aas our nation begins to assess the full scope Confronting Bird Flu Will Pandemic Avian Flu Be the Next Public Health Threat?

Transcription

1 Confronting Bird Flu Will Pandemic Avian Flu Be the Next Public Health Threat? Melinda Mercer Ray, MSN, RN Ann Walker-Jenkins, BA aas our nation begins to assess the full scope of the damage caused by the 2005 Hurricane season, an assessment of our public health infrastructure has been part of the discussion. We learned that public health planning in response to a disaster such as those experienced by victims of Hurricane Katrina was insufficient. As part of the assessment of the response and preparedness for future national events, the issue of pandemic avian flu has come to the surface. While experts in immunology and infectious disease have been pointing out the real threat for years, it s now, in the wake of the hurricanes, that we realize that the United States and many nations around the world may not be as prepared as we could be for a contagious pandemic flu. February March , AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses 21

2 Melinda Mercer Ray, MSN, RN, is director of Public Affairs with AWHONN in Washington, DC, with a background in critical care nursing, and she serves as an emergency preparedness volunteer in her community. Ann Walker-Jenkins, BA, is a legislative associate at AWHONN who specializes in government, communication and legislative affairs. DOI: /j x Preparing for Pandemic Whether or not the threat is imminent, it s clear that for leaders in our government, preparing for disaster is now on their minds. Many have learned this hard lesson from the poorly coordinated, and often inadequate, federal disaster response that we witnessed in the wake of Hurricane Katrina. Secretary Leavitt has indicated a need for our nation to take three initial steps in the preparation for a potential avian flu pandemic. The first would be for the United States to participate in an effective global surveillance program. The second priority is for the United States to strengthen our current disease surveillance in order to have our own comprehensive disease surveillance system. Finally, we must ensure that antiviral drug therapies and avian influenza vaccines are developed and available in a ready supply for the U.S. population (Department of Health and Human Services [DHHS], 2005a). In an Oct. 4, 2005 press conference, President Bush briefly commented on issues related to planning for the avian flu pandemic. He said, The policy decisions for a President in dealing with an avian flu outbreak are difficult. One example: If we had an outbreak somewhere in the United States, do we not then quarantine that part of the country, and how do you then enforce quarantine?... One option is the use of a military that s able to plan and move (Brown, 2005a). Currently, the active duty military is forbidden by law to be used in a law enforcement capacity. The Posse Comitatus Act, passed in 1878, allows the National Guard troops under state control to do police work. In response to the avian flu pandemic potential threat, President Bush has asked Congress to consider changing the 1878 law in order to provide military troops as a critical resource for initial response to major natural or other domestic disasters (Brown, 2005b). On Nov. 1, 2005, President Bush announced The National Strategy To Safeguard Against The Danger Of Pandemic Influenza. This document outlines the United States strategy to detect outbreaks, expand domestic vaccine program capacity, stockpile treatments, prepare a pandemic response and ensure the health and safety of American citizens (White House, Homeland Security Council, 2005). As part of the announcement of this plan, President Bush requested $7.1 billion in emergency funding to implement the national strategy for pandemic influenza. The breakdown of the funding request includes monies for detection and containment efforts, accelerated development of cell-culture technology, new treatment and vaccine development, national purchase of vaccine and antiviral medication, and infrastructure planning for all levels of government to ensure preparedness (White House, Homeland Security Council). In addition to funding, the document provides guidance for a national-level response in the event of an influenza pandemic. The three pillars of the document are preparedness and communication, surveillance and detection, and response and containment. The underlying principles in the plan are as follows (White House, Homeland Security Council, 2005): 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 In the cover letter to the The National Strategy for Pandemic Influenza, President Bush states: While your government will do much to prepare for a pandemic, individual action and individual responsibility are necessary for the success of any measures. Not only should you take action to protect yourself and your families, you should also take action to prevent the spread of influenza if you or anyone in your family becomes ill (White House, Homeland Security Council, 2005). Congress is working through the fiscal year 2006 funding bills at the writing of this article. The Senate passed its version of the fiscal AWHONN Lifelines Volume 10 Issue 1

3 Labor, Health and Human Services, and Education spending bill with the inclusion of an amendment to provide nearly $8 billion in emergency funding to combat the avian flu. A similar amendment for $3.9 billion was placed in the Defense appropriations bill for flu preparations. At the conclusion of the fiscal year 2006 appropriations process, the final funding levels will become clear, but until then, it s evident that both the Congress and the president are signaling a commitment to set aside funds for avian flu preparedness. The full plan can be found at The reality is, at some point in time, a flu pandemic will ultimately occur. History tells us that whenever it occurs, the results will be devastating. The question is: Will the current avian flu percolating in Southeast Asia become the pandemic we are waiting for? Viruses That Put Us at Risk Influenza A, B and C comprise the three major types of influenza viruses. But, only Influenza A and B have been associated with widespread outbreaks of disease. Generally, it s an influenza A and/or B virus that circulates each year and becomes responsible for the seasonal flu that so many experience. Pandemic flu is different than the yearly flu season that we have come to expect. Pandemic flu is the transmission of a novel or new influenza A virus that causes disease in humans. Not only is the virus novel and can affect humans but it also must develop the ability to spread easily from person to person. This novel virus is able to create such severe illness and death because it s previously unknown, and humans or other mammals do not have any immunity to the pandemic flu virus. Influenza A viruses tend to be the culprits of pandemic flu because of their molecular structure and the Box 1. Avian Influenza (Bird Flu) and Avian Influenza A (H5N1) virus Previous influenza pandemics have been related to avian influenza or bird flu. This would be an influenza that is readily found in avian populations that evolves the ability to infect humans directly and then be transmitted from human to human. During the 20th century, there have been three pandemics Spanish flu: The 1918 Spanish flu is typically used to illustrate the impact that a pandemic can have on world populations. It s estimated that approximately 20 to 40 percent of the worldwide population became ill and more than 20 to 40 million people died. There are accounts of individuals being well in the morning, feeling sick by lunchtime and by nightfall they would die (Fink, 2005). In addition, many died from complications related to the flu, such as secondary bacterial infections and pneumonia. As is feared with other pandemics, the Spanish flu attacked and killed young adults as well as those in the typical high-risk categories. The mortality for Spanish flu was highest among adults 20 to 50 years old (Fink). This deadly influenza was an avian influenza (Fink) Asian Flu: The Asian influenza pandemic started in the Far East. Due to enhanced technology, this pandemic was anticipated and limited quantities of a flu vaccine was developed. The pandemic flu outbreak started in May 1957, and the vaccine was available by the summer of This flu outbreak saw the highest infection rates among school children, young adults and pregnant women. The elderly had the highest death rates. A second wave of infection happened in December An estimated 69,800 people died in the United States Hong Kong Flu: This flu is considered one of the mildest pandemics in the 20th century. The Hong Kong flu was seen in the United States starting in December 1968 and January The elderly were the most likely to die of this flu. The same virus returned in 1970 and It s thought that a number of factors contributed to the milder experience of this pandemic. First, it s thought that there might have been a degree of immunity in the population due to earlier exposure to the Asian flu. There were some similarities in the two flu viruses. In addition, the flu pandemic reached its peak when school children were on vacation from school. The timing of the spread of the pandemic flu and the holiday vacation limited transmission of the virus. Last, improved science and medical care reduced the secondary infections that in the past had increased the severity of the pandemic infections (CDC, 2005b; DHHS, 2005c). basic propensity for viruses to mutate. In the category of three influenza viruses, A, B and C, influenza A viruses are the only ones that contain two surface proteins: hemagglutinin (H) and neuraminidase (N). A potentially pandemic influenza A virus develops when the virus acquires a new H or H + N surface protein (DHHS, 2005b). The process of change in the protein structure of an influenza A virus is known as an antigenic shift. The result of the antigenic shift is a new subtype of Influenza A. The antigenic shift does not always result in a virus that is more virulent or able to be communicable to humans, but it s a novel virus. It s when these novel viruses take on the characteristics of rapid transmissibility and virulence February March 2006 AWHONN Lifelines 23

4 among humans that the potential for a pandemic influenza virus infection may occur (Centers for Disease Control and Prevention [CDC], 2005b). The CDC and the World Health Organization (WHO) have established programs to monitor and detect these emerging influenza A virus subtypes and have established international communication mechanisms to alert nations to a potential viral threat. (CDC, 2005b). Before 1997, researchers believed that an antigenic shift in an influenza A virus was created when an intermediate host such as a pig is infected by a routine influenza virus that it contracted from a human and an influenza A virus that it contracted from a bird (Li et al., 2003) They theorized that this dual infection would allow a new hybrid virus to develop as the two different viruses interact and may develop a third virus with protein characteristics of each original virus. The National Institutes of Allergy and Infectious Diseases (NIAID), an institute of the National Institutes of Health, supported researchers who found that repeated cross transmission of the H9N2 avian flu virus between chickens and ducks resulted in sequential antigen coding changes as the flu virus moved back and forth between the two poultry species. The researchers believe that the high degree of gene assortment in the ducks provided the opportunity for the development of the new strains of H9N2 avian flu virus (Li et al., 2003). The demonstrated evolution of the H9N2 virus provides insight into the anticipated evolution of the H5N1 virus. To date, most of the cases of H5N1 virus have been found in people with direct contact with infected poultry or surfaces contaminated by infected poultry. On Oct. 15, 2005, the CDC announced that the researchers had reconstructed the influenza virus strain responsible for the 1918 pandemic flu. What is so fascinating about this research is that researchers were able to identify which genes made this virus so harmful. This research showed that the 1918 pandemic flu virus was actually an avian flu virus that adapted to become transmissible and virulent to humans. It s estimated that approximately 20 to 40 percent of the worldwide population became ill during the 1918 pandemic and more than 20 to 40 million people died (CDC, 2005d). The researchers were able to demonstrate that the 1918 pandemic flu virus contained some of the same proteins as the currently circulating H5N1 avian influenza. This research lends credibility to the growing concern about the potential risk for the H5N1 avian influenza to have potential to evolve to a pandemic influenza virus. Avian Influenza A/H5N1 Avian influenza refers to a large group of different influenza viruses that primarily affect birds. On the rare occasions that one of the avian influenza viruses infects another species, such as humans, pigs or other mammals, the first step toward a pandemic virus is under way. In reality, the majority of avian influenza viruses will evolve to infect humans. The terminology for the virus changes once the avian influenza Box 2. Get the Facts virus moves from a virus within the bird species to humans (CDC 2005a). Once the avian influenza virus is known to be contagious among humans, it becomes a human influenza virus. So, at this point, the avian H5N1 is an avian influenza strain with pandemic potential, since it might ultimately adapt into a strain that is contagious among humans. Influenza pandemics are caused by new influenza viruses that have adapted to humans ( Avian Influenza, 2005). Historically, this flu virus was first isolated from birds in South Africa in This flu is very contagious and deadly within the bird population. Cases of avian flu have been reported in chickens, pigs, ducks, dogs, tigers and possibly horses ( Avian Influenza, 2005). Since humans and other mammals can play host to the influenza virus, one question is how does an influenza A virus acquire the traits needed to become a human pandemic virus? The turning point among international health care experts came in 1997, when human cases of a new virulent virus began to be reported. Upon investigation, it was discovered this new virus was an avian influenza A/H5N1. Flocks of chickens were found to have the virus, Federal Information: Centers for Disease Control & Prevention: FDA Center for Biologics Evaluation and Research (CBER): gov/cber/index.htm National Institutes of Health (NIH), National Institutes of Allergy and Infectious Diseases: Animal and Plant Health Inspection Service, Veterinary Services, U.S. Department of Agriculture: The USDA Agricultural Research Service: The Department of Defense Global Emerging Infections Surveillance and Response System: The World Health Organization: 24 AWHONN Lifelines Volume 10 Issue 1

5 and it causes 100 percent mortality in these birds. Of greater concern was the fact that same virus that caused illness in avian populations had now found a mechanism to infect humans. While there were very few cases of human illness (18 initial cases in this outbreak), six individuals died of the infection ( Long-Predicted Flu, 2005). Most cases of the human infection of H5N1 have been found in Southeast Asia, where the culture provides the opportunity for families to live very closely with poultry. Chickens, ducks and other birds are frequently in and out of homes, and it s not unusual for individuals to eat poultry that has died or to consume raw or undercooked poultry products. The disease in these populations met with a mortality rate of three out of five cases ( Avian Influenza, 2005). This level of transmission is not considered a pandemic, but international agencies such as United States Agency for International Development (USAID) and the WHO among others are closely watching how this situation may evolve. The confirmation of human-to-human transmission cases will raise the level of international concern of the onset of a likely pandemic. As the birds have migrated, the Avian A/H5N1 flu has traveled from wild birds to domestic birds throughout Asia and into Central Asia and threatens Europe. At this point, humans who contract the disease appear to be infected through direct contact with infected birds. But, the potential for the virus to mutate further and acquire a more virulent infection capability is what is driving the concern that this virus may result in pandemic flu. Since Jan. 2004, outbreaks of the influenza H5N1 virus have occurred in poultry in eight countries in Asia. (USAID, 2005). Initially, this virus did not infect humans. In 1997, the first case of the spread of H5N1 virus to a human was reported. Box 3. Health Care Professionals: Evaluation of Ill People Health care providers should be alert for respiratory illness among people who may have been exposed to infected poultry. The following section provides recommendations for health care professionals who may need to evaluate symptomatic persons with possible avian influenza exposure. People who develop a febrile respiratory illness should have a respiratory sample (e.g., nasopharyngeal swab or aspirate) collected The respiratory sample should be tested by reverse transcription polymerase chain reaction (RT-PCR) for influenza A, and if possible for H1 and H3. If such capacity is not available in the state or if the result of local testing is positive, then CDC should be contacted and the specimen should be sent to CDC for testing Virus isolation should not be attempted unless a biosafety level 3+ facility is available to receive and culture specimens Optimally, an acute-phase (within one week of illness onset) and convalescent-phase (after three weeks of illness onset) serum sample should be collected and stored locally in case testing for antibody to the avian influenza virus should be needed Requests for testing should come through the state and local health departments, which should contact the CDC Director s Emergency Operations Center at before sending specimens for testing (CDC, 2005c) Medical Care Recommendations Regarding Symptoms of Avian Influenza in Humans The reported symptoms of avian influenza in humans have ranged from typical influenza-like symptoms (e.g., fever, cough, sore throat and muscle aches) to eye infections (conjunctivitis), pneumonia, acute respiratory distress, viral pneumonia and other severe and life-threatening complications. Antiviral Agents for Influenza Four different influenza antiviral drugs (amantadine, rimantadine, oseltamivir and zanamivir) are approved by the U.S. Food and Drug Administration (FDA) for the treatment of influenza; three are approved for prophylaxis. All four have activity against influenza A viruses. However, sometimes influenza strains can become resistant to these drugs and, therefore, the drugs may not always be effective. For example, analyses of some of the 2004 H5N1 viruses isolated from poultry and humans in Asia have shown that the viruses are resistant to two of the medications (amantadine and rimantadine). Monitoring of avian influenza A viruses for resistance to influenza antiviral medications is ongoing (CDC, 2005a). Cases of humans infected by the virus have been reported in Hong Kong, Thailand, Vietnam and Cambodia. As of Sept. 19, 2005, there have been a total of 113 human cases of avian influenza in humans. The death rate for these cases has been reported to be about 50 percent (USAID). On Oct. 13, 2005, reports of confirmed H5N1 virus in rural Turkey were announced. It s believed that the path of the H5N1 virus is likely to February March 2006 AWHONN Lifelines 25

6 follow the migratory path of the birds in this region into Africa. Still, the European Union is quite concerned. There are reports of ducks dying in Romania, but the testing of these ducks, at the writing of this article, has not confirmed H5N1 in these cases (Vick, 2005, p. A12). The propensity of the influenza viruses to evolve and jump from avian-to-human transmission to human-to-human transmission has experts concerned. If the virus evolves to not only transmit from human to human but also to readily spread within a population and is of a virulent nature, all the ingredients for an international influenza flu pandemic may be in place. There have been no truly Box 4. Anatomy of a Pandemic confirmed reports of human-to-human transmission of H5N1 in Asia. There is one case of a 37-year-old woman in Jakarta where human-to-human contact cannot fully be ruled out. What About a Vaccine? The NIAID has supported research on the H5N1 virus since its emergence as a potential human health threat in Sanofi Pasteur of Swiftwater, Philadelphia, manufactured the trial vaccine that is currently entering a trial phase. Sanofi Pasteur, previously known as Aventis Pasteur, was awarded the contract to manufacture the H5N1 vaccine in May Sites in Rochester, N.Y., Baltimore and Los Angeles will enroll healthy adults to trial the safety The WHO has developed a system to assist in preparation and response planning for pandemics. This planning tool can be found at who.int/csr/disease/influenza/pandemic/en/index.html. There is really no way to anticipate the duration of the development of a pandemic. There have been a number of novel viruses that have emerged and been unable to grow to a true pandemic because of the nature of the virus and the ability of the public health interventions to isolate the virus. A brief overview of the phases is as follows. Interpandemic period Phase 1: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low. Phase 2: No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease. Pandemic alert period Phase 3: Human infection(s) with a new subtype but no human-to-human spread, or at most rare instances of spread to a close contact. Phase 4: Small cluster(s) with limited human-to-human transmission but a highly localized spread, suggesting that the virus is not welladapted to humans. Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk). Pandemic period Phase 6: Pandemic: increased and sustained transmission in general population (WHO, 2005b). of this vaccine. It s anticipated that a number of dose levels of the vaccine will be tested to assess the vaccine s safety and ability to produce an immune response (National Institutes of Health NIAID, 2005a, 2005b). The questions we do not have a clear answer to at this point are, will the H5N1 vaccine work and will there be enough doses of the vaccine in enough time to curtail a pandemic? As of the writing of this article, the WHO reports that there is no vaccine available that is effective against the pandemic virus. Vaccines are produced each year for seasonal influenza but will not protect against pandemic influenza. Although a vaccine against the H5N1 virus is under development in several countries, no vaccine is ready for commercial production. In addition, the WHO reports that no vaccines are expected to be widely available until several months after the start of a pandemic (WHO, 2005a). If and when the vaccine becomes available, it s likely that it will be provided to certain categories of individuals initially. You can anticipate that health care providers and emergency responders will be the first citizens to be eligible to receive the vaccine. There are two other drugs that have proved to be of some benefit in the treatment of H5N1 in laboratory settings. The two drugs are oseltamivir (Tamiflu) and zanamivir (Relenza). These antiviral drugs are both expensive and available in limited quantities. Work will need to be done to enhance the production and stockpiling of these critical medications in order to allow for the availability of the drugs in the event of the eruption of the pandemic (Branswell, 2005). Preparation: What Should Health Professionals Know? The DHHS, the CDC and state and local health officials have been working 26 AWHONN Lifelines Volume 10 Issue 1

7 on a number of preparedness efforts since The planning that has been done to date will focus on surveillance and early detection of novel viruses and the establishment of a public health infrastructure to implement pandemic prevention/treatment measures. With the increased attention on the public health response to Hurricanes Katrina and Rita and with the continued spread of the avian flu to other countries, this preparedness plan is being reviewed and revised. It s hard to quantify the impact of a H5N1 pandemic. If the virus attains the virulence of the Spanish Flu of 1918 to 1919 and is carried by individuals on planes to different countries, the results could be swift and devastating. Dr. Michael Osterholm, a leading advocate for pandemic preparedness, raises this concern and ads that the pandemic could have a huge economic affect on the world (Branswell, 2005). Dana Milbank, a columnist for The Washington Post, quotes Constance Hanna, an occupational health specialist, who spoke at an Oct. 12, 2005 congressional briefing. Let me paint you a little picture, she began. Twenty to 30 percent of your employees don t show up to work... transportation systems are curtailed or Box 5. What is the Status of a Vaccine? In a statement on Oct. 5, 2005, timed with the publication of articles in Science and Nature, Anthony Fauci, MD, director, National Institutes of Allergy and infectious Diseases, National Institutes of Health, and Julie L. Gerberding, MD, MPH, director, CDC, discussed the significance of these new studies in the analysis of the H5N1 virus. The new studies used gene mapping from samples taken from two people who died in the 1918 to 1919 Spanish flu pandemic and compared it to the gene sequence in the current H5N1 virus. The researchers found that the H5N1 virus had acquired five of the 10 gene sequence changes association with human-to-human transmission in the 1918 virus. They also have determined in the test tube and in mice which genes are most likely to account for the lethal effects of the 1918 virus (Fauci & Gerberding, 2005). These studies are of great significance because they provide the opportunity for researchers to detect the ongoing changes in the H5N1 virus that may precede widespread transmission of the disease among humans (Fauci). shut down... Critical infrastructure will or may fail: food, water, power, gas, electricity (Milbank, 2005). Unlike the yearly flu season, if a public health system needed to respond to an influenza flu pandemic, it s likely that many more people will need to be vaccinated and the country will need a supply of the appropriate, effective, approved vaccine. In addition, the warning of an actual pandemic will likely not give any country much time to prepare. Vaccine preparation takes an estimated six months. Preparation and mass production of a vaccine may take longer. Therefore, it s likely that all of the population will not be able to receive a vaccination prior to the spread of the pandemic virus. Depending on the type of vaccine that is developed, there may be a possibility that individuals may need to receive two vaccinations to achieve immunity. This repetition of the vaccine administration will create public health management issues. If mass vaccination is not possible, the health care system will need to respond and manage the influenza pandemic. This will require efforts to isolate and treat the influenza pandemic cases and potentially prepare to manage a large number of cases in home and other community settings. If the H5N1 pandemic virus becomes readily transmissible from human to human and remains virulent, it s quite possible that the health care system will soon be overwhelmed. Hospitals may run out of beds, staff and supplies. The hospital staff may fall ill and require treatment. The widespread effect of a pandemic flu will likely overwhelm the resources of every nation that is affected. That means that state and local governments and their communities will need to shoulder the responsibility for the care of their citizens. Unlike other natural disasters like floods, hurricanes and earthquakes, where governments and international aid agencies and concentrate resources on a critical event, a H5N1 pandemic flu may hit with such quick intensity that these resources will be unavailable. This argues that we must all prepare for the potential of this pandemic flu. Health care professionals should learn about the treatment recommendations, follow the news reports and learn if their health facility and local government has a pandemic flu plan. February March 2006 AWHONN Lifelines 27

8 In addition, health professionals should consider implementing disaster preparedness for their own homes. The WHO has issued global guidance in a document titled Responding to the Avian Influenza Pandemic Threat. This document sets out specific recommendations for individual nations to prepare for a global influenza pandemic. Nations across the globe are working on detection and treatment plans in the event that the virus gains momentum and reaches pandemic levels. Increased attention to this issue is important now that the avian virus has traveled westward with the migratory birds infecting poultry in Central Asia, the Middle East and Europe (USAID, 2005). This migration of the avian influenza virus allows more opportunity for the virus to undergo an antigenic shift and acquire the characteristics of a pandemic influenza A virus. President Bush announced an international partnership at the United Nations General Assembly on Sept. 14, 2005, called the International Partnership on Avian and Pandemic Influenza (IPAPI). In a Sept. 15, 2005 press statement, Secretary of Health and Human Services Mike Leavitt described this international partnership as a way to conduct cooperative surveillance, epidemiological data and to leverage international scientific expertise to curtail this emerging threat. (DHHS, 2005d). Many nations including Canada, the European Union, Russia, the African nations and nations in Central America are increasing their surveillance for evidence of the H5N1 virus. The WHO is continuing to monitor for evidence of a breaking pandemic situation. The key to our survival of an H5N1 pandemic lies in the ability of the international community to work together on coordinated surveillance, reporting and preparedness. A key part of the preparedness will be the development of an effective and readily available vaccine in addition to the availability of the world s population to the appropriate antiviral drugs. This will take the commitment of significant resources from many nations. Ultimately, it may boil down to timing. Will the appropriate vaccine be made available, in the right quantity before the human-to-human transmission of a virulent H5N1 virus occurs? Gregory Poland of the Mayo Clinic and the Infectious Diseases Society of America was quoted as saying at the Oct. 12, 2005 congressional briefing, I want to emphasize the certainty that a pandemic will occur... When this happens, time will be described, for those left living, as before and after the pandemic (Milbank 2005). References Branswell, H. (2005, October 2). World as we know it may be at stake: UN pandemic czar. Canoe Network CNEWS. Retrieved November 22, 2005; from CNEWS/Canada/2005/10/02/ cp.html Brown, D. (2005a, October 5). Military s role in a flu pandemic. The Washington Post, p. A5. Brown, D. (2005b, November 7). Long-predicted flu finally tops agenda. The Washington Post, Retrieved November 7, 2005, from washingtonpost.com/wp-dyn/ content/article/2005/11/06/ AR html Centers for Disease Control and Prevention. (2005a). Avian influenza infection in humans. Retrieved October 17, 2005, from flu/avian/gen-info/avian-fluhumans.htm Centers for Disease Control and Prevention. (2005b). Information about influenza pandemics. Retrieved October 18, 2005, from avian/gen-info/pandemics.htm Centers for Disease Control and Prevention. (2005c). Interim recommendations for persons with possible exposure to Avian influenza during outbreaks among poultry in the US. Retrieved November 1, 2005, from avian/professional/ possible-exposure.htm Centers for Disease Control and Prevention. (2005d). Questions & answers: Reconstruction of the 1918 influenza pandemic virus. Retrieved November 14, 2005, from about/qa/1918flupandemic.htm Department of Health and Human Services (2005a). HHS releases pandemic influenza plan provides guidance to prepare Nation s Health Care System for a pandemic. Retrieved November 2, 2005, from pres/ html Department of Health and Human Services. (2005b). Influenza pandemics: How they start, how they spread, and their potential impact. Retrieved November 22, 2005, from gov/nvpo/pandemics/flu2.htm Department of Health and Human Services (2005c). Pandemics and pandemic scares in the 20th century. Retrieved October 18, 2005, from gov/nvpo/pandemics/flu3.htm Department of Health and Human Services. (2005d). Statement by Mike Leavitt Secretary of Health and Human Services International Partnership on Avian and Pandemic Influenza United Nations General Assembly. Retrieved October 1, 2005, from 28 AWHONN Lifelines Volume 10 Issue 1

9 2005pres/ a.html Fauci, A. S., & Gerberding, J. L., (2005, October). Unmasking the 1918 influenza virus: An important step toward pandemic influenza preparedness. Retrieved October 5, 2005, from National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID) Web site: www3.niaid.nih.gov/news/ newsreleases/2005/0510state.htm Fink, M. (Producer). (2005, September 20). Wide Angle. H5N1 Killer Flu [Television broadcast]. Vietnam: Public Broadcasting Service. Li, K. S., XU, K. M., Peiris, J. S. M., Poon, L. L. M., Yu, K. Z., Yuen, K. Y., et al. (2003, June). Characterization of H9 subtype influenza viruses from the ducks of Southern China: A candidate for the next influenza pandemic in humans [Electronic Version]. Journal of Virology, 77(12), Retrieved November 10, 2005, from pubmedcentral.gov/articlerender. fcgi?tool=pubmed&pubmedid= Milbank, D. (2005, October 13). Capitol Hill flu briefing was no trick, and no treat. The Washington Post, p. A02. National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID). (2005a). NIAID initiates trial of experimental Avian flu vaccine. Retrieved October 6, 2005, from gov/news/newsreleases/2005/ avianfluvax.htm National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID). (2005b, April). Questions and answers: H5N1 Avian flu vaccine trials. Retrieved October 6, 2005, from gov/news/newsreleases/2005/ H5N1QandA.htm USAID. (2005). Avian influenza response. Retrieved September 28, 2005, from usaid.gov/our_work/global_ health/home/news/news_items/ avian_influenza.html Vick, K. (2005, October 14). Bird flu in Turkey is same as in Asia. The Washington Post, p. A12. White House, Homeland Security Council. (2005, November). National Strategy for Pandemic Influenza. Retrieved November 2, 2005, from pandemic-influenza.html World Health Organization. (2005a). Avian influenza frequently asked questions. Retrieved October 14, 2005, from csr/disease/avian_influenza/ avian_faqs/en/ World Health Organization. (2005b). Current WHO phase of pandemic alert. Retrieved November 22, 2005, from avian_influenza/phase/en/ index.html World Health Organization. (2005c). Ten things you need to know about pandemic influenza. Retrieved October 15, 2005, from csr/disease/influenza/ pandemic10things/en/print.html February March 2006 AWHONN Lifelines 29