Issue No: 5 Implementation Date: 1 January 2017 Date to be reviewed: 1 January 2019 Pandemic Influenza Coordinator Dr Ken Oates Consultant in Public Health Medicine Contact Tel: 01463 704886 NHS Highland Intranet access: Emergency Planning S ection

29 December 2016

NHS HIGHLAND

CONTINGENCY PLAN

FOR

PANDEMIC INFLUENZA

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FOREWORD

This document sets out the plan for the management of an epidemic of influenza in the NHS Highland area, involving a pandemic strain, so-called ‘Pandemic Influenza’. A pandemic of influenza is an epidemic which strikes on a world-wide scale, usually because of a new strain or sub-type of influenza virus to which human populations are particularly vulnerable. It spreads from person-to-person and causes illness in a high proportion of the people infected. This plan is the result of an ongoing iterative process that has taken place over several years involving large numbers of NHS staff and key colleagues from other local agencies. It was updated to reflect developments in scientific advice, national and local planning, and experience gained from the H1N1 pandemic in 2009/10, and further amended in 2016. A pandemic of influenza is expected to cause widespread illness, large numbers of deaths and huge societal disruption, concentrated in just a few weeks or months. It is predicted that if 25% of the population were affected by illness, and up to 2.5% of those with symptoms died, which is in keeping with previous pandemics, 77990 people would become ill in the Highland area and up to 1950 could die. However, higher attack rates of up to 50% may apply, suggesting that many more people could become ill and die over a period of several months. A pandemic is likely to rapidly overwhelm normal services resulting in NHS resources being severely stretched and a consequent widespread disruption of health and other services. Flexibility and alternative models of care and service delivery will be required. The local plan identifies those individuals who will assume responsibility for the execution of the contingency arrangements and clearly allocates responsibilities. It also refers to the supporting roles offered by the local authorities, the blue light services, care homes, and the voluntary sector all of whom have links with NHS services. This document will be kept under review and revised as necessary in the light of new developments and experience and the emerging global situation. Ms Elaine Mead NHS Highland Chief Executive December 2016

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CONTENTS SECTION PAGE NO. Amendment Record .................................. .................................................................................. 5 1. INTRODUCTION ..................................................................................................................... 6

1.1 Activation of plan ............................................................................................................ 6 1.2 Activation of Resilience Partnerships .............................................................................. 7 1.3 Aims and Objectives ....................................................................................................... 7 1.4 Background .................................................................................................................... 8 1.5 Clinical Aspects .............................................................................................................. 9 1.6 Possible Interventions .................................................................................................... 9 1.7 The Scale of the Problem ............................................................................................... 9

2. IMPLICATIONS OF A PANDEMIC ..................... .................................................................... 11

2.1 Planning Assumptions .................................................................................................... 11 2.2 Worst case scenarios ..................................................................................................... 11 2.3 Impact of a Pandemic ..................................................................................................... 12 2.4 Health and Community Care Demand ............................................................................ 12 2.5 Absence from Work ........................................................................................................ 13 2.6 Schools and Other Closed Communities ........................................................................ 14 2.7 Prisons and Army Bases ................................................................................................ 15 2.8 Impact on Other Services ............................................................................................... 15 2.9 Impact on Travel ............................................................................................................. 15 2.10 Public, Political and Media Concern ................................................................................ 16

3. THE HIGHLAND RESPONSE .......................... ....................................................................... 17

3.1 Reducing Societal disruption .......................................................................................... 17 3.2 The Highlands & Islands Local Resilience Partnership ................................................... 17 3.3 Argyll and Bute Local Resilience Partnership ................................................................. 19 3.4 Highland Pandemic Influenza Co-ordinating Committee ................................................ 19 3.5 Operational Incident Management Teams ...................................................................... 21 3.6 Clinical Flu Advisory Group............................................................................................. 22 3.7 Control room ................................................................................................................... 22

4. DETECTION AND ASSESSMENT PHASE ................. ............................................................ 23

4.1 Key Actions………………………………………………………………………………… ....... 23 4.2 Surveillance, Testing, Diagnosis and Reporting ............................................................. 23 4.3 Prevention and Protection – Infection Control………………………………………… ........ 24 4.4 Service Delivery .............................................................................................................. 24 4.5 Antiviral drugs ................................................................................................................. 25 4.6 Pre-pandemic vaccine .................................................................................................... 26 4.7 Key Principles Underlying NHS Planning and Response ................................................ 26 4.8 Communication .............................................................................................................. 27

5. TREATMENT AND ESCALATION PHASE ................. ............................................................ 28 5.1 Key Actions .................................................................................................................... 28 5.2 Surveillance, Testing, Diagnosis and Reporting ............................................................. 29

5.3 National Flu Helpline....................................................................................................... 29 5.4 National Pandemic Flu Service ....................................................................................... 30 5.5 NHS 24 ........................................................................................................................... 31 5.6 Antiviral drugs ................................................................................................................. 31 5.7 Antiviral Collection Points ............................................................................................... 32

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5.8 Primary Care .................................................................................................................. 32 5.9 Operational Units ............................................................................................................ 33 5.10 Organisation of Local Health Services ............................................................................ 33 5.11 Acute Care ..................................................................................................................... 34 5.12 Critical Care .................................................................................................................... 34 5.13 Workforce Issues ........................................................................................................... 34 5.14 Partnership Working with Social Services and Independent Sector Providers ................ 35 5.15 Service Planning and Continuity ..................................................................................... 35 5.16 Communication .............................................................................................................. 35 5.17 Fatalities and Mortuary Facilities .................................................................................... 36

6. VACCINATION .................................... ................................................................................... 37

6.1 Vaccine Effectiveness .................................................................................................... 37 6.2 Vaccine Supply and Priority Groups ............................................................................... 37

7. RECOVERY PHASE ............................................................................................................... 40 7.1 Surveillance, Testing, Diagnosis and Reporting ............................................................ 40 7.2 Prevention and Protection .............................................................................................. 40 7.3 Service Planning and Continuity ..................................................................................... 40 7.4 Communication .............................................................................................................. 40 7.5 LRP Recovery Arrangements ......................................................................................... 40 8. COMMUNICATIONS - PUBLIC AND MEDIA INFORMATION .. .............................................. 41 8.1 National Co-ordination .................................................................................................... 41 8.2 Local Co-ordination ........................................................................................................ 41 8.3 Self-Help Information for the Public ................................................................................ 41 9. USEFUL SOURCES OF INFORMATION .................. ............................................................. 43 9.1 Websites ........................................................................................................................ 43 9.2 Supporting Documents ................................................................................................... 43 APPENDIX 1 - Membership of NHS Highland Pandemic In fluenza Co-ordinating

Committee (HPICC) ................................. ....................................................... 46 APPENDIX 2 - HPICC Roles and Responsibilities ..... ........................................................... 47 APPENDIX 3 - HPICC Draft Agenda ................... .................................................................... 50 APPENDIX 4 - Organisational Chart – Command and Con trol ........................................... 51 APPENDIX 5 - Functioning of the Highlands and Islan ds Local Resilience

Partnership in the Event of an Outbreak of Pandemic Disease.................. 52 APPENDIX 6 - Membership of Highlands & Islands and Argyll and Bute Local

Resilience Partnerships ........................... ..................................................... 53 APPENDIX 7 - NHS Mortuary Capacity ................ ................................................................. 57 APPENDIX 8 - Phased Response of National Organisati ons .............................................. 58 APPENDIX 9 - NHS Highland Response to Each Phase .. .................................................... 59

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APPENDIX 10 - Laboratory Tests .................... ........................................................................ 62 APPENDIX 11 - Hospital Bed Establishment .......... ................................................................ 63 APPENDIX 12 - Invasive and Non-Invasive Ventilators within NHS Highland ..................... 65 APPENDIX 13 - Membership and Remit of Clinical Flu Advisory Group .............................. 67 APPENDIX 14 - Priority Groups for Vaccination ..... ............................................................... 68 APPENDIX 15 - NHS Highland Impact – Predicted Numbe rs Affected ................................. 70 GLOSSARY .......................................... ........................................................................................ 72

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NHS HIGHLAND

CONTINGENCY PLAN FOR PANDEMIC INFLUENZA

RECORD OF AMENDMENTS

Amendment

Amended by

Date Issued

No. Date

1 31 Jan 2006 Ken Oates February 2006

2 1 July 2008 Ken Oates July 2008

3 31 July 2012 Ken Oates August 2012

4 29 December 2016 Ken Oates January 2017

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1. INTRODUCTION This document sets out NHS Highland's plans to respond to an influenza pandemic. It reflects the latest international guidance from the World Health Organization (WHO) and national guidance from the UK Health Departments. It also includes the lessons learned from the H1N1 (swine flu) pandemic in 2009. It will assist NHS Highland and other agencies to respond effectively and in an integrated manner. This document does not describe other agency’s contingency plans. Each local organisation is expected to develop their own Business Continuity Plan for during an influenza pandemic. The most recent national guidance for pandemic flu is available on various websites and is regularly updated. These websites and national documents supplement this document and should be read in conjunction with this plan. Some key websites are: https://www.gov.uk/guidance/pandemic-flu https://www.gov.uk/government/publications/respondi ng-to-a-uk-flu-pandemic https://www.gov.uk/government/publications/health-a nd-social-care-response-to-flu-pandemics http://www.gov.scot/Publications/2007/11/21141855/0 http://www.who.int/influenza/preparedness/pandemic/ en www.hps.scot.nhs.uk Published documents include specific and detailed pandemic flu guidance for critical care, adult community care; mental health services; infection control in acute and primary care settings; workforce issues; surge capacity; schools & children’s services and an ethical framework, among others. Web links to these are available in section 9. In addition, there are specific organisational business continuity plans for each operational unit in NHS Highland. These are available on NHS Highland Intranet site and not duplicated here. They should also be read in conjunction with this plan. 1.1 Activation of Plan and Highland Pandemic Influe nza Coordinating Committee This plan will be activated by the Director of Public Health, or his/her deputy. The WHO Phase system was not found to be directly applicable at a national level during the H1N1 pandemic, and in 2013 WHO revised the approach to global phases. The global phases – interpandemic, alert, pandemic and transition – describe the spread of the new influenza subtype, taking account of the disease it causes, around the world. See: http://www.who.int/influenza/preparedness/pandemic/GIP_PandemicInfluenzaRiskManagementInterimGuidance_Jun2013.pdf Therefore activation locally may take place either at WHO Alert Phase or at the Pandemic phase when a pandemic is declared globally, but will be dependent upon UK national risk assessment. Full activation of local arrangements will be a natural extension of this national risk assessment which will take into consideration the global risk assessment.

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The UK Influenza Pandemic Preparedness Strategy 2011 outlines the approach to indicators for action in the UK in a future pandemic response. This takes the form of a number of phases named: Detection, Assessment, Treatment, Escalation and Recovery. The UK has defined the “Detection and Assessment” phase as when human to human transmission of a novel influenza virus with pandemic potential, which poses a substantial risk to human health is detected in the UK. During this phase the NHS Highland Pandemic Influenza Coordinating Committee (HPICC) will be fully implemented after being convened by the Chief Operating Officer to co-ordinate the NHS response. (Note - The HPICC will probably have met earlier to consider the level of local preparedness) 1.2 Activation of the Regional Resilience Partnersh ip and Local Resilience

Partnership (formerly Strategic Coordinating Groups ) During the Detection and Assessment phase, in the event of large clusters of cases in other countries and a pandemic likely to affect the UK, an initial meeting of the Regional Resilience Partnerships (RRP) will be called. NHS Highland is unique among NHS Boards in having part of its geographical patch in 2 different Regional Resilience Partnership (RRP) areas – North of Scotland and West of Scotland. NHS Highland senior officers will primarily attend the North RP. For practical purposes either Greater Glasgow and Clyde Health Board will represent NHS Highland as required on the WoS RRP or senior managers from the Argyll and Bute Health and Social Care Partnership will attend. However, it is envisaged that the majority of strategic issues in a pandemic will be considered at national level rather than regional. More local strategic and all key multi-agency operational decision making will be at the Highlands and Islands Local Resilience Partnership (HILRP) and the local Emergency Liaison Groups (ELGs - 5 in mainland Highland and one each on the 3 Island groups) or at the Argyll & Bute Local Resilience Partnership (A&B LRP). The H&I LRP or A&B LRP can be called at the instigation of any of the Category 1 responders, including NHS Highland. The LRP may be chaired in the very early stages of a pandemic by NHS Highland but as the pandemic evolves and has greater consequence management issues for society then the LRP chair will be Police Scotland. During the latter stages and Recovery phase the chair will be the Chief Executive of the Local Authority. Secretarial support to the H&I LRP or A&B LRP will be provided by the lead agency. Meetings will take place at Divisional Police Headquarters, Inverness for NHS Highland (north) and for A&B LRP in Divisional Police Headquarters, Dumbarton with links to other parts by vc, with the Recovery phase meetings held at A&B Council Headquarters in Lochgilphead with the required vc links. The LRP will ensure an integrated response and report to the Scottish Government Resilience Room (SGoRR). See Appendix 4 for organograms of UK, Scottish and Highland organisational structures. 1.3 Aims and objectives Aim The aim of this plan is to assist health, emergency services and other planning partners in Highland to respond effectively to a pandemic of influenza in order to save lives, reduce the health impact and minimise disruption to essential services whilst maintaining business continuity and reducing disruption to society.

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Objectives The prime objectives are to a) Reduce morbidity and mortality from influenza.

b) Minimise transmission by optimum infection control and other public health measures

such as social distancing. c) Prevent infection by using isolation, quarantine, anti-viral treatments and vaccines,

when available and applicable. d) Provide treatment and care for large numbers of people ill with influenza and its

complications, both at home and in hospital. e) Minimise the impact on health and social services including the consequences for

other patients as a result of re-prioritisation of services.

f) Provide accurate, consistent, timely, authoritative and up-to-date information to professionals, the public and the media.

g) Ensure that essential services are maintained.

h) Cope with the potential large number of deaths in a high impact scenario.

i) Minimise the impact on daily life and business and the consequent economic losses.

1.4 Background Influenza viruses have the ability to exchange genetic material with each other and new viruses (to which populations have had no opportunity to acquire immunity) can thus emerge. A human viral sub-type which has been out of circulation for a long time can also emerge as a ‘new virus’. Rapid spread of a new virus through susceptible populations can lead to a pandemic i.e. infection on a worldwide scale with outbreaks or epidemics in many countries and in most world regions. Pandemic influenza is caused by influenza A virus which has multiple host species, including birds, pigs and other animals, as well as man. A new virus with pandemic potential may emerge at any time of year and thus an influenza pandemic may occur out with the normal influenza season. Occurrence of a pandemic (as distinct from an epidemic) requires the following co-existing criteria: • the emergence of a genetically new influenza virus • the ability of that virus to infect humans, to spread from person-to-person, and to cause

disease in a high proportion of those infected • a worldwide susceptible population lacking immunity to the new virus, enabling it to

spread rapidly and widely A new strain of virus could emerge in any country (including the UK) but is most likely to first present in China or the Far East where the close proximity of humans, poultry and pigs in farming communities facilitates mingling of human and animal viruses with possible exchange of genetic material. Unprecedented growth in international travel, deterioration in the public health infrastructure in many countries and widespread emergence of drug-resistant bacteria (which may cause secondary infections in influenza patients) all contribute to the possibility of the next pandemic being severe.

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Influenza pandemics are rare events but when they occur they usually result in major morbidity and mortality, huge demands on health services and a wide range of impacts beyond the healthcare system on daily activities, business and the economy. Health services and other services could be rapidly overwhelmed. The potentially devastating effects of a pandemic, together with characteristic unpredictability in timing, severity and target populations, underline the importance of appropriate alertness and preparedness, both nationally and internationally. A coherent response requires partnership between all levels of Government, the NHS, public agencies, industry and the public. 1.5 Clinical aspects Influenza is a highly infectious acute viral infection, usually transmitted by the respiratory route, by airborne droplets or by fine aerosols of infected secretions. Spread may also result from hand/face contact after touching a patient or a contaminated surface. The incubation period is 1-4 days, typically 2-3 days; the illness is usually self-limiting and of 2-7 days duration, characterised by fever, headache, muscle pains, sore throat, cold symptoms and, usually, cough. Serious complications can occur, particularly primary viral pneumonia and secondary bacterial pneumonia which can result in severe morbidity and mortality in any age group although the very young, the elderly and those with chronic illness are particularly at risk. Patients are highly infectious from the onset of symptoms for 3-5 days, or longer in the case of children or the immuno-compromised. One person in ten is likely to be infectious just before onset of symptoms and children have occasionally been shown to shed virus from 6 days before, to 3 weeks after, symptom onset. People with asymptomatic infection are likely to be infectious to some extent but are unlikely to be the source of an outbreak. In the absence of interventions, one patient will infect 2 others on average but this number will be greater in closed communities. 1.6 Possible interventions • An appropriate vaccine, if available, would offer the greatest reduction in cases,

complications and deaths and in disruption to health and other services. However, a lead time of several months is inevitable between identification of a pandemic virus and mass production of vaccine. Even when vaccine and circulating virus strains are well matched, vaccination reduces infection by only around 70%, hospital admissions of high-risk individuals by approximately 60%, and deaths by 40% or so.

• Antiviral prophylaxis could protect against clinical illness to a similar extent as vaccine but its use in a pandemic is may be restricted to specific, limited situations.

• It is likely that anti-viral treatment would be as effective in a pandemic as during seasonal influenza i.e. treatment within 48 hours of onset of illness could shorten illness by about one day, ameliorate symptoms, and reduce hospital admissions by 50%. The effectiveness of anti-virals in reducing mortality in severe disease (e.g. primary viral pneumonia) is not known.

1.7 The scale of the problem The usual clinical attack rate of seasonal influenza is 5-15%. On the basis of evidence from previous pandemics the WHO suggests that the most likely scenario for the next pandemic will involve a cumulative clinical attack rate of 25% - 35% over 15 weeks, while rates of up to 50% have also been considered. Although most people will be susceptible, many will have asymptomatic infection. Once influenza levels exceed the normal baseline threshold (50 GP

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consultations per 100,000 per week in Scotland) activity may last for 3 to 5 months, possibly with subsequent waves weeks or months after the first. In non-pandemic years severe illness and mortality from influenza predominantly affect high-risk groups such as the elderly and the chronically ill; this is the basis for the routine annual influenza immunisation programme. In a pandemic, however, severe illness (including potentially fatal viraemia and viral pneumonia) will probably occur more frequently and could affect all population groups. Planning assumes a uniform attack rate across all age groups; severity of illness, mortality and the age group most affected cannot be predicted in advance of established human-to-human transmission.

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2. IMPLICATIONS OF A PANDEMIC 2.1 Planning assumptions It is uncertain when a new pandemic virus might emerge. One of the key lessons from the H1N1 pandemic in 2009/10 was the unpredictability. So until a new strain emerges and affects a significant number of people it will not be possible to identify the key features of the disease, such as any pre-existing immunity, the groups most likely to be affected, and the effectiveness of clinical counter measures. Given this, there are 3 main principles that underpin planning: Precautionary - The plan will reflect the potential risk based on the best information available at the time Proportionality - The plan will be able to be scaled up or down depending on the risks and impact of the virus Flexibility – The plan will be adaptable to local circumstances and changing risks Despite the uncertainty there are some key assumptions that can be made: • A pandemic is most likely to be caused by a new subtype of the Influenza A virus but this and other relevant pandemic plans could be appropriately adapted and deployed for any epidemic infectious disease.

• An influenza pandemic could emerge at any time of the year anywhere in the world, including in the UK. Regardless of where or when it emerges, it is likely to reach the UK very rapidly and, from arrival, it will probably be a further one to two weeks until sporadic cases and small clusters of cases are occurring across the country.

• The potential scale of impact, risk and severity from related secondary bacterial infection and clinical risk groups affected by the pandemic virus will not be known in advance.

• It will not be possible to completely stop the spread of the pandemic influenza virus in the country of origin or in the UK, as it will spread too rapidly and too widely.

• Initially, pandemic influenza activity in the UK may last for up to three to five months, depending on the season. There may be subsequent waves of activity of the pandemic virus weeks or months apart, even after the WHO has declared the pandemic to be over.

• Following an influenza pandemic, the new virus is likely to persist as one of a number of seasonal influenza viruses. Based on observations of previous pandemics, subsequent winters are likely to see increased seasonal flu activity compared to pre-pandemic winters. 2.2 Worst case Scenario Influenza pandemic planning in the UK has been based on an assessment of the reasonable worst case. In a worst case scenario up to 50% of the population could experience symptoms spread over one or more waves each lasting 15 weeks. The nature and severity of symptoms would vary from person to person. Analyses suggest that up to 2.5% of those with symptoms could die, health services should prepare to provide advice and treatment for up to 30% of all symptomatic people. Between 1-4% of those who are symptomatic could require hospital care. Up to 25% of these may require critical care.

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In a widespread and severe pandemic affecting 50% of the population, between 15-20% of staff might be absent on any given day during the peak weeks. 2.3 Impact of a pandemic The impact of an influenza pandemic on health and social services will be intense, sustained and nation-wide. Significant factors are:

• increased workload due to large numbers of patients with influenza and complications • additional need for high dependency care, infection control facilities and equipment • increased demand for social and community care services • additional burden caused by anxiety and bereavement • depletion of workforce and of numbers of informal carers because of the effects of

influenza on them or their families • pressure on all emergency services • logistical problems due to interruption of supplies and utilities through absenteeism • delays in dealing with other medical conditions and probable cancellation of elective

admissions • pressure on mortuary facilities (possibly with associated delays in death registrations

and funerals.) • longer term macro effects on national and world economy and the structure of society

2.4 Health and Community Care Demand

• Modelling suggests that between 25% and 50% of the population could experience symptoms of pandemic flu although the nature and severity of symptoms will vary from person to person.

• Hospitalisations and deaths will depend upon the age profile affected, virulence and specific complications associated with the pandemic virus, but demand is likely to be greatest in children and the elderly.

• New healthcare contacts for influenza-like illness can be expected to exceed 10,000 per 100,000 population per week at the peak period (at a 50% attack rate). Peak consultations during seasonal influenza periods in recent years have been 400-900 per 100,000 per week.

• Peak demand could be sustained for one to two weeks with local epidemic waves for 6-8 weeks.

• Assuming a complication rate of 25%, an attack rate of 50% and those under 3 needing to see a health professional, general practices can expect to see 3600 influenza patients per 100,000 population per week at the peak.

• 2000 per 100,000 population may require hospital admission – an increase of at least 50% on normal demand

• Demand for hospital admission can be expected to increase up to 440 new cases per 100,000 per week at the peak and is unlikely to be met from available acute hospital capacity.

The following tables estimate anticipated cases and demand based upon a uniform attack rate across all age groups.

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Table 1 – Expected healthcare demand over the course of a pandemic, for 25%, 35% and 50% clinical attack rates and the upper end of the range for all other planning assumptions

Per 100,000 population 25% attack rate 35% attack rate 50% attack rate

Clinical cases 25,000 35,000 50,000 GP consultations 6,875 9,625 13,750 Hospital admissions 1,000 1,400 2,000 Deaths 625 875 1,250 Table 2 – Expected healthcare demand each week during the peak of a pandemic, for 25%, 35% and 50% clinical attack rates and the upper end of the range for all other planning assumptions

Per 100,000 population 25% attack rate 35% attack rate 50% attack rate

Clinical cases 5,500 7,700 11,000 GP consultations 1,800 2,500 3,600 Hospital admissions 220 308 440 Deaths 140 200 280 Assumptions: • 22% of the total demand occurs in the peak week. • All complications (@ 25% cases) and symptomatic children under the age of 3 (3.2% of

the population) are consulted by a GP. • Hospital admissions @ 4.0% of cases (=worst case scenario) • Deaths @ 2.5% of cases (=worst case scenario) Coping with a large influx of medical cases, accompanied by high staff sickness rates (possibly 25%) will require innovative approaches to staffing, triaging of patients and accommodating patients who cannot be admitted to hospital but who require more care than is normally available in the community. It may be necessary to cancel all elective surgery to enable surgical beds (including intensive care and high dependency beds) to be made available for medical cases, some of whom will require ventilation. Tables outlining the projected numbers affected each week in the NHS Highland area are in Appendix 16. 2.5 Absence from work Although data are available on sickness absence in previous pandemics, it is difficult to extrapolate with any confidence to what might happen now as work patterns are so different. Absence from work will depend on the age-related attack rate, although even if working age people are relatively spared, additional absenteeism may result from staff needing to take time off to care for family members. Accelerated transmission may occur in some workplaces, eg where people work in close proximity, resulting in staff being ill during a narrower time frame than in the general population.

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Planning assumptions for health care workers, in the absence of vaccination, have to assume a higher sickness absence rate than other population groups because of their higher risk of exposure. Normal sickness absence rates are around 2% and up to 4 to 6% in the NHS. • Up to 50% of the workforce may require time off at some stage of the entire period of the

pandemic with individuals absent for a period of seven to ten working days. Absence should follow the pandemic profile with an expectation that it will build to a peak lasting for 2-3 weeks when between 15% and 20% of staff may be absent and then decline.

• Additional staff absences are likely to result from other illnesses, taking time off to provide care for dependents, family bereavement, other psychosocial impacts, fear of infection and/or practical difficulties in getting to work.

• The Scottish Government may advise schools, nurseries and childcare settings in an area to close in order to reduce the spread of infection among children. Any such advice would probably be to close for a few, probably 2-3 weeks, but closures may be extended if the pandemic remains in the area.

• Modelling suggests that small organisational units (5 to 15 staff) or small teams within larger organisational units are likely to suffer higher percentages of absence – up to 30-35% over a 2-3 week peak period.

The skill mix required for some occupations, including health care, may limit the extent to which other staff can be re-deployed 2.6 Schools and other closed communities Influenza transmits readily whenever people are in close contact and is likely to spread particularly rapidly in schools. In 1957, for example, up to 50% of schoolchildren developed influenza, but even those schools which were most severely disrupted had returned to normal 4 weeks after the appearance of the first case. In residential schools, attack rates reached 90%, often affecting the whole school within a fortnight. So closing schools to pupils might reduce peak impact and clinical cases by 10%. However, closing schools has a significant impact on business continuity and maintenance of essential services, particularly health care, due to parent workers needing to stay at home for childcare. The same would apply to early years/childcare settings where groups of children mix. It is unlikely therefore that widespread school closures will be required except in a very high impact pandemic. The benefit of school closure would be undermined if children mix socially outside of the school environment. In addition, the impact on other organisations caused by absence of parents from key occupations due to child care needs may also be detrimental. However, specific local business continuity reasons (staff shortages or particularly vulnerable children) may lead to targeted individual or local school closures. The Scottish Government will advise whether or not to close schools based on an assessment of the character and impact of the pandemic. The LRP may also provide advice and local Directors of Public Health may advise localised closures in specific circumstances (individual schools or catchment areas, and in special schools with particularly vulnerable children) to reduce the initial spread of infection locally whilst awaiting more information about the spread of the virus. Ultimately though it is Education services and Head teachers who will take the final decision to close their local schools temporarily, or not.

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2.7 Prisons and Army Bases

Closed communities such as prisons, where large numbers of people live at close quarters, are a high-risk environment for transmission of influenza. Prisoners are more likely than many other sub-groups of the general population to have co-morbidities causing increased risk of severe or complicated influenza, eg asthma, respiratory disease secondary to smoking, and immunosuppression due to HIV/AIDS. Preventing transmission of the virus in prisons and other closed communities is necessary throughout the pandemic period. Close working between prison governors, community providers and HPTs will support this. Effective measures include isolation and cohorting of those affected, treatment with antiviral medicine for both cases and close contacts (in particular for persons in high-risk clinical groups), and use of vaccine, when available, for those in high risk groups. During the H1N1 (2009) influenza pandemic, these measures proved highly effective in preventing widespread illness, and in bringing outbreaks under control.

Inverness Prison has some 177 prisoners and over 100 staff and has a legitimate claim on antiviral chemotherapy and vaccines as and when they become available. Close liaison with prison authorities during a pandemic is essential. Fort George is an army regiment base and another potential site of rapid spread of illness. Faslane is a large naval base which faces the same risks due to its large working population in a relatively small area. Close liaison with military personnel, medical staff and public health staff will be required. 2.8 Impact on other services In the absence of early or effective interventions, there will be a widespread effect on all other services, through staff sickness, any travel restrictions imposed and through the knock on effects of other disrupted businesses and services. This includes all non-health services (police, fire, etc), the military, other essential services (eg fuel supply, food production and distribution, transport), prisons, education and businesses. Services such as death registration and funeral directors will have an increased work load. 2.9 Impact on travel There are no plans to close national borders in the event of an influenza pandemic. Modelling suggests that such a measure would have no significant impact on the spread of the virus whereas the social and economic impact such as disruption to supply chains would be substantial. The public may be advised to minimise non-essential travel but should continue travelling for essential journeys.

Travel may still be impacted through • any explicit restrictions on travel and public gatherings as a policy option • people opting not to travel (eg because of cancellation of work/school etc, fear of

acquiring infection through travel or fear of leaving home) • availability of fuel and transport workers There is also very little evidence that restrictions on mass gatherings or on internal travel arrangements will have any significant effect on influenza virus transmission. The emphasis will instead be on encouraging all those who have symptoms to follow the advice to stay at home and avoid spreading their illness.

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2.10 Public, political and media concern There will be high public and political concern and scrutiny at all stages of an influenza pandemic. Press interest, the need for information, and coverage will be intense. Managing people’s concerns and expectations will be a key part of the response. People’s concerns will extend to what is happening in other countries, particularly those with which they have family connections. Interest and concern will also extend to national and international events and mass gatherings. Other plans cover these issues in more detail.

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3. THE HIGHLAND RESPONSE 3.1 Reducing Societal Disruption This plan is concerned primarily with the health response but other government departments and other agencies will be required to assist with the successful implementation of the health response, particularly in terms of any necessary social countermeasures. All organisations, including businesses, need to consider implications, based on information in this plan, and make their own business continuity plans. Testing plans is part of the training framework. The civil emergency response is included in other contingency plans which will come into effect when the scale of a pandemic warrants it and which cover:

• maintenance of essential services including emergency services, transport, food distribution, pharmaceutical supplies, utilities and communications

• management of mass casualties • maintenance of public order • role of the police and armed forces

The Highlands and Islands LRP and Argyll and Bute LRP will co-ordinate the multi-agency response in their respective areas. (see Appendices 5-7) 3.2 The Highlands & Islands Local Resilience Partne rship The Highlands & Islands LRP will co-ordinate the overall Highlands and Islands response to the pandemic and liaise with the Scottish Government. The LRP will normally be chaired by the Chief Superintendent and will be located at the Divisional Police HQ Inverness. (Note in very early phases the HILRP may be chaired by the Chief Executive or Director of Public Health of NHS Highland until such time as wider societal issues or issues of public order supersede health matters when the Chief Superintendent assumes the chair). H&I LRP Membership Category 1 Responders Comhairle Nan Eilean Siar Maritime & Coastguard Agency NHS Highland NHS Orkney NHS Shetland NHS Western Isles Orkney Islands Council Police Scotland Scottish Ambulance Service Scottish Fire & Rescue Service Scottish Environment Protection Agency Shetland Islands Council The Highland Council

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Category 2 Responders Utilities (Gas, Water, Electricity, Telecommunications) Rail and Airport Operators Harbour Authorities Common Services Agency Health & Safety Executive Health Protection Scotland Scottish Ferry Operators Civil Nuclear Constabulary Other Organisations Military Authorities Procurator Fiscal Service British Red Cross Women’s Royal Voluntary Service (WRVS) Community Groups Meteorological Office Highland 4x4 Response Group Mountain Rescue Teams Other Voluntary Services NOTE: Other agencies may be co-opted into the response The Chair may wish to establish a Scientific & Technical Advice Cell chaired by the DPH or his/her deputy especially if there are wider health issues as a result of the impact on other services e.g. provision of water. Various experts may be asked to contribute

• Medical Microbiologist and Infection Control Doctor • Occupational Health Physician • Consultant in Pharmaceutical Public Health or Director of Pharmacy • Consultant Epidemiologist from HPS

LRP Tasks • co-ordinate maintenance of essential services e.g. emergency services, transport, food

distribution, pharmaceutical supplies, utilities and communications • ensure accurate, consistent, timely, authoritative and up-to-date information is provided

to professionals, the public and the media, • ensure systems are in place for safe distribution of anti-viral treatments and vaccine, if

available, • management of excessive/mass deaths • maintain public order During the pandemic, a Tactical Level multi-agency group will be set up as required. This will have tactical level representatives of pre-identified organisations including the NHS. Leadership of this will be provided by Highland Council. This will deal with societal/multi-agency issues out with the NHS response. At a district level in north Highland, the 5 Local Emergency Liaison groups (ELGs) will be established. The civil emergency response is described in other multi-agency contingency plans held elsewhere. A key role will be to ensure a co-ordinated media response through the work of the multi-agency public Communications cell and the implementation of the HILRP Response Guidance May 2015.

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3.3 Argyll and Bute Local Resilience Partnership The A&B LRP will be chaired by a senior police officer or his/her nominee during the initial stages of the outbreak and latterly by the chief executive or deputy of the local authority member of the A&B LRP during the recovery phase. Where there are a number of Category 1 responders from the same group of agencies eg NHS Boards or Local Authorities, a consensus approach could assist where they may nominate a single representative to sit on the WoS RRP to represent them all. A&B LRP Membership Police Scotland Scottish Fire and Rescue Service Scottish Ambulance Service NHS Highland MCA SEPA Calmac Ferries Western Ferries Peel Ports (was Clydeport Authority) Met Office BEAR Scotland Scottish Power Energy Networks Scottish and Southern Energy Scottish Water British Red Cross RVS Oban airport Site Operators – Faslane Site Operators – Oil Fuel Depots Site Operators – Finnart Site Operators – DM Glen Douglas The A&B LRP will come together to establish a framework for the overall coordination of the management of the response for the non-clinical or consequential aspects of a pandemic outbreak. In addition, it will determine and keep under review the strategic aim, objectives and policies. In so doing it should ensure the following:

• clear lines of communication with tactical managers • mutual assistance and support for local responders • long term recovery, resource and access to expertise for management at all levels • plan and coordinate recovery from the emergency and return to a state of normality • effective communications with the public and elected representatives • act as conduit for providing information to and from the national Government and

also from the Strathclyde Pandemic Influenza STAC to other category 1 responders.

3.4 Highland Pandemic Influenza Coordinating Commit tee When person-to-person transmission of a new influenza virus is confirmed, the Chief Operating Officer of NHS Highland will convene a meeting of the Highland Pandemic Influenza Co-ordinating Committee (HPICC) which has responsibility for co-ordination of

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arrangements for the management of influenza patients and for prevention of spread of infection. The HPICC will normally meet in the Board Room at Assynt House, Beechwood Park, Inverness. Administrative support, minute taking etc will be provided by corporate services and principally by the Chief Executive’s admin team. The HPICC will meet as necessary, probably on a daily basis when the pandemic is at its height. Membership of the HPICC committee is shown in Appendix 1. The Highland Pandemic Influenza Co-ordinating Committee will be the forum where strategic decisions are taken for NHS Highland throughout the pandemic and it will also oversee any major operational decisions that may have an impact across the whole NHS service or on several operational areas. Key decisions to be taken early by the HPICC will relate to:

• care of patients in their own homes and in the community • personal protective equipment for staff and others • availability, allocation, distribution and administration of antivirals (and vaccine if

available) • hospital and ITU admission policy • confirming essential and non-essential NHS services • reorganisation/cancellation of routine activity • exploring alternative models of care • maintaining supplies of equipment and pharmaceuticals • staffing levels and contingency arrangements • liaison with social services • mortuary arrangements • communication with staff, public and media particularly about local spread and

service provision & treatment • production of daily situation reports

One of the early tasks of the HPICC will be to confirm those services which are deemed to be essential, those that are non-essential during a pandemic, as well as the factors which will trigger cessation of non-essential activity. These decisions will be guided by the previously agreed essential services in business continuity plans. The core services which have been identified by NHS Highland that must be continued to be provided at a reasonable level in the event of an emergency are: Urgent Primary Care Medical Services Emergency Medical Services Emergency Surgical Services Maternity Services Cancer Services Renal Services Statutory Mental Health Services Emergency Diagnostic Services (to support all the a bove) And Pay roll Non-essential services are likely to include:

• elective surgery for non life threatening conditions • elective medical admissions for assessment of non life threatening conditions

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• chronic disease management and well women/men clinics • routine check up laboratory tests • all routine committee meetings • childhood immunisations • etc

As the pandemic progresses it may become necessary to prioritise patients as well as procedures. This will best be done by clinical consensus. New ways of working will be required and alternative models of care. These might include:

• utilising primary care emergency care centres for 24 hours a day • triage of patients before seen by a doctor • cohorting of infected patients into the same area, ward or floor • giving repeat prescriptions without review • restricting patient visiting

Staff may be asked to redeploy from their normal duties or to alter their working patterns. Changes might include redeploying:

• staff from outpatient to inpatient depts/areas • community staff to acute care settings or vice versa • junior medical staff in surgical specialities when elective procedures are postponed • doctors and nurses from the school health, community paediatric service • family planning staff • community health nurses • admin and clerical and other support staff

Or other more general changes like

• cancelling all study leave • using retired staff or volunteers as appropriate

All these measures and more may be required as patient demand and staff absence increase. In addition, clear deputizing/succession planning arrangements will need to be identified for all HPICC members and other key clinical and senior managers in case of absence, particularly if prolonged. Communication is of prime importance in outbreak management and information will be made available to the public and professionals utilising all appropriate means. The UK national flu line and NHS24 will provide a national information resource. At the end of the pandemic, the HPICC will be responsible for a comprehensive debrief and for amending this plan in the light of experience and lessons learned. 3.5 Operational Incident Management Teams Each Operational Unit including Raigmore Hospital will establish their own incident management teams to implement the policy and procedures advised by HPICC and to coordinate the local NHS response. These will be activated when advised by HPICC to assess preparedness and fully implemented in the Detection phase. IMTs will be responsible for producing a daily situation report on the services within their own area and reporting this into a central team, based in Assynt House in Inverness who will

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collate info on the whole system for HPICC and the Scottish Government. This will inform any changes to media and public information that may be required on any given day especially about local service availability. 3.6 Clinical Flu Advisory group – sub group of HPIC C During the 2009 H1N1 pandemic NHS Highland established a clinical flu advisory group and this was the ideal forum for establishing clinical priorities, discussing particular clinical management issues, agreeing admission and discharge protocols, and providing clinical advice to HPICC, etc. This group would be established again early in any future pandemic and be chaired by a senior physician. The membership and remit is outlined in Appendix 14. 3.7 Control room Early in any pandemic a control room would be opened within Assynt House or Larch House, within the Public Health department or Chief Execs department. This would operate a shift system and provide information, advice and local decision making. Contact tracing could be coordinated as require in the detection phase and data information collected and collated for onward transfer to HPS and SG. This may entail the setting up of a Helpline type arrangements within the department with dedicated flu phone lines, restricted telephone lines and numbers as well as establishing a generic “pandemic flu” email address.

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4. DETECTION AND ASSESSMENT PHASE The Detection and Assessment phases start when human-to-human transmission of a novel influenza virus with pandemic potential which poses a substantial risk to human health is detected in the UK. During these initial phases the main requirement is to identify the virus and to gain an understanding of its clinical, epidemiological and virological characteristics such as risk groups for severe disease and transmissibility. The Detection and Assessment phases therefore focus on

• intelligence gathering, • enhanced clinical surveillance, • the development of laboratory diagnostic tests, • swab testing by GPs and testing in hospitals of suspect cases, • presumptive treatment for affected individuals, • possible prophylaxis of contacts, • and good public communication.

4.1 Key Actions 1. Surveillance, Testing, Diagnosis and Treatment

Implement enhanced virological testing and data collection

2. Prevention and Protection

Implement enhanced infection control procedures in healthcare settings Prepare for anti-viral distribution Prepare for vaccination programme

3. Service Planning and Continuity

Review BCPs urgently Review plans for enhanced staff sickness absence surveillance

4. Communication LRP consider need for Communications Cell and / or Public Information Co-ordinator and Public Information Cell Communicate key issues on progress, prevention and preparation internally and externally

4.2 Surveillance, Testing, Diagnosis and Reporting The number of early cases of illness in the Highland area will determine the extent of local involvement in this phase. If cases mainly occur elsewhere, then our involvement may be minimal. If however, we are one of the hotspot areas then our involvement may be significant (as it was in 2009 in Argyll and Bute) Local clinicians (primary and secondary care) will be provided with guidelines and protocols for testing of Influenza-Like-Illness (ILI) cases. Patients presenting in primary care (at GP surgery or out-of-hours) will be managed as much as possible as per usual clinical care. However, in addition to usual management, relevant swabs should be taken for virology and minimum dataset information collected and returned. The minimum data set is likely to be similar to the FF100 dataset produced by HPS during the swine flu pandemic in 2009/10.

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The Microbiology department at Raigmore and the Regional Viral Laboratory in Glasgow will establish arrangements for handling influenza specimens. In north Highland throat swabs should be sent to Raigmore where PCR testing will be undertaken. In Argyll & Bute throat swabs submitted to the laboratory in Oban will be sent to the West of Scotland Specialist Virology centre. An acute and convalescent clotted blood sample may also be requested on certain patients and if so then further details will be given to clinicians. The Public Health Department, Health Intelligence team will establish arrangements for collecting surveillance information. There will be two main purposes to data gathering: o Identifying epidemiological and clinical features of the pandemic including numbers

affected, speed and geography of spread, severity of illness, risk groups affected. o Monitoring the likely impact on services and informing plans and responses. The responsibility for collecting, cleaning, collating and reporting information relating to the flu pandemic will be the responsibility of the NHS Highland Public Health Directorate. In practice, data collection is likely to be done by telephone with affected patients and/or their families using a minimum core dataset. The dataset will be provided at the time by Health Protection Scotland according to the specific nature of the pandemic threat and local practicalities. This will provide the basis for a definitive record for clinical and epidemiological information, monitoring and planning throughout the pandemic. Other sources of information will also be utilised including the bed management system and death records. The HI team will endeavour during the detection and assessment phase to implement an electronic system for gathering this information so that the datasheet can be completed from a computer at any location across NHS Highland and then electronically transferred to HPS. 4.3 Prevention and Protection - Infection Control HPICC will alert the Infection Control Team (ICT) and heads of service to review and be prepared to implement specific infection control measures and guidelines. This will include ensuring that all relevant training, such as fit testing for masks, and supplies of PPE are in place. In this initial phase in all healthcare settings, patients with symptoms of pandemic flu should be segregated from non-influenza patients as rapidly as possible. OHS will monitor sickness absence and provide psychological and social support to staff. 4.4 Service delivery During the 2009 swine flu pandemic when the Cowal peninsula and Bute were local hotspots the model of service delivery used was to open community hospitals as 24 hour primary care emergency centres and see all possible flu cases at these locations. These provided flu assessment, viral swabbing and antiviral distribution. They were predominantly staffed by community nursing teams alongside medical staff. An “incident” room was opened at each antiviral centre and these were managed by local service managers who coordinated the local response. Daily telephone conference calls were held with the public health team in Inverness who provided strategic coordination and ensured consistency of approach. This model worked extremely well and it is anticipated that a similar service would be provided as required in future.

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4.5 Anti-Viral Drugs The major medical countermeasure available against influenza is use of antiviral agents, alone or as an adjunct to immunisation. Treatment consists of 75mg oseltamivir (Tamiflu) orally twice daily for five days for adults and should commence within two days of symptom onset. Children require a weight related dose usually determined by age as a proxy. For very young children this may be in powder form which requires reconstitution as a suspension. Further treatment and dose details are available elsewhere. If antiviral treatment is as effective in a pandemic as during seasonal influenza, early treatment (within 48 hours of onset of illness) should shorten illness by around one day, may ameliorate symptoms, and should reduce hospitalisations by an estimated 50%. However their effectiveness in a pandemic and particularly in reducing mortality in cases of severe disease (including primary viral pneumonia) is not known. A national stockpile of antivirals is available. The drugs must be used in a way to maximise clinical effectiveness and cost-effectiveness, taking account of available stocks. Final decisions on priority groups and strategies for the use of antivirals will be made by the UKNIPC, informed by recommendations from WHO. Specific guidance on the use of anti-viral drugs will be issued at national level as the characteristics of the virus are understood. The HPT will be responsible for keeping clinicians in primary care updated as guidance becomes available on their appropriate use. In the Detection phase the HPICC will review plans for anti-viral distribution in preparation for more widespread use. National and Local PGDs will be provided for use of anti-virals without a prescription. In the early stages antivirals may be used for prophylaxis as well as for treatment. To employ post exposure prophylaxis to prevent infection in close contacts of a known case while that case was infectious the drug would need to be taken for the duration of the incubation period, usually seven days and would be given:

• early in the pandemic, when cases are few, to close contacts, possibly including health care workers, to contain the spread

• for a limited period during a pandemic to limit spread in certain situations e.g. in closed institutions.

Seasonal prophylaxis involves taking antiviral drugs for several weeks, throughout the period of possible exposure to infection, where vaccine is not available. Such use could be expected to prevent influenza to a similar extent as vaccination but, implemented on any scale, would consume very large quantities of drugs and would be very inefficient as many of those taking drugs would not have developed illness in any case. This strategy would therefore be limited to the very earliest phase of a pandemic, and to only a few selected individuals, to contain spread from initial cases and delay the establishment of a pandemic in the UK. Once the pandemic has progressed then antivirals could be made available more widely for individuals who develop clinical symptoms of influenza infection. This will depend on the disease characteristics and the availability of antivirals at the time. Details will emerge throughout the pandemic. Locally, a central stock of antiviral drugs will be held at Raigmore

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Hospital and Mid Argyll Community Hospital. Supplies will be distributed to, and administered from, all Highland and General Practices, Community Pharmacies, NHS Occupational Health services and Out of Hours centres. Access to drug treatment will be through the national helplines or the primary care team. For full details of the antiviral distribution points see the specific plan on the Intranet. Response plans provide for local distribution of antivirals to hospitals, health establishments, closed institutions and general practitioners, and should ensure that supplies are conveniently accessible to those local communities from pre-designated distribution points or collection centres across the area. Monitoring the effectiveness of antiviral drugs in reducing complications and deaths is an important part of the strategy. Data must be collected on the outcomes of treatment regimens to enable real-time international evaluation as a basis for future best practice. 4.6 Pre-pandemic vaccine Pre first wave immunisation with an influenza vaccine related, but not specific to, the pandemic strain might offer some limited protection. For example, currently the UK has very limited stocks of an A/H5N1 vaccine purchased specifically for the protection of health care workers. The use of this would be initiated based on the advice of international experts. Decisions on use will follow assessment of the likely degree of cross protection afforded (if any) and a balance of the risks versus benefit. In this early stage no pandemic specific vaccine wi ll be available. It is likely to be 4 – 6 months from the emergence of a new virus before supplies of vaccine would enable a population wide campaign. Some limited supplies may become available for priority groups sooner than this. Estimates of time required to manufacture supplies of the new pandemic flu vaccine for priority groups and for widespread use will be provided as soon as such information is available via the Joint Committee for Vaccination and Immunisation (JCVI) and Health Protection Scotland. Guidance will also be issued concerning who the priority groups will be as the characteristics of the virus are identified. This information will be widely circulated to the general public and the media locally. The HPICC will be responsible for reviewing vaccination plans including storage, distribution, delivery, priority groups and mass vaccination, in preparation for vaccine becoming available. 4.7 Key Principles underlying NHS Planning and Resp onse • Response arrangements should be based on strengthening and supplementing normal

delivery mechanisms as far as is practicable • Plans should be developed on an integrated multi-agency basis with risk sharing and

cross-cover between all organisations • Plans should encourage pan-organisation working, seeking to mobilise the capacity and

skills of all public and private sector healthcare staff (including students and those who are retired), contractors and volunteers

• Although visiting all cases will not be possible, primary care plans should be based on avoiding influenza patients having to leave home, as far as possible

• Initial telephone-based assessment is likely to be necessary to meet demand • Primary care response strategies should focus the available clinical capacity and skills

primarily on treating those suffering with the complications of influenza or requiring other essential clinical care and assessing young children or patients in groups identified as being at particular risk

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• Antiviral medicines should initially be available to all patients who have been symptomatic for less than 48 hours and ideally within 12-24 hours of reporting symptoms

• Treatment and admission criteria should remain clinically based and hospital admission criteria should be applied in a transparent, consistent and equitable way that utilises the capacity available for the seriously ill and most likely to benefit

During the Detection and Assessment Phase all Heads of Service will review and update their business continuity plans as a matter of urgency. The Occupational Health Service, Human Resources and operational managers will review and establish plans for enhanced surveillance in regard to staff absence. 4.8 Communication The LRP will decide on the formal establishment of a multi-agency Public Communications Group. Within NHS Highland the Communications team, with the advice of the Public Health Directorate, will be responsible for ensuring and facilitating the appropriate dissemination of information to external and internal audiences on key issues such as: • The progress of the pandemic at international, national and local level • The importance of good respiratory and hand hygiene • The establishment of resilience measures such as ‘flu-friends’ • The status of local health services

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5. TREATMENT AND ESCALATION PHASE The Treatment and Escalation Phase commences once there is evidence of sustained transmission of the virus in the community. By this time the LRPs and HPICC will be well established. The decision to move to “Treatment and Escalation” will be taken nationally although some hot spot areas may already have moved to this phase following consultation with SG and HPS. The HPICC will then confirm when the pandemic moves into a treatment and escalation phase locally. The impact on services will vary according to the characteristics of the virus, the number of people affected, and the severity of the illness. Low, moderate, or high impact scenarios are all possible. A high service impact pandemic causing widespread and severe illness in the population is likely to result in intense and sustained pressure on all parts of the health and social care system. Most age groups could be affected, and wider services and business sectors will be affected owing to higher levels of absence due to sickness, and deaths.

Each scenario (whether low, medium or high impact) will require different response strategies and an ability to adapt plans to cope with changing circumstances. 5.1 Key Actions – Low, Moderate or High Impact Scen arios The impact at any given time will determine the lev el and scale of actions required: 1. Surveillance, Testing, Diagnosis and Treatment

Follow patient management algorithms according to national guidance Virological testing not now routinely required Continue data collection and reporting

2. Prevention and Protection

Maintain enhanced infection control procedures in healthcare settings and implement isolation and cohorting measures (ie infected patients are cared for together in a single ward/unit by the same staff) Implement anti-viral distribution for treatment (and prophylaxis) according to national guidance Prepare for vaccination programme and implement prioritised roll-out in accordance with national guidance and availability

3. Service Planning and Continuity

Enhanced monitoring of capacity in priority services especially critical care and paediatrics Consider ceasing non-urgent elective activity and further activity as required Enhanced monitoring of staff sickness absence Consider and be prepared to implement local BCPs as required

4. Communication LRPs and HPICC establish Public Comms Group Communicate key issues on progress, prevention, self care, appropriate use of services, tailored information for high risk groups, update on use of anti-virals and vaccine. Provide regular updates on how services are coping and being managed.

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5.2 Surveillance, Testing, Diagnosis and Reporting Even in a low impact scenario it is important that a clear process is established for testing, diagnosis and appropriate treatment. It is anticipated that the vast majority (up to 95%) of flu cases can be managed at home. Depending on the availability of vaccine and anti-viral drugs, the management will be largely symptomatic. Eg Fluids and temperature control. For appropriate triage and management of patients presenting to GP Practices, Emergency Departments, and out-of-hours services, clinical algorithms will be issued nationally. It is very likely that at this stage taking swabs for virology will no longer be routinely required. Specific guidance on the use of anti-viral drugs will be given at the time depending on their availability and the nature of the virus. Antibiotics may also be appropriate in some cases. For uncomplicated illness in those people not in high-risk groups no antibiotics are necessary and home management is appropriate. For patients with non-severe pneumonia initial primary care assessment and treatment with antibiotics is appropriate. For severe pneumonia, and other complications, referral to hospital is indicated. The management and investigations for adults referred to hospital will be covered in clinical algorithms and admission policy will be detailed in local operational plans eg Raigmore pandemic flu plan (see Intranet). The assessment, management and investigation of children will also be outlined separately at the time. Note that all the treatment and diagnosis algorithms referred to above are likely to be modified according to the specific nature of the pandemic through national guidance at the time. There are current algorithms available from the British Thoracic Society / British Infection Society / Health Protection Agency: “Clinical guidelines for patients with an influenza-like illness during an influenza pandemic” and provide the most current advice available. These are available at: https://www.brit-thoracic.org.uk/document-library/clinical-information/flu/pandemic-flu-guideline/pandemic-flu-guideline (Drafting Note: The precise role of the National Flu Helpline, the National Pandemic Flu Service and NHS24 in Scotland are yet to be clarified. The following 3 sub-sections 5.3-5.5 are based on English guidance while a Scottish version in pending) 5.3 National Flu Helpline As cases increase, the national helpline service will expand to provide initial patient assessment and antiviral authorisation and both functions will then remain operational until the impact of the pandemic and the threat of further waves subside. The key objectives of the national influenza line service include:

• Provide pandemic influenza related advice and information • Provide access to a mechanism for rapidly assessing those suffering influenza-like

symptoms • Authorise access to antiviral treatment (if that is indicated) • Give information on the nearest antiviral medicine distribution point • Refer to some other part of the health and community care system if that is a more

appropriate disposition

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Initial assessment will focus on confirming that the caller has signs and symptoms of flu, no indicators of complications, is aged 3 or over, has been symptomatic for less than 48 hours and antiviral treatment is not otherwise contraindicated. Suitably trained staff using a decision tree algorithm will perform these tasks and authorise the collection of antiviral medication for the patient.

5.4 National Pandemic Flu Service (NPFS)

When there is evidence of sustained community transmission or a large number of de novo cases, in England a decision will be made to move from the initial response phase to a response designed to mitigate the impact of the disease on the individual, society and the NHS. (DN: It is assumed that the same will happen in Scotland.)

The NPFS will be initialised if the service is required to supplement normal primary care services because of pandemic pressures. The service may be implemented by any of the UK countries based on pressures in their respective primary care system. The NPFS aims to:

• reduce pressure on primary care services; • allow people with flu like symptoms to remain at home; • enable rapid self-service assessment, care advice, GP referral and antiviral authorisation, and • provide an additional source of data relating to trends in activity and profile of people assessed as suffering from pandemic symptoms. The service will be available through the web or a dedicated call centre facility for members of the public to be assessed and authorised antiviral medicines if appropriate. The process is:

National Flu Line: 0800 1513513

Flu Information

Service

Antiviral Assessment

Services

NHS24 Non-flu

symptoms

Antiviral collection

Antiviral delivery (exceptional)

GP Practice Complications (at risk assessment)

GP Practice Return cases (at risk assessment)

On-going Treatment

Hospital Care

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1. A symptomatic individual, or their Flu Friend, will contact the NPFS and an assessment using a clinical algorithm will be undertaken.

2. If required, the individual will be authorised to receive an antiviral medicine. The individual will then need to note down an authorisation number (12 alphanumeric characters). A Flu Friend

can do this on behalf of a symptomatic individual.

3. The Flu Friend (with their own identification and the symptomatic individual’s) will then attend an Antiviral Collection Point (ACP), provide the authorisation number and collect the antiviral medicines. The NPFS will also direct patients to a GP practice or other NHS service should they require any additional advice or treatment.

Prior to this time, ‘hotspot’ areas may choose to run local ACPs as a mechanism for rapid distribution of antiviral medicines. 5.5 NHS 24 NHS 24 will continue to play an important role in providing health advice through their usual telephone number and via the NHS 24 website. www.nhs24.com (DN: NHS Inform may also have a role but this is currently unclear.) http://www.nhsinform.co.uk NHS24 will focus primarily on maintaining their normal non-flu service and activity. Management protocols for patients and contacts will be agreed in advance but reviewed on the basis of experience gained as a pandemic evolves. The primary focus of their service continuity plan is the maintenance of core services in the face of high levels of demand and staff absence. Many NHS24 staff also have a job within local health care services which presents significant staffing challenges. Patients will be advised to seek medical advice if their symptoms become worse, if their temperature does not settle after 4-5 days or if they develop chest pain, become short of breath or feel very ill. 5.6 Anti-viral drugs Once the pandemic is established anti-virals are one of the first lines of defence until a vaccine is available and at this stage will most likely only be available to treat those with early symptoms and not for prophylactic use. Distribution and administration of antivirals will present a major challenge, particularly when supplies are limited, public demand is likely to be high and treatment should start within 48 hours of onset. Information and advice, together with appropriate media coverage, will be essential in encouraging the co-operation of the public. Clinical treatment algorithms are likely to be modified at the time through national guidance according to the nature of the specific pandemic. Anti viral distribution centres will be required to open and distribute treatment to patients from the various pre-identified locations. (See AV distribution plan on the Intranet)

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5.7 Antiviral Collection Points (ACPs)

Antiviral collection points are nominated locations within the community where flu friends can collect antiviral medicines on behalf of a symptomatic person, on presentation of the person’s valid authorisation. Antiviral collection points are likely to be required, irrespective of whether the NPFS is in use in Scotland.

The purpose of an antiviral collection point is to: • enable symptomatic patients to remain at home but still gain rapid access to antiviral medicines if necessary via a flu friend; and

• minimise the impact on healthcare facilities, enabling them to retain their operational capacity for the assessment of patients who have non influenza illnesses. ACPs are also intended to minimise the impact on secondary care facilities, as:

• hospitals will have antiviral medicines only for inpatients;

• A&E departments will not normally act as an issue point for antiviral medicines;

• GPs may not have stocks of antiviral medicines, and

• prescriptions may not be issued for antiviral medicines The majority of ACPs during the H1N1 (2009) influenza pandemic operated out of community pharmacies and this worked well in a relatively mild pandemic. However, a more severe pandemic is likely to increase the pressure on pharmacies and plans need to consider the potential for using other sites to enable collection of antiviral medicines by flu friends on behalf of symptomatic individuals. The plans utilised in 2009 will be used to build more robust and detailed arrangements. See Intranet for operational unit anti-viral distribution plans.

5.8 Primary Care The public will be given clear guidance on self-care and when to seek medical assistance. Patient information (leaflets and press/media statements) will advise those who have symptoms to stay at home, keep warm and rest. They should take plenty of fluids and anti-pyretic/analgesic drugs e.g. paracetamol. In addition to maintaining essential provision for non-influenza patients, the resources and skills available in general medical practices should focus primarily on patients who: • Are suffering influenza complications • Are less then three years of age • Have relevant pre-existing medical conditions • Are in identified ‘at-risk’ groups • Are not responding to treatment • Need higher levels of care but cannot be admitted to hospital • Are pregnant • Are dying • Are bereaved Persons presenting with febrile respiratory illness should be assessed by telephone or seen at home if possible. Clear infection control guidance for all health and social care establishments will be kept under review and is available on the PHE and HPS websites.

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If clinical severity warrants hospitalisation then admit. If not, consider use of antiviral therapy and arrange required follow up. 5.9 Operational Units Operational Units should carry out the local co-ordination of community services. This is likely to be done at District level in north Highland and at Locality or sub locality level in Argyll and Bute. In terms of functionality they should: • Act as a focal point, providing a link to and oversight of the local health response • Monitor and co-ordinate the local health response • Maintain the continuing provision of general practice and primary care services both in

and out of hours • Ensure the maintenance of all essential social care to support the delivery of care and

maintain patients at home • Provide support to care homes, both NHS and independent • Collect, collate and report information on the local health situation • Provide a local link and health input and advice to the wider multi-agency local co-

ordination arrangements and ELGs and Locality Emergency Planning and Business Continuity Groups in Argyll & Bute.

• Ensure that national messages are cascaded, reinforced and that the public are well informed and advised of local response arrangements.

Some single handed General Practices may be at high risk and so GPs should be encouraged to “buddy up” to share staff and other resources during a pandemic. Operational Units and Primary Care Managers may help coordinate this. 5.10 Organisation of local health services The NHS will need to care for numbers of patients on a scale outside normal experience, including patients of all ages requiring high dependency/critical care. The capacity to deliver essential and emergency services, both for influenza and non-influenza must be protected and preserved. To achieve this, the scaling back, limiting or temporary cessation of some services in primary and acute care is inevitable. It will probably be necessary to limit or postpone non-urgent work including screening and chronic disease management in primary care as well as elective hospital admissions. Patient assessment will be carried out in primary care although contingency arrangements including nurse triage and establishment of primary care emergency centres in community hospitals may become necessary. The Scottish Government have previously indicated that: • All elective targets and the A&E waiting time targets should be suspended during a

pandemic influenza outbreak. The Scottish Government Health Directorates would continue to monitor NHS Boards’ performance to help identify ‘hot spots’ in the care system and to ensure that the local, regional and national response to the pandemic was delivering appropriate care to patients.

• The following Scottish Government HEAT targets are likely to remain in place through an influenza pandemic:

o Access to cancer diagnosis and treatment following urgent referral o Access to specialist hip surgery following fracture o Access to cardiac intervention

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• Target suspensions would begin at a point to be agreed by SG • Further guidance will be issued in due course on a wider range of targets. This may

cover primary care, community care, NHS24 and the Scottish Ambulance Service. 5.11 Acute Care There will be no policy in Highland of designating specific hospitals to receive influenza patients. Movement of infectious patients should be restricted as far as possible and patients requiring hospital care should be admitted as normal to the appropriate hospital in their locality. Within each hospital, infection control procedures should be maximised and every effort made to separate flu and non flu patients. In Raigmore Hospital initial admissions should be made either to the designated rooms in Ward 7A or directly to Intensive Care, but not via A & E or Ward 6A. Increasing patient numbers may subsequently necessitate allocation of an entire floor or floors to influenza patients. In Argyll & Bute clinical pathways for adults and children will remain the same as usual into Greater Glasgow & Clyde Hospitals. Various admission criteria/scoring systems for hospitals and ITU are being further explored such as CURB65. It is anticipated that further definitive guidance on these will be issued in due course. There are also specific local issues concerning inpatient and intensive care of children. Specific arrangements are outlined further in the Raigmore Contingency plan. Rural General Hospitals and community hospitals also have agreed admission procedures. 5.12 Critical care Artificial ventilation will be in Raigmore and will probably require clinical prioritisation of those in greatest need and who are most likely to benefit. As the pandemic progresses all elective work will be scaled down except urgent cancer work. For further details on patient clinical management see the Raigmore pandemic flu plan on the Intranet. 5.13 Workforce Issues All organisations, including the NHS, must consider the implications of staff absence through sickness, or through the need to provide care for others, at a time of possible increase in workload. Measures could include:

• establishing minimum staffing levels • identifying ‘front-line’ essential staff • ensuring adequate break and leave periods to enable a sustainable response over

several weeks or months • transferring or redeploying staff to jobs they may be unfamiliar with or untrained for • recruiting additional staff or volunteers, with a system for vetting • providing accommodation e.g. portacabins to enable rest between shifts when travel

home is disrupted or difficult • training volunteers, and training regular staff to work with volunteers • maintaining a database of former/recently retired staff who may be called on

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Scottish Government guidance on Workforce Issues “Pandemic Flu: Guidance on Health Workforce Issues for NHS Scotland Boards” is available on http://www.scotland.gov.uk/Publications/2009/08/11132555/0 The main method of responding to absence will be internal redeployment. 5.14 Partnership Working with Social Services and I ndependent Sector Providers A Senior Social Services representative from Argyll & Bute Health and Social Care Partnership and NHS Adult Social Care will be a member of the HPICC. Close working will be required at a strategic and operational level. Early discussions and ongoing liaison will be required to maximise throughput of patients from NHS acute facilities → community hospitals → nursing and residential care → home with appropriate support services. These arrangements will utilise the existing Bed Management Protocols and Delayed Discharge policy. Local authorities, NHS Adult Social care, along with third and independent care providers need to consider if services such as day care centres, libraries and other community facilities should remain open. To help community care providers further guidance has been produced – “Planning for pandemic influenza in community care: An operational and strategic framework”. http://www.gov.scot/Publications/2007/10/23104313/0 5.15 Service Planning and Continuity As capacity to maintain isolation or cohorting under normal service arrangements is exhausted the HPICC will make decisions to implement specific measures such as designated flu general practices, ED areas, Wards and perhaps even in extreme circumstances, flu Hospitals. During a pandemic of influenza it may be necessary to retract from normal activity to a position in which hospital services manage more respiratory cases at the expense of managing fewer non-respiratory cases. The first step would be to stop all non-urgent elective activity. In these circumstances “non-urgent” would mean cases such as hernias or hip replacements in which, although the condition itself may be annoying, frustrating, limiting on daily activity and painful, it is not in any way life-threatening. At low impact it may not be necessary to implement such measures. Decisions to limit routine clinical activity and move to prioritised services will be taken by HPICC as and when required. A list of services which would remain critical to continuing NHS activity and which would be prioritised have been identified and agreed as part of business continuity planning. These are listed in section 3.4 of this plan. Each operational unit has also identified their local priority services and these are listed in operational plans on the Intranet. There will be enhanced monitoring of capacity in these services in particular and all Heads of Service will be prepared to implement local BCPs. 5.16 Communication Issues that will be considered for communication with both internal and external audiences at this time will include: o The progress of the pandemic o The importance of good respiratory and hand hygiene o How to access local help appropriately in order to minimise the impact on services

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o Self help and care information o Tailored information for at risk groups o Information about anti-virals and vaccination as it becomes available o Info about local health services 5.17 Fatalities and Mortuary Facilities In normal circumstances the mortuary at Raigmore has the capacity to accommodate up to 36 bodies, with suitable facilities to support post-mortem examinations. There is also capacity to accommodate a further 41 bodies in hospital mortuaries across North NHS Highland area, and 38 in Argyll & Bute. See Appendix 7. A High Impact Pandemic may result in the above arrangements being unable to accommodate the required demands for mortuary and body holding facilities. In the event of any emergency occurring within the Highland area requiring mortuary and body holding facilities greater than normal capacity, arrangements are outlined in the North of Scotland Mass fatalities Framework which would be overseen by the Local Resilience Partnership to ensure prompt certification of death, enhanced crematorium and burial services provided by the Local Authority and liaison with some local undertakers who have body storage facilities. The National Emergency Mortuary Arrangements (NEMA) facilities will not be able to be invoked during a flu pandemic. Death certification arrangements during a pandemic are likely to change. Guidance on death certification has been agreed and issued for medical practitioners to use in the event of a pandemic. The latest version of this guidance should be referred to as required.

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6. VACCINATION 6.1 Vaccine Effectiveness Influenza vaccine is not 100% effective in preventing illness, even when a good match is achieved between vaccine and circulating virus. In inter-pandemic years with a good match vaccine reduces infection by around 70-80%; hospitalisations in high risk individuals by around 60% and deaths by around 40%. The effectiveness of a pandemic vaccine will not be known until it is in use. However, immunisation with an appropriately formulated vaccine (once available) can be expected to reduce the impact of pandemic influenza, especially in groups most at risk of serious illness and death. One of the greatest challenges in response to a pandemic is to develop a safe, immunogenic vaccine specific to the pandemic virus strain. 6.2 Vaccine Supply and Priority Groups The Government has advanced supply contracts with manufacturers to make sufficient supplies of a matching vaccine available as soon as it is developed and continues to work actively with the international community and pharmaceutical industry to speed development, testing and licensing. Even with advance work to improve preparedness the lead time before a new vaccine is available is likely to be four to six months. It will take even longer before it can be produced in sufficient quantities for the entire population. It is therefore only likely to be of benefit in preventing cases from a second wave onwards. The national vaccine strategy therefore has three stages:

1. no vaccine available 2. vaccine in limited supply 3. vaccine widely available.

At some point during the course of a pandemic limited supplies of vaccine may become available to pre-determined priority groups. Advice will be given by WHO through to the Joint Committee on Vaccination and Immunisation (JCVI) on priority groups at each phase of the pandemic depending on the epidemiology, clinical features, natural history and overall risk profile of the new pandemic and on the availability of vaccine. It is likely that front line health and social care staff and clinical at risk groups would be high on the priority list. The LRPs and HPICC will follow this advice as appropriate to local circumstances. Monitoring of vaccine uptake, effectiveness, and side-effects will be recorded using a minimum dataset form. The public will need to be kept informed promptly and sensitively regarding issues of vaccine availability. In the early stages no vaccine will be available and the emphasis will be on conservative management and antiviral drugs. Thereafter, vaccine must be delivered as it becomes available to predetermined groups. International demand for vaccine will be high and it will be necessary to distribute it equitably and administer it according to predetermined priorities. The plan is to immunise tranches of the population in stages according to vaccine availability. The need to keep health and other essential services running necessitates prioritising health care workers and other essential workers ahead of the risk groups prioritised for vaccine in non-pandemic years. Final decisions on priority groups will be made by the UKNIPC on the basis of advice from WHO and JCVI. At present, the JCVI has recommended giving vaccine in order of priority, to:

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• protect health care workers who are occupationally most at risk. Those with patient contact are essential to the health service response and are likely to be at increased risk of acquiring infection from patients and of passing it on to vulnerable patients.

• prevent illness and absenteeism in workers required to maintain essential services. • prevent serious illness in the most vulnerable groups • reduce the spread of infection e.g. in closed communities such as residential care

homes • reduce spread by immunising those more likely to transmit the virus, such as

children. • prevent illness in the general population.

This priority list is likely to be tailored and amended according to the specific characteristics of the pandemic strain. In NHS Highland the Occupational Health Service along with trained peer vaccinators would deliver an Immunisation Programme for NHS staff. Staff at some of the smaller more rural locations would have to use their GP rather than travel to an Occupational Health Clinic. Priority groups for vaccination and responsibility for implementation PRIORITY 1 Healthcare staff with patient contact (including ambulance staff) and

staff in residential care homes for the elderly

Advantage Disruption of vital health and social care delivery is minimised

Administered By NHS Occupational Health Service, Trained Vaccinators and Primary Care Teams

PRIORITY 2 Providers of essential services e.g. fire, police, communications, utilities, undertakers, prison officers and armed forces.

Advantage Vital community functions which would be affected by absenteeism would be minimised.

Administered By All agencies OHS Contractors and Primary Care teams PRIORITY 3 Those with high medical risks e.g. chronic respiratory or heart

disease, renal failure, diabetes mellitus or immunosuppression due to disease or treatment, pregnant women

Advantage Consistent with normal influenza immunisation policy. Demand for health care to be minimised.

Administered By Primary Care Teams, NHS Highland PRIORITY 4 All aged 65 years and over.

Advantage Consistent with normal influenza immunisation policy. Demand for

health care will be minimised.

Administered By Primary Care Teams, NHS Highland PRIORITY 5 Selected industries

Advantage Maintenance of essential supplies of e.g. pharmaceuticals.

Administered By Company Occupational Health Service and/or with Primary Care

Contracts. PRIORITY 6 Selected age groups, depending on advice from WHO e.g. children

Advantage Minimise spread by those most likely to transmit virus and the impact

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in population groups showing highest impact.

Administered By Primary Care Teams, NHS Highland PRIORITY 7 Offer to all

Advantage Prevent illness and minimise the impact of pandemic in the UK.

Administered By Primary Care Teams, NHS Highland The numbers within these various priority groups fo r vaccination are shown in Appendix 15 Vaccine for the UK will be purchased by DH, in close collaboration with SGHD and allocated according to estimated needs on the basis of the predetermined priority groups. SGHD will be responsible for ensuring arrangements for distribution of vaccine within Scotland. Detailed arrangements for immunisation cannot be made until information is available on vaccine formulation, dose and dosage schedule but it is likely that occupational groups will receive vaccine through occupational health schemes based in the workplace. Patient groups will receive vaccine through their local GP Practice and any large scale vaccination of the population will be based on the mass vaccination model. The potential for administration by other groups such as pharmacists will be explored as required. An important aspect of the vaccination strategy will be public education as to why vaccine is not immediately and generally available and also on the differences between a pandemic vaccine and routine influenza vaccines. A pandemic vaccine is likely to contain components of one virus rather than three viruses, to contain an adjuvant to increase immunogenicity, to be associated with more adverse effects and may require a two-dose schedule. Pneumococcal immunisation may prevent some complications of influenza due to secondary bacterial infection and preparedness planning should include improving the uptake of pneumococcal vaccine by the recommended risk groups i.e. those with chronic illness and those aged 65 and over.

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7. RECOVERY PHASE Recovery can be defined as the process of restoring, rebuilding and rehabilitating individuals, the organisation and the wider community. Based on risk assessment the HPICC will advise the LRPs when levels of activity are reducing to a level that will allow a gradual return to a normalisation of services. Societal impacts may recover and normalize before health and social care services. The NHS recovery will be overseen by HPICC initially and then usual management groups and teams. They will consider: 7.1 Surveillance, Testing, Diagnosis and Reporting A heightened level of vigilance will need to be maintained to allow for early warning of a second wave of a pandemic in the coming months. Guidance will be issued at national level and this will be appropriately disseminated and implemented locally. 7.2 Prevention and Protection The HPT will be responsible for coordinating and ensuring any vaccination programme is completed and ensuring that uptake of seasonal flu vaccination in the following season is maximised. 7.3 Service Planning and Continuity In the recovery phase it will be important to ensure that staff are able to return to normal patterns of working and are encouraged, as service demands allow, to take time off for rest and relaxation. In relation to workforce planning it will be important to assess the impact of the pandemic across the organisation. Staff may be suffering from stress and fatigue. Some will have suffered bereavement. Particularly in a high impact scenario there will also be cases of severe illness, long term sickness absence and even deaths amongst the workforce. The OHS and HR teams will have an important role to play in caring for staff affected and planning for recovery. The Senior Management Team will need to address a wide range of NHS service issues. These will include establishing a sustainable plan to recover levels of NHS service across the organisation and address any backlog or waiting lists in key services. There will also be a need to plan to address any backlog in maintenance of equipment and facilities, recover levels of stocks and supplies and address any budget and financial issues arising from exceptional spend required in particular areas. 7.4 Communication It will be important that recovery actions are widely communicated to staff, partner agencies and the public in order to instill confidence and a sense of return to normality across the community. There will need to be plans put in place for debriefing activities. These will need to include all staff involved but also any volunteers and other service providers. The wider public community should also be provided with an opportunity to share experiences and feedback. Depending on the circumstances of a pandemic it may be appropriate to consider memorial activities to acknowledge losses within the community or organisation. Debriefing activities will need to be sensitive to the circumstances of the pandemic. It may be an opportunity to celebrate successes in any response as well as to acknowledge difficulties. An important aspect of the recovery phase will be to capture all the lessons learnt in a formal report that can be shared both locally and at national level. This will allow for plans and strategies to be revised and updated. 7.5 LRP Recovery Arrangements The LRPs will formally agree the transition to recovery phase and a Recovery Working Group (RWG) may be set up. This would normally be chaired by a senior representative from the Local Authority. This group will consider a range of wider societal issues.

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8. COMMUNICATIONS - PUBLIC AND MEDIA INFORMATIO N The UK Government’s News Co-ordination Centre (NCC) will be set up to manage communications. They will work to the policy direction of COBR. In Scotland the Scottish Government Operations Response Room (SGORR) will be activated. They will cascade information to NHS Boards and others through the RRPs and LRPs. 8.1 National Co-ordination

The aim will be to ensure consistency of message and information to the public and avoid any “postcode” issues. SGHD press office will lead on both media and public messages. NHS Highland will be expected to reinforce these locally. In addition local media will require situation reports, messages and spokespersons. 8.2 Local Co-ordination The aim will be to ensure a regular flow of local information; to use broadcast media for urgent public health and public order messages; and to reinforce this through social media, print media, with self-help information and relevant contact details e.g. helplines. Strategic local media/public activity communications will be led by NHS Highland, through the LRPs. Co-ordination of operational media activity will be through the LRPs Multi-Agency Public Communications Group as per the H&ILRP Response Guidance May 2015. This is a group with representatives, usually the communication leads, for all the emergency services, NHS, local authorities and related agencies. The NHS Highland spokesperson(s) will be nominated by the chair of the LRPs and HPICC. For operational issues, each agency will nominate its own spokesperson. Information about NHS services - which GP practices/pharmacies are open on a particular day will be organised and collected by operational units and then passed to Assynt House for collation and onward transfer to the SG. Public info will be put out using websites, local and national tv and radio, social media, plus the printed media. The DPH will ensure that the NHS Highland Chief Executive, SGHD and HPS are kept updated. Members of the LRPs will be responsible for keeping their own organisations briefed. 8.3 Self-Help Information for the Public SGHD will lead, using national media, website and NHS24. Plans for a print and broadcast advertising campaign and a public information plan have been developed. Locally, influenza factsheets and self-help advice will be widely available via media, NHS Highland website, and in printed form at all NHS premises, community centres, workplaces, schools etc.

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If a local helpline is required, it will be co-ordinated by the LRPs, and will be the NHS 24 Special Alert Helpline but may be supplemented by the Police helpline. Existing leaflets could be used or amended for a pandemic e.g. NHS Highland ‘Flu? So what can you do?’ and the NHS Scotland ‘Pandemic Flu – Important Information for you and your family’ Leaflets will advise symptomatic people to stay at home and rest in the warm, drink plenty of fluids and take anti-pyretic drugs. Patients will be advised to see their GP if their symptoms worsen or if their temperature does not settle after 4-5 days, or if they develop chest pain, shortness of breath or feel very ill. Many of those with chest infections can be treated at home by their GPs. Use of social media and other modern communication channels may assist in meeting these goals. For example, Facebook was used effectively to communicate accurate messages during the H1N1 (2009) influenza pandemic.

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9. USEFUL SOURCES OF INFORMATION 9.1 Websites Several websites contain the latest national and international guidance on pandemic flu: Scottish Government www.scotland.gov.uk/pandemicflu Health Protection Scotland www.hps.scot.nhs.uk Department of Health www.dh.gov.uk/pandemicflu Public Health England www.gov.uk/government/organisations/public-health-england World Health Organisation www.who.int/csr/en DEFRA www.defra.gov.uk Health and Safety Executive www.hse.gov.uk/biosafety/diseases/pandemic.htm 9.2 Supporting Documents This pandemic contingency plan is supported by various other national and local documents including: Pandemic Planning UK Influenza Pandemic Preparedness Strategy 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131040.pdf Department of Health: Health & Social Care Influenza Pandemic Preparedness and Response Guidance (the operational guidance) 2012 (NB. A Scottish version will be produced and should retain the key operational aspects of the DH guidance) http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_133656.pdf Escalation Critical Care Action Plan: http://www.scotland.gov.uk/Resource/Doc/924/0086278.pdf Pandemic Influenza: Surge Capacity & Prioritisation in Health Services (draft); http://www.scotland.gov.uk/Publications/2008/10/28141252/0 Recommendations of the Swine Flu Critical Care Group: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117129)

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Clinical Guidelines British Thoracic Society www.brit-thoracic.org.uk/ClinicalInformation/Influenza/PandemicFluGuideline/tabid/128/Default.aspx Workforce Issues Pandemic Flu: Guidance on Health Workforce Issues for NHS Scotland Boards http://www.scotland.gov.uk/Publications/2009/08/11132555/0 Swine Flu 2009/10 HPS: The Pandemic of Influenza A(H1N1) Infection in Scotland 2009-2010. A Report on the Health Protection Response http://www.documents.hps.scot.nhs.uk/respiratory/swine-influenza/outbreak-report/flu-a-h1n1-hp-response-2010-12.pdf HPS: Experience of management of influenza A (H1N1) in the early stages of the outbreak in NHS Greater Glasgow and Clyde. http://www.documents.hps.scot.nhs.uk/respiratory/swine-influenza/outbreak-report/flu-a-h1n1-hp-response-2010-12-ggc.pdf HPS : Managing a Swine Flu Cluster in the Containment Phase in Cowal and Bute (NHS Highland)

http://www.documents.hps.scot.nhs.uk/respiratory/swine-influenza/outbreak-report/flu-a-h1n1-hp-response-2010-12-hg.pdf

Vaccination HPS: The National vaccination programme to protect the Scottish population from influenza A(H1N1) infection 2009-2010.: http://www.documents.hps.scot.nhs.uk/respiratory/swine-influenza/outbreak-report/flu-a-h1n1-vac-prog-2010-21.pdf Mental Health: http://www.scotland.gov.uk/Publications/2008/05/01102733/0 Community Care: http://www.scotland.gov.uk/Publications/2007/10/23104313/12 Schools & Chldren’s Services Full: http://www.scotland.gov.uk/Publications/2006/07/05121311/9 Summary schools guidance: http://www.scotland.gov.uk/Publications/2006/07/05121221/2 Universities & Colleges http://www.scotland.gov.uk/Topics/Education/UniversitiesColleges/16640/guidanceonflu

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Infection Control National Infection Prevention & Control Manual http://www.nipcm.hps.scot.nhs.uk/ General information and infection control precautions to minimise transmission of Respiratory Tract Infections (RTIs) in the healthcare setting http://www.nipcm.hps.scot.nhs.uk/chapter-2-transmis sion-based-precautions-tbps/#a1091 Transmission Based Precautions http://www.nipcm.hps.scot.nhs.uk/chapter-2-transmission-based-precautions-tbps/ Guidance for infection control in hospitals and primary care settings http://www.hps.scot.nhs.uk/guidelines/detail.aspx?id=619 Infection control guidance for specific settings, including education etc. NB All of these documents date from 2008 so may be updated. http://www.hps.scot.nhs.uk/resp/pandemicinfluenzaplanning.aspx Highland specific plans NHS Highland Major Incident and Major Emergencies plan (September 2013 - currently under review) H&ILRP Response Guidance May 2015 NSRRP Public Communications Plan and Public Communications Cell (NSRRP PCC) WoSRRP Resilience Arrangements, Response and Recovery NHS Highland Business Continuity Management Plan, July 2013

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APPENDIX 1 MEMBERSHIP OF NHS HIGHLAND PANDEMIC INFLUENZA CO-OR DINATING COMMITTEE (HPICC) Deborah Jones Chief Operating Officer (Chair) Hugo Van Woerden Director of Public Health Ken Oates CPHM (Health Protection) Vacant Inner Moray Firth Operational Unit Director of Operations Katherine Sutton Deputy Director of Operations, Raigmore Georgia Haire Deputy Director of Operations, South & Mid Gill McVicar North & West Highland Director of Operations Tracy Ligema Deputy Director of Operations, North & West Christina West Chief Officer Argyll & Bute HSCP Joanne Macdonald Head of Adult Social Care, NHS Highland Eric Green Head of Facilities, NHS Highland Mirian Morrison Head of Clinical Governance and Risk Management Jonty Mills Consultant Microbiologist, Raigmore Hospital Mark Hilditch Consultant in Occupational Medicine, Raigmore Hospital Lorraine McKee Senior Health Protection Nurse Diane Stark Infection Control Nurse Ian Rudd Director of Pharmacy Sharon Pfleger Consultant in Pharmaceutical Public Health Peter MacPhee Emergency Planning Officer Maimie Thomson Media and Corporate Communications, NHS Highland Rod Harvey Board Medical Director Ken McDonald Associate Medical Director Rob Peel Senior Hospital Physician Ian Scott GP Lead Clinician John Burnside Business Continuity Manager Bill Alexander Director of Care & Learning Highland Council Louise Long Chief Social Worker Argyll & Bute HSCP Alan Yates Head of Environmental Health, Highland Council Alan Morrison Head of Environmental Health, Argyll & Bute Council Milne Weir General Manager, Scottish Ambulance Service A.N Other Police Liaison Officer

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APPENDIX 2

HPICC ROLES AND RESPONSIBILITIES All members of HPICC are expected to: • Liaise closely with their own staff, department and area to ensure a cascade of

information flows from and to HPICC. • Report on the staffing situation within their own area and how their service is coping

with demand. • Implement HPICC decisions. Chief Operating Officer • Contact members of the HPICC and co-ordinate meetings • Chair the HPICC meetings • Direct and co-ordinate the NHS Highland response • Ensure that each member of the HPICC understands his/her role and responsibilities • Liaising with media as appropriate Director of Public Health/Consultant in Public Heal th Medicine (Health Protection) • Ensure that the NHS Highland response is compatible with that of the LRPs planning

partners and with SG and HPS national policies • Collate information on the epidemiology and the spread of the pandemic and its local

impact • Communicate with SGHD and HPS • Produce a report of the outbreak in consultation with LRPs and the HPICC • Support the COO in chairing/leading the HPICC Medical Microbiologist • Advise on the specimens that should be taken and the laboratory tests required for

investigation of influenza and its infective complications • Advise on the collection and transportation of specimens • Advise on the management and treatment in conjunction with the Infectious Diseases

physicians/Senior Clinicians. • Ensure confirmation of the results are forwarded to the DPH or CPHM as soon as

possible after analysis. • Liaise with specialist agencies such as HPS and Reference Laboratories as required. Infection Control Doctor/Senior Infection Control N urse • Advise the HPICC on procedures to limit the spread of infection • Provide advice on infection control in Acute Care and Primary Care settings • Report to the HPICC on the effective implementation of the infection control measures. • Monitor the effectiveness of infection control procedures and identify potential hazardous

practices. • Advise on the need for protective clothing and or disposable equipment • Provide advice on Personal Protective Equipment (PPE) • Provide relevant training to key staff Health Protection Nurse Specialist • Advise the HPICC on procedures to limit the spread of infection with ICD/ICN • Provide infection control advice to the patients, families, and staff in care facilities e.g.

nurseries, care homes etc • Collate relevant community information for the HPICC

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• Maintain contact with affected individuals/establishments and keep HPICC updated • Arrange for appropriate specimens to be sent to the laboratory • Provide a list of individuals from whom samples are expected for laboratory staff • Help to collate epidemiological information on flu cases and contacts

Medical Director • Maintain effective and efficient communication with all hospital clinicians and GP

practices • Ensure that the facilities and medical staff are available to meet demand • Redeployment of staff and resources as necessary • Co-ordinate the availability of hospital beds, equipment and drugs • Co-ordinate the out of hours response Consultant in Pharmaceutical Public Health/Director of Pharmacy • Ensure procurement and distribution of vaccine supplies in line with national policy • Ensure procurement and distribution of anti-viral drugs in line with national policy • Co-ordinate liaison with community pharmacists and hospital pharmacists, and

dispensing general practices • Monitor incidence of influenza amongst pharmacists Lead Hospital Physician and Raigmore Associate Medi cal Director • Ensure that the clinical requirements agreed by the HPICC are implemented including

the redeployment of staff and resources necessary • Report on availability of beds, equipment and drugs • Ensure that adequate laboratory services are provided. • Ensure adequate communications on site • Re-direct future admissions Lead GP and Operational Unit Managers • Coordinate the primary care and community response • Consider alternative models of delivery as required • Ensure effective liaison with NHS 24 and out of hours arrangements • Report on the availability of beds, equipment and drugs in rural general and community

hospitals Occupational Health Physician • Advise on occupational health issues • Co-ordinate immunisation of staff in Primary and Secondary Care with the HPT • Co-ordinate distribution of antivirals to staff • Liaise with other occupational health providers to Local Authority, Fire and Rescue

Service and Police Scotland Director of Social Work/Head of Adult Social Care • Make arrangements for coping with the increased demand for Social Care in the

Community; • Make arrangements to cope with increased absenteeism in Social Care Staff in

Residential Care Homes, Day Centres, Meals-on-Wheels Services, Home Help Services or other as appropriate.

• Liaise with Primary Care Staff over immunisation of Residential Care Home residents against influenza pandemic strain (if enough vaccine is available)

• Liaise with Primary Care or other staff over immunisation of relevant staff against influenza pandemic strain (if enough vaccine is available.)

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Head of Environmental Health/Highland Council Emerg ency Planning Officer • Liaise with relevant personnel in making available appropriate mortuary arrangements

for large number of people dying NHS Emergency Planning Officer • Ensure adequate mortuary provision for those dying in hospital • Arrange for the provision of any helplines required • Assist the chairman of HPICC to ensure all aspects of contingency plan are followed • Liaise with EPOs of other Category 1 Responders and SG Resilience team Head of Facilities • Secure premises and control access as required. • Ensure all utilities are maintained to all health care premises Business Continuity Manager

• Assist the chairman of HPICC to ensure all aspects of business continuity plans are followed

Head of Clinical Governance and Risk Management • Assist the Information Services Manager to ensure all data for sitreps are collected and

collated for the SG and HPS. • Highlight and minimise any risks emerging from the models of care utilised to deal with

the pandemic Head of Media and Corporate Communications • Be responsible for all formal communications with the general public, press and staff. General Manager, Scottish Ambulance Service • Liaise with SAS and ensure patient transport services and emergency response services

are maintained Police Liaison Officer • Act as the main liaison person between Police Scotland, the LRP and the HPICC.

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APPENDIX 3 HPICC – DRAFT AGENDA

1. Introduction

2. Outbreak Resume and update

2.1 General situation – National reports 2.2 Virological report 2.3 Primary Care – workload, staffing

2.4 Secondary Care Bed availability (ICU and HDU) Equipment including ventilators Staff 2.5 Mental Health Services - Bed availability/Staff 2.6 Pharmacy

2.7 Infection Control

2.8 Social Care

3. Actions required

3.1 Social Distancing - Exclusions and closures

3.2 Infection Control measures

3.3 Anti-viral drugs

Criteria for use Supply and distribution Patient Group Directions 3.4 Vaccines Priority groups Supply/Administration Patient Group Directions Staffing 4. Management of cases

Advice to GPs Criteria for hospital admissions Criteria for admission to Intensive Care Criteria for admissions to Community Hospitals Support for patients at home

5. Advice to public - leaflets, helplines

6. Advice to professionals (GPs, hospital staff and other NHS Boards)

7. Collecting Information – SITREP systems

8. Issues from other agencies/LRP Liaison

9. Agree actions required by whom and a timetable for action.

10. Date and time of next meeting

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APPENDIX 4

ORGANISATIONAL CHART: COMMAND AND CONTROL

North of Scotland Regional Resilience Partnership

Clinical Flu Advisory Group

DoH UKNIPC PHE

Scottish Pandemic Influenza Co-ordinating Group SGHD HPS

Highlands and Islands Local Resilience Partnership (multi-

agency)

NHS Highland Pandemic Influenza Co-ordinating Committee

Operational Unit Incident Management Teams

West of Scotland Regional Resilience Partnership (multi-

agency)

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APPENDIX 5

FUNCTIONING OF THE HIGHLANDS AND ISLANDS LOCAL RESI LIENCE PARTNERSHIP IN THE EVENT OF AN OUTBREAK OF PANDEMIC DISEASE 1. INTRODUCTION In the event of an outbreak of pandemic disease affecting, or likely to affect, the United Kingdom, an initial meeting of the Highlands and Islands will be called at the instigation of the NHS to brief members as to the outbreak and likely progress of the disease. 2. STRATEGIC CO-ORDINATING GROUP At the briefing members will agree the establishment and membership of a LRP, to be chaired, in the first instance, by the Chief Executive or Director of Public Health, NHS Highland, and attended by the relevant agencies. As the pandemic progresses and essential services and public order begin to predominate the senior local police officer will assume the Chair. Secretarial support to the LRP will be provided by the lead agency. 3. MEETINGS OF THE LRP Meetings will take place at Police Headquarters, Inverness with video conferencing links to Stornoway, Kirkwall and Lerwick. The LRP will meet as and when required, as determined by the Chair. During the early stages of an outbreak this may be daily but is likely to be less frequent as the outbreak progresses. Meetings will, where possible, use video conferencing technology between the three island groups and Inverness. 4. LOCAL EMERGENCY COORDINATING GROUPS The Local Emergency Liaison group will be established in each Local Authority / Health Board area, with representatives of pre-identified organisations present. Policy on priorities determined by the LRP will be implemented by the Local Emergency Liaison Groups as far as practicable. 5. MEDIA Media issues will be dealt with through the multi-agency Public Communications Group as per the agreed strategy documents, with the lead taken by the NHS Highland Comms team.

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APPENDIX 6 MEMBERSHIP OF HIGHLANDS & ISLANDS LOCAL RESILIENCE PARTNERSHIP AND THE ARGYLL AND BUTE LOCAL RESILIENCE PARTNERSHIP

Name Designation Organisation Deputising Role

Address

Duncan Worsell Chief Supt. North and Scotland

Civil Nuclear Constabulary

Supt Andy Brotherston

PCCB Dounreay THURSO Caithness KW14 7TZ

Alan Cooper ACC Civil Nuclear Constabulary

CS Duncan Worsell

Force HQ Culham Science Centre Abingdon OX14 3DB

Malcolm Burr Chief Executive Comhairle Nan Eilean Siar

Robert Emmott, Director of Finance and Corporate Resources

Council Offices Sandwick Road STORNOWAY Isle of Lewis HS1 2BW

Ian Burgess Area Operations Manager

HM Coastguard

Battery Point STORNOWAY Isle of Lewis HS1 2RT

Elaine Mead

NHS Highland Chief Executive NHS Highland

Deborah Jones Chief Operating Officer Dr Hugo Van Woerden DPH

Beechwood Park INVERNESS IV3 3BW

Cathie Cowan

Chief Executive NHS Orkney Dr Louise Wilson

DPH

Balfour Hospital New Scapa Road KIRKWALL KW15 1BQ

Ralph Roberts Chief Executive NHS Shetland Susan Webb DPH

Brevik House South Road LERWICK ZE1 0RB

Gordon Jamieson

Chief Executive

NHS Western Isles

Dr Maggie Watts DPH

37 South Beach Street STORNOWAY HS1 2BB

Alistair Buchan Chief Executive Orkney Islands Council

Leslie Manson, Director, Education, Leisure and Housing.

Council Offices KIRKWALL KW15 1NY

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Name Designation Organisation Deputising Role

Address

CS Philip MacRae

Divisional Commander Highlands and Islands (Vice Chair of H&ILRP)

Police Scotland Supt

Divisional Headquarters Old Perth Road INVERNESS IV2 3SY

Milne Weir General Manager (North Division)

Scottish Ambulance Service

Graham MacLeod or Andy Fuller

Divisional HQ Thistle House Beechwood Park North, INVERNESS IV2 3ED

Andy Rosie Head of Operations North

Scottish Environment Protection Agency

Gresser House DINGWALL IV15 9XB

Scott Hay Local Senior Officer

Scottish Fire & Rescue Service

Harbour Road INVERNESS IV1 1TB

Billy Wilson Local Senior Officer

Scottish Fire & Rescue Service

Islands LSO

David Colthart

Utilities Representative

Scottish & Southern Energy

200 Dunkeld Road, PERTH PH1 3AQ

Mark Boden Chief Executive

Shetland Islands Council

Jan Riise, Head of Legal and Administration

Chief Executive Shetland Island Council 8 North Ness Lerwick ZE1 0LZ

Steve Barron (Chair of HILRP)

Chief Executive

The Highland Council

Glenurquhart Road INVERNESS IV3 5NX

Name Designation Organisation Address

Lt Col Gary Gordon

JRLO (Joint Regional Liaison Officer)

51 (Scottish) Brigade

Headquarters 51 (Scottish) Brigade Forthside STIRLING FK77RR

vacant North of Scotland Procurator Fiscal

Procurator Fiscal Service

Procurator Fiscal’s Office 2 Baron Taylor’s Street INVERNESS 1V1 1QL

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Name Designation Organisation Address

Julie Jefferson Resilience Partnership Coordinator (H&I)

NoS RRP Coordinator H&I

Divisional Police Headquarters Old Perth Road INVERNESS IV2 3SY

Mark Murphy

Head of Emergency Planning & Security

Scottish Water

Castle House 6 Castle Drive Carnegie Campus DUNFERMLINE KY11 8GG

Peter Melens

Veterinary Lead North of Scotland

Animal Health and veterinary Laboratories Agency (AHVLA)

Longman House 28 Longman Road INVERNESS IV1 1SY

Fiona Murray

ScoRDS Learning & Development Co-ordinator

NoS RRP

Divisional Headquarters Old Perth Road INVERNESS IV2 3SY

Gregor Lindsay Resilience Division Scottish Government

Resilience Division 1R St Andrew’s House Regent Road Edinburgh EH1 3DG

Category 2 Responders � Utilities (Gas, Water, Electricity, Telecommunications) � Rail and Airport Operators � Harbour Authorities � Common Services Agency � Health & Safety Executive � Health Protection Scotland � Scottish Ferry Operators

Other Organisations � Military Authorities � Procurator Fiscal Service � British Red Cross � Women’s Royal Voluntary Service (WRVS) � Other Voluntary Services � Community Groups � Meteorological Office

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Argyll and Bute LRP

Agency Member Argyll LRP

West of Scotland RRP Andy Ellison

Police Scotland Ian Wallace

Police Scotland – Emergency Planning Lyndsey Sutherland

Scottish Fire and Rescue Service Kenny Daye

Scottish Ambulance Service Donna Baillie

NHS Highland Peter MacPhee

MCA Jonathan Hart SEPA Lewis Allen

Calmac Ferries Punjab Singh / Pamela Lafferty

Western Ferries Graham Fletcher Peel Ports (was Clydeport Authority) Brian Forrest Met Office Catherine Sweetman

BEAR Scotland Nathan Downs

Scottish Power Energy Networks Tom Melrose

Scottish and Southern Energy Andrew Gilthorpe

Scottish Water Mark Murphy

British Red Cross James Jamieson

RVS Alison Love

ScoRDs Alan Simpson

Oban Airport Tom Eddleston

Site Operators – Faslane John Taylor

Site Operators – Oil Fuel Depots Billy Melville

Site Operators – Finnart Grahame Herd

Site Operators – DM Glen Douglas Aileen Fraser

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APPENDIX 7 NHS HIGHLAND MORTUARY CAPACITY North Highland Hospital Capacity Raigmore Hospital, Inverness 36* Caithness General 6 Dunbar, Thurso 2 Lawson Memorial, Golspie 3 Migdale, Bonar Bridge 2 County Hospital, Invergordon 4 Belford, Fort William 4 MacKinnon, Skye 3 Ian Charles, Grantown 5 Ross Memorial, Dingwall 3 St Vincents, Kingussie 3 Town and County, Nairn 6 Total 77

*Raigmore - 25 standard adult - 3 bariatric (i.e. patients with either a BMI over 40 or over 25 stone) - 5 children - 3 freezer (which can be converted to chiller spaces) Argyll and Bute Hospital Capacity LIRGH, Oban 14 Mull & Iona Community Hospital, Craignure 3 MACCHIC, Lochgilphead 6 Campbeltown Hosp 3 Islay Hospital, Bowmore 3 Cowal Community Hospital, Dunoon 6 Victoria Hospital Annex, Rothesay 3 Total 38

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APPENDIX 8 PHASED RESPONSE OF NATIONAL ORGANISATIONS A new UK approach to the indicators for action in a future pandemic response has been developed. This takes the form of a series of phases, named: Detection, Assessment, Treatment, Escalation and Recovery and incorporates indicators for moving from one phase to another. The phases are not numbered as they are not linear, may not follow in strict order, and it is possible to move back and forth or jump phases. It should also be recognised that there may not be a clear delineation between phases, particularly when considering regional variation and comparisons. When there is clear evidence of person to person sp read in the general population elsewhere, in another country (e.g. secondary cases; at least one outbreak lasting a minimum of 2 weeks; identification of new virus subtype in several countries with no explanation other than contact with infected people). DoH/SGHD The UK government will convene the National Security Council Committee (Threats, Hazards, Resilience and Contingencies) (NSC THRC), comprising Ministers from across Central Government departments and the Devolved Administrations, and coordinates national preparations. It is also likely that Cabinet Office Briefing Room (COBR) will activate a Scientific Advisory Group for Emergencies (SAGE) to coordinate strategic scientific and technical advice to support UK cross-government decision making. The Scottish Government will convene the Scottish Government Resilience Room (SGoRR) PHE and HPS will also implement their own preparedness plans

Planning assumptions

• It may take 2-4 weeks for the virus to become established in the UK and 7-9 weeks to reach a peak

• once there are outbreaks throughout the UK there will be intense pressure on health and on all other services for at least 6-8 weeks

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APPENDIX 9 NHS HIGHLAND RESPONSE TO EACH PHASE These phases are not linear and may not follow in s trict order. It is possible to move back and forward or jump phases. The Interpandemic Period: No new virus types repor ted. Planning assumptions

• seasonal influenza will be the major focus of attention • a new virus is most likely to emerge in the Far East • WHO has the lead in investigating any such events

Actions for NHS Highland

• maintains annual influenza immunisation programme according to national policy, including registers of patients ‘at risk’ in each General Practice

• ensures Highland contingency plan and local business continuity plans for pandemic influenza are up to date, including clear local organisation and accountability

• initiates discussions with local stakeholders and resilience partners on preparedness • undertakes exercises to test plan

DETECTION PHASE First report of a novel virus subtype from a single human case Two or more human infections with new virus subtype confirmed (with no confirmed evidence that the virus can spread readily person-to-person WHO declares a Public Health Emergency of Internati onal Concern (PHIEC) Planning assumptions

• a single case outside the UK represents a very small risk to the UK but closer vigilance will be required if it is associated with significant outbreaks of avian influenza in poultry, particularly if geographically close to the UK

• cases outside the UK are still likely to present a small risk to the UK unless there are many cases and strong travel links to the UK, or cases in a geographically close country

• if cases are associated with widespread avian influenza outbreaks the risk of further cases increases, especially if control measures are late or inadequate

• the longer the duration of the outbreak, the greater the risk and concern Actions for NHS Highland

• review, exercise and test local plans • consider infection control measures • follow PHE/HPS and relevant clinical algorithms for the management of any

suspected “imported” cases. ASSESSMENT PHASE A single case within the UK requires full investiga tion, containment and risk assessment Planning assumptions

• if cases are within the UK prompt investigation and risk assessment are required

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• surveillance of early cases would be active and detailed • active case finding, self isolation and treatment of cases

Actions for NHS Highland

• convene the HPICC (see Appendices 1 and 2) and operational incident management teams

• assist with surveillance and case management if cases occurring in our area

TREATMENT PHASE: Evidence of sustained community transmission in the UK Planning assumption

• risk to UK significantly increased • pandemic cannot be halted but needs to be managed

Actions for NHS Highland

• activate Contingency Plan for Pandemic Influenza (this plan) and all operational business continuity plans

• Treatment of community cases via NPFS or equivalent • if hospitalised, treat patients in single rooms with full infection control measures

follow PHE/HPS algorithms for patient management • ensures availability of information and advice to professionals, the public and the

media • plan distribution and administration of antivirals in line with national guidance • considers staffing levels and agree diversion of resources as necessary • liaises with social services and other relevant local agencies • agrees essential and non-essential services and triggers for action • consider social distancing measures • prepare to implement targeted vaccination programme if/when available

ESCALATION PHASE Increased and sustained transmission in the general population. Demands for services start to exceed capacity Planning assumptions

• from the first sporadic cases it may take 2-4 weeks for the virus to become established in the UK and 7-9 weeks to reach a peak

• once there are outbreaks throughout the country there will be intense pressure on health and on all other services for at least 6-8 weeks

• Pandemic flu vaccine unlikely to be available for first wave Actions for NHS Highland

• reports to SGHD on preparedness with daily SITREP report on local NHS • surge capacity arrangements implemented • triage and prioritisation of essential services • prepare to restrict hospital admissions and possibly to suspend some contracts;

renegotiation of some service level agreements may be needed to reflect new circumstances

• consider training needs for any redeployed staff

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• support and co-ordinate primary care and operational unit delivery of antivirals • HPICC meets on a regular basis and considers:

surveillance including numbers of cases viral isolates, sensitivity to antivirals (and vaccine) primary care resources and support for patients at home bed availability including ITU staffing situation and succession planning distribution and administration of antivirals, vaccines information and advice to professionals, public, media on local service provision and treatment

• Highlands & Islands and WoS LRPs considers: maintenance of essential services public order and security

End of first pandemic wave. For UK purposes, this is taken as the end of the first wave in

the UK. There may or may not be a second wave depending on the virus, its impact, availability of vaccine etc.

Actions for NHS Highland

• HPICC reviews the response and amends the Contingency Plan for Pandemic Influenza on the basis of experience of the first wave

• ensures professions, public and media are kept informed of the situation and of the possibility of subsequent waves

• prepare for future waves • implement vaccination programme once available

Onset of second or later waves of the pandemic Actions mainly involve reactivation of earlier phases informed by experience of the first wave of the pandemic. RECOVERY The pandemic will be deemed to have ceased when all epidemiological indices have returned to background levels. Pandemic response groups nationally and locally will be stood down. Actions for NHS Highland • oversees return of systems and services to normality • address staff exhaustion and implement support as required • post incident review - the HPICC will prepare a report reviewing effectiveness of the plan

and lessons learned • prepare for post pandemic seasonal influenza

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APPENDIX 10 LABORATORY TESTS Laboratory Tests for Influenza 1 First week of illness Standard Test: Viral (green) Throat swab for Respir atory PCR.

This will be processed at the Raigmore microbiology lab Monday-Saturday if it reaches the

lab by 11:00. Results will then be available the same day between 15:00-16:00.

For patients in Raigmore Hospital ward staff are advised that use of the pod tube system is

likely to be the most reliable for routine use. If the sample has been taken close to the

11:00 cut off time, staff are advised to arrange for the sample to be taken to the laboratory

by hand if same day result essential.

NB// A Nasopharyngeal aspirate (NPA) is an acceptable alternative to a viral throat swab in

paediatric patients (NOT in adults) from whom a NPA has already been taken for the RSV

Near-Patient Test (within the Paediatric admissions area). In this case a separate throat

swab is not required.

Rapid Testing (6A/Medical Receiving patients ONLY):

The machine is sited in Ward 6A. This uses a separate Viral (green) Throat swab (i.e.

patients need two viral swabs taking, one for the r apid test, one for the standard).

This will allow a rapid result to be achieved at any time of day within 1 hour of taking the

swab, and tests for several respiratory pathogens.

2. Second week of illness. Serological investigations on 10ml clotted blood. Clinical cohort studies on 10ml clotted blood from each individual. (only if requested nationally) Comments The use of laboratory tests will vary depending on the stage of an epidemic. Once a pandemic is established then laboratory confirmation is likely to be restricted to situations where patient management will be changed by the result.

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APPENDIX 11 HOSPITAL BED ESTABLISHMENT (Drafting note – numbers to be provided by operatio nal managers)

Beds

Total single rooms

Single en-suite rooms

2-bed rooms

3-bed rooms

4-bed rooms

6-bed rooms

Other size room Specify

Raigmore Hospital

Belford Hospital

Caithness General Hospital

Dunbar Hospital

16

2

0

1

1

5-bed x1

Town & County, Wick

19

11

1

2

Lawson Memorial Hospital

15

3

0

2

Cambusavie Unit

22

6

6

4

Migdale Hospital

32

2

0

1

4

4

County Community Hospital

30

22

22

2

Ross Memorial Hospital

17

3

0

1

1

8-bed x1

Rheumatology Unit

14

6

0

2

1

RNI Community Hospital

30

6

6

2

2

New Craigs Hospital

Aonach Mor, Inverness

15

15

15

Town & County, Nairn

19

7

0

2

Ian Charles Hospital

18

3

0

2

1

2

St Vincents Hospital

17

9

0

4

MacKinnon Memorial Hosp

25

1

0

6

3

Portree Hospital

8

1

0

1

5-bed x 1

Bellhaven Ward

23

5

5

3

64

Argyll and Bute Hospital Bed Establishment

Beds

Total single rooms

Single en-

suite rooms

2-bed rooms

3-bed rooms

4-bed rooms

6-bed rooms

Other size room Specify

Rothesay Victoria

14

8

4

0

2

0

0

Dunoon Hospital *

22

8

5

1

0

3

0

Campbeltown Hospital

33

4

3

0

0

1

4 Sunshine

room x 1

Islay Hospital

10

4

4

0

2

0

0

MACHICC, Lochgilphead

44

30

30

5

0

1

0

Lorn & Islands Hospital, Oban

67

0

17

0

0

5

5

Mull & Iona Community Hospital

3

0

3

0

0

0

0

Argyll and Bute Hospital

40

23

6

1

1

3

0

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APPENDIX 12 INVASIVE AND NON INVASIVE VENTILATORS WITHIN NHS HI GHLAND (DN: Numbers need updated by anaesthetists) North Highland Location Number Raigmore Hospital ITU 12 ITU in storage 1 6 Main Theatres 9 Anaesthetic Rooms ( inc. CT & MRI) 11 Bi Level 8 CPAP ( issued from Resp ward) c600 Neo Natal 6 Belford Hospital Transfer 2 ITU 1 Anaesthetic 1 Broadford Hospital Anaesthetic 2 Caithness General Transfer 3 Neo Natal 2 Bi PAP 2 ITU 1 Theatre 4 Lawson Memorial Theatre 2 Nairn Home Support 3 New Craigs Anaesthetic 1

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Argyll & Bute hospitals Location Number Rothesay Victoria Transfer 1 Cowal Community Hospital Transfer 1 Campbeltown Hospital CPAP 1 Islay Hospital Transfer 2 MACHICC, Lochgilphead Transfer 2 CPAP 1 LIRGH Anaesthetic 4 HDU 1 CPAP 2 BIPAP 2 Transfer 2 Mull & Iona Community Hospital None 0 Argyll and Bute Hospital None 0 Generally there are sufficient consumables in stock at each location at any point in time for 7 days. Medical air is available in most locations with the exception of Theatre Recovery

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APPENDIX 13

THE CLINICAL FLU ADVISORY GROUP Remit 1. Agree a joint primary and secondary care position on hospital admission and discharge pathways

and procedures for suspected cases (adults and children) 2. Explore and agree on the role of community hospitals and rural general hospitals throughout a flu

pandemic. 3. Collate work on essential and non-essential services and recommend appropriate trigger actions

for a staged response to a pandemic as it develops in severity and scale. 4. Act as a clinical service prioritisation group throughout a pandemic. 5. Support clinicians with decision making throughout a pandemic particularly issues of patient and

clinical intervention prioritisation during times of peak activity and demand. 6. To provide medical/clinical advice to Highland Pandemic Influenza Coordinating Committee

(HPICC) throughout the pre pandemic, pandemic and recovery phases of a flu pandemic. 7. Ensure recommendations are in keeping with national guidance and fair to all NHS Highland

patients. Membership

Dr Stewart Lambie - Consultant Physician (Chair)

Dr Rob Peel - Consultant Physician (Vice Chair)

Dr Ken Oates - Consultant in Public Health Medicine

Dr Rod Harvey - Medical Director

Dr Ken Macdonald - Associate Medical Director Raigmore

Dr Stephen Thomas - Consultant Chest Physician

Dr Wendy Beadles - Consultant Infectious Diseases

Dr Jonty Mills - Consultant Microbiologist

Dr ? - Consultant Surgeon, Caithness

Dr Gary Kerr - Consultant in A&E

Dr Mike Hall - GP, Clinical Lead, Argyll & Bute

Dr Paul Davidson - Associate Medical Director

Dr Ian Scott - GP, Clinical Lead, South & Mid Highland

Dr Brian Tregaskis - Consultant Physician, Belford

Dr Alan Webb - Consultant Paediatrician

Dr Jonathan Whiteside - Consultant Anaesthetist

Mr Graeme McLeod - Scottish Ambulance Service

Mr Peter MacPhee - Emergency Planning Officer

? - Chair of Area Medical Committee

? - GP / Chair of GP Sub-Committee

APPENDIX 14 PRIORITY GROUPS FOR VACCINATION Numbers in probable priority groups for influenza vaccine as of winter 2016

Job Family A&B

HSCP Corporate Services

Highland HSCP Raigmore North

and West South

and Mid Total

Medical Practitioner (other than GP)

39 11 358 46 52 506

General Practitioner (GP) 13 0 15 39 18 85 Nursing 653 55 1023 870 727 3328 Midwifery 37 11 158 46 18 270 Allied health professionals

152 14 171 135 232 704

Healthcare sciences 20 3 229 15 2 269 Other Therapeutic Services

27 9 103 25 55 219

Medical support 2 0 21 2 0 25 Support services 240 210 285 246 182 1163 Administrative services 281 479 498 301 271 1830 Community pharmacists n/a n/a n/a n/a n/a n/a Dentists & dental support 61 0 19 0 215 295 Emergency services n/a n/a n/a n/a n/a n/a Personal and Social Care 19 71 2 663 448 1203 Senior management 2 22 4 2 2 32

Other 0 13 0 10 0 23

TOTAL 1546 898 2886 2400 2222 9952

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The following children’s services staff are now part of Highland Council and are shown separately in the table below: Job Family Total Administrative Services 10 Allied Health Profession 49 Nursing/Midwifery 146 Personal and Social Care 6 Grand Total 211

(DN: Consider adding numbers for primary care and c ommunity pharmacy )

APPENDIX 15 NHS HIGHLAND IMPACT – PREDICTED NUMBERS AFFECTED The following tables illustrate the impact of an influenza pandemic on NHS Highland, by week of pandemic activity over a 15-week period, in terms of total clinical cases, excess GP consultations, excess hospital admissions and excess deaths. The figures are based on the baseline scenario in the UK Influenza Pandemic Contingency Plan and are based on a clinical attack rate of 25%, a GP consultation rate of 10%, a hospitalisation rate of 0.55%, and a case fatality rate of 0.37%. A range of clinical attack rates from 25% to 50%, GP consultation rates from 10% to 27.5%, hospitalisation rates from 0.55% to 4%, and a range of case fatality rates from 0.37% to 2.5%, are also considered in planning. (DN: Clarify prediction percentages and then calculate numbers u sing latest GRO population figures and new operational units/bounda ries) Highland Council area (Based on population of 222,370)

Week % of cases

Numbers Infected

GP Consultations

Extra Hospitalisations

Excess Deaths

Week 1 0.1 Week 2 0.2 Week 3 0.8 Week 4 3.1 Week 5 10.6 Week 6 21.6 Week 7 21.2 Week 8 14.3 Week 9 9.7 Week 10 7.5 Week 11 5.2 Week 12 2.6 Week 13 1.6 Week 14 0.9 Week 15 0.7 Total 100 Argyll & Bute Council area ( Based on population of 89,590)

Week % of cases

Numbers Infected

GP Consultations

Extra Hospitalisations

Excess Deaths

Week 1 0.1 Week 2 0.2 Week 3 0.8 Week 4 3.1 Week 5 10.6 Week 6 21.6 Week 7 21.2 Week 8 14.3 Week 9 9.7 Week 10 7.5 Week 11 5.2 Week 12 2.6 Week 13 1.6 Week 14 0.9

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Week 15 0.7 Total 100 Mid Highland CHP or South East Highland CHP (Based on population of 80,000)

Week Clinical cases Excess GP consultations

Excess hospital cases

Excess deaths

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Total North Highland CHP (Based on population of 40,000)

Week Clinical cases Excess GP

consultations Excess hospital

cases Excess deaths

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Total

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GLOSSARY CCC CCU CEO CMO CPHM CDEH DH DPH DMO EHO EISS EPO HCW HEPO HDU HPICC HPA HPNS HPS HSCP ICD ICN ITU MGCC NICE NHS NIBSC HPT OHS PCO PGD PIMT PMBS RVL SAS SECC SEER SGHD SHERT SITREP SPICG UKNIPC WHO

Civil Contingencies Committee Coronary Care Unit Chief Executive Officer Chief Medical Officer Consultant in Public Health Medicine Communicable Disease and Environmental Health Department of Health Director of Public Health Designated Medical Officer Environmental Health Officer European Influenza Surveillance System Emergency Planning Officer Health Care Worker Health Emergency Planning Officer High Dependency Unit Highland Pandemic Influenza Co-ordinating Committee Health Protection Agency Health Protection Nurse Specialist Health Protection Scotland Health and Social Care Partnership Infection Control Doctor Infection Control Nurse Intensive Therapy Unit Ministerial Group on Civil Contingencies National Institute for Clinical Effectiveness National Health Service National Institute for Biological Standards and Control Health Protection Team Occupational Health Service Primary Care Organisation Patient Group Direction Pandemic Incident Management Team Police Main Base Station Regional Virus Laboratory, Glasgow Scottish Ambulance Service Scottish Emergencies Co-ordinating Committee Scottish Executive Emergency Room Scottish Government Health Department SEHD Health Emergency Response Team Situation Report Scottish Pandemic Influenza Co-ordinating Group UK National Influenza Pandemic Committee World Health Organisation