Questions and Answers on Pandemic Influenza.24

7/30/2019 Questions and Answers on Pandemic Influenza.24

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50 AJN MJuly 2007 M Vol. 107, No. 7 http://www.nursingcenter.com

ing to local disasters such asfloods or hurricanesin whichcommunities provide support to astricken area and immediate aid isexpected from regional, state, ornational entitiescould be greatly

curtailed in a pandemic because ofits potentially global scope. Andthe weeks- or months-long dura-tion of a pandemic could result inthe exhaustion of essential person-nel and supplies that would needrepeated replenishing. But becausea pandemic makes every commu-nity vulnerable, little outside helpmight be available to those copingwith mass illness and death.Communities not yet affectedwould undoubtedly feel the need to

reserve resources to protect them-selves against the threat, while those recoveringwould be too overwhelmed and depleted to assist.

On the other hand, a pandemic with a nonviru-lent strain could be a very manageable event.Overreacting to a disease outbreak (by unnecessar-ily closing schools or limiting travel, for example)can also cause harm. The challenge in pandemicinfluenza planning is to find a balance between riskand preparedness that realistically estimates the conse-quences of a pandemic and doesnt rob resources fromthe many everyday health care and social challenges.Planners should be aware of preparations being madeat local, state, and federal levels; proceed logicallywith their own planning; and be able to interpretevidence that indicates an influenza pandemic isunfolding. Also, it should be noted, every month thatgoes by without an outbreak is an opportunity tostockpile antiviral drugs and protective equipmentand to develop plans for continuing to deliver healthcare and essential services in the event of a pan-demic outbreak.

SEASONAL OR PANDEMIC INFLUENZA?Influenza outbreaks occur every year. Called sea-

sonal, or interpandemic, influenza, the illness iscaused by viral strains that have circulated in

I

nfluenza killed more people in a year thanthe Black Death of the Middle Ages killedin a century; it killed more people intwenty-four weeks than AIDS has killedin twenty-four years. So writes John M.

Barry in his bestselling account of the horrificSpanish flu pandemic of 191820, The GreatInfluenza.1 Today, such knowledge of history is guid-ing disaster planners as they consider equally stag-gering scenarios among their forecasts for aninfluenza pandemic (see Table 1, page 52).

The prospect of an influenza pandemic causedby a lethal viral subtype is of great concern tonurses, who understand the impact such an eventcould have, and it poses unaccustomed challengesto disaster planners. The typical model for respond-

Questions and Answers on Pandemic InfluenzaStriking a balance between risk and preparedness.

Victoria J. Davey is deputy chief officer for public health andenvironmental hazards at the Department of Veterans Affairsin Washington, DC, and a doctoral student at UniformedServices University of the Health Sciences, Bethesda, MD.Contact author: [email protected]. Disaster Care is coordi-nated by Mary Chaffee, MS, RN, FAAN: [email protected] author of this article has no significant ties, financial orotherwise, to any company that might have an interest in the

publication of this educational activity.The views expressed in this article are those of the author

and are not necessarily those of the U.S. government, theDepartment of Veterans Affairs, or the Department of Defense.

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Overview: Disaster planning based on events such asfloods or hurricanes, which are local or regional in scale,may be inadequate for responding to a lethal influenza pan-demic that has the potential to overwhelm existing publichealth infrastructures. However, if a mild strain of the virus

achieves pandemic proportions, the current public health sys-tem may be able to manage the outbreak relatively easily.Therefore, the challenge in pandemic influenza planning is tofind a balance between risk and preparedness. Planners andpolicy makers must make realistic estimates of the conse-quences of a pandemic and allocate limited resources wisely,so that everyday health care and social needs arent short-changed. This article examines what weve learned from pastinfluenza pandemics and answers some frequently askedquestions about pandemics and how to prepare for them.


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[email protected] AJN MJuly 2007 M Vol. 107, No. 7 51

humans previously (thus, some peo-ple are immune) and for which thereare effective vaccines. Most peopleexperience seasonal influenza as amiserable week of fever, fatigue,aching muscles, and hacking cough.Yet in the United States, more than200,000 excess hospitalizations andperhaps 40,000 deaths occur annu-ally from complications of influenza,mostly among the very young andold.2, 3

The predominant mode of influ-enza transmission is probably virus-containing respiratory droplets (largerthan 10 microns in diameter). Aninfected person releases dropletswhen sneezing, coughing, or speak-ing, and a nearby person then inhalesthem into the respiratory tract, or thevirus is deposited on mucous mem-branes such as the eyes, nose, ormouth. Transmission may also occurvia inhalation of smaller airborneviral particles (smaller than 5 microns

in diameter) that can remain sus-pended in the air for minutes tohours, or by picking up virus fromsurfaces like countertops and thentouching the mucous membranes.4, 5

Efficient transmission is characteristic of influenza:infected people may shed virus for half a day beforethey feel symptoms. Influenzas brief incubationperiod (the time between infection and the develop-ment of symptoms) averages just two days. Theviruss reproduction ratio (the number of personsinfected by one source person) depends on the strainand subtype, the quantity and type of contactsamong people, and the susceptibility of the unin-fected person. An infected person will, on average,transmit the virus to one to two other people in aninfluenza outbreak, potentially resulting in rapidpropagation of the virus in a population.4, 6, 7

Minor genetic changes that accumulate in sea-sonal influenza viruses (a process known as anti-genic drift) make it necessary to reformulate andreadminister the influenza vaccine each season.8, 9

With its easy transmissibility and mutability,influenza poses constant challenges that nursesknow all too wellfrom teeming wintertime EDs

and pediatric waiting rooms to illness-relatedabsences that strain remaining staff.

Major viral-gene mutations or recombination oftwo different viral strains of human and animalinfluenza strains can create a new viral subtype (aprocess called antigenic shift) thats easily trans-mitted to and among humans.8-10 Isolation and iden-tification of new viral subtypes is necessary forvaccine development, which is itself a complexmanufacturing process that currently does not beginto produce doses in quantity for at least sixmonths.11 When a virus for which there is no vaccinebecomes easily transmissible among nonimmunepeople, the opportunity for a pandemic is created.

The historical record shows many accounts of dis-ease outbreaks that may have been influenza epi-demics or pandemics. Although the scale of theoutbreaks and their causative agents are not preciselyknown in many cases, most historians agree that anoutbreak that began in Asia in 1580 was an influenzapandemic.12 In the past 300 years, there have been atleast 10 influenza pandemics,13, 14 which, by defini-

tion, result in moderate to dramatic spikes in illnessesand deaths above average annual levels.15, 16

In this 1918 photograph, influenza victims crowd into an emergency hospital atCamp Funston, a subdivision of Fort Riley in Kansas. The flu, which some expertsbelieve originated in Kansas, killed at least 20 million people worldwide.

By Victoria J. Davey, MPH, RN

AssociatedPress/NationalMuseumofHealthandM

edicine,

ArmedForcesInstituteofPathology


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During the 20th century three pandemicsoccurred: in 191820, 195758, and 196869 (afourth worldwide outbreak that began in 1977 isnot accepted by all authorities as a true pandemic).The most fearsome of these, the 191820 pandemic(see Figure 1, page 53), sickened 25% of the U.S.population in several six-to-eight-week waves andrapidly killed an estimated 2.5% of its victims (thepercentage of ill people who die, known as the casefatality ratio, is an important indicator of the sever-ity of the outbreak; in 1918, some populations out-side the United States had much higher case fatalityratios).17 Communities were paralyzed for weeks,with hospitals and mortuaries filled beyond capac-ity, public services severely disrupted, and schools

and businesses shuttered. This experience wasechoed around the world, and estimates of theglobal loss of human life range between 30 millionand 50 million.18, 19 In contrast, the 195758 and196869 pandemics were clinically milder, thoughthey still resulted in worldwide death tolls of 1 mil-lion to 2 million, and they are remembered less asdisasters than as epidemiologic curiosities in whicha single influenza strain was tracked around theworld.15 Since the last influenza pandemic a newnetwork of global laboratories and surveillance sys-tems can speed the recognition of an emerging pan-demic and the identification of its cause, but

influenza pandemics remain difficult to predict.20

WHY WORRY NOW?Worldwide social and ecologic changes, including agrowing human population, crowded living condi-tions, and rising global mobility, have raised the riskthat a virulent influenza strain could spark a partic-ularly devastating pandemic. Larger populationshave resulted in higher numbers of food animals,leading to more humananimal interaction andtherefore to opportunities for viral-gene recombi-nation and transmission.21 Once a virus adapts tohumans, global air travel can greatly accelerate itsspread. Since 2003, a pathogenic avian influenzastrain, A (H5N1), has caused a pandemic in domes-tic poultry and wild birds in much of the world,as well as more than 300 laboratory-confirmedhuman cases, with a 60% case fatality ratio.20

Presently, avian A (H5N1) influenza is not readilytransmitted to humansmost of the people whohave fallen ill from A (H5N1) had direct exposure topoultry. It is not known whether the A (H5N1) viruswill cause a human pandemic.

Prototype vaccines for A (H5N1) are being testedin clinical trials, and small quantities have been stock-

piled.22

But a pandemic could be caused by an entirelydifferent influenza subtype, one for which a vaccine

Table 1. Estimated Rates of Health Care Use, Illness, andDeath in Moderate and Severe Influenza Pandemics

* The estimates presume that the same percentages of the populationwill be infected in a moderate and a severe pandemic; the virulenceof the influenza strain will determine the severity of illness.U.S. Department of Health and Human Services. HHS pandemic influenza plan part 1: strategicplan. The pandemic influenza threat. U.S. Department of Health and Human Services. 2005.

Characteristic Number of people affected*

Moderate pandemic(similar to 1958 and1968 outbreaks)

Severe pandemic(similar to 1918outbreak)

Illness 90 million (30% of population)

90 million (30% ofpopulation)

Outpatient med-ical care

45 million (50% ofthose who fall ill)

45 million (50% ofthose who fall ill)

Hospitalization 865,000 9,900,000

ICU care 128,750 1,485,000

Mechanicalventilation

64,875 742,500

Deaths 209,000 1,903,000

Personal Pandemic PlanningPreparing for a disease outbreak is similar to generalemergency preparedness.

Keep essential supplies on hand: nonperishable foods, bottledwater, medications, and personal hygiene products.

Keep your familys health information up-to-date, organized,and accessible.

Make sure you can communicate from your home by severalmethods (such as telephone and e-mail) and that you canget information from the outside world (including by battery-powered radio).

Get an annual seasonal influenza vaccination; it protects youand your contacts from seasonal influenza strains now andfrom any that might circulate later with a pandemic strain.

Participate in your facilitys emergency planning; get trainingin the implementation of the plans.

In case you cant work because of your own or a family mem-bers illness, be prepared to spend an extended period oftime at home; have supplies on hand to keep yourself busy.

Explore the possibility of telecommuting (for example, byassisting with telephone health care advice).

Contribute to your communitys preparedness (for example, byorganizing local response planning and being available tohelp in the event of an outbreak).


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wont be available in large enough quantities until atleast six months after the strain is isolated.11

Potentially effective antiviral medications are avail-able for treatment, postexposure prophylaxis, orlonger-term prophylaxis, and stockpiles are increas-ing. But the effectiveness of current antivirals againsta specific pandemic influenza strain is uncertain, andthe medications would need to be administeredswiftlywithin 48 hours of symptoms appearingwhich is a daunting challenge for distribution sys-tems.15 Experience from past influenza pandemicsand the ability to monitor for specific pathogens suchas the avian A (H5N1) subtype should help informour nations readiness for the next pandemic.

In addition to the emergence and spread of the A(H5N1) virus, disasters that have occurred in recentyears have made clear the advisability of planning foran influenza pandemic. The outbreak of severe acuterespiratory syndrome (SARS) in 2003 startled the

global public health community with its virulence,efficient transcontinental transmission, and signifi-

cant economic effects. Then the devastation causedby Hurricanes Katrina and Rita demonstrated thata large-scale disaster can overwhelm existing emer-gency response systems. Also, its only in the pasthalf decade that new information about the 1918influenza virus and reexamination of the long-lasting effects of that pandemic have returned it togeneral awareness.10, 15

HOW CAN WE PREPARE?In both the private and public sectors, and at thefederal, regional, state, and local levels, prepara-tions and planning are taking place.

Government strategy. On November 1, 2005,President Bush unveiled the National Strategy forPandemic Influenza, a document that outlines bothgovernment and private sector responsibilities inthree areas: preparedness and communications, sur-veillance and detection, and response and contain-

ment.23

A detailed national implementation plandeveloped from this document charged cabinet-level

Figure 1. Transmission of Influenza Around the World, 191820

Nicholson GK, et al., editors. Textbook of influenza. 1998. Adapted with permission of the authors and published with permission ofBlackwell Publishing, Oxford.


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federal agencies with devising plans to maintainoperations, protect employees, communicate withstakeholders, and support federal efforts during apandemic.11 The plan culminates in a list of actionitems and performance measures that require fed-eral agencies to work together and with state agen-cies and private groups, including businesses andfaith-based organizations, to prepare for aninfluenza pandemic (see Table 2, above, for a sam-ple action item that focuses on communications, anarea of special concern in large-scale events). A goalof the national strategy and implementation plan isto create and test disaster response and emergencymanagement systems to ensure that a well-pre-pared, communicative, and operational responsewill be in place if we are faced with an influenza pan-demic of any severity. Already under way are newvaccine development24; federal stockpiling of antivi-ral medications, personal protective equipment,and health care materiel22; modeling studies to fore-

cast potential outcomes of pandemic interven-tions25, 26; and a host of detailed plans drafted by


federal agencies, states, businesses, schools, andhealth care systems and facilities.

In February, the Centers for Disease Control andPrevention, in collaboration with numerous publicand private agencies, issued planning guidance forcommunity mitigation measures during a pan-demic. These are specific actions that a communitycould take to minimize the diseases spread, limit ill-ness and death, and keep essential services operat-ing. The measures would be applied according tothe severity of the pandemic and could includetreating those who had fallen ill with antiviral med-ications and providing prophylactic antivirals to

their household members, voluntary isolation of theill and quarantine of household members, schoolclosures and cancellation of public gatherings, andusing social distancing measures in the workplace.27

Other planning efforts. The federal govern-ments emphasis on pandemic planning as well as fed-eral funding of states pandemic planning havespurred planning efforts by regions, states, commu-nities, and the private sector. Nearly all states haveplans posted on the Internet. Details vary widely,but state plans include actions they would take inpandemic surveillance, management, and contain-ment, including distribution of antivirals and vac-

cines.28, 29 Checklists to help businesses, schools,colleges and universities, faith-based organizations,and health care settings with pandemic planningare available at www.pandemicflu.gov. (A quicksearch of the Internet reveals an abundance of pan-demic plans posted from a wide array of sources.) Toaddress concerns about allocating scarce resourcesduring a pandemic, federal agencies have initiatedpublic and private sector collaborations charged withdeveloping prioritization plans for distributing vac-cine and antiviral medications.30

WHATS THE RIGHT BALANCE?At every level, from the presidents cabinet to ruralhospitals, pandemic influenza planning takes timeand resources. Preparations are costly and compli-cated. If youve served in a hospital or communityplanning group, you may have estimated howmany N95 respirators or doses of antiviral medica-tions might be needed in a severe influenza pan-demicand been daunted by the cost and storagerequirements. Or perhaps youve faced the adminis-trative conundrum of how to quickly train retirednurses to replace those absent because of illness.And you may have questioned the worth of planning,

and the cost of stockpiling resources, when your facil-ity has so many present needs.

Ensuring Effective Risk Communication

6.3.8 Ensure that timely, clear, coordinated messages are deliv-ered to the American public from authoritative sources at all lev-els of government and assist the governments of affected nationsto do the same.

6.3.8.1 HHS, in coordination with DHS, DOD, and VA, shalldevelop and disseminate a risk communication strategy within6 months, updating it as required. Measure of performance: imple-mentation of risk communication strategy on www.pandemicflu.gov

and elsewhere.6.3.8.2 DOD and VA, in coordination with HHS, shalldevelop and disseminate educational materials, coordinatedwith and complementary to messages developed by HHS buttailored for their respective departments, within 6 months.Measure of performance: up-to-date risk communication materialpublished on DOD and VA pandemic influenza websites, HHSwebsite www.pandemicflu.gov, and in other venues.

HHS = Department of Health and Human Services, DHS =Department of Homeland Security, DOD = Department ofDefense, VA = Department of Veterans Affairs.

Table 2. Sample Action Item from the National Strategy forPandemic Influenza: Implementation Plan

White House Homeland Security Council. National strategy for pandemic influenza: implemen-tation plan. Washington, DC; 2006 May. http://www.whitehouse.gov/homeland/pandemic-influenza-implementation.html.


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But as you grapple with these difficult questions,consider the fact that influenza pandemics will hap-pen because we cannot prevent them. A renownedhistorian of the 191820 pandemic, Alfred W.Crosby, said, I know how not to get AIDS. I dontknow how not to get the flu.31

Perhaps the 1918 pandemic was a once-in-a-

millennium event, or maybe a pandemic caused bya similarly lethal influenza A (H5N1) strain will

strike in the next five years. Its wise to plan, alwaysconsidering how the resources might be useful forother situations. All hazards emergency plans aredesigned to be of use in managing nearly any kindof disaster or emergency. Harking back to the SARSepidemic, every all hazards emergency planshould include measures for dealing with any infec-tious disease outbreak. Your list of retired nurseswilling to return to work might prove useful in theaftermath of an earthquake. Immunization clinicsfor seasonal influenza can help you plan how youwill distribute vaccine or antivirals in a pandemic(see Emerging Infections, Using Seasonal Influenza

Clinics for Public Health Preparedness Exercises,October 2006). The search for an A (H5N1)influenza vaccine has stimulated research that willimprove vaccine production in general.24 Finally,think of pandemic planning the way you think ofcar insuranceas something you must have buthope never to have to use.M

REFERENCES

1.Barry JM. The great influenza: the epic story of the dead-liest plague in history. New York: Viking; 2004.

2.Dushoff J, et al. Mortality due to influenza in the UnitedStatesan annualized regression approach using multiple-

cause mortality data. Am J Epidemiol2006;163(2):181-7.3.Harper SA, et al. Prevention and control of influenza.

Recommendations of the Advisory Committee onImmunization Practices (ACIP). MMWR Recomm Rep2005;54(RR-8):1-40.

4.Bridges CB, et al. Transmission of influenza: implicationsfor control in health care settings. Clin Infect Dis 2003;37(8):1094-101.

5.Goldmann DA. Transmission of viral respiratory infectionsin the home. Pediatr Infect Dis J2000;19(10 Suppl):S97-S102.

6.Weiss RA. The Leeuwenhoek Lecture 2001. Animal originsof human infectious disease. Philos Trans R Soc Lond B BiolSci 2001;356(1410):957-77.

7.Longini IM, Jr., et al. Containing pandemic influenza at thesource. Science 2005;309(5737):1083-7.

8.Gabriel G, et al. The viral polymerase mediates adaptationof an avian influenza virus to a mammalian host. Proc NatlAcad Sci USA 2005;102(51):18590-5.

9.Kilbourne ED. Influenza pandemics: can we prepare for theunpredictable? Viral Immunol2004;17(3):350-7.

10.Taubenberger JK, et al. Characterization of the 1918influenza virus polymerase genes. Nature 2005;437(7060):889-93.

11.White House Homeland Security Council. National strategyfor pandemic influenza: implementation plan. Washington,DC; 2006 May. http://www.whitehouse.gov/homeland/pandemic-influenza-implementation.html.

12.Potter CW. A history of influenza.J Appl Microbiol2001;91(4):572-9.

13.Hope-Simpson RE. Recognition of historic influenza epi-demics from parish burial records: a test of prediction from

a new hypothesis of influenzal epidemiology.J Hyg (Lond)1983;91(2):293-308.

Face Masks or Respirators?

Apress release on May 3 from the Centersfor Disease Control and Prevention (CDC)

introduced interim guidance for the use of facemasks and respirators in public settings duringan influenza pandemic, which is summarized atwww.pandemicflu.gov/vaccine/maskguidance.html. Here are the three main recommendationsin the summary. Whenever possible, rather than relying on

the use of masks or respirators, close contactand crowded conditions should be avoidedduring an influenza pandemic.

Facemasks should be considered for use byindividuals who enter crowded settings, bothto protect their nose and mouth from otherpeoples coughs and to reduce the wearerslikelihood of coughing on others; the timespent in crowded settings should be as shortas possible.

Respirators should be considered for use byindividuals for whom close contact with aninfectious person is unavoidable. This caninclude selected individuals who must care for

a sick person ([for example, a] family memberwith a respiratory infection) at home.In the press release, Dr. Michael Bell, associ-

ate director for infection control in the Division ofHealthcare Quality Promotion at the CDC, said,Facemasks are not designed to protect peoplefrom breathing in very small particles, such asviruses. . . . Rather, facemasks help stop poten-tially infectious droplets from being spread bythe person wearing them. . . . Respirators aredesigned to protect people from breathingin very small particles, which might containviruses. Thus, if you are caring for someone

who is ill with pandemic flu, proper use of awell-fitted respirator may be a reasonablechoice.Dana Carey, associate editor


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14.Patterson KD. Pandemic influenza, 17001900: a study inhistorical epidemiology. Totowa, NJ: Rowman andLittlefield; 1986.

15.Knobler SL, et al., editors. The threat of pandemicinfluenza: are we ready? Washington, DC: NationalAcademies Press; 2005.

16.Osterholm MT. Preparing for the next pandemic. N Engl JMed2005;352(18):1839-42.

17.Schoch-Spana M. Hospitals full-up: the 1918 influenzapandemic. Public Health Rep 2001;116 Suppl 2:32-3.

18.Gostin LO. Pandemic influenza: public health preparednessfor the next global health emergency.J Law Med Ethics2004;32(4):565-73.

19. Patterson KD, Pyle GF. The geography and mortality of the1918 influenza pandemic. Bull Hist Med1991;65(1):4-21.

20.World Health Organization. Epidemic and pandemic alert

and response (EPR): avian influenza. World HealthOrganization. 2007. http://www.who.int/csr/disease/avian_influenza/en/index.html.

21.Wilson ME. The traveler and emerging infections: sentinel,courier, transmitter.J Appl Microbiol2003;94 Suppl:1S-11S.

22.U.S. Department of Health and Human Services. Pandemicplanning update II. Washington, DC; 2006 Jun 29. http://www.pandemicflu.gov/plan/pdf/PanfluReport2.pdf.

23.White House Homeland Security Council. National strategyfor pandemic influenza. Washington, DC; 2005 Nov.http://www.whitehouse.gov/homeland/nspi.pdf.

24.U.S. Department of Health and Human Services. HHSawards contracts totaling more than $1 billion to developcell-based influenza vaccine. 2006. http://www.hhs.gov/news/press/2006pres/20060504.html.

25.Germann TC, et al. Mitigation strategies for pandemicinfluenza in the United States. Proc Natl Acad Sci USA2006;103(15):5935-40.

26.Committee on Modeling Community Containment forPandemic Influenza. Board on Population Health and PublicHealth Practice. Modeling community containment for pan-demic influenza: a letter report. Washington, DC: Institute ofMedicine of the National Academies; 2006. http://www.nap.edu/catalog/11800.html.

27.Centers for Disease Control and Prevention. Interim pre-pandemic planning guidance: community strategy for pan-demic influenza mitigation in the United Statesearlytargeted, layered use of nonpharmaceutical interventions.Atlanta: U.S. Department of Health and Human Services;2007 Feb. http://www.pandemicflu.gov/plan/community/community_mitigation.pdf.

28.Holmberg SD, et al. State plans for containment of pan-

demic influenza. Emerg Infect Dis 2006;12(9):1414-7.29.U.S. Department of Health and Human Services. State pan-

demic plans. 2007. http://www.pandemicflu.gov/plan/states/stateplans.html.

30.U.S. Department of Health and Human Services. Tests,vaccines, medications, and masks: vaccine prioritization.2006. http://www.pandemicflu.gov/vaccine/index.html#vprioritization.

31.Kolata GB. Flu: the story of the great influenza pandemic of1918 and the search for the virus that caused it. New York:Farrar, Straus and Giroux; 1999.


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Questions and Answers on Pandemic Influenza.24