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FINAL DRAFT

INFLUENZA PANDEMIC PREPAREDNESS PLAN

National Department of Health

Communicable Disease Control

Emerging and Re-Emerging Infectious Diseases

South Africa

February 2006

DRAFT INFLUENZA PANDEMIC PREPAREDNESS PLAN

**1. Introduction**

The World Health Organisation \[WHO\] and health authorities throughout
the world have recognised the threat of influenza pandemic, which could
potentially have serious effects on the health of the human population.
Previously, major pandemics have occurred in 1889, 1918/19, 1957 and
1968. Due to the advent of new subtypes of highly pathogenic bird flu,
otherwise know as Avian Influenza, health experts anticipate the
occurrence of major pandemics in the near future.

The 1918/19 influenza pandemic was one of the most deadly pandemics of
communicable diseases to have affected the world. This pandemic was
directly responsible for over 20 million deaths worldwide. In South
Africa the pandemic killed over 300 000 people, and in turn overwhelmed
the ability of the authorities to dispose of the corpses. Furthermore it
resulted in total paralysis of the health care system, which struggled
to manage patients.

The main challenge to health authorities is the inadequacy of the tools
to predict where and when future pandemics will occur. It is against
this background that the WHO and its Member States are encouraged to
prepare contingency plans to best prevent and control future pandemics.
South Africa is one of the countries that supports epidemic/pandemic
preparedness and as a result, has developed these plans to safeguard the
health of everyone in the country.

Management of pandemics requires large stock of antivirals, access to an
effective vaccine, human resources, and a multisectoral and
multidisciplinary approach. South Africa faces the challenge of
competing with first world countries for limited supplies of drugs and
vaccines. To add to this, such a pandemic would potentially make very
serious demands on the healthcare system and create a great deal of
public consternation.

It is for these reasons that this pandemic preparedness plan has been
developed as a working document. The WHO has established an Influenza
Pandemic Task Force to prepare a "blueprint plan" to guide governments
in preparing for future pandemics. This document is adapted from the WHO
"blueprint plan" and its main objective is to assist the South African
Department of Health and its partners best prepare for potential
pandemics.

**1.1 Potential Flu Pandemic Threats**

The extent and the impact of a future major pandemic cannot be predicted
with any degree of certainty. However, data from previous influenza
pandemics may be of some value in contingency planning. The WHO reported
the 1918/19 Spanish Flu killed over 40 to 50 million people worldwide.
Furthermore, many countries experienced serious social disruption and
economic losses. Influenza experts predict that if a flu pandemic were
to occur, the world would face up to 233 million outpatient visits, 5.2
million hospitalisations, and 7.4 million deaths, within a very short
period.

Due to improved health systems, therapeutic care and global preparedness
strategies; it is unlikely for the world to have the same number of
deaths as in 1918/19. However, there are more risk factors that may
predispose most people to infections. For example, increased travel,
population displacements, conflicts, poverty, overcrowding, possibly HIV
and AIDS and inadequate infrastructure. South Africa is not an exception
and is likely to be affected at the same time as the first world
countries.

In the UK, it has been predicted that new general practitioner
consultations would exceed 500/100 000 population in a new major
pandemic. This would mean that a practice with a patient base of 10 000
would see at least 50 new patients per week. At the peak of the 1957
pandemic general practitioners recorded seeing 80-100 cases per day,
whereas in the 1969 pandemic these reached up to 1,260/100 000
population over a 2 week period. In the UK at the peak of the 1957
pandemic, between 25-30 000 additional cases of acute respiratory
disease were admitted to National Health Service hospitals.

In the UK new sickness benefit claims totaled 2.5 million out of 17.5
million insured. In 1968/69 more than 1 million were received over a
5-month period. It was estimated that 8-10% of the insured population
lost 3 or more working days during the 1957 epidemic. Healthcare workers
were particularly adversely affected with 12.6 to 19.4% of nurses absent
in one district and in one hospital, nearly a third of nurses were
absent.

**2. THE INFLUENZA VIRUS**

**2.1 Influenza**

Influenza or \'flu\' is a respiratory illness associated with infection
by influenza virus. Symptoms frequently include headache, fever, cough,
sore throat, aching muscles and joints. There is a wide spectrum of
severity of illness ranging from minor symptoms through to pneumonia and
death.

**2.1.1 Influenza Virus**

The influenza virus was first isolated in 1933. There are three main
types that cause infection: Influenza A, B and C (of respectively
importance). Influenza A usually causes a more severe illness than
influenza B. The influenza virus, like most Ribonucleic Acid \[RNA\]
viruses, is genetically highly variable and this variability gives rise
to a constant changing of the antigenicity of the virus. However, what
is characteristic to the virus is that the antigenic changeability
constantly gives rise to new strains of virus, which are able to escape
the immunity, which the population builds up, to the predecessor strain,
which it now replaces. The epidemiology of influenza is thus
characterised by the constant advent of new antigenic strains of the
virus resulting in recurring outbreaks or epidemics.

2.  **Classification of Influenza Viruses**

Influenza is classified into 3 types based on the antigenicity of a
protein called nucleoprotein, which surrounds the RNA genome of the
virus. The 3 types are referred to as type A, type B and type C. Type A
influenza virus is further subdivided into **subtypes** based on the
antigenicity of the 2 proteins embedded in the envelope of the virus,
which are used to attach and to penetrate into the host cell. These are
haemagglutinin (HA) and neuraminidase (NA). Sixteen different HA viruses
and nine different NAs have been identified in various combinations in
wild aquatic birds, the reservoir host for influenza viruses. Only 3
subtypes are known to infect humans and these are H1N1, H2N2 and H3N2.
Presently 2 of the subtypes are circulating in humans, namely H1N1 and
H3N2.

**2.1.3 Mechanisms of Influenza Virus Variability**

There are 2 ways in which an influenza virus changes its antigenicity,
i.e. antigenic shift and antigenic drift.

**Antigenic Shift**

Influenza virus is one of the few viruses where the individual genes
occur on separate and discrete pieces of nucleic acid instead of the
more usual complete single strand for the whole genome. As a result of
this if two different subtypes happen to infect the same cell, genes
from different origins may be swopped when the progeny virus is put
together in the assembly phase of the virus' replication. The alien gene
or genes then produces hybrid progeny virus, which usually dies off.
This process is called reassortment and the hybrid offspring are
referred to as reassortants.

The primary mixing bowls where reassortment is thought to take place in
nature are the vast flocks of wild birds, including waterfowl, found in
China and human influenza virus is the pig, which can act as an
intermediate host for man. In China and the Far East the human
populations come into close contact with these animal reservoirs that
harbour a great variety of influenza subtypes. Nevertheless,
reassortment producing a new human virus is a rare event, which can give
rise to a new pandemic about once every 10-40 years.

When reassortment occurs, it gives rise to a completely new subtype of
virus acquiring a totally new HA or/and sometimes a new NA protein. As a
result, the human population becomes susceptible due to dramatic and
sudden classical pandemics such as the 1918/19 Spanish Flu, the 1957
Asian Flu, and the 1968 Hong Kong Flu. The sudden and major change in
antigenicity of the virus is hence called **antigenic shift**.

**Antigenic Drift**

This is a more subtle change in the antigenicity of the HA protein,
which is critical in the attachment of the virus to its receptor on the
host cell. Even subtle changes (i.e. sometimes only 1 or 2 amino acids)
may enable the virus to elude the host's immunity. These HA mutations
occur readily and continually although point mutations (i.e.
substitution of 1 amino acid) usually do not translate on their own into
a significant antigenic change. However, accumulation of these point
mutations under the selective pressure of antibodies formed in
innumerable human hosts will eventually produce meaningful antigenic
change resulting in a virus, which can then spread throughout the human
population, causing widespread epidemic activity. This more gradual but
progressive change is thus called **antigenic drift** and it gives rise
to new antigenic strains of influenza approximately every 3-5 years.

**2.2 Definition**

An influenza pandemic or global epidemic occurs when a new influenza
virus subtype appears, against which no one is immune. This may result
in several simultaneous epidemics worldwide with high numbers of cases
and deaths. Improved transport systems, rapid urbanization and increased
travel are more likely to facilitate the spread of new viruses
worldwide.

Influenza virus causes outbreaks of influenza every winter season. This
is seasonal influenza. These outbreaks are of variable intensity but
usually affect between 5-30% of the population resulting in a highly
variable degree of morbidity and some mortality, which is virtually
confined to elderly individuals, especially those with underlying
medical conditions.

When significant antigenic variation occurs in the virus so that the
population is largely susceptible, significantly greater epidemic
activity occurs which is often global in extent, with varying intensity
in different countries often depending on population immunity. The
widespread epidemics of influenza that affect almost all the continents,
are sometimes referred to as pandemics.

What is very important to understand that there is a difference between
seasonal, Avian and human pandemic influenza. The human pandemic
influenza involves a new influenza virus subtype, which is rapidly
transmitted between people and Avian flu is a type of flu diagnosed in
birds. This is an animal disease.

3.  **PANDEMIC PREPAREDNESS PLAN**

**3.1 Elements of Preparedness**

A complete pandemic preparedness plan should comprise of all the
essential minimum elements aimed at guiding those involved in the
prevention and control of infectious diseases. The WHO and its Member
States recommend that countries use a checklist in order to ensure
smooth implementation of the plans.

The plans should be prepared in consultation with all government
departments, including the public sectors and community representatives.
Advocacy and commitment from heads of states and department is crucial.
Preparedness teams must ensure that the following seven essential
elements of the checklist are sufficiently planed and implemented:

1.  Preparing for an Emergency

2.  Surveillance

3.  Case Investigation and Treatment

4.  Prevention of Spread of Disease

5.  Maintaining Essential Services

6.  Research and Evaluation

7.  Implementation, Testing and Revision of National Plans

**3.1 Preparation for an Emergency**

It is of vital importance for both political and bureaucratic processes
to work in harmony with the technical team in case of an emergency.
Government must recognise the potential human, social and economic
impacts of pandemics at its highest levels of management and governance.
The following enablers should be readily available at various levels of
government, particularly within the health care system:

-   Recognition and acknowledgement of preparedness plans

-   Committed funding

-   Responsible organizations, committees and technical expertise

-   Realistic timelines for completion of preparedness plans

-   Roles and responsibilities should be clearly documented

-   Periodic meetings should be held and proceedings be documented

-   Political, government and professional groups should be informed of
    the plans

**3.1.1 Command and Control**

In order to make clear and timely decision and implementation of uniform
policies endorsed by all role players, it is essential to know who is
responsible for various activities within communicable disease control.
Who and when to enforce key elements of response like travel or trade
bans and quarantine should be clearly stipulated, e.g. President,
Ministers, Director Generals, etc. These should be instituted in all
organisations participating in the development of the plans.

In addition to high level command and control plans, technical experts
from various sectors and disciplines should know their roles and
responsibilities in order to avoid confusion. Wherever necessary,
standard operating procedures like outbreak investigation, laboratory
confirmation, case management, political decision-making, information to
be disseminated and any other relevant guidelines need to be developed
and implemented.

**3.1.2 Risk Assessment**

South Africa is classified by WHO,UN and IOE as a low risk country. The
risk of a pandemic is great and will persist, but the timing and
severity are unknown. Risks need to be defined immediately. Various
sectors that are more likely to be affected are encouraged to conduct
studies on expected impact of the pandemic. Modelling studies on the
impact of the pandemic on varying attack rates should be done as well as
systems for early detection, testing and reporting. Impact measures
should include health facility attendance, admissions, and deaths. The
social and economic impact should also be assessed. An estimation of the
effects of potential interventions with antiviral medication and/or
vaccines in various groups should be computed.

**3.1.3 Communication**

Communication strategies are an important component in the management of
any infectious disease outbreak risk and especially management
communication. Communications that address various target groups, e.g.
community, press, politicians, health workers, should be developed.
Dissemination strategies, e.g. website, leaflets, newspapers, radio,
television and languages to be used should be well planned and executed.
Communication also involves regular meetings between various
stakeholders, countries, including reporting to the WHO. Socio-cultural
aspects of the country should be well understood, e.g. religion and
language. South Africa endorses and will use the "WHO Communication
During Outbreaks" document. Communication should be clear and objective
to prevent confusion. Messages should be consistent within the country,
but also in across boarder countries.

**3.1.4 Legal and Ethical Issues**

During pandemics it may be necessary for government to overrule existing
legislations and rights, e.g. school, sporting and port closure,
quarantine or travel ban. Any decisions should comply with the
International Health Regulations.

**3.1.5 Response Plan**

The WHO recommends that different stages of responding to the epidemic
be instituted. This includes various triggers that will be activated at
various levels of the response.

The applicable sections are equally important for animal flu outbreaks,
e.g. Avain flu.

4.  **SURVEILLANCE**

####### National Surveillance Programmes

Within the Department of Health, both clinical and laboratory
surveillance systems should be sensitive enough to detect any suspected
human cases. The Department of Agriculture is responsible for
surveillance in poultry and other animals. The surveillance systems
should:

-   Be comprehensive and cover the whole country

-   Facilitate rapid response

-   Allow that laboratory and epidemiological data be integrated

-   Ensure national security

-   Contribute to capacity and improvement of the system

-   Fit in with the global information network system

**NB**: What is said here for human flu viruses and surveillance is
equally important for animal viruses and surveillance.

**4.1.1 Laboratory Surveillance**

The influenza laboratory of the National Institute for Communicable
Diseases \[NICD\] is the major surveillance site for influenza in South
Africa. There are smaller sites situated in the Department of
Microbiology, University of Cape Town and Department of Virology,
University of Natal.

Both active and passive surveillance is carried out at the NICD. The
active surveillance programme consists of a network of sentinel sampling
sites; at present some 80 general practitioners, clinics and staff
health centers, which provide routine upper respiratory tract specimens
from patients with acute respiratory disease for virus isolation. On
average between 50 and 100 virus isolates are made annually. These
isolates are antigenically typed at the NICD using reagents supplied by
the WHO.

In addition, molecular studies are carried out at the NICD to determine
the polypeptide sequence of the surface proteins of new isolates in
order to determine subtle sequence changes. Supplementing this acute
surveillance programme is the resource of clinical material sent to the
NICD for routine diagnostic purposes. Virus isolation data is coupled
with investigation of school and work absenteeism, which is used as a
rough determinant of the extent and impact of influenza.

The NICD influenza laboratory is part of the international global
network of some 116 reference centers throughout the world. Close ties
are maintained with these centers as well as with the four WHO
Collaborating Centers for Reference and Research on Influenza:

-   The Commonwealth Serum Laboratories, Melbourne, Australia

-   National Institute for Medical Research, Mill Hill, London

-   National Institute of Infectious Diseases, Tokyo, Japan

-   Influenza Branch, National Center for Infectious Diseases, CDC,
    Atlanta, Georgia.

Links are maintained through the internet via a programme called FluNet.
All participating laboratories supply information regarding influenza
activity and characteristics of virus isolates. Three influenza
collaborating laboratories have been established in China to act as
international early warning sentinel laboratories to warn of the
appearance of new strains of influenza virus.

**4.1.2 Monitoring Antigen Drifts**

The regular monitoring of human influenza virus isolates for the more
regular antigenic drifts is carried out by some 125 national influenza
centers throughout the world. These laboratories obtain influenza virus
isolates either from routine patient diagnostic material sent into
clinical virology laboratories or, alternately, specimens are actively
recruited from sentinel medical practitioners or clinics who
purpose-fully take throat swabs from patients with upper respiratory
tract infections.

A successful viral watch programme with a network of sentinel
practitioners has been operating successfully on the Witwatersrand since
1982. Preliminary characterization of influenza isolates is carried out
by the NICD and a representative number of virus isolates are then sent
to the WHO Collaborative Centres for Reference and Research on
Influenza, in London and Melbourne, Australia; for detailed antigen and
genetic characterisation.

5.  **Potential Control Measures for Human Infection**

To reduce the opportunity or risk of transmission, the following should
be done:

-   Use the best available information to act and to inform countries

-   Control the flu in animals and contain the source of infection

-   Contain seasonal flu outbreaks through an effective flu immunisation
    programme to surge capacity for pandemics

-   Avoid high risk behaviour, e.g. eating of raw poultry, big
    gatherings, wet slaughtering, co-habitation

-   Improve personal hygiene, e.g. washing hands with soap, covering
    mouth and nose if coughing or sneezing

-   Voluntary quarantine/isolation

-   Improve infection control

-   Immediate investigation in suspected subtype cases

-   Improve diagnosis, treatment and overall service provision

-   Improve human and animal surveillance systems

**6. CASE INVESTIGATION AND TREATMENT**

Good diagnostic capacity is possible where the clinical staff is well
supported by laboratory confirmation of causative agents. It is
therefore very critical that health facilities and laboratory services
maintain good communication. Moreover, outbreak response teams should
have necessary skills and knowledge on case investigation. Laboratory
and case investigation should inform case management in terms of
procurement and use of vaccines, prophylaxis and other drugs.

**6.1 Case Management**

To ensure effective and safe treatment of cases, clinical guidelines
should be readily available and if not, WHO guidelines should be adapted
and implemented. All provinces in South Africa are expected to identify
designated health facilities where treatment protocols will be well
implemented. In case of large epidemics, additional facilities should be
identified after assessment, and support should be provided to such
facilities. The choice of intervention depends on the virus, severity,
age group, etc

**6.2 Vaccine Formulation**

Twice a year, towards the end of the northern and southern hemisphere
influenza season, a meeting is convened by the WHO consisting of
representatives of the Influenza Collaboration Centers and other
influenza experts, to review the past influenza season and to examine
laboratory data on the antigenicity of new isolates. On this basis an
estimate is made as to which strains in each of the subtype viruses are
likely to circulate in the population the following influenza season.

Prototype influenza strains are then selected and used for preparing
seed virus strains for vaccine manufacturers to process into vaccines.
Influenza vaccines are inactivated (killed) vaccines made by inoculating
fertilized chicken eggs with influenza virus, harvesting the fluid and
then extensively purifying out the virus which is then chemically
inactivated, usually with formaldehyde.

The formulation of the vaccine is announced biannually in February and
October in the WHO publication, the Weekly Epidemiological Record. This
then allows for approximately 4-5 months for manufacturers to produce
and package vaccine in time to vaccinate the northern hemisphere
population before the onset of their winter.

**6.3 Antiviral Chemoprophylaxis**

Influenza vaccines are, by far, the most important means of preventing
influenza. On occasion, however, it may be necessary to supplement
vaccine prophylaxis with chemoprophylaxis using oseltamivar \[Tamiflu\],
or zanamavir \[Relenza\], which inhibits influenza virus replication.
Chemoprophylaxis should be administered under the following
circumstances:

a.  In very high-risk situations to subjects who may already have been
    vaccinated or, if not, together with influenza vaccine, for example
    to frail, elderly inmates of an institution before a threatening
    outbreak.

b.  In an emergency situation where vaccine has been omitted in a
    high-risk patient. As the protective effects of vaccination only
    commence after 14 days.

c.  Where vaccine is contraindicated - in persons who have a history of
    severe hypersensitivity to egg protein.

d\. Where vaccine is not available or vaccines containing the correct
strains are not procurable, e.g. travellers going from summer to winter
season.

**6.4 Antiviral Chemotherapy**

Oseltamivar or zanamavir may also be used as a therapy for influenza
provided it is administered early in the course of the illness, i.e.
within 48 hours after onset of influenza. Therapeutic responses have
been demonstrated in the treatment of influenza pneumonia.

NB: Oseltamivar is the drug of choice but zanamavir \[relenza\] is also
available.

**7. ROLES AND RESPONSIBILITIES**

**Department of Health**

The Deputy-Director General should provide leadership to the
multidisciplinary teams involved in developing preparedness strategies.
The National, Provincial and Local Departments of Health together with
the National Institute for Communicable Diseases and health partners
from the private sector need to establish and sustain a well-constituted
and well-functioning outbreak response team. The overall aim of the
outbreak response team is to:

-   Provide leadership and identify infectious disease outbreaks by
    ensuring the existence of a functional surveillance system

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-   Investigate outbreaks, prepare adequately and timeously for
    emergencies

-   Ensure rapid response and systematic management of outbreaks, in
    order to reduce morbidity, and mortality

-   Enhance coordination at each level, e.g. establish a Joint
    Operations Center \[JOC\]

**General Responsibilities of the Outbreak Response Team at ALL Levels**

The activities of the outbreak response team should be underscored by
the common understanding of reducing morbidity and mortality due to
infectious diseases. However, this objective can be realised by the
following general responsibilities of the team:

-   To prepare plans of action for epidemic preparedness and response

-   To mobilise human, material and financial resources for epidemic
    prevention and control locally

-   To provide information and education to the public before, during
    and after outbreaks/epidemics

-   To monitor the implementation of outbreak/epidemic control actions

-   To coordinate assistance for epidemic prevention and control from
    various partners

-   To monitor resource utilisation (drugs, vaccines, supplies,
    disinfectants, logistics and financial resources)

-   To verify any rumour of disease outbreak and carry out outbreak
    investigation

-   To recommend appropriate strategies and measures for the rapid
    containment of epidemics to the local outbreak response teams

-   To coordinate the implementation of the plan of action and
    participate actively in the implementation of epidemic prevention
    and control strategies

-   To provide technical support to the health facilities during
    outbreaks/epidemics

-   To monitor and evaluate overall preparedness, investigation and
    response to ensure documentation of all outbreaks

-   To coordinate communication and activities

**Directorate: Communicable Disease Control (CDC) \[National and
Provincial\]**

-   Coordinate Epidemic Preparedness and Response (EPR) and
    epidemiological investigation at appropriate level \[s\] of the
    health care systems

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-   Develop guidelines on control, prevention and management of
    influenza

-   Coordinate activities e.g. rumour verification, early detection,
    outbreak investigation, case management and epidemic preparedness
    and response

-   Provide technical support to appropriate level\[s\] on the control,
    prevention and treatment of epidemic-prone infectious diseases

-   Facilitate and support laboratory surveillance activities for early
    detection of outbreaks and monitoring of circulating pathogenic
    strains

-   Develop mechanisms for systematic monitoring and evaluation of
    strategic plans of EPR on influenza at appropriate level\[s\] and
    feedback

-   Liaise with other programmes, government departments and other
    partners

-   Participate in inter-country epidemic preparedness and response
    activities, e.g. SADC EPR Initiatives

-   Facilitate resource mobilisation (human, financial, infrastructure,
    etc) for rapid response and timely preparedness

-   Facilitate cooperation with international agencies at appropriate
    levels

-   Develop and disseminate information of disease outbreaks to the
    public, managers, and appropriate level\[s\]

-   Prepare and submit reports/information to strategic managers and
    political heads and structures such as the Directors General,
    Minister, parliament, cabinet, etc.

**Directorate: Epidemiology with NICD**

-   Surveillance (data collection, capturing, cleaning, analysis and
    presentation) for rapid response and systematic investigation and
    management of the pandemic.

-   Ensure that an Early Warning System for potential outbreaks is
    established and functional for early detection of potential
    epidemics.

-   Disseminate data for prompt and appropriate response, to all levels
    of the health system and international organisations, in the form of
    reports, website, etc. timeously

-   Collect and disseminate data, on a daily basis during an outbreak,
    for prevention and control purposes

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-   Conduct epidemiological investigations, and develop reports on the
    epidemiology of the disease outbreak

-   Develop mechanisms for systematic monitoring and evaluation of
    strategic surveillance plans for influenza in the region and provide
    feedback

-   Provide technical support to provincial and district health
    information managers

-   Support in epidemic intelligence (rumour verification, clinical
    surveillance of suspected cases, laboratory surveillance for
    confirmed cases, investigation, control and prevention)

**Directorate: Health Promotion \[National and Province\]**

-   Coordinate health promotion messages at national level

-   Develop and distribute information, education and communication
    \[IEC\] materials, e.g. poster, pamphlets and audio-visuals, for
    public awareness in all relevant settings including bordering
    communities.

-   Increase public awareness on risk of influenza and pandemic through
    electronic media, television, radio, and internet

-   Develop active community participation strategies \[excluding large
    gatherings\], and ensure community involvement during outbreaks

-   Train health promotion practitioners on the various techniques
    useful for attitude and behavioural change, healthy life styles and
    disease prevention

-   Involve community-based organisations \[CBOs\], non-governmental
    organisations \[NGOs\] and community health workers in outbreak
    response

-   Promote voluntary isolation

-   Inform workers at ports of entry

**Directorate: Environmental Health \[National and Province\]**

-   Conduct environmental assessment and management of risk factors
    predisposing individuals to influenza

-   Coordinate port health activities, e.g. isolate suspected cases and
    inform masters of vessels, pilots and other relevant persons at
    ground crosses on prevention and best management practices of
    suspected cases

**Directorate: Food Control \[National and Provincial\]**

-   Play a central role in the implementation of Food Control
    Regulations to prevent foodborne diseases and provide technical and
    legal support in case of food borne or related outbreaks

-   Coordinate food recall activities during food-borne outbreaks

-   Collaborate with the Department of Agriculture on food-related
    issues

**Cluster: Communication \[National and Provincial\]**

-   Work together with the Department of Communications as media liaison
    between Departments \[especially the Department of Tourism\], health
    partners and the public in a coordinated way

-   Develop communication protocols and routines: patients
    confidentiality, press releases and briefings and clear
    misconceptions

-   Manage foreign and international communications in order to protect
    and maintain diplomatic ties with other countries

-   Develop strategies in case of an outbreak, epidemic or pandemic

-   Develop a communication strategy for both government and private
    sector

**Directorate: Human Resources \[All Levels and Sectors\]**

-   Facilitate capacity development of members of the team and relevant
    employees

-   Facilitate technical support and training on epidemic preparedness
    and response to outbreak response teams

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-   Motivate for availability of human resources \[contingency plan\]
    during an outbreak

**Directorate: Health Information Systems \[National and Provincial\]**

-   Ensure that health information systems for information flow, during
    and in the absence of epidemics, are implemented

-   Publish information on disease outbreaks daily on the Departmental
    Website and Intranet

-   Health information should be transparent ands accessible to allow
    rapid response

**Directorate: Pharmaceutical Policy and Planning \[National
Provincial\]**

-   Ensure the provision of medical supplies before and during
    outbreaks, e.g. drugs, vaccines,

-   Ensure that influenza vaccine is on the primary level Essential Drug
    List \[EDL\] and available at that level

-   Encourage seasonal influenza vaccination

-   Develop strategies for securing of drugs and deployment of
    antivirals and vaccines as part of preparedness, if so required

-   Implement, monitor and evaluate drug levels and deployment of
    antivirals, vaccines and other related resources

-   Negotiate with industry on capacity, availability and equity issues

**Directorate: Emergency Medical Services and Disaster Management \[All
Levels\]**

-   Coordinate transportation of patients and coordination of designated
    facilities

-   Coordination of all EMS activities, both private and public

-   Play a role in incident management

-   Assist other disciplines with planning and implementation of
    preventive, operational and contingency plans

-   Audit of health facilities, both private and public

**Directorate: Hospital Management \[National and Province\]**

-   Prepare a list of designated hospitals with isolation facilities,
    and determine capacity per facility

-   Prepare contingency plans and ensure capacity for ventilators and
    other tertiary requirements for severe acute respiratory patients

-   Ensure infection control in designated facilities together with
    Quality Assurance Directorate

-   Prepare a list of mortuary \[not forensic\] capacity per province

**Directorate: Financial Management \[National\]**

-   Provide additional and emergency financial support

**South African Military Health Services**

-   Provide technical assistance, infrastructure and human resources
    during and in the absence of outbreaks on request

**Department of Finance \[National Treasury\]**

-   Make available emergency funding in case of an epidemic or a
    pandemic

**Department of Provincial and Local Government**

-   Finalise Disaster Management Plan and oversee implementation

-   Participate in outbreak control

-   Provide a list of all private burial services per local government
    and their capacity

-   Provide safe drinking water together the Department of Water Affairs
    and Forestry

**Department of Agriculture**

-   Provide legal framework for notification of animal diseases

-   Provide surveillance and information sharing on zoonotic diseases

-   Coordinate the investigation and control of outbreaks related to
    animals

-   Investigate compensation possibilities for loss of infected stock by
    culling

-   Develop risk communication strategy

-   Ensure stock movement and control

**Department of Social Development**

-   Ensure the availability of basic social needs during outbreaks

-   Community mobilisation and support

**Department of Safety and Security**

-   Ensure safety and order in the case of unrest due to outbreaks

**Department of Home Affairs**

-   Manage movements across the borders

**Department of Education**

-   Social mobilisation and involvement in health promotion activities

-   Manage closure of educational facilities, if required

**Department of Foreign Affairs**

-   Ensure diplomatic relations

-   Mobilisation of international assistance

-   Dissemination of information to embassies /missions abroad and
    foreign missions in South Africa

-   Assist with cross-border communication and control

-   Establish call center for South Africans abroad and foreign
    nationals

**Department of Correctional Services**

-   Inform prisoners and visitors regarding the risk of the pandemic

-   Improve health promotion activities

-   Arrange for case management, and hospital admissions and isolation

**Private Health Sector**

-   Provide a plan for relevant support (laboratories, specialists,
    infrastructure, etc) to the Department of Health to ensure Public
    Private Partnership and multisectoral initiatives are well
    implemented and coordinated

**International Organisations \[WHO, CDC, etc\]**

-   Provide support (laboratories, specialists, infrastructure, funds,
    etc) to South Africa

**Southern African Development Community (SADC)**

-   Participate in SADC EPR activities to strengthen cross-border and
    inter-country epidemic preparedness and response strategies.

-   Strengthen mechanisms for increasing social mobilisation and ensure
    active country participation in the region

**ALL DEPARTMENTS SHOULD HAVE THEIR OWN CONTIGENCY PLAN**

These terms of reference are expected to be dynamic in nature and should
be continuously reviewed, given the nature of the disease and methods to
manage it. The involvement of various stakeholders will also be
determined by the nature of the outbreak, epidemic or pandemic**.**

**8 NEW PHASES AND OVERARCHING PUBLIC HEALTH GOALS**

**8.1 Pandemic Periods**

For international planning purposes, the WHO has defined phases in the
progression of an influenza pandemic from the first emergence of a novel
influenza virus, to wide international spread. These phases allow a
step-wise escalating approach to preparedness planning and response.
They are global classifications based on the overall international
situation and are used internationally for planning purposes.

####### A. Interpandemic period

**Phase 1**

No new influenza virus subtypes have been detected in humans. An
influenza virus subtype that has caused human infection may be present
in animals. If present in animals, the risk of human infection or
disease is considered to be low.

-   **Strengthen influenza pandemic preparedness at the global,
    regional, national and sub-national levels.**

**Phase 2**

No new influenza virus subtypes have been detected in humans. However, a
circulating animal influenza virus subtype poses a substantial risk of
human disease.

-   **Minimize the risk of transmission to humans; detect and report
    such transmission rapidly if it occurs.**

####### B. Pandemic Alert Period

**Phase 3**

Human infection(s) with a new subtype, but no human-to-human spread, or
at most rare instances of spread to a close contact.

-   **Ensure rapid characterization of the new virus subtype and early
    detection, notification and response to additional cases.**

**Phase 4**

Small cluster(s) with limited human-to-human transmission but spread is
highly localized, suggesting that the virus is not well adapted to
humans.

-   **Contain the new virus within limited foci or delay spread to gain
    time to implement preparedness measures, including vaccine
    development**

**Phase 5**

Larger cluster(s) but human-to-human spread still localized, suggesting
that the virus is becoming increasingly better adapted to humans, but
may not yet be fully transmissible (substantial pandemic risk).

-   **Maximize efforts to contain or delay spread, to possibly avert a
    pandemic, and to gain time to implement pandemic response
    measures**.

####### C. Pandemic Period

**Phase 6**

Pandemic: increased and sustained transmission in general population

-   **Minimize the impact of the pandemic.**

a.  The distinction between ***phase 1*** and ***phase 2*** is based on
    the risk of human infection or disease resulting from circulating
    strains in animals. The distinction is based on various factors and
    their relative importance according to current scientific knowledge.
    Factors may include pathogenicity in animals and humans, occurrence
    in domesticated animals and livestock or only in wildlife, whether
    the virus is enzootic or epizootic, geographically localized or
    widespread, and/or other scientific parameters.

b.  The distinction between ***phase 3***, ***phase 4*** and ***phase
    5*** is based on an assessment of the risk of a pandemic. Various
    factors and their relative importance according to current
    scientific knowledge may be considered. Factors may include rate of
    transmission, geographical location and spread, severity of illness,
    presence of genes from human strains (if derived from an animal
    strain), and/or other scientific parameters.

> **NB: Annexure A gives detailed objectives and activities during the
> different phases of the pandemic.**

**ANNEXURE A: OVERARCHING GOALS, OBJECTIVES AND ACTIVITIES BY PHASES**

**Interpandemic Period: Phase 1**

**Overarching Goal: Strengthen Influenza Pandemic Preparedness**

+------------------------+--------------------------+------------+-----+
| **Planning and         |                          |            |     |
| Coordination**         |                          |            |     |
+------------------------+--------------------------+------------+-----+
| Objectives             | Activities               | R          | C   |
|                        |                          | esponsible | ost |
|                        |                          |            | \[  |
|                        |                          |            | Ran |
|                        |                          |            | d\] |
+------------------------+--------------------------+------------+-----+
| -   Develop and        | -   Establish and        | -   NORT   |     |
|     maintain national  |     strengthen           |     and    |     |
|     pandemic           |     multisectoral        |            |     |
|     contingency plans  |     influenza pandemic   |  Provinces |     |
|                        |     committees at all    |            |     |
| -   Promote early      |     levels of care       | -   NORT   |     |
|     reporting of new   |                          |            |     |
|     influenza viruses, | -   Advocate             | -   NORT,  |     |
|     mobilise, and      |     preparedness plans   |     EMS    |     |
|     develop effective  |     to top               |     and    |     |
|     resource           |     decision-makers in   |            |     |
|     mobilisation       |     government and with  |  Provinces |     |
|     mechanisms for     |     relevant partners in |     and    |     |
|     early response     |     and outside the      |     Local  |     |
|                        |     health sector        |     Gov    |     |
| -   Develop mechanisms |                          |            |     |
|     for                | -   Identify and train   | -   NICD   |     |
|     decision-making    |     key personnel to be  |            |     |
|     for rapid response |     mobilised in case of | -   Pharm  |     |
|     through            |     emergency            |     Policy |     |
|     intersectoral and  |                          |            |     |
|     multidisciplinary  | -   Ensure good          |  Planning, |     |
|     collaboration      |     laboratory and       |     NHLS   |     |
|                        |     clinical             |     and    |     |
|                        |     surveillance of      |     EMS    |     |
|                        |     novel strains of     |            |     |
|                        |     influenza            | -          |     |
|                        |                          |    Cabinet |     |
|                        | -   Consider the         |            |     |
|                        |     development of       | -   GCIS   |     |
|                        |     domestic stockpile   |     and    |     |
|                        |     (antivirals,         |     Comm   |     |
|                        |     vaccines, protective | unications |     |
|                        |     clothing, laboratory |            |     |
|                        |     diagnostics and      |            |     |
|                        |     other technical      |            |     |
|                        |     support) for rapid   |            |     |
|                        |     deployment,          |            |     |
|                        |     including a          |            |     |
|                        |     management and       |            |     |
|                        |     distribution plan    |            |     |
|                        |                          |            |     |
|                        | -   Consider providing   |            |     |
|                        |     support to           |            |     |
|                        |     resource-poor        |            |     |
|                        |     countries with foci  |            |     |
|                        |     of influenza         |            |     |
|                        |     activity             |            |     |
|                        |                          |            |     |
|                        | -   Develop a risk       |            |     |
|                        |     communication plan   |            |     |
+------------------------+--------------------------+------------+-----+

+-----------------------+---+--------------------------+---+-----------+-----+
| **Situation           |   |                          |   |           |     |
| Monitoring and        |   |                          |   |           |     |
| Assessment**          |   |                          |   |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+
| Objectives            | A |                          | R |           | C   |
|                       | c |                          | e |           | ost |
|                       | t |                          | s |           | \[  |
|                       | i |                          | p |           | Ran |
|                       | v |                          | o |           | d\] |
|                       | i |                          | n |           |     |
|                       | t |                          | s |           |     |
|                       | i |                          | i |           |     |
|                       | e |                          | b |           |     |
|                       | s |                          | l |           |     |
|                       |   |                          | e |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+
| -   Maintain updated  | - |                          | - |           |     |
|     information on    |   |                          |   |           |     |
|     trends in human   |   |                          |   |           |     |
|     infection with    |   |                          |   |           |     |
|     seasonal strains  | D |                          | E |           |     |
|     of influenza      | e |                          | p |           |     |
|                       | v |                          | i |           |     |
| -   Identify          | e |                          | d |           |     |
|     potential human   | l |                          | e |           |     |
|     and animal        | o |                          | m |           |     |
|     sources of        | p |                          | i |           |     |
|     infection and     |   |                          | o |           |     |
|     assess risk       |   |                          | l |           |     |
|                       |   |                          | o |           |     |
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+-----------------------+---+--------------------------+---+-----------+-----+
| **Prevention and      |   |                          |   |           |     |
| Containment**         |   |                          |   |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+
| Objectives            |   | Activities               |   | Re        | C   |
|                       |   |                          |   | sponsible | ost |
|                       |   |                          |   |           | \[  |
|                       |   |                          |   |           | Ran |
|                       |   |                          |   |           | d\] |
+-----------------------+---+--------------------------+---+-----------+-----+
| -   Agree in advance  |   | -   Develop national     |   | -   NORT, |     |
|     on a range of     |   |     guidelines for       |   |     CDC   |     |
|     strategies based  |   |     public health        |   |           |     |
|     on                |   |     interventions, and   |   | -   Pharm |     |
|                       |   |     discuss them with    |   |           |     |
|    non-pharmaceutical |   |     aut                  |   |  Planning |     |
|     public health     |   | horities/decision-makers |   |           |     |
|     actions           |   |     in and outside the   |   |    Policy |     |
|                       |   |     health sectors       |   |           |     |
| -   Develop           |   |                          |   | -   Pharm |     |
|     strategies for    |   | -   Develop table-top    |   |           |     |
|     stockpiling of    |   |     exercises and use    |   |  Planning |     |
|     antivirals and    |   |     plans to improve     |   |           |     |
|     vaccines,         |   |     strategies/plans,    |   |    Policy |     |
|     deployment        |   |     e.g. stockpiling     |   |           |     |
|                       |   |                          |   | -   Pharm |     |
|   strategies/criteria |   | -   Set priorities and   |   |           |     |
|                       |   |     criteria for         |   |  Planning |     |
|                       |   |     deployment and use   |   |           |     |
|                       |   |     of antivirals and    |   |    Policy |     |
|                       |   |     vaccines during      |   |           |     |
|                       |   |     pandemic alert and   |   | -   Pham  |     |
|                       |   |     pandemic periods     |   |     Plan  |     |
|                       |   |                          |   |           |     |
|                       |   | -   Consider             |   |    Policy |     |
|                       |   |     participating in     |   |           |     |
|                       |   |     research for         |   | -   Pharm |     |
|                       |   |     antiviral resistance |   |     Plan  |     |
|                       |   |     and vaccine          |   |           |     |
|                       |   |     production           |   |    Policy |     |
|                       |   |                          |   |           |     |
|                       |   | -   Explore strategies   |   |           |     |
|                       |   |     for vaccine access   |   |           |     |
|                       |   |     from producing       |   |           |     |
|                       |   |     countries, through   |   |           |     |
|                       |   |     bilateral agreements |   |           |     |
|                       |   |                          |   |           |     |
|                       |   | -   Negotiate with       |   |           |     |
|                       |   |     industry to increase |   |           |     |
|                       |   |     capacity             |   |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+

+-----------------------+---+--------------------------+---+-----------+-----+
| **Health System       |   |                          |   |           |     |
| response**            |   |                          |   |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+
| Objectives            | A |                          | R |           | C   |
|                       | c |                          | e |           | ost |
|                       | t |                          | s |           | \[  |
|                       | i |                          | p |           | Ran |
|                       | v |                          | o |           | d\] |
|                       | i |                          | n |           |     |
|                       | t |                          | s |           |     |
|                       | i |                          | i |           |     |
|                       | e |                          | b |           |     |
|                       | s |                          | l |           |     |
|                       |   |                          | e |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+
| -   Ensure up-to-date | - |                          | - |           |     |
|     contingency plans |   |                          |   |           |     |
|     and strategies    |   |                          |   |           |     |
|     are in place for  |   |                          |   |           |     |
|     pandemic response | I |                          | N |           |     |
|     in the            | n |                          | O |           |     |
|     health-care       | v |                          | R |           |     |
|     sector            | o |                          | T |           |     |
|                       | l |                          |   |           |     |
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|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       | l |                          |   |           |     |
|                       | i |                          |   |           |     |
|                       | s |                          |   |           |     |
|                       | t |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       | m |                          |   |           |     |
|                       | a |                          |   |           |     |
|                       | d |                          |   |           |     |
|                       | e |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       |   |                          |   |           |     |
|                       | a |                          |   |           |     |
|                       | v |                          |   |           |     |
|                       | a |                          |   |           |     |
|                       | i |                          |   |           |     |
|                       | l |                          |   |           |     |
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|                       | b |                          |   |           |     |
|                       | l |                          |   |           |     |
|                       | e |                          |   |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+
| **Communication**     |   |                          |   |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+
| Objectives            |   | Activities               |   | Re        | C   |
|                       |   |                          |   | sponsible | ost |
|                       |   |                          |   |           | \[  |
|                       |   |                          |   |           | Ran |
|                       |   |                          |   |           | d\] |
+-----------------------+---+--------------------------+---+-----------+-----+
| -   Develop           |   | -   Establish            |   | -   NORT, |     |
|     communication     |   |     communication        |   |     Commu |     |
|     strategies        |   |     strategy and         |   | nications |     |
|     between health    |   |     infrastructure       |   |           |     |
|     authorities,      |   |                          |   | -         |     |
|     partners and      |   | -   Establish            |   |    ORT's, |     |
|     public            |   |     communication        |   |     Comm  |     |
|                       |   |     networks among       |   | unication |     |
| -   Ensure            |   |     stakeholders         |   |           |     |
|     collaboration     |   |                          |   | -   Commu |     |
|     between           |   | -   Familiarise media    |   | nications |     |
|     government,       |   |     with preparedness    |   |           |     |
|     partners and      |   |     and response         |   | -   NORT, |     |
|     public and        |   |     measures             |   |     Commu |     |
|     develop clear     |   |                          |   | nications |     |
|     roles and         |   | -   Develop feedback     |   |           |     |
|     responsibility    |   |     mechanisms for       |   |           |     |
|                       |   |     public, address      |   |           |     |
|                       |   |     rumours and correct  |   |           |     |
|                       |   |     misinformation       |   |           |     |
+-----------------------+---+--------------------------+---+-----------+-----+

**NORT -- National Outbreak Response Team, ORT -- Outbreak Response
Team, NICD - National Institute for Communicable Diseases, NHLS --
National Health Laboratory Service, JOC -- Joint Operations Committee**

**Interpandemic Period: Phase 2**

**Overarching Goal: Minimise Risk of Transmission to Humans, Early
Detection and Reporting**

+------------------------+--------------------------+-----------+-----+
| **Planning and         |                          |           |     |
| Coordination**         |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Ensure a           | -   Activate joint       | -   NORT, |     |
|     heightened         |     mechanisms of action |     CDC   |     |
|     response capacity  |     with animal health   |           |     |
|     to address         |     authorities and      | -   NORT, |     |
|     possible human     |     other relevant       |     CDC   |     |
|     cases              |     stakeholders         |           |     |
|                        |                          | -   NORT, |     |
| -   Coordinate         | -   Assess preparedness  |     CDC   |     |
|     implementation of  |     status and identify  |           |     |
|     measures in close  |     immediate actions to | -   NORT, |     |
|     collaboration with |     address gaps \[use   |     Pharm |     |
|     animal health      |     WHO checklist\]      |     Plan  |     |
|     authorities to     |                          |           |     |
|     minimise risk of   | -   Ensure ability to    |    Policy |     |
|     human infection    |     mobilise and rapidly |           |     |
|                        |     deploy multisectoral |           |     |
|                        |     expert response team |           |     |
|                        |                          |           |     |
|                        | -   Ensure ability to    |           |     |
|                        |     rapidly deploy       |           |     |
|                        |     stockpile resources  |           |     |
|                        |     from national or     |           |     |
|                        |     international        |           |     |
|                        |     sources, according   |           |     |
|                        |     to risk assessment   |           |     |
+------------------------+--------------------------+-----------+-----+

+-----------------------+--------------------------+-----------+-----+
| **Situation           |                          |           |     |
| Monitoring and        |                          |           |     |
| Assessment**          |                          |           |     |
+-----------------------+--------------------------+-----------+-----+
| Objectives            | Activities               | Re        | C   |
|                       |                          | sponsible | ost |
|                       |                          |           | \[  |
|                       |                          |           | Ran |
|                       |                          |           | d\] |
+-----------------------+--------------------------+-----------+-----+
| -   Identify          | -   Implement human and  | -         |     |
|     interspecies      |     animal health        |    Health |     |
|     transmission at   |     surveillance and     |     \[All |     |
|     an early stage    |     report to national   |     Faci  |     |
|     and report to WHO |     and international    | lities\], |     |
|     and other         |     authorities          |     NICD, |     |
|     authorities       |                          |     Agric |     |
|                       | -   Transmit             |           |     |
| -   Provide ongoing   |     representative       | -         |     |
|     risk assessment   |     isolates to national |    Health |     |
|     for transmission  |     and international    |     \[All |     |
|     of viruses with   |     reference            |           |     |
|     pandemic          |     laboratories for     | Levels\], |     |
|     potential to      |     confirmation,        |     Agric |     |
|     humans            |     characterisation,    |           |     |
|                       |     reagent and vaccine  | -   NICD, |     |
|                       |     development          |     Epid  |     |
|                       |                          |     and   |     |
|                       | -   Conduct              |     Agric |     |
|                       |     la                   |           |     |
|                       | boratory/epidemiological | -   Epid, |     |
|                       |     field investigation  |     NICD, |     |
|                       |     in the affected      |     CDC,  |     |
|                       |     areas                |     agric |     |
|                       |                          |           |     |
|                       | -   Participate actively | -   NICD, |     |
|                       |     in assessment of     |     Epid  |     |
|                       |     risk of transmission |     and   |     |
|                       |                          |     Agric |     |
|                       | -   Ensure expertise and |           |     |
|                       |     virological          | -   NICD, |     |
|                       |     surveillance in      |     Epid  |     |
|                       |     national             |     and   |     |
|                       |     laboratories         |     Agric |     |
|                       |     according to         |           |     |
|                       |     international        | -   NICD, |     |
|                       |     standards \[WHO      |     Epid  |     |
|                       |     standards\]          |     and   |     |
|                       |                          |     Agric |     |
|                       | -   Continue to collect  |           |     |
|                       |     and exchange virus   |           |     |
|                       |     isolates and other   |           |     |
|                       |     scientific           |           |     |
|                       |     information with     |           |     |
|                       |     partner organisation |           |     |
|                       |                          |           |     |
|                       | -   Conduct serological  |           |     |
|                       |     surveillance of      |           |     |
|                       |     farmers and their    |           |     |
|                       |     families, animal     |           |     |
|                       |     workers and selected |           |     |
|                       |     family members       |           |     |
|                       |     involved in animal   |           |     |
|                       |     influenza outbreak   |           |     |
+-----------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+-----------+-----+
| **Prevention and       |                          |           |     |
| Containment**          |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   To minimise risk   | -   Ensure optimal       | -         |     |
|     of human infection |     response to animal   |    Health |     |
|     from contact with  |     outbreaks and ensure |     Promo |     |
|     infected animals   |     minimum infection of |     and   |     |
|                        |     response team        |     Agric |     |
| -   Assess national    |                          |           |     |
|     availability of    | -   Recommend measures   | -         |     |
|     antiviral drugs    |     to reduce human      |    Health |     |
|                        |     contact with         |           |     |
| -   Reduce risk of     |     potentially infected |    Promo, |     |
|     co-infection in    |     animals, and prepare |           |     |
|     humans to minimise |     use of further       |    Agric, |     |
|     virus reassortment |     intervention if      |     Local |     |
|                        |     humans are infected  |     Gov   |     |
|                        |                          |           |     |
|                        | -   Update information   | -   Pharm |     |
|                        |     on available         |     Plan  |     |
|                        |     supplies of          |           |     |
|                        |     antivirals,          |    Policy |     |
|                        |     prophylaxis and      |           |     |
|                        |     vaccines             | -   Pharm |     |
|                        |                          |     Plan  |     |
|                        | -   Ensure national      |           |     |
|                        |     stockpile strategy   |   Policy, |     |
|                        |     for deployment at    |     NORT  |     |
|                        |     provincial, district |           |     |
|                        |     and municipal level  | -   Pharm |     |
|                        |                          |     Plan  |     |
|                        | -   Develop contingency  |           |     |
|                        |     plans for procuring  |    Policy |     |
|                        |     seasonal/specific    |           |     |
|                        |     vaccines for         | -   Epid, |     |
|                        |     distribution         |     NORT, |     |
|                        |                          |     NICD, |     |
|                        | -   Establish mechanisms |     Agric |     |
|                        |     for exchange of      |           |     |
|                        |     epidemiological and  |           |     |
|                        |     virological data     |           |     |
+------------------------+--------------------------+-----------+-----+

+-----------------------+--------------------------+------------+-----+
| **Health System       |                          |            |     |
| Response**            |                          |            |     |
+-----------------------+--------------------------+------------+-----+
| Objectives            | Activities               | R          | C   |
|                       |                          | esponsible | ost |
|                       |                          |            | \[  |
|                       |                          |            | Ran |
|                       |                          |            | d\] |
+-----------------------+--------------------------+------------+-----+
| -   Ensure that if    | -   Alert local health   | -   NORT,  |     |
|     human infections  |     care providers to    |     NICD,  |     |
|     occur, they will  |     consider new         |     CDC    |     |
|     be quickly        |     influenza infection  |            |     |
|     recognised and    |     in ill patients with | -   NORT,  |     |
|     that health       |     epidemiological link |     Pro    |     |
|     systems will      |     to affected animals  | v/District |     |
|     responsed         |                          |     ORT    |     |
|     appropriately     | -   Implement infection  |            |     |
|                       |     control measures,    | -   Pro    |     |
|                       |     report cases         | v/District |     |
|                       |     immediately and      |     ORT    |     |
|                       |     provide algorithms   |            |     |
|                       |     to assist in         | -   NHLS   |     |
|                       |     case-finding and     |            |     |
|                       |     management           | -   NORT,  |     |
|                       |                          |     CDC    |     |
|                       | -   Verify availability  |            |     |
|                       |     and distribution     | -   Prov   |     |
|                       |     procedures for       |     ORT    |     |
|                       |     personal protective  |            |     |
|                       |     equipment,           |            |     |
|                       |     antivirals and       |            |     |
|                       |     vaccines             |            |     |
|                       |                          |            |     |
|                       | -   Ensure rapid         |            |     |
|                       |     deployment of        |            |     |
|                       |     diagnostic tests or  |            |     |
|                       |     transportation of    |            |     |
|                       |     specimen to          |            |     |
|                       |     laboratories         |            |     |
|                       |                          |            |     |
|                       | -   Alert health system  |            |     |
|                       |     to review            |            |     |
|                       |     preparedness plans   |            |     |
|                       |     and prepare for      |            |     |
|                       |     small numbers of     |            |     |
|                       |     patients for         |            |     |
|                       |     isolation            |            |     |
|                       |                          |            |     |
|                       | -   Assess health system |            |     |
|                       |     capacity to detect   |            |     |
|                       |     and contain outbreak |            |     |
|                       |     of human disease in  |            |     |
|                       |     hospital setting     |            |     |
+-----------------------+--------------------------+------------+-----+

+------------------------+--------------------------+-----------+-----+
| **Communication**      |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Ensure that        | -   Establish rapid      | -         |     |
|     appropriate        |     communications to    |    Health |     |
|     information is     |     answer questions     |     P     |     |
|     shared rapidly     |     from health care     | romotion, |     |
|     among health       |     providers and the    |     Comm  |     |
|     authorities and    |     public               | unication |     |
|     other partners     |                          |           |     |
|                        | -   Communicate          | -         |     |
| -   Ensure that        |     information on risk  |    Health |     |
|     messages are       |     and prevention       |     P     |     |
|     coordinated and    |     \[risk of infection, | romotion, |     |
|     standardised       |     safe food, animal    |     Commu |     |
|                        |     handling\] based on  | nication, |     |
|                        |     WHO recommendations  |     Agric |     |
|                        |                          |           |     |
|                        | -   Address possible     | -         |     |
|                        |     stigmatisation of    |    Health |     |
|                        |                          |     P     |     |
|                        |  individuals/populations | romotion, |     |
|                        |     in contact with      |     Commu |     |
|                        |     animal strain        | nication, |     |
|                        |                          |     Agric |     |
|                        | -   Update national      |           |     |
|                        |     authorities, other   | -         |     |
|                        |     partners and         |    Health |     |
|                        |     stakeholders,        |     P     |     |
|                        |     including at-risk    | romotion, |     |
|                        |     groups and public ,  |     Comm  |     |
|                        |     with current         | unication |     |
|                        |     information on virus |           |     |
|                        |     spread and risk to   |           |     |
|                        |     humans               |           |     |
+------------------------+--------------------------+-----------+-----+

**Pandemic Alert Period: Phase 3**

**Overarching Goal: Ensure rapid characterisation of the New Virus
Subtype and Early Detection, Notification and Rapid Response**

+------------------------+--------------------------+------------+-----+
| **Planning and         |                          |            |     |
| Coordination**         |                          |            |     |
+------------------------+--------------------------+------------+-----+
| Objectives             | Activities               | R          | C   |
|                        |                          | esponsible | ost |
|                        |                          |            | \[  |
|                        |                          |            | Ran |
|                        |                          |            | d\] |
+------------------------+--------------------------+------------+-----+
| -   Coordinate timely  | -   Activate national    | -   NORT,  |     |
|     interventions to   |     pandemic contingency |     CDC    |     |
|     reduce the risk of |     planning             |            |     |
|     onset of pandemic  |     arrangements         | -   NORT,  |     |
|                        |                          |     Pro    |     |
| -   Ensure that        | -   Implement            | v/District |     |
|     mechanisms exist   |     interventions to     |     ORT    |     |
|     so that imminent   |     reduce burden in the |            |     |
|     potential human    |     initial foci and     | -   NORT , |     |
|     health threats can |     contain or delay the |     Comm   |     |
|     be recognised and  |     spread of infection  | unications |     |
|     dealt with         |                          |            |     |
|                        | -   Brief appropriate    | -          |     |
|                        |     officials in all     |            |     |
|                        |     relevant government  | -   NORT,  |     |
|                        |     departments (e.g.    |     CDC    |     |
|                        |     health, agriculture, |            |     |
|                        |     legislative) at all  |            |     |
|                        |     levels of governance |            |     |
|                        |                          |            |     |
|                        | -   Provide assistance   |            |     |
|                        |     to provincial and    |            |     |
|                        |     district authorities |            |     |
|                        |     in implementing      |            |     |
|                        |     interventions        |            |     |
+------------------------+--------------------------+------------+-----+

+-----------------------+--------------------------+-----------+-----+
| **Situation           |                          |           |     |
| Monitoring and        |                          |           |     |
| Assessment**          |                          |           |     |
+-----------------------+--------------------------+-----------+-----+
| Objectives            | Activities               | Re        | C   |
|                       |                          | sponsible | ost |
|                       |                          |           | \[  |
|                       |                          |           | Ran |
|                       |                          |           | d\] |
+-----------------------+--------------------------+-----------+-----+
| -   Early detection   | -   Confirm and report   | -   Epid  |     |
|     and reporting of  |     cases promptly,      | emiology, |     |
|     human-to-human    |     excluding laboratory |     NICD  |     |
|     transmission and  |     incidents and        |           |     |
|     identification of |     intentionally        | -   NICD, |     |
|     risk factors      |     released cases       |     Epi   |     |
|                       |                          | demiology |     |
|                       | -   Determine the        |           |     |
|                       |     epidemiology of      | -   NORT, |     |
|                       |     human cases          |     NICD  |     |
|                       |     \[sources,           |           |     |
|                       |     incubation periods,  | -   CDC,  |     |
|                       |     infection of         |     NICD, |     |
|                       |     contacts, period of  |     ORTs  |     |
|                       |     communicability\]    |           |     |
|                       |                          | -   NICD  |     |
|                       | -   Establish national   |           |     |
|                       |     case definition      | -   Epid  |     |
|                       |     based on WHO         | emiology, |     |
|                       |     guidelines           |           |     |
|                       |                          |    Agric, |     |
|                       | -   Assess clinical      |     NICD  |     |
|                       |     characterisation of  |           |     |
|                       |     infections in humans | -   CDC,  |     |
|                       |     and share with       |     ORTs, |     |
|                       |     relevant             |     Agric |     |
|                       |     authorities/partners |           |     |
|                       |                          | -         |     |
|                       | -   Ensure rapid         |    Health |     |
|                       |     characterisation of  |     care  |     |
|                       |     viruses responsible  |           |     |
|                       |     for human infection, |  Workers, |     |
|                       |     and share            |     QA,   |     |
|                       |     information with     |     Hosp  |     |
|                       |     partners             |           |     |
|                       |                          |  services |     |
|                       | -   Enhance human/animal |           |     |
|                       |     surveillance and     |           |     |
|                       |     collaborate with     |           |     |
|                       |     international        |           |     |
|                       |     partners in          |           |     |
|                       |     assessing the        |           |     |
|                       |     pathogenicity in     |           |     |
|                       |     humans               |           |     |
|                       |                          |           |     |
|                       | -   Identify             |           |     |
|                       |     geographical areas   |           |     |
|                       |     and risk groups for  |           |     |
|                       |     targeting with       |           |     |
|                       |     preventive measures  |           |     |
|                       |                          |           |     |
|                       | -   Assess effectiveness |           |     |
|                       |     of treatment         |           |     |
|                       |     protocols and        |           |     |
|                       |     infection control    |           |     |
|                       |     measures and conduct |           |     |
|                       |     sero-prevalence      |           |     |
|                       |     studies in risk      |           |     |
|                       |     groups and expand to |           |     |
|                       |     general population   |           |     |
|                       |     \[sy                 |           |     |
|                       | mptomatic/asymptomatic\] |           |     |
+-----------------------+--------------------------+-----------+-----+

+------------------------+---+--------------------------+-----------+-----+
| **Health Systems       |   |                          |           |     |
| Response**             |   |                          |           |     |
+------------------------+---+--------------------------+-----------+-----+
| Objectives             |   | Activities               | Re        | C   |
|                        |   |                          | sponsible | ost |
|                        |   |                          |           | \[  |
|                        |   |                          |           | Ran |
|                        |   |                          |           | d\] |
+------------------------+---+--------------------------+-----------+-----+
| -   Prevent nosocomial |   | -   Activate JOC's and   | -         |     |
|     transmission and   |   |     ORT's                |    JOC's, |     |
|     laboratory         |   |                          |     ORT's |     |
|     infection          |   | -   Train health workers |           |     |
|                        |   |     to detect/identify   | -   CDC,  |     |
| -   Heighten awareness |   |     cases                |     NICD  |     |
|     among health care  |   |                          |           |     |
|     providers          |   | -   Implement infection  | -   NICD, |     |
|     regarding isolated |   |     control and ensure   |     QA,   |     |
|     cases or clusters  |   |     laboratory biosafety |     Hosp  |     |
|                        |   |                          |     serv  |     |
|                        |   | -   Explore strategies   |           |     |
|                        |   |     to fast-track        | -   Pharm |     |
|                        |   |     deployment of        |     Plan  |     |
|                        |   |     vaccines and         |           |     |
|                        |   |     prophylaxis          |    Policy |     |
|                        |   |                          |           |     |
|                        |   | -   Provide case         | -   CDC,  |     |
|                        |   |     definitions,         |     Hosp  |     |
|                        |   |     protocols and        |     Serv  |     |
|                        |   |     algorithms           |           |     |
|                        |   |                          | -   Hosp  |     |
|                        |   | -   Activate infection   |     Serv, |     |
|                        |   |     control committees   |     QA,   |     |
|                        |   |                          |     NICD  |     |
+------------------------+---+--------------------------+-----------+-----+
| **Prevention and       |   |                          |           |     |
| Containment**          |   |                          |           |     |
+------------------------+---+--------------------------+-----------+-----+
| Objectives             | A |                          | Re        | C   |
|                        | c |                          | sponsible | ost |
|                        | t |                          |           | \[  |
|                        | i |                          |           | Ran |
|                        | v |                          |           | d\] |
|                        | i |                          |           |     |
|                        | t |                          |           |     |
|                        | i |                          |           |     |
|                        | e |                          |           |     |
|                        | s |                          |           |     |
+------------------------+---+--------------------------+-----------+-----+
| -   Contain or reduce  | - |                          | -   CDC,  |     |
|     human-to-human     |   |                          |     ORTs, |     |
|     virus transmission |   |                          |           |     |
|                        |   |                          | -   Pharm |     |
| -   Limit morbidity    | A |                          |     Plan  |     |
|     and mortality      | c |                          |           |     |
|     associated with    | t |                          |    Policy |     |
|     current human      | i |                          |           |     |
|     infections         | v |                          | -   ORT's |     |
|                        | a |                          |           |     |
| -   Increase readiness | t |                          | -   CEOs  |     |
|     for possible       | e |                          |     of    |     |
|     pandemic           |   |                          |           |     |
|     development        |   |                          | Hospitals |     |
|                        |   |                          |           |     |
|                        |   |                          | -   NICD  |     |
|                        | J |                          |           |     |
|                        | o |                          | -   NORT  |     |
|                        | i |                          |           |     |
|                        | n |                          | -         |     |
|                        | t |                          |    Health |     |
|                        |   |                          |           |     |
|                        |   |                          |    Facil, |     |
|                        |   |                          |     QA,   |     |
|                        |   |                          |     CEO   |     |
|                        | O |                          |           |     |
|                        | p |                          |           |     |
|                        | e |                          |           |     |
|                        | r |                          |           |     |
|                        | a |                          |           |     |
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|                        |   |                          |           |     |
|                        | C |                          |           |     |
|                        | o |                          |           |     |
|                        | m |                          |           |     |
|                        | m |                          |           |     |
|                        | i |                          |           |     |
|                        | t |                          |           |     |
|                        | t |                          |           |     |
|                        | e |                          |           |     |
|                        | e |                          |           |     |
|                        | s |                          |           |     |
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|                        | f |                          |           |     |
|                        | o |                          |           |     |
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|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        | i |                          |           |     |
|                        | m |                          |           |     |
|                        | p |                          |           |     |
|                        | l |                          |           |     |
|                        | e |                          |           |     |
|                        | m |                          |           |     |
|                        | e |                          |           |     |
|                        | n |                          |           |     |
|                        | t |                          |           |     |
|                        | i |                          |           |     |
|                        | n |                          |           |     |
|                        | g |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        | i |                          |           |     |
|                        | n |                          |           |     |
|                        | f |                          |           |     |
|                        | e |                          |           |     |
|                        | c |                          |           |     |
|                        | t |                          |           |     |
|                        | i |                          |           |     |
|                        | o |                          |           |     |
|                        | n |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        | c |                          |           |     |
|                        | o |                          |           |     |
|                        | n |                          |           |     |
|                        | t |                          |           |     |
|                        | r |                          |           |     |
|                        | o |                          |           |     |
|                        | l |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        |   |                          |           |     |
|                        | p |                          |           |     |
|                        | r |                          |           |     |
|                        | o |                          |           |     |
|                        | c |                          |           |     |
|                        | e |                          |           |     |
|                        | d |                          |           |     |
|                        | u |                          |           |     |
|                        | r |                          |           |     |
|                        | e |                          |           |     |
|                        | s |                          |           |     |
+------------------------+---+--------------------------+-----------+-----+

+-----------------------+--------------------------+-----------+-----+
| **Communication**     |                          |           |     |
+-----------------------+--------------------------+-----------+-----+
| Objectives            | Activities               | Re        | C   |
|                       |                          | sponsible | ost |
|                       |                          |           | \[  |
|                       |                          |           | Ran |
|                       |                          |           | d\] |
+-----------------------+--------------------------+-----------+-----+
| -   Communicate       | -   Provide regular      | -   Epid, |     |
|     transparently and |     updates to WHO and   |     Comm, |     |
|     coherently with   |     other international  |     NICD  |     |
|     the public        |     and domestic         |           |     |
|     regarding         |     partners on the      | -   NORT, |     |
|     outbreak          |     national situation   |     ORT,  |     |
|     progression and   |                          |     CDC   |     |
|     management        | -   Identify target      |           |     |
|                       |     groups for delivery  | -   ORTs, |     |
| -   Ensure rapid      |     of key messages,     |     CDC,  |     |
|     sharing of        |     develop appropriate  |     H     |     |
|     appropriate       |     materials, format    |     Prom, |     |
|     information among |     and language options |     Comm  |     |
|     health            |                          |           |     |
|     authorities,      | -   Review and update    | -   Comm  |     |
|     other government  |     information          |           |     |
|     departments and   |     materials for news   |           |     |
|     partners          |     media, general       |           |     |
|                       |     public, health       |           |     |
|                       |     workers and policy   |           |     |
|                       |     makers               |           |     |
|                       |                          |           |     |
|                       | -   Review               |           |     |
|                       |     communications       |           |     |
|                       |     systems and          |           |     |
|                       |     facilities to ensure |           |     |
|                       |     that they are        |           |     |
|                       |     functioning          |           |     |
|                       |     optimally            |           |     |
+-----------------------+--------------------------+-----------+-----+

**Pandemic Alert Period: Phase 4**

**Overarching Goal: Contain New Virus and Delay Spread to Gain Time to
Implement Preparedness and Vaccine Development**

+------------------------+--------------------------+-----------+-----+
| **Planning and         |                          |           |     |
| Coordination**         |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Ensure that        | -   Ensure highest level | -   ORTs, |     |
|     systems exist to   |     of political         |     CDC   |     |
|     early detect and   |     commitment for       |           |     |
|     characterise       |     ongoing and          | -   ORTs, |     |
|     outbreak, and      |     potential            |     CDC   |     |
|     asses the risk of  |     interventions        |           |     |
|     escalation into    |                          | -   ORTs, |     |
|     the pandemic       | -   Activate overarching |     CDC   |     |
|                        |     national command and |           |     |
| -   Coordinate the     |     control of response  | -   ORTs, |     |
|     implementation of  |     activities           |     CDC   |     |
|     procedures that    |                          |           |     |
|     will delay or      | -   Deploy operational   |           |     |
|     contain the spread |     response teams       |           |     |
|     of human infection |     across all relevant  |           |     |
|                        |     sectors              |           |     |
|                        |                          |           |     |
|                        | -   Ensure cross-border  |           |     |
|                        |     collaboration with   |           |     |
|                        |     surrounding          |           |     |
|                        |     countries for        |           |     |
|                        |     information sharing  |           |     |
|                        |     and coordination of  |           |     |
|                        |     emergency response   |           |     |
+------------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+-----------+-----+
| **Situation Assessment |                          |           |     |
| and Monitoring**       |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Assess the extent  | -   Describe and         | -   NICD, |     |
|     of human-to-human  |     re-assess            |           |     |
|     transmission,      |     epidemiological,     |    Health |     |
|     detect, notify and |     virological and      |     Care  |     |
|     characterise       |     clinical features of |           |     |
|     clusters,          |     infection, identify  | Providers |     |
|     including risk     |     possible sources,    |           |     |
|     factors            |     and report to        | -   NICD, |     |
|                        |     relevant authorities |     Epid  |     |
| -   Assess the threat  |                          |           |     |
|     to human-to-human  | -   Assessment           | -         |     |
|     health and the     |     sustainability of    |    NICD\] |     |
|     impact to any      |     human-to-human       |           |     |
|     control measures   |     transmission, and    | -   NICD, |     |
|     and identify       |     conduct clinical     |     Epi   |     |
|     resources required |     research             | demiology |     |
|     for enhance        |                          |           |     |
|                        | -   Collect and share    |           |     |
|                        |     strains and          |           |     |
|                        |     information needed   |           |     |
|                        |     to develop or adjust |           |     |
|                        |     diagnostic reagents  |           |     |
|                        |     and prototype        |           |     |
|                        |     vaccines             |           |     |
|                        |                          |           |     |
|                        | -   Forecast likely      |           |     |
|                        |     impact of the spread |           |     |
|                        |     of infection and     |           |     |
|                        |     assess impact of     |           |     |
|                        |     containment measures |           |     |
+------------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+-----------+-----+
| **Prevention and       |                          |           |     |
| Containment**          |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Contain/delay      | -   Implement prevention | -   ORTs, |     |
|     human to human     |     and containment      |           |     |
|     virus transmission |     strategies,          |    Pharm, |     |
|                        |     including use of     |     Plan  |     |
| -   Deploy and use     |     antivirals and       |           |     |
|     antivirals and     |     vaccines             |    Policy |     |
|     vaccines to reduce |                          |           |     |
|     morbidity and      | -   Provide prophylaxis  | -   Pharm |     |
|     mortality          |     for contact, and     |     Plan  |     |
|                        |     vaccinate wherever   |           |     |
|                        |     appropriate          |    Policy |     |
|                        |                          |           |     |
|                        | -   Deploy vaccines and  | -   Pharm |     |
|                        |     antivirals to        |     Plan  |     |
|                        |     at-risk and affected |           |     |
|                        |     areas                |    Policy |     |
+------------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+-----------+-----+
| **Health Systems       |                          |           |     |
| Response**             |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Ensure capacity,   | -   Update contingency   | -   NORT, |     |
|     prevent nosocomial |     plans and algorithms |     CDC   |     |
|     infection and      |     for case finding,    |           |     |
|     maintain biosafety |     management,          | -   ORTs, |     |
|                        |     infection control    |     CDC   |     |
|                        |     and surveillance     |           |     |
|                        |                          | -   ORTs, |     |
|                        | -   Activate contingency |     CDC   |     |
|                        |     plans for response   |           |     |
|                        |     and identify         |           |     |
|                        |     alternative          |           |     |
|                        |     strategies for case  |           |     |
|                        |     isolation and        |           |     |
|                        |     management           |           |     |
|                        |                          |           |     |
|                        | -   Implement surge      |           |     |
|                        |     capacity             |           |     |
|                        |     arrangements and     |           |     |
|                        |     contingency for      |           |     |
|                        |     staff shortage, and  |           |     |
|                        |     emphasize infection  |           |     |
|                        |     control              |           |     |
+------------------------+--------------------------+-----------+-----+

+-----------------------+--------------------------+------------+-----+
| **Communications**    |                          |            |     |
+-----------------------+--------------------------+------------+-----+
| Objectives            | Activities               | R          | C   |
|                       |                          | esponsible | ost |
|                       |                          |            | \[  |
|                       |                          |            | Ran |
|                       |                          |            | d\] |
+-----------------------+--------------------------+------------+-----+
| -   Ensure rapid      | -   Reinforce and        | -   Health |     |
|     sharing of        |     intensify key        |            |     |
|     appropriate       |     messages on          | Promotion, |     |
|     information among |     prevention of human  |     Comm   |     |
|     health            |     to human             | unications |     |
|     authorities and   |     transmission         |            |     |
|     prepare public    |                          | -   Commu  |     |
|     and partners for  | -   Update public on all | nications, |     |
|     possible          |     aspect of the        |     GCIS   |     |
|     progression of    |     outbreak and provide |            |     |
|     events            |     instruction for      | -   NORT,  |     |
|     contingency       |     self-protection      |     Commu  |     |
|     measures          |                          | nications, |     |
|                       | -   Update national      |     GCIS   |     |
|                       |     authorities, the     |            |     |
|                       |     public and partners  | -   Comm   |     |
|                       |     on domestic and      | unication, |     |
|                       |     international        |     GCIS   |     |
|                       |     epidemiological      |            |     |
|                       |     situation            | -   Health |     |
|                       |                          |            |     |
|                       | -   Activate emergency   | Promotion, |     |
|                       |     communication plans  |     GCIS   |     |
|                       |     in conjunction with  |            |     |
|                       |     partners             | -   Health |     |
|                       |                          |            |     |
|                       | -   Develop general      | Promotion, |     |
|                       |     health protection    |     GCIS,  |     |
|                       |     education materials  |            |     |
|                       |     for national         | -   Hosp   |     |
|                       |     application          |     Serv,  |     |
|                       |                          |     QA     |     |
|                       | -   Re-emphasise         |            |     |
|                       |     infection control    |            |     |
|                       |     measures in the      |            |     |
|                       |     community and health |            |     |
|                       |     care facilities      |            |     |
+-----------------------+--------------------------+------------+-----+

**Pandemic Alert Period: Phase 5**

**Overarching Goal: Maximise Efforts to Contain/Delay Spread or Avert
Pandemic**

+------------------------+--------------------------+-----------+-----+
| **Planning and         |                          |           |     |
| Coordination**         |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Coordinate and     | -   Designate special    | -   NORT, |     |
|     ensure maximum     |     status to affected   |     CDC   |     |
|     efforts to delay   |     areas in order to    |           |     |
|     or possibly avert  |     facilitate           | -   NORT, |     |
|     a pandemic         |     interventions \[e.g. |     CDC   |     |
|                        |     state of emergency\] |           |     |
|                        |                          | -   ORTs  |     |
|                        | -   Finalise preparation |           |     |
|                        |     for imminent         |           |     |
|                        |     pandemic, including  |           |     |
|                        |     activation of        |           |     |
|                        |     internal             |           |     |
|                        |     organisational       |           |     |
|                        |     arrangements and     |           |     |
|                        |     staffing surge       |           |     |
|                        |     capacity             |           |     |
|                        |                          |           |     |
|                        | -   Adjust and maximise  |           |     |
|                        |     efforts and          |           |     |
|                        |     resources to reduce  |           |     |
|                        |     disease burden and   |           |     |
|                        |     contain or delay the |           |     |
|                        |     spread of infection  |           |     |
+------------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+------------+-----+
| **Situation Monitoring |                          |            |     |
| and Assessment**       |                          |            |     |
+------------------------+--------------------------+------------+-----+
| Objectives             | Activities               | R          | C   |
|                        |                          | esponsible | ost |
|                        |                          |            | \[  |
|                        |                          |            | Ran |
|                        |                          |            | d\] |
+------------------------+--------------------------+------------+-----+
| -   Determine pandemic | -   Report increased     | -   NICD,  |     |
|     risk and monitor   |     spread through       |     Ep     |     |
|     public health      |     appropriate means to | idemiology |     |
|     resources          |     authorities          |            |     |
|                        |                          | -   Pharm  |     |
|                        | -   Implement real-time  |     Plan   |     |
|                        |     monitoring of        |     Policy |     |
|                        |     essential resources  |            |     |
|                        |     (medical supplies,   | -   NICD,  |     |
|                        |     pharmaceutical,      |     Ep     |     |
|                        |     infrastructure,      | idemiology |     |
|                        |     vaccines, hospital   |            |     |
|                        |     capacity and human   |            |     |
|                        |     capacity)            |            |     |
|                        |                          |            |     |
|                        | -   Conduct enhanced     |            |     |
|                        |     surveillance for     |            |     |
|                        |     respiratory disease  |            |     |
|                        |     and forecast the     |            |     |
|                        |     likely impact of     |            |     |
|                        |     both infection       |            |     |
|                        |     spread and control   |            |     |
|                        |     measures             |            |     |
+------------------------+--------------------------+------------+-----+

+------------------------+--------------------------+-----------+-----+
| **Prevention and       |                          |           |     |
| Containment**          |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Make massive       | -   Implement            | -   NORT, |     |
|     effort to contain  |     interventions        |     CDC   |     |
|     or delay human to  |     identified during    |           |     |
|     human virus        |     contingency planning | -   Pharm |     |
|     transmission       |     and consider use of  |     Plan  |     |
|                        |     antivirals           |           |     |
| -   Limit morbidity    |                          |    Policy |     |
|     and mortality and  | -   Assess feasibility   |           |     |
|     assess antivirals  |     of prophylaxis and   | -   Pharm |     |
|     and vaccine use    |     determine target     |     Plan  |     |
|                        |     populations for      |           |     |
|                        |     vaccine deployment   |    Policy |     |
|                        |                          |           |     |
|                        | -   Plan for vaccine     |           |     |
|                        |     distribution and     |           |     |
|                        |     accelerate           |           |     |
|                        |     preparation for mass |           |     |
|                        |     vaccination          |           |     |
+------------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+-----------+-----+
| **Heath System         |                          |           |     |
| Response**             |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Ensure that health | -   Full mobilisation of | -   CDC,  |     |
|     system is ready to |     health services and  |     Hosp  |     |
|     scale up response  |     full implementation  |     Serv, |     |
|     and implement      |     of emergency plans   |     EMS   |     |
|     triage and         |     in affected areas    |           |     |
|     treatment          |                          | -   CDC,  |     |
|     priorities         | -   Commence triage      |           |     |
|                        |     arrangements and     |    Health |     |
| -   Prevent nosocomial |     emergency procedures |     Care, |     |
|     transmission and   |                          |     Hosp  |     |
|     maintain biosafety | -   Fully deploy health  |           |     |
|                        |     care workers and     | -   ORT's |     |
|                        |     ensure health and    |           |     |
|                        |     other needs of       | -   ORT's |     |
|                        |     individuals in       |           |     |
|                        |     quarantine           | -   CDC   |     |
|                        |                          |     and   |     |
|                        | -   Arrange for          |           |     |
|                        |     additional human and |    ORT's, |     |
|                        |     material resources,  |           |     |
|                        |     and implement corpse |    Pharm, |     |
|                        |     management           |     Hosp  |     |
|                        |     procedures           |     Serv  |     |
|                        |                          |           |     |
|                        | -   Prepare health care  |           |     |
|                        |     workers for possible |           |     |
|                        |     change in treatment  |           |     |
|                        |     protocols            |           |     |
+------------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+------------+-----+
| **Communication**      |                          |            |     |
+------------------------+--------------------------+------------+-----+
| Objectives             | Activities               | R          | C   |
|                        |                          | esponsible | ost |
|                        |                          |            | \[  |
|                        |                          |            | Ran |
|                        |                          |            | d\] |
+------------------------+--------------------------+------------+-----+
| -   Prepare public and | -   Re-define key        | -   Health |     |
|     other partners for |     messages, set        |     Pro,   |     |
|     likely rapid       |     reasonable public    |     CDC,   |     |
|     progression of     |     expectations, and    |     Commu  |     |
|     events, additional |     emphasise need to    | nications, |     |
|     contingency plans  |     comply               |     GCIS   |     |
|     and disruption of  |                          |            |     |
|     normal life        | -   Inform public about  | -   CDC,   |     |
|                        |     interventions that   |     NICD,  |     |
| -   Ensure rapid       |     may be modified or   |     Health |     |
|     sharing of         |     implemented during a |     Pro,   |     |
|     appropriate        |     pandemic             |     Commu  |     |
|     information among  |                          | nications, |     |
|     authorities and    |                          |     GCIS   |     |
|     partners           |                          |            |     |
+------------------------+--------------------------+------------+-----+

**Pandemic Period: Phase 6**

**Overarching Goal: Minimise the Impact of the Pandemic**

+------------------------+--------------------------+------------+-----+
| **Planning and         |                          |            |     |
| Coordination**         |                          |            |     |
+------------------------+--------------------------+------------+-----+
| Objectives             | Activities               | R          | C   |
|                        |                          | esponsible | ost |
|                        |                          |            | \[  |
|                        |                          |            | Ran |
|                        |                          |            | d\] |
+------------------------+--------------------------+------------+-----+
| -   Provide leadership | -   Implement all        | -   CDC,   |     |
|     and coordination   |     relevant elements of |     ORT's  |     |
|     of multisectoral   |     national pandemic    |            |     |
|     resources that     |     plan, including      | -   CDC,   |     |
|     will minimise      |     coordination of      |     NICD,  |     |
|     morbidity and      |     response and         |     Epid,  |     |
|     mortality,         |     implementation of    |     EMS    |     |
|     preserve health    |     specific             |            |     |
|     system             |     interventions        | -   P      |     |
|     effectiveness,     |                          | oliticians |     |
|     minimise societal  | -   Assess and publish   |            |     |
|     disruption and     |     current and          |            |     |
|     minimise economic  |     cumulative national  |            |     |
|     impact             |     impact and consider  |            |     |
|                        |     applying emergency   |            |     |
| -   Ensure access to   |     powers               |            |     |
|     pharmaceutical     |                          |            |     |
|     supplies and       | -   Address              |            |     |
|     vaccines           |     psychological,       |            |     |
|                        |     economic and social  |            |     |
|                        |     impact, and consider |            |     |
|                        |     assistance from      |            |     |
|                        |     other countries      |            |     |
+------------------------+--------------------------+------------+-----+

+------------------------+--------------------------+-----------+-----+
| **Surveillance         |                          |           |     |
| Monitoring and         |                          |           |     |
| Assessment**           |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Monitor the        | -   Monitor geographic   | -   NICD, |     |
|     epidemiological,   |     spread of disease    |     Epid, |     |
|     virological and    |     from points of       |     ORTs  |     |
|     clinical features, |     introduction         |           |     |
|     course and impact  |                          | -   NICD, |     |
|     of the pandemic    | -   Use enhanced         |     Epid, |     |
|                        |     surveillance and     |     ORTs  |     |
| -   Assess             |     case management      |           |     |
|     effectiveness of   |     database to identify | -   CDC,  |     |
|     interventions to   |     initial              |     NICD, |     |
|     guide future       |     case/contacts and    |     Epid  |     |
|     actions            |     track initial        |           |     |
|                        |     geographical spread  | -   CDC,  |     |
|                        |                          |     NICD, |     |
|                        | -   Monitor for possible |     Epid  |     |
|                        |     changes in           |           |     |
|                        |     epidemiology,        | -   CDC,  |     |
|                        |     clinical             |     NICD, |     |
|                        |     presentation and     |     Epid  |     |
|                        |     virological features |           |     |
|                        |                          |           |     |
|                        | -   Assess and monitor   |           |     |
|                        |     national impact      |           |     |
|                        |     (morbidity,          |           |     |
|                        |     mortality, work      |           |     |
|                        |     absenteeism, areas   |           |     |
|                        |     affected, capacity,  |           |     |
|                        |     admissions, etc)     |           |     |
|                        |                          |           |     |
|                        | -   Assess needs for     |           |     |
|                        |     emergency, forecast  |           |     |
|                        |     trends and impact of |           |     |
|                        |     treatment and        |           |     |
|                        |     nonpharmaceutical    |           |     |
|                        |     interventions        |           |     |
+------------------------+--------------------------+-----------+-----+

+------------------------+--------------------------+-----------+-----+
| **Prevention and       |                          |           |     |
| Containment**          |                          |           |     |
+------------------------+--------------------------+-----------+-----+
| Objectives             | Activities               | Re        | C   |
|                        |                          | sponsible | ost |
|                        |                          |           | \[  |
|                        |                          |           | Ran |
|                        |                          |           | d\] |
+------------------------+--------------------------+-----------+-----+
| -   Contain or delay   | -   Fully implement      | -   Pharm |     |
|     the spread using   |     vaccine procurement  |     Plan  |     |
|     public health      |     plans and monitor    |           |     |
|     interventions and  |     supplies             |    Policy |     |
|     limit societal     |                          |           |     |
|     disruption         | -   Implement and asses  | -   DOH   |     |
|                        |     public health        |     \[All |     |
| -   Minimise morbidity |     interventions at all |           |     |
|     and mortality      |     levels of care       | Levels\], |     |
|     through use of     |                          |     CDC   |     |
|     pharmaceuticals    | -   Re-evaluate use of   |           |     |
|                        |     antivirals based on  | -   NORT, |     |
|                        |     clinical studies and |     Pharm |     |
|                        |     evidence of          |     Plan  |     |
|                        |     resistance           |           |     |
|                        |                          |    Policy |     |
+------------------------+--------------------------+-----------+-----+

+-----------------------+--------------------------+------------+-----+
| **Heath System        |                          |            |     |
| Response**            |                          |            |     |
+-----------------------+--------------------------+------------+-----+
| Objectives            | Activities               | R          | C   |
|                       |                          | esponsible | ost |
|                       |                          |            | \[  |
|                       |                          |            | Ran |
|                       |                          |            | d\] |
+-----------------------+--------------------------+------------+-----+
| -   Provide guidance  | -   Keep emergency       | -          |     |
|     on ways to        |     coordination         |   Facility |     |
|     optimise patient  |     arrangements and     |     CEOs   |     |
|     care with limited |     chains of command    |            |     |
|     resources         |     for health system    | -   P      |     |
|                       |     fully functional     | oliticians |     |
|                       |                          |            |     |
|                       | -   Maintain health care | -   ORT's, |     |
|                       |     workers vigilance    |     CDC    |     |
|                       |     for the onset of     |            |     |
|                       |     cases and clusters   | -   ORT's, |     |
|                       |                          |     Pharm  |     |
|                       | -   Fully implement      |     Plan   |     |
|                       |     pandemic plans for   |     Policy |     |
|                       |     health systems and   |            |     |
|                       |     essential services,  |            |     |
|                       |     adjust triage,       |            |     |
|                       |     deploy workforce and |            |     |
|                       |     provide              |            |     |
|                       |     social/psychological |            |     |
|                       |     support              |            |     |
|                       |                          |            |     |
|                       | -   Implement            |            |     |
|                       |     vaccination          |            |     |
|                       |     according to         |            |     |
|                       |     priority status and  |            |     |
|                       |     availability         |            |     |
+-----------------------+--------------------------+------------+-----+

+-----------------------+--------------------------+------------+-----+
| **Communication**     |                          |            |     |
+-----------------------+--------------------------+------------+-----+
| Objectives            | Activities               | R          | C   |
|                       |                          | esponsible | ost |
|                       |                          |            | \[  |
|                       |                          |            | Ran |
|                       |                          |            | d\] |
+-----------------------+--------------------------+------------+-----+
| -   Ensure public     | -   Maintain capacity    | -   NORTs  |     |
|     access to updated |     for meeting expected |            |     |
|     information and   |     domestic and         | -   Commu  |     |
|     maintain          |     international        | nications, |     |
|     accessible        |     information demand   |     GCIS,  |     |
|     channels for      |                          |     P      |     |
|     advice and        | -   Activate elements of | oliticians |     |
|     support           |     communication plans  |            |     |
|                       |     and acknowledge      | -   ORT's  |     |
| -   Share information |     public anxiety,      |            |     |
|     with health       |     grief and distress   | -   Commu  |     |
|     authorities,      |     associated with the  | nications, |     |
|     government and    |     pandemic             |     GCIS,  |     |
|     other partners    |                          |     ORT's  |     |
|                       | -   Inform public about  |            |     |
|                       |     interventions that   |            |     |
|                       |     may be modified or   |            |     |
|                       |     implemented during   |            |     |
|                       |     the pandemic         |            |     |
|                       |                          |            |     |
|                       | -   Keep news media,     |            |     |
|                       |     public and           |            |     |
|                       |     professional         |            |     |
|                       |     partners informed    |            |     |
|                       |     about the progress   |            |     |
|                       |     of the pandemic in   |            |     |
|                       |     affected countries   |            |     |
+-----------------------+--------------------------+------------+-----+

9.  **References**

```{=html}
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```
1.  World Health Organisation. WHO Checklist for Influenza
    Preparedness. 2005. WHO, Geneva, Switzerland

2.  World Health Organisation. WHO Global Influenza Preparedness Plan:
    The role of WHO and recommendations for national measures before and
    during pandemic. 2005. WHO, Geneva, Switzerland

3.  World Health Organisation. Responding to the avian influenza
    pandemic threat: Recommended Strategic Actions. 20005. WHO, Geneva,
    Switzerland