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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.

Review non-medical interventions in the event
of an influenza pandemic.

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.

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.

This article was

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

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.

NURSING STANDARD

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).

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
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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).

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

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).

Preparation and planning

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

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

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)

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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)

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

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

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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.

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

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)

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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).

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?

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

Public health communication campaign

Time out 8

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

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 (2006) Bird Flu and Pandemic Influenza:

What are the Risks? The Stationery Office, London.

Department of Health
www.dh.gov.uk/PolicyAndGuidance/EmergencyPlanning/PandemicFlu/fs/en

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.

Department for Environment, Food and Rural Affairs

www.defra.gov.uk/animalh/diseases/notifiable/disease/ai/index.htm

World Health Organization (2005a) WHO Outbreak

Communication Guidelines. WHO, Geneva.

Health Protection Agency

www.hpa.org.uk/infections/topics_az/influenza/avian/

World Health Organization (2005b) Influenza Pandemic Risk

Assessment and Preparedness in Africa. WHO, Brazzaville.

European Centre for Disease Prevention and Control

www.ecdc.eu.int/avian_influenza/index.php

World Health Organization (2005c) WHO Checklist for

Influenza Pandemic Preparedness Planning. WHO, Geneva.

Food and Agriculture Organization of the United Nations

www.fao.org/AG/AGAInfo/subjects/en/health/diseases-cards/special_avian.html

World Health Organization (2005d) Responding to the Avian

Influenza Pandemic Threat: Recommended Strategic Actions.
WHO, Geneva.

World Health Organization

www.who.int/csr/disease/avian_influenza/en/

World Health Organization (2005e) WHO Outbreak

Communication. WHO Handbook for Journalists: Influenza
Pandemic. WHO, Geneva.

Foreign and Commonwealth Office

www.fco.gov.uk

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

World Health Organization (2006) Advice on use of

Oseltamivir. WHO, Geneva.

NURSING STANDARD