Preparing for Pandemic Influenza in Manitoba - Public Health - A Guide for the Public from the Office of the Chief Medical Officer of Health
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Public Health
Emergency Preparedness and Response
Preparing for Pandemic
Influenza in Manitoba
A Guide for the Public from the Office
of the Chief Medical Officer of Health
March 2006Manitoba’s Public Health Pandemic Influenza Plan
This is a living document that will be reviewed and updated on a regular basis by the
Office of the Chief Medical Officer of Health. The document will be a reflection of its time,
as new scientific information becomes available and as a result of our ongoing planning
process.
There is currently not an influenza pandemic in Canada or the world. It is important,
however, to be prepared and ready to respond in the event that one does occur.
This is a summary document that highlights key facts about pandemic influenza, public
health preparedness activities in Manitoba and how a public health response to pandemic
influenza will be handled in Manitoba. The goal of this document is to provide information
to the public about pandemic influenza, how public health is preparing, and how
individuals and families can prepare themselves.
Manitoba’s public health plan for pandemic influenza is based on the Canadian Pandemic
Influenza Plan. The Canadian Pandemic Influenza Plan can be accessed at the following
website: www.phac-aspc.gc.ca/cpip-pclcpi/
Preparing for Pandemic Influenza 1Table of Contents
Introductory Comments from Manitoba’s Chief Medical Officer of Health 3
1. Understanding Influenza
“Ordinary” Influenza and Pandemic Influenza 5
History of Influenza Pandemics 14
2. How will Pandemic Influenza affect Manitoba and What Can I Do?
The Potential Impact of Pandemic Influenza in Manitoba 15
What Can I do to Prepare Myself and My Family 16
3. Responding to Pandemic Influenza in Manitoba
Threat Levels for Pandemic Influenza 18
Assumptions used in Planning for a Pandemic Response 18
Pandemic Influenza Response Goals 20
Public Health Pandemic Influenza Strategy in Manitoba 20
Specific Components of Public Health Pandemic Preparedness
Efforts in Manitoba 21
List of Figures and Tables
Table 1.1 The Differences Between Ordinary Flu and Pandemic Flu 12
Table 2.1 History of Pandemic Influenza 14
2 Preparing for Pandemic InfluenzaPandemic Influenza and Other Respiratory Disease Threats
Introductory Comments from Manitoba’s Chief Medical Officer of Health
Manitobans are familiar with influenza – Avian (bird) influenza has been identified
“the flu” – which returns to Manitoba every in poultry and birds for many years. The
winter. Although symptoms of the flu – H5N1 strain was first discovered in a
fever, cough, tiredness and muscle aches – small number of humans in Hong Kong in
are often severe, most people are back 1997. Avian flu is not a pandemic influenza
on their feet within a few days. Influenza because it does not spread easily from
and other respiratory infections cause human to human.
increased absenteeism from school and
work in the winter months. For some, Manitobans, like others around the world,
serious complications and death can occur may not know when the next pandemic
– especially the very young, the elderly will be, but are preparing to respond
and those with chronic medical conditions. when the next pandemic arrives. How
Although not always confirmed by bad could it be? Perhaps, not as bad as
diagnostic tests, it is estimated that about some are fearing. Nevertheless, we need
100 deaths are associated with influenza to be prepared. An effective response
every year in Manitoba. to a pandemic, including appropriate
use of vaccines, antivirals, other public
To fight these effects, Manitobans at high health measures and treatment, should
risk, their caregivers and all health care significantly reduce the rate of severe
workers are encouraged to get an annual illness and death, as well as the levels of
flu shot. Getting a flu shot every year is fear and social disruption. The health of
necessary because there are many different Manitobans and the abilities of our health
influenza strains and each year they system are much better now than they were
undergo mild changes (drifts). About three during previous pandemics, so we have
times a century, a more dramatic change good reasons to be optimistic about our
(shift) occurs in an influenza strain. When ability to withstand the next pandemic.
that happens our immune systems have
no specific antibodies or immune cells to
fight the new strain. When a new strain
of influenza causes significant illness and
spreads from human to human around the
world, it is called a pandemic influenza.
We do not have a pandemic influenza in
Canada or anywhere in the world at
this time.
Preparing for Pandemic Influenza 3The public health plan described here diseases such as diabetes, injuries
is the result of the hard and good work and mental health. If we can address
of many – but there is more to do. Our the underlying causes of our major
goal is that every Manitoban – whether health problems, especially for those
a health care worker, essential service populations and groups at greatest risk,
provider or parent - will know what they we will go a long way to reduce the
need to do to care for themselves and impact of any new public health threat,
others. This will help reduce illness not only a pandemic influenza.
and keep our province and its towns
and cities functioning well during a While focusing on pandemic influenza,
pandemic. it is intended that these plans can be
used to address other new or emerging
Like all public health issues, it is public health problems.
important to keep things in perspective.
While it is necessary to prepare for the As Manitoba’s planning evolves, this
next pandemic, we must also continue document will be updated to keep
to address today’s public health everyone informed of the progress.
threats – infectious diseases such as
Dr. Joel Kettner
tuberculosis and HIV/AIDS; chronic
4 Preparing for Pandemic Influenza1. Understanding Influenza
“Ordinary” Influenza and Pandemic Influenza: Key Facts
What is “ordinary” influenza (flu)? Every year during the winter months,
Influenza, commonly called “the flu,” is Manitoba experiences an epidemic of
caused by the influenza virus, which infects influenza. There are three types of influenza
the respiratory tract (nose, throat, lungs). - A, B and C - as well as subtypes, all of
Influenza is highly infectious and can which can cause infection in humans.
spread easily from person to person. Influenza A viruses are the most common
cause of winter influenza epidemics.
What are the symptoms of the flu? Influenza B viruses circulate at lower levels
causing less severe outbreaks, particularly
Influenza affects people with different
among young children in schools. Influenza
degrees of seriousness, ranging from minor
C viruses are typically mild and usually
symptoms through to pneumonia and
not considered a public health concern.
death. Influenza usually appears with a
Influenza viruses undergo minor changes
sudden onset of symptoms that typically
every year, causing the need for annual
feature fever and a cough, and may include
influenza immunization to protect against
one or more other symptoms such as:
circulating strains of flu viruses.
• aching muscles and joints
• headache Fortunately, this annual variation in
influenza viruses is usually minor. This
• severe weakness and fatigue
allows scientists to guide vaccine
• sore throat manufacturers in producing annual
• runny nose vaccines that are generally effective for
circulating viruses. These vaccines protect
Children can have additional gastro-
individuals at high risk of developing
intestinal symptoms, such as nausea,
complications from influenza. Over the
vomiting and diarrhea, but these symptoms
years, most people have acquired some
are uncommon in adults.
resistance to circulating types of influenza.
Although the term "stomach flu" is As a result, the effects of influenza from
sometimes used to describe vomiting, year to year are greatest in people with
nausea or diarrhea, these illnesses are lowered immunity, such as young children,
caused by other viruses, bacteria or the elderly and those with chronic diseases.
possibly parasites, and are rarely related to This is why these high-risk groups are
influenza. targeted for immunization each year, along
with those at risk of spreading influenza to
them, such as health care workers.
Preparing for Pandemic Influenza 5How is influenza spread? How do I know if I have influenza?
Influenza is easily passed from person Respiratory illnesses caused by
to person by droplets and small influenza are hard to distinguish
particles released into the air when from other respiratory illnesses by
infected people cough or sneeze. symptoms alone. Generally speaking,
The virus can travel about one metre in if you have a fever and a cough when
the air and has been shown to survive influenza viruses are known to be
on hard, non-porous surfaces (ex: circulating in the community, there
telephones and doorknobs) for 24 to 48 is a good chance that you may have
hours; on cloth, paper and tissue for influenza. Swabs may be taken from
eight to 12 hours and on hands for five sick individuals by doctors and sent
minutes. The virus survives better at for laboratory testing. This helps to
low humidity, like we experience during determine when the flu has reached
winter. Manitoba and to monitor the types of
flu viruses circulating in the province.
The influenza virus enters the body This testing is performed by some
through the nose or throat. This physicians in Manitoba as part of the
can happen when someone inhales national FluWatch program.
droplets produced by the coughing or
sneezing of others; after hand-to-hand During confirmed influenza outbreaks,
contact with infected individuals; or, many people seeking medical advice
after handling objects contaminated by for upper respiratory tract infections
infected individuals, then touching their could be infected by influenza. Testing
mouth, eyes or nose. Once infected of all affected individuals is neither
with the influenza virus, it usually takes necessary nor practical. Rapid
from one to three days to develop diagnostic tests that can be used
symptoms. However, someone with to detect influenza viruses within
influenza can be contagious from the 30 minutes have recently become
day before they develop symptoms available. However, these tests are not
up to seven days afterwards. Not widely available and are reserved in
everyone who is infected with influenza Manitoba for specific circumstances,
gets sick, but it is still possible for them such as to confirm an outbreak in a
to spread it to others. The disease personal care home.
spreads very quickly, especially in
crowded situations. Because of this,
and the fact that the virus can survive
outside the body longer in cold and
dry weather, seasonal epidemics
in Manitoba (and the Northern
Hemisphere) occur in the late fall and
winter and are generally over by spring.
6 Preparing for Pandemic InfluenzaHow is flu activity monitored? The most recent Influenza A pandemics
Manitoba participates in the national occurred in 1957 (Asian influenza) and
FluWatch program to monitor flu activity in 1968 (Hong Kong influenza). Each caused
Canada. Volunteer doctors take part in the significant illness and death around the
FluWatch program in Manitoba and submit world. The most infamous pandemic was
weekly reports to the Public Health Agency the Spanish Flu, which is believed to have
of Canada (PHAC) on the number of people killed at least 40 million people worldwide
they see with flu-like illnesses in a typical in 1918 and 1919. During this pandemic,
day. Samples are submitted to the public the death rate was highest among healthy
health laboratory for flu testing. The PHAC young adults. This is directly opposite to
monitors and identifies circulating strains annual influenza epidemics, which identify
of the influenza virus in Canada. The World high-risk groups like the youngest and
Health Organization (WHO) analyzes data oldest, and those with chronic illnesses.
from around the world and, early in the This explains why a pandemic could pose
year, recommends strains to include in the such an impact on everyday activities and
vaccine to make sure it is effective against essential functions.
recently circulating strains.
Based on historical patterns, public
What is pandemic influenza and how is it health experts predict that a pandemic
different from ordinary flu? will occur. However, it is not known when
this will happen, where it will emerge,
Influenza A is the type involved in all or how severely people will be affected.
known influenza pandemics. This is Theoretically, it is possible that a new
because these viruses can undergo major influenza virus could emerge from a re-
changes or shifts in makeup, producing a assortment of genetic material among
completely new strain. Most people have different sources of influenza viruses,
not built up any immunity to a new strain including human, avian (bird) and swine
of influenza. As a result, large numbers of (pig) origin. This could happen if someone
people become infected as it spreads. An were infected with a human influenza virus
epidemic like this that spreads throughout and an avian or swine influenza virus at
the world is known as a pandemic. For a the same time. This is why public health
pandemic to occur, it must be a new virus officials are concerned about outbreaks
(to which the population has no immunity) of avian or swine influenza where humans
and easily spread from person to person. become infected.
There were at least three pandemics in the
last century.
Preparing for Pandemic Influenza 7What are the key characteristics of It is obvious that the effects of a
pandemic influenza? pandemic would be much wider than
Experts look at a number of key just the health sector. As a result,
characteristics when deciding if all parts of society and government
a particular flu virus is a potential must review their business continuity
pandemic strain. planning as a priority, paying
particular attention to human resource
For a new influenza virus to be contingency planning. Given the
capable of causing a pandemic, potential effects of a pandemic and the
it must be able to: broad scope of preparedness activities,
the Government of Manitoba has the
• infect people (not just responsibility to make sure that co-
mammals and birds) ordinated preparedness and response
• cause illness in a high efforts are undertaken in our province.
proportion of those infected
• spread easily from person to Is this something Manitobans should
person be afraid of?
All previous influenza pandemics Pandemic influenza could affect much
exhibited these characteristics. more than the health sector. As people
avoid business or entertainment
Why should we be prepared for a activities, a pandemic could affect all
pandemic? parts of society including the delivery of
critical services.
In a typical flu season, up to 20 per
cent of the population could get In a pandemic, we expect there may
sick. In a pandemic, this number not be enough health care providers
could be much higher, and cause or resources to meet the increased
more serious illness. When planning demand for health services.
for a pandemic, we must prepare for
situations where many health care Some Manitobans may find it scary
workers and other essential workers to think about the effects a pandemic
could become ill when there is an may have on rates of illness and death.
increase in demand for their services. However, we must put these fears into
perspective. There is no confirmed
evidence of any human-to-human
spread of a new influenza virus at
this time. In addition, Canadians are
generally healthier now than during
previous pandemics and our health
system is better than ever before.
Measures are being taken to increase
our capacity to respond to the threat of
a pandemic.
8 Preparing for Pandemic InfluenzaManitoba Health is working with Manitoba’s What is being done to protect people
regional health authorities, other provinces from pandemic influenza?
and territories and the Public Health Agency Due to the widespread effects of pandemic
of Canada, to make sure an excellent influenza, planning for a pandemic
public health surveillance system is in place requires the involvement of the health
locally, provincially and nationally. The sector, other government sectors, non-
system will detect new strains of influenza government organizations and ultimately,
and other communicable diseases early so the participation of all Manitobans.
we can respond quickly and effectively. In
turn, the Public Health Agency of Canada is Manitoba Health is working within the
working with the World Health Organization department and with the regional health
to make sure a strong global surveillance authorities and other partners in health
system is in place. service delivery, to make sure that business
continuity plans are in place for the health
Through global surveillance systems, sector. These business continuity plans will
the avian influenza situation is being help us respond to any emergency affecting
monitored closely. Measures are being the health sector, whether a public health
taken internationally to reduce the chances emergency (ex: pandemic) or another type
that human and avian influenza strains will of emergency (ex: natural disaster).
mix, as this could create a new strain of
influenza to which people would not be We do not know what strain of influenza will
immune. cause the next pandemic. Some believe
that it will be caused by an avian influenza
The collaborative efforts of all levels of virus that mutates into a virus that is able
government to contain the avian influenza to infect people and be transmitted from
outbreak in British Columbia in spring 2004 person to person. For this reason, public
demonstrated how well animal and human health officials and scientists monitor avian
surveillance and health systems can work influenza outbreaks and instances where
together. Manitoba Health has a close people have become infected. International
working relationship with counterparts in public health alerting mechanisms are in
the animal health field and is working to place and Canada plays a key role in this
enhance links between animal and human global public health surveillance network.
influenza surveillance.
Preparing for Pandemic Influenza 9An effective vaccine1 is the main • Improve your overall health.
defence against an influenza pandemic. In general, healthier people are
But, until that vaccine is available, better at fighting off disease.
antivirals2 may be an important part of To stay healthy, you should eat
healthy foods, live an active
our response. This shows the need for
lifestyle, don’t smoke and avoid
a balanced and multi-faceted strategy,
heavy alcohol consumption.
including providing information to the Get enough sleep and try
public on self-care and care of others to maintain a positive and
at home, communicating when to stay balanced outlook.
home and when to go to work during
a pandemic, and where and how to • Wash your hands often.
access health services. Washing hands is the most
effective way of preventing the
The purpose of this document is to spread of disease. Get into the
give Manitobans information about habit of washing your hands
pandemic influenza and efforts to often with soap and warm
prepare for such a public health water, scrubbing your wrists,
palms, fingers and nails for 10
emergency. More information about
to 15 seconds. Rinse and dry
specific readiness and response
with a clean towel. This should
measures is outlined in the sections be done especially before
that follow. meals, after using the toilet,
and after you cough, sneeze
What can I do to prevent myself from or blow your nose. Teach your
getting infected with influenza during children to do the same.
a pandemic?
• Avoid visiting people who have
Public health officials expect that if the flu if you are able to do so.
a new type of influenza emerges and This will help prevent you from
causes a pandemic, this virus will becoming infected. This advice
spread like the influenza viruses that must be balanced with the
cause outbreaks each winter. Influenza need to provide support and
is highly contagious, so it spreads care to sick people. Caregivers
quickly in families and communities. to sick people should wear a
There are, however, some steps you mask when coming face to
face with a coughing individual
can take to reduce your risk
to reduce the risk of catching
of infection.
influenza.
1
Vaccines are given by a needle in your arm. Vaccines cause 2
Antivirals are drugs prescribed by your doctor and used for
the body to produce antibodies against the flu virus in the the prevention and early treatment of influenza. Antiviral drugs
vaccine, providing immunity from the virus. The influenza work by reducing the ability of the virus to reproduce; however,
vaccine contains inactive virus, so it cannot cause influenza. they do not provide immunity from the virus. Some antiviral
In a pandemic, a vaccine specific to the pandemic influenza drugs are available as capsules (pills) that must be swallowed
virus affecting people will need to be developed. This is and some of these are available as a liquid; others are powders
considered to be the most effective tool to protect the public in that must be inhaled.
a pandemic.
10 Preparing for Pandemic Influenza• Avoid large crowds. including the influenza virus,
Large crowds are ideal for the although they will be effective
spread of influenza, so at the time against complications caused
of a pandemic, public health may by bacteria such as pneumonia.
recommend that people avoid large Avoid going to work or social
gatherings. In general, the wearing gatherings if you are sick. During
of masks by well individuals a pandemic, if you are sick with
during daily activities is not a symptoms of influenza and need to
recommended preventive measure. visit your doctor, you should wear
At the time of a pandemic, specific a face mask to prevent spreading
recommendations will be made by infection to others. At the time of
public health officials as needed. a pandemic, Manitoba Health will
provide information on steps you
• Don’t share eating utensils can take to help care for yourself if
or drinks. you have influenza.
If a family member is sick, keep
their personal items (ex: towels and • What if my child is sick?
toothbrushes) separate from those Like adults, most children get
of the rest of the family. better from influenza without any
specific treatment. Sick children
• Get a vaccine when available. should be kept home from school
Vaccination is the main way to and daycare. At the time of a
prevent influenza and reduce the pandemic, Manitoba Health will
effects of epidemics. Various types provide information on steps you
of influenza vaccines have been can take to help care for your
available and used for more than 60 children if they have influenza.
years.
During a pandemic, it will be
• Take antivirals if recommended important to:
by your doctor.
When taken before or immediately • follow directions given by
after exposure to influenza virus, public health officials.
but before symptoms have These may change over time
occurred, antivirals may help as more information becomes
prevent illness. If symptoms available about the characteristics
have already occurred, their early of the particular virus causing the
administration may reduce the outbreak.
duration and severity of symptoms.
• follow infection control
• What if I think I have the flu? procedures if caring for
Most people with influenza recover a person with influenza.
without any serious problems. Providing care to a person with
The disease can last for four to an influenza-like illness will be
seven days and leave a cough common during a pandemic.
and tiredness for several weeks. The likelihood of transmitting the
In general, there is no specific disease is reduced by following
treatment for influenza. Antivirals basic precautions. Watch the
may occasionally be prescribed Manitoba Health website for
by your doctor. Antibiotics are updates.
not effective against any virus,
Preparing for Pandemic Influenza 11Table 1.1: The differences between ordinary flu and pandemic flu:
Ordinary Flu Pandemic Flu
When, Where Every year during the winter months in Occurs about three times a century and
Canada and the rest of the Northern can take place in any season.
Hemisphere. A pandemic is a global event.
Who Affects Manitobans every winter. Affects more people than ordinary flu;
one-quarter or more of the world’s
population.
How • Severe illness and deaths are • Pandemic flu is associated with
generally confined to people much higher rates of illness, and a
over age 65; people with existing higher severity of illness and death.
medical conditions like lung
diseases, diabetes, cancer, kidney • The worst flu pandemic of the last
or heart problems; people with century - the 1918 Spanish Flu
weak immune systems and the - caused about 30,000 to 50,000
very young. deaths in Canada alone and at least
20 to 40 million deaths worldwide.
• Four thousand deaths in Canada Some experts believe that these
and approximately 100 deaths in estimates are low.
Manitoba are attributed to influenza
each year. These are cases where
flu is known or highly suspected
to have played a role in a person’s
death.
Prevention • A slightly new vaccine is produced • A vaccine against a pandemic type
—Vaccines every year to ensure protection from of influenza will not be available at
the types of influenza expected to the start of a pandemic.
circulate in the community.
• This is because the virus type
• This is required every year due to will be completely new. It will
small changes in influenza viruses be different from the viruses that
from one year to the next year. circulated the previous winter, and
not predictable in the same way.
• The vaccine is effective because
scientists are able to predict fairly • Once a pandemic is detected,
reliably which types of influenza scientists need to identify the
virus will circulate during the virus. A specific vaccine is then
annual flu season in the Northern manufactured based on the
Hemisphere, based on flu activity in scientific findings.
other parts of the world.
• It is anticipated that a specific
vaccine will become available for
use on a prioritized basis within four
months.
12 Preparing for Pandemic InfluenzaOrdinary Flu Pandemic Flu
Prevention and • Antiviral drugs can be used to • Antiviral drugs are expected to be
Treatment— both treat and prevent influenza in limited supply.
Antivirals infections.
• Countries, including Canada,
• Currently, antiviral drugs are used are stockpiling the antiviral drug
to manage outbreaks of influenza oseltamivir (Tamiflu ).
®
in long-term care facilities and to a
lesser extent, to protect and provide • Manitoba has participated in
early treatment for people at risk of national purchasing initiatives
becoming seriously ill due to stockpile Tamiflu for use in a
®
to influenza. pandemic. The use of antivirals
during a pandemic will depend on
the nature and characteristics of the
outbreak.
Preparing for Pandemic Influenza 13History of Influenza Pandemics
Historical Background differences. These differences are not only
Despite predictions that an influenza between pandemics, but even within a
pandemic will occur at some point in single pandemic in different geographical
the future, there is much that we can’t areas. The following is a brief overview of
predict. The influenza pandemics that the major influenza pandemics in the last
took place in the last century share some century.
similarities; however, there have also been
Table 2.1
Pandemic “Spanish Flu” “Asian Flu” “Hong Kong Flu”
Strain A(H1N1) A(H2N2) A(H3N2)
Year 1918-1919 1957-1958 1968-1969
Likely origin Not known (first China China
cases identified
in Europe and the
U.S.)
Estimated Deaths:
Global At least 20 to 40 1-2 million 1-4 million
million – some
experts believe this
is a low estimate
Canada 30,000-50,000 not known not known
Age Group Most Healthy young Very young and Very old and those
Affected adults (20 to 50 very old with underlying
years) medical conditions
14 Preparing for Pandemic Influenza2. How Will Pandemic Influenza Affect Manitoba and
What Can I Do?
It is not possible to predict when a The potential effects of
pandemic will occur. However, it will pandemic influenza in Manitoba
likely start elsewhere in the world, then
We will not know how big the effects
spread across the globe. Therefore,
of an influenza pandemic in Manitoba
once a pandemic starts, it will only
will be until it happens. A pandemic
be a matter of time before it reaches
may affect the population like ordinary
Canada and Manitoba. It is also
influenza, where the youngest
not possible to predict who will be
and oldest and those with chronic
most affected by the pandemic or
conditions are most severely affected.
how severely they will be affected.
Or, a different age group or section
There is much uncertainty associated
of the population might be affected.
with estimating the scale of illness,
A model for estimating the potential
hospitalization rates and death rates.
impact of an influenza pandemic has
We are still learning about pandemics
been used to calculate estimates for
that occurred in the 20 century. What
th
planning purposes. In Canada, it is
we do know, however, is that there
thought that approximately 4.5 to
will likely be a significant impact on
10.6 million people could become ill,
Manitobans and the health services
resulting in 11,000 to 58,000 deaths.
they rely on for routine, emergency and
long-term care. Health care providers The same model applied to Manitoba
and other service providers will be at would lead to approximately 176,000
risk like the rest of the population, just to 410,000 people becoming ill,
as the demand for their services will resulting in 700 to 1,600 deaths.
rise greatly. To make sure the province is prepared,
Manitoba is developing plans to
prepare for 410,000 Manitobans
becoming ill and between 4,100 to
6,100 potential deaths. There is still
much we do not know about previous
pandemics, such as the precise effects
on the population. However, we are
a considerably healthier population
now than in the past; and we have
access to a wide range of interventions,
such as antiviral drugs, vaccines and
antibiotics, supported by a highly
developed health care system. Careful
and comprehensive planning will help
reduce the illness and deaths that could
possibly result from a pandemic.
Preparing for Pandemic Influenza 15i. Impact on Health Care closing schools to minimize
A pandemic will place great the spread within a community,
pressure on Manitoba’s health particularly if school-age children
system. Higher-than-usual are among the groups most
numbers of people will seek affected by the virus. School
care for influenza and its and child care authorities will
complications. Health care and collaborate with public health
other pandemic responders officials during a response to a
will also become ill. This will pandemic.
decrease the health workforce
and increase demand for iv. Impact on Services
services, likely resulting in The manufacture and
service delays. Some services transportation of goods and all
may be unavailable. Health kinds of services are likely to be
human resource contingency affected by a pandemic influenza
planning takes into account the due to the number of people
varying degrees of a pandemic’s expected to get sick. Disruption
effects. Appropriate self-care may also result from public
and care for family members health and other types of control
at home will be more important measures that countries around
than usual. the world may implement,
such as restrictions on public
ii. Impact on Business gatherings and other activities.
A pandemic will also affect
businesses, with staff getting sick What Can I do to Prepare Myself
and staying home. Customers and My Family?
may decrease in numbers due
to illness or because people are • Plan ahead. We don’t know
staying at home. This could have if the next emergency facing
a negative economic impact Manitoba will be pandemic
on business and therefore, on influenza or a natural disaster.
Manitoba. Business continuity Therefore, you should make
plans should identify core general family emergency
services and address how preparedness plans, such as
services will be maintained in making sure your family has
the event of an increase in staff enough food, drinks and basic
absenteeism rates. household items to last for
at least one week. For more
iii. Impact on Schools information on general family
Influenza spreads rapidly in preparedness, please refer to the
schools each winter. During Manitoba Emergency Measures
a pandemic, this spread is Organization’s family emergency
expected to occur even more preparedness checklist:
quickly. Higher than normal www.gov.mb.ca/emo/
student and staff absenteeism handbook/checklist.html
rates are expected during a
pandemic. Schools may also
be affected by disruptions to
transportation services. Public
health officials may consider
16 Preparing for Pandemic Influenza• Plan with your neighbours Have a plan to check on sick
and community to support people living alone. Remember
each other in times of that schools and child care
emergency. Make sure you centre may be closed. Have
have someone you could call a backup plan to care for your
for help if you were to become children.
seriously sick.
Some key points to remember:
Ordinary Influenza—what you can do now
• During influenza season, you should wash your hands regularly, cover your
mouth when you cough, cover your nose and mouth when you sneeze, and
teach these basic hygiene practices to children. Stay home when you are sick
to avoid spreading it to others.
• High-risk individuals and health care providers should be vaccinated annually
against influenza.
• For more information on Manitoba Health’s eligibility criteria for influenza vaccine,
visit www.gov.mb.ca/health/flu/
Pandemic Influenza—what you should know
• We can’t prevent a pandemic from happening and we don’t know when one
might take place.
• Should a pandemic occur, specific advice to the public will be communicated
through regular channels, such as the media, Health Links-Info Santé, websites
and health care providers.
• Direction and advice to the public, health care providers and others will be
based on the immediate situation and will include actions people can take to
help themselves, their families, their neighbours and their communities.
• Watch the Manitoba Health website (www.gov.mb.ca/pandemic/)
for information on pandemic influenza and listen to your local news
for important updates on preparedness and current events.
Preparing for Pandemic Influenza 173. Responding to Pandemic Influenza
Threat Levels for Pandemic Assumptions Used in Planning
Influenza for a Pandemic Response
Globally, we are currently in a Since we do not know the precise
pandemic alert period. There are characteristics of a future pandemic,
several levels indicating the threat of a planning is based on several
pandemic. Determining the level of risk assumptions. We know that rapid
is based on knowing if a new influenza virus identification and analysis will
virus has been detected, how people be important to allow our plans to
are being affected, whether the new adapt quickly as events unfold. These
virus is able to spread from person to assumptions include:
person, and if so, how easily it can be
spread. Each alert level requires a set of Characteristics of a Pandemic Virus:
specific public health activities. These • The virus causing the next
activities prepare the health system to infuenza pandemic will be a
detect, report, respond to and analyze new strain of influenza A virus
any cases of human illness caused to which the population may
by the new virus, and to manage the have little or no immunity.
demands on the health sector should an
• The incubation period, or the
outbreak or pandemic occur.
length of time from exposure to
symtom onset, is expected to
Key actions during the pandemic
be that of a typical influenza A
alert period include enhancing normal
virus – one to three days.
operating systems and making sure
contingency plans are in place for • The time frame when the virus
managing a surge or increased demand can spread from one infected
on regular systems. The specific person to others will be from
type and intensity of these activities 24 hours before onset of
depends on how many people have symptoms up to seven days
been affected by the new virus, the afterwards. This time frame
location of the outbreak, and whether may be longer in children and
people with decreased immune
the virus has shown it is able to spread
systems.
from person to person.
• Many people will be infected
but show no symptoms or mild
symptoms. These people could
still spread the virus to others.
• The virus will be spread by
droplets from coughing and
sneezing, and by touching
objects that have been
contaminated with droplets
from infected people.
18 Preparing for Pandemic InfluenzaOnset of a Pandemic: Impact of a Pandemic:
• A new flu virus could arise in • In general, most people will
any country. However, it is not have specific immunity
most likely to occur in Asia, to a new strain of influenza
where the close proximity of virus and will be susceptible
dense populations to domestic in a pandemic. How well our
animals may allow for mixing immune systems will be able
of influenza genes. to fend off disease during a
pandemic will, in part, depend
• The emergence of a new on our overall health.
influenza virus does not
necessarily mean the onset • The intensity of a new flu virus
of a pandemic. For this to and the age groups it targets
happen, three factors are will have a major influence on
thought to be important: little its effects.
or no human immunity to the
new virus, the ability of the • The improved health of
virus to cause serious illness people today, antivirals,
in people, and the ability of vaccines and modern health
the virus to spread efficiently services will have positive
from person to person. False effects on mortality rates,
alarms are also possible. compared to previous
pandemics. However,
Spread of a Pandemic: much will depend on the
characteristics of the new flu
• The first peak of illness in virus.
Canada may occur within two
to four months after the virus For more background information on
arrives in Canada. The first pandemic influenza, please refer to the
peak in deaths is expected Canadian Pandemic Influenza Plan:
about one month after the www.phac-aspc.gc.ca/cpip-pclcpi/
peak in illness.
• Historically, pandemics tend to
spread in two or more waves,
either in the same year or in
successive influenza seasons.
A second wave may occur
within three to nine months of
the initial outbreak wave and
may cause more serious illness
and deaths than the first.
• In any place, including
Manitoba, the length of each
wave of illness is likely to be
six to eight weeks.
Preparing for Pandemic Influenza 19Pandemic Influenza Response Goals • developing public health
measures to prevent or delay the
Manitoba’s goals are the same as those spread of infection
of the Canadian Pandemic Influenza Plan,
namely: • developing effective and accurate
methods of diagnosis and
• to minimize serious illness treatment, including supportive
and deaths care and antibiotics for bacterial
complications
• to minimize societal disruption
Strategy Principles:
Manitoba’s response to public health
Public Health Pandemic Influenza emergencies, including pandemic
Strategy in Manitoba influenza, is based on the following
principles:
Manitoba Health has done considerable
work to prepare for public health • Strengthening existing systems
emergencies, specifically pandemic and processes
influenza. This work is part of our daily Pandemic planning is being
efforts to provide quality public health included, as much as possible, in
policy direction and program support to regular operations. For example,
the regional health authorities, who provide expanded immunization programs
public health programs and services to strengthen the capacity of related
Manitobans. This work is ongoing, and we systems and infrastructure.
work hard to make improvements as new
• Building generic systems
information becomes available and processes
Manitoba needs to prepare
While we are confident in our health system,
for many possible health
we know there is more work ahead. Both emergencies, including an
within and beyond public health, we need influenza pandemic or any other
to prepare for a public health emergency on respiratory disease outbreak.
the scale that an influenza pandemic could Since we cannot predict
create. We can’t prevent a pandemic from emergencies before they happen,
occurring and it is unlikely that the global we must have a system that can
spread of a pandemic flu virus could be readily adapt to meet the needs
prevented once it emerges. The emphasis of any emergency response. It
in pandemic flu response, therefore, is on is more efficient to build a core
reducing the effects. There are several ways response system and adapt it to
meet the needs of a single event
the health system can do this, including:
than to build individual response
systems for each possible event.
• providing vaccines (once they
become available)
• using antiviral drugs
20 Preparing for Pandemic Influenza• Collaborating with and i. Surveillance
being consistent with other Surveillance is critical to the work
jurisdictions of public health and is required
Due to the far-reaching effects of to detect and assess an outbreak
a significant respiratory disease and to identify the cause. Canada
outbreak, such as a pandemic, it is participates in global surveillance
essential for Manitoba’s plan to be efforts for influenza and other
as consistent as possible with the diseases, and within Canada, the
nationally agreed-upon approaches, provinces and territories participate
and for our actions to be in national surveillance efforts.
co-ordinated. This co-ordination The national system is in place for
occurs with many organizations the rapid detection of respiratory
including regional health authorities, illnesses causing unusually severe
the Public Health Agency of illness and/or death. This system
Canada, First Nations and Inuit allows public health to provide
Health Branch of Health Canada early warning and assessment of
and other provinces and territories. potential new cases of emerging
respiratory infections, such as with
a pandemic strain of influenza.
Specific Components of Public Established Systems and Processes for
Health Pandemic Preparedness Influenza and Other Respiratory Disease
Efforts in Manitoba Surveillance in Manitoba
Manitoba Health receives information on
Manitoba already has existing systems
influenza activity through the following
and resources to deal with respiratory
routine surveillance initiatives:
disease outbreaks. We are also working
to make improvements as needed and
• Outbreak detection, reporting and
ensure these systems have the capacity to
management: Regional medical
deal with a public health emergency such officers of health, healthcare
as a pandemic. In keeping with nationally practitioners and regional health
agreed-upon approaches, the components authorities report significant
of Manitoba’s plan that address a influenza developments to Manitoba
respiratory disease outbreak complement Health, such as outbreaks of
corresponding national plans. influenza in hospitals, nursing
homes and schools.
• School absenteeism: Schools
report absenteeism rates above
10 per cent to public health in
their region. When authorized by
a medical officer of health, public
health nurses will test a small
number of ill children for influenza
to find out if an outbreak of
influenza is occurring.
Preparing for Pandemic Influenza 21• Influenza-like illness activity • National guidelines on
monitoring: A number of pre- surveillance and reporting of
identified doctors report weekly emerging respiratory diseases
on influenza-like illness activity are in place and Manitoba
in their practices. They also follows these guidelines.
contribute to influenza virus
surveillance by performing • When there is a situation
throat swabs on some patients. of concern about severe
respiratory illness in Manitoba,
• Influenza virus activity– key public health responders
laboratory monitoring and at the regional and provincial
reporting: Cadham Provincial levels are notified. When such
Laboratory reports all an alert is issued, efforts are co-
confirmed influenza results ordinated to further investigate
by rapid antigen testing and sick individual(s), their contacts
culture. In Manitoba, both the and the possible source of
Cadham Provincial Laboratory infection.
and the National Microbiology
Laboratory in Winnipeg perform • Any laboratory detection
testing to identify the specific of a new respiratory virus
types of influenza virus causing in Manitoba is reported to
illness in the province. Manitoba Health. The director
of the Cadham Provincial
The following systems are currently Laboratory participates in
in place for emerging respiratory the Canadian Public Health
diseases, including a new strain of Laboratory Network. This
influenza. These systems will be used network provides surveillance
for pandemic influenza: recommendations and
standards for public health and
• When a new or re-emerging laboratories, especially during
respiratory disease is detected evolving crises.
anywhere in the world, the
• Other provinces, territories
World Health Organization
and the Public Health Agency
informs the Public Health
of Canada are notified of
Agency of Canada, which
situations of concern or known
notifies provincial and territorial
or suspected cases, through
public health officials. Through
a secure national electronic
a variety of national networks,
surveillance system.
the provinces, territories and
federal government discuss
and develop recommendations
for enhanced surveillance and
for any actions that are being
taken or should be taken.
22 Preparing for Pandemic Influenzaii. Vaccine and Antiviral Strategy Manitoba’s Vaccine Strategy for
General information is provided below on Pandemic Influenza
vaccines and antiviral drugs, followed by Pandemic preparedness for vaccines
details of Manitoba’s strategy for vaccine includes making sure we have the capacity
and antiviral use during a pandemic. to carry out mass immunization campaigns.
As vaccine becomes available, the goal
General information about vaccines and is to immunize the entire population. It
antiviral drugs may be neccessary to provide two doses
Vaccination is considered the most effective of vaccine to each individual. However,
way to protect the public from pandemic since the vaccine will be available in a
influenza. Influenza vaccine causes the series of shipments, priority groups will
body to produce antibodies against the flu be first to receive the vaccine. As soon
virus in the vaccine, providing immunity as Health Canada approves the new
from the virus. The vaccine contains vaccine, Manitoba Health, regional health
inactive virus, so it cannot cause influenza. authorities and other health service delivery
organizations will work together to mount
Antivirals are drugs used for the prevention a province-wide mass immunization
and early treatment of influenza. When campaign. Planning for mass immunization
taken before or immediately after exposure is underway.
to influenza virus, but before symptoms
have occurred, antivirals may help prevent How will vaccine be distributed during a
illness. If taken very soon after getting sick pandemic?
(within 48 hours), they can reduce influenza Vaccination is the cornerstone of the
symptoms, shorten the length of the Canadian and Manitoba pandemic influenza
illness and potentially reduce any serious preparedness plans.
complications. Antivirals work by reducing
the ability of the virus to reproduce; The goal of Canada’s pandemic vaccine
however, they do not provide immunity from strategy is to produce enough vaccine
the virus. to protect all Canadians as quickly as
possible. Manitoba shares this goal for its
Influenza is a viral infection and antibiotics population. Once available, the goal is to
do not work against viruses; however, immunize all Manitobans on a priority basis.
antibiotics may be prescribed to treat
secondary bacterial complications such as We understand that during a pandemic,
pneumonia. Manitobans will be eager to have
themselves and their families immunized.
Antiviral drugs may have an important, However, when vaccine becomes available,
though limited, role to play in an outbreak it will likely be available in batches. This is
of pandemic influenza. Since a vaccine why priority groups have been identified to
specific to the strain of disease is not likely receive the first doses of vaccine. These
to be available for at least several months groups will likely include health care
after the virus is detected, antivirals may be workers, paramedics and other essential
the only treatment available until a vaccine workers who will be needed to care for
is developed. the sick.
Preparing for Pandemic Influenza 23Priority groups for vaccines are required Established System and Processes
because the vaccine will be available for Vaccine Programs in Manitoba
in batches as it is produced. As with Manitoba has a well-established annual
vaccination programs for annual flu, influenza immunization program. The
individuals at highest risk of getting annual influenza vaccine becomes
infected and developing complications available in the fall of each year and is
should be immunized as soon as distributed to regional health authorities
possible. During a pandemic, it is and doctors’ offices. Manitoba has the
critical that essential responders following systems and processes in
are protected so they can provide place:
essential health care, emergency and
social response services. Therefore, • vaccine acquisition, storage
nationally agreed-upon priority groups and distribution (also applies to
will be used in Manitoba for influenza antiviral drugs)
vaccination during a pandemic.
• storage and handling protocols
It is important to note that priority for vaccines
groups may be adjusted, depending on
the epidemiology of the pandemic (ex: • established ways for health
care practitioners to get the
age and high-risk groups affected). We
vaccine
won’t know who will be at greatest risk
until the time of a pandemic. • defined target populations
for vaccination (identified by
For more information on vaccine vaccine eligibility criteria)
for an influenza pandemic,
please visit our website at: • contracts in place to ensure
www.gov.mb.ca/pandemic central storage and co-
ordinated distribution of all
publicly-funded vaccines
• electronic database for
vaccination coverage and
reporting system for vaccine-
associated adverse events (a
component of all immunization
programs in Manitoba)
In preparation for pandemic influenza,
Manitoba’s existing systems are being
tested and enhanced. The province
has experience in mass immunization
campaigns and rapid implementation of
such campaigns (ex: meningitis).
24 Preparing for Pandemic InfluenzaManitoba’s Strategy for the Use of About Antiviral Drugs
Antiviral Drugs during a Pandemic There are only a small number of antiviral
Uses of Antiviral Drugs drugs licensed for use for influenza in
Canada. These are:
In an influenza pandemic, Manitoba will use
antiviral drugs in a way that is consistent
• Oseltamivir (Tamiflu ), a
®
with the national approach and based
neuraminidase inhibitor, licensed for
on the best evidence available. Once we
both prevention and treatment of
know how the new virus is affecting the influenza A and B
population, a public health assessment
of risk will be made to guide the use of • Amantadine, an M2 ion channel
antiviral drugs. inhibitor, licensed in Canada for
both the prevention and treatment
Antiviral drugs can be used for either of influenza A infections
treatment or prophylaxis.
• Zanamivir, a neuraminidase
Treatment: Antiviral drugs can be inhibitor, licensed for treatment
taken to treat illness from of influenza A and B
influenza, after symptoms It is important to note that antiviral drugs
have occurred. To be are not a cure-all remedy. There are several
effective, antivirals must be issues surrounding the use of antiviral drugs
taken within 48 hours of the in an influenza pandemic. They include:
onset of symptoms.
• Effectiveness: It is not known
Prophylaxis: Antiviral drugs can be
for sure how well any specific
taken to prevent illness antiviral drug will work against a
from influenza, either new influenza virus. Oseltamivir
before exposure occurs or (Tamiflu ), currently recommended
®
immediately after exposure, for the treatment and prevention
but before symptoms occur. of influenza, is the drug being
stockpiled by governments in
Canada (including Manitoba), and
around the world.
• Resistance: It is possible that
the influenza virus causing the
pandemic could become resistant
to a particular antiviral drug. The
scientific and medical community
currently monitor for antiviral drug
resistance in influenza viruses. This
monitoring would continue during a
pandemic.
Preparing for Pandemic Influenza 25• Safety: The most common • Ethics: There are many
side-effect of oseltamivir ethical issues surrounding the
is nausea. Safety and potential use of antivirals in a
effectiveness of repeated pandemic. Because there will
treatment or prevention courses likely be insufficient supply
of drugs like oseltamivir have of drugs available, decisions
not been studied. However, will need to be made how
there is some evidence of its best to use them. Much
safety for continuous use for up discussion has taken place
to six weeks. on this topic and guidelines
have been developed by the
• Availability: There are a limited Canadian Pandemic Influenza
number of manufacturers of Committee. These guidelines
antiviral medication. Manitoba, will be reviewed on an ongoing
along with the other provinces basis as our collective scientific
and territories, continues understanding evolves.
to work with the Public
Health Agency of Canada For more information on antiviral drugs
to strengthen provincial and their potential use in Manitoba
and national stockpiles of during an influenza pandemic,
oseltamivir. please visit our website at:
It is widely recognized that www.gov.mb.ca/pandemic
antiviral drugs are in relatively
scarce supply internationally.
Therefore, a national stockpile
is required to secure a supply
of antiviral drugs in preparation
for a pandemic. Furthermore,
even with a national stockpile,
the demand may exceed the
stockpiled supply, as available
supplies will be used up rapidly
at the start of a pandemic either
for early treatment of cases or
for preventative treatment
of contacts.
26 Preparing for Pandemic InfluenzaEstablished Systems, Plans and iii. Other Public Health Measures or
Processes for the use of Antiviral “Societal” Measures
Drugs in Manitoba
In Manitoba, The Public Health
• Manitoba Health has protocols Act gives public health officials the
in place for the use of antiviral authority to deal with public health
drugs in the management of
emergencies, such as pandemic
influenza outbreaks in facilities
influenza. Through provincial-regional
such as personal care homes.
Manitoba Health maintains an networks, Manitoba Health provides
annual stock of the antiviral doctors and regional health authorities
drug oseltamivir (Tamiflu )® with regularly updated information
specifically for this purpose. on how to detect, report and manage
cases of severe respiratory illness.
• Manitoba acquired a Regional health authorities are
stockpile of this drug through updated on provincial and national
participation in nationally planning for public health threats,
co-ordinated cost-shared
such as pandemic influenza, and
stockpile purchasing
are consulted on adapting nationally
initiatives, where provinces,
territories and the federal produced guidelines for use in
government purchased Manitoba.
antiviral drugs based on
population proportions. During an outbreak or pandemic,
Manitoba Health will provide doctors,
• Central storage and regional regional health authorities and health
distribution mechanisms care facilities/agencies with direction
for antivirals are in place. on managing patients with the
Planning is underway to make disease, and those who have come
sure this system can support in contact with infected individuals.
mass distribution that would A rapid communication system is in
be needed during an influenza
place to transmit information to health
pandemic.
providers on a same-day basis.
This direction will help protect the
health of the public and that of health
care workers.
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