State Of Florida

STATE OF FLORIDA
Department of Health

Pandemic Influenza Appendix

Version 11.2

March 2009

Plan Approval

The Department of Health Emergency Operations Plan, Pandemic Influenza Appendix,
outlines the department’s approach to a Pandemic Influenza Event, in alignment with
federal emergency management plans and guidance as well as the state’s
Comprehensive Emergency Management Plan (CEMP). According to the CEMP, the
Department of Health is the coordinating agency for Emergency Support Function 8
(ESF 8), which coordinates all the State's public health and medical resources,
capabilities and capacities in an emergency or disaster event.

Questions and comments regarding this document should be directed to the Florida
Department of Health, Division of Emergency Medical Operations, Office of Emergency
Operations.

Reviewed and adopted this date __________________________ by:

Ana M. Viamonte Ros, M.D., M.P.H.

State Surgeon General, Florida Department

of Health

This plan supersedes all previous versions of this plan.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009

I. Introduction………………………………………………………………………………..................1
A. Table of Contents................................................................................................................. i
B. Purpose ...............................................................................................................................1
C. Scope ................................................................................................................................. 1
II.

Situation........... .
.. ...................................................................................................................... 1
A. Risk Assessment..................................................................................................................1
B. Vulnerability Assessment ................................................................................................. 2
1. Potential Global Impact of Pandemic Influenza ...........................................................2
2. Potential Impact on the United States.......................................................................... 3
Table 1: Predictions of National Level Illness, Healthcare Utilization, and Death
Associated with Moderate and Severe Pandemic Influenza Scenarios ...................... 3
Table 2: Pandemic Severity Index............................................................................... 4
3. Potential Impact on Florida .........................................................................................5
Table 3: Severe Pandemic Influenza Impact in Florida Community Health
Assessment Resource Tool Set (CHARTS), Florida 2008 .......................................... 5
Table 4: Impact on the Florida Healthcare System with No Antiviral Medication ........ 5
Table 5: Impact on the Healthcare System with Antiviral Medication to Treat 20%-
25% of Population ....................................................................................................... 5
C. Planning Assumptions.........................................................................................................6
1. Disease Control
........................................................................................................6
2. Public Health Services ..............................................................................................7
3. Antiviral Medications .................................................................................................8
4. Vaccines ....................................................................................................................8
5. Resource Support .....................................................................................................9
III. Concept of Operations .......................................................................................................... 9
A. Alert, Notification, Activation, Deactivation .......................................................................9
1. Assessment ..................................................................................................................9
Table 6: Pandemic Influenza Classification Matrix........................................................9
Table 7: Matrix of Surveillance Goals by Pandemic Period ....................................... 10
Table 8: WHO Pandemic Sub-Phases and Key Events Requiring Intervention..........11
Table 9: Interventions by Pandemic Sub-Phase ........................................................ 13
2. Thresholds of WHO Phase Activities ......................................................................... 17
a. WHO Phases 1 and 2, Interpandemic Period: Watch Mode .............................. 17
b. Novel Influenza Virus Laboratory Surveillance and Diagnostics......................... 17
c. Components of Current Surveillance Activities................................................... 18
d. WHO Phase 3 Through Early Phase 6 Activities................................................. 18
e. Case and Community-Based Interventions..............

............................................ 19
f. Planning Assumptions and Recommended Interventions on Case and
Contact Management............................................................................................21
Table 10: Recommended Interventions of Case-Based Containment Strategy.......... 21
g. Preconditions for Successful Implementation of Protocol Phases 3-5 ............... 22
h.

Transition to Community Mitigation Measures......................................................23
i.
Operational Aspects.............................................................................................24
Table 11: Threshold Determinants for the Use of Community Containment
Intervention ..................................................................................................................25
j. Community Mitigation Strategies ......................................................................... 25
Table 12: Summary of the Community Mitigation Strategy by Pandemic Severity.......26
k.

Categories of Interventions...................................................................................27
l.
Monitoring, Isolation, and Quarantine
.............................................................
......
28
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
i

Table 13: Case-Based Control: Uses of Monitoring, Isolation and Quarantine..................31
m.

Interstate and International Ports of Entry..................................................................31
n. Strategic National Stockpile (SNS) and Other Federally Held Critical Medical
Assets.........................................................................................................................32

o.
State Level SNS Plan Activation and Changes to the State SNS Plan

specific to Pandemic Influenza...................................................................................34
Table 14: Pharmaceutical Distribution Methodology .........................................................35
p. WHO Mid to Late Phase 6 Activities.........................................................................35
(1) Antiviral and Vaccine Distribution .........................................
..... ..........................35
B. Command and Coordination..................................................................................................37
.
C. Communication
....................................................................................................
.....
.........38
1. Risk Communication ....................................................................................................38
2. Intra-agency and Interagency Communications ............................................................38
D.
Emergency Management Roles and Responsibilities
.
........ ...............................................39
1.

Preparedness
.................................................................................................
..........
....39
CDC Watch Phase WHO Phase 1 and 2 ......................................................................... 39
CDC Watch Phase-Surveillance WHO Phase 3 and 4..................................................... 40
CDC Alert Phase ............................................................................................................. 41
2. Response
............................................................................................................... 49
WHO Phase 5 or 6 (Pandemic Alert Period) CDC Response Phase............................... 49
WHO Phase 6 Pandemic Response ................................................................................ 51
3. Recovery/Mitigation Phase between Waves and End of Pandemic ............................54
IV. Continuity of Government (COG).......................................................................................... 56
V. Continuity of Operations Plan (COOP) .................................................................................56
A. Concept ............................................................................................................................56
B. Objective ..........................................................................................................................56
C.
.................................................................................................
Tier I (First Priority)
...........57
D. Tier II (Second Priority) ....................................................................................................57
VI.

Authorities and References.......... .................................................................................
.
.........58
A. Authorities ........................................................................................................................ 58
VII.

Plan Review and Maintenance
............................................................................
............
........59
A. Director of the Division of Disease Control .....................................................................59
B. Other Divisions, Bureaus, and Offices ..............................................................................59
C. Record of Updates ...........................................................................................................60
VIII. Addenda...................................................................................................................................60
A. Acronyms and Abbreviations............................................................................................60
B. Glossary of Terms ............................................................................................................62
C. Table(s) of Organization (To Be Developed) ....................................................................65
D. Responsibility Matrix ........................................................................................................66
Table 15: Pandemic Influenza Roles and Responsibilities by Florida Department of
Health Organizational Unit and Emergency Management Phase ....................................67
E. Notification/Call-Down Lists (required) .............................................................................72
F. Standard Operating Guidelines ........................................................................................73
G. Others, as needed (e.g., checklists, forms, flowcharts, database locations and

layouts, maps)
..............................................................................................................74
H. Pandemic Influenza Antivirals and Vaccines ...................................................................75
1. Antiviral Planning Assumptions................................................................................75
2.
Vaccine Planning Assu
..........................................................................
mptions
.......75
Table 16: Florida Antiviral Priority Groups ...............................................................77
Table 18: Vaccination and Target Groups for a Severe Pandemic .........................79
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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Table 19: Sub-Prioritization of Vaccination among Tier 1 Target Groups when
Vaccine Supply is Limited .........................................................................................80
Table 20: Target Groups in Homeland and National Security..................................81
Table 21: Target Groups in Health Care and Community Support Services............83
Table 22: Vaccine Allocation for Target Groups in Critical Infrastructure.................85
IX. Annexes...................................................................................................................................88
X. Appendices..............................................................................................................................88
Hazard-Specific Plan(s) ............................................................................................................88

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
iii

I. Introduction

B. Purpose
1.
The purpose of this Florida Department of Health (FDOH) Pandemic
Influenza Appendix is to serve as guidance for preparedness, response,
recovery, and mitigation activities in the event of a pandemic in
order to minimize morbidity and mortality in residents and visitors
within the state of Florida. This effort will be achieved by:
a.
Detecting outbreaks with pandemic influenza potential.
b.
Responding to pandemic influenza outbreaks.
c.
Delaying the introduction, and slowing the transmission of
influenza.
d.
Assisting local and tribal health authorities in the
management and mitigation of an influenza pandemic event.
2.
Critical tasks are arranged by the World Health Organization (WHO)
phases of disease progression indicating what must be
accomplished during each of the phases, before and during the
pandemic.
3.
U.S. Government stages are included in this Appendix for reference.
The phases and stages are a useful tool for pandemic influenza
planning. Response, recovery, and mitigation activities will be driven
by the epidemiology and virology of the pandemic influenza virus.

C. Scope
1.
This Appendix and its associated activities will apply to the FDOH Central
Office and County Health Departments (CHDs). It references
coordinated, complementary activities of the department’s public
health partners. Activities start in preparedness and continue
through recovery.
2.
In addition to the specified tasks that this Appendix identifies and assigns
to various work units, there are implied tasks that must be
satisfactorily performed in order for the specified tasks to be
completed successfully within the time frames that this Plan
describes. One of the most important of these implied tasks is
training. Training is not within the scope of this Appendix.

II.
Situation

A.
Risk
Assessment
1.
Influenza viruses have threatened the health of animal and human
populations for centuries. Their genetic and antigenic diversity and
their ability to mutate rapidly make it difficult to develop a universal
vaccine or highly effective antiviral drugs. A pandemic occurs when
a novel strain of influenza virus emerges with the ability to infect and
efficiently spread among humans. Because humans lack immunity
to the new virus, a worldwide epidemic, or pandemic, can result.
Each of the three pandemics in the last century resulted in the
infection of approximately 30% of the world’s population and the
death of 0.2%-2% of infected individuals. Conversely, this indicates
that 98%-99.8% survived the pandemics.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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2.
Avian viruses were involved in all three 20th century pandemics. In
terms of total death toll, the 1918 pandemic is generally regarded as
the deadliest disease event in recorded history in such a
compressed time frame. In 1997, the H5N1 avian influenza virus
appeared in poultry in Hong Kong and infected 18 people, resulting
in six deaths. Since then, the virus has spread among domestic and
wild bird populations in Asia, Europe, and Africa, resulting in the
loss of over 200 million birds. In addition to birds and poultry, this
virus can infect other animals, including pigs, cats, and humans.
Evidence strongly indicates that Highly Pathogenic Avian Influenza
(HPAI) H5N1 is now endemic in parts of Asia having established a
permanent ecological niche in poultry.
3.
As of June 1, 2008, there have been close to 400 confirmed cases
of human H5N1 infection from 12 countries, with a case-fatality rate
of over 60%. This avian virus has met all prerequisites for the start
of a pandemic, except one; the ability to spread efficiently in a
sustained manner among humans. The current focus is on the
possibility that the next pandemic might be due to H5N1, but it is
possible that a different strain of influenza will result in a pandemic.

B. Vulnerability
Assessment
1.
Potential Global Impact of Pandemic Influenza
a.
All nations face considerable challenges in mounting an
unprecedented, coordinated global response to an influenza
pandemic. Once a fully transmissible virus emerges to which
there is no human immunity, its global spread is considered
inevitable. Countries might, through measures such as
border closures and travel restrictions, delay arrival of the
virus, but they will not be able to stop it. Pandemics of the
previous century circled the globe in six to nine months, at a
time when the majority of international travel was limited to
ship or rail. Given the speed and volume of current
international air travel, the virus could spread more rapidly,
possibly reaching all continents within a matter of weeks.
Health officials expect that a substantial percentage of the
world’s population infected with the pandemic strain of the
virus will require medical care.
b.
Supplies of effective antiviral drugs, an important medical
intervention for reducing illness and deaths during an
influenza pandemic, will be inadequate in all countries at the
start of a pandemic, and for many months thereafter.
Vaccines are of particular concern, as they are generally
considered the best countermeasure for protecting
populations. Currently, effective vaccines cannot be
produced in anticipation of a pandemic virus. Many
resource-poor countries have limited supplies of infection
control and supportive care material and may have no
access to vaccines throughout the duration of a pandemic.
Even countries with large investments in healthcare and
public health infrastructures will face the challenges of
scarce medicines and vaccines during a pandemic.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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c.
Accurate predictions of mortality cannot be made before the
pandemic influenza virus emerges and begins to spread.
Death rates are largely determined by four factors: the
number of people who become infected, the virulence of the
virus, the underlying characteristics and vulnerability of
affected populations, and the effectiveness of clinical
interventions and preventive measures. Those countries that
do not have effective medical care during inter-pandemic
periods, for example, resulting in low rates of influenza
vaccine coverage, are likely to experience more deaths from
pandemic influenza.
d.
Economic and social disruptions may be great. High rates of
illness, hospitalization, and worker absenteeism are
expected, and these will contribute to social and economic
disruption. These disruptions may be greatest when rates of
absenteeism impair essential services such as healthcare,
public safety, power and other public utilities, food supply,
transportation, and communications.
2.
Potential Impact on the United States
a.
An estimated 36,000 influenza deaths and 226,000
hospitalizations occur each year in the United States as a
result of seasonal influenza. Based on current models of
disease transmission, a pandemic could infect 30% or more
of the U.S. population and result in the deaths of 209,000 -
1,903,000 U.S. residents (See Table 1 and Table 2).
Table 1: Predictions of National Level Illness, Healthcare Utilization, and Death
Associated with Moderate and Severe Pandemic influenza Scenarios*
Characteristic
Moderate (1957/68-like)
Severe (1918-like)
Illness
90 million (30%)
90 million (30%)
Outpatient medical care
54 million (60%)
54 million (60%)
Hospitalization
865,000
9,900,000
Intensive Care Unit (ICU)
128,750
1,485,000
Mechanical ventilation
64,875
745,500
Deaths
209,000
1,903,000
*Estimates based on extrapolation from past pandemics in the United States. Note that these
estimates do not include the potential impact of interventions not available during the 20th century
pandemics. (http://www.pandemicflu.gov/plan/pandplan.html last accessed: March 2008)
b.
Following the Centers for Disease Control and Prevention’s
(CDC) Interim Guidance for Community Mitigation, this Appendix
ties the scope and intensity of response in an influenza
pandemic to the Pandemic Severity Index (PSI) once WHO
Phase 6 characteristics are established. The similar well-
known Saffir–Simpson scale for hurricane intensity is keyed
to sustained wind speed. Category 5 hurricanes, with higher
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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winds, have much more destructive potential than Category
1 hurricanes. Similarly, Category 5 pandemics, with higher
case-fatality rates, have the potential both for more illness
and death and for more social disruption and economic
impact than milder Category 1 or 2 pandemics (See Table 2,
Pandemic Severity Index for a description of the Categories).

Table 2: Pandemic Severity Index

c.
A pandemic’s impact will extend beyond human health. It will
undermine many of the day-to-day functions within society
and could significantly weaken the national economy and
national security. Worker absentee rates due to illness, care
giving, exposure avoidance, etc., are projected to reach 40%
at the height of a pandemic.
d.
The longer it takes for an influenza pandemic to spread, the
more likely it is that its effects can be mitigated by public
health systems, prepared healthcare professionals, informed
citizens, and proactive leaders. Ultimately, the center of
gravity, where the application of resources will have the
greatest impact, of the influenza pandemic response will be
in local communities where coordinated efforts will be
essential.
e.
As with other illnesses and diseases, disparities in access to
healthcare will result in disproportionate morbidity and
mortality. Efforts to distribute vaccines and antiviral drugs in
disadvantaged or “at risk” populations may be hampered by
limited availability of health resources. Real or perceived
injustices may impede the acceptance and effectiveness of
isolation and quarantine measures.

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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3.
Potential Impact on Florida
a.
In accordance with the U.S. Department of Health and
Human Services (HHS) planning guidance, Florida is
planning for a severe influenza pandemic similar to the
pandemic that occurred in 1918-1919. The following tables
estimate pandemic impacts on Florida.

Table 3: Severe Pandemic Influenza Impact in Florida Community Health
Assessment Resource Tool Set (CHARTS), Florida 2008 Population Estimate of
19.23 million
Characteristic
Percentage
Florida

Attack Rate
30%
5.77 million
Seeking Treatment
60% of cases
3.46 million
Hospitalization Rate
10% of cases
577,000
Case-Fatality Rate
2%
115,400

Table 4: Impact on the Florida Healthcare System with No Antiviral Medication

Per Wave

Characteristic
(Two Waves
Florida
Total)
Cases
2.89 million
5.77 million
Hospitalized (10% of cases)
288,500
577,000
Surge Beds (20% of Hosp.)
57,700
115,400
ICU Beds – Total (15% of
43,275
86,550
Hospitalized)
ICU-Ventilators (50% of ICU beds)
21,673
43,175
Case-Fatality Rate (2%)
57,700
115,400

Table 5: Impact on the Healthcare System with Antiviral Medication to Treat
20%-25% of Population*

Per Wave

Characteristic
(Two Waves Total)
Florida
Hospitalized
72,125 – 144,250
144,250 - 288,500
Case-Fatality Rate
28,850
57,700
*Estimates a 50%-75% reduction in the number hospitalized. Estimates a 50% reduction
in case-fatality rate.

b.
Estimates are that Florida’s economic losses could
approximate $38.7 billion during a severe influenza
pandemic representing a 5.74% drop in the State Domestic
Product.
c.
Tourism, entertainment, and food services could experience
an 80% decline in business, while agriculture, construction,
retail trade, finance, and insurance could face a 10%
reduction. The healthcare and social assistance industries
are projected to have an increased demand during the
pandemic (“Pandemic Flu and the Potential for U.S.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
5

Economic Recession-A State by State Analysis,” Trust for
America’s Health. 2007).
d.
The impact from early rapid response and containment
efforts could have associated disruptions at various ports of
entry.

C. Planning
Assumptions
These planning assumptions are based on federal planning assumptions
for use in a severe case scenario.
1. Disease
Control
a.
Introduction of pandemic influenza into Florida could come
from a variety of sources. When it occurs, its virulence and
infectivity is uncertain.
b.
If the pandemic occurs outside the U.S., the first U.S. cases
are likely to occur within two to four weeks following
recognition, absent effective intervention.
c.
Measures to control and contain pandemic influenza through
enhanced Public Health surveillance, Rapid Response and
Containment Protocol and border screenings will delay the
appearance of a statewide epidemic by two to four or more
weeks and reduce the overall rate of morbidity and mortality.
d.
Multiple waves of illness, periods during which community

outbreaks take place across the country, could occur with

each wave lasting up to 12 weeks.
e.
The seasonality of a pandemic cannot be predicted with
certainty.

f.
An influenza pandemic will be a long term event, lasting from

weeks or months, to over a year.
g.
An estimated 30% of the general population will become ill
with influenza, of which 60% will seek outpatient medical
care. It is expected that people who are not ill will also seek
care.
h.
Isolation and quarantine at international ports-of-entry is
a federal responsibility with state support and follow-up.
i.
A case fatality rate {(CFR) the proportion of ill people who
die} equal to or greater than 2% could occur in a severe
pandemic.
j.
Risk groups for complications and death from influenza will
include infants and the elderly, but may also include others.
k.
A severe pandemic could result in the deaths of 209,000-
1,903,000 U.S. residents or 115,400 Florida residents.
l.
Susceptibility to the pandemic influenza virus will be
universal.
m.
Highest risk groups for severe and fatal infection cannot be

predicted with certainty, but are likely to include infants, the

elderly, pregnant women, and people with chronic medical
conditions.
n.
Illness rates will be highest among school-aged children

(about 40%) and decline with age. Among working adults,
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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an average of 20% will become ill during a community
outbreak.
o.
In a severe pandemic, absenteeism attributable to illness,

the need to care for ill family members and fear of infection

may reach 40% during the peak weeks of a community

outbreak, with lower rates of absenteeism during the

weeks before and after the peak.
p.
The typical incubation period, the interval between infection

and onset of symptoms, for influenza will be approximately
two
days.
q.
In an affected community, a pandemic wave will last about

six to eight weeks.
r.
Increased public anxiety will cause increased psychogenic
and stress-related illness compounding the strain on
healthcare
facilities.
s.
Community mitigation strategies, if implemented effectively,
are assumed to reduce the attack rate to 15%.

t.
Some people infected with the virus will not have clinically
significant symptoms but will develop immunity to
subsequent infection. Despite any obvious symptoms, these
same people, will be able to transmit infection to others
at rates probably lower than those for people with full
symptoms.
u. People who become ill will shed the virus and transmit
infection up to one day before the onset of illness. Viral
shedding and the risk of transmission will be greatest
during the first two days of illness. For those that develop
symptomatic illness, the greatest risk of transmission is early
in the course of illness.
v. Children typically shed the greatest amount of virus and
therefore, are likely to pose the greatest risk for disease
transmission.
w.
On average, an infected person will transmit infection to

approximately 1.5 to 2 other people (R0=1.5-2). This number
will be lower during the latter part of a pandemic wave when
many people are immune.
x.
Infection is spread primarily by respiratory droplets, possibly

with some contribution by short distance aerosols and by

hand-to-face contact with contaminated surfaces.
y.
Influenza virus can survive up to 48 hours on hard surfaces,

but the time during which it remains infectious is unclear.
2.
Public Health Services
a.
Some public health interventions, such as school closure,

work closure, and quarantining household contacts of

infected individuals are likely to increase rates of
absenteeism
from
work.
b.
Social and economic disruption may limit FDOH’s ability to

provide public health services, resulting in unintended
consequences.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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c.
Public health services will be reduced to those services
determined to be life-saving, mission-essential, or life-
sustaining.
d.
The initial responsibility for a domestic pandemic response

rests with state, local, and tribal authorities.
e. A pandemic will increase the demand for safety and public
services, possibly creating sudden and potentially
significant gaps in a community’s ability to provide these
services.
f.
The State Emergency Operations Center (SEOC) will be
manned at the “Alert Mode” upon declaration of WHO Phase
4 and U.S. Government (USG) Stage 2 (See Table 6).
g.
Under certain scenarios included within WHO Phases 4-6
(USG Stages 2-6), the State Surgeon General will order that
some of the less critical functions and activities within the
FDOH be significantly reduced, or ceased, in order to permit
a surge in efforts to accomplish FDOH’s essential pandemic
response functions, and to support critical local and tribal
public health functions. The CDC and other federal agencies
will find themselves in similar situations.
3. Antiviral
Medications

a.
Antiviral drug availability will be what has been stockpiled
before
the
pandemic.
b.
Florida will receive a pro rata 2.5 million treatment courses

of antiviral medications from the Strategic National Stockpile

(SNS). Based on federal guidelines, these antivirals

will be designated for treatment of the sick based on HHS
priority
groups.
c.
Additional antiviral medications will likely not be available

for prophylaxis in Florida.
d.
Mathematical models suggest that early treatment,
containment, control, and prevention strategies for pandemic
influenza may be most effective when antiviral medications
for treatment and pre- and post-exposure prophylaxis are
included with non-pharmaceutical interventions.
4. Vaccines
a.
When the pandemic occurs, vaccine will not be available,

or will be in short supply and will be allocated on a priority

basis following federal guidelines from HHS.
b.
Vaccine will be available for pandemic influenza

prophylaxis approximately four to six months after the

pandemic begins. Once the vaccine is produced, it will be

available incrementally, based on U.S. production
capability.
c.
With the emergence of a novel influenza virus strain, all

people identified for vaccination may need two doses

of vaccine to achieve optimal antibody response.
d.
The vaccine supply will be under the control of the federal
government.

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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5. Resource
Support
a.
State, interstate, and federal assistance and resource

support to local communities will be limited or unavailable.

III.
Concept of Operations

A.
Alert, Notification, Activation, Deactivation
1.
Assessment
a.
Ongoing surveillance activities will provide information to
assess the current status of the pandemic. See Table 6 for
various categorizations related to Pandemic Influenza and
Table 7, Matrix of Surveillance Goals by Pandemic Period.

Table 6: Pandemic Influenza Classification Matrix
Source Classification

Periods Inter-pandemic
Pandemic
Alert
Pandemic
WHO
Phases 1,
2
3,4,5
6

Sub Phases
1,2
3A, 3B, 3C, 3D
6A, 6B, 6C, 6D
FDOH
4A, 4B, 4C, 4D
5A, 5B, 5C, 5D

Activation
Level 3:
Level 3: Monitoring
FDOH, DEM
Levels
Monitoring
Level 2: Partial Activation

Level 1: Full Activation
Phases
Preparedness, Response, Recovery, Mitigation (→↓)

CDC
Modes
Watch, Alert, Response, Recover (→↓)

Severity Index
-
-
1,2,3,4,5

Intervals

Investigation Initiation

Recognition Acceleration
Peak Transmission
Deceleration
Resolution

USG
Response
0
1,2,3,4,5,6
Stages

Florida National Guard
Phases
Prepare:
Respond:
Recover:
Steady State
1. Mobilize and
4.Redeploy
Deploy
2. Decisive
Operations
3. Transition
Northern Command
Phases
0: Shape
1. Prevent
4. Stabilize
(NORTHCOM) Response
2. Contain
5. Recover
to Pandemic Influenza
3. Interdict
Phases (Response, Virus,
and Geography Driven)

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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Table 7: Matrix of Surveillance Goals by Pandemic Period
Interpandemic
Pandemic Alert
Pandemic Period
Period
Period

1
2
3
4
5
6A 6B
6C
6D
Goals:
Detect the onset, peak, and close of
influenza seasons as well as determine
*
*
*
*
*

community impact.
Document circulating virus strain and
changes in order to plan and implement
control measures including vaccine
*
*
*
*
*
*
*
*
*
development and/or emergence of
antiviral resistance.
Determine geographic distribution and
spread of circulating virus.
*
*
*
*
*
*
*
*
*
Ensure rapid characterization of the new
virus subtype and early detection,
notification and response to additional
cases to document the presence of a
novel virus in the population, to promptly
*
*
*
*
*
*

*
locate 100% of the individuals with the
new infection in order to take preventive
action.
Detect and investigate individual cases of
influenza-associated encephalitis and
*
*
*
*
*
*

*
pediatric mortality.
Detect and report transmission of animal
influenza virus to humans.
*
*
*
*
*

Document presence or absence of
person-to-person spread of a novel virus.
Result will be to contain the new virus
within limited foci or delay spread to gain

*
*
*

time to implement preparedness
measures, including vaccine
development.
Estimate mortality due to novel or
pandemic influenza strains.

*
*
*
*

Estimate morbidity due to novel or
pandemic influenza strains.

*
*

Monitor effectiveness of community-
based control measures to minimize

*
*

pandemic impact.

b.
Florida divides several of the WHO phases to show that
different events and responses will occur at different periods
of the epidemic’s development and subsequent decline(s).
Subdivision of the WHO phases will provide for a more
nuanced and measured response during the pandemic.
(See Table 8).

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
10

Table 8: WHO Pandemic Sub-Phases and Key Events Requiring Intervention

FDOH Phase WHO Phase Description
1
1
2
2

3A
3
Disease in wild animals and birds in Florida

3B
3
Disease in poultry flocks in Florida

3C
3
Human cases in Florida, resulting from

exposure outside Florida, minimal or no

risk of human-to-human spread

3D
3
Human cases in Florida, resulting from

exposure in Florida, minimal or no risk of

human-to-human spread

4A
4
Disease in wild birds in Florida

4B
4
Disease in poultry flocks in Florida

4C
4
Human cases in Florida, resulting from

exposure outside Florida, small risk of

human-to-human spread

4D
4
Human cases in Florida, resulting from

exposure in Florida, small risk of human-to-

human spread

5A
5
Disease in wild birds in Florida

5B
5
Disease in poultry flocks in Florida

5C
5
Human cases in Florida, resulting from

exposure outside Florida, moderate degree

of human-to-human spread

5D
5
Human cases in Florida, resulting from

exposure in Florida, moderate degree of

human-to-human spread

6A
6
Human cases with potential for sustained

person-to-person spread, scattered cases

allow case-based control measures

6B
6
Human cases with sustained person-to-

person spread, no vaccine available,

community-based control measures

6C
6
Human cases with sustained person-to-

person spread, vaccine available,

community-based control measures plus selective

vaccination, then widespread vaccination

6D
6
First wave of epidemic receding, recovery,

alertness for next wave

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
11

c.
Florida’s public health response during the various phases and

and stages of a pandemic will be drawn from seven key areas

of intervention:
(1) laboratory tests
(2) surveillance
(3) case-based containment measures
(4) community-based mitigation
(5) isolation / quarantine
(6) access and distribution of SNS
(7) vaccine and antiviral distribution.
d.
Certain interventions such as lab tests and surveillance will
span the duration of the pandemic, while others such as
isolation / quarantine and antiviral distribution will be used
only at specific points in the pandemic (see Table 9).
e.
Transition to later WHO phases and accompanying
response interventions will be determined based on the
number of laboratory confirmed individual cases, small case
clusters and/or evidence of community spread. Florida will
apply a layered approach to the implementation of the seven
key interventions listed above in order to slow the
progression of the pandemic as recommended by the CDC.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
12

Table 9: Interventions By Pandemic Sub-Phase 1 2 3A 3B 3C 3D 4A 4B 4C 4D 5A 5B 5C 5D 6A 6B 6C 6D
Interventions and Phase
Key:

an
an

Activity is not appropriate at this stage
ine
♦
Activity is optional component of response at this
man
man
man
ine
stage

y

♦♦
Activity is important component of response at this
stage
♦♦♦ Activity is core component of response at this stage
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Scattered human
cases
Widespread hum
cases, no vacc
Widespread hum
cases, vacc
Recover
Planning
♦♦
♦♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
Wild bird surveillance

♦
♦♦♦
♦♦
♦
♦♦♦ ♦♦♦
♦♦
♦♦
♦♦♦ ♦♦♦
♦♦
♦♦
♦♦♦
♦

Domestic poultry surveillance
♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦

Surveillance for human impact
♦♦
♦♦

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
Surveillance for human cases

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦

Laboratory strain surveillance
♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
Public health laboratory support for interventions

♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦♦

♦♦
Surveillance for disease in poultry workers

♦♦ ♦♦♦

♦♦♦ ♦♦ ♦♦♦

♦♦♦ ♦♦ ♦♦♦

♦♦♦ ♦♦

Personal Protective Equipment (PPE) for poultry
responders

♦♦ ♦♦♦

♦♦♦ ♦♦ ♦♦♦

♦♦♦ ♦♦ ♦♦♦

♦♦♦ ♦♦

Antiviral prophylaxis for poultry responders

♦♦ ♦♦♦

♦♦♦ ♦♦ ♦♦♦

♦♦♦ ♦♦ ♦♦♦

♦♦♦ ♦♦

Antiviral treatment of hospitalized human cases

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
Antiviral treatment of all human cases within 24 hours
of onset

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
Prophylactic antiviral treatment of all household and
other close contacts within 24 hours

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
PPE for healthcare workers (HCW)

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
Antiviral prophylaxis for all Healthcare Workers

♦♦ ♦♦♦ ♦♦♦

Infection control in Healthcare Facilities

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
Directed voluntary isolation of cases at home

♦♦♦ ♦♦♦

♦♦
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
13

Table 9: Interventions By Pandemic Sub-Phase
1 2 3A 3B 3C 3D 4A 4B 4C 4D 5A 5B 5C 5D 6A 6B 6C 6D
Interventions and Phase
Key:

an
an

Activity is not appropriate at this stage
ine
♦
Activity is optional component of response at this
man
man
man
ine
stage

y

♦♦
Activity is important component of response at this
stage
♦♦♦ Activity is core component of response at this stage
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Scattered human
cases
Widespread hum
cases, no vacc
Widespread hum
cases, vacc
Recover
Self-isolation of cases

♦♦♦ ♦♦♦

Compulsory isolation of cases by CHD

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦ ♦♦♦

Monitoring of contacts by CHD

♦♦♦ ♦♦♦

Directed voluntary quarantine of contacts

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦

♦♦
Compulsory quarantine of contacts by CHD

♦♦♦

Self-quarantine of contacts

♦♦
♦♦

Support home management of ill people, keeping ill
people out of healthcare facilities and medical offices.

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦

♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦♦
Support the social expectation that people ill with
respiratory symptoms will strictly self-isolate at home.

♦♦♦ ♦♦♦ ♦♦
Support the social expectation that people who
become ill while away from home will take prescribed
control measures and proceed directly home or to a
healthcare facility.

♦♦♦ ♦♦♦ ♦♦
Develop practical measures in day-cares, schools,
workplaces, colleges etc. to immediately detect and
exclude people ill with influenza-like illness.

♦♦
♦♦

♦♦
♦♦

♦♦
♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦
Provide community support for people who are
confined to home to reduce breaches of isolation and
quarantine.

♦♦
♦♦

♦♦
♦♦

♦♦
♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦
Support organizational policies that support workers
and students for staying home while ill, or with an ill
family member.

♦♦
♦♦

♦♦
♦♦

♦♦
♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
14

Table 9: Interventions By Pandemic Sub-Phase
1 2 3A 3B 3C 3D 4A 4B 4C 4D 5A 5B 5C 5D 6A 6B 6C 6D
Interventions and Phase
Key:

an
an

Activity is not appropriate at this stage
ine
♦
Activity is optional component of response at this
man
man
man
ine
stage

y

♦♦
Activity is important component of response at this
stage
♦♦♦ Activity is core component of response at this stage
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Disease in wild
birds
Disease in poultry
Imported hu
cases
Local human cases
Scattered human
cases
Widespread hum
cases, no vacc
Widespread hum
cases, vacc
Recover
Develop practical measures in day-cares, schools,
workplaces, colleges, etc. to immediately detect and
exclude people ill with influenza-like illness.

♦♦
♦♦
♦♦
♦♦
♦♦
♦♦
Provide ongoing prophylactic antiviral medications for
healthcare workers, EMS workers, public health workers,
agricultural and veterinary workers, and other first
responders who are exposed repeatedly.

♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦
Assure that appropriate PPE is provided for all those
whose essential occupation puts them at increased
risk for exposure and infection (e.g. HCWs, public
safety workers, teachers, transit drivers, food store
workers).

♦♦
♦♦

♦♦
♦♦

♦♦
♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦
Provide antiviral prophylaxis promptly for all children
in same classroom as a case or who have attended
classes with a case.

♦♦♦ ♦♦♦ ♦♦♦

Provide antiviral prophylaxis promptly for all members
of a case’s work group who have regular face-to-face
with the case – goal would be 5 to 30 contacts per
case.

♦♦♦ ♦♦♦ ♦♦♦

Support temporary social changes that result in
greatly reduced face-to-face interactions throughout
the community, i.e. social distancing.

♦
♦♦♦ ♦♦♦

Schools: graded response including strict exclusion,
targeted antiviral prophylaxis, reactive closure, and
community-wide closure.

♦♦
♦♦ ♦♦♦ ♦♦♦ ♦♦♦ ♦♦
Close theme parks, ocean cruises and other tourist
attractions.

♦♦
♦♦

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
15

2.
Thresholds of WHO Phase Activities
a.
WHO Phases 1 and 2, Interpandemic Period: Watch Mode
(1) Takes place when there is growing evidence of a threat.
(2) The State Surgeon General will alert Deputies, Division
Directors, Bureau Chiefs, and office leaders of a
developing situation as needed.
(3) Watch activities begin in the WHO Inter-Pandemic
Phases 1 and 2, and may extend to Pandemic Alert
Phases 3 and 4. Watch activities consist of the
surveillance of wild birds, domestic poultry, and humans,
as well as laboratory strain surveillance.
b.
Novel Influenza Virus Laboratory Surveillance and
Diagnostics
(1) Purpose
(a) Clinical and public health laboratories have multiple
roles that vary with pandemic phase and laboratory
type. These include:
(i) Assays for confirmation of etiology of ILI
(ii) Clinical healthcare
(iii) Influenza strain typing
(iv) Laboratory-based surveillance studies
(b) Clinical laboratories perform the assays and clinical
healthcare using rapid, point of care testing to screen
for influenza and monitoring patient clinical status
with multiple health indicator assays.
(c) Public health laboratories perform confirmatory
assays and influenza strain surveillance testing,
support outbreak investigations, and conduct special
surveillance studies, in an attempt to detect or
identify novel, emerging viruses.
(2) Strategy
To collect information through laboratory-based
surveillance and diagnostic testing to assist public health
officials in their effort to prevent, treat, vaccinate, and
respond to influenza in the community.
(3) Objectives
(a) Perform rapid detection and identification of novel
influenza
strains.
(b) Monitor circulating influenza strain types.
(c) Monitor respiratory disease etiology in the state
across time and space.
(d) Provide laboratory guidance to county CHDs,
healthcare providers, and laboratories.
(4) Action Items
(a) Update Bureau of Laboratories (BOL) Influenza Test
Algorithm as new developments and CDC
recommendations warrant.
(b) Stockpile testing reagents and laboratory supplies.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
17

(c) Assure information on appropriate specimen
collection and shipping is available to CHDs and the
medical community.
(d) Maintain updated call lists.
c.
Components of Current Surveillance Activities
(1) Statewide and local activities will include collection and
compilation of data from multiple partners. Information
gathered will include:
(a) Laboratory testing
(b) Data and outbreak reports
(c) Syndromic surveillance
(d) Outpatient sentinel ILI surveillance by age group
(e) Sentinel influenza and pneumonia mortality
surveillance (all ages)
(f) Reportable disease surveillance, including pediatric
influenza-associated deaths, influenza-associated
encephalitis, human cases due to novel influenza
strains.
(2) The Division of Disease Control (DDC) will direct
modification or enhancement to these routine systems
during an influenza pandemic or pandemic alert periods.
(3) During the Pandemic Alert periods, individual human
case reporting will follow traditional notifiable disease
surveillance methods using the Merlin database.
Epidemiology staff will utilize this system in the
application of the following surveillance and investigation
techniques in the event of a novel influenza virus:
(a) Reporting suspect and confirmed cases of novel

strains of influenza utilizing Merlin.
(b) Collecting extended data on risk exposures and

entering it into the Merlin Outbreak Module.
(c) Collecting case information from close contacts and
entering this data into the Merlin Outbreak Module.
(d) Linking this data to confirmed cases that have been
reported to Merlin.
(4) The Bureau of Epidemiology (BOE) and the Bureau of
Community and Environmental Health will work
collaboratively to develop a process for surveillance and
investigation of animal-to-human and/or human-to-
human disease transmission.
d.
WHO Phase 3 Through Early Phase 6 Activities
(1) Alert Mode
Takes place once disease is detected in wild birds.
Florida will transition from Watch Mode to Alert Mode.
The primary interventions throughout Phases 3-5 will
continue to be laboratory and surveillance activities.
Other Alert activities will include: Surveillance, PPE and
Antiviral prophylaxis for poultry and healthcare workers,
antiviral treatment of all human cases and their close
contacts within 24 hours, infection control in healthcare
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
18

facilities, voluntary and compulsory isolation and
quarantine, monitoring of contacts by CHD staff.
(2) As imported or local human cases appear, case and
community-based Interventions will be applied in an
attempt to interrupt and or contain local human-to-human
transmission.
(3) The CDC will contact the State Surgeon General to
communicate the need to implement specific portions of
the Appendix, such as Points of Entry Screening. This action
is most likely to occur during WHO Phase 5.
(4) During the Alert Phase, FDOH employees will not
change their normal work schedules or leave work
unless directed to do so by the Executive Management
Team (EMT).
(5) Once WHO or the CDC declares a pandemic, the DDC
will monitor:
(a) Changes in the circulating virus, including
development of antiviral resistance and shifts in the
affected populations.
(b) Impacts on human health by conducting ongoing
assessment of morbidity and mortality.
(c) Effects of community and population-based control
measures, as applicable.
(6) In conjunction with recommendations from other public
health partners, such as the CDC and WHO, FDOH will
provide updated guidance to medical providers and
CHDs on an ongoing basis. Surveillance activities will be
contingent upon local, state, national, and international
influenza activity at the time.
e.
Case and Community-Based Interventions
(1) Concept
(a) The intent of FDOH case and community-based
interventions is to interrupt and/or contain local
human-to-human transmission of the novel influenza
agent as part of a larger strategy to attempt to delay
a full-scale influenza pandemic.
(b) If the influenza pandemic can be delayed long
enough, an effective vaccine can be manufactured,
distributed, and administered in time to save lives.
Flattening out the epidemic curve can spread out the
demand on healthcare facilities as well.
(c) If the public health authority controls the supply of
antivirals, then access to antiviral medications can be
a strong incentive for cases and contacts to come
forward to be identified and treated by public health
officials. The success of this strategy will depend on
the effective statewide implementation of surveillance
and containment measures.
(d) The local CHDs, with assistance from the DDC, will
take the lead responsibility for organizing assets and
disease control activities to intervene in individual
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
19

cases or small clusters of disease to delay the
spread of the novel virus, allowing time for vaccine
development and distribution.
(e) Objectives
(i) Prevent those who are ill from infecting others.
(ii) Prevent those infected or exposed from becoming
ill.
(iii) Prevent those not infected from becoming
infected.
(f) Interventions
(i) Isolate cases in the community or at point of entry
through voluntary or compulsory measures.
(ii) Monitor voluntary and/or compulsory quarantine.
(iii) Receive and distribute antivirals and other
medical countermeasures.
(iv) Provide antiviral medications to people known to
be infected, as well as to those who have been in
contact with infected people.
(v) Provide information to the public on measures to
reduce transmission.
(g) Management
The Emergency Coordinating Officer (ECO), in
coordination with the director of the DDC, shall
oversee case and community-based interventions
and maintain communication with the State Surgeon
General and the Deputies.
(h) Voice Data and External Communications
The director of the DDC, in accordance with the DOH
Emergency Operations Plan, Communication Annex,
will work with the Office of Communications to
establish a Technical Advisory Group (TAG) to:
(i) Assist in formulating appropriate disease control
messages.
(ii) Disseminate information to FDOH staff, internal
and external partners, including at minimum,
elected officials, healthcare professionals, the lay
public, people with disabilities, and people whose
first language is not English.
(i) Coordinating Agencies
Establish and maintain relationships of trust and
cooperation with public and private sector health
professionals, organizations, and institutions
including:
(i) BOL
(ii) Bureau of Statewide Pharmaceutical Services
(BSPS)
(iii) Office of Emergency Operations
(iv) Office of Communications
(v) Public Health Nursing
(vi) Family Health Services
(vii) CHDs
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
20

(j) During Phase 6B, interventions are needed to control
and mitigate an influenza pandemic after individual
case-based interventions that were appropriate to
Phase 6A are no longer effective, and before an
effective vaccine is available in quantity, in Phase
6C. These interventions include community
containment and related interventions to prevent
people with disease from infecting others. The basis
for these control measures is that reducing
unprotected face-to-face contacts between people
will reduce the likelihood of virus transmission. (See
Table 10).
f.
Planning Assumptions and Recommended Interventions on
Case and Contact Management
(1) At the start of the pandemic, no one in the population will
have pre-existing immunity against the circulating strain.
(2) No well-matched vaccine will be available.
(3) Adequate supplies of antiviral medications will be made
available to support this containment strategy.
(4) The amounts of antiviral medication needed for
containment will be very small compared to the amount
needed during the later community-based control
measures phase.

Table 10: Recommended Interventions of Case-Based Containment Strategy

Phase 3
Phase 4/5
Early Phase 6
Triggers
High-suspicion: act without
High-suspicion: act without
High-suspicion: act without

waiting for lab result
waiting for lab result
waiting for lab result

Moderate-suspicion: act without Moderate-suspicion: treat as
Moderate-suspicion: treat as

waiting for lab result if rapid
Phase 3 pending lab result
Phase 4/5 pending lab result

testing shows influenza A is

present, otherwise wait for lab

confirmation
Management Isolate in healthcare facility if in Formal isolation order for case in Formal isolation order for case in
of case
need of healthcare
hospital if in need of healthcare
hospital if in need of healthcare
Self-isolate at home
Order formal isolation for case at
Order formal isolation for case at
home
home
Treatment includes a full
Treatment includes a full course
Treatment includes a full course
course of antiviral agent to
of antiviral agent to which the
of antiviral agent to which the
which the virus is sensitive, if
virus is sensitive, if any
virus is sensitive, if any
any
CHD checks on patient location CHD checks on patient location
CHD checks on patient location
and status daily
and status daily
and status twice daily
Definition of Household members and
People who have been in the
People who have been in the
contacts
others in similar prolonged
same room with the patient or
same room with the patient or
face-to-face contact with the
talking with the patient face-to-
talking with the patient face-to-
patient or meeting bird
face for five minutes or more, or
face for five minutes or more, or
exposure criteria
meeting bird exposure criteria
meeting bird exposure criteria
Management Locate all contacts, on and off-
Locate all contacts, on and off-
Locate all contacts, on and off-
of contacts
site
site
site
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
21

Phase 3
Phase 4/5
Early Phase 6
No activity restrictions for
Immediate self-quarantine of all
Formal quarantine order for all
contacts
contacts to home
contacts to stay home or in
designated location
Instruct contacts to contact
Instruct contacts to contact CHD
Instruct contacts to contact CHD
CHD immediately if symptoms
immediately if symptoms develop
immediately if symptoms develop
develop

CHD checks on location and
CHD checks on location and
-
status of all contacts daily
status of all contacts twice daily

If any contacts have or develop
If contacts have or develop
If contacts have or develop
symptoms suggesting
symptoms suggesting influenza,
symptoms suggesting influenza,
influenza, manage case as
treat contact as a new case of
treat patient as a new case of
Phase 4/5 infection until proven Phase 4/5 infection and initiate
Phase 6 infection and initiate
not to be H5N1
contact tracing, until proven not to contact tracing, until proven not to
be H5N1
be H5N1
Antivirals for all contacts,
Antivirals for all contacts,
Antivirals for all contacts,
including exposed healthcare
including exposed healthcare
including exposed healthcare
workers
workers
workers

g.
Preconditions for Successful Implementations of Protocol
Phases 3-5
(1) Local Level Training
All appropriate DDC staff (central office and CHDs) need
to be trained on the protocol for rapid response to a
contagious respiratory pathogen.
(2) Accessibility and Response
Designated FDOH staff member in every county as well
as Central Office must be accessible by phone within 15
minutes to physicians, hospitals, CHDs, or others
wanting to report a case of the novel influenza or to
obtain a consultation, 24/7/365.
(3) Surveillance, Case Response, and Laboratory Services
Once Phase 4 has been declared:
(a) Each CHD must be able to actively ensure that every
primary-care physician in the county, every
emergency department (ED), and every freestanding
urgent care clinic knows what to report and how to do
so 24/7.
(b) CHD staff must also actively ensure that the same
information about surveillance and management of
cases and contacts is conveyed to:
(i) Jails
(ii) Prisons
(iii) Colleges and universities
(iv) Military schools
(v) Occupational health nurses
(vi) Clinics operating in their jurisdiction
(c) CHD staff must be able to activate their core
response team within 15 minutes of receiving a high-
suspicion case report.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
22

(d) The BOL must be prepared to handle potentially
large volumes of tests for suspected cases of avian
influenza as part of the case finding and containment
strategies from all parts of the state in the early part
of the pandemic.
(4) Case Management
(a) All practicing physicians and healthcare facilities

should know how to manage ill people and others in

the office or healthcare setting; for example, staff,

family, patients in the waiting area, and other

patients, while awaiting further instructions from

public health officials. The FDOH needs the full

cooperation of the organized medical professions

and healthcare facilities to facilitate the

implementation of these measures.
(5) Contact Elicitation and Management
(a) CHD staff with skills in partner elicitation and
notification from their work with sexually transmitted
diseases (STD), tuberculosis (TB), or HIV, as well as
other communicable diseases, must be part of the
core response team to enable rapid complete
ascertainment of each new case’s whereabouts,
movements, exposures, and contacts.
(b) In accordance with the State’s SNS plan, locals will
implement protocols developed by Central Office for
how and by whom prescriptions for antiviral
medications for infected people and their contacts will
be written and how the medication will be dispensed
without delay.
(c) A ready supply of antivirals must be available for use
in managing both cases and contacts at all locations
where cases may occur.
(d) Every CHD must know how to invoke quarantine
powers to isolate cases and quarantine or otherwise
limit the movement of contacts including:
(i) Who has the authority?
(ii) Who has to be consulted?
(iii) Who is needed for enforcement?
(iv) How would enforcement occur?
(6) Support and Management of Quarantined People
(a) Using interagency collaboration managed through its
Emergency Operation Center (EOC), every CHD
must know how its community will provide needed
support to numerous households containing isolated
and/or quarantined people for food, necessary
supplies, communication, child care, elder care, etc.
h.
WHO Phase 6 Transition to Community Mitigation Measures
(1) The case-based interventions described in this Appendix will

be implemented with individual cases or small clusters of

disease due to a novel influenza agent. This case-based

intervention strategy will continue as long into Phase 6
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as practical in terms of public health staffing capabilities.

Interventions will be discontinued as the community

mitigation measures are put into effect.
(2) Activities will continue to include laboratory tests,
surveillance, voluntary and compulsory isolation and the
use of antivirals. Additional activities will include the
restriction of public events, reduction of transmission
among those seeking treatment at healthcare facilities
and the communication of information to the public.
(3) The CDC has published Interim Guidance for Community
Mitigation, accessible at:
http://www.pandemicflu.gov/plan/community/mitigation.html
(4) Response operations are designed to be consistent with
the CDC Guidance as adapted to Florida conditions.
(a) The Guidance assumes that the world, including the
United States, is in a WHO Phase 6 pandemic
situation.
(b) Trigger events are provided in the Guidance for
initiating the recommended community mitigation
measures in any given state or metropolitan area.
(c) The recommended measures actually implemented
would depend on the PSI at the time.
(d) More vigorous control measures would be
recommended if the PSI is high (4 or 5), with a high
mortality rate in infected people, than if it is low.
(e) The CDC’s trigger conditions for initiating Community
Mitigation Measures are described as a laboratory-
confirmed cluster of cases and evidence of
community spread (i.e., epidemiologically linked
cases from more than one household).
i. Operational
Aspects
(1) Once a decision has been made by public health
officials to shift from case-based to community-based
control measures, a series of decision criteria will
guide the implementation of various components of the
overall strategy described in this Appendix. The CDC has
provided Interim Guidance for Community Mitigation,
and this section is consistent with the CDC’s guidance.
(2) Table 11 outlines the determinants for using community
containment interventions. At each decision point,
consider:
(a) What information is needed?
(b) Who are the key personnel?
(c) What is the scope of authority for decision makers?
(3) Partnership entities involved in decision making may
include:
(a) Emergency Support Function (ESF) 8
(b) Law enforcement
(c) First Responders
(d) Other government service workers
(e) Utilities
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
24

(f) Transportation industry
(g) Local businesses
(h) Schools and school boards
(i) Colleges and universities
(j) Governor and elected officials

Table 11: Threshold Determinants for the Use of Community Containment Interventions

j. Community
Mitigation Strategies
(1) Implementat
ion
Table 12 illustrates the Community Mitigation Strategies for
social distancing during Phase 6B and uses the following
definitions:
(a) Generally Not Recommended
Unless there is a compelling rationale for specific
populations or jurisdictions, social distancing measures
are generally not recommended for entire populations
as the consequences may outweigh the benefits.
(b) Consider
Important to consider these alternatives as part of a
prudent planning strategy, considering characteristics
of the pandemic, such as:
(i) Age-specific illness rate
(ii) Geographic distribution
(iii) Magnitude of adverse consequences
These factors may vary globally, nationally, and locally.

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(c) Recommend
Generally accepted as an important component
of the planning strategy.

Table 12: Summary of the Community Mitigation Strategy by Pandemic Severity

Community Mitigation
Severity Index
Severity Index
Severity Index
Severity Index
Measures by Pandemic
1
2 or 3
4
5
Severity Index
Interventions in CDC’s Table

Voluntary isolation of ill at home
Recommend Recommend Recommend Recommend
(adults and children)
Voluntary quarantine of
General y not
Consider Recommend
Recommend
household members in homes
recommended
with ill people (adults and
children)
If available, antiviral treatment of Recommend Recommend Recommend Recommend
cases as available and indicated
If available, antiviral prophylaxis
General y not
Consider Recommend
Recommend
of household members if
recommended
effective, feasible, and
quantities sufficient
Dismissal of students from
General y not
Consider < 4
Recommend <
Recommend <
schools and school-based
recommended
weeks
12 weeks
12 weeks
activities
Closure of child care programs
General y not
Consider < 4
Recommend <
Recommend <
recommended
weeks
12 weeks
12 weeks
Reduce out of school contacts
General y not
Consider < 4
Recommend <
Recommend <
and community mixing by
recommended
weeks
12 weeks
12 weeks
school-age children
Decrease number of social
General y not
Consider Recommend
Recommend
contacts at workplace (e.g.
recommended
teleconferences and other
alternatives to face-to-face
meetings)
Increase distance between
General y not
Consider Recommend
Recommend
people (e.g. reduce density in
recommended
public transit, workplace)
Modify, postpone, or cancel
General y not
Consider Recommend
Recommend
selected public gatherings to
recommended
promote social distance (e.g.
stadium events, theater
performances)
Modify workplace schedules
General y not
Consider Recommend
Recommend
and practices (e.g. telework,
recommended
staggered shifts)

Florida Interventions

Infection control in health- care
Recommend Recommend Recommend Recommend
facilities and alternate treatment
sites
Support home (rather than
Consider Recommend
Recommend
Consider
hospital) management of ill
people
Support behavior of going home Consider
Recommend
Recommend
Recommend
immediately if ill
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Community Mitigation
Severity Index
Severity Index
Severity Index
Severity Index
Measures by Pandemic
1
2 or 3
4
5
Severity Index
Provide information to support
Recommend Recommend Recommend Recommend
isolation of ill people at home
Provide community support for
Consider
Recommend
Recommend
Recommend
those staying at home while ill
or quarantined
Support institutional policies that Consider
Recommend
Recommend
Recommend
encourage desired behaviors
Reinforce exclusion of ill people
Consider
Recommend
Recommend
Recommend
from day cares, school,
workplaces, colleges, etc.
Recommend barrier and other
Recommend Recommend Recommend
Recommend
personal protective measures
for those occupationally
exposed
If available, provide pre-
General y not
Consider Recommend
Recommend
exposure antiviral prophylaxis
recommended
for those occupationally
exposed, if antivirals available
If available, antiviral post-
General y not
Recommend Recommended
General y not
exposure prophylaxis for
recommended
when schools
recommended
exposed children at school
open
Strict exclusion of ill students
Recommend Recomme
Recomme
nd
nded General y not
and staff from day cares,
when schools
recommended
schools, colleges, etc.
open
If available, provide post-
General y not
Consider
Consider
Consider
exposure prophylaxis for
recommended
exposed coworkers
Close theme parks, cruises, and General y not
General y not
Consider Recommend
other tourist attractions
recommended
recommended
Encourage individual protective
Recommend Recommend Recommend Recommend
behavioral changes such as
masks on the ill, selective use of
masks by the well in crowded
settings, and hand-washing
Respirators for use by
Recomme
Recomme
nd
Recomme
nd
Recomme
nd
nd
individuals for whom close
contact with an infectious
person is unavoidable.

k. Categories
of
Interventions
(1) The Interventions applied during Phase 6B fall into three
categories:
(a) Interventions that reduce the opportunities for people
who are ill to infect others.
(b) Interventions that reduce the likelihood that people
who have been potentially exposed to infection
develop disease.
(c) Interventions that reduce the likelihood that those
who are not infected and not identifiably exposed
become infected.
(2) The choice of which interventions to implement depends
on the estimated category of the pandemic, based on the
PSI.
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(3) Choice of non-pharmaceutical interventions will generally
follow the guidance in Table 12 excerpted from the CDC
Interim Guidance, but this Appendix also provides guidance
about the recommended use of antiviral medications by
category.
(4) The interventions that require use of antivirals will be
undertaken in a manner consistent with national priorities
for antiviral use. If the virus responsible for the outbreak
is resistant to the available antivirals, then none of the
interventions that require antivirals will be possible and
the remaining interventions will necessarily receive more
emphasis.
(a) These interventions cannot be carried out by CHD
staff acting alone. The main role of public health
organizations during this phase of the response will
be to assure that clear messages are received by all
citizens, and to build and maintain public support for
and compliance with the needed interventions.
(b) The most logistically difficult of these recommended
operational aspects is assuring that all people ill with
the novel virus get a prompt course of their
therapeutic antiviral medication, and assuring that all
of their contacts get a prompt course of prophylactic
antiviral medication. This combination of
interventions is likely to be very effective in reducing
community spread, if carried out completely and in
concert with the other recommended interventions.
Achieving this goal without also providing medication
to a large number of people who are not candidates
for it will require numerous entities within each
community to work closely and creatively together.
l.
Monitoring, Isolation, and Quarantine
(1) Concept
The local CHDs, with assistance from the DDC, will take
the lead responsibility for organizing disease control
assets and activities to monitor the spread of a novel
virus, and then intervene to delay the spread of the novel
virus. These acts will entail gaining and maintaining the
cooperation of public health and private sector health
professionals, organizations, and institutions.
(2) Objectives
(a) Monitor for, then identify outbreaks and analyze
trends through surveillance.
(b) Prevent those who are ill from infecting others.
(c) Prevent those infected or exposed from becoming ill.
(d) Prevent those not infected from becoming infected.
(3) Interventions
(a) Isolation or quarantine of cases through voluntary or
compulsory measures.
(b) Provision of information to the public on measures to
reduce transmission.
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(c) Restriction or limitation of public events, including
reduction of transmission among those seeking care
at medical facilities.
(d) Targeted use of antivirals when available.
(4) Management
(a) The ECO, in coordination with the director of the
DDC, shall:
(i) Oversee monitoring, isolation, and quarantine
activities.
(ii) Maintain communications with the State Surgeon
General, Deputies and CHDs.
(5) Voice Data and External Communications
The director of the DDC, in accordance with the DOH
Emergency Operations Plan, Crisis and Risk Communications Annex,
will work with the Office of Communications to establish a
TAG for assistance in formulating appropriate messages
and dissemination of information within the department
and external to the department, including at minimum,
elected officials, healthcare professionals, the lay public,
people with disabilities, and people whose first language
is not English.
(6) Coordinating Agencies
(a) BOL
(b) Office of Emergency Operations
(c) Office of Communications
(d) Public Health Nursing
(e) Family Health Services
(f) CHDs
(7) Purpose
(a) The overall purpose of isolation and quarantine
activities is to provide a method with which to limit the
spread and reduce the mortality/morbidity in
communities in the early stages of an influenza
pandemic (Phases 3, 4, and 5, and the early part of
Phase 6).
(b) Containing the virus is the ultimate goal.
(c) The use of voluntary and mandatory monitoring with
isolation and quarantine can limit viral transmission
and reduce the number of cases that occur before a
vaccine becomes available.
(d) The most recent FDOH Isolation and Quarantine Annex
is the overall guidance for the use of these
strategies as mandatory interventions for the
containment of diseases. This Annex outlines the
procedures to be used during a pandemic to
implement legally mandated isolation and quarantine.
(8) Triggers for Action
(a) The triggers for implementation of the case-based
monitoring, isolation and quarantine procedures
described in this Plan are declarations by WHO and
the CDC that the world, including the United States,
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is in WHO Phases 3, 4, 5, or 6 of an influenza
pandemic.
(b) The transition from case-based (including isolation
and quarantine) to community-based control
measures will generally occur when the number of
cases and contacts exceeds the capacity of the
public health system to respond on a case-by-case
basis.
(9) Uses of Monitoring, Isolation, and Quarantine
Interventions during Case-Based and Community-Based
Control Measure Implementation
(a) Isolation and Quarantine as Part of Case-based
Control Measures
(i) The interventions named ‘isolation’ and
‘quarantine’ as well as monitoring, will be
implemented differently at different phases of the
epidemic.
(ii) Table 13 describes how case isolation and
contact quarantine will be used during the early
phases of a pandemic, including the beginning of
Phase 6. These measures will be implemented
under the leadership of CHDs with the
cooperation and support of other components of
their local EOC.
(iii) The use of monitoring, isolation and quarantine
differs depending on the phase of the epidemic,
becoming more stringent as the risk of
widespread transmission from each case goes up
later in the course of the pandemic.
(iv) Implementation of legally mandated isolation and
quarantine orders will require close partnerships
and cooperation with law enforcement at the local
and state levels. Federal law enforcement
resources, including the National Guard, may
also be available in some situations.

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Table 13: Case-Based Control: Uses of Monitoring, Isolation and Quarantine

Phase 3
Phase 4/5
Phase 6
Management Isolate in healthcare Formal isolation order for case in Formal isolation order for case
of case
facility if in need of
hospital if in need of healthcare
in hospital if in need of
healthcare (Active
(Active Monitoring with Activity
healthcare (Active Monitoring
Monitoring without
Restriction)
with Activity Restriction)
Activity Restriction)
Self-isolate at home Order formal isolation for case at
Order formal isolation for case
home
at home
CHD checks on case CHD checks on patient location
CHD checks on patient location
location and status
and status daily
and status twice daily
daily
Management Locate all contacts,
Locate all contacts, on and off-
Locate all contacts, on and off-
of contacts
on and off-site
site
site
No activity
Immediate self-quarantine of all
Formal quarantine order for all
restrictions for
contacts to home (Active
contacts, to stay home or in
contacts (Passive
Monitoring without required
designated location (Active
Monitoring)
Activity Restriction)
Monitoring with Activity
Restriction)
Instruct contacts to
Instruct contacts to contact CHD
Instruct contacts to contact
contact CHD
immediately if symptoms develop
CHD immediately if symptoms
immediately if
develop
symptoms develop

CHD checks on location and
CHD checks on location and
status of all contacts daily
status of all contacts twice daily

(10) Isolation and Quarantine as Part of Community-Based
Control Measures
As the pandemic continues and grows in Phase 6:
(a) The number of importations of disease into Florida
will get larger.
(b) There will be increased spread within the state from
unrecognized cases, contacts who are not identified
and located, etc.
(c) As case-based containment, led by CHD staff, is no
longer effective or feasible, transition into a
community-based control and mitigation approach
will be made. In this approach, it is still critical for
disease control that individual cases are isolated and
their contacts (as far as possible) stay home. These
measures will be exclusively voluntary and self-
directed, and will be only one part of an overall
strategy to reduce face-to-face interactions so that
transmission of the virus can be reduced.
m.
Interstate and International Ports of Entry
(1) Concept
Response activities at ports of entry (POE) will involve
investigating reports of ill travelers with ILI to identify and
evaluate individuals with a high likelihood of being
infected with novel influenza virus.
(2) Objective
Delay the entry of novel influenza viruses into Florida.

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(3) Interventions
(a) Prior to the occurrence of cases in the United States,
international travelers infected with pandemic
influenza may simultaneously arrive at multiple POE.
However, some POE are more likely to be the site of
importation and will require staff augmentation.
(b) Travel-related interventions can be classified as pre-
departure measures, en route measures, and arrival
measures.
(c) Pre-Departure Measures
Effective host country/host state health screening of
individuals prior to departure may reduce the risk of
travelers exposing fellow travelers, aircraft and
vessel crews, and others to pandemic influenza. This
activity would include:
(i) Developing pre-departure measures and
identifying the necessary staffing resources.
(ii) Screening for signs of illness (e.g., temperature
scanning) and for risk factors (e.g., contacts,
travel history).
(iii) Restricting movement of potentially exposed
individuals for one incubation period prior to
international travel.
(d) En Route Measures
Given the short incubation period of influenza and the
length of some international flights, some travelers
with influenza will develop their first symptoms during
their journey. When combined with pre-departure exit
screening, this strategy would detect those who
developed signs of illness while en route. Procedures
may include:
(i) Training of flight and vessel crews to detect and
manage ill travelers.
(ii) Moving an ill person away from other travelers and, if
possible, placing a surgical mask on the ill
person.
(iii) Emphasizing the importance of hygiene
measures, such as hand hygiene.
(iv) If a mask is not available, covering coughs and
sneezes with a tissue or cloth, and proper
disposal of these items.
(v) Reporting illness or death of traveler(s) by the
ship captain, aircraft commander, bus driver, or
railroad conductor to the Quarantine Station, if
international, or to state/local health authorities, if
interstate.
(e) Arrival Measures
Arrival screening may serve as an important
additional layer of containment if adequacy and
effectiveness of previous containment measures
cannot be assured, and may help identify individuals
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
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who became ill during travel. Arrival screening can
be imposed as a precautionary measure. Arrival
measures include:
(i) Isolating and performing diagnostic testing
(especially with a rapid diagnostic test, when
available) of travelers with ILI.
(ii) Quarantining potentially exposed travelers until
definitive testing is complete or antiviral
prophylaxis is given.
(iii) Educating travelers on pandemic influenza.
Local authorities will report ill international
travelers to the DDC which will, in turn, notify the
CDC Quarantine Station. Pursuant to Title 21
CFR Part 240.25, reports of interstate travelers
will go to “local health authorities,” who in turn will
transmit the report to the DDC. Arrival screening
will place additional demands on the CDC
Quarantine Station personnel, Customs and
Border Protection officers, as well as FDOH
employees statewide.
n.
Strategic National Stockpile (SNS) and Other Federally Held
Critical Medical Assets
(1) Concept
The decision to request federally held critical medical
assets will be a collaborative effort among local, state,
and federal officials in accordance with State Emergency
Response Team procedures as well the as the DOH
Emergency Operations SNS Annex.
(2) Objectives
Sustainment of healthcare systems.
(3) Interventions
(a) Push Packages
Caches of medical assets including selected
pharmaceuticals, medical supplies, and equipment
that are available for immediate deployment
(delivered within 12 hours of request) for response to
an incident.
(b) Managed Inventory
Additional supplies from various sources that are
available for deployment in support of a continued
response (24 to 36 hours and beyond from request).
(c) Antivirals
State allocation of federal stockpile.
(d) Federal Medical Stations (FMS)
Equipment for the provision of non-acute care
provided in 50 bed modules for use for:
(i) Special Needs Shelters
(ii) Alternate Medical Treatment Sites
(iii) Quarantine sites
The FMS provides equipment, supplies, and
pharmaceuticals, but does not provide personnel.
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(e) Other federal assistance will be requested in
accordance with State Emergency Response Team
(SERT) procedures.
(4) Management
As per existing SNS and other state medical
countermeasures deployment plans.
(5) Voice Data and External Communications
The director of the DDC, in accordance with the DOH
Emergency Operations Plan, Crisis and Risk Communications Annex,
will work with the Office of Communications to establish a
TAG for assistance in formulating appropriate messages
and dissemination of information within the department
and external to the department, in accordance with
established SERT procedures, including at minimum,
elected officials, healthcare professionals, the lay public,
people with disabilities, and people whose first language
is not English.
(6) The FDOH SNS Annex is incorporated by reference into
the current Pandemic Influenza with the following
adjustments:
(a) While existing SNS logistical and operational
systems will be used to receive, manage, and
distribute antivirals, currently, antivirals are not
considered part of the federal SNS.
(b) In anticipation of need, the federal government may
deploy antivirals and other medical countermeasures
to Florida without a request from the state.
(i) Anticipated need medications will be received,
managed, and distributed by the BSPS.
(ii) Other non-pharmaceutical medical
countermeasures will be received, managed, and
distributed as directed by the Office of
Emergency Operations or the ESF 8 Health and
Medical Operations section.
o.
State Level SNS Annex Activation and Changes to the State
SNS Annex Specific to Pandemic Influenza
(1) Incident treatment protocol decisions will be made by a
member of the executive staff with prescriptive authority
(M.D. or D.O.). This authority may be delegated to
physicians with prescriptive authority in the DDC.
(a) The state ECO will appoint technical specialists to
the ESF 8 Planning Section to assist with the
allocation of material based on the degree of impact,
resources available, and requests made.
(b) Potential Allocation Methodologies
(i) County population
(ii) Per staffed hospital bed
(iii) Hospital catchment area
(iv) Population density
(v) Region based on percent of state population total
(vi) Physician density
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Table 14: Pharmaceutical Distribution Methodology
Target Population
Location
Mechanism
Most severely ill
Hospitals
RSS to hospitals
Ill presenting to the hospital
Clinics associated
RSS to hospitals
seeking treatment
with hospitals
Ill in the community attempting
Other healthcare
Drug wholesalers
to access a healthcare provider system treatment
centers
Ill in the community attempting
Physicians Drug
wholesalers
to access a healthcare provider
Ill in the community attempting
Clinics associated
BSPS
to access a healthcare provider with CHD/CMS

p.
WHO Mid to Late Phase 6 Activities
(1) Antiviral and Vaccine Distribution
(a) Concept
The FDOH mobilizes its resources, including the
BSPS, the Bureau of Immunization, and CHDs to
distribute antivirals and vaccines to public health and
private sector healthcare practitioners for efficient
delivery to affected populations.
(b) Objective
Rapid deployment of available antivirals and
vaccines.
(c) Activities will continue to include laboratory tests,
surveillance, voluntary and compulsory isolation and
the use of antivirals. Additional activities will include
the restriction of public events, reduction of
transmission among those seeking treatment at
healthcare facilities and the communication of
information to the public.
(d) Interventions
(i) The BSPS Central Pharmacy will order product
from an approved manufacturer or distributor
following that vendor’s ordering protocols, or from
a Receiving, Staging, and Storing (RSS) site
following the protocols in the FDOH SNS Annex.
(ii) Vaccine shipments may be sent from a
manufacturer, distributor, or the CDC to a single
location or to multiple locations.
(iii) Any location receiving shipments of vaccine must
be permitted or authorized to be in possession of
legend/prescription-only drugs. These locations
have been permitted by the Board of Pharmacy
as a pharmacy, drug wholesaler, or drug
distributor, or are the offices of licensed medical
practitioners who are authorized to prescribe
medications including legend drugs (M.D., D.O.,
A.R.N.P., P.A.).
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(iv) All orders for pharmaceuticals to support
response to pandemic influenza at the local level
must be submitted pursuant to the existing
standard ordering procedures to initiate the
request. Once ESF 8 approves that request, it will
forward the order to the appropriate BSPS
pharmacy logistics specialist, who will then
facilitate the delivery of pharmaceuticals to the
requesting sites.
(v) Managers of each vaccine receiving point (e.g.,
BSPS Central Pharmacy, RSS, CHDs and
Children's Medical Services [CMS]) will develop
primary, secondary, and tertiary plans for vaccine
distribution. These plans will also address
storage, security, and transportation issues.
(e) Storage
Facilities that will store pharmaceuticals (vaccine or
antivirals) will environmentally maintain these items
pursuant to the manufacturer’s recommendations.
(f) Security
Facilities that will store pharmaceuticals will be in a
secure location with internal product access limited
only to authorized personnel.
(g) Transportation
BSPS will coordinate with ESF 8 logistics and the
state SEOC/ESF 1 (Transportation), ESF 13 (Military
Support) and ESF 16 (Law Enforcement) for
transportation of pharmaceuticals to RSS/Logistical
Staging Area (LSA) or alternative sites. If military
support is necessary, ESF 8 and BSPS will
coordinate with ESF 13 (National Guard).
Pharmaceuticals will require temperature control
while being transported.
(h) Pharmaceutical Return and Recovery
(i) Each CHD/CMS will develop plans to retain
pharmaceuticals at its locations, if necessary.
(ii) Each CHD/CMS will report to BSPS and the
Bureau of Immunization any remaining unused
pharmaceuticals when requested to do so.
(iii) When the products expire, each CHD/CMS will
utilize the third party reverse distributor process
for expired returns unless otherwise instructed by
the FDOH.
(i) Reporting of Adverse Events
The system currently in use for reporting adverse
drug events to influenza vaccine is the Vaccine
Adverse Events Reporting System (VAERS). For
adverse reactions to antiviral medications, MedWatch
is used. Any change in reporting procedures will be
communicated during the pandemic.

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(j) Management
(i) The director of the DDC, in coordination with the
ECO, shall oversee case and community
containment activities, including the use of
stockpiled pharmaceuticals and will maintain
communications with the State Surgeon General,
Deputies and CHD directors and administrators.
(ii) All ordering entities must report any pharmaceutical
transfers (e.g., to another CHD/CMS), or receipts
(e.g., from another CHD/CMS, from a
manufacturer) to the BSPS Central Pharmacy.
(k) Voice Data and External Communications
The director of the DDC, in accordance with the DOH
Emergency Operations Plan, Crisis and Risk Communications
Annex, will work with the Office of Communications to
establish a TAG to develop appropriate messages and
dissemination of information within the department and
external to the department, including at minimum,
elected officials, healthcare professionals, the lay
public, people with disabilities, and people whose first
language is not English.

B.
Command and Coordination
1.
Normal Business Operations
a.
During normal day to day operations when the risk of human
disease from a novel and potentially pandemic virus in Florida is
low - WHO Levels 3 and 4, U.S. Government Stages 0-2, and Pre-
pandemic Interval for investigation and recognition, command
of the emerging event shall be maintained by the Division of
Disease Control and coordinated and communicated as
appropriate with the internal and external partner agencies.
2.
State Emergency Operations Center Partial/Full Activation
a.
Within the scope of the SERT activation for the pandemic, the
State Surgeon General may serve in a Unified Command Role
with the State Coordinating Officer to develop the strategic and
operational direction for overall response and recovery actions
conducted pursuant to the Florida Comprehensive Emergency
Management Plan Annex F - the State of Florida Pandemic
Influenza Plan.
b.
When the risk of human disease from a potential pandemic
virus in Florida has increased - WHO Level 5, US
Government Stages 2 and 3, and Pandemic Interval -
Initiation, the SERT will be activated to a Level 2: Partial
Activation and the State ESF 8 activated. Through this
activation level and any subsequent Level 1 activation,
operational command and coordination responsibilities for the
ESF 8 response shall be the responsibility of the State ESF 8
Emergency Coordinating Officer. This command and
coordination function shall be executed through the ESF 8
Incident Command Structure (ICS) developed consistent with
the scope, size and requirements of the event. The ECO shall
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
37

request technical specialists and ICS Functional staff, as
needed, from ESF 8 agencies to serve within ESF 8 in response
to the pandemic through recovery and planning for subsequent waves.

c.
During the active pandemic phase, in Florida, the SEOC will

be fully activated and be responsible for the command,

coordination, and support of multiple local responses and

application of state assets to support the local response.

State resources mobilized through these actions would then

be available and placed under the command of the local

Unified Command and/or MAC.
d.
Additionally, it is recognized that due to the statewide
concurrent impact of the pandemic, state ESF 8 command

and control may be expanded and executed on a broader

scale, consistent with the roles and responsibilities as

outlined in this annex.
C. Communication
1. Risk
Communications
a.
The Office of Communications, with the technical assistance

from disease control technical specialists working in the ICS

structure, will establish and maintain public confidence through

implementation of its Crisis and Risk Communications Annex.
b.
The Office of Communications will participate in the Joint

Information Center (JIC) operation of the SEOC, and will

coordinate its work and messages with all domestic levels
of
public
information
outlets.
c.
The director of the disease control branch or division of the

ICS structure, will work with the Office of Communications to

establish a TAG for assistance in formulating appropriate

messages and dissemination of information within the

department and external to the department, including at

minimum, elected officials, healthcare professionals, the lay

public, people with disabilities, and people whose first
language
is
not
English.

2.
Intra-agency and Interagency Communications

a.

Human
See
SERT
Pandemic
Influenza
Annex
b. Non-Human
(1)
Concept

During the preparedness phase, the Division of

Environmental Health will work with partners on avian and

animal surveillance, disease control efforts, and serve as an

FDOH liaison for zoonotic response and recovery activities.
(2)
Objective

Prevent or minimize zoonotic avian influenza

transmission to humans in Florida.
(3)
Intervention

The ESF 8 incident command structure is responsible for:

(a) Human disease surveillance.

(b) Human disease control, including providing

recommendations for vaccines and antivirals.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
38

(c) Recommendations on personal protective

equipment
(PPE).

(d) Support activities related to the education of animal

disease
responders
on
appropriate
PPE.

(e) Facilitating animal responder access to vaccines,

antivirals,
and
PPE.

(f) Providing safe handling and disposal guidelines for

infected
birds.

(g) Testing, treating, quarantine or isolation of human

cases, identifying their contacts and monitoring,

quarantine or isolation of those contacts.

(h) Collection of dead wild birds for testing is the

primary responsibility of the Fish and Wildlife

Conservation Commission (FWC) in collaboration

with the United States Department of Agriculture

(USDA) Wildlife Services. CHDs may become

involved in bird collection surge activities.

(i) Coordination of human disease investigations

associated with a commercial poultry outbreak of

Avian Influenza (AI) with ESF 17 (Department of

Agriculture and Consumer Services [DOACS]).

When the outbreak response is managed by a

Unified Command system, human case surveillance

and reporting is coordinated by Epidemiology Strike

Teams working in the Incident Command structure

(see operational protocol).

(j) Human cases with animal exposure should be

interviewed using the animal contact case report

form. The surveillance data should be entered into

the Merlin Outbreak Module. Human cases and

human and animal case contacts are managed per

the case-based containment section of the FDOH

pandemic
influenza appendix.

D.
Emergency Management Roles and Responsibilities
This section contains anticipated job actions to be performed in relation to a
Pandemic Influenza response. Different or additional responsibilities might
become necessary and will be determined as needed. (See also the DOH
Emergency Operations Plan [EOP] which is incorporated by reference)
1. Preparedness
a.
CDC Watch Phase WHO Phases 1 and 2
(1) Deputies, Division Directors, Bureau Chiefs, Office
Directors
(a) Review needed competencies to ensure that staff
received sufficient training to meet mission
requirements.
(b) Conduct exercises to test plans and staff capabilities
and knowledge.
(c) Conduct COOP exercises to test plans and systems.

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39

(2) Bureau of State Laboratories

The BOL receives samples for detection of respiratory

viruses from multiple sources throughout the year.

Specimens are evaluated by assays that are appropriate

to the study type.

(a) CHDs will recruit community-based physicians to

participate in the CDC/WHO Influenza Sentinel

Physician Network. Specimens from select patients

with ILI are submitted to the BOL for virus detection

and influenza strain typing. Results are reported to

the CDC, the submitter, and the BOE. Selected

samples are forwarded to the CDC for additional

studies.
(b) The BOL will work closely with CHD epidemiologists

to detect and type respiratory viruses in reported
outbreaks.

(c) Suspect Cases of Avian or Other Novel Influenza

Virus. If approved by the BOE, the BOL will

conduct appropriate testing and will send samples to

the CDC for additional or confirmatory testing on

patients suspected of infection with a non-seasonal
influenza
virus.
(d) The BOL regularly receives influenza isolates from

commercial and hospital laboratories that do not

have sub-typing capability, with a request for typing.
(e) The BOE and CHDs will review laboratory

surveillance data and will maintain contact with

potential specimen providers.
b.
CDC Watch Phase-Surveillance WHO Phase 3-4

(1) CHDs will recruit additional sentinel providers to submit

specimens for viral isolation and strain typing. The BOL

will distribute guidelines electronically to hospitals,

healthcare providers and clinical laboratories describing

how to request testing for novel influenza virus online.

(2) CHDs will request specimens from outbreaks of

respiratory illness for submission to the BOL. Each CHD

epidemiology unit will be provided with specimen

collection kits (swabs, shipping boxes, directions) for

rapid sampling from suspect cases of novel influenza.

(3) The BOL will continue to perform influenza testing as for

Phase 1 and 2, will increase intra-laboratory cross

training of staff, and will have supplies and reagents

for the potential increase in testing. The BOL will provide

guidance on specimen collection and shipping to

clinical laboratories, and consults with the BOE and

CHDs.

(4) The BOE will use the current clinical case definition

and travel history to determine if testing for Influenza A

H5 is appropriate. At this time, no testing is to be

performed for Influenza A H5, unless authorized by the

BOE.

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40

(5) The BOE will ensure that the most current guidelines on

specimen submission are posted on its website.
c.
CDC Alert Phase

Takes place after the CDC contacts the State Surgeon

General to communicate the possible need to implement

specific portions of the FDOH and SERT Pandemic

Influenza Plan, most likely during WHO Phase 5.

Additionally, the DOH EOP, State Comprehensive

Emergency Management Plan (CEMP) and Pandemic

Influenza Appendix will be activated by the State Coordinating

Officer. During this Alert Phase, the following people and

units will take the following actions (Note: team members

should not switch work schedules or leave work unless

directed to do so by leadership):
(1) State Surgeon General
(a) Inform the Office of the Governor, DEM, other

department leadership, and CHD

directors/administrators of the status of the incident

and progression of pandemic influenza preparedness

efforts as appropriate.

(b) As per the State EOP, may convene all or a portion

of a DOH Executive Management Team (EMT).

(c) Activate the DOH COOP plan as needed.

(d) Provide formal authority and responsibility for

pandemic influenza operations to the EMT, and

performance expectations of the Deputies and their

subordinate divisions, bureaus, and offices in

relation to the EMT.
(e) Designate Executive Medical Advisor to provide

technical consultation to state policy and decision
makers.
(2) Chief of Staff
(a) Direct the DDC to coordinate pandemic
preparedness activitiespreparedness activities
across the department, including intensified
trainings and targeted exercises to test plans
and skill sets. This action will include
implementation of the department’s Crisis and Risk
Communication Annex for pandemic influenza.

(b) Coordinate pandemic influenza preparedness

activities for departmental executive leadership.

(c) Review COOP plans prior to their implementation to

ensure common understandings, levels of

accountability, and seamless performance standards.

(3) Deputies

(a) Supervise pandemic influenza preparedness

activities within their areas of responsibilities. This

will include coordination of efforts with and among

CHDs.

(b) Review COOP plans to meet the Chief of Staff’s

directions.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
41

(c) Update call lists if not already done.
(d) Advise staff of the situation.
(e) Begin to evaluate the work situation for the possibility
of staff being reassigned from their jobs for a period
of 7-10 days.

(4) Office of the General Counsel

(a) Collaborate with the DEM and the Governor’s Office

General Counsel on development of executive order

language.

(b) Assign on-call staff to EMT.

(c) Develop public health model orders to support

response to an influenza pandemic.

(d) Review legal authority and language related to local

quarantine authority, and disseminate guidance to

CHD leadership and attorneys as applicable, county

government leadership (political and civil), and law

enforcement. In this latter area, coordinate efforts

with, and possibly through, the Office of the Governor

and
Attorney
General.

(5) Division of Disease Control

(a) Provide overall guidance to the DDC’s Central

Office Bureaus as well as to CHDs.

(b) Coordinate with the BSPS, BOL, Division of Family

Health Services, CMS, DEMO, CHDs, and other

offices on activities involved in pandemic influenza

response efforts to ensure development of logistical

plans for receiving, storing, deploying, and retrieving

pharmaceuticals, medical equipment, and supplies.

(c) Provide technical assistance to the Office of

Communications.

(d) Provide technical assistance to and coordinate with

Poison
Control
Centers.

(e) Implement pandemic influenza preparedness

activities appropriate to the Alert Phase within the

division's areas of responsibilities.

(f) Ensure a mechanism for daily reporting of cases to

national authorities, including information on the

possible
source
of
infection.

(g) Serve as the ESF 8 liaisons for SERT in pandemic

influenza
preparedness
activities.

(h) Monitor federal guidance and develop Florida-

specific prioritization strategies for various levels of

influenza vaccine and antiviral drug availability.

(i) Within seven days of an alert, ensure that staff have

the competencies necessary to perform assigned

roles and responsibilities during a pandemic

response.

(j) Within 10 days of an Alert, prepare to implement (if

directed to do so by command staff) appropriate

COOP plans to ensure continuation of mission-

essential or life-sustaining departmental services.
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42

(k) Within 10 days of an Alert, review and test, in

conjunction with the BSPS and DEMO, the ordering,

receiving, shipping, dispensing, storage, and retrieval

procedures that the department will use for various

levels of vaccine and antiviral drugs.

(l) Within 10 days of an Alert, review the procedures for

reporting adverse events through the VAERS.
(m) Translate science-based concepts into
recommendations for actions and interventions.
(i) Circulate recommendations to relevant work units
for comment.
(ii) Provide the recommendations to the EMT.
(n) Provide technical assistance in public health and
healthcare system interventions to internal and
external response partners.
(o) Work closely with the Office of Communications in
the development of accurate, appropriate risk
communications messages to the target audience.

(6) Bureau of Epidemiology

(a) Investigate influenza outbreaks in conjunction with

CHDs.

(b) Provide consultation to CHDs and healthcare

providers, as needed, on suspect novel influenza

cases, including those suspected to be due to animal

to human transmitted influenza.

(c) Develop protocols for using surge capacity

epidemiology staff for surveillance activities.

(d) Work with CHDs and BOL to coordinate influenza

testing.

(e) Work with external partners (FWC, DOACS, and the

USDA) to remain informed of coordination efforts

related to non-human animal disease control.

(f) Disseminate the case definition established by the

CDC and/or WHO.

(g) Establish a system for revising the pandemic case

definition, given the availability of additional clinical

information (WHO will recommend global case

definitions according to different global phases).

(h) Distribute targeted educational materials to

healthcare providers about novel and pandemic

influenza.

(i) Continue to provide updated case definitions,

protocols, or algorithms for case finding, inclusive of

clinical data and travel or exposure history.

(j) Develop materials and help educate healthcare

providers, veterinarians, and animal disease

responders about pandemic influenza strains.

(7) BOE, Communications

(a) Identify and enumerate communication groups.

(b) Communicate regularly with key response partners.
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(c) Facilitate the implementation of a statewide

syndromic surveillance system.

(d) Facilitate a coalition of surveillance system partners.

(e) Continue work with CHDs to recruit medical providers

to participate in Florida Sentinel Influenza Provider

Network (FSIPN).

(f) In conjunction with the BOL and partner agencies,

provide guidance to hospital and clinical laboratories

for testing people for influenza when a novel strain

is suspected.

(g) Facilitate dissemination of pandemic influenza-

related materials to CHDs, partner agencies, and the

public.

(h) Ensure a mechanism for daily reporting of cases to

national authorities, including information on the

possible source of infection.

(8)
BOE, Surveillance
Systems

(a) Ensure that surveillance systems are in place to
detect aberrations, which may indicate the presence
of a novel influenza virus in humans.

(b) Within two days of an Alert, field test protocols for
enhanced statewide pandemic human and non-
human influenza surveillance and reporting.

(c) Monitor statewide syndromic surveillance data
through either local or statewide syndromic
surveillance systems.

(d) Maintain updated pandemic influenza screening
protocol and screening criteria on the BOE website.

(e) Develop protocols for using surge capacity
epidemiology staff for surveillance activities.

(f) Enhance surveillance to include the monitoring of the
following groups:

(i) People involved in culling birds or animals

infected with influenza (single cases and/or
clusters).

(ii) Other people exposed to birds or animals

infected with influenza; for example, farmers, and

veterinarians (single cases or clusters).

(g) Monitor National Retail Data Monitor (NRDM) data to
detect aberrations in sales of over-the-counter (OTC)
pharmaceuticals statewide.

(h) Monitor BioSense surveillance data.

(i) Monitor mortality trends as reported by four Florida
cities reporting data to the CDC's 122 Mortality
Surveillance Cities (Jacksonville, Miami, St. Petersburg,
and Tampa).

(j) Access local syndromic surveillance systems to
monitor respiratory and ILI in various locations across
the state.

(k) Maintain and monitor the Pneumonia and Influenza
Mortality Surveillance System.
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44

(l) Maintain and enhance Merlin and the Merlin
Outbreak Module to facilitate the reporting and
management of cases and contacts during
outbreaks.
(m)
Implement
system enhancements developed for
electronically reporting laboratory influenza
surveillance data to CHDs via Merlin.

(n) Work with BOL and the private sector to implement
system enhancements for the receipt of influenza
results from hospital laboratories.

(o) Maintain the Florida Pneumonia and Influenza
Reporting System (FPIRS).

(p) Establish a system for monitoring antiviral use and
adverse events that may be attributed to their use.

(q) Work with Bureau of Immunization to establish a
system for:

(i) Monitoring vaccine usage for routine and
pandemic strain influenza vaccines, if these are
available.

(ii) Monitoring adverse vaccine events attributed to
the pandemic strain vaccine, if available.

(iii) Collecting data for later use in the calculation of
vaccine effectiveness for the pandemic strain
vaccine.

(iv) Monitoring pneumococcal vaccine use and
adverse events associated with its use.

(v) Monitoring hospital admissions for suspected or
confirmed cases of pandemic strain influenza.
(9) BOE, Analysis and Decision Making
(a) Establish/refine a mechanism for data aggregation
and interpretation for decision making.

(b) Determine and report weekly state-level influenza

activity to the CDC and disseminate to CHDs.

(c) Establish criteria to indicate when to move from one

level of surveillance to a higher or lower level, as well

as indicators for movement from case-based control

measures to community-based control measures.

(d) Consider how recovered cases can be identified by
occupation (healthcare workers or workers in
designated essential services) in order to facilitate
the development of a cadre of skilled workers
presumed to be immune.

(e) Analyze excess deaths attributable to pneumonia

and
influenza.

(f) Aggregate and interpret animal disease exposure

case reports to determine the need for modified

infection
control
guidelines.
(10) Bureau of Laboratories
(a) In conjunction with the DDC and partner agencies,

provide guidance to hospital and clinical laboratories
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45

for specimen collection, handling, and transport when

a novel strain is suspected.
(b) Procure appropriate reagents from the CDC or other

appropriate resources to detect and identify the novel
virus
strain.

(c) Partner with local private sector labs that do not have

virus strain identification capacity to obtain and use

rapid antigen testing kits.
(d) Implement pandemic influenza preparedness

activities appropriate to Alert Phase within their areas
of
responsibilities.
(e) Within seven days of an Alert, ensure that staff have

the competencies necessary to perform assigned

roles and responsibilities during a pandemic
response.
(f) Within 10 days of an Alert, review and test the

Statewide Laboratory Surge Plan to ensure

functionality in a pandemic influenza event.
(g) Within 10 days of an Alert, prepare to implement (if

directed to do so by command staff) appropriate

COOP plans to ensure continuation of mission-

essential, life-saving, or life-sustaining departmental
services.
(11) Bureau of Statewide Pharmaceutical Services
(a) Develop, document, and implement pandemic
influenza preparedness activities within their areas of
responsibilities.
(b) Within 10 days of an Alert, review and test plans and
procedures in conjunction with the DDC and DEMO,
for ordering, receiving, shipping and dispensing, in
addition to the storing and retrieval procedures that
the department will use for various levels of vaccine
and antiviral drug availability.
(c) Within seven days of an Alert, review and refine
contingency plans related to antibiotic and other
pharmaceutical shortages.
(d) Within seven days of an Alert, ensure that staff have
the competencies necessary to perform assigned
roles and responsibilities during a pandemic
response.
(e) Within 10 days of an Alert, prepare to implement
(if directed to do so by EMT) appropriate COOP
plans to ensure continuation of mission-essential,
life-saving, or life-sustaining departmental services.
(12) Division of Family Health Services
(a) Review contingency plans for distribution of WIC,
and other childhood nutritional items.
(b) Review educational materials to distribute to client
families.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
46

(c) Review COOP plans and prepare to implement on
order of the FDOH EMT.
(13) Division of Emergency Medical Operations
(a) Review plans for logistical support of the DDC and
BSPS.
(b) Review COOP plans and prepare to implement on
order of the EMT.
(c) Review hospital, outpatient, and medical surge plans
with the Agency for Health Care Administration
(AHCA) and private sector healthcare providers.
(d) Review plans with Emergency Management
Assistance Compact (EMAC) partners.
(14) Children’s Medical Services
(a) Appoint liaison to FDOH EMT.
(b) Review COOP plans and prepare to implement on
order of the FDOH EMT.
(c) Provide educational materials to local CMS offices for
distribution to client families.
(d) Review plans with appropriate CHD ICs.
(15) County Health Departments
(a) In conjunction with local emergency management
and community partners, review and test local plans
to assess existing healthcare resources and
coordinate responses with key stakeholders at the
local level.
(b) Implement pandemic influenza preparedness
activities appropriate to the Alert Phase within their
areas of responsibilities.
(c) Investigate influenza outbreaks in the county in
conjunction with BOE. In the case of a novel
influenza strain, one case is considered an
outbreak.
(d) Report individual human cases through established
methods used for notifiable disease surveillance.
(e) Work with the county’s healthcare community to
heighten response activities and monitor the impact
of the pandemic on healthcare facilities and systems
and communicate regularly with key response
partners.
(f) Identify and recruit private practice physicians and
those who work in walk-in clinics in areas where hard
to reach people reside, and remote areas within the
county, to serve as sentinel physicians.
(g) Assist in identifying and recruiting medical providers
willing to participate in FSIPN.
(h) If available at the CHD, monitor the local Syndromic
Surveillance System daily for detection of respiratory
infection or ILI data. If a syndromic surveillance
system is in place, develop written response
protocols for detected aberrations in syndromic
surveillance data.
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(i) Register for access to NRDM, if not already done,
to view county specific OTC medication data.
(j) Consult with BOL on collection of specimens for
influenza and suspected novel influenza testing.
(k) Make contact with every laboratory in the county that
tests for respiratory viruses to ensure that they
contact the CHD immediately if they get a request for
testing for the novel strain of influenza or receive a
specimen for such testing. Facilitate the transfer of
specimens to an appropriate BOL facility.
(l) Develop partnerships with schools and large
businesses to monitor ILI rates and school/work
absenteeism.
(m) Work with hospitals in the development of an
operational plan that will interface with local and state
public health emergency plans.
(n) Identify points of contacts at airports, sea ports, bus
and train stations, and other forms of mass transit for
communication of information.
(o) Establish and implement, as indicated, a public
information call-in/rumor control telephone number
and/or website.
(p) Communicate with medical examiners (ME) to
request reporting of reportable influenza deaths.
(q) Ensure epidemiologic investigation of pediatric
influenza deaths and influenza-associated
encephalitis of county residents in conjunction with
the BOE.
(r) Report October though May County Influenza Activity
Levels via EpiCom.
(s) Help educate healthcare providers about novel and
pandemic influenza.
(t) Provide local audiences with targeted, up-to-date
information on the occurrence of novel human
influenza viral infections.
(u) Educate the public on the symptoms of influenza,
including what to do if they suspect cases, clusters,
or outbreaks of infection.
(v) Within seven days of an Alert, ensure that staff have
the competencies necessary to perform assigned
roles and responsibilities during a pandemic
response.
(w) Review COOP and other contingency plans for
sustainment of essential community services and
anticipated shortages of critical resources.
(x) Within 10 days of an Alert, prepare to implement
appropriate COOP plans to ensure continuation of
mission-essential, life-saving, or life-sustaining
departmental services.

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48

(16) Division of Environmental Health
(a) The Zoonotic and Vector-borne Disease Program will
serve as a liaison between FDOH, DOACS, and
FWC in the monitoring of avian influenza in birds.
(b) Develop and update guidelines in conjunction with
state partner agencies that will ensure the safety of
the food supply and mitigate the risk of exposure
from wildlife.
(c) Implement pandemic influenza preparedness
activities appropriate to the Alert Phase within their
areas of responsibilities.
(d) Within seven days of an Alert, ensure that staff have
the competencies necessary to perform assigned
roles and responsibilities during a pandemic
response.
(e) Ensure the continuation of mission-essential or life-
sustaining departmental services.
(17) All Other Divisions, Bureaus, Offices, and A.G. Holley
Hospital
(a) Implement pandemic influenza preparedness
activities as appropriate to the Alert Phase within
their areas of responsibilities.
(b) Within seven days of an Alert, ensure that staff have
the competencies necessary to perform assigned
roles and responsibilities during a pandemic
response.
(c) Within 10 days of an Alert, implement appropriate
COOP plans (as directed by the department EMT) to
ensure continuation of mission-essential, life-saving,
or life-sustaining departmental services.
2. Response
a.
WHO Phase 5 or 6 (Pandemic Alert Period) CDC Response
Phase
(1) State Surgeon General
(a) Regularly brief the Governor of the phase and status
of the event.
(b) Regularly brief other elected officials of the status of
the event.
(c) Direct the EMT and Chief of Staff regarding
implementation of COOP plans.
(2) Office of Communications
(a) Continue to implement the Pandemic Influenza Appendix
and Crisis and Risk Communications Annex.
(b) Participate in JIC operations.
(c) Designate PIO to support ESF 8 and ESF 14.
(d) Coordinate and develop effective and accurate
public, healthcare provider, private sector, and
political leadership messages.
(e) Provide periodic updates on the event status to
FDOH divisions, bureaus, CHDs, CMS clinics, and
A.G. Holley Hospital.
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(f) Assist CHD PIOs with their local risk communications
efforts.
(g) Monitor information flow, analyze message
effectiveness, and initiate corrective measures to
address rumors and misinformation.
(3) Office of the General Counsel
(a) Implement Executive Order routing, if requested to
do so by senior leadership.
(b) Assist local CHDs regarding isolation and quarantine
orders, as requested.
(c) Maintain event specific legal documentation.
(d) Serve as liaison to the Attorney General and other
state agency legal staff.
(4) Division of Disease Control
(a) The Division of Disease Control will identify staff with
appropriate skills and experience who can be
activated to carry out necessary functions within the
ICS structure.
(5) Bureau of Epidemiology
(a) The Bureau of Epidemiology will identify staff with
appropriate skills and experience who can be
activated to carry out necessary functions within the
ICS structure.

(b) The Bureau of Epidemiology will provide access to
surveillance systems maintained by the bureau to
support Pan Flu command structure needs.
(6) Bureau of State Laboratories
(a) The Bureau of Laboratories will identify staff with
appropriate skills and experience who can be
activated to carry out necessary functions within the
ICS structure.
(b) The Bureau of Laboratories will provide access to
laboratory facilities, equipment, and supplies
maintained by the bureau to support Pan Flu
command structure needs.
(7) County Health Departments
(a) Continue and intensify surveillance efforts
undertaken in prior phase, to include:
(i) Soliciting first responders to assist with
community surveillance.
(ii) Increasing surveillance of incoming travelers from
infected regions at POE.
(b) Request epidemiologic surge capacity staff to
support phones, data entry, and investigations.
(c) Increase review of syndromic surveillance data for
respiratory disease surveillance to twice daily.
(d) Establish system to monitor workforce absenteeism
among staff in essential service jobs.
(e) Enhance surveillance to include monitoring of the
following groups:

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(i) Healthcare workers caring for patients with
suspected or confirmed pandemic strain
influenza infection (single cases and/or clusters).
(ii) Laboratory workers handling clinical specimens
from patients with suspected or confirmed
pandemic strain influenza infection (single cases
and/or clusters).
(iii) School students.
(iv) Mortuary workers.
(f) Vital Statistics offices’ reports of county deaths on a
daily (instead of weekly) basis using the Florida
Pneumonia and Influenza Mortality Reporting System
(FPIMRS).
b.
WHO Phase 6 Pandemic Response
(1) State Surgeon General
(a) In conjunction with the State Coordinating Officer
(SCO), regularly brief the Governor of the phase and
status of the event.

(b) Regularly brief other elected officials of the status of
the
event.

(c) Serve as a member of the state Unified Command

staff, as directed by the Governor.

(d) Direct the EMT and Chief of Staff regarding

implementation of COOP.

(2) Executive Management Team (EMT)

(a) Advise the Surgeon General and SCO on possible

impacts of control measures on the operations of the

rest of the agency.

(3) Chief of Staff

(a) Provide oversight of routine FDOH and COOP
operations.

(b) Coordinate with Deputies and Division Directors the

temporary re-assignment of staff to support

necessary department functions.
(4)
Deputies

(a) Supervise COOP activities within their jurisdictional
areas.

(b) Coordinate the backfill and mutual support to other

Deputies, divisions, bureaus, and offices, to ensure

continuation of core FDOH operations.

(5) Office of Communications
(a)
See
above.

(6) Office of the General Counsel
(a)
See
above.

(7) Division of Disease Control

The Division of Disease Control will identify staff with
appropriate skills and experience who can be activated
to carry out necessary functions within the ICS structure.

(a) The Division of Disease Control will maintain other
disease control activities consistent with the DOH
COOP plan.
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(8) Bureau of Epidemiology

The Bureau of Epidemiology will identify staff with

appropriate skills and experience who can be activated

to carry out necessary functions within the ICS structure.

Such functions may include:

(a) Monitor and trend impact, change in epidemiology,

clinical presentation, and virologic features.

(b) Conduct respiratory disease surveillance system

monitoring twice daily.

(c) Monitor vital statistics and MEs for mortality
surveillance.

(d) Consult with BOL to determine whether to limit or

discontinue both routine and early warning
surveillance
testing.

(e) Assess the effectiveness of interventions.

(f) Implement system for monitoring antiviral use and

adverse events that may be attributed to antiviral

use, if applicable.

(g) Work with Bureau of Immunizations to implement a
system
for:

(i)
Monitoring vaccine usage for routine and

pandemic strain influenza vaccines, if these
are
available.

(ii)
Monitoring adverse vaccine events attributed

to the pandemic strain vaccine, if available.

(iii)
Collecting data for later use in the calculation

of vaccine effectiveness for the pandemic
strain
vaccine.

(iv)
Monitoring pneumococcal vaccine use and

adverse events associated with its use, if this

vaccine is available and being used.
(h) The Bureau of Epidemiology will provide access to
surveillance systems maintained by the bureau to
support Pan Flu command structure needs.

(9) Bureau of Laboratory Services
The Bureau of Laboratories will identify staff with appropriate
skills and experience who can be activated to carry out
necessary functions within the ICS structure. Such functions
may include:

(a) Implement the Laboratory Surge Plan, as

appropriate, to ensure specimen testing capacity and

capability is not exceeded.

(b) Work with the DDC in surveillance and reporting
operations.

(c) Implement COOP plans, as necessary.

(d) Shift testing priorities as required by the event and

specimen volume.

(e) Continue to perform surveillance testing on a select

number of specimens in collaboration with the BOE
and
CHDs.

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52

(f) Inform public and private labs and the healthcare

community of policy shifts in specimen testing.

(g) Sentinel surveillance and outbreak investigation

testing will continue following the first wave of the

pandemic and any additional subsequent waves.

(h) Continue to test specimens for genetic shifts.
(i) The Bureau of Laboratories will provide access to

laboratory facilities, equipment, and supplies

maintained by the Bureau to support Pan Flu

command structure needs.
(10) Bureau of Statewide Pharmaceutical Services

The Bureau of Statewide Pharmacy Services will identify
staff with appropriate skills and experience who can be
activated to carry out necessary functions within the ICS
structure, which may include:

(a) Work on allocation and apportionment issues.

(b) Support SNS and Managed Inventory operations.

(c) Support ordering, receiving, shipping, dispensing,

storage, and retrieval of vaccines and antivirals,

based on state and federal guidelines.

(d) Monitor for antibiotic and other pharmaceutical

shortages and implement contingency plan(s) for

maintaining adequate supplies.

(e) Monitor utilization and implement re-supply plans for

redistribution of vaccines and antivirals, as
necessary.

(f) Provide a staff member who can serve as the

ordering officer for requisitioning of antivirals under
HHS
managed
antiviral
contracts.
(g)Provide access to pharmaceuticals, facilities,

equipment, and supplies maintained by the bureau

to support Pan Flu command structure needs.

(11) Division of Emergency Medical Operations

(a) Upon mobilization of the SERT, the ECO will assume

the role of lead for ESF 8.

(b) The ECO will direct and coordinate incident response

activities per the instructions of the department’s EMT.

(c) The ECO will serve as the entity authorizing official

for requisitioning of antivirals under HHS managed
antiviral
contracts.

(d) Implement COOP plans, as needed.
(12) County Health Departments
(a) Continue to implement appropriate response
activities as defined in local pandemic influenza plans
and as directed by the FDOH EMT.
(b) Implement CHD COOP plans as directed.
(c) Conduct select individual case or outbreak
investigations, as needed, to guide prevention and
control
recommendations.
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(d) Work with the BOE to assess the effectiveness of

community-based disease control interventions,
including:
(i) Antivirals.

(ii)
Vaccine, when available.

(iii)
Social distancing.
(e) School closures, as applicable.

(f) Collect aggregate data on the number of patients

seen meeting case definition, as provided by the

BOE, from healthcare providers.

(g) Work with community partners to support aggregate

monitoring of morbidity and mortality.

(h) In conjunction with the BOE and DDC, provide

regular updates to key response partners on local

disease trends as they become available, including:

(i)
Case incidence as well as morbidity and
mortality.

(ii)
Range of clinical presentations and other

characteristics of the circulating strain(s).

(iii)
Risk factors associated with increased

morbidity and mortality.

(iv)
Local populations that may be at increased
risk.

(i) Levels of absenteeism in public

services designated as essential.
(13) All Other Divisions, Bureaus, Offices, and A.G. Holley

Hospital

(a) Implement pandemic influenza response activities

within areas of responsibility.

(b) Implement appropriate COOP plans to assure

continuation of mission-essential, life-saving, or life-

sustaining departmental services.

(c) Assign staff to support state/county health and

medical response as directed by the Chief of Staff.
3.
Recovery/Mitigation Phase between Waves and End of Pandemic
a.
The FDOH response efforts will be scaled down in an
appropriate and proportionate way based on the course of
the pandemic and the reduction of illness within the state.
Divisions and bureaus will gradually re-establish routine
operations as per existing FDOH COOP plans.
b.
Divisions and bureaus involved in response efforts will
actively participate in the development and review of the
After Action Report (AAR) and other mitigation efforts. FDOH
recovery operations will be guided by the following
principles:

(1) Identify those organizational functions that are key and

essential to be performed throughout the pandemic

period.
(2) Temporarily assign staff, particularly those who have
recovered from the pandemic influenza virus, to fill
essential positions.
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54

(3) Identification of FDOH employees for pandemic influenza
vaccinations in priority sequence, based upon risk factors
and criticality for mission accomplishment.
(4) Identification of those employees who are likely to be
long-term absentees, such as those who must be
caregivers for children who are not in school due to
school closings.
(5) Develop or adapt COOP plans to accommodate
absences to enable work to continue.
(6) Implement disaster behavioral health services, as
necessary, being proactive in implementation.
(7) Phased return to normal staffing and normal conduct of
business based on prevalence of the pandemic and
availability of staff. In compliance with Department of
Management Services (DMS) guidance, the department
will give consideration to staff for return to their regular
activities.
(8) Update job descriptions of deceased employees and
others who do not return to work. Expedite the
recruitment and hiring processes to fill these vacancies.
(9) Assist CHDs in their recovery, as necessary and within
department resources.
c.
Position Specific Roles and Responsibilities

(1) State Surgeon General

(a) Provide recommendation to the Governor when an

Executive Order may be rescinded.

(b) Stand down the EMT and the EMT staff.
(2) Chief of Staff
(a) Direct normalization from COOP implementation
activities.
(b) Direct the development of a consolidated and
comprehensive AAR to be submitted to the State
Surgeon General within 90 days of the declaration of
the end of the Executive Order.
(3) Deputies
(a) Implement recovery activities within their areas of
responsibility.

(b) Ensure that AARs are completed within areas of
responsibility.
(4) Office of Communications
(a) Continue Crisis and Risk Communications Annex implementation
for Recovery Phase.

(b) Compose and submit AAR to Chief of Staff.
(5) Division of Disease Control

(a) In conjunction with the BOL, continue surveillance

program to detect antigenic drift variants or re-

assortment viruses for detection of possible changes

in the original pandemic strain.
(b) In conjunction with the BSPS, implement plan for the

recovery of unused vaccine, antivirals, antibiotics,
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55

and other pharmaceuticals in collaboration with
DEMO.
(c) Compose and submit AAR to Chief of Staff.
(6) Bureau of Statewide Pharmaceutical Services
(a) In conjunction with the Bureau of Immunization and

in coordination with DEMO, implement a plan for the

recovery of unused vaccine, antivirals, antibiotics and
other
pharmaceuticals.

(b) Compose and submit AAR to Chief of Staff.
(7) Bureau of State Laboratories
(a) Continue to test specimens for genetic shift, drift, or
recurrence
of
infection.
(b) Compose and submit AAR to Chief of Staff.
(8) Division of Emergency Medical Operations
(a) Assist DDC and BSPS in the recovery of antivirals
and
vaccines.
(b) Compose and submit AAR to Chief of Staff.
(9) County Health Departments/Children’s Medical Services
(a) Return to pre-pandemic operations.
(b) Compose and submit AAR to Chief of Staff.
(10) All Other Divisions/Bureaus/Offices/ and A.G. Holley
Hospital
(a) Return to normal operations as appropriate.
(b) Compose and submit AAR to Chief of Staff.

IV.
Continuity of Government (COG)

In compliance with the direction of the Governor, DOH Executive Leadership shall

serve to ensure Continuity of Government. See FDOH Continuity of Government
Plan.

V.
Continuity of Operations Plan (COOP)

A. Concept
The local CHD/CMS may implement COOP plans that prioritize the delivery
of essential services, using a tiered approach.

B. Objective
Maintain essential core public health services interventions.

C.
Tier I (First priority)
1.
Division of Disease Control
a. Immunizations
(1) Tetanus and Diphtheria [(Td) acute]
(2) Rabies Post Exposure Prophylaxis (PEP)
(3) Hepatitis A/B
(4) Pneumovax, childhood (outbreak only)
b.
Tuberculosis (TB)
(1) Treatment
(2) Directly Observed Therapy (DOT) for cases only
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56

c.
HIV-AIDS Drug Assistance Program (ADAP)
(1) Treatment
d.
Sexually Transmitted Diseases
(1) Treatment only
e.
Bureau of Epidemiology
(1) Urgent cases only
2. Medical
Services
a. Family
Planning
(1) Provide appropriate Family Planning (FP) method only
(most expeditious way)
b. WIC
(1) Certification and check issuance only
c. Adult
health
(1) Acute care only
(2) Triage
d. Pediatrics
(1) Acute care only
e. Maternity
(1) Routine care
3. Environmental
Health
a. Rabies

(1) Bite investigations
b. Water
(1) Bacteriological testing
c. Child/Group
care
(1) Inspections
d.
Onsite Sewage Treatment and Disposal System (OSTDS)
(1) Repair inspections
(2) Permits
4. Administrative
a.
Vital Statistics
(1) Current birth records
(2) Current death records
b. Finance
(1) Medicaid billing
(2) Accounts receivable
(3) Accounts payable
(4) Purchasing Cards
(a) Purchases
(b) Current inventories
c.
Information Technology
(1) Keep all networks and phone systems operational
d.
Human Resource
(1) Payroll
(2) Critical vacancies

D.
Tier II (Second Priority)
1.
Division of Disease Control
a. Immunizations
(1) All childhood resumed

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57

b. Tuberculosis

(1) Rule out TB in contacts
c.
HIV-AIDS Drug Assistance Program (ADAP)
(1) Take case reports for new cases
(2) High-risk counseling/testing
d.
Sexually Transmitted Diseases
(1) Follow-up pregnant females
e.
Bureau of Epidemiology
(1) Investigate for reportable diseases
2. Medical
Services
a. Healthy
Start
(1) Highest risk screenings
b. School
Health
(1) Dependant on whether school open
c. WIC
(1) Certifications, age 1-5
3. Environmental
Health
a. Complaint
Response
(1) Programs with enforcement actions
b.
Onsite Sewage Treatment and Disposal System (OSTDS)
(1) New inspections
c. Inspections
(1) Begin prioritization
4. Administrative
a.
Vital Statistics
(1) Work with funeral directors for records
b. Purchasing
(1) Supplies inventory
c.
Information Technology
(1) Hardware procurement and replacement

E.
Staff will wear appropriate PPE when in direct contact with clients.

F. DOH operations will be coordinated by the Executive Management Team as

outlined in the DOH, Emergency Operations Plan, and COOP Plan. CHD

directors/administrators shall oversee COOP plans within their areas of

responsibility, maintaining communication with the State Surgeon General
and
Deputies.

VI.
Authorities and References

A. Authorities
1. Section
120.54,
Florida Statutes (F.S.)
a.
State Agencies
(1) Allows state agencies to adopt temporary emergency
rules when there is immediate danger to public health,
safety, or welfare, without going through the normal rule-
making process.

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58

2. Section
381.003,
F.S.
a.
Governor/Division of Emergency Management:
(1) Allows Governor to declare a state of emergency.
(2) Gives Governor direction and control of emergency
management.
(3) Allows Governor and division to delegate authority to
carry out critical functions to protect the peace, health,
safety, and property of the people of Florida.
3. Section
381.0011,
F.S.
a. FDOH
(1) Authorizes the department to administer and enforce
laws and rules relating to the control of communicable
disease.
(2) Authorizes the department to declare, enforce, modify,
and abolish quarantine of people, animals, and premises.
(3) Authorizes the department to specify the conditions and
procedures for imposing and releasing a quarantine
order.
4. Section
381.0012,
F.S.
a. FDOH
(1) Authorizes the department to maintain the necessary
legal action; request warrants for law enforcement
assistance; and directs state and county attorney, law
enforcement, and city and county officials, upon request,
to assist the department to enforce the state health laws
and rules adopted under Chapter 381, F.S.
5. Section
381.00315,
F.S.
a. FDOH
(1) Authorizes the State Surgeon General to declare public
health emergencies and issue public health advisories.
6. Section
768.28,
F.S.
a. State
Agencies
(1) Protects state employees who administer immunizations
as part of their official duties.

VII.
Plan Review and Maintenance

A.
Director of the Division of Disease Control, will:
1.
Take the lead in revising the pandemic influenza plan.
2.
Complete the pandemic influenza plan review, and update annually,

or more frequently as needed.

B.
Other Divisions, Bureaus, and Offices

1.
Assist the DDC as tasked by the Director of the DDC.

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59

C. Record of Updates
Update
Status
V.11.2
Approved 03/2009
V10.4 Authorized by Secretary
Completed 09/2006
V10.0 Draft
Completed 09/2006
Develop Technical Appendices
Completed 03/2006
V9.1
Completed 02/2006
Develop Flu Aid Tables for Vulnerability Analysis
Completed 13/2005
Cross Reference Nov. 2005 HHS Plan
Completed 11/2005
Develop Preparedness, Response and Recovery Matrices
Completed 11/2005
Incorporate “White Paper” Planning Recommendations
Completed 09/2005
Incorporate CHD Advisory
Completed 03/2005
Compare WHO Phases to Phase of Emergency Management
Completed 11/2005
Convert to Standard Format
Completed 06/2005
Update Pandemic Influenza Plan V8.0
Completed 03/2004

VIII. Addenda

A.
Acronyms and Abbreviations
AAR
After Action Report
AHCA
Agency for Health Care Administration
AI
Avian Influenza
ARNP
Advanced Registered Nurse Practitioner
BOE
Bureau of Epidemiology
BOL
Bureau of Laboratories
BSPS
Bureau of Statewide Pharmaceutical Services
CDC
Centers for Disease Control and Prevention
CFR
Code of Federal Regulations
CHARTS
Community Health Assessment Resource Tool Set
CHD
County Health Department
CMS
Children’s Medical Services
COOP
Continuity of Operations
COG
Continuity of Government
DDC
Division of Disease Control
DEM
Division of Emergency Management
DEMO
Division of Emergency Medical Operations
D.O.
Doctor of Osteopathic Medicine
DOACS
Department of Agriculture and Consumer Services
DOT
Directly Observed Therapy
DSNS
Division – Strategic National Stockpile (CDC)
ECO
Emergency Coordinating Officer
ED
Emergency Department
EMAC
Emergency Management Assistance Compact
EMS
Emergency Medical Services
EMT
Executive Management Team
EOC
Emergency Operations Center
EOP
Emergency Operations Plan
ESF
Emergency Support Function
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60

ESF-8
Emergency Support Function 8: Health and Medical Services
ESF-14
Emergency Support Function14: Public Information
FDA
Food and Drug Administration
FDOH
Florida Department of Health
FLNG
Florida National Guard
FMS
Federal Medical Station
FPIRS
Florida Pneumonia and Influenza Reporting System
F.S.
Florida Statute
FSIPN
Florida Sentinel Influenza Provider Network
FWC
Florida Fish and Wildlife Conservation Commission
H5N1
Hemagglutinin subtype 5 Neuraminidase subtype 1 (influenza virus)
HAN
Health Alert Network
HCW
Healthcare Worker
HHS
Health and Human Services
HIV – ADAP
Human Immunodeficiency Virus – AIDS Drug Assistance Program
HMO
Health Maintenance Organization
HPAI
Highly Pathogenic Avian Influenza
IC
Incident Commander
ICU
Intensive Care Unit
ILI
Influenza Like Illness
IT
Information Technology
JIC
Joint Information Center
JIS
Joint Information System
LSA
Logistical Staging Area
M.D.
Medical Doctor
ME
Medical Examiner
NRDM
National Retail Data Monitor
OSTDS
Onsite Sewage Treatment and Disposal Systems
OTC
Over The Counter
P.A.
Physician Assistant
PEP
Post-Exposure Prophylaxis
PI
Pandemic Influenza
PIO
Public Information Officer
POE
Points Of Entry
PPE
Personal Protective Equipment
PSI
Pandemic Severity Index
R/O
Rule Out
RRC
Rapid Response and Containment
RSS
Receiving, Staging, and Storing Site
SEOC
State Emergency Operations Center
SERT
State Emergency Response Team
SNS
Strategic National Stockpile
STD
Sexually Transmitted Disease
TAG
Technical Advisory Group
TB
Tuberculosis
TBD
To Be Developed/Determined
Td
Tetanus and Diphtheria
U.S.
United States
USG
United States Government
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USDA
United States Department of Agriculture
VAERS
Vaccine Adverse Event Reporting System
VS
Vital Statistics
WHO
World Health Organization
WIC
Women, Infants, and Children

B.
Glossary of Terms

Activation Levels: These levels reflect the operational stage of the State Emergency
Operations Center in reaction to an actual or anticipated event.
Alert Phase: Takes place after the CDC contacts the State Surgeon General to
communicate the possible need to implement specific portions of the Florida Department
of Health and SERT Pandemic Influenza Plan.
Antiviral Medication: Medications for use in treating viral infections, in this case
influenza. Influenza antivirals include Zanamivir and Oseltamivir.
Asymptomatic: The period when an infected patient will not experience any symptoms.
Avian Influenza: Influenza-type virus found in both wild and domestic birds.
Case-Based Containment: Restrictions applied to individuals to reduce disease spread.
Community-Based Containment: Restrictions placed on communities to reduce
disease spread.
Contact (of a case): A person or animal that has been in such association with an
infected person or animal or contaminated environment as to have the opportunity to
acquire the infection.
Continuity of Operations Plan (COOP): A plan to ensure that critical operations
continue in the case of catastrophic events.
Contaminated: The presence, or the reasonably anticipated presence, of blood or other
potentially infectious materials on an item or surface.
Cough Etiquette: Infection control procedures that emphasize covering coughs in
tissues or sleeves, and frequent cleaning of hands.
Critical Infrastructure: Systems and assets, whether physical or virtual, so vital to the
United States that the incapacity or destruction of such system and assets would have a
debilitating impact on security, national economic security, national public health or
safety, or any combination of those systems.
Decontamination: The use of physical or chemical means to remove, inactivate, or
destroy pathogens on surfaces or items to the point where the pathogens are no longer
capable of transmitting infectious particles, and the surface or item is rendered safe for
handling, use, or disposal.
Epidemiology: The study of the distribution and determinants of health-related states or
events in specified populations, and the application of this study to control health
problems.
Essential Function: Functions that are absolutely necessary to keep an agency or
business operating during an influenza pandemic, and critical to survival and recovery.
First Wave: The initial outbreak of influenza in the population. This could last four to
eight weeks, and be followed by two to three subsequent waves.
Florida Emergency Mortuary Operations Response System (FEMORS): An
organization that responds to and advises on mass fatality incidents using trained
personnel from multiple state and local agencies. Online at: http://www.femors.org.
Hand Washing Facilities: A facility providing an adequate supply of running potable
water, soap, and single use towels or hot air drying.
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Health Alert Network (HAN): A nationwide system that communicates vital health
information and the infrastructure that supports the dissemination of health information at
the state and local levels, online: http://www2a.cdc.gov/HAN/Index.asp.
Infection Control: Measures taken to prevent further infections and the spread of
disease. These precautions include separate waiting facilities, pre-arranged triage
mechanisms, spatial separation, use of personal protective equipment, and
encouragement of respiratory hygiene.
Interpandemic Phase: The period when no new virus subtypes are detected in humans;
surveillance is used to assess seasonal burden of influenza.
Isolation: Measures taken to segregate ill and infectious people to prevent disease
transmission to others.
Joint Information Center (JIC): A place where public information officers of agencies
affected by an event work together to provide coordinated/consolidated public
information as quickly as possible to promote effective and timely review and release of
information to the public.
Joint Information System (JIS): A system in which multiple agencies coordinate their
message/response to an event without being physically located at a specific site.
Medical Surge: Increased need for medical personnel in a catastrophic health event or
pandemic.
Mode: A given condition of functioning, a status.
Morbidity: The measure or rate of disease occurrence.
Mortality: The measure or rate of death.
Novel Influenza Virus: A new strain of influenza with limited to no immunity, and has the
potential to create a pandemic.
Occupational Health: Branch of medicine concerned with protecting the safety, health,
and welfare of people engaged in work or employment.
Pandemic Influenza (PI): Spread of influenza over a wide geographic area affecting
much of the human population.
Personal Protective Equipment (PPE): Specialized clothing or equipment worn by an
employee for protection against a hazard. These items may include: disposable gloves,
protective clothing, rubber or polyurethane boots, safety goggles, and particulate
respirators.
Phases: Progressive stages of disease progression of a pandemic influenza.
Prophylaxis: Measures taken to prevent disease. Primary prophylaxis prevents the
development of disease, while secondary prophylaxis refers to when the disease has
already developed, but measures are taken to protect against the worsening of the
patient’s condition.
Quarantine: Segregation of people who are currently well, but who have been exposed
to an infectious disease agent.
Rapid Response and Containment: Immediate measures (e.g., isolation and
quarantine, treatment, and prophylaxis) that are taken to control and contain disease
spread.
Recovery Phase: Takes place when the response efforts are scaled down in an
appropriate and proportionate way based on the course of the pandemic and the
reduction of illness within the state. Divisions, bureaus, and units will gradually re-
establish routine operations as per existing FDOH COOP plans. Divisions, bureaus and
units involved in response efforts will actively participate in the development and review
of the After Action Report.
Respiratory Protection: Procedures and equipment that are used to protect personnel
from breathing in infectious particles (e.g., wearing respirators).
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63

Response Phase: Takes place at the point where preparedness evolves to response.
Indicates that staff are needed to support incident activities. Team members will report
fully prepared to focus only on incident activities.
Second Wave: A subsequent outbreak of influenza that occurs after the first wave has
diminished. May last four to eight weeks, and potentially followed by a third wave.
Pandemic Severity Index (PSI): A proposed classification scale for reporting the
severity of influenza pandemics in the United States. The PSI accompanied by a set of
guidelines intended to help communicate appropriate actions for communities to follow in
potential pandemic situations. Released by the U.S. Department of Health and Human
Services (HHS) on February 1, 2007, the PSI is designed to resemble the Saffir-Simpson
Hurricane Scale classification scheme.
Sheltering in Place: Procedures that involve individuals isolating themselves within their
homes.
Social Distancing: Steps taken to reduce face-to-face interactions throughout the
community.
Strategic National Stockpile (SNS): Large quantities of medicines and medical supplies
retained at the federal level for shipment to the local level in response to a public health
emergency.
Surveillance: Measures and procedures used to monitor and assess the progression of
disease occurrence.
Surge: Describes the ability to provide adequate medical evaluation and care during
events that exceed the limits of the normal medical infrastructure of an affected
community.
Symptomatic: The stage of infection when a patient shows symptoms.
Tamiflu (Oseltamivir): Antiviral drug that is used for treatment and prophylaxis of both
Influenza type A and type B.
Threshold Determinant: A change of significant intensity to evoke a response.
Transmission-Based Precautions: Infection control procedures that are instituted in a
hospital setting to prevent the spread of disease based on how the disease is
transmitted.
Trigger: Initiate or start.
Vaccines: Preparations of killed or modified microorganisms that can stimulate an
immune response in the body to prevent future infection of a similar type.
Vector: An insect or any living carrier that transports an infectious agent from an infected
individual, or its wastes, to a susceptible individual, or its food or immediate
surroundings.
Viral Shedding: The release of virus from a host.
Virulence: The inherent ability of an infectious agent to cause illness or disease.
Watch Mode: Takes place when there is growing evidence of a threat. The State
Surgeon General will assemble Deputies, Division Directors, Bureau Chiefs, and office
leaders to provide notification of a developing situation.
Wave: Periods during which community outbreaks occur across a country, each lasting
two to three months.
Zoonotic: Diseases which are communicable from animals to humans.

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C.
Table(s) of Organization (To Be Developed)

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65

D. Responsibility
Matrix (see Table 15)

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Table 15: Pandemic Influenza Roles and Responsibilities by FDOH Organizational Unit and Emergency Management Phase

All
Bureau of
SEOC
Divisions/ Division of
Division of
Statewide
County
Activation
Bureaus/ Emergency
Disease
Division of
Bureau of Pharmaceutical Health
Level 3,
Executive
CHD/CMS/ Operations
Control
Environmental Laborator- Services
Departments
Trigger Events
ESF 8
Office (1)
A.G. Holley (DEMO) (2)
(DDC)
Health
ies (BOL) (BSPS)
(CHDs)
1. Preparedness
Level 3:
Inform
Implement Develop and
activities
Monitoring Governor,
activities as maintain FDOH Ensure
Serve as
Review
Review and
Develop and

FDEM, and
per plan. EOP Pandemic surveillance liaison to
and test
test plans for
test
Emergency
other leaders
Influenza Appen- systems and Department of Laboratory vaccine and
community-
Management
of
Ensure
dix.
procedures Agriculture
Surge
antiviral drug
based
Preparedness Phase
preparedness staff is

are in place to and
Capacity management. response

status.
trained to Develop and
detect
Consumer
Plan.

plan.
WHO Inter-Pandemic

perform
maintain
aberrations in Services &

Develop

Phases 1 and 2, and
Disseminate assigned logistical plans need of
Florida Fish Provide
contingency
Assess
Pandemic Alert
expectation of response for
interventions. and Wildlife
guidance to plans for
healthcare
Phases 3 and 4
department’s roles.
pharmaceuticals
Commission. partners for pharmaceutical resources

role in

and medical
Provide

specimen shortages.
and develop

preparedness. Develop
supplies and
guidance to Develop and collection,
contingency

and
equipment.
partners on maintain
handling,
plans.

Direct
maintain

testing
guidelines to and

development COOP
Responsible for persons for ensure safety transport.

of plans
plans.
coordination of influenza.
of food supply.

including
ESF 8

Procure

continuity of
resources.
Disseminate
reagents

operations of

case
from CDC.

mission critical

definition.

and life-

sustaining

services.

67

Table 15: Pandemic Influenza Roles and Responsibilities by FDOH Organizational Unit and Emergency Management Phase

All
Bureau of
SEOC
Divisions/ Division of
Division of
Statewide
County
Activation
Bureaus/ Emergency
Disease
Division of
Bureau of Pharmaceutical Health
Levels 1-2 Executive
CHD/CMS/ Operations
Control
Environmental Laborator- Services
Departments
Trigger Events
ESF 8
Office (1)
A.G. Holley (DEMO) (2)
(DDC)
Health
ies (BOL) (BSPS)
(CHDs)
2. Response activities Level 2:
Inform
Implement Serve as lead for Inform and
Serve as
Implement Support
Implement

Partial
Governor of
response ESF 8 on SERT. provide
liaison to
Laboratory distribution and local
Emergency
Activation phase and
activities.
information to Department of Surge
re-supply of
response
Management
or Level 1, status of

Implement
executive
Agriculture
Capacity antivirals and plans.
Response Phase:
Full
event.
Implement COOP plans for staff when
and
Plan.
vaccines

Response
Activation.
COOP
ESF 8.
surveillance Consumer
through ESF 8. Assign staff

Serve in
plans.

system has Services and

to participate
WHO Pandemic Alert
Unified

detected
Florida Fish
Monitor
with health
Phases 3 and 4 and
Command as Assign staff
aberration. and Wildlife
pharmaceutical and medical
Pandemic Phases 5
designated by to support

Commission.
shortages and system
and 6
Governor.
state health
Direct

implement
response.

and
surveillance
contingency

Direct FDOH medical
activities.
plans.

Pandemic
response

Influenza
through

response.
ESF 8.
Distribute

case

definition to

Serve at JIC.
partners.

Coordinate
Implement

and review
disease

public health
control

messages.
interventions.

69

Table 15: Pandemic Influenza Roles and Responsibilities by FDOH Organizational Unit and Emergency Management Phase

All
Bureau of
SEOC
Divisions/ Division of
Division of
Statewide
County
Activation
Bureaus/ Emergency
Disease
Division of
Bureau of Pharmaceutical Health
Levels 2-3 Executive
CHD/CMS/ Operations
Control
Environmental Laborator- Services
Departments
Trigger Events
ESF 8
Office (1)
A.G. Holley (DEMO) (2)
(DDC)
Health
ies (BOL) (BSPS)
(CHDs)
Recovery Activities
Level 2:
Inform
Assess

Implement
Maintain
Maintain
Implement plan

partial
Governor
staff
plan for
liaison with
testing to for recovery of
WHO Pandemic
Activation when
availability
recovery of Department of detect
unused
Phase 6
or Level 3: Executive
and ability
unused
Agriculture
antigenic vaccines,

Monitoring Order is no
to resume
vaccine.
and
drift, shift, antivirals, and

longer needed. normal
Consumer
or virus
other

operations.
Services and changes. pharmaceutical

Implement

Florida Fish
products.

recovery
Implement
and Wildlife

activities within plans to
Commission.
FDOH.
return to

normal
Coordinate
operations.
AAR

completion
Develop
within 90 days. AAR as

directed.

Mitigation Activities
Level 3:
Establish
Participate Coordinate

Monitoring workgroup to in
revision of

WHO phases 1 or 2
implement
Pandemic Pandemic
mitigation
Influenza Influenza Appen-
actions.
Appendix dix.

revision.
Implement
mitigation
activities.
71

E.
Notification/Call-Down Lists (required) maintained within each Division, Bureau or Office

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
72

F.
Standard Operating Guidelines
See Pandemic Influenza Operations Manual

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
73

G.
Others, as needed (e.g., checklists, forms, flowcharts, database locations
and layouts, maps)

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
74

H. Pandemic Influenza Antivirals and Vaccines
1.
Antiviral Planning Assumptions
a.
The primary source of a
l drugs for
ntivira
nd
a pa emic
response will be the fede
antiviral drugs that
ral supply of
have been stockpiled as part of the CDC’s SNS.
b.
The CDC will identify priority groups for antivirals based on
multiple factors, including the amount of drug that is
stockpiled (See Table 16, Antiviral Priority Groups).
c.
Current indications are that treatment with a
neuraminidase inhibitor (Oseltamivir [Tamiflu®] or
Zanamivir [Relenza®]) will decrease the duration of illness,
the risk of pneumonia, and hospitalization rates by
approximately 50%-70% and mortality by approximately
50%.
d.
Generally, antiviral treatment should begin within the first
48 hours after the onset of symptoms in order to be
effective.
e.
Antiviral resistance to the adamantanes (amantadine and
rimantadine) may limit use during a pandemic.
f.
Florida has a small, state-held stockpile, tentatively
earmarked for use as outlined in the Case-Based
Containment Strategy and the Zoonotic Avian Influenza
Surveillance and Response Protocol.
g.
The CDC Division of the Strategic National Stockpile
Program (DSNS) pandemic influenza response will begin
as the pandemic enters WHO Pandemic Phase 4, starting
with a “push” of antivirals to the states. This push may
comprise a portion or the total of Florida's allocation, 2.5
million courses of antivirals. Approximately 80% of this
allocation is oseltamivir [Tamiflu®] (oral), 20% is zanamivir
[Relenza®] (inhaled).
h.
As of October 2007, no pediatric formulations of antivirals
are available in the SNS.
i.
Current stockpiling only allows the state of Florida to treat
the first five or six priority groups as outlined in the HHS
Pandemic Influenza Plan (See Table 16, Florida Antiviral
Priority Groups). This number is insufficient to treat all who
are anticipated to fall ill and prophylaxis is not likely to be
continued after shifting response from a Case-Based
Containment Strategy to a Community-Based Containment
Strategy.
j.
Antiviral distribution will likely be to hospitals and treatment
centers for dispensing to inpatients or treatment of the ill.
Antiviral inventories must be closely controlled. Dispensing
must adhere to the priority group guidance that the
department receives (See Table 17, Pro Rata Distribution of
Antivirals by County).
2.
Vaccine Planning Assumptions
a.
Vaccine production will require four to six months from the

time the pandemic vaccine strain is selected.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
75

b.
Only vaccines manufactured in the U.S. will be

available for purchase during a pandemic.
c.
The CDC will establish priority groups for initial and

sequential distribution. Priority groups are divided into

occupationally-defined groups and risk-based groups. (See

Table 18, Prioritization of Pandemic Influenza Vaccine)
d.
Priority groups for pre-pandemic and pandemic vaccination

are currently under review. Priority group

recommendations are subject to change based on

epidemiological information once a pandemic begins.
e.
Availability of FDA approved pandemic vaccine will be a

function of both manufacturing capacity and use of

adjuvants. The amount of vaccine produced monthly will

cover 1.5% of the population with two doses (See Table

23, Anticipated County Allocation for Pandemic Influenza
Vaccine)
f.
Medical material to support the administration of vaccine

will be the responsibility of the administering entity.
g.
A pandemic vaccination program will take place over

several months and require vaccinating large numbers of

people. Pandemic vaccine distribution and administration

programs will follow existing protocols in a multi-phase
operation:

(i) Phase 1: Vaccination with stockpiled pre-

pandemic vaccine, conducted by public health.

(ii) Phase 2: Vaccination with pandemic vaccine,

conducted by public health (or designees).

(iii) Phase 3: Vaccination with pandemic vaccine,

conducted by the private sector.
h.
Maintaining sufficient staffing for the vaccination effort will
be a key challenge given the anticipated duration of the
pandemic vaccination program. Delegation of vaccine to
other institutions or agencies when appropriate (and as
directed by BSPS) will help ensure that public health
personnel are available for other activities.

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
76

Table 16: Florida Antiviral Priority Groups
Number of Antiviral Courses

Estimated
For Target
Priority Group
Population*
Strategy **
Group
Rationale
Cumulative
1
Hospitalized
658,897
T
494,173
Consistent with medical practice and ethics to
494,173
treat those with serious illness and who are most
likely to die.
2
Emergency Medical Service
757,217
T
198,770
Healthcare workers are required for quality
692,943
(EMS) providers and other
medical care. There is little surge capacity
direct care HCW
among healthcare sector personnel to meet
increased demand.
3
High-risk outpatient
156,488
T
41,078
Groups at greatest risk of hospitalization and
734,021
death; immunocompromised people cannot be
protected by vaccination.
4
Critical-event personnel
206,935
T
54,320
Groups are critical for an effective public health
788,341
response to a pandemic.
5
Increased-risk outpatient
5,329,134
T
1,398,898
Groups are at high risk for hospitalization and
2,187,239
death.
6
Outbreak response in nursing
N/A
PEP
55,000
Treatment of patients and prophylaxis of
2,242,239
homes and other residential
contacts is effective in stopping outbreaks;
settings
vaccination priorities do not include nursing
home residents.
7
HCWs in emergency
78,685
P
1,258,963
These groups are critical to an effective
3,501,202
departments (EDs), intensive
healthcare response and have limited surge
care units (ICUs), dialysis
capacity. Prophylaxis will best prevent
centers, and EMS providers
absenteeism.
8
Infrastructure workers
635,613
T
166,848
Infrastructure groups that have impact on
3,668,050
maintaining health, implementing a pandemic
response, and maintaining societal functions.
9
Other outpatients
11,088,941
T
2,910,847
Includes others who develop influenza and do
6,578,897
not fall within the above groups.
10
Highest-risk outpatients
81,751
P
1,308,014
Prevents illness in the highest-risk groups for
7,886,910
hospitalization and death.
11
Other HCWs with direct patient
678,532
P
10,856,513
Prevention would best reduce absenteeism and
18,743,423
contact
preserve optimal function.
Adapted from National Vaccine Advisory Committee Antiviral Drug Priority Group Recommendations, HHS Pandemic Influenza Plan Appendix D.
* 2007 population data estimates from Florida CHARTS and priority group population estimated as a comparative ratio to NVAC population estimates for priority groups nationwide.
**Strategy is defined as: T= Treatment, 1 course (twice daily dosing for 5 days); PEP= Post Exposure Prophylaxis, 1 course (once daily dosing for 10 days);
P= Prophylaxis, 16 course (assumed to be once daily dosing for 80 days per wave, 2 waves)

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
77

Table 18: Vaccination and Target Groups for a Severe Pandemic
Population
Rest of population
300
123 million
Critical occupations
High risk population
- Military support
- High risk adults
- Border protection Critical occupations - Elderly
- Other active duty
- National Guard - Other healthcar
74 million
e
- Intelligence services - Other CI sectors
- Other natl. security
- Other govt.
- Pharmacists
Critical occupations - Mortuary services High risk population
- Deployed forces
- Community services - Healthy children
- Critical healthcare
- Utilities
- EMS
- Communications
64 million
- Fire
- Critical govt.
- Police
High risk population
High risk population - Infant contacts
- Pregnant women
- High risk children
- Infants
- Toddlers
15 million
24 million
Tier 1
Tier 2
Tier 3
Tier 4
Tier
Vaccination tier
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
79

Table 19: Sub-Prioritization of Vaccination among Tier 1 Target Groups when Vaccine Supply is Limited
Priority
Group
Rationale
Estimated
Population
1
Front-line inpatient and
Critical role in providing care for the sickest persons;
1,000,000
hospital-based health
highest risk of exposure and
care workers (persons
occupational infection
essential for maintaining
function in emergency
departments, intensive
care units, and other
front-line medical and nursing
staff)
2
Deployed and mission-critical Essential role in national and homeland security: high
700,000
personnel
risk due to living conditions and possibly geographic
location
3
Front-line Emergency Medical Provide critical medical care including
8000,000
Service Personnel (those
procedures such as intubation that increase risk
providing patient assessment,
of aerosol exposure and occupational infection
triage, and transport).
4
Front-line outpatient
Effective outpatient care is critical to decrease
1,000,000
health care providers
the burden on hospitals; high risk of exposure
(physicians, nurses,
and occupational infection
respiratory therapy;

includes public health
personnel who provide
outpatient care for
underserved groups)
5
Front-line fire and law
Essential to public order and safety; less substantial
1,000,000
enforcement personnel
and more predictable risk of
exposure
6
Pregnant women and infants
High-risk documented in prior pandemics
5,150,000*
6-11 months old
and annually; reflects public values to protect children;
vaccination of a pregnant woman also will protect the
infant; infants 6-11 months old
are at high-risk and antiviral drugs are not FDA-
approved for children <1 year old
7
Others in Tier 1 (includes Tier Includes people in critical settings who have
14,100,000**
1 health care
less exposure and toddlers who are less at risk of
workers not vaccinated
severs disease or death than younger infants and who
previously in hospitals,
are able to receive antiviral treatment based
outpatient settings, home
on FDA approval of antiviral drugs
health, long-term care
facilities, and public
health; emergency service
providers; manufacturers
of pandemic vaccine, antiviral
drugs, and other key pandemic
response materials; and
children
12-35 months old)
*Because infants would be expected to receive one-half a regular vaccine dose, the number of adult vaccine dose-
equivalents for this group would be about 4,125,000
**Toddlers 12–35 months old may receive a lower vaccine dose; thus, the number of adult vaccine dose-equivalents
for this group may be less

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
80

Table 20: Target Groups in Homeland and National Security
Tier
Group
Definition
Estimated
Rationale
(severe
Group
pandemic)
Size*
1
Deployed and Military forces and other mission 700,000
Critical to protect national
mission
critical personnel not limited to
security; unable to tolerate
critical
active duty military or USG
projected pandemic personnel
personnel
employees; includes some
loss and fulfill mission; potential
diplomatic and intelligence
greater risk of infection due to
service personnel, and public
geographic location and crowded
and private sector functions
living or working conditions
identified by federal agencies as
unique and critical to national
security
2
Essential
Military and other essential
650,000
Maintaining function is
support and
personnel needed to support and
essential to mission success for
sustainment
sustain deployed forces
deployed personnel; risk of
personnel
infection may be less from
geographical location and living
conditions
2
Intelligence
Critical personnel in the
150,000
Essential to homeland and
services
intelligence community serving
national security; opportunities
at domestic and international
for social distancing limited
posts
because of inability to telework
due to need for secure facilities;
some personnel may be at
increased risk based on
geographical location
2
Border
Critical personnel in agencies
100,000
Essential to homeland security;
protection
providing U.S. border security,
in close contact with many
personnel
including but not limited to
potential infected people
Customs and Border
throughout a pandemic; limited
Protection,Border Patrol,
ability to apply social distancing
Immigration and Customs
strategies
Enforcement, Transportation
Security Administration, and
Coast Guard personnel
2
National
National Guard personnel not
500,000
Likely to be activated in a
Guard
included above who are likely to
pandemic to support critical
personnel
be activated to maintain public
response or community
order during a pandemic or to
functions; may be at increased
support pandemic response
risk of exposure and infection
services or critical infrastructure
based on mission

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
81

Table 20: Target Groups in Homeland and National Security (contd)

Tier
Group
Definition
Estimated
Rationale
(severe
Group
pandemic)
Size*
3
Remaining
Active duty personnel not
1.5
Important to national and
active duty
included in higher priority
million
homeland security
military and
groups and essential support
essential
personnel
support
personnel
*Estimates of group size from Department of Defense, Department of Homeland Security, and from
working group representatives from other federal agencies

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
82

Table 21: Target Groups in Health Care and Community Support Services
Tier
(severe
Group
Definition
Estimated
Rationale
pandemic)
Group Size *
1
Public health
Public health responders 300,000
Essential to implementing the
personnel
at federal, state, and
pandemic response, including
local levels
the vaccination program and
other pharmaceutical and
non-pharmaceutical response
measures; also provide care
for poor and underserved
populations; personnel have a high
risk of exposure to people with
pandemic illness
1
Inpatient
Includes two-thirds of
3.2 million
Maintaining quality inpatient
health care
personnel at acute care
health care is critical to reducing
providers
hospitals who would
mortality from pandemic
be identified by their
influenza and from other illnesses
institution as critical to
that will occur concurrently with
provision of inpatient
the pandemic; inpatient health
health care services;
care burden will be markedly
primarily will include
increased during a pandemic;
people providing care
studies show health outcomes are
with direct patient
associated with staff-to-patient
exposure but also will
ratio; personnel have high risk of
include people essential
exposure, including to infectious
to maintaining hospital
aerosols; infected health care
infrastructure
personnel may transmit infection
to vulnerable people hospitalized
for non-influenza illnesses
1
Outpatient and Includes two-thirds of
2.5 million
Maintaining outpatient and
home health
personnel identified
home health care is critical to
care providers by their organization
reducing pandemic mortality
at outpatient facilities,
and morbidity and reducing the
including but not limited
burden on inpatient services;
to physicians’ offices,
outpatient health care burden will
dialysis centers, urgent
be markedly increased during
care centers, and blood
a pandemic; personnel have
donation facilities; and
high risk of exposure, possibly
skilled home health care
including infectious aerosols;
personnel
infected health care personnel may
transmit infection to vulnerable
people receiving care for non-
influenza illness
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
83

Table 21: Target Groups in Health Care and Community Support Services (contd)
1
Health care
Includes two-thirds
1.6 million
Essential to provide care to more
personnel in
of personnel at LTCFs
than 3 million people in LTCFs
long-term
identified by their
who are particularly vulnerable to
care facilities
organization as critical to
influenza illness and death; risk of
(LTCFs)
the provision of care
pandemic outbreaks in LCTFs may
best be reduced by vaccinating
staff and limiting exposure of
residents to infection; if outbreaks
occur, personnel have high risk
of exposure, possibly including to
infectious aerosols
2
Community
Personnel from
600,000
Community level support will
support service community
be critical for people who are ill
personnel
organizations including
and isolated in their homes or are
(emergency
the Red Cross who
complying with recommendations
management
will provide essential
for voluntary household
and
support and have direct
quarantine during community
community
contact with people
pandemic outbreaks, for elderly
and faith-
and families affected
people who live alone and may
based support during community
be afraid of going out during a
organizations) pandemic outbreaks, and
pandemic, for people who are
emergency management
homeless, and for other vulnerable
personnel who
populations; support may include
coordinate pandemic
providing food and medications,
response and support
as well as other social and mental
activities
health services; personnel will
be at high risk of exposure to ill
people and, if infected could
transmit illness to a high-risk
population
2
Pharmacists
Includes pharmacists
150,000
Essential to dispense medications
dispensing drugs at
for pandemic influenza and other
retail locations (note that
illnesses; may have increased
pharmacists in hospitals
exposure risk to people with
or outpatient centers
pandemic infection
may be targeted as part
of those groups)
2
Mortuary
Includes funeral
50,000
Increased burden likely during
services
directors
a pandemic; may have increased
personnel
occupational exposure to ill family
members of deceased people
3
Other
Includes groups that
300,000
Personnel provide important
important
provide important
health care services but are not in
health care
health care services but
as close contact with ill people
personnel
are at less occupational
and at less risk of occupational
risk, such as laboratory
infection
personnel
*Estimates of group size from Department of Health and Human Services. Community social service provider estimate assumes 300,000 volunteers from
national organizations (e.g., Red Cross) and additional allocation of 1 per 1000 population.
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
84

Table 22: Vaccine Allocation for Target Groups in Critical Infrastructure

Tier
(severe
Group
Definition
Estimated
Rationale
pandemic)
Group Size *
1
Emergency
Includes groups
2 million
Provide critical public
services personnel
supporting emergency
safety and emergency
– EMS, fire, law
response and public
response services;
enforcement, and
safety. EMS personnel
contribute to pandemic
corrections
include those who
response activities by
are fire department-
maintaining public order
based, hospital-based
and contributing to medical
or private; fire fighters
care services; increased
include professionals
occupational risk for
and volunteers;
emergency medical services
law enforcement
due to exposure to people
includes local police,
with pandemic illness
sheriff ’s officers, and
State troopers; and
corrections officers
include those at prisons
and jails
1
Manufacturers of
Includes critical
50,000
Reducing pandemic
pandemic vaccine
personnel required for
health impacts requires
and antiviral drugs, ongoing production
production of pandemic
of pandemic medical
vaccine and antiviral drugs
countermeasures to
support a pandemic
response
2
Communications/
Personnel who are
1.75 million
These sectors provide
IT, Electricity,
critical to support
products and services that
Nuclear, Oil & Gas, essential services
general y cannot be stored,
and Water sector
provided by the defined
are required for community
personnel, and
sectors
health and safety, and
Financial clearing
are essential to the
and settlement
functioning of other critical
personnel
infrastructure sectors
2
Critical government Federal, state, local,
400,000
Government personnel are
personnel –
and tribal government
critical for implementing
operational and
employees and
and monitoring
regulatory functions contractors who
components of the
perform critical
pandemic response, and
regulatory or
performing regulatory
operational functions
or operational functions
required for essential
essential to critical
operations of other CI
infrastructures that protect
sectors
public health and safety and
preserve security
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
85

Table 22: Vaccine Allocation for Target Groups in Critical Infrastructure (contd)
3
Banking & Finance, Personnel who are
3.0 million
These sectors provide
Chemical, Food
critical to support
essential products
& Agriculture,
essential services
and services; however
Pharmaceutical,
provided by the defined
compared with Tier 2
Postal & Shipping,
sectors
sectors, products can
and Transportation
more likely be stored,
sector personnel
facilities and personnel
are more fungible and
better able to maintain
essential functions with
high absenteeism, and
other strategies can be
implemented to protect
workers
3
Other critical
Federal, State, local
400,000
Continuity of key
government
and tribal government
government functions
personnel
employees and
is important to support
contractors who
communities and critical
perform important
infrastructures
government functions
included in agency
continuity-of-operations
plans
*Group sizes for critical infrastructure sectors are estimated as 25% of the workforce in Tier 2 sectors and 7.5% of the work
force in Tier 3 sectors. These estimates track general y with estimates from the NIAC report, The Prioritization of Critical
Infrastructure for a Pandemic Outbreak in the United States (www.dhs.gov/niac) and with estimates provided by the Depart
ment of Homeland Security. Estimates for federal, state, local, and tribal government personnel are 5% of workers in Tier 2
and 5% in Tier 3
Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
86

IX. Annexes

X.
Appendices
A. Hazard-Specific Plan(s)

Florida Department of Health Pandemic Influenza Appendix, Version 11.2 March, 2009
88

Document Outline

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