Pandemic Influenza Planning Scenarios issued by NZ Ministry of Health

Issued by NZ Ministry of Health
http://www.med.govt.nz/upload/27552/planning-guide.pdf

Appendix 2: Pandemic Influenza Planning Scenarios


These scenarios are produced for planning purposes only. Scenarios deliberately represent extremes and are not predictions.


Scenario 1 – Pandemic Disease Recognised Overseas


It is a Friday before a holiday weekend, with fine weather forecast over the whole country.
For several weeks there have been many rumours and unconfirmed reports of large clusters of person-to-person spread of H5N1 in two south-east Asian countries – Sealand and Beeland. The situation in neighbouring countries is quiet, but in some regions the situation is unknown, with a total communications blackout from some provinces. The World Health Organisation (WHO) is intensively investigating, but has not yet confirmed person-to-person spread of H5N1 in any region, although the level of suspicion is high and increasing all the time. Nothing much else is happening in the world, so there has been intense and increasing interest in these developments from the world and New Zealand media.
Intensive surveillance in New Zealand has not found any evidence of H5N1 among the influenza-like illnesses that are normally present at low levels in the general population.
The Ministry of Health (MoH) has been monitoring the situation and has informed the health sector of the domestic and overseas situations through Code White (information) messages to District Health Boards (DHBs).
At 1200 on Friday, MoH receives information from the WHO in Manila that H5N1 influenza appears to have been responsible for a number of sudden deaths among Beeland citizens in the large capital city, Beeville. The people who died had no known exposure to infected poultry, or connection with the areas where H5N1 spread is suspected.
From Southern Beeland, there are unconfirmed reports of the sudden deaths of three German tourists who recently took a bus trip to the interior, and of influenza-like illnesses among other tourists. Some tourists are thought to have flown to Singapore or other regional destinations while unwell.
At 1230, while the MoH is attempting to verify the information received, CNN reports that “pandemic influenza has broken out in Beeland, and is causing many deaths in the slums of Beeville and the villages in the interior. Tourists have died, and many are ill”. The report also says that the Beeland government has denied that pandemic influenza is present.


MoH assembles its crisis team and identifies people for Co-ordinated Incident Management System (CIMS) team roles. By 1430 a Code Yellow (standby/warning) message has gone out to the health sector informing them of the situation. Also by this time, the WHO in Manila has confirmed the information received earlier that 120 people are ill in hospital, a further 30 are thought to have died of a new form of influenza and an unknown but “large” number are thought to be affected. It adds that a pandemic declaration will be made at 1600 New Zealand time.
Advice from the Australian Health Disaster Management Committee states that Australia has closed borders to all incoming flights.
MoH issues a Code Red message (pandemic alert) to the health sector at 1615, following the WHO declaration.
At 1630 the MoH national controller issues the first pandemic advice to the government.
The advice is:
. • To enable an effective response to be mounted, the Minister of Health should immediately unlock the special powers available to Medical Officers of Health, in the Health Act; and
. • To immediately close the border, for an indefinite period, to all incoming flights.

At 1800, the Government’s Ministerial-level Domestic and External Security Committee accepts all the Ministry of Health’s recommendations and directs the appropriate agencies to action them immediately.

Outline of likely Health Sector Actions
After unlocking of powers, Medical Officers of Health (MOoHs) have a wide range of special powers available to detain, quarantine or isolate people who have, or may have, infectious diseases.

At the time the border was closed there were 7 aircraft in the air enroute to New Zealand. For safety reasons they may land in New Zealand if the Captain decides that it is inappropriate to divert or turn back. All elect to continue, with 5 to land in Auckland and 2 for Christchurch.

Using the MOoH’s special powers, incoming passengers and aircrew will be held at the airports until health services carry out risk assessments and decide the most appropriate actions.

Outcomes could include:
1. 1. Encouragement of incoming foreign nationals to leave on the next available aircraft without entering New Zealand.
2. 2. Release of some low-risk incoming New Zealanders, with medication as required and arrangements for intensive follow-up by Public Health Units.
3. 3. Quarantine all the remaining passengers and aircrew for 8 days before allowing entry to New Zealand.

Planners should assume that it might take up to 24 hours, and possibly longer, to complete the processing of the people held at the airport, and/or make the necessary arrangements and dispositions. Health services will also review the health declarations of all passengers arriving from South East Asian airports within the last 4-5 days to assess the risks to New Zealand.

Passenger and contact tracing will be done if there are any grounds for suspicion. Surveillance will be stepped up to the highest possible state, especially in communities close to airports and on the normal tourist pathways.
MoH will make supplies of anti-viral medication available to assist with border management operations. Health staff resources will be made available by the appropriate District Health Board(s).




Scenario 2 – Cluster(s) in New Zealand



It is Mid-February. H5N1 influenza is now spreading person-to-person in Western Sealand. The virus is not yet an efficient spreader so there is no widespread outbreak, although several thousand people have been infected. The case fatality rate is very high, at about 20%. Many of the fatalities collapse and die within a short time of becoming symptomatic, mostly with cyanotic mottling and/or subcutaneous haemorrhage. WHO and the Sealand government are making strenuous efforts to contain the situation, with internal travel restrictions in place and draconian penalties for non-compliance with government directives.
H5N1 is known to exist in birds in many other parts of Asia, but intensive surveillance of these regions has not provided evidence of person-to-person spread. It appears the pandemic strain is contained in Sealand. WHO has not yet issued a world pandemic alert, although it has issued a regional alert for South East Asia and Sealand.
New Zealand borders are closed to Sealand nationals except for those who demonstrate that they are from unaffected regions, pass an exit screening examination in Sealand, and undergo health assessments on arrival in New Zealand. These people are mostly students, business people, and those with family in New Zealand. The flow of people from Sealand is low, because of Sealand government restrictions.
General tourist traffic from Asia is substantially reduced from normal because of uncertainties associated with the pandemic situation. Tourists from Asian countries other than Sealand are not undergoing health assessments at the border, although all aircraft are now required to inform authorities of the health status of people on board before arrival in New Zealand.
In New Zealand there is intensive surveillance concentrated on regions surrounding airports and the normal tourist trails.
On a Saturday afternoon, a Medical Officer of Health (MOoH) of Crossville (in the North Island) contacts the MoH. Two people of Asian extraction turned up at a local GP medical centre on Friday with influenza-like illnesses. They were assessed and swabs taken. They were provided with advice and then discharged.
At about 1100 on Saturday morning, one of these people was found dead in their motel. The hotelier rang the police as part of normal process. The other person cannot be found, and the car in which they came is missing, not having been seen since the night before. The two people had been in the motel for two days since arriving in the country.
The MOoH has seen the body, and noted cyanotic mottling and the fact that the person had been dead for some hours. He is very concerned. He has directed that the unit be sealed for the time being until full infectious disease precautions can be provided for the removal of the body to the morgue.
MoH assembles a CIMS team and informs the Minister of developments. As a number of conditions could be involved, it is decided to wait until results from swabs and a post-mortem become available before making any decisions. MoH liaises


with Police about the missing person and advises that if found, the person should be treated as infectious and appropriate precautions taken. MoH also alerts all DHBs and PHUs via a Code Yellow message.
During Sunday, several people present at a nearby Emergency Department (ED) had influenza-like illnesses. Most are itinerant market garden workers and backpacking tourists, living in various hostels and similar accommodation. None require admission. ED is taking full infection control precautions on MoH recommendation.
MoH also recommends that the after-hours surgery takes full infection control precautions, but can only recommend this, as primary care is essentially private business. MoH learns that about a dozen people have turned up at the after-hours surgery with flu-like symptoms, an unusual number for this time of year.
At 2300 on Sunday, the MOoH contacts the Ministry again. After complaining of being unwell in the early evening a receptionist from a local GP medical centre collapsed and died on arrival at the ED. During an attempted resuscitation, infection control precautions were inevitably less than perfect. Another person, whom relatives state went to the after-hours surgery earlier in the day because of the ‘flu’, is now seriously ill in intensive care.
The Ministry re-convenes its CIMS team. In conversations with the local hospital the MoH learns that at around midnight, two more patients turned up at the ED with respiratory and circulatory collapse. At 0300 on Monday morning, the team advises the government that:
. • An unknown disease causing respiratory collapse and death is present in the district;
. • It may be H5N1 pandemic influenza, but this cannot yet be confirmed;
. • The Ministry will put regional DHBs on full pandemic alert through Code Red messages;
. • Local hospital staff and facilities, and other medical staff and facilities in the area have probably been exposed;
.• The Ministry recommends that:
a. o The Minister unlocks the special powers available to Medical Officers of Health under the Health Act;
b. o That the Medical Officer of Health in charge establishes travel restrictions for the area;
c. o Until appropriate medical screening arrangements can be made, no people or goods should be allowed to move into or out of the area without the express permission of the Medical Officer of Health in charge;
d. o Public gatherings in the area should be prohibited until further notice;
e. o Schools, kindergartens, crèches, play-centres, educational campuses of all kinds, public libraries, video stores, game arcades and casinos in the area should not open on the Monday morning, and may be required to remain closed for an indefinite period; and


o All possible efforts are made to find the missing Asian person, and to track anybody who is known to have left the area since Saturday.
The Government accepts all the Ministry’s recommendations and expects them to be actioned immediately by the appropriate agencies.
Outline of Health Sector Actions
After a declaration of a national Health Emergency, Medical Officers of Health (MOoHs) have a wide range of powers available to detain, quarantine or isolate people who have or may have infectious diseases.
MoH will immediately issue a Code Red pandemic alert message, informing all health practitioners of the situation.
MoH, through their Regional Co-ordinators, will direct relevant DHBs to prepare for the release of PPE to identified hospitals, primary health care centres and first responders
No hospital-to-hospital transfers will be made from the Hospital to places outside the infected area. Surveillance will be stepped up to the highest possible state, both in the area and in the rest of the country.
Intensive investigations of the cases in the Hospital will be made, with rapid PCR investigations to confirm or rule out H5N1 avian influenza. Initial results are likely to be available within 12 hours.
MoH will make ready-use supplies of anti-viral medication available to assist with the management of the situation.
MoH’s CIMs team will advise the government on appropriate courses of action as the situation develops.




Scenario 3 – Severe Pandemic in New Zealand


It is mid-July. About eight weeks ago, H5N1 pandemic influenza achieved an explosive breakout from South East Asia, appearing in Europe, North and South America, Africa and India within a couple of weeks. The disease is impacting heavily on all age groups, but particularly on younger adults. The case fatality rate is about 2% over all age groups but up to 8-10% for people under 30. The pandemic disease has a high reproductive rate and spreads very rapidly once the first few cases have appeared in any country or region. International trade and travel is more or less at a standstill as all impacted countries attempt to adjust to the new situation. Very limited amounts of airfreight are still moving, but flights are arranged more or less as required, rather than to a timetable, and even so it is very difficult to find aircrew willing to fly to some countries. Very few passengers are being carried. Merchant ships at sea on the way to New Zealand when the pandemic broke out, have either turned around and gone home, have berthed and are unable to leave, or are remaining offshore, waiting to assess the onshore situation before berthing. One of the ships that turned around was a tanker carrying a large shipment of petrol, and there has not been a petrol delivery at Marsden Point for over six weeks now. Despite strenuous border control efforts, pandemic influenza appeared suddenly in one urban area a bit over four weeks ago. Efforts at containment were abandoned, as many other cases were reported throughout the country over the next week. Health authorities shifted efforts to attempt to ameliorate the impacts of the pandemic. Medical Officers of Health have directed all crèches, kindergartens, schools, colleges, universities, public libraries, video stores, game arcades and casinos to close indefinitely. Public gatherings are prohibited, and people are advised to avoid crowded places as much as possible. Wherever practical, people are working from home, or have taken leave – either paid or unpaid. So far, the epidemiology of the disease in New Zealand appears much the same as in other countries, with the heaviest impact on young adults. Over 100,000 people have become ill since the development of the pandemic in New Zealand, and nearly 3,000 have died. About 2,000 of these are under the age of 30. Case numbers are still increasing very fast. Initial forecasts indicate that this wave could involve up to 40% of the population, implying that there may be another 1.5 million people becoming ill over the next six weeks or so, with a peak in about another 2-3 weeks. Given the current epidemiology, this may result in between 30,000 – 35,000 deaths in total. The Ministry of Health has directed DHBs to release their PPE supplies to hospitals, the primary health care sector (in previously agreed locations), and to local services to support first responders.


The Ministry of Health has released the national reserve of anti-viral medication for use. The medication is being distributed through about 80 special temporary facilities. It is strictly prioritised to people who meet clinical criteria for influenza and time since onset of symptoms. After several incidents at the distribution stations the Ministry asked for Police or Defence Force assistance with security as civilian security firms could not manage this. Anti-viral medication has been allocated for all health services, Police and Defence Force, and staff from some other organisations providing direct pandemic responses. This guarantees treatment for any staff from these services that become ill. Despite this, there is a degree of absence in both the health sector and Police force that is not related to direct illness. Between 10%-15% of the Police force is not available for duty. The overall absence rate is still increasing, and may reach about 40%-50% in a few weeks time – around the expected peak of the current pandemic wave. The Army has about 10% of its troops not available for duty from illness, and the Air Force about the same. The Navy has one frigate on its way back from the Persian Gulf, and doesn’t have enough crew available to man the other, currently moored in Auckland. Navy volunteers are assisting health services in Auckland. Primary health services in most districts are shifting priorities, as case numbers climb, and are mostly still functioning although increasingly in a directive and support role. Secondary hospitals and DHBs in most affected areas are moving to a coordination
and logistic supply role for primary and volunteer groups while attempting to maintain hospital services as much as possible. Hospitals are hampered by very high rates of sickness and absences among their staff, and are down to between 50% and 60% of their normal capacity. Hardly any influenza patients are being admitted to hospitals. It is probable that things will get worse for hospitals before they get better. Health services in the most affected urban area and much of the surrounding region are no longer functioning in a co-ordinated manner. Here, the primary and secondary health workforce has been very heavily impacted, with only about 40% of the normal staff available for duty. The pandemic is developing very fast in some population sub-groups, and there have been a large number of deaths. A number of very young children have been orphaned by the deaths of both their parents. Several hundred bodies are in freezer storage in the district, and more containers are being brought in. People of all ages who live alone, and solo parents with small children, are especially vulnerable, as the disease comes on suddenly and is extremely incapacitating. Sufferers can do very little for themselves for several days. People who have few supplies or resources at home, or who have no support, are quickly in dire straits. Some very young children are attempting to look after their sick parents with little or no support. A number of people have died alone in their homes, and it is feared that many more may follow.

In all affected areas people are at home looking after sick children and spouses, and in many cases friends and neighbours in their homes. Some areas have quickly organised networks to support this initiative, but in others people are working as individuals with little co-ordination or support. Many people in the most affected urban area have moved to rural areas. Rapidly increasing case numbers are being reported from these districts. Health service capacity in these areas is very limited, and cannot manage anything remotely approaching the demand now being experienced. Availability of supplies varies across the country, but everywhere there are shortages of fuel and some foodstuffs, partly as a result of people buying up large quantities of basic foods in the early days. Anybody with reserve food or petrol is hoarding it for an uncertain future. Telephone, text and email communication is heavy as people try to keep in touch with each other and keep checking on their friends and relatives in New Zealand and overseas. So far, water, electricity, gas and sewerage systems are still operating, although some are becoming more vulnerable to breakdown and interruptions because of unusual demand patterns and a progressive lack of routine maintenance, as staff availability dwindles. Postal services have stopped providing daily deliveries because so many staff are absent, and courier services are severely handicapped by shortages of fuel. Many New Zealand citizens and residents overseas are stranded, unable to return to New Zealand. People who were overseas on holiday have run out of money, and businessmen overseas are in great difficulty as their incomes have often dried up completely. They are appealing to the government for assistance. About 150,000 tourists and other transient people are stranded in this country. Many are out of money, or their currencies now have virtually no value. International electronic banking is still mostly operating, as are telecommunications and media links. However currency fluctuations are extreme and nobody knows what their money will be worth tomorrow. Many of the tourists and transients are living more or less on the goodwill of moteliers and accommodation suppliers, who are now vociferously demanding the government “do something” to help the critical business situation developing in the sector from both the downturn in normal business and accommodating people with no funds. Around 100,000 overseas students are likewise stuck. Although most have enough money to last a while, they are mostly not normally eligible for publicly funded health services in New Zealand, although they are in an age group that is being heavily impacted.



Outline of Health Sector Actions
Generally, the health sector is shifting from provision of direct care to the coordination, direction, logistic support and assistance of care provision by volunteers, community groups and individuals caring for sick family members.
Nation-wide, direction of release of PPE to primary and secondary sectors occurs when Code Red alerts are issued.
The health sector will be providing direct care to only a very small proportion of all people who get sick.
Anti-virals will be released to the general population early in the wave, but there will not be sufficient to provide treatment for everybody who gets sick in a large wave. It is possible more stringent prioritisation may be adopted (in this case likely to be age-based), which may exacerbate issues around the distribution of the medication.