Table of Contents ri g ec han sf om p .T i ncl u det h spr af mg t h ec ri sof ul ngv .T ine r ao l,...

Preface and Acknowledgements ................................................................................................iExecutive Summary......................................................................................................................ii

1. Introduction ...............................................................................................................................1-1Seasonal Influenza ..............................................................................................................1-2Pandemic.............................................................................................................................1-2Pandemic Planning ..............................................................................................................1-2

2. Planning Environment And Assumptions..............................................................................2-1WHO Pandemic Phases ........................................................................................................2-2Canadian Pandemic Phases .................................................................................................2-3Planning Assumptions .........................................................................................................2-6Inter-Jurisdictional Planning and Collaboration ..................................................................2-7Incident Management System (IMS) ....................................................................................2-8Ethical Considerations for Decision Making.........................................................................2-8Legislation and Policy Environment .....................................................................................2-8

3. Strategic Approach ...................................................................................................................3-1Goals of Pandemic Preparedness and Response...................................................................3-2Strategic Considerations......................................................................................................3-2

4. Preparedness – Planning, Training & Exercising .................................................................4-1

5. Surveillance................................................................................................................................5-1Objectives of Surveillance Program......................................................................................5-2Interpandemic Period ..........................................................................................................5-2Pandemic Alert Period..........................................................................................................5-2Pandemic Period ..................................................................................................................5-3Post-Pandemic Period ..........................................................................................................5-3

6. Antiviral Drugs ..........................................................................................................................6-1Objectives of Antiviral Program ...........................................................................................6-2Interpandemic Period ..........................................................................................................6-2Pandemic Alert Period..........................................................................................................6-2Pandemic Period ..................................................................................................................6-2Post-Pandemic Period ..........................................................................................................6-3

7. Vaccines.......................................................................................................................................7-1Objectives of Vaccination Program ......................................................................................7-2Interpandemic Period ..........................................................................................................7-2Pandemic Alert Period..........................................................................................................7-2Pandemic Period ..................................................................................................................7-2Post-Pandemic Period ..........................................................................................................7-3

Table of Contents

Pandemic InfluenzaPlanning Guidelines, Roles and

Responsibilities for the Health Sector

8. Public Health Measures............................................................................................................8-1Objectives of Public Health Measures ..................................................................................8-2Interpandemic Period ..........................................................................................................8-2Pandemic Alert Period..........................................................................................................8-2Pandemic Period ..................................................................................................................8-2Post-Pandemic Period ..........................................................................................................8-3

9. Health Services ..........................................................................................................................9-1Objectives of Health Services...............................................................................................9-2Interpandemic Period ..........................................................................................................9-2Pandemic Alert Period..........................................................................................................9-3Pandemic Period ..................................................................................................................9-3Post-Pandemic Period ..........................................................................................................9-3

10. Laboratory Services................................................................................................................10-1Objectives of the Public Health Laboratory Services...........................................................10-2Interpandemic Period.........................................................................................................10-2Pandemic Alert Period........................................................................................................10-2Pandemic Period ................................................................................................................10-2Post-Pandemic Period ........................................................................................................10-2

11. Communications ......................................................................................................................11-1Objectives of an Effective Communications Plan ...............................................................11-2Interpandemic and Pandemic Alert Periods ........................................................................11-2Pandemic Period ................................................................................................................11-2Post-Pandemic Period ........................................................................................................11-3

AppendicesAcronyms ............................................................................................................................A-2Legislation and Policy..........................................................................................................A-3References ..........................................................................................................................A-6

List of TablesTable 2.1: WHO Pandemic Periods and Phases ................................................................................2-2Table 2.2: Canadian Pandemic Phases.............................................................................................2-3Table 2.3: Pandemic Impact for Newfoundland and Labrador at 35% Attack Rate ..........................2-7Table 3.1: Pandemic Planning Periods and Health Emergency Management

Components (HEMC) ......................................................................................................3-4Table 4.1: Preparedness by Pandemic Phase....................................................................................4-3Table 5.1: Surveillance Activities by Pandemic Phase.......................................................................5-4Table 6.1: Antiviral Drug Activities by Pandemic Phase....................................................................6-3Table 7.1: Vaccination Activities by Pandemic Phase .......................................................................7-4Table 8.1: Public Health Measures by Pandemic Phase....................................................................8-3Table 9.1: Health Services Activities by Pandemic Phase..................................................................9-4Table 10.1: Laboratory Service Activities by Pandemic Phase...........................................................10-3Table 11.1: Communication by Pandemic Phase..............................................................................11-3

Pandemics of influenza occur at regular intervals,approximately two or three times a century. Thenext pandemic is inevitable, although its timing andseverity remain unpredictable. Canadian federal,provincial and territorial (FPT) officials haveincreased public health awareness and planningactivities to prepare for this threat. Internationalinitiatives led by the World Health Organization(WHO) have increased surveillance and globalpandemic planning.

The Department of Health and Community Services(The Department) of Newfoundland and Labradordrafted its first pandemic influenza planningdocument in 2001. Similar to other pandemicinfluenza plans this is a living document that will beupdated periodically to reflect the outcomes of thepandemic working groups.

This planning tool will guide the health sector bothat the provincial and community levels to enhanceawareness, planning and response. It references theCanadian Pandemic Influenza Plan1 which reflectsthe Federal/Provincial/Territorial (FPT) collaborationon a consistent pan-Canadian approach to planningand response. The annexes of the Canadian plancontain the details necessary for provinces andregions to prepare for and operationalize theresponse during a pandemic. This is referenced butnot duplicated in the provincial planning document.

This Newfoundland and Labrador influenzaplanning document for the health sector wasdeveloped through a collaborative and consultativeprocess including representatives of severalGovernment Departments (including Fire andEmergency Services Newfoundland and Labrador),and the Regional Health Authorities, with inputfrom experts and references from other pandemicplanning documents.

This material is provided for clarification ofrespective roles and responsibilities, generalinformation purposes and as a guideline to supportconsistent and comprehensive planning,

preparedness, response and recovery for the healthsector.

The Department wishes to thank the manyindividuals who have contributed to this planningeffort. These individuals represent:

Department of Health and Community ServicesEastern Regional Health AuthorityCentral Regional Health AuthorityWestern Regional Health AuthorityLabrador/Grenfell Regional Health AuthorityDepartment of Human Resources, Labour andEmploymentAssociation of Registered Nurses of Newfoundlandand LabradorFire and Emergency Services Newfoundland andLabrador

The Department also wishes to acknowledge:

• Public Health Agency of Canada,Government of Canada

• Ministry of Health and Long Term Care,Government of Ontario

• Ministry of Health,Government of British Columbia

for their permission to utilize their respectivepandemic plans for general and specific reference inthe preparation of this document.

Preface and Acknowledgments

i

Influenza is an acute viral disease of the respiratorytract which occurs every year in the population.Outbreaks or epidemics occur every few years and cancause widespread illness in the population resulting inthousands of medical visits, hospitalizations, anddeaths across Canada. Complications of influenza,such as pneumonia, are most likely to occur in infants,the elderly and persons with underlying healthconditions. A flu shot each fall can prevent annual or“seasonal” influenza.

At regular intervals, but usually two or three times percentury, a new influenza virus appears causing aworldwide epidemic or “pandemic”. When thishappens widespread disease, increasedhospitalizations and high mortality will occurchallenging the health care system and causingwidespread social disruption.

Comprehensive early planning will reduce the effectsof a pandemic on society. It will be too late to takeany of the actions that can mitigate the impact of apandemic if preparation is delayed until it arrives.

Effective planning requires a collaborative effort by allhealth organizations and partners throughout theprovince. This will provide the public with informationon appropriate public health measures, self-care andtreatment to help reduce the negative impacts of theillness. Planning across the health sector will ensurethe development of common operational pandemicinfluenza plans for the greatest care and protection ofthe population. These plans should be comprehensive,strategic, sustainable, and resilient and allow fortrans-jurisdictional integration and coordination.

The goal of the pandemic planning process is tominimize serious illness and mortality, and to reducesocietal disruption in the population during aninfluenza pandemic. Planning will consider possiblerisks, hazards and vulnerabilities in order to reducethe negative impacts both on individuals and societyas a whole. The planning process will identify thehuman and physical resources required to respond toa pandemic and to mitigate its effects.

To ensure consistency in planning for the pandemic,standard assumptions have been adopted in keepingwith the Canadian Pandemic Influenza Plan. Theseassumptions will also provide a basis for the actionsundertaken during the planning for and response tothe pandemic.

Planning will include an assessment of the existingresources, skill sets and activities relative to thoserequired to ensure response capability. The gapsidentified must be addressed through thereassignment of the existing resources and activities,training, and addition of required new resources.

This process is a collaborative effort of theDepartment of Health and Community Services, thefour Regional Health Authorities, and other healthpartners. As this planning process continues at theregional level throughout the provinces other partnerswill contribute and link operationally to provide aseamless, coordinated, emergency managementapproach to dealing with a pandemic.

Through a process of regular review, consultation, andthe addition of new information, this planningdocument will provide guidance for effectivepreparedness and response to a pandemic influenza.

ii

Executive Summary

1.1 Seasonal Influenza

Influenza is an acute viral disease of the respiratorytract characterized by fever, headache, myalgia,prostration, coryza, sore throat, and cough. Diarrhea,nausea, and vomiting may also be present in children.Influenza occurs every year in the population withoutbreaks or “epidemics” occurring every few yearscausing widespread illness resulting in thousands ofmedical visits, hospitalizations and deaths acrossCanada. Complications such as pneumonia are mostlikely to occur in infants, the elderly and persons withunderlying health conditions. An influenza shot eachfall can prevent this annual or “seasonal” influenza.

This highly communicable disease is transmitteddirectly from one person to another primarily throughthe spread of droplets from sneezing or coughing. Thevirus can survive for up to 48 hours on hard, non-porous surfaces and up to 12 hours on cloth or paperproducts. Thus, touching these surfaces with yourhands and then touching your mouth, nose or eyescan also result in transmission of infection. Theincubation period for influenza is from one to threedays. People with influenza can shed the virus for upto 24 hours before symptoms appear and are thusable to transmit the virus before knowing that theyare infected. Adults are infectious for three to fivedays after symptoms appear while children can beinfectious for up to seven days after symptomsappear.

Influenza viruses are unstable and undergo regularchange from one season to another. This process ofgradual mutation in the virus is called antigenic drift.New influenza vaccines are produced each year toprotect against these new influenza virus strains.

1.2 Pandemic

At regular intervals, usually two to three times percentury, an influenza pandemic occurs. An influenzapandemic is a global outbreak that occurs when anew influenza A virus, to which virtually no one isimmune, spreads easily from person to person causing

serious human illness. In contrast to the pattern ofantigenic drift, which typically occurs from oneinfluenza season to another, sometimes the change inthe virus is so great that a new virus emerges. Thissudden and major change to the virus is an antigenicshift. Because of the extreme change in the virus,there is little or no immunity within the population,infection spreads rapidly and disease is more severe.When this happens on a global scale it is considered apandemic.

Over the past century, three influenza pandemics haveoccurred (1918-19, 1957-58, and 1968-69), eachcausing higher rates of illness and death than thatcaused by an annual influenza. In the Spanishinfluenza epidemic of 1918-19, an estimated 20-50million people died worldwide. In Canada anestimated 30,000-50,000 people died of influenza in1918-19; this is in contrast to 4 thousand influenzadeaths in Canada annually. The pandemics of 1957-58and 1968-69 each claimed approximately one millionlives worldwide.

1.3 Pandemic Planning

The next pandemic is expected to cause widespreaddisease, increased hospitalizations and high mortalitywhich will challenge the health care system and resultin significant social disruption.

Comprehensive early planning will reduce the effectsof a pandemic on society. It will be too late to takeany of the actions that can mitigate the impact of thepandemic if preparations are delayed until themoment it arrives. The goal of the pandemic planningprocess is to minimize serious illness and mortality, aswell as to reduce societal disruption in the populationduring an influenza pandemic.

Effective planning requires a collaborative effort by allhealth organizations and partners throughout theprovince. This will provide the public with informationon appropriate public health measures, self-care, andtreatment to help reduce the negative impacts of theillness. Planning across the health sector will ensure

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1. Introduction

the development of common operational pandemicinfluenza plans for the greatest protection and care ofthe population. These plans should becomprehensive, strategic, sustainable and resilient,and allow for trans-jurisdictional integration andcoordination.

This process is a collaborative effort of theDepartment of Health and Community Services(DHCS), the four Regional Health Authorities andother health partners. As this planning processcontinues at the regional level throughout theprovince, other partners will contribute and linkoperationally to provide a seamless, coordinated,emergency management approach to dealing with apandemic.

Planning will consider possible risks, hazards andvulnerabilities in order to reduce the negative impactsboth on individuals and society as a whole. Theplanning process will identify the human and physicalresources required to respond to a pandemic and tomitigate its effects.

Planning will include an assessment of the existingresources, skill sets and activities relative to thoserequired to ensure response capacity and capability.The gaps identified through this process must beaddressed through the reassignment of existingresources and activities within the system, increaseddesired skillset training, and the addition of essentialand required new resources.

TheWorld Health Organization (WHO) is active withgovernments and other organizations throughout theworld to promote planning activities. Many countriesare moving forward with their planning processes.Planning within Canada is well advanced relative tomany other countries. The Department in this provinceis working closely with Regional Health Authoritiesand other organizations to promote planningactivities. This document will provide guidelines,planning activities, roles and responsibilities forplanning within the health sector and otherorganizations.

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2.1 WHO Pandemic Phases

The World Health Organization (WHO) has identifiedfour distinct pandemic periods before, during andafter an influenza pandemic. The post-pandemicperiod is a time for recovery, evaluation and returnto the interpandemic period.

Specific phases subdivide each period, according tothe assessed risk of a pandemic. Several factorstrigger changes from one phase to another. Theseinclude the spread of the disease among humans andthe characteristics of circulating viruses. There areinternational, national, provincial and local planningand response actions associated with each phase.

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2. Planning Environment and Assumptions

Table 2.1: WHO Pandemic Periods and Phases5

Period Phase Description

InterpandemicPeriod

Phase 1

No new influenza virus subtypes have beendetected in humans. An influenza virus subtypethat has caused human infection may be presentin animals. If present in animals, the riska ofhuman infection is considered to be low.

Phase 2

No new influenza virus subtypes have beendetected in humans. However, a circulatinganimal influenza virus subtype poses a substantialriska of human disease.

Pandemic AlertPeriod

Phase 3Human infection(s) with a new subtype, but nohuman-to-human spread, or at most rareinstances of spread to a close contact.

Phase 4

Small cluster(s) with limited human-to-humantransmission but spread is highly localized,suggesting that the virus is not well adapted tohumansb

Phase 5

Large cluster(s) but human-to-human spread stilllocalized, suggesting that the virus is becomingincreasingly better adapted to humans, but maynot yet be fully transmissible (substantialpandemic risk).b

Pandemic Period Phase 6Increased and sustained transmission in generalpopulationb

Post-Pandemic Period Return to interpandemic period

a The distinction between phase 1 and phase 2 is based on the risk of human infection or disease resulting from circulating strains inanimals. The distinction is based on various factors and their relative importance according to current scientific knowledge.Factors may include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife,whether the virus is enzootic or epizootic, geographically localized or widespread, and/or other scientific parameters.

b The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors andtheir relative importance according to current scientific knowledge may be considered. Factors may include rate of transmission,geographical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain),and/or other scientific parameters.

2.2 Canadian Pandemic Phases

The phases used in Canadian planning have beenadapted from the WHO phases. Sub phases havebeen added to identify levels of novel virus activityin Canada.

The Canadian levels are: 0 – no activity observed inCanada; 1 – single case(s) observed in Canada (i.e.no clusters) and; 2 – localized or widespreadactivity in Canada.

Table 2.2: Canadian Pandemic Phases

Definition Hypothetical Example(s) WHO Phase

Interpandemic Period - Phase 1.0

No new virus subtypes have been detected in humans.An influenza virus subtype that has caused humaninfection may be present in animals located outside ofCanada. If present in animals, the risk of humaninfection/disease is considered to be low.

Highly pathogenic H7N3detected in poultry outsideof Canada

1


No new virus subtypes have been detected in humans.An influenza virus subtype that has caused humaninfection is present in animals in Canada but the risk ofhuman infection/disease is considered to be low.

Highly pathogenic H7N3detected in poultry inCanada

1


No new virus subtypes have been detected in humans.However, an animal influenza virus subtype that posessubstantial risk to humans is circulating in animalslocated outside of Canada.

Highly pathogenic H5N1detected in poultry flocksoutside of Canada

2

2-3

2-4


No new virus subtypes have been detected in humans.However, an animal influenza virus subtype that posessubstantial risk to humans is circulating in animals inCanada.

Highly pathogenic H5N1detected in poultry flocksin Canada

2

Pandemic Alert Period – Phase 3.0

Outside Canada human infection(s) with a new subtypeare occurring, but no human-to-human spread, or at mostrare instances of spread to a close contact has beenobserved. No cases identified in Canada.

Outside Canada, sporadichuman cases are occurringin connection to an avianoutbreak.

3


Single human case(s) with a new subtype detected inCanada. Virus is not known to be spreading fromhuman-to-human, or at most rare instances of spread toa close contact have been observed.

Case imported intoCanada from area outsideCanada experiencing anavian outbreak. Casearising in Canada de novoOR in association with anavian outbreak in Canada.

3


Outside Canada, small cluster(s) with limited human-to-human transmission are occurring but spread is highlylocalized, suggesting that the virus is not well adapted tohumans. No cases identified with these cluster(s) havebeen detected in Canada.

Outside Canada, smallcluster(s) of human casesare occurring inconnection to an avianoutbreak.

4


Single human case(s) with virus that has demonstratedlimited human-to-human transmission detected inCanada. No cluster(s) identified in Canada.

Detection of an importedcase in Canada that isinfected with the virusknown to be causing smallclusters of human casesoutside Canada.

4


Small localized clusters with limited human-to-humantransmission are occurring in Canada but spread is highlylocalized, suggesting that the virus is not well adapted tohumans.

Detection of a localizedcluster of cases in Canadalinked to an imported caseOR from cases arising inCanada.

4

Post-Pandemic Period –Following phase 6 there would be a return to the interpandemic period andrecovery activity. There would be a need to address backlog of services, psychosocial effects on staff, stafffatigue, review and analysis of response, debrief of response and adjustment to the plan.


Outside Canada larger cluster(s) are occurring buthuman-to-human spread still localized, suggestingthat the virus is becoming increasingly better adaptedto humans but may not yet be fully transmissible(substantial pandemic risk). No cases identified withthese clusters have been detected in Canada.

Outside Canada, largercluster(s) of human cases areoccurring in connection to anavian outbreak.

5


Single human case(s) with virus that is better adaptedto humans detected in Canada. No cluster(s)identified in Canada.

Detection of an imported casein Canada that is infectedwith the virus known to becausing larger clusters ofhuman cases outside Canada.

5


Larger localized cluster(s) with limited human-to-human transmission are occurring in Canada buthuman-to-human spread still localized, suggestingthat virus is becoming increasingly better adapted tohumans but may not yet be fully transmissible(substantial pandemic risk).

Detection of a large butlocalized cluster of cases inCanada linked to an importedcase OR from cases arising inCanada.

5

Pandemic Period – Phase 6.0

Outside Canada increased and sustained transmissionin general population has been observed. No casesidentified with the affected populations have beendetected in Canada.

Countries outside of Canadahave reported sustainedtransmission of the new virusin their populations.

6


Sporadic infection(s) with the pandemic virus detectedin Canada. No cluster(s) identified in Canada.

Detection of an imported casein Canada that is infectedwith the pandemic virus.

6


Localized or widespread pandemic activity observed inCanadian population.

Large numbers of clinicalcases being rapidly identifiedwith no history of travel to anaffected area.

6

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2.3 Planning Assumptions

Past pandemics have varied greatly in terms ofseverity and impact and the characteristics of thenext pandemic will not be known until thepandemic occurs. To ensure consistency in planningfor the pandemic standard assumptions have beenadopted in keeping with the Canadian PandemicInfluenza Plan. These assumptions will also providea basis for the actions taken during the planning forand response to the pandemic.

It is important for all health planners to use thesecommon assumptions to ensure preparation andresponse compatibility. The assumptionssummarized below should not be consideredpredictions for a pandemic but reflect a currentview of reasonable assumptions to guide planningactivities.

Origin and Timing• The influenza pandemic will be due to a novel,

highly infectious, influenza A subtype likelyoriginating in Southeast Asia.

• Most of the world’s population will have littleor no resistance to the virus. The severity ofillness and the number of people dying will besignificantly higher than a seasonal influenzaepidemic.

• The virus will be present in Canada andpossibly in Newfoundland and Labrador withinthree months of the WHO declaring a pandemicand it may arrive at any time of year.

• The pandemic will last 12-18 months with morethan one wave in a 12 month period.

• The first wave of illness will peak within two tofour months after the virus arrives in Canada.

• A second wave may occur within three to ninemonths of the initial wave and each wave willlast approximately six to eight weeks.

• Pandemic strain will predominate over otherinfluenza strains.

Epidemiology• The incubation period is one to three days.

• The period of communicability is approximately24 hours before and five days after onset ofillness.

• Transmission while asymptomatic is possiblebut is more efficient in the early stages ofillness when the person is symptomatic andviral shedding is high.

• Mode of transmission is primarily large dropletand contact (direct and indirect).

• Possibility for airborne route is controversial(underscores the need for surveillance).

• Initial clinical presentation will be consistentwith that of known influenza strains.

• Individuals who recover will be immune.• Sub-clinical infection will occur. Approximately

50% of the infected population will beasymptomatic.

• The groups that are at high risk forcomplications or poor outcomes due to annualinfluenza will be at risk during the pandemic.

Pandemic Impact• The exact impact and the extent of spread may

differ from annual influenza, however this willnot be known until the novel virus startsspreading efficiently in the human population.

• The majority of the population (over 70%) willbe infected during the pandemic but only 15-35% of the population will become ill.

• The majority of cases will become infectedduring the first wave, with about 25% of thepopulation clinically ill.

• If the pandemic is mild to moderate (consistentwith previous pandemics) and in the absenceof any interventions, of those who becomeclinically ill:

• Up to 50% will seek outpatient care• 1% will be hospitalized• 0.4% will die

• Sound medical and ethical judgment willdictate the priorities guiding the use of scarceresources.

• Influenza will likely impact all regions at thesame time, thus, there may be no assistanceavailable from other regions.

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• Influenza will lead to increased employeeabsenteeism as a result of personal illness,care-giving responsibilities, fear of contractingthe illness at work and/or carrying theinfluenza virus back to family and friends.

• Workplace-avoidance absenteeism may occurand must be considered in planning for apandemic; however, based on analysis ofprevious pandemics and similar outbreaksthere is no evidence for this assumption.

• Absenteeism of about 20-25% may beexpected at the peak of the first wave of thepandemic.

doses of the vaccine may be necessary toachieve protection.

• Public health staff will deliver the vaccinethrough mass immunization, once it isavailable.

• Vaccines are not 100% effective. Seasonalvaccines protect approximately 70% of healthyadults.

• Antiviral drugs may be useful for treatment iftaken within 48 hours of the first symptoms.

2.4 Inter-Jurisdictional Planningand Collaboration

Pandemic influenza planning for the health sector isa collaborative effort of the Department, theRegional Health Authorities and various healthpartners. As this planning process continues at theregional level throughout the province otherpartners will contribute and link operationally toprovide a seamless, coordinated, emergencymanagement approach to dealing with a pandemic.The establishment of the Regional HealthEmergency Management Committees and theProvincial Health Emergency Management AdvisoryCommittee are key components of the inter-jurisdictional approach to pandemic planning.

Contagious viruses such as influenza are not limitedby geographic or political boundaries, thus theinternational, national, provincial, and local healthand other sectors must work together to ensure themost positive outcome for the population of therespective jurisdiction.

The development of a National Framework forHealth Emergency Management provides a standardguide to emergency management programdevelopment and is another tool that will allowease of collaboration and sharing in thedevelopment of a seamless pan Canadianemergency management system.

Pandemic influenza is “not just a health issue” andall government departments and agencies,

Table 2.3: Pandemic Impact forNewfoundland and Labrador at 35%Attack Rate (Maximum Impact forModerate Influenza)

Total Deaths 836

Hospitalization (non-death) 2762

Hospitalization (Deaths)(Assumes 70% of total deaths willoccur in hospital)

585

Total Hospitalization 3347

Note:The Regional Health Authorities, with theDepartment, will complete detailed impactassessment on the health system by region.

* Calculation derived from the use of FluAid Model of the United

States Centers for Disease Control

Antivirals and Vaccines• It is unlikely that an effective vaccine will be

available at the start of pandemic activity inCanada but it may be available for a secondwave of illness.

• Because the population will have had noprevious resistance to the pandemic strain, two

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municipal councils, non-government agencies andthe private sector must develop their own pandemicplans. All groups must collaborate throughout theemergency management process to integrate forthe most effective response.

2.5 Incident ManagementSystem (IMS)

An incident management system (IMS) is a keyelement of the response component of anyemergency management program. The use of IMSacross different sectors and organizations providesa structure and process for managing a response toany emergency or disaster. This system allows anorganized response by a single agency to a smallincident or a coordinated multi-agency response toa major incident.

An incident management system provides structureand function for an emergency response as it:

• Standardizes the processes for delivery of acoordinated response

• Clarifies functions of related and/oroverlapping response groups

• Clarifies and enhances communication withinand between response groups

• Establishes use of common terminology• Establishes common management standards

and position descriptions at each level ofresponse

• Uses common report and documentation forms• Recommends interoperability of

communication response equipment• Provides management of personnel,

equipment, facilities and other resources foreach layer of authority having responsibility forthe incident response

• Adjusts to the nature and scope of the incident

Training in IMS has been introduced in RHAs,however system wide training, and mock exercisesare necessary to integrate this into all levels of thehealth system.

2.6 Ethical Considerations forDecision Making

The Canadian Pandemic Influenza Plan (CPIP)sets out several overarching goals for pandemicpreparedness and response. These goals are tominimize serious illness and overall deaths, and tominimize social disruption among Canadiansbecause of a pandemic influenza. These goals serveto guide the decision-making around the use ofscarce resources.

Health decisions during a pandemic must be basedon sound science, accepted ethical values andconstructed through open discussion. Before apandemic, the general population must be informedof the reasoning behind any prioritized allocation oruse of scarce resources. Examples of these resourcesmay include things like antiviral drugs, vaccines,diagnostic testing, hospital beds and otherequipment. The public must also understand therationale for any possible reduction of individualliberties that may occur if isolation or quarantine isrequired. In addition, health care workers need tobe comfortable with, and accepting of, the level ofrisk to which they may be exposed if providing care.The public must be educated about the process sothat most people may understand the decisions asbeing fair and in the best interest of the health andwell-being of the public.

2.7 Legislation and PolicyEnvironment

The Newfoundland and Labrador health sectorderives its authority from the established legislativeand policy direction of the government. Thislegislation and policy are summarized in Appendix1. The Regional Health Authorities should reviewAppendix 1 and other legislation and policydocuments to determine their authority to functionduring pandemic. The gaps identified through thisprocess will be the foundation for recommendingchanges in policy or legislation.

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3.1 Goals of PandemicPreparedness and Response

The goals of influenza pandemic planning are first,to minimize serious illness and overall deaths andsecond, to minimize societal disruption inNewfoundland and Labrador. Planning activities willconsider risks, hazards, and vulnerabilitiesassociated with pandemic influenza in order toreduce the negative impacts on individuals andsociety as a whole. Planning will include anassessment of the existing resources, skill sets andactivities relative to those required to ensureresponse capability.

The gaps identified must be addressed through thereassignment of existing resources and activities,training and addition of required new resources.These may include capital improvements,stockpiling, training, organized redistribution ofassets and human resources and the prioritizationof service delivery.

Neither organizational mandate nor governmentboundaries will restrict the influenza virus; it willinfect multiple jurisdictions at the same time.Therefore, each region must plan to respond withthe resources available within their jurisdiction.Most areas of the country will be involved in theirown response to pandemic influenza and will not beavailable to provide aid to their neighbours.

A collaborative approach within the health sector,among different areas and levels of government,and across related public and private organizations,is essential to successful readiness, prevention,response and recovery activities. The health sectorrelies on public and private organizations to providea wide range of daily services and supplies. Withoutmany of these services and supplies, the healthsector will find it difficult to carry out its businesspriorities. Regional Health Authorities mustencourage their regional public and private partnersto engage in their own emergency managementplanning activities.

During the pandemic, it may be difficult if notimpossible to maintain the current level of healthservices. An expert collaborative group within eachRHA is required to make ethically-based decisionsas to what services the organization will retain,reduce, or curtail during a pandemic. RegionalHealth Authorities will need to discuss theirtentative priority services with other RegionalHealth Authorities, service partners and otherrelated groups to ensure compatibility across theprovince during response. The plans must beexercised to refine the ability of the system torespond in a well-organized fashion, and to ensurethe most effective and efficient response. Thisplanning guide will help the health sector and itspartner organizations to achieve maximumreadiness.

3.2 Strategic Considerations

It is important to use a common approach to thepandemic planning process in a pan-Canadian,cross-jurisdictional manner. This Newfoundland andLabrador document provides common guidelines forregional pandemic influenza planning. It has beendeveloped with consideration of the nationalCanadian Pandemic Influenza Plan in order toassure a common approach across the country.Regional Health Authorities while using this guideto develop their regional plans must also refer tothe Canadian Plan for details on specific topicsreferenced in the provincial document.

A detailed critical review of the preparedness andresponse resources, as well as the training neededto address the identified hazards, risks, andvulnerabilities will be required. Addressing theidentified gaps will require the collaboration ofmany individuals and organizations as the gapsidentified may not all be within the health sector.Realignment or reassignment of resources willrequire agreement on prioritization of programdelivery, sharing and cross-training for specific skillsets. The development of mutual aid agreementsbetween organizations, an information sharing

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3. Strategic Approach

agreement, and agreements on such things asemergency transportation and alternative care siteswill be required.

Since it is assumed that there will be little or noassistance from other jurisdictions each RHA shouldhave plans and programs that will allow them to beas self sufficient as possible and that arecompatible with those of partner organizations.Inter-regional planning will be necessary for sharedand specialized services as well as for coordinationof service reduction plans which may have animpact on another region.

The National Framework for Health EmergencyManagement Guidelines for Program Development8

should be used in developing a programmedapproach. Consideration should be given to the fivekey components of emergency management:

1.Hazard, risk and vulnerability assessment willguide the planning process by helping tounderstand what could be mitigated,identifying the specific items needed to beaddressed and clarifying the underlyingassumption and working environment.

2.Mitigation includes the activities required toprevent or reduce the negative impacts of adisaster. An activity to prevent a disaster maybe as universal as the development andutilization of a vaccination to prevent a diseaseor as simple as education on hand washing orthe use of personal protective equipment (PPE)to control the spread of a disease.

3. Preparedness is the process of planningwhich includes the assessment of resourcesand skills necessary to respond to a disasterand the actions necessary to fill the gapsidentified. Exercising the plan is a crucialcomponent of preparedness. A key part of theeducational component is to practice executionof the plan and to refine the plan further byaddressing additional identified gaps orweaknesses.

4.Response begins simultaneously with themeasured coordinated mobilization ofresources to act on both the impact of thedisaster event and on the assessment of otherpossible impacts with mitigation wherepossible. Evaluating the response andaddressing identified shortfalls is critical tocontinuous improvement of the emergencymanagement program.

5.Recovery includes the actions required tobring the system back to normal operatinglevels and to deal with the residual healthissues. In the case of the health sector, thiswould involve: restocking supplies; ensuringavailability of adequate staff; addressingpsychosocial effects on staff; reducing serviceback-log; and rescheduling staff work andclient appointments. The recovery componentmay be at different stages for differentprogram areas and different regions.

The World Health Organization’s approach topandemic planning is organized into periods andphases which will assist with local planning andresponse activities. These also serve as a referencefor understanding the progression of the pandemicand the associated threat to the world’s population.

The pandemic periods and phases outlined in detailin the previous section are: (1) InterpandemicPeriod, (2) Pandemic Alert Period, (3) PandemicPeriod, and (4) Post-Pandemic Period. Tounderstand how the five components of HealthEmergency Management Programming relate tothese pandemic periods see Table 3.1.

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Table 3.1: Pandemic Planning Periods and Health Emergency ManagementComponents (HEMC)

Period Phase Pandemic Planning PeriodsDescription

Health EmergencyManagement ComponentsDescription

Interpandemic Period

Phase 1 No new influenza virus subtypeshave been detected in humans. Aninfluenza virus subtype that hascaused human infection may bepresent in animals. If present inanimals, the risk of human infectionis considered to be low.

Hazard risk and vulnerabilityassessment, mitigation andpreparedness (includingplanning, training andexercising)

Phase 2 No new influenza virus subtypeshave been detected in humans.However, a circulating animalinfluenza virus subtype poses asubstantial risk of human disease.

Pandemic AlertPeriod

Phase 3 Human infection(s) with a newsubtype, but no human-to-humanspread, or at most, rare instances ofspread to a close contact.

Hazard risk and vulnerabilityassessment, mitigation andpreparedness (includingplanning, training andexercising)

Phase 4 Small cluster(s) with limited human-to-human transmission but spreadis highly localized, suggesting thatthe virus is not well adapted tohumans.

Phase 5 Large cluster(s) but human-to-human spread still localized,suggesting that the virus isbecoming increasingly betteradapted to humans, but may not yetbe fully transmissible (substantialpandemic risk).

PandemicPeriod

Phase 6 Increased and sustainedtransmission in general population

Response including initialimpact assessment andmitigation activity

Post-PandemicPeriod

Return to interpandemic period Recovery including businessresumption response evaluationand return to normal activities

The purpose of preparedness is to ensure theavailability of resources, the clarification of rolesand responsibilities, and the application of anorganized and skilled approach to disaster responsewithin the health sector and between it and partnerorganizations. The goal of this activity is to mountan effective response to achieve the most positiveoutcomes for the people of the province.

Preparedness for any disaster is accomplishedthrough emergency management which includespre-disaster planning, training and exercising of theplans. Emergency management must be an integralcomponent of all program areas throughout theentire organization.

Planning must include an assessment of the currentresources, skill sets and activities relative to theneeded resources to ensure response capability. Thegaps identified can be addressed through: theaddition of new resources; planned reassignment ofexisting resources and activities on a priority basis;cross-training of current staff; and training ofadditional people to ensure effective operation ofcritical activities during a disaster.

The response component of the plan must identifythe specific response activities as determined by theorganization and client services needs.

Recovery planning will identify the resourcesrequired to allow the organization to return tonormal operation as quickly as possible after adisaster. This stage of the process must considerand secure all the resources required to recover, aswell as the human resources and supportsnecessary to help employees deal with any negativepersonal or emotional impacts of a disaster.

The preparedness process is only as good as theknowledge, training, and capability of the planningteam involved. Education in emergencymanagement and training to eliminate gapsthroughout the organization are necessary tominimize the disaster. This will ensure thatresponse systems are resilient and robust.

The exercising of emergency plans, through tabletopor mock exercises, is an invaluable training tool tosimulate the response, clarify internal and externalroles and responsibilities, identify planning andoperational gaps and to further refine the planningactivities.

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4. Preparedness - Planning, Training & Exercising

Table 4.1 – Preparedness – Planning, Training and Exercising Roles andResponsibilities by Pandemic Phase

Preparedness During Interpandemic PeriodPhase 1 - No new influenza subtypes have been detected in humans. A new influenza virus

subtype may be present in animals, but the risk for human infection is low.

National Provincial Regional

• Establish a nationalpandemic planningcommittee

• Develop and updatenational plans incollaboration with relevantdecision-makers

• Exercise pandemic plans andadjust as required

• Identify and train staff whomay be reassigned during apandemic

• Explore need to stockpile(e.g. syringes and othermedical supplies)

• Identify how essentialservices will be maintainedduring a pandemic

• Ensure that the responsenetwork is ready to respond

• Provide technicalinformation liaison

• Share PHAC/HC informationwith PSEPC, federal regionalofficers and with provincialand territorial partners

• Facilitate sharinginformation between animaland health authorities

• Establish a provincialpandemic planningcommittee

• Assess the hazards, risks andvulnerabilities for apandemic

• Develop and updateprovincial plans incollaboration with relevantdecision-makers

• Work with RHA’s to ensureregional pandemic plans arein place

• Identify human and materialresources required during apandemic

• Identify, inform and train keypersonnel who will beinvolved in pandemicplanning and response

• Work with EMO to ensuremunicipalities haveemergency plans in place

• Communicate andcollaborate with otheremergency managementpartners

• Develop continuity ofbusiness plans within theDepartment


• Establish a regionalpandemic planningcommittee

• Assess the regional hazards,risks and vulnerabilities for apandemic

• Develop and updateregional and local plans incollaboration with relevantstakeholders

• Work with communities toensure pandemic plans arein place

• Identify regional human andmaterial resources requiredduring a pandemic

• Identify critical gaps in localhealth infrastructure andresources

• Develop continuity ofbusiness plans to maintainnecessary regional healthservices

• Identify and plan for therequired human resources,training, supplies andequipment


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Preparedness – Planning, Training and Exercising Interpandemic PeriodPhase 2 - New influenza subtype in animals posing a substantial risk of human disease


• Continue activities ofprevious phase

• Develop surge-capacitycontingency plans for theinternal management ofdomestic resources andessential workers during apandemic

• Establish national guidanceto address food safety, safeagricultural practices andother public health issuesrelated to infected animals

• Activate joint mechanismsfor actions with animalhealth authorities and otherrelevant organizations

• Assess preparedness statusand identify actions neededto fill gaps

• Ensure ability to mobilizeand rapidly deploy amultisectoral expertresponse team

• Ensure ability to rapidlydeploy stockpile resourcesto field locations

• Establish compensationpolicies for loss of animalsthrough culling


• Propose a PandemicEmergency ManagementStructure for the DHCS andthe Provincial Government

• Develop surge-capacitycontingency plans for theinternal management ofdomestic resources andessential workers during apandemic

• Assess preparedness statusand identify actions neededto fill gaps

• Develop with RHAs a planfor stockpiles of essentialitems

• Develop plan to rapidlydeploy stockpile resourcesto regions


• Propose a regionalemergency managementstructure for pandemicresponse

• Coordinate planningactivities with borderingjurisdictions in collaborationwith provincial and federalauthorities

• Ensure additional effectivecommunication plansbetween health andemergency response systems

• Exercise pandemic plans anduse the results to improveand refine plans andpreparedness

• Develop training programsand pre train wherepractical for essential tasks

• Develop plan to rapidlydeploy stockpile throughoutregion

Table 4.1 – Continued.

Preparedness – Planning, Training and Exercising Pandemic Alert PeriodPhase 3 - New influenza subtype identified in at least one human case. No human-to-human

transmission or rare cases of spread through very close contact only.


• Continue activity of previousphase(s)

• Activate national pandemiccontingency planningarrangements

• Mobilize national responseand provide guidance torelevant authorities inreviewing, updating andimplementing contingencyplans

• Brief appropriate officials inall relevant governmentdepartments (e.g. health,agriculture, executive,legislative/judicial) atnational and provinciallevels, regarding the statusof the incident and thepotential need for additionalresources, interventions andthe use of emergencypowers

• Provide assistance toregional, district and localauthorities (including privateessential services) inimplementing interventions


• Review business continuityplan, ensure all essentialservices including outsidecontractor/suppliers areidentified and covered fortemporary or permanent lossof resources

• Plan for up to 25% ofabsent staff/contractors/suppliers for 2-4 weeksaround the peak of the firstwave

• Ensure training programsare conducted or ready toteach non essential staff andvolunteers essential tasks

• Meet with appropriatepartners and stakeholders toreview planning activities

• Ensure emergency healthservice providers are awareof infection controlprecautions

• Test decision makingprocedures and chains ofcommand and plans


• Activate regional pandemiccontingency planningarrangements (planningcommittees and workinggroups)

• Review regional readinessfor response and provideguidance to relevantauthorities in reviewing,updating and implementingcontingency plans

• Review business continuityplan, ensure all essentialservices including outsidecontractor/suppliers areidentified and covered fortemporary or permanent lossof resources

• Ensure training programsare conducted or ready fordelivery to essential staffand volunteers for essentialtasks


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Preparedness – Planning, Training and Exercising Pandemic Alert PeriodPhase 4 - Localized small clusters of limited human-to-human transmission


• Continue activities ofprevious phase(s)

• Confirm plans are in place• Activate national pandemic

contingency planningarrangements

• Reassess current state ofpreparedness; implementactions required to closepriority gaps

• Identify ability to respond torequests for internationalassistance

• Ensure highest levels ofpolitical commitment forongoing and potentialinterventions/countermeasures

• Activate procedures toobtain additional resources;consider invokingemergency powers

• Activate overarchingnational command andcontrol of responseactivities, either by formalmeans or de facto (closeoversight of district andlocal activities)

• Deploy operational responseteams across all relevantsectors

• Ensure cross-bordercollaboration withsurrounding countries forinformation-sharing andcoordination of emergencyresponses


• Update RHAs and all staffabout status of pandemicinfluenza

• Mobilize provincial responseand provide guidance torelevant authorities inreviewing, updating andimplementing contingencyplans

• Activate provincialpandemic contingencyplanning arrangements


• Review results of anypreviously conductedsimulation exercises andconsider what (if any)significant changes haveoccurred since and confirmthat corrective actions havebeen taken

• Identify ability to respond torequests for provincial andnational assistance

• Activate business continuitycomponents of plan asnecessary

• Ensure highest levels ofpolitical commitment forongoing and potentialinterventions/countermeasures


• Notify emergency servicemanagers of virus reportand current monitoringactivities

• Ensure emergency healthservice providers are awareof infection controlprecautions

• Review results of anypreviously conductedsimulation exercises andconsider what (if any)significant changes haveoccurred since and confirmthat corrective actions havebeen taken

• Update partners and all staffabout status of pandemicinfluenza

• Activate regional pandemiccontingency planningarrangements as necessary


• Identify ability to respond torequests for assistancewithin the region

• Continue training to ensurecontinuation of essentialservices

• Meet with appropriatepartners and stakeholders toreview planning activities


Preparedness – Planning, Training and ExercisingPandemic Alert Period

Phase 5 - Localized larger clusters of human-to-human transmission



• Identify needs forinternational assistance

• As needed, designate specialstatus to affected area inorder to facilitateinterventions (e.g. state ofemergency)

• Assist in the ongoingevaluation of interventions

• Finalize preparations forimminent pandemic,including activation ofinternal organizationalarrangements (withincommand-and-controlsystem) and staffing surgecapacity

• Adjust and maximize effortsand resources to reducedisease burden and containor delay the spread ofinfection


• Ensure cross-bordercollaboration withsurroundingcountries/provinces forinformation-sharing andcoordination of emergencyresponses

• Identify needs for nationalassistance



• Finalize preparations forimminent pandemic,including activation ofinternal organizationalarrangements (withincommand-and-controlsystem) staffing for surgecapacity and businesscontinuity


• Activate procedures toobtain additional resourcesas needed; considerinvoking emergency powers


• Ensure collaboration withsurrounding regions forinformation-sharing andcoordination of emergencyresponses

• Identify needs for provincialassistance



• Finalize preparations forimminent pandemic,including activation ofinternal organizationalarrangements (withincommand-and-controlsystem) and staffing surgecapacity


• Activate procedures toobtain additional resourcesas needed, considerinvoking emergency powers


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Preparedness – Planning, Training and Exercising Pandemic PeriodPhase 6- Increased and sustained transmission in general population


• Continue activities ofprevious phases as theyrelate to response

• Implement specificpandemic response activitieswhen pandemic reachesCanada


• Implement specificpandemic response activitieswhen pandemic reachesNewfoundland and Labrador



• Implement specificpandemic response activitieswhen pandemic reaches theregion


Preparedness – Planning, Training and ExercisingPost-Pandemic Period -- Recovery


• Review activities; compileand analyze data and report

• Evaluate response• Debrief with relevant

partners• Revise pandemic plans

based on review, evaluationand analysis

• Return to Phase 1












Surveillance activity not only leads to earlydetection of virus activity within the population butby tracking the occurrence, progression, andseverity of the pandemic, it helps guide preventionand control efforts.

Surveillance is the collection, collation, and analysisof data and the timely dissemination of thatinformation to those who need to know in order totake action.9 In this instance, surveillance is used todetermine when, where, and what influenza virusesare circulating and the disease epidemiology.Influenza surveillance takes place in all phases ofthe pandemic with tracking, investigation andevaluation of both clinical and laboratory confirmedcases.

Surveillance starts locally and feeds into provincial,national, and international systems. TheDepartment, Regional Health Authorities and theProvincial Public Health Laboratory must ensurethat they have a plan and the capacity to increasesurveillance activities as the novel influenza virusbecomes more widespread.10

5.1 Objectives of SurveillanceProgram

An effective surveillance system will provideinformation on which to base decisions forprevention and treatment. The objectives ofinfluenza surveillance are to:

• Provide data on currently circulating strainsand facilitate comparison with vaccinecomposition and vaccine recommendations;

• Describe the affected population, therebyfacilitating the identification of high-riskgroups and comparison with other populationsor with other influenza seasons;

• Detect unusual events including unusual ornew strains, unusual outcomes and orsyndromes, or unusual distribution or severityof the disease in the population;

• Inform the pandemic response through theearly detection and tracking of the emergence,spread and impact of novel influenza viruses inthe population.

The epidemiological knowledge derived fromsurveillance will guide the process of the health andother sectors in disease prevention, treatment andcontrol activities. Ongoing evaluation ofsurveillance activities for each pandemic phase isimportant so that the appropriate adjustments canbe made. The Department, Regional HealthAuthorities, Provincial Public Health Laboratory, andother health partners must collaborate on theirsurveillance activities to achieve these objectives.

5.2 Interpandemic Period

The Department and Regional Health Authorities inthe province participate year-round in the PublicHealth Agency of Canada (PHAC) FluWatch programfor laboratory confirmed influenza and forinfluenza-like illness (ILI) surveillance. Regionsreport the ILI activities on a weekly basis fromworkplace, long-term care, childcare, outpatientdepartments, hospital emergency settings andphysicians’ offices. This information providescommunity based data on the ILI activity within theregion and on the severity of illness during theregular influenza season. The Provincial PublicHealth Laboratory reports all confirmed influenzacases to the Medical Officers of Health. Summarydata from all sources is sent to PHAC for use inFluWatch reports.

5.3 Pandemic Alert Period

The alert period is a time of enhanced surveillancefor the detection of the first appearance of thenovel influenza virus strain in Canada. Surveillanceactivities continue as in the Interpandemic Period,with enhanced Severe Respiratory Illness (SRI)surveillance carried out in physicians’ offices andhospital emergency settings. SRI is reported to theRHA, who then report to the office of the ChiefMedical Officer of Health.

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5. Surveillance

5.4 Pandemic Period

Surveillance activities during the Pandemic Period(Phase 6) are intended to detect the arrival of thepandemic virus in Canada (and in Newfoundlandand Labrador) in order to track its occurrence andspread through communities. Surveillance activitiesmay be modified from routine annual influenzasurveillance in order to best capture the dataneeded to manage the outbreak and to report it in atimely manner. These activities must take intoaccount the scarcity of human resources to conductsurveillance. Once the presence of the pandemicstrain has been confirmed some disease surveillanceactivities may be reduced while surveillance forantiviral drug resistance and events associated withvaccine may be added.

5.5 Post-Pandemic Period

The post-pandemic phase begins when the numberof cases of influenza returns to normal pre-pandemic levels. The results of applied researchand epidemiologic analysis will be shared.Surveillance-related information will contribute tothe knowledge of the pandemic for future planning.

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Table 5.1 - Surveillance Roles and Responsibilities by Pandemic Phase

SurveillanceInterpandemic Period

Phase 1 - No new influenza subtypes have been detected in humans. A new influenza virussubtype may be present in animals, but the risk for human infection is low.


• Provide ongoing leadershipthrough organization ofteleconferences/meetings,providing guidance andadvice as needed

• Participate in the WHOGlobal InfluenzaSurveillance Network

• Coordinate routineinterpandemic surveillanceactivities via FluWatch andCanadian IntegratedOutbreak SurveillanceCentre (CIOSC)

• Gather and disseminate P/Tdata with weekly reporting

• Develop case definitions,minimum data elements andmechanisms for datacollection and reportingduring the pandemic period

• Provide regulardissemination ofsurveillance information andspecific alerts andrecommendations

• Ensure links to veterinarycounterparts are in place

• Provide provincial leadership• Coordinate provincial

surveillance activities(FluWatch, CIOSC, SRI, Labconfirmed cases)

• Participate in national andregional surveillanceactivities and reporting

• Inform Regional HealthAuthorities of national andinternational plans

• Align NL pandemicsurveillance plan withCanadian and WHOpandemic surveillance plans

• Ensure capacity to meetnational standards for casedefinitions, minimum dataelements and mechanismsfor data collection andreporting during thepandemic period

• Assess burden of seasonalinfluenza to help estimateadditional needs during apandemic

• Disseminate surveillanceinformation and specificalerts and recommendationsto Regional HealthAuthorities

• Develop continuity plans toincrease capacity andtraining required forsurveillance during thepandemic period

• Link with provincialveterinarian

• Provide regional leadership• Coordinate regional

surveillance activities• Weekly FluWatch• Reporting of lab-

confirmed cases• Enhanced surveillance for

SRI• Inform stakeholders in

region of provincial andnational plans

• Align regional pandemicsurveillance plan withProvincial pandemicsurveillance plan

• Ensure capacity to meetnational standards for casedefinitions, minimum dataelements and mechanismsfor data collection andreporting during thepandemic period

• Assess burden of seasonalinfluenza to help estimateadditional needs during apandemic

• Disseminate surveillanceinformation and specificalerts and recommendationsto regional stakeholders

• Develop continuity plans toincrease capacity andtraining required forsurveillance during thepandemic period

SurveillanceInterpandemic Period

Phase 2 – New influenza subtype in animals posing a substantial risk of human disease





SurveillancePandemic Alert Period

Phase 3 – New influenza subtype identified in at least one human case. No human transmissionor rare cases of spread through very close contact only



• Verify epidemiological dataand current risk assessmentfrom official sources

• Review and confirm that allinterpandemic surveillanceactivities are operatingoptimally

• Convey current internationalrisk assessment in aCanadian context

• Provide information andnational recommendationsto F/P/T stakeholders


• Coordinate enhanced SRIsurveillance and report anyactivity to PHAC

• Determine best method forand coordinate mortalitysurveillance with funeraldirectors, emergencysettings etc.


• Maintain enhanced SRIsurveillance and report anyactivity to province

• Advise, update and monitorpartners regarding enhancedsurveillance, including SRI

• Identify resources and trainfor increased surveillancecapacity


Phase 4 – Localized small clusters of limited human-to-human transmission



• Enhance current surveillanceactivities based oncircumstances


• Disseminate informationand educate regarding casedefinitions and SRI tools


• Implement revised casedefinitions and SRI tools

• Enhance surveillanceactivities based on situation


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Phase 5 – Localized larger clusters of human-to-human transmission



• Describe and communicateclinical picture and how itvaries from annual influenza

• Review, confirm anddisseminate the datarequirements for cases,report forms etc.

• Implement border-basedsurveillance (depending onorigin of cases) coordinatedby the Centre for EmergencyPreparedness and Response(CEPR); include notificationsto ill and well travellers


• Communicate clinicalpicture and how it variesfrom annual influenza to aidin reporting

• Ensure a process is in placefor Regional HealthAuthorities to report toprovince and province toPHAC

• Disseminate national reportforms and reporting processto PHL and Regional HealthAuthorities


• Communicate clinicalpicture of illness toclinicians and how it variesfrom annual influenza to aidin reporting

• Ensure a process is in placefor local authorities toreport to region

• Disseminate national reportforms and reporting processto all health care workers(HCW) involved

• Report to province all dataas per national report forms;including cases, deaths,hospitalizations and eventsfollowing administration ofantiviral drugs

SurveillancePandemic Period

Phase 6 – Increased and sustained transmission in general population



• Review epidemiology ofpandemic to direct priorities

• Monitor surveillanceactivities; compile andreport outcomes


• Review epidemiology ofpandemic to direct priorities

• Monitor surveillanceactivities; compile andreport outcomes includingmortality surveillance


• Implement surveillanceactivities for pandemicperiod

• Review regionalepidemiology to directresponse

• Provide timely data andreport to the province


SurveillancePost-Pandemic Period

Recovery


• Review activities; compileand analyze reports
















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Antiviral drugs are effective for treatment andprophylaxis of annual influenza. During thepandemic, particularly during the first wave ofillness when vaccine is not yet available, antiviraldrugs are expected to be effective. The Departmentand the Regional Health Authorities must plan forthe strategic use of a limited supply of antiviraldrugs. The creation of a provincial stockpile ofantiviral drugs will ensure their availability for theprovince during the pandemic.

Drugs currently approved for the prevention andtreatment of influenza in Canada include:

• Amantadine®, has been available for severaldecades but has limited use because of its sideeffects and the rapid development of resistancewhen used for treatment;

• Tamiflu® (oseltamivir phosphate) andRelenza® (zanamivir), the neuraminidaseinhibitors, when administered within two daysof onset of the first symptoms, have beenshown to reduce the duration of illness,complications, antibiotic use, hospitalizationsand deaths.

During the pandemic, antiviral drugs will be used inthe province in accordance with establishednational priorities and best practices. The finalrecommendations for antiviral use will bedetermined after the pandemic begins and will beadjusted in light of the epidemiology of thepandemic, what is known about the effectiveness oftreatment and resistance and the antiviral supplyavailable at the time.

6.1 Objectives of AntiviralProgram

The objectives of an effective antiviral drug programinclude to:

• Provide a secure supply of antiviral drugs(neuraminidase inhibitors) for treatment ofresidents of Newfoundland and Labrador

• Store, allocate, distribute and administerantiviral drugs efficiently and appropriately

• Monitor the safety and effectiveness of theantiviral program and monitor resistance to theantiviral drugs.


Antiviral drugs are currently used to controlseasonal influenza outbreaks in long term carefacilities in Newfoundland and Labrador. Individualphysicians may also prescribe antiviral drugs asindicated for their patients.


As part of the national pandemic planning process,Canada has secured and cost-shared a stockpile ofantiviral drugs for use in the provinces andterritories based on populations in each jurisdiction.The stockpile is sufficient to treat persons ill withinfluenza and requiring treatment during the firstwave of the pandemic.

The Department of Health and Community Servicesmaintains the provincial supply of antiviral drugs inproper storage ready for distribution to the RegionalHealth Authorities when needed. The RegionalHealth Authorities must begin to plan for securestorage and distribution throughout the regions aswell as a system of rapid distribution to patientswithin the treatment window.

6.4 Pandemic Period

Distribution and Administration – TheDepartment will provide secure storage andtransportation to the regions for antiviral drugs heldby the province. On receipt of the antiviral drugs,the Regional Health Authorities will provide securestorage and distribution of the antiviral drugsaccording to the nationally agreed upon protocolsand treatment plans.

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6. Antiviral Drugs

Surveillance for Antiviral Drug AdverseEvents – Recipients of neuraminidase inhibitorswill be monitored for severe and unexpectedadverse events, as is the protocol for all newmedications. Information will be provided forpatients and health care providers outlining what tolook for and how to report.

The Provincial Public Health Laboratory will ensureongoing monitoring of viral isolates for antiviralresistance as part of a national surveillance plan.Additional studies should be conducted if there isevidence of ineffectiveness of antiviral drugs, eg.,failure to control an outbreak in a nursing home.


Research and epidemiologic analysis will becompleted in this phase. To facilitate analysis it isimportant for RHA’s to gather required informationon clinical presentation, effectiveness, antiviral druguptake and antiviral drug resistance. Protocols willbe provided. Information is shared with nationalteams for further analysis. Resultingrecommendations should be shared with allrelevant stakeholders.

Table 6.1: Antiviral Roles and Responsibilities by Pandemic Phase

Antiviral DrugsInterpandemic Period

Phase 1 - No new influenza subtypes have been detected in humans. A new influenza virussubtype may be present in animals, but the risk for human infection is low



• Provide updates on ongoingrisk assessment forpandemic influenzapotential.



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6-4

Antiviral DrugsPandemic Alert Period



• Develop or modify plans toacquire, store and distributeantiviral drugs

• Confirm security of supply ofantiviral drugs

• Review recommendedpriority groups and plans forantiviral drug use based onavailable epidemiologicaldata

• Ensure that RHAs haveidentified antiviralrequirements

• Develop or modify plans toacquire, store and distributeantiviral drugs

• Acquire recommendedantiviral stockpile

• Ensure that RHAs haveidentified their needs forstorage and distribution ofantiviral drugs

• Work collaboratively withRHA on developingstrategies for rapidtreatment

• Confirm security of supply ofantiviral drugs

• Identify antiviralrequirements

• Develop or modify plans foradequate supply, storageand distribution of antiviraldrugs

• Identify human resources,training and supplies foradministering antiviral drugs

• Develop strategies for rapidtreatment





• Assess antiviral inventoryrelative to perceived need

• Confirm distribution points,shipping requirements andsecurity for antiviral drugs

• Provide training materialsfor use and monitoring ofantiviral drugs


• Assess antiviral inventoryrelative to perceived need

• Confirm distribution points,shipping requirements andsecurity for antiviral drugs

• Review and updateeducational materials onadministering antiviral drugs

• Provide training materialsfor use and monitoring ofantiviral drugs

• Continue activities of previousphase(s)

• Assess antiviral requirementsrelative to perceived need

• Confirm distribution points,shipping requirements andsecurity for antiviral drugs,including isolated communities

• Review regional treatmentplan

• Provide training materials foruse and monitoring ofantiviral drugs

• Provide additionaltraining/education as required



Phase 5– Localized larger clusters of human-to-human transmission




• Distribute antiviral drugs asrequired for earlycontainment


• Distribute antiviral drugs asrequired for earlycontainment

• Ensure staff are trained andinfrastructure is in place

• Track recipients of antiviraldrugs and report adverseevents and drug resistance

Antiviral DrugsPandemic Period




• Monitor antiviral drugssupply, demand, distribution,uptake adverse events andresistance


• Distribute antiviral drugs• Coordinate and compile

data on use in RHAs• Monitor antiviral drug

supply, demand, distribution,uptake adverse events anddrug resistance


• Distribute antiviral drugs• Coordinate and compile

data on use• Manage antiviral drug

supply and demand• Monitor distribution, uptake

adverse events and drugresistance


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Antiviral DrugsPost-Pandemic Period

Recovery


















Following their development more than 50 yearsago, influenza vaccines have become thecornerstone of influenza prevention and control.Influenza vaccine is effective in reducing influenzaillness, hospital admissions and deaths duringannual influenza outbreaks.

Vaccination will be the primary measure forprevention and control of influenza and itscomplications during the pandemic. Since thepandemic vaccine cannot be manufactured until thepandemic strain of the influenza virus is identified itis unlikely that the vaccine will be ready before thefirst wave of illness in Canada.

Canada’s capacity to manufacture influenza vaccinehas been increased to a level that will ensure adomestic supply of the pandemic vaccine. Thevaccine will be produced in batches necessitating aprioritization of the groups to be vaccinated.Newfoundland and Labrador participates in thenational annual influenza vaccine procurementprocess and this will continue for the procurementof the pandemic vaccine.

While production will be a national initiative, theDepartment of Health and Community Services, withthe Regional Health Authorities, must be preparedfor the challenges of secure storage, distributionand safe administration of the vaccine as rapidly aspossible.

7.1 Objectives ofVaccinationProgram

Objectives for an effective vaccine program includeto:

• Prevent illness, hospitalization and death• Provide a secure supply of safe, effective vaccine

for residents of Newfoundland and Labrador• Allocate, distribute, and administer vaccine as

rapidly as possible to the appropriate groups ofpeople

• Monitor the safety and effectiveness of thevaccine program


The Department of Health and Community Servicesprovides an annual influenza vaccination programfor persons at risk of complications due toinfluenza.11 The mandate of this program is toreduce influenza related illness and death.

During the interpandemic period, the RegionalHealth Authorities should identify the resourcesrequired to deliver a two-dose mass vaccinationprogram for the total population. The RegionalHealth Authorities should also consider the sitelocations and supplementary vaccination staff thatmay be required.


During this period the Department should continueto work with Federal/Provincial/Territorial partnersto ensure an adequate and timely supply ofeffective and safe vaccine. The purchase ofimmunization supplies should be included in thebusiness continuity plans of RHAs. Secure storageand distribution plans for vaccines and relatedsupplies should be established.

Plans for mass immunization should be reviewedwith more attention to operational details includingsupplies, staffing requirements and massimmunization sites.12 Any required trainingprograms for non traditional vaccinators andsupport staff should be developed.

7.4 Pandemic Period

Distribution and Administration – Whenpandemic vaccine becomes available it will bedistributed throughout the province. TheDepartment of Health and Community Services willprovide secure storage and transportation forvaccines held by the province. The provincial depotwill distribute vaccines to RHA vaccine depots ordesignated locations according to establisheddistribution procedures.

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7.Vaccines

On receipt of vaccine, each of the Regional HealthAuthorities must provide secure storage,transportation, and distribution to the massimmunization sites. RHAs are responsible foradministration of vaccine throughout their regions.The cold chain must be maintained at all times forinfluenza vaccine as per the Newfoundland andLabrador Immunization Policy Manual.

Vaccine Dosage – During interpandemic periods,one dose of vaccine is generally sufficient to provideprotection against influenza. In contrast, childrenwithout any previous exposure to the influenzavirus require two doses to produce an immuneresponse. In a pandemic situation, the population’simmunity is similar to that of unexposed children.Two doses of vaccine spaced at least three weeksapart will likely be required to confer adequatelevels of immunity. The Regional Health Authoritiesmust consider the possibility of this dosing schedulein their mass vaccination plans.

Vaccine Access During Limited Supply Period– Because the production of vaccine will take placeover several months, vaccine will not be availablefor everyone in Canada at the same time. During aperiod of limited supply vaccine will be provided ona priority basis as established in the CanadianPandemic Plan and according to the goal ofminimizing serious illness, overall deaths andsocietal disruption. It is important to keep in mindthat these priorities may change as moreinformation on the epidemiology of the pandemicbecomes available.

The Regional Health Authorities will identifymembers of these priority groups in theirjurisdictions and develop procedures to vaccinatethem. The Department, with the Regional HealthAuthorities, will develop a communication plan toinform the public of the immunization strategy.

Surveillance for Adverse Events – The provinceand Regional Health Authorities should plan forenhanced surveillance for severe or unexpected

adverse events following immunization. Enhancedsurveillance is essential when a new vaccine isintroduced and more so during a pandemic whenlarger numbers of people are being vaccinated.Vaccine recipients and health care providers willreceive information on reporting of severe orunexpected events. If a significant adverse event isidentified, appropriate responses will berecommended.


Regions should report their vaccination programdata during this period according to the nationalprotocol provided. The Department will facilitatethe collection and epidemiologic analysis of thisdata.

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Table 7.1: Vaccination Roles and Responsibilities by Pandemic Phase

VaccinesInterpandemic Period


Phase 2 - New influenza subtype in animals posing a substantial risk of human disease


• Maintain up-to-date plansto acquire, store anddistribute vaccine

• Facilitate the bulk purchaseof vaccine administrationsupplies

• Promote annual influenzaand pneumococcalimmunization programs

• Increase coverage ratesamong high risk and healthcare workers (HCW)

• Develop records systems forinfluenza immunization

• Develop inventory systemsfor vaccine managementand control

• Promote annual influenzaand pneumococcalimmunization programs

• Increase influenza vaccinecoverage rates among highrisk and HCW

• Plan to implement recordssystems for influenzaimmunization

• Plan to implement inventorysystems for vaccinemanagement and control

VaccinesPandemic Alert Period




• Assess vaccine requirements• Review pandemic vaccine

infrastructure readiness withdomestic manufacture


• Assess vaccine requirements• Confirm security of supply of

vaccine• Work with RHAs to identify

a strategy to stockpilevaccine related supplies

• Develop and maintain up-to-date plans to acquire, store,secure and distributevaccine

• Arrange for security ofvaccine stocks and transport

• Work with Regional Health


• Assess vaccine requirements• Identify persons who meet

the priority definitions ifvaccine supply is limited

• Identify and pre-arrange foralternate vaccineadministration sites

• Identify numbers of dosesand related supplies needed

• Work with the DHCS toidentify a strategy tostockpile vaccine relatedsupplies


Authorities and stakeholders(e.g. professionalorganizations, labourassociations) for humanresource requirements toadminister vaccine

• Acquire vaccine supplies• Identify and arrange secure

storage facilities for vaccine• Identify required human

resources and training toadminister vaccine

• Work with DHCS andstakeholders for humanresource requirements toadminister vaccine





• Confirm distribution points,shipping requirements andsecurity for vaccines

• Review, update anddistribute educationalmaterials on administeringvaccine


• Confirm distribution points,shipping requirements andsecurity for vaccines

• Review, update anddistribute educationalmaterials on administeringvaccine


• Confirm distribution points,shipping requirements andsecurity for vaccines, noteisolated communities

• Review regional massimmunization plans andensure list of qualifiedvaccinators is up to date


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Phase 5 – Localized larger clusters of human-to-human transmission in Canada



• Review estimates of thenumber of people within theP/Ts who fall within each ofthe priority groups forvaccination


• Work with regions to ensureall aspects of massvaccination plans arecompleted

• Review estimates of thenumber of people within theprovince who fall withineach of the priority groupsfor vaccination


• Confirm persons who meetthe priority definitions ifvaccine supply is limited

• Finalize mass vaccinationplan

• Develop training programfor mass vaccination

• Ensure staff are trained andinfrastructure is in place

VaccinesPandemic Period




• Continue involvement invaccine development,testing and productioninitiatives

• Review and if necessaryrevise recommended prioritygroups based on availableepidemiological data

• Coordinate vaccine purchase• Distribute vaccine once

available• Monitor vaccine coverage

and adverse event activities;compile and reportoutcomes


• Refine nationally definedpriority target groupsdepending on provincialcircumstances

• Confirm and communicatepriority group definitionsand update estimates fromRHAs

• Refine other aspects of thenational guidelines(protocols, report forms,etc.) as needed forprovincial and localapplication

• Confirm security for vaccinestorage and transportation

• Receive, store and distributevaccine when available

• Monitor vaccine coverageand adverse events; compileand report results


• Confirm and communicatepriority groups and updateestimates

• Establish secure storagefacilities and transportationfor vaccine

• Confirm security for vaccinestorage and transportation

• Receive, store and distributevaccines

• Implement massimmunization plan

• Monitor vaccine supply,demand, distribution, uptakeand adverse events

• Monitor vaccine coverage andadverse events; compile andreport results


VaccinesPost-Pandemic Period

Recovery
















• Return to Phase1


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Public health measures are actions taken to prevent,control or mitigate the effects of a pandemic. Thesedecisions will range from population basedrecommendations to individual measures. The typeof public health measures used and their timing willdepend on the epidemiology of the outbreak.

Newfoundland and Labrador will use the publichealth measures outlined in the Canadian PandemicInfluenza Plan which were developed through acollaborative federal, provincial, and territorialplanning effort. They are based on the best availableadvice fromWHO and other experts, includingmathematical modelling studies13.Public health is a comprehensive preventativeapproach that may include:

• Public health advice on general personalhygiene and education programs for the public

• Case and contact management during the earlystages of pandemic

• Measures to increase social distance, such asclosing schools or limiting public gatherings

• Travel restrictions• Communication plan for the public

Public health measures must consider not only thepublic at large but should also include public healthpractices in health services facilities.

8.1 Objectives of Public HealthMeasures

The objectives of public health measures include:

• Making recommendations regarding publichealth measures (e.g. cancellation of publicgatherings, school closings, quarantine, etc).

• Planning occurs at all levels to raise awarenessabout the potential impact of these measuresso that the necessary partnerships andconsultations with external stakeholders startduring the interpandemic and continue throughall pandemic periods.

• Compliance with public health measures.


The effectiveness of public health measures for apandemic is dependent on the overall strength ofthe public health system. The interpandemic periodwill be a time to develop the mechanisms andstrategies that will allow the public health system tomove quickly to pandemic preparedness andresponse.

During the interpandemic period public health will:

• Work with F/P/T and regional partners toincrease annual influenza vaccination uptake

• Review the public education campaign strategyfor personal hygiene practices and revise ifnecessary

• Promote healthy living practices

8.3 Pandemic Alert

During the pandemic alert period the increasedlikelihood of a pandemic will enhance the need for amore aggressive approach to prepare for thepandemic. The Department of Health andCommunity Services will work with health partnersto clarify their roles and responsibilities in preparingfor the pandemic. The Department and the RHAs willpromote personal emergency preparedness as a partof their pandemic planning.

8.4 Pandemic Period

During this period of the pandemic, public healthmeasures will concentrate on the response activitiesof the plan. These may include:

• administration of antiviral drugs and vaccines• promotion of public health messages on how to

avoid infection• monitoring self health and the health of the

family• self care practices to reduce the need for clinic

or hospital care

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8. Public Health Measures


In the post-pandemic period all the activities areevaluated and analyzed. This will involve debriefingsessions with relevant partners. This may result inreview of the current pandemic plan with revisionsbased on the learnings from the pandemicexperience.

Table 8.1 – Public Health Measures Roles and Responsibilities by Pandemic Phase

Public Health MeasuresInterpandemic Period

Phase 1 – No new influenza subtypes have been detected in humans. A new influenza virussubtype may be present in animals, but the risk for human infection is low



• In collaboration withprovinces and territoriesmonitor seasonal influenzaactivity including animalinfluenza

• If there are animaloutbreaks provide travelhealth information

• Share surveillanceinformation with RHAs

• Promote annual influenzaimmunization to targetgroups

• Promote public healthmeasures that reducetransmission of influenza

• Promote healthy livingpractices

• Share surveillanceinformation

• Promote annual influenzaimmunization to targetgroups

• Promote public healthmeasures that reducetransmission of influenza

• Manage influenza outbreakwithin the RHA jurisdictionfollowing standard protocols

• Promote healthy livingpractices

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Public Health MeasuresPandemic Alert Period




• Review and updateeducational materials on allaspects of influenza for healthcare professionals, travellers,other special audiences andthe general public


• Review and updateeducational materials on allaspects of influenza for healthcare professionals, travellers,other special audiences andthe general public


• Case and contactmanagement of any suspectcases of severe respiratoryillness (SRI) identified bysurveillance





• Inform health professionalsand public on key messages


• In conjunction withcommunication groupdevelop public healthmessages as required

• Ensure adequate resourcesare available to implementpublic health measures



• Ensure adequate resourcesare available to implementpublic health measuresincluding isolation of cases



Phase 5 – Localized larger clusters of human-to-human transmission



• Review nationalrecommendations as perAnnex M for public healthmanagement of cases andother control measures


• Review nationalrecommendations as perAnnex M for public healthmanagement of cases andother control measures andmodify as necessary


• Implement national publichealth measures

• Implement infection controlmeasures and personalprotective practices



• Develop public educationmaterials about infectioncontrol and personalprotective measures

• Work with RHAs regardingthe national public healthguidelines

• Distribute public educationmaterials about infectioncontrol and personalprotective measures

Public Health MeasuresPandemic Period





• Implement communicationsstrategy

• Distribute antiviral drugs andmonitor their use

• Distribute vaccines andmonitor their use

• Implement public healthmeasures to reduce socialcontact as required

• Promote self and familyhealth care to reduce theneed for clinic or hospital care


• Distribute antiviral drugsand monitor their use

• Distribute vaccines andmonitor their use

• Implement public healthmeasures to reduce socialcontact as required

• Promote self and familyhealth care to reduce theneed for clinic or hospitalcare


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Public Health MeasuresPost-Pandemic Period

Recovery



• Evaluate response• Debrief with relevant partners• Revise pandemic plans based

on review, evaluation andanalysis


• Review activities; compile andanalyze data and report









The demand for health services during a pandemicwill increase significantly. The health care system isexpected to be challenged by the increased demandfor care at a time when the level of absenteeismcould affect the capacity to respond. RegionalHealth Authorities must collaborate withmunicipalities and other local agencies to developcomprehensive and co-ordinated regional responseand recovery plans. Local governments, serviceorganizations, private health care providers andvolunteers may be asked to provide facilities,material and personnel to support the best possiblecare for people who become ill.

Many institutions in Newfoundland and Labradorare currently operating at maximum or nearmaximum capacity and have limited surge capacity.Comprehensive planning is essential to ensure thatsurge capacity has been addressed such thatservices are available when required. FluSurge is aplanning tool developed by the United StatesCenters for Disease Control and Prevention to assistthe health care sector in determining their needsand capacity during a pandemic. This tool may beuseful for RHAs in developing their plans.

The Regional Health Authorities have broad regionalresponsibilities for a wide range of services. Inaddition to the traditional health care facilities andclinics, consideration must be given to othercommunity-based services. These provideresidential services and include: personal carehomes, community care homes, family care homes,foster care homes, alternate family care homes, co-operative apartments, group homes, and others.Similarly, the services provided by homesupport/care agencies and others should beconsidered in the planning processes.

Regional Health Authorities should work withphysicians and other health care providers to ensurethat plans are in place for provision of appropriatecommunity based medical and other health servicesduring a pandemic. Private medical and otherhealth service providers should plan for continuity

of their specific practices during a pandemic. Theseplans should be compatible with the overallpandemic plans within the regions.

Pandemic planning should also include specificsupport to correctional facilities where these exist inthe region. The local Department of Justicerepresentatives must be included in the planningprocess for these unique services.

During a pandemic essential services in manycommunities may be disrupted. The RegionalHealth Authorities may have to adapt protocols andstandards of practice to meet the needs during thisemergency. Depending on the severity of thepandemic, it may be necessary for the health caresystem to consolidate, reduce or curtail someservices. Health care organizations must ensure asupply of goods and services necessary for facilityoperation. This may require stockpiling of someessential supplies. The Department, RHAs andpartner organizations should encourage thesuppliers of goods and services to develop theirown contingency plans to maintain supply chains.

9.1 Objectives of HealthServices

Key objectives for effective health servicesemergency planning include to:

• Minimize pandemic related morbidity andmortality

• Maintain essential health services• Develop surge capacity within the health sector• Ensure that the population is aware of the

potential impact of a pandemic on the healthcare system


During the interpandemic period RHAs incollaboration with community groups must begindevelopment of a pandemic plan for the healthregion. This should include strategies that will

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9. Health Services

allow RHAs to continue to provide essential healthservices to the public during periods of increaseddemand. In anticipation of the increased demandon health services the plan must include attentionto surge capacity, resource allocation andcommunications. It is important that plans beflexible so that they can adapt to new informationas the characteristics of the illness and the impacton the population become known. The HealthServices Emergency Planning and ResponseChecklist of the Canadian Pandemic Plan14 identifieskey areas necessary for health services planning.


In this period Regional Health Authorities shouldhave their pandemic plans developed including:

• establishing priority operations within theorganization which ensure the provision ofessential and emergency services

• planning to increase surge capacity• ensuring an adequate complement of human

resources• ensuring adequate supplies and equipment• arranging for alternate and non-traditional care

sites• reviewing the infection control program• reviewing the occupational health and safety

program• establishing effective information systems and

databases for operational management andevaluation

• ensuring a comprehensive communicationsplan is in place

The Regional Health Authorities must ensure thateach regional service and facility has a plan toaddress the surge during a time when staffing maybe reduced significantly. The region must plan for aphased deferral or scale-back of certain services toensure that essential services are available.Collaboration between Regional Health Authoritieswill be necessary to ensure that service adjustmentsin one region will not adversely affect another

region. There may be a need to plan for alternateand non-traditional care sites.15

RHAs should ensure that agreements are in placewith regulatory bodies where workers may be askedto work in non-traditional settings. Staff should beprovided with education and training relevant totheir responsibilities during a pandemic.

Regional Health Authorities should focus onenhancing infection control and occupational healthand safety practices. Occupational Health andSafety legislation requires that information,instruction and training be provided to ensure thehealth, safety and welfare of workers. It alsorequires that workplace activity, where reasonablypractical, does not cause health and safety hazardexposure to persons visiting or outside workplace.The Canadian Pandemic Plan provides extensivedetails on this approach.16

9.4 Pandemic Period

Once a pandemic is declared emergency plansshould be operationalized as needed. It will beessential for RHAs to inform the public, healthprofessionals, service providers and other partnersabout the provision of health services during thepandemic.


The Department will notify the RHAs when thepandemic is considered to be officially over. TheDepartment and the RHAs will do final deactivationof emergency plan and redeploy human and otherresources to enhance recovery of health caseservices throughout the province. The HealthServices plan and activities will be evaluated andthe plan will be revised as required. Activities willchange to deal with recovery and then return tointerpandemic period levels.

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Table 9.1: Health Services Roles and Responsibilities by Pandemic Phase

Health ServicesInterpandemic Period




• Rapid sharing of informationamong animal and humanhealth professionals

• Provide updates on on-goingrisk assessment forpandemic influenzapotential and makerecommendations forincreased vigilance forsurveillance and publichealth action


• Provide updates on on-goingrisk assessment forpandemic influenzapotential and makerecommendations forincreased vigilance forsurveillance and publichealth action

• Establish regulations,agreements and policies tosupport the use of alternatecare providers

• In conjunction with RHAs,and other stakeholdersestablish guidelines fortraining and use of alternateworkers and redeploymentof staff

• Identify information requiredto evaluate the impact ofthe pandemic on healthservices

• Establish informationsystems to manage thepandemic and to evaluateits impact


• Develop pandemic plan forthe health services sector

• Identify issues that mayrequire legislativeadjustments andagreements to support theuse of alternate careproviders

• Identify information requiredto evaluate the impact ofthe pandemic on healthservices

Health ServicesPandemic Alert Period




• Alert health system toreview preparednessplans

• Ensure that estimatesof health carepersonnel capacity arecurrent

• Develop nationalrecommendations forclinical management ofcases


• Alert health sector toreview preparednessplans

• Ensure that estimatesof health carepersonnel capacity arecurrent

• Plan for theredeployment of non-essential departmentalstaff

• Determine with RHAsthe essential healthservices to be providedduring a pandemic

• Share nationalrecommendations

• Continue activities of previous phase(s)• Review pandemic plans with special

attention to cross jurisdictional issues• Review infection control and occupational

health and safety policies and procedures• Ensure that estimates of health care

personnel capacity are current• Determine staff levels necessary for

emergency demands and redeploymentstrategies

• Identify how human resources gaps willbe filled

• Educate all health care workers oninfection control core competencies

• Identify initiatives that may be sharedwith service and supply partners (food,utilities, transportation, training,communications, facilities, corpsemanagement, etc)

• Determine the number and type of healthcare facilities needed (including alternateand non-traditional care sites), and theirestimated capacity

• Determine how essential services will beprovided

• Develop a pandemic influenza caremanagement plan

• Determine need for stockpiling of supplies• Ensure information management system

is in place to manage the pandemic andto evaluate its impact

• Determine the social and psychologicalsupports necessary for health care sectorand the affected public

• Develop recovery plans


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Health ServicesPandemic Alert Period

Phase 4 – Localized small clusters of limited human-to-human transmissionPhase 5 – Localized larger clusters of human-to-human transmission



• Review and revise ifnecessary, infectioncontrol precautions forcase management

• Review nationalrecommendations forclinical management ofcases and modify ifnecessary

• Anticipate and plan tomobilize human andfinancial resources

• Disseminate informationon medical supplystockpiles and potentialneed for, and sources of,additional supplies

• Disseminate strategy forcollecting andmonitoring data onhealth care services, useand demands

• Evaluate infectioncontrol and occupationalhealth and safetyrecommendations andpractices and revise asnecessary


• Review and revise ifnecessary, infectioncontrol precautions forcase management

• Review nationalrecommendations forclinical management ofcases

• Anticipate and plan tomobilize human andfinancial resources

• Review and updateregional data on thenumber and type ofhealth care facilities andcapacity

• Disseminate informationon medical supplystockpiles and potentialneed for, and sources of,additional supplies

• Disseminate strategy forcollecting andmonitoring data onhealth care services, useand demands

• Evaluate infectioncontrol and occupationalhealth and safetyrecommendations andpractices and revise asnecessary


• Implement and audit infectioncontrol practices for casemanagement and revise as necessary

• Implement nationalrecommendations for clinicalmanagement of cases and modifytreatment if necessary

• Anticipate and plan to mobilizehuman and financial resources

• Review and update data on thenumber and type of health carefacilities and capacity

• Conduct availability assessment ofmedications, supplies and equipmentpotentially needed for the response

• Increase extra supplies andequipment required to providemedical care

• Review and modify detailed regionaland facility plans for providing healthservices during a pandemic

• Implement strategy for collecting andmonitoring data on health careservices, use and demands

• Evaluate infection control andoccupational health and safetyrecommendations and practices andrevise as necessary

• Verify availability and distributionprocedures for personal protectiveequipment

• Ensure that necessary guidelines andprotocols are distributed to regionaland local service providers

• Alert voluntary organizations of needfor their services


Health ServicesPandemic Period




• Evaluate infectioncontrol and occupationalhealth recommendationsand practices and reviseas necessary

• At end of first pandemicwave debrief to assessimpact of first wave, andthen regroup

• Collect available data oneffectiveness and safetyof clinical interventionsand share these with allhealth care areas not yetaffected and WHO


• Facilitate implementationof regional pandemicplans

• Evaluate infection controland occupational healthrecommendations andpractices and revise asnecessary

• Review protocols andguidelines forprioritization oflaboratory services duringtimes of high servicedemand and staff andsupply shortages

• Facilitate health servicesactivities between regionsto avoid migration tocentres of perceivedenhanced services

• Consider strategies tomitigate shortfalls ofsupplies and equipment

• At end of first pandemicwave debrief to assessimpact of first wave, andthen regroup


• Implement pandemic contingencyplans for health systems andessential services; monitor healthsystem status; deploy additionalworkforce; providesocial/psychological supports

• Evaluate infection control andoccupational healthrecommendations and practices andrevise as necessary

• Review protocols and guidelines forprioritization of laboratory servicesduring times of high servicedemand and staff and supplyshortages

• Review mechanisms forcoordinating patient transport andtracking/managing beds

• Assign volunteer organizations asrequired

• Operationalize alternate and non-traditional health care sites asneeded

• Coordinate clinical care and healthservices activities within regionsand between bordering jurisdictionsto avoid migration to centres ofperceived enhanced services

• Consider strategies to mitigateshortfalls of supplies and equipment

• At end of first pandemic wavedebrief to assess impact of firstwave, and make necessaryadjustments to response plan


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9-8

Health ServicesPost-Pandemic Period

Recovery


















Currently, the Provincial Public Health Laboratory(PHL) is the only facility in the province that has thecapability to provide influenza testing. The labsupports both public health surveillance and clinicaldiagnostic services. The PHL has the capacity tomeet routine annual demands, and has developedadditional capacity to meet the anticipatedincreased demands during the different phases ofthe pandemic.

As the provincial reference centre, the PHL will playa central and critical role in the surveillance of theemergence of the pandemic strain in the province,its early detection in the communities at large, andtyping and further characterization of the pandemicvirus strain. The provincial Laboratory is a partnerwithin the National Laboratory Network and willmaintain activities that are consistent with theCanadian Pandemic Plan.

10.1 Objectives of the PublicHealth Laboratory Services

The objectives include:

• Provide support to the hospital labs for theirsurveillance activities

• Detect the arrival and progression of the virusin the province

• Monitor virus strain drift and antiviralresistance

• Support clinical diagnostic practice


During the interpandemic period, as part of theroutine provincial influenza surveillance program,specimens are collected from suspect cases acrossthe province and positive findings are reported tothe hospital lab, Regional Medical Officer of Healthand the Chief Medical Officer of Health (CMOH).Results are also reported to the Canadian VirusReporting Program. Representative influenzaisolates are forwarded to the National MicrobiologyLaboratory (NML) promptly for furthercharacterization, and the information disseminated.


During this period the PHL will increase the stock ofessential reagents and supplies to meet theanticipated increased demand for testing during thistime. Technologists will be cross-trained to create abuilt-in redundancy to ensure uninterrupted service.The PHL will provide guidelines on specimencollection, handling, submission, and bio-safety. ThePHL will also establish a fan-out plan for laboratoryinformation including emergency contact lists forhospital labs, MOHs and CMOH.

10.4 Pandemic Period

Depending on the extent and severity of thepandemic, the demand for influenza testing will farexceed the PHL capacity. It will be necessary tocurtail some of the routine laboratory servicesprovided by the PHL. It will also be necessary tolimit testing of influenza specimens once the spreadof the pandemic strain within the province isestablished. The PHL will use the services of theNML and other satellite reference centresestablished as part of the national laboratorypandemic preparedness plan.


The PHL will review and analyse its response to thepandemic, replenish supplies and return to theinterpandemic phase for surveillance and otherlaboratory services.

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10. Laboratory Services

Table 10.1 – Laboratory Service Roles and Responsibilities by Pandemic Phase

Laboratory ServicesLaboratory Services – Interpandemic Period




• Routine surveillanceactivities including straincharacterization

• Develop and updatenational guidelines for labtesting methodologies andissues relating to bio-safety,reagent stockpile, etc

• Provide proficiency testingprograms

• Provide training in newtesting methodologies

• Routine diagnostic andsurveillance activities

• Develop a list of servicesthat can be reduced orcurtailed during a pandemic

• Provide guidelines onspecimen collection,handling, submission, andbio-safety.

• Participate in national andinternational proficiencytesting programs.

• Increase the inventory ofsupplies and reagents tomeet projected testingdemands

• Maintain specimencollection supplies forannual flu season

• Develop a list of servicesthat can be reduced orcurtailed during a pandemic

• Apply PHL guidelines onspecimen collection andsubmission including bio-safety

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Laboratory ServicesPandemic Alert Period




• Increased surveillance toensure prompt detection ofpandemic strain in Canada

• Provide confirmation andstrain characterizationreference services

• Provide proficiency testingprograms to provincial labs

• Ensure provincial labs havethe capacity for rapiddetection of pandemic strain


• Increased surveillance toensure early detection ofnew virus entry in theprovince

• Submit to NML isolates fromflu cases, cases with severerespiratory illness and caseswith a link to avian influenza

• Assess projected needs forhuman resources, diagnosticsupplies and reagents forscaled up activity

• Participate in internationaland national proficiencytesting


• Review and updatepandemic plan as necessary

• Obtain additional specimencollection and transportsupplies

• Submit specimens to thePHL in accordance withguidelines

Laboratory ServicesPandemic Alert Period

Phase 4 – Localized small clusters of limited human-to-human transmissionPhase 5 – Localized larger clusters of human-to-human transmission



• Scale up testing and straincharacterization services tomeet increased demand

• Develop and assess rapidtesting methodologies toidentify pandemic strain andmake appropriaterecommendations

• Monitor anti-viral resistanceand emergence of variants

• Review and recommendappropriate bio-safetyguidelines


• Scale up to manageincreased numbers ofspecimens

• Review inventory• Ensure all hospital labs have

up-to-date information andnecessary supplies forincreased testing

• Implement selective testing• Review, update and

distribute plan as necessaryincluding bio-safetyguidelines


• Ensure information onselective testing, screeningprotocols and bio-safetyguidelines are current


Laboratory ServicesPandemic Period




• Conduct surveillanceactivities to track the trendsof the pandemic in differentregions of Canada


• Initiate recommended testingmethods

• Redirect resources toaccommodate increaseddemand for influenza testing,with suspension of otherroutine services

• Review inventory and restrictinfluenza testing whenappropriate

• Assess laboratory capacityand resources and resumeroutine testing wherepossible

• Forward representativepandemic strains to the NMLto monitor antiviralresistance and antigenicchanges


• Assess laboratory capacityand resources and resumeroutine testing wherepossible

Laboratory ServicesPost-Pandemic Period

Recovery


















10-5

Communications is a vital component of planningfor pandemic influenza. Effective communicationswith external and internal audiences as well as aconsistent and coordinated approach with federaland regional partners is essential to the provincialpandemic strategy.

A comprehensive communications plan is critical toincrease the awareness of the public regarding thepandemic, to provide direction on healthmaintenance and available health care services, andto alleviate unnecessary anxiety. The key to asuccessful communications plan is a coordinatedapproach with the dissemination of information toall stakeholders in an efficient and timely mannerthroughout all pandemic phases.

Communications planning is coordinated from theinternational level through national, provincial andthe regional levels. The Public Health Agency ofCanada has an established link with the WorldHealth Organization and communicates keyinformation on international influenza activity,which in turn is communicated to the provinces andregions. The communications staff of theDepartment participate on theFederal/Provincial/Territorial Pandemic InfluenzaCommunications Committee which coordinatesinformation and strategies with the PHAC, and withother provinces and territories. The Department’scommunications staff meets regularly withcommunications directors from the four RegionalHealth Authorities to coordinate communicationsplanning.

11.1 Objectives of an EffectiveCommunications Plan

An effective communications plan will:

• inform the people of this province (includinghealth care workers) about the pandemic andthe provincial pandemic plan

• educate the public on measures that can betaken in advance that will reduce the risk ofinfluenza infection and its consequences

• identify roles and responsibilities forcommunications during the pandemic phases

• establish communications networks for useduring the pandemic

• provide timely information during thepandemic

11. 2 Interpandemic andPandemic Alert Periods

The focus of communications in this period will beon educating the key audiences on seasonal andpandemic influenza, respiratory hygiene,immunization and the need for optimizing healthservices during a pandemic. If during the PandemicAlert Period clusters of human-to-humantransmission were to occur in Newfoundland andLabrador, many of the crisis communicationsstrategies outlined for the pandemic period wouldbe implemented.

11.3 Pandemic Period

Once a pandemic is declared, the need to provideinformation will be intense and sustained forseveral months. A pandemic has uniquecharacteristics which must be considered whenplanning a communications strategy including:

• global in scope• threat to the health of the population with the

possibility of high mortality• may occur in waves over an eighteen month

period• significant disruption to communities and

businesses• unpredictable occurrences and effects• events will likely overwhelm normal emergency

planning measures

The Department will activate its pandemiccommunications response providing regular, timelyinformation to all audiences about the status of thepandemic, identifying the steps being taken to

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11. Communications

respond and advising the public about what to doduring each phase.

The Department will use a number of differentcommunications mechanisms during a pandemic,including daily internal briefings, media briefings,news releases, website updates and public serviceannouncements.


The Department will notify the public when thepandemic is considered to be officially over inNewfoundland and Labrador. The communicationsplan and communications activities throughout allphases of the pandemic will be evaluated andadjustments to the plan will be made as required.

Table 11.1 – Communication Roles and Responsibilities by Pandemic Phase

CommunicationsInterpandemic Period

Phase 1 - No new influenza subtypes have been detected in humans. A new influenza virussubtype may be present in animals, but the risk for human infection is low.

Phase 2 - No new influenza subtype in animals posing a substantial risk of human disease


• Develop a comprehensivecommunications plan for allaspects of the pandemicplan

• Establish networks withinternational, national andP/T stakeholders and defineroles and responsibilities

• Inform Ministers,governments and key policydecision-makers of thepotential risks of apandemic

• Provide national andinternational information toP/Ts

• Provide key messages andtemplate materials that canbe adapted to P/T needs

• Promote business continuityplanning

• Participate on F/P/Tcommunications committees

• Develop a provincialpandemic communicationsplan

• Provide key messages andtemplate materials that canbe adapted to regionalneeds

• Establish networks withprovincial and regionalstakeholders and defineroles and responsibilities

• Ensure RHA communicationsplans are compatible withthe provincial strategy

• Inform Ministers, RHAs andkey policy decision-makersof the potential risks of apandemic

• Participate in provincial andregional communicationscommittees

• Develop communicationsplan compatible withprovincial communicationsplan

• Promote personal hygienepractices and self-care

• Encourage and promotepandemic planning forhealth facilities andcommunity stakeholders

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11-4

CommunicationsPandemic Alert Period

Phase 3 - New influenza subtype identified in at least one human case. No human to humantransmission or rare cases of spread through very close contact only



• Inform P/Ts and other keystakeholders of increasedrisk and its implications

• Engage and prepare mediafor their informationsupport role

• Coordinate F/P/Tcommunications response

• Update communicationsplans

• Coordinatecommunications on thetechnical and scientificinformation


• Establish a provincial pandemiccommunications working group

• Communicate the elevation ofpandemic risk to provincial andregional partners including thepublic

• Update communications plans• Ensure that key provincial

stakeholders have accurateinformation to provide to theiraudiences/media

• Communicate technical andscientific information to regionalhealth authorities


• Update communicationsplans

• Communicate theelevation of pandemicrisk to local partners andprovide updates to keystakeholders in the region

• Inform the public

CommunicationsPandemic Alert Period

Phase 4- Localized small clusters of limited human-to-human transmissionPhase 5 - Localized larger clusters of human-to-human transmission



• Inform federal governmentdepartments, P/Ts andNGOs of global pandemicactivity including thehealth response

• Implement nation-widepublic education andawareness campaign


• Update prepared messages inlight of current information

• Inform provincial departmentsand RHAs of global pandemicactivity including the provincialresponse

• Provide detailed updates to thepublic, health care workers andother key stakeholders onclusters of human-to-humantransmission of influenza

• Enhance public education andawareness campaign


• Provide detailed updatesto the public, health careworkers and other keystakeholders on clustersof human-to-humantransmission of influenza

• Enhance public educationand awareness campaign


CommunicationsPandemic Period

Phase 6 - Increased and sustained transmission in general population



• Implement pandemic phaseof national communicationsplan

• Coordinate response withprovinces, territories andfederal populations

• Update key stakeholders• Inform the public• Assess ongoing

effectiveness ofcommunications activities

• Fully implement high profilenation-wide publiceducation and awarenesscampaign

• Keep stakeholders up todate with the latestinformation, and emphasizetheir roles andresponsibilities


• Implement pandemic phaseof provincial plan

• Establish provincialspokesperson(s) for health

• Share information withfederal, provincial andregional stakeholders

• Fully implement high profileprovince-wide publiceducation and awarenesscampaign, aligned withnational campaign

• Ensure consistency inmessaging with otherjurisdictions

• Inform public of self-carepractices, antiviral treatmentand vaccination availability

• Assess ongoing effectivenessof communications activities

• Keep stakeholders up to datewith the latest information,and emphasize their rolesand responsibilities

• Ensure the media have up-to-date information


• Implement pandemic phaseof regional and local plans

• Establish regionalspokesperson(s) for health

• Share information withprovincial, regional and localstakeholders

• Support education andawareness campaigns forhealth professionals and thepublic

• Inform public of self-carepractices, antiviral treatmentand vaccination access

• Ensure consistency inmessaging with provinceand local bodies

• Keep stakeholders/partnersup-to-date with the latestinformation, and aware oftheir roles/responsibilities

• Assess ongoingeffectiveness ofcommunications activities


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CommunicationsPost-Pandemic Period

Recovery


















ACPHHS Advisory Committee on Population Health and Health SecurityCCMOH Council of Chief Medical Officers of HealthCEPR Canadian Integrated Outbreak Surveillance CentreCESSD Council of Emergency Social Services DirectorsCHEMD Council of Health Emergency Management DirectorsCIDPC Centre for Infectious Disease Prevention and ControlCIOSC Canadian Integrated Outbreak Surveillance CentreCMOH Chief Medical Officer of HealthCPIP Canadian Pandemic Influenza PlanCUPE Canadian Union of Public EmployeesDHCS Department of Health and Community ServicesEMO Emergency Measures OrganizationEOC Emergency Operation CentreF/P/T Federal/Provincial/TerritorialFRI Febrile Respiratory InfectionHCW Health Care WorkerHRLE Department of Human Resources, Labour and EmploymentILI Influenza Like IllnessIMS Incident Management SystemMOH Medical Officer of HealthNAPE Newfoundland and Labrador Association of Public and Private EmployeesNGO Non-Government OrganizationNLMA Newfoundland and Labrador Medical AssociationNLNU Newfoundland and Labrador Nurses UnionNML National Microbiology LaboratoryP/T Provincial/TerritorialPHAC Public Health Agency of CanadaPPE Personal Protective EquipmentPPHL or PHL Provincial Public Health LaboratoryRHA Regional Health AuthorityRMOH Regional Medical Officer of HealthSRI Severe Respiratory IllnessWHO World Health Organization

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Acronyms

The purpose of this is to outline the legislative andpolicy directives currently in effect that create aneed for, or give effect to, a departmentalemergency management plan and program. Thisinformation is provided for quick reference only andnot for the purpose of guiding decisions or actions.Decisions and actions will be based on carefulreview of relevant legislation and upon the receiptof legal advice from solicitors with the Departmentof Justice or the Regional Health Authorities.

A. Legislative Directives

The Department of Health and Community ServicesNotice, 2003 identifies that the Minister of Healthand Community Services is responsible for a numberof matters including:

• the promotion and preservation of health• the prevention and control of disease• public health• services to children, youth and families• child care services• the control of drugs• facilities and programs for dependent persons

and persons with disabilities.

The Health and Community Services Act in:

• section 3 requires that officials of publicinstitutions, medical officers of health, clerks orsecretaries of municipalities, school boardofficials, medical practitioners, nurses, socialworkers, dentists, and pharmacists to answercommunications from the Departmentpromptly, gather requested information andsubmit the same to the Department in relationto matters impacting on public health or theprovision of services to families, children andyouth;

• section 5 authorizes health officers, inspectorsor other persons designated by the Minister orauthorized by the Chief Medical Officer ofHealth to enter into buildings or onto land andto issue orders or give directions as necessary

to protect the public health;• section 8 authorizes the Minister to declare an

area to be a restricted area; and• section 11 authorizes the Minister to make

regulations applicable to many aspects ofhealth and community services.

The Communicable Diseases Act in:

• section 4 requires physicians to give notice,within 24 hours, to the deputy minister orhealth officer of the relevant jurisdiction that aperson is believed to be infected with acommunicable disease;

• section 5 requires that officials in charge ofhospitals, residential institutions andteachers/instructors in educational facilitiesgive notice to the deputy minister or healthofficer of the respective jurisdiction that aperson is believed to have a communicabledisease;

• section 6 authorization is provided to healthofficers, upon receipt of notification that a caseof communicable disease exists, to inspectpremises where the disease is reported to existand obtain information as to the personssuspected of being infected or as to the sourceof the infection;

• section 14 enables the Minister, in writing, toauthorize and direct qualified persons toinvestigate outbreaks of infectious disease andunusual and unexplained mortality, suchpersons may exercise the powers conferredupon a commissioner under the Public InquiriesAct;

• section 15 provides a medical health officer,with reasonable grounds, to issue a writtenorder that a person having or suspected tohave an infectious disease, submit to a medicalexamination by the medical health officer orphysician acceptable to the medical healthofficer, where it appears that a person isinfected with a communicable disease themedical health officer may, with the approvalof the Minister or Deputy Minister in writing

Legislation and Policy

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order the treatment necessary to protect thepublic, should the person not comply themedical health officer may by written orderrequest police assistance in removing the non-compliant person to a place of treatment orexamination;

• section 17 authorizes a health officer, or personauthorized by them, to remove persons with acommunicable disease from public conveyancesand detain the conveyance until it is properlydisinfected;

• section 18 enables the Lieutenant-Governor inCouncil to take those precautions necessary toprevent the spread of an epidemic ofcommunicable disease into the province;

• section 21 enables the Minister, in anemergency situation relating to acommunicable disease, make immunization orre-immunization compulsory;

• section 23 requires that certificates ofimmunization be provided to the personresponsible for children recently immunized;

• section 30 authorizes the Minister, subject toapproval by the Lieutenant-Governor inCouncil, to make general and particularquarantine orders and regulations; and

• section 31 authorizes the Minister to issueorders declaring an epidemic and orderingquarantine, isolation, vaccination, disinfectionand the closure of schools, public and privategatherings necessary to stop the spread ofinfectious disease.

A schedule of communicable diseases is attached tothe Act.

The Emergency Measures Act in:

• section 2(b) defines a “civil disaster”; in thiscontext it is an actual or potential event, otherthan war, that may or does endanger publichealth and safety, including disease;

• section 2(f)(v) defines the emergency medicalservices and public health and welfaremeasures as emergency measures,

• section 7 identifies that the Lieutenant-Governor in Council, by proclamation, candeclare a state of civil disaster,

• section 8 identifies that the Lieutenant-Governor in Council, upon proclamation of astate of civil disaster, enact a plan and/or takethose measures to protect persons fromsuffering and maintain and coordinate medicaland welfare services; he or she may also makeregulations necessary for public health andwelfare; it also authorizes the Minister ofMunicipal and Provincial Affairs to conscriptand empower persons with appropriatequalifications to perform medical, dental,nursing, pharmaceutical and optometryservices;

• section 10 enables local disasters to bedeclared in areas of the province where anemergency threatens safety, welfare and well-being and that cannot be handled locally, insuch circumstances the Minister of Municipaland Provincial Affairs may designate an officerto take charge of emergency operationsincluding the control and co-ordination ofhealth and welfare services; and

• section 15 stipulates that the Lieutenant-Governor in Council may order that eachdepartment identify, by title, interim successorsto act in place of the Deputy Minister duringperiods of civil disaster and may specify theirorder of seniority; there are to be at least twoand not more than six interim successors, thesesuccessors shall when the Deputy Minister isunavailable during civil emergencies act in thecapacity of the Deputy Minister; each Ministershall also compile a list of senior departmentalofficers below the rank of Deputy Minister toact in the capacity of Minister should he or shebe unavailable during times of civil disasterand shall specify the order of succession; and

• section 16 outlines matters applicable toauxiliary police.

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B. Policy Directives

The Public Health Division is mandated as primarilyresponsible for epidemiology, surveillance andcontrol of communicable diseases throughimmunization, disease reporting, follow-up andcontrol of disease outbreaks. This Division isresponsible for the disease surveillance, control,immunization and environmental health programs.It is headed by the Chief Medical Officer of Healthand will take a lead role in the coordination ofdepartmental activities relating to the managementof communicable disease outbreaks and will assistin the coordination of public health measuresneeded to respond to major emergencies anddisasters.

The Health Emergency Management Division has aprogram mandate for emergency preparedness inthe provincial health sector. As such, this Divisionwill play a key role in departmental emergencymanagement activities and assist in thecoordination of the Department’s response to majoremergencies and disasters.

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1.) Public Health Agency of Canada. (2006). Canadian Pandemic Influenza Plan for Health Sector (Health Canada Publication). Ottawa, Canada:Canadian Government Printing Office.

2.) Same as above3.) Same as above4.) Same as above5.) World Health Organization. (2005). WHO global influenza preparedness plan

(World Health Organization Publication). Geneva, Switzerland.6.) Same as no. 17.) Manitoba Health. (October, 2004) Incident Management System Guideline – Manitoba Health

Disaster Management. (Government of Manitoba Publication) Manitoba, Canada.8.) National Health Emergency Management Framework, F/P/T Network on Emergency Preparedness and

Response, 2004 9.) Last, John. (2001). A Dictionary of Epidemiology. New York, New York: Oxford University Press.

10.) Same as no. 111.) Government of Newfoundland and Labrador. (2006). Influenza and Immunization Policy. Retrieved

February 10, 2007 fromhttp://www.health.gov.nl.ca/health/publications/immunization/S5/influenza_immunization_policy.htm

12.) Public Health Agency of Canada. (2006). The Canadian Pandemic Influenza Plan for the Health Sector.Retrieved February 10, 2007 from http://www.phac-aspc.gc.ca/cpip-pclcpi/ann-a_e.html#annexa12http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&list_uids=16989268&cmd=Retrieve&indexed=google

13.) Same as above 14.) Same as above15.) Same as above16.) Same as above17.) Same as above18.) Same as above19.) Same as above

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References

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