Pandemic preparedness has been a boon for US flu surveillance, but it won’t maintain itself

Pandemic preparedness has been a boon for US flu surveillance, but it won’t maintain itself. |

by Kim Krisberg

At the peak of the 2009 H1N1 flu pandemic, the Wisconsin state public health lab was routinely testing up to 300 specimens every day. On one day, the lab hit a record of nearly 500.

To generate results within 24 hours of receiving a specimen and keep up with its duties outside of flu surveillance, the lab added a second shift of flu testing on the weekdays and worked through the weekends. H1N1 definitely stressed the lab’s capacities, said Peter Shult, PhD, associate director of the Wisconsin State Laboratory of Hygiene, but it also demonstrated the value of years of investing in pandemic preparedness and response. In fact, Shult said that if the lab had received 300 flu specimens in a day only a few years before the H1N1 pandemic, “we’d have been backlogged immediately — it would have taken us weeks to catch up.”

As one might expect, years of preparing for another worldwide flu pandemic has also boosted the lab’s seasonal flu response. During the 2017-2018 flu season — one of the most severe in recent memory with an estimated 80,000 U.S. deaths — Shult said the Wisconsin lab was easily able to keep pace with a surge in testing demands, which while much lower than peak pandemic levels, were still about 30% higher than the average flu season.

“We were busy, but we could comfortably handle the specimen load without expanding testing hours or impacting turnaround times, and we could still carry out all of our other routine testing responsibilities,” said Shult, who also serves as director of the lab’s Communicable Disease Division. “All that speaks to the capacity we’ve developed regarding testing platforms and our staff being able to do this flu testing. …But funding is still needed to maintain this kind of capacity.”

That capacity building goes back more than 20 years when global health officials detected the first human infections of H5N1 avian influenza; a few years later in 2003, the virus re-emerged, spreading from Asia to Europe and Africa. While the virus very rarely spread from person to person, fears that H5N1, which has a mortality rate of about 60%, could evolve to easily transmit between people sparked a new chapter of pandemic preparedness that included billions in federal funding support and a key focus on improving flu surveillance and detection. By the time H1N1 hit in 2009, public health labs had transformed their flu capacities.

Just a few years before the H1N1 pandemic, for example, most public health labs relied on the traditional viral culture to gather data on the flu. Viral cell culture is a reliable way to identify flu strains and monitor which antivirals work best to treat infections, but getting results can take more than a week, which is hardly ideal in any disease outbreak, let alone a flu pandemic. By 2009, however, most labs had built the capacity to use and quickly deploy highly sensitive molecular assays — in particular, a technique known as real-time reverse transcription-polymerase chain reaction (RT-PCR) — that could turnaround flu results in less than a workday.

With a week shaved off testing times, as well as years of cross-training and drilling lab staff in pandemic response, it’s little surprise that investments in pandemic preparedness have also been a boon for seasonal flu surveillance.

“The last flu season was a high-volume one for public health labs, but it was also considered business as usual at this point,” said Stephanie Chester, MS, manager of APHL’s Respiratory Disease Program. “That’s a capacity that labs had been working toward for years, but you do need to maintain that warm base. If funding went down, it could certainly erode that capacity.”

In New Hampshire, the state public health lab tested more than 4,000 flu specimens during the 2009 pandemic. During a more typical year, it tests between 300 and 500 flu specimens from sentinel sites across the state, such as hospital labs and long-term care facilities, according to Carol Loring, MS, supervisor for the Virology and STD Laboratory at the New Hampshire Department of Health and Human Services’ Public Health Laboratories. Compared to clinical flu testing, which typically determines if a patient has influenza A or B, the state lab performs genotyping and subtyping to identify the specific strains circulating in the community, including potential pandemic strains, and to help monitor the effectiveness of each year’s flu vaccine. All that data, Loring said, helps clinicians make better diagnostic and prescribing decisions and helps public health workers more precisely target their prevention resources.

During the 2017-2018 flu season, Loring said the lab didn’t experience a significant increase in testing volumes, but it was prepared to face a surge.

“In my experience, our surge capacities evolve with each event,” she said. “We’re constantly training, drilling and preparing for the next pandemic.”

Loring noted that routine flu surveillance isn’t especially different from pandemic response — “the day-to-day tasks are the same, the only difference often is that there’s less interest from the public,” she said. Still, both capacities are heavily reliant on funding from CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), which is scheduled to begin a new five-year funding cycle in August 2019. A substantial portion of ELC funding, about $40 million a year comes from the Affordable Care Act’s Prevention and Public Health Fund, which the law established as the nation’s first mandatory funding stream dedicated to improving the public health system. If the ACA were repealed and those funds not replaced, it would be a major blow to the country’s flu surveillance system.

Inside the New Hampshire state lab, Loring said at least two instruments that the lab needs to perform nucleic acid extraction, a key step in the RT-PCR process, are slated for retirement by their manufacturers in the next few years. Replacement costs could run up to $100,000 and that’s just for the initial purchase, not the costs of regular maintenance.

“ELC funding is critical to enable us to purchase instruments,” she said. “If I don’t have the financial resources to maintain our instrumentation or update it, we’ll be that much less prepared for a pandemic.”

Also on Loring’s lab wish list: its own courier system for getting flu specimens into the lab. Right now, the lab depends on its clinical partners across the state to send in specimens for surveillance. Some send in their samples via US mail, others use courier services and some drive their samples over and drop them off. The hodgepodge of delivery methods makes it hard to predict when specimens will show up, and many don’t arrive within the recommended three days of being collected.

“A better specimen transport system would definitely help improve our efforts,” Loring said.

In Wisconsin, the state’s public health lab is also one of the country’s three National Influenza Reference Centers (NIRCs), which serve as extensions of the CDC Influenza Division’s Virology, Surveillance and Diagnosis Branch and allow the federal agency to focus on more advanced testing and global flu monitoring. As a state lab, the Wisconsin State Laboratory of Hygiene subtypes every flu specimen it receives, testing samples for flu as well as 18 other respiratory pathogens. As a NIRC, the flu specimens it receives from around the country have already been subtyped ; the center’s job is to conduct genetic sequencing and grow the specimen up with the traditional viral culture. The sequencing, in particular, is key to detecting signs of evolving genetic change and antiviral resistance.

Data generated by public health laboratory testing helps form the basis of CDC’s FluView, the agency’s weekly flu surveillance report. Data and specimens coming out of the three NIRCs — also located in New York and California — go onto CDC for additional study, inclusion in FluView and are fundamental to planning each year’s flu vaccine composition.

Shult, the Wisconsin lab’s associate director, said it’s critical to maintain the ability to quickly detect both novel and seasonal flu viruses across the public health system if responders hope to stay one step ahead of a potential outbreak.

“In 2009, H1N1 went across the country and the globe in a matter of weeks,” he said. “That’s how quickly a novel virus can emerge and spread globally.”

In 2009, at the peak of the pandemic’s first wave, the Wisconsin lab was routinely testing up to 300 specimens a day; in a more typical flu season, it receives a couple-hundred of specimens in a week. In the early days of the pandemic, the lab was the only one in the state that could perform real-time RT-PCR on H1N1 samples. Now, Shult said nearly 50 labs in the state use real-time RT-PCR in their flu testing.

“It was game-changing in terms of how we were able to respond,” said Shult of the shift to RT-PCR. “The results were reliable and the turnaround time was remarkably quicker. …If we had received 400 specimens in a day (like we did in the H1N1 pandemic) and we were still depending on viral culture, we’d have been immediately behind.”

To further illustrate how far flu surveillance has come, Shult noted that only about 15 years ago — before the influxes of federal pandemic and preparedness funds — a flu season as severe as the 2017-2018 one would have significantly strained the lab’s capacities. Instead, Shult said the Wisconsin lab was “able to take on a season like the past one more or less in stride.”

Like his colleague in New Hampshire, Shult is concerned about sufficient federal funding to both preserve the country’s investment in flu surveillance and response and ready the system for the future.

“We’ve had a lot of funding to build this capability and capacity, and slightly less funding to maintain it,” he said. “We have staff to pay and train, we have equipment that ages out and needs maintenance … there are considerable ongoing costs.”

Shult’s laboratory wish list? Enough funding to keep getting better and faster at chasing the flu.

“My wish is having enough dollars to maintain what we’ve built and keep on top of new technologies that will help us respond even quicker,” he said. “Right now, if we were to face a severe pandemic, we’d be stressed but we’d still be in the game. But if funding were severely cut? Then we’d be in trouble.”


The post Pandemic preparedness has been a boon for US flu surveillance, but it won’t maintain itself appeared first on APHL Lab Blog.

Partnerships Help Save Lives When Disaster Strikes

Emergency responders gathered in a circle.

Public health emergencies occur every day across the United States. Tornadoes, hurricanes, wildfires, floods, infectious disease outbreaks, terrorist attacks, and other emergencies have all occurred within the past few years and likely will happen again. Communities must be ready in the event of a public health emergency – both those they expect and those that come without warning.

Since 2002, CDC’s Public Health Emergency Preparedness (PHEP) program has provided funding and guidance to 50 states, four cities, and eight territorial health departments across the nation to protect communities. Planning and exercising plans help ensure that health departments are ready to respond and save lives when emergencies occur.

While we all hope that emergencies never happen, they are inevitable and the true test of any preparedness system. The following stories are examples of how CDC’s PHEP program works with states and local communities to ensure they are ready to respond to any emergency. Some of CDC’s partners include health departments, community organizations, national public health organizations, and private companies.

Restoring California Communities after Devastating Wildfires

A fire truck responds to a brush fire.In 2017, nearly 9,000 fires, almost double the average annual number, burned 1.2 million acres in California. The fires destroyed more than 10,800 structures and killed at least 46 people. However, thanks to years of planning for such events and building a public health infrastructure through the PHEP program, state and local health departments were ready to respond immediately and help their communities recover over the following months.

Through partnerships and support provided by the PHEP program in and around Sonoma County, local officials evacuated more than 1,160 patients from area hospitals and many other healthcare facilities. Additionally, because of the relationship the state built with the California National Guard through the PHEP program, more than 100 volunteer troops cleaned the Sonoma Developmental Center in one day. More than 200 patients with disabilities were then able to return safely to the facility.

Ensuring Access to Medication during an Influenza Outbreak in Maine

Package of Oseltamivir (i.e., Tamiflu) capsulesIn March 2017, an influenza outbreak on Vinylhaven, a remote island off the coast of Maine with a population of about 1,165, sickened half of the island’s residents. The outbreak depleted the medical center’s Tamiflu® supply. Tamiflu® can greatly lessen the severity of influenza but it must be taken early in treatment.

Because of a partnership agreement established under PHEP with the Northern New England Poison Center, local pharmacies, and other organizations, and the Maine Department of Health staff quickly delivered 100 treatment courses of Tamiflu®. As a result, the state successfully reduced the impact of the influenza outbreak on the island.

Responding to a Water Contamination Incident in Illinois

Bottles of water on a conveyor belt.On May 2017, a water main break under a river contaminated water in Cumberland County, Illinois, and left some residents without water entirely. Health department staff funded through PHEP established water distribution sites with bottled water donated by private partners such as Walmart, Coca-Cola, and Anheuser-Busch. Staff also went door-to-door to check on residents and distribute materials about safe water.

The PHEP program ensures public health emergency management systems and experts are ready to respond when emergencies occur. Preparedness efforts throughout the years have saved lives and helped communities return to normal operations as quickly as possible.

From natural disasters to infectious diseases, the PHEP program protects America’s health, safety, and security to save lives. Check out the PHEP Stories from the Field to find out more about how the PHEP program has helped communities prepare for, respond to, and recover from public health emergencies.

Influenza prevention and response requires a One Health approach

Influenza prevention and response requires a One Health approach |

By Jill Sutton, respiratory diseases intern, APHL

Did you know there’s no known influenza A subtype that’s only found in humans? That makes influenza a perfect example of why a One Health approach is critical to disease prevention and response.

One Health is about breaking down the silos between human, animal and environmental health and adapting a synergistic approach for planning and responding to threats. When it comes to influenza, this multi-disciplinary approach can make us better prepared to evaluate, predict and respond to infections in both humans and animals.

Toward the end of last year’s flu season, I decided I wanted to delve deeper into One Health. I registered for my first One Health Academy talk, which covered the 1918 influenza pandemic and ended with a discussion around the adjacent possibilities in 2018. As I learned more about influenza, I realized the flu wasn’t just a disease infecting humans each winter, but rather a year-round burden causing severe disease in animals too. Eight months later, here I am as the respiratory diseases intern at APHL, and I haven’t missed a single One Health talk yet. If there’s one thing I’ve learned thus far in my career in public health, it’s that we can’t control the future, but we can control how we respond to try and shape the future.

What are some implications of influenza for human & animals?

Influenza prevention and response requires a One Health approach | www.APHLblog.orgZoonotic diseases, such as avian influenza, can infect and cause severe disease in both animals and humans. According to the CDC, 60% of known infectious diseases in humans are of animal origin and 75% of new and emerging infectious diseases are spread from animals. Not only does the flu infect humans, influenza also infects a number of other animals (both domesticated and wild) and can cause severe disease.

The primary threat, of course, is the spread of new influenza strains. Influenza pandemics occur when a novel influenza virus emerges in an animal host, changes to the point where it is able to infect humans, and then changes further so it can continue to spread from one person to another.

Once the virus can be transmitted from human to human, a pandemic becomes possible. Global population movement directly influences the spread of influenza pandemics. Looking back to the 1918 influenza pandemic, troop movement during World War I was a major factor in the spread of the virus between continents. Today, international trade and travel has connected every region of the world. Transportation of humans, animal and goods increases the risk of exposure to pathogens. Did you know the influenza virus can remain infectious on surfaces for up to 48 hours? And when airborne, viral particles from a cough or sneeze can remain suspended in the air for up to 30 minutes. That is, if someone who is infected with the flu sneezes while on an elevator or in the bathroom of an airplane and 10 minutes later you enter that elevator or bathroom, you could become infected from those particles.

Aside from humans moving around the globe, animal travel is capable of spreading influenza too. Each year, birds such as ducks, swans and geese migrate between continents. If the any of those birds are infected with avian influenza, the virus can be carried and transmitted. If agricultural operations, domesticated animals or other potential hosts come in contact with infected birds or their feces, new influenza infections can be sustained.

Because we live in a shared environment where global travel is fast, global trade is easy and plenty of opportunities for inter-species transmission of influenza viruses exist, it’s important that experts work collaboratively. Within the veterinary community, areas of knowledge exist that can complement existing areas of knowledge in human health, and vice versa. One Health allows for an easier exchange of information and support between those professional communities.

In addition to the risk of transmission, influenza pandemics can have serious economic impacts. Societies around the world depend on the health of humans, animals and the environment for food, income and health security. Influenza is a major threat to animal agriculture as it can be fatal to chickens, turkeys and pigs. When a new influenza strain emerges, the livelihood for global communities, especially those who are largely dependent on agriculture cultivation, is put at risk. For example, live poultry markets have been identified as significant risk factors for transmission of avian influenza. Because many people who sell poultry at live bird markets are dependent on their operation for income, they are less likely to implement measures of prevention especially if it means closure of the market even temporarily and are at higher risk for exposure to avian influenza. Their poultry can continue to transmit the virus and, if they themselves become infected, they might also transmit the virus to other customers, their families or community members. In these cases, it’s important to include and understand all stakeholders such as farmers, consumers, market operators, supply chain transporters, and human and animal health professionals by taking a One Health approach to implement long term management for control and prevention of avian influenza.

What gaps exist?

The health of our ever-changing world depends on breaking down the walls between animal, human and environmental sectors. To effectively detect, respond to and prevent outbreaks of pandemic potential, epidemiological and laboratory data needs to be shared across sectors.

Integrated human, animal and environmental health/management systems promotes communication and collaboration among human-animal-eco sectors, thus optimizing success. Multi-sector coordination helps address joint issues and opens discussion on what to anticipate, what gaps exists, how to reduce duplication of efforts and enhances risk reduction. We need harmonized human and animal surveillance and research efforts that compliment and build upon one another. This is important because it can help human and animal health professionals identify the determinants that affect disease transmission such as pathogenicity, infectivity, antigenicity and resistance. By capitalizing on existing systems and infrastructure and by investing in capacity building, we can enhance our understanding of circulating viruses within animals, and better predict when and where a spillover could occur. Increasing laboratory and data sharing capacity at both the human and animal levels so that they’re equally capable to diagnose both human and animal influenza can help prevent knowledge gaps and identify where intervention is needed to prevent exposure. Furthermore, this can increase surge capacity so that more laboratories are able to provide the necessary help for when an outbreak occurs.

As we move forward, we must use a One Health approach to prevent multi-disciplinary threats like influenza pandemics. By collaborating between professionals with a range of experience and expertise, we can better address the unanswered questions around the risks for pandemic influenza at human-animal-environmental interface.


The post Influenza prevention and response requires a One Health approach appeared first on APHL Lab Blog.

A Little Girl and a Deadly Virus

A Little Girl and a Deadly Virus |

By Linette Granen, director, Marketing & Membership, APHL

This story begins as many others. A young lady met a young man, got married and had a baby, whom they adored. They were children of immigrants — her family was from Germany and his from Italy. They began their lives together in the early part of the 20th century in New Orleans, Louisiana. He worked for the New Orleans Park Service — he always had a green thumb and immensely enjoyed working outdoors — while she settled down as a housewife, raising a variety of animals on their small property. One room of their shotgun-house was devoted to a small flock of canaries, and outside they had a plethora of chickens, geese, rabbits and guinea pigs. They shared their double shotgun-house with her brother, a chief in the New Orleans Fire Department. In 1916 they had a baby girl.

A Little Girl and a Deadly Virus | www.APHLblog.orgYes, they were happy — until October 1918, when their only child, nearly three years old, got very sick. She had influenza, although at the time they didn’t know what was wrong. This disease spread quickly through New Orleans, and it became suddenly clear that it was spiraling out of control. On October 7, just one week before the young girl’s untimely death, the New Orleans Board of Health made this then-unknown illness a mandatory reportable disease in order to understand the impact on their population and to track the epidemic’s progress. Two days later, at the recommendation of health officials, the mayor closed all schools, churches, theaters, movie houses and anywhere else people might congregate. Quickly, additional actions were taken to prevent crowding and gathering in the hopes of slowing or stopping the epidemic.

As was mandated, case reports of influenza began to flood the New Orleans Board of Health. On October 12 and 13 alone, there were 4,875 cases reported in the city. At that point, the US Surgeon General instructed the health department to secure additional hospital space for ill military personnel from nearby military installations. Within days, 17 wards of the city’s Charity Hospital were totally dedicated to influenza care. The newly appointed medical advisor, Dr. Gustave Corput, began working with the Red Cross to convert another facility, the Sophie Gumbel building on the Touro-Shakespeare almshouse property, into a 300-bed emergency hospital. At that time, the health department did not employ nurses, so the Red Cross began recruiting nurses and physicians for the emergency facility — some volunteering time and some working part-time. Through funding from the Red Cross and the Public Health Service, the facility was opened and maintained, along with smaller facilities at the Southern Yacht Club on Lake Pontchartrain and a Knights of Columbus hall across the river.

The little girl died on October 15, 1918.

By the end of October, two weeks after the little girl’s death, Tulane University scientists developed and produced a vaccine for local use against a bacteria called Bacillus influenzae (now known as Haemophilus influenzae). Despite being untested, deploying this type of vaccine was worth any risks because of the large number of cases in a city desperate for relief. Laboratories at local hospitals began manufacturing the Tulane vaccine and more than 4,000 city government employees and factory workers were immunized. Medical and nursing students were deployed all over the state: third-year nursing students staffed the emergency hospitals and fourth-year Tulane medical students were appointed as assistant US Public Health Service surgeons. Later that month, it appeared that the tide was beginning to turn, perhaps due to the actions taken by the health department and the Tulane vaccine.

By the spring, the devastating epidemic in New Orleans was finally declared over. Between October 1918 and April 1919, the city experienced over 54,000 cases of influenza and almost 3,500 deaths. The case-fatality rate was 6.5%; only Pittsburgh and Philadelphia had higher death rates.

This story is very personal to me. Not only am I a career public health scientist from New Orleans, that little girl who died on October 15, 1918 was my aunt, Gladys Mary Cucinello. Her parents – my grandparents – later had four sons, one of whom was my father who recently passed away at the age of 95. Born in 1922, he was not alive for the epidemic and never met his sister, but he remembered the heartache my grandmother expressed whenever she talked about that time. The only picture of my Aunt Gladys lives in a place of honor in my house. Such a tiny girl was no match for such a deadly virus.


*Much of the historical information about New Orleans during the 1918 influenza pandemic came from the Influenza Encyclopedia.

The post A Little Girl and a Deadly Virus appeared first on APHL Lab Blog.

3 Reasons Why Handwashing Should Matter to You

Unseen woman washing her hands with soap in a sink.

Most of us are familiar with the parental-like voice in the back of our minds that helps guide our decision-making—asking us questions like, “Have you called your grandmother lately?” For many that voice serves as a gentle, yet constant reminder to wash our hands.

Handwashing with soap and water is one of the most important steps you can take to avoid getting sick and spreading germs to loved ones. Many diseases are spread by not cleaning your hands properly after touching contaminated objects or surfaces. And although not all germs are bad, illness can occur when harmful germs enter our bodies through the eyes, nose, and mouth. That’s why it is critical to wash hands at key times, such as after a flood or during a flu pandemic, when germs can be passed from person to person and make others sick.

Washing hands with soap and water is the best way to reduce the number of germs on them, however during a disaster clean, running water may not be available. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol. Alcohol-based hand sanitizers can quickly reduce the number of germs on hands in some situations, but sanitizers do not eliminate all types of germs.

Here are three key reasons why you should always care about handwashing:Your hands carry germs you can't see. Wash your hands.

  1. Handwashing can keep children healthy and in school. Handwashing education can reduce the number of young children who get sick and help prevent school absenteeism.
  2. Handwashing can help prevent illness. Getting a yearly flu vaccine is the most important action you can take to protect yourself from flu. Besides getting a flu vaccine, CDC recommends everyday preventive actions including frequent handwashing with soap and water.
  3. Handwashing is easy! Effective handwashing is a practical skill that you can easily learn, teach to others, and practice every day to prepare for an emergency. It takes around 20 seconds, and can be done in five simple steps:
    1. Wet your hands with clean, running water, turn off the tap, and apply soap
    2. Lather your hands by rubbing them together with the soap
    3. Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice
    4. Rinse your hands well under clean, running water
    5. Dry your hands using a clean towel or air-dry them

Promote Handwashing in Your Community

Global Handwashing Day is celebrated annually on October 15 to promote handwashing with soap as an easy and affordable way to prevent disease in communities around the world. This year’s theme, “Clean Hands—A Recipe for Health,” calls attention to the importance of handwashing at key times, such as before eating or feeding others, and before, during, and after preparing food.

Learn how you can get involved and promote handwashing at home, your child’s school or daycare, and your local community:

Personal Protective Actions You Can Take in a Flu Pandemic

Young woman under the covers in bed blowing her nose.

Every fall and winter the United States experiences epidemics of seasonal influenza (flu). Sometimes a flu pandemic occurs due to a new flu virus that spreads and causes illnesses around the world. We cannot predict when a flu pandemic will occur, but over the past 100 years, we have documented four flu pandemics resulting in close to 1 million deaths in the United States alone. 1Get a flu vaccine! The most important way to prevent the flu in everyone 6 months and older is to get a yearly flu vaccine.

When a flu pandemic happens, it can take up to 6 months before a vaccine against a new flu virus is available. Antiviral drugs can help manage the symptoms of the flu, shorten the time you are sick by 1 or 2 days, and prevent serious flu complications, like pneumonia. But, there may be a limited supply of these medications during a pandemic so nonpharmaceutical interventions (or NPIs) may be the only prevention tools available during the early stages of a pandemic.

There are things you can do, apart from getting vaccinated and taking medications, to help slow the spread of a flu pandemic. NPIs, also known as “community mitigation measures,” are important because they will be the first line of defense in the absence of a pandemic vaccine. NPIs may be more effective when used early and in a layered approach (i.e., using more than one measure at a time). During the 1918 pandemic, cities that put NPIs in place quickly reported fewer deaths.2,3 NPIs may be used in different settings, including homes, schools, workplaces, and places where people gather (e.g., parks, theaters, and sports arenas).

Personal protective measures to prevent flu at all times

Photo of someone washing their hands in a sink.CDC recommends using some NPIs to prevent seasonal flu and other respiratory infections. To help prevent the flu, you should always:

  • Stay home when sick and away from others as much as possible,
  • Stay away from people who are sick as much as possible,
  • Cover your coughs and sneezes with a tissue,
  • Wash your hands often with soap and water,
  • Avoid touching your eyes, nose, or mouth, and
  • Regularly clean surfaces and objects that you use a lot.

Personal protective measures to prevent flu during a pandemic

Many of these NPIs would still be recommended during a pandemic, but some would be reserved for use during a flu pandemic. Depending on the severity of a pandemic, CDC might recommend:

  • Stay home if exposed to a sick household member,
  • Use a face mask when sick and out in crowded community settings, and
  • Implement community measures to reduce exposure to pandemic flu (coordinating school closures, limiting face-to-face contact in workplaces, and postponing or canceling mass gatherings).

CDC is preparing for a flu pandemic

There is always a threat that a flu pandemic will arise, so CDC is taking steps to prepare. In 2017, CDC issued updated community mitigation guidelines to help state and local public health departments and their community partners make plans before the next pandemic happens. Visit to access the updated guidelines; plain-language planning guides for the general public and community settings; and additional NPI communication, education, and training materials. You can find more information about seasonal and pandemic flu at and at


1 Past Pandemics:

2 Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci U S A. 2007; 104:7582-7.

3 Markel H, Lipman HB, Navarro JA, et al. Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic. JAMA. 2007; 298:644-54.

Lab Culture Ep. 11: What if there were no public health labs?

Lab Culture Ep. 11: What if there were no public health labs? |

Maybe the saying is true: you don’t know what you had until it is gone. For the families in this episode, the absence of public health laboratories turned their worlds upside down and negatively impacted both the present and future. These families represent us all and highlight the vulnerabilities that would exist if there were no public health laboratories working continuously to keep our communities and populations safe.

This is the second episode in the series produced by members of the Emerging Leader Program cohort 10.

You can listen to our show via the player embedded below or on iTunes, Stitcher or wherever you get your podcasts. Please be sure to subscribe to Lab Culture so you never miss an episode.

Lab Culture Ep. 11: What if there were no public health labs? | www.APHLblog.orgEmerging Infectious Disease Response:

APHL’s Infectious Disease Program

Laboratory Response Network (LRN)

Interviewer: Kate Wainwright, PhD, D(ABMM), HCLD (ABB), MPH, MSN, RN, deputy director, Public Health Protection and Laboratory Services, Indiana State Department of Health

Expert: Peter Shult, PhD, director, Communicable Disease Division; associate director, Wisconsin State Laboratory of Hygiene, School of Medicine and Public Health, University of Wisconsin-Madison


Lab Culture Ep. 11: What if there were no public health labs? | www.APHLblog.orgNewborn Screening:

APHL’s Newborn Screening Program


Baby’s First Test

Interviewer: Josh Rowland, MBA, MT(ASCP), manager, Training and Workforce Development, Association of Public Health Laboratories

Expert: Miriam Schachter, PhD, research scientist 3, New Jersey Department of Health, Newborn Screening Laboratory


Lab Culture Ep. 11: What if there were no public health labs? | www.APHLblog.orgFoodborne Illness:

APHL’s Food Safety Program

5 Things You Didn’t Know (but Need to Know) About Listeria

Interviewer: Samir Patel, PhD, FCCM, (D)ABMM, clinical microbiologist, Public Health Ontario; Toronto, Canada

Expert: Vanessa Allen, MD, MPH, medical microbiologist, chief of microbiology, Public Health Ontario; Toronto, Canada


Narrator:  Erin Bowles, B.S., MT(ASCP), Wisconsin Clinical Laboratory Network coordinator and co-biosafety officer, Communicable Disease Division, Wisconsin State Laboratory of Hygiene, School of Medicine and Public Health, University of Wisconsin-Madison

Contributor: Emily Travanty, PhD, scientific director, Laboratory Services Division, Colorado Department of Public Health and Environment

Special thanks to Jim Hermanson at the Wisconsin State Laboratory of Hygiene for his help in recording this episode.

The post Lab Culture Ep. 11: What if there were no public health labs? appeared first on APHL Lab Blog.

The 1918 Flu Pandemic: Why It Matters 100 Years Later

Group photo of Red Cross nurses in Boston wearing personal protective equipment.

100 years ago, an influenza (flu) pandemic swept the globe, infecting an estimated one-third of the world’s population and killing at least 50 million people. The pandemic’s death tollAmerican soldiers returning home on the Agamemnon, Hoboken, New Jersey was greater than the total number of military and civilian deaths from World War I, which was happening simultaneously.  At the time, scientists had not yet discovered flu viruses, but we know today that the 1918 pandemic was caused by an influenza A (H1N1) virus. The pandemic is commonly believed to have occurred in three waves. Unusual flu-like activity was first identified in U.S. military personnel during the spring of 1918. Flu spread rapidly in military barracks where men shared close quarters. The second wave occurred during the fall of 1918 and was the most severe. A third wave of illness occurred during the winter and spring of 1919.

Here are 5 things you should know about the 1918 pandemic and why it matters 100 years later.

1. The 1918 Flu Virus Spread Quickly

500 million people were estimated to have been infected by the 1918 H1N1 flu virus. At least 50 million people were killed around the world including an estimated 675,000 Americans. In fact, the 1918 pandemic actually caused the average life expectancy in the United States to drop by about 12 years for both men and women.Flu patients in Iowa

In 1918, many people got very sick, very quickly. In March of that year, outbreaks of flu-like illness were first detected in the United States. More than 100 soldiers at Camp Funston in Fort Riley Kansas became ill with flu. Within a week, the number of flu cases quintupled. There were reports of some people dying within 24 hours or less. 1918 flu illness often progressed to organ failure and pneumonia, with pneumonia the cause of death for most of those who died.  Young adults were hit hard. The average age of those who died during the pandemic was 28 years old.

2. No Prevention and No Treatment for the 1918 Pandemic Virus

In 1918, as scientists had not yet discovered flu viruses, there were no laboratory tests to detect, or characterize these viruses. There were no vaccines to help prevent flu infection, noPolicemen patrol the streets in masks in Seattle to ensure public safety. antiviral drugs to treat flu illness, and no antibiotics to treat secondary bacterial infections that can be associated with flu infections. Available tools to control the spread of flu were largely limited to non-pharmaceutical interventions (NPI’s) such as isolation, quarantine, good personal hygiene, use of disinfectants, and limits on public gatherings, which were used in many cities. The science behind these was very young, and applied inconsistently. City residents were advised to avoid crowds, and instructed to pay particular attention to personal hygiene. In some cities, dance halls were closed. Some streetcar conductors were ordered to keep the windows of their cars open in all but rainy weather. Some municipalities moved court cases outside. Many physicians and nurses were instructed to wear gauze masks when with flu patients.

3. Illness Overburdened the Health Care System

An estimated 195,000 Americans died during October alone. In the fall of 1918, the United States experienced a severe shortage of professional nurses during the flu pandemic because large numbers of them were deployed to military camps in the United States and abroad.A black-and-white advertisement for the Chicago School of Nursing. This shortage was made worse by the failure to use trained African American nurses. The Chicago chapter of the American Red Cross issued an urgent call for volunteers to help nurse the ill. Philadelphia was hit hard by the pandemic with more than 500 corpses awaiting burial, some for more than a week. Many parts of the U.S. had been drained of physicians and nurses due to calls for military service, so there was a shortage of medical personnel to meet the civilian demand for health care during the 1918 flu pandemic. In Massachusetts, for example, Governor McCall asked every able-bodied person across the state with medical training to offer their aid in fighting the outbreak.

As the numbers of sick rose, the Red Cross put out desperate calls for trained nurses as well as untrained volunteers to help at emergency centers. In October of 1918, Congress approved a $1 million budget for the U. S. Public Health Service to recruit 1,000 medical doctors and more than 700 registered nurses.

At one point in Chicago, physicians were reporting a staggering number of new cases, reaching as high as 1,200 people each day. This in turn intensified the shortage of doctors and nurses.  Additionally, hospitals in some areas were so overloaded with flu patients that schools, private homes and other buildings had to be converted into makeshift hospitals, some of which were staffed by medical students.

4. Major Advancements in Flu Prevention and Treatment since 1918

The science of influenza has come a long way in 100 years!A man dress in personal protective equipment in a laboratory. Developments since the 1918 pandemic include vaccines to help prevent flu, antiviral drugs to treat flu illness, antibiotics to treat secondary bacterial infections such as pneumonia, and a global influenza surveillance system with 114 World Health Organization member states that constantly monitors flu activity. There also is a much better understanding of non-pharmaceutical interventions–such as social distancing, respiratory and cough etiquette and hand hygiene–and how these measures help slow the spread of flu.

There is still much work to do to improve U.S. and global readiness for the next flu pandemic. More effective vaccines and antiviral drugs are needed in addition to better surveillance of influenza viruses in birds and pigs. CDC also is working to minimize the impact of future flu pandemics by supporting research that can enhance the use of community mitigation measures (i.e., temporarily closing schools, modifying, postponing, or canceling large public events, and creating physical distance between people in settings where they commonly come in contact with one another). These non-pharmaceutical interventions continue to be an integral component of efforts to control the spread of flu, and in the absence of flu vaccine, would be the first line of defense in a pandemic.

5. Risk of a Flu Pandemic is Ever-Present, but CDC is on the Frontlines Preparing to Protect Americans

Four pandemics have occurred in the past century: 1918, 1957, 1968, and 2009. The 1918 pandemic was the worst of them. But the threat of a future flu pandemic remains. A pandemic flu virus could emerge anywhere and spread globally.A crowd of people with the Washington Monument in the distance.

CDC works tirelessly to protect Americans and the global community from the threat of a future flu pandemic. CDC works with domestic and global public health and animal health partners to monitor human and animal influenza viruses. This helps CDC know what viruses are spreading, where they are spreading, and what kind of illnesses they are causing. CDC also develops and distributes tests and materials to support influenza testing at state, local, territorial, and international laboratories so they can detect and characterize influenza viruses.  In addition, CDC assists global and domestic experts in selecting candidate viruses to include in each year’s seasonal flu vaccine and guides prioritization of pandemic vaccine development. CDC routinely develops vaccine viruses used by manufacturers to make flu vaccines. CDC also supports state and local governments in preparing for the next flu pandemic, including planning and leading pandemic exercises across all levels of government. An effective response will diminish the potential for a repeat of the widespread devastation of the 1918 pandemic.

Visit CDC’s 1918 commemoration website for more information on the 1918 pandemic and CDC’s pandemic flu preparedness work.

New Lab Matters: 100 Years of Influenza

New Lab Matters: 100 Years of Influenza |

In 1918, no one even knew for sure that influenza was a viral disease; but then, the field of public health laboratory practice was still in its infancy. One hundred years later, public health is in a much better place, but critical preparedness gaps still persist. As our feature article shows, public health laboratories are working to keep their communities safe, through often difficult funding circumstances.

Here are just a few of this issue’s highlights:

Subscribe and get Lab Matters delivered to your inbox, or read Lab Matters on your mobile device.


Key words: APHL, public health, laboratory, laboratory testing, public health laboratory, laboratory assessment, Measles, bioinformatics, parvo, PFAS, chemical testing

The post New Lab Matters: 100 Years of Influenza appeared first on APHL Lab Blog.

6 Things You Need to Know About This Flu Season

Sick boy lying in bed having his temperature taken with a thermometer.

Seasonal flu activity has been intense this season.  As of February 16, 2018 most of the United States continues to experience intense and widespread flu activity, with record-breaking levels of influenza-like-illness and hospitalization rates recorded. While H3N2 viruses are still most common, there is an increasing number of influenza B viruses being detected. It’s not uncommon for second waves of B virus activity to occur during a flu season. It’s likely that flu activity will continue for several more weeks.

Here are some important things to know right now to protect yourself and your loved ones from flu:

1.  What are the symptoms of flu?

Flu viruses can cause mild to severe illness, and at times can lead to death. The flu is different from a cold. The flu usually comes onIf you have the emergency warning signs of flu sickness, you should go to the emergency room. These include: In children • Fast breathing or trouble breathing • Bluish skin color • Not drinking enough fluids • Not waking up or not interacting • Being so irritable that the child does not want to be held • Flu-like symptoms improve but then return with fever and worse cough • Fever with a rash; In addition to the signs above, get medical help right away for any infant who has any of these signs: • Being unable to eat • Has trouble breathing • Has no tears when crying • Significantly fewer wet diapers than normal; In adults • Difficulty breathing or shortness of breath • Pain or pressure in the chest or abdomen • Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms that improve but then return with fever and worse cough. suddenly. People who have the flu often feel some or all of these symptoms:

  • Fever* or feeling feverish/chills
  • Cough
  • Sore throat
  • Runny or stuffy nose
  • Muscle or body aches
  • Headaches
  • Fatigue (tiredness)
  • Some people may have vomiting and diarrhea, though this is more common in children than adults

* It’s important to note that not everyone with flu will have a fever.

2.  What do I do if I get sick?

Most people with the flu have mild illness and do not need medical care or antiviral drugs. If you get flu symptoms, in most cases you should stay home and avoid contact with other people, except to get medical care.

CDC recommends that antiviral drugs be used early to treat people who are very sick with the flu (for example, people who are in the hospital) and people who are sick with the flu and are at high risk of serious flu complications, either because of their age or because they have a high risk medical condition.

3. Is it too late to get a flu shot?

No!  As long as flu viruses are still circulating, it is not too late to get a flu shot.  Flu vaccination is the best way to prevent flu illness and serious flu complications, including those that can result in hospitalization. Unfortunately, flu vaccines don’t work as well against H3N2 viruses, which means that some people who got vaccinated will still get sick; however, there are some data to suggest that flu vaccination may make illness milder. Flu vaccines usually work better against H1N1 viruses, which is another good reason to get vaccinated, since H1N1 is circulating too.

4.  Why should I get a flu shot?

In addition to protecting yourself, getting vaccinated also protects people around you, including people who are more vulnerable to serious flu illness, like babies and young children, older people, pregnant women and people with certain chronic health conditions.

5.  Does the flu shot work?

Vaccine effectiveness data for this season are not available yet, but we know that flu vaccines do not work as well against H3N2 viruses, which are predominant so far this season.

6.  What else can I do to protect myself from flu?

Definitely try to avoid close contact with sick people.  If you do get sick, limit contact with others as much as possible to keep from infecting them. Stay home for at least 24 hours after your fever is gone without the use of fever-reducing drugs (unless you need medical care or other necessities).

Other tips for stopping the spread of germs:

  • Make sure you cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
  • Wash your hands often with soap and water.
  • Avoid touching your eyes, nose, and mouth. Germs spread this way!
  • Clean and disinfect surfaces and objects that may be contaminated with germs like the flu.