Influenza A/H1N1v Pandemic
in Grampian
April 2009 – February 2010
Dr Helen Howie, Consultant in Public Health Medicine
Mrs Dianne Donald, Civil Contingencies Manager
On behalf of the Director of Public Health
Acknowledgement
I would like to take this opportunity to thank all staff who contributed so willingly and effectively to NHS Grampian’s response. It was truly impressive to see the professionalism and commitment of all staff which enabled us to respond to the pandemic and to maintain the service for our patients with other illnesses
I would also like to acknowledge the support and actions of our partner organisations in the North East which enabled us to work together to protect the public’s health. This will stand us in good stead for any future emergencies.
Dr Lesley Wilkie
Director of Public Health and Planning
Index Page
1. Introduction……………………………………………………………4
2. Aim of report…………………………………………………………..4
3. Initial actions…………………………………………………………..4
4. Background……………………………………………………………5
5. Strategic, Tactical and Operational response……………………..6
6. Epidemiology of the pandemic in Grampian……………………...12
7. Management…………………………………………………………12
8. Debriefs and lessons identified…………………………………….15
9. Reflections from SCG partners…………………………………….21
10. Conclusion……………………………………………………………22
11. Recommendations…………………………………………………..22
Appendix 1 Planning assumptions
Appendix 2 Summary of epidemiology in Grampian
Appendix 3 Glossary
1. Introduction
On Saturday 25 April 2009 Health Protection Scotland (HPS) informed the public health on call staff across Scotland that they were closely monitoring an outbreak of respiratory illness associated with a number of deaths in Mexico and that there were also reports of a similar illness in individuals in the USA. The first cases of this novel influenza were detected in Scotland on 27 April.
The WHO Emergency Committee, established in compliance with the International Health Regulations (2005), met on 27 April 2009 and considered the available data on confirmed outbreaks of Influenza A/H1N1v in the USA, Mexico, and Canada and the reports of the possible spread to other countries. The WHO Director-General raised the level of influenza pandemic alert to Phase 4 indicating that the likelihood of a pandemic had increased. The WHO subsequently declared a pandemic on 11 June 2009.
2. Aim of report
The purpose of this report is to describe the impact of the pandemic in Grampian, how we responded and to identify lessons we learnt to inform the revision of the Grampian Pandemic Influenza Plan (2008) and other emergency plans. We will also have the opportunity to contribute to the revision of the Scottish Framework for responding to an Influenza Pandemic.
There are several other UK and Scottish reports that have been published or are being drafted and these include:
· The 2009 Influenza Pandemic: An Independent review of the UK response to the 2009 influenza pandemic, Hine D, July 2010
· The Health Protection Response to Influenza A/H1N1v Pandemic in Scotland – Containment Phase: Lesson learned: A Report to the Directors of Public Health - HPS draft
· Report of the H1N1v Immunisation programme – HPS draft
· Health Protection Response to Pandemic Influenza in Scotland -draft
· Epidemiological report of pandemic (H1N1) 2009 in UK, HPA
· Various publications in peer reviewed journals
3. Initial actions
The Strategic Co-ordinating Group (SCG) and the NHS Grampian Executive Team were briefed on Monday 27 and Tuesday 28 April, respectively, and the following initial actions were taken:
· The Grampian Pandemic Influenza Plan (2008) was activated.
· NHS Grampian led the overall response on behalf of the SCG with the Director of Public Health as the Tactical lead.
· The Health Advisory Group (HAG), Pandemic Influenza Management Team (PIMT) and Tactical Mullti-agency Group (TMAG) were convened on 28 April.
· All sectors of NHS Grampian were asked to review their contingency plans, be prepared to activate plans at very short notice and to ensure good infection control was integral to these plans.
· Regular teleconferences took place with Scottish Government and HPS.
· The Communication plan, led by Director of Corporate Communications, was implemented to ensure the public, patients and staff across the public sector had access to up to date information.
· The Control Room was established at Summerfield House.
· The Public Health team worked with GP colleagues to investigate and manage all possible cases of Influenza A/H1N1v returning from affected areas and traced contacts as part of the containment strategy.
4. Background
Pandemics, or world-wide epidemics of influenza, are rare and occur when an influenza A virus emerges that:
· is a new virus type
· can cause serious illness
· can spread easily from person to person, and
· against which the population has no immunity from past exposure.
Previous pandemics, in 1918, 1957 and 1968, were accompanied by high levels of morbidity and mortality and caused widespread disruption to health and other services.
The Grampian Pandemic Influenza plan was based on the Scottish Framework for responding to an Influenza Pandemic, 2007. This Framework advised that NHS Board plans should anticipate illness in up to 50% of the population with illness lasting 1-2 weeks, with up to 6,700 excess deaths in Grampian (2.5% case fatality rate). Pandemic influenza may be more severe than seasonal influenza with higher attack rates, higher case fatality rates and different age groups affected. These planning assumptions were revised downwards as clinical data was collated on the 2009 pandemic – see Appendix 1.
The WHO declared the first pandemic of this century in June 2009. Influenza A/H1N1v caused higher rates of illness in children and young adults and lower rates of illness in adults over 60 years old. For most people the disease was mild and symptoms were similar to seasonal influenza. There were fewer than 500 confirmed deaths from Influenza A/H1N1v in the UK. Most of the serious complications occurred in individuals with underlying health conditions with the highest mortality in those with chronic neurological disease, respiratory disease, immunosuppression and in pregnant women. However, a significant proportion of serious complications did occur in those who were previously healthy.
5. Strategic, Tactical and Operational response
The Grampian Pandemic Influenza plan outlines the response structure and the plan was implemented in Phase 4 to ensure a state of preparedness if, and when, a pandemic was declared.
5.1 Strategic response
The Grampian SCG first met in response to the pandemic on 27 April 2009 under the chairmanship of the Chief Fire Officer, Grampian Fire and Rescue Service, in the absence of the Chief Constable.
The SCG agreed that NHS Grampian would take the role of lead agency based on the agreed SCG strategic, tactical and operational response structure. As Health was the lead agency the NHSG Chief Executive chaired subsequent meetings of the SCG and had the authority to call meetings of the SCG as required. It was agreed that the chair of the SCG would transfer to the Chief Constable by mutual agreement, should circumstances require this.
The responsibility for the overall tactical coordination of the Grampian response was delegated to the Director of Public Health (DPH).
The SCG was briefed on Monday 27 April and met again to consider the implications of the pandemic on 1 May and 11 June. Members were briefed at these meetings by the Director of Public Health. The SCG was also updated on developments related to the pandemic at the routine meeting on 25 August. The response was stood down by the SCG at the routine meeting on 4 March 2010.
NHS Grampian retained the lead agency role throughout the pandemic response as there were limited wider consequences.
NHS Strategic Team was briefed on a regular basis throughout the pandemic and SCG members were provided with regular written updates.
5.2 Tactical response
5.2.1 Tactical Co-ordination
The Director of Public Health led the overall Grampian Tactical response and was required to fulfil three key roles:
· To chair the HAG and via the HAG advised the SCG, NHS Strategic Team and the PIMT on the management of the outbreak and coordinated the risk assessment, risk management and risk communication.
· At phase 5 as the SCG Grampian Tactical lead, the DPH had the responsibility to protect the public’s health by ensuring that the overall response was co-ordinated and managed effectively across the Grampian community (NHS and our SCG partners). This included co-ordinating the work of the three Tactical groups i.e. the HAG, the PIMT and the TMAG and the other cross cutting functions. This continued in Phase 6 as Health retained the lead role.
· Ensuring that the public health operational response was maintained for both influenza and non-influenza incidents.
The Director of Public Health convened regular ‘Bird table’ meetings of senior staff to ensure ongoing co-ordination of NHS response.
5.2.2 Communication
This Tactical response required the delivery of an effective communications strategy which was led by the NHSG Director of Corporate Communications and a dedicated support team led by a Response Manager. The support team ensured:
· the collation and completion of agreed actions of the tactical groups
· an effective system was in place to meet the demands for Sitreps from the Scottish Government (SGoRR and SGHD) and Health Protection Scotland
· the effective control and management of information via an information control centre.
Effective communisation is essential in managing any outbreak and although the SGHD took the lead for communication during the pandemic in Scotland NHS Grampian supplemented this with some useful strategies:
· The Director of Corporate Communication worked closely with the Director of Public Health and other senior colleagues within the NHS and partner agencies
· Developed Good Visitor Guide – widely disseminated across hospital sites
· Developed the Health Advisory Group Template – regularly updated summary of advice for NHS and partners
· Developed single page Flu briefs for NHS and SCG members
· Regular updates were provided for clinical colleagues in primary and secondary care
· Undertook regular liaison with affected schools, Education departments and Universities
· Worked with UK Oil Industry and HPS to develop guidance for offshore
· HAG template and Flu briefs were shared with NHS Orkney.
5.2.3 Health Advisory Group (HAG)
The Grampian Pandemic Influenza Plan outlines the tasks of the HAG as follows:
· Advise the SCG on the management of public health aspects of the outbreak and co-ordinating the risk assessment, risk management and risk communication
· Risk assessment – investigation and surveillance
· Risk management
• Use of antivirals
• Vaccination strategy
• Infection control in the community and other organisations
• Protection of staff
• Social distancing and isolation
• School closures
• Travel and port health
• Mass gatherings
· Risk communication - Public Health Advice to SCG, emergency planning partners, public (including self care) professionals and local businesses.
The HAG met regularly throughout the Pandemic and produced a regularly updated summary of advice to the NHS and partners.
5.2.4 Pandemic Influenza Management Team (PIMT)
The Grampian Pandemic Influenza Plan outlines the tasks of the PIMT as follows:
· Tactical decisions about maintaining and prioritising services across Grampian
· Managing the service interface between primary and secondary care and with social services/community care
· Support staff to deliver services.
However, in early stages of our response the main task of the PIMT was to ensure that all sectors were prepared to respond to a pandemic and provide assurance of this to the Chief Executive, the NHS Board and NHS Scotland. Essential to this was the immediate assessment of readiness, an audit of plans, identification of the risks and outstanding actions. This was led by the PIMT and supported by the Clinical Governance and Risk Management Unit.
The PIMT met regularly and was initially co-chaired by the Medical Director and the Deputy Medical Director, but given the role of the PIMT this was revised and co-chaired by the Deputy Chief Executive and the Deputy Medical Director who provided clinical leadership and advice.
5.2.5 Tactical Multi-agency Group (TMAG)
The SCG Tactical/Support Group met on 1 May 2009, 18 May 2009 and on 21 July 2009 to consider pandemic influenza issues. Thereafter, the functions of this group merged with the Health Advisory Group which continued to meet regularly as described above with multi-agency representation.
Partners focussed on business continuity preparation, and on plans to deal with large numbers of additional deaths in the community. At various points during the pandemic members of the SCG offered assistance to NHS Grampian which fortunately was not required.
The Grampian SCG Resilience Support Team (RST) liaised closely with NHS Grampian and Scottish Resilience during this period through meeting attendance and teleconferences. Individual responders channelled situation reports through the RST to report at HAG meetings. The Local Authorities collaborated closely with NHS Grampian through the Community Health Partnerships.
5.2.6 NHS Grampian Board Control Room
The purpose of the Board Control Room was to provide co-ordination for NHS Grampian’s strategic and tactical response to the emergency and liaise with partner organisations/agencies.
· The Control Room communicated and received information, acting as an information hub for the organisation. The Control room provided access to, and co-ordination of, intelligence around the incident and facilitated the provision of up-to-date status report for strategic and tactical leads, managers, employees, government and the public.
· The Control Room provided a mechanism to coordinate the steps taken to respond to the event and provided a means of creating a formal record of the response by logging and documenting information received, actions taken and decisions made.
· The Control Room supported the command and control functions necessary to manage the NHS Grampian response and recovery by:
• Acting as the focal point for NHS strategic and tactical response information and management
• Being the main point of contact for all operational areas, including the Acute sector, Primary Care and CHPs
• Co-ordinating the information regarding allocation of resources to NHS boards, HPS etc
• Acting as single point of contact for NHS Grampian incident response
• Maintaining distribution lists and cascading of information as appropriate across the whole system and to partner organisations on a very regular basis