Pandemic Influenza: A Practical Approach to Preparedness

1. Pandemic Influenza: A Practical Approach to Preparedness Ryan Forrey, Pharm.D., M.S. The Ohio State University Medical Center

2. Objectives • Understand how past experiences have helped with current preparedness • Identify key stakeholders in hospital and university pandemic influenza planning • Identify the sections of the HHS Pandemic Influenza Plan which can help in pharmacy department planning

3. Anthrax/Bioterrorism Threats • Purchased additional supplies of doxycycline and ciprofloxacin • Removed ciprofloxacin from the automated drug distribution system cabinets • Staff theft and personal stockpiling

4. SARS Experiences • Southeast Asia in 2003 • Singapore, July 2003 • Alexandra Hospital (non-SARS hospital) • Changes to social behavior • Catholic mass bowing • Taxi drivers refusing routes • Surgical masks in public

5. SARS Experiences • Thermal screening at the airports and hospital entrances • Temperature monitoring for hospital staff • Initially three times daily, reduced to once daily • Including days off

6. SARS Experiences • Emergency Department • Triage tents • Electronic tracking system for all patients, visitors, and staff in Emergency Department • Surgical masks worn by all patients/visitors in the ED • Off-premises medication pick-up point for outpatients • Home delivery established

7. SARS and Pharmacy • Specialty clinics closed • Refill authorization service established • N-95 masks worn while dispensing in the outpatient pharmacy • Pharmacist on duty for dispensing to isolation cases (febrile patients) • Gown, gloves, face shield, N-95 mask

8. SARS Experiences • Hospital supplies • N-95 masks and fit testing • Thermometers (for all employees) • Medications/Vaccines • Not available • Isolation of patients • SARS patients at Tan Tock Seng Hospital and the CDC (attached) • Restricted visitation policy

9. SARS Experiences • Isolation of inpatient pharmacists from outpatient pharmacists • SARS ward pharmacists were isolated from all other pharmacy staff • Tube system used for medication delivery • Satellite pharmacies on the wards • SARS elevators • Cafeteria closed

10. SARS N-95 masks Negative pressure isolation rooms Fever an important symptom Supportive care only Pandemic Flu Surgical masks Droplet isolation Fever an important symptom Oseltamivir treatment if within 48 hours SARS vs. Pandemic Flu

11. Coordination of OSU Planning • OSUMC Medical Director mobilized the emergency preparation committee • Created pandemic flu subgroup including: • OSU Provost representative • OSU Student Health medical director • OSUMC • medical director • epidemiology • pharmacy • ED director • public relations • Plan must encompass the medical center as well as the university • Report to the Provost Office, Board of Trustees

12. Questions Asked • What is our institution’s supply of oseltamivir? • What is the area/county supply available? • Local Department of Health • How many doses do we need? • What do we do if our institution does not have any oseltamivir?

13. Questions Asked • How many patients should the institution expect? • What is the responsibility for providing medications/vaccines to the University students? • How can prescribing be best controlled: • within the institution? • within the community?

14. Questions Asked • How many isolation beds do we have? • Do we need to designate a “pandemic flu” unit/floor/hospital? • What protection does the pharmacy staff need? • Technicians • Pharmacists • Miscellaneous others • What is the minimum staffing needed for the pharmacy?

15. HHS Pandemic Flu Plan • Part 2: Public Health Guidance for State and Local Partners • Supplement 6: Vaccine Distribution and Use • Supplement 7: Antiviral Drug Distribution and Use • Supplement 3: Healthcare Planning • Part 1, Appendix D: NVAC Recommendations on Antiviral Drug Use

16. HHS Pandemic Flu Plan • Supplement 3: Healthcare Planning • Develop a stratification scheme for prioritizing vaccination of healthcare personnel who are most critical for patient care • “Healthcare facilities should consider how antiviral drugs might be used…and determine if a reserve supply should be stockpiled” • Assess surge capacity

17. HHS Pandemic Flu Plan • Part 1, Appendix D- Vaccine Priorities • Tier 1, A: Vaccine and antiviral manufacturers; medical workers with direct patient contact • Tier 1, B: Persons ≥ 65 years with 1 or more risk factors; persons 6 months to 64 years with 2 or more risk factors • Immunocompromised and elderly in nursing homes excluded

18. HHS Pandemic Flu Plan • Part 1, Appendix D- Antiviral Use • Priority Group 1: Patients Admitted to the hospital (Treatment) • If stockpiled antiviral drug supplies are very limited, the priority of this group could be reconsidered • Priority Group 2: Healthcare workers with direct patient contact and EMS workers (Treatment)

19. HHS Pandemic Flu Plan • Part 1, Appendix D • Priority Group 3: Highest risk outpatients— immunocompromised persons and pregnant women (Treatment) • Priority Group 7: HCWs in emergency departments, intensive care units, dialysis centers, and EMS providers (Prophylaxis)

20. OSU Plan Assumptions • WHO pandemic alert period as a baseline • No supply will be available from strategic national stockpile

21. Pharmacy Pandemic Flu Plan • Hybrid of standard disaster plan, drug shortage response plans • Staffing plans • Medication/vaccine prioritization • Communication

22. Pharmacy Staffing Plans • Availability of pharmacy personnel for hospital labor pool if needed • Consider VPN access for off-site verification of orders • Consider changing delivery systems • Tubing of medications • Reconfigure automated drug distribution system

23. Medication Prioritization • Assuming limited supply of oseltamivir, but not enough to treat all patients in a pandemic • Restrict use to pandemic flu cases only • Restrict use for prophylaxis • Healthcare workers • Vaccination for seasonal influenza • Treatment for confirmed cases • Post-exposure prophylaxis

24. Staff Communication • Communicate restrictions to formulary for oseltamivir • Reassurance for staff safety concerns • Communicate parts of plan as appropriate • Communication and coordination with other hospital departments • Epidemiology, ED, etc.

25. University Planning • Seasonal flu vaccinations for international students • Before winter break • Hand washing signage and sanitizer • Isolation/quarantine dormitory • For international students who can’t return home in event of pandemic • Cancellation of classes • Local/State Department of Health determines

26. Media Relations • Go through the hospital media relations department • Administration does not like surprises • Know what the lay press is printing

27. Media Relations

28. Media Relations • Know what you are going to say before you agree to the interview • e.g. oseltamivir and suicide in Japan • Be honest, but limit your scope • A large supply of antiviral drugs may be portrayed as hording • A small supply of antiviral drugs may be portrayed as unprepared • Convey the message without creating panic

29. “Given that an influenza pandemic may not unfold in a completely predictable way, decision-makers must regularly reassess their strategies and actions and make adjustments as necessary.” -HHS Pandemic Influenza Plan