Deidre Jackson, PharmD Candidate, The Ohio State University, and OPA Extern; and Amy Bennett, R.Ph.
Governor Bob Taft established the Pandemic Preparedness Coordinating Committee, under the State of Ohio Security Task Force umbrella, to ensure integrated pandemic influenza preparedness among all state agencies. The committee is chaired by J. Nick Baird, M.D., Director of the Ohio Department of Health. He will be coordinating efforts with the Ohio Departments of Agriculture and Public Safety as well.
There were three influenza pandemics in the 20th century:
1918-19 Spanish Flu A (H1N1)
1957-58 Asian Flu A (H2N2)
1968-69 Hong Kong Flu A (H3N2)
Although there is no evidence of H5N1 in the U.S. at this time, experts believe it is only a matter of time before the first pandemic of the 21st century emerges. The H5N1 avian influenza ("bird flu") circulating in Asia and Europe may spark the next pandemic, or an unknown, novel strain may emerge.
Ohio Pandemic Flu Summit
Governor Taft hosted the Ohio Pandemic Flu Summit, attended by more than 500 Ohio leaders in health care, business and government on February 17 in Columbus. Governor Taft and U.S. HHS Secretary Mike Leavitt spoke on state and federal preparedness before signing the pandemic flu planning agreement detailing state and federal roles. Secretary Leavitt brought a commitment of $3.2 million in federal funding to help Ohio with its planning. The Director of the Ohio Department of Health, a CDC Director, a coordinator for the Department of Homeland Security, representatives from the U.S. and Ohio Departments of Agriculture, the Director of the Ohio Emergency Management Agency, American Red Cross, Ohio Hospital Association, Ohio Council of Churches and the senior health manager of occupational health at Procter & Gamble presented. Early detection and prevention, moving away from egg-based vaccines, dose-sparing technology, a more stable vaccine distribution system, the role of current antiviral medicines, overload of health care systems, reliance on mutual aid and volunteers, allocation of scarce resources, ethical issues and alternate care, and economic and social disruption were several of the many issues discussed. Secretary Leavitt emphasized the importance of local community planning in businesses, schools, churches, and households.
Some good background information follows.
1. What is pandemic flu?
A pandemic flu is a global outbreak of disease that occurs when a new influenza A virus appears or emerges in the human population for which there is little to no immunity. Pandemic flu causes serious illness and spreads easily from person to person worldwide. Pandemic outbreaks are caused by new subtypes of influenza that have not previously circulated among people. Past influenza pandemics have led to high levels of illness, death, social disruption, and economic loss. The last pandemic flu ("Hong Kong flu" or A [H3N2]) occurred in 1968-1969 and resulted in 34,000 U.S. deaths.
2. How does pandemic flu differ from seasonal flu?
Symptoms of pandemic flu are similar to those of the common flu, which include fever, cough, runny nose, and muscle pain. However, symptoms of pandemic flu may be more severe. During pandemic flu, healthy adults may be at an increased risk for serious complications, such as secondary pneumonia. This is not typically the case for seasonal flu, in which the very young and elderly, and those with certain underlying conditions, are most at risk. Seasonal flu is caused by subtypes of influenza virus that have already circulated (e.g., A [H3N2] and A [H1N1]) among people. The best protection against seasonal flu is vaccination.
The major difference is social disruption. Seasonal flu generally has a modest impact on society, whereas a severe pandemic could result in economic and social disruption from travel bans, school closings, and work absenteeism. A pandemic flu may also result in health care system overload and a medical supply shortage, including medications and vaccines.
3. Is Avian/Bird Flu the next pandemic flu?
Avian influenza (the bird flu) is caused by a virus that infects domestic poultry (e.g., quail, cranes, geese, chickens and ducks) and pet birds (e.g., parrots). Bird flu viruses do not usually infect humans, but since 1997 there have been a number of confirmed cases of human infection from these viruses. Most of these infections resulted from direct or close contact with infected birds. The spread of bird flu viruses from an infected person to another person has rarely been reported, and has never been reported to continue beyond one person.
Bird flu is still a bird disease. The H5N1 strain in Asia does not spread well from person to person, but has caused an unprecedented epidemic in poultry and wild birds across Asia and Eastern Europe. It is not known if this strain will cause the next pandemic flu, but the widespread nature of H5N1 in birds and the likelihood of mutations over time have caused concerns that the virus will become transmissible between humans, with potentially catastrophic consequences.
Bird flu could become a human strain in one of two ways. If a person were infected with a human influenza strain and a bird influenza strain at the same time, the two viruses could swap genes and reassort (rearrange) and a human version of bird flu could emerge. This mechanism resulted in the flu pandemics of 1957 and 1968. Alternatively, bird flu could evolve into a form adapted to humans, as was the case in the 1918 pandemic. There is some evidence that the H5N1 bird flu virus has started this process. A few H5N1 viruses isolated from humans have acquired some mutations similar to that of the virus that caused the 1918 flu pandemic.
4. What can pharmacists do?
Intensifying surveillance and collaborating on containment methods, both international and domestic, is critical in pandemic flu preparedness planning. How can pharmacists help? Pharmacists can be alert to increased sales of OTC cough and cold medications beyond the typical seasonal flu increase, or an increasing number of prescription medications for cough and cold in the healthy adult population, and report this to the local health department. Pharmacists can help educate their patients and their communities. Education can include symptoms to watch for, how to limit the spread of germs to prevent infection, food and other items to have on hand for an extended stay at home, etc. Pharmacists can volunteer to serve on community committees that are working to prepare for an influenza pandemic.
5. How will pandemic flu be treated?
There are currently four influenza antiviral medications (amantadine, rimantadine, oseltamivir, and zanamivir) approved by FDA for the treatment or prevention of influenza. The drugs are not always effective due to resistance. The H5N1 strain of the bird flu is resistant to amantadine and rimantadine. More recently, testing of the current seasonal influenza A has shown a 91 percent resistance to amantadine and rimantadine. As a result, CDC issued a health alert on January 14, 2006 recommending that neither drug be used for the treatment or prevention of influenza A in the United States for the remainder of the flu season.
Relenza (zanamivir) and Tamiflu (oseltamivir) will most likely be used for treatment and prevention of pandemic flu. Zanamivir is a powder for oral inhalation. In vitro it has been shown to be effective against some strains of avian influenza A, while others are resistant. Tamiflu is available as a tablet or liquid suspension. It has been used to treat several avian flu strains, including H5N1 in humans, but resistance has developed in some patients. Cross-resistance between Tamiflu and Relenza has been demonstrated in vitro, but is not clinically documented. Relenza should not be used in patients under seven years of age or in patients with asthma or COPD. These populations are usually at high risk for serious complications from influenza.
Tamiflu is currently the medication recommended for use for treatment of pandemic flu. Tamiflu, when used within 40 hours of symptom onset, decreases severity and duration of influenza symptoms. Duration of symptoms is generally decreased by one to 1.5 days. If Tamiflu is taken within 24 hours of the onset of symptoms, the duration may be decreased by up to two days. Tamiflu may also be used for the prophylaxis of influenza A and B virus infections in patients older than 12 years of age. Results of community studies in healthy adults indicate an 80 percent efficacy in preventing febrile, laboratory-confirmed influenza illness post-exposure. Current influenza vaccines will not prevent pandemic flu, but research is ongoing to find an effective vaccine.
6. What should your patients know about pandemic flu?
Remind patients that the most effective way to prevent spread of influenza is to practice good hygiene and maintain health. The influenza vaccine will not help prevent pandemic flu, but may help the patient remain in good health. Recommend that your patients with certain chronic conditions and those over age 65 receive pneumococcal vaccine if indicated. This is important since secondary pneumonia will likely be a major cause of morbidity and mortality. Advise patients that they should not stock up on antiviral medications. The medications are in short supply and will be needed to treat people who are actually exposed to the disease. Furthermore, it is difficult to distinguish between viral and bacterial infections, so patients may take the medication unnecessarily or incorrectly.
Here are some good websites for additional information:
www.pandemicflu.gov (official U.S. government website)
www.usda.gov/birdflu (U.S. Department of Agriculture)
www.dhs.gov (U.S. Department of Homeland Security)
www.odh.state.oh.us/ Ohio Pandemic Flu Strategic Plan (Ohio Department of Health)
A vaccine update program at the OPA Annual Conference (April 21) will include information on pandemic flu.