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					National Public Health Service for Wales         North Wales Pandemic Influenza Plan for Dental
                                                                                      Services




     Summary of North Wales
    Pandemic Influenza Plan for
         Dental Services
Authors: Ilona Johnson, modified by Sandra Sandham following preliminary
meeting of the Dental Pandemic Influenza Team on 2 June 2009
Date: 04/06/2009                        Version: 2
Status: Draft
Intended Audience:
North Wales Dental Advisory Forum; North Wales Local Dental Committee;
Local Health Board(s); General Dental Service; Hospital Dental Services;
Community Dental Service; NHS Direct Wales.
Purpose and Summary of Document:
 Provide a plan of action for the delivery of dental services in the event of
   pandemic influenza.
 Be integrated into the Local Health Board(s) Pandemic Influenza Plan(s).
Publication/Distribution:
 North Wales Dental Advisory Forum
 North Wales LDC
 Chief Executive(s) Local Health Boards
 Regional Director of Public Health (NPHS)
 Chief Executives of North Wales (NHS) Trusts
 General Dental Practitioners
 Consultants in Dental / Maxillofacial disciplines
 Clinical Director for North Wales Community Dental Service
 NHS Direct Wales
 A&E Departments
 Occupational Health Department




Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09    Status: Final Version
                                           Page: 1 of 11     Intended Audience: NWDAF/
                                                             NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                             GDS/ NHS Direct /Occ Health
National Public Health Service for Wales         North Wales Pandemic Influenza Plan for Dental
                                                                                      Services

1.    Pandemic Influenza and Dental Services

Purpose of this document:

This document is based on a plan written by Ilona Johnson, Specialist Registrar in
Dental Public Health (NPHS) and is designed to provide a planning framework for
use in North Wales in the event of pandemic influenza.

It is supported by a web based Pandemic Influenza Toolkit for dental practices which
provides checklists of actions to assist dental practices in formulating their own
contingency plans. This is accessible via the web based Form Builder using the
password that dentists have been issued to access the Self Assessment QAS form.

Dental defence organisations are urging dental practices to develop their
contingency plans and to put policies in place. The General Dental Council has also
issued guidance regarding professional responsibility in the event of an influenza
pandemic, www.gdc-uk.org.

Guidance is also provided in Welsh Assembly Government documentation 'Guidance
on the delivery of and contract arrangements for primary care dentistry'
www.wales.gov.uk/pandemicflu.

The Chief Dental Officer Website via www.cmo.wales.gov.uk and Department of
Health Pandemic Influenza Guidance for Dental Practices at www.dh.gov.uk are also
useful resources.


2.    Influenza Clinical Features and Transmission
Although seasonal influenza is a common occurrence, pandemic influenza is a much
rarer event. It arises as a result of a new strain of virus to which humans have little
or no immunity. Pandemics occurred three times in the last century during which 25-
35 percent of the population contracted the infection. It has, however, been
predicted that new pandemics could affect up to 50 percent of the population.
Although pandemic influenza may result in serious complication or fatalities in any
age group, historically those at highest risk have been the vulnerable groups - older
people, pregnant women, very young children and immuno-compromised people.
The anticipated duration of a pandemic is 11 to 14 weeks although local epidemics
may last for a shorter period of 6 to 8 weeks.

  2.1 Clinical Features

           An infectious viral respiratory illness characterised by rapid onset of a wide
            range of symptoms including: - fever; cough; headache; sore throat;
            aching muscles and joints.
           Bronchitis and Pneumonia can develop.

Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09    Status: Final Version
                                           Page: 2 of 11     Intended Audience: NWDAF/
                                                             NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                             GDS/ NHS Direct /Occ Health
National Public Health Service for Wales         North Wales Pandemic Influenza Plan for Dental
                                                                                      Services

  2.2 Transmission

           Average incubation period is 2 to 3 days.
           Symptoms develop within 1 to 4 days of infection.
           People are most infectious soon after they develop symptoms.
           Transmission is through respiratory secretions as droplets and aerosol
            (coughing and sneezing).
           Transmission is most commonly from person to person.


3.    Containing the Infection
The main measures for containing the infection are:
     Good general hygiene procedures. Hand washing with soap and water or
       alcohol hand rub and environmental cleaning will deactivate the virus and
       help control spread through contact.
       Standard infection control measures and droplet precautions.
       'Stay at home' approach for anyone with symptoms.
       Separation of flu infected patients from well patients when care is required.
       Excluding symptomatic visitors.


4.    Provision of Dental Care
  4.1 Patients

           Fewer patients will attend for treatment during a pandemic. Illness and
            anxiety is likely to result in cancelled or failed appointments.
           Asymptomatic patients can be treated with routine infection control
            procedures The treatment provided, however, will depend on the level of
            dental alert, which is covered later in this document.
           Some patients, both well and infected, will require urgent or emergency
            dental care even when the level of alert dictates that routine care needs to
            be delayed. (Appendices 1 and 2).
           All patients and accompanying persons should, wherever possible, be
            screened by telephone for flu symptoms before attending the practice.
           People with symptoms should be discouraged from entering the practice.
            Notices at the door should alert patients to this fact.


Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09    Status: Final Version
                                           Page: 3 of 11     Intended Audience: NWDAF/
                                                             NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                             GDS/ NHS Direct /Occ Health
National Public Health Service for Wales         North Wales Pandemic Influenza Plan for Dental
                                                                                      Services

           Infected patients should be segregated from well patients. Treatment of
            infected patients should be at designated sites and limited to pain relief.
            Aerosol-generating procedures should be avoided wherever possible.

  4.2 Dental Staff

           Staff within practices/clinics will also be affected and staff shortages will
            impact on service provision. It has been estimated that 35 percent of staff
            will be absent for 2 to 3 weeks as a result of illness, caring for dependents
            or other related difficulties.
           Local co-operation between practices is encouraged to maintain a service
            provision for 'well' patients.
           Staff who have recovered from influenza and have immunity to the virus
            may be required to assist with the provision of a service to patients with
            symptoms who require urgent or emergency care.
           Uniforms must not be worn outside of the working environment and if
            laundered at home, should be transported in a tied plastic bag.
           Disposable plastic aprons worn over uniforms are recommended.
           In addition to routine personal protective equipment (PPE), enhanced
            FFP3 masks must be used by clinical staff treating infected patients.
            Training on the fitting, wearing and removal of these will be provided for
            identified staff treating infected patients in dedicated facilities.
           Practices may fail to deliver contracted UDAs. The guidance recommends
            that contractual payments continue with no penalties if providers have
            done everything within their power to comply. Local Health Boards and
            providers would be expected to agree a reasonable and proportionate
            response to the disruption of normal service provision. Records should
            also be kept of activity, staff and other tasks undertaken relevant to
            General Dental Service contracts e.g. clinical audits, clinical governance.

  4.3 Supplies / Services

           Use of consumables for infection control may increase.
           Facilities for hand washing/hand rubs will need to be provided for
            patients/visitors.
           Supply of dental consumables; equipment servicing/repair and laboratory
            services may be affected.
           Disruption in fuel supply may impact on travel/transport arrangements for
            staff, patients and suppliers.


Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09    Status: Final Version
                                           Page: 4 of 11     Intended Audience: NWDAF/
                                                             NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                             GDS/ NHS Direct /Occ Health
National Public Health Service for Wales         North Wales Pandemic Influenza Plan for Dental
                                                                                      Services

5.    Levels of Alert

In the event of pandemic influenza the disease is unlikely to have an immediate
effect on dental services. However, with the spread of disease, services are likely to
have increasing difficulty in delivering dental care. There are 6 phases to National
and International Alerts. Effectively there are 3 dental phases, Green, Amber and
Red. Table 1 shows the dental alert system for the impact of influenza on dental
services. The transitions and thresholds between the stages of alert may differ from
area to area.

The level of alert for dental services will be determined by the Dental Pandemic
Influenza Team led by the Local Health Board/Lead Local Health Board supported
by the Director of Dental Public Health in accordance with any direction from the
Local Resilience Forum.
Table 1

                                              Routine Treatment
                                                  provided
                                                                       Dental activity levels
Dental alert     Normal Dental Services          Establish and         and staffing levels are
level Green      are unaffected.              activate emergency       normal.
                                                treatment sites

                                               Emergency Dental
                                            Treatment for infected
                                            patients at designated
                                             sites and emergency
Dental alert     Normal Dental Services                            Dental activity levels
                                               treatment for non
level Amber      are affected                                      are reduced
                                              infected patients at
                                               multiple surgeries
                                                  and clinics.

                                               Emergency Dental
                                                  Services for
                 Dental Services are
                                             emergency treatment
                 severely affected by                                  Dental activity levels
Dental alert                                   only, treating non
                 pandemic. Emergency                                   are significantly
level Red                                    infected and infected
                 dental services only                                  reduced
                                              patients at separate
                 provided
                                                      sites.


  5.1 Pre-Planning Phase

A Dental Pandemic Influenza Team comprising stakeholders involved in the planning
of dental services will review the Pandemic Influenza plan and discuss the impact
and actions to be taken in the event of a pandemic influenza outbreak.

     5.1.1 Membership of the Dental Pandemic Influenza Team

The team will include representatives from:

Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09    Status: Final Version
                                           Page: 5 of 11     Intended Audience: NWDAF/
                                                             NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                             GDS/ NHS Direct /Occ Health
National Public Health Service for Wales                North Wales Pandemic Influenza Plan for Dental
                                                                                             Services

             Local Health Board
             National Public Health Service
             Local Dental Committee
             Hospital Dental Service
             Community Dental Service
             Welsh Assembly Government (Regional Office)

    5.1.2 Communication

The planning of dental services will complement the wider influenza plan. The
Dental Pandemic Influenza Team will provide a route of communication with dental
service providers. All representatives will require a deputy in case of illness.
General Dental Practitioners will be kept informed by the Local Health Board(s).



                             Local Resilience Forum/NPHS




                           Dental Pandemic Influenza team




 Community Dental Service         Hospital Dental Service         Emergency Dental Service


                                                    Local Health Board



               Local Dental Committee          General Dental Practitioners




                                                  Dental Practice Teams



The level of alert will be determined by the Dental Pandemic Influenza Team and
communicated to the dental professions and other key players.


  5.2 Dental Treatment for Infected Patients

              Routine care will be deferred until symptom free.

Author: Ilona Johnson, Sandra Sandham           Date: 01/07/09       Status: Final Version
                                                Page: 6 of 11        Intended Audience: NWDAF/
                                                                     NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                                     GDS/ NHS Direct /Occ Health
National Public Health Service for Wales         North Wales Pandemic Influenza Plan for Dental
                                                                                      Services

           Dedicated treatment centres for the urgent dental treatment will be
            provided using dedicated mobiles/fixed premises.
           Emergency cases (swelling threatening the airway or tracking towards the
            eye, prolonged dental bleeding, trauma) to be directed to relevant District
            General Hospital A&E Department. A&E department to be contacted in
            advance to advise patient where to report to as dedicated areas are likely
            to have been identified for different client groups.
           Symptomatic patients requiring urgent treatment (toothache lasting more
            than 5 minutes at a time; localised swelling) will be advised to contact NHS
            Direct for triage and referal to local helpline (EDS) for appointment at
            identified locations. Dedicated teams will be given priority regarding
            vaccinations/antivirals as appropriate and issued with enhanced PPE and
            will be trained in its use. The Occupational Health Department will monitor
            all identified staff treating symptomatic/infected patients in dedicated
            clinics.
           Dental staff who have recovered from influenza will be asked to volunteer
            to assist in the delivery of the service.

    5.3 Alert Level Green

At this stage dental services are unlikely to be affected.

Alert level Green

Plan: Deliver normal dental services where this is appropriate to do so.
Deliver Emergency Care to Patients infected with Flu at designated treatment centres
for emergency dental care for patient with symptoms of flu

Action:
 Dental Pandemic Influenza Team to ensure media and public notices
   discouraging patients with flu symptoms attending dental surgeries.
    Practice based influenza screening of patients by telephone. (Screening
     algorithm Appendices 1 and 2).
    Advice provided for those with symptoms requiring emergency/urgent treatment.
    Notices on practice doors discouraging people with flu symptoms entering the
     practice. Notice to include telephone number of NHS Direct for those with
     urgent/emergency problems (Dental Line Tel: 0845 60 10 128).
    Mobilisation of dedicated emergency dental service(s) for patients who are
     infected.
    Routine Emergency Dental Service continuation for asymptomatic patients.



Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09    Status: Final Version
                                           Page: 7 of 11     Intended Audience: NWDAF/
                                                             NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                             GDS/ NHS Direct /Occ Health
National Public Health Service for Wales           North Wales Pandemic Influenza Plan for Dental
                                                                                        Services

It is anticipated that the Green phase will be short in duration as pandemic flu is
expected to travel quickly across the country. The dental alert may pass directly
from Green to Red Alert dependant on virulence/rate of spread.

    5.4 Alert Level Amber

With the anticipated rapid spread of pandemic influenza this phase may be
transitional or missed completely. However, this phase may be instituted after the
pandemic, when services are being restored.

Alert level Amber

Aims: Deliver Emergency Care to Patients with symptoms of flu at designated
emergency dental care treatment centres
Deliver emergency and urgent dental care to patients without influenza at most dental
practice sites and emergency sites for non infected patients.

Action:
 Dental Pandemic Influenza Team to ensure media and public notices
   discouraging attendance at dental surgeries for non-urgent treatment.
   Emergency and urgent treatment only should be provided avoiding the use of
   aerosols.
    Dental Pandemic Influenza Team to co-ordinate supply of enhanced cross
     infection control measures for all emergency sites in anticipation of Red Alert.
    Continue practice based screening of patients.
    Redirection of infected patients with urgent problems to dedicated sites for
     symptomatic patients as per Algorithm (Appendix 1).
    Record dental activity and staffing levels.
    If reduced staffing consider increased provision of emergency dental services for
     non-infected patients.
    Inform Local Emergency Dental Service appointment line of available
     appointments in practices/clinic for emergency/urgent treatment of non infected
     patients.
    Avoid use of aerosol generating procedures wherever possible for all patients.

    5.5 Alert Level Red

During this phase dental services will be severely affected and limited to
emergency/urgent treatment at separate sites for well and symptomatic patients.

Red level Alert
Delivery of core emergency dental services to key areas. Merging the available local
resources to support emergency dental sites.

Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09      Status: Final Version
                                           Page: 8 of 11       Intended Audience: NWDAF/
                                                               NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                               GDS/ NHS Direct /Occ Health
National Public Health Service for Wales         North Wales Pandemic Influenza Plan for Dental
                                                                                      Services

Action:
 Dental Pandemic Influenza Team to ensure media and public notices
   discouraging attendance unless urgent/emergency care required.
    Emergency/urgent dental services only will be delivered.
    Redirection of patients to designated emergency sites                   with   separate
     facilities/teams providing care to 'well' and 'infected' patients.
    Pooling of 'well' and 'recovered' workforce to deliver emergency dental services.
    Continue practice based screening of patients and redirection of patients to
     appropriate urgent/emergency dental care (Algorithm Appendices 1 and 2). This
     may be conducted by a receptionist or where necessary an answer phone.
    NHS Direct will triage urgent cases and refer to appropriate local appointment
     lines.
    Walk in emergency sessions, which normally operate at some sites, will be
     replaced with appointment-based systems to enable telephone screening.
    Recording of dental activity and staffing levels.
    Monitoring of attendance at individual emergency dental service sites.


    5.6 Post Pandemic Period

When the pandemic is declared over, this information will be disseminated by the
Dental Pandemic Influenza Team. Dental Practices will be re-established as quickly
as possible. The Alert phase will be reduced from Red to Amber and return to Green
as soon as possible and normal working arrangements resumed.

Actions:
 Dental Pandemic Influenza Team to engage the media to promote dental practice
   attendance at re-opened practices.
    Dental Pandemic Influenza Team to co-ordinate and support the process of re-
     establishment of normal dental services.
    Practices will be encouraged to identify the resources required to enable the
     return to "normal" practice.
    Resource sharing between practices will be encouraged to facilitate the return to
     business as usual.

 Progressive cessation of Influenza Treatment centres and return to normal
     services as soon as possible.




Author: Ilona Johnson, Sandra Sandham      Date: 01/07/09    Status: Final Version
                                           Page: 9 of 11     Intended Audience: NWDAF/
                                                             NWLDC/ LHBs/ Trusts/ HDS/ CDS/
                                                             GDS/ NHS Direct /Occ Health
Appendix 1

           Telephone Screening Algorithm for Dental Practices and Clinics for patients with flu symptoms

                                                Do you have the following flu symptons?
                                                     General Illness
                                                     Headache
                                                     Sore throat
                                                     Aching muscles or joints



                                                                      Yes



               Emergency                                              Urgent                                        Non-Urgent
  -    Hot, swollen face                              -   Localised swelling
  -    Swelling - threat to airway or                 -   Toothache lasting over 5 minutes at
       tracking towards eye                               a time                                          Defer treatment until symptom-free
  -    Persistent dental bleeding
  -    Trauma - tooth knocked out or
       fractured in last 48 hours                               NHS Direct Wales
                                                              Dedicated Dental Line:
                                                                 0845 60 10 128
  Telephone local A&E Department for
   advice regarding dedicated area to                  Local EDS line to arrange appointment
                report to                               at dedicated site for infected patients



      Out of Hours
      Telephone message should advise patients to contact NHS Direct for advice alerting them to the fact that the patient has flu
      symptoms. (Dental Line Tel: 0845 60 10 128)
Appendix 2
        Telephone Screening Algorithm for Dental Practices and Clinics for patients with no flu symptoms

                                            Do you have the following flu symptoms?
                                                 General Illness
                                                 Headache
                                                 Sore throat
                                                 Aching muscles or joints


                                                                     No



              Emergency                                            Urgent                                         Non-Urgent
  -   Hot, swollen face                          -      Localised swelling
  -   Swelling - threat to airway or             -      Toothache lasting over 5 minutes at
      tracking towards eye                              a time
  -   Persistent dental bleeding
  -   Tooth knocked out or fractured in
      last 48 hours                         Green:                Amber:                 Red:          Green:        Amber:    Red:
                                            See in                  See in            Telephone         See in        Defer    Defer
                                          Practice as             Practice,           NHSDirect        Practice
        Attend A&E Department               normal              neighbouring       0845 60 10 128        as
                                                                   practice                            normal
                                                                according to
                                                                     local
                                                                arrangement
                                                                                     Local EDS line
                                                                                     to arrange appt
                                                                                        at site for
                                                                                       non-infected
                                                                                         patients

  Out of Hours
  Telephone message should advise patients to contact NHS Direct for advice. (Dental Line Tel: 0845 60 10 128)

				
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