TAHSN Pandemic Influenza Planning Guidelines

Questions and Answers

General

Q: What is an influenza pandemic?

A: An influenza pandemic is an outbreak of influenza that spreads rapidly around the world and infects the majority of the world’s population. Flu pandemics arise when a new strain of the virus which is easily spread from human to human emerges, and against which people have little or no immunity.

Q: When was the last influenza pandemic?

A:  In the last century, the world experienced influenza pandemics in 1918, 1957 and 1968.

 

Q: Should we be expecting a pandemic in Canada?

A:  The World Health Organization (WHO) and the Public Health Agency of Canada are warning that an influenza pandemic is overdue and inevitable. Historically, influenza pandemics have occurred about every 30-40 years. The highly infectious strain of avian influenza in Asia, parts of Europe and Africa have fueled concerns that this particular strain will mutate and trigger an influenza pandemic. When the new pandemic begins, it will affect a large portion of the world population, in both industrialized and developing countries.

Q: How is a pandemic different from a regular influenza outbreak?

A:  The main difference is that a pandemic will affect a large proportion of the world population – potentially billions of flu cases will be caused by one subtype of flu – in a relatively short period of time. Normally, the flu virus is seasonal (i.e., in the late fall and winter) and does not necessarily affect such a high percentage of the world population.

As well, a pandemic may come in several “waves”. The second wave may be more severe than the first one. Unlike regular influenza outbreak, pandemic influenza won’t be seasonal.

Q: Is there any way to prevent a pandemic?

A: There are no proven methods to permanently stop flu pandemics from happening.

Impact

Q: How severely would a pandemic impact Canadians?

A: It is estimated that in Canada alone an influenza pandemic would result in 15-35 percent of the population becoming mild to moderately ill, two to five million people seeking out-patient care, 34,000 – 138,000 people requiring hospitalization, and a possible 11,000 – 58, 000 deaths. We can also expect major disruptions in schools, businesses, and social services across the country, because a high number of individuals will be absent from work due to illness or to care for sick loved ones.

Q: Who will be at risk during an influenza pandemic?

A: Everyone is potentially at risk of becoming ill during an influenza pandemic. Certain groups may be at greater risk that others, depending on the type of flu strain that emerges.

With seasonal influenza, adults over 65 with high-risk medical conditions and infants and children are at greatest risk. However, all age groups are at risk of contracting the virus. With a pandemic, it is impossible to predict which segments of the population will be hardest hit—for example, during the 1918 pandemic, it was young healthy adults that were the hardest hit, especially pregnant women.  In 1957 and 1968, it was the usual seasonal high risk groups that had the worst disease. Until a pandemic virus is identified, we won’t know the make-up of the virus and who will be worse affected.

Q: Do I have a greater chance of getting pandemic influenza if I work in a hospital?

A: Influenza – whether a regular strain or a pandemic strain – is a community-acquired illness, meaning it will be “everywhere” such as restaurants, on the subway and other settings. This is a key difference from SARS, which was largely confined to a hospital setting and spread by prolonged close contact.

The difficulty with influenza is that a person with the virus may be contagious for up to 48 hours before any symptoms appear. Since there is no way to know who is incubating the illness, techniques like isolation, gowning, masking, and avoiding public spaces may not be particularly effective outside of the hospital.

In addition, the influenza virus is good at living for long periods of time on all surfaces, which means that you are just as likely to pick up the virus on your way to work as you are at the hospital. This is why good hand-washing technique remains a prime method of preventing influenza.

Q: What will a pandemic mean for GTA?

A: It is estimated that a pandemic of moderate severity will result in 400,000 to one million people becoming ill. Up to 420,000 people will require some level of medical assistance, up to 12,000 people will require hospital admission and 1,000 to 5,000 people could die.

Q: What can we expect to happen when the pandemic reaches Canada?

A: When the pandemic reaches Canada, the federal, provincial and local health and administrative authorities will deploy pandemic response plans, which are currently being developed. We can expect the first wave to last six to eight weeks and may be followed by one or two more waves, possibly of stronger severity. A vaccine will not be available for the first wave since its development can’t begin until the virus has been identified. For the same reason, we aren’t sure how effective anti-viral drugs like Oseltamivir (Tamiflu®) and Zanamivir (Relenza™) will be. However, even if they do help ease symptoms, there will be far more people than the drug supply can handle. Large numbers of patients will require triage; we may have more patients in need of limited hospital beds, health care providers, ventilators, etc.

Q: What is the city doing to prepare for the possibility of influenza pandemic?

A: Toronto Public Health is the lead agency for the City of Toronto’s pandemic preparedness and response. Professionals from hospitals, government agencies, emergency services and community organizations have been working together to develop a local pandemic plan. These stakeholders are building relationships, defining responsibilities and coordinating communication between agencies at the national, provincial and local levels.

The Toronto Influenza Planning Advisory Committee has been working with community partners to identify key issues and to provide an opportunity for input from all stakeholders. The committee meets regularly and has established a process to focus on specific areas such as health services and emergency measures. Through this consultation, Toronto Public Health will update their current influenza pandemic plan that will be widely distributed and promoted throughout the community. The Toronto Public Health’s pandemic plan is available at www.toronto.ca

Toronto Academic Health Sciences Network (TAHSN)

Q: Why are Toronto teaching hospitals planning together for an influenza pandemic?

A: The federal, provincial and City of Toronto pandemic plans are broad frameworks outlining each level of government’s roles and responsibilities, such as surveillance, social distancing, and the stockpiling of anti-virals. These plans do not address specifically how hospitals should prepare for and operate during an influenza pandemic.

It is estimated that 420,000 people in the GTA will require some level of medical assistance and up to 12,000 people will require hospital admission. Therefore, we can expect hospitals to be under extraordinary strain caring for additional influenza patients. This is in addition to patients who require other health services (such as cancer treatment, cardiac surgery). Hospital resources (such as staffing, beds, ventilators) will be extremely limited.

Contingency planning is critical to coping with the impact of an influenza pandemic. Last May, the nine Toronto academic teaching hospitals (TAHSN) struck a Pandemic Task Force to coordinate pandemic planning, and to share resources and expertise. One of the key lessons from Toronto’s experience with SARS is the need for a coordinated and consistent approach by hospitals and governments. St. Joseph’s Health Centre, Toronto East General Hospital, Toronto Public Health and the Ministry of Health and Long-Term Care joined the Task Force as observers to share their unique perspectives and to ensure linkages.

By developing common hospital pandemic planning guidelines, our goal is to reduce unnecessary confusion and anxiety about how Toronto teaching hospitals will respond to a pandemic. Other hospitals may find the TAHSN Pandemic Guidelines helpful in developing their organization’s pandemic plan.

Q: What is the purpose of the TAHSN Pandemic Planning Guidelines?

A: The TAHSN Pandemic Planning Guidelines were developed following the federal and provincial pandemic plans and is consistent with existing health and emergency management legislation. This document describes the role, responsibilities and actions of the TAHSN pandemic subcommittees before and during the pandemic. Specifically, the document will:

  • provide guidance and tools to assist hospitals prepare at the organizational level;
  • ensure optimal coordination between the nine TASHN hospitals;
  • outline strategies for the delivery of prophylactic antiviral medications and vaccine to priority groups;
  • provide technical background underlying recommendations;
  • outline measures for capacity assessment, patient assessment and triage; and
  • provide a resource that can be adapted to hospitals outside of TAHSN.

Q: Now that you have this hospital pandemic document, what’s next?

A: This is a dynamic document that will be updated as new information emerges about the pandemic and as we do further work. We encourage hospitals to use this document to initiate discussions with staff, patients and other stakeholders in order to develop an operational pandemic plan that’s specific to your hospital and patients. Although we can’t predict when and in what form the pandemic will take shape, it’s important that organizations develop a plan so that everybody clearly understands their roles and responsibilities in advance. For hospitals that have not begun the difficult task of pandemic planning, we invite you to review the TAHSN’s document and tools and consider whether it can be applicable to your organization.

Q: What ethical considerations have been taken in planning for a pandemic?

A: Plans to deal with a pandemic must be based on commonly held values and people need to understand in advance the kinds of choices that will have to be made. Decision makers and the public need to be engaged in the discussions about ethical choices so that plans reflect what the majority of people will accept as fair and good for public health.

The University of Toronto Joint Centre for Ethics has created a 15-point ethical guide for pandemic planning. The ethical framework contained in this document has been used to develop the hospital’s pandemic plan and will be used to develop the TASHN plan. Chapter 2 of the TAHSN Pandemic Guidelines addresses an Ethical Framework.

Vaccine and Anti-virals

Q: Is there a vaccine?

A: Currently, there are no fully tested and approved vaccines that would work against the next pandemic influenza. We can only develop an effective vaccine after the actual pandemic strain is identified. We will need to wait for the beginning of pandemic to isolate the virus and then develop a new vaccine. It will take up to four to six months to develop a vaccine once a pandemic is identified.

Q: What are anti-viral drugs?

A: Anti-viral drugs Oseltamivir (Tamiflu®) and Zanamivir (Relenza™) are used for the prevention or treatment of some viral infections. Anti-virals destroy a virus or interfere with its ability to grow and reproduce. When used for prevention (or prophylaxis), people must take the medication daily for as long as they are exposed to the virus. When used for treatment, infected people receive the drug to reduce symptoms, shorten the length of illness and minimize serious complications. Anti-virals must be taken within 48 hours of the first symptoms of influenza to be effective.

In the event of an influenza pandemic, anti-virals will be helpful for both treatment and prophylaxis, particularly during the period where there is no vaccine available (it will take time to analyze the pandemic flu strain so they can develop a vaccine).

Q: Why are Toronto teaching hospitals ordering anti-virals for all staff?

A: Randomized controlled trials during seasonal influenza have shown that using anti-virals for prophylaxis is highly effective at preventing the development of influenza symptoms. The Ministry of Health and Long-Term Care will have a supply of anti-virals that will be used largely to treat defined priority groups (such as front-line health care workers and key decision makers). These priority groups may change when the national plan is updated.

After much discussion, TAHSN hospitals have placed an order for a supply of anti-virals so we can remain healthy in order to keep hospitals open for patient care during the pandemic. We also feel an obligation to protect all of our staff from getting sick in the first place, and infecting patients and others.

Prevention is key; however, the use of this supply of anti-virals may change from our original plans if a pandemic hits and we have new information about the nature of the virus and how it is spread. For example, should it turn out that the pandemic predominantly affects young children (which is what happened in 1957), we may be asked to share our stockpile with health-care centres treating children. Furthermore, we are making the assumption that the antivirals will be effective; however, this is a reasonable assumption given that clinical trials have shown that prophylaxis is highly effective during seasonal influenza.

Q: Why will every hospital staff member receive anti-virals as preventive treatment? I’m not involved in direct patient care.

A: To keep the health-care system running, we need to ensure that we provide as much protection to staff to lessen chances they become ill. This includes not just direct patient care team members, but also support service staff and others we can draw upon as resources. The goal is to keep hospitals running so we can care for patients. We can’t do this without staff to administer medications, prepare food for patients or sterilize surgical equipment.

Q. Will pregnant staff be able to take anti-virals?
A. Yes, pregnant staff will be able to take anti-virals. The TASHN group has purchased zanamivir which may be safer for pregnant women than oseltamivir because it is not systemically absorbed. Neither drug however has been proven to be unsafe in pregnancy. Stockpiling of these anti-virals will depend on the availability, which are currently produced in small quantities. Pregnant women may also be offered alternative work arrangements if they are unable to take anti-virals.

Q: How will vaccinations and antiviral agents be distributed?

A: Anti-viral medication will be distributed by Occupational Health & Safety Services in each hospital in accordance to protocols established by Health Canada and/or the Ministry of Health and Long-Term Care.

Workplace Safety Measures

Q: What is TAHSN recommending to protect staff?

A: All health care settings and workers are expected to follow routine infection control practices on a daily basis. This includes practicing regular hand hygiene, wearing and discarding personal protective equipment (ex. gloves, gowns, masks) appropriately when dealing with patients presenting with febrile respiratory illness/influenza-like illness. To increase staff protection during a pandemic, TAHSN hospitals are planning on giving antivirals to prevent all staff from getting sick in the first place and to keep hospitals running.

Q: What masks are you recommending?

A: There is no clinical evidence to support the use of any masks – including N95 – to reduce the exposure to an influenza pandemic. One of the main reasons for this is because influenza is just as likely to be acquired in the community – not just in hospitals. Even if masks work well in the health care setting, healthcare workers may be exposed to the virus once they step outside of the workplace. Nonetheless, in accordance with the current federal and provincial pandemic plans, we recommend the use of surgical or procedure masks for front-line staff caring for influenza patients as protection against droplet transmission. This is in accordance with the current federal and provincial pandemic plans It is understood however, that these recommendations may change in the future and we will consider revisions at that time.

Further, infection control experts believe that any potential small advantage to wearing an N95 mask would be offset by reduced compliance: N95 masks are quite uncomfortable to wear and it is extremely difficult to wear them for any prolonged length of time. Our experience with SARS taught us that staff may frequently manipulate and move the masks, which puts one at higher risk of self-contamination. Having said all of that, we recognize that N95 masks may put some staff more at ease, so hospitals may choose to make them available. Anti-virals for prophylaxis are a key part of our strategy to protect staff and to keep hospitals running.

Q. Do I have to take anti-virals in order to come to work?

A. Staff will be encouraged to take anti-virals as preventative treatment. This is about keeping staff safe and ensuring that hospitals continue to operate.

Q. I work at another organization as well. Where will I get my Tamiflu?

A. There is more work to be done on the logistics of providing Tamiflu to part-time staff who work in multiple hospitals. We are now at the point where we can begin to determine how we will manage these scenarios.

Impact on Hospital Programs/Services

Q: During a pandemic, what programs and services will be affected at (insert name of hospital)?

A: Given the projected global impact of a pandemic, we can expect the health-care system to come under extraordinary strain caring for influenza patients. This is on top of patients who require other hospital services (such as chemotherapy, hemodialysis, etc). Hospitals are already running at 95% capacity with very little flexibility.

During a pandemic, we can expect urgent or emergent programs at the hospital to continue as much as possible. We can also expect, given limited resources (such as staffing, beds, etc.), that many non-urgent programs and elective surgeries may be postponed or scaled back so that focus our resources where they’re needed most. To create capacity, TAHSN recommends that hospitals assess current services and outline a triage strategy for canceling and/or postponing services. Each service should evaluate its patient population and stratify patients based on urgency of care. It is critical to consult with other area hospitals to ensure that some degree of continuity of care available in the health care system.

Q: How will the public know what services and programs will be affected?

A: During the pandemic, patients and the public will need to contact individual hospitals directly for an update on service and program changes. Once hospitals have finalized their pandemic plans, they should communicate their plan with patients and the public.

Patient Screening

Q: How will hospitals identify new patients with influenza-like symptoms?

A: Fast identification and separation of patients into these two groups is critical for infection control and patient flow purposes. TAHSN recommends that hospitals post signs at entrances, asking individuals with a fever and/or cough to head to the influenza assessment area. Those without influenza symptoms should go to the routine assessment area. Chapter 4 of the TAHSN Guidelines document provides recommendations and tools on triaging, assessing and discharging patients.

 

Human Resources

Q: Health care workers have experienced emotional and mental stress coping with SARS. How will (name of hospital) help staff cope with a pandemic?

A: Given Toronto’s recent experience with SARS, we can expect health care workers to experience a heightened sense of anxiety or even a “SARS flashback” during a pandemic. Unlike SARS, a pandemic’s impact will be widespread in society and the world, thereby increasing the level of confusion and panic. Hospital staff may be confronted with difficult ethical decisions given extremely limited resources and large numbers of sick patients. As well, hospital staff will be dealing with fears that they, their families or colleagues will become ill. Finally, a pandemic may come in several waves, so maintaining operations and staff morale will be a challenge.

During the Pre-Pandemic period, hospitals should initiate several activities to help ease anxiety and support staff. Leaders must communicate regularly, to educate staff and engage them in planning. TAHSN recommends that hospitals establish a staff distress and resiliency committee with representatives from psychiatry, social work, chaplaincy, human resources, bioethics, occupational health, the provider of the Employee Assistance Plan (EAP), senior administration and communication.

Hospitals should prepare a list of resources available for staff, such as counseling services, assistance with elder and childcare. Hospitals should also discuss with their individual Employee Assistance Program (EAP) provider regarding their needs during a pandemic and how they plan to meet those needs.

Q: Health-care workers will have to cope with several waves of the pandemic and ill friends and family. The workload may be overwhelming. What will hospital employers do to help them cope?

A: Health-care and hospital staff are vital to fighting a pandemic. However, hospitals understand that in addition to providing key services during a pandemic, our staff will have to manage events in their personal lives as well. TASHN recommends that all hospitals work closely with their staff to help them plan for managing elder care and child care, in order to ensure that staff can be at work during the pandemic. In addition, all hospitals have EAP and will ensure that counseling services and support are available to staff during a pandemic.

 

Staffing and Redeployment

Q: How will hospitals deal with staffing shortages?

A: Due to the fact that a pandemic influenza is a world-wide community-acquired infection and not contained within a few hospitals like SARS, it will be far more of a challenge to recruit additional staff required during this event. The TASHN plan recommends that managers discuss with their casual and part-time staff the need for extra staffing during a pandemic. In addition, each hospital will look at recruiting recent retirees, existing students, family members of staff and volunteers to assist in meaningful work during a pandemic event.

Q: Will you force staff to come to work during a pandemic?

A: (name of hospital)’s attendance policy is applicable during an influenza pandemic; therefore, regular attendance by all staff is expected. As a hospital, we have a responsibility to keep the health-care system running and for providing quality and safe service to patients.

Q: Why is TAHSN recommending that staff be redeployed to other roles?

A: To keep the hospital system running during a period where there will be significant staffing shortages, staff may be redeployed to other areas of the hospital that are experiencing shortages. This strategy was also used during SARS, when many of our non-clinical staff handled other roles in the hospital, such as overseeing the screening stations.

TAHSN recommends that hospitals create a Redeployment Centre staffed by Human Resources with experience in redeploying employees with specialized talents or abilities. All requests for additional staff will be assessed and decisions will be based on the hospital’s overall plan to manage effectively during a pandemic event

Q: Can you force staff to fill alternate roles?

A: Staff will be expected to accept reassignment and continue to work. However, staff will be redeployed only into work that is suitable to their skills and if it is safe for them to do.Utilizing all staff and their valuable talents will make an enormous difference to the hospital’s ability to successfully manage a pandemic influenza. Work refusals or redeployment refusals will be managed in accordance with the existing hospital policies, legislation and/or collective agreements.

Q: How will hospitals care for pregnant employees?

A: Hospitals will continue to manage all staff with health related issues in accordance with current occupational health practice. Each health related issue will be managed in accordance with the facts of each situation.

Q: Will health-care workers be encouraged to work while they are ill?

A: Staff will be managed within existing surveillance protocols approved by Occupational Health Services and Infection Prevention and Control Services. We assume that during a pandemic event, many health-care workers could be absent from work due to illness (we are assuming this despite having purchased prophylactic antivirals as a worse case scenario). Each hospital already has protocols for reporting and managing illnesses. Individuals will be assessed and will return to work within safe guidelines and practices.

Q: When can an ill staff person return to work?

A: All health-care workers will be cleared to return to work by the Occupational Health Department within their hospital based on their protocols.

Q: Will staff have the option to take a leave of absence or vacation time during the pandemic influenza?

A: Hospitals will be proactively discussing with their employees what their role and contributions will be during a pandemic event. In accordance with existing hospital policy and/or collective agreements and past practice, hospitals will be required to discuss with their employees how to manage leaves or vacation approved prior to the pandemic. During the pandemic, each individual case will have to be discussed, but as a rule all staff will be strongly encouraged to come to work and not take holidays during a pandemic.

Q: Will (name of hospital) consider opening a temporary daycare so I can continue to come to work?

A: If schools and daycares are closed by the local Public Health unit, it would be inappropriate for hospitals to open temporary daycare facilities. Rather, staff are encouraged to plan with their families for alternate child care arrangements in the event of all emergences.

Q: Are TASHN hospitals planning on paying extra to staff during the pandemic outbreak?

A: No. Staff will be compensated in accordance to each hospital’s existing compensation practices and/or collective agreements.

Students and Volunteers

Q: Are you planning on using medical, health care students and volunteers to work during a pandemic?

A: The TAHSN Guidelines recommend that hospitals continue using existing medical, nursing and other health students to help with keeping hospitals running. Students are an invaluable resource in our hospitals. They have the necessary knowledge and training, as well as the familiarity with the hospital. Plus, hospitals can expect to face a shortage of staff given illness and other factors. If hospitals decide to continue using students, it is recommended that they are treated as staff. Students will be used in roles appropriate for their level of training.

TAHSN recommends that individual hospitals decide on whether to continue using volunteers.

Q: How will students be compensated?

A: TAHSN recommends that students be compensated in the same way as they are now. There are no plans for additional or “danger” pay to any staff or students during a pandemic.

Recovery

Q: Once the pandemic is declared over, how will (name of hospital) return to normal and resume services?

A: During the post-pandemic period, hospitals should focus efforts on ending pandemic response activities, reviewing the impact of the pandemic, and identifying lessons learned that may guide future planning activities. Hospitals should develop a plan with timeline for the reinstatement of services that were postponed or cancelled. We can expect the pandemic to have a profound emotional and physical impact on staff, as we saw post-SARS. Hospitals should look for creative opportunities to recognize staff commitment and contributions during the emergency, and provide ongoing support after the pandemic has ended. For more information, refer to the Chapter 11 on Recovery.

More Information

Q: How can I protect myself and my family from a flu pandemic?

A: The Ministry of Health and Long-Term Care offers useful practical tips for reducing your risk in the event of an influenza pandemic. These actions are the same things you do to protect yourself and your family from ordinary flu :

  • Get your flu shot every year – the flu shot will not protect you from a pandemic flu virus, but it will protect you from getting ordinary flu, which could weaken your immune system or resistance to the pandemic flu.
  • Wash your hands with soap thoroughly and often – good hand hygiene is a good way to prevent the spread of all respiratory viruses.
  • Keep an alcohol-based sanitizer (gel or wipes) handy at work, home and in the car.
  • Cover your mouth and nose with a tissue when you cough or sneeze .
  • Stay home when you are sick.
  • Avoid large crowds of people where viruses can spread easily.
  • Reduce non-essential travel.
  • Follow any instructions given by public health officials.

For more information, visit the Ministry of Health’s website at www.health.gov.on.ca

Q: Where can I get more information?

A: Pandemic Related Web Sites:

http://www.phac-aspc.gc.ca/cpip-pclcpi/