VERSION 5A March 2009 To Be Reviewed in December 2009
This plan has been agreed and was signed off by the Essex Resilience Forum Management Group on 10th December 2008 This plan is the overarching Essex Pandemic Flu Plan and details the overall Essex response to pandemic flu. It is supported by the plans from the following organisations that will contain a more detailed response in certain areas:
PCTs Acute Trusts Mental Health Trusts County Council Local Authorities Unitary Authorities Essex Police Essex Fire East of England Ambulance Service
Should you require access to the publicly available versions of these plans please contact the relevant agency/organisation directly.
East of England Regional Concept of Operations for Pandemic Influenza
Terms of Reference for ERF Health Working Group and ERF Pandemic Flu Group
1. INTRODUCTION/ACKNOWLEDGMENTS This plan sets out the arrangements for the Essex response to influenza pandemic. It does not replace existing organisational major incident plans. Rather, it is a supplement to these, providing additional information and guidance specific to an influenza pandemic. It should be read in conjunction with related national planning guidance, in particular:
Pandemic Influenza - a national framework for responding to influenza pandemic and associated supplementary guidance including:
Guidance on preparing acute hospitals in England (issued 2007)
Guidance for ambulance services and their staff in England (issued 2007)
Guidance for primary care trusts and primary care professionals on the provision of healthcare in a community setting in England (issued 2007)
Planning for pandemic influenza in adult social care (issued 2007)
The ethical framework for policy and planning (issued 2007)
Guidance on the management of death certification and cremation certification (draft 2007)
Human Resources guidance for the NHS (draft 2007)
Guidance on preparing mental health services in England (draft 2007)
Possible amendments to medicines and associated legislation during an influenza pandemic (draft 2007)
Surge capacity and prioritisation in health services (draft 2007)
Link to National framework:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080734 This plan is the overarching plan for Essex and the plans from all other agencies sit underneath it, these agencies include: PCTs, Acute Trusts, Mental Health Trusts, Essex County Council, Essex Local Authorities (inc Unitary Authorities), Police, Fire Service, Ambulance Service)
Within the broader context of Essex Resilience arrangements, the plan identifies additionally matters of multi-agency co-ordination and action.
A huge debt is owed to the following whose work on Pandemic Flu planning has played a key part in the development of this plan:
Essex Resilience Forum Health Working Group
Essex Resilience Forum Pandemic Flu Working Group
Essex Resilience Forum Body Management Group
Essex Resilience Forum Warn and Inform Group
David Freeman – Assistant Director of Communications and Public Involvement, Mid Essex PCT
Jane Bazzali – Infection Control Nurse, North East Essex PCT
Julia Sheilds – Infection Control Nurse, Mid Essex PCT
Essex County Council
Essex County Council Social Care
Department of Health
East of England Strategic Health Authority
Cambridgeshire & Peterborough Resilience Forum
2. AIMS The aims of the plan are to:
Reduce the impact of a flu pandemic on the population of Essex; and
Maintain all essential services in Essex as far as is reasonable practicable and possible
Detail command and control procedures
3. OBJECTIVES The objectives of this plan are to:
Protect citizens and visitors against the adverse health consequences as far as possible
Prepare proportionately in relation to the risk
Support international efforts to prevent and detect its emergence and prevent, slow or limit its spread
Minimise the potential health, social and economic impact
Organise and adapt the health and social care systems to provide treatment and support for the large numbers likely to suffer from influenza or its complications whilst maintaining other essential care
Cope with the possibility of significant numbers of additional deaths
Support the continuity of essential services and protect critical national infrastructure as far as possible
Support the continuation of everyday activities as far as practicable
Uphold the rule of law and the democratic process
Instill and maintain trust and confidence by ensuring that the public and the media are engaged and well informed in advance of and throughout the pandemic period
Promote a return to normality and the restoration of disrupted services at the earliest opportunity.
4 PLANNING ASSUMPTIONS National planning assumptions have been issued by the Department of Health detailing a range of parameters:
Up to a 50% Clinical Attack Rate
0.4 to 2.5% dead (of those affected)
22% of cases peak week (of those affected)
28.5% requiring GP or healthcare treatment (of those affected)
4% requiring Hospital admission (of those affected)
25% admitted to hospital requiring critical care (of those admitted to hospital)
It is expected that the pandemic will come in waves, with each wave lasting between 12 – 15 weeks, with the peak of activity being between weeks 6 and 8.
A future influenza pandemic could occur at any time. Plans therefore need to be in place that reflect the current level of national preparedness and guidance. These plans need to be flexible in order to incorporate future developments as more information becomes available.
Modeling suggests that from the time a pandemic begins in the country of origin it may take as little as two to four weeks to increase from just a few cases to around 1,000 cases and the pandemic could reach the UK within another two to four weeks. This will allow some time to compare planning assumptions against emerging data as the pandemic develops.
From the arrival of the pandemic in the UK, it will probably be a further one to two weeks until sporadic cases and small clusters that will act as initiators of local epidemics are occurring across the whole country. i.e. once in the UK, it is likely to spread to all major population centres within one to two weeks. It is possible that the peak will be only 50 days after initial entry into the UK.
An influenza pandemic can occur either in one wave, or in a series of waves, weeks or months apart. To inform preparedness planning, a temporal profile based on the three pandemics that occurred in the last century and current models of disease transmission has been constructed (see Figure 1).
Figure 1: Single wave national profile showing proportion of new clinical cases by week. Note – more than one wave may be expected.
The planning profile reflects what we might expect to happen nationally; of particular importance is the rapid increase in the number of cases within the first few weeks of the pandemic. This planning profile is not a forecast of what will happen in every region or locality.
Local epidemics may be over faster and be more highly peaked than the national average. Local epidemics may only last for 6-8 weeks, or they may last longer. Experience from the 1918 pandemic shows a wide variation in the length of local epidemics, the clinical attack rates and the peak attack rates in areas similar to the size of modern Primary Care Trusts.
People are highly infectious for four to five days from the onset of symptoms (longer in children and those who are immunocompromised) and may be absent from work for up to ten days.
Local planners need to plan to the peak of the national profile assuming a 50% clinical attack rate. The 50% recommendation takes account of the possibility that local peaks may be higher. Local planners should expect between 10% and 12% of the local population to become ill each week during the peak of the local epidemic. It is not possible to make detailed forecast of when this might be.
Figure 2 shows the distribution of pandemic lengths for UK regions in the 1918 pandemic measured over the period of more than 1.2 deaths per 100,000. Using this threshold the planning profile would give an epidemic length of 12 weeks. As it is not possible to predict the length of the pandemic for each region, planners should assume a length of up to 12-15 weeks.
It is not possible to predict what proportion of the local population will become ill, need to go to hospital or die on a week to week basis during a pandemic. Therefore, planners should assume peak figures based on a 50% clinical attack rate sustained over a period of 2-3 weeks.
Figure 2: the distribution of pandemic lengths for UK regions in 1918 measured over the period of more than 1.2 deaths per 100,000.
Attack and Death rate Depending upon the virulence of the influenza virus, the susceptibility of the population and the effectiveness of countermeasures, up to half the population could have developed illness and between 50,000 and 750,000 additional deaths (that is deaths that would not have happened over the same period of time had a pandemic not taken place) could have occurred by the end of a pandemic in the UK.
Until the characteristics of the pandemic are known, relevant planning should be carried out against the reasonable worst case set out below:
Cumulative clinical attack rates of up to 50% of the population in total spread over one or more waves each of around 12-15 weeks, each some weeks or months apart. If they occur, a second or subsequent wave could possibly be more severe than the first. Response plans should recognise the possibility of a clinical attack rate of up to 50% in a single-wave pandemic.
Up to 4% of those who are symptomatic may require hospital admission.
Up to 2.5% of those who are symptomatic may die.
To inform planning, the following table shows the potential impacts in Essex of a 25%, 35% and 50% clinical attack rate and overall case fatality rates of between 0.4% and 2.5%
Please note – The figures shown are for the entire 1st wave of the pandemic, with the exception of the peak week column, which shows numbers just for 1 week.
5. IMPACT OF INFLUENZA PANDEMIC The impact of pandemic flu on all agencies is likely to be intense, sustained and nationwide and may be overwhelming, and the potential issues that agencies are required to respond to are:
Illness and death at home
Difficulties in arranging hospital admissions/increase in early discharges
Staff sickness in all areas
Higher A&E attendance
Pressure on HDU/ITU beds
Infection control processes
Bed-blocking because of reduced community capacity
Pressure on admissions
Difficulty admitting patients to secondary care
Higher transmission among residential institutions
Sickness in clients/carers
High transmission in residential homes/daycare
Children whose parents are too ill to care for them
Difficulties in providing services which support vulnerable adults
Need to draft in ‘volunteers’ (indemnity/CRB checks etc)
Domestic pressures on staff if schools close or members of the family are ill
Pressure on mortuary facilities
Long-term effects on the national and world economies and societal structures
Logistical problems due to interruption of supplies, utilities and transport
All agencies/organisations will suffer a reduction in their workforce of, estimated 50% with absenteeism at peak week of the pandemic of up to 35%
6. DECLARATION OF INFLUENZA PANDEMIC The World Health Organisation will announce the various phases in the progression of an influenza pandemic from the first emergence of a novel influenza viral strain to wider international spread as soon as each phase is confirmed.
World Health Organisation Pandemic Alert Phases are:
WHO international phases
No new influenza virus subtypes detected in humans
UK not affected unless infection starts in the UK or it has strong travel and trade connections with affected country
Large cluster(s) but person-to-person spread still localised, suggesting that the virus is becoming increasingly better adapted to humans
Increased and sustained transmission in general population
UK Alert Levels (see below)
1 Virus/Cases only outside the UK
2 New virus isolated in the UK
3 Outbreak(s) in the UK
4 Widespread activity across the UK
On being informed by WHO of the isolation of a new influenza virus with pandemic potential (normally when person to person spread has been confirmed) the Secretary of State for Health, on the advice of the Chief Medical Officer, England, will convene the UK National Influenza Pandemic Committee (UKNIPC). The Department of Health will inform the Civil Contingencies Secretariat (CCS). The CCS will inform other Government Departments. The DH will advise the NHS and other relevant services and agencies. The Civil Contingencies Committee will be convened at this stage, if not already convened earlier.
For the United Kingdom influenza pandemic will be declared at the UK alert level 3.
UK Alert Levels
No cases anywhere in the world
Cases only outside the UK
New virus isolated in the UK
Outbreak(s) in the UK
Widespread activity across the UK
7. ALERT MECHANISMS
The communication cascade mechanism within Essex will be via the Regional SHA and Lead PCT initially. All local NHS organisations and partner Category 1 and 2 responder agencies will be notified of changes in alert levels. For PCTs and NHS Trusts the Influenza Pandemic Co-ordinator will be the initial point of contact or, in his/her absence, the on-call Director. They in turn will cascade the alert to the rest of their organisations in line with internal major incident procedures.
8. Key Actions at Each Alert Level Please refer to section 3 of the DH National Framework for details of action to be carried out at various alert levels of any pandemic
9. COMMAND AND CONTROL Concept of Operations The Command and Control structures described in this plan are based on the East of England Regional Concept of Operations (2008) relating to Pandemic Influenza. It is assumed that in the event of a Pandemic Influenza, the DH will provide the Lead Government Department and that locally, the multi-agency Strategic Co-ordinating Group (Gold Command) (SCG (Gold)) will be chaired by a senior Health Service representative.
Locally, Essex Resilience Forum organisations will interface with three Command and Control structures:
The local SCG (Gold).
The Regional Civil Contingencies Committee (RCCC).
The NHS Strategic Command (Strategic Health Authority).
All trigger levels in this document correspond with those detailed in the WHO Global Influenza Preparedness Plan for International Alert Phases (2005) and the Department of Health National Framework for responding to an influenza pandemic (2007).
For planning purposes, all Regional activity will be triggered on the declaration of WHO Phase 5. This phase is defined in the above document as:
“WHO Phase 5: Large cluster(s) but person-to-person spread still localised, suggesting that the virus is becoming increasingly better adapted to humans’
It should be noted that if sufficient intelligence is available at WHO Phase 4, the Regional Director of Resilience, Government Office for the East of England (GO-East), in consultation with the Regional Director of Public Health (RDPH) and the Regional Director, Health Protection Agency (RDHPA), may decide to activate this Concept of Operations before WHO Phase 5.
Locally the Lead PCT will initially assume strategic control and take responsibility for implementing Command and Control structures and mechanisms.
The following diagram shows the central and local reporting structure that should be put into place during a pandemic:
Essex Multi-Agency Strategic Co-ordinating Group Please see appendix C for more details In the first instance of the UK Alert Level being raised, the lead PCT CEO or On Call Director will convene and chair a meeting of the Strategic Coordinating Group (SCG) at Essex Police HQ Strategic Coordination Centre (SCC) Membership of the SCG will comprise of Essex Police, EoE Ambulance Trust, Essex County Fire and Rescue Service, Essex County Council (Emergency Planning and Social Care), Southend Borough Council, Thurrock Borough Council, Communications Lead (Health or Police), a Director of Public Health. It is likely that the military and also the Environment Agency will sit at regional RCCC (Regional Civil Contingency Committee)
Having regard to the scale and impact of unfolding events, a Strategic Co-ordination Centre (SCC) will be established at Essex Police Headquarters, with the Strategic Coordinating Group (SCG) under health leadership of the Lead PCT CEO or on call NHS CEO, to assure the effectiveness and resilience of overall strategic co-ordination and control. This chair of this SCG will be known as the Gold Commander. Please see Essex Police SCC plan for detailed instructions on the set up of and running of an SCC. Please see appendix C for details of Essex SCC
The key objectives of the SCG will be to:
To minimise the adverse impact on the health and safety of the people of Essex.
To minimise the disruption to the community as a result of a major outbreak of infectious disease in the county.
To promote recovery from Pandemic Flu outbreak and assist the rapid return to normality.
Assure effective surveillance and information gathering;
Assess and respond to business continuity issues in key services and utilities including prioritisation and discontinuation of routine work as necessary;
Establish a multi agency communications team to manage communications;
Inter-pandemic wave recovery and preparation for subsequent waves;
End of pandemic and restoration of services.
When possible a Director of Public Health and the Health Emergency Planning Adviser will support the Gold Commander at the SCC.
Strong communication links will be maintained with all agencies involved in or affected by the response. The Lead PCT will coordinate and communicate with the Health Trusts either directly or via the PCT Multi Agency Pandemic Response Teams. Essex County Council will coordinate and communicate with all local borough and district councils.
In line with national guidance, the function of the lead Public Health Director will be to:
Co-ordinate the necessary health, public health, health protection and other scientific advice to input into the strategic management of the incident
Agree via the Lead PCTs Communications officer clear public health messages via SCG to be given to the public and incident responders especially health care professionals
Ensure effective two-way communications with the Regional or National Scientific and Technical Advice Cell (STAC).
The importance of providing clear and consistent public health and health protection messages and advice will be of paramount importance. For major incidents within Local Resilience Forum boundaries a Scientific and Technical Advice Cell will normally provide Public Health Advice. The resource and coordination implications for establishing six Scientific and Technical Advice Cells within the East of England would be counter-productive to the response effort. To ensure effective, consistent and accurate health advice, a Regional Scientific and Technical Advice Cell (Regional STAC) will be established. This cell will sit as part of the Regional Response and will normally be located at the Government Office for the East of England.
The Regional STAC will be chaired by the Health Protection Agency Regional Director or nominated deputy and will have representation as detailed in the East of England Regional Communicable Disease Management Plan (detailed under Regional Outbreak Control Team).
The Lead PCT will ensure a pool of suitable Directors of Public Health to act as Regional STAC representatives at the SCG. The DPHs will communicate the key messages from the Regional STAC into the local response. Regular briefings from the Regional STAC will ensure that all key messages are understood.
Please see the Essex STAC plan for more details about setting up and running a STAC.
Existing local resilience forum plans will come into effect should the scale of the pandemic warrant it. These cover, for example:
Maintenance of essential services such as emergency services, transport, food distribution, pharmaceutical supplies, utilities and communication
Management of mass casualties
Maintenance of public order
The role of the Police and Armed Forces
Management of the dead/body storage
In these circumstances, a judgement will be made on the transfer of Gold leadership of the SCG from Health to the Police, and transfer from the Police to County Council (including Unitary Authorities) for the recovery phase. The SCG needs to have in place some subgroups to look at specific issues around the pandemic. These groups are:
Vulnerable Persons Sub Group This group will be chaired by Social Care, does not need to be at SCC, but the chair may need to attend SCG or at least provide a report to SCG. Its main function is to identify vulnerable people and groups and will need to have access to organisations that hold lists of vulnerable people/groups. There may be work passed to and information required from the subgroup directly to SCG. See section 12 and appendix G for more details about vulnerable people/groups
Excess Death Sub Group This group will be chaired by Essex County Council, it does not need to be based at SCC, but the chair may need to attend SCG or at least provide a report to SCG. Its main function is monitor how the county is coping with the increase in dead bodies and the funeral process, and also to manage the Essex Excess Death Plan – see appendix E.
Lead PCT Coordination Cell
The co-ordination of information to support the SCG (Gold) decisions and activities, and the provision of upward reporting to the RCCC and national organisations, will require the establishment of a Lead PCT Coordination Cell.
CEO, Mid Essex PCT, is responsible for the establishment of a Lead PCT Coordination Cell that will, ideally, be co-located with the SCG, but could operate from Mid Essex PCT, or the Strategic Operations Room at EoE Ambulance Offices, Broomfield Essex.
The primary aims of Lead PCT Coordination Cell are to:
Act as the focal point linking the ERF partners’ individual agencies Command and Control arrangements with the SCG.
Collate Pandemic Flu data from ERF partner organisations.
Interpret Pandemic Flu data and provide analysis of the impact of the pandemic across Essex
Provide accurate, timely and consistent pandemic information to the SCG (Gold) via regular Situation Reports (SITREP).
Regional Civil Contingencies Committee Pandemic Influenza will be a nationally coordinated response effort. The Regional Civil Contingencies Committee will have a key role in coordinating activities over the Region and in reporting activity to Central Government.
The RCCC will fulfil a coordination function at levels 1 and 2. At RCCC level 3 this will change to an executive command function with the Lead Government Department nominating a Regional Nominated Coordinator. For Pandemic Influenza this is likely to be the Regional Director of Public Health. Annexes A to C detail a pictorial view of the RCCC levels.
The areas the RCCC should focus on include:
Ensuring the coordinated communication of Public Health Advise and actions across the health economy.
Assisting the 6 SCGs by marshalling central resources and helping to priorities use of scarce resources (Voluntary Sector and some Category 2 responders).
Acting as an information conduit between Central Government and SCGs.
Ensuring consistency of response throughout the Region.
Facilitate strategic consideration for the recovery and restoration of the Region following a pandemic.
Provide region wide Situation Reporting (SITREPS) to SCGs, Civil Contingencies Committee, Office of the Deputy Prime Minister, Lead Government Department etc.
The RCCC will include relevant representation from key organisations that normally attend the Regional Resilience Forum (RRF) and other organisations and agencies deemed to have a relevant input in the response to Pandemic Influenza.
Health Sector membership will be provided by the Regional Director of Public Health, Regional Director of the Health Protection Agency and a Chief Executive/Medical Director from a Strategic Health Authority (responsible for NHS Strategic Management throughout the Region).