Pandemic Flu: A Scottish framework for responding to an influenza pandemic

Assessment of risk

• Seasonal influenza will be the major focus of attention
• Although a new virus could first emerge in the UK this is unlikely - it is considered most likely to emerge in South East Asia, the Middle East or Africa. This could happen at any time, but risk to the UK low.

Priorities:

• Improve knowledge, prevention and management of seasonal influenza, including vaccines and antiviral medicines
• Maintain effective international surveillance (including animal/bird influenza surveillance)
• Develop and maintain international and UK capability to identify a novel animal or human virus promptly
• Develop and improve pandemic preparedness plans across all sectors
• Maintain close liaison with animal health colleagues (especially Phase 2)
• Maintain public engagement on seasonal influenza but start to prepare them for a possible pandemic
• Take action to improve personal and respiratory hygiene

Scottish Government working in a UK Government framework

• Monitor international developments
• Support multinational initiatives to address surveillance and prevention
• Maintain and test international and national arrangements for collaboration, coordination and response

Scottish Government Health Directorates ( SGHD) in collaboration with Department of Health ( DH)

• Provide policy lead for management of seasonal influenza
• Set policies, provide overall framework and monitor the development, testing and review of pandemic health plans
• Maintain WHO/ EU links and provide UK input at international level. Identify and support research/development priorities ( DH lead)
• Maintain liaison with vaccine manufacturers to optimise development and supply ( DH lead)
• Provide specialist advice and information
• Liaise with Environment Directorates on animal/human health aspects and with FCO on travel advice

Environment Directorates in collaboration with Defra

• Maintain international developments and support multinational surveillance and prevention initiatives (Defra lead)
• Maintain links with OIE (Defra lead)
• Implement relevant actions in response to avian influenza outbreaks in Scotland
• Identify and support research and development priorities
• Provide specialist advice
• Link to SGHD and Defra

Scottish Government directorates

• Advise, encourage and test preparedness and business continuity planning across all sectors in Scotland

Health Protection Scotland

• Support SGHD
• Support NHS Boards
• Develop and maintain routine national influenza surveillance and reporting systems - including vaccine uptake in Scotland.
• Maintain national arrangements for early detection and alert in Scotland
• Liaise with HPA to provide Scottish data for overall UK picture as needed
• Contribute to WHO/ EU surveillance activities ( HPA Lead)
• Support the development and testing of health response plans in Scotland

NHS and Community Care

• Implement annual seasonal influenza vaccination programme
• Respond to seasonal outbreaks/epidemics
• Develop, maintain and test robust, resilient and integrated local response plans within national guidelines and in conjunction with partners
• Maintain virology services and laboratory arrangements and report results to HPS

Phase 3

Assessment of risk

• The risk to the UK will vary widely according to circumstances, which will need to be taken into account during this phase
• A single, or even several sporadic, human case(s) of infection due to a novel virus (e.g. an avian influenza virus) outside the UK still represents a very small risk to the UK, especially if associated with an identified source (e.g. contact with sick poultry). Closer vigilance will be required if cases are associated with significant ongoing outbreaks of avian influenza in poultry, particularly if geographically close to the UK
• The risk of mutation or re-assortment to produce a virus more adapted to humans will need to be taken into account, but may be impossible to predict
• A single human case of influenza due to an avian or other novel virus within the UK requires full investigation, appropriate containment measures and a risk assessment

Priorities

• Maintain close liaison with international organisations such as WHO and OIE
• Assist with identification of the virus and its characteristics
• Assess pandemic preparedness and identify and implement actions needed to fill gaps/weaknesses
• Take action to improve personal and respiratory hygiene
• Develop communications strategy and prepare materials for all future phases

Main capabilities required

• Diagnostic capability for the new virus
• To recognise illness potentially due to a new strain in people in the UK, confirm it virologically and investigate the possible source

Scottish Government working in a UK Government framework

• Monitor and review pandemic risk assessment
• Convene SECC(Flu) to address policy/preparedness issues in Scotland
• Review/test communication links and preparedness /coordination arrangements
• Brief and convene Cabinet Sub-Committee on Civil Contingencies ( SEER- CSC) if required

SGHD in collaboration with DH

• Inform Justice Directorates and NHS Scotland of change of phase and UK significance
• Liaise with Environment Directorates and relevant Scottish Government directorates over wider implications. Issue information/advice to travellers, public and health professionals in Scotland
• Provide information/briefings.
• With DfID, HPA and HPS, consider need and options for Scotland to support WHO/international response
• Review options and development plans for a potential pandemic (or pre-pandemic) vaccine with NIBSC and manufacturers ( DH lead)
• Refine intervention strategies for Phases 4, 5 and 6. Review pharmaceutical and other supply needs in Scotland
• Review operational guidance for NHS Scotland, community services and others
• Begin to prepare the public for the possibility of an influenza pandemic
• Prepare information materials for future phases
• Launch online communications
• Review preparedness plans for future phases
• If within Scotland, confirm with HPS, HPA , DH and report to WHO and EU (via EWRS)

Scottish Government directorates

• Work with key stakeholders to review pandemic preparedness
• FCO: issue information/advice to travellers/ UK nationals abroad in consultation with DH and SGHD
• DfID: consider need for assistance abroad

Health Protection Scotland

• Monitor international situation and advise SGHD on Scottish health risk
• Liaise with virology labs providing serological investigations as required
• Provide guidance on management of suspected UK cases and contacts, support NHS response, maintain database and review/revise/test pandemic plans

NHS and Community Care

• Ensure arrangements in place to identify, investigate, report and manage any suspected case of infection with a novel virus
• Review/revise/test pandemic plans
• Maintain diagnostic capability and provide serological investigations as required

Phase 4

Assessment of risk

• Small clusters in people outside the UK are still likely to present only a small risk to the UK; the risk increases if there are many cases, there is no identifiable epidemiological link between clusters, there are strong travel links to the UK or cases are in a geographically close country
• Risk of further cases increases if they are associated with widespread, ongoing avian outbreaks, especially if control measures late or inadequate
• The longer such outbreaks continue, the greater the concern

Priorities

• Assist with identification of the virus and its characteristics
• Assist international investigation
• If associated with avian/animal influenza, close liaison with animal health colleagues
• Review pandemic plans, including business continuity arrangements
• Review effectiveness of antiviral medicines
• Assess potential candidate vaccine strains

Main capabilities required

• If in the UK: ability to identify epidemiologically linked human cases of influenza which might indicate person-to-person spread

Scottish Government working in a UK Government framework

• Review risk assessment, informed by Health Directorates
• Continue to review and refine policies and pandemic management arrangements at official and Ministerial levels, including business continuity plans

SGHD in collaboration with DH

• Notify Justice Directorates and NHS Scotland of change in Phases
• Advise on Scottish public health risk and ensure rapid reassessment if circumstances change
• Liaise with Environment Directorates over implications for farming/poultry industry
• Provide information /advice to Scottish travellers and residents abroad in conjunction with FCO
• Advise health professionals on identification, management and reporting of any UK case
• Update and distribute public information more widely
• Review plans for storage, distribution and access to antiviral medicines in Scotland
• Liaise with NIBSC and vaccine manufacturers ( DH lead)
• Ensure NHS operational plans are in place. Review patient management protocols. Reports to WHO and the EU

Scottish Government directorates

• Work with key stakeholders to support preparedness planning in Scotland
• FCO: issue information/advice to travellers/ UK nationals abroad, in consultation with DH and SGHD
• DfID: consider need for assistance abroad

Health Protection Scotland

• Closely monitor international situation - including emerging epidemiological and treatment outcome data and advise SGHD on risk to UK public health
• Produce update reports as agreed with SGHD
• Liaise with SGHD over advice to travellers and link with HPA and Scottish Government communications offices
• Liaise with NHS laboratories
• Heighten surveillance for imported cases/clusters of infection, particularly in communities with travel contact with sites of confirmed infection clusters
• Amend algorithms for managing suspected/confirmed cases, including for use at ports
• Support local NHS investigation and management of incidents/clusters
• Work with WHO to enhance surveillance, fully investigate, develop case definitions and consider seroprevalence studies if origin in the UK

NHS and Community Care

• Ensure arrangements in place to identify, investigate and manage cases/clusters following HPS guidance
• Refine pandemic response plans
• Continue to test plans for phases 5 and 6, in conjunction with local stakeholders
• Maintain diagnostic capability and capacity for new strain, including antiviral susceptibility testing
• Fully characterise any viruses from Scottish cases and maintain database

Phase 5

Assessment of risk

• Risk to UK significantly increased: plans must assume progression to Phase 6. If not, arrangements can be stood down/ maintained as precaution

Priorities

• Put all pandemic preparedness and operational response arrangements on standby for implementation
• Vaccine development
• Review of antiviral supply
• International coordination of actions

Main capabilities required

• To monitor clinical and virological spread, using emerging data to reassess planning assumptions (acknowledging that virus is still not a pandemic virus and may further evolve)

Scottish Government working in a UK Government framework

• Review risk assessment for Scotland and put in place cross-Government emergency management structures and procedures, with DH as lead Department, including cross-Government communications strategy and co-ordination

SGHD in collaboration with DH

• Notify change in Phase and implications for the Scotland
• Assess and advise on public health risk
• Initiate arrangements for regular close liaison with HPS
• Finalise health coordination and communications structure
• Activate Scottish Health Emergency Response Team
• Set up daily situation reporting to Cabinet Office
• Alert NIPC and convene as necessary (by most efficient means) to review available information and advise on the response
• Alert Scientific Advisory Group and convene as necessary to review and advise on emerging evidence
• Review vaccine availability and supply. Implement plans for any pre-pandemic vaccination
• With FCO issue information/advice for UK travellers and residents abroad. Issue information and advice to the health service, including any updates to operational plans
• Activate automated helpline
• Implement public communications strategy, including regular media briefings and a national pandemic leaflet door drop
• Finalise research proposals for implementation during a pandemic

Scottish Government directorates

• Activate business continuity plans, work with key stakeholders to support their response and maintain critical national infrastructure
• FCO: in consultation with DH and SGHD, issue information/advice to travellers/ UK nationals abroad, including arrangements for UK residents abroad
• DfID: consider need for assistance abroad

Health Protection Scotland

• Monitor international situation, using emerging epidemiological and other information to review pandemic models
• Collaborate with international organisations to assess the epidemiology of the disease and efficiency of transmission
• Ensure communications are integrated nationally with health departments/directorates and locally with NHS and other partners
• Increase awareness to enhance case detection and identification of entry of the virus into the UK at the earliest possible time
• Establish routine for collecting, collating and analysing data and reporting to central Government
• Provide interpretation of surveillance data to avoid spurious reporting of outbreaks
• Provide scientific and professional public health advice to health departments/directorates
• Maintain heightened surveillance and database of UK cases
• Maintain diagnostic and management algorithms and advise on management of suspected cases
• Support local investigation and management of cases/ outbreaks
• Support NHS in implementing any vaccination programme
• Establish plan to send appropriate specimens for antiviral susceptibility to HPA CfI

NHS and Community Care

• Ensure plans in place to identify, investigate, manage and report suspect cases in the UK, according to Health Protection Agencies' protocols and pandemic operational plans 'ready to go'
• Prepare to implement a national or targeted vaccination programme, if instructed by Health Directorates
• Review diagnostic capability and capacity for new virus, and roll out diagnostic tests/reagents as required
• Develop plan to implement serological tests for assessment of susceptibility and immunity to new virus, when supplied with these by HPA CfI

Phase 6 and UK alert levels 1-4

Assessment of risk

• UK Alert level 1 may last as little as 2 weeks from declaration of the onset of the pandemic
• From onset of Alert level 2, it may take 2-4 weeks for the virus to become widely established and 7-9 weeks for activity to reach a peak
• Once Alert level 3 has been reached, there will be intense pressure on health and all other services locally for at least 6-8 weeks
• A specific pandemic influenza vaccine is unlikely to be available during the first wave

Priorities

• Reduce the impact of a pandemic in the UK
• At alert level 2, surveillance and containment of cases
• At alert levels 3 and 4, the full strategic response:
  • use public health measures to reduce transmission/cases
  • provide treatment and care
  • maintain health and other essential services
  • reduce social disruption
  • provide up to date information and advice to maintain public confidence and morale
  • monitor impact on organisations and services against expectations and modify if necessary
• Vaccine development - implementation of immunisation strategy when vaccine available

Main capabilities required

• Surveillance adapted to inform treatment and planning
• Interventions to reduce the impact
• Health and community care capacity to treat and care for patients
• Civil emergency response capability
• Effective communications strategy

UK alert level 1 (actions in addition to phase 5 above)

Scottish Government working in a UK Government framework

• Continue cross-Government management.
• Activate Government News Co-ordination Centre to ensure co-ordinated media handling/response

SGHD in collaboration with DH

• Confirm declaration of pandemic and advise on implications for Scotland
• Provide public health advice
• Complete organisational arrangements for day-to-day coordination of health response, including re-deployment of staff
• Maintain daily 'battle rhythm' for reporting between HPS, SGHD, DH and COBR and provision of press briefings
• Establish public telephone help-lines
• Activate full public information campaign to prepare public for arrival of pandemic
• Prepare NHS for management of initial cases and for imminent need to move to essential care only
• With HPA/ NHS/Academia, prepare to implement prepared pandemic research protocols ( DH lead)

Scottish Government directorates

• Inform stakeholders to implement pandemic plans

Health Protection Scotland

• Finalise algorithms for management and reporting of initial Scottish
• Establish official level daily teleconferences with relevant NHS board, Health Protection staff and Scottish Government health protection staff
• Enhance surveillance in groups likely to be exposed to infection
• Prepare to implement research protocols (see above)

NHS and Community Care

• Ensure arrangements in place for identification, investigation, management and reporting of first UK cases
• Prepare for imminent implementation of pandemic plans, and move to essential care only
• Communicate on issues of local service provision and treatment

UK alert level 2

Scottish Government working in a UK Government framework

• Fully activate government arrangements for managing and coordinating national response

SGHD in collaboration with DH

• Update information to health professionals
• Instruct NHS to move to essential care only and to activate pandemic plans
• Monitor/support implementation
• Provide press briefings, and adapt public communications in response to new information and people's concerns

Scottish Government directorates

• Monitor activation of response and business continuity plans. Initiate monitoring/reporting arrangements

Health Protection Scotland

• Notify CMO of suspected/confirmed cases and agree change in UK alert level
• Ensure first 100-200 cases reported and entered in avian influenza database, including outcome of treatment
• Liaise with HPA CfI regarding their production of detailed antigenic and genetic characterisation of all novel Scottish influenza viruses and compare them with those from across UK and other countries
• Produce daily international and UK situation reports to Health Departments, to fit with battle rhythm
• Use emerging epidemiological and other data to refine modelling projections and inform policy

NHS and Community Care

• Manage initial cases and contacts as advised
• Cooperate with HPS to investigate, report and treat the first 100-200 cases
• Liaise with SGHD over public communications about suspected/confirmed cases
• Activate pandemic preparedness plans and prepare to restrict hospital admissions to meet the expected increased demand for hospital beds
• Support CHP's co-ordination of antiviral distribution arrangements. Monitor research projects

UK alert levels 3 and 4

Scottish Government working in a UK Government framework

• Manage and coordinate cross government response
• Develop national response strategy
• Assess impact on services, critical infrastructure etc.
• Consider whether and if to invoke emergency powers

SGHD in collaboration with DH

• Notify escalating UK Alert level and implications.
• Coordinate NHS response
• Maintain daily assessments of spread, and impact on health and health services
• Review planning assumptions in light of emerging information
• Review response policies in the light of changing assumptions
• Review clinical management guidelines in light of emerging information
• Monitor antiviral and other pharmaceutical usage and address logistical/supply problems
• Monitor adverse reactions to antivirals ( MHRA)
• Review antiviral policies in light of usage and supply
• Provide regular media briefings
• Continue public information campaign, using all media. Continue to monitor vaccine development/supply/policy options
• Monitor research

Scottish Government directorates

• Monitor maintenance of critical supplies/services and impacts on national infrastructure

Health Protection Scotland

• Change surveillance to reporting of aggregate data to agreed protocols
• Assess efficacy of interventions
• Monitor effectiveness of antivirals
• Collate information on bacteria causing complications (community and hospital) If appropriate, monitor vaccine uptake

NHS and Community Care

• Adapt response according to capacity
• Maintain local public information on health access, local policies (e.g. school closures)
• Report to Health Directorates on preparedness and prepare daily situation reports on the NHS in its area

Assessment of risk

• This phase is assumed to refer to the end of the first pandemic wave in the UK
• Pandemic virus may still be circulating both in the UK and internationally
• A further wave may occur weeks or months later

Priorities

• Prepare systems and services for any next wave(s)
• Review all aspects of the response and regroup in light of the first wave experience
• Continue surveillance
• Review vaccination options

Main capabilities required

• Ability to pick up re-emergence (clinical illness and laboratory confirmation)
• Ability to respond to a second or subsequent wave

Actions

Scottish Government working in a UK Government framework

• Monitor international developments
• Develop and implement recovery plans

SGHD in collaboration with DH

• Prepare report
• Continue to monitor Scottish situation
• Develop recovery plans, for Health Departments/Directorates and NHS
• Review policies for second wave - or subsequent seasonal influenza - due to the pandemic strain - in light of experience and resources
• Review antiviral/other pharmaceutical needs/supplies
• Review vaccine suitability/supply/options

Scottish Government directorates

• Develop and monitor recovery plans, and prepare for possible subsequent waves

Health Protection Scotland

• Continue heightened surveillance
• Monitor virus for significant antigenic variations
• Monitor antiviral susceptibility
• Assess attack rate during the pandemic and current population susceptibility
• Continue to assess efficacy of interventions during the pandemic

NHS and Community Care

• Develop and implement recovery programme, assuming that further waves - or bad seasonal influenza - possible
• Prepare to implement vaccination strategies on instruction from Health Directorates

Assessment of risk

• Pandemic virus may still be circulating internationally
• UK alert levels 1-4 may be relevant
• Pandemic virus may have evolved
• Impact may be less or even greater than first phase
• Response may be affected by level of recovery achieved following first wave

Priorities

• Maintaining vigilance
• Monitoring and early detection of any second wave in the UK
• Providing an effective response

Assessment of risk

• This or a similar virus likely to remain in circulation
• It may take months or even several years for some national services to recover to normality
• Many people are likely to suffer on-going health problems
• Backlog demand for health care is likely
• Long term effects associated with virus may be possible
• Personnel, plant and supplies likely to be exhausted

Priorities

• Implementation of measures aimed at a prioritised, gradual and sustainable return towards normality
• Managing public and other expectations accordingly
• Provision for continuing care and treatment backlog requirements
• Staff support, re-supply, refurbishment/backlog maintenance
• Analysis of response
• Assessment, evaluation and revision of contingency arrangements in light of lessons learnt.