomplished by determining and executing the preferred course of action for response. Decisive tasks and courses of action will be in support of critical centers of gravity. These centers of gravity encompass components of the response that, if not supported, will ultimately lead to the failure of the response. For the purpose of this CONOP these centers of gravity with supporting decisive tasks and courses of action have been grouped into four phases. Certain centers of gravity apply to multiple phases, while others are specific to certain phases. The triggers for both the start and completion of these phases are operational in nature not chronologically based and, as such, phases may occur simultaneously (nonotice event) or may be separated by significant periods of time (pandemic outbreak). These phases are: • • • • Phase I: Normal Operations Phase II: Credible Threat Phase III: Response Phase IV: Recovery • • • • • • • • • • • • • • Identify Critical Resources and Personnel Alert and Movement of Essential Resources and Personnel Population Protection Critical Infrastructure/Key Resource Protection Dissemination of Public Information Establish Joint Territory/Federal Response Maintain Situational Awareness and Common Operating Picture Life Saving and Sustaining Efforts Establish Communications Mass Care and Shelter Identification of Critical Needs Establish Transportation Corridors Resource Management Transition to Recovery Coordinating Effort In the event of a pandemic influenza outbreak on the island, Guam’s Pandemic Influenza Plan will be supported by the emergency response infrastructure developed and coordinated by both the Guam Emergency Response Plan and the Guam All-Hazards Catastrophic Incident CONOP wit Annexes. Details and specific actions for each of these plans are outlined in their respective documents and are referenced as necessary to support the Guam Pandemic Influenza Plan. Centers of Gravity (capabilities and functions that enable response entities to accomplish their objectives) threaded throughout the above Phases include: • Situational Awareness and Common Operating Picture Guam Pandemic Influenza Plan 11-4 List of Acronyms AAFB ACIP ADA AG AOC APHIS ARDS ARFF BCDC BFHNS BPCS BPSS BSL CBP CBT CCU CDC CERT CFR CHC COOP CPC CPHO CQA CSR CSS CTT DepCor DoAg DoD DEH DGR DHHS DISID DLS DMAT DMHSA DMORT DOA DOC DOT DPHSS DPR DPW Andersen Air Force Base Advisory Committee on Immunization Practices Americans with Disabilities Act Office of the Attorney General Airport Operations Committee Animal and Plant Health Inspection Service Acute Respiratory Distress Syndrome Aircraft Rescue and Fire Fighting Unit Bureau of Communicable Disease Control Bureau of Family Health and Nursing Services Bureau of Primary Care Services Bureau of Professional Support Services Biosafety Level U.S. Customs and Border Protection Computer-based Training Consolidated Commission on Utilities U.S. Centers for Disease Control and Prevention Community Emergency Response Team Code of Federal Regulations Community Health Centers Continuity of Operations Plan Corps Processing Center Chief Public Health Officer Customs and Quarantine Agency Customer Service Representative Catholic Social Service Corpse Transportation Team Department of Corrections Department of Agriculture U.S. Department of Defense Division of Environmental Health Dangerous Goods Regulation U.S. Department of Health and Human Services Department of Integrated Services for Individuals with Disabilities Diagnostic Laboratory Services Disaster Medical Assistance Team Department of Mental Health and Substance Abuse Disaster Mortuary Operational Response Team Department of Administration Department Operations Center U.S. Department of Transportation Department of Public Health and Social Services Department of Parks and Recreation Department of Public Works APPENDIX A-1 DSC DYA EAP ED EMS EOC ER ERL ERT ESF ESAR-VHP FAA FAQ FCC FDA FEMA GAIMFT GCA GCC GEDCA GEPA GERP GFD GHS GHRA GIAA GMHA GMS GNA GNASW GNG GNS GPA GPD GPHL GPSS GSA GTA GUARNG GVB GWA HAN HEALTH HPAI HPERD HPLO Division of Senior Citizens Department of Youth Affairs Employee Assistance Program Emergency Department Emergency Medical Services Emergency Operations Center Emergency Room Emergency Response Level Epi Response Team Emergency Support Function Emergency System for Advanced Registration of Volunteer Healthcare Professionals Federal Aviation Administration Frequently Asked Question Federal Communication Commission Food and Drug Administration Federal Emergency Management Agency Guam Association of Individual, Marriage, and Family Therapists Guam Code Annotated Guam Community College Guam Economic Development and Commerce Authority Guam Environmental Protection Agency Guam Emergency Response Plan Guam Fire Department Guam Homeland Security Guam Hotel and Restaurant Association Guam International Airport Authority Guam Memorial Hospital Authority Guam Medical Society Guam Nursing Association Guam National Association of Social Workers Guam National Guard Guam Nursing Services Guam Power Authority Guam Police Department Guam Public Health Laboratory Guam Public School System General Services Agency Teleguam Holdings, LLC Guam Army National Guard Guam Visitors Bureau Guam Waterworks Authority Health Alert Network Health Emergency Assistance Line and Triage Hub Highly Pathogenic Avian Influenza UOG Health, Physical Education, Recreation, and Dance Program Health Professional Licensing Office APPENDIX A-2 HQS HSLD IATA IC ICS IFA IFS ILI IND IRB JIC MCG MIC MOA MOU NDMS NGO NIMS NRCHC NRP NVAC OCD OCME OVS PAG PHA PHI PIC PIHOA PIO PMC POC POD PPE RAC SARS SBA SDA SNS SNIP SOB SRCHC TDC TNT TRM TSA Honolulu Quarantine Station Honolulu State Laboratory Division International Air Transport Association Incident Commander Incident Command System Immunofluorescence Assay Individual and Family Support Influenza-Like Illness Investigational Drug Institutional Review Board Joint Information Center Mayors Council of Guam Mass Immunization Clinic Memorandum of Agreement Memorandum of Understanding National Disaster Medical System Non-Governmental Organization National Information Management System Northern Region Community Health Center National Response Plan National Vaccine Advisory Committee Office of Civil Defense Office of the Chief Medical Examiner Office of Vital Statistics Port Authority of Guam Public Health Authority Protected Health Information Pandemic Influenza Committee Pacific Islands Health Officers Association Public Information Officer Pacific Medical Center Point of Contact Point of Distribution Personal Protective Equipment Response Activity Coordinator Severe Acute Respiratory Syndrome Small Business Administration Seventh Day Adventist Strategic National Stockpile Special Needs Identification Project Shortness of Breath Southern Region Community Health Center The Doctors Clinic/The Family Practice Thomas Nationwide Transport Temporary Refrigeration Morgue Transportation Security Administration APPENDIX A-3 UH UOG USDA USNH VAERS VAPPC VFC WHO University of Hawaii University of Guam U.S. Department of Agriculture U.S. Naval Hospital Vaccine Adverse Events Reporting System Vaccine and Antiviral Prioritization Policy Committee Vaccines for Children Program World Health Organization APPENDIX A-4 List of Supporting Local Authorities, Response Plans, Protocols & SOPs ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ 10 GCA Chapter 19, Emergency Health Powers Act 4 GCA Chapter 4, Personnel Policy and the Civil Service Commission Governor's Executive Order: 2008-04 Guam All-Hazards Catastrophic CONOP Base Plan Guam Emergency Response Plan Basic Plan Guam Emergency Response Plan Annex H Civil Unrest Guam Emergency Response Plan Functional Annex F Federal Response Coordination Guam Tactical Interoperable Communications Plan Guam Police Department General Order #03-004, Unusual Occurrence Control Procedures; Guam Police Department General Order #08-003, Handling Cases of Influenza Pandemic; Guam Fire Department EMS Policies and Protocols ADMIN 1.0 General Patient Treatment Policies Guam Fire Department EMS Policies and Protocols ADMIN 6.1 Restocking of EMS Supplies Guam Fire Department EMS Policies and Protocols ADMIN 6.2 Guam Fire Department E-9-1-1 Pandemic Protocols (Adopted) Guam Public School System Emergency Response Plan (Sept 2007) Guam Education Policy Board, Board Policy # 515 Guam Memorial Hospital Authority Emergency Management Plan: IX. Communications Guam Memorial Hospital Authority Pan Flu Draft #5 Department of Administration’s Personnel Rules and Regulations Department of Administration Proposed Executive Order (HR) Department of Public Health & Social Services SNS Plan (Jan 2008) Department of Public Health & Social Services Continuity of Operations Plan o Division of Public Health (DPH) o Division of Environmental Health (DEH) Emergency Food Assistance Act of 1983 7 CFR, Part 280.1, Emergency Food Assistance for Victims of Disasters APPENDIX A-5