Is New Zealand prepared for an outbreak of avian 'flu? Nurses--the largest health group in New Zealand--are in a strong position to either help prevent an epidemic of avian 'flu or to minimise its effects. We must act now.

A storm unprecedented in its fury is approaching New Zealand. Its destructive power is beyond anything we have seen before and far beyond our capabilities to either prevent or even minimise its impact.

Fact or fiction? According to professor at the University of Minnesota's School of Public Health, Michael Osterholm, it is a distinct possibility. (1) A storm in the form of the avian (bird) 'flu N5H1 is on the way. It has the potential to be the most destructive public health epidemic in the history of humankind. Its effects could be so devastating that the world's economy will come to a stand still. Hospitals will spill out into local gymnasiums; there will be too few health care workers to look after the sick; a significant number of nurses will be sick or looking after their own fatuities; hospitals will be overwhelmed; pandemonium will reign.

Avian 'flu is not a new phenomenon. It last raised its ugly head after the First World War when an estimated 50-100 million people died from its effects. Despite its then reliance on slow boats for its spread, it easily encircled the globe dispersing its fatal effect. Today's rapid transport will ensure the avian 'flu's rapid spread. Australian Nobel laureate for medicine, Peter Doherty, warns that "if it comes, it will probably come out of somewhere like South East Asia and it will probably come very fast." (2)

According to Osterholm, the closest the world has come to seeing this type of epidemic has been with the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. (1) Over a period of five months, around 8000 people were infected by a novel human coronavirus. About 1-0 percent of them died. It was amazing just how quickly this infection spread.

New Zealand will not be spared by its geographical isolation from the rest of the world. A possible scenario is that at feast 200,000 people in New Zealand will die, half of them between the ages of 18-40.

At present people catch the avian virus from infected birds. Governments' responses have been to cull millions from the bird populations where outbreaks have occurred. However, some governments do not have the infrastructure or resources to deal with the growing problem. The chances of the situation getting out of control subsequently increases.

The virus has now spread to the wild bird population. It has appeared in a population of migratory geese in western China. (3) Tens of thousands of these birds could be carrying the virus. This month, they will be migrating south toward Australia and New Zealand.

The virus has also appeared in the Indonesian pig population. Scientific journalist for the Asia/ Pacific region, David Cyranowski, states that in some areas it could be affecting up to half of all pigs. (4) The presence of the virus in pigs is a particular worry, because the animals can harbour both bird and human 'flu viruses, and act as a "mixing vessel" for the emergence of a strain of avian 'flu that can easily affect humans. Indonesia is struggling with its limited resources to keep on top of this situation.

Presently there is no evidence to suggest that the H5N1 strain can be transmitted from one person to another. But it could only be a matter of time before a mutation occurs that will allow this to happen.

Producing a vaccine is not that easy. The initial outbreak will be so devastating that by the time scientists have had time to develop and produce a vaccine, the damage may have already been done. Currently the world does not have the capacity to generate the amount of vaccine required to combat an epidemic. Osterholm claims that each person would need at least two doses for adequate protection. In addition, because the structure of the virus changes so rapidly, vaccine development could only start once the pandemic began. (1)

There are some encouraging developments, however. Recent tests of an experimental vaccine show it is effective at stimulating the immune system to fight the avian H5N1 strain. (5) While this news is encouraging, the world needs to immediately increase its capacity to produce an unlimited amount of vaccine. What use is a vaccine if we can't produce enough to vaccinate the entire world? Clinical trials need to continue as a priority and any effective vaccine must be rapidly mass produced.

According to Osterholm, the antiviral agent Tamiflu could play a significant role in reducing the severity of illness and the subsequent complications. (1) However, he suggests it will work best if taken before exposure. Most countries are preparing to give the medication once the illness has occurred, as happens with present strains of influenza.

Because Tamiflu is only made in one factory in Switzerland, most countries do not have enough Tamiflu to cover even a small proportion of the population. For most of the world, it will not be available. New Zealand has recently ordered 800,000 doses of Tamiflu.

There have been a number of scenarios put forward about the impact of the disease. At worst, it could break out tomorrow and hundreds of millions of people could become infected and die. On the other hand, it could break out in five years, people could become mildly ill, with death rates no different from normal outbreaks of influenza. To this point, there has been a 60 percent fatality rate from those infected.

What can nurses in New Zealand do to help prevent this epidemic occurring or to minimise its effects? We must do much and do it fast. We must prepare for both the best and the worst scenarios. We are not just facing a potential Y2K scenario. Human lives are involved.

Nurses are the largest health group in New Zealand. The burden of combating an epidemic of bird 'flu will fall to us. We must have a say in accordance with our influence. The only effective way to combat the effects of this 'flu is to stop it in its tracks.

New Zealand does have a national emergency plan (see box at right). Virologist at the Christchurch School of Medicine and Health Sciences, Lance Jennings, suggests that, while we do have a level of preparedness, we must strengthen this by incorporating the lessons learned from the current avian "flu outbreaks. (6) Expert nurses need to evaluate this plan and examine our current preparedness. This should happen now and our recommendations should be made public.

We need to prepare, not scare the population. The nation needs to be educated about the risks, signs and symptoms of the disease. This should happen now. We need to ensure our emergency plan is ready to combat the epidemic wherever people live, work and go to school. It must involve both the public and private sectors.

All medical practitioners and nurses need to be skilled at recognising the symptoms of the disease. Our medical laboratories need to have a level of preparedness not seen before in this country.

Tamiflu should be made available for everyone. The costs of purchasing this drug cannot be compared with the costs that would occur if we have an outbreak of the 'flu. If an outbreak occurs, we need to make sure we can get doses of Tamiflu to the population, in an orderly way, quickly. Ideally every family in New Zealand should be given doses of Tamiflu to use in preparation for an outbreak.

Nurses must learn from their international colleagues' experiences, and support and encourage international initiatives.

New Zealand and Australia need to take responsibility for the initiatives developed for our Pacific neighbours. Their populations could be far more vulnerable that ours.

We need to be careful about getting bogged down in ethical debates, such as the use of Tamiflu, or whether or not we should be encouraging the development of a vaccine that will most likely be genetically modified.

No one can really say for sure how this expected epidemic will pan out. As nurses we should not become active observers in the debate but active participants in its resolution. Nurses are in a strong position to get things going. Let's do it.

References

(1) Osterholm, M. T. (2005) Preparing for the next pandemic. Foreign Affairs, July/August 2005. http://www.foreignaffairs.org/author/michael-t-osterholm/index.html. Retrieved August 2005.

(2) Radford, T. (2005) Nobel scientist warns on bird flu. Guardian Unlimited. http:www.guardian.co.uk/birdflu/story/0,14207,1458128,00.html Retrieved July 2005.

(3) Adam, D. (2005) Avian flu found in migrating geese. The Guardian. http://www.guardian.co.uk/birdflustory/0,14207,1522733,00.html. Retrieved July 2005.

(4) Cyranoski, D. (2005) Bird flu spreads among Java's pigs. Nature. http://www.nature.com/nature/journal/v435/n7041/full/435390a.html. Retrieved May 2005.

(5) Richwine, L. (2005) Tests show promise for human avian influenza vaccine. Reuters Health Information. http://Medscape.com/viewarticle/510272_print. Retrieved August 2005.

(6) Jennings, L. (2004) Avian influenza: a public health rise for New Zealand. Journal of the New Zealand Medical Association; 11: 1192, April 23.

(7) Ministry of Health (2005) National Health Emergency Plan: Infectious Diseases. www.moh.govt.nz/pandemicinfluenza. Retrieved August 2005.

(8) Maunder, R. (2003) Stress, coping and lessons learned from the SARS outbreak. Hospital Quarterly; 6:4, 49-50.

MINISTRY OF HEALTH SETS UP NATIONAL HEALTH EMERGENCY PLAN

The Ministry of Health has begun preparing for a possible outbreak of avian influenza. This was added to the schedule of notifiable diseases in July this year, despite the fact there have been no cases of the disease in New Zealand so far. The Ministry has also begun briefing national nursing organisations on the National Health Emergency Plan: Infectious Diseases. (7) This plan prepares health professionals and health organisations for managing an outbreak of influenza, including the highly pathogenic avian influenza. The guiding principles of the National Health Emergency Plan (NHEP) are to:

* Provide the greatest possible protection for the population, all health services workers, and health and disability consumers.

* Protect and maintain normal health services locally, regionally and nationally as far as possible.

* Provide the best available clinical care. Nurses and other health care workers will be the occupational group first and most directly affected by an influenza pandemic. Nurses and health workers need to be informed now about the issues that will directly affect them, especially how to protect themselves and maintain health and safety. The public expects nurses and health workers to be informed.

Given that the key to an effective response to a major influenza outbreak is preparation, early participation of nurses and all health care workers in contingency planning is essential in order to respond effectively.

The SARS outbreak of 2003 identified significant weaknesses in the ability and capacity of the international health system to respond to a major public health crisis. There were also significant gaps in New Zealand's response. Important lessons can be learnt from that experience--the most important is that an outbreak of infectious disease is not the time to establish effective processes, procedures and protocols. Canadian psychiatrist Robert Maunder reviewed the psychological and occupational impact of the 2003 SARS outbreak and identified some essential lessons in responding to such an emergency. (8) His key point is that health care workers are by and large a resilient group who perform well in difficult situations, if well supported. He identifies the importance of good information and protection in order to increase people's feelings of security; of people being well supported, practically and emotionally, of good communication; of people being listened to and respected; and of professionals being given an environment in which they can effectively do the jobs at which they are expert.

A major conflict for nurses and health workers in such a crisis is the duty to one's family vs the duty to society. Other concerns are about access to adequate personal equipment and to antiviral medications. Managing the demands of people in a crisis will be significantly stressful, as there will be restrictions on admissions and movements between health services.

The NHEP identifies that preparation for an infection disease outbreak requires:

* Staff to be trained and skilled in infection prevention and control and ongoing competency to be maintained.

* Regular updates of infection control training programmes.

* A safe working environment for all staff.

* All staff to have access to required personal protective equipment.

NZNO representatives and other health sector unions will request a briefing on the NHEP from the Ministry of Health. Issues to be discussed will include workforce planning, the provision of sufficient numbers of health professionals with the required training to deal with an influenza pandemic, and adequate supplies of antivirals and persona| protective equipment.

Report by NZNO policy analyst Eileen Brown

Wayne Bradshaw, RN, DipTchg, BEd, MPH, is a nursing lecturer at the Waikato Institute of Technology's School of Health.