Operator:

Good day everyone and welcome to today's RHC preparedness pandemic flu conference call. Today's conference is being recorded.

At this time, I'd like to turn the conference over to Deb Havens. Please go ahead.

Deb Havens:

Good afternoon, everybody. I'd like to welcome all the callers and the participants to today's presentation on RHC preparedness pandemic flu with our speakers Dr. Niranjan Bhat with the influenza branch of the National Center of Infectious Diseases at the Center of Disease Control and Prevention and Dr. Adam Cohen, an Epidemic Intelligence Officer with the Division of Healthcare Quality Promotion at the CDC.

Also joining us on the call today during the question and discussion segment is Captain Nancy Egbert the Senior Clinical Advisor of the Office of Rural Health Policy.

This program is scheduled for an hour. The first 45 minutes is going to consist of our speakers' presentations. The remaining 15 minutes will be dedicated to questions and discussion. The series of calls is sponsored by HRSA, Federal Office of Rural Health Policy, in conjunction with the National Association of Rural Health Clinics.

The purpose of the Rural Health Clinic's technical assistance conference call series is to provide Rural Health Clinic staff with valuable technical assistance and RHC-specific information. Today's call is our eighth call in the series, which began in 2005.

There's no charge to participate in the Rural Health Clinic's technical assistance conference call series. Individuals can sign up to receive announcements regarding the call dates, topics, and speakers' presentations at the following Web site: www.ruralhealth.hrsa.gov/RHC.

During our question and discussion segment of the call, we request that all callers please provide their name and their location before you ask your question. In the future, you can also email your question to the following Web site, info@narhc.org and put the teleconference question in the subject line.

All of your questions and answers will be posted at the (ORHP) conference call series Web site and the NARHC Web site, which is www.narhc.org.

You should have received an email already in advance of today's call providing a link to both of our speakers' PowerPoint presentations to follow along during the call. The call transcript will also be available at the ORHP Web site at http://www.ruralhealth.hrsa.gov/rhc/.

And now I'd like to welcome our first speaker, Dr. Niranjan Bhat. So take it away, Dr. Bhat.

Niranjan Bhat:

Thanks. My name's Niranjan Bhat. I'm with the Influenza Branch at the CDC. And I'd like to talk this afternoon about seasonal, avian, and pandemic influenza.

I hope most of you have been able to download my slides, and I will be following along those. So I'll try to indicate when I'll be moving to the next slide.

So starting with slide two, first I want to say that influenza definitely has a public health impact. It is an annual public health problem that occurs predictably. We know that we will have an influenza season every year, and its health impact is substantial.

It infects 10 to 35 percent of children each year and five to 20 percent of adults. And this has substantial economic consequences, including lost work, lost school days, and during the peak of the season, overwhelmed medical care systems at times.

In addition, because of the possibility of influenza pandemics, influenza represents a singular global infectious disease threat as well.

Next slide. So what is influenza? Influenza is often called the flu, which in general terms is an acute febrile respiratory illness. But what the general public considers a flu illness may actually be caused by any of a number of pathogens, mainly respiratory viruses.

But influenza particularly is caused by infection with an influenza virus. classically this is characterized by fever plus cough or sore throat, often called an "influenza-like illness" since it's usually not laboratory confirmed.

Next slide. There are other features of influenza that most people are familiar with, including headaches, fatigue, and body aches. One of the signal features of influenza, as opposed to the common cold for instance, is its rapid onset. But also the range of symptoms differs by age.

In children, vomiting and diarrhea can be present, but this is usually absent in adults. And in infants, influenza can present as fever alone, or as apnea.

Because of its non-specific nature, influenza is often confused with other illnesses. other viral illnesses, colds, as well as stomach flu, are some of the other illnesses that can be confused with influenza.

Next slide. Among respiratory viruses, influenza is considered to be highly contagious and transmission is primarily person to person with an incubation of one to four days. Serologic studies have shown that subclinical infection can occur.

Next slide. The infectious period for influenza may begin one day before symptom onset in adults. And it may even be longer or earlier in children. The peak viral shedding for influenza is on the first day of symptoms and adults shed for four to six days.

Infants and children may shed longer than this, and immuno-compromised patients have been shown in anecdotal reports to shed for months.

Influenza is unique among respiratory viruses in the degree of morbidity and mortality that it causes. In the United States, influenza is attributed to cause an average of more than 200,000 influenza-related hospitalizations and about 36,000 influenza-related deaths annually.

The highest rates are in persons with chronic high-risk conditions in all groups and in certain age groups, in particular, children with highest rates in the young children less than two years of age and adults age 65 or older. In fact, of those 36,000 influenza-related deaths, more than 90 percent are in the elderly.

Influenza vaccination is recommended but based on high risk categories. These are initially or primarily age groups, that age 65 or older, children age six to 59 months, as well as those age 50 to 64 years.

Of course, those with high-risk medical conditions age six months or older are recommended for influenza vaccination as well. In addition, household contacts of high-risk persons and healthcare workers are recommended for influenza vaccination.

In terms of treatment, there are a number of anti-viral influenza drugs. Regardless of the medication, treatment for influenza is usually a five-day course but needs to be started within 48 hours of illness onset for maximum benefit.

Influenza antiviral drugs are shown to reduce symptoms by approximately one day. And other studies have indicated that they also have an ability to decrease hospitalizations. In addition, influenza antiviral drugs reduce viral shedding.

Antivirals are also used for another indication, chemoprophylaxis. These antivirals are 70 to 90 percent effective in preventing illness from influenza. While infection may still occur, viral shedding, and therefore transmission, is reduced.

Examples of chemoprophylaxis are for control of nosocomial outbreaks in hospitals or long-term care facilities and for patients who cannot receive vaccine, for instance due to hypersensitivity.

There are two classes of influenza antivirals. The first class, known as adamantanes, are an older class of drugs that include amantadine and rimantadine. These are effective against only type A influenza viruses and are not currently recommended because there's a high frequency of resistance among currently circulating strains.

The other class of drugs are neuraminidase inhibitors and include oseltamivir and zanamivir. This is a newer class of drugs that are effective against both influenza A and B viruses.

The approved ages for these four drugs varies by drug and indication, and there is no treatment or prophylaxis approved for children aged less than one year.

In terms of influenza testing, viral culture is gold standard. This requires growth in cell culture and takes anywhere from four to 10 days for results. Serology is also another method that has been around for a while but usually requires paired samples so that background non-specific reactivity, which is common, can be compared to a rise in convalescent titers.

Immunofluorescence is another method that is relatively rapid but requires good technical skill. Reverse-transcriptase polymerase chain reaction is a test that is becoming more popular due to its rapid turnaround time as well as high sensitivity and standard technology.

And finally rapid diagnostic testing, which many clinics may be familiar with, is a very popular method because it is relatively simple to perform, and your are able to get an answer within 30 minutes. some brands can be used in the clinic itself. However, there are problems with their sensitivity.

The ideal specimen for seasonal influenza is a nasopharyngeal swab. But nasal swabs, nasopharyngeal aspirates and nasal aspirates are also useful and preferred over pharyngeal swabs.

Because viral shedding is highest at the beginning of the illness, it's best if these specimen is taken close to illness onset, at least within four days. And it's interesting to note that optimal specimen sites can differ for non-human influenza viruses such as avian influenza, also known as bird flu.

So now to a little bit of virology. Influenza illness is caused by infection with an influenza virus, and this virus primarily infects the upper respiratory tract. The virus is a negative single-stranded RNA virus, and it contains eight gene segments that code for 10 proteins. This segmented nature of the virus is important in understanding its biology.

Influenza viruses are classified into types A, B, and C, with A and B causing most human illnesses of significance.

Influenza A viruses are further characterized by subtype, and these subtypes are determined by two surface glycoproteins: the hemagglutinin protein and the neuraminidase protein. Hemagglutinin is the site of attachment to host cell surface receptors and antibodies to hemagglutinin are protective. Therefore, that's the target for vaccination.

The neuraminidase is a protein that is an enzyme that takes part in the release of virions from the cell.

Influenza A subtypes can come in 144 varieties. There are 16 H types and 9 N types. And so influenza A viruses are designated by the H and a number and an N and a number, such as H1N1 or H3N2.

The subtypes are specific to certain species of animal so that for instance humans can only be infected by a certain subset of H types. only H1, H2, and H3 are in common circulation in the human population while sporadic infections have been detected for H5, 7, and 9.

As the figure shows, there are subtypes that can infect swine, marine mammals, horses. All subtypes can infect migratory water fowl, such as ducks, geese, and seagulls. Therefore, avian influenza viruses are thought to have its reservoir in the bird population. And this population serves as a source of influenza viruses for other species.

There are two ways that influenza viruses can change to evade the immunity of the population. The first type is called antigenic drift, characterized by minor antigenic changes to the hemagglutinin protein.

This is a continuous process because influenza is an RNA virus, there is a poor quality of replication, so there's continuous mutation that goes on. This antigenic drift allows for escape from population immunity and can lead to a new replacement strain over the year for a particular subtype.

Antigenic drift leads to seasonal epidemics, and therefore vaccine strains must be updated each year. The US Influenza vaccine typically contains two type A strains, H1N1 and H3N2, and one type B strain, which covers all subtypes that currently circulate in the human population

The other method for change in influenza viruses is antigenic shift. This is where there's an emergence of a novel human influenza A subtype, usually from another animal population into the human population.

This can occur in two different ways. One is through direct bird-to-human transmission, through the mutational adaptation to the human host, or through genetic reassortment between human and animal influenza viruses.

Here is where that segmented nature of the influenza genome becomes important, because if a host, either a human host or an intermediate animal host, is infected with two different subtypes of influenza virus, those two different strains could swap genetic segments and gain the ability of transmission for one and the virulence of another.

This diagram, which is slide 18, demonstrates the first type of direct infection from birds to humans. And then slide 19 shows reassortment through an intermediate host.

Antigenic shift is important because it can lead to influenza pandemics. The requirements for influenza pandemic is the emergence of a novel human influenza A subtype into the human population, in other words, antigenic shift, and efficient human-to-human transmission, and also that the virus causes significant human disease.

A pandemic can result in increased overall morbidity and morality. But in particular, there's usually a higher proportion of deaths in younger adults.

Within the past century there have been three influenza pandemics: One in 1918 which led to 20 to 50 million deaths worldwide and over half a million deaths in the U.S. alone; the 1957 pandemic, which led to 70,000 U.S. deaths; and the 1968 pandemic, which led to 34,000 deaths.

It is thought that at least three pandemics have occurred per century on average based on historical records. But since the influenza virus was not identified until the 1930s, it's unknown whether influenza was the cause for each.

You may notice that the pandemics of '57 and 1968 had substantially fewer deaths. But the morbidity was still quite high.

You may also notice that mortality in recent years is, on average, 36,000 U.S. deaths per year, which is greater than the 34,000 you'll see in the 1968 pandemic. The thought is that during that time the population in the United States was smaller, that the proportion of the U.S. population that were elderly or had underlying medical conditions were smaller, as well as the fact that while the H3 antigen did change, the N2 remained the same from the previous years.

And all of these are thought to have factored into the difference between the 34,000 and the 36,000 currently.

You can also notice that these pandemics signaled the entry of a new subtype. In 1918, it was H1N1. In 1957, it was H2N2, and in 1968, it was H3N2. And currently the H3N2 strain and H1N1 strains are still in circulation.

Well, what would be the impact of a new influenza pandemic? Back in 1999, we projected the impact of a future pandemic based on the '57 and '68 pandemics. And the number of deaths are projected to be between 89,000 and 207,000; hospitalizations between 300,000 and 700,000; outpatient visits as well as other additional illnesses range in the millions; economic impact over 150 billion; and the population affected could be around 15 to 35 percent.

So slide 23, pandemic influenza, it's important to compare this with what has been in the media lately, which is avian influenza A H5N1, also known as bird flu. It's important to know that avian influenza H5N1 is not a pandemic virus at the moment. It is a new subtype from an animal source, and it does cause significant disease in those infected.

But it hasn't gotten the third requirement for a pandemic virus, which is easy human-to-human transmission. The clinical features of a pandemic influenza virus would be expected to be similar to a seasonal influenza but perhaps more severe in its presentation.

These would include fever and respiratory symptoms, and this is based on experience with the previous pandemics.

Because of the non-specific nature of, or non-specific symptoms of influenza, diagnosis, definitive diagnosis would still require laboratory confirmation. But during the midst of a pandemic, laboratories will likely be overwhelmed, and one would expect that clinical features alone will be sufficient for management of a pandemic influenza patient.

A pandemic influenza virus would be expected to be susceptible to neuraminidase inhibitors such as oseltamivir (Tamiflu) or zanamivir (Relenza). And it is possible that it may be still sensitive to the adamantanes.

Prevention of pandemic influenza would rely on the development of a pandemic vaccine as well as through non-pharmaceutical interventions, including isolation, quarantine, social distancing, and infection control. Interventions can range widely in their degree of intrusiveness, and the current idea is to keep them as minimal as possible while remaining effective. For instance, quarantine can be instituted on a completely voluntary basis, asking people to stay at home as much as they can for example, which is more likely in a country like the US, or enforced quarantine, which would involve many complex legal and logistical issues, would only be used in extreme situations.

And control during an outbreak will again rely on treatment, prophylaxis, and non-pharmaceutical interventions.

Department of Health and Human Services has developed a pandemic influenza plan that supports the National Strategy for Pandemic Influenza. And this pandemic influenza plan outlines planning assumptions and the doctrine for health sector pandemic preparedness and response.

There's also guidance for state and local partners with 11 supplements that give guidance on surveillance, testing, infection control, clinical management, as well as community interventions.

All of these documents can be accessed at the Web site listed on slide 24, pandemicflu.gov.

The objectives of the pandemic plan are to first prevent or at least delay introduction of a pandemic virus into the United States. And this may involve travel advisories, exit or entry screening, and for the first cases, it may involve isolation or short-term quarantine of arriving passengers.

Now in this age of rapid travel and mobility, it may be very difficult to prevent the introduction of a pandemic virus into the United States. Therefore, our next objective is to at least slow the spread, decrease illness and death, and buy time once the pandemic arrives.

This can be achieved through many ways, including antiviral treatment and isolation for people with illness, quarantine for those exposed, if feasible, social distancing, vaccine when available, and many of these decisions will have to be made locally.

On the graph that's shown on slide 26, it shows the difference between an unprepared and a prepared response to a pandemic. And the goal is to decrease the height of that peak because even if we can't completely prevent the pandemic virus from entering a community, we can at least try to slow its spread and decrease the peak so that services won't be stretched beyond surge capacity

Another objective of the pandemic plan is to include a clear communications strategy for the public. We want to be able to prepare people with information ahead of time. For instance, I've been asked before whether it's still safe for children to visit petting zoos or farms, to interact with chickens at school. at this time it's considered safe to do that, but it's important for people to know that there may come a time when it may not be safe. It's important for the public to understand ahead of time what the realm of possible interventions could be, and when they may be started, so that they are not taken by surprise or don't overreact to a perceived threat.

We want to encourage the public to take steps to prepare now, we want to provide updates when new information emerges, to use trusted messengers, to coordinate to ensure consistent messages across agencies, and to address rumors and inaccuracies.

We also hope to develop a pandemic vaccine. This can best be done by expanding and stabilizing production of the current influenza vaccine for seasonal influenza. We want to evaluate dose-sparing technology so that we can spread the current vaccine production capacity to cover more people.

We'd like to accelerate development of moderate vaccine technology. Currently, influenza vaccines are produced by using chicken eggs, which is a very slow process. We also want to target new antigens that are conserved from one influenza strain to the next so that we don't have to update the vaccine strains every year, or design a specific vaccine just for a pandemic virus strain.

In terms of antivirals, the U.S. government plans to stockpile a certain amount of antivirals, including oseltamivir, zanamivir, and the goal is to get enough quantity to treat 25 percent of the United States population.

Now, how antivirals and vaccines are going to be distributed is a matter of great complexity that involves issues regarding ethics, social justice, effectiveness, and science, and will take some time before concrete plans can be disseminated. But the U.S. government is working in close collaboration with the states as well as influenza experts, the vaccine manufacturers and the antiviral manufacturers to work this issue out.

Again, the strategy with antivirals is for use in initial containment, if that's feasible, and for treatment, especially those who are at higher risk. there is going to be an issue with prioritization of both antivirals and vaccine.

We'll have to balance the science with values regarding what is the most fair method for prioritizing antivirals and vaccine. this matter is being discussed at all levels and has engaged the public in many venues.The two objectives for the pandemic response are to preserve societal functioning and to protect those most at risk. And deciding which takes precedence is really a matter of quite a lot of debate.

Of course, the pandemic plan includes the evaluation of new antiviral candidates.

In terms of funding for states, the pandemic plan includes $350 million for state and local response capacity. And at this point, $100 million has already been awarded to all 50 states, seven territories, and this amount has been allocated according to a base figure plus a population formula.

In addition, $250 million will be awarded later this year.

Pandemic planning involves a network of responsibilities from the local to the state to the federal level, both domestic U.S. plans as well as coordinating with international plans, international agencies, and other countries.

It both involves the public sector as well as the private sectors as businesses plan. And it's non-partisan. It involves animal as well as the human health sectors and involves protection of health, security, as well as the economics of this country.

To help prepare, HHS has put together a series of pandemic influenza checklists. These are basically lists of things that different organizations need to think about and plan for in order to become prepared for a pandemic.

There are different checklists that are available on the pandemicflu.gov Web site, those for state and local organizations, businesses, schools, faith-based and community organizations, and the travel industry. And most relevant for this group, checklists for physician offices and ambulatory care, home health and emergency medical services.

In particular, the state and local public health checklists include items on community leadership and networking; surveillance; health system partnerships; infection control and clinical care; vaccine distribution and use; antiviral drug distribution and use; community disease control and prevention; communications and workforce support; while for medical offices and clinics, they include sections on starting a planning committee; developing a plan, surveillance and detection among their patients, communications with public health, other facilities, staff, and patients; education and training; triage management and infection control of infected patients; occupational health and surge capacity planning; and then antivirals and vaccines.

Now, these checklists are probably not at the level of detail that the public would like at this stage, but it is an ongoing process. And as the HHS develops its operational plan, further details will be available as time goes along.

There is advice for individuals, that advise families to store and supply some water and food, to have non-prescription drugs and other health supplies on hand, to talk about what will be needed to care for family members in the home, and for individuals to get involved in the community to volunteer with local groups to prepare.

So future directions for pandemic planning include more detailed guidance, including universal preparedness that can be used for any type of health emergency; to develop exercises at all levels -- local, state, as well as federal; to go through their pandemic plans; integration of different sectors within health, security, economic, and animal sectors; and, of course, all of these pandemic plans will require frequent updates and adaptation as events change.

The overall goal is preparedness but not panic, to inform but not to inflame.

So I'd like to end with just a summing up of seasonal, avian, and pandemic influenza viruses.

Seasonal influenza viruses are a public health problem that occurs every year. Seasonal influenza viruses circulate through the human population, and they spread easily from person to person.

Avian influenza A H5N1, also known as bird flu, is a devastating global outbreak in poultry. It's a pandemic for poultry, but only causes rare, but severe, human infections and currently does not spread easily from person to person.

A pandemic influenza virus appears in the human population periodically, and avian influenza A H5N1 is a likely candidate but it is not a pandemic virus yet. The next slide, slide 38, just is a note to say that these slides only represent our state of knowledge currently and that it's a rapidly changing field.

And so the best thing to do is keep up to date by keeping track of things on the CDC Web site and other Web sites, and there is a list of resources for Web sites you can use to keep current on pandemic and avian influenza issues.

And so with that, I thank you, and ask for questions.

Deb Havens:

Thank you, Dr. Bhat. And I think the second portion of our presentation is going to be from Dr. Adam Cohen. Dr. Cohen?

Adam Cohen:

Yes.

Deb Havens:

OK. You can start.
Adam Cohen:

Great. Thank you very much. My name is Dr. Adam Cohen. I work at the Division of Healthcare Quality Promotion at the CDC. That's the group at the CDC that works with other groups, such as the flu branch, on infection control issues.

I will start on slide number three and give you a little bit of a background on infection control and then lead into the specifics of infection control for flu.

The goals of infection control are manyfold. We seek to define and identify cases, to stop the spread of disease, both in facilities and in larger populations, to ensure safety for personnel providing care, to confirm the effectiveness of infection control practices, and to prevent inappropriate responses.

Slide four. There are some challenges to infection control of respiratory pathogens, and that's that transmission can occur by respiratory droplets or droplet nuclei. People can get infected simply by coming near infected patients.

And many symptoms, as we heard in the last talk, are non-specific. Recognition of the infection may be delayed.

Slide five. The approaches to controlling transmission are not new, however. Isolation precautions to prevent the transmission of pathogens are well-established. And I'll now quickly go through some of the basic infection control practices, which we'll revisit when we talk about the specifics for the different types of flu.

There are standard precautions which are recommended for all patient interactions, and then there are transmission-based precautions for specific pathogens. And there are three of those: contact, droplet and airborne.

Slide six discusses standard precautions. This also used to be called universal precautions. This includes constant use of gloves and handwashing for any contact with blood, moist body substances, mucous membranes, or non-intact skin. Gloves should be removed and discarded immediately after completing a task and hands should be washed every time gloves are removed.

The next three slides (seven, eight, and nine) go through contact, droplet and airborne precautions. With contact precautions, which are used for diseases such as shigellosis, Ebola, and MRSA, include limiting patient movement, providing private rooms, wearing disposable gowns and gloves when entering the patient room, and continuing to wash hands. You can review the rest of that slide later.

Droplet precautions, which are used for diseases such as Neisseria meningitis, pertussis, and seasonal influenza, includes using a face shield or goggles and a surgical mask, not an N-95 mask. Patients should be separated by about one to two meters or grouped with other patients with the same infection or colonization status.

Negative pressure rooms are not recommended or needed for droplet precautions.

The third type of transmission precautions are airborne isolation. These are for diseases that are spread by very small particles that remain infectious while suspended in the air, such as tuberculosis, measles, and chicken pox.

With these patients, a negative pressure room is recommended. The patient should wear a surgical mask, and an N-95 mask should be used for personnel.

As part of standard precautions, a new section was added on respiratory hygiene and cough etiquette. And this came out of our experience with SARS. Slides 10 through 14 go through the respiratory etiquette and cough etiquette.

I will let you read that on your own so that we can get to the question and answer session, but these are commonsense recommendations on how to prevent transmission through cough.

Slide 15 continues with other infection control considerations, which are that healthcare personnel are advised to observe droplet precautions when examining and caring for patients with signs and symptoms of a respiratory infection and that these measures should also apply to accompanying family or friends and any other person with respiratory symptoms entering the facility.

Slide 16 discusses recommendations for physical separation of patients. There have been some studies that suggest that a proximity of less than three feet has been associated with increased risk for transmission of infections through respiratory droplets. Increasing the distance between infected patients and others may decrease transmission risk.

Slide 17 reinforces that hand hygiene is very important. It has been shown to reduce the incidence of respiratory infections both in and out of the healthcare setting.

Slide 18 discusses why hand hygiene might be important with flu. Influenza virus can survive on a variety of surfaces at room temperature and moderate humidity. On surfaces such as steel and plastic, the influenza virus can survive for one to two days. On more porous materials, such as cloth and tissues, it can survive for up to 12 hours.

So the good news on slide 19, however, is that the virus can only be recovered on hands for about five minutes after inoculation, and even then, only after contamination with high viral titers. Therefore, alcohol-based hand rubs have a good and rapid activity against influenza.

These data are indirect evidence that influenza can be transmitted by contact but that hand hygiene, such as with alcohol-based hand rubs, will easily address this route of transmission.

Slide 21 discusses a controversy within the infection control world of how to treat influenza, particularly pandemic influenza. It comes back to the discussion of the difference between airborne and droplet transmission.

With droplet transmission, the contagious droplets are propelled a short distance and come into contact with conjunctiva or mucous membranes. They're typically large, greater than five micrometers, and typically travel only a few feet. They do not reach the lower airways.

And droplets, unlike with airborne transmission, do not stay suspended in the air or travel distances.

With airborne transmission, the production of infectious droplet nuclei can remain suspended in the air and travel over distances. This is because they are smaller in size and they do reach the lower airways.

The important point is that seasonal influenza and what we know about influenza from previous studies, is that flu is transmitted by droplet and not airborne. Therefore, droplet precautions have been recommended by HICPAC and employed by healthcare facilities for many years in the prevention of flu.

In slide 24 there is a discussion that several studies suggesting that at least some component of flu transmission is through airborne.

Slide 25 is where we discuss the infection control guidelines for the three types of influenza that Dr. Bhat discussed at the end of his talk: seasonal, avian, and pandemic. There are specific recommendations for each one.

Slide 26 discusses that with seasonal influenza, which is the typical influenza that we see each year, droplet precautions plus standard precautions are important for the duration of the illness, which is generally five days from symptom onset in adults with normal immune system.

Patients should also be housed in private rooms with negative air pressure as much as possible and feasible, and private rooms without negative pressure and cohorting are acceptable options.

Slide 27 discusses our recommendations for avian influenza. Patients with a history of travel within 10 days to country with avian influenza and are hospitalized with a severe febrile respiratory illness should be under evaluation for avian influenza.

And in addition to current standard precautions, we also recommend airborne precautions. It is very likely that avian flu, like most other flus, is transmitted through droplet. At this time, we're evaluating the little data we have right now about the transmission of avian flu. To be on the safe side, we currently still recommend airborne precautions.

With pandemic influenza, the recommendations are slightly different, and that's because in slide 28, early in the pandemic, it may not be clear that a patient with severe respiratory illness has pandemic influenza. Therefore, precautions consistent with all possible etiologies, including a newly emerging infectious agent, should be implemented.

Slide 29 starts discussing our recommendations for infection control with pandemic influenza. Patients with known or suspected pandemic influenza should be placed on droplet precautions for a minimum of five days from onset of symptoms. That's similar to the infection control recommendations with seasonal influenza.

However, with pandemic influenza, during procedures that might generate aerosols, such as bronchoscopy, intubation, and suctioning, we are recommending airborne precautions, which include a negative pressure isolation room and a particulate respirator, such as an N95.

We also recommend contact precautions and eye protection.

Slide 31. With pandemic influenza we should also consider the addition of airborne precautions for strains of influenza exhibiting increased transmissibility during the initial stages of an outbreak of an emerging or novel strain of influenza as determined by other factors.

But if pandemic flu behaves like seasonal flu, as we expect, then changing to airborne plus contact precautions will add very little to control efforts since most of transmission will still occur via large droplets.

In conclusion, a respiratory hygiene and cough etiquette strategy will serve as the first line of defense against all respiratory pathogens, including pandemic influenza, and should be implemented as part of standard precautions.

Specific infection control recommendations for pandemic and avian non-pandemic influenza will evolve as we learn more. And our infection control strategies must be adaptable.

The last few slides discuss some of the specific procedures that should be considered for causing aerosol and the airborne precautions should be used for.

Thank you very much. I think at this point we could open this up for questions.

Deb Havens:

All right. Thank you very much. I just want to remind everyone that during the question and answer, our discussion segment of the call which we are on right now, we please request that everyone identify themselves by stating their name and the location from which they're calling from and ask the question.

So I guess we'll open it up, operator.

Operator:

If anyone does have a question, you can signal at this time by pressing star one on your touch-tone telephone. If you're on speakerphone, please make sure your mute function has been turned off to allow your signal to reach our equipment. A voice prompt on your phone line will indicate when your line is open to ask a question. Please state your name before posing your question. Once again if you have a question, please press star one now. And we'll pause for just a moment. Once again if you have a question, please press star one now.

And we have no questions at this time.

Deb Havens:

I'll start off the questions. This is Debbie Havens. And the first question I'd like to ask our panel is how should a rural health clinic start setting up and preparing for the flu season or for a pandemic or for avian flu?

Niranjan Bhat:

Well, this is Niranjan Bhat. I can start off by saying that part of, part of the planning for a pandemic influenza occurrence is to just increase your preparations for any type of health emergency where you would expect a larger number of patients and a larger severity, increase in severity of illness.

I think that the checklists help to kind of guide you in terms of looking at all of the issues that would be relevant, including surveillance and detection of the pandemic influenza virus as well as in occupational health and surge capacity issues as well as contacting and communicating with your local public health agencies so that the support, including antivirals or vaccine, if they're available, would be distributed.

A lot of the preparation just goes into finding out what is your state pandemic plan, what stage is it in, who are the people you can talk with to help you make plans, and just to basically keep up to date.

I think that a lot of people take a sort of doomsday scenario when thinking about a pandemic, and I would just make it important to remember that a pandemic is not a situation where, like a hurricane, where facilities are destroyed or roads are impassable or even like a large snow storm.

It is a question of availability of people and speed of services. And unfortunately in this era of just-in-time supply, there is some fragility to the transport and delivery of goods, including food. And so that's why people end up recommending stockpiling of food and other essential goods.

Deb Havens:

Should we be stockpiling the medicines now?

Niranjan Bhat:

We would not recommend stockpiling antivirals, specifically. This is something that we would hope that people will understand in terms of the danger of having personal stockpiles, mainly because, as has been demonstrated this season, resistance of influenza viruses to antivirals can occur. And it's much more likely when the unregulated use of these prescription drugs are frequent.

And therefore, we really would recommend against people having a stockpile because there is really a high risk for inappropriate or inadequate treatment in the development of resistance.

It is something to think about to have just an extra supply of non-prescription medications, including symptomatic therapy, like pain relievers and fever, fever treatment. But also keep in mind that, you know, a pandemic activity would come to a community at a different time from other parts of the country.

And so while a pandemic across the globe may last a few months, it would only come to a community for a few weeks. And so it's not something that's going to be a long-term issue.

However, there is a possibility of second waves that have occurred with previous pandemics. But usually those who have been affected by the first wave are immune to the second wave.

Deb Havens:

In terms of treating the patients, if we do get that wave of patients, is your advice, or would your advice be that we'd be better off telling the patients to stay home and phone in a prescription and not have them come into the office? Or have them come into the office and perhaps have a quarantined area?

Niranjan Bhat:

That is a very good question. And it relies on the ability of the clinic to triage or determine the severity of the illness of the person. I think that it may very well be a good idea for those with mild infections to stay home and consider home treatment.

And in particular, since antivirals won't be likely available for every person in the United States, and much less the world, there's probably going to be a need for those with mild infections and with a low risk for development of complications to defer antiviral treatment.

As I said before, antivirals only really show most benefit if they're begun within the first 48 hours of illness. And what they do is mainly decrease the number of days of symptoms by one day. This may have some benefit for reducing complications due to a pandemic virus, but that is one issue.

In regards to whether a person would need to stay at home versus come to the clinic, we are developing guidance to help develop some guidelines for assessment as well as by the public as well as by clinic providers to determine whether a person needs to come in.

But we would expect that the types of complications that occur from pandemic influenza would be similar to those occurring with seasonal influenza but in greater frequency and severity. And so a lot of the common sense directions in triage that we currently use today for seasonal influenza could probably be used during a pandemic situation.

And in terms of quarantining an area, it is advised, even currently, in the post-SARS era, that clinics and emergency rooms, during the respiratory season set off an area for people with respiratory symptoms so that they can decrease transmission to other patients.

Deb Havens:

Operator, do we have any other questions?

Operator:

We do have a question in the queue. Caller, please state your name before posing your question.

Beth Harrison:

Hi. This is Beth Harrison from (ETMC) Fairfield. The question we have is, is there any plan, federally or privately, to increase manufacturing of flu vaccine just to increase our volume?

Niranjan Bhat:

Yes, this is Niranjan Bhat. I can answer that. There is the hope and the plan to increase the production as well as the demand for our seasonal influenza vaccine because it's felt that the, if we can expand the capacity and the stability of the influenza vaccine market that will help the vaccine manufacturers to develop the ability and capacity to produce a pandemic vaccine, should a pandemic occur. This is not intended to just generate money for the vaccine industry. But it is to get to some stability.

And there have been gains in the influenza uptake over the past several years. It's been complicated the vaccine shortages, but, and supply issues. But that is a major component of the pandemic influenza funding that Congress has allocated.

Deb Havens:

Operator?

Operator:

Yes, ma'am.

Deb Havens:

Do we have another question?

Operator:

We do not.

Deb Havens:

All right. This is Debbie Havens. I'll ask some questions we received by email. The first is can either of you describe the signs and symptoms of seeing it in birds, in the case of bird flu? Like what do you look for in birds?

Niranjan Bhat:

Adam, I think I can take that, too, unless you'd like to take it.

Adam Cohen:

Yes.

Niranjan Bhat:

Well, neither of us are veterinarians, of course, and we at the CDC deal mainly with human health. But I do have some experience with the veterinary side of things when working with bird flu.

And so the signs and symptoms of avian influenza in animals is primarily seen in domestic poultry. This is primarily a disease of domestic poultry, chickens and turkeys and ducks.

And in chickens particular you'll see edema of the waddles and combs as well as edema of the feet. You'll see cyanotic waddles and combs and you'll see respiratory secretions. You'll see diarrhea, and you'll see neurologic symptoms, including (sound lessens), balance problems, and such.

And it is a very severe disease and a rapid disease. It's almost 100 - the bird flu that's circulating in Asia and Europe and Africa right now is a very severe disease in poultry. It causes almost 100 percent fatality.

It has been seen to affect some wild migratory birds. So you may hear about reports of wild swan or a crane being found and tested and confirmed for influenza A H5N1. But influenza H5N1 has not been detected so far in the Western Hemisphere, either in domestic poultry or in birds or in wild migratory birds.

And it does infect mammals, such as horses or dogs. But it has been shown to infect cats as well as humans.

Deb Havens:

Very good.

Male: Operator, do we have any other questions lined up?

Operator:

We do not.

Deb Havens:

We have one minute left. Would anyone like to address, either doctor, would you like to make one more point in a wrap up? No.

OK. I'd like to thank the speakers and the call participants. I'd also like to thank the Office of Rural Health Policy for the call series.

We will be announcing the next call on the topics shortly and will email all that information to those who have registered for the call series. If you'd like to suggest a topic, we're always interested in your ideas, and we welcome them greatly.

And for any future ideas, please email them to info@narhc.org. I'd also like to encourage others who may interested to register for the technical assistance call series at the ruralhealth.hrsa.gov/rhc/ Web site, and be sure to include your email address in order to be notified by email or any future call or information that we have to offer.

So I'd like to thank you on a beautiful day here in Washington, D.C. and hope you've all learned something. I found it informative and hope you can use the information in your rural health clinics.

Thank you all.

Operator:

That does conclude today's conference. We thank you for your participation. You may now disconnect.

END