Avian Flu Infection Control Guidelines

by Aruna Vadgama, RN, MPA, CSP, CPHQ, CPE, COHN-S

Editor’s Note: Aruna Vadgama, Healthcare Practice Specialty (HPS) Administrator, wrote this article in response to increasing numbers of inquiries from HPS members and non-members alike. With all of the attention to this topic, everyone wanted an overview of this Avian Flu issue. This is not a reprint; Vadgama has done extensive research into this current and potentially vital topic.

Although it is seen as a potential threat to public health, Avian Flu may be even more threatening to employees of poultry farms especially those involved in the initial culling of the birds, other farm workers and animal handlers (especially pigs, in addition to poultry). Ironically, these same people may be our first line of defense for both the protection of human health and the reduction of large loses in the agricultural industry, according to US Department of Labor, Occupational Safety and Health Administration’s Guidance for Protecting Workers Against Avian Flu. It is they who are most likely to recognize an infected bird or animal.

Employees of wild game preserves are also at risk. On the medical front, laboratory workers, medical transport workers, and doctors and nurses are also at risk.

In its Avian Influenza Frequently Asked Questions(http://www.who.int/csr/disease/avian_influenza/avian_faqs/en/), the World Health Organization notes that “In an agricultural setting, animal manure containing influenza virus can contaminate dust and soil, causing infection when the contaminated dust is inhaled. Contaminated farm equipment, feed, cages, or shoes can carry the virus from farm to farm. The virus can also be carried on the bodies and feet of animals, such as rodents. "The virus can survive, at cool temperatures, in contaminated manure for at least three months. In water, the virus can survive for up to four days at 72º F and more than 30 days at 32º F. For the highly pathogenic form (of influenza A), studies have shown that a single gram of contaminated manure can contain enough virus to infect 1 million birds.

In a food handling/preparation setting, there is also some concern that avian influenza could be transmitted from uncooked birds or bird products. The World Health Organization has also reported a study that found avian influenza A (H5N1) in imported frozen duck meat. Eggs from infected poultry could also be contaminated with the virus.

OSHA’s workers’ protection guidance document observes that there are other federal agencies and international organizations that have further resources on avian flu.

The U.S. Centers for Disease Control and Prevention (CDC) has established avian flu public hotlines: Public 888-246-2675; Spanish 888-246-2857; and for Clinicians 877-246-4625. The CDC has additional online resources at http://www.cdc.gov/flu/avian/index.htm.
The World Health Organization has information on avian flu online at http://www.who.int/csr/disease/avian_influenza/en/.
Physicians, employers and employees should contact their state or local health department ( http://www.cdc.gov/mmwr/international/relres.html) to notify them of any symptomatic employees or suspected exposure incidents.

This article provides the reader with a comprehensive review of the current status of the research, planning and strategies for a pandemic influenza outbreak, especially in the United States. We would certainly welcome comments and potential best responses to this problem and/or practices from our readers to be sent to rheath@asse.org.

Introduction

In recent months the media has bombarded the community with the news about influenza, shortage of influenza vaccine and injecting fear about possibility of avian flu pandemic worldwide. In order to write this paper the author conducted a literature search to learn the message from the World Health Organization (WHO) and the United States Department of Health and Human Services (DHHS) scientists and experts in preventing the spread of the avian flu. The paper addresses the national and internal synergistic efforts to plan an for effective exposure control plan for averting the influenza outbreaks.

According to the WHO, avian flu is an infectious disease of birds caused by type A strains of the influenza virus. Although there have been avian flu outbreaks in China, Vietnam, Thailand and some parts of Europe in the last few years, the disease (avian flu) was first identified in Italy more than 100 years ago, and it occurs worldwide.

All birds are thought to be susceptible to infection with avian influenza, though some species are more resistant to infection than others. Infection causes a wide spectrum of symptoms in birds, ranging from mild illness to a highly contagious and rapidly fatal disease that may result in severe epidemics. The latter is known as “highly pathogenic avian influenza”. This type of disease is characterized by sudden onset, severe illness, and rapid death, with a mortality that can result in 100%.

Recent research has shown that viruses of low pathogenicity can mutate into highly pathogenic viruses after circulation for sometimes short periods in a poultry population. In the 1983–1984 epidemic in the United States of America, the H5N2 virus initially caused low mortality, but within six months became highly pathogenic, with a mortality rate of 90% in the poultry population. Control of the outbreak required destruction of more than 17 million birds at a cost of nearly US$ 65 million. An epidemic of H5N2 avian influenza, which began in Mexico in 1992, started with low pathogenicity, evolved to the highly fatal form, and was not controlled until 1995. During the1999–2001epidemic in Italy, the H7N1 virus, initially of low pathogenicity, mutated within 9 months to a highly pathogenic form. More than 13 million birds died or were destroyed to control further infections in the poultry populations in Italy.

Infection Control Methodology in Farms

The quarantining of infected farms and destruction of infected or potentially exposed flocks are standard control measures aimed at preventing spread to other farms and eventual establishment of the virus in a country’s poultry population. Apart from being highly contagious, avian influenza viruses are readily transmitted from farm to farm by mechanical means, such as by contaminated equipment, vehicles, feed, cages, shoes, and or clothing. Highly pathogenic viruses can survive for long periods in the environment, especially when temperatures are low. Stringent sanitary measures on farms can retrieve some degree of protection.

In the absence of prompt control measures backed by good surveillance, epidemics can last for years. For example, an epidemic of H5N2 avian influenza in Mexico in 1992 started with low pathogenicity and evolved into the highly fatal form that was not controlled until 1995.

Background

Avian influenza A (H5N1) viruses usually affect wild birds but have infected and caused serious disease among poultry, such as chickens, in Asia and Europe. Human infections with H5N1 viruses are rare, but have occurred during 2003 - 2005 in Vietnam, Thailand, Cambodia, Indonesia, and China.

Most cases of H5N1 infection in humans are thought to have occurred from direct contact with infected poultry in the affected countries in Asia.

The threat of new influenza subtypes such as influenza A (H5N1) will be greatly increased if the virus gains the ability for sustained spread from one human to another. Such transmission has not yet been observed. However, a few cases of probable person-to-person spread of H5N1 viruses have been reported, with no instances of transmission continuing beyond one person. For example, one case of probable person-to-person transmission associated with close contact between an ill child and her mother is thought to have occurred in Thailand in September 2004.

H5N1 infections in humans can cause serious disease and death. There currently is no commercially available vaccine to protect people against the H5N1 virus that is being seen in Asia and Europe. However, vaccines are being developed. Research studies to test a vaccine to protect people against the H5N1 virus began in April 2005, and a series of clinical trials is under way. For more information about vaccine development, visit the National Institutes of Health website.

When possible, care should be taken to avoid contact with poultry that has no apparent symptoms, as well as with sick or dead poultry and any surfaces that may have been contaminated by poultry or their feces or secretions. Transmission of H5N1 viruses to two persons through consumption of uncooked duck blood may also have occurred in Vietnam in 2005. Therefore, uncooked poultry or poultry products, including blood, should not be consumed.

Disease Management Challenges

Although the scientific community has made remarkable strides in science and medicine during the past century in preventing and curing diseases, they are constantly challenged by new strengths of multi-drug resistant microbes - viruses, bacteria, protozoa and fungi that are forever changing and adapting themselves to the human host and the defenses that humans create.

Likewise, the influenza viruses are notable for their resilience and adaptability. While science has been able to develop highly effective vaccines and treatments for many infectious diseases that threaten public health, developing an effective treatment medium is an ongoing challenge with the influenza virus. Changes in the genetic makeup of the virus require pharmaceutical companies and scientists to develop new vaccines on an annual basis and forecast which strains are likely to predominate.

The H5N1 viruses currently infecting birds in Asia and Europe and some humans in Asia are resistant to amantadine and rimantadine, two antiviral medications commonly used for influenza. The H5N1 viruses are susceptible in a laboratory setting to the antiviral medications oseltamavir and zanamavir, although the effectiveness of these drugs when used for treatment of H5N1 virus infection is unknown. For more information about influenza antiviral drugs, see http://www.cdc.gov/flu/professionals/treatment/.

Every year when humans receive influenza vaccinations, questions arise whether the vaccination will prevent influenza of all types. The challenge is that all type A influenza viruses, including those that regularly cause seasonal epidemics of influenza in humans, are genetically labile and well adapted to elude host defenses. Influenza viruses lack mechanisms for the “proofreading” and repair of errors that occur during replication. As a result of these uncorrected errors, the genetic composition of the viruses changes as they replicate in humans and animals, and the existing strain is replaced with a new antigenic variant. These constant, permanent and usually small changes in the antigenic composition of influenza A viruses are known as antigenic “drift”, which is commonly described as mutation of the virus.

Influenza viruses have a second characteristic of great public health concern: influenza A viruses, including subtypes from different species, can swap or “reassort” genetic materials and merge. This reassortment process, known as antigenic “shift”, results in a novel subtype different from both parent viruses. As populations will have no immunity to the new subtype, and as no existing vaccines can confer protection, antigenic shift has historically resulted in highly lethal pandemics. For this to happen, the novel subtype needs to have genes from human influenza viruses that make it readily transmissible from person to person for a sustainable period. (Source: World Health Organization and CDC)

The tendency of influenza viruses to undergo frequent and permanent antigenic changes necessitates constant monitoring of the global influenza situation and annual adjustments in the composition of influenza vaccines. Both activities have been a cornerstone of the WHO Global Influenza Program, and the DHHS.

Conditions favorable for the emergence of antigenic shift have long been thought to involve humans and working in close proximity to domestic poultry and pigs. Because pigs are susceptible to infection with both avian and mammalian viruses, including human strains, they can serve as a “mixing vessel” for the scrambling of genetic material from human and avian viruses, resulting in the emergence of a novel subtype. Recent events, however, have identified a second possible mechanism. Evidence is mounting that, for at least some of the 15 avian influenza virus subtypes circulating in bird populations, humans themselves can serve as the “mixing vessel”.

Risk Factors for Avian Influenza in Humans

Avian influenza viruses do not normally infect species other than birds and pigs. According to the WHO, the first documented infection of humans with an avian influenza virus occurred in Hong Kong in 1997, when the H5N1 strain caused severe respiratory disease in 18 humans, of whom 6 died. The infection of humans coincided with an epidemic of highly pathogenic avian influenza, caused by the same strain, in Hong Kong’s poultry population.

Extensive investigation by the WHO of that outbreak determined that close contact with live infected poultry was the source of human infection. Studies at the genetic level further determined that the virus had jumped directly from birds to humans. Limited transmission to health care workers occurred, but did not cause severe disease.

The WHO reported that a rapid destruction (within three days) of Hong Kong’s entire poultry population, an estimated at around 1.5 million birds, reduced opportunities for further direct transmission to humans and may have averted a pandemic.

The 1997 Honk Kong Flu alarmed public health authorities worldwide, as it marked the first time that an avian influenza virus was transmitted directly to humans and caused severe illness with high mortality. Alarm raised a concern again in February 2003, when an outbreak of H5N1 avian influenza in Hong Kong caused 2 cases and 1 death in members of a family who had recently traveled to southern China. Another child in the family died during that visit, but the cause of death was not known.

Two other avian influenza viruses have recently caused illness in humans. An outbreak of highly pathogenic H7N7 avian influenza, which began in the Netherlands in February 2003, caused the death of one veterinarian two months later, and mild illness in 83 other humans. Mild cases of avian influenza H9N2 in children occurred in Hong Kong in 1999 (two cases) and in mid-December 2003 (one case). H9N2 is not highly pathogenic in birds. (Source: World Health Organization)

The most recent cause for alarm occurred in January 2004, when laboratory tests confirmed the presence of H5N1 avian influenza virus in human cases of severe respiratory disease in the northern part of Viet Nam.

Why H5N1 is of Particular Concern?

Of the 15 avian influenza virus subtypes, H5N1 is of particular concern for the following reasons:

H5N1 mutates rapidly and has a documented propensity to acquire genes from viruses infecting other animal species.
Its ability to cause severe disease in humans has now been documented on two occasions.
Laboratory studies have demonstrated that isolates from this virus have a high pathogenicity and can cause severe disease in humans. Birds that survive infection excrete virus for at least 10 days, orally and in feces, thus facilitating further spread at live poultry markets and by migratory birds.
The epidemic of highly pathogenic avian influenza caused by H5N1, which began in mid-December 2003 in the Republic of Korea and is now being seen in other Asian countries, is therefore of particular public health concern.
H5N1 variants demonstrated a capacity to directly infect humans in 1997, and have done so again in Viet Nam in January 2004.
The spread of infection in birds increases the opportunities for direct infection of humans. If more humans become infected over time, the likelihood also increases that humans, if concurrently infected with human and avian influenza strains, could serve as the “mixing vessel” for the emergence of a novel subtype with sufficient human genes to be easily transmitted from person to person. Such an event would mark the start of an influenza pandemic.

Influenza pandemics: Can They Be Prevented?

Pandemics happen when a new type or mutation of influenza virus emerges that infects and is efficiently transmitted between humans. Animals are the most likely reservoir for these emerging viruses; avian viruses played a role in the last three influenza pandemics. Two of these pandemic-causing viruses remain in circulation and are responsible for the majority of influenza cases each year.

As discussed in a previous heading, pandemics have occurred intermittently over centuries. The last three pandemics, in 1918, 1957 and 1968, killed approximately 40 million, 2 million and 1 million people worldwide, respectively. Although the timing cannot be predicted, history and science suggest that we will face one or more pandemics in this century.

The current pandemic threat stems from an unprecedented outbreak of avian influenza in Asia and Europe, caused by the H5N1 strain of the Influenza A virus. To date, the virus has infected birds in 16 countries and has resulted in the deaths, through illness and killing, of approximately 200 million birds across Asia. While traditional control measures have been attempted, the virus is now endemic in Southeast Asia, present in long-range migratory birds, and unlikely to be eradicated soon.

A notable and worrisome feature of the H5N1 virus is its ability to infect a wide range of hosts, including birds and humans. According the DHHS, the virus is known to have infected over 121 people in four countries, resulting in 62 deaths over the past two years. Although the virus has not yet shown an ability to transmit efficiently between humans, as is seen with the annual influenza virus, there is concern that it will acquire this capability through genetic mutation or exchange of genetic material with a human influenza

As a result, and despite annual vaccinations, the United States faces a burden of influenza that result in approximately 36,000 deaths and more than 200,000 hospitalizations each year. In addition to this human toll, influenza is annually responsible for a total cost of over $10 billion in the U.S. (Source: DHHS)

A pandemic, or worldwide outbreak of a new influenza virus, could enhance this impact by overwhelming our health and medical capabilities, potentially resulting in hundreds of thousands of deaths, millions of hospitalizations, and hundreds of billions of dollars in direct and indirect costs. To control the pandemic, the DHHS has published the following national Strategy guidelines for preparedness and response activities to mitigate that impact in the United States of America.

The United States of America’s National Strategy for Pandemic Influenza guidelines are based on preparedness and response to an influenza pandemic, with the intent of (1) stopping, slowing or otherwise limiting the spread of a pandemic to the United States; (2) limiting the domestic spread of a pandemic, and mitigating disease, suffering and death; and (3) sustaining infrastructure and mitigating impact to the economy and the functioning of society. (Source: DHHS)

The Strategy is a guiding document to provide a framework for future U.S. Government planning efforts that is consistent with The National Security Strategy and the National Strategy for Homeland Security. This document clearly recognizes that preparing for and responding to a pandemic cannot be viewed as a purely federal responsibility, and that the nation must have a system of plans at all levels of government and in all sectors outside of government that can be integrated to address the pandemic threat. It is guided by the following principles:

The federal government will use all instruments of national power to address the pandemic threat.
States and communities should have credible pandemic preparedness plans to respond to an outbreak within their jurisdictions.
The private sector should play an integral role in preparedness before a pandemic begins, and should be part of the national response.
Individual citizens should be prepared for an influenza pandemic, and be educated about individual responsibility to limit the spread of infection if they or their family members become ill.
Global partnerships will be leveraged to address the pandemic threat.

The Essential Elements of the National Strategy

The US DHHS Strategy addresses the full spectrum of events that link a farmyard overseas to a farmyard, processing plant, laboratory, etc., to a living room in America. While the circumstances that connect these environments are very different, the strategic principles remain relevant. The pillars of Strategy are:

Preparedness and Communication : Activities that should be undertaken before a pandemic to ensure preparedness, and the communication of roles and responsibilities to all levels of government, segments of society and individuals.
Surveillance and Detection : Domestic and international systems that provide continuous “situational awareness,” to ensure the earliest warning possible to protect the population.
Response and Containment : Actions to limit the spread of the outbreak and to mitigate the health, social and economic impacts of a pandemic.

Implementation of the National Strategy

This Strategy reflects the Federal government’s approach to the pandemic threat. While it provides strategic direction for the departments and agencies of the U.S. Government, it does not attempt to catalogue and assign all responsibilities to the federal government. The implementation of this Strategy and specific responsibilities has still to be developed and communicated.

Pillar One: Preparedness and Communication

Preparedness is the underpinning of the entire spectrum of activities, including surveillance, detection, containment and response efforts. In accordance with this plan, the Federal government through the DHHS will support pandemic planning efforts, and clearly communicate expectations to individuals, communities and governments, whether overseas or in the United States, recognizing that all share the responsibility to limit the spread of infection in order to protect populations beyond their borders.

A critical element of pandemic planning is ensuring that people and entities not accustomed to responding to health crises understand the actions and priorities required to prepare for and respond to a pandemic. Those groups include political leadership at all levels of government, non-health components of government, and members of the private sector. Essential planning also includes the coordination of efforts between human and animal health authorities. In order to accomplish this, the following plan of action is essential:

Strategy	Plan of Action
Pillar One: Preparedness and Communication
Communicating Expectations and Responsibilities	Ensure clear, effective and coordinated risk communication, domestically and internationally, before and during a pandemic. This includes identifying credible spokespersons at all levels of government to effectively coordinate and communicate helpful, informative messages in a timely manner. Provide guidance to the private sector and critical infrastructure entities on their role in the pandemic response, and considerations necessary to maintain essential services and operations despite significant and sustained worker absenteeism. Provide guidance to individuals on infection control behaviors they should adopt pre-pandemic, and the specific actions they will need to take during a severe influenza season or pandemic, such as self-isolation and protection of others if they themselves contract influenza. Provide guidance and support to poultry, swine and related industries on their role in responding to an outbreak of avian influenza, including ensuring the protection of animal workers and initiating or strengthening public education campaigns to minimize the risks of infection from animal products.
Producing and Stockpiling Vaccines, Antivirals and Medical Material	In combination with traditional public health measures, vaccines and antiviral drugs form the foundation of national infection control strategy. Vaccination is the most important element of this strategy, but we acknowledge that a two-pronged strategy incorporating both vaccines and antivirals is essential. To establish production capacity and stockpiles in support of our containment and response strategies, the following measures need to be implemented: Encourage nations to develop production capacity and stockpiles to support their response needs, to include pooling of efforts to create regional capacity. Encourage and subsidize the development of state-based antiviral stockpiles to support response activities. Ensure that our national stockpile and stockpiles based in states and communities are properly configured to respond to the diversity of medical requirements presented by a pandemic, including personal protective equipment, antibiotics and general supplies. Establish domestic production capacity and stockpiles of countermeasures to ensure: Sufficient vaccine to vaccinate front-line personnel and at-risk populations, including military personnel; Sufficient vaccine to vaccinate the entire U.S. population within six months of the emergence of a virus with pandemic potential; and Antiviral treatment for those who contract a pandemic strain of influenza. Facilitate appropriate coordination of efforts across the vaccine manufacturing sector. Address regulatory and other legal barriers to the expansion of our domestic vaccine production capacity. Expand the public health recommendations for domestic seasonal influenza vaccination and encourage the same practice internationally. Expand the domestic supply of avian influenza vaccine to control a domestic outbreak of avian influenza in bird populations.
Establishing Distribution Plans for Vaccines and Antivirals	It is essential to prioritize the allocation of countermeasures (vaccines and antivirals) that are in limited supply and define effective distribution modalities during a pandemic. Thus it is important to: Develop credible countermeasure distribution mechanisms for vaccine and antiviral agents prior to and during a pandemic. Prioritize countermeasure allocation before an outbreak, and update this prioritization immediately after the outbreak begins based on the at-risk populations, available supplies and the characteristics of the virus.
Advancing Scientific Knowledge and Accelerating Development	Research and development of vaccines, antivirals, adjuvants and diagnostics represents our best defense against a pandemic. To realize the goal of next-generation countermeasures against influenza, we must make significant and targeted investments in promising technologies. Thus it will be necessary to: Ensure that there is maximal sharing of scientific information about influenza viruses between governments, scientific entities and the private sector. Work with our international partners to ensure that we are all leveraging the most advanced technological approaches available for vaccine production. Accelerate the development of cell culture technology for influenza vaccine production and establish a domestic production base to support vaccination demands. Use innovative investment strategies to advance the development of next-generation influenza diagnostics and countermeasures, including new antivirals, vaccines, adjuvant technologies, and countermeasures that provide protection across multiple strains and seasons of the influenza virus.

Pillar Two: Surveillance and Detection

Early warning of a pandemic and our ability to closely track the spread of avian influenza outbreak is critical to being able to rapidly deploy resources to contain the spread of the virus. An effective surveillance and detection system will save lives by allowing us to activate our response plans before the arrival of a pandemic virus to the U.S., activate additional surveillance systems, and initiate vaccine production and administration.

Pillar Two: Surveillance and Detection Ensuring Rapid Reporting of Outbreaks	To support our need for “situational awareness,” both domestically and internationally, it will be necessary to: Corroborate with the International Partnership on Avian and Pandemic Influenza, as well as through other political and diplomatic channels such as the United Nations and the Asia-Pacific Economic Cooperation forum, to ensure transparency, scientific cooperation and rapid reporting of avian and human influenza cases. Support the development of the proper scientific and epidemiologic expertise in affected regions to ensure early recognition of changes in the pattern of avian or human outbreaks. Support the development and sustainment of sufficient U.S. and host nation laboratory capacity and diagnostic reagents in affected regions and domestically, to provide rapid confirmation of cases in animals or humans. Advance mechanisms for “real-time” clinical surveillance in domestic acute care settings such as emergency departments, intensive care units and laboratories to provide local, state and federal public health officials with continuous awareness of the profile of illness in communities, and leverage all federal medical capabilities, both domestic and international, in support of this objective. Develop and deploy rapid diagnostics with greater sensitivity and reproducibility to allow onsite diagnosis of pandemic strains of influenza at home and abroad, in animals and humans, to facilitate early warning, outbreak control and targeting of antiviral therapy. Expand the domestic livestock and wildlife surveillance activities to ensure early warning of the spread of an outbreak to our shores.
Using Surveillance to Limit Spread	Although influenza does not respect geographic or political borders, entry to and egress from affected areas represent opportunities to control or at the very least slow the spread of infection. In parallel to our containment measures, it will be necessary to: Develop mechanisms to rapidly share information on travelers who may be carrying or may have been exposed to a pandemic strain of influenza, for the purposes of contact tracing and outbreak investigation. Develop and exercise mechanisms to provide active and passive surveillance during an outbreak, both within and beyond our borders. Expand and enhance mechanisms for screening and monitoring animals that may harbor viruses with pandemic potential. Develop screening and monitoring mechanisms and agreements to appropriately control travel and shipping of potentially infected products to and from affected regions if necessary, and to protect unaffected populations.

Pillar Three: Response and Containment We recognize that a virus with pandemic potential anywhere represents a risk to populations everywhere. transmission to locations around the globe.
Containing Outbreaks	The most effective way to protect the American population is to contain an outbreak beyond the borders of the U.S. While we work to prevent a pandemic from reaching our shores, we recognize that slowing or limiting the spread of the outbreak is a more realistic outcome and can save many lives. In support of our containment strategy, it will be necessary to: Work through the International Partnership to develop a coalition of strong partners to coordinate actions to limit the spread of a virus with pandemic potential beyond the location where it is first recognized in order to protect U.S. interests abroad. Where appropriate, offer and coordinate assistance from the United States and other members of the International Partnership. Encourage all levels of government, domestically and globally, to take appropriate and lawful action to contain an outbreak within the borders of their community, province, state or nation. Where appropriate, use governmental authorities to limit non-essential movement of people, goods and services into and out of areas where an outbreak occurs. Provide guidance to all levels of government on the range of options for infection-control and containment, including those circumstances where social distancing measures, limitations on gatherings, or quarantine authority may be an appropriate public health intervention. Emphasize the roles and responsibilities of the individual in preventing the spread of an outbreak, and the risk to others if infection-control practices are not followed. Provide guidance for states, localities and industry on best practices to prevent the spread of avian influenza in commercial, domestic and wild birds, and other animals.
Leveraging National Medical and Public Health Surge Capacity	Rather than generating a focal point of casualties, the medical burden of a pandemic is likely to be distributed in communities across the nation for an extended period of time. In order to save lives and limit suffering, it will be necessary to: Implement state and local public health and medical surge plans, and leverage all federal medical facilities, personnel and response capabilities to support the national surge requirement. Activate plans to distribute medical countermeasures, including non-medical equipment and other material, from the Strategic National Stockpile and other distribution centers to federal, state and local authorities. Address barriers to the flow of public health, medical and veterinary personnel across state and local jurisdictions to meet local shortfalls in public health, medical and veterinary capacity. Determine the spectrum of public health, medical and veterinary surge capacity activities that the U.S. military and other government entities may be able to support during a pandemic, contingent upon primary mission requirements, and develop mechanisms to activate them.
Sustaining Infrastructure, Essential Services and the Economy	Movement of essential personnel, goods and services, and maintenance of critical infrastructure are necessary during an event that spans months in any given community. The private sector and critical infrastructure entities must respond in a manner that allows them to maintain the essential elements of their operations for a prolonged period of time, in order to prevent severe disruption of life in our communities. To ensure this, it will be necessary to: Encourage the development of coordination mechanisms across American industries to support the above activities during a pandemic. Provide guidance to activate contingency plans to ensure that personnel are protected, that the delivery of essential goods and services is maintained, and that sectors remain functional despite significant and sustained worker absenteeism. Determine the spectrum of infrastructure-sustainment activities that the U.S. military and other government entities may be able to support during a pandemic, contingent upon primary mission requirements, and develop mechanisms to activate them.
Ensuring Effective Risk Communication	Effective risk communication is essential to inform the public and mitigate panic. It will be necessary to: Ensure that timely, clear, coordinated messages are delivered to the American public from trained spokespersons at all levels of government and assist the governments of affected nations to do the same. Work with state and local governments to develop guidelines to assure the public of the safety of the food supply and mitigate the risk of exposure from wildlife. Roles and Responsibilities Because of its unique nature, responsibility for preparedness and response to a pandemic extends across all levels of government and all segments of society. No single entity alone can prevent or mitigate the impact of a pandemic.
The Federal Government	While the Federal government plays a critical role in elements of preparedness and response to a pandemic, the success of these measures is predicated on actions taken at the individual level and in states and communities. Federal responsibilities include the following: Advancing international preparedness, surveillance, response and containment activities. Supporting the establishment of countermeasure stockpiles and production capacity by: Facilitating the development of sufficient domestic production capacity for vaccines, antivirals, diagnostics and personal protective equipment to support domestic needs, and encouraging the development of production capacity around the world; Advancing the science necessary to produce effective vaccines, therapeutics and diagnostics; and Stockpiling and coordinating the distribution of necessary countermeasures, in concert with states and other entities. Ensuring that federal departments and agencies, including federal health care systems, have developed and exercised preparedness and response plans that take into account the potential impact of a pandemic on the federal workforce, and are configured to support state, local and private sector efforts as appropriate. Facilitating state and local planning through funding and guidance. Providing guidance to the private sector and public on preparedness and response planning, in conjunction with states and communities. Lead departments have been identified for the medical response (Department of Health and Human Services), veterinary response (Department of Agriculture), international activities (Department of State) and the overall domestic incident management and Federal coordination (Department of Homeland Security). Each department is responsible for coordination of all efforts within its authorized mission, and departments are responsible for developing plans to implement this Strategy.
States and Localities	Our communities are on the front lines of a pandemic and will face many challenges in maintaining continuity of society in the face of widespread illness and increased demand on most essential government services. State and local responsibilities include the following: Ensuring that all reasonable measures are taken to limit the spread of an outbreak within and beyond the community’s borders. Establishing comprehensive and credible preparedness and response plans that are exercised on a regular basis. Integrating non-health entities in the planning for a pandemic, including law enforcement, utilities, city services and political leadership. Establishing state and community-based stockpiles and distribution systems to support a comprehensive pandemic response. Identifying key spokespersons for the community, ensuring that they are educated in risk communication, and have coordinated crisis communications plans. Providing public education campaigns on pandemic influenza and public and private interventions.
The Private Sector and Critical Infrastructure Entities	The private sector represents an essential pillar of our society because of the essential goods and services that it provides. Moreover, it touches the majority of our population on a daily basis, through an employer-employee or vendor-customer relationship. For these reasons, it is essential that the U.S. private sector be engaged in all preparedness and response activities for a pandemic. Critical infrastructure entities also must be engaged in planning for a pandemic because of our society’s dependence upon their services. Both the private sector and critical infrastructure entities represent essential underpinnings for the functioning of American society. Responsibilities of the U.S. private sector and critical infrastructure entities include the following: Establishing an ethic of infection control in the workplace that is reinforced during the annual influenza season, to include, if possible, options for working offsite while ill, systems to reduce infection transmission, and worker education. Establishing contingency systems to maintain delivery of essential goods and services during times of significant and sustained worker absenteeism. Where possible, establishing mechanisms to allow workers to provide services from home if public health officials advise against non-essential travel outside the home. Establishing partnerships with other members of the sector to provide mutual support and maintenance of essential services during a pandemic.
Individuals and Families	The critical role of individuals and families in controlling a pandemic cannot be overstated. Modeling of the transmission of influenza vividly illustrates the impact of one individual’s behavior on the spread of disease, by showing that an infection carried by one person can be transmitted to tens or hundreds of others. For this reason, individual action is perhaps the most important element of pandemic preparedness and response. Education on pandemic preparedness for the population should begin before a pandemic, should be provided by all levels of government and the private sector, and should occur in the context of preventing the transmission of any infection, such as the annual influenza or the common cold. Responsibilities of the individual and families include: Taking precautions to prevent the spread of infection to others if an individual or a family member has symptoms of influenza. Being prepared to follow public health guidance that may include limitation of attendance at public gatherings and non-essential travel for several days or weeks. Keeping supplies of materials at home, as recommended by authorities, to support essential needs of the household for several days if necessary.
International Partners	The international partnerships and corroboration, with the United Nations, international organizations and private non-profit organizations, to amplify our efforts, and will engage them on a multilateral and bilateral basis. Our international effort to contain and mitigate the effects of an outbreak of pandemic influenza is a central component of our overall strategy. In many ways, the character and quality of the U.S. response

Based on historical patterns, influenza pandemics can be expected to occur, on average, three to four times each century when new virus subtypes emerge and are readily transmitted from person to person. However, the occurrence of influenza pandemics is unpredictable. Experts do agree though that another influenza pandemic is inevitable and possibly imminent. Most influenza experts also agree that the prompt culling of Hong Kong’s entire poultry population in 1997 probably averted a pandemic.

Influenza Exposure Control Plan

The following measures can help minimize the global public health risks that could arise from large outbreaks of highly pathogenic H5N1 avian influenza in birds. An immediate priority is to halt further spread of epidemics in poultry populations. This strategy works to reduce opportunities for human exposure to the virus. Vaccination of persons at high risk of exposure to infected poultry, using existing vaccines effective against currently circulating human influenza strains, can reduce the likelihood of co-infection of humans with avian and influenza strains, and thus reduce the risk that genes will be exchanged. Workers involved in the culling of poultry flocks must be protected and therefore hopefully reduce the likelihood of illness or gene swapping or mutation. These workers should also receive antiviral drugs as a prophylactic measure.

Editor’s Note: Again from OSHA’s workers’ protection guidance document: Exposure to infected poultry and their feces or dust contaminated with feces has been associated with human infection; however this is a rare occurrence. The following summarizes the recommendations that have been developed by the CDC and the WHO because human infections have occurred in Asia during the current poultry epidemic. They will be updated as more information becomes available. http://www.who.int/csr/don/2004_01_15/en/

All persons who have been in close contact with the infected animals, contact with contaminated surfaces, or after removing gloves, should wash their hands frequently. Hand hygiene should consist of washing with soap and water for 15-20 seconds or the use of other standard hand-disinfection procedures as specified by state government, industry, or USDA outbreak-response guidelines.
All workers involved in the culling, transport, or disposal of avian influenza-infected poultry should be provided with appropriate personal protective equipment:

Protective clothing capable of being disinfected or disposed, preferably coveralls plus an impermeable apron or surgical gowns with long cuffed sleeves plus an impermeable apron;
Gloves capable of being disinfected or disposed; gloves should be carefully removed and discarded or disinfected and hands should be cleaned;
Respirators: the minimum recommendation is a disposable particulate respirator (e.g. N95, N99 or N100) used as part of a comprehensive respiratory protection program. The elements of such a program are described in 29 CFR 1910.134. Workers should be fit tested for the model and size respirator they wear and be trained to fit-check for facepiece to face seal;
Goggles;
Boots or protective foot covers that can be disinfected or disposed.

Environmental clean up should be carried out in areas of culling, using the same protective measures as above.
Unvaccinated workers should receive the current season's influenza vaccine to reduce the possibility of dual infection with avian and human influenza viruses.
Workers should receive an influenza antiviral drug daily for the duration of time during which direct contact with infected poultry or contaminated surfaces occurs. The choice of antiviral drug should be based on sensitivity testing when possible. In the absence of sensitivity testing, a neuramindase inhibitor (oseltamavir) is the first choice since the likelihood is smaller that the virus will be resistant to this class of antiviral drugs than to amantadine or rimantadine.
Potentially exposed workers should monitor their health for the development of fever, respiratory symptoms, and/or conjunctivitis (i.e., eye infections) for 1 week after last exposure to avian influenza-infected or exposed birds or to potentially avian influenza-contaminated environmental surfaces. Individuals who become ill should seek medical care and, prior to arrival, notify their health care provider that they may have been exposed to avian influenza.

When cases of avian influenza in humans occur, information on the extent of influenza infection in animals as well as humans and on circulating influenza viruses is urgently needed to aid the assessment of risks to public health and to guide the best protective measures. Thorough investigation of each case is also essential. While WHO and the members of its global influenza network, together with other international agencies, can assist with many of these activities, the successful containment of public health risks also depends on the epidemiological and laboratory capacity of affected countries and the adequacy of surveillance systems already in place.

Editor’s Note: OSHA’s workers’ protection guidance document notes that highly pathogenic avian influenza A (H5N1) is classified as a select agent and must be worked with under Biosafety Level (BSL) 3+ laboratory conditions. Furthermore, all employers processing biologic specimens suspected of being infected with influenza A (H5N1) must ensure that their employees comply with all provisions of 29 CFR 1910.1030 for employee protection against bloodborne pathogens.

While all these activities can reduce the likelihood that a pandemic strain will emerge, the question of whether another influenza pandemic can be averted cannot be answered with certainty.

Clinical Course and Treatment of Human Cases of H5N1 Avian Influenza

Published information about the clinical course of human infection with H5N1 avian influenza is limited to studies of cases in the 1997 Hong Kong outbreak. In that outbreak, patients developed symptoms of fever, sore throat, and cough and, in several of the fatal cases, severe respiratory distress secondary to viral pneumonia. Previously healthy adults and children, and some with chronic medical conditions, were affected.

Tests for diagnosing all influenza strains of animals and humans are rapid and reliable. Many laboratories in the WHO global influenza network have the necessary high-security facilities and reagents for performing these tests as well as considerable experience. Rapid bedside tests for the diagnosis of human influenza are also available, but do not have the precision of the more extensive laboratory testing that is currently needed to fully understand the most recent cases and determine whether human infection is spreading, either directly from birds or from person to person.

Antiviral drugs, some of which can be used for both treatment and prevention, are clinically effective against Influenza A virus strains in otherwise healthy adults and children, but have some limitations. Some of these drugs are also expensive and supplies are limited.

Experience in the production of influenza vaccines is also considerable, particularly as vaccine composition changes each year to match changes in circulating virus due to antigenic drift. However, at least four months would be needed to produce a new vaccine, in significant quantities, capable of conferring protection against a new virus subtype.

Conclusion

Communities, Workplaces and Individuals Should :

Everyone should develop preparedness plans as you would for other public health emergencies.
Participate and promote public health efforts in your state and community.
Participate in influenza vaccination program annually, especially if you are a high risk to acquire influenza infections.
If you are a healthcare worker, school teacher, work in protecting public safety, prison population and emergency responder, participate in annual health promotion program to prevent airborne, Bloodborne, waterborne, food borne and contact types of diseases and infections.
Talk with your local public health officials and health care providers; they can supply information about the signs and symptoms of a specific disease outbreak.
Implement prevention and control actions recommended by your public health officials and providers.
Adopt business/school practices that encourage sick employees/students to stay home.
Anticipate how to function with a significant portion of the workforce/school population absent due to illness or caring for ill family members.
Practice good health habits, including eating a balanced diet, exercising daily, and getting sufficient rest and take these common-sense steps to stop the spread of germs.
Wash hands frequently with soap and water.
Wash your hands before eating, drinking and before applying cosmetics, lip balm to prevent accidental ingestion of pathogens.
Eat only cooked meats and poultry.
Cover coughs and sneezes with tissues.
Stay away from others as much as possible if you are sick.
Stay informed about pandemic influenza and be prepared to respond.
Use national and local pandemic hotlines that will be established in the eventuality of a global influenza outbreak.
Listen to radio and television and read media stories about pandemic flu.
Consult www.pandemicflu.gov frequently for updates on national and international information on pandemic influenza.

Aruna Vadgama is Director of Quality Resources at the Menninger Clinic in Houston TX. She is Administrator for the ASSE Healthcare Practice Specialty. She can be contacted at avadgama@menninger.edu.