Department of Veterans Affairs (VA)

VA Pandemic Influenza Plan

![](media/image1.png){width="1.75in" height="1.75in"}

**VA Pandemic Influenza Plan**

Table of Contents

[CURRENT SITUATION v](#current-situation)

[FOREWORD BY THE SECRETARY OF VETERANS AFFAIRS
vi](#foreword-by-the-secretary-of-veterans-affairs)

[EXECUTIVE SUMMARY vii](#executive-summary)

[ACKNOWLEDGMENTS ix](#acknowledgments)

[Section 1: INTRODUCTION 1](#introduction)

[1.1 Responsibilities of and Facts about the Department of Veterans
Affairs
1](#responsibilities-of-and-facts-about-the-department-of-veterans-affairs)

[1.1.1 Veterans Health Administration (VHA) -- Health care
1](#veterans-health-administration-vha-health-care)

[1.1.2 Veterans Benefits Administration (VBA) -- Financial assistance
1](#veterans-benefits-administration-vba-financial-assistance)

[1.1.3 National Cemetery Administration (NCA) -- Burials and memorials
2](#national-cemetery-administration-nca-burials-and-memorials)

[1.1.4 VA Geography -- Nationwide, state-to-state, and overseas
2](#va-geography-nationwide-state-to-state-and-overseas)

[1.1.5 Workforce 2](#workforce)

[1.2 Relationship of This Plan with Other VA Emergency Plans
2](#relationship-of-this-plan-with-other-va-emergency-plans)

[1.3 Background -- VA and Pandemic Influenza Planning
3](#background-va-and-pandemic-influenza-planning)

[1.4 Planning Assumptions 4](#planning-assumptions)

[1.5 Goals of the VA Pandemic Influenza Plan
5](#goals-of-the-va-pandemic-influenza-plan)

[1.6 Organization of This Plan 6](#organization-of-this-plan)

[Section 2: PREPARING FOR PANDEMIC INFLUENZA
7](#preparing-for-pandemic-influenza)

[2.1 VA-Wide/VA Central Office Preparations
7](#va-wideva-central-office-preparations)

[2.1.1 Leadership 7](#leadership)

[2.1.2 Coordination 7](#coordination)

[2.1.3 VA Central Office Preparations
7](#va-central-office-preparations)

[2.1.4 Roles and Responsibilities 8](#roles-and-responsibilities)

[2.1.4.1 Public Affairs/Communications 8](#public-affairscommunications)

[2.2 VHA Preparations 9](#vha-preparations)

[2.2.1 Leadership 9](#leadership-1)

[2.2.2 Coordination 9](#coordination-1)

[2.2.2.1 Collaboration 9](#collaboration)

[2.2.2.2 Use of emergency plans 10](#use-of-emergency-plans)

[2.2.2.3 Acquisition of and allocation policies for vaccines,
antivirals, diagnostics, materiel, and staffing
10](#acquisition-of-and-allocation-policies-for-vaccines-antivirals-diagnostics-materiel-and-staffing)

[2.2.3 Roles and Responsibilities 10](#roles-and-responsibilities-1)

[2.2.3.1 Creation of facility and network pandemic influenza plans
10](#creation-of-facility-and-network-pandemic-influenza-plans)

[2.2.3.2 Workforce preparation (education, skill identification,
credentialing, Pandemic Response Teams)
11](#workforce-preparation-education-skill-identification-credentialing-pandemic-response-teams)

[2.2.3.3 Physical site (space planning, building and engineering
systems, support for infection control, transportation of patients,
fatality management)
12](#physical-site-space-planning-building-and-engineering-systems-support-for-infection-control-transportation-of-patients-fatality-management)

[2.2.3.4 Infection control and precautions (heightened surveillance,
staff illness, supplies and their management, transmission and
precautions for health care facility staff)
13](#infection-control-and-precautions-heightened-surveillance-staff-illness-supplies-and-their-management-transmission-and-precautions-for-health-care-facility-staff)

[2.2.3.5 Countermeasures (vaccines, antiviral medications, diagnostics)
14](#countermeasures-vaccines-antiviral-medications-diagnostics)

[2.2.3.6 Medical materiel (equipment and supplies)
15](#medical-materiel-equipment-and-supplies)

[2.2.3.7 Health care delivery (triage, waiting areas, novel/innovative
care delivery, including home care)
16](#health-care-delivery-triage-waiting-areas-novelinnovative-care-delivery-including-home-care)

[2.2.3.8 Support and management of exposed and ill staff
17](#support-and-management-of-exposed-and-ill-staff)

[2.2.3.9 Mental health support for patients and staff
18](#mental-health-support-for-patients-and-staff)

[2.2.3.10 Surveillance and reporting, VHA facility-level (including
first case) and VHA Central Office-level response (use of diagnostics,
data on cases, local collaboration, reporting mechanisms)
18](#surveillance-and-reporting-vha-facility-level-including-first-case-and-vha-central-office-level-response-use-of-diagnostics-data-on-cases-local-collaboration-reporting-mechanisms)

[2.2.3.11 Security (facilities, supplies)
20](#security-facilities-supplies)

[2.2.3.12 Communication, VHA facility-level and VHA Central Office-level
20](#communication-vha-facility-level-and-vha-central-office-level)

[2.3 VBA Preparations 23](#vba-preparations)

[2.3.1 Leadership 23](#leadership-2)

[2.3.2 Coordination 23](#coordination-2)

[2.3.3 Roles and Responsibilities 23](#roles-and-responsibilities-2)

[2.3.3.1 Creation of VBA regional office pandemic influenza plans
23](#creation-of-vba-regional-office-pandemic-influenza-plans)

[2.3.3.2 Workforce (staffing, education)
23](#workforce-staffing-education)

[2.3.3.3 Infection control 24](#infection-control)

[2.3.3.4 Security 24](#security)

[2.3.3.5 Communication 24](#communication)

[2.4 NCA Preparations 24](#nca-preparations)

[2.4.1 Leadership 24](#leadership-3)

[2.4.2 Coordination 24](#coordination-3)

[2.4.3 Roles and Responsibilities 25](#roles-and-responsibilities-3)

[2.4.3.1 Creation of network- and cemetery-level pandemic influenza
plans
25](#creation-of-network--and-cemetery-level-pandemic-influenza-plans)

[2.4.3.2 Workforce (staffing, education)
25](#workforce-staffing-education-1)

[2.4.3.3 Infection control 25](#infection-control-1)

[2.4.3.4 Communication 26](#communication-1)

[2.5 VA-Wide Pandemic Influenza Outbreak Exercises
26](#va-wide-pandemic-influenza-outbreak-exercises)

[Section 3: RESPONDING TO PANDEMIC INFLUENZA
27](#responding-to-pandemic-influenza)

[3.1 VA Response Actions 27](#va-response-actions)

[3.1.1 Leadership 27](#leadership-4)

[3.1.2 Coordination and Communication
27](#coordination-and-communication)

[3.1.3 VA Central Office Response 27](#va-central-office-response)

[3.1.4 Roles and Responsibilities: VA-wide
27](#roles-and-responsibilities-va-wide)

[3.1.4.1 Vigilance and notification 27](#vigilance-and-notification)

[3.1.4.2 Implementation of emergency plans
28](#implementation-of-emergency-plans)

[3.1.4.3 Limiting disease spread 28](#limiting-disease-spread)

[3.2 VHA Response Actions 28](#vha-response-actions)

[3.2.1 Leadership 28](#leadership-5)

[3.2.2 Coordination and Communication
28](#coordination-and-communication-1)

[3.2.3 Roles and Responsibilities 29](#roles-and-responsibilities-4)

[3.2.3.1 Surveillance, including possible first case
29](#surveillance-including-possible-first-case)

[3.2.3.2 Refocusing of patient care priorities
29](#refocusing-of-patient-care-priorities)

[3.2.3.3 Infection control (transmission and precautions for health care
facility staff, hand and respiratory hygiene)
30](#infection-control-transmission-and-precautions-for-health-care-facility-staff-hand-and-respiratory-hygiene)

[3.2.3.4 Support for and management of exposed or ill staff (monitoring,
triage, absences, public health measures)
31](#support-for-and-management-of-exposed-or-ill-staff-monitoring-triage-absences-public-health-measures)

[3.2.3.5 Countermeasures (antiviral drugs, vaccines, diagnostics)
31](#countermeasures-antiviral-drugs-vaccines-diagnostics)

[3.2.3.6 Workforce (availability, flexible work standards,
credentialing, broadened practice standards)
32](#workforce-availability-flexible-work-standards-credentialing-broadened-practice-standards)

[3.2.3.7 Patient care (changing demands and surge, advice
lines/telemedicine, triage, diagnosis, isolation, expansion to include
alternative space and sites, altered standards of care)
33](#patient-care-changing-demands-and-surge-advice-linestelemedicine-triage-diagnosis-isolation-expansion-to-include-alternative-space-and-sites-altered-standards-of-care)

[3.2.3.8 Medical materiel (medications and supplies, access to caches)
35](#medical-materiel-medications-and-supplies-access-to-caches)

[3.2.3.9 Security for health care sites
36](#security-for-health-care-sites)

[3.2.3.10 Fatality management 36](#fatality-management)

[3.2.3.11 Mental health support 36](#mental-health-support)

[3.3 VBA Response Actions 37](#vba-response-actions)

[3.3.1 Leadership 37](#leadership-6)

[3.3.2 Coordination and Communication
37](#coordination-and-communication-2)

[3.3.3 Roles and Responsibilities 37](#roles-and-responsibilities-5)

[3.3.3.1 Workforce actions 37](#workforce-actions)

[3.3.3.2 Closure of regional offices 37](#closure-of-regional-offices)

[3.3.3.3 Infection control 37](#infection-control-2)

[3.3.3.4 Security 37](#security-1)

[3.4 NCA Response Actions 38](#nca-response-actions)

[3.4.1 Leadership 38](#leadership-7)

[3.4.2 Coordination and Communication
38](#coordination-and-communication-3)

[3.4.3 Roles and Responsibilities 38](#roles-and-responsibilities-6)

[3.4.3.1 Workforce actions 38](#workforce-actions-1)

[3.4.3.2 Closure of network offices or cemeteries
38](#closure-of-network-offices-or-cemeteries)

[3.4.3.3 Infection control 38](#infection-control-3)

[3.5 Communication Within and Outside of VA During a Pandemic
38](#communication-within-and-outside-of-va-during-a-pandemic)

[3.5.1 Leadership 38](#leadership-8)

[3.5.2 Coordination 39](#coordination-4)

[3.5.3 Roles and Responsibilities 39](#roles-and-responsibilities-7)

[3.5.3.1 VA-wide communication 39](#va-wide-communication)

[3.5.3.2 VHA communication 39](#vha-communication)

[3.5.3.3 VBA communication 41](#vba-communication)

[3.5.3.4 NCA communication 41](#nca-communication)

[Section 4: RECOVERING FROM PANDEMIC INFLUENZA
43](#recovering-from-pandemic-influenza)

[Section 5: ACRONYMS, ABBREVIATIONS, GLOSSARY
44](#acronyms-abbreviations-glossary)

[5.1 LIST OF ACRONYMS AND ABBREVIATIONS
44](#list-of-acronyms-and-abbreviations)

[5.2 GLOSSARY OF TERMS 47](#glossary-of-terms)

[Appendix Group A: VA Background 56](#va-background)

[Appendix A-1: DIAGRAM OF VA ORGANIZATION 56](#AppGroupA)

[Appendix A-2: MAPS RELATED TO THE THREE ADMINISTRATIONS OF THE
DEPARTMENT OF VETERANS AFFAIRS (VA) 57](#__RefHeading___Toc130728408)

[Appendix A-3: FACTS ABOUT VA HEALTH CARE CAPABILITIES
60](#__RefHeading___Toc130728409)

[Appendix Group B: Legal Authorities and Responsibilities
63](#legal-authorities-and-responsibilities)

[Appendix B-1: SUMMARY OF POTENTIAL VA EXPANDED RESPONSIBILITIES
63](#AppGroupB)

[Appendix B-2: TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT TO
EMERGENCIES - Advice on Changes in Usual VA Practices During a Pandemic
65](#__RefHeading___Toc130728412)

[Appendix Group C: References 72](#references)

[Appendix C-1: REFERENCE LIST FOR VA EMERGENCY PLANS AND OTHER RESOURCES
72](#_Appendix_C-1%3A__Reference_List_for_V)

[Appendix Group D: Planning Tools 79](#planning-tools)

[Appendix D-1: VA PANDEMIC PREPARATION ACTION GRIDS 79](#AppGroupD)

[Appendix D-2: SAMPLE EMERGENCY MANAGEMENT PROGRAM STANDARD OPERATING
PROCEDURE (SOP) 95](#__RefHeading___Toc130728417)

[Appendix D-3*:* REVIEW AND LIST OF COMMUNICATION PRINCIPLES AND
ELEMENTS TO USE BEFORE, DURING, AND AFTER A PANDEMIC
102](#__RefHeading___Toc130728418)

[Appendix D-4: SUGGESTED INVENTORY OF DURABLE AND CONSUMABLE SUPPLIES
FOR VA HEALTH CARE FACILITIES DURING A PANDEMIC INFLUENZA
106](#__RefHeading___Toc130728419)

[Appendix Group E: Response Tools 108](#response-tools)

[Appendix E-1: VA PANDEMIC RESPONSE ACTION GRIDS 108](#AppGroupE)

[Appendix E-2: CHART OF PANDEMIC INFLUENZA PRECAUTIONS FOR VA HEALTH
CARE FACILITY STAFF 121](#__RefHeading___Toc130728422)

[Appendix E-3: CHART OF PUBLIC HEALTH MEASURES AGAINST PANDEMIC
INFLUENZA FOR INDIVIDUALS, HEALTH CARE PROVIDERS, AND ORGANIZATIONS
122](#__RefHeading___Toc130728423)

[Appendix E-4: ACTIONS CHECKLIST---FIRST CASE
124](#__RefHeading___Toc130728424)

[Appendix E-5: SAMPLE SELF-TRIAGE ALGORITHM
126](#__RefHeading___Toc130728425)

[Appendix E-6: HOME CARE GUIDE FOR INFLUENZA, Symptom and care log,
Infection control measures for the home
127](#__RefHeading___Toc130728426)

# CURRENT SITUATION {#current-situation .unnumbered}

The current situation as this plan is finalized is as follows:

-   A virulent influenza strain, H5N1, is currently causing a pandemic
    among migratory birds and poultry flocks around the world. H5N1 is
    the subject of focus and concern because humans lack immunity to it,
    because there are no available human vaccines against H5N1, and
    because there is close contact between humans and
    poultry---conditions that combined could enable the strain to mutate
    or genetically re-assort with a human influenza strain to spark a
    human pandemic.

-   The National Institutes of Health is testing a candidate human
    vaccine for the H5N1 strain and the Centers for Disease Control and
    Prevention is evaluating rapid diagnostic tests for the H5N1 avian
    influenza strain.

-   Oseltamivir (Tamiflu®) is an antiviral medication presumed effective
    for prevention or treatment of the H5N1 avian influenza strain and
    is stockpiled in relatively small amounts in the U.S. VA owns a
    supply of approximately 500,000 treatment courses that is maintained
    in a manner consistent with the requirements of the Shelf Life
    Extension Program of the Food and Drug Administration.

-   Public health and influenza experts are not certain that the next
    influenza pandemic will be caused by an H5N1 strain. A pandemic
    could arise from a different novel strain with little warning.
    Planning and preparations need to anticipate both observed threats,
    like H5N1, and threats from new unrecognized strains of influenza
    viruses.

# FOREWORD BY THE SECRETARY OF VETERANS AFFAIRS {#foreword-by-the-secretary-of-veterans-affairs .unnumbered}

I am pleased to present this VA Pandemic Influenza Plan, which describes
how the Department of Veterans Affairs (VA) will protect employees,
maintain continuity of operations, communicate with stakeholders, and
support and coordinate with Federal, national, state, local, and tribal
efforts. We are proud to build this plan on the foundation of our
successful influenza vaccination program and our well-established
emergency programs, which this plan now augments. We are also pleased
that developing this plan continues the actions VA has been taking in
the past 2 years to be prepared. I thank the 70-some VA staff across the
country who contributed to this plan and the thousands more that are
preparing and will be responding all over the Department.

VA serves millions of veterans in terms of health care, financial
assistance benefits, and burial and memorial services. VA facilities and
staff are located in every state and territory, nearly every community,
and even overseas. Pandemic influenza will affect VA somewhere in the
country at some time, and the Department at all levels must coordinate
with their government and private sector counterparts and be prepared to
respond.

![](media/image2.jpeg){width="2.6979166666666665in" height="1.0in"}We
don't know when the next pandemic influenza will come to this country or
how severe it will be. We do know that even the best plans cannot cover
all facets of an emergency. VA will continue to take whatever actions
are needed to protect our veterans and staff, keep vital VA operations
going, communicate effectively, and contribute to the national response
effort to help this country delay and lessen the impact of an influenza
pandemic.

#  {#section .unnumbered}

#  {#section-1 .unnumbered}

#  {#section-2 .unnumbered}

#  {#section-3 .unnumbered}

#   {#section-4 .unnumbered}

# EXECUTIVE SUMMARY {#executive-summary .unnumbered}

The *VA Pandemic Influenza Plan* is an operational document that is
being added to existing emergency plans of the Department of Veterans
Affairs (VA) to provide VA and its three administrations with a
foundation for preparation, response, and recovery stages of an
influenza pandemic. The VA's three administrations are the Veterans
Health Administration (VHA), the Veterans Benefits Administration (VBA),
and the National Cemetery Administration (NCA).

**Section 1 -- Introduction** provides an overview of the functions and
nationwide scope of the Department of Veterans Affairs. It describes
VA's three major missions of caring for veterans, providing benefits,
and memorializing them, as well as its fourth mission of assisting with
emergencies and disasters. This section also explains how this plan
augments established emergency plans, describes what VA has already done
to be prepared for pandemic influenza, and lists planning assumptions
about pandemic influenza and its impact.

This section states the goals of VA's plan, which are:

-   To describe how VA will protect its staff and the veterans we serve,
    maintain operations, cooperate with other organizations, and
    communicate with stakeholders.

-   To assist VA staff at the local level establish and implement
    pandemic influenza-specific emergency procedures.

-   To assist VA,VHA, VBA, and NCA leadership at the national, regional,
    and network levels to support our staff and functions at all levels
    and all sites.

-   To be clear and understandable, with easy-to-find material that can
    be rapidly disseminated.

**Section 2 - Preparing for Pandemic Influenza** outlines the actions
that VA, its three administrations, and its regional, network, and local
facilities (medical, benefits, and memorial) will take to increase
understanding of the risks of pandemic influenza, and enhance
preparedness for it. The section defines procedures and processes that
would be used to prepare VA, throughout the Department, for the special
and dire circumstances that would result from pandemic influenza. VA
health care is in the special situation of preparing to care for those
who are ill with pandemic influenza, so the VHA discussion includes:

-   How the workforce and physical sites will be prepared

-   What infection control and countermeasures will be put into to place
    or enhanced, and assessments of what medical materiel will be
    necessary

-   Identification of essential functions

-   Estimation of the possible surge in demand

-   Plans for health care delivery under the dynamic environment caused
    by pandemic influenza

-   Support of health care facility staff who are exposed to or become
    ill with pandemic influenza

-   Provision of mental health support for patients and staff

-   Surveillance and reporting

-   Increased security

-   Effective communications

Subsections for VBA and NCA describe workforce planning, infection
control, security, and communication. The section ends with a
description of VA-wide pandemic influenza outbreak exercises that will
help the Department test and refine its plans.

**Section 3 -- Responding to Pandemic Influenza** describes how VA will
use its plans to stop, slow, or limit the spread of disease, reduce
suffering and death, and sustain operations. The discussion includes:

-   Surveillance, including possible first case

-   Refocusing of patient care priorities to maximize care of patients
    with pandemic influenza

-   Infection control, including the precautions and personal protective
    equipment by health care facility staff

-   Support for and management of exposed or ill staff

-   Use of countermeasures (antiviral drugs, vaccines, diagnostics)

-   Workforce considerations including flexible work standards,
    credentialing, and approaches to staffing

-   Patient care including changing demands, providing assistance via
    phone, triage, diagnosis, isolation, use of alternative space and
    sites, and altered standards of care that may become necessary

-   Medication and supply issues

-   Security

-   Fatality management

-   Mental health support

-   Communication within and outside of VA

**Section 4 -- Recovering from Pandemic Influenza** briefly reviews key
steps toward resuming normal operations.

**Section 5** provides a list of acronyms and abbreviations, as well as
a glossary of terms.

The last section provides more than 15 **appendices** in five groups:

-   [*Appendix Group A*](#AppGroupA) includes a diagram and maps of VA
    and facts about VA health care.

-   *[Appendix Group B](#AppGroupB)* covers VHA's potentially expanded
    responsibilities and legal authorities and policies relevant to
    emergencies.

-   [*Appendix Group C*](#references) includes references to VA
    emergency plans and other key documents.

-   *[Appendix Group D](#AppGroupD)* offers planning tools, including
    sample standard operating procedures for pandemic influenza,
    planning action grids, communication principles and elements, and
    lists of durable and consumable supplies for medical facilities.

-   *[Appendix Group E](#AppGroupE)* contains response action grids,
    charts of precautions for health care facility staff and public
    health measures for all, an actions checklist for a first case of
    pandemic influenza, a sample self-triage algorithm, and a home care
    guide.

This plan augments VA's existing emergency plans and provides an
operational foundation for preparation, response, and recovery stages of
an influenza pandemic, VA will develop and disseminate more information
and planning and response documents and will test our plans to further
strengthen our preparedness and response.

# ACKNOWLEDGMENTS {#acknowledgments .unnumbered}

Development of the VA Pandemic Influenza Plan was led by

Victoria Davey, Connie Raab, and Troy Knighton

Public Health Strategic Health Care Group

VHA Office of Public Health and Environmental Hazards

Contributors to the plan also included the following staff of VA at the
Department level and from its three administrations, from both Central
Office programs and VA facilities across the country:

John Baffa

Karen Biancolillo

Arnie Bierenbaum

Peter Brewster

Dan Bruneau

MaryAnn Bruno

Joseph Canzolino

Geraldine Coyle

Linda Danko

Kathleen DeRoos

Pam Del Monte

Anna Diehl

Lawrence Deyton

Noel Eldridge

Stephen Ezeji-Okoye

Michael Feeser

Judy Feldman

Joseph Francis

Jeff Gering

Matthew Goetz

Robert Grasso

Kevin Hanretta

Pam Hebert

Pam Hirsch

Michael Hodgson

Mark Holodniy

Beverly Johnson

Jane Joyner

Douglas Katcher

Paul Kim

Joseph Kime

Linda Kinsinger

Laurent Lehmann

Susan Lenz

Tammy LeSane

Odette Levesque

Vicki Macks

Mary Marchetto

Carter Mecher

Trish Moore

Sandra Murbach

Nhi Nguyen

Gina Oda

Robert O'Hara

Karen Ott

Rosemarie Paradis

Jeffrey Potts

Abid Rahman

Robin Rice

Cathy Rick

David Rimland

Fred Rodriguez

Gary Roselle

Chris Scheer

Julie Schroeder

Sherrie Schuldheis

Margie Scott

Virginia A. Sharpe

Mark Shelhorse

Steve Sloane

Mary Standridge

Rosemary Strickland

Richard Suchinsky

Rita Tjoelker

Virginia Torrise

William Van Stone

Michael Vojtasko

Donna Wells-Taylor

Keith Wilson

Bruce Young

Laurie Zephyrin

# INTRODUCTION

## Responsibilities of and Facts about the Department of Veterans Affairs

The Department of Veterans Affairs (VA) provides federal benefits to
veterans and their families and operates nationwide programs for health
care, financial assistance and burial benefits. VA is the second largest
of the 15 federal-level Cabinet departments. VA is led by the Secretary
of Veterans Affairs and VA headquarters, known as Central Office, is
comprised of several staff offices in Washington, DC and other
locations. (To see the basic structure of VA, see [Appendix A-1: DIAGRAM
OF VA ORGANIZATION](#_Appendix_A-1:__DIAGRAM_OF_VA_ORGANI).)

### Veterans Health Administration (VHA) -- Health care

VHA, the VA health care system, is the largest integrated health care
provider in the Nation.  VHA serves the health care needs of veterans by
providing primary care, specialized care, and related medical and social
support services.

VHA runs more than 1,300 sites of care across the country and in each
state, as well as the Philippines, Guam, and Puerto Rico. These sites
include:

-   Over 150 medical centers

-   Over 800 ambulatory care and community-based clinics

-   Over 130 nursing homes

-   Over 40 residential rehabilitation programs

-   Over 200 readjustment counseling centers (Vet Centers)

These sites are organized into 21 Veterans Integrated Service Networks
(VISNs). VHA is led by the Under Secretary for Health and several staff
offices based largely in Washington, DC.

VHA provided care to over 5 million enrolled veterans in 2004, including
almost 600,000 inpatients. There were about 54 million outpatient
visits. VA provides health care (and benefits) to more than 100,000
homeless veterans each year. VHA supports about 3,000 researchers at 115
VA medical centers (see [Appendix A-3: FACTS ABOUT VA HEALTH CARE
CAPABILITIES](#_Appendix_A-3:__FACTS_ABOUT_VA_HEALT)).

The VA health care system serves as a backup to the Department of
Defense medical systems to care for active duty military during war or a
national emergency and as a federal support organization during major
disasters. These national emergency functions are sometimes known as
VA's "fourth mission" after health care, financial benefits, and burial
benefits. For more information on these roles, see [Appendix B-1:
SUMMARY OF POTENTIAL VA EXPANDED
RESPONSIBILITIES](#_Appendix_B-1:__SUMMARY_OF_POTENTIAL) and [Appendix
B-2: TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES -
Advice on Changes in Usual VA Practices During a
Pandemic](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO).

For more information on VHA, see [Appendix A-3: FACTS ABOUT VA HEALTH
CARE CAPABILITIES](#_Appendix_A-3:__FACTS_ABOUT_VA_HEALT).

### Veterans Benefits Administration (VBA) -- Financial assistance

VBA provides financial assistance to millions of veterans through:

-   Compensation and pension programs, including disability
    compensation, as well as death compensation and pension, for over 3
    million people a year

-   Funding for education and training for over 400,000 people a year

-   Home loan assistance for over 300,000 loans a year

-   Life insurance for over 7 million individuals

-   Vocational rehabilitation and employment

VBA operates through four Area Offices and 57 Regional Offices, with at
least one in every state. VBA staff members are also located in the
Philippines, Guam, Italy, Germany, Japan, and South Korea. VBA is led by
the Under Secretary for Benefits and staff offices in Washington, DC.

### National Cemetery Administration (NCA) -- Burials and memorials

NCA maintains about 120 national cemeteries in 39 states and Puerto
Rico. These are coordinated by four Memorial Service Network offices and
NCA Central Office. Every year, NCA:

-   Buries about 93,000 people (veterans and in some cases spouses and
    dependent children)

-   Provides over 300,000 headstones or grave markers a year

-   Issues over 400,000 Presidential Memorial Certificates

NCA is led by the Under Secretary for Memorial Affairs and staff offices
in Washington, DC.

### VA Geography -- Nationwide, state-to-state, and overseas

VA facilities and staff are located in every state, the District of
Columbia, Puerto Rico (all three administrations), Guam (VHA), and other
US territories, the Philippine Islands (VHA and VBA), and South Korea,
with some staff also providing benefits services in Germany, Italy, and
Japan. For a sense of where VA facilities and staff are located, see
[Appendix A-2: MAPS RELATED TO THE THREE ADMINISTRATIONS OF THE
DEPARTMENT OF VETERANS AFFAIRS
(VA)](#_Appendix_A-2:__MAPS_RELATED_TO_THE_).

### Workforce

Among all the departments and agencies of the federal government, VA is
second only to the Department of Defense in terms of numbers of
employees. VA had about 235,000 employees on the rolls as of April 2005.
Of these employees

-   214,000 are in the Veterans Health Administration

-   13,000 are in the Veterans Benefits Administration

-   1,500 are in the National Cemetery Administration

-   3,200 are in the Veterans Canteen Service (snack shops, stores, and
    cafeterias)

-   400 support VA Franchise Fund/VA Enterprise Centers (certain central
    administrative functions)

-   3,600 are in staff and facility offices.

An additional 83,000 health professionals train in VA medical centers
each year. At least 94,000 volunteers provide service to VA, 90,000 of
them working in the facilities of the VHA. VA also hires contractors to
do a variety of work.

## Relationship of This Plan with Other VA Emergency Plans 

The *VA Pandemic Influenza Plan* is intended to augment existing
emergency plans of the Department of Veterans Affairs and provide VA
staff and leadership, particularly at a local level, with additional,
in-depth information about a single type of emergency -- pandemic
influenza -- and the special circumstances that would occur,
particularly if the strain is virulent.

Every major part of VA has well-established, comprehensive, all-hazards
emergency management plans and Continuity of Operations Plans that
provide leaders and staff with guidance and procedures for handling a
variety of natural, technological, and human-caused emergency events.
There are experts in emergency planning and preparedness at the national
level for VA and all three of its administrations and emergency managers
guiding operations throughout the country. The VHA Emergency Management
Program Guidebook has become recognized as a "best practice" by the
Nation's medical emergency management community. VA medical centers have
had emergency plans in place for a long time, and in the last few years,
they have adapted to the new standards of the Joint Commission on
Accreditation of Healthcare Organizations that require an "all-hazards"
approach to emergency management.

Every VA facility should have a Standard Operating Procedure (SOP) for
managing the risks associated with each major hazard. This plan provides
the basis for developing a VA facility-based SOP that addresses pandemic
influenza. This plan should serve as a minimum baseline for a
facility-based SOP and can be modified and enhanced to meet local needs.
The goal is to ensure that all VA facilities have a comprehensive
pandemic influenza plan as part of their emergency management program.
(A sample SOP for a VA medical center appears at [Appendix D-2](#D2).)

VA and its subordinate administrations also have emergency operations
plans. In addition, VA essential functions are covered by a variety of
VA Continuity of Operations Plans required of Executive Branch
departments and agencies to "provide vital services, exercise civil
authority, maintain the safety and well being of the general populace,
and sustain the industrial/economic base in an emergency," as specified
by law.

Existing VA emergency plans are cited in several places in this document
and also are listed under [Appendix C-1: REFERENCE LIST FOR VA EMERGENCY
PLANS AND OTHER RESOURCES](#_Appendix_C-1:__Reference_List_for_V). For a
discussion of how VA responsibilities may be augmented during
emergencies, see [Appendix B-1: SUMMARY OF POTENTIAL VA EXPANDED
RESPONSIBILITIES](#_Appendix_B-1:__SUMMARY_OF_POTENTIAL).

## Background -- VA and Pandemic Influenza Planning

VA has taken several steps to prepare for an influenza pandemic. These
steps include:

-   Leading an organized, well-supported, and results-driven national
    seasonal influenza vaccination program that yields patient
    vaccination rates higher than any other health care organization for
    which there are data.

-   Building on seasonal influenza prevention efforts, combined with
    well-established emergency management programs, as a foundation for
    leadership, policies, procedures, systems, education, and
    communication, using multidisciplinary teams at the national and
    local levels.

-   Increasing an emphasis on prevention of respiratory disease,
    particularly through vaccination for seasonal influenza and
    pneumococcal pneumonia.

-   Creating VA's own emergency stockpile of oseltamivir to be used if
    pandemic influenza occurs in our medical system. Oseltamivir
    (Tamiflu®) is the only available, potentially effective antiviral
    against the current strain of avian influenza (H5N1).

-   Establishing a Respiratory Infectious Diseases Emergency Plan for
    Facilities to supplement the existing VHA Emergency Management
    Guidebook, March 2005.

-   Launching and actively promoting "Infection: Don't Pass It On," a VA
    campaign to engage staff, patients, and visitors in preventing
    infections, particularly through hand and respiratory hygiene.

-   Appraising the use of personal protective equipment (PPE) and
    developing educational materials on PPE in a pandemic, which are
    also part of the "Infection: Don't Pass It On" campaign.

-   Participating with other Federal agencies in the development of the
    Department of Health and Human Services National Pandemic Influenza
    Plan, the National Strategy for Pandemic Influenza, and the National
    Implementation Plan for Pandemic Influenza.

VA will continue working to prepare for pandemic influenza by:

-   Disseminating and implementing this VA Pandemic Influenza Plan.

-   Accomplishing VA actions in the National Implementation Plan for
    Pandemic Influenza.

-   Planning and executing a series of pandemic influenza exercises
    conducted within VA and with relevant Federal agencies (HHS, DHS,
    DoD) and state and local health agencies to focus on patient flow,
    employee needs, and system functionality.

-   Carrying out a clinical study to determine if oseltamivir can be
    extended by co-administration with the drug probenicid (which slows
    elimination of some drugs) and, if so, extend the effective supply
    of oseltamivir.

-   Continuing to emphasize and promote public health and other
    non-vaccine, non-drug measures to prevent transmission of infection
    through the "Infection: Don't Pass It On" campaign.

## Planning Assumptions

For planning purposes, VA is making the following assumptions in concert
with experts at the White House Homeland Security Council and the
Department of Health and Human Services:

-   Efficient and sustained person-to-person transmission that is
    documented by authoritative US and international scientists and that
    occurs anywhere in the world will be a trigger, that is, it will
    indicate an imminent pandemic that might affect VA (sporadic human
    cases or outbreaks that are not sustained would not constitute a
    pandemic).

-   Susceptibility to the pandemic influenza virus may be universal.

-   The clinical disease attack rate is assumed to be 30% in the overall
    population during the pandemic. Illness rates may be highest among
    school-aged children (about 40%) and decline with age. Among working
    adults, it is assumed that an average of 20% may become ill during a
    community outbreak.

-   Some persons will become infected but may not develop clinically
    significant symptoms, i.e., they will not be aware that they have
    been infected with the influenza virus.

-   As would symptomatic individuals, individuals who have influenza but
    no or minimal symptoms may be capable of transmitting infection and
    may become immune to subsequent infection.

-   The typical incubation period (interval between infection and onset
    of symptoms) for influenza is approximately 2 days.

-   Persons who become ill may shed virus (via respiratory secretions
    from the nose and mouth) and can transmit infection for ½ to 1 day
    before the onset of illness. Viral shedding and the risk of
    transmission will be greatest during the first 2 days of illness.

-   Children will play a major role in transmission of infection as
    their illness rates are likely to be higher, they usually shed more
    virus, and they control their secretions less well.

-   About 50% of those who become ill will seek care. If effective
    antiviral drugs are available for treatment, more people will be
    expected to seek medical care.

-   Rates of serious illness, hospitalization, and deaths will depend on
    the virulence of the pandemic virus and differ by tenfold between
    more and less severe scenarios. A moderate pandemic, similar to the
    1957 and 1968 pandemics, in the absence of intervention, could cause
    200,000 deaths and 900,000 hospitalizations among Americans. A
    severe pandemic influenza virus with similar virulence to the 1918
    strain, in the absence of intervention, could cause 1.9 million
    deaths and almost 10 million hospitalizations among Americans over
    the course of the pandemic.

-   Risk groups for severe or fatal infection cannot be predicted with
    certainty but are likely to include infants, the elderly, pregnant
    women, and persons with chronic medical conditions.

-   In a severe pandemic, absenteeism may reach 40% attributable to
    illness, the need to care for ill family members, or fear of
    infection during the peak weeks of a community outbreak, with lower
    rates of absenteeism during the weeks before and after the peak.

-   There may be critical shortages of health care resources, such as
    staffed hospital beds, mechanical ventilators, morgue capacity,
    temporary holding sites with refrigeration for storage of deceased,
    and other resources.

-   Public health measures of temporarily closing schools and declaring
    other "snow days" or closures, and quarantining household contacts
    of infected individuals are likely to increase rates of absenteeism.

-   Epidemics will last 6 to 8 weeks in affected communities.

-   Multiple waves of epidemics are likely to occur across the country,
    lasting many months altogether. Historically, the largest waves have
    occurred in the fall and winter, but the seasonality of a pandemic
    cannot be predicted with certainty.

-   Effective response to pandemic influenza will require coordinated
    efforts of a wide variety of organizations.

-   An influenza pandemic could be initiated by any of a number of known
    or unknown strains of influenza.

-   VA will provide personal protective equipment for health care
    facility staff.

A note on transmission and precautions: Because the mode of transmission
of the virus will not be known for some time, VA advises taking a
conservative approach that provides a high level of protection for staff
caring for patients. This level of protection, known as Airborne
Infection Isolation and Contact Precautions, include the use of
fit-tested N95 masks, as well as gowns, gloves, and eye protection, such
as goggles.

-   Leadership and responsibilities for a global influenza pandemic are
    divided in the following manner:

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-   The **[international community]{.underline}** will agree on
    transparent and mutual reliance to coordinate planning and response
    based on principles that place protection of health and lives in the
    highest priority.

-   The **[Federal government]{.underline}** will work internationally
    and domestically on:

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-   Surveillance to target and coordinate response and containment

-   Advanced vaccine and antiviral drug development

-   Supporting the production, purchase, stockpiling, and distribution
    of vaccine and antiviral drugs

-   Facilitating Federal, state, and local health systems preparation
    for and response to pandemic influenza

-   Guiding the private sector on planning and operations during a
    pandemic

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-   **[Federal health care systems]{.underline}**, such as those of VA,
    the Department of Defense, the Indian Health Service, and the Bureau
    of Prisons, will coordinate their pandemic influenza preparations
    and responses at the Federal, state, and local levels.

-   **[VA Central Office, networks, area and regional offices, and
    facilities]{.underline}** will coordinate planning, response, and
    recovery efforts with each other and with their Federal, state, and
    local counterparts.

-   **[State and local governments]{.underline}** will develop plans,
    train responders, and incorporate their communities into their
    plans, including health care, law enforcement, local services, and
    political leadership.

-   **[Private sector and critical infrastructure
    entities]{.underline}** (such as utilities, food distributors and
    medical supply companies) perform key roles in producing and
    delivering goods and services and will be full participants in
    planning.

-   **[Individuals and families]{.underline}** will employ public health
    measures that protect them and prevent the spread of disease.

## Goals of the VA Pandemic Influenza Plan

The goals of the VA Pandemic Influenza Plan are as follows:

-   To describe how VA will protect its staff and the veterans we serve,
    maintain operations, cooperate with other organizations, and
    communicate with our stakeholders.

-   To assist VA staff at the local level establish and implement
    pandemic influenza-specific emergency procedures.

-   To assist VA, VHA, VBA, and NCA leadership at the national,
    regional, and network levels support our staff and functions at all
    levels and all sites.

-   To be clear and understandable, with easy-to-find material that can
    be rapidly disseminated.

In addition, this plan is intended to be used to supplement and provide
additional detail for existing VA emergency plans, such as Continuity of
Operations Plans (COOPs) and other emergency management plans.

## Organization of This Plan

This plan is organized consistent with comprehensive emergency
management practices and provides:

-   Overview with planning assumptions and useful background information
    concerning the responsibilities of the Department as well as the
    scope of the threat of pandemic influenza (**Section
    1---Introduction**)

-   Mitigation and preparedness strategies and actions to reduce the
    risk of the threat to VA operations (**Section 2---Preparing for
    Pandemic Influenza**)

-   Response strategies and actions (Section 3---Responding to Pandemic
    Influenza)

-   Recovery actions necessary (Section 4---Recovering from Pandemic
    Influenza)

-   References and planning and educational documents (**Section 5** and
    five groups of **appendices**)

Additional plans, tools, and educational materials will be developed as
this plan is implemented.

While an influenza pandemic may have broad effects on VA as a Federal
agency, ultimately events will be managed in cooperation with local
public health agencies. To be most effective, VA staff will need to
remain innovative, flexible, and responsive to local conditions, and to
always act in the best interests of veterans.

# PREPARING FOR PANDEMIC INFLUENZA

The aim of this phase of VA's plan is to increase understanding of the
risks of pandemic influenza, and enhance our preparedness for it by
defining procedures and processes that would be used for the special and
dire circumstances that would result.

The major actions described below also appear in [Appendix D-1: VA
PANDEMIC PREPARATION ACTION
GRID](#_Appendix_D-1:__VA_Pandemic_Preparat)S.

## VA-Wide/VA Central Office Preparations

### Leadership

The VA Secretary will plan to lead the overall Department of Veterans
Affairs response to an influenza pandemic, assisted principally by the
Deputy Secretary and the Under Secretary for Health and their designees.

### Coordination

VA will perform the following:

-   Coordinate its efforts throughout the Department with Federal and
    national, state, local, and tribal agencies and organizations.

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-   Meet its responsibilities under the National Implementation Plan for
    Pandemic Influenza.

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-   Establish an ongoing VA-wide Pandemic Influenza Advisory Group to
    assist with implementing this plan and provide advice in the event
    that responses to pandemic influenza become necessary. The VA
    Pandemic Influenza Advisory Group will be coordinated by the VHA
    Office of Public Health and Environmental Hazards.

-   Coordinate actions and responses under operating structures and
    guidelines from VA emergency management resources.

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-   Execute, as needed, the VA Comprehensive Emergency Management
    Program, including VA's Continuity of Operations Plan (COOP).

-   Execute, as needed, the Incident Command System (ICS), including
    Emergency Operations Plan (EOP) and Standard Operating Procedures
    (SOP), as developed by VHA, VBA and NCA and defined within
    administration policy (see [Appendix D-2: SAMPLE EMERGENCY
    MANAGEMENT PROGRAM](#_Appendix_D-2:__SAMPLE_EMERGENCY_MAN) STANDARD
    OPERATING PROCEDURE: *Pandemic Influenza Affecting a VA Health Care
    Facility*).

### VA Central Office Preparations

VA Central Office will make plans to prepare for an influenza pandemic
that would have the potential to interrupt the headquarters and program
office functions of the Department and its three administrations. VA
Central Office actions will include:

-   Planning to follow the guidance outlined in Continuity of Operations
    Plans for ensuring that essential functions are maintained, as well
    as the guidance of the Office of Personnel Management concerning
    Washington, DC, Federal work status.

-   Identifying essential functions and considering how to get work
    accomplished in an environment with altered work conditions (such as
    significant absenteeism), including telephone reroute procedures,
    plans to broker work to other locations, plans to reroute mail to
    alternate facilities.

-   Considering staffing issues including use of employment of flexible
    work standards, such as telecommuting and flexible (shorter) work
    hours if necessary, and the use of the use of liberal leave,
    authorized absences, advanced sick leave, and family medical leave
    policies.

-   Planning for education of and communication with staff on the status
    of pandemic influenza, what individuals can do to protect themselves
    and their families, infection control practices (including
    information from the "Infection: Don't Pass It On" campaign), and
    plans and policies regarding staffing, and changes in work
    procedures.

-   Planning to obtain and administer to staff, if possible,
    countermeasures such as antiviral medications and vaccine

### Roles and Responsibilities

#### Public Affairs/Communications

Public Affairs/Communications responsibilities are as follows:

-   VA communication will follow established practices and principles
    outlined in [Appendix D-3: REVIEW AND LIST OF COMMUNICATION
    PRINCIPLES AND ELEMENTS TO USE BEFORE, DURING, AND AFTER A
    PANDEMIC](#_Appendix_D-3:__REVIEW_AND_LIST_OF_C), and will take into
    account the many stakeholders, channels, and tools listed in order
    to reach veterans, VA staff, and the vast number of organizations
    and individuals concerned with VA programs.

-   Communications planning actions at the Network (VHA, NCA) or Area
    Office (VBA) level and at the local facility level, such as medical
    centers, benefits offices, or cemeteries, will follow the actions
    described under the VHA, VBA, and NCA parts later in this section
    (specifically 2.1.3.12, 2.3.3.5, and 2.4.3.4).

-   With support and subject-matter expertise of the VHA Office of
    Public Health and Environmental Hazards, Central Office VA, VHA, VBA
    and NCA public affairs staffs will collaborate on setting
    national-level communications priorities for the
    prepandemic/preparing phase using the actions below as a starting
    point for setting these priorities. The VHA Office of Public Health
    and Environmental Hazards and VHA Communications will assist the VA
    Office of Public and Intergovernmental Affairs and VA public affairs
    officers. Communications actions will include:

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-   Providing representatives on the VA Pandemic Influenza Advisory
    Group and encouraging public affairs participation in network,
    facility, and community planning efforts.

-   Developing a national Internet VA Pandemic Influenza Web site and
    mirror Intranet site that will:

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-   House the VA Pandemic Influenza Plan and related documents

-   Be maintained on a real-time basis

-   Have back up support for making changes

-   Be routinely publicized

-   Have links to Web sites within and outside of VA and seek other
    sites to link to it, including Federal, state, and local partners

-   Be managed by the VHA Office of Public Health and Environmental
    Hazards

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-   Encouraging leadership and public affairs staffs in VA facilities
    and network and regional offices to:

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-   Develop or adapt communications plans in concert with the VA
    Pandemic Influenza Plan

-   Maintain regular and emergency contact information for leadership,
    staff, media, and other key stakeholders

-   Assess and enhance resources such as key staff to maintain Web
    sites, respond to inquiries, give presentations, and work with the
    media

-   Establish contingency plans for increased information demands and
    back ups for staff and technology

-   Keep up to date on developments

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-   Developing and distributing materials in multiple formats to staff,
    veterans, outside groups, other agencies, and other stakeholders to

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-   Provide consistent, timely, and accurate information

-   Explain pandemic influenza and its impact on VA and on individuals

-   Help people know how to protect themselves against illness

-   Outline steps VA is taking to be prepared

-   Explain roles and responsibilities

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-   Identifying and training key spokespersons, usually medical experts
    or leaders who are knowledgeable, credible, articulate, willing, and
    prepared, at the national, regional, network, and local levels.

-   Knowing who the federal and state health contacts and national
    public health and health care organizations are, keep current
    contact information for them, and provide them with VA contact
    information as well.

-   Disseminating announcements and other materials and providing
    subject matter experts as needed to be proactive in keeping the
    media informed.

-   Creating communication tools and templates that can be used for
    basic messages and information in the event of a pandemic and for
    updates during the prepandemic/preparing period.

-   Providing regular updates at the national, regional, network, and
    local levels about situations having impact on the status of
    operations and service delivery to VA's many stakeholders via
    multiple means.

-   Avoiding rumors and misinformation by providing real time, clear,
    and open communication about what is known and not known to staff,
    veterans, the media, and other key stakeholders. This includes
    addressing rumors and false reports immediately with factual
    information and guidance; seeking information from and share
    responses with facilities, media contacts, and state and local
    officials; and encouraging facilities to establish similar rumor
    control/inquiry response systems locally.

-   Anticipating or receiving questions and preparing answers and
    information in a variety of formats for staff, veterans, the media,
    Congress, other agencies, and other stakeholders.

-   Establishing or renewing relationships with national Federal and
    private partners through pre-, pandemic, and recovery phases.
    Contact and monitor them for information and policy guidance.
    Encourage state, local, community and tribal contacts.

-   Briefing national media outlets and Veterans Service Organizations
    on the VA pandemic response plan.

-   Encouraging managers in facilities and offices to make news sources
    (such as the Internet, TV, and radio) available to staff,
    particularly in emergencies.

## VHA Preparations

### Leadership

The Under Secretary for Health will lead the VHA response to an
influenza pandemic, assisted by the Principal Deputy Under Secretary,
the Assistant Deputy Under Secretary for Management and Operations, the
Chief Public Health and Environmental Hazards Officer, and the Chief
Patient Care Services Officer, and advised by the VHA Emergency
Management Strategic Health Care Group and the VA Pandemic Influenza
Advisory Group.

### Coordination 

#### Collaboration

VHA Central Office will:

-   Work across its offices and networks and with national/Federal,
    state, and local health care agencies and organizations

-   Participate in and coordinate the VA-wide Pandemic Influenza
    Advisory Group

-   Organize VHA state contacts for pandemic influenza and also ask
    VISNs and facilities to name a lead contact for pandemic influenza

-   Participate in national surveillance efforts against pandemic
    influenza

#### Use of emergency plans

VHA Central Office will:

-   Prepare to execute an Incident Command System (ICS) and applicable
    plans as outlined in VA Operations Plan \"Safe Harbor\" (including
    the VHA Emergency Management Program Guidebook) and in Standard
    Operating Procedures (SOP) maintained by VHA, VBA and NCA.  (See
    [Appendix D-2, SAMPLE EMERGENCY MANAGEMENT PROGRAM STANDARD
    OPERATING PROCEDURE: *Pandemic Influenza Affecting a VA Health Care
    Facility*](#D2).)

#### Acquisition of and allocation policies for vaccines, antivirals, diagnostics, materiel, and staffing

VHA Central Office will:

-   Support the needs of its medical centers and other facilities to
    protect patients and VA staff across the Department by such actions
    as

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-   Developing plans and Memoranda of Understanding or Agreement
    (MOUs/MOAs) to acquire countermeasures against pandemic influenza,
    such as vaccines (anticipating their availability), antiviral
    medications, and diagnostics, as well as medical materiel such as
    personal protective equipment and other medications. This will
    include:

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-   Maintaining regular communications with other Federal agencies in
    order to be aware of vaccine availability and systems to acquire the
    vaccine.

-   Planning to acquire sufficient quantities of FDA-approved vaccine
    against a pandemic strain to vaccinate veterans enrolled for VA
    health care as well as VA staff in all three administrations.

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-   Supporting or assisting other Federal agency initiatives to develop
    domestic vaccine production capacity, according to its mission and
    abilities.

-   Developing criteria and procedures for distribution of these
    countermeasures and other supplies.

-   Developing criteria and transparent processes for allocation
    decisions regarding resources that may not be available in
    sufficient quantities during a pandemic: antivirals, respirators,
    vaccines, staff resources

-   Considering the usefulness of acquiring mobile clinics or modular
    medical stations, such as Federal Medical Shelters (FMSs), scalable,
    modular, 250-bed deployable facilities that require approximately
    40,000 square feet of space and are configured to provide basic but
    essential medical care.

### Roles and Responsibilities

#### Creation of facility and network pandemic influenza plans 

-   VISNs, medical centers and satellite facilities such as
    community-based outpatient clinics (CBOCs), should be encouraged to
    develop and test pandemic influenza plans that address the elements
    described in the rest of this subsection and to coordinate with
    other local organizations. These elements should include:

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-   How the workforce and physical sites will be prepared;
    transportation of staff and patients

-   What infection control and countermeasures will be put into place or
    enhanced, and assessments of what medical materiel will be necessary

-   Identification of essential functions

-   Estimation of the possible surge in demand due to a pandemic

-   Plans for health care delivery in the dynamic environment caused by
    pandemic influenza

-   Support of health care facility staff who are exposed to or become
    ill with pandemic influenza

-   Provision of mental health support for patients and staff

-   Surveillance and reporting

-   Increased security

-   Effective communications

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-   Medical centers, CBOCs, other VHA facilities and VISNs will
    participate in community public health and state-sponsored pandemic
    drills, and carry out drills within their own facilities. Lessons
    learned will be incorporated into response plans.

-   Facilities will take in account the possibility of assisting the
    community (see [Appendix B-1: SUMMARY OF POTENTIAL VA EXPANDED
    RESPONSIBILITIES](#_Appendix_B-1:__SUMMARY_OF_POTENTIAL)).

-   Refer also to [Appendix D-2: SAMPLE EMERGENCY MANAGEMENT
    PROGRAM](#_Appendix_D-2:__SAMPLE_EMERGENCY_MAN) STANDARD OPERATING
    PROCEDURE: *Pandemic Influenza Affecting a VA Health Care Facility.*

#### Workforce preparation (education, skill identification, credentialing, Pandemic Response Teams)

-   VHA facilities recognize that health care providers have a duty to
    care for the sick even in high-risk situations. VHA will provide for
    the health and safety of front-line providers and other health care
    facility staff.

-   VHA facilities recognize that health care providers have a duty to
    protect patients by minimizing the transmission of disease. VHA will
    provide personal protective equipment and institute necessary safety
    protocols for front-line providers and other health care facility
    staff, consistent with the standards and requirements of the
    Occupational Safety and Health Administration. (OSHA).

-   VHA facilities will prepare for situations in which work will be
    done in an environment with altered working conditions and
    constraints. Changes to anticipate include:

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-   A substantial decrease in available staff (by as much as 40%)

-   An expanded scope of practice by some staff

-   Use of staff recruited from the community (volunteers, retirees,
    etc)

-   Delivery of care according to alternative standards

-   The potential need to provide care to enrolled veterans as well as
    non-enrolled veterans and non-veterans if necessary (see [Appendix
    B-2: TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT TO
    EMERGENCIES - Advice on Changes in Usual VA Practices During a
    Pandemic](#B2))

-   Creation and training a pool of non-medical responders to support
    health and medical care operations

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-   VHA facility workforce planning will include these actions:

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-   Identify functions essential to maintain during a pandemic.

-   Provide education for staff concerning:

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-   Pandemic influenza and its symptoms and management

-   Infection control and public health measures

-   Emergency procedures

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-   Identify skill sets of practitioner groups (e.g., clinical
    pharmacists, paramedics, nurse clinical specialists, nurse
    educators, etc.), so as to optimize reassignment potential.

-   Consider identifying non-VA providers as potential clinicians prior
    to an emergency and registering and credentialing them in advance
    through a sponsoring VA entity (see [Appendix B-2: TABLE OF LEGAL
    AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES - Advice on Changes
    in Usual VA Practices During a Pandemic]{.underline}).

-   Create a system to track skills, location of assignment, location of
    residence, health status (including pandemic influenza immunity
    status) of VA staff and volunteers to serve in a pandemic.

-   Determine which staff members will require N-95 or PAPR-type
    respirators and fit test all that may be called upon to maintain
    critical systems in situations where they may be exposed to
    influenza virus.

-   Name a Pandemic Response Team that will be prepared to work during a
    pandemic and that includes the following disciplines:

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-   Intensive care nurses, emergency room/urgent care nurses, primary
    care nurses

-   Nurse practitioners/physician assistants

-   Intensive care, emergency room/urgent care, primary care, infectious
    disease physicians

-   Infection control personnel

-   Pharmacists

-   Respiratory therapists

-   Radiology technicians

-   Laboratory personnel

-   Information technology staff

-   Engineers

-   VA police or security staff

-   Telephone advice nurses

-   Patient safety specialists

-   Safety and industrial hygienists

-   Occupational health staff

-   Transportation staff

-   Housekeeping

-   Receptionists/clerks/telephone operators

-   Mental health professionals, chaplains, social workers

-   Hospital administrators

-   Public affairs officers

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-   Consider flexible work standards, such as flexible hours (shorter or
    staggered shifts), telecommuting for some functions such as
    answering advice lines.

-   Identify shared or facility-based child-care and other home support
    systems.

#### Physical site (space planning, building and engineering systems, support for infection control, transportation of patients, fatality management)

VHA facility physical site planning will include the following:

-   Develop plans to free up existing clinical space and consider
    flexible, creative use of other facility space in anticipation of
    higher workloads.

-   Identify space for separate waiting rooms and separate emergency
    care areas for patients with pandemic influenza.

-   Identify and develop clear plans for alternative space, that is, to
    expand capacity in space that is currently nonoperational or unused
    and that can be converted to space for triage, waiting, outpatient
    or inpatient (infirmary) care, as well as to locate space outside
    the facility that might be used if necessary.

-   Consider reactivating closed units or buildings to create surge
    capacity for isolating pandemic influenza patients.

-   Map patient flow to plan for restricted use of areas, visitor
    restriction.

-   Assess building and engineering systems as follows:

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-   Check exhaust air systems and air handling units for proper
    operation, flow rate and proper fit and type of filters.

-   Assure all negative airflow rooms are operationally checked and
    staff trained to use and maintain airflow systems.

-   Prepare air zone diagrams to inform medical center staff of the
    areas that share the same reservoir of air and plan cohorting or
    isolation of patients accordingly.

-   Maintain spare sets of filters for critical areas (these may become
    very difficult to obtain in a pandemic). Consider keeping a 4-week
    supply of these filters.

-   Obtain appropriate filters for heating, ventilating, and air
    conditioning units serving areas that may be designated as surge
    areas for patients.

-   Inventory portable exhaust fans used in construction areas for
    possible use in creating surge negative air airflow areas and review
    the location of exhaust vents relative to intake vents to ensure
    that no infectious recirculation situations exist or are created
    when areas are converted to surge negative air flow rooms.

-   Plan the set-up of hand wash/hand cleaning stations at all entries
    to the health care facility to emphasize the requirement for
    extraordinary attention to infection control.

-   Plan for cohorting of patients with pandemic influenza; consider
    identifying physically distant or separate space or buildings for
    infected patients. Such plans will be proportional to the disease
    impact, necessary, relevant, applied equitably, and employ the least
    restrictive means if options are available.

-   Plan for security measure to protect the integrity and safety of
    structures, staff, equipment, and supplies.

-   Plan for transportation of staff/patients.

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-   Arrange carpool or van transport systems in the event public
    transportation breaks down or pandemic situation precludes public
    travel (see [Appendix B-2: TABLE OF LEGAL AUTHORITIES AND POLICIES
    RELEVANT TO EMERGENCIES - Advice on Changes in Usual VA Practices
    During a Pandemic](#B2)).

-   Consider that non-health care providers might accompany patients if
    necessary.

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-   Plan for management of large numbers of fatalities.

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-   Assess current capacity for refrigeration of remains.

-   Discuss and establish mass fatality plans with local and state
    health officials and medical examiners.

-   Work with local health officials and medical examiners to identify
    temporary morgue sites, such as refrigerated warehouses and trucks.

-   Plan to have staff use Airborne Infection Isolation and Contact
    Precautions for handling remains of individuals who die from
    pandemic influenza (see [Appendix E-2: CHART OF PANDEMIC INFLUENZA
    PRECAUTIONS FOR VA HEALTH CARE FACILITY
    STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN)).

-   Determine the scope and volume of supplies needed to handle an
    increased number of remains.

#### Infection control and precautions (heightened surveillance, staff illness, supplies and their management, transmission and precautions for health care facility staff)

VHA facilities will plan infection control programs containing the
following measures:

-   Ensure that there is ongoing education for employees and information
    for patients and visitors that includes regular updates on basic
    infection control practices (hand hygiene, respiratory etiquette,
    and the basic principles of infection transmission and isolation
    strategies) using the materials of the VA "Infection: Don't Pass It
    On" campaign and other appropriate resources.

-   Establish and maintain active employee seasonal influenza
    vaccination campaigns each year, making use of the annual Influenza
    Toolkit.

-   Heighten institutional surveillance for influenza, including early
    recognition of institutional outbreaks, increased numbers of
    patients being seen in ambulatory settings for influenza-like and
    other respiratory illnesses, and increased employee absenteeism.

-   When the VHA Health Care Acquired Infection and Influenza
    Surveillance System is available, use automatically produced data
    that will identify and track indicators of such infections and
    provide information to VA facilities and leadership and to other
    national databases.

-   Encourage staff to recognize signs and symptoms of influenza before
    they report for duty and take appropriate action; develop a
    procedure for them to be able to call and report availability for
    work and their health status.

-   Develop criteria for limiting visitor access if it becomes necessary
    during a pandemic.

-   Develop protocols for tracking and managing staff that are ill with
    influenza.

-   Develop strategies for maintaining supplies during a pandemic,
    including security and control measures to ensure that supplies are
    not removed from the facility or used incorrectly.

-   Develop strategies to ensure that adequate supplies of personal
    protective equipment and hand hygiene products are available.

Note: The mode of transmission of a pandemic influenza strain cannot be
known at this writing. Transmission may be by large respiratory droplets
(particle size \> 5 microns) or by very small droplets (≤ 5 microns),
i.e., aerosol means. The mode of transmission defines the level of
precautions and isolation required to care for patients in the health
care setting. Seasonal influenza strains are generally agreed to be
transmitted largely by respiratory droplets, requiring wearing of
surgical-type or procedure masks by health care providers and staff
working within 3 feet of infected patients. It is possible that a
pandemic strain, because of its virulence or potential for aerosol
transmission, would warrant a higher level of protection. Therefore,
until the transmission mode of a pandemic influenza is fully understood,
the VA Pandemic Influenza Plan advises a conservative approach with the
use of Airborne Infection Isolation and Contact Precautions for staff
caring for patients in the health care setting. These precautions
include the use of approved respirators (N95 level masks or powered air
purifying respirators or PAPRs), gowns, gloves, and goggles, and the
isolation of patients in negative airflow rooms.

#### Countermeasures (vaccines, antiviral medications, diagnostics)

VHA facilities will take the following steps to acquire and distribute
countermeasures against pandemic influenza:

-   Use established acquisition and contracting programs, including
    local, VISN, and national programs.

-   In the event of difficulties with local acquisition capabilities,
    plan to go through the National Acquisition Center (NAC) or through
    the Office of Acquisition and Materiel Management (OA&MM).

-   With VHA Central Office, develop criteria and transparent processes
    for decisions regarding allocation of resources that may not be
    available in sufficient quantities (antivirals, respirators,
    vaccines, staff resources).

-   Plan to administer vaccine, when available, according to established
    criteria and with guidance issued at the time by the Under Secretary
    for Health. (It is expected that VHA will obtain vaccine from
    Federal sources.)

-   Plan to acquire antivirals and to distribute them according to
    established criteria and with guidance issued at the time by the
    Under Secretary for Health.

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-   VA holds a central supply of oseltamivir (Tamiflu®) that will be
    made available to patients and staff during an influenza pandemic.

-   Use of the central VA oseltamivir supply will be based on an
    implementation plan issued by the Under Secretary for Health.

-   Staff should familiarize themselves with access procedures for VA's
    oseltamivir supply. Information is available thru VHA Information
    Letter 10-2005-016, "VHA Oseltamivir Stockpile" (see [Appendix C-1:
    REFERENCE LIST FOR VA EMERGENCY PLANS AND OTHER
    RESOURCES](#_Appendix_C-1:__Reference_List_for_V)).

-   Staff should familiarize themselves with procedures to access
    supplies of oseltamivir that their own facilities have acquired for
    treatment or prevention of outbreaks of seasonal influenza A or B.
    These supplies may be used as appropriate for pandemic influenza.

-   Routine prescribing of oseltamivir by VA clinical staff and
    dispensing of oseltamivir by VA pharmacies for personal stockpiles
    for veteran patients or VA staff is not authorized as of this
    writing. This decision may be reassessed.

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-   Plan to acquire diagnostic and laboratory tests, considering that:

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-   At present (early 2006), commercial test kits and protocols that
    distinguish between specific strains of influenza are not widely
    available. VHA staff may combine use of influenza rapid test kits
    with those for other seasonal respiratory infections, such as
    respiratory syncytial virus (RSV), to narrow the differential
    diagnoses of respiratory illness.

-   VA participates in the CDC's Laboratory Response Network. The
    commitment of the LRN is that molecular methods would be available
    through the nearest LRN facility within 3 months or less of a
    defined pandemic within the United States. VA staff may use LRN as a
    diagnostic testing referral system.

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-   VA laboratory staff should:

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-   Ensure that adequate testing and specimen collection supplies are
    available for the anticipated patient workload as the pandemic
    evolves.

-   Ensure that capacity is available for storage of serum, respiratory,
    and tissue samples for testing or epidemiologic studies at a later
    point in time.

-   Consider developing Memoranda of Understanding (MOUs) with local
    vendors as needed to ensure testing and other critical diagnostic
    supplies are available and delivered.

-   Test infection control communications and reporting systems within
    the facility, to the VISN, and to local and state health
    departments.

-   Review proper specimen handling techniques with all appropriate
    personnel, as well as appropriate use of precautions (see [Appendix
    E-2: CHART OF PANDEMIC INFLUENZA PRECAUTIONS FOR VA HEALTH CARE
    FACILITY STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN)).

-   Plan and establish enhanced surveillance systems to monitor for
    influenza-like illness in all personnel handling respiratory
    samples.

#### Medical materiel (equipment and supplies)

VHA facility plans for acquisition of medical materiel should include
these actions:

-   Identify all existing and potential intensive care beds, negative
    airflow rooms; ventilators, personal protective equipment,
    medications, and general medical supplies and equipment needed to
    treat and care for infected individuals (see [Appendix D-4 SUGGESTED
    INVENTORY OF DURABLE AND CONSUMABLE SUPPLIES FOR VA HEALTH CARE
    FACILITIES DURING A PANDEMIC
    INFLUENZA](#__RefHeading___Toc130728419)).

-   Be familiar with means of obtaining any centrally stockpiled
    consumable material and consider creating facility stockpiles of
    durable and consumable materials.

-   Identify how/where to store durable equipment and consumable
    supplies for a pandemic. Consider how to achieve a balance between
    access to these supplies and security.

-   Evaluate existing contracts for equipment and supplies and, if
    needed, update contracts or develop MOUs to enable rapid purchase of
    additional quantities should the need arise; identify critical links
    in supply chains and consider whether contingent contracts with
    additional or alternative vendors would provide security against
    acute shortages.

-   Identify transportation routes to be used and vehicles to be
    deployed to move equipment and materiel .

-   Identify and address potential security issues.

-   Develop criteria for how equipment and supplies will be distributed
    in the event of shortages (i.e., who will have access, who will make
    decisions).

-   Participate in VA-wide pandemic influenza tabletop exercises to
    familiarize criteria personnel with criteria and procedures for
    allocation of scare equipment and supplies.

#### Health care delivery (triage, waiting areas, novel/innovative care delivery, including home care)

-   VHA facilities will ensure that their Pandemic Response Teams are
    prepared, educated, equipped and ready in the event of an influenza
    pandemic.

-   VHA facilities should consider that they may have the first case of
    pandemic influenza in their area (see [Appendix E-4: ACTIONS
    CHECKLIST---FIRST CASE).](#_Appendix_E-4_:__ACTIONS_CHECKLIST:) If
    so, they should plan to:

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-   Assess symptoms and make a clinical or laboratory diagnosis and
    trigger public health emergency plans.

-   Take care of the patient.

-   Take care of their staff members.

-   Let public health authorities and their VISN know.

-   Work to contain the illness through use of isolation in a negative
    airflow room, staff use of personal protective equipment.

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-   VHA facilities will estimate the potential surge in demand that may
    occur in a pandemic and their capacity for expanding ambulatory,
    acute, and medication treatment services to handle this surge.

-   VHA facilities, including medical centers and CBOCs, will plan the
    following actions for health care delivery during a pandemic:

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-   Plan for triage systems to:

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-   Identify persons who might have pandemic influenza.

-   Separate them from others to reduce the risk of disease transmission
    (such plans must be proportional to the degree of disease,
    necessary, relevant, applied equitably, and employ the least
    restrictions if options are available).

-   Use emergency rooms, urgent care centers and primary care clinics
    and other locations for triage.

-   Identify the type of care required (e.g., outpatient or home care or
    hospitalization).

-   Assign staff to work with either "well" patients or ill patients,
    but not both.

-   Assess urgency of care needs guided by vital signs, clinical
    assessment and pulse oximetry.

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-   Establish separate waiting areas for persons with respiratory
    symptoms.

-   Plan to address increased demand for negative airflow rooms,
    intensive care units, and assisted ventilation.

-   Develop strategies to provide information to large numbers of
    patients, such as telephone hot lines, automated phone messages, and
    mailings.

-   Plan to add or enhance telehealth and advice lines to facilitate
    home care.

-   Plan to staff and promote novel and innovative care delivery
    strategies:

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-   Use self-triage algorithms that enable veterans and staff to help
    identify symptoms in themselves and others to decide who may need
    emergency care, referral to outpatient care, or care at home. Post
    and promote this algorithm on the Web (see [Appendix E-5: SAMPLE
    SELF-TRIAGE ALGORITHM FOR PERSONS WITH INFLUENZA
    SYMPTOMS](#_Appendix_E-5:__SAMPLE_SELF-TRIAGE_A)).

-   Establish "drive-through" clinics utilizing triage personnel to
    rapidly assess patients, obtain vital signs and pulse oximetry to
    make decisions about further evaluation, hospitalization, or home
    care.

-   Develop and provide advice via telephone, print material, and the
    Internet (MyHealth*[e]{.underline}*Vet and other Web sites) on a
    variety of pandemic influenza-related topics, including home care,
    with instructions to contact VA facilities if symptoms worsen (see
    [Appendix E-6: HOME CARE GUIDE FOR
    INFLUENZA](#_Appendix_E-6:__HOME_CARE_GUIDE_FOR_)).

-   Consider suggesting the home as a site of care and creating "home
    care kits" to send to veterans and staff being cared for at home
    that might include supplies such as a thermometer with instructions,
    cough medications, acetaminophen or ibuprofen as appropriate,
    rehydration powders, and information on home care, with a symptom
    and care log (see [Appendix D-4 SUGGESTED INVENTORY OF DURABLE AND
    CONSUMABLE SUPPLIES FOR VA HEALTH CARE FACILITIES DURING A PANDEMIC
    INFLUENZA](#__RefHeading___Toc130728419) and [Appendix E-6: HOME
    CARE GUIDE FOR INFLUENZA Symptom and care
    log](#_Appendix_E-6:__HOME_CARE_GUIDE_FOR_)).

-   Communicate with staff about these strategies and establish training
    modules, protocols and algorithms using the current definitions of
    possible cases and approaches to treatment. For those facilities
    with capabilities for Telehealth connections, plan to extend current
    collaborations.

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-   Be prepared for increased demands for service and for responding to
    it in this general sequence, which may change depending on the
    geography and epidemiology of the pandemic:

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-   Address the needs of the facility's enrolled patients.

-   Work with the VISN to address any unmet needs of enrolled patients
    within the network.

-   Work as a system within VHA to meet the needs of enrolled patients.

-   Take care of additional patients as part of VA's potentially
    expanded role in an emergency (see [Appendix B-1: SUMMARY OF
    POTENTIAL VA EXPANDED
    RESPONSIBILITIES](#_Appendix_B-1:__SUMMARY_OF_POTENTIAL)). These
    include DoD active duty patients, non-enrolled veterans, and
    non-veterans.

-   Consider that altered standards of care may become necessary and
    include this possibility in presentations with stakeholders to
    ensure a transparent process. (The term \"altered standards\" means
    a shift to providing care and allocating scarce equipment, supplies,
    and personnel in a way that saves the largest number of lives in
    contrast to the traditional focus on individuals. See further
    discussion of this concept in [Section 3.2.3.7 Patient care
    (changing demands and surge, advice lines/telemedicine, triage,
    diagnosis, isolation, expansion to include alternative space and
    sites, altered standards of
    care](#patient-care-changing-demands-and-surge-advice-linestelemedicine-triage-diagnosis-isolation-expansion-to-include-alternative-space-and-sites-altered-standards-of-care).)

#### Support and management of exposed and ill staff

VHA facilities have a duty to protect patients and staff by minimizing
the transmission of disease. VHA facilities will plan for the management
of exposed, suspected and/or confirmed infectious staff. Actions should
include:

-   Providing immunizations, medications, and supplies of personal
    protection equipment to protect staff against influenza.

-   Developing a call-in system for monitoring staff who are ill.

-   Treating suspected and/or confirmed infectious staff.

-   Monitoring occurrences and establishing triage and isolation of
    suspected and/or confirmed cases of respiratory illness in staff.;

-   Implementing plans for laboratory testing and processing of employee
    specimens.;

-   Using mechanisms for reporting and disclosure of test results, and
    maintaining employee confidentiality.;

-   Excluding staff with symptoms, or after high risk exposures at work
    or at home, or confirmed diagnosis of pandemic influenza from duty.;

-   Providing home care kits (see [Appendix E-6: HOME CARE GUIDE FOR
    INFLUENZA, Symptom and care
    log](#_Appendix_E-6:__HOME_CARE_GUIDE_FOR_), Infection Control for
    the Home).

-   In the case of a particularly severe pandemic wave, providing
    personal protective equipment, antiviral medications, and vaccine to
    family members to keep health care facility staff healthy and
    available to take care of patients, depending on the inventory of
    equipment, supplies, and medications, and the facility's
    responsibilities and assignments under the National Response Plan
    (see [Appendix B-1: SUMMARY OF POTENTIAL VA EXPANDED
    RESPONSIBILITIES](#_Appendix_B-1:__SUMMARY_OF_POTENTIAL)).

#### Mental health support for patients and staff

VHA facilities should:

-   Develop plans to address mental health and chaplain services for
    patients and families and for health care and emergency workers and
    their families, especially when workers must be away from home. Such
    plans will include mental health professionals in facilities (such
    as psychiatrists, psychologists, social workers, specialized nurses,
    and chaplains), readjustment counseling (Vet Center) staff, and
    staff of employee assistance programs, and may also include local
    psychiatry, psychiatry, psychology, social work, nursing, and
    faith-based or pastoral care organizations.

-   Describe a mental health consultation process to make such expertise
    available to all who require assistance at the local level. This
    process will include Central Office mental health and readjustment
    counseling services and VISN mental health councils.

#### Surveillance and reporting, VHA facility-level (including first case) and VHA Central Office-level response (use of diagnostics, data on cases, local collaboration, reporting mechanisms)

***VHA facility-level surveillance and possible first case***

-   VHA facilities (medical centers, CBOCs and other facilities) should
    plan for the possibility that they would have a first case in their
    region and plan to act accordingly (see [Appendix E-4: ACTIONS
    CHECKLIST---FIRST CASE)](#_Appendix_E-4_:__ACTIONS_CHECKLIST:).

-   VHA facilities should understand and plan to use a provisional case
    definition of pandemic influenza from the Centers for Disease
    Control and Prevention (CDC) (see next page for a hypothetical
    example of such a definition).

**[Hypothetical]{.underline}**

**example of provisional case definition**

**of possible pandemic influenza by CDC**

The current definition is an illness that meets criteria for an
influenza-like illness:

Temperature above 38C (100.4F) plus one of the following: sore throat,
cough, or dyspnea,

AND

+-------------------------------+---+---------------------------------+
| > *Travel risk---recently     | * | > *Occupational risk---persons  |
| > visited or lived in an area | * | > who work on farms or live     |
| > affected by a highly        | O | > poultry markets who process   |
| > pathogenic avian influenza  | R | > or handle poultry infected    |
| > A or confirmed human cases  | * | > with known or suspected avian |
| > of novel influenza viruses  | * | > influenza viruses or health   |
| > and had direct contact with |   | > care workers in direct        |
| > birds or person(s) with     |   | > contact with a suspected or   |
| > confirmed or suspected      |   | > confirmed pandemic influenza  |
| > novel influenza.*           |   | > patient.*                     |
+-------------------------------+---+---------------------------------+

**AND**

The maximum interval between potential exposure and symptom onset is
less than 10 days.

Once confirmed pandemic disease is widespread, cases will be identified
based on clinical presentation alone.

-   VHA facilities should plan to use diagnostics if available and
    recommended, but consider that:

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-   Laboratory evaluation for novel influenza A viruses during the
    prepandemic and early pandemic alert periods might be recommended
    for:

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-   Hospitalized patients with severe influenza-like illness, including
    pneumonia.

-   Non-hospitalized patients with influenza-like illness who have
    strong epidemiologic suspicion for exposure manifested by travel
    risk or occupational risk.

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-   In a pandemic situation VA staff should use any FDA approved test
    for point-of-care diagnostics consistent with good laboratory
    practices and licensing or recommendation by official oversight
    groups.

-   Non-FDA approved tests may become available for pandemic influenza
    strains. If so, VA staff should follow recommendations of CDC for
    provisional use of such testing.

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-   VHA facilities should plan to use established reporting mechanisms
    for cases or outbreaks of pandemic influenza (Incident or Situation
    Reports).

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-   If staff at a VHA facility suspect or confirm an outbreak of a
    pandemic strain of influenza, they should contact local and state
    public health authorities.

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-   VHA facilities will take the following into account:

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-   VA diagnostic and procedure codes data are currently reported to CDC
    via the BioSense system.

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-   VA currently provides transmissions twice daily on weekdays and once
    daily on weekends to CDC of all VA ICD-9-CM codes for diagnosis and
    procedures from outpatient and emergency room visits, sent through a
    secure electronic conduit.

-   After analysis and evaluation at the CDC, the data are immediately
    available to state and local health departments to enhance the local
    early warning value of the information.

-   This type of "syndromic" information is important for early warning
    for influenza like illness that can trigger further specific
    investigation.

-   A VHA Health Care Acquired Infection and Influenza Surveillance
    System that when operational will automatically identify and track
    indicators of such infections and provide information to VA
    facilities and leadership and to other national databases.

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-   Individual VHA facilities may already have other surveillance
    systems in place for unusual disease clusters.

-   Collaboration with state and local health departments in
    surveillance and reporting should occur to the extent possible.

-   Additional active surveillance by VHA facilities is not required by
    this plan.

***VHA Central Office-level response***

VHA actions in the event of suspected or confirmed cases or outbreaks
are as follows:

-   If staff at a VHA facility suspect or confirm an outbreak of a
    pandemic strain of influenza, they should contact local and state
    health authorities and their VISN leadership, who will communicate
    the information to VA Central Office.

-   If VHA Central Office receives information from a VISN or facility
    that there is a suspected or confirmed case or outbreak, then after
    consideration of local and national situations, VHA emergency plans
    will be activated and the VA Pandemic Influenza Advisory Group will
    convene in order to provide advice to the Under Secretary for
    Health, (and the Under Secretaries for Benefits and Memorial
    Affairs).

-   VHA facilities should be familiar with reporting mechanisms and
    ensure that their staffs are familiar with them.

#### Security (facilities, supplies)

VHA facilities will plan for security of all VA health care facilities
to prevent or minimize civil unrest and limit visitor access, as
necessary, by performing the following:

-   VA Police will apply existing National Threat Level Responses to
    civil unrest incidents, including pandemics.

-   National Threat Level responses specify procedures for facility lock
    down, entry control requirements, and additional police staffing
    needs.

-   Facility VA Police Chiefs will review support agreements with local
    law enforcement.

-   These support agreements and threat responses will be part of
    facility emergency plans and exercised on a regular basis.

-   Specific threat responses and support agreement requirements will be
    part of continuing VA police officer in-service training.

-   Storage locations for critical medical supplies will be subject to
    annual security surveys.

-   VA Police will be trained in the use of personal protective
    equipment either as first receivers of patients with possible
    pandemic influenza or as first responders to disturbances.

#### Communication, VHA facility-level and VHA Central Office-level

***VHA facility center-level communication***

-   VHA facility center public affairs staff should consider that in the
    prepandemic/preparing stage communications planning and efforts
    should take into account both:

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-   Communicating "now," i.e., before a pandemic, with the goals of
    increasing understanding of health, prevention, and health care
    issues and of roles and responsibilities.

-   Planning for communicating during the pandemic, with the goals of
    being able to provide information, address misinformation,
    facilitate effective operations, and lessen anxiety.

These efforts should be done in concert with (and with the support of)
medical center leadership and pandemic influenza planning staff and VHA
Central Office.

[Appendix D-3: REVIEW AND LIST OF COMMUNICATION PRINCIPLES AND ELEMENTS
TO USE BEFORE, DURING, AND AFTER a
PANDEMIC](#_Appendix_D-3:__REVIEW_AND_LIST_OF_C), covers general
principles for use before and during a pandemic, and provides lists of
stakeholders, vehicles, and channels to consider in creating plans.

-   Communicating before a pandemic:

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-   Steps in communicating now about pandemic influenza preparedness
    include:

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-   Developing consistent and accurate information about:

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-   What pandemic influenza is, what may happen, implications for the
    medical center

-   What individuals can do to protect themselves and prevent
    transmission

-   What VA, VHA, and the medical center are doing via their planning
    efforts

-   Roles and responsibilities as outlined in the medical center plan
    for before and during a pandemic

-   Local resources including public health departments and health care
    facilities

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-   Identifying key internal and external stakeholders for this
    information, such as:

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-   Staff -- clinical, nonclinical, security, telephone operators and
    receptionists, medical trainees, volunteers, contractors

-   Patients and their families

-   Veterans Service Organizations

-   Local public health and health care agencies

-   The media

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-   Engaging stakeholders in a dialogue during the early stages of
    planning to ensure a clear and common understanding of concepts such
    as rationing of resources, quarantine, and obligations of clinical
    caretakers.

-   Listening to stakeholders to assess their understanding, answer
    questions and concerns, and seek their input and ideas.

-   Using a variety of vehicles to convey information to key
    stakeholders, such as:

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-   Newsletter articles

-   Fact sheets and trifolds

-   Announcements and news release

-   Email announcements

-   Presentations/discussions at meetings (staff, community at large,
    local health counterparts)

-   Slide sets

-   Briefings

-   Conference calls

-   Easily found Internet and Intranet sites where this information is
    posted

-   Scripts for receptions and telephone operators -- both information
    on the current situation and template for information updates during
    a pandemic

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-   Considering the use of alternative formats for individuals with
    disabilities, translation for staff, patients, and families as
    necessary and easier-to-read wording for individuals who do not read
    well.

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-   Planning for communicating during a pandemic:

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-   Steps in planning for communication during a pandemic include:

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-   Developing a process to create consistent, accurate, and timely
    information using a streamlined approval procedure.

-   Identifying spokespersons, usually medical or leadership, who are
    knowledgeable, credible, articulate, willing, and prepared to speak
    to the media and other key stakeholders when needed before a
    pandemic and during a pandemic; rehearsing with them and obtaining
    media training for them as necessary.

-   Updating fact sheets and general information about the medical
    center (such as key facts, key staff).

-   Developing templates to convey information (announcements, status
    reports, news releases) during a pandemic as well as distribution
    lists for this information.

-   Considering how to work with the media. Besides having one or more
    identified spokespersons, consider telephone or teleconference
    briefings.

-   Developing a means for staying up to date, including identifying and
    addressing rumors, inaccuracies, and misperceptions.

-   Updating or establishing key contact lists, such as:

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-   For key staff -- direct work phone, home phone, cell phone, fax
    numbers, email addresses

-   For media -- phone, email, fax

-   For local public health (including communications staff) and health
    care sites -- phone, email, fax

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-   Establishing ways to seek input from stakeholders and provide
    information that they need.

-   Establishing or updating ways to communicate in emergencies such as:

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-   Telephone trees, i.e. structured lists of phone numbers (home, cell)
    that can be used to get the word out to staff or other individuals

-   Call-in systems for use during a pandemic for staff to report
    availability for work and their own health status

-   Live advice hotlines for patients to call in on

-   Recorded information lines that patients and staff can use to obtain
    information

***VHA Central Office-level communication***

VHA Office of Communications, the office of the Deputy Under Secretary
for Management and Operations, and the VHA Office of Public Health and
Environmental Hazards will work together to:

-   Ensure that Central Office staff and contractors receive pandemic
    influenza preparedness messages and materials.

-   Convey requirements and responsibilities regarding communication
    about pandemic influenza to staff throughout the VA health care
    system.

-   Ensure that VHA staff and veterans have consistent, accurate
    information.

-   Provide information to Veterans Service Organizations and other
    partners.

-   Provide up-to-date information to Voluntary Service directors.

-   Establish and maintain employee telephone lists and consider using
    telephone trees for notifications of large numbers of staff.

-   Develop procedures for staff unable to work, such as a toll-free
    number for staff to use to call in about work availability and
    health status.

-   Plan to conduct frequent conference calls with VISNs and facilities
    affected by pandemic influenza and those in immediate risk of a
    pandemic wave.

-   Plan for efficient communication with Federal, state, local, and
    community partners.

-   Establish mechanisms for two-way communication with
    local/state/private health care community partners that include:

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-   Appointing and announcing facility and state VA points of contacts
    for local/state/private health care agencies, as well as for VHA
    purposes.

-   Coordinating local planning with needed facilities.

-   Sharing pandemic influenza plans, educational materials, and other
    resources.

-   Developing mechanisms to share scarce resources and expertise.

-   Developing templates that outline procedures for announcements, such
    as closing of hospitals, restriction of visitors, alternative sites
    for or approaches to care.

-   Meeting with community partners to assure understanding of plans and
    responsibilities.

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-   Establish mechanisms for two-way communication with VA facilities
    that include:

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-   Generating pandemic influenza plans in accordance with the VA
    national plan.

-   Coordinating their local planning with community and state agencies.

-   Locating and utilizing information on ways to prevent the spread of
    pandemic influenza for staff, clinicians, patients, visitors,
    vendor, supplier and community members.

-   Preparing written/audio information to inform staff of the
    facility's pandemic influenza plan and how each employee can take
    part in slowing the pandemic.

-   Providing easy access for clinicians/staff/patients/others on how to
    protect themselves from pandemic influenza.

-   Assuring that clinical staff is aware of the current probability of
    pandemic influenza, and how to prevent the spread of pandemic
    influenza in the health care setting.

-   Establishing a phone number for staff to use for updates.

-   Providing information on the current status of the influenza.

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-   Establish mechanisms for two-way communication with key stakeholders
    in and out of VHA, including:

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-   Developing a prioritized list of these stakeholders.

-   Developing mechanisms to communicate with stakeholders on the status
    of pandemic preparedness.

-   Providing information on how to prevent the spread of pandemic
    influenza to each audience.

-   Ssending information or speakers to each audience present on the
    status of the epidemic, what can be done to slow the transmission of
    the virus to others (see [Appendix E-3: CHART OF PUBLIC HEALTH
    MEASURES AGAINST PANDEMIC INFLUENZA FOR INDIVIDUALS, HEALTH CARE
    PROVIDERS, AND ORGANIZATIONS](#_Appendix_E-3:__CHART_OF_PUBLIC_HEAL)
    on public health measures), and the elements of the VA Pandemic
    Influenza Plan.

-   Developing a list of prevention activities that Veterans Service
    Organizations and other community partners could do to assist with
    or enhance VA's effort to manage the epidemic.

## VBA Preparations

### Leadership 

The Under Secretary for Benefits will lead the VBA response to an
influenza pandemic, assisted by the Under Secretary for Health and
advised by the VA Pandemic Influenza Advisory Group.

### Coordination

VBA central or regional offices will plan to:

-   Utilize existing Continuity of Operations Plans to ensure mission
    essential functions continue uninterrupted.

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-   Alternatives for face-to-face meetings with veterans are:

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-   PAO announcements to encourage use of toll free line; and

-   Mail drop off points on the exterior of the facility for veteran
    information.

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-   Consider that overall VBA operations are likely to be able to
    continue and not be affected by the closure of one or more regional
    office as all offices are connected to a centralized data system,
    and each office has procedures in place to reroute telephone
    connections and veterans' claims information for processing.

VBA will be represented on the VA Pandemic Influenza Advisory Group.

### Roles and Responsibilities

#### Creation of VBA regional office pandemic influenza plans 

-   VBA regional offices will develop plans that address how work will
    be done in an environment with altered work conditions. These plans
    should address:

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-   Staff telephone tree update

-   Telephone reroute procedures

-   Plans to broker work to other regional offices (if needed)

-   Plans to reroute mail to alternate facility(ies)

-   The placement of vital information on the Internet and Intranet

#### Workforce (staffing, education)

VBA regional offices will take these staffing issues into consideration:

-   Daily staff accounting

-   The employment of flexible work standards (telecommuting, flexible
    work hours, work from alternate sites)

-   Information technology/computer support for employees who are
    telecommuting (help desk function)

-   The use of liberal leave, authorized absence, and advanced leave
    policies

VBA central and regional offices will prepare their workforce by taking
these actions:

-   Provide education for all employees about the potential for pandemic
    influenza, including regular updates on infection control practices.

-   Encourage receipt of seasonal influenza vaccinations.

-   Develop protocols for managing employees who are ill with influenza.

-   Plan to ensure that sufficient supplies of personal protective
    equipment and hand hygiene products are available.

VBA may need to close a regional office during a pandemic and if so will
take these actions:

-   Prepare plan to reroute telephones to an open regional office.

-   Create line of communications to inform VBA Central Office of
    actions.

#### Infection control

-   VBA employees will be provided with educational materials on
    pandemic influenza, respiratory and hand hygiene.

-   VBA employees will be provided with information on the availability
    of pandemic influenza antivirals and vaccine from VA sources through
    their representative on the VA Pandemic Influenza Advisory Group.

#### Security

The following actions are needed to maintain VBA offices' security:

-   Ensure guard staff is trained on signs and symptoms of influenza to
    limit visitor access.

-   Plan to provide guard staff with appropriate PPE to ensure their
    welfare and safety.

#### Communication

Two-way communication with VACO employees, contractors, and tenant
organizations will include:

-   VBA will develop a communication plan for all of its employees to
    alert them to the potential for pandemic influenza.

-   VBA will coordinate these plans with VACO for refinement and
    alignment to the VA National Pandemic Influenza Plan.

-   VBA will plan alternate ways to communicate with VACO and their
    staff during times when traditional methods may not be available.

-   VBA will articulate to employees the areas of their jobs that put
    them at the greatest risk for pandemic influenza and how to minimize
    these risks.

-   VBA will ensure that employees have access to information on how to
    protect themselves from the spread of influenza.

-   Employ methods such as email, V-tel, web, written policies, memos,
    flyers, brochures, satellite TV, net meetings to review plans,
    prevention and home care kits.

-   Provide information to Veterans Service Organizations via
    established telephone trees and other mechanisms for dissemination.

## NCA Preparations

### Leadership

The Under Secretary for Memorial Affairs will lead the NCA response to
an influenza pandemic, assisted by the Under Secretary for Health and
advised by the VA Pandemic Influenza Advisory Group.

### Coordination

NCA Memorial Service Network offices and National Cemeteries will follow
the guidance outlined in Continuity of Operations Plans for ensuring
that mission essential functions are maintained.

-   Utilize existing Continuity of Operations Plans to ensure mission
    essential functions continue uninterrupted.

-   Review how overall NCA operations will be affected by the closure of
    one or more office or cemetery.

-   Review of how burial procedures may need to change because of
    increased numbers of requests and decreased staffing.

-   Develop criteria and transparent processes for allocation decisions
    regarding resources needed (cemetery staff, plots) for significant
    numbers of burials if closure and rescheduling is not an adequate
    response.

NCA will be represented on the VA Pandemic Influenza Advisory Group.

### Roles and Responsibilities

#### Creation of network- and cemetery-level pandemic influenza plans 

NCA Memorial Service Network (MSN) offices and National Cemeteries will
develop plans that address how work will be done in an environment with
altered work conditions. These plans should address:

-   Staff telephone tree update

-   Telephone reroute procedures

-   Plans to broker work to other Network Offices (if needed)

-   Plans to reroute mail to alternate facility(ies)

#### Workforce (staffing, education)

NCA Memorial Service Network offices and National Cemeteries will take
these staffing issues into consideration:

-   Daily staff accounting

-   The employment of flexible work standards (telecommuting, flexible
    work hours, work from alternate sites)

-   Information technology/computer support for employees who are
    telecommuting (help desk function)

-   The use of liberal leave, authorized absence, and advanced sick
    leave policies.

NCA Memorial Service Network offices and National Cemeteries will
prepare their workforce by taking these actions:

-   Provide education for all employees about the potential for pandemic
    influenza, including regular updates on infection control practices.

-   Encourage receipt of seasonal influenza vaccinations.

-   Develop protocols for managing employees who are ill with influenza.

-   Ensure that sufficient supplies of personal protective equipment and
    hand hygiene products are available.

NCA Memorial Service Network offices and National Cemeteries may need to
close during a pandemic and if so will take these actions:

-   Prepare to reroute telephones to an open office.

-   Create line of communications to inform NCA Central Office of
    actions.

-   Develop plan to contact funeral homes and the next of kin of the
    deceased to notify parties of the situation and to reschedule the
    affected burials.

#### Infection control

Infection control actions for NCA staff will include:

-   Providing staff with educational materials on pandemic influenza,
    respiratory and hand hygiene (see [Appendix E-3: CHART OF PUBLIC
    HEALTH MEASURES AGAINST PANDEMIC INFLUENZA FOR INDIVIDUALS, HEALTH
    CARE PROVIDERS, AND
    ORGANIZATIONS](#_Appendix_E-3:__CHART_OF_PUBLIC_HEAL) and [Appendix
    E-2: CHART OF PANDEMIC INFLUENZA PRECAUTIONS FOR VA HEALTH CARE
    FACILITY STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN)).

-   Providing staff with information on the availability of pandemic
    influenza antivirals and vaccine from VA sources through their
    representative on the VA Pandemic Influenza Advisory Group.

#### Communication

Two-way communication with VACO will include the following (see also
[Appendix D-3: REVIEW AND LIST OF COMMUNICATION PRINCIPLES AND ELEMENTS
TO USE BEFORE, DURING, AND AFTER A
PANDEMIC](#_Appendix_D-3:__REVIEW_AND_LIST_OF_C)):

-   NCA will develop a communication plan for all of its employees to
    alert them to the potential for pandemic influenza.

-   NCA will coordinate these plans with VACO for refinement and
    alignment to the VA National Pandemic Influenza Plan.

-   NCA will plan alternate ways to communicate with VACO and their
    staff during times when traditional methods may not be available.

-   NCA will articulate to employees the areas of their jobs that put
    them at the greatest risk for pandemic influenza and how to minimize
    these risks.

-   NCA will ensure that employees have access to information on how to
    protect themselves from the spread of influenza.

-   Employ methods such as: email, V-tel, web, written policies, memos,
    flyers, brochures, satellite TV, net meetings to review plans,
    prevention and home care kits.

-   Provide information to Veterans Service Organizations via
    established telephone trees and mechanisms for dissemination.

## VA-Wide Pandemic Influenza Outbreak Exercises

The Department of Veterans Affairs will conduct interactive tabletop
exercises of a large-scale outbreak of pandemic influenza. The exercises
will focus on two or three VISNs of the VA health care system and
involve VA Central Office, VA facilities (including medical centers,
community-based outpatient clinics, a VBA regional office, and a
cemetery within each of those VISNs), and the relevant Federal, state
and local partners. Goals of the exercises are:

-   Practice coordination between VA, other Federal agencies and public
    health departments and local health care delivery partners in the
    following key response categories:

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-   Surveillance and epidemiology

-   Command and control and communications

-   Internal and external risk communication

-   Coordination of surge capacity

-   Infection control and patient care

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-   Clarify roles among VA, other Federal agencies and health care
    partners and public health agencies while facilitating response.

-   Identify strengths of the response and areas for improvement.

# RESPONDING TO PANDEMIC INFLUENZA

Strategic goals of response and containment efforts will be to stop,
slow, or limit the spread of disease, reduce suffering and death, and
sustain the operations of the Department of Veterans Affairs.

Note that the major actions described here also appear in [Appendix E-1:
VA PANDEMIC RESPONSE ACTION
GRID](#_Appendix_E-1:__VA_PANDEMIC_RESPONSE)S.

## VA Response Actions

### Leadership

The VA Secretary will lead the overall Department of Veterans Affairs
Response to an influenza pandemic, assisted principally by the Deputy
Secretary and the Under Secretary for Health and their designees.

### Coordination and Communication

VA will:

-   Via the Secretary, the Office of Policy, Planning and Preparedness,
    the Office of Public and Intergovernmental Affairs, and the VHA
    Office of Public Health and Environmental Hazards, activate a
    coordinated response within the Department and between VA and
    federal, state, and local agencies, health care, and Veteran Service
    Organizations.

-   Via the Secretary, regularly consult with the VA Pandemic Influenza
    Advisory Group.

-   Via the Office of Public and Intergovernmental Affairs and VHA
    Communications, put VA communications plans and principles into
    action (see [Section 3.5 Communication Within and Outside of VA
    During a
    Pandemic](#communication-within-and-outside-of-va-during-a-pandemic)
    and [Appendix D-3: REVIEW AND LIST OF COMMUNICATION PRINCIPLES AND
    ELEMENTS TO USE BEFORE, DURING, AND AFTER A
    PANDEMIC](#_Appendix_D-3:__REVIEW_AND_LIST_OF_C)).

### VA Central Office Response

VA Central Office will use the plans developed under 2.1.3 to respond to
pandemic influenza if a wave comes through the Washington, DC, area and
affects headquarters and program office functions of the Department and
its three administrations. VA Central Office will:

-   Follow the guidance outlined in Continuity of Operations Plans for
    ensuring that essential functions are maintained, as well as that of
    the Office of Personnel Management concerning the local Federal work
    status and operating conditions.

-   Carry out essential functions and make use of plans to reroute
    telephones, get work done via staff at other locations, and reroute
    the mail.

-   Use flexible work standards, such as telecommuting and flexible
    (shorter) work hours if necessary, and the use of the use of liberal
    leave, authorized absences, advanced sick leave, and family medical
    leave policies.

-   Plan for continued and open communication on the status of the
    pandemic, Central Office operating status and expectations, and
    changes in policies regarding staffing and work procedures.

-   Obtain and administer to staff, if possible, countermeasures such as
    antiviral medications and vaccine.

### Roles and Responsibilities: VA-wide

#### Vigilance and notification

VA will maintain situational awareness, being vigilant for "trigger"
points at which local actions on pandemic influenza will escalate from
passive to active.

-   A trigger point will be defined by authoritative international
    scientists and will be relayed by the World Health Organization, the
    Department of Health and Human Services (HHS), and the Centers for
    Disease Control and Prevention (CDC). VA will use HHS/CDC guidance
    on the definition of a trigger.

####  {#section-5 .unnumbered}

#### Implementation of emergency plans

VA will activate, as appropriate, its Continuity of Operations Plans
(COOPs), this pandemic influenza plan, and other emergency plans for the
Department, VHA, VBA, and NCA (see [Appendix C-1: REFERENCE LIST FOR VA
EMERGENCY PLANS AND OTHER
RESOURCES](#_Appendix_C-1:__Reference_List_for_V)).

#### Limiting disease spread

VA will act to limit disease spread, including taking these steps:

-   Emphasizing the general principles of VA's "Infection: Don't Pass It
    On" campaign: wash or clean hands frequently, cover coughs and
    sneezes, stay home when ill, and avoid contact with persons who are
    ill, when possible.

-   Encouraging VA staff and facilities to follow local public health
    guidance for action, such as limiting public gatherings, holding
    "snow days" during which events and activities are closed.
    Activating plans for alternative work schedules and staffing.

-   Using established distribution mechanisms to provide antiviral
    medications to VHA patients and to VHA, VBA, and NCA staff.
    Prioritization will depend on the availability of antivirals and
    characteristics of the pandemic, and will be determined through
    coordination with HHS and DoD. The VHA Pharmacy Benefits Management
    Strategic Healthcare Group will distribute the antiviral oseltamivir
    from the VHA stockpile to local VA facilities in VHA, VBA, and NCA
    as determined by an implementation plan from the Under Secretary for
    Health.

-   Using established distribution mechanisms to provide vaccine, when
    available, to VHA patients and to VHA, VBA, and NCA staff.
    Prioritization will depend on the availability of vaccine and
    characteristics of the pandemic, and will be determined through
    coordination with HHS and DoD. Distribution of the vaccine to local
    VA facilities in VHA, VBA, and NCA will be determined by an
    implementation plan from the Under Secretary for Health.

## VHA Response Actions 

### Leadership

The Under Secretary for Health will head the VHA response to an
influenza pandemic, assisted by Principal Deputy Under Secretary for
Health, the Assistant Deputy Under Secretary for Management and
Operations, the Chief Public Health and Environmental Hazards Officer,
and the Chief Patient Care Services Officer, and advised by the VA
Pandemic Influenza Advisory Group.

### Coordination and Communication

VHA and its facilities and VISNs will collaborate as diligently as
possible within VA as well as with local authorities (including State
and local health care agencies and organizations) for:

-   Information and guidance about surveillance, response, and
    containment activities.

-   Use of vaccine when available and indicated.

-   Use of antiviral drugs when available and indicated.

-   Effective and timely communication following established plans and
    principles (see [Section 3.5 Communication Within and Outside of VA
    During a
    Pandemic](#communication-within-and-outside-of-va-during-a-pandemic)
    and [Appendix D-3: REVIEW AND LIST OF COMMUNICATION PRINCIPLES AND
    ELEMENTS TO USE BEFORE, DURING, AND AFTER A
    PANDEMIC](#_Appendix_D-3:__REVIEW_AND_LIST_OF_C))

### Roles and Responsibilities

#### Surveillance, including possible first case

VHA facilities will consider the possibility that they may see the first
case of pandemic influenza in their community or region (see [Appendix
E-4: ACTIONS CHECKLIST---FIRST
CASE](#_Appendix_E-4_:__ACTIONS_CHECKLIST:)). If pandemic influenza is
highly suspected or confirmed, key steps would include:

-   Isolating the patient in negative airflow room on Airborne Infection
    Isolation and Contact Precautions, if possible, in addition to
    Standard Precautions.

-   Recording information about possible case contacts (patients and
    staff) within the facility.

-   Implementing the facility emergency plan for pandemic influenza in
    term of infection control, notification of key facility staff, local
    public health, VISN leadership.

-   Convening the Pandemic Response Team, the staff designated to assist
    in an influenza pandemic.

-   Coordinating with leadership and public affairs to communicate with
    staff, patients, media, and community.

VHA facilities will rely on their surveillance plans (developed under
2.2.3.10) and use surveillance systems to:

-   Collect and report cases to state and local public health
    departments, according to local agreements and practices.

-   When the VHA Health Care Acquired Infection and Influenza
    Surveillance System is available, obtain automatically produced data
    that will identify and track indicators of pandemic influenza and
    use this information for their own purposes.

-   If available, use data received from the CDC Biosense program to
    assist with triggering of local containment actions.

-   Carry out plans to use diagnostics, if available, and use care in
    handling testing and shipping specimens, including appropriate
    precautions (see [Appendix E-2: CHART OF PANDEMIC INFLUENZA
    PRECAUTIONS FOR VA HEALTH CARE FACILITY
    STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN)).

#### Refocusing of patient care priorities

VHA facilities will maximize ability to care for patients with pandemic
influenza, including enrolled veterans, and in response to the needs of
other individuals, such as active duty military, non-enrolled veterans,
and non-veterans, as necessitated by local situations and as outlined in
VA-DoD contingency plans and the National Response Plan. Actions will
include:

-   Postponing elective hospital admissions and appointments.

-   Discharging patients capable of being cared for at home. Where
    possible provide guidance on home care, offer advice lines and
    contact information, and consider the use of home care kits (see
    [Appendix E-6: HOME CARE GUIDE FOR
    INFLUENZA](#_Appendix_E-6:__HOME_CARE_GUIDE_FOR_)).

#### Infection control (transmission and precautions for health care facility staff, hand and respiratory hygiene)

VHA facilities will implement appropriate infection control measures as
planned (see also [Section 2.2.3.3 Physical site (space planning,
building and engineering systems, support for infection control,
transportation of patients, fatality
management](#physical-site-space-planning-building-and-engineering-systems-support-for-infection-control-transportation-of-patients-fatality-management)
and [Section 2.2.3.4 Infection control and precautions (heightened
surveillance, employee illness, supplies and their management,
transmission and precautions for health care facility
staff](#infection-control-and-precautions-heightened-surveillance-staff-illness-supplies-and-their-management-transmission-and-precautions-for-health-care-facility-staff)).

At the beginning of a pandemic influenza outbreak, health care facility
staff members are advised to use Airborne Infection Isolation and
Contact Precautions for VHA health care facility staff (see [Appendix
E-2: CHART OF PANDEMIC INFLUENZA PRECAUTIONS FOR VA HEALTH CARE FACILITY
STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN)):

-   Use fit-tested N95 level masks or powered air purifying
    respirators---PAPRs, gowns, gloves, and goggles.

-   Place patient in negative air flow room to provide maximum
    protection of VHA staff until the mode of transmission has been
    established.

A note on transmission and precautions: Because the mode of transmission
of the virus will not be known for some time, VA advises taking a
conservative approach that provides a high level of protection for
health care facility staff. This level of protection, known as Airborne
Infection Isolation and Contact Precautions, includes the use of
fit-tested N95 respirators or PAPRs, as well as gowns, gloves, and eye
protection, such as goggles.

-   Adjust level of infection control practices and isolation throughout
    the pandemic period according to capability of the facility and
    epidemiology of the pandemic.

-   If the epidemiology of the pandemic virus does not warrant Airborne
    Infection Isolation and Contact Precautions or if the Airborne
    Infection Isolation and Contact Precautions cannot be maintained
    because of staffing, space, supplies, or patient flow, employ
    Droplet Precautions as follows:

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-   Staff wear surgical or procedure-type masks within 3 feet of
    patients.

-   Patients wear masks, if able; staff with potential body fluid
    contact wear gloves and gowns.

-   Segregate exposed patients away from non-exposed patients.

-   Isolate or cohort symptomatic/ill patients.

-   Handle soiled linens and waste according to usual health care
    facility procedures.

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-   No matter the mode of transmission, facilities should:

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-   Continue to promote and practice hand hygiene (patients and staff
    wash hands with soap and water or alcohol-based hand rub after
    having contact with respiratory secretions and/or contaminated
    individuals, objects, and materials).

-   Continue to promote and practice respiratory hygiene (patients and
    staff cover noses and mouths when sneezing, use facial tissues to
    contain respiratory secretions and dispose of them in a waste
    container).

-   Practice contact avoidance; individuals with influenza symptoms
    should be kept at least three feet from others as much as possible.

-   Screen incoming patients for influenza-like illness (ILI) with
    up-to-date algorithms for clinical symptoms and recent exposure and
    travel history.

-   Implement visitor restriction policies according to criteria.

-   Use rapid testing for influenza A if needed to differentiate
    pandemic influenza from other respiratory illnesses.

-   Follow quarantine measures and other public health measures issued
    by Federal, State and local government agencies (see [Appendix E-2:
    CHART OF PANDEMIC INFLUENZA PRECAUTIONS FOR VA HEALTH CARE FACILITY
    STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN)).

#### Support for and management of exposed or ill staff (monitoring, triage, absences, public health measures)

VHA will make use of plans developed to manage exposed, suspected and/or
confirmed infectious staff (see [Section 2.2.3.8 Support and management
of exposed and ill
staff](#support-and-management-of-exposed-and-ill-staff)). Facilities
have a duty to protect patients and staff by minimizing the transmission
of disease. Actions will include:

-   Providing immunizations, medications and supplies of personal
    protection equipment to protect staff against respiratory infection.

-   Doing daily fever monitoring of staff exposed to presumptive
    pandemic influenza cases.

-   Screening staff for influenza-like illness (ILI) with up-to-date
    algorithms for clinical symptoms and recent travel history.

-   Using rapid testing for influenza A.

-   Treating suspected and/or confirmed infectious staff.

-   Monitoring occurrences and establishing triage and isolation of
    suspected and/or confirmed cases of respiratory illness in staff.

-   Laboratory testing and processing of staff specimens.

-   Reporting and disclosure of test results, and maintaining staff
    confidentiality.

-   Excluding staff with symptoms, or after high risk exposures from
    duty, or confirmed diagnoses; requiring staff to stay home when ill.

-   Encouraging contact avoidance to the extent possible---individuals
    with influenza-like symptoms should be kept at least three feet from
    others.

-   Granting authorized absences as appropriate (see [Appendix B-2:
    TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES -
    Advice on Changes in Usual VA Practices During a
    Pandemic](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO)).

-   Following quarantine measures, social distancing measures, or, as
    possible, closures and "snow day" decrees issued by Federal, State
    and local government agencies (see [Appendix E-3: CHART OF PUBLIC
    HEALTH MEASURES AGAINST PANDEMIC INFLUENZA FOR INDIVIDUALS, HEALTH
    CARE PROVIDERS, AND
    ORGANIZATIONS](#_Appendix_E-3:__CHART_OF_PUBLIC_HEAL)).

#### Countermeasures (antiviral drugs, vaccines, diagnostics)

VHA facilities will activate plans to employ other available
countermeasures (see [Section 2.2.3.4 Infection control and precautions
(heightened surveillance, employee illness, supplies and their
management, transmission and precautions for health care facility
staff)](#infection-control-and-precautions-heightened-surveillance-staff-illness-supplies-and-their-management-transmission-and-precautions-for-health-care-facility-staff)),
including antiviral drugs, vaccines, and diagnostic and laboratory
tests, following the advice of the VA Under Secretary for Health (who
will be working closely with HHS and DoD). Such advice cannot be
specified at this time, but could include:

-   Use of antiviral medications:

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-   For pre-exposure prevention/prophylaxis (generally for the duration
    of the local outbreak) in order to:

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-   Prevent severe illness and death in those persons at highest risk
    from pandemic influenza.

-   Preserve delivery of health care and other essential critical
    services by providing prophylaxis to staff most likely to be
    exposed.

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-   For post-exposure prevention/prophylaxis (generally for 10 days
    after a possible exposure) in order to:

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-   Control well-defined disease clusters, such as outbreaks in nursing
    homes, other institutions, or small communities.

-   Protect individuals exposed to pandemic influenza, including health
    care providers and patients who have had significant exposure.

-   Provide mass prophylaxis (i.e., wide dispensing of antiviral drugs)
    to VHA staff and patients, if supplies are adequate and pandemic
    situation allows, usually in coordination with local and state
    plans.

-   After a vaccine becomes available, protect persons who might have an
    inadequate vaccine response (e.g., the elderly and those with
    underlying immunosuppressive disease) and individuals with
    contraindications to vaccination, such as anaphylactic
    hypersensitivity to eggs or other vaccine components.

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-   For treatment of staff and patients with pandemic influenza.

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-   Use of vaccine against pandemic influenza (when it is available)

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-   VHA leadership will maintain regular communications with other
    Federal agencies in order to be aware of vaccine availability and
    systems to acquire it.

-   VA will acquire sufficient quantities of FDA-approved vaccine
    against a pandemic strain to vaccinate veterans enrolled for VA
    health care, as well as VA staff in VHA, VBA, and NCA, and any
    others according to guidance in place at the time.

-   In proceeding to distribute and administer vaccine to staff and
    patients, VA will follow the prioritization guidance of the
    Secretary of VA and the VA Under Secretary for Health, in
    collaboration with HHS and DoD.

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-   Use of diagnostic and laboratory tests

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-   Combine the use of influenza rapid test kits with those for other
    seasonal respiratory infections, such as respiratory syncytial virus
    (RSV), to narrow the differential diagnoses of respiratory illness.

-   Use CDC's Laboratory Response Network as a diagnostic testing
    referral system.

-   Maintain testing and specimen collection supplies for the patient
    workload as the pandemic evolves and use established Memoranda of
    Understanding (MOUs) to obtain more supplies.

-   Ensure continued capacity for storage of serum, respiratory, and
    tissue samples for testing or for later epidemiologic studies.

-   Make sure that all personnel use proper specimen handling techniques
    and precautions (see [Appendix E-2: CHART OF PANDEMIC INFLUENZA
    PRECAUTIONS FOR VA HEALTH CARE FACILITY
    STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN)).

#### Workforce (availability, flexible work standards, credentialing, broadened practice standards)

-   VHA facilities will implement staffing plans (see [Section 2.2.3.2
    Workforce preparation (education, skill identification,
    credentialing, Pandemic Response
    Teams)](#workforce-preparation-education-skill-identification-credentialing-pandemic-response-teams):

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-   Track staff availability, credentialing status, skills and training,
    health and influenza status.

-   Employ flexible worksite standards (e.g., telecommuting for certain
    functions) and flexible work hours (e.g., staggering shifts or using
    longer or shorter work schedules).

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-   Provide information technology support for staff who are
    telecommuting.

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-   Support the physical and mental health of staff and enable healthy
    staff to provide patient care. Develop a triage approach for staff
    that includes:

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-   Morning check of influenza symptoms and other physical and mental
    health issues

-   Re-assignment or removal of staff based on influenza symptoms and
    other physical and mental health indicators

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-   Implement check-in procedures (by phone or email) that enable staff
    to provide information on availability to work, as well as on health
    status.

-   Supplement staff where necessary and possible with retired or
    inactive clinicians, and an expanded group of providers such as
    mental health professionals, dentists and dental auxiliary
    providers, pharmacists, social services, and health professional
    students. (See [Appendix B-2: TABLE OF LEGAL AUTHORITIES AND
    POLICIES RELEVANT TO EMERGENCIES - Advice on Changes in Usual VA
    Practices During a
    Pandemic](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO)).

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-   Coordinate with local public health/emergency planning office.

-   Allow practice on a temporary basis through the length of the
    declared emergency period of a pandemic.

Note: Credentials of VA providers who have active credentials and
privileges in a VA facility can be shared electronically through VA's
computerized credentialing system, VetPro.

-   The receiving facility can use these credentials during the pandemic
    for the purpose of granting "Temporary Privileges for Urgent Patient
    Care Needs" within VetPro.

-   Verification of licenses and a query of the National Practitioner
    Database [are]{.underline} required for Temporary Privileges for
    Urgent Patient Care Needs.

-   If necessary, the Credentialing and Privileging Team in the Office
    of Quality and Performance (OQP) provides temporary/emergency access
    and is available under the VA Central Office and OQP Emergency Plan.

-   Disaster credentialing appointment processes must be followed for
    non-VA personnel. These processes include the following
    requirements:

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-   A description of the verification process at the time disaster
    privileges are granted that will include:

    -   a current hospital photo identification card AND evidence of
        current license to practice; or

    -   identification indicating that the individual is a member of a
        Disaster Medical Assistance Team (DMAT); or

    -   identification indicating that the individual has been granted
        authority to render patient care in emergency circumstances,
        such authority having been granted by a federal, state, or
        municipal entity.

-   A specified period of time under which these health care
    professionals granted disaster privileges may practice on these
    disaster privileges. This period may not exceed 10 calendar days of
    the length of the declared disaster, whichever is shorter. At the
    end of this period the practitioners needs to be converted to
    Temporary Privileges as defined by VA policy.

-   A defined process to ensure the verification process of the
    credentials and privileges of health care professionals who receive
    disaster privileges that will begin as soon as the immediate
    situation is under control. This process will be identical to the
    process for granting Temporary Privileges and ultimately results in
    complete credentialing of these practitioners.

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-   Allow broadened scope of practice standards among various trained
    providers.

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-   Staff and volunteers may be needed to function at levels above their
    formal scope of practice, with training as possible, and may do so
    where additional skills have been verified by an appropriate staff
    member.

-   Volunteers and nonclinical staff may be assigned to perform lower
    level clinical tasks like taking temperatures and other vital signs,
    changing linen, and assisting with record-keeping. It may be
    necessary to include training and verification of skills by
    appropriate staff.

#### Patient care (changing demands and surge, advice lines/telemedicine, triage, diagnosis, isolation, expansion to include alternative space and sites, altered standards of care)

In general, VHA facilities must be prepared for the rapid pace and
dynamic characteristics of a pandemic. Facilities need to be equipped
and ready to care for:

-   A limited number of patients with a pandemic influenza virus, or
    other novel strain of influenza, as part of normal operations

-   A surge or large number of patients in the event of escalating
    transmission of pandemic influenza

In addition, facilities may have demands from the community as well (see
[Appendix B-1: SUMMARY OF POTENTIAL VA EXPANDED
RESPONSIBILITIES](#_Appendix_B-1:__SUMMARY_OF_POTENTIAL)).

Facilities will:

-   Implement advice lines/telemedicine with pre-developed telephone
    capabilities and materials.

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-   Consider using staff that are recovering or need to be out of from
    work for quarantine or family care.

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-   Employ strategies for triage, diagnosis, and isolation of possible
    pandemic influenza patients.

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-   Triage should be conducted to (1) identify persons who might have
    pandemic influenza; (2) separate them from others to reduce the risk
    of disease transmission; and (3) determine whether they can be
    treated in an outpatient setting, or at home or require
    hospitalization.

-   Use phone triage to separate patients who need emergency care and
    those who can be referred to an outpatient clinic or non-urgent care
    facility or to home care.

-   Promote the use of a self-triage algorithm (see [Appendix E-5:
    SAMPLE SELF-TRIAGE ALGORITHM FOR PERSONS WITH INFLUENZA
    SYMPTOMS](#_Appendix_E-5:__SAMPLE_SELF-TRIAGE_A)) that enables
    patients (and staff) to review their own symptoms and consider
    appropriate settings and use of care.

-   Adopt a "drive-through triage" option to reduce close contact with
    potentially infected patients.

-   Assign separate waiting areas for persons with respiratory symptoms.

-   Assign separate triage evaluation areas for persons with respiratory
    symptoms.

-   Assign one or more "triage coordinators" to manage patient flow.

-   Consider that triage duties may require less physical strength and
    may be possible for staff recovering from influenza to perform for
    less than 8-hour shifts.

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-   Expand care delivery to alternative space and sites as identified in
    the planning period.

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-   Employ home-based care strategies.

-   Use telephone advice lines or refer to web-based self-triage
    algorithms (see [Appendix E-5: SAMPLE SELF-TRIAGE ALGORITHM FOR
    PERSONS WITH INFLUENZA
    SYMPTOMS](#_Appendix_E-5:__SAMPLE_SELF-TRIAGE_A)) to provide advice
    on whether to stay home or to seek care.

-   Update home care advice to reflect the epidemiology and natural
    history of the pandemic influenza (see [Appendix E-6: HOME CARE
    GUIDE FOR INFLUENZA)](#_Appendix_E-6:__HOME_CARE_GUIDE_FOR_).

-   Document home-based care advice given to patients in the electronic
    medical record system or by other means.

-   Employ drive-through clinics.

    -   Consider locating such drive-through clinical sites in or near
        guard stations, mobile clinics, or parking lots.

    -   Provide health care facility staff with equipment to provide
        care including portable equipment to measure vital signs and
        oxygenation, standardized questionnaires, printed patient advice
        materials, wheelchairs or stretchers for transport of patients
        who need additional assessment or care, and home supply kits
        (see [Appendix E-6: HOME CARE GUIDE FOR
        INFLUENZA).](#_Appendix_E-6:__HOME_CARE_GUIDE_FOR_)

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-   Employ altered standards of care when necessary.

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-   The term \"altered standards\" means a shift to providing care and
    allocating scarce equipment, supplies, and personnel in a way that
    saves the largest number of lives in contrast to the traditional
    focus on individuals.

-   VA staff should use the following principles as a guide for
    employing Altered Standards of Care:

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-   *Principle 1*: In planning for a mass casualty event, the aim should
    be to keep the health care system functioning and able to deliver
    acceptable quality of care to preserve as many lives as possible.

-   *Principle 2*: Planning a health and medical response to a mass
    casualty event must be comprehensive, community-based, and
    coordinated at the regional level.

-   *Principle 3*: There must be an adequate legal framework for
    providing health and medical care in a mass casualty event (see
    [Appendix B-2: TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT TO
    EMERGENCIES - Advice on Changes in Usual VA Practices During a
    Pandemic](#B2)).

-   *Principle 4*: Health care providers have a duty to care for the
    sick even in high-risk situations and to not harm patients by
    transmitting disease. VHA will provide for the health and safety of
    health care facility staff, including providing personal protective
    equipment and instituting safety protocols.

-   *Principle 5*: The rights of individuals must be protected to the
    extent possible and reasonable under the circumstances. Decisions to
    restrict or override the right of individuals to achieve public
    health goals must be proportional to the degree of disease or
    injury, necessary, relevant, applied equitably, and should employ
    the least restrictive means.

-   *Principle 6*: Clear communication with the public concerning the
    possible use of altered standards of care is essential before,
    during, and after mass casualty events.

Provided below is a framework regarding how health care standards may
have to be modified during a pandemic by the stage of disease and the
degree to which the pandemic impacts health care demand.

+-------------+-------------+-------------+-------------+-------------+
| **Stage of  | **Health    |             |             |             |
| Disease in  | Care        |             |             |             |
| the         | Standards** |             |             |             |
| Population  |             |             |             |             |
| and Demand  |             |             |             |             |
| for Medical |             |             |             |             |
| Services**  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
|             | **Normal    | **Near      | **Focus on  | **Total     |
|             | Medical     | Normal      | Key         | System/     |
|             | Care        | Medical     | Lifesaving  | Standards   |
|             | Standards** | Care        | Care**      | A           |
|             |             | Standards** |             | lteration** |
|             |             |             |             |             |
|             |             | *           |             | **(triage   |
|             |             | *(alternate |             | care        |
|             |             | sites of    |             | according   |
|             |             | care, use   |             | to local    |
|             |             | of atypical |             | demands and |
|             |             | devices,    |             | capa        |
|             |             | expanded    |             | bilities)** |
|             |             | scope of    |             |             |
|             |             | practice    |             |             |
|             |             | for         |             |             |
|             |             | cl          |             |             |
|             |             | inicians)** |             |             |
+-------------+-------------+-------------+-------------+-------------+
| P           | X           |             |             |             |
| re-Pandemic |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Early       | X           | X           |             |             |
| Pandemic    |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Moderate    |             | X           | X           |             |
| Demand      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Severe      |             |             | X           | X           |
| Demand      |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+

Figure 1: Framework for Altered Standards of Care

Chart adapted from Altered Standards of Care in Mass Casualty Events,
Agency for Healthcare Research and Quality, HHS, 2005; original source
Dr. Michael Allswede, University of Pittsburgh, UPMC Medical System

#### Medical materiel (medications and supplies, access to caches)

-   Activate plans for medical materiel (see [Section 2.2.3.6 Medical
    materiel (equipment and
    supplies)](#medical-materiel-equipment-and-supplies).

-   Assess facility supplies of materiel.

-   Contact VHA Central Office for centrally stockpiled consumable
    materiel. Determine availability of medical materiel, including
    pharmaceutical and other medical items, through the Pharmacy
    Benefits Management Strategic Healthcare Group and the National
    Acquisitions Center.

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-   VHA Emergency Caches of medications will be made available through
    the Office of the Deputy Under Secretary for Health for Operations
    and Management.

-   VHA antiviral stockpile (oseltamivir) will be made available and
    distributed under the guidance of the Under Secretary for Health.

#### Security for health care sites

VHA facilities will activate security plans (under 2.2.3.11), providing
security for critical medical supplies and for health care and
alternative care facilities, to:

-   Ensure entry to and exit from facilities is limited and secure.

-   Enforce visitor restrictions to health care facilities.

-   Ensure that countermeasures are secure including personal protective
    equipment, vaccine, and antiviral medications.

-   Utilize temporary security procedures, such as lockdowns, to enforce
    safety.

-   Activate agreements with local law enforcement.

#### Fatality management

VHA facilities will manage fatalities according to plan (see [Section
2.2.3.3 Physical site (space planning, building and engineering systems,
support for infection control, transportation of patients, fatality
management)](#physical-site-space-planning-building-and-engineering-systems-support-for-infection-control-transportation-of-patients-fatality-management)
:

-   Provide personal protective equipment to enable health care facility
    staff to use Airborne Infection Isolation and Contact Precautions
    for handling remains of individuals who die from pandemic influenza
    (see [Appendix E-2: CHART OF PANDEMIC INFLUENZA PRECAUTIONS FOR VA
    HEALTH CARE FACILITY STAFF](#_Appendix_E-2:__CHART_OF_PANDEMIC_IN).

-   Use identified refrigeration capacity for remains.

-   Coordinate mass fatality plans with local and state health officials
    and medical examiners, using, as necessary, temporary morgue sites,
    such as refrigerated warehouses and trucks.

#### Mental health support

VHA facilities will activate plans (see [Section 2.2.3.9 Mental health
support for patients and
staff](#mental-health-support-for-patients-and-staff)), including:

-   Providing mental health and chaplain services for patients and
    families and for health care and emergency workers and their
    families, especially when workers must be away from home.

-   Deploying mental health professionals such as psychiatrists,
    psychologists, social workers, specialized nurses, and chaplains, as
    well as readjustment counseling (Vet Center) staff, and staff of
    employee assistance programs.

-   Recruiting local psychiatry, psychiatry, psychology, social work,
    nursing, and faith-based or pastoral care organizations, as
    necessary.

-   Using a mental health consultation process to make such expertise
    available to all who require assistance at the local level,
    including Central Office mental health and readjustment counseling
    services and VISN mental health councils.

## VBA Response Actions

### Leadership

The Under Secretary for Benefits will head the VBA response to an
influenza pandemic, assisted by the Under Secretary for Health and
advised by the VA Pandemic Influenza Advisory Group, as needed.

### Coordination and Communication

VBA central and regional offices will follow the guidance outlined in
existing Continuity of Operations Plan for ensuring that mission
essential functions are maintained.

VBA will work in concert with the other VA administrations and VBA
facilities will coordinate with state and local public health and other
agencies.

### Roles and Responsibilities

#### Workforce actions

VBA facilities will make use of emergency plans, as well as pandemic
influenza plans.

VBA staffing considerations will include:

-   Accounting for staff daily

-   Employing flexible work standards to the extent possible, such as
    flexible work hours

-   Using liberal and administrative leave policies (see [Appendix B-2:
    TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES -
    Advice on Changes in Usual VA Practices During a
    Pandemic](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO))

-   Granting up to 240 hours of advanced sick leave for employees
    without sufficient sick leave

#### Closure of regional offices

If circumstances dictate, VBA will prepare to close regional offices.

-   Reroute telephones to an open regional office.

-   Inform VBA central office of actions.

-   Inform veterans.

#### Infection control

-   Provide employees with educational materials on pandemic influenza
    and on respiratory and hand hygiene (see [Appendix E-3: CHART OF
    PUBLIC HEALTH MEASURES AGAINST PANDEMIC INFLUENZA FOR INDIVIDUALS,
    HEALTH CARE PROVIDERS, AND
    ORGANIZATIONS](#_Appendix_E-3:__CHART_OF_PUBLIC_HEAL)).

-   Provide employees with information on the availability of pandemic
    influenza antivirals and vaccine from VA sources through their
    representative on the VA Pandemic Influenza Advisory Group.

#### Security

-   Ensure guard staff is trained on signs and symptoms of influenza to
    limit visitor access; provide them and visitors with self-triage
    algorithm (see [Appendix E-5: SAMPLE SELF-TRIAGE ALGORITHM FOR
    PERSONS WITH INFLUENZA
    SYMPTOMS](#_Appendix_E-5:__SAMPLE_SELF-TRIAGE_A)).

-   Provide guard staff with appropriate personal protective equipment
    to ensure their welfare and safety.

## NCA Response Actions

### Leadership

The Under Secretary for Memorial Affairs will head the NCA response to
an influenza pandemic, assisted by the Under Secretary for Health and
advised by the VA Pandemic Influenza Advisory Group, as needed.

### Coordination and Communication

NCA central and Memorial Service Network office will follow the guidance
outlined in Continuity of Operations Plans and other emergency plans for
ensuring that mission essential functions are maintained.

NCA will work in concert with the other VA administrations and NCA
facilities will coordinate with state and local public health and other
agencies.

### Roles and Responsibilities

#### Workforce actions

NCA staffing considerations will include:

-   Accounting for staff daily.

-   Employing flexible work standards to the extent possible, such as
    flexible work hours;

-   Using liberal and administrative leave policies (see [Appendix B-2:
    TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES -
    Advice on Changes in Usual VA Practices During a
    Pandemic](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO))

-   Granting up to 240 hours of advanced sick leave for employees
    without sufficient sick leave

#### Closure of network offices or cemeteries 

A wave of pandemic influenza may affect the staff of NCA and the
surrounding community and may make it necessary to temporarily suspend
operations. In this case:

-   Reroute telephones to an open office or cemetery.

-   Inform NCA central office of actions.

-   Contact funeral homes and the next of kin of the deceased to notify
    parties of the situation and to reschedule the affected burials.

#### Infection control

-   Provide employees with educational materials on pandemic influenza
    and on respiratory and hand hygiene (see [Appendix E-3: CHART OF
    PUBLIC HEALTH MEASURES AGAINST PANDEMIC INFLUENZA FOR INDIVIDUALS,
    HEALTH CARE PROVIDERS, AND
    ORGANIZATIONS](#_Appendix_E-3:__CHART_OF_PUBLIC_HEAL)).

-   Provide employees with information on the availability of pandemic
    influenza antivirals and vaccine from VA sources through their
    representative on the VA Pandemic Influenza Advisory Group.

## Communication Within and Outside of VA During a Pandemic

### Leadership

The VA Secretary and the Office of Public and Intergovernmental Affairs
will lead the overall communications efforts of the Department of
Veterans Affairs during an influenza pandemic, assisted principally by
the VHA Office of Communications and the VHA office of the Deputy Under
Secretary for Management and Operations, in coordination with the VA
Pandemic Influenza Advisory Group.

### Coordination

VA will:

-   Build on relationships, channels, and vehicles developed and
    established during the prepandemic planning phase.

-   Adjust communication strategies and practices in accordance with
    emerging needs, demands, and expectations for information caused by
    a pandemic. (See [Appendix D-3: REVIEW AND LIST OF COMMUNICATION
    PRINCIPLES AND ELEMENTS TO USE BEFORE, DURING, AND AFTER A
    PANDEMIC](#_Appendix_D-3:__REVIEW_AND_LIST_OF_C)).

-   Focus on being constituent, timely, accurate, and open about
    providing information and on supporting VA staff in the field -- the
    health facilities, regional offices, and memorial services -- as
    they deal directly with pandemic influenza and an increased demand
    for good and clear communication.

-   Consider the information needs of VA staff, veterans, and the many
    organizations and individuals concerned with VA programs and promote
    a steady flow of information throughout the Department and with
    national and Federal, state, and local agencies.

### Roles and Responsibilities

#### VA-wide communication 

VA leadership, supported by public affairs and communication officers,
will:

-   Continue to provide tools and information through VA Web sites
    (updated on a real-time basis).

-   Work through pre-identified lead spokespersons and provide talking
    points and up-to-date information on the status of operations and
    the epidemiology of pandemic influenza within VA.

-   Coordinate information and responsibilities with regional and
    facility managers and with national and international efforts.

-   Provide web and email updates on situations having and impact on
    status of operations and service delivery within facilities and
    within states.

-   Distribute updated education and information to the effected VA
    health care community.

-   Address rumors and false reports immediately with factual
    information and guidance.

-   Make use of its list of national, state, local, and community
    partners. and share information and updates with state, local, and
    community partners.

-   Brief media outlets and veteran service organizations on the status
    of VA operations and respond to questions, concerns, and offers of
    assistance.

-   Prepare answers and information in a variety of formats.

-   Ensure that VA facilities are prepared to report to the public
    specific information regarding the impact of the pandemic on
    operations.

-   Provide messages and guidance to support direct communication with
    staff.

-   Work via OA&MM to inform VA contractors and vendors of their
    responsibilities during a global pandemic.

#### VHA communication 

***VHA Central Office actions:***

-   VHA Communications and the VHA Office of Public Health and
    Environmental Hazards will work with VA public affairs and VHA
    public affairs officers to:

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-   Rapidly produce and update information after the announcement of the
    global outbreak.

-   Update Web sites as needed, daily if necessary.

-   Provide updates to facilities for VA advice lines, telephone
    operators, and receptionists.

-   Disseminate information to VA staff, unions, volunteers and academic
    affiliates about changes in work assignments, call-ins for
    absentees, and general epidemiological information about influenza
    symptoms.

-   Participate in conference calls between VA central office, VISN
    directors, chiefs of staff, and medical center directors. These
    leaders will communicate with medical personnel, other staff, and
    volunteers via real or virtual town hall meetings and other means.

External communication in VHA during a global pandemic will include
regular updates for the White House, Congress, Congressional oversight
committees, other government agencies and news media, local and state
governments, Veterans Service Organizations, academic affiliates,
professional organizations and unions, contractors, vendors and
community partners.

***VHA facility actions***

-   VHA facilities will make use of their pandemic influenza
    communications plans and other emergency communications plans.
    Aspects of these plans will include:

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-   Using consistent and accurate information about the status of what
    is going on the medical center, what individuals can do to protect
    themselves and prevent transmission, what VA is doing.

-   Regularly informing internal and external stakeholders of news and
    developments, including

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-   Staff -- clinical, nonclinical, security, telephone operators and
    receptionists, medical trainees, volunteers, contractors

-   Patients and their families

-   Veterans Service Organizations

-   Local public health and health care agencies

-   The media

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```
-   Using a variety of vehicles to convey this information, such as

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-   Announcements and news releases

-   Email announcements

-   Scripts for receptions and telephone operators with basic
    information for veterans and staff who call in

-   Fact sheets

-   Presentations/discussions at meetings (staff, community at large,
    local health counterparts)

-   Briefings

-   Conference calls

-   Easily found Internet and Intranet sites where this information is
    posted

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```
-   Using a streamlined but effective process to create and get approval
    on consistent, accurate, and timely information.

-   Making available pre-identified spokespersons, usually medical or
    leadership to speak to the media and other key stakeholders.

-   Using templates to help convey consistent information and standard
    distribution lists so that there is a record of who has been told
    what.

-   Being proactive with staff, veterans, the media, veterans groups,
    and the community possibly offering telephone or teleconference
    briefings.

-   Staying up to date, including identifying and addressing rumors,
    inaccuracies, and misperceptions

-   Having on hand (at work and at home) key contact lists for key
    staff, the media, and local public health departments.

-   Making use of alternative means of communicating in emergencies,
    such as telephone trees to get the word out, call-in systems (live
    or recorded with or without answering machine capability), recorded
    information on the status of operations.

#### VBA communication 

VBA will:

-   Conduct weekly conference calls with field facilities.

-   Gather regular (weekly or possibly daily) facility status reports
    through Area offices. Communicate frequently with local, state and
    private health care partners.

-   Collaborate to produce news releases and public service
    announcements as needed to communicate with veterans, staff and the
    general public in the local area concerning the status of VBA
    operations and how to obtain services in the event of an office
    closure.

#### NCA communication 

NCA Central Office (NCACO) will have the following functions.

-   Internal Communications:

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-   Provide information to NCA staff and other staff (contractors,
    volunteers, unions, etc.) concerning the onset of the influenza
    pandemic. This information will include, but is not limited to:

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-   Guidance on preventing or minimizing employee infection or spreading
    of the influenza

-   Any changes to cemetery operation policy

-   Frequently asked questions regarding the influenza

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-   Adopt and amend these communications based on guidance provided by
    VACO, VHA, CDC, and other sources as appropriate for NCA workplaces.

-   Work with VACO staff to implement One-VA communications through all
    available channels, including the use of a 1-800 telephone number
    and website information.

-   Utilize multiple modes of communication (e-mail, conference calls,
    flyers, etc.) to ensure that all NCA staff members receive these
    communications.

-   Develop a communications plan to coordinate the communications
    activities of all NCA field sites where current policies and
    procedures are insufficient.

-   Ensure that NCA provides a consistent message to all parties.

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```
-   External Communications

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-   Provide information concerning the onset of the influenza pandemic
    to external parties, most notably funeral home directors, next of
    kin of individuals scheduled for interment at a national cemetery,
    visitors, and VSOs. Utilize multiple modes of communication to
    ensure that appropriate external parties receive these
    communications.

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```
-   Communications between NCA facilities and local/state/private
    agencies

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-   Coordinate with local, state, and private agencies to ensure that
    the spread of an influenza pandemic is minimized and that the
    general public is informed of NCA's efforts regarding the influenza
    pandemic.

-   Respond to inquiries from local, state, and private agencies in
    accordance with the NCACO communication plan.

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```
-   Communications between NCA facilities

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```
-   Communicate with each other utilizing non-pandemic communications
    (for example, quarterly conference calls) to ensure continuity of
    operations. Special communications between NCA facilities will be
    either be directed by NCACO or developed at the local level to
    ensure the flow of critical information as needed.

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```
-   Communications between NCA facilities and stakeholders

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```
-   Communicate according to standard policies at the local level or in
    accordance with the NCA communications plan as appropriate.

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-   Communications between VACO and NCA facilities

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-   Ensure that all interested parties, both internal and external to
    NCA, are informed regarding the influenza pandemic. NCACO will
    assist with providing guidance to NCA facilities and with
    communications from NCA facilities to VACO.

# RECOVERING FROM PANDEMIC INFLUENZA 

The goal of recovery is to resume normal operations and services.

VA, VHA, VBA, and NCA actions will include:

-   Remaining vigilant for signs of influenza returning to staff,
    patients, and the community.

-   Keeping staff alert to the possibility of returning to the pandemic
    state of operations.

-   Possibly providing antiviral medications to patients and staff to
    prevent recurrences.

-   Restocking depleted supplies.

-   Returning to usual job functions and scopes of practice.

-   Closing alternative health care sites.

-   Resuming usual standards of care.

-   Resuming seasonal influenza programs for patients and staff.

-   Continuing to promote principles of the "Infection: Don't Pass It
    On" campaign with adherence to hand washing and respiratory hygiene.

-   Analyzing data from the pandemic and drafting or contributing to
    "after-action" reports at the facility, community, network, state,
    and Federal levels.

-   Completing work for financial reimbursement through national
    emergency plans.

-   Assessing, providing counseling, and treating veterans and staff for
    bereavement issues and post-traumatic stress (VA mental health
    professionals, readjustment counseling staff, and employee
    assistance).

-   Providing death benefits to surviving family members of staff who
    died from exposure to pandemic influenza in the course of their
    duties.

-   Continuing essential partnerships to foster recovery.

-   Preparing debriefing materials and data including:

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-   Morbidity and mortality rates

-   Lessons learned, including psychological sequelae

-   Uses and roles of VA in local, state, and national responses

-   Cooperation between VA and its counterparts at all levels

# ACRONYMS, ABBREVIATIONS, GLOSSARY

## LIST OF ACRONYMS AND ABBREVIATIONS

  ------------------------------------------------------------------------
  **Acronym**   **Description**
  ------------- ----------------------------------------------------------
  **AA**        Authorized absence

  **ADC**       Average Daily Census

  **BAL**       Bronchoalveolar lavage

  **CBOC**      Community-based outpatient clinics (VA)

  **CDC**       Centers for Disease Control and Prevention

  **COOP**      Continuity of Operations Plan

  **CPRS**      Computerized Patient Record System (VA)

  **DHS**       Department of Homeland Security

  **DMAT**      Disaster Medical Assistance Team

  **DoD**       Department of Defense

  **Dom**       Domiciliary

  **EMS**       Environmental Management Services

  **EMSHG**     Emergency Management Strategic Healthcare Group (VHA)

  **ER**        Emergency room

  **FDA**       Food and Drug Administration

  **FEMA**      Federal Emergency Management Agency

  **FMS**       Federal medical shelter

  **FTCA**      Federal Tort Claims Act

  **FTE**       Full-time employee

  **HCAI**      Health care acquired infection

  **HHS**       Department of Health and Human Services

  **HR**        Human Resources

  **HVAC**      Heating, ventilation, air conditioning

  **I:DPIO**    "Infection: Don't Pass It On" (VA)

  **ICD9-CM**   International Classification of Diseases, 9^th^ Edition,
                Clinical Modification

  **ICU**       Intensive care unit

  **IHS**       Indian Health Service

  **ILI**       Influenza-like illness

  **IT**        Information technology

  **LRN**       Laboratory Response Network

  **MICU**      Medical intensive care unit

  **MOA**       Memorandum of Agreement

  **MOU**       Memorandum of Understanding

  **MSN**       Memorial Service Network (VA)

  **N95**       A type of fit-tested respirator

  **NAC**       National Acquisition Center

  **NCA**       National Cemetery Administration (VA)

  **NDMS**      National Disaster Medical System

  **NIH**       National Institutes of Health

  **NRP**       National Response Plan

  **NSAIDS**    Non-steroidal anti-inflammatory drugs

  **OA&MM**     Office of Acquisition and Materiel Management (VA)

  **OQP**       Office of Quality & Performance (VA)

  **OSHA**      Occupational Safety and Health Administration

  **OWCP**      Office of Workers\' Compensation Programs

  **PAO**       Public affairs officer

  **PAPR**      Powered air purifying respirator

  **PHSHG**     Public Health Strategic Health Care Group (VHA)

  **PPE**       Personal protective equipment

  **PTSD**      Post traumatic stress disorder

  **RSV**       Respiratory syncytial virus

  **SCI**       Spinal cord injury

  **SICU**      Surgical intensive care unit

  **SNS**       Strategic National Stockpile

  **TAP**       Telephone Advice Program (VA)

  **VA**        Department of Veterans Affairs

  **VACO**      VA Central Office

  **VAERS**     Vaccine Adverse Event Reporting System

  **VAMC**      VA medical center

  **VANTS**     VA Nationwide Teleconferencing System

  **VARO**      VA Regional Office (VBA)

  **VBA**       Veterans Benefits Administration (VA)

  **VHA**       Veterans Health Administration (VA)

  **VISN**      Veterans Integrated Service Network (VA)

  **VistA**     Veterans Integrated System Technology Architecture (VA)

  **VSO**       Veterans Service Organization

  **WHO**       World Health Organization
  ------------------------------------------------------------------------

## GLOSSARY OF TERMS

  -----------------------------------------------------------------------
  **Term**                 **Definition**
  ------------------------ ----------------------------------------------
  **Aerosol-generating     Procedures that spread fine particles
  procedures**             suspended in air, such as airway suctioning.

  **Air zone diagram**     The flow and control diagrams for air and the
                           sequence of operation for all heating,
                           ventilation and, air-conditioning (HVAC)
                           systems and sub-systems.

  **Airborne Infection     Actions to reduce the risk of airborne
  Isolation Precautions**  transmission of infectious agents via airborne
                           droplet nuclei (small particle residue \[5 µm
                           or smaller in size\] of evaporated droplets
                           that may remain suspended in the air for long
                           periods of time) or dust particles containing
                           the infectious agent. Microorganisms carried
                           in this manner can be dispersed widely by air
                           currents and may become inhaled by or
                           deposited on a susceptible host within the
                           same room or over a longer distance from the
                           source patient, depending on environmental
                           factors; therefore, special air handling and
                           ventilation are required to prevent airborne
                           transmission. Airborne Precautions apply to
                           patients known or suspected to be infected
                           with epidemiologically important pathogens
                           that can be transmitted by the airborne route.

  **Altered standards of   In an emergency situation, a shift to
  care**                   providing care and allocating scarce
                           equipment, supplies, and personnel in a way
                           that saves the largest number of lives in
                           contrast to the traditional focus on
                           individuals.

  **Antiviral**            Medication used for the prevention or
                           treatment of viral infections such as
                           influenza.

  **Antiviral              Medications given to prevent or minimize the
  prophylaxis**            effects of a viral infection.

  **Area Offices (VBA)**   Responsible for the oversight, support and
                           management of VBA Regional Offices.

  **Authorized absence     Term used to describe an approved absence
  (AA)**                   granted to an employee by a supervisor without
                           charge to sick or annual leave.

  **Avian flu**            A form of influenza that occurs in birds.

  **Bronchial washing**    Technique used to obtain secretions and cells
                           from the trachea and large bronchi for
                           microscopic examination or culture.

  **Bronchoalveolar lavage A procedure to sample secretions containing
  (BAL)**                  both cellular and non-cellular components from
                           the lower respiratory tract; performed during
                           a bronchoscopy.

  **Bronchoscopy**         Diagnostic procedure in which a tube with a
                           tiny camera on the end is inserted through the
                           nose or mouth into the lungs. The procedure
                           provides a view of the airways and allows the
                           collections of secretions or tissue specimens.

  **Cache**                See VA Pharmaceutical Cache Program.

  **CDC BioSense**         The current designated central reporting site
                           for human data related to intentional and
                           non-intentional epidemic threats to the
                           population. VA currently provides transmission
                           twice daily on weekdays and once daily on
                           weekends of national data from all outpatient
                           and emergency room visits from all medical
                           center reporting sites. Simultaneous with the
                           analysis and evaluation at the CDC for
                           national surveillance, for added value, the
                           data are made available to state and local
                           health departments to improve the local early
                           warning value of information.

  **Centers for Disease    One of the 13 major operating components of
  Control and Prevention   the [Department of Health and Human Services
  (CDC)**                  (HHS)](http://www.hhs.gov/); agency for
                           preventing and controlling infectious and
                           chronic diseases, injuries, workplace hazards,
                           disabilities, and environmental health
                           threats.

  **Consumable supplies**  Items utilized and requiring routine
                           replacement such as gloves and hand hygiene
                           supplies.

  **Contact Precautions**  Applies to certain diseases or conditions
                           spread by direct contact, and involves placing
                           the patient in a private room, and using
                           gloves and cover gown for contact with the
                           patient or any items/surfaces in the patient's
                           immediate vicinity.

  **Continuity of          An internal effort within an organization to
  operations plan or       assure that the capability exists to continue
  planning (COOP)**        essential business functions across a wide
                           range of potential emergencies, including
                           localized acts of nature, accidents, and
                           technological and/or attack/terrorist-related
                           emergencies.

  **Countermeasures (with  Materials and actions used to interrupt the
  reference to the         course of an influenza pandemic; for example,
  preparation for or       vaccines and antiviral medications.
  response to pandemic     
  influenza)**             

  **Department of Defense  Responsible for the management of members of
  (DoD)**                  the United States Armed Forces, to include the
                           Army, Navy, Air Force, Marines, and Coast
                           Guard.

  **Department of Veterans A Cabinet-level Department that assists
  Affairs (VA)**           veterans through nationwide programs for
                           health care, financial assistance, and burial
                           benefits. VA is the second largest of the 15
                           federal departments.

  **Domiciliary or "dom"** A VA care facility that provides the least
                           intensive level of inpatient care for
                           ambulatory veterans disabled by age or illness
                           who are not in need of more acute
                           hospitalization and who do not need the
                           skilled nursing services provided in nursing
                           homes.

  **Drive-through clinic** Concept of providing innovative care where
                           health care providers would evaluate and
                           provide treatment to selected patients who
                           remain in or close to their motor vehicles.
                           Maybe be used in coordination with
                           drive-through triage.

  **Drive-through triage** A process of assessing patients, while they
                           remain in or close to their motor vehicles,
                           and directing them to care, based on their
                           need for or likely benefit from immediate
                           medical evaluation or treatment.

  **Droplet Precautions**  Actions to reduce the risk of transmission of
                           infectious agents via large-particle droplets
                           (larger than 5 µm in size) generated from the
                           infected person primarily during coughing,
                           sneezing, or talking and during the
                           performance of certain procedures such as
                           airway suctioning and bronchoscopy.

  **Durable supplies**     Items or equipment designed for repeated use
                           such as hospital beds and wheelchairs.

  **Emergency risk         A discipline involving communication of risks
  communication**          and benefits related to an emergency (either
                           in preparation or response) to individuals,
                           organizations, and the community to help them
                           make decisions about their well being.

  **Facility**             In VA, a medical center or other care setting
                           (VHA), a benefits office (VBA), or a cemetery
                           (NCA).

  **Federal health care    Direct providers of health care by agencies of
  system**                 the federal government, including the medical
                           systems of VA, Department of Defense, the
                           Indian Health Service, and the Bureau of
                           Prisons.

  **Federal medical        A temporary unit that is a scalable, modular,
  shelter (FMS)**          250- or more bed deployable facility
                           configured to allow basic but essential
                           medical care.

  **ICD9--CM**             The International Classification of Diseases,
                           9^th^ Revision, Clinical Modification. A
                           coding system that allows international
                           comparability in the collection,
                           classification, processing, and presentation
                           of health data. In the US, ICD9-CM is the
                           system used for medical billing purposes. 

  **Incubation period**    The period between the infection of an
                           individual by a pathogen and the manifestation
                           of the disease it causes.

  **Infection: Don't Pass  A VA national public health initiative
  It On (I:DPIO)**         launched in the VA health system in fall 2004.
                           This ongoing educational campaign focuses on
                           decreasing transmission of infection through
                           hand and respiratory hygiene, seasonal
                           influenza vaccinations, and preparedness for
                           infectious disease emergencies, including
                           pandemic influenza. The goal of the campaign
                           is to involve staff, patients, and visitors in
                           taking basic steps to prevent infection,
                           whether occurring daily, seasonally, or
                           occurring during infectious disease
                           emergencies (natural or manmade).

  **Influenza**            An acute highly contagious disease
                           characterized by sudden onset of fever, severe
                           aches and pains, dry cough, and progressive
                           inflammation of the respiratory mucous
                           membranes caused by an influenza virus.

  **Influenza-like         A clinical definition of influenza used in
  illness**                research and surveillance. Typically includes
                           symptoms of upper respiratory infection or
                           'common cold' with fever or having fever of
                           100 degrees F lasting at least one day along
                           with a cough or sore throat.

  **Information technology The development, installation, implementation
  (IT)**                   and maintenance of computer systems and
                           applications.

  **Isolation**            Separation of infected individuals from those
                           who are not infected.

  **Laboratory Response    An integrated network of state and local
  Network (LRN)**          public health, federal, military, and
                           international laboratories that can respond to
                           bioterrorism, chemical terrorism and other
                           public health emergencies.

  **Mask**                 A type of personal protective equipment used
                           in health care to protect the wearer from
                           inhaling or respiring droplets of infectious
                           body fluids. **Surgical masks** cover the nose
                           and the mouth of the person wearing them and
                           have high air filtration capability, although
                           not as high as N95, N99, or N100. **Procedure
                           masks** usually have less filtration. (**Full
                           face shields** that offer protection for the
                           whole face may be used in certain
                           circumstances in addition to a mask.) See term
                           Respirator for devices providing more
                           protection.

  **Memorandum of          A written statement outlining the terms of an
  Understanding (MOU)/     agreement between two or more entities.
  Memorandum of Agreement  
  (MOA)**                  

  **Mode of transmission** Mechanism by which an infectious agent is
                           spread through the environment or to another
                           person.

  **Modular medical        Temporary units such as Federal medical
  stations**               stations (FMSs), which are scalable, modular,
                           250-bed deployable facilities that are
                           configured to allow basic but essential
                           medical care.

  **My HealtheVet**        A VA Web site that provides access to health
                           information, links to Federal and VA benefits
                           and resources, the Personal Health Journal,
                           and more.

  **Nasopharyngeal         A technique used to obtain secretions and
  washing**                cells from the nose and pharynx for
                           microscopic examination or culture.

  **National Acquisition   The largest combined contracting activity
  Center (NAC)**           within the Department of Veterans Affairs, NAC
                           falls under the VA's Office of Acquisition and
                           Materiel Management (OA&MM).   It is
                           responsible for supporting the health care
                           requirements of VA as well as the needs of
                           other Government agencies.   The NAC solicits,
                           awards, and administers VA\'s Federal Supply
                           Schedule and National Contract Programs
                           including the acquisition and direct delivery
                           of pharmaceuticals, medical/surgical/dental
                           supplies, high technology medical equipment
                           and just-in-time distribution programs (also
                           known as Prime Vendor Distribution Programs).
                            

  **National Cemetery      The VA administration that provides burial
  Administration (NCA)**   space and interment services for veterans and
                           their eligible family members, maintains
                           national cemeteries and provides headstones or
                           markers for graves.

  **National Disaster      A federally coordinated initiative that
  Medical System (NDMS)**  augments the Nation\'s emergency medical
                           response capability. The four federal partners
                           in NDMS are Department of Health and Human
                           Services (Public Health Service), Federal
                           Emergency Management Agency (FEMA), Department
                           of Defense, and Department of Veterans
                           Affairs. The overall purpose of NDMS is to
                           establish a single national medical response
                           capability for assisting state and local
                           authorities in dealing with the medical and
                           public health effects of major peacetime
                           disasters and to provide support to the
                           military medical system in caring for
                           casualties resulting from overseas armed
                           conflicts.

  **National Institutes of The primary Federal agency for conducting and
  Health (NIH)**           supporting medical research; a component of
                           the U.S. Department of Health and Human
                           Services[.]{.underline}

  **National Response Plan An all-hazards approach to enhance the ability
  (NRP)**                  of the United States to manage domestic
                           incidents.  It forms the basis of how the
                           federal government coordinates with state,
                           local, and tribal governments and the private
                           sector during incidents.

  **National Threat Level  A five-level system that prompts the
  Responses**              implementation of an appropriate set of
                           protective measures. Protective measures are
                           the specific steps an organization shall take
                           to reduce its vulnerability or increase its
                           ability to respond during a period of
                           heightened alert. The authority to craft and
                           implement Protective Measures rests with the
                           Federal departments and agencies. It is
                           recognized that departments and agencies may
                           have several preplanned sets of responses to a
                           particular Threat Condition to facilitate a
                           rapid, appropriate, and tailored response.
                           Department and agency heads are responsible
                           for developing their own Protective Measures
                           and other antiterrorism or self-protection and
                           continuity plans, and resourcing, rehearsing,
                           documenting, and maintaining these plans.

  **Negative airflow       A room with air at negative pressure to its
  area**                   environment, and, where air is exhausted to
                           the outdoors or through high-efficiency
                           filtration.

  **Oseltamivir**          An antiviral medication, also known as
                           Tamiflu®, used for the prevention and
                           treatment of influenza.

  **Pandemic influenza**   Worldwide epidemic that occurs when a new or
                           novel influenza strain emerges for which
                           humans have little or no immunity. The spread
                           can be rapid and have severe consequences of
                           illness, death and societal disruption.

  **Pathogenicity**        The capacity of a microorganism (e.g.,
                           bacteria, viruses, or parasites) to cause
                           disease in humans, animals, or plants.

  **Personal protective    Specialized clothing and equipment, such as
  equipment (PPE)**        goggles, gloves, gowns, and masks or
                           respirators, designed to protect people
                           against infectious diseases or other health
                           hazards.

  **Pneumonia**            Inflammation of the lungs characterized by
                           fever, chills, muscle aches, chest pain,
                           cough, shortness of breath, rapid heart rate
                           and difficulty breathing.

  **Post traumatic stress  An anxiety disorder resulting from direct
  disorder (PTSD)**        personal exposure to a situation that involves
                           actual or threatened death or serious injury.

  **Post-exposure          Providing medications to prevent or minimize
  prophylaxis**            an infectious disease after exposure.

  **Probenicid**           A medication used primarily to treat chronic
                           gout and gouty arthritis. It is also used to
                           increase blood levels of some medications by
                           preventing the body from passing them in the
                           urine.

  **Public affairs officer A professional who plans and implements
  (PAO)**                  communications strategies concerning an
                           organization's programs, policies, and
                           initiatives within and outside of the
                           organization.

  **Public health          Actions to prevent or limit the spread of
  measures**               disease in a population such as use of
                           vaccines or hand hygiene techniques.

  **Quarantine**           Separation of individuals who have been
                           exposed to a transmissible infection, but are
                           not yet ill, from others who have not been
                           exposed.

  **Regional Office        Field office composed of divisions that carry
  (VBA)**                  out the functions of VBA. Fifty-seven such
                           offices currently exist, with at least one
                           office in every state.

  **Respirator**           A piece of personal protective equipment that
                           covers the nose and mouth and filters the air
                           to protect the person from airborne
                           transmission of microorganisms. Sometimes
                           referred to as a mask, but the term respirator
                           is the preferred term. Types of respirators
                           include **N95s**, which should be fit tested
                           for highest protection and which can be
                           disposable, **elastomeric respirators,** in
                           which the filter is attached to a separate
                           face piece made of rubber, silicone, neoprene,
                           etc., and **positive air purifying respirators
                           (PAPRs**), full head-covering, battery-powered
                           units that have HEPA filters purifying air
                           coming into the hood; the air is expelled at
                           the edge and through the bottom holes of the
                           face seal.

  **Seasonal influenza**   an acute contagious disease characterized by
                           sudden onset fever, severe aches and pains,
                           and progressive inflammation of the
                           respiratory mucous membranes caused by an
                           influenza virus circulating in humans, usually
                           in winter, and against which vaccines are
                           developed annually; can cause significant
                           illness and, in some cases, death.

  **Self -triage           A document that provides guided, step-by-step
  algorithm**              problem-solving procedures for individuals to
                           determine their own need for medical care.

  **Snow day**             A public health measure involving closure or
                           cancellation of public gatherings (or granting
                           absence from the work place) in order to
                           prevent transmission of infection.

  **Social distancing**    A public health measure to reduce the
                           frequency of contact between people in order
                           to limit the transmission of infection.

  **Stakeholder**          An organization or individual who has a vested
                           interest in the activities of an organization.

  **Standard Precautions** Precautions that apply to all patients
                           receiving care in hospitals, regardless of
                           their diagnosis or presumed infection status.
                           Standard Precautions involves the use of
                           appropriate PPE (gloves) and hand hygiene when
                           coming in contact with any patient's 1) blood;
                           2) all body fluids, secretions, and excretions
                           except sweat, regardless of whether or not
                           they contain visible blood; 3) nonintact skin;
                           and 4) mucous membranes. Standard Precautions
                           are designed to reduce the risk of
                           transmission of microorganisms from both
                           recognized and unrecognized sources of
                           infection in hospitals.

  **Surveillance (public   The ongoing, systematic collection, analysis,
  health surveillance)**   and interpretation of health data. This
                           activity also involves timely dissemination of
                           the data and use for public health programs.

  **Tamiflu®**             An antiviral medication, whose generic name is
                           oseltamivir, used for the prevention and
                           treatment of influenza.

  **Telecommuting**        The process of working from home or
                           alternative site through telecommunications,
                           usually using computer access.

  **Telehealth**           The use of communications and information
                           technology by health care providers to deliver
                           health and health care services.

  **Telephone Advice       VA\'s program monitored with a representative
  Program (TAP)**          who is \"on the line\" 24 hours a day, 7 days
                           a week to assist with medical, pharmacy,
                           eligibility, and billing questions by
                           telephone.

  **Triage**               A process of separating patients based on
                           their need for or likely benefit from
                           immediate medical evaluation or treatment;
                           used in hospital emergency rooms, on
                           battlefields, and at disaster sites when
                           limited medical resources must be allocated.

  **VA Central Office      The recognized national headquarters of VA,
  (VACO)**                 located in Washington, DC, housing leadership
                           personnel and offices, including those of VHA,
                           VBA and NCA.

  **VA medical center      A VA health care facility that may include
  (VAMC)**                 inpatient and outpatient units, and
                           residential units.

  **VA Nationwide          The primary audio teleconferencing system for
  Teleconferencing System  VA employees.
  (VANTS)**                

  **VA Pharmaceutical      Stockpiles of pharmaceutical supplies that are
  Cache Program**          maintained and readied for deployment, usually
                           during an emergency event.

  **VA Regional Office     a relatively large VA office that generally
  (VARO)**                 includes a Veterans Service Center,
                           Director\'s Office, Vocational Rehabilitation
                           and Counseling Division, and Support Services
                           Division.

  **VA Regional Office and An office located in Philadelphia that
  Insurance Center         includes the Director\'s Office, the Veterans
  (VAROIC)**               Service Center, Vocational Rehabilitation and
                           Counseling Division, and Support Services
                           Division.

  **Vet Centers**          Common term for VA's Readjustment Counseling
                           Centers Program. Vet Centers assist veterans
                           and their family members toward a successful
                           post-war adjustment in or near their
                           communities; provide professional readjustment
                           counseling, community education, outreach to
                           special populations, the brokering of services
                           with community agencies; and link veterans to
                           other services within VA.

  **Veteran (military)**   A person who has served in the armed forces.

  **Veterans Benefits      The VA administration that provides financial
  Administration (VBA)**   assistance to millions of veterans and their
                           families through compensation and pension
                           programs, funding for education and training,
                           home loan assistance, life insurance and
                           vocational rehabilitation and employment.

  **Veterans Health        The VA administration that serves the health
  Administration (VHA)**   care needs of veterans by providing primary
                           care, specialized care, and related medical
                           and social support services through 21
                           Veterans Integrated Service Networks (VISNs),
                           consisting of hospitals and other facilities
                           such as community-based clinics, nursing
                           homes, residential rehabilitation programs,
                           and readjustment counseling centers (Vet
                           Centers).

  **Veterans Health        Veterans Health Information Systems and
  Information Systems &    Technology Architecture, VistA, is an
  Technology Architecture  integrated system of software applications
  (VistA)**                that directly supports patient care within the
                           VHA health care facilities. It connects VHA
                           facilities\' workstations and personal
                           computers with nationally mandated, locally
                           adapted software applications that are
                           accessed by end users through a graphical user
                           interface known as the Computerized Patient
                           Record System (CPRS).

  **Veterans Integrated    Geographic clusters of VA health facilities;
  Service Network          21 VISNs coordinate and support care in a
  (VISNs)**                total of over 1300 such facilities throughout
                           the Nation.

  **Veterans Service       An organization dedicated to advocating
  Organization (VSO)**     veterans\' causes and interests, and assisting
                           veterans in their interactions with VA.
                           Examples include the Disabled American
                           Veterans (DAV), American Legion (AL), the
                           Veterans of Foreign Wars (VFW), and many
                           others.

  **Virulence**            The ability of any agent of infection to
                           produce disease. The virulence of a
                           microorganism (such as a bacterium or virus)
                           is a measure of the severity of the disease it
                           is capable of causing. The adjective
                           **virulent** implies extremely noxious,
                           damaging, deleterious, disease-causing
                           (pathogenic).
  -----------------------------------------------------------------------

#########  VA Background

[]{#AppGroupA .anchor}Appendix A-1: DIAGRAM OF VA ORGANIZATION

[]{#__RefHeading___Toc130728408 .anchor}Appendix A-2: MAPS RELATED TO
THE THREE ADMINISTRATIONS OF THE DEPARTMENT OF VETERANS AFFAIRS (VA)

***Veterans Integrated Service Networks (VISNs) of the***

***Veterans Health Administration (VHA)***

![](media/image3.png){width="5.0in" height="3.298611111111111in"}

VHA runs more than 1,300 sites of care across the country and in each
state, as well as the Philippines, Guam, and Puerto Rico. These sites
are organized into 21 Veterans Integrated Service Networks:

VISN 1: VA New England Healthcare System\
VISN 2: VA Healthcare Network Upstate New York\
VISN 3: VA NY/NJ Veterans Healthcare Network\
VISN 4: VA Stars & Stripes Healthcare Network\
VISN 5: VA Capitol Health Care Network\
VISN 6: VA Mid-Atlantic Health Care Network\
VISN 7: VA Southeast Network\
VISN 8: VA Sunshine Healthcare Network\
VISN 9: VA Mid South Healthcare Network\
VISN 10: VA Healthcare System of Ohio\
VISN 11: Veterans In Partnership\
VISN 12: The Great Lakes Health Care System\
VISN 15: VA Heartland Network\
VISN 16: South Central VA Health Care Network\
VISN 17: VA Heart of Texas Health Care Network\
VISN 18: VA Southwest Health Care Network \
VISN 19: Rocky Mountain Network\
VISN 20: Northwest Network\
VISN 21: Sierra Pacific Network\
VISN 22: Desert Pacific Healthcare Network\
VISN 23: VA Midwest Health Care Network

*(VISNs 13 and 14 were combined into VISN 23 for a total of 21 VISNs)*

***Area Offices of the Veterans Benefits Administration (VBA)***

![](media/image4.png){width="5.25in" height="3.1930555555555555in"}

VBA operates through four Area Offices and 57 Regional Offices, with at
least one in every state. VBA staff members are also located in the
Philippines, Guam, Italy, Germany, Japan, and South Korea. The Western,
Central, Eastern, and Southern Area Offices cover the shaded areas
above.

***Memorial Service Networks (MSNs) of the National Cemetery
Administration (NCA)***

![](media/image5.png){width="4.875in" height="3.127083333333333in"}

NCA maintains about 120 national cemeteries in 39 states and Puerto
Rico. NCA has five Memorial Service Networks (shaded areas) and NCA
Central Office.  The MSNs covered the shaded areas above and are I:
Philadelphia Memorial Service Network, II: Atlanta Memorial Service
Network, III: Denver Memorial Service Network, IV: Indianapolis Memorial
Service Network, and V: Oakland Memorial Service Network.

.

[]{#__RefHeading___Toc130728409 .anchor}Appendix A-3: FACTS ABOUT VA
HEALTH CARE CAPABILITIES

***Inpatient Capacity: Operating Beds in VA facilities***

VHA's "operating" or usable beds are those that are staffed and
available for admission of patients. The table below shows VHA's average
operating beds and occupancy rates for its formal bed services as of the
end of FY 05. Overall, occupancy rates for inpatient beds (includes
medicine, neurology, rehabilitation medicine, blind rehab, spinal cord
injury, intermediate medicine, surgery and psychiatry) was 67% in FY 05.

  ----------------- ---------------- ----------------- -------------------
  **VHA Inpatient                                      
  Bed Occupancy                                        
  Rates As of End                                      
  of FY 05**                                           

  **Bed Service**   **Average Usable **Average Daily   **Occupancy Rate**
                    Beds**           Census(ADC)**     

  Medicine          7,100.70         5,298.85          74.62%

  Neurology         218.9            95.65             43.69%

  Rehab Med.        392              212.05            54.09%

  Blind Rehab       242              195.79            80.90%

  Spinal Cord       1,084.00         740.1             68.28%

  Intermediate Med. 1,121.50         476.21            42.46%

  Surgery           2,976.70         2,020.80          67.89%

  Psychiatry        7,218.30         4,558.69          63.15%

  **TOTAL           **20,354.10**    **13,598.14**     **66.81%**
  INPATIENT**                                          
  ----------------- ---------------- ----------------- -------------------

+------------+-------------+----------------+-------------------------+
| *          |             |                |                         |
| *Long-term |             |                |                         |
| Care       |             |                |                         |
| Fa         |             |                |                         |
| cilities** |             |                |                         |
|            |             |                |                         |
| **Bed      |             |                |                         |
| Occupancy  |             |                |                         |
| Rates As   |             |                |                         |
| of End of  |             |                |                         |
| FY 05**    |             |                |                         |
+------------+-------------+----------------+-------------------------+
| **Bed      | **Average   | **Average      | **Occupancy Rate**      |
| Service**  | Operating   | Daily          |                         |
|            | Beds**      | Census(ADC)**  |                         |
+------------+-------------+----------------+-------------------------+
| VA Dom     | 6,267.30    | 4,836.32       | 77.17%                  |
+------------+-------------+----------------+-------------------------+
| VA Nurs    | 15,109.10   | 11,957.52      | 79.14%                  |
| Home       |             |                |                         |
+------------+-------------+----------------+-------------------------+

A 2004 survey of Intensive Care Unit (ICU) beds revealed that VHA has
approximately 213 ICUs and a total of 2,042 authorized and 1906
operating ICU beds. This survey also estimates that in addition to the
authorized 2,045 ICU beds, an additional 353 ICU beds could be made
available in case of local and/or national emergency.

The table below shows the distribution of the types of authorized and
operating ICU beds.

  ------------------- ---------------------- -----------------------------
  **FY 2004 Operating                        
  ICU Beds**                                 

  **ICU Type**        **Authorized ICU       **Operating ICU beds**
                      Beds**                 

  MICU                248                    244

  SICU                553                    518

  CCU                 168                    165

  MICU/CCU            362                    316

  MICU/SICU           275                    258

  Mixed               388                    358

  Specialty           51                     47

  Total               2045                   1906
  ------------------- ---------------------- -----------------------------

***Outpatient Capacity: Community-Based Outpatient Clinics***

As of the end of FY 05, VHA had 712 community based outpatient clinic
(CBOC) sites of care (this includes multiple site contracts). In
general, CBOCs are structured and managed through primary care panels.
Staffing may vary depending on the size of the CBOC and types of
specialty services offered. Typically, the types of staff anticipated
include: physicians (primary care and mental health physician), nurses
(APNs, RNs, and LPNs/LVNs), physician assistants, health technicians,
and administrative staff.

In FY 05, CBOCs had 11.2 million patient visits that accounted for 23%
of VHA's total ambulatory care visits. In FY 05, approximately half of
the veterans served by VHA received their care at CBOCs (2.5 million
unique patients seen at CBOCs). CBOCs are access points for our high
priority veterans that live fair distances from other VHA health care
sites.

***Definitions***

  -----------------------------------------------------------------------
  **Term**                 **Definition**
  ------------------------ ----------------------------------------------
  **Average Daily Census** Number of beds that [are]{.underline} filled
                           or utilized within a defined period of time.

  **Average Operating      Number of beds that [can be]{.underline}
  Beds**                   utilized within a defined period of time.

  **[CCU]{.underline}:     An identified unit for the care of patients
  Cardiac Care Unit**      who have suffered acute myocardial infarction
                           (MI) or are experiencing heart related
                           problems.

  **[MICU]{.underline}:    An identified unit for the care of patients
  Medical Intensive Care   with medical conditions or emergencies.
  Unit**                   

  **Mixed Unit ICU**       An identified multi-purpose unit for the care
                           of patients requiring a combination of
                           specialized intensive care services.
                           (Combinations include
                           Medical/Surgical/Cardiac, Surgical/Burn, etc.)

  **Occupancy Rate**       The percentage of beds utilized within a
                           defined time period.

  **Other ICU Unit Types** An identified unit for the specialized care of
                           patients with certain
                           diagnoses/classifications/procedures such as
                           Burn ICU; Transplant ICU; Neurology ICU;
                           Neuro-Surgery ICU; Cardio-Thoracic ICU;
                           Respiratory ICU.

  **[SICU]{.underline}:    An identified unit for the care of surgical
  Surgical Intensive Care  patients (pre-operative, post-operative, and
  Unit**                   other non-operative patients such as trauma).
  -----------------------------------------------------------------------

######### Legal Authorities and Responsibilities

[]{#AppGroupB .anchor}Appendix B-1: SUMMARY OF POTENTIAL VA EXPANDED
RESPONSIBILITIES

The primary function of VHA is to provide a complete medical and
hospital service for the medical are and treatment of eligible veterans.
Various provisions in title 38, United States Code, authorize VHA to
provide care to others, such as family members of veterans under CHAMPVA
(the Civilian Health and Medical Program of the Department of Veterans
Affairs). VHA also has authority to enter into agreements to share
health-care resources.

**Special circumstances that expand VA responsibilities:**

***[VA Resource Sharing]{.underline}***

-   VHA has general authority to share health-care resources with any
    health care provider or entity according to local determination of
    needs through pre-established sharing agreements. Resources can also
    be provided in accordance with the National Response Plan. The
    National Response Plan may be implemented during a disaster or
    emergency declared by the President, during other Incidents of
    National Significance, or during a public health emergency declared
    by the Secretary of the Department of Health and Human Services.
    When the National Response is implemented, VA may be asked to
    provide resources through a Mission Assignment or sub-tasking
    (either with or without reimbursement) or through a request for
    Federal-to-Federal assistance. Information on Mission Assignments,
    sub-taskings, and Federal-to Federal support is detailed in the
    Financial Management Support Annex of the National Response Plan.
    (See Appendix B-2: TABLE OF LEGAL AUTHORITIES AND POLICIES RELEVANT
    TO EMERGENCIES - Advice on Changes in Usual VA Practices During a
    Pandemic and [Appendix C-1: REFERENCE LIST FOR VA EMERGENCY PLANS
    AND OTHER RESOURCES](#_Appendix_C-1:__Reference_List_for_V).)

***[Back Up to the Department Of Defense Medical System]{.underline}***

-   Under 38 USC § 8111A, VA serves as a back up for the Department of
    Defense health care system to care for active duty service members
    during war or a national emergency (see [Appendix B-2: TABLE OF
    LEGAL AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES - Advice on
    Changes in Usual VA Practices During a
    Pandemic](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO)).

***[Care Provision to Non-Enrolled or Non-Veterans]{.underline}***

-   As stated above, VA may provide care for non-veterans or
    non-enrolled veterans through a Mission Assignment or sub-tasking,
    or through a request for Federal-to-Federal assistance, as described
    in the National Response Plan. Hospital care or medical services may
    also be provided as a humanitarian service in emergency cases (38
    USC § 1784). The Secretary is obligated to charge for services
    provided under Section 1784. (See [Appendix B-2: TABLE OF LEGAL
    AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES - Advice on Changes
    in Usual VA Practices During a
    Pandemic](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO).)

***[VA National Response Plan Responsibilities]{.underline}***

-   VA has expanded responsibilities under the Federal government's
    National Response Plan in terms of certain Emergency Support
    Functions (ESFs). An ESF is a response activity established to
    facilitate coordinated Federal delivery of assistance required
    during the response phase of a catastrophic event to save lives,
    protect property and health, and maintain public safety. These
    functions represent those types of Federal assistance which States,
    local governments, or tribal authorities will likely need most
    because of the overwhelming impact of a catastrophic event on local
    and State resources.

```{=html}
<!-- -->
```
-   VA is responsible for providing support under the following
    Emergency Support Functions:

```{=html}
<!-- -->
```
-   ESF #3 Public Works and Engineering

-   ESF #5 Emergency Management

-   ESF #6 Mass Care, Housing, and Human Services

-   ESF #7 Resource Support

-   ESF #8 Public Health and Medical Services

-   ESF #13 Public Safety and Security

-   ESF #15 External Affairs

    -   Unless otherwise directed by the Secretary, under the National
        Response Plan VA provides available resources as requested
        either directly by the Federal Emergency Management Agency
        (FEMA) or through the respective ESF lead agency (for example,
        HHS is the lead agency for ESF #8). These requests, or
        "sub-tasking," are provided to the VA Readiness Operations
        Center (ROC) in VA Central Office which, in turn, directs them
        to the applicable administration or staff office for action. For
        VHA, the VA ROC will forward them the VHA Emergency Management
        Strategic Healthcare Group (EMSHG) Operations Center. (A table
        of laws and authorities that apply to VA's responsibilities in a
        pandemic appear in [Appendix B-2: TABLE OF LEGAL AUTHORITIES AND
        POLICIES RELEVANT TO EMERGENCIES - Advice on Changes in Usual VA
        Practices During a
        Pandemic.](#_Appendix_B-2:__TABLE_OF_LEGAL_AUTHO))

[]{#__RefHeading___Toc130728412 .anchor}Appendix B-2: TABLE OF LEGAL
AUTHORITIES AND POLICIES RELEVANT TO EMERGENCIES - Advice on Changes in
Usual VA Practices During a Pandemic

***Table of Legal Authorities Relevant to Emergencies***

[]{#B2 .anchor}

  -----------------------------------------------------------------------
  **Issue**               **Authority**           **Discussion**
  ----------------------- ----------------------- -----------------------
  ***I. VA Authority to                           
  Provide Hospital Care                           
  and Medical Services***                         

  A. Care to veterans     38 U.S.C. Chapters 17   The primary function of
                          and 73; 38 C.F.R. §§    the Veterans Health
                          17.36 -- 17.38          Administration is to
                                                  provide a complete
                                                  medical and hospital
                                                  service for the medical
                                                  care and treatment of
                                                  veterans. Enrollment
                                                  priorities are set by
                                                  Congress.

  B. Care to members of   38 U.S.C. §§ 8111,      The Secretary is
  the armed forces        8111A; 38 C.F.R. §      authorized to share
                          17.230; VHA Directive   health care resources
                          2005-045, Treatment of  with DOD, and to
                          Active Duty Service     provide care to members
                          Members in VA Health    of the Armed Forces
                          Care Facilities         during a time of war or
                          (October 4, 2005); VHA  national emergency.
                          Handbook 1660.4, VA-DOD 
                          Health Care Resources   
                          Sharing                 

  C. Care to non-VA       38 U.S.C. § 1784; 38    The Secretary is
  beneficiaries           C.F.R. §§ 17.37, 17.43, authorized to furnish
                          17.95, 17.102           hospital care or
                                                  medical services as a
                                                  humanitarian service to
                                                  non-VA beneficiaries in
                                                  emergency cases. VA
                                                  must charge for such
                                                  care.

  D. Care to non-VA       38 U.S.C. § 1785        \(i\) The Secretary is
  beneficiaries in a                              authorized to provide
  disaster or emergency                           hospital care and
                                                  medical services to
                                                  non-VA beneficiaries
                                                  responding to, involved
                                                  in, or otherwise
                                                  affected by a disaster
                                                  or emergency. Section
                                                  1785 codifies VA's
                                                  existing obligations
                                                  under the National
                                                  Response Plan,
                                                  including VA's
                                                  obligations under the
                                                  Stafford Disaster
                                                  Relief and Emergency
                                                  Assistance Act
                                                  (42 U.S.C. §§ 5121, et
                                                  seq.), and during
                                                  activation of the
                                                  National Disaster
                                                  Medical System (42
                                                  U.S.C. § 300hh-11).
                                                  Regulations to
                                                  implement this
                                                  authority are currently
                                                  under development.

                                                  \(ii\) In a disaster or
                                                  emergency declared by
                                                  the President under the
                                                  Stafford Act, VA can be
                                                  directed to utilize its
                                                  authorities and
                                                  resources (including
                                                  personnel, equipment,
                                                  supplies, facilities,
                                                  and managerial,
                                                  technical, and advisory
                                                  services) in support of
                                                  State and local
                                                  assistance efforts.
                                                  This is generally done
                                                  through the auspices of
                                                  the National Response
                                                  Plan through a Stafford
                                                  Act tasking or
                                                  sub-tasking. The
                                                  Financial Management
                                                  Support Annex of the
                                                  National Response Plan
                                                  details this process.

                                                  \(iii\) During
                                                  non-Stafford Act
                                                  Incidents of National
                                                  Significance, the
                                                  Financial Management
                                                  Support Annex of the
                                                  National Response Plan
                                                  describes a process for
                                                  signatories of the NRP
                                                  to provide needed
                                                  support to one another
                                                  on a reimbursable
                                                  basis. The Memorandum
                                                  of Agreement detailing
                                                  this process is set
                                                  forth in the Financial
                                                  Management Support
                                                  Annex. The general
                                                  authority for providing
                                                  this assistance is the
                                                  Economy Act (31 U.S.C.
                                                  § 1535).

  E. VA's general         38 U.S.C. § 8153; VHA   
  authority to share      Directive 1660.1,       
  health care resources   Enhanced Health Care    
                          Resources Sharing       
                          Authority - Selling     

  ***II. Priorities for                           
  Providing Medical                               
  Care***                                         

  Considerations for      A. The explicit         When faced with
  prioritization of VA    language in 38 U.S.C. § individuals who require
  health care             8111A and the           emergency medical
                          legislative history of  treatment (for example,
                          38 U.S.C. § 1785        during a disaster or
                          indicate that during    emergency situation),
                          declared major          VHA practitioners
                          disasters and           generally prioritize
                          emergencies and         based on medical need.
                          activation of NDMS, the Life-threatening
                          highest priority for    conditions are treated
                          receiving VA care and   prior to less severe or
                          services goes to        routine conditions.
                          service-connected       This may require
                          veterans, followed by   deferring routine or
                          members of the armed    elective care for
                          forces receiving care   higher priority
                          under section 8111A and veterans in order to
                          then by individuals     treat medical
                          affected by a disaster  emergencies. This
                          or emergency described  prioritization based on
                          in section 1785 (i.e.,  medical need is not
                          individuals requiring   dictated by a specific
                          care during a declared  statute or regulation.
                          disaster or emergency,  Rather, it is derived
                          or during activation of from the general
                          the NDMS).              authority granted to
                                                  the Secretary (and
                                                  through delegation to
                                                  the Under Secretary for
                                                  Health and to health
                                                  care providers) to
                                                  provide "needed care"
                                                  to veterans. Thus,
                                                  during a disaster or an
                                                  emergency, VA has
                                                  flexibility and
                                                  discretion in
                                                  determining what
                                                  constitutes needed
                                                  care.

  ***III. Quarantine and                          
  Isolation***                                    

  A. State law            A. The authority to     If a VHA practitioner
                          compel quarantine or    seeks to isolate or
                          isolation is derived    quarantine a VA
                          from a state's inherent patient, the authority
                          "police power," a power to involuntarily
                          reserved to the states  isolate or quarantine
                          under the 10th          an individual will
                          Amendment of the United likely be determined,
                          States Constitution.    at least initially, by
                          There is significant    state law. Regional
                          variation among states  Counsel must be
                          regarding isolation and contacted for guidance
                          quarantine laws. Some   on applicable state
                          states have laws that   law.
                          include specific,       
                          detailed procedures and 
                          provisions to impose    
                          and enforce mandatory   
                          isolation and           
                          quarantine, while other 
                          states have broader,    
                          more outdated laws and  
                          regulations. Further,   
                          some localities within  
                          states have laws        
                          applicable to           
                          quarantine and          
                          isolation.              

  B. Federal Law          B. The Secretary of the The Federal
                          Department of Health    government's authority
                          and Human Services      to act under this
                          (HHS) has statutory     statute is limited to
                          authority to prevent    communicable diseases
                          the introduction,       identified by the
                          transmission, or spread President. The current
                          of communicable         list of communicable
                          diseases from foreign   diseases includes
                          countries into the      Cholera; Diphtheria;
                          United States, or from  Infectious
                          one state or possession Tuberculosis; Plague;
                          into another. CDC may   Smallpox; Yellow Fever;
                          intervene in intrastate Viral Hemorrhagic
                          incidents if requested  Fevers; and Severe
                          by state or if local    Acute Respiratory
                          control efforts         Syndrome (SARS), and
                          considered inadequate.  "Influenza caused by
                          42 U.S.C. § 264; 42     novel or reemergent
                          C.F.R. Part 70,         influenza viruses that
                          Interstate Quarantine   are causing, or have
                          and Part 71, Foreign    the potential to cause,
                          Quarantine.             a pandemic.\" (Pandemic
                                                  influenza was added in
                                                  April 2005. See
                                                  Executive Order 13375
                                                  (April 1, 2005)).

                          C. 42 U.S.C. § 266.     Special quarantine
                                                  powers are available to
                                                  the Surgeon General in
                                                  a time of war. The
                                                  Surgeon General may
                                                  apprehend, examine, and
                                                  detain individuals
                                                  reasonably believed
                                                  infected with
                                                  communicable disease if
                                                  they present a probable
                                                  risk of infection to
                                                  the armed forces or its
                                                  suppliers.

  ***IV. Liability                                
  Issues***                                       

  Liability in general    A. VA personnel acting  
                          within the course and   
                          scope of their Federal  
                          employment are          
                          generally protected     
                          from personal liability 
                          under the Federal Tort  
                          Claims Act (FTCA). A    
                          determination of        
                          whether a person's      
                          actions were within the 
                          scope of employment     
                          would be made by the    
                          Department of Justice   
                          in the event of legal   
                          action involving the    
                          employee's acts." 28    
                          U.S.C. §§ 1346(b), 2670 
                          -- 2680; 38 U.S.C. §    
                          7316.                   

  Liability in declared   B. The Stafford Act     
  (Stafford Act)          includes an explicit    
  emergencies             "nonliability"          
                          provision. 42 U.S.C. §  
                          5148; 44 C.F.R. §       
                          206.9, that protects    
                          the Federal Government  
                          from liability for      
                          discretionary acts      
                          performed by Federal    
                          agencies and employees  
                          in carrying out their   
                          duties.                 

  ***V. Transportation of                         
  Employees During an                             
  Emergency***                                    

  Home-to-work            A. Federal law          \(i\) The authority to
  transportation of       generally prohibits     make this determination
  employees               home-to-work            rests with the agency
                          transportation of most  head and cannot be
                          employees, but          delegated. The
                          authorizes agencies to  requirement for an
                          approve such            advance determination
                          transportation in an    can be excepted if it
                          emergency situation. 31 is impracticable.
                          U.S.C. § 1344; 41       
                          C.F.R. Part 102.5       

                                                  \(ii\) If a VA medical
                                                  center faces an
                                                  emergency requiring
                                                  transportation of
                                                  personnel in order to
                                                  keep the hospital up
                                                  and running, VA could
                                                  craft a compelling
                                                  argument that it was
                                                  impractical to obtain
                                                  the necessary
                                                  permission in advance. 
                                                  However, the facility
                                                  must maintain logs of
                                                  the transportation
                                                  provided, and the
                                                  Secretary's decision to
                                                  authorize the
                                                  transportation must be
                                                  submitted to Congress,
                                                  as required by the
                                                  regulations.

                          B. The Secretary has    \(i\) The statute
                          emergency authority     requires the Secretary
                          under title 38, United  to establish
                          States Code, to use     "reasonable rates" to
                          Government-owned or     cover the cost of such
                          leased vehicles to      services. If VHA wants
                          transport VA employees  to utilize this
                          to and from their place emergency authority, VA
                          of employment and the   must establish rates to
                          nearest public          cover the cost of such
                          transportation or, if   services.
                          public transportation   
                          is unavailable or not   
                          feasible, to and from   
                          work to home. 38 U.S.C. 
                          § 703(f)                

                                                  \(ii\) To expedite the
                                                  use of this authority,
                                                  VHA can seek a
                                                  delegation to the Under
                                                  Secretary for Health.
  -----------------------------------------------------------------------

***Table of Policies Relevant to Emergencies***

+-----------------------+-----------------------+-----------------------+
| **Relevant Policy**   | **Reference**         | **Discussion**        |
+=======================+=======================+=======================+
| ***I. Credentialing   |                       |                       |
| and Privileging       |                       |                       |
| Health Care           |                       |                       |
| Providers***          |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       | VHA Handbook 1100.19, | Credentialing and     |
|                       | Credentialing and     | privileging actions   |
|                       | Privileging;          | that might be changed |
|                       |                       | in a pandemic are     |
|                       | VHA Directive         | described in Section  |
|                       | 2001-022,             | 3.2.3.6               |
|                       | Implementation of     |                       |
|                       | VETPRO, VHA's         |                       |
|                       | National Credentials  |                       |
|                       | Databank;             |                       |
|                       |                       |                       |
|                       | VHA Directive         |                       |
|                       | 2001-005,             |                       |
|                       | Credentialing and     |                       |
|                       | Privileging of        |                       |
|                       | Telemedicine and      |                       |
|                       | Telehealth Services   |                       |
|                       | provided in Hospitals |                       |
|                       | and Clinics           |                       |
|                       |                       |                       |
|                       | VHA Directive         |                       |
|                       | 2002-042, The         |                       |
|                       | Credentialing and     |                       |
|                       | Privileging of VA     |                       |
|                       | Health Care Providers |                       |
|                       | Remotely Delivering   |                       |
|                       | Health Care to        |                       |
|                       | Patients at Home, in  |                       |
|                       | Vet Centers, and in   |                       |
|                       | Non-Health Care       |                       |
|                       | Settings Via          |                       |
|                       | Telemedicine and/or   |                       |
|                       | Telehealth            |                       |
|                       |                       |                       |
|                       | VHA Directive         |                       |
|                       | 2002-076, Expedited   |                       |
|                       | Medical Staff         |                       |
|                       | Appointment Process   |                       |
+-----------------------+-----------------------+-----------------------+
| ***II. VA Provision   |                       |                       |
| of Disaster Emergency |                       |                       |
| Medical Personnel***  |                       |                       |
+-----------------------+-----------------------+-----------------------+
|                       | VHA Directive         | Database of VHA       |
|                       | 2003-052, Disaster    | medical personnel who |
|                       | Emergency Medical     | have volunteered to   |
|                       | Personnel System      | be deployed in the    |
|                       | (DEMPS) Program and   | event of a disaster   |
|                       | Database              | internal or external  |
|                       |                       | to VA.                |
+-----------------------+-----------------------+-----------------------+
| ***III. Occupational  |                       |                       |
| Health Issues***      |                       |                       |
+-----------------------+-----------------------+-----------------------+
| Absence for employees | Family Medical Leave  | Facilities should     |
| affected by a         | Act;                  | work with their Human |
| pandemic, such as     |                       | Resources staff to    |
| those exposed to an   | Authorized Absence in | identify applicable   |
| infectious disease    | emergencies, see VA   | policies addressing   |
|                       | Handbook 5011/3 Part  | employee absences. VA |
|                       | II, Chapter 3 (March  | is authorized to      |
|                       | 2005);                | grant employees       |
|                       |                       | "authorized absence"  |
|                       | VA Handbook 5011/6    | when there is a       |
|                       | Part II (January      | national emergency.   |
|                       | 2006)                 | An employee's absence |
|                       |                       | that is necessary to  |
|                       |                       | prevent transmission  |
|                       |                       | of an infectious      |
|                       |                       | disease may meet the  |
|                       |                       | definition of an      |
|                       |                       | emergency.            |
+-----------------------+-----------------------+-----------------------+

***Additional Comments on Providing VA Health Care in Emergency
Situations***

The organization and delivery of health care is highly regulated.
Depending upon the severity of a pandemic, it is possible that the
Federal, state, or local government entities regulating the delivery of
health care may temporarily modify some statutory or regulatory
requirements. Alternatives may include enhancing, modifying, or waiving
laws and regulations pertaining to the delivery of health and medical
care in normal conditions.

If the VA Secretary (or designate) determines that circumstances require
revision of current VA regulations governing VA hospital care and
medical services, such revision must be made in accordance with
applicable law. VA has no authority to unilaterally waive non-VA
regulations. Further, VA has no authority to unilaterally waive
statutory provisions or requirements. During an influenza pandemic, VA
facilities are urged to work with Regional Counsel to monitor any
changes, modifications, or waivers of the laws and regulations that
govern the delivery of hospital care and medical services in VA
facilities. Any such waivers or modifications are likely to be targeted
to the affected area for a temporary and specified period of time. In
the case of a pandemic that moves form region to region, it will be
important for VA to correctly and appropriately apply any such waivers
or modifications.

######### References

[]{#_Appendix_C-1%3A__Reference_List_for_V .anchor}

Appendix C-1: REFERENCE LIST FOR VA EMERGENCY PLANS AND OTHER RESOURCES

[Federal Pandemic Influenza Web site]{.underline}

[www.pandemicflu.gov](http://www.pandemicflu.gov/)

**VA Emergency Plans**

**Other Relevant VA Policies**

**VA Web sites**

**International Agencies**

**Federal Departments and Agencies**

**State Web sites**

**Emergency Preparedness**

**Influenza and Respiratory Infectious Diseases**

**VA Emergency Plans**

> VA Directive 0320, Comprehensive Emergency Management Program, March
> 24, 2005
>
> <http://www.va.gov/pubs/directives/Policy-Planning-Preparedness/0320dir.doc>
>
> VA Handbook 0320, Comprehensive Emergency Management Program, March
> 24, 2005
>
> <http://www.va.gov/pubs/handbooks/Policy-Planning-Preparedness/0320hbk.Doc>
>
> [Veterans Health Administration (VHA) Emergency Management Program
> Procedures](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=326)
>
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=326>
>
> [[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=326]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=326)
>
> VHA Emergency Management Program Guidebook, March 2005
>
> <http://vaww.ceosh.med.va.gov/Guidebooks/EMP2005/2005_EMP.htm>
>
> <http://www1.va.gov/emshg/page.cfm?pg=114>
>
> VHA Directive 2002-026, Pharmaceutical Caches in a Weapons of Mass
> Destruction Event, May 13, 2002
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1134>
>
> VHA Directive 2004-046, Inspection of the VHA Pharmaceutical Caches by
> the Emergency Management Strategic Healthcare Group, August 24,2004
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1149>
>
> [[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1149]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1149)

VHA Handbook 0320.2, Emergency Management Program Procedures, June 12,
2000
<http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=326>

VHA Handbook 0320.3, Disaster Emergency Medical Personnel System
(DEMPS), July 21, 2000

<http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=334>

[[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=334]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=334)

VHA Respiratory Infectious Disease Emergency Plan for Facilities\
 <http://www.publichealth.va.gov/watch/respiratoryID.htm>

> VBA Emergency Preparedness
>
> <http://vbaw.vba.va.gov/bl/20/201f/emer-prep/>
>
> VBA Continuity of Operations Plan (COOP)
>
> [http://vbaw.vba.va.gov/bl/20/201f/emer-prep/COOP/VBACO%20Revised%20Signed%20MasterCOOP%20Apr%2027.doc](http://vbaw.vba.va.gov/bl/20/201f/emer-prep/COOP/VBACO Revised Signed MasterCOOP Apr 27.doc)
>
> VBA Continuity of Operations Plan Template
>
> <http://vbaw.vba.va.gov/bl/20/201f/emer-prep/ro_coop.htm>
>
> VBA Facility Director Order of Succession
>
> [http://vbaw.vba.va.gov/bl/20/201f/emer-prep/Order%20of%20Succession%20Form.doc](http://vbaw.vba.va.gov/bl/20/201f/emer-prep/Order of Succession Form.doc)
>
> NCA Emergency Preparedness Planning
>
> <http://vaww.vairm.vaco.va.gov/ncamis/legis_handdir_pdf/0320_Directive.pdf>
>
> NCA Emergency Preparedness Planning Procedures
>
> <http://vaww.vairm.vaco.va.gov/ncamis/legis_handdir_pdf/0320_Handbook.pdf>

**Other Relevant VA Policies**

> VHA Hand Hygiene Practices 2005
> <http://vaww1.va.gov/optometry/docs/Hand_Hygiene_Directive.pdf> or
> internet at

<http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1214>

> [VHA Oseltamivir
> Stockpile](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1323),
> Under Secretary for Health's Information Letter, September 2005
>
> <http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1323>
>
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1323>
>
> Telephone Care and Service
>
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=79>
>
> VHA Handbook 1100.19, Credentialing and Privileging
>
> [[http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=357]{.underline}](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=357)
>
> [[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=357]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=357)
>
> VHA Directive 2001-022, Implementation of VetPro
>
> [[http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=87]{.underline}](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=87)
>
> [[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=87]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=87)
>
> VHA Directive 2001-005, Credentialing and Privileging of Telemedicine
> and Telehealth Services Provided in Hospitals and Clinics
>
> [[http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=127]{.underline}](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=127)
>
> [[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=127]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=127)
>
> VHA Directive 2002-076, Expedited Medical Staff Appointment Process
>
> [[http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=222]{.underline}](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=222)
>
> [[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=222]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=222)
>
> [Credentialing and Privileging of VHA Health Care Providers Remotely
> Delivering Health Care to Patients at Home, in Vet Centers, and in
> Non-Health Care Settings Via Telemedicine and/or Tele
> Health](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=189)
>
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=189>
>
> [[http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=189]{.underline}](http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=189)
>
> [Respiratory Protection Used for Infectious Disease and Annual
> Fit-testing](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1349)
>
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1349>
>
> <http://www1.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=1349>
>
> Authorized Absence in emergencies, see VA Handbook 5011/3 Part II,
> Chapter 3 March 30, 2005
>
> <http://www1.va.gov/ohrm/Directives-Handbooks/Direct_Hand.htm>
>
> VA Handbook 5011/6, January 26, 2006
>
> <http://www1.va.gov/ohrm/Directives-Handbooks/Direct_Hand.htm>
>
> [Spiritual and Pastoral Care
> Procedures](http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1231)
>
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1231>
>
> http://www1.va.gov/vhapublications/viewpublication.asp?pub_id=1231
>
> NCA Directives and Handbooks
>
> <http://vaww.vairm.vaco.va.gov/ncamis/legis_handdir.htm>

**VA Web sites**

> Department of Veterans Affairs
>
> <http://www.va.gov/> or <http://vaww.va.gov/>

VA "Infection: Don't Pass It On" campaign Web site - hand and
respiratory hygiene, personal protective equipment information;
extensive downloadable, printable material

> [www.publichealth.va.gov/InfectionDontPassItOn](http://www.publichealth.va.gov/InfectionDontPassItOn)
>
> VA influenza and pandemic influenza information

<http://www.publichealth.va.gov/flu/>

> *My* *Health***[e]{.underline}***Vet* -- VA's gateway to veteran
> health and wellness
>
> <http://www.myhealth.va.gov/>

VA Emergency Management Strategic Health Care Group

> <http://www.va.gov/EMSHG/>
>
> VA Public Health Strategic Health Care Group -- Public health issues
> and concerns
>
> [www.publichealth.va.gov](http://www.publichealth.va.gov/)

Pharmacy Benefits Management Strategic Healthcare Group

> <http://www.vapbm.org/PBM/menu.asp>
>
> VA Office of Acquisition and Materiel Management
>
> <http://vaww1.va.gov/oamm/>
>
> <http://www1.va.gov/oamm/>
>
> NCA Directives and Handbooks
>
> <http://vaww.vairm.vaco.va.gov/ncamis/legis_handdir.htm>

**International Agencies**

World Health Organization (WHO)

<http://www.who.int/en/>

**Federal Departments and Agencies**

> Department of Veterans Affairs
>
> <http://www.va.gov/> or <http://vaww.va.gov/>

Department of Homeland Security

<http://www.dhs.gov/dhspublic/theme_home2.jsp>

> Centers for Disease Control (CDC)
>
> http://[www.cdc.gov](http://www.cdc.gov/)
>
> Department of Health and Human Services (HHS)
>
> <http://www.hhs.gov/>
>
> Agency for Healthcare Research and Quality (AHRQ)
>
> <http://www.ahrq.gov/>
>
> Federal Emergency Management Agency (FEMA)
>
> <http://www.fema.gov/>
>
> Food and Drug Administration (FDA)
>
> <http://www.fda.gov/>
>
> Health Resources and Services Administration (HRSA)
>
> <http://www.hrsa.gov/>
>
> National Institutes of Health (NIH)
>
> <http://www.nih.gov/>
>
> NIH, National Institute of Allergy and Infectious Diseases
>
> <http://www.niaid.nih.gov/>
>
> Department of Defense
>
> <http://www.defenselink.mil/>
>
> Occupational Safety and Health Administration (OSHA)
>
> [http://www.osha.gov](http://www.osha.gov/)

**State Web sites**

> CDC - Web directory for State and Local Health Departments
> <http://www.cdc.gov/doc.do/id/0900f3ec80226c7a>
>
> Federal Web directory for State-by-State Pandemic Information
>
> <http://www.pandemicflu.gov/plan/tab2.html>

**Emergency Preparedness**

> HHS Office of Public Health Emergency Preparedness (OPHEP)
>
> <http://www.hhs.gov/ophep/index.html>
>
> HHS Office of the Assistant Secretary for Public Health Emergency
> Preparedness (ASPHEP)
>
> <http://hhs.gov/asphep>
>
> HHS Office of Public Health Emergency Preparedness (OPHEP)
>
> <http://www.hhs.gov/ophep/index.html>
>
> HHS Office of the Assistant Secretary for Public Health Emergency
> Preparedness (ASPHEP)
>
> <http://hhs.gov/asphep>
>
> CDC: A Voluntary Rapid Self-Assessment of State and Local Capacity to
> Respond to Bioterrorism, Outbreaks of Infectious Disease, and Other
> Public Health Threats and Emergencies.
>
> <http://www.phppo.cdc.gov/od/inventory/index.asp>

CDC Emergency Preparedness and Response

> <http://www.bt.cdc.gov/>

CDC Surveillance Guidance

> <http://www.bt.cdc.gov/episurv/>

CDC Epidemic Information Exchange

> <http://www.cdc.gov/mmwr/epix/epix.html>

AHRQ Public Health Preparedness

<http://www.ahrq.gov/prep/>

Worker Protection: OSHA\'S Role During Response to Catastrophic
Incidents

> <http://www.osha.gov/SLTC/emergencypreparedness/guides/osha_role.html>
>
> OSHA Safety and Health Topics: Emergency Preparedness and Response
> <http://www.osha.gov/SLTC/emergencypreparedness/index.html>
>
> OSHA Best Practices for Hospital-Based First Receivers of Victims
> <http://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.html>
>
> Department of Homeland Security: the [National Incident Management
> System
> (NIMS](http://www.dhs.gov/dhspublic/interweb/assetlibrary/NIMS-90-web.pdf))
>
> <http://www.dhs.gov/dhspublic/display?content=3697>
>
> <http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web.pdf>

Department of Homeland Security: Training & Exercises

> <http://www.dhs.gov/dhspublic/display?theme=63>

Department of Homeland Security: Response and Recovery

> <http://www.dhs.gov/dhspublic/display?theme=15>

**Influenza and Respiratory Infectious Diseases**

VA Influenza Information

> <http://www.publichealth.va.gov/flu/>
>
> <http://vaww.vhaco.va.gov/phshcg/Flu/Default.htm>)
>
> VA Influenza Vaccine Recommendations for 2005 -- 2006
>
> <http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1334>
>
> VA Influenza Toolkit Manual 2005 - 2006
>
> <http://www.publichealth.va.gov/flu/documents/VA_Flu_Manual.pdf>

HHS Pandemic Influenza Response and Preparedness Plan

<http://www.hhs.gov/pandemicflu/plan/>

Centers for Disease Control and Prevention (CDC) Influenza Information

> <http://www.cdc.gov/flu/index.htm>
>
> CDC Guideline for Environmental Infection Control in Health-Care
> Facilities, 2003
> <http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html>"
>
> CDC Hand Hygiene in Healthcare Settings
>
> <http://www.cdc.gov/handhygiene/>

CDC Severe Acute Respiratory Syndrome (SARS) Information

> <http://www.cdc.gov/ncidod/sars/>
>
> CDC Preparedness for SARS in Healthcare facility
> <http://www.cdc.gov/ncidod/sars/guidance/C/pdf/c.pdf>

CDC Information on Avian Influenza

> <http://www.cdc.gov/flu/avian/>
>
> CDC Recommendations for Infection Control -- Avian Influenza -
> <http://www.cdc.gov/flu/avian/professional/infect-control.htm>
>
> CDC Background and testing/lab information -- influenza & SARS
> <http://www.cdc.gov/flu/avian/professional/han020302.htm>
>
> Department of Health and Human Services (HHS) Pandemic Influenza
> Preparedness
>
> <http://www.hhs.gov/nvpo/pandemicplan/>

HHS National Vaccine Program Office

> <http://www.hhs.gov/nvpo/pubs/pandemicflu.htm>

CDC Flu surge calculations

> <http://www.cdc.gov/flu/flusurge.htm>

World Health Organization Influenza Information

> <http://www.who.int/csr/disease/influenza/pandemic/en/>
>
> U.S. Food and Drug Administration (FDA)-Center for Drug Evaluation and
> Research -- Discussion of influenza antiviral drugs and related
> information.
> <http://www.fda.gov/cder/drug/antivirals/influenza/default.htm>  
>
> Occupational Safety and Health Agency (OSHA) Information Regarding
> Severe Acute Respiratory Syndrome (SARS).
>
> <http://www.osha.gov/dep/sars/index.html>
>
> OSHA Anthrax e-Tool: Protecting the Worksite Against Terrorism.
> <http://www.osha.gov/SLTC/etools/anthrax/index.html>
>
> OSHA Guidance for Protecting Workers Against Avian Flu
>
> <http://www.osha.gov/dsg/guidance/avian-flu.html>

######### Planning Tools

[]{#AppGroupD .anchor}Appendix D-1: VA PANDEMIC PREPARATION ACTION GRIDS

Following are several grids that outline planning steps for pandemic
influenza. These reflect the text in Section 2 and provide numbers of
subsections (e.g., 2.1.2 Coordination) for cross reference.

The grids cover:

-   VA Central Office

-   VHA facilities

-   VBA

-   NCA

These grids can be a starting point to identify steps, name responsible
offices and individuals to carry out these steps, and track progress.

+----+------------------------+---------+---------+---------+---------+
| *  |                        |         |         |         |         |
| *P |                        |         |         |         |         |
| re |                        |         |         |         |         |
| pa |                        |         |         |         |         |
| ri |                        |         |         |         |         |
| ng |                        |         |         |         |         |
| f  |                        |         |         |         |         |
| or |                        |         |         |         |         |
| Pa |                        |         |         |         |         |
| nd |                        |         |         |         |         |
| em |                        |         |         |         |         |
| ic |                        |         |         |         |         |
| In |                        |         |         |         |         |
| fl |                        |         |         |         |         |
| ue |                        |         |         |         |         |
| nz |                        |         |         |         |         |
| a: |                        |         |         |         |         |
| ** |                        |         |         |         |         |
|    |                        |         |         |         |         |
| ** |                        |         |         |         |         |
| VA |                        |         |         |         |         |
| C  |                        |         |         |         |         |
| en |                        |         |         |         |         |
| tr |                        |         |         |         |         |
| al |                        |         |         |         |         |
| Of |                        |         |         |         |         |
| fi |                        |         |         |         |         |
| ce |                        |         |         |         |         |
| Ac |                        |         |         |         |         |
| ti |                        |         |         |         |         |
| on |                        |         |         |         |         |
| Gr |                        |         |         |         |         |
| id |                        |         |         |         |         |
| ** |                        |         |         |         |         |
+====+========================+=========+=========+=========+=========+
| *  | **Preparation Action** | **Resp  | **Resp  | **Com   | **Com   |
| *S |                        | onsible | onsible | pletion | pletion |
| ec |                        | O       | P       | Date    | Date    |
| ti |                        | ffice** | erson** | (Pla    | (Ac     |
| on |                        |         |         | nned)** | tual)** |
| ** |                        |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
| ** |                        |         |         |         |         |
| *2 |                        |         |         |         |         |
| .1 |                        |         |         |         |         |
| .2 |                        |         |         |         |         |
| C  |                        |         |         |         |         |
| oo |                        |         |         |         |         |
| rd |                        |         |         |         |         |
| in |                        |         |         |         |         |
| at |                        |         |         |         |         |
| io |                        |         |         |         |         |
| n* |                        |         |         |         |         |
| ** |                        |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Coordinate efforts     |         |         |         |         |
|    | with Federal, state,   |         |         |         |         |
|    | local, tribal          |         |         |         |         |
|    | organizations &        |         |         |         |         |
|    | agencies               |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Meet VA obligations    |         |         |         |         |
|    | under National         |         |         |         |         |
|    | Implementation Plan    |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Establish VA Pandemic  |         |         |         |         |
|    | Influenza Advisory     |         |         |         |         |
|    | Group                  |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Plan to respond to     |         |         |         |         |
|    | pandemic outbreak      |         |         |         |         |
|    | using emergency        |         |         |         |         |
|    | management resource    |         |         |         |         |
|    | plans                  |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
| ** |                        |         |         |         |         |
| *2 |                        |         |         |         |         |
| .1 |                        |         |         |         |         |
| .3 |                        |         |         |         |         |
| VA |                        |         |         |         |         |
| C  |                        |         |         |         |         |
| en |                        |         |         |         |         |
| tr |                        |         |         |         |         |
| al |                        |         |         |         |         |
| Of |                        |         |         |         |         |
| fi |                        |         |         |         |         |
| ce |                        |         |         |         |         |
| P  |                        |         |         |         |         |
| re |                        |         |         |         |         |
| pa |                        |         |         |         |         |
| ra |                        |         |         |         |         |
| ti |                        |         |         |         |         |
| on |                        |         |         |         |         |
| s* |                        |         |         |         |         |
| ** |                        |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Develop plan to use    |         |         |         |         |
|    | COOP, identify         |         |         |         |         |
|    | essential functions,   |         |         |         |         |
|    | consider flexible work |         |         |         |         |
|    | standards, leave       |         |         |         |         |
|    | options                |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Communicate with staff |         |         |         |         |
|    | on pandemic influenza, |         |         |         |         |
|    | protecting themselves, |         |         |         |         |
|    | public health          |         |         |         |         |
|    | measures, plans, and   |         |         |         |         |
|    | policies               |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Plan to obtain and     |         |         |         |         |
|    | administer antivirals  |         |         |         |         |
|    | and vaccine            |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
| ** |                        |         |         |         |         |
| *2 |                        |         |         |         |         |
| .1 |                        |         |         |         |         |
| .4 |                        |         |         |         |         |
| .1 |                        |         |         |         |         |
| Pu |                        |         |         |         |         |
| bl |                        |         |         |         |         |
| ic |                        |         |         |         |         |
| A  |                        |         |         |         |         |
| ff |                        |         |         |         |         |
| ai |                        |         |         |         |         |
| rs |                        |         |         |         |         |
| /C |                        |         |         |         |         |
| om |                        |         |         |         |         |
| mu |                        |         |         |         |         |
| ni |                        |         |         |         |         |
| ca |                        |         |         |         |         |
| ti |                        |         |         |         |         |
| on |                        |         |         |         |         |
| s* |                        |         |         |         |         |
| ** |                        |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Develop central        |         |         |         |         |
|    | Internet and intranet  |         |         |         |         |
|    | sites                  |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Encourage facilities   |         |         |         |         |
|    | and networks to create |         |         |         |         |
|    | communication plans    |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Develop education and  |         |         |         |         |
|    | information material   |         |         |         |         |
|    | for distribution       |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Identify & train key   |         |         |         |         |
|    | lead spokespersons at  |         |         |         |         |
|    | all levels             |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Gather all emergency   |         |         |         |         |
|    | information from key   |         |         |         |         |
|    | partners at all levels |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Disseminate            |         |         |         |         |
|    | announcements thru     |         |         |         |         |
|    | subject matter experts |         |         |         |         |
|    | to media               |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Create tools &         |         |         |         |         |
|    | templates for basic    |         |         |         |         |
|    | messages               |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Update all levels on   |         |         |         |         |
|    | Plan and pandemic      |         |         |         |         |
|    | influenza              |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Strengthen             |         |         |         |         |
|    | relationships with     |         |         |         |         |
|    | national, Federal, and |         |         |         |         |
|    | private partners       |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Anticipate and prepare |         |         |         |         |
|    | for questions and      |         |         |         |         |
|    | answers                |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Brief Congress, VSOs,  |         |         |         |         |
|    | media                  |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
| ** |                        |         |         |         |         |
| *2 |                        |         |         |         |         |
| .2 |                        |         |         |         |         |
| .2 |                        |         |         |         |         |
| V  |                        |         |         |         |         |
| HA |                        |         |         |         |         |
| C  |                        |         |         |         |         |
| oo |                        |         |         |         |         |
| rd |                        |         |         |         |         |
| in |                        |         |         |         |         |
| at |                        |         |         |         |         |
| io |                        |         |         |         |         |
| n* |                        |         |         |         |         |
| ** |                        |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Work across offices,   |         |         |         |         |
|    | networks, Federal,     |         |         |         |         |
|    | state, local partners  |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Participate in and     |         |         |         |         |
|    | organize VA Pandemic   |         |         |         |         |
|    | Influenza Advisory     |         |         |         |         |
|    | Group                  |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Prepare to use         |         |         |         |         |
|    | emergency plans as     |         |         |         |         |
|    | needed                 |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Plan to acquire        |         |         |         |         |
|    | vaccines, antivirals,  |         |         |         |         |
|    | diagnostics, and       |         |         |         |         |
|    | materiel               |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Develop transparent    |         |         |         |         |
|    | process of allocating  |         |         |         |         |
|    | these and other        |         |         |         |         |
|    | resources in a         |         |         |         |         |
|    | pandemic               |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Assess acquisition of  |         |         |         |         |
|    | mobile clinics or      |         |         |         |         |
|    | modular medical        |         |         |         |         |
|    | stations               |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
| ** |                        |         |         |         |         |
| *2 |                        |         |         |         |         |
| .5 |                        |         |         |         |         |
| D  |                        |         |         |         |         |
| ev |                        |         |         |         |         |
| el |                        |         |         |         |         |
| op |                        |         |         |         |         |
| &  |                        |         |         |         |         |
| C  |                        |         |         |         |         |
| on |                        |         |         |         |         |
| du |                        |         |         |         |         |
| ct |                        |         |         |         |         |
| Ta |                        |         |         |         |         |
| bl |                        |         |         |         |         |
| et |                        |         |         |         |         |
| op |                        |         |         |         |         |
| Ex |                        |         |         |         |         |
| er |                        |         |         |         |         |
| ci |                        |         |         |         |         |
| se |                        |         |         |         |         |
| s* |                        |         |         |         |         |
| ** |                        |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Practice coordination  |         |         |         |         |
|    | within VA and with     |         |         |         |         |
|    | Federal, state, local  |         |         |         |         |
|    | and tribal             |         |         |         |         |
|    | organizations          |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Clarify/identify roles |         |         |         |         |
|    | and responsibilities   |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+
|    | Identify strengths &   |         |         |         |         |
|    | areas of improvement   |         |         |         |         |
+----+------------------------+---------+---------+---------+---------+

+----+------------------------+------+----------+-----------+---------+
| *  |                        |      |          |           |         |
| *P |                        |      |          |           |         |
| re |                        |      |          |           |         |
| pa |                        |      |          |           |         |
| ri |                        |      |          |           |         |
| ng |                        |      |          |           |         |
| f  |                        |      |          |           |         |
| or |                        |      |          |           |         |
| Pa |                        |      |          |           |         |
| nd |                        |      |          |           |         |
| em |                        |      |          |           |         |
| ic |                        |      |          |           |         |
| In |                        |      |          |           |         |
| fl |                        |      |          |           |         |
| ue |                        |      |          |           |         |
| nz |                        |      |          |           |         |
| a: |                        |      |          |           |         |
| ** |                        |      |          |           |         |
|    |                        |      |          |           |         |
| *  |                        |      |          |           |         |
| *V |                        |      |          |           |         |
| HA |                        |      |          |           |         |
| Fa |                        |      |          |           |         |
| ci |                        |      |          |           |         |
| li |                        |      |          |           |         |
| ty |                        |      |          |           |         |
| Ac |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| Gr |                        |      |          |           |         |
| id |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+====+========================+======+==========+===========+=========+
| *  | **Preparation Action** | *    | **Res    | **C       | **Com   |
| *S |                        | *Res | ponsible | ompletion | pletion |
| ec |                        | pons | Person** | Date      | Date    |
| ti |                        | ible |          | (P        | (Ac     |
| on |                        | Offi |          | lanned)** | tual)** |
| ** |                        | ce** |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .1 |                        |      |          |           |         |
| Fa |                        |      |          |           |         |
| ci |                        |      |          |           |         |
| li |                        |      |          |           |         |
| ty |                        |      |          |           |         |
| Pa |                        |      |          |           |         |
| nd |                        |      |          |           |         |
| em |                        |      |          |           |         |
| ic |                        |      |          |           |         |
| I  |                        |      |          |           |         |
| nf |                        |      |          |           |         |
| lu |                        |      |          |           |         |
| en |                        |      |          |           |         |
| za |                        |      |          |           |         |
| Pl |                        |      |          |           |         |
| an |                        |      |          |           |         |
| s* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop and test plans |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Participate in         |      |          |           |         |
|    | state/local drills     |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Adapt sample SOP for   |      |          |           |         |
|    | use during a pandemic  |      |          |           |         |
|    | (see [Appendix         |      |          |           |         |
|    | D-2](#D2))             |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| W  |                        |      |          |           |         |
| or |                        |      |          |           |         |
| kf |                        |      |          |           |         |
| or |                        |      |          |           |         |
| ce |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify essential     |      |          |           |         |
|    | functions              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Provide education      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify provider      |      |          |           |         |
|    | skill sets             |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Recruit & credential   |      |          |           |         |
|    | non-VA providers       |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Create staff &         |      |          |           |         |
|    | volunteer tracking     |      |          |           |         |
|    | system                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify staff able to |      |          |           |         |
|    | work using respirators |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Name & create a        |      |          |           |         |
|    | Pandemic Response Team |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify child care,   |      |          |           |         |
|    | home support           |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| Ph |                        |      |          |           |         |
| ys |                        |      |          |           |         |
| ic |                        |      |          |           |         |
| al |                        |      |          |           |         |
| Si |                        |      |          |           |         |
| te |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop plans to free  |      |          |           |         |
|    | clinical space         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify space for new |      |          |           |         |
|    | separate waiting and   |      |          |           |         |
|    | emergency room areas   |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Consider reactivating  |      |          |           |         |
|    | closed space or        |      |          |           |         |
|    | buildings              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Map patient flow to    |      |          |           |         |
|    | plan use of restricted |      |          |           |         |
|    | areas                  |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify and develop   |      |          |           |         |
|    | plans for alternative  |      |          |           |         |
|    | usable space           |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Assess building &      |      |          |           |         |
|    | engineering systems    |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan locations of hand |      |          |           |         |
|    | cleaning stations      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify space & plan  |      |          |           |         |
|    | for cohorting of       |      |          |           |         |
|    | infected patients      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for               |      |          |           |         |
|    | transportation of      |      |          |           |         |
|    | staff & patients       |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for management of |      |          |           |         |
|    | fatalities             |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .4 |                        |      |          |           |         |
| I  |                        |      |          |           |         |
| nf |                        |      |          |           |         |
| ec |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| C  |                        |      |          |           |         |
| on |                        |      |          |           |         |
| tr |                        |      |          |           |         |
| ol |                        |      |          |           |         |
| &  |                        |      |          |           |         |
| P  |                        |      |          |           |         |
| re |                        |      |          |           |         |
| ca |                        |      |          |           |         |
| ut |                        |      |          |           |         |
| io |                        |      |          |           |         |
| ns |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Ensure ongoing         |      |          |           |         |
|    | employee education     |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Establish & maintain   |      |          |           |         |
|    | seasonal influenza     |      |          |           |         |
|    | vaccinations           |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Heighten institutional |      |          |           |         |
|    | surveillance for       |      |          |           |         |
|    | influenza              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan to educate staff  |      |          |           |         |
|    | re symptoms and        |      |          |           |         |
|    | develop call-in system |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Work with HR on        |      |          |           |         |
|    | authorized absences    |      |          |           |         |
|    | and other leave        |      |          |           |         |
|    | policies               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop protocols to   |      |          |           |         |
|    | track & manage sick    |      |          |           |         |
|    | staff                  |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop criteria for   |      |          |           |         |
|    | limiting visitor       |      |          |           |         |
|    | access.                |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Create strategy for    |      |          |           |         |
|    | supply maintenance     |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Ensure adequate        |      |          |           |         |
|    | personal protective    |      |          |           |         |
|    | equipment and hand     |      |          |           |         |
|    | hygiene supplies       |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .5 |                        |      |          |           |         |
| Co |                        |      |          |           |         |
| un |                        |      |          |           |         |
| te |                        |      |          |           |         |
| rm |                        |      |          |           |         |
| ea |                        |      |          |           |         |
| su |                        |      |          |           |         |
| re |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Use established        |      |          |           |         |
|    | acquisition and        |      |          |           |         |
|    | contracting systems or |      |          |           |         |
|    | the NAC                |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for vaccine       |      |          |           |         |
|    | administration         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for antiviral     |      |          |           |         |
|    | acquisition &          |      |          |           |         |
|    | distribution           |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for lab &         |      |          |           |         |
|    | diagnostic resources   |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .6 |                        |      |          |           |         |
| M  |                        |      |          |           |         |
| ed |                        |      |          |           |         |
| ic |                        |      |          |           |         |
| al |                        |      |          |           |         |
| Ma |                        |      |          |           |         |
| te |                        |      |          |           |         |
| ri |                        |      |          |           |         |
| el |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify all           |      |          |           |         |
|    | resources, supplies &  |      |          |           |         |
|    | equipment needed to    |      |          |           |         |
|    | treat infected         |      |          |           |         |
|    | patients               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Obtain & stockpile     |      |          |           |         |
|    | durable & consumable   |      |          |           |         |
|    | supplies               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify systems for   |      |          |           |         |
|    | how/where to store     |      |          |           |         |
|    | supplies               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Evaluate existing      |      |          |           |         |
|    | contracts for          |      |          |           |         |
|    | supplies, enhance if   |      |          |           |         |
|    | necessary              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify security      |      |          |           |         |
|    | issues                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Assess transportation  |      |          |           |         |
|    | routes for supplies    |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop distribution   |      |          |           |         |
|    | plan for supplies      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Participate in table   |      |          |           |         |
|    | top exercises on       |      |          |           |         |
|    | supply management      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .7 |                        |      |          |           |         |
| He |                        |      |          |           |         |
| al |                        |      |          |           |         |
| th |                        |      |          |           |         |
| Ca |                        |      |          |           |         |
| re |                        |      |          |           |         |
| De |                        |      |          |           |         |
| li |                        |      |          |           |         |
| ve |                        |      |          |           |         |
| ry |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Prepare and ready the  |      |          |           |         |
|    | Pandemic Response Team |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Know response &        |      |          |           |         |
|    | "trigger" for first    |      |          |           |         |
|    | case                   |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Estimate potential     |      |          |           |         |
|    | surge in demand        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop triage systems |      |          |           |         |
|    | for care delivery      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify separate      |      |          |           |         |
|    | waiting areas for the  |      |          |           |         |
|    | symptomatic            |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for isolation     |      |          |           |         |
|    | rooms, intensive care  |      |          |           |         |
|    | & assisted ventilation |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for novel care    |      |          |           |         |
|    | delivery strategies    |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .8 |                        |      |          |           |         |
| S  |                        |      |          |           |         |
| up |                        |      |          |           |         |
| po |                        |      |          |           |         |
| rt |                        |      |          |           |         |
| f  |                        |      |          |           |         |
| or |                        |      |          |           |         |
| a  |                        |      |          |           |         |
| nd |                        |      |          |           |         |
| Ma |                        |      |          |           |         |
| na |                        |      |          |           |         |
| ge |                        |      |          |           |         |
| me |                        |      |          |           |         |
| nt |                        |      |          |           |         |
| of |                        |      |          |           |         |
| E  |                        |      |          |           |         |
| xp |                        |      |          |           |         |
| os |                        |      |          |           |         |
| ed |                        |      |          |           |         |
| &  |                        |      |          |           |         |
| I  |                        |      |          |           |         |
| ll |                        |      |          |           |         |
| St |                        |      |          |           |         |
| af |                        |      |          |           |         |
| f* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan provisions to     |      |          |           |         |
|    | protect staff          |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for treatment of  |      |          |           |         |
|    | staff                  |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Create surveillance &  |      |          |           |         |
|    | triage systems         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify lab           |      |          |           |         |
|    | diagnostic systems     |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Create lab reporting & |      |          |           |         |
|    | disclosure system      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop plans for      |      |          |           |         |
|    | excluding staff from   |      |          |           |         |
|    | work based on health   |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan possible          |      |          |           |         |
|    | provisions for staff's |      |          |           |         |
|    | family members in      |      |          |           |         |
|    | order to keep staff at |      |          |           |         |
|    | work in an emergency,  |      |          |           |         |
|    | depending on           |      |          |           |         |
|    | availability of        |      |          |           |         |
|    | equipment, supplies,   |      |          |           |         |
|    | and medications and on |      |          |           |         |
|    | responsibilities and   |      |          |           |         |
|    | assignments of         |      |          |           |         |
|    | facility under the     |      |          |           |         |
|    | National Response Plan |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .9 |                        |      |          |           |         |
| Me |                        |      |          |           |         |
| nt |                        |      |          |           |         |
| al |                        |      |          |           |         |
| He |                        |      |          |           |         |
| al |                        |      |          |           |         |
| th |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan resources for     |      |          |           |         |
|    | increase in services   |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan consultation      |      |          |           |         |
|    | processes              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| *  |                        |      |          |           |         |
| ** |                        |      |          |           |         |
| 2. |                        |      |          |           |         |
| 2. |                        |      |          |           |         |
| 3. |                        |      |          |           |         |
| 10 |                        |      |          |           |         |
| Su |                        |      |          |           |         |
| rv |                        |      |          |           |         |
| ei |                        |      |          |           |         |
| ll |                        |      |          |           |         |
| an |                        |      |          |           |         |
| ce |                        |      |          |           |         |
| a  |                        |      |          |           |         |
| nd |                        |      |          |           |         |
| R  |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| or |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| ng |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for use of        |      |          |           |         |
|    | available diagnostics  |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan to use            |      |          |           |         |
|    | established reporting  |      |          |           |         |
|    | mechanisms             |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan to collaborate    |      |          |           |         |
|    | with state and local   |      |          |           |         |
|    | health departments     |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| *  |                        |      |          |           |         |
| ** |                        |      |          |           |         |
| 2. |                        |      |          |           |         |
| 2. |                        |      |          |           |         |
| 3. |                        |      |          |           |         |
| 11 |                        |      |          |           |         |
| Se |                        |      |          |           |         |
| cu |                        |      |          |           |         |
| ri |                        |      |          |           |         |
| ty |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for security of   |      |          |           |         |
|    | facilities to prevent  |      |          |           |         |
|    | unrest and assist with |      |          |           |         |
|    | flow of crowds         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Review local support   |      |          |           |         |
|    | agreements             |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Educate on medical     |      |          |           |         |
|    | procedures, especially |      |          |           |         |
|    | use of personal        |      |          |           |         |
|    | protective equipment   |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| *  |                        |      |          |           |         |
| ** |                        |      |          |           |         |
| 2. |                        |      |          |           |         |
| 2. |                        |      |          |           |         |
| 3. |                        |      |          |           |         |
| 12 |                        |      |          |           |         |
| Co |                        |      |          |           |         |
| mm |                        |      |          |           |         |
| un |                        |      |          |           |         |
| ic |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| ns |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Provide information &  |      |          |           |         |
|    | education on pandemic- |      |          |           |         |
|    | related issues for     |      |          |           |         |
|    | stakeholders           |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Establish              |      |          |           |         |
|    | communication plans    |      |          |           |         |
|    | for use before and     |      |          |           |         |
|    | during a pandemic      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop information on |      |          |           |         |
|    | the Plan, roles,       |      |          |           |         |
|    | responsibilities,      |      |          |           |         |
|    | pandemic influenza,    |      |          |           |         |
|    | its mitigation, local  |      |          |           |         |
|    | resources              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify stakeholders  |      |          |           |         |
|    | in and out of VA       |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Engage in dialogue     |      |          |           |         |
|    | where possible         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan streamlined       |      |          |           |         |
|    | information approval   |      |          |           |         |
|    | process for            |      |          |           |         |
|    | emergencies            |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Identify and train     |      |          |           |         |
|    | spokespersons          |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop information    |      |          |           |         |
|    | templates              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Update contact lists   |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Expand emergency       |      |          |           |         |
|    | communications         |      |          |           |         |
|    | capabilities           |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *O |                        |      |          |           |         |
| th |                        |      |          |           |         |
| er |                        |      |          |           |         |
| :* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Other:                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Other:                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Other:                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+

+----+------------------------+------+----------+-----------+---------+
| *  |                        |      |          |           |         |
| *P |                        |      |          |           |         |
| re |                        |      |          |           |         |
| pa |                        |      |          |           |         |
| ri |                        |      |          |           |         |
| ng |                        |      |          |           |         |
| f  |                        |      |          |           |         |
| or |                        |      |          |           |         |
| Pa |                        |      |          |           |         |
| nd |                        |      |          |           |         |
| em |                        |      |          |           |         |
| ic |                        |      |          |           |         |
| In |                        |      |          |           |         |
| fl |                        |      |          |           |         |
| ue |                        |      |          |           |         |
| nz |                        |      |          |           |         |
| a: |                        |      |          |           |         |
| ** |                        |      |          |           |         |
|    |                        |      |          |           |         |
| *  |                        |      |          |           |         |
| *V |                        |      |          |           |         |
| BA |                        |      |          |           |         |
| Ac |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| Gr |                        |      |          |           |         |
| id |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+====+========================+======+==========+===========+=========+
| *  | **Preparation Action** | *    | **Res    | **C       | **Com   |
| *S |                        | *Res | ponsible | ompletion | pletion |
| ec |                        | pons | Person** | Date      | Date    |
| ti |                        | ible |          | (P        | (Ac     |
| on |                        | Offi |          | lanned)** | tual)** |
| ** |                        | ce** |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| Co |                        |      |          |           |         |
| or |                        |      |          |           |         |
| di |                        |      |          |           |         |
| na |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Be familiar with       |      |          |           |         |
|    | Continuity of          |      |          |           |         |
|    | Operations Plans       |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Review how all         |      |          |           |         |
|    | operations will be     |      |          |           |         |
|    | affected               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Be represented on the  |      |          |           |         |
|    | VA Pandemic Influenza  |      |          |           |         |
|    | Advisory Group         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .1 |                        |      |          |           |         |
| Cr |                        |      |          |           |         |
| ea |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| of |                        |      |          |           |         |
| Pa |                        |      |          |           |         |
| nd |                        |      |          |           |         |
| em |                        |      |          |           |         |
| ic |                        |      |          |           |         |
| I  |                        |      |          |           |         |
| nf |                        |      |          |           |         |
| lu |                        |      |          |           |         |
| en |                        |      |          |           |         |
| za |                        |      |          |           |         |
| Pl |                        |      |          |           |         |
| an |                        |      |          |           |         |
| s* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for operations    |      |          |           |         |
|    | under altered work     |      |          |           |         |
|    | conditions             |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
| W  |                        |      |          |           |         |
| or |                        |      |          |           |         |
| kf |                        |      |          |           |         |
| or |                        |      |          |           |         |
| ce |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan to provide PPE,   |      |          |           |         |
|    | hand hygiene supplies, |      |          |           |         |
|    | vaccine, and antiviral |      |          |           |         |
|    | medications            |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Prepare policies to    |      |          |           |         |
|    | cover a range of       |      |          |           |         |
|    | staffing issues        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Provide staff          |      |          |           |         |
|    | education              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan procedures for    |      |          |           |         |
|    | temporary office       |      |          |           |         |
|    | closings               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| I  |                        |      |          |           |         |
| nf |                        |      |          |           |         |
| ec |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| C  |                        |      |          |           |         |
| on |                        |      |          |           |         |
| tr |                        |      |          |           |         |
| ol |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Provide education      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop protocols to   |      |          |           |         |
|    | track & manage sick    |      |          |           |         |
|    | staff                  |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .4 |                        |      |          |           |         |
| Se |                        |      |          |           |         |
| cu |                        |      |          |           |         |
| ri |                        |      |          |           |         |
| ty |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Educate security on    |      |          |           |         |
|    | pandemic influenza and |      |          |           |         |
|    | the use of PPE         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .5 |                        |      |          |           |         |
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| on |                        |      |          |           |         |
| s* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop a              |      |          |           |         |
|    | communications plan    |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan alternate         |      |          |           |         |
|    | pathways of            |      |          |           |         |
|    | communications for use |      |          |           |         |
|    | during a pandemic      |      |          |           |         |
|    | outbreak               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Other:                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Other:                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+

+----+------------------------+------+----------+-----------+---------+
| *  |                        |      |          |           |         |
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| pa |                        |      |          |           |         |
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| id |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+====+========================+======+==========+===========+=========+
| *  | **Preparation Action** | *    | **Res    | **C       | **Com   |
| *S |                        | *Res | ponsible | ompletion | pletion |
| ec |                        | pons | Person** | Date      | Date    |
| ti |                        | ible |          | (P        | (Ac     |
| on |                        | Offi |          | lanned)** | tual)** |
| ** |                        | ce** |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
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| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Be familiar with       |      |          |           |         |
|    | Continuity of          |      |          |           |         |
|    | Operations Plans       |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Review how all         |      |          |           |         |
|    | operations will be     |      |          |           |         |
|    | affected               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Be represented on the  |      |          |           |         |
|    | VA Pandemic Influenza  |      |          |           |         |
|    | Advisory Group         |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .4 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .1 |                        |      |          |           |         |
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| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| of |                        |      |          |           |         |
| Pa |                        |      |          |           |         |
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| em |                        |      |          |           |         |
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| nf |                        |      |          |           |         |
| lu |                        |      |          |           |         |
| en |                        |      |          |           |         |
| za |                        |      |          |           |         |
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| an |                        |      |          |           |         |
| s* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan for operations    |      |          |           |         |
|    | under altered work     |      |          |           |         |
|    | conditions             |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .4 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .2 |                        |      |          |           |         |
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| or |                        |      |          |           |         |
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| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan to provide PPE,   |      |          |           |         |
|    | hand hygiene supplies, |      |          |           |         |
|    | vaccine, and antiviral |      |          |           |         |
|    | medications            |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Prepare policies to    |      |          |           |         |
|    | cover a range of       |      |          |           |         |
|    | staffing issues        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Provide staff          |      |          |           |         |
|    | education              |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan procedures for    |      |          |           |         |
|    | temporary office and   |      |          |           |         |
|    | cemetery closings      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .4 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
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| ec |                        |      |          |           |         |
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| on |                        |      |          |           |         |
| tr |                        |      |          |           |         |
| ol |                        |      |          |           |         |
| Pr |                        |      |          |           |         |
| ep |                        |      |          |           |         |
| ar |                        |      |          |           |         |
| at |                        |      |          |           |         |
| io |                        |      |          |           |         |
| n* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Provide education      |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop protocols to   |      |          |           |         |
|    | track & manage sick    |      |          |           |         |
|    | staff                  |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
| ** |                        |      |          |           |         |
| *2 |                        |      |          |           |         |
| .4 |                        |      |          |           |         |
| .3 |                        |      |          |           |         |
| .4 |                        |      |          |           |         |
| C  |                        |      |          |           |         |
| om |                        |      |          |           |         |
| mu |                        |      |          |           |         |
| ni |                        |      |          |           |         |
| ca |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| P  |                        |      |          |           |         |
| re |                        |      |          |           |         |
| pa |                        |      |          |           |         |
| ra |                        |      |          |           |         |
| ti |                        |      |          |           |         |
| on |                        |      |          |           |         |
| s* |                        |      |          |           |         |
| ** |                        |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Develop a              |      |          |           |         |
|    | communications plan    |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Plan alternate         |      |          |           |         |
|    | pathways of            |      |          |           |         |
|    | communications for use |      |          |           |         |
|    | during a pandemic      |      |          |           |         |
|    | outbreak               |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Other:                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+
|    | Other:                 |      |          |           |         |
+----+------------------------+------+----------+-----------+---------+

[]{#__RefHeading___Toc130728417 .anchor}Appendix D-2:
[SAMPLE]{.underline} EMERGENCY MANAGEMENT PROGRAM STANDARD OPERATING
PROCEDURE (SOP)

[]{#D2 .anchor}***PANDEMIC INFLUENZA AFFECTING A VA HEALTH CARE
FACILITY***

*(Modify for your facility)*

Emergency Management Program Guidebook Department of Veterans Affairs

**THE DEPARTMENT OF VETERANS AFFAIRS**

**MEDICAL CENTER**

**(LOCATION)**

**EMERGENCY MANAGEMENT PROGRAM (DATE)**

**STANDARD OPERATING PROCEDURE NO. ( )**

**SUBJECT**: VA Health Care Facility's Preparation and Response to an
Influenza Pandemic

***Description of the Threat/Event.***

a.  *Agent.* A pandemic occurs when a new strain of influenza virus
    emerges that has the ability to infect and be passed between humans.
    Because humans would have little immunity to the new virus, a
    worldwide epidemic, or pandemic, can ensue. Influenza viruses have
    threatened the health of human populations for centuries. The
    diversity and propensity for of influenza viruses for mutation have
    thwarted efforts to develop both a universal vaccine and highly
    effective antiviral drugs. As a result, and despite annual
    vaccination programs and modern medical technology, even seasonal
    influenza in the United States results in approximately 36,000
    deaths and 226,000 hospitalizations each year. A pandemic strain of
    influenza could cause many-fold more. Transmission of influenza is
    aided by the fact that infected people may shed virus and spread the
    infection for one-half to one day *before* symptoms begin.

b.  *Clinical Disease***.** Symptoms of influenza typically begin 2 days
    after exposure, often starting with a sudden onset of fever, severe
    fatigue or muscle pain, sore throat, and a dry cough. Uncomplicated
    seasonal influenza commonly leads to three to five days of acute
    illness, including fever and prostration, leaving the sufferer
    feeling weakened and with a residual cough for two or more weeks
    longer. A new strain may present a different clinical course and be
    much more serious, causing severe morbidity and mortality from
    influenza pneumonia or pneumonitis and secondary bacterial
    infections.

c.  *Public Health Response.* Public health measures to slow or stop a
    pandemic influenza will likely include a number of actions that will
    have range of success. A monovalent influenza vaccine made for the
    specific pandemic strain will be manufactured, but this will take
    several months. An antiviral medication, oseltamivir, that can be
    given to exposed persons to prevent illness and help limit
    transmission is available but supplies are limited and manufacturing
    is a complex process. Oseltamivir may be effective against the H5N1
    avian influenza that has infected humans in Asia and Europe; VA
    holds a 500,000 treatment course stockpile of oseltamivir. Other
    public health measures include commonsense actions, like hand
    washing, respiratory hygiene, staying home when sick, and using
    telework or telecommuting options when able. Health care facility
    actions involve isolating the sick, having staff wear appropriate
    personal protective equipment (PPE), and screening for influenza
    illness or exposure before permitting entry to a facility.
    Community, regional, and nationally-mandated measures may include
    declaration of snow days, postponing of large public gatherings,
    quarantine of the exposed, and restrictions on travel.

***Impact on Mission Critical Systems.***

-   An influenza pandemic can quickly overwhelm a VA medical center's or
    community-based outpatient clinic's normal capacity to provide
    timely and accessible medical care. Because of the ease with which
    influenza is transmitted, health care facilities can quickly become
    sites of intensive exposure for staff and non-infected patients.
    Breaks in procedure or unanticipated exposures may overwhelm a whole
    Medical Center, for example, by exposing personnel and requiring
    quarantine of the Medical Center. For this reason it is incumbent
    that VHA facilities prepare for the possibility of an influenza
    pandemic.

-   An influenza pandemic can quickly overwhelm a hospital's or CBOC's
    mission critical systems, causing such problems as

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-   Staffing shortages from community quarantine and competing family
    interests

-   Depleted supplies of vaccines and antivirals

-   Stretched bed capacity and operational space required for patient
    care or quarantine

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-   A pandemic, by definition, will be a widespread---even
    national---event, so close coordination and cooperation with local,
    county, state public health agencies; and private sector health care
    facilities will be necessary and vital. It will also be necessary
    for VA medical centers to anticipate VA's mission to back up the
    Department of Defense (and provide care to designated members of the
    military) and VA's responsibilities to the National Response Plan
    (and provide care and resources for care to non-enrolled veterans
    and non-veterans).

***Operating Units and Key Personnel with Responsibility to Manage this
Threat.***

-   *Facility Director-*Responsible for assuring the organization
    implements the necessary preparatory measures for a potential
    influenza pandemic. The Director is also responsible for initiating
    the organization's disaster plan.

-   *Infection Control Team/Epidemiology* -- Key role in: tracking
    potential and confirmed cases; infection control management of
    patients using airborne precautions (private room, negative airflow,
    N95 respirator use by staff) or, when the Medical Center is
    overwhelmed, using droplet precautions and cohorting (isolation of
    infectious patients together, but away from non-exposed); working
    with and reporting to local and state public health; serving as a VA
    medical center information resource on changing public health
    recommendations and on the community/outbreak; assisting with
    vaccination decisions affecting staff and patients; advising on mass
    distribution systems for vaccine and antivirals.

-   *Engineering Service* -- Key role in: assessment of negative airflow
    rooms and negative airflow systems; identification of areas suitable
    for cohorting patients both in waiting areas and after
    hospitalization.

-   *Clinical Laboratory* -- Key role in: obtaining and performing
    diagnostic tests for the pandemic strain; knowing availability of
    reference laboratories for diagnosis (like the CDC's Laboratory
    Response Network \[LRN\] or state laboratories); advising on
    specimen collection; safe handling, storage, and shipping of
    specimens.

-   *Safety/Industrial Hygiene* -- Key role in: support of N95
    respirator usage (fit-testing) program.

-   *Police and Security* -- Key role in: crowd control, managing the
    flow of patients and visitors. If the situation warrants, police
    have key role in perimeter control, site access. Police may be
    called upon to protect the supply of influenza vaccines and supplies
    like oseltamivir, vaccine, N95 masks, and surgical or procedure-type
    masks. Perimeter access and site control may pertain to staff, staff
    relatives/family, and patients and require ingress and egress
    control. Site control may include assisting with drive-through
    triage stations or drive-through clinic sites, and mass distribution
    of vaccine and antivirals.

-   *Medical Service* -- Key role in: clinical diagnosis of cases;
    treatment of cases; providing health care advice via telephone;
    staffing innovative care delivery sites, advising/assisting with
    mass delivery of vaccine and antivirals.

-   *Nursing Service* -- Key roles in: staffing and bed support for
    inpatient, outpatient, and innovative care delivery sites; assisting
    with restriction of non-essential personnel from patient rooms
    (i.e., environmental management service, nutrition and food service
    personnel); providing health care advice via telephone; advising/
    assisting with mass delivery of vaccine and antivirals.

-   *Emergency Department* -- Key role in: monitoring incoming patients
    suspected of exposure or disease; making decisions on maintaining
    separate clinical activities.

-   *Pharmacy* -- Key role in managing the supply of vaccines and
    antivirals.

-   *Employee/Occupational Health* -- Key role in: employee
    vaccination/clinical care (identification of vaccine
    contraindications), information flow/risk communication to staff;
    advising/assisting with advice to staff about their ability to work,
    maintaining health care records for staff, including immune status..

-   *EMS/Safety* -- Key role in: advising on cleaning of rooms;
    equipment; communication of advice on cleaning measures.

-   *Volunteer Service* -- Key role in: coordinating volunteers
    (existing and community members) willing to assist. Voluntary also
    should assist in establishing an area for child care and respite for
    health care facility staff unable to leave the facility.

-   *Public Affairs* -- Key role in: keeping staff and patients
    informed, updating Web site, working with VSOs, media

***Mitigation/Preparedness Activities of the Threat/Event.***

The mode(s) of transmission, degree of morbidity and mortality, and
amount of societal disruption that a pandemic influenza might cause will
be uncertain until the specific influenza strain is identified and
observed. From applying what is known about seasonal influenza, it might
be expected that a pandemic influenza would follow some of the same
transmission patterns: ready transmission by respiratory droplets (and
perhaps by aerosolized particles) from person to person; shedding and
transmission of virus before persons are ill, a short incubation period
of approximately 2 days, and thus a potential doubling of cases every 2
to 3 days.

a.  Hazard Reduction.

-   Notification/risk communications plan.

-   Activation of hospital emergency plan.

-   Perimeter control potential: need for increased security staffing,
    heightened security requirements for access control.

-   Building systems assessment for cohorting potential and confirmed
    patients.

-   Implementation of measures to provide added capacity for a potential
    surge of inpatient and ambulatory care.

-   Exposure control/Infection control: Airborne Infection Isolation and
    Contact Precautions are advised for a potentially lethal strain of
    pandemic influenza, in order to maximally protect staff. Patients
    should be placed in room with negative airflow and HEPA exhaust; and
    should wear surgical masks when transported through the Medical
    Center. If facilities are unable to exercise this degree of
    isolation, cohorting of patients in common, exposed areas with HVAC
    isolation and exhaust (if possible) and use of respiratory droplet
    precautions by staff are advised.

-   Separation of new, unexposed patients from potential pandemic
    influenza cases.

-   Use of Airborne Infection Isolation and Contact Precautions, if
    possible, or Droplet Precautions.

-   Visitor restriction policies.

-   If necessary, control of the perimeter: need for increased security
    staffing, heightened security requirements for access control.

d.  Preparedness Strategies and Resources.

-   Establishment of Pandemic Response Team that will be prepared to
    work during a pandemic.

-   Vaccination (if available).

-   Antiviral medications prescribed to prevent illness in the exposed
    or unvaccinated (if available).

-   Public health measures of hand washing, respiratory hygiene, staying
    home when ill, respecting quarantine, isolation, "snow day" and
    travel, and public gathering limitations

-   Education (on public health measures, infection control guidelines,
    home care, self-triage \[to determine when medical care is
    necessary\]).

-   Plan for Airborne infection Isolation and Contact Precautions for
    all personnel with patient contact.

-   Anticipation of need to manage a large number of fatalities.

***Response/Recovery from the Event/Threat.***

a.  Hazard Control and Monitoring Strategies.

-   First case identified at a VAMC.

    1.  Should be immediately reported: any suspected case(s) of
        pandemic influenza to Infection Control for confirmation.
        Infection Control would then brief the Chief of Medicine and the
        Chief of Staff. If case is confirmed, the Director, Safety
        Officer, Police and Occupational Health would be notified (this
        will most likely occur when a known pandemic virus is
        circulating elsewhere in the world and a VA medical center
        suspects it has the first US or regional case).

    2.  Activate Infection Control Team for initiation of
        patient/exposed staff tracking system, patient/staff educational
        information.

    3.  Clear all patients and employees from the vicinity of the
        suspected case.

    4.  Document details of incident and names of all persons within the
        immediate "at risk" area (i.e., who have become contacts and may
        require quarantine, antiviral medications).

    5.  Contact local/state public health contacts for diagnostic sample
        collection and shipping instructions.

    6.  Contact local/state public health, Pharmacy Benefits Management,
        or VACO Office of Public Health and Environmental Hazards to
        obtain vaccine, depending on guidance provided at the time (if
        pandemic vaccine is available).

    7.  Contact Pharmacy Benefits Management, or VACO Office of Public
        Health and Environmental Hazards for access to VA's oseltamivir
        (antiviral medication) stockpile.

    8.  Activate Infection Control Team for initiation of
        patient/exposed employee tracking system, patient/employee
        educational information.

    9.  Initiate antiviral medication for all potential exposed persons
        as appropriate after discussion with local/state public health,
        if appropriate.

    10. Notify internal personnel, as appropriate, including Chief of
        Staff, Health Care Providers, Nursing Service, Pharmacy,
        Microbiology Laboratory, and Engineering for immediate inventory
        of critical resources.

    11. Immediately assess potential impact of actual event on
        mission-critical systems to include staffing, critical supplies,
        operational space, potential for patient and staff exposures and
        HVAC system.

-   Cases already identified among existing enrolled veterans.

1.  VA personnel must maintain communications and awareness with local
    and state public health of progression of the pandemic in the
    community. Information must be shared with internal VA personnel,
    including VAMC Director, Chief of Staff, Police and Security, Chief
    Nurse Executive, Safety Officer/Industrial Hygienist,
    Employee/Occupational Health, Emergency Room Personnel, Health Care
    Providers, Pharmacy, and Microbiology Laboratory for immediate
    inventory of critical resources.

    A.  Perform active surveillance for pandemic influenza appearing
        among hospitalized inpatients, or outpatients according to the
        prevailing case definition.

    B.  Notify the Clinical Microbiology Laboratory of potential for use
        of rapid diagnostic tests or sending of specimens to reference
        laboratories.

    C.  Immediately assess potential impact of reported community events
        on mission critical systems to include staffing, critical
        supplies and operational space.

    D.  Await follow-up information from local authorities and prepare
        for potential presentation of patients.

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e.  Resource Issues.

-   Staffing needs will be monitored and addressed by Chief of Staff,
    Chief of Nursing, VAMC Director, and other involved Service Chiefs.

-   Critical Supplies -- Vaccine (if available at the time) will likely
    be distributed through state health departments or through VA
    Central Office Pharmacy Benefits Management Strategic Healthcare
    Group. Additional timely information about vaccine may be expected
    from VACO. Other critical supplies to assess in the event of
    pandemic influenza include respiratory support equipment (oxygen,
    and oxygen-delivery equipment, ventilators), personal protective
    equipment, antimicrobial soap and alcohol-based hand cleaners,
    antibiotics to treat secondary bacterial pneumonias, morgue kits.

-   Resource Allocation -- Develop criteria and transparent processes
    for allocation decisions regarding resources that may not be
    available in sufficient quantities during a pandemic: antivirals,
    respirators, vaccines, staff.

-   Space Management -- Assess negative airflow room and cohorting bed
    and space availability; refrigerated space to store bodies.

-   Emergency Room capabilities, acute care clinic capabilities and
    current/projected bed availability should be immediately assessed.

-   Exposed patients and staff might expect short-term quarantine on
    site or relocation to alternate care sites or alternate health care
    facilities.

-   Consideration should be made to providing pandemic influenza
    countermeasures that are in short supply to staff members' families
    (vaccine, antivirals, personal protective equipment), depending on
    availability and on the facility's responsibilities and assignments
    under the National Response Plan. If staff members' families can be
    protected, staff will be more available to take care of patients.

f.  Clinical Response.

-   Treatment protocols will be based upon prevailing knowledge of the
    pandemic influenza strain and will include supportive care
    (respiratory support, hemodynamic support) and use of antivirals.

-   Clinical admission/treatment decisions will be made by the health
    care providers.

-   All quarantine and visitor restriction decisions will be made by the
    VAMC Director based upon recommendations of the Infection Control
    Team or pandemic influenza response team following local/state
    public health guidance and decisions, and advice of regional VA
    counsel, if needed. Such decisions will be proportional to the
    disease impact, necessary, relevant, and applied equitably, and will
    employ the least restrictive means if options are available.

-   All patients treated and evaluated for potential pandemic influenza
    must be reported to the Infection Control Team or designated
    pandemic influenza response team for data-collection.

-   Patient and staff record-keeping must be maintained according to
    usual standards, if possible.

-   The Infection Control Team or designated pandemic influenza response
    team will monitor all potential cases and make appropriate reports
    to the VAMC Director and state and local public health.

**Notes:**

1.  Vaccination of Health Care Providers: Vaccine for a pandemic
    influenza strain will be developed once the strain is known. This
    vaccine will most likely be distributed to states and then to public
    and private medical centers. Changes and updates on vaccine
    availability will be communicated to VISNs and VAMCs from VACO.

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i.  The Infection Control Team, or designated pandemic influenza
    response team, working with the Chief of Staff and VAMC Director
    will notify Health Care Providers when treatment/exposure guidelines
    are updated or as new resources are made available. The Infection
    Control Team can monitor the VA pandemic influenza web sites for
    these updates. Note that VA guidance may differ from CDC guidance.

```{=html}
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```
g.  Recovery Strategies.

-   Periodic critical supply inventories with re-supply or
    supplementation from outside facilities, as needed.

-   Periodic staffing census with workload redistribution, as needed.

-   Close monitoring of patient census and bed status.

-   Monitoring of staff and patient mental health.

**External Notification Procedures.**

a.  *Within VA*. VISN, VACO.

```{=html}
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```
h.  *Other State and Federal Agencies.* Local and State public health
    departments who will notify CDC.

-   OSHA --follow prevailing rules for notification of employee
    fatalities and hospitalizations.

i.  *Community Entities.* Neighboring hospitals, emergency response
    systems (police, firefighters, emergency medical services, 911
    operators).

***Specialized Staff Training.***

-   Health Care Provider Training -- Recognition of clinical syndromes
    associated with influenza, treatment protocols, guidelines for
    personal protective equipment.

-   Infection Control Team Training -- Passive and active surveillance
    systems for monitoring reportable infectious disease pathogens.

-   Safety Specialist/Industrial Hygienist -- N95 respirator usage.

-   Clinical Laboratories -- Diagnostic tests, specimen collection,
    handling, and shipping.

-   Social Work Service -- Introductory training on pandemic influenza,
    risks, treatments, family implications, and follow-up.

-   Police and Security -- Introductory training on pandemic influenza,
    PPE recommendations.

-   Environmental Management Service Personnel -- Introductory training
    on pandemic influenza risks, decontamination of environments,
    bed-clothing management, PPE recommendations.

***References and Further Assistance.***

-   The VA Pandemic Influenza Plan.

```{=html}
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-   The VA Respiratory Infectious Diseases Emergency Plan (an amendment
    to the VHA Emergency Management Guidebook). Available at
    <http://www.publichealth.va.gov/watch/respiratoryID.htm>

```{=html}
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```
-   VHA Under Secretary for Health Influenza Advisories. Available at
    <http://www.publichealth.va.gov/flu/advisory.htm>

-   Local, County, State Health Departments (24/7 contact information
    *[must]{.underline}* be part of your emergency plans for pandemic
    influenza).

-   VA guidance and Web sites on pandemic influenza
    [www.publichealth.va.gov/infectiondontpassiton](http://www.publichealth.va.gov/infectiondontpassiton)

-   [[http://www.publichealth.va.gov/flu/pandemicflu.htm]{.underline}](http://www.publichealth.va.gov/flu/pandemicflu.htm)

-   Federal Web sites on pandemic influenza
    [www.pandemicflu.gov](http://www.pandemicflu.gov/)

-   Phone Numbers.

```{=html}
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```
-   VACO Office of Public Health and Environmental Hazards -
    202-273-8575, 8567

-   VACO Pharmacy Benefits Management - 708-786-7886

    ***Review Date***

(NAME)

Chief, (SERVICE NAME)

Attachment:

Key Activity Management Tool/Structure

[]{#__RefHeading___Toc130728418 .anchor}Appendix D-3*:* REVIEW AND LIST
OF COMMUNICATION PRINCIPLES AND ELEMENTS TO USE BEFORE, DURING, AND
AFTER A PANDEMIC

[]{#D3 .anchor}

***General Communication Principles***

VA communications will be carried out in accordance with existing VA
public affairs policy and guidance and will include the following
principles in communicating before, during, and after the pandemic
period:

-   Aim for maximum disclosure with minimum delay.

-   Be consistent ("speak with one voice") as well as timely, accurate,
    and appropriate.

-   Provide regular and direct information about what is known and not
    known.

-   Keep all key stakeholders informed and engaged: staff, veterans, and
    stakeholders external to VA.

-   Employ multiple channels and formats for information.

-   Be clear and use plain language.

***Emergency Risk Communication Principles***

VA communications will use other principles in addition, particularly
during a response to a pandemic, which are derived from emergency risk
communications practice, such as:

-   Use streamlined approval processes that enable accurate but rapid
    information.

-   Provide information frequently and proactively.

-   Listen to assess understanding, answer questions and concerns, and
    seek input and ideas.

-   Be open and transparent.

-   Seek information on and address rumors, inaccuracies, and
    misperceptions.

-   Minimize stigmatization.

-   Acknowledge anxiety, grief, and stress.

-   Give people things that they can do.

***Stakeholders***

A wide array of individuals and organizations are concerned with VA and
its actions before and during a pandemic. VA communication planning and
actions will take into account as many of these stakeholders as
possible.

[Internal Stakeholders]{.underline}

-   Every VA staff member, including those in

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```
-   Central Office

-   Veterans Health Administration

-   Veterans Benefits Administration (VBA)

-   National Cemetery Administration

-   Veterans Integrated Service Network Offices

-   Medical centers

-   Community based outpatient clinics, nursing homes, domiciliaries

-   Readjustment counseling (vet) centers

-   VBA Area Offices

-   Regional Offices (VBA benefits offices)

-   Memorial Network Offices

-   National cemeteries

```{=html}
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```
-   VA leadership, including the

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```
-   Office of the Secretary and key staff

-   Offices of the Under Secretaries for Health, Benefits, and Memorial
    Affairs and key staff

```{=html}
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```
-   VA clinical staff, including doctors, nurses, and other health care
    providers

-   VA nonclinical staff in health settings

-   VA contract staff

-   Staff in special positions such as residents and interns

-   Volunteers

-   Unions

-   VA chartered advisory committees

-   Telephone operators

-   VA emergency planners

-   VA security and police staff

-   VA Canteen Service

-   VA Franchise Fund/VA Enterprise Centers

-   VA public affairs officers and professional and patient educators
    and trainers

[Veteran Stakeholder Groups]{.underline}

-   Veterans enrolled in VA health care or served by VBA or NCA

-   Veterans in general, from the oldest veterans (World War I) to the
    newest (veterans of Operations Enduring Freedom and Iraqi Freedom)

-   Families of veterans -- parents, children, spouses, significant
    others

-   Veterans Service Organizations -- national, state, and local

-   Veterans Service Officers -- local and state

-   County veteran service officers

[External Stakeholders]{.underline}

-   The White House

-   Congress and Congressional Staffs

-   Other Federal health care systems

```{=html}
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```
-   Indian Health Service

-   Department of Defense/military health care system

-   Bureau of Prisons health care system

```{=html}
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```
-   Other Federal Agencies

```{=html}
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```
-   Department of Health and Human Services, including the Centers for
    Disease Control and Prevention, the National Institutes of Health,
    and other components

-   Department of Defense

-   Department of State

-   Department of Homeland Security

```{=html}
<!-- -->
```
-   State government officials, including health and veterans affairs
    departments, and state legislators

-   Local government officials

-   Indian tribes

-   National Guard units

-   Community public health departments, health facilities, and health
    care providers

-   Private sector health care and community partners

-   Academic affiliates of VA medical centers (i.e., universities)

-   Vendors (pharmaceutical firms, suppliers)

-   VA building tenants and tenant organizations

-   Local law enforcement

-   Local emergency management and response

-   The media -- print, Internet, television, and radio at the
    international, national and local levels

***Channels for Reaching Stakeholders***

VA will use a variety of channels to communicate both before and during
a pandemic to insure that its many concerned stakeholders are reached.
Channels of communication during a pandemic will need to include those
that can be used rapidly and reach people in nontraditional ways. During
a pandemic, traditional channels may work for parts of the country or
community not currently affected by the pandemic and others may work for
parts of the country or community that are affected. Information needed
to access these channels should be up to date (for example, email lists,
phone numbers). Communications channels include:

-   Email (individual as well as Outlook groups)

-   Internet (and VA Intranet from VA computers only)

-   Telephone - hotlines, conference calls, recorded messages for
    incoming calls, recorded messages for outgoing calls, call trees
    (cascades or call down systems)

-   Satellite conferences/videoconferences

-   Meetings -- small to large, including all-employee or "town hall"
    meetings that may involve staff or the community or both

-   Media briefings -- face to face, phone, videoconference

-   Faxes

-   Mailings (of letters, postcards, trifolds, notices)

-   Printed materials (such as brochures, fact sheets, wallet cards,
    pocket cards, flyers, trifolds, posters, notices, tent cards, tray
    liners)

-   Newsletters and magazines

-   Public service announcements (via print, Web, radio, TV)

-   Public address system

-   Closed circuit TV

-   Employee home email and home phone numbers

-   Ham radio system based on collaboration of VA facilities and ham
    radio clubs throughout country

-   Employee email/telephone tree system for each organization and
    facility

-   Commercial radio/TV public service air time

-   Emergency contact call/email list (national and local) -- for
    national and local veteran service organizations, local military
    installations, public safety organizations, public health
    organizations, health facilities outside VA, municipal governments

***Communication Tools/Vehicles***

VA will use a variety of tools that will be employed to describe
pandemic influenza, what individuals can do, and what VA is doing to
prepare, and in the event of a pandemic, to provide this information
plus updates on VA responses and status. Of the list below, tools most
useful in a pandemic will be those that can be used quickly and widely.
Materials and templates that have been prepared in advance will help
speed up the process of providing information. Templates can also help
ensure consistency of messages.

-   Vanguard magazine (4-8 week lead time needed)

-   Hey VA all-employee daily email/intranet messages

-   Earnings and leave statement messages (2 or longer week lead time
    needed)

-   VA Internet --- National VA site and MyHealtheVet

-   VA Intranet

-   VA Knowledge Network satellite TV system programming --- VA News,
    The American Veteran, public service announcements, education
    programs, including those with audience questions and answers

-   VA Content Delivery System (i.e., posted video material on demand)

-   Brochures, posters, fact sheets, trifolds (produced centrally and
    locally and shared via email)

-   Organizational channels

-   Management communications channels: VA headquarter program offices
    and administrations down to and up from regional and local levels
    via conference calls, meetings, newsletters, email

-   Management communications channels at mid-level and local facility
    levels -- newsletters, email, web sites

-   Cross disciplinary communications channels, e.g., for infection
    control professionals, occupational health, public affairs,
    prevention managers via conference calls, meetings, newsletters,
    email

-   Education and training programs - in person, by phone, by
    teleconference, and Web-based

-   Facility level -- town hall meetings (hosted by director with
    involvement of facility and community experts and local veterans,
    media, and community), health fairs, planning meetings,
    participation in local meetings of first responder and health
    organizations communications channels at national, state and local
    levels

-   Veteran services organizations at national state, and local levels
    -- newsletters, Web sites, email, meetings, gatherings, annual and
    other regular conferences and events

-   News media at national and local levels and print, Web-based, TV,
    and radio via briefings, public service ads and announcements

-   VA Canteen Service -- posters, tray liners, etc.

[]{#__RefHeading___Toc130728419 .anchor}Appendix D-4: SUGGESTED
INVENTORY OF DURABLE AND CONSUMABLE SUPPLIES FOR VA HEALTH CARE
FACILITIES DURING A PANDEMIC INFLUENZA

***Durable resources***

-   Mechanical ventilators

-   Manual resuscitators (bag-valve mask)

-   Beds

-   Stretchers/gurneys

-   IV pumps

-   Positive air purifying respirators (PAPRs) or other equivalent
    respirators

***Consumable resources (consider stockpiling a 4-week supply)***

-   Hand hygiene supplies (antimicrobial soap and alcohol-based
    \[\>60%\], waterless hand hygiene gels or foams)

-   Disposable fit-testable N95 respirators

-   Elastomeric respirators with P100 filters

-   Surgical and procedure-type masks

-   Goggles

-   Gowns

-   Gloves

-   Facial tissues

-   Central line kits

-   Morgue packs

-   IV equipment and solutions

-   Syringes and needles for vaccine administration

-   Respiratory care equipment

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```
-   portable oxygen

-   regulators and flow meters

-   oxygen and ventilator tubing, cannulae, masks

-   Endotracheal tubes, various sizes

-   Suction kits

-   Tracheotomy tubes

-   Vacuum gauges for suction and portable suction machines

```{=html}
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```
-   Intensive care unit (ICU) monitoring equipment

***Medications (consider stockpiling a 4-week supply)***

-   Nonsteroidal anti-inflammatory drugs (NSAIDs), pill and liquid forms

-   Acetaminophen (pill, suppository, liquid)

-   Antibiotics (consider ciprofloxacin, levofloxacin po and iv,
    vancomycin, piperacillin/tazobactam, ceftriaxone)

-   Antivirals (oseltamivir)

-   Vaccines (pandemic and seasonal influenza, pneumococcal)

-   Vasopressors

-   Benzodiazepines, propofal

-   Proton pump inhibitors

-   Bronchodilators

Items to consider including in home care kits

-   Thermometers

-   NSAIDs or acetaminophen

-   Cough suppressants

-   Oral re-hydration mix packs

-   Surgical or procedure-type masks for the patient to wear around
    others and for care providers to wear around the patient

-   Printed home care instructions, including VA facility contact
    information and information about symptoms that should prompt the
    patient to see a health care provider

######### Response Tools

[]{#AppGroupE .anchor}Appendix E-1: VA PANDEMIC RESPONSE ACTION GRIDS

Following are several grids that list steps in responding to pandemic
influenza. These reflect the text in Section 3 and provide numbers of
subsections (e.g., 3.1.2 Coordination) for cross reference.

The grids cover:

-   VA Central Office

-   VHA Facilities

-   VBA

-   NCA

These grids provide a snapshot of key actions and enable the user to
note responsible offices and individuals to carry out these steps and
keep records of what was done.

+----+-----------------------+---------+---------+---------+---------+
| ** |                       |         |         |         |         |
| Re |                       |         |         |         |         |
| sp |                       |         |         |         |         |
| on |                       |         |         |         |         |
| di |                       |         |         |         |         |
| ng |                       |         |         |         |         |
| to |                       |         |         |         |         |
| Pa |                       |         |         |         |         |
| nd |                       |         |         |         |         |
| em |                       |         |         |         |         |
| ic |                       |         |         |         |         |
| In |                       |         |         |         |         |
| fl |                       |         |         |         |         |
| ue |                       |         |         |         |         |
| nz |                       |         |         |         |         |
| a: |                       |         |         |         |         |
| ** |                       |         |         |         |         |
|    |                       |         |         |         |         |
| ** |                       |         |         |         |         |
| VA |                       |         |         |         |         |
| C  |                       |         |         |         |         |
| en |                       |         |         |         |         |
| tr |                       |         |         |         |         |
| al |                       |         |         |         |         |
| Of |                       |         |         |         |         |
| fi |                       |         |         |         |         |
| ce |                       |         |         |         |         |
| Ac |                       |         |         |         |         |
| ti |                       |         |         |         |         |
| on |                       |         |         |         |         |
| Gr |                       |         |         |         |         |
| id |                       |         |         |         |         |
| ** |                       |         |         |         |         |
+====+=======================+=========+=========+=========+=========+
| *  | **Response Action**   | **Resp  | **Resp  | **Com   | **Com   |
| *S |                       | onsible | onsible | pletion | pletion |
| ec |                       | O       | P       | Date    | Date    |
| ti |                       | ffice** | erson** | (Pla    | (Ac     |
| on |                       |         |         | nned)** | tual)** |
| ** |                       |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
| ** |                       |         |         |         |         |
| *3 |                       |         |         |         |         |
| .1 |                       |         |         |         |         |
| .2 |                       |         |         |         |         |
| C  |                       |         |         |         |         |
| oo |                       |         |         |         |         |
| rd |                       |         |         |         |         |
| in |                       |         |         |         |         |
| at |                       |         |         |         |         |
| io |                       |         |         |         |         |
| n* |                       |         |         |         |         |
| ** |                       |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Activate a            |         |         |         |         |
|    | coordinated response  |         |         |         |         |
|    | within and outside of |         |         |         |         |
|    | VA                    |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Consult with VA       |         |         |         |         |
|    | Pandemic Influenza    |         |         |         |         |
|    | Advisory Group        |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Put communication     |         |         |         |         |
|    | principles & plans    |         |         |         |         |
|    | into action           |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
| ** |                       |         |         |         |         |
| *3 |                       |         |         |         |         |
| .1 |                       |         |         |         |         |
| .3 |                       |         |         |         |         |
| VA |                       |         |         |         |         |
| C  |                       |         |         |         |         |
| en |                       |         |         |         |         |
| tr |                       |         |         |         |         |
| al |                       |         |         |         |         |
| Of |                       |         |         |         |         |
| fi |                       |         |         |         |         |
| ce |                       |         |         |         |         |
| R  |                       |         |         |         |         |
| es |                       |         |         |         |         |
| po |                       |         |         |         |         |
| ns |                       |         |         |         |         |
| e* |                       |         |         |         |         |
| ** |                       |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Activate plan         |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
| ** |                       |         |         |         |         |
| *3 |                       |         |         |         |         |
| .1 |                       |         |         |         |         |
| .4 |                       |         |         |         |         |
| .1 |                       |         |         |         |         |
| V  |                       |         |         |         |         |
| ig |                       |         |         |         |         |
| il |                       |         |         |         |         |
| an |                       |         |         |         |         |
| ce |                       |         |         |         |         |
| a  |                       |         |         |         |         |
| nd |                       |         |         |         |         |
| n  |                       |         |         |         |         |
| ot |                       |         |         |         |         |
| if |                       |         |         |         |         |
| ic |                       |         |         |         |         |
| at |                       |         |         |         |         |
| io |                       |         |         |         |         |
| n* |                       |         |         |         |         |
| ** |                       |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Be vigilant for       |         |         |         |         |
|    | "trigger" points      |         |         |         |         |
|    | throughout the        |         |         |         |         |
|    | country               |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
| ** |                       |         |         |         |         |
| *3 |                       |         |         |         |         |
| .1 |                       |         |         |         |         |
| .4 |                       |         |         |         |         |
| .2 |                       |         |         |         |         |
| Im |                       |         |         |         |         |
| pl |                       |         |         |         |         |
| em |                       |         |         |         |         |
| en |                       |         |         |         |         |
| ta |                       |         |         |         |         |
| ti |                       |         |         |         |         |
| on |                       |         |         |         |         |
| of |                       |         |         |         |         |
| E  |                       |         |         |         |         |
| me |                       |         |         |         |         |
| rg |                       |         |         |         |         |
| en |                       |         |         |         |         |
| cy |                       |         |         |         |         |
| Pl |                       |         |         |         |         |
| an |                       |         |         |         |         |
| s* |                       |         |         |         |         |
| ** |                       |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Activate emergency    |         |         |         |         |
|    | plans                 |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
| ** |                       |         |         |         |         |
| *3 |                       |         |         |         |         |
| .1 |                       |         |         |         |         |
| .2 |                       |         |         |         |         |
| .3 |                       |         |         |         |         |
| Li |                       |         |         |         |         |
| mi |                       |         |         |         |         |
| ti |                       |         |         |         |         |
| ng |                       |         |         |         |         |
| D  |                       |         |         |         |         |
| is |                       |         |         |         |         |
| ea |                       |         |         |         |         |
| se |                       |         |         |         |         |
| S  |                       |         |         |         |         |
| pr |                       |         |         |         |         |
| ea |                       |         |         |         |         |
| d* |                       |         |         |         |         |
| ** |                       |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Emphasize infection   |         |         |         |         |
|    | control measures such |         |         |         |         |
|    | as those from I:DPIO  |         |         |         |         |
|    | campaign              |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Encourage use of      |         |         |         |         |
|    | local public health   |         |         |         |         |
|    | guidance              |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Distribute vaccine    |         |         |         |         |
|    | and antiviral         |         |         |         |         |
|    | medications           |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
| ** |                       |         |         |         |         |
| *3 |                       |         |         |         |         |
| .5 |                       |         |         |         |         |
| .3 |                       |         |         |         |         |
| .1 |                       |         |         |         |         |
| V  |                       |         |         |         |         |
| A- |                       |         |         |         |         |
| Wi |                       |         |         |         |         |
| de |                       |         |         |         |         |
| Co |                       |         |         |         |         |
| mm |                       |         |         |         |         |
| un |                       |         |         |         |         |
| ic |                       |         |         |         |         |
| at |                       |         |         |         |         |
| io |                       |         |         |         |         |
| n* |                       |         |         |         |         |
| ** |                       |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Post the latest       |         |         |         |         |
|    | information on Web    |         |         |         |         |
|    | sites                 |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Provide regular       |         |         |         |         |
|    | updates to staff,     |         |         |         |         |
|    | veterans, other       |         |         |         |         |
|    | stakeholders by       |         |         |         |         |
|    | multiple vehicles     |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Address rumors and    |         |         |         |         |
|    | false reports         |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Share information     |         |         |         |         |
|    | with Federal, state,  |         |         |         |         |
|    | and local partners    |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Brief Congress, VSOs, |         |         |         |         |
|    | and media             |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+
|    | Ensure facilities can |         |         |         |         |
|    | report important      |         |         |         |         |
|    | information on        |         |         |         |         |
|    | operations to         |         |         |         |         |
|    | stakeholders          |         |         |         |         |
+----+-----------------------+---------+---------+---------+---------+

+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| Re |                       |       |         |          |          |
| sp |                       |       |         |          |          |
| on |                       |       |         |          |          |
| di |                       |       |         |          |          |
| ng |                       |       |         |          |          |
| to |                       |       |         |          |          |
| Pa |                       |       |         |          |          |
| nd |                       |       |         |          |          |
| em |                       |       |         |          |          |
| ic |                       |       |         |          |          |
| In |                       |       |         |          |          |
| fl |                       |       |         |          |          |
| ue |                       |       |         |          |          |
| nz |                       |       |         |          |          |
| a: |                       |       |         |          |          |
| ** |                       |       |         |          |          |
|    |                       |       |         |          |          |
| *  |                       |       |         |          |          |
| *V |                       |       |         |          |          |
| HA |                       |       |         |          |          |
| Fa |                       |       |         |          |          |
| ci |                       |       |         |          |          |
| li |                       |       |         |          |          |
| ty |                       |       |         |          |          |
| Ac |                       |       |         |          |          |
| ti |                       |       |         |          |          |
| on |                       |       |         |          |          |
| Gr |                       |       |         |          |          |
| id |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+====+=======================+=======+=========+==========+==========+
| *  | **VHA Response        | **R   | **Resp  | **Co     | **Co     |
| *S | Action**              | espon | onsible | mpletion | mpletion |
| ec |                       | sible | P       | Date     | Date     |
| ti |                       | Off   | erson** | (Pl      | (A       |
| on |                       | ice** |         | anned)** | ctual)** |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| Co |                       |       |         |          |          |
| or |                       |       |         |          |          |
| di |                       |       |         |          |          |
| na |                       |       |         |          |          |
| ti |                       |       |         |          |          |
| on |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Collaborate on        |       |         |          |          |
|    | information,          |       |         |          |          |
|    | guidance, vaccines,   |       |         |          |          |
|    | antivirals with VISNs |       |         |          |          |
|    | and facilities as     |       |         |          |          |
|    | well as Federal,      |       |         |          |          |
|    | state, and local      |       |         |          |          |
|    | partners              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Act on VA             |       |         |          |          |
|    | Communications        |       |         |          |          |
|    | Principles in         |       |         |          |          |
|    | [Appendix D-3](#D3)   |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .1 |                       |       |         |          |          |
| Su |                       |       |         |          |          |
| rv |                       |       |         |          |          |
| ei |                       |       |         |          |          |
| ll |                       |       |         |          |          |
| an |                       |       |         |          |          |
| ce |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Implement             |       |         |          |          |
|    | surveillance plans    |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Access & use          |       |         |          |          |
|    | provisional CDC case  |       |         |          |          |
|    | definition            |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use recommended       |       |         |          |          |
|    | diagnostics           |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use CDC diagnostic    |       |         |          |          |
|    | and procedure codes   |       |         |          |          |
|    | for surveillance      |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| Re |                       |       |         |          |          |
| fo |                       |       |         |          |          |
| cu |                       |       |         |          |          |
| si |                       |       |         |          |          |
| ng |                       |       |         |          |          |
| P  |                       |       |         |          |          |
| at |                       |       |         |          |          |
| ie |                       |       |         |          |          |
| nt |                       |       |         |          |          |
| Ca |                       |       |         |          |          |
| re |                       |       |         |          |          |
| P  |                       |       |         |          |          |
| ri |                       |       |         |          |          |
| or |                       |       |         |          |          |
| it |                       |       |         |          |          |
| ie |                       |       |         |          |          |
| s* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Postpone elective     |       |         |          |          |
|    | admissions &          |       |         |          |          |
|    | appointments          |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Discharge patients    |       |         |          |          |
|    | capable of being      |       |         |          |          |
|    | cared for at home     |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| I  |                       |       |         |          |          |
| nf |                       |       |         |          |          |
| ec |                       |       |         |          |          |
| ti |                       |       |         |          |          |
| on |                       |       |         |          |          |
| C  |                       |       |         |          |          |
| on |                       |       |         |          |          |
| tr |                       |       |         |          |          |
| ol |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Implement appropriate |       |         |          |          |
|    | infection control     |       |         |          |          |
|    | measures (e.g.        |       |         |          |          |
|    | airborne/contact,     |       |         |          |          |
|    | droplet)              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Ensure use and        |       |         |          |          |
|    | availability of PPE   |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Continue to promote   |       |         |          |          |
|    | and practice          |       |         |          |          |
|    | respiratory & hand    |       |         |          |          |
|    | hygiene practices     |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Screen incoming       |       |         |          |          |
|    | patients for          |       |         |          |          |
|    | influenza-like        |       |         |          |          |
|    | illness               |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Implement visitor     |       |         |          |          |
|    | restriction policies  |       |         |          |          |
|    | according to criteria |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use rapid testing for |       |         |          |          |
|    | influenza A           |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Follow quarantine &   |       |         |          |          |
|    | other public health   |       |         |          |          |
|    | measures according to |       |         |          |          |
|    | Federal, state, and   |       |         |          |          |
|    | local agencies        |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .4 |                       |       |         |          |          |
| S  |                       |       |         |          |          |
| up |                       |       |         |          |          |
| po |                       |       |         |          |          |
| rt |                       |       |         |          |          |
| a  |                       |       |         |          |          |
| nd |                       |       |         |          |          |
| Ma |                       |       |         |          |          |
| na |                       |       |         |          |          |
| ge |                       |       |         |          |          |
| me |                       |       |         |          |          |
| nt |                       |       |         |          |          |
| of |                       |       |         |          |          |
| E  |                       |       |         |          |          |
| xp |                       |       |         |          |          |
| os |                       |       |         |          |          |
| ed |                       |       |         |          |          |
| a  |                       |       |         |          |          |
| nd |                       |       |         |          |          |
| I  |                       |       |         |          |          |
| ll |                       |       |         |          |          |
| St |                       |       |         |          |          |
| af |                       |       |         |          |          |
| f* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Initiate surveillance |       |         |          |          |
|    | & triage systems      |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use lab diagnostic    |       |         |          |          |
|    | systems               |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Utilize lab reporting |       |         |          |          |
|    | & disclosure system   |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Treat & monitor       |       |         |          |          |
|    | suspected and/or      |       |         |          |          |
|    | confirmed infectious  |       |         |          |          |
|    | staff                 |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .5 |                       |       |         |          |          |
| Co |                       |       |         |          |          |
| un |                       |       |         |          |          |
| te |                       |       |         |          |          |
| rm |                       |       |         |          |          |
| ea |                       |       |         |          |          |
| su |                       |       |         |          |          |
| re |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use antiviral         |       |         |          |          |
|    | medications           |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Administer available  |       |         |          |          |
|    | vaccine               |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Utilize lab &         |       |         |          |          |
|    | diagnostic resources  |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .6 |                       |       |         |          |          |
| W  |                       |       |         |          |          |
| or |                       |       |         |          |          |
| kf |                       |       |         |          |          |
| or |                       |       |         |          |          |
| ce |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Implement staffing    |       |         |          |          |
|    | plans                 |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Implement check-in    |       |         |          |          |
|    | procedures for        |       |         |          |          |
|    | availability of work  |       |         |          |          |
|    | and health status     |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Supplement staffing   |       |         |          |          |
|    | where necessary       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Allow broadened scope |       |         |          |          |
|    | of practice standards |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .7 |                       |       |         |          |          |
| P  |                       |       |         |          |          |
| at |                       |       |         |          |          |
| ie |                       |       |         |          |          |
| nt |                       |       |         |          |          |
| Ca |                       |       |         |          |          |
| re |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Expect surge of       |       |         |          |          |
|    | patients              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Execute telephone     |       |         |          |          |
|    | advice lines          |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Employ plan for       |       |         |          |          |
|    | triage, diagnosis,    |       |         |          |          |
|    | and isolation of      |       |         |          |          |
|    | infected patients     |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Expand & use          |       |         |          |          |
|    | alternative space and |       |         |          |          |
|    | sites                 |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Employ altered        |       |         |          |          |
|    | standards of care as  |       |         |          |          |
|    | needed                |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .8 |                       |       |         |          |          |
| M  |                       |       |         |          |          |
| ed |                       |       |         |          |          |
| ic |                       |       |         |          |          |
| al |                       |       |         |          |          |
| Ma |                       |       |         |          |          |
| te |                       |       |         |          |          |
| ri |                       |       |         |          |          |
| el |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Activate plans for    |       |         |          |          |
|    | use of medical        |       |         |          |          |
|    | materiel              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Assess & track        |       |         |          |          |
|    | supplies              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Consider use of       |       |         |          |          |
|    | national supply       |       |         |          |          |
|    | stockpiles of         |       |         |          |          |
|    | consumable materiel   |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .9 |                       |       |         |          |          |
| Se |                       |       |         |          |          |
| cu |                       |       |         |          |          |
| ri |                       |       |         |          |          |
| ty |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Ensure entry to and   |       |         |          |          |
|    | exit from facilities  |       |         |          |          |
|    | is limited & secure   |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Enforce visitor       |       |         |          |          |
|    | restrictions          |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Ensure security of    |       |         |          |          |
|    | countermeasures &     |       |         |          |          |
|    | supplies              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Activate agreements   |       |         |          |          |
|    | with local law        |       |         |          |          |
|    | enforcements          |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| *  |                       |       |         |          |          |
| ** |                       |       |         |          |          |
| 3. |                       |       |         |          |          |
| 2. |                       |       |         |          |          |
| 3. |                       |       |         |          |          |
| 10 |                       |       |         |          |          |
| Fa |                       |       |         |          |          |
| ta |                       |       |         |          |          |
| li |                       |       |         |          |          |
| ty |                       |       |         |          |          |
| Ma |                       |       |         |          |          |
| na |                       |       |         |          |          |
| ge |                       |       |         |          |          |
| me |                       |       |         |          |          |
| nt |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Provide supplies such |       |         |          |          |
|    | as PPE to staff       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use identified        |       |         |          |          |
|    | refrigeration         |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Coordinate mass       |       |         |          |          |
|    | fatality plans with   |       |         |          |          |
|    | local and state       |       |         |          |          |
|    | agencies              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| *  |                       |       |         |          |          |
| ** |                       |       |         |          |          |
| 3. |                       |       |         |          |          |
| 2. |                       |       |         |          |          |
| 3. |                       |       |         |          |          |
| 11 |                       |       |         |          |          |
| Me |                       |       |         |          |          |
| nt |                       |       |         |          |          |
| al |                       |       |         |          |          |
| He |                       |       |         |          |          |
| al |                       |       |         |          |          |
| th |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Provide increased     |       |         |          |          |
|    | services              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Locate additional     |       |         |          |          |
|    | providers as needed   |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use consultation      |       |         |          |          |
|    | process               |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .5 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| Co |                       |       |         |          |          |
| mm |                       |       |         |          |          |
| un |                       |       |         |          |          |
| ic |                       |       |         |          |          |
| at |                       |       |         |          |          |
| io |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Produce up to date    |       |         |          |          |
|    | information on status |       |         |          |          |
|    | of operations, how    |       |         |          |          |
|    | people can protect    |       |         |          |          |
|    | themselves, what VA   |       |         |          |          |
|    | is doing              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Regularly inform      |       |         |          |          |
|    | stakeholders,         |       |         |          |          |
|    | including staff,      |       |         |          |          |
|    | patients, VSOs, and   |       |         |          |          |
|    | the media             |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use a variety of      |       |         |          |          |
|    | information vehicles; |       |         |          |          |
|    | keep Web site up to   |       |         |          |          |
|    | date                  |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use streamlined       |       |         |          |          |
|    | information approval  |       |         |          |          |
|    | process               |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Make pre-identified   |       |         |          |          |
|    | spokespersons/subject |       |         |          |          |
|    | matter experts        |       |         |          |          |
|    | available             |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use templates to      |       |         |          |          |
|    | convey consistent     |       |         |          |          |
|    | information and       |       |         |          |          |
|    | standard distribution |       |         |          |          |
|    | lists; keep track of  |       |         |          |          |
|    | dissemination         |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Stay up to date,      |       |         |          |          |
|    | address rumors        |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Have on hand up to    |       |         |          |          |
|    | date contact lists    |       |         |          |          |
|    | for key staff, public |       |         |          |          |
|    | health departments,   |       |         |          |          |
|    | media                 |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use alternative means |       |         |          |          |
|    | to get the word out,  |       |         |          |          |
|    | such as telephone     |       |         |          |          |
|    | trees, call-in        |       |         |          |          |
|    | systems with live or  |       |         |          |          |
|    | recorded messages     |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Other:                |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Other:                |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+

+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| Re |                       |       |         |          |          |
| sp |                       |       |         |          |          |
| on |                       |       |         |          |          |
| di |                       |       |         |          |          |
| ng |                       |       |         |          |          |
| to |                       |       |         |          |          |
| Pa |                       |       |         |          |          |
| nd |                       |       |         |          |          |
| em |                       |       |         |          |          |
| ic |                       |       |         |          |          |
| In |                       |       |         |          |          |
| fl |                       |       |         |          |          |
| ue |                       |       |         |          |          |
| nz |                       |       |         |          |          |
| a: |                       |       |         |          |          |
| ** |                       |       |         |          |          |
|    |                       |       |         |          |          |
| *  |                       |       |         |          |          |
| *V |                       |       |         |          |          |
| BA |                       |       |         |          |          |
| Ac |                       |       |         |          |          |
| ti |                       |       |         |          |          |
| on |                       |       |         |          |          |
| Gr |                       |       |         |          |          |
| id |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+====+=======================+=======+=========+==========+==========+
| *  | **Response Action**   | **R   | **Resp  | **Co     | **Co     |
| *S |                       | espon | onsible | mpletion | mpletion |
| ec |                       | sible | P       | Date     | Date     |
| ti |                       | Off   | erson** | (Pl      | (A       |
| on |                       | ice** |         | anned)** | ctual)** |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| Co |                       |       |         |          |          |
| or |                       |       |         |          |          |
| di |                       |       |         |          |          |
| na |                       |       |         |          |          |
| ti |                       |       |         |          |          |
| on |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Implement Continuity  |       |         |          |          |
|    | of Operations Plans   |       |         |          |          |
|    | or other emergency    |       |         |          |          |
|    | procedures            |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Coordinate            |       |         |          |          |
|    | information and       |       |         |          |          |
|    | actions within VA and |       |         |          |          |
|    | with other agencies   |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .1 |                       |       |         |          |          |
| W  |                       |       |         |          |          |
| or |                       |       |         |          |          |
| kf |                       |       |         |          |          |
| or |                       |       |         |          |          |
| ce |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Use staffing plans,   |       |         |          |          |
|    | including flexible    |       |         |          |          |
|    | work standards, leave |       |         |          |          |
|    | policies              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .2 |                       |       |         |          |          |
| C  |                       |       |         |          |          |
| lo |                       |       |         |          |          |
| su |                       |       |         |          |          |
| re |                       |       |         |          |          |
| of |                       |       |         |          |          |
| re |                       |       |         |          |          |
| gi |                       |       |         |          |          |
| on |                       |       |         |          |          |
| al |                       |       |         |          |          |
| of |                       |       |         |          |          |
| fi |                       |       |         |          |          |
| ce |                       |       |         |          |          |
| s* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Act on plans, such as |       |         |          |          |
|    | rerouting phones,     |       |         |          |          |
|    | informing veterans    |       |         |          |          |
|    | and Central office    |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| I  |                       |       |         |          |          |
| nf |                       |       |         |          |          |
| ec |                       |       |         |          |          |
| ti |                       |       |         |          |          |
| on |                       |       |         |          |          |
| C  |                       |       |         |          |          |
| on |                       |       |         |          |          |
| tr |                       |       |         |          |          |
| ol |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Provide PPE as        |       |         |          |          |
|    | needed, as well as    |       |         |          |          |
|    | hand hygiene and      |       |         |          |          |
|    | other supplies.       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Provide information   |       |         |          |          |
|    | on availability of    |       |         |          |          |
|    | antivirals and        |       |         |          |          |
|    | vaccine               |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Provide information   |       |         |          |          |
|    | to employees on the   |       |         |          |          |
|    | status of the         |       |         |          |          |
|    | pandemic, and on      |       |         |          |          |
|    | public health         |       |         |          |          |
|    | measures, including   |       |         |          |          |
|    | hand and respiratory  |       |         |          |          |
|    | hygiene.              |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .4 |                       |       |         |          |          |
| Se |                       |       |         |          |          |
| cu |                       |       |         |          |          |
| ri |                       |       |         |          |          |
| ty |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Inform on the status  |       |         |          |          |
|    | of the pandemic and   |       |         |          |          |
|    | on operations;        |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Train on signs and    |       |         |          |          |
|    | symptoms of influenza |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Provide PPE, hand     |       |         |          |          |
|    | hygiene supplies      |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
| ** |                       |       |         |          |          |
| *3 |                       |       |         |          |          |
| .5 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| .3 |                       |       |         |          |          |
| C  |                       |       |         |          |          |
| om |                       |       |         |          |          |
| mu |                       |       |         |          |          |
| ni |                       |       |         |          |          |
| ca |                       |       |         |          |          |
| ti |                       |       |         |          |          |
| on |                       |       |         |          |          |
| R  |                       |       |         |          |          |
| es |                       |       |         |          |          |
| po |                       |       |         |          |          |
| ns |                       |       |         |          |          |
| e* |                       |       |         |          |          |
| ** |                       |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Rapidly produce and   |       |         |          |          |
|    | disseminate updated   |       |         |          |          |
|    | information           |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Update Web sites      |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Disseminate           |       |         |          |          |
|    | information to        |       |         |          |          |
|    | stakeholders in and   |       |         |          |          |
|    | out of VA             |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Hold regular          |       |         |          |          |
|    | conference calls      |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+
|    | Other:                |       |         |          |          |
+----+-----------------------+-------+---------+----------+----------+

+---+------------------------+-------+---------+----------+----------+
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| R |                        |       |         |          |          |
| e |                        |       |         |          |          |
| s |                        |       |         |          |          |
| p |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| d |                        |       |         |          |          |
| i |                        |       |         |          |          |
| n |                        |       |         |          |          |
| g |                        |       |         |          |          |
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| o |                        |       |         |          |          |
| P |                        |       |         |          |          |
| a |                        |       |         |          |          |
| n |                        |       |         |          |          |
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| e |                        |       |         |          |          |
| m |                        |       |         |          |          |
| i |                        |       |         |          |          |
| c |                        |       |         |          |          |
| I |                        |       |         |          |          |
| n |                        |       |         |          |          |
| f |                        |       |         |          |          |
| l |                        |       |         |          |          |
| u |                        |       |         |          |          |
| e |                        |       |         |          |          |
| n |                        |       |         |          |          |
| z |                        |       |         |          |          |
| a |                        |       |         |          |          |
| : |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
|   |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| N |                        |       |         |          |          |
| C |                        |       |         |          |          |
| A |                        |       |         |          |          |
| A |                        |       |         |          |          |
| c |                        |       |         |          |          |
| t |                        |       |         |          |          |
| i |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| G |                        |       |         |          |          |
| r |                        |       |         |          |          |
| i |                        |       |         |          |          |
| d |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
+===+========================+=======+=========+==========+==========+
| * | **Response Action**    | **R   | **Resp  | **Co     | **Co     |
| * |                        | espon | onsible | mpletion | mpletion |
| S |                        | sible | P       | Date     | Date     |
| e |                        | Off   | erson** | (Pl      | (A       |
| c |                        | ice** |         | anned)** | ctual)** |
| t |                        |       |         |          |          |
| i |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 4 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 2 |                        |       |         |          |          |
| C |                        |       |         |          |          |
| o |                        |       |         |          |          |
| o |                        |       |         |          |          |
| r |                        |       |         |          |          |
| d |                        |       |         |          |          |
| i |                        |       |         |          |          |
| n |                        |       |         |          |          |
| a |                        |       |         |          |          |
| t |                        |       |         |          |          |
| i |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| R |                        |       |         |          |          |
| e |                        |       |         |          |          |
| s |                        |       |         |          |          |
| p |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| s |                        |       |         |          |          |
| e |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Implement Continuity   |       |         |          |          |
|   | of Operations Plans or |       |         |          |          |
|   | other emergency        |       |         |          |          |
|   | procedures             |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Coordinate information |       |         |          |          |
|   | and actions within VA  |       |         |          |          |
|   | and with other         |       |         |          |          |
|   | agencies               |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 4 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 1 |                        |       |         |          |          |
| W |                        |       |         |          |          |
| o |                        |       |         |          |          |
| r |                        |       |         |          |          |
| k |                        |       |         |          |          |
| f |                        |       |         |          |          |
| o |                        |       |         |          |          |
| r |                        |       |         |          |          |
| c |                        |       |         |          |          |
| e |                        |       |         |          |          |
| R |                        |       |         |          |          |
| e |                        |       |         |          |          |
| s |                        |       |         |          |          |
| p |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| s |                        |       |         |          |          |
| e |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Use staffing plans,    |       |         |          |          |
|   | including flexible     |       |         |          |          |
|   | work standards, leave  |       |         |          |          |
|   | policies               |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 4 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 2 |                        |       |         |          |          |
| C |                        |       |         |          |          |
| l |                        |       |         |          |          |
| o |                        |       |         |          |          |
| s |                        |       |         |          |          |
| u |                        |       |         |          |          |
| r |                        |       |         |          |          |
| e |                        |       |         |          |          |
| o |                        |       |         |          |          |
| f |                        |       |         |          |          |
| n |                        |       |         |          |          |
| e |                        |       |         |          |          |
| t |                        |       |         |          |          |
| w |                        |       |         |          |          |
| o |                        |       |         |          |          |
| r |                        |       |         |          |          |
| k |                        |       |         |          |          |
| o |                        |       |         |          |          |
| f |                        |       |         |          |          |
| f |                        |       |         |          |          |
| i |                        |       |         |          |          |
| c |                        |       |         |          |          |
| e |                        |       |         |          |          |
| s |                        |       |         |          |          |
| o |                        |       |         |          |          |
| r |                        |       |         |          |          |
| c |                        |       |         |          |          |
| e |                        |       |         |          |          |
| m |                        |       |         |          |          |
| e |                        |       |         |          |          |
| t |                        |       |         |          |          |
| e |                        |       |         |          |          |
| r |                        |       |         |          |          |
| i |                        |       |         |          |          |
| e |                        |       |         |          |          |
| s |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Act on plans, reroute  |       |         |          |          |
|   | phones as necessary    |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Contact funeral homes, |       |         |          |          |
|   | next of kin, notify,   |       |         |          |          |
|   | reschedule             |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 4 |                        |       |         |          |          |
| . |                        |       |         |          |          |
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| . |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| I |                        |       |         |          |          |
| n |                        |       |         |          |          |
| f |                        |       |         |          |          |
| e |                        |       |         |          |          |
| c |                        |       |         |          |          |
| t |                        |       |         |          |          |
| i |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| C |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| t |                        |       |         |          |          |
| r |                        |       |         |          |          |
| o |                        |       |         |          |          |
| l |                        |       |         |          |          |
| R |                        |       |         |          |          |
| e |                        |       |         |          |          |
| s |                        |       |         |          |          |
| p |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| s |                        |       |         |          |          |
| e |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Provide PPE as needed, |       |         |          |          |
|   | as well as hand        |       |         |          |          |
|   | hygiene and other      |       |         |          |          |
|   | supplies.              |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Provide information on |       |         |          |          |
|   | availability of        |       |         |          |          |
|   | antivirals and vaccine |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Provide information to |       |         |          |          |
|   | employees on the       |       |         |          |          |
|   | status of the          |       |         |          |          |
|   | pandemic, and on       |       |         |          |          |
|   | public health          |       |         |          |          |
|   | measures, including    |       |         |          |          |
|   | hand and respiratory   |       |         |          |          |
|   | hygiene.               |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 5 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 3 |                        |       |         |          |          |
| . |                        |       |         |          |          |
| 4 |                        |       |         |          |          |
| C |                        |       |         |          |          |
| o |                        |       |         |          |          |
| m |                        |       |         |          |          |
| m |                        |       |         |          |          |
| u |                        |       |         |          |          |
| n |                        |       |         |          |          |
| i |                        |       |         |          |          |
| c |                        |       |         |          |          |
| a |                        |       |         |          |          |
| t |                        |       |         |          |          |
| i |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| R |                        |       |         |          |          |
| e |                        |       |         |          |          |
| s |                        |       |         |          |          |
| p |                        |       |         |          |          |
| o |                        |       |         |          |          |
| n |                        |       |         |          |          |
| s |                        |       |         |          |          |
| e |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
| * |                        |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Rapidly produce and    |       |         |          |          |
|   | disseminate updated    |       |         |          |          |
|   | information            |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Update Web sites       |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Disseminate            |       |         |          |          |
|   | information to         |       |         |          |          |
|   | stakeholders in and    |       |         |          |          |
|   | out of VA              |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Hold regular           |       |         |          |          |
|   | conference calls       |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+
|   | Other:                 |       |         |          |          |
+---+------------------------+-------+---------+----------+----------+

[]{#__RefHeading___Toc130728422 .anchor}Appendix E-2: CHART OF PANDEMIC
INFLUENZA PRECAUTIONS FOR VA HEALTH CARE FACILITY STAFF

Airborne Infection Isolation and Contact Precautions, in addition to
Standard Precautions

This combination of precautions offers the best protection for health
care facility staff, especially at the onset of a pandemic before
transmission patterns are well understood.

+-------+------------+--------+-------+-------+------------+---------+
|       | **Hand     | **Gl   | **Go  | **Eye | **Res      | *       |
|       | cleaning** | oves** | wns** | pr    | piratory** | *Room** |
|       |            |        |       | otect |            |         |
|       |            |        |       | ion** | **pr       |         |
|       |            |        |       |       | otection** |         |
+-------+------------+--------+-------+-------+------------+---------+
| **Air | -          | -      | -     | -     | -   Use    | -   N   |
| borne |    Between |   When |  With |  When |            | egative |
| Infe  |            |        |       |     w | Fit-tested |         |
| ction |   patients | caring |    pa | ithin |     N95    | airflow |
| Isol  |            |        | tient |     3 |     mask   |         |
| ation | -   I      |    for |       |       |     OR     | private |
| +**   | mmediately |     pa |    co |  feet |            |         |
|       |     after  | tients | ntact |       | -          |    room |
| *     |     glove  |        |       |    of |   Positive |         |
| *Cont |            | -      |       |       |     air    |    when |
| act** |    removal |   When |       |    pa |            |     p   |
|       |            |     to |       | tient |  purifying | ossible |
|       | -          | uching |       |       |            |         |
|       |   Whenever |     ar |       | -     | respirator | -   Air |
|       |     hands  | eas/ha |       |  With |     (PAPR) |     ex  |
|       |     may be | ndling |       |       |     or     | hausted |
|       |     co     |        |       |  aero |            |     o   |
|       | ntaminated |  items |       | sol-g | fit-tested | utdoors |
|       |     by     |        |       | enera |     el     |     or  |
|       |     secre  | contam |       | -ting | asto-meric |         |
|       | tions/body | inated |       |     p |            | through |
|       |     fluids |     by |       | roce- | respirator |     h   |
|       |            |     pa |       | dures |            | igh-eff |
|       | -   Use an | tients |       |       |            | iciency |
|       |     alc    |        |       |       |   Patients |         |
|       | ohol-based |        |       |       |     wear   |    filt |
|       |     hand   |        |       |       |            | ration. |
|       |     rub or |        |       |       | -   Masks  |         |
|       |     wash   |        |       |       |     during | -       |
|       |     with   |        |       |       |            |    Door |
|       |     ant    |        |       |       | transport. |         |
|       | imicrobial |        |       |       |     Use    |    kept |
|       |     soap   |        |       |       |     masks  |         |
|       |     and    |        |       |       |     with   | closed. |
|       |     water  |        |       |       |            |         |
|       |            |        |       |       |    elastic |         |
|       |            |        |       |       |            |         |
|       |            |        |       |       |    straps; |         |
|       |            |        |       |       |     avoid  |         |
|       |            |        |       |       |     masks  |         |
|       |            |        |       |       |     that   |         |
|       |            |        |       |       |     tie    |         |
|       |            |        |       |       |     on.    |         |
+-------+------------+--------+-------+-------+------------+---------+

Droplet Precautions, in addition to Standard Precautions

This combination of precautions should be used if droplet transmission
appears to be the common mode of transmission or when incapable of using
Airborne Infection Isolation and Contact Precautions.

+-------+-----------+---------+------+--------+-------------+--------+
|       | **Hand    | **G     | *    | **Eye  | **Re        | **     |
|       | c         | loves** | *Gow | protec | spiratory** | Room** |
|       | leaning** |         | ns** | tion** |             |        |
|       |           |         |      |        | **p         |        |
|       |           |         |      |        | rotection** |        |
+-------+-----------+---------+------+--------+-------------+--------+
| *     | -         | -       | -    | -      | -   Wear    | -   P  |
| *Drop |   Between |    When |  Not |   With |             | rivate |
| let** |           |         |      |     a  |    surgical |        |
|       |  patients |  caring | requ | erosol |     or      |   room |
|       |           |     for | ired | -gener |     pro     |        |
|       | -   Im    |     p   |      | a-ting | cedure-type |   when |
|       | mediately | atients |      |        |     masks   |     po |
|       |     after |         |      |  proce |     in      | ssible |
|       |     glove | -       |      | -dures |     patient |        |
|       |           |    When |      |        |     rooms   | -      |
|       |   removal |     t   |      |        |     or when |   Door |
|       |           | ouching |      |        |     within  |        |
|       | -         |         |      |        |     3 feet  |    may |
|       |  Whenever | areas/h |      |        |     of      |     be |
|       |     hands | andling |      |        |             |        |
|       |     may   |         |      |        |   patients; |  open. |
|       |     be    |   items |      |        |     change  |        |
|       |     con   |         |      |        |     when    |        |
|       | taminated |   conta |      |        |     moist   |        |
|       |     by    | minated |      |        |             |        |
|       |     s     |     by  |      |        | -   Wear    |        |
|       | ecretions |     p   |      |        |             |        |
|       |     /body | atients |      |        |  fit-tested |        |
|       |           |         |      |        |     N95     |        |
|       |    fluids |         |      |        |             |        |
|       |           |         |      |        |  respirator |        |
|       | -   Use   |         |      |        |     or      |        |
|       |     an    |         |      |        |             |        |
|       |     alco  |         |      |        |  equivalent |        |
|       | hol-based |         |      |        |     with    |        |
|       |     hand  |         |      |        |             |        |
|       |     rub   |         |      |        |    aerosol- |        |
|       |     or    |         |      |        | genera-ting |        |
|       |     wash  |         |      |        |             |        |
|       |     with  |         |      |        |  procedures |        |
|       |     anti  |         |      |        |             |        |
|       | microbial |         |      |        | Patients    |        |
|       |     soap  |         |      |        | wear        |        |
|       |     and   |         |      |        |             |        |
|       |     water |         |      |        | -   Masks   |        |
|       |           |         |      |        |     during  |        |
|       |           |         |      |        |             |        |
|       |           |         |      |        |  transport. |        |
|       |           |         |      |        |     Use     |        |
|       |           |         |      |        |     masks   |        |
|       |           |         |      |        |     with    |        |
|       |           |         |      |        |     elastic |        |
|       |           |         |      |        |     straps; |        |
|       |           |         |      |        |     avoid   |        |
|       |           |         |      |        |     masks   |        |
|       |           |         |      |        |     that    |        |
|       |           |         |      |        |     tie on. |        |
+-------+-----------+---------+------+--------+-------------+--------+

[]{#__RefHeading___Toc130728423 .anchor}Appendix E-3: CHART OF PUBLIC
HEALTH MEASURES AGAINST PANDEMIC INFLUENZA FOR INDIVIDUALS, HEALTH CARE
PROVIDERS, AND ORGANIZATIONS

The measures in the chart below may be important to reduce transmission
of pandemic influenza in VA facilities and other settings.

  --------------------------------------------------------------------------
  **Who Can Act?**  **What Public Health          **Why?**
                    Measures?**                   
  ----------------- ----------------------------- --------------------------
  **Individuals**   Cleaning hands regularly.     Reduces transfer of
                                                  microorganisms from the
                                                  hands to the eyes, nose,
                                                  or mouth. Reduces
                                                  transmission of
                                                  microorganisms carried on
                                                  hands from person to
                                                  person.

                    Following respiratory hygiene Prevents dispersal of
                    rules (covering the mouth and respiratory viruses in the
                    nose with tissues when        air.
                    coughing or sneezing).        

                    Getting seasonal influenza    Prevents individuals from
                    vaccinations.                 getting/transmitting
                                                  seasonal influenza, which
                                                  reduces burden on health
                                                  care system, and keeps the
                                                  individual well and able
                                                  to conduct daily business.
                                                  Reduces likelihood of
                                                  genetic re-assortment of
                                                  influenza strains when a
                                                  person is infected with
                                                  more than one strain.
                                                  Helps people become
                                                  accustomed to getting
                                                  vaccinations.

                    Avoiding contact with sick    Reduces likelihood of
                    persons---staying at least    one's getting and
                    three to five feet away.      transmitting influenza.

                    Staying home when sick---from Reduces transmission of
                    work, school, public places   influenza to other
                                                  persons.

                    Wearing masks when sick with  Reduces transmission to
                    influenza, if able to         others.
                    tolerate.                     

  Who Can Act?      What Public Health Measures?  Why?

  **Health care     Tracing contacts.             Locates and allows
  providers**                                     potentially exposed
                                                  persons to be informed and
                                                  able to take measures to
                                                  avoid exposing others.

                    Isolating people with         Reduces transmission of
                    suspected or confirmed        influenza to others.
                    influenza.                    

  **Health care     Quarantining people exposed   Reduces transmission of
  providers         to influenza.                 influenza to other
  (continued)**                                   persons. Because the
                                                  incubation period of
                                                  influenza is about 2 days,
                                                  quarantine time would also
                                                  be short (actual time will
                                                  be determined by the
                                                  characteristics of the
                                                  pandemic influenza virus).

                    Wearing personal protective   Reduces risk of getting
                    equipment---masks or          influenza and potential of
                    respirators, gowns, gloves,   transmitting it to others.
                    goggles.                      

  Who Can Act?      What Public Health Measures?  Why?

  **Business,       Developing, manufacturing,    Treats influenza or
  community,        stockpiling, and distributing prevents its spread.
  regional, and     antiviral medications.        
  national                                        
  organizations and                               
  leaders**                                       

                    Developing, manufacturing,    Prevents influenza
                    stockpiling, and distributing 
                    vaccine.                      

                    Reducing non-essential        Reduces the number of
                    travel.                       persons an individual has
                                                  contact with and slows the
                                                  spread of influenza from
                                                  region to region.

                    Closing schools.              Children usually have many
                                                  more close contacts than
                                                  adults; closing schools
                                                  greatly reduces
                                                  transmission of influenza
                                                  within schools, within
                                                  families, and within
                                                  communities.

                    Declaring "snow days"         Reduces contacts among
                    (temporarily closing          persons; has potential to
                    businesses, offices),         reduce transmission
                    postponing public gatherings  

                    Enabling employees to work    Reduces contacts among
                    from home; making             persons; has potential to
                    teleworking/telecommuting     reduce transmission
                    possible.                     

                    Partitioning space.           Limiting access to a
                                                  building or facility by
                                                  screening those who enter
                                                  for fever, respiratory
                                                  symptoms, and possible
                                                  recent exposure.
  --------------------------------------------------------------------------

[]{#__RefHeading___Toc130728424 .anchor}

Appendix E-4: ACTIONS CHECKLIST---FIRST CASE

**If the region's first case of pandemic influenza comes to
[this]{.underline}**

**VA health care facility** *(Modify for your facility)*

+-------------------------------------------+--------+-----------+----+
| **Actions (these may be done              | **Det  | *         | *  |
| concurrently)**                           | ails** | *Assigned | * |
|                                           |        | to**      | ** |
+===========================================+========+===========+====+
| Isolate the patient in negative airflow   |        |           |    |
| room on Airborne Infection Isolation +    |        |           |    |
| Contact Precautions, if possible.         |        |           |    |
+-------------------------------------------+--------+-----------+----+
| Record names and address/phone/email of   |        |           |    |
| possible case contacts within your        |        |           |    |
| facility (patients and staff).            |        |           |    |
+-------------------------------------------+--------+-----------+----+
| Implement your facility's emergency plan  |        |           |    |
| for pandemic influenza. This will likely  |        |           |    |
| include the following steps:              |        |           |    |
+-------------------------------------------+--------+-----------+----+
| Contact infection control.                |        | Name1 at  |    |
|                                           |        | (phone;   |    |
|                                           |        | email)    |    |
|                                           |        |           |    |
|                                           |        | etc.      |    |
+-------------------------------------------+--------+-----------+----+
| Contact others pertinent to your facility |        | Name1 at  |    |
| (for example, VAMC leadership, emergency  |        | (phone;   |    |
| manager, safety officer, occupational     |        | email)    |    |
| health, clinical laboratory, public       |        |           |    |
| affairs etc).                             |        | etc.      |    |
+-------------------------------------------+--------+-----------+----+
| Contact local public health per your plan |        | Name1 at  |    |
| to:                                       |        | (phone;   |    |
|                                           |        | email)    |    |
| -   Review epidemiology.                  |        |           |    |
|                                           |        | etc.      |    |
| -   Plan diagnostic testing: specimens,   |        |           |    |
|     handling, transport.                  |        |           |    |
|                                           |        |           |    |
| -   Review patient care strategies,       |        |           |    |
|     including use of antivirals.          |        |           |    |
|                                           |        |           |    |
| -   Review your VA facility's             |        |           |    |
|     responsibilities in public health     |        |           |    |
|     measures likely to be used (vaccine,  |        |           |    |
|     quarantine, contact tracing, etc).    |        |           |    |
+-------------------------------------------+--------+-----------+----+
| Contact VISN leadership per your plan.    |        | Name1 at  |    |
|                                           |        | (phone;   |    |
|                                           |        | email)    |    |
|                                           |        |           |    |
|                                           |        | etc.      |    |
+-------------------------------------------+--------+-----------+----+
| Assemble team per plan to prepare for     |        |           |    |
| surge of patients. Consider:              |        |           |    |
|                                           |        |           |    |
| -   Space availability (triage space,     |        |           |    |
|     negative airflow or isolation rooms;  |        |           |    |
|     cohorting areas)                      |        |           |    |
|                                           |        |           |    |
| -   Staffing                              |        |           |    |
|                                           |        |           |    |
| -   Critical supplies                     |        |           |    |
+-------------------------------------------+--------+-----------+----+
| Coordinate with leadership and public     |        |           |    |
| affairs to communicate with staff,        |        |           |    |
| patients, media, community at large.      |        |           |    |
+-------------------------------------------+--------+-----------+----+
| Update, download, print, and distribute   |        |           |    |
| instructions, educational materials, and  |        |           |    |
| signage for patients and staff (screening |        |           |    |
| on entry, hand and respiratory hygiene,   |        |           |    |
| home care, self-triage, what is pandemic  |        |           |    |
| influenza?) available on Web from VA      |        |           |    |
| ([www.publichealth.v                      |        |           |    |
| a.gov/infectiondontpassiton](http://www.p |        |           |    |
| ublichealth.va.gov/infectiondontpassiton) |        |           |    |
| ), and from Federal government at         |        |           |    |
| [www.pand                                 |        |           |    |
| emicflu.gov](http://www.pandemicflu.gov/) |        |           |    |
+-------------------------------------------+--------+-----------+----+

[]{#__RefHeading___Toc130728425 .anchor}Appendix E-5:
[SAMPLE]{.underline} SELF-TRIAGE ALGORITHM

**FOR PERSONS WITH INFLUENZA SYMPTOMS**

You may have influenza (flu).

When should you seek additional help from a health care provider?

**The symptoms of influenza are:**

-   Fever---low (99 F) to high (104 F), usually for 3 days, but may
    persist for 4 to 8 days. Sometimes fever will go away and return a
    day later.

-   Aching muscles

-   Cough

-   Headache

-   Joint aches

-   Eye pain

-   Feeling very cold or having shaking chills

-   Feeling very tired

-   Sore throat

-   Runny or stuffy nose

    **If you have some of these symptoms:**

**But IF you Or IF you**

**CALL your health care provider GO RIGHT AWAY for health care**

[]{#__RefHeading___Toc130728426 .anchor}Appendix E-6: HOME CARE GUIDE
FOR INFLUENZA, Symptom and care log, Infection control measures for the
home

A person with influenza will often become ill very suddenly. Fever and
the worst symptoms often last 3 days, but sometimes last as many as 8
days. The person may feel weak, tired, or less energetic than normal for
weeks afterward, and may have a long-lasting hacking cough.

***Common symptoms:***

-   Fever---low (99 F) to high (104 F), usually for 3 days, but may
    persist for 4 to 8 days. Sometimes fever will go away and return a
    day later.

-   Extreme fatigue

-   Muscle and body aches

-   Feeling very cold or having shaking chills

-   Joint aches

-   Headache (may be severe)

-   Eye pain

-   Sore throat

-   Stuffed nose or runny nose

-   Dry cough initially, may become a deep, hacking, and painful cough
    over the course of several days

-   No appetite for food or desire to drink fluids

***Supplies to have on hand:***

-   Thermometer

-   Acetaminophen or ibuprofen

-   Cough suppressants/cough syrup

-   Drinks---fruit juices, sports drinks, soda, tea

-   Light foods---clear soups, crackers, applesauce

-   Blankets; warm covers

***Caring for a person with influenza:***

-   Comfort measures

```{=html}
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```
-   Have the patient rest in bed.

-   Allow the sick person to judge the amount of bed covers needed; when
    fever is high the person may feel very cold and want several
    blankets.

-   Give acetaminophen (Tylenol or other brand names) or ibuprofen
    (Advil, Motrin, or other brand names) according to the package label
    or a health care provider's direction to reduce fever, headache, and
    muscle, joint or eye pain.

```{=html}
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```
-   Fluids---give frequently, extremely important to replace body fluids
    that are lost as a result of fever.

-   Feeding

```{=html}
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```
-   Give light foods as the person wants; fluids are more important than
    food especially in the first days when the fever may be highest.

***[When to seek additional medical advice:]{.underline}***

-   If the person is short of breath or breathing rapidly at rest

-   If the person's skin is dusky or bluish in color

-   If the person is disoriented ("out of it")

-   If the person is so dizzy or weak that standing is difficult (in a
    person who was able to walk before the illness)

-   If the person has not urinated in 12 or more hours

**Symptom and Care Log for Home Care**

*(Copy, fill out, and bring log sheets to health care provider visits)*

Name of patient\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Name of health care
provider\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  ---------- ---------- ---------------------- ----------------- ---------------------
  **Date**   **Time**   **Observations\***     **Temperature**   **Medications**

                                                                 

                                                                 

                                                                 

                                                                 

                                                                 

                                                                 

                                                                 

                                                                 
  ---------- ---------- ---------------------- ----------------- ---------------------

\*How the person looks; what the person is doing; fluids or foods taken
since the last observation

***Infection control measures for the home to prevent spreading of
infection***

-   Persons who have not been exposed to pandemic influenza and who are
    not essential for the sick person's care or support should not enter
    the home -- especially while the sick person still has a fever.

-   If unexposed persons must enter the home, they should avoid close
    contact with the patient.

-   Sick persons should be separated from other household members as
    much as possible. Consider designating one person as the primary
    care provider.

-   Household members should be vigilant for the development of
    influenza symptoms in themselves. Consult with health care providers
    to determine whether a pandemic influenza vaccine (if available) or
    preventive antiviral medications should be considered.

-   The sick person should follow respiratory hygiene/cough
    etiquette---cover the mouth and nose when coughing and sneezing.

-   Care providers should wash their hands with soap and water, or use
    alcohol based hand cleaners, before and after attending to sick
    persons.

-   Care providers may wear surgical or procedure-type masks during
    interactions with the sick person if masks are available.

-   The sick person may wear a surgical or procedure-type mask when
    others are around if masks are available and the sick person can
    tolerate wearing it.

-   Sick persons should not leave the home unless they must seek
    additional medical care during the period when they are most likely
    to be infectious to others, which is when they have a fever or for
    about 5 days after they first became ill.

-   If the sick person must leave the household to see a health care
    provider, attempt to contact a health care provider by phone or
    email so that appropriate advice can be given and isolation
    arrangements can be made at the health care site. When movement
    outside the home is necessary the patient should follow respiratory
    hygiene/cough etiquette and should wear a mask if available and can
    be tolerated.

-   Tissues used by the ill patient should be placed in a bag and
    disposed with other household waste.

-   Eating utensils should be washed in a dishwasher or by hand with
    soap and warm water; other separation or sterilization is not
    necessary.

-   Laundry may be washed in a standard washing machine with warm or
    cold water and detergent. It is not necessary to separate soiled
    linen and laundry used by a patient with influenza from other
    household laundry. Care should be used when handling soiled laundry
    (i.e., avoid "hugging" the laundry) to avoid self-contamination.
    Wash hands after handling soiled laundry.

-   Surfaces in the home should be cleaned using regular household
    cleaning sprays or solutions.

    The VA Pandemic Influenza Plan and related materials will be posted
    at

**[http://www.va.gov](http://www.va.gov/) and
<http://www.publichealth.va.gov/flu/>**

Leads for the development and dissemination of this plan, as well as
resulting material, are:

Victoria Davey, RN, MPH

Deputy Chief Consultant, Public Health Strategic Health Care Group

<victoria.davey@va.gov> - (202) 273-8590

Connie Raab, BA

Director, Public Health Communications

<connie.raab@va.gov> - (202) 273-6368

Troy Knighton, EdS, LPC

Senior Project Manager/Director, Training and Education

<troy.knighton@va.gov> - (202) 273-8382

Public Health Strategic Health Care Group

Office of Public Health and Environmental Hazards (13)

Veterans Health Administration, Department of Veterans Affairs

**VA Pandemic Influenza Advisory Group**

**c/o Office of Public Health and Environmental Hazards (13)**

**Veterans Health Administration**

**Department of Veterans Affairs**

**Washington, DC 20420**

**(202) 273-8567**

**March 2006**