Questions and Answers

General questions

Q: What is an influenza pandemic?
A:  An influenza pandemic is an outbreak of influenza that spreads rapidly around the world. Flu pandemics arise when a new strain of the virus which is easily transmittable from human to human emerges, and against which people have little or no immunity.

Q: How will a pandemic differ from a regular Influenza outbreak?
A: The main difference is that a pandemic will affect large proportion of the world population - millions of flu cases will be caused by one subtype of flu - in a short period of time. A normal flu virus is seasonal and does not necessarily affect a large number of people at the same time.

As well, a pandemic will come in waves, the second wave usually being more severe than the first one. Unlike regular influenza outbreak, pandemic influenza won't be seasonal.

Q: When was the last influenza pandemic?
A: The world experienced influenza pandemics in 1918, 1957 and 1968.

Q: Should we be expecting a pandemic in Canada?
A: Public health officials have warned that a global influenza pandemic is overdue. Historically, influenza pandemics have occurred about every 30-40 years. When the new pandemic begins, it will affect a large portion of the world population, in both industrialized and developing countries.

Q: How many years before the pandemic is declared?
A: We don’t know exactly when the pandemic will start. What we do know is that pandemics historically occur every 30 to 40 years and it is now 38 years since the last pandemic. Knowing that, we expect that anytime between now and the next five years a pandemic may occur.

Q: How long does a pandemic last?
A: A pandemic can last 12 to 24 months. It unfolds in waves. A wave can last six to 12 weeks and is characterized by the sharp rise of illness, followed by the sharp decline. A sharp rise occurs because the general population is susceptible to new virus, which quickly saturates community. Sharp decline occurs after the infection achieved initial saturation level. After the first wave, we will have a “calm” period, lasting approximately three to nine months, where some sporadic infections in people appear. Then the second wave will come and last six to 12 weeks followed by another “calm” period. After the second low period, we may see the third wave. That’s how the total duration of pandemic (waves and calm periods together) may reach 24 months.

Q: Is there any way to fend off a pandemic.
A: There are no proven methods to permanently avert flu pandemics.

Q: What can we expect to happen when the pandemic reaches Canada? 
A:  When the pandemic reaches Canada, the federal, provincial and local health and administrative authorities will deploy pandemic response plans, which are being developed now. We can expect the first wave to last six to eight weeks and be followed by one or two more waves, possibly of stronger severity. Vaccine will not be available for the first wave. Antiviral agents will be in inadequate supply. Large numbers of patients will require triage and current hospital beds and ventilator capacity will be overwhelmed.  

Q: How severely would a pandemic impact Canadians?
A: It is estimated that in Canada alone an influenza pandemic would result in 15-35 percent of the population becoming mild to moderately ill, two to five million people seeking out-patient care, 34,000 - 138,000 people requiring hospitalization and a possible 11,000 - 58, 000 deaths.

Q: What will a pandemic mean for GTA?
A: It is estimated that a pandemic of moderate severity will result in 400, 000 to one million people becoming ill. Up to 420, 000 people will require some level of medical assistance, up to 12,000 people will require hospital admission and 1,000 to 5,000 people could die.

Q: How severe will the pandemic be?
A: At this point no one knows how severe the pandemic will be because the pandemic flu strain is unknown – it could be H5N1 or another strain. The virulence of the strain is also unknown. Virulence determines the degree of disease severity the virus may cause. Right now, everyone is planning for a worst case scenario.

Q: Do you have any advice for travellers? Have their been any travel warnings?
A: Right now , June 2006, there are no special travel advisories or restrictions for people travelling to or from the areas affected by animals outbreaks of H5N1. For more extensive information about travel advice please refer to this link on WHO website.

Disease characteristics

Q: Are there many different types of H5 avian influenza "bird flu" viruses?
A: There are many types of H5, which may have been in circulation for thousands of years. The first thing to know is that it's a huge leap for a bird virus to become a human virus that spreads efficiently in people
Influenza A viruses are divided into categories or subtypes based on their two surface proteins they carry - hemaglutinin and neuraminidase. To date, scientists have found 16 hemagluttinins and nine neuraminidases, the H and the N in a flu virus's name.

In theory there may be 144 different combinations.' But some Hs and Ns have never been found together, leading experts to think that some combinations cannot be formed. Most of the known combinations have shown no talent at infecting people.

Even within a subtype, there is a lot of variation among viruses. There is no cookie cutter that punches out identical H5N1s. So when H5N1 viruses have been found scientists needed to perform genetic analysis on them to see how closely matched they are to the Asian viruses.

Q: How does a "bird flu" virus infect humans?
A: The first thing to know is that it's a huge leap for a "bird flu" virus to become a human virus that spreads efficiently in people. At this point, H5N1 is not easily transmitted from birds to humans, and there is no human-to-human transmission.

However, with the rapid international spread of H5N1 virus following the patterns of bird migration, this bird virus gains more exposure to humans and human flu viruses. Such "mixing" leads to the exchange of genes between human and flu viruses, which may, in turn, lead to H5N1 acquiring an ability to easily transmit from human-to-human. Nobody knows when H5N1 will become efficient in human-to-human transmission, which would mark the beginning of pandemic.

Q: If you eat an infected, cooked bird will you be sick?
A: Influenza viruses are very susceptible to dying. Therefore, eating chicken immediately after the bird has died poses some risk, if the bird is not properly cooked, but in a matter of hours after the bird is dead the virus will die. It is also important to recognize that this virus is not in North America yet. Currently, in North America, the risk of virus going from birds to humans is minimal. And there is no risk of eating chicken meat, as long as it is properly cooked. The flu virus is heat-sensitive and dies at 70oC.

Q: With the recent earthquake in May 2006 in Indonesia, is the more of a chance for the pandemic to spread at a faster pace (as a result of the consumption of bad or uncooked meat)?
A: If improperly cooked meat of H5N1-infected poultry is consumed by people, chances are these people will get infected. However, this is unlikely to lead to epidemic, as the virus still is not efficient in human-to-human transmission. Thus, the exposure to infected poultry meat would probably result in one round of infection.

Q: Who will be at the risk of becoming ill during a pandemic?
A: Based on global health authority projections, we know that adults over 65 with high risk medical conditions and infants and children are at most risk. However, all age groups are at risk of contracting the virus, so at this point it is hard to tell what age group will be most affected. We must keep in mind that every virus is different and we don't know how virulent (how easily it transmits from human-to-human) the virus will be.

Q: Will health care workers be affected by the pandemic more than other community members?
A: Influenza is a community-based organism and is highly contagious. Healthcare workers will be affected equally with the general population.  The Ontario Health Pandemic Influenza Plan stipulates that healthcare workers are considered a priority group for immunization and antiviral prophylaxis. 

Q: Why young people are dying from this influenza?
A: There are lot of scientists and medical professionals trying to figure out why young people in the affected areas are dying from this influenza (H5N1). They are looking at immune responses and attempting to understand why it is that people die from this disease.  

Q: How can I protect myself and my family from a flu pandemic?
A: The Ministry of Health and Long-Term Care offers useful practical tips for reducing your risk in the event of an influenza pandemic. These actions are the same things you do to protect yourself and your family from ordinary flu :

• Get your flu shot every year – the flu shot will not protect you from a pandemic flu virus, but it will protect you from getting ordinary flu, which could weaken your immune system or resistance to the pandemic flu.
• Wash your hands with soap thoroughly and often – good hand hygiene is a good way to prevent the spread of all respiratory viruses.
• Keep an alcohol-based sanitizer (gel or wipes) handy at work, home and in the car.
• Cover your mouth and nose with a tissue when you cough or sneeze.
• Stay home when you are sick.
• Avoid large crowds of people where viruses can spread easily.
• Reduce non-essential travel.
• Follow any instructions given by public health officials.

For more information, visit the Ministry of Health’s website at http://www.health.gov.on.ca

Q: How will the getting a flu shot help me in a pandemic?
A: While there is no vaccination against a pandemic at this time, a flu shot is a good way to increase your overall immunity against this year's known flu strains. The more flu shots you receive over time, the greater protection you'll have against different viruses, some of which may have some similarities to an eventual pandemic strain.

Q: What are anti-viral drugs?
A: Anti-viral drugs Oseltamivir (Tamiflu®) and Zanamivir (Relenza™) are used for the prevention or treatment of influenza. These anti-virals interfere with the ability of the flu virus to grow and reproduce. When used for prevention (or prophylaxis), people must take the medication daily for as long as they are exposed to the virus. When used for treatment, infected people receive the drug to reduce symptoms, shorten the length of illness and minimize serious complications. Anti-virals must be taken within 48 hours of the first symptoms of influenza to be effective.

In the event of an influenza pandemic, anti-virals will be helpful for both treatment and prophylaxis, particularly during the period where there is no vaccine available (it will take time to develop a vaccine and manufacture it in sufficient quantities).

Q: Is Tamiflu effective against avian influenza?
A: The World Health Organization expects that Tamiflu will be effective if given as preventive medicine against all strains of flu including the known avian strains based on its effectiveness during regular influenza seasons. No clinical trials have been conducted on efficacy of these antivirals against avian flu, as only a handful of people had been infected with this disease - too small of a sample size to conduct a clinical trial. However, using anti-virals as a preventive measure against regular seasonal influenza has been extensively studied, and its effectiveness exceeds 90 percent and allows us to make reasonable assumptions about their potential effectiveness during actual pandemic.

Q: Have there been any studies completed about the long-term use of Tamiflu? What are the side-effects of taking it for eight weeks?
A: There's been a number of studies on the long-term use (up to 8 weeks) of Tamiflu as prophylactic (preventative) agent in immunized and unimmunized adult populations, including geriatric settings. The medication appears to be safe and well-tolerated. Both in short and long-term use of Tamiflu, nausea and vomiting are the most common adverse effects, which usually last only for the first 1-2 days of the therapy.

Q: Why are the TASHN hospitals ordering anti-virals for all staff?
A: Randomized controlled clinical trials during seasonal influenza have shown that using anti-virals for prophylaxis (prevention) is highly effective at preventing influenza. The Ministry of Health and Long-Term Care will have a supply of anti-virals, but it will likely be sufficient only for treatment of hospitalized individuals sick with influenza.

To keep hospitals running and functional when they’ll be needed most, it is important to protect healthcare workers by providing them with anti-viral prophylaxis. After much discussion, TAHSN hospitals have placed an order for a supply of anti-virals that would be used for prophylaxis (preventive treatment). Our goal is to help protect all of our staff from getting sick in the first place, and infecting patients and others.

Prevention is key; however, the use of this supply of anti-virals may change from our original plans if a pandemic hits and we have new information about the nature of the virus and how it is spread. For example, should it turn out that the pandemic predominantly affects young children (which is what happened in 1957), we may be asked to share our stockpile with health-care centres treating children. Furthermore, it is important to note that this is based on the assumption that the antivirals will be effective; however, this is a reasonable assumption given that clinical trials have shown that prophylaxis is highly effective during seasonal influenza.

Q: Why will every hospital staff member even those not involved in direct patient care receive anti-virals as preventive treatment?
A: To keep the health-care system running, Baycrest and TASHN need to ensure that we provide protection to staff to lessen chances they become ill. This includes not just direct patient care team members, but also support service staff and others we can draw upon as resources. The goal is to keep hospitals running so we can care for patients. We can’t do this without staff to administer medications, prepare food for patients or sterilize surgical equipment.

Q: Will pregnant staff be able to take anti-virals?
A: Yes, pregnant staff will be able to take anti-virals. The TASHN group, including Baycrest, has purchased Zanamivir (Relenza™) which may be safer for pregnant women than Oseltamivir (Tamiflu®) because it is not systemically absorbed. Neither drug however has been proven to be unsafe in pregnancy. Stockpiling of these anti-virals will depend on the availability, which are currently produced in small quantities. To further reduce the risk to pregnant women, they may also be offered alternative work arrangements.

Q: Will Baycrest residents and hospital patients receive anti-virals?
A: We are currently developing precisely who should receive anti-virals. We are working with the assumption that we will give our most frail in patients and residents priority.

Q: How will vaccinations and antiviral agents be distributed?
A: Anti-viral medication will be distributed by Occupational Health & Safety Services in each hospital in accordance to protocols established by Health Canada and/or the Ministry of Health and Long-Term Care.

Q: Will avian flu build up a resistance to Tamiflu because we will be using it for a long period of time?
A: If you use an antibiotic or antiviral, the virus may eventually develop resistance. At this point, there is not significant resistance to the class of drugs that Tamiflu belongs to. Usually, when a virus develops resistance, it does so at the expense of becoming less virulent. So, if avian flu virus develops resistance to Tamiflu, it will, at the same time, become a weaker virus.

Q: Will generic drugs be used or developed?
A: There is a lot of discussion at an international level with Roche and GlaxoSmith Kline to enhance supplies, which may mean the licensing of another manufacturer to produce generic drugs.

Q: Is the Chinese fruit star anise as effective as Tamiflu?
A: Tamiflu is made from a particular variant of star anise that grows in China, so star anise on its own has not been proven to be effective. There have also been a lot of other remedies that have been proposed for Influenza, but there is nothing else that has been demonstrated to be effective.

Q: Is there a vaccine?
A: Currently, there are no fully tested and approved vaccines that would work against the next pandemic influenza. Current technology allows us to develop an effective vaccine only after the actual pandemic strain is identified. Unless there is a technological breakthrough, we'll need to wait for the beginning of pandemic to isolate the virus and then develop a new vaccine.

Q: How long it will take to make vaccine?
A: The length of time that it takes to make a vaccine depends on a number of factors. 

If it is a regular influenza virus, production time in Canada is 102 days. Once in production, the pharmaceutical company will generate 8 million doses a month. Each person will probably need two doses and it will take a period of months to get one dose into everybody. This is based on an ideal scenario.

If it is H5N1 the process is different. Production of influenza vaccines is based on the method when the virus is grown in chicken embryos - eggs. The problem with H5N1 is this virus is fatal for chickens and their embryos, and so you can’t grow it in chicken, using traditional methods. A solution to this problem is inoculating embryos with antigens from the fatal virus implanted in non-fatal type of flu virus.   Unfortunately, this method requires an amount of antigen (which is in very short supply anyway) eight times higher than in regular flu vaccine.  This drastically reduces vaccine manufacturing capacity and sharply increases the cost of vaccine. So instead of being able to produce 8 million doses per month, we can only produce 1 million doses per month and the time it takes is up from 102 up to 200 days. People working on this method are trying to reduce this production time.

Pandemic planning

Q: What is the city doing to prepare for the possibility of influenza pandemic?
A: Toronto Public Health is the lead agency for the City of Toronto’s pandemic preparedness and response. Professionals from hospitals, government agencies, emergency services and community organizations have been working together to develop a local pandemic plan. These stakeholders are building relationships, defining responsibilities and coordinating communication between agencies at the national, provincial and local levels.

The Toronto Influenza Planning Advisory Committee has been working with community partners to identify key issues and to provide an opportunity for input from all stakeholders. The committee meets regularly and has established a process to focus on specific areas such as health services and emergency measures. Through this consultation, Toronto Public Health will update their current influenza pandemic plan which will be will be widely distributed and promoted throughout the community. The Toronto Public Health’s pandemic plan is available at http://www.toronto.ca

Q: What are GTA hospitals doing to prepare for the possibility of influenza pandemic?
A: Planning at the hospital level has included:

• Looking at strategies to optimize beds and staff capacities, such as re-deploying staff to the areas of the hospital where they are most needed.
• Examining overflow areas within the hospital to treat patients who become ill with the flu.
• Examining ways to ensure the organization has sufficient staffing during the pandemic flu outbreak, including approaching recent retirees and students in their final studies and volunteers.
• Examining occupational health issues, such as determining when staff is fit to return to work after being sick.
• Engaging in discussions with other area hospitals, the Ministry of Health and Long-Term Care and Toronto Public Health.

Q: What is Baycrest doing in terms of pandemic planning?
A: Baycrest is developing a multi-phase preparedness and response plan. We are also working with the Toronto group of university-affiliated hospitals - known as the Toronto Academic Health Services Network organizations - on pandemic preparedness planning. It's important that we all share the best practices and have a uniform plan.

Our plans are extensive and address many areas including staffing, patient care, clinical information, staff education, communication, occupational health and safety, and infection prevention and control.

Q: When will Baycrest’s Pandemic Influenza Plan presented to staff?
A: Baycrest’s plan has been in the works for many months and the strategic directions are established. The specific, details, are now be worked out. Components of the plan will continue to be highlighted in various communication media and forums, as we have all along. The TASHN planning guidelines, released on May 31, 2006, are helping to guide and further refine the Baycrest plan. We expect that the Baycrest Plan will be ready to present to the Baycrest Board of Directors and staff in fall 2006.

Q: You mention that Baycrest is working with the Toronto Academic Health Sciences Network on pandemic influenza planning. What is this network?
A: The Toronto Academic Health Sciences Network (TAHSN) is a network of academic health organizations, affiliated with the University of Toronto, providing leading-edge research, teaching and clinical care.

Members consist of: Baycrest; Bloorview Kids Rehab; Centre for Addiction and Mental Health; Mount Sinai Hospital; St. Michael’s Hospital; Sunnybrook Health Sciences Centre; The Hospital for Sick Children; Toronto Rehabilitation Institute; and University Health Network. Each of these institutions has national/international standing in their particular fields.

Q: Why is TASHN planning together for an influenza pandemic?
A: The federal, provincial and City of Toronto pandemic plans are broad frameworks outlining each level of government’s roles and responsibilities, such as surveillance, social distancing, and the stockpiling of anti-virals. These plans do not address specifically how hospitals should prepare for and operate during an influenza pandemic.

It is estimated that 420,000 people in the GTA will require some level of medical assistance and up to 12,000 people will require hospital admission. Therefore, we can expect hospitals to be under extraordinary strain caring for additional influenza patients. This is in addition to patients who require other health services (such as cancer treatment, cardiac surgery). Hospital resources (such as staffing, beds, ventilators) will be extremely limited.

Contingency planning is critical to coping with the impact of an influenza pandemic. Last May, the nine Toronto academic teaching hospitals (TAHSN) struck a Pandemic Task Force to coordinate pandemic planning, and to share resources and expertise. One of the key lessons from Toronto’s experience with SARS is the need for a coordinated and consistent approach by hospitals and governments. St. Joseph’s Health Centre, Toronto East General Hospital, Toronto Public Health and the Ministry of Health and Long-Term Care joined the Task Force as observers to share their unique perspectives and to ensure linkages.

By developing common hospital pandemic planning guidelines, our goal is to reduce unnecessary confusion and anxiety about how Toronto teaching hospitals will respond to a pandemic. Other hospitals may find the TAHSN Pandemic Guidelines helpful in developing their organization’s pandemic plan.

Q: What is the purpose of the TAHSN Pandemic Planning Guidelines?
A: The TAHSN Pandemic Planning Guidelines were developed following the federal and provincial pandemic plans and is consistent with existing health and emergency management legislation. This document describes the role, responsibilities and actions of the TAHSN pandemic subcommittees before and during the pandemic. Specifically, the document will:

• provide guidance and tools to assist hospitals prepare at the organizational level;
• ensure optimal coordination between the nine TASHN hospitals;
• outline strategies for the delivery of prophylactic antiviral medications and vaccine to priority groups;
• provide technical background underlying recommendations;
• outline measures for capacity assessment, patient assessment and triage; and
• provide a resource that can be adapted to hospitals outside of TAHSN.

This is a dynamic document that will be updated as new information emerges about the pandemic and as we do further work.

Q: How can I get a copy of the TASHN Influenza Pandemic Planning Guidelines?
A: To read a copy of the TASHN Influenza Pandemic Planning Guidelines, please go to http://www.tahsn.ca/

Q: During a pandemic, what programs and services will be affected in GTA Hospitals?
A: Given the projected global impact of a pandemic, we can expect the health-care system to come under extraordinary strain caring for influenza patients. This is on top of patients who require other hospital services (such as chemotherapy, hemodialysis, etc). Hospitals are already running at 95% capacity with very little flexibility.

During a pandemic, we can expect urgent or emergent programs at hospitals to continue as much as possible. We can also expect, given limited resources (such as staffing, beds, etc.), that many non-urgent programs and elective surgeries may be postponed or scaled back so that the focus of the resources is where its needed most. The major impact on Baycrest programs and services will, however, result from the lockdown and visitor restrictions which we will implement upon the onset of the first wave of pandemic.

Q: How will hospitals identify new patients with influenza-like symptoms?
A: Fast identification and separation of patients into these two groups is critical for infection control and patient flow purposes. TAHSN recommends that hospitals post signs at entrances, asking individuals with a fever and/or cough to head to the influenza assessment area. Those without influenza symptoms should go to the routine assessment area. Chapter 4 of the TAHSN Guidelines document provides recommendations and tools on triaging, assessing and discharging patients.

At Baycrest, we are considering active surveillance of our clients for symptoms of influenza-like illness (ILI) during pandemic. Diagnosis will most probably be just based on symptoms as lab tests likely won’t be available in the midst of pandemic wave. Consecutively, people suspected for influenza will be cohorted on a designated influenza care unit at Baycrest. Active daily surveillance of staff for ILI symptoms will also be undertaken in a form of screening at the entrance to the facility.

Q: Once the pandemic is declared over, how will Baycrest return to normal and resume services?
A: During the post-pandemic period, hospitals should focus efforts on ending pandemic response activities, reviewing the impact of the pandemic, and identifying lessons learned that may guide future planning activities. Hospitals should develop a plan with timeline for the reinstatement of services that were postponed or cancelled. We can expect the pandemic to have a profound emotional and physical impact on staff, as we saw post-SARS. Hospitals should look for creative opportunities to recognize staff commitment and contributions during the emergency, and provide ongoing support after the pandemic has ended. For more information, refer to the Chapter 11 on Recovery in TAHSN Guidelines.

Q: Where do I get more information?
A: Pandemic Related Web Sites:

• World Health Organization Fact Sheet: Avian influenza ("bird flu") and the significance of its transmission to humans
• World Health Organization Avian influenza frequently asked questions
• Health Canada: It's Your Health - Avian Influenza (Bird Flu)
• Public Health Agency of Canada: Canadian Influenza Pandemic Plan
• Toronto Public Health
• Ministry of Health and Long-Term Care: Influenza Pandemic - Public Information