Statement to the press by WHO Director-General Dr Margaret Chan
11 June 2009
World now at the start of 2009 influenza pandemic
Dr Margaret Chan
Director-General of the World Health Organization

Ladies and gentlemen,

In late April, WHO announced the emergence of a novel influenza A virus.

This particular H1N1 strain has not circulated previously in humans. The virus is entirely new.

The virus is contagious, spreading easily from one person to another, and from one country to another. As of today, nearly 30,000 confirmed cases have been reported in 74 countries.

This is only part of the picture. With few exceptions, countries with large numbers of cases are those with good surveillance and testing procedures in place.

Spread in several countries can no longer be traced to clearly-defined chains of human-to-human transmission. Further spread is considered inevitable.

I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose.

On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met.

I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6.

The world is now at the start of the 2009 influenza pandemic.

We are in the earliest days of the pandemic. The virus is spreading under a close and careful watch.

No previous pandemic has been detected so early or watched so closely, in real-time, right at the very beginning. The world can now reap the benefits of investments, over the last five years, in pandemic preparedness.

We have a head start. This places us in a strong position. But it also creates a demand for advice and reassurance in the midst of limited data and considerable scientific uncertainty.

Thanks to close monitoring, thorough investigations, and frank reporting from countries, we have some early snapshots depicting spread of the virus and the range of illness it can cause.

We know, too, that this early, patchy picture can change very quickly. The virus writes the rules and this one, like all influenza viruses, can change the rules, without rhyme or reason, at any time.

Globally, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity. As we know from experience, severity can vary, depending on many factors, from one country to another.

On present evidence, the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery, often in the absence of any form of medical treatment.

Worldwide, the number of deaths is small. Each and every one of these deaths is tragic, and we have to brace ourselves to see more. However, we do not expect to see a sudden and dramatic jump in the number of severe or fatal infections.

We know that the novel H1N1 virus preferentially infects younger people. In nearly all areas with large and sustained outbreaks, the majority of cases have occurred in people under the age of 25 years.

In some of these countries, around 2% of cases have developed severe illness, often with very rapid progression to life-threatening pneumonia.

Most cases of severe and fatal infections have been in adults between the ages of 30 and 50 years.

This pattern is significantly different from that seen during epidemics of seasonal influenza, when most deaths occur in frail elderly people.

Many, though not all, severe cases have occurred in people with underlying chronic conditions. Based on limited, preliminary data, conditions most frequently seen include respiratory diseases, notably asthma, cardiovascular disease, diabetes, autoimmune disorders, and obesity.

At the same time, it is important to note that around one third to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people.

Without question, pregnant women are at increased risk of complications. This heightened risk takes on added importance for a virus, like this one, that preferentially infects younger age groups.

Finally, and perhaps of greatest concern, we do not know how this virus will behave under conditions typically found in the developing world. To date, the vast majority of cases have been detected and investigated in comparatively well-off countries.

Let me underscore two of many reasons for this concern. First, more than 99% of maternal deaths, which are a marker of poor quality care during pregnancy and childbirth, occurs in the developing world.

Second, around 85% of the burden of chronic diseases is concentrated in low- and middle-income countries.

Although the pandemic appears to have moderate severity in comparatively well-off countries, it is prudent to anticipate a bleaker picture as the virus spreads to areas with limited resources, poor health care, and a high prevalence of underlying medical problems.

Ladies and gentlemen,

A characteristic feature of pandemics is their rapid spread to all parts of the world. In the previous century, this spread has typically taken around 6 to 9 months, even during times when most international travel was by ship or rail.

Countries should prepare to see cases, or the further spread of cases, in the near future. Countries where outbreaks appear to have peaked should prepare for a second wave of infection.

Guidance on specific protective and precautionary measures has been sent to ministries of health in all countries. Countries with no or only a few cases should remain vigilant.

Countries with widespread transmission should focus on the appropriate management of patients. The testing and investigation of patients should be limited, as such measures are resource intensive and can very quickly strain capacities.

WHO has been in close dialogue with influenza vaccine manufacturers. I understand that production of vaccines for seasonal influenza will be completed soon, and that full capacity will be available to ensure the largest possible supply of pandemic vaccine in the months to come.

Pending the availability of vaccines, several non-pharmaceutical interventions can confer some protection.

WHO continues to recommend no restrictions on travel and no border closures.

Influenza pandemics, whether moderate or severe, are remarkable events because of the almost universal susceptibility of the world’s population to infection.

We are all in this together, and we will all get through this, together.

Thank you.

The HHS and the CDC have developed lots of widgets that you can place on your practice website to give your patients the latest information on the swine flu.  You can get a widget for your practice website from HHS here or from CDC here. These sites also provide podcasts and other resources that you can use to develop your practice protocols and education materials for staff and patients globally for a pandemic illness, or specifically for the A(H1N1) swine influenza illness.

This article will provide resources for three areas:

1. Protocol for your practice for potential pandemic illness (swine flu or other)
2. Plan to provide information to your patients about swine flu
3. Plan for your practice to function during the swine flu or a pandemic illness episode

The good news about the swine flu is that it is a wake-up call for all practices to have a protocol in place going forward.  Most practices have their hands full with Red Flags Rules, Medicare enrollment rules, PQRI, e-Prescribing , etc.but none of this will matter if a practice cannot manage its sick and scared patients, or if there are no staff to run the practice.

The first distinction between protocols should be whether your practice is primary-care based or not.  In almost all cases, a primary care practice will do the heavy lifting for outpatients during an illness outbreak, whether pandemic or not.  The fluWiki says this about a pandemic illness:

Practical definitions of a pandemic vary. “Pan” suggests everywhere, but the World Health Organization (WHO) Level 6 requirement for a pandemic indicates that there are serious outbreaks in communities two or more different WHO regions.

According to the WHO, a pandemic can start when three conditions have been met:

• Emergence of a disease new to a population.
• Agents infect humans, causing serious illness.
• Agents spread easily and sustainably among humans.

A disease or condition is not a pandemic merely because it is widespread or kills many people; it must also be infectious. For instance, cancer is responsible for many deaths but is not considered a pandemic, because the disease is not infectious or contagious.

If you are not a primary care practice, most experts advise not risking the spread of illness by treating patients experiencing symptoms that may or may not be the swine flu.

What follows is an excellent discussion of the question surrounding just how seriously the swine flu should be taken.  It is written by a physician whose blog I read regularly, Dr. Rob:

Is this worth getting panicked about?  Is it worth all the press coverage?

I have to say, I find myself wondering this myself.  But my experience as a doctor teaches me that it is far better to overreact to something than to not take it seriously enough.  If we get all worked-up about the flu and it ends up being something that is not serious, I will be very happy.  The world will be spared a big tragedy.  But if we take this threat lightly and it ends up being a virus as deadly as some previous pandemic viruses, a lot of life will be lost because of our fear of overreaction.

But is the flu worth worrying about?  There haven’t been many deaths due to it so far – at least in the US.  So why should we get worked up about it?  Here is the rationalle for a strong reaction:

• This is a virus against which nobody is immunized.
• The fact that it was a pig virus that mutated means that it is significantly different from other flu viruses our bodies have been exposed to in the past.  This is the reason pandemics are so deadly – the body takes longer to build up defenses and fight off the virus because it is basically new to the person.
• The type of influenza – Influenza A, is a more virulent strain in general than Influenza B.
• Even if this virus is an “average” or a “mild” influenza virus, the death tolls could still be quite high without aggressive action.  Each year there are over 40,000 deaths in the US attributable to influenza  – and this is in a population that has a significant percentage of immunized people.
• The H1N1 strain of this virus is the same strain found in the 1918 Spanish flu virus that cause the worst pandemic on record.  20 to 100 million people died of that pandemic – a large proportion of which were younger, more healthy individuals, not the people who typically succumb to flu each year.

No, it doesn’t seem that this virus is as virulant as the 1918 strain, but early indications in Mexico was that the death rate was quite high.  The decision to exercise caution and act as if this would be similar to the Spanish flu virus is wise.  Delay could result in the unnecessary deaths of thousands, even millions of people.

Key Elements of a Pandemic Illness Protocol

1. Review and reinforce basic infection control guidelines with all staff.  Confirm the importance of Standard and Droplet Precautions when caring for patients with acute, febrile, respiratory illness.  Standard Precautions are basic precautions designed to minimize direct unprotected exposure to potentially infected blood, body fluids or secretions.   Droplet Precautions require healthcare workers to wear a medical mask if working within 3 feet of the patient suspected of having A(H1N1).
2. Review and reinforce respiratory hygiene and cough etiquette with all staff: cover mouth and nose with a tissue when coughing, discard the used tissue without touching the waste container and perform hand hygiene afterwards. There are great stations that you can purchase that have a poster illustrating cough etiquette and a place for respiratory masks, tissues, a trash can and hand sanitizer.  These stations educate patients and family members while in the practice.  Simple stations can be devised by mounting dispensers on the wall with a relevant poster.
3. Place hand sanitizer at all workstations and in all patient and staff rooms.
4. Confirm triage policy.  Answer the question “Do we see patients suspected of having A(H1N1) influenza?”  If no, prepare script for staff to advise patients where to go for care.  If yes, prepare script to consider A(H1N1) swine influenza infection in patients with acute, febrile, respiratory illness who have been in an affected region within the one week prior to symptom onset and/or who have had exposure to an A(H1N1) swine influenza infected patient or animal.  Script should include education on symptoms that necessitate an office visit and those that do not.
5. Change schedules of physicians and staff as needed to accommodate volume of sick patients.
6. Place suspected A(H1N1) patients in adequately-ventilated exam rooms.  If one or more rooms can be dedicated just to suspected A(H1N1) patients, containment can be more successful.  Limit the number of staff serving patients in these room.  Dedicate separate equipment to A(H1N1) swine influenza patients. If not possible,
   clean and disinfect equipment before reuse in another patient.
7. Review and reinforce the use of Standard and Droplet Precautions for specimen collection and for specimen transport to the laboratory.
8. For patient transport within health-care facilities, suspected or confirmed A(H1N1) swine influenza patients should wear a medical/surgical mask. All patients couging should be offered a medical/surgical mask at the time they enter the practice.
9. Monitor health of health-care workers exposed to A(H1N1) swine influenza patients.  Antiviral prophylaxis should follow local policy.  Staff with with symptoms should stay at home.
10. Treat any waste that could be contaminated with A(H1N1) swine influenza virus as infectious clinical waste and dispose of properly.
11. Clean soiled and/or frequently touched surfaces regularly with a disinfectant. e.g. door handles.
12. Wash all linen and laundry with routine procedures, water and detergent; avoid shaking linen/laundry during handling before washing. Use non-sterile rubber gloves.

Providing Information to Your Patients During a Pandemic Illness

1. Provide information on your website about:
   • Information about swine flu symptoms and possible contagion
   • Whether or not your practice will be seeing patients with these symptoms
   • Where patients you cannot see should go for care
   • Information on healthy habits to stay well during the swine flu episode
   • Podcasts, printable information and links to CDC or HHS about the swine flu
   • Information on any changes to your hours, or any any special clinic hours for urgent-care style care
2. If you use a Message on Hold product, duplicate the information above and point listeners to your website for more information.  If you are adding hours or “no-appointment” clinic to your practice for patients with swine flu, emphasize this information.
3. Develop patient handouts with information in an easily readable Question & Answer style.  Remember that it is recommended that patient education material be written at an 8th grade level.
4. If you have a system to mass email your patients, use it to send information to all your patients, pointing them to the resources on your website.

Staff Management During a Pandemic Illness

Now is the ideal time to improve your staffing protocols for being short-staffed.  Staff who are sick should stay home. If staff come to work exhibiting signs of influenza, they should be examined by a practice physician, and advised by that physician whether or not they are approved for work.

Short-staffing will bring into play the cross-training you’ve hopefully already achieved, and reassignment from staff in secondary task positions to primary task positions.  Answer the question “what needs to be done today to make the practice run” which are primary tasks, versus “what can slide for awhile until we get back on our feet?” which are secondary tasks.

Although many physicians reject the idea that employees can be productive at home, an illness episode like the swine flu is the ideal time to have employees work at home.  If you are not in need of employees physically in the clinic, they are well enough to work at home, and you have set up their home computer to VPN into the office server, this is a win/win situation for everyone.

If schools and daycares close duing an illness episode and many staff are unable to come to work due to no childcare, you may need to consider consolidating daycare at the home of one or more employees (fully funded by the practice, of course) or even bringing a temporary daycare onsite if you can turn an area into a safe and comfortable area for children, and assign employees to the daycare.

After the episode is over, you will probably have a number of employees concerned about losing so much time from work.  You may need to review your time-off policy with your physicians and decide if you want to make a single exception due to the length and severity of the episode and grant all staff additional paid time off.  Consider it carefully, however, as any single change has the potential of potentially setting a precedent.  You may want to discuss this with you HR attorney if you are unsure.

Again, make sure your staff have been thoroughly reviewed on Standard Precautions, Droplet Precautions and correct hand hygiene.  Masks should be available to any staff who request them.

Links for more resources:

CDC Swine Flu Public Service Announcements

CDC Guidance on Specimen Collection for Patients with Suspected Swine Flu

CDC Antiviral Recommendations for Patients with Confirmed or Suspected Swine Flu

CDC Guidance for Infection Control for Care of Patients with Confirmed or Suspected Swine Flu

Pandemic Flu Preparedness Guides for Families, Businesses, Medical Providers, and Community Groups Released by Trust for America’s Health

Knowledgeable, frequently-updated reports and discussion by a collective of public health scientists and practitioners

Sample Q & A for Patients

(Adapted from Thomas E. Gaiter, M.D. and chief medical officer, Community and Family Medicine at Howard University Hospital, online discussion Thursday, April 30. Full articlehere.

Q: Can H1N1 be spread in the swimming pool?

A: Thomas E. Gaiter: At this time, there are no reports that swine flu can be transmitted through the use of swimming pools. It is commonly believed that chlorine is effective in killing the virus. As with any situation in which individuals congregate, all precautions should be adhered to so as to prevent the spread of infection between individuals.

Q: Is it true that instant hand sanitizers offer no protection against catching this virus?

A: Hand hygiene is very important in decreasing the spread of this virus from human-to-human. This includes appropriate handwashing and the use of alcohol-based hand sanitizers which are effective. Hand sanitizers along with other measures of avoidance are recommended.

Q: Do  you recommend avoiding domestic flying at this time?

A: The Center for Disease Control (CDC) has not issued restrictions for domestic travel. However, if you are planning to travel, the following recommendations will help you to reduce your risk of infection: monitor the national international situation, prepare for your trip before you leave by visiting CDC’s website which discusses disease risks and health recommendations, practice healthy habits to help prevent the spread of infection, seek medical care if you feel sick and upon your return, monitor yourself for flu-like symptoms. Contact your physician as necessary.

Q: What immediate steps should a person take who suspects that he/she has contracted the virus?

Q:  There are still people here at the office coming in with ‘colds.’ We can’t open any windows here — as the building is completely sealed. Doesn’t matter if company policy tells you to STAY HOME if you’re sick…individuals STILL come in to spread the germs around. Not much you can do!

A: I must reiterate that those individuals who may be exhibiting flu-like symptoms should stay home and avoid close contact with others. This will assist in limiting the spread of any virus. It is important from an infectious disease standpoint that contact be limited by individuals manifesting respiratory symptoms until they are cleared by their physician.

Q: I’ve heard that face masks are not useful in preventing the spread of or catching the virus. Is that true? If so, why are people wearing it?

A: Face masks alone are not 100% effective in preventing the spread of infection. However, when used correctly, the mask functions as a barrier to minimizing the transmission of respiratory droplets amongst individuals.

Q: If, in fact, a pandemic occurs, what plans have been made for distribution of available medicines? Will the drugs be distributed only to hospitals, or to pharmacies as well?

A: The Department of Homeland Security has released 25% of its stockpile of Tamiflu and Relenza (antivirals to treat flu)to various states. Tamiflu is available by prescription at pharmacies and hospitals. The Department of Health in the various states and jurisdictions will identify their need and distribute these antivirals appropriately if necessary.

Q: I got a flut shot and a pneumonia shot too. Am I still safe?

A: I applaud your efforts in getting pneumococcal and influenza vaccines. These vaccines however are of little to no effect in fighting this virus. Currently no vaccine is available for swine flu.

Q: If you got the flu, how can you tell if its Swine Flu or just plain old regular flu? Is there a blood test or something?  If you go to the hospital, your waiting rooms are going to be unbelievably busy. What better place to catch it then the emergency room?

A: Some individuals have commented that we are fortunate from the standpoint of being at the end of the seasonal flu period. The signs and symptoms of swine flu are very similar to seasonal flu and only your physician can properly diagnose flu type. The swine flu is diagnosed via swab testing of the throat and nasal cavities. If testing is positive, specimens are generally sent for additional testing to the appropriate health department and/or CDC for confirmation.

Q:: As what point should people stop gathering in large groups? I know of a daily gathering of 435 people, and I am beginning to wonder if maybe we should ask the group to stop meeting for awhile until this threat is over.

A: Currently no recommendation is in place to completely avoid gathering of groups when there is no evidence of illness. Keep in mind that precautions must be adhered to inclusive of hand hygiene efforts. If individuals are ill, they should absolutely avoid large crowds or settings where close contact is required. Some jurisdictions have closed schools and public areas due to suspected cases of swine flu in an effort to minimize or decrease the spread of infection. It is important to continue to monitor the day-to-day developments of this health concern.

Q: How long until this has run its course?

A: The short answer is that we don’t know at this time. Recreational activities such as walking, biking, jogging, etc., still help us to maintain good health. Sunshine is also helpful so continue to enjoy.

Q: A lot of the people coming in with “colds” probably have allergies!

A: The pollen count has been reportedly high in a number of states. Reactions to such may indeed mimic some of the symptoms of the flu. Knowledge of the virus and the specific symptoms such as fever, fatigue, body aches, diarrhea, and vomiting should contrast allergies from flu syndromes.

Q: Why is swine flu different?:

A: Swine flu affects pigs and is not commonly found in humans. It is suspected that a mutation has taken place with this virus. We are therefore seeing infections passed from human-to-human contact. The other difference is that we are able to anticipate the strain of the seasonal flu in which vaccines are available for use. However, there is no vaccine available for swine flu virus (H1N1). The various health departments across the country are extremely concerned because of the ease of transmission. Although there has only been one reported death, as this virus moves across the country, the expectation is that we may begin to see more deaths associated with this virus. As you mentioned, there are thousands of deaths associated with seasonal flu and this is with a vaccine on board, so therefore, without a vaccine, this health concern raises a question as to the expected mortality rate associated with this virus.

Q: . We are roughly a month (or less) from: high school graduations, college graduations, college reunions and June weddings.  What is your take on this? Do you think a lot of these either will or should be canceled by the end of May? Is it just too soon to tell? I was looking forward to a really major college reunion but of course it’s not worth risking lives. What to do?

A: There is currently no CDC recommendation to cancel ceremonies. As always, one should assess the day-to-day situation because frankly, we are unable to indicate with a degree of certainty the duration of this health concern. Individuals who suspect that they are sick should avoid participating in large gatherings to prevent the spread of infection. I wish I could be more definitive, however, this is the information as we know it today.

Q: How long does the virus remain on objects? I’ve been wondering since I got a package from out of state recently. Is it possible for an infected person to cough/sneeze on something, mail it to a friend far away, and leave a trail of infection in his wake?

A: Droplets main remain viable on objects for a period of two or more hours. A package going through the mail system would have little to no viable droplets as you have described.

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Q: I can’t help but believe that all this hype about swine flue is way out of proportion to the risk involved. Why is there so much concern about swine flu when many more people are going to die from other causes (traffic accidents, heart desease, AIDS, drug wars) than from swine flue? Do we have our priorities straight?

A: In fact, we are aware from a previous pandemic that millions of people can become infected by viruses. It is prudent to address this health concern quickly to limit the spread nationally. You are correct in stating that other disease entities will in fact contribute to mortality rates in the U.S. with the number one killer being heart disease.