UNIVERSITY OF MEMPHIS STUDENT HEALTH SERVICES

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Last updated: July 18, 2007

To see the Preparedness and Response Plan: http://bf.memphis.edu/crisis/avian.pdf

To see an avian influenza training video: https://itweb2.memphis.edu/pandemictrain/loginptrain.php

Current phase of pandemic influenza alert, according to the World Health Organization:

Summer 2007   

Dear Students and Families,

The University of Memphis has developed a comprehensive Avian Influenza Preparedness and Action Plan. In order to ensure the effectiveness of the plan, we need every member of the college community to participate. Student Health Services is asking for your help in making sure all members of the University community are prepared for emergency situations that could take place on our campus.

Over the past several years, many colleges have been impacted by unexpected crises, and over the last couple of years, there have been numerous media reports about “avian flu” outbreaks and the possibility of a pandemic.

Student Health Services encourages all students on our campus to develop an emergency plan. In an emergency, like a pandemic, it is possible the campus could close for eight to twelve weeks and all students, faculty and staff would be asked to evacuate. University services could be extremely limited. Airports might not be functioning at full levels and international flights might be canceled.

Your personal emergency plan should include:

• A realistic place you could live off campus
• Transportation you would need
• Provisions for money, food, water and assistance
• Programming personal emergency contact information into your cell phone as “In Case of Emergency”
• Getting a seasonal flu shot each fall

We ask you and your family to create this plan for yourselves with attention to detail and share it with each other. The Centers for Disease Control and Prevention (CDC) has published useful guidelines for family and personal emergency plans. Below are the links to the CDC site and other informative sites.

• http://www.pandemicflu.gov/plan/tab3.html (multi-lingual)
• http://www.getreadyforflu.org/newsite.htm
• http://www.cidrap.umn.edu
• http://www.who.int/csr/disease/avian_influenza/en/ (multi-lingual)

Student Health Services has developed this blog devoted to the avian influenza pandemic. We ask that you monitor it throughout the year for current information: www.uofmshs.typepad.com

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IF YOU ARE AN INTERNATIONAL STUDENT

The University of Memphis Student Health Services recommends that you arrive in this country at least seven days before the start of classes.

Monitor your health during these seven days.

If you become ill with a fever and cough during this seven-day period, consult a health-care provider. Before you visit a health-care setting, tell the provider the following: 1) your symptoms, 2) where you live and where you have traveled, and 3) if you have had direct contact with poultry or close contact with a severely ill person. This way, they can be aware that you live in or have traveled to an area reporting avian influenza.

Do not travel while ill, unless you are seeking medical care. Limiting contact with others as much as possible can help prevent the spread of an infectious illness.

IF YOU TRAVEL INTERNATIONALLY

University of Memphis faculty, staff, and students traveling overseas are asked to stay informed about avian influenza and to take steps to reduce risk of exposure to this disease. At present, travelers to areas affected by avian influenza in birds are not considered to be at elevated risk of infections unless they are directly exposed to infected birds.

Avian influenza A (H5N1) viruses usually affect wild birds but have infected and caused serious disease among poultry, such as chickens, ducks, and turkeys. Most cases of H5N1 influenza in humans are thought to have occurred from direct contact with infected poultry. Travelers are advised to avoid contact with high-risk environments in affected countries, such as live animal markets, poultry farms, and any free-ranging or caged poultry. Contact with sick or dead wild birds or poultry, as well as with poultry that have no apparent symptoms should be avoided. Contact with surfaces that may have been contaminated by poultry feces or secretions should also be avoided. Uncooked poultry or poultry products, including blood, should not be consumed.

As of June 2007, there are no international travel restrictions as a result of avian flu.

The World Health Organization (WHO), the CDC and the U.S. Department of State issue travel information, alert, warnings, and announcements for public safety, personal security, and health issues. Before you travel internationally, please consult WHO, CDC, and State Department web sites. Their advisories are updated often and may differ. When they differ, the University of Memphis SHS recommends erring on the side of caution by following the most conservative advice. If an area has a travel advisory or warning in effect, the safest decision is not to travel unless it is absolutely necessary. For more international travel health information, see:

• U.S. Centers for Disease Control and Prevention (CDC) health information and recommendations for travel to specific destinations
• U.S. Department of State Current Travel Warnings
• WHO recommendations to travelers coming from and going to countries experiencing avian flu outbreaks

As of June 2007, WHO does not recommend screening travelers from countries where avian flu is present.

Before any international travel to an area affected by H5N1 avian influenza

• The CDC's Travelers' Health website (http://www.cdc.gov/travel) has information about disease risks and health recommendations for specific regions. For other information, see CDC's Avian Influenza website: http://www.cdc.gov/flu/avian/index.htm.
• Be sure you are up to date with all routine vaccinations. See your health-care provider four to six weeks before travel to get additional vaccination medications or information you may need.
• Assemble a travel health kit containing basic first aid and medical supplies, including a thermometer and alcohol-based hand gel for hand hygiene.
• Identify in-country health-care resources in advance of your trip.
• Check your health insurance plan or get additional insurance that covers medical evacuation in case you become sick. Information about medical evacuation services is provided on the U.S. Department of State web page Medical Information for Americans Traveling Abroad, at http://travel.state.gov/travel/tips/health/health_1185.html.

During travel to an affected area

• Avoid all direct contact with poultry, including touching well-appearing, sick, or dead chickens and waterfowl. Avoid places such as poultry farms and bird markets where live poultry are raised or kept, and avoid handling surfaces contaminated with poultry feces or secretions.
• As with other infectious illnesses, one of the most important preventive practices is careful and frequent handwashing. Cleaning your hands often with soap and water removes potentially infectious material from your skin and helps prevent disease transmission. Waterless alcohol-based hand gels may be used when soap is not available and hands are not visibly soiled.
• All foods from poultry, including eggs and poultry blood should be cooked thoroughly. Egg yolks should not be runny or liquid. Heat destroys influenza viruses; cooking temperature for poultry meat should be 180F.
• If you become sick with fever accompanied by a cough, sore throat, or have difficulty breathing or if you develop any illness that requires prompt medical attention, a U.S.consular officer can help you locate medical services and inform your family or friends. Inform your health-care provider of any possible exposures to avian influenza. Notify your emergency contacts in the US. Defer further travel until you are free of symptoms, unless traveling locally for medical care.

After your return

• Plan your trip so that you arrive seven days before the first day of classes.
• Monitor your health during these seven days.
• If you become ill with a fever and cough during this seven-day period, consult a health-care provider. Before you visit a health-care setting, tell the provider the following: 1) your symptoms, 2) where you traveled, and 3) if you have had direct contact with poultry or close contact with a severely ill person. This way, he or she can be aware that you have traveled to an area reporting avian influenza.
• Do not travel while ill, unless you are seeking medical care. Limiting contact with others as much as possible can help prevent the spread of an infectious illness.

UofM PLANS FOR PANDEMIC FLU (General Information)

• UofM has formulated an Avian Influenza Preparedness and Response Plan of Action to help plan and prepare specific pandemic flu response procedures. Level 1 is preparedness; Level 2 is activated when there is concern of spread of Human Avian Influenza virus to the University campus; Level 3 is activated when a case of Avian Flu is suspected/confirmed on the University of Memphis campus.
• The UofM emergency crisis plan is being updated to include response actions relevant to a pandemic event.
• A pandemic coordinator (Director of Environmental Health and Safety) has been identified for Level 1, whose primary responsibility is to assist the Incident Commander of the Crisis Management Committee in developing and coordinating all aspects of Level 1 of the University's pandemic planning.
• A pandemic coordinator (Medical Director of Student Health Services) has been identified for Level 2 and Level 3, whose primary responsibility is to assist the Incident Commander of the Crisis Management Committee in coordinating all aspects of Level 2 and 3.
• A "Pandemic Influenza Social Distancing (Isolation) Policy" has been approved by the executive leadership of the University
• Under this plan, key trigger points/decision points will be used to guide the executive leadership who may have to make decisions about curtailing public events or suspending classes. The plan recognizes that social distancing is necessary and inevitable in a pandemic emergency to: Limit the spread of disease and Protect emergency crucial (essential) personnel when performing their duties to ensure continuity of operations.
• Key departments are developing business continuity plans specific to a pandemic event.
• Crucial Emergency (essential) Personnel and essential functions are being identified for the University's continued functioning during a pandemic event.
• In an outbreak or pandemic, the Shelby County Health Department and the State of Tennessee have authority to direct public health actions (including quarantine and isolation) and establish priorities as to who will get vaccines and antiviral medication.
• In conjunction with the Shelby County Health Department, procedures for mass administration/distribution of vaccines and medicines to students, faculty and staff will be developed. If either(or both) is in limited supply, then the Health Department will establish a priority list and the University will be restricted by the priority list.
• The Department of Environment, Health and Safety will analyze the need for respiratory hygiene equipment (PPE) and is developing a procedure for their use.
• Each student, faculty, and staff should take responsibility for being able to take care of himself/herself and their family if a pandemic occurs and to keep informed about the ways to prevent and protect themselves and their families.
• Flu prevention information is provided to students via the Student Health Services' blog www.uofmshs.typepad.com. Throughout the seasonal flu season, SHS promotes a "Hand Washing Campaign." Hand washing is a basic element of personal hygiene to prevent the spread of influenza and many other contagious diseases.

The purpose of this Preparedness and Response Plan of Action is to ensure that if an influenza pandemic occurs, the University will be prepared to deal with it in such a manner that the academic mission continues without disruption or if there is a disruption, it is restored as rapidly as possible. It is based on the following strategies

• Reducing spread of the virus within the university community; reducing morbidity and mortality; and
• Sustaining essential services
• Continuation and maintenance of research specimens, animals, biomedical specimens, research archives.
• Delivery of teaching/learning process and student-related services: registration, faculty assignments, classroom scheduling, drop/add, financial aid services, government reports, grades, admissions, housing, etc.
• Security and preservation of University facilities and equipment.
• Maintenance of support for community/University partnerships.

This plan recommends steps that each department/unit should develop/implement in order to prepare and respond to an avian influenza pandemic including, but not limited to the following:

(1) Internal and external communications regarding the pandemic virus

(2) Activities to reduce the spread of the virus

• Reducing risk of infected persons entering the business facility
• Social distancing (reduce person to person interaction)
• Cleaning of facilities
• Educating employees to reduce concern
• Handling employees who become ill at work and those who may have been exposed to the virus at work

(3) For Travelers

• Travel advice
• Monitoring travel
• Restricting travel if so mandated by state or federal agencies

(4) Prevention/Treatment

• Avian Influenza vaccine if available
• Anti-viral medication if available
• Antibiotics if appropriate
• Promotion of vigorous Hand Washing campaign on campus
• Educating the campus community on proper cough etiquettes
• Educating the campus community on avian influenza pandemic

(5) Maintenance of Essential Functions

• Identification of essential business functions and emergency crucial personnel
• Planning for absenteeism and supplier disruption
• Communication with employees and students
• Alternate means of conducting education for students
• Short, medium and long term planning
• Cross train personnel

The main purpose of this Preparedness and Response Plan of Action for Student Health Services (SHS) is to assist in managing the impact of an influenza pandemic on student, faculty, and staff based on the following strategy:

• Reducing the spread of the virus within the university community and the community-at-large, and reducing morbidity and mortality

Secondary objectives include preserving a functional society and minimizing economic disruption.

SHS's approach to the avian influenza pandemic threat is to: educate the University communtity on how to prepare and plan for a possible pandemic from a health stand viewpoint, and reduce the spread of the virus. We will strive to do all three by aligning with other University departments/units, CDC, WHO, local public health agency and the Tennessee Department of Public Health to avoid causing unnecessary hardship, stress and/or panic.

To see the Preparedness and Response Plan click http://bf.memphis.edu/crisis/avian.pdf

To see an avian influenza training video click https://itweb2.memphis.edu/pandemictrain/loginptrain.php

BUSINESS AVIAN INFLUENZA PANDEMIC PLANNING

Disasters can seriously threaten the integrity of the university and its financial health. The university is committed to preparing, developing and maintaining an integrated enterprise-level business continuity planning framework. The program would coordinate risk management, disaster preparedness, emergency response management, disaster recovery, and business continuity activities across the university using experts who can provide the necessary leadership, consultation, communication and training.

Why Plan?

These are just a few of the reasons why business continuity planning is necessary:

• Some problems will be overlooked, ignored, or work will not be completed on time.
• There will not be enough time or money to fix everything.
• Some solutions may not be available or work in time because they were overlooked, too complex, too costly, or implemented incorrectly.
• It is impossible to ensure that other organizations and groups, both internal and external, will have working systems.

Benefits

• Improves the university’s ability to assess and mitigate risk
• Quantifies the potential impact of risks to academic and business functions
• Enables colleges and business units to create and maintain plans which manage risk and minimize impact
• Enhances our ability to recover and resume academic and business operations following an adverse event
• Supports a coordinated response to resuming normal operations
• Provides a global view of risks and impacts thus helping to prioritize activities and optimize resource allocation
• Reassures university stakeholders that critical processes will be supported in adverse conditions
• Improves the university’s chances of survival in the event of a catastrophe
• Allows for coordinated backup and recovery services to optimize value
• Increases the likelihood of meeting regulatory requirements
• Protects the university resources and image

Each unit/department is to assist the business continuity planning and disaster recovery committee in developing a business continutity and disaster recovery plan and once adopted to assist in managing the impact of an influenza pandemic on employees and business based on the following strategies:

• Reducing spread of the virus within the unirvesity community; reducing morbidity and mortality; and
• Sustaining essential services
• Continuation and maintenance of research specimens, animals, biomedical specimens, research archives.
• Delivery of teaching/learning process and student-related services: registration, faculty assignments, classroom scheduling, drop/add, financial aid services, government reports, grades, admissions, housing, etc.
• Security and preservation of University facilities and equipment.
• Maintenance of support for community/University partnerships.

Each department/unit should examine contracts in the area of food services, maintenance, landscaping (mowing), janitorial supplies, with an eye to developing contingencies in case those service providers are severely impacted by a global pandemic, in the event that avian influenza develops into a human pandemic flu.

Departments/units should identify in advance and prepare for implementation of telecommuting for vital University business. This includes, but not limited to necessary arrangements for home work stations with computer/phone access.

Departments/units should make necessary arrangements for video and teleconferencing for meetings, etc. Avoid face-to-face by using telephone, video conferencing and Internet to conduct business as much as possible. If face-to-face meeting required, minimize meeting time, choose large conference room, and sit at least six feet away from others if possible.

Avoid all unnecessary travel and cancel or postpone nonessential meetings, gatherings, workshops, and training sessions.

Advise employees to avoid public transportation. If employee must do so then allow them to arrive early or late to avoid rush-hour crowding on public transport.

Introduce staggered lunchtimes to minimize numbers of employees in cafeteria. Encourage employees to bring lunch and eat at their desk or away from others and to avoid eating in crowded restaurants or cafeteria.

Advise employees not to congregate in break rooms or where people socialize.

Avoid employees to avoid shaking hands or hugging.

Promote and encourage hand washing. If at all possible, place a dry hand sanitizer washing unit in an accessible area of your office and building.

Cross train personnel to maximize assignment flexibility when faced with multiple simultaneous absences.

Because of the potential threat of a global avian influenza human pandemic, the University employees may face many challenges.

• The ability to get to work will be difficult. Transportation services such as buses may be disrupted. Employees should think about alternative means of getting to work.
• Infection control measures, such as social distancing, mask use, and hand hygiene may be put in place at the workplace.
• Social distancing - Infection control strategies that reduce the duration, frequency or intimacy of social contacts in order to limit the transmission of influenza. Social distancing may include, for example, increased use of telework, placing employees on shifts, use of face masks, closing offices or buildings, and canceling large gatherings or closure of school. The University policy will embrace social distancing techniques as a key component of its planning and to limit the spread of infection. Employees who have symptoms will be instructed to stay home. Employees who have been in close (six feet or less) contact with someone who has or is suspected of having avian flu may be instructed to stay home. This period of time could be as long as ten days.
• An employee may need to miss work to be a caregiver for someone in the family who has the avian flu. This might be a ten day period of absence for this reason.

• Improves the university’s ability to assess and mitigate risk
• Quantifies the potential impact of risks to academic and business functions
• Enables colleges and business units to create and maintain plans which manage risk and minimize impact
• Enhances our ability to recover and resume academic and business operations following an adverse event
• Supports a coordinated response to resuming normal operations
• Provides a global view of risks and impacts thus helping to prioritize activities and optimize resource allocation
• Reassures university stakeholders that critical processes will be supported in adverse conditions
• Improves the university’s chances of survival in the event of a catastrophe
• Allows for coordinated backup and recovery services to optimize value
• Increases the likelihood of meeting regulatory requirements
• Protects the university resources and image

DISASTER RECOVERY PLAN

Steps for building a disaster recovery plan

BUSINESS IMPACT ANALYSIS

Identifies the financial, operational, and service impacts that may result from a disruption in daily business or organization’s operations.

PREVENTION

Addresses the plans and issues that deal with reducing the possibilities of a disruption occurring and minimizing exposures.

RESPONSE

Assessing the potential damage or impact of an incident or emergency and planning emergency response procedures, crisis management, and crisis communication.

RESUMPTION

Restoring the most time-sensitive, essential business operations as quickly as possible, including the transfer of business operations and resources from temporary facilities to permanent facilities.

RECOVERY

Implementing expanded recovery operations for less time-sensitive business operations.

RESTORATION

Implementing the repair or relocation of the primary site of operations and the restoration of normal business operations at the primary site.

DEBRIEFING

Reviewing and adjusting disaster recovery plans based on experiences learned.

ASSUMPTIONS ABOUT DISEASE TRANSMISSION

ASSUMPTIONS:

• No one is immune
• Approximately 30-40% of population will become ill
• Will most likely move through community in two to four waves stretched out over 18-24 months, with each wave lasting six-eight weeks
• Disease may break out in multiple locations simultaneously
• Most will become ill in two days (range one-ten) after exposure
• May be contagious up to 24-48 hours before illness begins
• Most contagious the first two days of illness
• On average, each ill person infects two or three others (if no precautions are taken)
• Highest risk: young adults and pregnant women and immunocompromised individuals
• Global spread in: three months
• Vaccine availability: six months after initial outbreak and most likely be given on a priority basis due to limited availability
• Anti-viral treatment: Likely to be in short supply and given on a priority basis and may not be effective

POTENTIAL IMPACT:

• Large percentage of the working population (40%) may be unable to work for days to weeks during the pandemic because of illness, fear or to care for a sick person
• Forty percent of school-age children may be ill
• Diminished numbers of people and expertise
• Diminished emergency and essential services - fire, police and medical
• Diminished other services - retail, transport, government departments, etc.
• Food and water supplies may be interrupted and limited
• Medical care for people with chronic illnesses would be disrupted
• Schools and day cares may be closed
• Estimated that greater than 25% more patients than normal needing hospitalization during a local wave

BUSINESS EFFECTS:

• Loss of people to operate the business or university
• Loss of services from suppliers
• Operations (e.g. production) and support (e.g. information technology) may be affected
• Business and leisure travel may be affected

The plans that are being implemented nationwide, including the Mid-South area and this University, is based upon the 1918 influenza pandemic. This virus (H5N1) is very similar,at this time, to the 1918 virus. However, the following should be kept in mind:

• NO ONE KNOWS IF THIS VIRUS WILL MUTATE INTO A VIRUS THAT WILL BE EFFICIENTLY AND SUSTAINABLY TRANSMITTED FROM HUMAN TO HUMAN.
• No one knows (if it does mutate) whether our present anti-virals will work or not.
• No one knows what the mortality rate or the attack rate will be They are basing their plans on the 1918 influenza pandemic, which had a mortality rate of 2%- 2.5%. At the present time (August 2006), the H5N1 virus has a mortality rate of 55%. No one expects that it will have that high of a mortality once it gains the ability to efficiently and sustainably pass from human to human. Most experts believe it will give up some of its virulence to gain efficient and sustainable transmission.
• The vaccine they are developing now is based upon how the H5N1 virus existed previous to it mutating into an efficient and sustainable virus, if it does. Therefore, how much immunity the vaccines they are working on now offers no one knows. However, most experts expect that it will offer some immunity.
• If the virus does mutates, it will take six months before any vaccine becomes available that is custom tailored to that specific virus. And it will be distributed on a priority basis as determined by local state or federal authorities.

What has the experts worried:

• Widespread and spreading prevalence in migratory birds: broad host range
• Continued outbreaks among domestic poultry
• Mammalian infection (cats, pigs, etc.) lethal
• Virus is evolving
• Sporadic human cases (rare person-to-person transmission as it exists now)
• Most in young and health adults
• Case fatality rate of 55-56%
• It can occur at any time of the year, unlike the seasonal influenza which normally occurs between December-March
• Risk exists as long as it continues to infect birds with human contact

Did you ask about masks during a pandemic, if it occurs?

Recommended for:

• Health care workers with direct patient contacts
• Those at high risk for flu complications
• Ill persons
• Close contacts of ill persons. (Close contact is defined as six feet or less.)
• Caregivers of ill persons

However, if you don't fit into one of the above categories, but wish to wear a surgical mask that can be bought at most drug stores, the following is recommended:

• Keep your hands away from your face
• Clean your hands each time you touch your mask
• Dispose of it in a proper receptacle
• Follow all recommendations and guidelines regarding general measures to cut down your chance of getting the virus.

WILL H5N1 BECOME THE NEXT PANDEMIC?

• Impossible to know

IF NOT H5N1, THEN ANOTHER WILL COME, according to all the expert .

PRUDENT TIME TO PLAN: NOW

HOME CARE OF AN FLU PANDEMIC PATIENT

Home care will be the predominant mode of care for most people infected with influenza and the ill person can be cared for by other family members or others who live in the household. Anyone residing in a household with an influenza patient during the incubation period and illness is at risk for developing influenza. A key objective in this setting is to limit transmission of pandemic influenza within and outside the home. When care is provided by a household member, basic infection control precautions should be emphasized (e.g., segregating the ill patient (social distancing), hand hygiene). Infection within the household may be minimized if a primary caregiver is designated, ideally someone who does not have an underlying condition that places them at increased risk of severe influenza disease. Although no studies have assessed the use of masks at home to decrease the spread of infection, use of surgical or procedure masks by the patient and caregiver during interactions may be of benefit.

1. Monitor the patient for improvement or worsening of symptoms. Write down the date and time of all observations: temperature, coughing, sneezing, amount the patient has had to drink and eat.
2. Supportive care
   • Over-the-counter medicines that bring fever down like Tylenol or ibuprofen. No aspirin (acetylsaliclic acid or salicylic acid) should be used in anyone less than 18 years of age. Remember that acetylsaliclic acid or salicylic acid is a component in some over-the-counter preparations and may be unintentionally given to a child with fever.
   • Pain relievers – medications or carefully monitored heating pads
   • Cough medications, as ordered and needed
   • Cool cloth to the head
   • Limited light in the room
   • An encouraging, positive but not overly exuberant attitude
3. Maintain the patient’s fluid intake – water, juices, Popsicles, ice cubes, broths.
4. Provide any foods that are appealing to the patient – however, fluid intake is more critical than solid food intake.  It is not just “an old wives tale” – chicken soup, broth-based (not cream-based), often is appealing.
5. Provide tissues and a disposal place that the patient can reach – wastebasket or plastic bag pinned to the bed.
6. Assist the patient to the bathroom, if needed.
7. Continue any routine medications, if possible.  Check with the doctor if the patient can’t take or vomits the medications of if the medication needs to be taken with food and the patient isn’t eating.
8. Persons on insulin should have their blood sugar carefully monitored – blood sugar may go up because of the disease process or go down because of poor food intake.
9. Keep the patient orientated as to time of day and date by telling him/her the time (and day), if needed, whenever they awaken.  Napping can lead to disorientation especially in the elderly patient.  Some patients may also need to be reminded where they are.
10. Provide a way for the patient to summon help – a bell, whistle, or some other method.
11. If caring for someone with avian influenza, use a mask during encounters and wear gloves in handling the sick or when handling bodily secretions.
12. If caring for someone, get away from the house for a period of time each day, such as taking a walk.
13. Think of someone you can call for help if you become very ill with the flu, and discuss this possibility with him or her.
14. Think of someone you could call upon to care for your children if you were required to work and their school or day care was closed because of the influenza pandemic; discuss the possibility with them.
15. Do not smoke, except outside.
16. Restrict visitors to the home.
17. Patients should not leave the home during the period when they are most likely to be infectious (around 10 days). When movement outside the home is necessary (e.g., for medical care), the patient should follow cough etiquette, hand hygiene, and wear procedure or surgical masks.

Infection Control Measures in the Home

• All persons in the household should carefully follow recommendations for hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) after contact with an influenza patient or the environment in which care is provided.
• Use a surgical or procedure masks for the patient and caregiver. Gowns are not recommended for household members providing care in the home. Neither is gloves, but use your discretion here.
• Soiled dishes and eating utensils should be washed either in a dishwasher or by hand with warm water and soap. Separation of eating utensils for use by a patient with influenza is not necessary.
• Laundry can be washed in a standard washing machine with warm or cold water with detergent. It is not necessary to separate soiled linen and laundry used by a patient with influenza from other household laundry. Care should be used when handling soiled laundry (i.e., avoid "hugging" the laundry) to avoid contamination. Hand hygiene should be performed after handling soiled laundry.
• Tissues used by the ill person should be placed in a bag and disposed with other household waste. Consider placing a bag for this purpose at the bedside.
• Normal cleaning of environmental surfaces in the home should be followed.
• Persons who have not been exposed to pandemic influenza and who are not essential for patient care or support should not enter the home while persons are actively ill with pandemic influenza.
• If unexposed persons must enter the home, they should avoid close contact with the patient.
• Persons living in the home with the pandemic influenza patient should limit contact with the patient to the extent possible; consider designating one person as the primary care provider.
• Household members should monitor closely for the development of influenza symptoms and contact a medical care provider if symptoms occur.

TO PROTECT THE PATIENT INFECTED WITH INFLUENZA, INDIVIDUALS HAVING CONTACT WITH THE PATIENT, AND THE COMMUNITY IN GENERAL, CERTAIN CONTROL MEASURES SHOULD BE PRACTICED:

• Wash hands frequently with soap and water, scrubbing for 15-20 seconds
• Family members should wash hands or use waterless hand sanitizer after contact with the patient
• Do not share eating utensils or drinks
• Do not rub eyes, touch nose or mouth
• Patients should cover their mouth and nose with tissue when coughing or sneezing, dispose of used tissues immediately after use. Wash hands after using tissues.
• In general, wearing goggles or a face shield for routine contact with patients with pandemic influenza is not necessary. If sprays of infectious material is likely, goggles or a face shield should be worn.
• In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over antimicrobials
• Physically separate the patient with influenza from non-ill persons living in the home as much as possible. Ideally, all family members, except the one who is the caregiver, should find other accommodations until the patient is not infectious.

Selection of hand-hygiene agents:

• Alcohol-based rubs are the most efficacious agents for reducing the number of bacteria on the hands. Antiseptic soaps are the next most effective, and non-antimicrobial soaps are the least effective.
• Soap and water are recommended for visibly soil hands.

Methods to maintain hand skin health: Lotions and creams can prevent or minimize dryness and irritation.

Limitations of glove use:

• Hand contamination may occur as a result of small, undetected holes in examination gloves
• Wearing gloves does not replace the need for hand hygiene
• Contamination may occur during glove removal
• Failure to remove gloves after caring for an ill person may lead to transmission of microorganism from one person to another

AVIAN FLU PREPAREDNESS RESOURCES

The following resources are available for further information on Influenza and related Avian Flu related to Travel and Treatment.  For further information, University of Memphis travelers should contact their local health care provider or the University of Memphis Student Health Services.

MAJOR INFORMATION WEBSITES:

• CDC - Pandemic Influenza: Worldwide Preparedness

• US Gov. - Pandemic Flu.gov

• WHO - Epidemic and Pandemic Alert and Response

• Global Resources  Global Resources

Additional resources, guidelines, checklists:

For Institutions:

For travelers:

General Resources:

For Institutions:

• From Medex Assist (includes travel recommendations/precautions/overview Medex Special Report: Avian Flu Report for organizations and agencies
• US Gov.: Colleges and Universities Pandemic Influenza Planning Checklist
• Blueprint for Pandemic Flu Preparedness Planning for Colleges and Universities.
  (http://www.ajg.com/highereducation)

For travelers:

• From Medex Assist (includes travel recommendations/precautions/overview) Medex Special Report: Avian Flu Report For Travelers
• CDC - Guidelines and Recommendations -Interim Guidance about Avian Influenza A (H5N1) for U.S. Citizens Living Abroad http://www.cdc.gov/travel/other/avian_flu_ig_americans_abroad_032405.htm
• US Gov.: Challenges and Preparation -- Individuals and Families
• US travelers should make sure they register with the local US embassy in countries where you will be residing, studying, traveling https://travelregistration.state.gov/ibrs/home.asp)

General Resources:

• NAFSA: Avian Flu resource home page
• SOS International Avian Flu and Pandemic Preparedness
• Overseas Security Advisory Council Resources for Information on Avian Influenza
• US Department of State Avian Flu Fact Sheet http://www.travel.state.gov/travel/tips/health/health_1181.html 
• Influenza Fact sheet from the US CDC http://www.cdc.gov/flu/
• AVIAN Influenza Fact sheet from the US CDC http://www.cdc.gov/flu/avian/
• Influenza Fact sheets from the World Health Organization (WHO)http://www.who.int/csr/disease/influenza/en/
• AVIAN Influenza Fact sheet from WHO: http://www.who.int/csr/disease/avian_influenza/en/
• and WHO Ten Things to Know about pandemic influenza http://www.who.int/csr/disease/influenza/pandemic10things/en/index.html
• OSHA Avian Flu information for workers www.osha.gov/dsg/guidance/avian-flu.html
• FROM SAFETI: Preparing for the Possibility of an Avian Flu Pandemic Issues to Consider for Study Abroad Programs
• From the official US government website for information on pandemic flu and avian influenza.

CARING FOR YOURSELF TO PREVENT FLU

1. Get the flu shot. Flu vaccination shot clinic locater www.findaflushot.com/lungusa/results.php?zip=38138&radius=5&from=&to=mm-dd-yyyy
2. Wash your hands frequently – use soap, make a good lather, rub lather all over your hands for 15 seconds, rinse well, dry with a paper towel or with your own towel at home.  The process should take at least 20 seconds.
   
   • After shaking hands
   • After being around someone who is coughing/sneezing
   • After care for someone who is sick • As soon as you get home
3. Avoid touching your mouth, nose, or eyes.
4. Wear a mask when you take care of someone with the flu.
5. Get seven to eight hours rest in 24 hours.
6. Drink at least six to eight glasses of water each day.  Sodas don’t count.
   
   • If one is tiring of water, putting it in a colored glass helps.
   • Room temperature water is easier to drink in quantities.
7. Eat at least five or more servings of fruits and vegetables each day.
8. If caring for someone, get away from the house for a period of time each day.
   
   • Take a walk
9. Avoid alcohol and tobacco.

FOURTEEN THINGS YOU NEED TO KNOW ABOUT PANDEMIC INFLUENZA

June 1, 2007

1. Pandemic influenza is different from avian influenza. Avian influenza refers to a large group of different influenza viruses that primarily affect birds. On rare occasions, these bird viruses can infect other species, including pigs and humans. The vast majority of avian influenza viruses do not infect humans. An influenza pandemic happens when a new subtype emerges that has not previously circulated in humans. For this reason, avian H5N1 is a strain with pandemic potential, since it might ultimately adapt into a strain that is contagious among humans. Once this adaptation occurs, it will no longer be a bird virus - it will be a human influenza virus. Influenza pandemics are caused by new influenza viruses that have adapted to humans.

2. An influenza pandemic is a rare but recurrent event. Three pandemics occurred in the previous century: “Spanish influenza” in 1918, “Asian influenza” in 1957, and “Hong Kong influenza” in 1968. The 1918 pandemic killed an estimated 40–50 million people worldwide. That pandemic, which was exceptional, is considered one of the deadliest disease events in human history. Subsequent pandemics were much milder, with an estimated two million deaths in 1957 and one million deaths in 1968. A pandemic occurs when a new influenza virus emerges and starts spreading as easily as normal seasonal influenza – by coughing and sneezing. Because the virus is new, the human immune system will have no pre-existing immunity. This makes it likely that people who contract pandemic influenza will experience more serious disease than that caused by normal seasonal influenza.

3. The world may be on the brink of another pandemic. Health experts have been monitoring a new and extremely severe influenza virus – the H5N1 strain – for almost nine years. The H5N1 strain first infected humans in Hong Kong in 1997, causing 18 cases, including six deaths. Since mid-2003, this virus has caused the largest and most severe outbreaks in poultry on record. In December 2003, infections in people exposed to sick birds were identified. Since then, over 100 human cases have been laboratory confirmed in four Asian countries (Cambodia, Indonesia, Thailand, and Viet Nam), and more than half of these people have died. Most cases have occurred in previously healthy children and young adults. Fortunately, the virus does not jump easily from birds to humans or spread readily and sustainably among humans. Should H5N1 evolve to a form as contagious as normal seasonal influenza, a pandemic could begin.

4. All countries will be affected. Once a fully contagious virus emerges, its global spread is considered inevitable. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but cannot stop it. The pandemics of the previous century encircled the globe in six to nine months, even when most international travel was by ship. Given the speed and volume of international air travel today, the virus could spread more rapidly, possibly reaching all continents in less than three months.

5. Widespread illness will occur. Because most people will have no immunity to the pandemic virus, infection and illness rates are expected to be higher than during seasonal epidemics of normal influenza. Current projections for the next pandemic estimate that a substantial percentage of the world’s population will require some form of medical care. Few countries have the staff, facilities, equipment, and hospital beds needed to cope with large numbers of people who suddenly fall ill.

6. Medical supplies will be inadequate. Supplies of vaccines and antiviral drugs – the two most important medical interventions for reducing illness and deaths during a pandemic – will be inadequate in all countries at the start of a pandemic and for many months thereafter. Inadequate supplies of vaccines are of particular concern, as vaccines are considered the first line of defense for protecting populations. On present trends, many developing countries will have no access to vaccines throughout the duration of a pandemic.

7. Large numbers of deaths will occur. Historically, the number of deaths during a pandemic has varied greatly. Death rates are largely determined by four factors: the number of people who become infected, the virulence of the virus, the underlying characteristics and vulnerability of affected populations, and the effectiveness of preventive measures. Accurate predictions of mortality cannot be made before the pandemic virus emerges and begins to spread. All estimates of the number of deaths are purely speculative. WHO has used a relatively conservative estimate – from two million to 7.4 million deaths – because it provides a useful and plausible planning target. This estimate is based on the comparatively mild 1957 pandemic. Estimates based on a more virulent virus, closer to the one seen in 1918, have been made and are much higher. However, the 1918 pandemic was considered exceptional.

8. Economic and social disruption will be great. High rates of illness and worker absenteeism are expected, and these will contribute to social and economic disruption. Past pandemics have spread globally in two and sometimes three waves. Not all parts of the world or of a single country are expected to be severely affected at the same time. Social and economic disruptions could be temporary, but may be amplified in today’s closely interrelated and interdependent systems of trade and commerce. Social disruption may be greatest when rates of absenteeism impair essential services, such as power, transportation, and communications.

9. Every country must be prepared. WHO has issued a series of recommended strategic actions for responding to the influenza pandemic threat. The actions are designed to provide different layers of defense that reflect the complexity of the evolving situation. Recommended actions are different for the present phase of pandemic alert, the emergence of a pandemic virus, and the declaration of a pandemic and its subsequent international spread.

10. WHO will alert the world when the pandemic threat increases. WHO works closely with ministries of health and various public health organizations to support countries' surveillance of circulating influenza strains. A sensitive surveillance system that can detect emerging influenza strains is essential for the rapid detection of a pandemic virus. Six distinct phases have been defined to facilitate pandemic preparedness planning, with roles defined for governments, industry, and WHO. The present situation is categorized as phase 3: a virus new to humans is causing infections, but does not spread easily from one person to another.

11. Even if H5N1 acquires the ability needed for human-to-human transmission, a pandemic will be prevented if those infected are rapidly quarantined. Vigilance is the most effective weapon - even at this early stage.

12. Are there any vaccines?  About 30 potential vaccines are being tested for safety and effectiveness in the United States and Europe, but the results have been disappointing. The tests show that very high doses of vaccine - and at least two shots - are needed to prevent infection, which means much greater quantities will be necessary than for seasonal flu, and far more than can be produced by current technology. It will take six years to have enough vaccine for 20 percent of the world's population. It may take eight to ten years to solve this problem. Furthermore, the virus keeps changing, so a vaccine developed for one type of flu may not work against another variant. The H5N1 type that began in Asia already has split into two main branches. They are different enough that we may need two stockpiles of vaccine.

13. If I get pandemic flu, will I be put in quarantine? Depending upon the severity of diseases, people who have symptoms of pandemic flu will be advised to stay at home or special housing or will be cared for in a hospital (in isolation from other patients without pandemic flu). Depending on the timing and severity of the pandemic outbreaks, quarantining of contacts (family or friends) of pandemic influenza patients may occur. Quarantine or isolation measures may be used to help stop pandemic flu coming into the United States or spreading once it arrives in this country or on this campus.

14. How long will people be quarantined? Based on current bird flu strains, individuals may be quarantined 7-10 days. This will need to be reviewed according to the characteristics of the pandemic virus itself.

[From the World Health Organization] http://www.who.int/csr/disease/influenza/pandemic10things/en/index.html

Clinical Features of H5N1 in Humans

The incubation period for most patients with H5N1 influenza is two to four days; however, the range appears to be as long as eight days. A recent report summarized the clinical presentations for different groups of patients in Asia; the information is presented in the table below (see References: WHO Writing Committee of the WHO Consultation on Human Influenza A/H5).

Clinical Presentation for Different Groups of Patients in Asia
	Hong Kong (N=18)	Thailand, 2004 (N=17)	Vietnam, 2004 (N=10)	Ho Chi Minh City, 2005 (N=10)	Cambodia, 2005 (N=4)
Outcome or Measure	No./Total No.(%)	No./Total No. (%)	No./Total No. (%)	No./Total No. (%)	No./Total No. (%)
Fever (>38:C)	17/18 (94)	17/17 (100)	10/10 (100)	10/10 (100)	4/4 (100)
Headache	4/18 (22)	NS	NS	1/10 (10)	4/4 (100)
Myalgia	2/18 (11)	9/17 (53)	0	2/10 (20)	NS
Diarrhea	3/18 (17)	7/17 (41)	7/10 (70)	NS	2/4 (50)
Abdominal pain	3/18 (17)	4/17 (24)	NS	NS	2/4 (50)
Vomiting	6/18 (33)	4/17 (24)	NS	1/10 (10)	0
Cough	12/18 (67)	16/17 (94)	10/10 (70)	10/10 (100)	4/4 (100)
Sputum	NS	13/17 (76)	5/10 (50)	3/10 (30)	NS
Sore throat	4/12 (33)	12/17 (71)	0	0	<(25)
Rhinorrhea	7/12 (58)	9/17 (53)	0	0	NS
Shortness of breath	1/18 (6)	13/17 (76)	10/10 (100)	10/10 (100)	NS
Pulmonary infiltrates	11/18 (61)	17/17 (100)	10/10 (100)	10/10 (100)	4/4 (100)
Lymphopenia	11/18 (61)	7/12 (58)	NS	8/10 (80)	= (50)
Thrombocytopenia	NS	4/12 (33)	NS	8/10 (80)	= (50)
Increased aminotransferase levels	11/18 (61)	8/12 (67)	5/6 (83)	7/10 (70)	NS
Development of respiratory failure (usually with ARDS)*	8/19 (44)	13/17 (76)	9/10 (90)	7/10 (70)	4/4 (100)
Abbreviations: ARDS: Acute respiratory distress syndrome; NS: Not stated. *High levels of inflammatory mediators may contribute to ARDS and multiorgan failure. Data were obtained from a recent WHO report and are derived primarily from several separate studies (see References: WHO Writing Committee of the WHO Consultation on Human Influenza A/H5; Chan 2002; Chotpitayasunondh 2004, Tran 2004, Yuen 1998).

HOW WORRIED SHOULD YOU BE ABOUT AVIAN INFLUENZA (Bird Flu) and AVIAN INFLUENZA A (H5N1) VIRUS?

You may have been hearing about “bird flu,” but do you know what it is? Many people don’t. Basically, the influenza virus comes in three general varieties: A, B, and C. These reflect differences in the M protein on the envelope that contains the virus. The A influenza viruses are the ones that cause both human and bird flu outbreaks. Each virus contains an RNA strand that has eight segments. These segments break apart during replication and can mix and re-assort with other segments. The potential for constant evolution of these viruses is therefore built into the system.

The bird flu virus (H5N1) mainly affects domesticated poultry, including chickens, ducks, and turkeys. It also affects migratory birds, and we believe that the spread into Europe has been through wild ducks, geese, and swans. Ordinary avian viruses circulate within the wild migratory-bird population all the time, and they do not usually cause much disease. However, H5N1 moved into domestic birds and started killing them, and now it has moved back into the wild bird populations and is killing them as well. This development suggests that the virus has gained the ability to cause disease in wild birds, and that is worrisome.

Perhaps even more alarming, researchers are now concerned that the virus might gain entry into human populations via an indirect method, with household pets like cats serving as an intermediary host.

It has been demonstrated in the lab that the virus can be transmitted from cat to cat. If the virus finds a permanent home in domesticated mammals like cats or dogs, it is theoretically more likely to mutate into a form which is easily transmitted to humans.

This means the bigger threat would not be direct bird-to-human transmission, but bird-to-cat and cat-to-human transmission - and eventually, human-to-human transmission. According to experts, if this were to occur, a pandemic could be quickly sparked, killing millions of people worldwide and crippling the global economy.

So far, the virus has been found in felines in Asia, Iraq, and Germany.

While cats are able to acquire the virus through their respiratory system just like humans, they are more likely to acquire it through their digestive systems by eating infected birds or coming into contact with their droppings.

Officials in Europe are advising pet owners to keep cats indoors if the bird flu virus has been confirmed within a six-mile radius.

If the cat begins to show signs of infection, quarantining them away from people and other animals is the best measure. There has also been discussion regarding the need for a separate bird flu vaccine for cats.

To quiet fears, WHO issued the following statement: “There is no present evidence that domestic cats play a role in the transmission cycle of H5N1 viruses. To date, no human case has been linked to exposure to a diseased cat. No outbreaks in domestic cats have been reported.”

In order for a new strain of influenza to become pandemic, three things must happen; it must infect humans whose immune systems are naïve to the virus (humans have no immunity to avian influenza); it must be virulent; and it must spread easily from person to person. The first two conditions have already been met. Moreover, there have been instances in which H5N1 went from one person to another. To date, the infection has dead-ended at the second person, usually a family member.

Infected birds shed flu virus in their saliva, nasal secretions, and feces. Susceptible birds become infected when they have contact with contaminated excretions or surfaces that are contaminated with excretions. It is believed that most cases of bird flu infection in humans have resulted from contact with infected poultry or contaminated surfaces.

However, in parts of  Asia, there is a practice of drinking raw blood, and there have been a couple of cases in which we think infection may have resulted from drinking duck blood. The experst also think eating raw eggs might put people at risk.

In addition, there is increasing evidence, experts say, that a thriving international trade in smuggled poultry products - including birds, chicks, eggs, meat, feathers and other products - is making a substantial contribution to the spread of the H5N1 bird flu virus.

Poultry smuggling has turned out to be a huge and previously largely overlooked business, perhaps second only to narcotics in international contraband, experts and government officials believe.

Nevertheless, keep in mind that for the United States, we do not import live poultry from parts of the world that are infected with the avian flu. In fact, the United States has an embargo on poultry imported from countries where there have been outbreaks in humans. For this reason, there is no concern about eating poultry in this country. Nevertheless, people should cook all poultry and poultry products thoroughly (until the internal temperature reaches 180 degrees) and the same for waterfowl.

For people to be infected, the virus has to enter the respiratory tract. They must breathe in the virus or get it on their hands and then put it in contact with the respiratory mucosa via the nose or mouth. People at the highest risk are those who are exposed to live birds, like poultry farmers, people who clean chicken coops, or those involved with cockfighting. Once someone is infected, the virus is transmitted through the respiratory route, via sneezing, kissing, and touching.

The strain of H5N1 virus found in Asia has not been found in the United States. There have been no human cases of H5N1 flu in the United States. It is possible that travelers returning from affected countries in Asia could be infected. However, experts want you to be aware that the threat is out there and that you should certainly make efforts to prepare. Nevertheless, you should not panic, since the risk is not immediate; it is not on our doorstep.

If you travel to an affected country, you are only at risk if you have contact with poultry (mainly through contact with feces). Therefore, you should avoid contact with infected birds or contaminated surfaces; therefore avoid bird markets and poultry yards and farms, and be careful when handling and cooking poultry.

Experts believe this virus has to go through many cycles in humans in order to acquire the mutations that would make it a pandemic strain. They learned from reconstructing the 1918 “Spanish Flu” virus that pandemics are not the result of just one genetic change. Rather, a variety of small and large changes taken together resulted in that lethal strain. In addition, in 1918, there were societal conditions, including severe crowding and a lack of protection against contagion, which fostered the ability of a lethal virus to emerge. For all these reasons, experts are hopeful that H5N1 will not acquire all the mutations that would allow it to become easily transmissible in humans. (The 1918 Spanish Flu occurred for ten months in 1918-1919, and resulted in an estimated 21 million deaths worldwide, with proximately 500,000 of these deaths in the United States.)

To keep abreast of the situation during the coming months, there are a number of helpful Web sites. Besides the CDC’s influenza Web site (www.cdc.gov/flu/avian), check the Web sites of the World Health Organization (www.who.int/csr/disease/influenza) and the Infectious Diseases Society of America (www.idsociety.org) or these sites (www.dhs.ca.gov), (www.astho.org), (WWW.apic.org), (www.promedmail.org). For more information about the H5N1 vaccine development process, visit the NIH Web site (www.nih.gov).

PANDEMIC UPDATE TIDBITS

At least four strains of bird flu are capable of sparking the next pandemic, including the H5N1 virus that’s killed more than half the 306 (as of May 16, 2007) people it’s known to have infected since 2003. Avian influenza strains identified as H2, H9, and H7 subtypes also may change into forms that can be passed easily from human to human.

H2 avian-flu subtypes have been circulating since at least as early as the 1890s and are capable of infecting poultry and wild birds. One variant, H2N2, was responsible for a flu pandemic in 1957 that killed an estimated two million people.

H9, which has been found in parts of Europe and Asia and may share similarities with H5, is also cause for concern.  A subtype of the H7 virus, H7N7 infected poultry in the Netherlands in 2003, resulting in the slaughter of 30.7 million fowl. The outbreak sickened 89 poultry and animal health workers, killing one of them.

In almost all human bird flu cases, infection was caused by close contact with sick or dead birds, such as children playing with them, or adults butchering them or taking off the feathers. Unlike seasonal influenza viruses that are passed easily between people, H5N1 has a difficult time of attaching to cells in the nose, throat, and upper airways according to recent studies. However, it readily attaches to cells deep in the lung. This suggests that people need close and heavy exposure to the H5N1 virus for it to get into the lungs, where it can take hold. But once there, it causes extensive damage to the respiratory process. Seasonal influenza viruses typically infect cells in the upper respiratory tract.

Experts agree that the H5N1 virus will need to accumulate many mutations in its genetic material before it can become a pandemic strain, but there's no way to know when or if that will ever happen. "All of those mutations are out there, but the virus hasn't succeeded in bringing it together," one expert said. Fortunately, because of this, scientists and public health agencies worldwide may have more time to prepare for an eventual pandemic.

At the two-day Singapore conference (May 3-4, 2006), Dr. Robert Webster, a top bird flu expert, predicted that the H5N1 virus may not reach the U.S. this year through migratory birds, and warned that bird smuggling poses a bigger threat for transmitting the deadly disease. He went on to say that “if it doesn’t come this year, don’t relax, because it will eventually come.” He said he is most concerned about H5N1 becoming established in the world’s wild bird population because most highly pathogenic bird flu viruses usually do not last long in nature. They typically start in wild birds, infect domestic birds, and eventually die out. “This one has broken the rules and gone back from the domestics into the wild birds. Is it going to be perpetuated there as a killer? That’s the million dollar question,” he said. “Will that virus go to the breeding grounds in Siberia and  Africa and come back again? If it does, then the chances are eventually it will learn to go human to human.”

He went on to say the virus has mutated, although the mutation is not the much-feared change that would make the virus more easily transmissible between humans, possibly causing a pandemic. The next three paragraphs shows how the virus has mutated.

Scientist had hoped that reports of avian-influenza outbreaks would slow during the summer months of 2006, as older samples of H5N1 were most transmissible during the cooler months, from fall to early spring.

Webster warned against complacency, stating, “When we tested the virus in Hong Kong from 1997, the virus was killed at 37 degrees Celsius (98 Fahrenheit) in two days. The current H5N1 is still viable for six days at 37 Celsius. H5N1 at room temperature can stay (alive) for at least a week in wet conditions. One of the often overlooked facts about influenza is that it’s more heat stable than people realize, especially under moist, damp conditions.”

As the virus becomes more resilient in warm, moist climates, such as those found in Southeast Asia, Webster warns, “It is also adapting itself to water, raising the distinct and unnerving possibility that untreated water may no longer be potable. This means that water supplies for feeding chickens, or water supplies where people are swimming and water supplies for villages have got to be treated.”

St. Jude Children's Research Hospital, Memphis, also reported (May 2, 2006) about a promising new flu vaccine described as the “Holy Grail.” The new vaccine protected mice and ferrets from the highly lethal avian virus. The vaccine developed by Vical Incorporate seems to protect against bird and human influenza. This finding, coupled with results of previous studies that showed protection against multiple human influenza strains, suggest that such a vaccine would protect humans against multiple variants of the bird and human influenza viruses. Such a vaccine could protect humans against an H5N1 “bird flu” virus that mutates so that it adapts to humans and can readily spread from person to person. Such cross-protection against bird and human influenza is considered by researchers to be the "Holy Grail" of flu viruses. By stimulating immune responses against targets not likely to mutate, the vaccine could trigger an immune defense against a broad rang of variants of the virus. Even if the bird flu virus mutates so it becomes adapted to humans, this kind of cross protection will allow the immune system to track and attack such an emerging new variant without missing a beat. We wouldn't have to wait to start developing a vaccine against it until after the original virus mutated.

Research so far has shown that all mice and ferrets that received the DNA vaccine survived the challenge  with the virulent H5N1 strain, while those that received a "blank" vaccine control did not survive.

So far, this vaccine has only been tested in mice and ferrets and not in humans. Therefore, further testing will need to be done.

A vaccine currently under development is safe, but effective in only about 50% of patients. It also requires 12 times stronger than a regular annual flu shot. Therefore, two shots are also required instead of one.

Another area of interest has been whether Tamiflu would work in humans or not. We are one step closer to finding the answer after St. Jude Children's Research Hospital, Memphis, found that all ferrets given the drug after being infected with the deadly H5N1 virus circulating in Vietnam survived. After being infected for four hours, ferrets were given a dose equal to half the conventional human dosage for five days. It saved their lives. A higher dose was also given to ferrets 24 hours after being infected. Again, all of the ferrets given the drug survived, while those not treated all died.

The research will be used to create a model to help predict how much Tamiflu people would need to take and for how long if a new pandemic strain emerges. The World Health Organization is expected to announce revised dosing recommendations for Tamiflu soon.

                                                                                                                     

Cleaning and Sterilizing (Keeping Living and Work Areas Clean)
H5N1 is killed by alcohol and bleach. Cleaning furniture, work areas, food prep areas, etc. with household detergents (e.g. dishwashing liquid, laundry detergent, hand soap) followed by a sterilizing solution (alcohol or bleach) is recommended. The table gives you directions on how to prepare and use a sterilizing solution.
Sterilizing Agent	Recommended Use	Precautions
Bleach
Household (Laundry) Bleach	Disinfection of material	Use in a well ventilated area.
Dilute 3/4 cup of Bleach into	contaminated with blood	Wear gloves while using or
one gallon of water.	and body fluids.	handling bleach.
		Only mix bleach with WATER.
Rubbing Alcohol
(e.g. 70% isopropyl alcohol	Smooth metal surfaces,	Flammable and toxic.
or 60% ethyl alcohol.)	tabletops, and other	Use in a well ventilated area.
Do NOT dilute; use straight	surfaces on which bleach	Keep away from heat sources,
from bottle. Items with lower	cannot be used.	electrical equipment, flames,
alcohol concentrations		and hot surfaces.
such as whiskey, vodka,		Allow to dry completely.
and rum will NOT		Keep in a safe place from
be effective.		children when not in use.

Quarantine Fact Sheet

Modern quarantine is used when:
• a person or a well-defined group of people has been exposed to a highly dangerous and highly contagious disease
• resources are available to care for quarantined people and
• resources are available to implement and maintain the quarantine and deliver essential services.

Modern quarantine includes a range of disease control strategies that may be used individually or in combination, including:
• Short-term, voluntary home curfew.
• Restrictions on the assembly of groups of people (for example, school events).
• Cancellation of public events.
• Suspension of public gatherings and closings of public places (such as theaters).
• Restrictions on travel (air, rail, water, motor vehicle, pedestrian).
• Closure of mass transit systems.
• Restrictions on passage into and out of an area.

Modern quarantine is used in combination with other public health tools, such as:
• Enhanced disease surveillance and symptom monitoring.
• Rapid diagnosis and treatment for those who fall ill.
• Preventive treatment for quarantined individuals, including vaccination or prophylactic treatment, depending on the disease.

Modern quarantine does not have to be absolute to be effective. Research suggests that in some cases partial quarantine (that is, quarantine of many exposed persons but not all of them) can be effective in slowing the rate of the spread of a disease, especially when combined with vaccination.

Modern quarantine is more likely to involve limited numbers of exposed persons in small areas than to involve large numbers of persons in whole neighborhoods or cities. The small areas may be thought of as "rings" drawn around individual disease cases. Examples of "rings" include:
• People on an airplane or cruise ship on which a passenger is ill with a suspected contagious disease for which quarantine can serve to limit exposure to others.
• People in a stadium, theater or similar setting where an intentional release of a contagious disease has occurred.
• People who have contact with an infected person whose source of disease exposure is unknown—and therefore may be due to a covert release of a contagious disease.

Implementation of modern quarantine requires the trust and participation of the public, who must be informed about the dangers of contagious diseases subject to quarantine before an outbreak or intentional release of biological agents, as well as during an actual event.

HIGH RISK GROUPS THAT SHOULD RECEIVE THE SEASONAL INFLUENZA VACCINE

Persons over 65 years of age and older have the highest fatality and hospitalization rate from influenza and its complications.

Persons 50 to 64 years of age are also considered to be a high-risk group for influenza because many of the people in this age bracket have chronic diseases (29% in 2002).

Persons with chronic health problems who are six months of age or older are at high risk from complications from influenza or exacerbation of their condition. Such chronic conditions include:

•  Cardiac disease, such as congestive heart failure
• Pulmonary disease, such as chronic obstructive pulmonary disease, cystic fibrosis, or asthma
•  Renal disease
•  Diabetes and other metabolic diseases
•  Anemia and blood disorders, such as sickle cell disease

Persons with compromised immune systems from any cause – HIV/AIDS, autoimmune conditions, cancer, and long term steroid treatment – should receive the inactivated vaccine.

Persons with conditions or diseases that may compromise respiratory function or increase the risk of aspiration should also be vaccinated against influenza to prevent any possible complications or damage.

ALL healthcare providers should receive the influenza vaccine annually.

Persons who reside in skilled nursing facilities (nursing homes) or other chronic care facilities are at high risk for influenza-related problems because of their weakened physical state and close living arrangements.

Person six months to 18 years of age on long-term aspirin therapy should be immunized against influenza because of the interaction of the influenza virus and aspirin that can lead to Reye’s Syndrome.

Pregnant women in the second or third trimester have the same complication and hospitalization rate from influenza as persons with chronic diseases and, therefore, should receive the vaccine.

Children six to 23 months of age, even without any chronic conditions, should receive the annual influenza immunization because they are at a substantially increased risk for influenza-related hospitalization.

OTHER GROUPS ADVISED TO RECEIVE THE INFLUENZA VACCINE

Basically, this includes anyone who has contact with those at risk of complications, hospitalization, or death from influenza. This contact could be through living or caregiving arrangements. This would include those with patient contact in acute and chronic care facilities, in doctor's offices or clinics, in emergency rooms, and in-home care providers. Family members of infants, from newborns to 23 months of age, are advised to protect their child/sibling by being immunized. This is especially critical for infants less than 6 months of age for whom no current influenza vaccine is licensed.

Persons who provide essential services such as law enforcement and firefighters, also should be immunized.

Students living in dormitories should receive the vaccine in order to avoid disruption of their studies.

Travelers should be evaluated for influenza immunization when "travel shots" are being recommended.

Obviously, the vaccine should be given to anyone who desires it. However, in times of vaccine shortage or slow production, high-risk groups and their close contacts will receive the vaccine first, then when more vaccine becomes available, others should be immunized.

PEOPLE WHO SHOULD NOT RECEIVE THE INFLUENZA VACCINE

• Persons with al