Flu Pandemics

Pandemic viruses emerge as a result of a process called “antigenic shift,” which causes an abrupt or sudden, major change in influenza A viruses. These changes are caused by new combinations of the HA and/or NA proteins on the surface of the virus. Changes results in a new influenza A virus subtype. The appearance of a new influenza A virus subtype is the first step toward a pandemic; however, to cause a pandemic, the new virus subtype also must have the capacity to spread easily from person to person.

Once a new pandemic influenza virus emerges and spreads, it usually becomes established among people and moves around or “circulates” for many years as seasonal epidemics of influenza. The U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have large surveillance programs to monitor and detect influenza activity around the world, including the emergence of possible pandemic strains of influenza virus.

Influenza Pandemics during the 20th Century

During the 20th century, the emergence of several new influenza A virus subtypes caused three pandemics, all of which spread around the world within a year of being detected.
• 1918-19, “Spanish flu,” [A (H1N1)], caused the highest number of known influenza deaths. (However, the actual influenza virus subtype was not detected in the 1918-19 pandemic). More than 500,000 people died in the United States, and up to 50 million people may have died worldwide. Many people died within the first few days after infection, and others died of secondary complications. Nearly half of those who died were young, healthy adults. Influenza A (H1N1) viruses still circulate today after being introduced again into the human population in 1977.
• 1957-58, “Asian flu,” [A (H2N2)], caused about 70,000 deaths in the United States . First identified in China in late February 1957, the Asian flu spread to the United States by June 1957.
• 1968-69, “Hong Kong flu,” [A (H3N2)], caused about 34,000 deaths in the United States . This virus was first detected in Hong Kong in early 1968 and spread to the United States later that year. Influenza A (H3N2) viruses still circulate today.

Both the 1957-58 and 1968-69 pandemics were caused by viruses containing a combination of genes from a human influenza virus and an avian influenza virus. The 1918-19 pandemic virus appears to have an avian origin.

Pandemic Stages
The World Health Organization (WHO) has developed a global influenza preparedness plan, which defines the stages of a pandemic, outlines the role of WHO, and makes recommendations for national measures before and during a pandemic. The phases are:

Interpandemic period
Phase 1: No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk of human infection or disease is considered to be low.
Phase 2: No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial
risk of human disease.

Pandemic alert period
Phase 3: Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact.
Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.
Phase 5: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk).

Pandemic period
Phase 6: Increased and sustained transmission in general population.

Notes: The distinction between phases 1 and 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The
distinction is based on various factors and their relative importance according to current scientific knowledge. Factors may include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife, whether the virus is enzootic or epizootic, geographically localized or widespread, and other scientific parameters.

The distinction among phases 3, 4, and 5is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include rate of transmission, geographical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain), and other scientific parameters.

Preparing for the Next Pandemic
Many scientists believe it is only a matter of time until the next influenza pandemic occurs. The severity of the next pandemic cannot be predicted, but modeling studies suggest that the impact of a pandemic on the United States could be substantial.

In the absence of any control measures (vaccination or drugs), it has been estimated that in the United States a “medium–level” pandemic could cause 89,000 to 207,000 deaths, 314,000 and 734,000 hospitalizations, 18 to 42 million outpatient visits, and another 20 to 47 million people being sick. Between 15% and 35% of the U.S. population could be affected by an influenza pandemic, and the economic impact could range between $71.3 and $166.5 billion.

Influenza pandemics are different from many of the threats for which public health and health-care systems are currently planning:
•A pandemic will last much longer than most public health emergencies and may include “waves” of influenza activity separated by months (in 20th century pandemics, a second wave of influenza activity occurred 3 to 12 months after the first wave).
•The numbers of health care workers and first responders available to work can be expected to be reduced. They will be at high risk of illness through exposure in the community and in health-care settings, and some may have to miss work to care for ill family members.
•Resources in many locations could be limited, depending on the severity and spread of an influenza pandemic.
Because of these differences and the expected size of an influenza pandemic, it is important to plan preparedness activities that will permit a prompt and effective public health response. The U.S. Department of Health and Human Services (HHS) supports pandemic influenza activities in the areas of surveillance (detection), vaccine development and production, strategic stockpiling of antiviral medications, research, and risk communications.

In May 2005, the U.S. Secretary of HHS created a multi-agency National Influenza Pandemic Preparedness and Response Task Group. This unified initiative involves CDC and many other agencies (international, national, state, local and private) in planning for a potential pandemic. Its responsibility includes revision of a U.S. National Pandemic Influenza Response and Preparedness Plan.