You are on page 1of 6

learning zone

CONTINUING PROFESSIONAL DEVELOPMENT


Page 58 Avian influenza multiple choice questionnaire Page 59 Read Melanie Halls practice profile on chlamydia Page 60 Guidelines on how to write a practice profile

Avian influenza:are you prepared?


NS363 Campbell S (2006) Avian influenza: are you prepared? Nursing Standard. 21, 5, 51-56. Date of acceptance: June 14 2006.

Summary
This article aims to assist healthcare workers to prepare, both in their professional and personal life, for a possible influenza pandemic. It identifies the medical and non-medical interventions that may be required.

Review non-medical interventions in the event of an influenza pandemic. Outline the features of an effective public health communication campaign.

Influenza
Influenza viruses have affected humans for generations as well as many species of birds and mammals. The viruses are grouped into three types: influenza A, B and C, subtypes of which can cause infection in humans. Influenza A viruses circulate most years, generally cause more serious illness than B and C and are the cause of most winter epidemics and all known pandemics. These viruses can mutate more readily than influenza B viruses. Influenza B viruses circulate at low levels most years causing sporadic and generally less severe outbreaks and epidemics, particularly among young children in school settings. Influenza C viruses usually cause only minor respiratory illness, such as symptoms of the common cold, and are generally not considered a public health concern (Department of Health (DH) 2006).

Author
Susan Campbell is volunteer community health adviser, Kampala, Uganda. Email: masc@utlonline.co.ug

Keywords
Infection control; Public health; Respiratory system and disorders These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

Aims and intended learning outcomes


Influenza pandemics have spread rapidly around the world on a regular basis. Concern has been raised about a possible new pandemic from the H5N1 subtype of influenza A. This article focuses on influenza and the public health response following an influenza pandemic. It aims to help health workers understand influenza and the implications of a new pandemic affecting humans. After reading this article you should be able to: Discuss influenza generally and avian influenza specifically. Summarise the planning required for an influenza pandemic. Defend the need for global and national strategies to deal with a pandemic. Critically discuss public health interventions, including vaccines and antiviral drugs.

Time out 1
List the signs and symptoms of influenza A. What are the possible complications, and which groups of people are at higher risk of more serious illness?

What is a pandemic?
A pandemic is the worldwide spread of a disease, with outbreaks or epidemics occurring in many countries and in most regions of the world. Influenza pandemics in the last century occurred in 1918/19 (Spanish flu), 1957/58 (Asian flu) and 1968/69 (Hong Kong flu). Up to one quarter of the UK population developed illness in each of october 11 :: vol 21 no 5 :: 2006 51

This article was first published in Primary Health Care (2006) 16, 7, 39-43.

NURSING STANDARD

learning zone respiratory focus


these pandemics, many thousands of people died and the associated economic and social disruption was huge. The most severe that of 1918/19 is estimated to have killed around 250,000 people in the UK and between 20 and 40 million people worldwide (DH 2005a, 2006, World Health Organization (WHO) 2005a). These are different from the UK seasonal influenza epidemics that occur most winters (DH 2005b).

highly pathogenic avian influenza (HPAI) and can reach epidemic levels among birds (DH 2006).

From avian influenza to pandemic influenza


The widespread occurrence and continued spread of H5N1 in poultry have increased concern that it could provide the seedbed for the emergence of a new human influenza virus with pandemic potential. H5N1 has crossed the species barrier, although to date those who have become infected have been in close contact with infected birds. While international efforts are being directed at preventing such an event, or aborting it early in its tracks, the opportunities to do this are limited. Once established, the virus will spread rapidly. The tools to reduce its spread and impact are also limited (DH 2005a). Historically, human infection with avian influenza viruses has usually caused mild conditions such as conjunctivitis (eye infection) and mild flu-like symptoms. More severe infections can lead to pneumonia, acute respiratory distress, viral pneumonia and bronchitis (DH 2006). As of September 19 2006, 247 reported cases of H5N1 infection in people had occurred in seven countries; 144 of these have been fatal. Updates are available from the WHO website: www.who.int/csr/disease/avian_influenza/country. All prerequisites for the start of a pandemic have been met save one: the establishment of efficient and sustained human-to-human transmission of the virus. The risk that the H5N1 virus will acquire this ability is difficult to assess, but the risk will continue as long as opportunities for human infections occur. These opportunities will persist as long as the virus continues to circulate in birds, and this situation is expected to endure for several years to come. The virus is now considered endemic in poultry populations in large parts of Asia, and timeframes for control of the disease are now being measured in years. Moreover, the virus has changed in ways that greatly complicate control efforts. First, domestic ducks are now acting as a silent reservoir of the virus, perpetuating transmission to other domestic birds. They can excrete large quantities of viral pathogens yet appear to be perfectly healthy. Second, migratory birds are almost certainly now spreading the virus along their flyways; experts agree that control of the virus in wild birds is impossible (WHO 2005b).

Time out 2
With a colleague, identify why the impact of influenza cannot reasonably be described as minor? From time to time a major mutation of a virus, or exchange of genetic material between influenza viruses, including between those of different species, results in a major change in the surface antigens called antigenic drift of the virus. Antigenic shift is specific to influenza A viruses, and these changes can confer pandemic potential as long as the resulting virus can infect and cause disease in people (rather than just mammals or birds), can spread efficiently from person to person and a high proportion of the population is susceptible (DH 2006).

Avian influenza
Avian influenza or bird flu is a highly contagious disease of birds, caused by influenza A viruses. It was documented as a possible threat to humans in the document Getting Ahead of the Curve (DH 2002). In birds, the viruses can present with a range of symptoms from mild illness and low mortality to a highly contagious disease with a near 100 per cent fatality rate. The bird flu virus currently affecting poultry and some people is the highly pathogenic H5N1 strain of the virus. Because the virus can remain viable in contaminated droppings for long periods, it can be spread among birds, and from birds to other animals, through ingestion or inhalation. All bird species are thought to be susceptible to avian influenza. Migratory birds such as wild ducks and geese can carry the viruses, often without any symptoms of illness, and show the greatest resistance to infection. Domestic poultry flocks, however, are particularly vulnerable to epidemics of a rapid, severe and fatal form of the disease. There are many different subtypes of the influenza A virus. The most virulent are called 52 october 11 :: vol 21 no 5 :: 2006

Preparation and planning


The human morbidity and mortality, the social disruption and the economic consequences caused by an influenza pandemic would be immense. NURSING STANDARD

Time out 3
What is the potential social disruption that an influenza pandemic could cause locally? Perhaps you could discuss this with some colleagues. What could be the economic consequences of such a pandemic? Think about the impact on hospitals, schools and travel, for example. Have a look at the document Checklist for Influenza Pandemic Preparedness Planning (WHO 2005c) for a possible scenario following a pandemic. The UK Influenza Pandemic Contingency Plan (DH 2005a) also examines possible social disruption. Pandemic planning enables countries to recognise and manage an influenza pandemic. Planning may help to reduce transmission of the pandemic virus strain, to decrease cases, hospitalisations and deaths, to maintain essential services and to reduce the economic and social impact of a pandemic. Blueprints for an influenza pandemic preparedness plan can easily be used for broader contingency plans encompassing other disasters caused by the emergence of new, highly transmissible and/or severe communicable diseases (WHO 2005c). Disruption is likely to be less if people know what to expect, what to do and have had time to think through the consequences for themselves, their families, communities and organisations (DH 2005a). Global strategy According to the United Nations Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (OIE), there are a number of reasons why a global strategy needs to be adopted for progressive control of HPAI (Box 1). As well as a global strategy WHO has recommended that all countries develop a national strategy for the control of avian influenza (WHO 2005c).

Other guidelines are available for emergency planning such as the WHO Checklist for Influenza Pandemic Preparedness Planning (WHO 2005c) and Influenza Pandemic Risk Assessment and Preparedness in Africa (WHO 2005b). A great deal of experience has been gained from events such as the outbreak of severe acute respiratory syndrome (SARS) in 2003. Public health interventions The objective of public health interventions following an avian influenza pandemic is to reduce morbidity, mortality and social disruption (WHO 2005d). Vaccines and antiviral drugs are the two most important medical interventions for reducing morbidity and mortality during a pandemic, but will not be available in adequate supplies. Vaccines are universally considered the first line of defence. Because their supply will be inadequate in every country at the start of a pandemic, antiviral drugs assume a critical early role (WHO 2005d).

Vaccine research and development


For several reasons, no country will have adequate supplies of vaccine at the start of a pandemic. Large-scale commercial vaccine production is not expected to commence until about three to six months following the emergence of a pandemic virus. Manufacturing capacity for influenza vaccines is concentrated in Europe and North America. Current production capacity, estimated at around BOX 1 Key reasons for a global strategy
Highly pathogenic avian influenza (HPAI) is an infectious and dynamically evolving disease that spreads rapidly and widely across countries and continents. HPAI is often zoonotic (a disease humans can get from animals) and transboundary in nature, with the potential to cause a global human pandemic. HPAI has emerged and spread rapidly as a consequence of globalised markets. HPAI impacts on the livelihoods of millions of people, especially people in deprived rural areas. HPAI threatens regional and international trade and places the global poultry industry in the developed and developing worlds at risk. HPAI results from low pathogenic avian influenza (LPAI), which is present in wild birds in many parts of the world. People in all countries in the world are at risk of unexpected infections. HPAI outbreaks are beyond the scope and resources of a single country or region to control. Protecting global human health and wellbeing is a responsibility of the international community.
(FAO/OIE 2005)

Time out 4
Obtain a hard or soft copy of the UK Influenza Pandemic Contingency Plan (www.dh.gov.uk/PolicyAndGuidance/ EmergencyPlanning/PandemicFlu). Which areas in it are particularly important for your work? Ensure you are familiar with the relevant sections. UK influenza pandemic contingency plan In 2005 the UK developed an influenza contingency plan, with a number of key headings, and intended to be comprehensive (DH 2005a). It is also transferable to planning for other emergencies. The specific objectives of the contingency plan for an influenza pandemic are outlined in Box 2. NURSING STANDARD

october 11 :: vol 21 no 5 :: 2006 53

learning zone respiratory focus


300 million doses of trivalent seasonal vaccine per year, falls far below the demand that will arise during a pandemic. The WHO, through its network of specialised influenza laboratories, has monitored the evolution of the H5N1 virus since its initial infection of humans in Hong Kong in 1997. These laboratories prepare the prototype vaccine strain provided to industry as the seed for vaccine development. Constant molecular analyses of viruses by the laboratories ensure that work on vaccine development stays on track. This is particularly important because of the virus mutations detected during 2005 (WHO 2005e). Working on a pandemic vaccine ahead of time also allows countries and vaccine manufacturers to develop a fast-track licensing and regulation process that can be used once a pandemic strain emerges. Regardless of which avian influenza strain causes the next pandemic, countries will still need to determine processes for licensing an eventual vaccine, as well as negotiating with companies to determine legal issues such as BOX 2 Contingency plan objectives
Set up a system for a flexible response to unpredictable events. Prevent the emergence of a potentially pandemic virus, to the extent that this is possible. Recognise a novel strain of influenza virus with pandemic potential, and the resulting clinical illness. Minimise the spread of the new virus and, if possible, prevent the development of a pandemic. Rapidly assess the emerging epidemiology of a new pandemic, such as the age groups predominantly affected, to inform control measures. Limit morbidity and mortality due to infection with the pandemic strain. Provide treatment and care for large numbers of people ill from influenza and its complications. Cope with the eventuality of large numbers of people dying. Reduce the impact on health and social services resulting from an influenza pandemic, including any consequences for other patients because of re-prioritisation of services or cancellation of routine work. Provide timely, authoritative and up-to-date information for professionals, the public and the media throughout the period of a potential or actual pandemic. Ensure that essential services are maintained. Reduce the impact on daily life and business. Anticipate and plan for other consequences. Minimise economic loss.
(DH 2005a)

liability. All of these issues should be considered in advance to expedite the eventual production and distribution of a pandemic vaccine (WHO 2005e). In October 2005, the UK Chief Medical Officer invited manufacturers to tender for a contract to supply pandemic influenza vaccine once the pandemic strain is known. The UK will need approximately 120 million doses to be available as soon as possible (DH 2006).

Antiviral drugs
Pending the availability of vaccines, several antiviral drugs are expected to be useful for prevention or treatment purposes. Two drugs, oseltamivir (commercially known as Tamiflu) and zanamivir (commercially known as Relenza) have been shown in laboratory studies to reduce the severity and duration of illness caused by seasonal influenza (DH 2005a, WHO 2005b). The efficacy of these neuraminidase inhibitors depends on their administration within 48 hours of symptom onset. For cases of human infection with H5N1, the drugs may reduce the severity of disease and improve prospects of survival if administered early, but clinical data are limited. In the absence of clinical trial evidence, the optimal dose and duration of oseltamivir used for seasonal influenza continue to be recommended, but as further research is conducted this may change. No trials have been conducted in pregnant women (WHO 2006). The H5N1 virus is expected to be susceptible to the neuraminidase inhibitors in these drugs. For the neuraminidase inhibitors, the main constraints are substantial and include limited production capacity and prohibitively high prices. Because of the complex and timeconsuming manufacturing process, the sole manufacturer of oseltamivir is unable to meet demand. Present manufacturing capacity, which has recently quadrupled, would need a decade to produce enough oseltamivir to treat 20 per cent of the worlds population (WHO 2005e). Since supplies are severely limited, countries stockpiling antiviral drugs need to decide in advance on priority groups for administration. Frontline healthcare workers would be an obvious priority, but such decisions are the responsibility of governments. While antiviral drugs can confer some measure of protection pending the availability of vaccines, these drugs should not be used to perform the same public health role as vaccines, even if supplies would permit. Mass administration of prophylactic antiviral drugs to large numbers of healthy people for extended periods is not recommended because it could accelerate the development of drug resistance (WHO 2005e). NURSING STANDARD

54 october 11 :: vol 21 no 5 :: 2006

Roche has offered to provide WHO with an international stockpile of oseltamivir (three million treatment courses, which equals 30 million capsules). This stockpile would be used to treat people in the greatest need at the site of an emerging influenza pandemic in an attempt to contain it. The success of this strategy, which has never been tested, depends on several assumptions about the early behaviour of the pandemic virus such as its virulence and the attack rate. Success would also depend on sensitive surveillance and logistics capacity in the initially affected areas, combined with an ability to regulate the movement of people in and out of the area (WHO 2005e). The UK government expanded its stockpile of antiviral drugs with the procurement of 14.6 million treatment courses of the antiviral Tamiflu (enough to treat one quarter of the UK population) in March 2005 (DH 2006).

Non-medical health interventions


At the start of a pandemic, all countries will face inadequate supplies of vaccines and antiviral drugs. Whether or not classic public health measures, such as quarantine, isolation, travel recommendations, will be useful depends largely on the characteristics of the pandemic virus, for example, attack rate, virulence, age groups affected, modes of transmission between countries, none of which will be known in advance. Recommendations about the most effective measures will become more precise as information about the virus becomes available.

school and workplace closures, as well as avoiding mass gatherings, for example, large conferences, public events and congregations. These measures may be recommended if evidence indicates an association of certain settings or events with increased transmission opportunities into the wider population. Such measures will have limited effectiveness in stopping human infections once the pandemic begins, but they may be of use in helping to slow the pandemics spread. During the pandemic, there is likely to be much discussion and debate over the usefulness of travel recommendations, quarantine or isolation policies and social distancing. Depending on the extent of the circulation of the virus, such measures may help to delay the pandemics spread to countries not immediately affected by the strains emergence. Personal hygiene intervention measures include hand-washing, cold etiquette and the use of face masks. Because the influenza virus is highly infectious, the role of personal hygiene may be important in reducing disease spread during a pandemic. While WHO has existing technical BOX 3 Key mass communication points
Trust The overriding goal for outbreak communication is to inform the public in ways that build, maintain or restore trust. The consequences of losing the publics trust can be severe in health, economic and political terms. Announcing early The parameters of trust are established in the outbreaks first official announcement. This messages timing, candour and comprehensiveness may make it the most important of all outbreak communications. In todays globalised world it is almost impossible to keep hidden from the public information about outbreaks. Transparency Maintaining the publics trust throughout an outbreak requires transparency, for example, communication that is candid, easily understood, complete and factually accurate. The public Understanding the public is critical to effective communication. It is usually difficult to change pre-existing beliefs unless those beliefs are explicitly addressed. It is nearly impossible to design successful messages that bridge the gap between the expert and the public without knowing what the public thinks. Planning Risk communication is most effective when it is integrated with risk analysis and risk management. Individual communities are, legitimately, concerned to know whether they are at risk, and if so, what the nature of that risk is, and what they can do about it. In such situations, undue alarm caused by faulty information can do much damage. The key responsibility of journalists is to ensure that the information they disseminate is as accurate as it can be in the circumstances. This does not mean that it has to be scientifically proven. However, it does mean that what is being described must be consistent with what is either known and proven, or considered by those most familiar with the field to be likely.
(WHO 2005e)

Time out 5
In what ways do modern patterns of living and working influence our ability to contain the spread of a pandemic? You may, for example, consider how urban living and commuting influence the spread of communicable diseases. Because influenza is highly infectious, travel recommendations (including entry and exit screening) and other measures restricting the movement of people in and out of affected areas, may only be of limited use. If implemented immediately after the identification of the first clusters of cases, such interventions may succeed in delaying spread. However, once the pandemic strain is detected in the general community, it may be too late to contain it. At this point, measures will be intended primarily to slow the pandemic, allowing authorities time to strengthen their response. Other non-medical interventions include social distancing. This involves measures such as NURSING STANDARD

october 11 :: vol 21 no 5 :: 2006 55

learning zone respiratory focus


guidance for issues such as personal hygiene, primarily for healthcare workers, such guidance is based on general transmission patterns of seasonal human influenza. It is not known how effective this guidance would be in slowing the spread of a pandemic. Thus, any recommendations that WHO provides in the pre-pandemic period, and even once the pandemic starts, may be modified once more information about the pandemic strain is obtained, such as its infection rate and fatality (WHO 2005c).

experiencing outbreaks of avian influenza in poultry flocks, including countries which have also reported cases in humans (DH 2006).

Time out 7
What precautions should travellers to countries affected by outbreaks in poultry flocks take?

Conclusion
Preparation for a possible influenza pandemic is essential and timely. A great deal of experience has been gained from previous public health emergencies such as the outbreak of SARS. This article can assist health workers to prepare professionally and personally for a possible influenza pandemic. It identifies medical and nonmedical interventions that may be required following a pandemic. The effectiveness of some of these cannot be confirmed until the final virus is identified. Accurate and timely communication with the public is also an essential requirement NS

Time out 6
Reflect on a public health issue that has been reported in the media. How well do you think the key points for public health were addressed? In what ways might such issues be either politicised or used to sell newspapers or other publications?

Public health communication campaign


The role of the media is key to ensuring that accurate and timely information is given to the public to ensure co-operation and trust. Because of the importance of the media in major public health issues, WHO has developed guidelines for communicating key messages to the public (Box 3). Risk communication should be incorporated into preparedness planning for major events and in all aspects of an outbreak response (WHO 2005a). WHO does not at present recommend any restrictions on travel to any country currently

Time out 8
Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 60.

References
Department of Health (2002) Getting Ahead of the Curve. A Strategy for Combating Infectious Diseases (Including Other Aspects of Health Protection). The Stationery Office, London. Department of Health (2005a) UK Health Departments Influenza Pandemic Contingency Plan. The Stationery Office, London. Department of Health (2005b) Pandemic Flu Key Facts. October. The Stationery Office, London.

RESOURCES
There are a number of websites that provide useful and regularly updated information on avian influenza (Last accessed: September 21 2006): Department of Health www.dh.gov.uk/PolicyAndGuidance/EmergencyPlanning/PandemicFlu/fs/en Department for Environment, Food and Rural Affairs www.defra.gov.uk/animalh/diseases/notifiable/disease/ai/index.htm Health Protection Agency www.hpa.org.uk/infections/topics_az/influenza/avian/ European Centre for Disease Prevention and Control www.ecdc.eu.int/avian_influenza/index.php Food and Agriculture Organization of the United Nations www.fao.org/AG/AGAInfo/subjects/en/health/diseases-cards/special_avian.html World Health Organization www.who.int/csr/disease/avian_influenza/en/ Foreign and Commonwealth Office www.fco.gov.uk

Department of Health (2006) Bird Flu and Pandemic Influenza: What are the Risks? The Stationery Office, London. Food and Agriculture Organization/World Organisation for Animal Health (2005) A Global Strategy for the Progressive Control of Highly Pathogenic Avian Influenza. FAO/OIE in collaboration with World Health Organization, Rome. World Health Organization (2005a) WHO Outbreak Communication Guidelines. WHO, Geneva. World Health Organization (2005b) Influenza Pandemic Risk Assessment and Preparedness in Africa. WHO, Brazzaville. World Health Organization (2005c) WHO Checklist for Influenza Pandemic Preparedness Planning. WHO, Geneva. World Health Organization (2005d) Responding to the Avian Influenza Pandemic Threat: Recommended Strategic Actions. WHO, Geneva. World Health Organization (2005e) WHO Outbreak Communication. WHO Handbook for Journalists: Influenza Pandemic. WHO, Geneva. World Health Organization (2006) Advice on use of Oseltamivir. WHO, Geneva.

56 october 11 :: vol 21 no 5 :: 2006

NURSING STANDARD

You might also like