key: cord-0966655-ihf78ket authors: Huston, Patricia title: Thinking Locally About Pandemic Influenza date: 2004-05-01 journal: Can J Public Health DOI: 10.1007/bf03403644 sha: a3bd39e0e6d0a2179034a9893e5a611c9e3851e0 doc_id: 966655 cord_uid: ihf78ket nan The risk of pandemic Are we really at risk for pandemic? Very much so. Avian influenza is well known for jumping the species barrier -both between fowl and human, and between fowl and pig and human, among others. So far, avian influenza has not been transmissible from human to human. What could turn this into a pandemic is a unique feature of Influenza Aits capacity for antigenic shift. Antigenic shift arises from a reassortment of the surface glycoproteins of the virus. Influenza viruses are classified according to their two surface glycoproteins: hemagglutinin and neuraminidase. The hemagglutinin (H) is the surface glycoprotein that mediates the entry of the virus into host cells. The neuraminidase (N) is an enzyme that facilitates cell-to-cell spread. An antigenic shift occurs when there are two concurrent influenza A infections in a host that lead to reassortment of the H and N glycoproteins. A new hemagglutinin, such as H5 or H7 from the current avian influenza outbreaks, reassorted into a human influenza virus is the most likely source of a pandemic. 4, 5 WHO has recently noted that the control of H5N1 avian influenza in Asia has proven difficult, and will likely not be eradicated in the short term. 3 At the beginning of March, the Canadian Food Inspection Agency noted that in addition to a benign outbreak, there was a highly pathogenic H7N3 virus outbreak in a farm in British Columbia. 6 There are a number of challenges in developing a vaccine for an H5 or H7 virus. First is the pathogenicity of these viruses -neither H5 nor H7 can be grown in the usual egg medium as they are both lethal to egg embryos. Plasmid-based reverse genetics technologies are being developed and represent a promising alternative. However, these involve the use of cell lines and present their own set of challenges: intellectual property issues, issues of availability and suitability, and an unknown safety profile. 5 A pandemic influenza could begin anywhere in the world, and would likely spread quickly. Based on a model developed by Melzer and colleagues, 6 the Canadian plan estimates that between 4.5 to 10.6 million people in Canada could contract this disease, with 2-5 million people seeking outpatient care and 34-138,000 requiring hospitalization. 1 In Canada, 43 people died from severe acute respiratory syndrome (SARS) last year; pandemic influenza could kill 43,000. Pandemic influenza has the potential to be 1000 times worse than SARS. It is difficult to imagine how our local health, public health and emergency services could respond to such a situation, in light of our recent experience with SARS. SARS revealed a lack of surge capacity locally, provincially and nationally. 7 It also revealed the need for health, public health and emergency services to work more closely together. 8 The need for public health leadership The Canadian Pandemic Influenza Plan points out that "local public health authorities are responsible for planning the local response to an influenza pandemic. This involves liaising with local partners (e.g., emergency responders, hospitals, mortuary services) in advance of a pandemic to facilitate a coordinated response." It is time for local public health departments to rise to this challenge. Some have begun by conducting simulation exercises with their local partners. 9 Ottawa has recently launched an Ottawa Pandemic Coalition, with a focus on communication and capacity building. We are planning a prevention strategy for decreasing the spread of respiratory infections, which we plan to launch in schools, long-term care institutions and physicians' offices later this year. Others have launched a website promoting business continuity planning. 10 Challenges abound. For example, although the Canadian Pandemic Influenza Plan highlights numerous local responsibilities regarding a pandemic, it is silent on where the funding for the local planning, mitigation and response will come from. It is also silent on who is responsible for setting up and staffing alternative (or non-traditional) assessment and treatment sites to care for patients when the hospitals are overwhelmed. Pandemics know no boundaries and disregard overstretched budgets, poor timing and jurisdictional challenges. Now more than ever, we need to reach beyond our silos to create an integrated, inter-agency, multidisciplinary response. Local public health professionals are well placed to lead this effort. The World Health Organization and other international agencies have been active in monitoring, planning and coordi-nating efforts to contain avian influenza and prevent the antigenic shift that could transform it into a human pandemic. In concert with the work being done to act globally, it is time to "think locally" about being prepared for pandemic influenza. • Promote pneumococcal vaccination of NACI recommended "high-risk" groups (to reduce the incidence and severity of secondary bacterial pneumonia). • Review existing public materials on influenza and influenza pandemics. • Review/Update educational materials on all aspects of influenza (for health care professionals, other special audiences and the general public). Vaccine Programs • Conduct initial availability assessment of supplies (e.g., syringes, adrenalin, sharps disposal units), equipment and locations potentially required for a vaccine-based response (i.e., mass clinics). • Develop a list of currently qualified vaccinators and sources of potential vaccinators. • Review educational materials re: administration of vaccines and adapt/update as needed. • Ensure that any legal issues that may impede rollout of a mass immunization program are addressed. • Review staffing requirements for implementation of a pandemic response, including mass immunization clinics, control measures, and public education. • Consider delaying introduction of public health programs that may not be adequately resourced if situation evolves into a pandemic, or other alternatives such as contracting out. • Prepare educational material for public inquiry phone-line staff. • Establish or increase current surveillance activities. • Consider implementation of emergency room surveillance (especially in areas known to receive a lot of travelers from affected areas). • Implement real-time influenza mortality surveillance. • Determine what information needs to be collected on cases and screening measures and how this will be done (e.g., data collection forms, database issues, data flow). • Ensure staff are trained and infrastructure is in place to record immunizations, including requirements for a two-dose immunization program (i.e., re-call and record-keeping procedures). • Review estimates of the number of people who fall within teach of the priority groups for vaccination (i.e., high-risk groups, health care workers, emergency service workers, specific age groups) and access strategies. • Ensure adequate resources are available to implement recommended public health measures, including isolation of cases. • Prepare/revise educational and guidance materials for public health partners (specifically local health departments who will be on the front lines with respect to prevention and control measures), the general public; documents for the public should emphasize infection control in homes, schools, places of work. • Review estimates of the number of people who fall within teach of the priority groups for antivirals (i.e., high-risk groups, health care workers, emergency service workers, specific age groups) and access strategies. • Ensure staff is trained and infrastructure is in place to track who is receiving the drugs for the purpose of treatment and prophylaxis. WHO Communicable Disease Surveillance and Situation (poultry) in Asia: need for a long-term response at Influenza vaccine: Outmaneuvering antigenic shift and drift Are we ready for pandemic influenza? The economic impact of pandemic influenza in the United States: Priorities for intervention Lessons learned from a provincial perspective SARS: A local public health perspective Responding to pandemic influenza: A local perspective First Steps to Business Continuity Planning. Available at: www.region.peel