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Pandemic influenza preparedness.

Influenza kills an average of 36,000 Americans and is responsible for 142,000 hospitalizations every year.


While these are tragic events, they do not compare to the morbidity and mortality that occurs with a pandemic. There have been three influenza pandemics this century.

* The first in 1918 (Spanish flu) was responsible for the worse infectious epidemic in modern history. During this period, influenza circled the globe and killed over 20 million people worldwide. In the United States 500,000 died.

* The second epidemic in 1957 (Asian flu) left 70,000 dead in the U.S.

* And the third in 1968 (Hong Kong flu) resulted in 34,000 deaths in the country.

Public health officials are preparing for the next pandemic of influenza. The recent outbreak of Severe Acute Respiratory Syndrome (SARS) brought some urgency to pandemic planning.


The three major types of influenza viruses A, B and C all cause human disease. Types A and B are responsible for the majority of significant disease in humans. Type A viruses are divided into subtypes based on two surface antigens nuraminidase (N) and hemagglutinin (H); the B virus is not categorized by subtypes.

The influenza viruses currently circulating in the community undergo mutations or genetic reassortment in their surface antigens frequently enough that an annual reformulation of the influenza vaccine is required to achieve adequate protection.

On occasion, there is a mutation in key major antigenic components such that the population-based background immunity provides no protection from the virus. Should the prepared immunization also not contain protection from the new viral strain and the virus is transmissible from person to person, a global pandemic can occur.

Influenza viruses also infect animals other than humans. In fact pigs, horses and birds are also commonly infected. The reservoir for influenza A is believed to be wild birds. In general these animal viruses can occasionally jump species or reformulate in a third species to create a novel virus that is highly pathogenic. These novel viruses are a potential cause of pandemic disease.

Vaccine decisions

The World Health Organization (WHO) works through a network of collaborating national influenza centers to track the types of influenza strains infecting humans and measure the effectiveness of current vaccines. Twice a year an international consultation is held to evaluate the various virus strains and make decisions concerning future vaccine composition.

In the spring and fall of each year a recommendation is made to the vaccine manufactures concerning the makeup of the vaccine to be used.

Pandemic influenza planning

An influenza pandemic is defined by six functional stages:

1. Novel Virus Alert -- During this stage a novel virus is detected in one or more humans where there is little or no immunity in the general population. There is no clearly documented person-to-person spread. The WHO has subdivided this phase into several levels that are useful to define the stage of investigation of a novel virus found in humans prior to the recognition of disease spread.

2. Pandemic Alert -- The virus shows person-to-person transmission and demonstrates geographic spread.

3. Pandemic Imminent -- Novel virus is causing increased rates of death and morbidity in multiple, widespread areas.

4. Pandemic Phase -- Virus continues to spread over several continents.

5. Second Wave -- Recrudescence of disease activity within several months following the initial wave of infection.

6. Pandemic Ends -- Successive pandemic waves cease and the traditional seasonal epidemic pattern returns.

Major components of a traditional plan include: command and control, surveillance, disease control (vaccine delivery, antiviral medication delivery, isolation and quarantine), prehospital care, hospital care, communications and logistics. Health system administrators should build these components into their disaster response plans.

Hospital planning

The annual influenza season results in significant strain on the overburdened hospital. The chief management problem is anticipating and managing surge.

Two tools available to hospital administrators and disaster planners to manage the surge capacity in a large influenza outbreak are available from the U.S. Centers for Disease Control and Prevention (CDC). The programs called FluAid 2.0 and FluSurge 1.0 are available to help plan for the epidemic.

FluAid 2.0 is used to estimate the number of visits (inpatient and outpatient) and deaths from an outbreak. FluSurge 1.0 is a planning tool used to estimate the demand for regular and intensive care hospital beds as well as ventilators. These tools are available free of charge at

Hospital laboratory plans should also ensure appropriate protocols are in place to handle highly infectious specimens. Highly pathogenic strains should not be cultured routinely and require Biosafety Level 3+ (BSL) or higher facilities for culture. They should not be routinely cultured in most hospital laboratories and plans should provide proper guidance to prevent inadvertent culture.


Guidance should be sought from the local or state health department should there be concern about the need for diagnostic cultures. Clinical specimens for PCR testing can be done in a BSL 2 laboratory with a Class II biological safety cabinet and should be part of the laboratory plan.

Infection control plans should recognize that hospital workers are at extreme risk for infection and plans should include their protection as part of the occupational health component of the plan. Vaccination, antiviral agents, barrier protection procedures should be included. Procedures for isolation and quarantine of workers and family supports should be included in any worker plan.

Global disease control

Activities used to prevent a pandemic include banning appropriate animals from affected countries and culling animals found to have highly pathogenic strains. Protective gear, vaccination and antiviral use by animal workers who handle infected animals is also required.

The goal is to prevent interspecies spread and both "save" the animals but also to prevent the potential spread to humans. For example, the recent outbreak of a highly pathogenic "bird flu" Influenza A (H5N1) in Asia resulted in the killing of over 25 million birds.

Annual vaccination with influenza vaccine is recommended for groups at high risk and is the mainstay of prevention when a vaccine is available. High risk populations include seniors, residents of chronic care facilities and nursing homes, children age 6-23 months, pregnant women, patients with immunosuppressed conditions, and people (children and adults) with chronic diseases of the cardiovascular and respiratory systems.

During annual epidemics health care workers are an especially important group to vaccinate to create herd immunity and prevent spread to patients in hospitals and long-term care facilities. Hand washing and appropriate infection control measures are an important disease control activity. All of these activities remain important during a pandemic.

Disease reporting procedures should be understood by all appropriate hospital staff and included as part of the pandemic plan.

Planning for the next pandemic is a necessary preparedness activity. Health care executive should start the process now. Local and state health officials are actively working on plans now. Hospital and health systems plans should ensure full integration with public health activities.


1. Meltzer MI, Cox NJ, Fukuda K. "The economic impact of pandemic influenza in the United States: Priorities for intervention." Emerging Infectious Diseases. 5, 1999.

2. Avian Flu Information: World Health Organization,

3. Human Influenza: Center for Disease Control & Prevention,

4. Prevention and Control of Influenza, Morbidity and Mortality Weekly Report, 53,6, May 28, 2004.

5. Patriarca PA, Cox NJ. "Influenza pandemic preparedness plan for the United States." J Infect Dis. 176 (Suppl 1) August, 1997.

By Georges C. Benjamin, MD, FACP

Georges C. Benjamin, MD, FACP, is executive director of the American Public Health Association in Washington, D.C. He can be reached by phone at 202-777-2430 or by e-mail to
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Title Annotation:Health Policy Update
Author:Benjamin, Georges C.
Publication:Physician Executive
Geographic Code:1USA
Date:Sep 1, 2004
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