Pandemic Flu - Kitsap Public Health District

New
Study
School closures and other community strategies designed to reduce the possibility of spreading disease
between people during an epidemic can save lives, particularly when the measures are used in combination
and implemented soon after an outbreak begins in a community, according to a new study based
on public records from the 1918-1919 influenza pandemic.
The findings, which are published in the Aug. 8 issue of the Journal of the American Medical Association, provide vital clues to help public
officials planning for the next influenza pandemic and highlight the importance of community strategies. These strategies are particularly
important because the intervention most likely to provide the best protection against pandemic influenza -- a vaccine -- is unlikely to be
available at the outset of a pandemic. Community strategies that delay or reduce the impact of a pandemic (also called non-pharmaceutical
interventions) may help reduce the spread of disease until a vaccine that is well-matched to the virus is available.
Scientists from the Centers for Disease Control and Prevention (CDC) and the University of Michigan Medical School′s Center for the
History of Medicine completed an exhaustive review of public records such as health department reports, U.S. Census mortality data and
newspaper archives.
"Communities that were most successful during the 1918 pandemic quickly enacted a variety of measures,"
said Dr. Martin Cetron, director of CDC′s Division of Global Migration and Quarantine and senior author of the study. "Those
planning for the next pandemic need to carefully consider how to best use these strategies to protect people and decrease the potential impact
of the next pandemic in their communities."
These strategies— voluntary isolation and quarantine, dismissal of students from school classrooms,
and social distancing in the workplace and community— form the basis for CDC’s guidelines for how
American communities can empower themselves to confront the next influenza pandemic.
The JAMA study evaluated public health measures such as school closures and cancellation of public events, which 43 American cities
took during the 1918 pandemic. The researchers sought to determine whether the timing, duration and combination of such measures impacted
the city′s death rate during the pandemic.
To determine the public health measures′ effectiveness, the researchers analyzed each city′s excess death rate - the number of pneumonia
and influenza deaths in excess of the amount expected for the time period.
During a 24-week period in 1918-1919, more than 115,000 excess pneumonia and influenza deaths in
the 43 cities were attributed to the pandemic. Cities that began interventions earlier had more success in
decreasing excess deaths than those that implemented the measures later, regardless of how long the
later interventions were in place or how they were executed.
In a telling example, New York City’s early and sustained response, including isolation and quarantine
and staggered business hours, resulted in the lowest excess death rate for any city on the East Coast during
the time period reviewed. By contrast, Pittsburgh was well into its outbreak before implementing the
interventions and experienced the highest excess death rate of any of the 43 cities.
"In a world faced by the threat of avian influenza or other novel strains of influenza, it is critical to determine if such costly and socially
harsh measures as school closures and cancellation of public gatherings might not only lower death and case rates, but also delay the spread
and allow time for the development and distribution of effective vaccines and antivirals," said Dr. Howard Markel, director of the University
of Michigan Medical School′s Center for the History of Medicine and lead author of the study. "We have demonstrated that
these measures can have a real impact."
The interventions assessed fell into three major categories: school closures, bans on public gatherings and isolation of sick people and
quarantine of their healthy household contacts. The most common approach was closing schools combined with banning public gatherings.
All but three of the 43 communities closed schools during the 24-week period studied.
Influenza pandemics occur when a new influenza virus emerges to which most people have little or no immunity and the virus gains the
ability to spread easily between people. The 1918 pandemic sickened about 20 percent of the world′s population and caused an estimated
40 million deaths worldwide, about 550,000 of them in the United States.
For more information about community strategies for pandemic influenza, please http://www.pandemicflu.gov/plan/community/
community_mitigation.pdf. Page Located on the Web at www.cdc.gov/od/oc/media/pressrel/2007/r070807.htm
CDC Pan Flu Prevention Study.pub/rw/Revised 9/21/07

Influenza Pandemic Facts
What is an influenza pandemic ?
Influenza viruses cause infections of the respiratory tract (breathing tubes and lungs). In some persons,
complications of influenza can be severe, including pneumonia.
An influenza pandemic is a global outbreak of disease from a new influenza A virus that is unlike past
influenza viruses. Because people have not been infected with a similar virus in the past, most or all
people will not have any natural immunity (protection) to a new pandemic virus.
How is a pandemic different from regular flu season?
A flu pandemic is a new influenza virus that could be a much more serious flu virus than seen in a
typical flu season. Different from the typical strains of flu, humans would have no or little natural
resistance to a new strain of influenza. Also, there is a vaccine for seasonal flu, which is prepared each
season against new variations of the seasonal influenza. There is no vaccine available at this time for a
flu pandemic, and it is expected to take at least six months after a flu pandemic appears to develop a
vaccine.
Why is an influenza pandemic so serious?
Because most or all people would not have immunity to a new pandemic virus, large numbers of
persons around the world can be infected. If the pandemic virus causes severe disease, many people
may develop serious illnesses.
Once a pandemic virus develops, it can spread rapidly causing outbreaks around the world. The U.S.
Centers for Disease Control and Prevention (CDC) predicts that as much as 25% to 30% of the US
population could be affected.
Can a flu pandemic be prevented?
Public Health in Region 2 (Kitsap, Jefferson and Clallam Counties) is working with federal, state, and
other local government agencies to respond to an influenza pandemic and to maintain essential health
care and community services if an outbreak should occur. In fact, governments all around the world are
preparing for the possibility of a pandemic outbreak under the leadership of the World Health
Organization.
It is not possible to prevent or stop a pandemic once it begins. A person infected with influenza virus
can be contagious for 24 hours before the onset of symptoms, and for seven days thereafter, making it
extremely easy for the virus to spread rapidly to large numbers of people.
Although the federal government is stockpiling medical supplies and antiviral drugs, no country in the
world has enough antiviral drugs to protect all their citizens. Anti-viral drugs can be used to treat
severe cases as long as there was a reasonable chance that the drugs might help save lives. Antiviral
drugs might also be prioritized for people who work in essential occupations, such as health care
workers.

Other strategies for slowing the spread of a severe influenza outbreak could include temporarily closing
schools, sports arenas, theaters, restaurants, taverns, and other public gathering places and facilities.
There currently is no vaccine to protect humans against a pandemic influenza virus because the
pandemic virus has not yet fully developed. However, vaccine development efforts are under way to
protect humans against a pandemic influenza virus that might develop from the current bird flu virus
in Asia. (See information on bird flu below).
When is an influenza A pandemic expected?
Influenza pandemics occur naturally. There were 3 pandemics in the 20th century. The pandemic of
1918-19 was the most severe pandemic on record, in which 50 million or more persons around the
world died, including approximately 650,000 Americans.
It is not possible to predict accurately when influenza pandemics will occur or how severe they will be.
However, the current outbreak of avian influenza in Asia has influenza experts concerned that a
pandemic is developing that may be severe.
Why does the current bird flu outbreak in Southeast Asia pose a risk of causing an
influenza A pandemic outbreak in humans?
New human influenza viruses arise from bird influenza viruses that then change to a form that can
infect humans and spread readily from person to person. The current bird flu outbreak in Asia is caused
by a type of influenza A virus called “H5N1.” The H5N1 outbreak among domestic chickens and ducks
in Asia is widespread and uncontrolled. Human infections and deaths due to the avian H5N1 virus
have occurred, although the virus has at this time not developed the ability to pass easily from person to
person and cause outbreaks in humans.
What are the symptoms of bird flu in humans?
The reported symptoms of bird flu 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.
What can the public do to reduce their risk of an influenza pandemic ?
• Stay informed. These web sites provide regularly updated information about bird flu and flu
pandemic:
Kitsap Public Health District www.kitsappublichealth.org
Clallam County Health & Human Services www.clallam.net/HealthServices/
Jefferson County Public Health www.jeffersoncountypublichealth.org
Centers for Disease Control and Prevention (CDC) www.cdc.gov
For information on the vaccine development process, visit the National Institutes of Health
at www.niaid.nih.gov
• Stop germs from spreading.
Cover your mouth and nose with tissue when coughing and sneezing
Wash your hands often
Wear a mask if you’re asked
Stay home when you are sick
Visit Cover Your Cough at www.cdc.gov/flu/protect/covercough.htm
Rev3/1/2012

P r e v e n t i n g t h e S p r e a d o f I n f l u e n z a
Most patients with pandemic influenza will be able to remain at home
during the course of their illness and can be cared for by others who live
in the household. This information is intended to help you recognize the
symptoms of influenza and care for ill persons in the home, both during a
typical influenza season and during an influenza pandemic.
At the outset of an influenza pandemic, a vaccine for the pandemic flu virus will not be available for
several months. However, it’s still a good idea to get a seasonal flu vaccine to protect from seasonal flu
viruses.
Because influenza can spread easily from person to person, anyone living in or visiting a home where
someone has influenza can become infected. For this reason, it is important to take steps to prevent
the spread of influenza to others in the home.
S y m p t o m s o f I n f l u e n z a
Sudden onset of illness
Fever higher than 100.4º F (38º C)
Chills
Cough
Headache
Sore throat
Stuffy nose
Muscle aches
Feeling of weakness and/or exhaustion
Diarrhea, vomiting, abdominal pain (occur more
commonly in children)
C a r e g i v e r s — W h a t Y o u C a n D o
Separate influenza patients from other people as much as possible. When practical, the ill person
should stay in a separate room where others do not enter. Other people living in the home should
limit contact with the ill person as much as possible.
Designate one person in the household as the main caregiver for the ill person. Ideally, this
caregiver should be healthy and not have medical conditions that would put him or her at risk for
severe influenza disease. Medical conditions that are considered “high risk” include:
Pregnancy
Diabetes
Heart problems
Kidney disease
Disease or treatment that suppresses the immune systems
Chronic lung disease, including asthmas, emphysema, cystic
fibrosis, chronic bronchitis, bronchiectasis and tuberculosis (TB)
Over 65 years of age
Watch for influenza symptoms in other household members.
Contact your health care provider if you have questions about caring for the ill person. However, it
may be difficult to contact your usual healthcare provider during a severe influenza pandemic. Public
Health in Region 2—Clallam County Health & Human Services, Jefferson County Public Health and
Kitsap Public Health District—will provide frequent updates, including how to get medical advice.
Special telephone hotlines will be used. These numbers will be on the websites and announced
through the media.
Wear surgical masks (with ties ) or procedure masks (with ear loops). Masks may be useful in
decreasing spread of influenza when worn by the patient and/or caregiver during close contact
(within 3 feet). To be useful masks must be worn at all times when in close contact with the patient.
The wearing of gloves and gowns is not recommended for household members providing care in the
home but washing hands frequently is.

I n t h e H o u s e h o l d — W h a t Y o u C a n D o
Wash hands with soap and water. If soap and water are not available, use an alcohol-based hand
cleanser after each contact with an influenza patient or with objects in the area where the patient is
located. Thorough hand cleaning by everyone in the household is the single best preventative
measure against the spread of the flu.
Don’t touch your eyes, nose or mouth without first washing your hands for 20 seconds. Wash
hands before and after using the bathroom
Wash soiled dishes and eating utensils either in a dishwasher or by hand with warm water and
soap. It’s not necessary to separate eating utensils used by a patient with influenza.
Laundry can be washed in a standard washing machine with warm or cold water and detergent. It is
not necessary to separate soiled linen and laundry used by a patient with influenza from other
household laundry. Do not grasp the laundry close to your body or face, in order to avoid
contamination. Wash hands with soap and water after handling soiled laundry.
Place tissues used by the ill patient in a bag and throw them away with other household waste.
Consider placing a bag at the bedside for this purpose.
Clean counters, surfaces and other areas in the home regularly using everyday cleaning products.
I n t h e C o m m u n i t y — W h a t Y o u C a n D o
Stay at home if you are sick. Ill persons should not leave the home until they have recovered
because they can spread the infection to others. In a typical influenza season, person with influenza
should avoid contact with others for about 5 days after onset of the illness. During an influenza
pandemic, public health authorities will provide information on how long persons with influenza
should remain at home.
If the ill person must leave home (such as for medical care), he or she should wear a surgical
or procedure mask and should be sure to take the following steps:
Cover the mouth and nose when coughing and sneezing, using tissues or the crook of the
elbow instead of the hands.
Use tissues to contain mucous and watery discharge from the mouth and nose.
Dispose of tissues in the nearest waste bin after use or carry a small plastic bag (like a ziplock
bag ) for used tissues.
Wash hands with soap and water or use an alcohol-based hand cleanser after covering your
mouth for a cough or sneeze after wiping or blowing your nose and after handling
contaminated objects and materials, including tissues.
During an influenza pandemic only people who are essential for patient care or support should
enter a home where someone is ill with pandemic influenza unless they have already had influenza.
If other persons must enter the home, they should avoid close contact with the patient and
use the infection control precautions recommended on this sheet.
More Information
This guidance is based on current information from the U.S. Department of Health & Human services
Pandemic Influenza Plan and is subject to change. Up-to-date guidance will be available from your healthcare
provider and at these websites:
Clallam County Health & Human Services www.clallam.net/HealthServices/
Jefferson County Public Health www.jeffersoncountypublichealth.org
Kitsap Public Health District www.kitsappublichealth.org
Washington State Department of Health www.doh.wa.gov
Centers for Disease Control and Prevention www.cdc.gov
Region 2 Public Health, Kitsap, Clallam and Jefferson Counties
Kitsap Public Health District, 345 Sixth St., Suite 300, Bremerton, WA 98337, (360) 337-5235 3/5/2012

C a r i n g f o r S o m e o n e w i t h I n f l u e n z a
During a severe influenza outbreak or pandemic, the residents of Region
2—Kitsap, Clallam & Jefferson Counties - will be informed by the media
and healthcare providers about how to obtain medical advice and receive
medical care.
The following information is a general guide and is not intended to take
M o n i t o r i n g
& C o m f o r t i n g
Keep a care log. Write down the following information about the ill person at least once each
day— or more often as symptoms change—along with the date and time.
Check the patient’s temperature.
Check the patient’s skin for color (pink, pale or how much the patient drinks each day and
through the night
Write down how many times the ill person urinates each day and the color of the urine
(clear to light yellow, dark yellow, brown, or red)
Write down all medications, dosages and times given.
Keep the ill person as comfortable as possible. Rest is important.
Tissues and a trash bag should be within reach of the patient.
Fever is a sign that the body is fighting the infection. It will go away as the patient is getting better.
Sponging with lukewarm (wrist-temperature) water may lower the patient’s temperature but only
during the period of sponging. Do not sponge with alcohol.
Watch for complications of influenza. Complications are more common in individuals with
health conditions such as diabetes, heart and lung problems, but may occur with anyone who has the
flu. Call your healthcare provider if the ill person:
Has difficulty breathing, is breathing fast, or has a bluish color to the skin or lips
Begins coughing up blood
Shows signs of dehydration and cannot take enough fluids
Does not respond or communicate appropriately or appears confused
Complains of pain or pressure in the chest
Has convulsions (seizures)
Is getting worse again after appearing to improve
Is an infant younger than 2 months old with fever, poor feeding, urinating less than 3 times
per day or other signs of illness
M e d i c a t i o n s
Use ibuprofen or acetaminophen or other measures, as recommended by your healthcare provider,
for fever, sore throat and general discomfort.
Do not use aspirin in children or teenagers with influenza because it can cause Reye’s syndrome,
a life-threatening illness.

F l u i d s & N u t r i t i o n
If Not Vomiting offer small amounts of fluid often to prevent dehydration, even if he or she does
not feel thirsty. If the ill person is not eating solid foods, include fluids that contain sugars and salts,
such as broth or soups, sports drinks (diluted half and half with water), Pedialyte® or Lytren®,
ginger ale and other sodas, but not diet drinks or drinks with caffeine. Regular urination is a sign of
good hydration.
Recommended minimum daily fluid intake, if not eating solid food:
Young children—1 ½ ounces per pound of body weight per day
(Example: A 20 pound child needs approximately 30 ounces fluid per day)
Older children and adults—1 ½ to 2½ quarts per day
If Vomiting do not give any fluid or food by mouth for at least 1 hour. Let the stomach rest. Next,
offer a clear fluid, like water, in very small amounts. Start with 1 teaspoon to 1 tablespoon of clear
fluid every 10 minutes. If the patient vomits, let the stomach rest again for an hour. Again, try to give
small frequent amounts of clear fluid. When there is no vomiting, gradually increase the amount of
fluid offered and use fluids that contain sugars and salts. After 6-8 hours of a liquid diet without
vomiting, add solid food that is easy to digest, such as saltine crackers, soup, mashed potatoes or rice.
Gradually return to a regular diet.
Babies. Breastfed babies who are vomiting can continue to nurse. Feed smaller amounts more often
by breastfeeding on only one breast for 4-5 minutes every 30-60 minutes or by offering teaspoonfuls of
Pedialyte® or Lytren® every 10 minutes.
Alcohol and Tobacco. No alcohol or tobacco use by the patient. Smoking should not be allowed
in the home.
Dehydration. Watch for signs of dehydration which can include:
? Weakness or unresponsiveness
? Decreased saliva/dry mouth and tongue
? Skin tenting: check this by picking up layers of skin between your thumb and forefinger
and gently pinching for 1 second. Normally, the skin will flatten out into its usual shape
right away. If patient is dehydrated, the skin will “tent” or take 2 or more seconds to flatten
out. This is best checked on the belly skin of a child and on the upper chest of an adult.
? Decreased output of urine which becomes dark in color. Ill persons who are getting
enough fluids should urinate at least every 3-12 hours.
If the ill person is dehydrated, give sips or spoonfuls of fluids frequently over a 4-hour period. Watch
for an increase in urination, a lighter color of the urine and improvement in the patient’s overall
condition. These are signs that the increased fluids are working.
O t h e r R e s o u r c e s
Clallam County Health & Human Services www.clallam.net/HealthServices/
Jefferson County Public Health www.jeffersoncountypublichealth.org
Kitsap Public Health District www.kitsappublichealth.org
Washington State Department of Health www.doh.wa.gov
Centers for Disease Control and Prevention www.cdc.gov
Region 2 Public Health, Kitsap, Clallam and Jefferson Counties
Kitsap Public Health District, 345 Sixth St., Suite 300, Bremerton, WA 98337, (360) 337-5235 5-10-11(6/04/07)

Returning to Work—Guidance for Employers
When should workers who have been ill with influenza return to the
workplace? This document provides an overview of influenza symptoms,
criteria for employee return, and important qualifications for use of this
information during a pandemic flu.
I n f l u e n z a V i r u s
How it spreads—Influenza viruses are spread from person to person primarily through respiratory droplet
transmission (e.g., when an infected person coughs or sneezes in close proximity, normally 3 feet or less, to
an uninfected person). The virus may also be spread through contact with infectious respiratory secretions
on the hands of an infected person or by touching objects or surfaces contaminated with the virus.
Incubation & Infection—The typical incubation period for influenza is 1—4 days, with an average of 2 days.
Adults can be infectious from the day before symptoms begin through approximately 5-7 days after illness
onset. Children can be infectious for 10 days after the onset of symptoms. Severely immunocompromised
persons can be infectious for weeks or months.
C u r r e n t C r i t e r i a f o r R e t u r n i n g t o W o r k
Workers who have become ill with influenza should stay home for at least 24 hours after their fever
(100° Fahrenheit or 37.8° Celsius or greater ) is gone without the use of fever-reducing medicine and
regardless of whether or not antiviral medications are used.
This guidance does not apply to health care settings where the exclusion period continues to be for 7
days from symptom onset or until 24 hours after the resolution of symptoms, whichever is longer.
GUIDANCE IS CONSTANTLY CHANGING. Check for updates at www.cdc.gov/h1n1flu/
Upon returning to the work environment, employees should continue to follow cough etiquette and hand
washing protocols.
C r i t e r i a f o r P a n d e m i c I n f l u e n z a
Experts do not know whether the mode of transmission, incubation period, or contagious period of
pandemic strains of the influenza virus will remain similar to those of seasonal influenza (recurring yearly).
Because of this, employers must be vigilant for specific recommendations from Public Health during an
influenza pandemic regarding management of illness in the workplace, including when it is safe for
workers to return to the work environment after illness with influenza.
M o r e I n f o r m a t i o n
Kitsap Public Health District www.kitsappublichealth.org
Jefferson County Public Health www.jeffersoncountypublichealth.org
Clallam County Health & Human Services www.clallam.net/HealthServices/
Washington State Department of Health www.doh.wa.gov
Centers for Disease Control and Prevention www.cdc.gov
Public Health working to prevent the spread of disease
Region 2 Clallam, Jefferson & Kitsap Counties
Rev 3/01/2012 (KCHD 08/14/09)