Bird Flu Pandemic in USA

Health and Human Services Pandemic Influenza Plan The HHS Pandemic Influenza Plan is a blueprint for pandemic influenza preparation and response. In particular, the HHS Plan provides guidance to national, state, and local policy makers and health departments. The goal is for all involved to achieve a state of readiness and quick response.
The HHS Plan is based on the knowledge that once a pandemic is triggered by the emergence of a novel influenza A virus subtype, it is a global event and all countries are at risk. The U.S. will work in concert with the World Health Organization and other international partners on containment and response activities abroad that also will assist the planning and monitoring for disease outbreaks in the U.S.
The HHS Plan includes an overview of the threat of pandemic influenza, a description of the relationship of this document to other Federal plans and an outline of key roles and responsibilities during a pandemic. In addition, the HHS Plan specifies needs and opportunities to build robust preparedness for and response to pandemic influenza. The preparations made for a pandemic today will have lasting benefits for the future.
Major components of the critical preparedness and ready response actions include:
Intensifying surveillance and collaborating on containment measures – both international and domestic;
Stockpiling of antivirals and vaccines and working with industry to expand capacity for production of these medical countermeasures;
Creating a seamless network of Federal, state and local preparedness, including increasing health care surge capacity; and
Developing the public education and communications efforts that will be so critical to keeping the public informed.
Strategies outlined in the HHS plan are based on an understanding of pandemics and influenza disease, and are guided by several overarching principles.
Preparedness will require coordination among Federal, state and local government and partners in the private sector.
An informed and responsive public is essential to minimizing the health effects of a pandemic and the resulting consequences to society.
Domestic vaccine and production capacity sufficient to provide vaccine for the entire U. S. population is critical.
Quantities of antiviral drugs sufficient to treat 25 percent of the U.S. population should be stockpiled.
Sustained human-to-human transmission anywhere in the world will be the triggering event to initiate a pandemic response by the U.S.
When possible and appropriate, basic public health measures will be employed to reduce person-to-person viral transmission and prevent or delay influenza outbreaks.
At the start of a pandemic, vaccine, which will initially be in short supply, will be procured and distributed to state and local health departments for immunization of predetermined priority groups.
At the onset of a pandemic, antiviral drugs from public stockpiles will be distributed to predetermined priority groups.
For a copy of the HHS Pandemic Influenza Plan visit: http://www.pandemicflu.gov/.
The Public Health Guidance for State and Local Partners (Part 2 of the HHS Plan) provides 11 supplements on specific aspects of pandemic influenza planning and response..
Surveillance (Supplement 1) provides guidance on monitoring for influenza viruses and the health impact of influenza.
Laboratory Diagnostics (Supplement 2) provides guidance on the use of diagnostic tests to detect, characterize, and monitor novel subtypes of influenza, including avian influenza A (H5N1) and other viruses with pandemic potential. Occupational health issues for laboratory workers are also covered.
Healthcare Planning (Supplement 3) provides guidance for plans to include pandemic influenza surveillance, decision-making structures for responding to a pandemic, hospital communications, education and training, patient triage, clinical evaluation and admission, facility access, occupational health, distribution of vaccines and antiviral drugs, surge capacity, and mortuary issues. Planning for the provision of health care in non-hospital settings is also addressed.
Infection Control (Supplement 4) provides guidance on principles of infection control for limiting the spread of pandemic influenza including on the selection and use of personal protective equipment, hand hygiene and safe work practices, cleaning and disinfection of environmental surfaces, handling of laboratory specimens and post-mortem care. The guidance also covers infection control practices related to the management of infectious patients, the protection of persons at high-risk for severe influenza or its complications, and issues of occupational health.
Clinical Guidelines (Supplement 5) provides a guide related to clinical procedures for the initial screening, assessment, and management of patients as well as an assessment of locally available resources, such as rapid diagnostics, antiviral drugs and hospital beds.
Vaccine Distribution and Use (Supplement 6) provides guidance on the elements of a pandemic vaccination program, including planning for vaccine distribution, vaccination of priority groups, monitoring of adverse events, tracking of vaccine supply and administration, vaccine coverage and effectiveness studies, communications, legal preparedness, and training.
Antiviral Drug Distribution and Use (Supplement 7) provides guidance on the distribution and use of antiviral drugs for treatment and prophylaxis during an influenza pandemic. This section also covers the use of antiviral drugs in managing and containing infection with novel strains of influenza, including avian influenza A (H5N1) and human strains with pandemic potential.
Community Disease Control and Prevention (Supplement 8) provides guidance on the use of disease containment strategies to prevent or decrease transmission.
Managing Travel-Related Risks of Disease (Supplement 9) provides guidance on travel-related containment strategies that can be used during different phases of an influenza pandemic, ranging from distribution of health alert notices, to isolation and quarantine of new arrivals, to restriction or cancellation of nonessential travel.
Public Health Communications (Supplement 10) outlines key influenza pandemic risk communications concepts and addresses how CDC will provide timely and accurate information.
Workforce Support: Psychosocial Considerations and Information Needs (Supplement 11) focuses on psychosocial support services that will help workers manage emotional stress during an influenza pandemic and resolving related personal, professional, and family issues.

Draft Guidance on Allocating and Targeting Pandemic Influenza Vaccine
Goals and Objectives
The goal of the pandemic influenza vaccination program is to vaccinate all persons in the United States who choose to be vaccinated.
It is recognized that vaccine supply to meet this goal will likely not be available all at once, but rather, develop at varying rates depending on both vaccine characteristics (antigen required) and production capacity. Given that influenza vaccine supply will increase incrementally as vaccine is produced during a pandemic, allocation decisions will have to be made. Such decisions should be based on publicly articulated and discussed program objectives and principles. The overarching objectives guiding vaccine allocation and use during a pandemic are to reduce the impact of the pandemic on health and minimize disruption to society and the economy.
One of the most important findings of the working group analysis, and the strongest message from the public and stakeholder meetings, was that there is no single, overriding objective for pandemic vaccination and no single target group to protect at the exclusion of others. Rather, there are several important objectives and, thus, vaccine should be allocated simultaneously to several groups. Each of the meetings came to the same conclusions about which program objectives are most important:
Protecting those who are essential to the pandemic response and provide care for persons who are ill,
Protecting those who maintain essential community services,
Protecting children, and
Protecting workers who are at greater risk of infection due to their job.
In addition to these, working group discussions highlighted the important Federal objective of maintaining homeland and national security.


General Guidance on Pandemic Vaccination
General guidance of the working group includes the following:
The need to target vaccine to maintain security, health care, and essential services will depend on how severe the pandemic is, as rates of absenteeism and the ability to supply essential products and services will differ between more and less severe pandemics. As a result, groups targeted for earlier vaccination will differ by pandemic severity.
Allocation of pandemic vaccines to States will be in proportion to the State’s population.
Whereas States should follow the national guidance, they will have some flexibility in defining the target groups and implementing the guidance to best fit their local situations.


Within the parameters of the guidance, a small proportion of each State’s vaccine allocation may be maintained at the State level for distribution based on the specific needs of that jurisdiction.
In past pandemics, groups at increased risk for serious illness and death have differed by age and health status.

Because the high-risk groups in the next pandemic are not known, this guidance will be reassessed and may be modified at the time of the pandemic.
Guidance on pandemic vaccine allocation and targeting will be re-assessed periodically to consider the potential impacts of new scientific advances, changes in vaccine production capacity, and advances in other medical and public health measures.


Framework for Targeting Pandemic Influenza Vaccine
Guidance for targeting vaccination was developed in a structure that defines target groups in four broad categories – people who: 1) protect homeland and national security, 2) provide health care and community support services, 3) maintain critical infrastructure, and 4) are in the general population.
Within categories, vaccination target groups are clustered into levels. In general, all groups within a category and level will have the same priority for vaccination. Within a category, levels are listed in descending order of priority for vaccine. Levels across categories are not necessarily comparable in terms of vaccine prioritization.
Allocation and targeting of vaccine integrating categories occurs in tiers. By design, groups in a tier (cutting across categories) are vaccinated simultaneously unless vaccine supply is so limited that sub-prioritization is needed. Finally, groups in vaccination tiers differ depending on pandemic severity, defined as severe, moderate, and less severe as described in the Pandemic Severity Index.

The Pandemic Severity Index (PSI)
The Pandemic Severity Index defines categories of pandemic severity based on the proportion of individuals with pandemic illness who die (the “case fatality rate”). Pandemic severity will be determined soon after its initial outbreak based on surveillance of cases and their outcomes before large areas of the world are affected. Government organizations will use the PSI to determine how best to implement responses such as vaccination and community strategies to reduce disease transmission. For a diagram and additional information on the PSI, please refer to Appendix B.
Pandemic Vaccination Categories and Levels within Each Category
Target groups for pandemic vaccination are defined in four categories corresponding to major objectives of the pandemic vaccination program, which are to protect:
Homeland and National Security,
Health Care and Community Support Services,
Critical Infrastructures, and the
General Population.
Everyone in the United States is included in at least one of these categories. Where persons are included in more than one category, defined by their occupational role as well as their age and health status, they would be targeted for vaccination with the earliest group in which they are included.
Groups within each category are clustered into priority “levels” based on national pandemic response and vaccination program goals (Table 1). Within each category, groups in level A will receive vaccine first, in general followed by those in levels B, C, D, and E. All groups included in the same level within a vaccination category have equal priority. The exceptions are in the General Population, Level B, where because of the large number of children, sub-prioritization is proposed, and in Level C where younger persons would be targeted first when vaccine supply is very limited because of the greater vaccine effectiveness in this group.
Vaccination target groups in the Homeland and National Security, Health Care and Community Support Services, and Critical Infrastructure categories include only persons who are deemed critical to provide services that are essential to maintain during a pandemic, not the entire workforce. Identification of the functions considered to be “critical” was partly based on an analysis of critical sectors and workforces conducted by the U.S. Department of Homeland Security’s National Infrastructure Advisory Council (NIAC) (www.dhs.gov/niac), along with input from Federal agencies. Because a pandemic differs from other national emergencies in the threats it poses and the duration over which it will affect our nation and communities, target groups within each sector may be different from those defined in other emergency response planning. Further work is being undertaken to more specifically define critical occupations whose members should receive early vaccination.
It should be emphasized that the primary objective of vaccinating persons in critical infrastructure sectors is not to reduce absenteeism generally, through an incremental reduction in pandemic illness afforded by vaccination. Rather, vaccination is targeted to protect workers with critical skills, experience, or licensure status whose absence would create bottlenecks or collapse of critical functions, and to protect workers who are at especially high occupational risk.

Other pandemic response strategies (e.g., avoiding close contact with others, use of personal protective equipment such as facemasks, good handwashing, etc.), and worker education are likely to have greater overall effects in decreasing absenteeism.
For additional information on the definition of groups in each category, the rationales for how groups are ordered, and the estimated size of the target population, please refer to Appendix C.
Table 1. Categories and target groups for pandemic vaccination (see Appendix C for more specific definitions of priority groups and rationales). In each category, levels cluster target groups having a similar priority for vaccination. Occupation-based groups include only persons deemed essential to support the critical functions of the group.

All persons in the United States are included in at least one targeted group.
LEVEL
Homeland & National Security (HNS)
A
Deployed and mission critical personnel
B
Essential support and sustainment personnel
Intelligence services
Border protection personnel
National Guard personnel (who are not already included in Level A)
Other domestic national security personnel
C
Remaining active duty military and essential support personnel
LEVEL
Health Care & Community Support Services (HC/CSS)
A
Public health personnel
Inpatient health care providers
Outpatient and home health care providers
Health care providers in long-term care facilities (LTCFs)
B
Community support services and emergency management personnel
C
Other important health care personnel
LEVEL
Critical Infrastructure (CI)
A
Emergency Medical Services personnel
Law enforcement personnel
Fire services personnel
Manufacturers of pandemic vaccine, antiviral drugs, and other key pandemic response materials
Key government leaders
B
Energy sector personnel (electricity and natural gas)
Communications personnel (telephony and IT)
Water sector personnel (potable and waste water)
Government personnel
C
Transportation sector personnel
Food and agriculture sector personnel
Banking and finance sector personnel
Pharmaceutical sector personnel
Chemical sector personnel
Oil sector personnel
Postal and shipping sector personnel
Other important government personnel
LEVEL
General Population (GP)
A
Pregnant women
Infants and toddlers, 6 – 35 months old
B
Household contacts of infants under 6 months old
Children 3 – 18 years old with high-risk medical conditions
Children 3 – 18 years old without high-risk medical conditions
C
High risk persons 19 – 64 years old
Persons 65 years and older
D
Healthy adults, 19 – 64 years old, not included in other categories

Integrating Priorities for Pandemic Vaccination in Pandemics of Different Severity

Recognizing the need to address several important objectives for a pandemic vaccination program, vaccine should be allocated simultaneously to target groups across categories. To do so, target groups from different categories are integrated into tiers for vaccination.
The order in which target groups in Table 1 are vaccinated is defined separately for severe, moderate, and less severe pandemics (see Table 2). All groups designated for vaccination within a tier have equal priority for vaccination (see Figure 1 as an example of vaccination tiers for a severe pandemic). In general, vaccine allocation within a tier will be proportional to the populations of the targeted groups, though changes in this allocation scheme at the time of the pandemic may occur based on the impacts of the pandemic and the specific needs identified at that time.
Defining vaccination tiers differently by pandemic severity reflects differences in the threats more or less severe pandemics pose to society and individuals. Pandemics with higher case fatality rates are more likely to disrupt essential services, increase workplace absenteeism (due to illness, caring for family members, or to decrease risk of exposure), threaten public order and homeland security, and disrupt international and domestic supply chains compared with less severe pandemics. Thus, tailoring strategies to pandemic severity will best achieve national pandemic response goals and objectives. Pandemics are defined as “severe” (PSI categories 4 or 5), “moderate” (PSI category 3), and “less severe” (PSI categories 1 and 2).
It should be noted that members of occupational target groups are defined by the functions individuals within that target group are anticipated to perform over an extended period of time during the pandemic outbreak; it does not distinguish among staff performing these duties as part of their usual functions, those being reassigned to perform the function as a new response role, or those performing the function as a volunteer. It should also be noted that vaccine does not replace, but adds to other measures taken to protect the workforce and general population.