H1N1 Novel Swine Influenza A Pandemic

June 11, 2009 the World Health Organization announced the 2009 H1N1 Novel Swine Influenza to be a Phase-6 Pandemic, this agency’s highest alert level for an infectious disease. Up to this point the majority of those who have contracted the 2009 H1N1 virus have displayed only mild symptoms. The rapid spread of this disease across 74 countries and the potential for the virus to turn deadly on a wide scale requires a heightened level of vigilance from health professionals as they prepare for what may yet come.

The influenza virus is typically a respiratory illness with mild to debilitating symptoms whose complications when severe may lead to hospitalization or even death. Annually influenza severely affects from 3 to 5 million persons resulting in 500,000 deaths globally (Kamps, & Preiser, 2006).

New epidemic strains of the influenza virus crop up every 1 to 2 years, producing outbreaks of disease that spread more quickly and more extensively among a group of people than would normally be expected of seasonal influenza. This makes localized outbreaks of epidemic influenza a somewhat common and expected occurrence when viewed from a global perspective.

Pandemics however are uncommon events. While pandemic influenza is by its nature unpredictable, incidents with mild to moderate severity tend to occur every 10 to 40 years, with severe or devastating disease strains occurring even less frequently. The difference between an epidemic and a pandemic is that where an epidemic may spread rapidly it remains confined to a set geographic area or regional population. Pandemics, in contrast, rapidly cross geographic and population boundaries. The 2009 H1N1 Novel Swine Flu has exhibited such a spread by documented widespread community transmission occurring on at least two continents.

Documentation regarding the characteristics of pandemics during the last 400 years has revealed that influenza pandemics tend to circumnavigate the globe in successive waves, eventually reaching everywhere, and potentially infecting every human being within the span of only a few years.

The reason that understanding the wave-like spread pattern of pandemic influenza is essential is found in history. The 1918 Spanish Flu, which had a higher death rate than the entirety of World War I, was initially highly contagious yet not particularly deadly. That is, not first time around during the spring of 1918. This pandemic flu travelled through Europe, Asia, and the Americas in a series of three distinct waves over a time period of 12 to 18 months. It was during its second wave, starting in September 1918 that the massive death tolls truly began, with the wave of primary influenza able to kill young healthy individuals within 2-days and leaving many of the survivors vulnerable to secondary bacterial pneumonias which added greatly to the suffering. For those keeping track, yes, the 2009 Novel Swine Flu is also a type of H1N1 influenza, similar in many ways to the 1918 H1N1 Spanish Flu (Kamps & Preiser, 2006).

Infectious influenza comes in a variety of strains, some of which are human specific, some that are distinct to a single species of animal, and some that can be shared across species from one animal type to certain others, or from certain animals to a human.

Antigenic Shift is the term used when a flu strain makes the jump across species. Influenza strains which can cross from an animal species and create symptoms in a human are always a concern to epidemiologists. Animals such as birds can carry a viral strain great distances very quickly as well as serving as a vast repository for an active, contagious virus. Swine can also transmit a virus amongst themselves as individuals or herds are shipped and intermingled. Due to the widespread farming of domestic pork, pigs provide a large potential reserve for a virus able to make the leap from animal to human host.

In this day of modern air travel, humans are the most efficient carrying agent of all. A couple vacationing in Sydney coming down with a respiratory spread virus can board a transoceanic flight and transport the illness to Paris and points beyond in the span of a single day. So while the origin and potential reserve of the 2009 H1N1 flu is important, the fact that it is now transmitting from human to human takes center stage.

Reassortment is a term to know when conversing about epidemic or pandemic influenza strains. To “Reassort” is the bio-genetics lingo for a virus (or more often multiple viral strains co-infecting a single host) shuffling genetic sequence and producing a “variant” viral strain or even a new “novel” virus.

Picture the genetic segments in a virus as individual cards in a deck of playing cards. Not a big deck. According to the National Institute of Allergy and Infectious Diseases (NIAID) the typical flu virus consists of eight gene packets or segments. When a virus infects a host cell be it bird, human or swine, these eight gene segment cards sort themselves out and produce copies, creating multiple genetic decks of the same identical virus. What if the cards (genetic segments) became shuffled? The genetic sequence of the reproduced virus then becomes something different from the original. It has been “reassorted”.

Reassortment of a virus may also occur when the host is infected with two different influenza viruses simultaneously, allowing two sets of the eight gene segments to intermix into a new deck of merged genetic viral material. Viral co-infection with reassortment may result in an all together new or “novel” shuffling of the viral genetic deck, producing unexpected results.

National Institute of Allergy and Infectious Diseases (http://www3.niaid.nih.gov/topics/Flu/Research/basic/AntigenicShiftIllustration.htm)

So, how do pigs fit into this picture?

Swine have the dubious pleasure of being able to “catch” certain infections from both human and avian sources. Domestic pigs also live in close proximity to both humans and domestic fowl such as chickens and ducks, especially in developing countries. An avian flu, a human flu, and the mystery of reassortment in a susceptible host (this is where the pig comes in during some scenarios) and a novel reassortment of influenza may occur. In the 2009 H1N1 novel swine influenza A pandemic, virus researchers have identified genetic segments from two swine viral strains, one human strain, and one avian strain of influenza, making the 2009 H1N1 swine flu a “quadruple reassortment” virus (Kamps & Preiser, 2006) (Thorner, 2009).

Before you start blaming the poor porkers for the 2009 H1N1 influenza pandemic, please be aware that influenza viruses containing gene segments from avian, swine, and human sources are not new. Influenza strains containing all three species (bird, pork, and people) have been documented among North American swine herds since the 1990’s. While the specifics of the origin of this current H1N1 strain have yet to be determined please remind clients that there is no risk of becoming infected with 2009 H1N1 pandemic influenza virus from eating pork or using pork products (Thorner, 2009).

In late March 2009 an unusual, unseasonal outbreak of respiratory illness was reported already in progress in Mexico. This outbreak was eventually identified as being related to a new strain of influenza A virus. Further cases of illness associated with the same virus began to appear in other regions of Mexico, and quickly after from other countries. On May 2, 2009 the Canadian government released a report of the identical virus, now known to be a H1N1 influenza A virus, being found in sick swine from a herd located in Alberta. Investigation revealed that the pigs had become ill following exposure to a farm worker who had recently visited Mexico and returned with flu like symptoms. With this strong indication that the infecting agent could be passed back and forth from human to swine the 2009 H1N1 Swine-Origin influenza watch began to attract public attention.

Influenza is a virus known for an annoying ability to adapt and change. In some strains of virus this occurs seasonally. With the 2009 H1N1 swine influenza it is unknown if, when, or how much it will differ at a later date from what it is currently.

Current signs and symptoms of the 2009 H1N1 Pandemic Swine Influenza include the following;

•   Fever
•   Cough
•   Sore throat
•   Malaise
•   Headache
•   Vomiting (often, yet not in all cases)
•   Diarrhea (often, yet not in all cases)
•   Chills (less common)
•   Myalgia – muscle pain (less common)
•   Arthralgia – joint pain (less common)

Key differences between the 2009 pandemic swine flu and seasonal influenza are being reported. Researchers in both the United States and the Netherlands note an increase in gastrointestinal distress and vomiting as compared with seasonal influenza. This increase is observed both in laboratory animal subjects and among the symptoms being reported from human cases. Among the laboratory findings is evidence that the H1N1 pandemic virus replicates more extensively in the respiratory tract than is typical of influenza A, spreading more invasively into the lungs and intestinal tract than seasonal influenza (Reinberg, 2009).

The majority of cases identified as the 2009 H1N1 novel swine influenza have experienced mild to moderate symptoms. Only two to five percent of confirmed cases in Canada and the United States have required hospitalization, as compared to around six percent in Mexico, with the most common reasons for admission being dehydration and secondary pneumonia. Among the cases in Mexico are reports of respiratory failure, acute respiratory distress syndrome, and rapidly progressing pneumonia (Thorner, 2009).

Person-to-person transmission has been identified as the primary means of infection in the 2009 H1N1 pandemic influenza. Information from the World Health Organization indicates that transmissibility of this virus is substantially higher than that of seasonal influenza (Thorner, 2009).

As with all influenza A types, viral particles are present in respiratory secretions. This means that large particle droplets such as are produced by coughing or sneezing can readily convey the infection to a new host. Contact transmission from infected surfaces may also occur, and good practice around influenza A types indicates caution should be exercised when exposed to other bodily fluids such as diarrhea stool.

Viral shedding is likely to begin the day before onset of symptoms and continue until the resolution of the fever. Due to the early stage of research into the peculiarities of the 2009 H1N1 novel swine influenza individuals should be considered contagious until seven days after the illness onset. Differing periods of contagious viral shedding may be present in the immunocompromised person, those with chronic illnesses, the elderly or young infants and children. On a related note, the incubation time from viral contraction until onset of illness may range from one to seven days with the most likely timeframe being the first four days post contraction (Thorner, 2009).

Recommendations differ according to regional or state authorities as to who should undergo specific testing for the 2009 H1N1 pandemic swine influenza virus. Please be aware that not all clients presenting with flu-like symptoms require testing. Some degree of professional discretion exists even where H1N1 is suspected, especially when the symptoms of illness are mild and cases have already been confirmed in that area. Be sure to check specific community or state public health guidelines.

Testing for the presence of the 2009 H1N1 virus is recommended in patients presenting with an acute febrile respiratory illness or sepsis-like syndrome. Acute febrile respiratory illness can be identified by the presence of a marked fever, 100ºF or higher, and the recent onset of at least one of the following; cough, sore throat, rhinorrhea, or nasal congestion (Thorner, 2009) (CDC, “Interim guidance for clinicians on identifying and caring for patients”, 2009).
Viral identification of the 2009 H1N1 pandemic swine influenza particle can be accomplished by either culture or real-time reverse-transcriptase PCR (the abbreviation PCR stands for polymerase chain reaction). By preference, real-time reverse-transcriptase PCR testing for influenza A, B, H1, and H3 can be conducted through state health department laboratories with the CDC confirming positive tests.

Specimens for testing consist of an upper respiratory sample; i.e., nasal swab, throat swab, nasopharyngeal swab, or nasal aspirate. Sample kits are generally available through state health departments and are preferred, as swabs with cotton tips, wooden shafts or components composed of calcium alginate are NOT ACCEPTABLE. Swabs that do meet the testing criteria (e.g. synthetic polyester or Dacron tipped with aluminum or plastic shafts), need placed in 1 to 3 mL of viral transport media. Refrigeration until testing including transportation both to the in-house laboratory and outside public health laboratory is essential.

CDC developed PCR diagnostic test kit to detect Novel H1N1 virus (http://www.cdc.gov/h1n1flu/images.htm)

Rapid antigen tests are tempting to use, yet any results obtained require interpretation with great caution. Current rapid influenza antigen tests which are commercially available distinguish between influenza A and B viruses. Unfortunately the specificity for use with the 2009 H1N1 swine influenza A virus is unknown, and poor sensitivity during testing of seasonal influenza has been demonstrated with existing rapid antigen tests. Confirmation of the 2009 H1N1 swine influenza virus can currently only be made using real-time reverse-transcriptase PCR testing, or by culture (CDC, “Use of rapid influenza diagnostic tests”, 2009).

A similar caution goes with Immunofluorescent Antibody Testing, whether direct (DFA) or indirect (IFA). Both DFA and IFA are able to distinguish between influenza A and B, however a negative DFA or IFA does not exclude the 2009 H1N1 influenza A infection as testing sensitivity to detect this virus has not yet been established (CDC, “Interim guidance on specimen collection”, 2009).

Dancing around the issue of risk associated with the 2009 H1N1 pandemic influenza has frequently occurred. The bottom line is this – no one knows. The “novel” H1N1 influenza virus could fade into the background of the seasonal influenza profile and never be heard of again, except by public health epidemiology trackers. On the flip side of the coin the H1N1 pandemic virus could turn into an all encompassing wave, hammering through the populations of both developed and developing countries in a fast moving and devastating contagion. Probability dictates that neither extreme will occur, that the actuality will be somewhere in the middle. We have learned a few things from previous influenza pandemics, and what we have learned we can apply to this new, novel, pandemic.

Pandemics happen. Because influenza is easily transmitted within communities, and society is a fluid structure of mobile individuals, the transmission of easily spread illnesses will occur. We also know from history that the pandemic forms of influenza spread through areas, and then return to travel through the same regions again either in the same form or a slightly altered version. The 1918 Spanish Flu showed us just how deadly the second visit of a similar H1N1 virus could be.

We know that the 2009 H1N1 novel swine flu virus can spread rapidly and can cause deaths. Since awareness of this specific disease in late March of 2009, confirmed cases have been reported in 74 countries and on four continents. In Mexico, where the longest time line for this illness exists, deaths from the H1N1 swine flu have passed the hundred mark and reports continue to come in. As of June 15, 2009 reported deaths in Mexico are 108, with most related to respiratory failure and acute respiratory distress syndrome. Accompanying the respiratory failure in one quarter of the deaths are reports of renal or multi-organ failure (World Health Organization, 2009).

Due to the general pattern of behavior found in pandemic events, the World Health Organization Global Influenza Preparedness Plan defines specific phases of preparedness for organisms which have the potential to create a pandemic. Matching those phases are guidelines for suggested international and national public health actions. The current rating of the 2009 H1N1 novel swine influenza as of June 11, 2009 is that of Phase 6 (Kamps & Preiser, 2006).

Phase 6, the “Pandemic Period” of the World Health Organization Global Pandemic Preparedness Plan acknowledges that Pandora has opened the box and that a rapidly spreading influenza virus has gained human-to-human transmission and is being identified on an international, (e.g. global), scale. The primary objective of the WHO plan becomes containment.

On a global scale this means intense monitoring and surveillance of suspected and confirmed pandemic influenza cases with supportive treatment provided to those who are already infected and targeted prophylaxis applied in areas key to containing or slowing the virus spread. Some areas have already felt the mounting institution of international containment planning as shown by infrared body temperature screening of air passengers in many international airports. This quick screening process is used to divert passengers with fever into isolation/ holding areas until they are cleared by medical authorities to continue their travels. The World Health Organization recognizes that plans may be implemented for heightened border control in some regions in an effort to contain or slow the spread of the infective agent.

On a local level, community education concerning respiratory hygiene and social distancing needs to occur, as does the preparation of available healthcare personnel, in the event that the spreading pandemic becomes even more deadly.

The best way to prevent infectious disease is to never be exposed. When dealing with influenza avoiding exposure is a tricky process. Infection control procedures are terrific aids inside of healthcare facilities, and the CDC has specific recommendations concerning the 2009 H1N1 novel influenza A swine origin pandemic virus;

• Respiratory Hygiene/ Cough Etiquette infection control measures should be implemented at the first point of contact with a potentially infected person
• Mechanisms to screen for signs and symptoms of febrile respiratory illness should be established at any point of entry to a healthcare facility

The CDC also recommends that all patients presenting on admission that meet the following criteria be handled with caution (CDC, “Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A”, 2009).

1. Clients who live, work or are present in a community where “novel” H1N1 has been identified AND who exhibit a febrile respiratory illness ~OR~
2. Are in a community where no cases of “novel” H1N1 have been identified yet exhibit a febrile respiratory illness and has had close contact with a suspected H1N1 infectious person, or traveled within the last 7 days into a community with a confirmed H1N1 case.

Standard and contact infection control precautions should be continued for seven full days after the onset of the febrile respiratory symptoms in order to assure that the virus has completed its contagious shedding cycle. The CDC (2009) also encourages healthcare workers to wear fit-tested N95 respirators during the provision of routine care.

Standard N95 Disposable
 Respirator, image from CDC
(Reference link)

Surgical masks and respirators (such as the N95 type) are not the same! Surgical masks are designed to be physical barriers to incoming hazards such as large droplets or splashes. A good surgical mask also prevents outgoing contamination by trapping large particles of bodily fluids that might contain infectious organisms being expelled by the wearer. Surgical masks are not designed nor are they certified for the prevention of inhalation of small airborne contaminants. Surgical/ procedure masks are NOT designed to seal tightly against a user’s face resulting in potentially contaminated air passing through the gaps between face and mask during inhalation. Respirators however are designed to tightly fit and filter varying sizes of particles from the air. The rating, such as N95 which indicates a “filtering facepiece respirator” capable of removing 95-percent of airborne particles, designates the filtering ability of the respirator. Please be aware that in order for respirators to work properly they must be “fit tested” for the individual using them. Not all persons have the same facial characteristics, therefore one size or type of respirator will not “fit all”. Be aware that N95 respirators which are designed to catch airborne particles will eventually become “clogged” and unusable due to trapped particulate accumulation (OSHA, 2009).

Social Distancing is a method of limiting exposure to the 2009 H1N1 pandemic influenza endorsed by the World Health Organization and the CDC and can work in two ways. First, by uninfected individuals who are at high risk for complications (such as persons with chronic medical problems, pregnant women, the youngest children) using measured judgment and limiting social contact that may heighten risk of exposure. This can vary from maintaining a personal space of between three to six feet from others to staying home and avoiding people altogether during times of heightened risk. Most importantly, in influenza, is the avoidance of situations involving large numbers of people in close proximity. This is particularly important in communities where cases of the 2009 H1N1 pandemic influenza have already been identified.

The use of home isolation for mildly ill patients diagnosed with or suspected of having the novel H1N1 virus could be thought of as a form of social distancing, though in a pandemic situation it is likely that all but the most severely symptomatic will be instructed to stay away from hospitals due to limited inpatient capability. If the use of home isolation is anticipated in your community, be sure to carefully instruct individuals and family members on proper hygiene precautions, and supply adequate face masks or respirators for their use.

Home isolation is not for everyone. Individuals with severe symptoms or at risk for complications resulting from their symptoms are not candidates for home isolation. Those who are participating in a home isolation program should have their own room (and bathroom which can be cleaned daily with a household disinfectant) if at all possible, away from the rest of the family. One family member should be designated as the primary care giver in order to limit infectious contact with other members of the family. Even when in home isolation a face mask should be used by the ill person if available and tolerated, in order to minimize spread of the virus to others. Clear fluids should be encouraged in order to prevent dehydration as well as getting plenty of rest. Coughs and sneezes should be covered, and all parties should engage in frequent handwashing with soap and water (or use of an alcohol based hand rub).

Once the home isolation person is feeling better remind them of the importance of staying at home for at least 7 days, or for 24-hours AFTER all symptoms have resolved, whichever time period is LONGER. Encourage the use of the phone for those seeking social contact rather than having visitors who would be placed at risk for infection, and do remember to clean the phone, with special attention to the mouthpiece, using disinfectant before it is used by other family members. Those who are still in the home isolation time period who must go out into the community should wear a face mask and limit contact with others as much as possible.

Vaccination, when available, is a tool for use in those individuals at risk for contact with a potentially deadly viral strain, such as the 2009 H1N1 pandemic influenza. Influenza A viruses, a category into which the 2009 H1N1 novel swine flu falls, require a vaccine tailored to specific antigens to be effective. None of the recent seasonal influenza vaccines include the necessary antigens required for effect on the 2009 pandemic strain. This means that there is no effective “broad spectrum” vaccine readily available, and prior vaccination for seasonal influenza will provide no, or at most, very limited protection.

In May 2009 the CDC distributed what is referred to as “seed stocks” to vaccine manufacturers that were distinctive of the 2009 H1N1 pandemic strain. With the release of these samples work could begin in earnest on vaccine production. Best predictions indicate that it will take from six to nine months to produce an effective vaccine for the 2009 H1N1 influenza, which will put the northern hemisphere well into the seasonal influenza period. Although two manufacturers have already, as of July 1st 2009, indicated they have workable vaccine seed lines, production in any quantity will require time and financial incentive.

Prophylaxis represents an action taken in an effort to prevent a disease, or at least to stop it from spreading further. Antiviral prophylaxis guidelines related to the 2009 H1N1 novel swine influenza are available from the CDC, and are updated as new information becomes known. In general post exposure antiviral chemoprophylaxis may be considered for individuals with a high risk for complications of influenza that have been in close contact with persons confirmed or suspected to be in the infectious stage of the disease. Those under high risk of influenza complications include pregnant women, the elderly, and persons who are suffering from debilitating chronic medical conditions. Also, healthcare workers or first responders who were not using appropriate personal protective equipment during close contact with confirmed or suspected H1N1 patients during that individual’s infectious period may be candidates for antiviral prophylaxis (CDC, “Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A”, 2009).

Two antiviral medications are recommended by the CDC for post exposure prophylaxis with the 2009 H1N1 pandemic influenza virus. They are oseltamivir and zanamivir. Dosing regimens for these agents follow the schedules established for seasonal influenza exposure, and both antiviral medications must be continued for 10 days after the last known exposure to the virus occurred. The CDC is guarded on the use of antiviral agents for pre-exposure chemoprophylaxis yet recommends that should antiviral medication be used in this manner, continuation of the medication during the entire exposure period AND for 10 days after the end of exposure to the virus must occur (CDC, “Interim guidance on antiviral recommendations”, 2009).

Treatment of the 2009 H1N1 pandemic influenza revolves around disease prevention and supportive care. Treatment of symptoms, especially dehydration and avoidance of secondary bacterial pneumonia, are essential and must occur on an individual case basis. Particular vigilance is required for the occurrence of community acquired pneumonia (CAP) in the patient rendered vulnerable by H1N1.

Complications that arise from influenza may be as deadly as the primary viral infection itself. During the 1918 Spanish Flu many of the deaths occurred from secondary bacterial pneumonia rather than the 1918 H1N1 influenza virus itself.

Secondary bacterial pneumonia is a complication associated in the past with pandemic influenza outbreaks as well as seasonal influenza. Most often secondary bacterial pneumonia is a matter of dealing with “the usual suspects” such as Streptococcus pneumoniae and Staphylococcus aureus, though other bacterial agents will take the opportunity presented by the debilitation created in the wake of the primary viral infection. Healthcare professionals need to remain observant as clients may appear initially to be recovering from the acute influenza episode. At times a lapse of two to three days occurs following the worst of the viral symptoms before temperatures again begin to rise heralding the onset of classical bacterial pneumonia symptoms such as a cough with purulent sputum. Diagnosis can be achieved by x-ray for indications of pulmonary consolidation and sputum culture.

Primary viral pneumonia can occur as a complication of any severe influenza, seasonal or pandemic. During the 1918 pandemic, primary viral influenza pneumonia with pulmonary hemorrhaging was a common finding. Clinical findings are those of an acute influenza episode that fails to spontaneously resolve and instead worsens. Chest x-rays may show the presence of diffuse interstitial infiltrates. Acute respiratory distress syndrome with marked hypoxia is often present, frequently requiring supplemental ventilator support.

Exacerbation of chronic health conditions frequently occurs in conjunction with pandemic influenza outbreaks. Existing respiratory and cardiac disease is often worsened by the bodily assault of severe influenza. COPD clients will need careful monitoring and when possible prophylactic antiviral medication should be on hand for these individuals.

Both the young and the old are vulnerable to influenza outbreaks. In children, croup secondary to influenza is often more severe than that caused by a parainfluenza virus. Failure of recovery is also a phenomenon seen during epidemic influenza outbreaks when clients, particularly the elderly, simply fail to respond to treatment and continue to deteriorate from underlying cardiac, pulmonary or multi-organ failure (Kamps & Preiser, 2006).

Past experience with epidemic and pandemic influenza outbreaks has demonstrated a high level of need for taking proper care of the healthcare workforce. Those who provide essential care for others often fail to adequately care for themselves over the long duration in times of need. Both the CDC and WHO have recommendations for monitoring the health of workers during an infectious disease outbreak and ask health professionals to; 1) be aware of their own needs, 2) observe those they work with for signs of illness or fatigue, and 3) insist that workplaces institute processes and procedures to maintain the health of their workers.

CDC guidelines stress that in areas where the 2009 H1N1 pandemic virus is occurring healthcare personnel be monitored daily for symptoms of febrile respiratory illness. Any personnel developing these symptoms should be instructed not to report for work, or if at work should notify their supervisor and infection control personnel (CDC, “Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A”, 2009).

Experience in recent years with the SARS and Avian Flu epidemics in Asia have demonstrated that healthcare workers experience high levels of stress originating from outside of the primary work environment during a contagious outbreak. Stresses may include their own fear over risk of personal illness, the real or potential illness of immediate family members, especially those who would require their direct care, the possible unavailability of daily living requirements due to societal breakdown, and even the stress surrounding the phenomena of social ostracism from other individuals fearing that the healthcare worker may be contagious. Recommendations for pandemic preparation on both an institutional and a personal level are available from various sources such as the CDC and OSHA, and the latest government information can be obtained from the website PandemicFlu.gov.

Healthcare professionals will find it difficult to focus on the care of the sick unless a measure of assurance is present that their own personal households are in order. On an institutional level absenteeism during a pandemic event must be anticipated and prepared for as employee illness, employee dependent illness, and societal reasons for being unable to be at work may occur (e.g., social distancing or home isolation, loss of home power or water, closure of grocery stores, school closures, rationing or unavailability of gas for cars or public transport). Plans for safe housing for children or dependents must be established and kept current. Essential supplies such as a two week supply of food, water, toiletries, and both prescription and non-prescription medications should be stocked and rotated on a regular basis to maintain freshness. When making preparations do not neglect to stock food and supplies for pets as well! Standard survival disaster preparation items should also be gathered and maintained such as flashlights, portable radios, batteries, a manual can opener, garbage bags, etc. Be sure to have on hand a thermometer and over the counter medicines for treating both fever and diarrhea.

Pandemics happen. The 2009 H1N1 novel swine origin influenza A pandemic is a fast spreading human-to-human virus that will very likely sweep through an area and then return in successive waves over a period of several years. In its first sweep through the Northern Hemisphere since its first appearance in Mexico in March 2009 it has caused mild to moderate symptoms more often than severe illness and death. Influenza viruses change however and the next sweep through may well show a dramatic increase in flu related death. Preparation for the return of the 2009 pandemic flu must occur in organized healthcare, among the general public, and especially amongst healthcare workers personal and family lives.

Kamps, Bernd, Hoffmann, Christian, & Preiser, Wolfgang. (2006). Influenza Report 2006. Paris: Flying Publisher.

Reinberg, Steven. (2009). Why Swine Flu Differs From Seasonal Flu. HealthDay News. Retrieved July 2, 2009, from Web site: http://www.healthfinder.gov/news/newsstory.aspx?docID=628674

Thorner, AR. (2009). Epidemiology, Clinical Manifestations, and Diagnosis of Swine H1N1 Influenza A. In: Hirsch MS (Ed.) UpToDate 17.1. Waltham, MA.

United States Centers for Disease Control and Prevention. (2009). Interim guidance for clinicians on identifying and caring for patients with swine-origin influenza A (H1N1) virus infection. Retrieved June 30, 2009, from Web site: http://www.cdc.gov/h1n1flu/identifyingpatients.htm

United States Centers for Disease Control and Prevention. (2009). Use of rapid influenza diagnostic tests for patients with influenza-like Illness during the novel H1N1 influenza virus (swine flu) outbreak: Information for health care professionals. Retrieved June 30, 2009, from Web site: http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm

United States Centers for Disease Control and Prevention. (2009). Interim guidance on specimen collection, processing, and testing for patients with suspected swine-origin influenza A (H1N1) virus infection. Retrieved May 12, 2009, from Web site: http://www.cdc.gov/h1n1flu/specimencollection.htm

United States Centers for Disease Control and Prevention. (2009). Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A (H1N1) virus infection in a healthcare setting. Retrieved May 14, 2009, from Web site: http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm

United States Centers for Disease Control and Prevention. (2009). Interim guidance on antiviral recommendations for patients with novel influenza A (H1N1) virus infection and their close contact. Retrieved May 7, 2009, from Web site: http://www.cdc.gov/h1n1flu/recommendations.htm

United States Occupational Safety and Health Agency. (2009). Guidance on Preparing Workplaces for an Influenza Pandemic. Doi: OSHA 3327-05R 2009. Retrieved July 6, 2009, from Web site: http://www.osha.gov/Publications/OSHA3327pandemic.pdf

United States Department of Health and Human Services National Institutes of Allergy and Infectious Diseases. (2009). Antigenic Shift. Retrieved July 17, 2009, from web site: http://www3.niaid.nih.gov/topics/Flu/Research/basic/AntigenicShiftIllustration.htm

World Health Organization. (2009). Human infection with new influenza A (H1N1) virus: clinical observations from Mexico and other affected countries. Weekly Epidemiological Record 2009. 84(185), from Web site: http://www.who.int/wer/2009/wer8421.pdf