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

7 PANDEMIC AND POST-PANDEMIC PERIOD

7.1 Declaring a pandemic

WHO will inform the UK Government of any change in alert levels, usually after international consultation. The UK Government will communicate this information, together with an assessment of risk to the UK, to the Scottish Government. The Scottish Government will inform the relevant responders and stakeholders in Scotland. The Civil Contingencies Committee (again with Scottish Ministers represented) will be convened at this stage, if not already convened at Phase 5 and the relevant committees will be convened in Scotland as appropriate.

7.2 International phase 6 - UK alert levels 1 to 4

The Scottish response during an influenza pandemic has six major elements:

• monitoring its emergence, spread and the impact/effectiveness of interventions
• slowing and limiting the spread of disease
• ensuring those who are affected get appropriate treatment and care
• maintaining business/service continuity and social order
• dealing with large numbers of deaths and
• ensuring that all involved in the response, including the public, are consistently well-informed.

7.2.1 UK Alert level 1 (no cases in the UK)

Planning: detection and alert

The response at this stage will be an extension of activity at Phase 5, but with the certainty that the UK will be affected. This level could last between 2-4 weeks, during which heightened public concern, suspected cases and false alarms should be anticipated before the virus actually reaches the UK. Organisations therefore need to be prepared for that demand and ensure that it does not detract from steps to finalise preparations for the arrival of the pandemic.

Public Information

Public information messages will acknowledge concerns whilst preparing the public for the imminent arrival of the pandemic, provide advice on the response measures and encourage those who are well to adopt sensible precautions and preparations, but continue to attend work and undertake other essential activities.

7.2.2 UK Alert level 2 (sporadic cases in the UK)

This level is anticipated to last about two weeks, until cases are occurring in all major centres of population in Scotland.

Planning

Public and private sector organisations need to focus on essential activities, implementing pre-planned measures to maintain core service/business continuity and adjusting activity levels to cope with additional demand and allow for potential disruption.

Public health response

As suspected cases occur in the UK, public health priorities will be to:

• promptly investigate cases and contacts to confirm or refute the diagnosis at the earliest possible time
• provide appropriate care
• apply measures to control/slow spread of infection
• collect sufficient epidemiological and virological information to refine projections and inform public health and clinical management policies. (The HPA will maintain a central database with information collation coordinated across all UK Health Protection Organisations on the first 100-200 cases for this purpose.)

Early cases

In the very early stages of the arrival of a pandemic in the UK, the mitigation strategies employed are likely to be focused differently with the aim of trying to contain the virus for a short period of time and slow its spread. This strategy would only be employed for the first tranche of cases. As the virus spreads, which is inevitable, wider and longer term mitigation strategies as described in this chapter would be employed.

An early cases strategy, based on short term containment of the virus, is likely to cover the following key areas:

• Adequate port health arrangements to ensure we can deal with suspected symptomatic passengers arriving at points of entry to the UK - airports and ports in Scotland
• Adequate surveillance arrangements to recognise the arrival of the virus and track its early spread and virology
• Arrangements to track and treat close contacts of suspected influenza cases
• Prophylactic use of antiviral drugs for suspected cases and their close contacts
• Advice on infection control for early cases
• Operational guidance for NHS Boards, GPs and other frontline staff.

Further work is being undertaken on port health and surveillance/tracking of close contacts. Further guidance will be published in due course.

Surveillance Arrangements

The monitoring requirements during a pandemic will fulfil 2 functions:-

• to track the spread of the virus, inform appropriate clinical action and assess success of interventions
• to inform decision makers and planners at both national and local level on the level of impact on services and the most appropriate use of resources.

Not only will the information flow into the Health Directorates, arrangements will be made to feed back to NHS Boards and their local planning partners on the latest position locally, regionally and nationally.

In the early stages of a pandemic, NHS Boards will be required to liaise very closely with HPS in identifying and monitoring the first few hundred cases of the emerging virus. This will involve detailed information on individual patients being monitored and follow up of their contacts.

As time moves on and we begin to deal with a more widespread outbreak, monitoring will still be required but will become more generic and less intensive. System Watch will provide details of activity within the acute sector as well as monitoring NHS24 call volumes, ambulance service activity and the numbers of deaths recorded through General Register Office of Scotland. Primary Care data will be fed through HPS and combined with the System Watch data to provide a clear picture of pressure and activity in the system. As far as possible this data will be automatically extracted from health systems, reducing pressure on frontline staff to duplicate effort in collecting data. There will still exist a form that will need to be submitted during a pandemic that will briefly describe any pressures or concerns not readily identifiable from the systems data. However, this will be a short form and easily completed.

While the immediate use of this information will be for Scotland, the information will also be passed to Department of Health through the Pandemic Influenza Portal, so that a UK perspective can be maintained and ensure that the relevant issues are taken up at Cabinet Office.

Public information

Anyone who is ill and suspect they may have influenza-like symptoms will be advised to stay at home, contact the national influenza line and inform a relative or friend to collect their antiviral medicine if necessary. Otherwise, the overall aim will be to maintain normal services and social and economic activities for as long as, and as far as, that is possible. Personal and respiratory hygiene messages will be reinforced ahead of an escalation to UK alert level 3.

7.2.3 UK Alert level 3 (outbreaks occurring in the UK)

Planning

By the time outbreaks are occurring in centres of population, preparatory steps should have been completed. National and local response measures should be implemented proportionately as the pandemic impacts. National priorities will include:

• reviewing/revising the response strategy
• coordinating the implementation of response measures
• monitoring the initial adequacy and effectiveness of measures
• securing vaccine supply
• maintaining public communications.

Health and public health response

As the pandemic becomes established, health priorities will include:

• ensuring patients have access to appropriate assessment, treatment and care, including rapid access to antiviral medicines for those with symptoms compatible with pandemic influenza
• adapting health and community care services to ensure the maximum amount of surge capacity is available in primary and secondary care in anticipation of additional demand
• ensuring infection control recommendations are put into practice in all healthcare settings
• engaging with staff and implementing staffing contingency plans - including necessary training.

Public information

In addition to reinforcing previous public messages and providing advice and general information, local information and advice on service provision, any school closures, restrictions or other countermeasures should be available.

7.2.4 UK Alert level 4 (widespread pandemic activity in the UK)

It is anticipated that activity will rise to a peak across the UK about 7 weeks from the first recognition of cases, following the pattern described. Initially all organisations should monitor the impact on service/business against planned expectations in order to modify responses appropriately if necessary.

Overall planning and co-ordination

National priorities are to:

• monitor spread/impact (including deaths), refine projections, review response effectiveness, adapt strategies and tactics accordingly
• maintain essential services/supplies and critical infrastructure
• minimise social disruption
• identify unexpected impacts or problems.

Many services are likely to be under increased pressure, particularly from staff absences and possibly from disruption of supplies. Some - including health and community care organisations and funeral directors/ burial services - will experience rapidly escalating demand as the pandemic evolves.

Health and public health response

Health priorities include:

• surveillance - all UK health protection organisations will have moved from detailed to aggregate reporting of cases by geographic region together with assessment of the efficacy of antivirals (and, if relevant, vaccine), monitoring of the cause and antimicrobial susceptibility of bacterial complications, and reviewing the clinical effectiveness of the response
• monitoring antiviral consumption against expected use and adapting policies accordingly
• monitoring and responding to pressures on health and community care services, maximising the effective use of the capacity available, supplementing staffing, maintaining essential care for those who are suffering from other emergencies or illness, conserving essential supplies and maintaining services
• vaccine development and supply.

7.3 Post-pandemic period

7.3.1 End of the first wave: preparing for subsequent waves

A single wave pandemic profile with a sharp peak provides the most prudent basis for planning as that would put a greater strain on services than a lower level but more sustained wave or the first wave of a multi-wave pandemic. However, second or subsequent waves have occurred in previous pandemics, weeks or months after the first. While the first priority at the end of the first wave will be to develop recovery plans and gradually restore supplies, services and activities depleted or curtailed during the pandemic, plans must assume that some regrouping may be necessary in anticipation of a future wave. In this respect, national priorities should be to:

• assess the overall attack rate during the first wave, in order to assess the susceptible population and construct models of a second wave
• continue to monitor the virus for genetic variations which might affect the degree of protection afforded by previous infection or vaccination, and thus vaccine formulation
• continue to monitor antiviral susceptibility of the virus
• review the efficacy of all interventions to inform future policies
• review antiviral and other pharmaceutical needs/supplies.

Health plans should assume that heightened monitoring and surveillance will be required for some time beyond the first wave and that all plans require review and revision in the light of lessons learnt. In particular, the likelihood of ongoing constraints on supplies and services and continuing pressures on health and community services should be taken into account. Updated information on the epidemiology of the virus, effectiveness of treatment, availability of countermeasures and lessons learnt from the first wave will help inform and shape the response measures that plans in all sectors should recognise may need to be maintained or implemented to respond to second or subsequent waves. In addition, health plans may be required for targeted or population-wide vaccination programmes in this period.

7.3.2 Second and subsequent waves

Second or subsequent waves may be more or less severe than the first: UK Alert levels 1-4 will come into play again, informed by epidemiological and mathematical modelling following the first wave. The Health Directorates will issue guidance to inform health plans following review of the first wave and the availability of countermeasures.

7.3.3 The recovery phase

As the impact of the pandemic subsides and it is considered that there is no threat of further waves occurring, the UK will move into the recovery phase. Although the objective is to return to pre-pandemic levels of functioning as soon as possible, the pace of recovery will depend on the residual impact of the pandemic, on-going demands, backlogs, staff and organisational fatigue and continuing supply difficulties in most organisations. Therefore, a gradual return to normality should be anticipated and expectations shaped accordingly. Plans at all levels should recognise the potential need to prioritise the restoration of services and to phase the return to normal in a managed and sustainable way.

Health services are likely to experience persistent secondary effects for some time with increased demand for continuing care from:

• patients whose existing illnesses have been exacerbated by influenza
• those who may continue to suffer potential medium or long term health complications (e.g. the encephalitis that followed the 1918 pandemic)
• a backlog of work resulting from the postponement of treatment for less urgent conditions.

The reintroduction of performance targets and normal care standards also needs to recognise that many staff will have been working under acute pressure for prolonged periods and are likely to require rest and continuing support. Facilities and essential supplies may also be depleted, re-supply difficulties might persist and critical physical assets are likely to be in need of backlog maintenance, refurbishment or replacement therefore impact assessments are required.

Other sectors and services are likely to face similar problems and may also experience difficulties associated with income loss, changes in competitive position, loss of customer base, lack of raw materials, the potential need for plant start up etc.