Issues in Responding to Pandemic Influenza

Past Issue

Vol. 12, No. 7
July 2006

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•	Acknowledgments
•	References
•	Table

Conference Summary

Critical Issues in Responding to Pandemic Influenza

James W. Buehler,* Allen S. Craig,† Carlos del Rio,‡ Jeffrey P. Koplan,§ David S. Stephens,‡§ and Walter A. Orenstein‡
*Emory University Rollins School of Public Health, Atlanta, Georgia, USA; †Tennessee Department of Health; Nashville, Tennessee, USA; ‡Emory University School of Medicine, Atlanta, Georgia, USA; and §Emory University Woodruff Health Sciences Center, Atlanta, Georgia, USA

Suggested citation for this article

Pandemic Influenza Planning: The Reality of Implementation in the Southeast
Atlanta, Georgia USA
November 11, 2005

On November 11, 2005, shortly after the US government issued updated pandemic influenza planning guidance (1), the Southeastern Center for Emerging Biologic Threats convened a meeting of public health officials and academic healthcare providers from Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee (2). Participants reflected on pandemic planning efforts to date, sought to identify key challenges and response strategies, and separated into 4 workgroups to address surveillance and containment, vaccination, healthcare and antiviral drugs, and the animal-human health interface. This report summarizes the core issues, solutions, and unmet planning needs that were identified (Table) (a full report is available from http://www.secenterbiothreats.org/PanFluPlan.htm).

The Surveillance and Containment Workgroup focused on strategies to delay introduction of influenza into a state and slow transmission once cases appear. These measures will be aimed at "buying time" to allow for increased vaccine and antiviral drug availability. The group concluded that individual case reporting, investigations, and mandatory isolation or quarantine are likely to be feasible and effective only at the earliest stages, when few cases have occurred. As infections increase, attention will shift to "social distancing" interventions such as closing schools or canceling public events, despite uncertainties about their effectiveness, costs, and adverse consequences (e.g., if schools close, parents may be unable to work) (3). Similar questions surround the value of using masks in public (3). Strategies for influenza surveillance will evolve over the course of a pandemic, but this is more familiar ground, and planning is largely based on augmenting existing surveillance methods (4).

The Vaccination Workgroup recognized that translating federal guidance into practice will invoke questions of values, fairness, and logistics. The group's consensus was that states should follow federal priority guidelines, with the possible exception of elevating the priority of critical infrastructure workers, and that refinements may be necessary if supply is inadequate to cover the highest priority groups. Procedures for validating priority status will be necessary to avoid tension at vaccination sites. As vaccine availability increases, delivery will shift from administration by public health agencies to involvement of multiple partners, similar to current procedures for seasonal influenza vaccine. Procedures for monitoring vaccine use, efficacy, and side effects should build on existing information systems.

The Healthcare and Antiviral Drugs Workgroup anticipated that healthcare institutions may be unable to meet needs and expectations for care, despite efforts to bolster "surge capacity." To address this concern, health departments and hospitals are developing strategies to maximize space use in hospitals, identify facilities that can be adapted for lower-level inpatient care, and promote home care. This strategy will require triage systems and procedures to transfer patients to higher or lower levels of care when indicated. Staffing will depend on maintaining the current workforce in the face of personal or family illness and "burnout" and on enlisting, training, and credentialing volunteers. A spirit of professional or civic responsibility will motivate many, but the limits of such dedication during a modern pandemic are unknown. Protecting staff will require judicious use of limited antiviral medications, vaccines, or personal protective equipment (PPE), which will require difficult decisions regarding the definition of priority groups among healthcare workers. Participants generally concurred with federal recommendations to prioritize treatment over prophylactic use of antiviral drugs, and they recommended that prophylaxis be reserved for those who care for patients with respiratory illness and those essential for providing urgent care to patients with other severe illnesses. Questions about surge capacity also involve other medications, diagnostics, and supplies. Disparities in the availability of drugs or supplies among institutions will require advance planning for sharing resources.

As capacities are strained, standards of care must be adjusted (5). Plans should ascertain who is responsible for invoking and lifting alternative standards and for coordinating these actions within a region. Managing the healthcare response will require ongoing communication between government agencies and healthcare institutions and within institutions. To this end, the group emphasized the value of exercises to foster relationships and model future crisis interactions.

The Animal-Human Health Interface Workgroup noted several possible routes of introduction of an animal influenza strain with pandemic potential in the United States: migratory birds, illegal importation, or deliberate introduction. Advances in security and surveillance have substantially reduced the potential for distribution of a highly pathogenic avian influenza strain within the commercial poultry industry. Nonetheless, even a limited outbreak would have a dramatic impact, requiring collaboration among animal and human health officials and industry. The group cited examples of successful collaborations in planning for avian influenza and conducting exercises, a trend that merits further development. Such planning is complicated by limitations in the understanding of the health risks for poultry workers, the effectiveness of different forms of PPE for those involved in depopulation and disposal activities, and the role of environmental sampling methods for detecting animal pathogens. The group expressed special concern about the vulnerability of nonindustrial "backyard" flocks or live bird markets. Improving outbreak detection among noncommercial or unregulated facilities will require collaboration among a broad range of groups, such as law enforcement, animal control, natural resource agencies, and agricultural extension services.

The group recommended that heightened attention be given to strengthening surveillance for avian disease among noncommercial birds. It also recommended strengthening the effort to protect the health of poultry industry workers, including programs to expand annual vaccination with trivalent influenza vaccine; preidentifying, training, and PPE fit-testing those who would cull and dispose of birds; developing rapid diagnostic tests that can be used in field settings to detect avian influenza strains; and expanding research on the risk of occupational transmission of influenza from birds to humans.

In conclusion, the public health, healthcare, and veterinary experts who participated in this conference identified and considered responses to a series of major challenges they will face during an influenza pandemic, and participants reported that the conference enhanced their ability to prepare for a pandemic. The conference did not involve the full spectrum of perspectives necessary for planning. Draft state plans extant at the time of the meeting reflected an array of perspectives, and this engagement will expand as states act on federal planning guidance.

Acknowledgments

We thank Rachel B. Eidex, James Cope, Nina Marano, and Tonya Dixon for their contributions and support of this project.

J.W.B. was supported by a contract with the Southeastern Center for Emerging Biologic Threats.

References

Department of Health and Human Services. Pandemic influenza plan. 2005 Nov [cited 2006 Feb 20]. Available from http://www.hhs.gov/pandemicflu/plan/
Southeastern Center for Emerging Biologic Threats (SECEBT). [cited 2006 Feb 20]. Available from http://www.secenterbiothreats.org/
World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, national and community measures. Emerg Infect Dis. 2006;12:88–94.
Centers for Disease Control and Prevention. Fact sheet: overview of influenza surveillance in the United States. 2006 Jan 11 [cited 2006 Feb 20]. Available from http://www.cdc.gov/flu/weekly/pdf/flu-surveillance-overview.pdf
Agency for Healthcare Research and Quality. Altered standards of care in mass casualty events. Prepared by Health Systems Research Inc. under contract no. 290–04–0010. AHRQ Publication No. 05–0043. Rockville (MD): The Agency; 2005 Apr [cited 2006 Feb 20]. Available from http://www.ahrq.gov/research/altstand/altstand.pdf

Table. Key challenges, recommendations, and summary of deliberations of 4 workgroups for pandemic influenza planning*

Challenge or issue		Recommendations or points of consensus

Surveillance and Containment Workgroup
Role of individual case finding/reporting and isolation/quarantine		Most likely to be useful in response to initial case reports in an area. May be difficult to determine when such measures should be abandoned.
Role of social distancing measures, such as school closures and cancellation of public events		Participants anticipated that such measures would likely be invoked, but no consensus was reached on optimal timing of such measures, reflecting paucity of relevant evidence regarding effectiveness.
Whether to recommend or mandate mask use in public settings		No consensus, reflecting uncertainties about effectiveness.

Vaccination Workgroup
How to deliver vaccine and shift delivery methods during periods when vaccine is initially scarce but eventually more widely available		This will require an evolving logistics plan involving multiple partners at state and local levels, including healthcare providers, volunteer organizations, and businesses. Strategy will evolve from tight health department control of administration outlets (during period of scarcity) to involvement of multiple partners and vaccination sites, including mass vaccination facilities (during period of ready availability).
Translating federal guidelines for prioritization of vaccine use into actual practice		Participants concurred with priorities described in the DHHS plan, with a proviso that heightened priority should be given to law enforcement and security officials. Priorities may need revision depending on epidemiology of pandemic and vaccine availability. Subpriorities may be necessary at early stage if vaccine supply is insufficient even for those in highest priority group(s).

Healthcare and Antiviral Drugs Workgroup
Meeting anticipated surges in demands for healthcare services may be our nation's greatest vulnerability in an influenza pandemic, including needs for facilities, medications, equipment, supplies, and staff.	Participants agreed on overall strategy but recognized need for substantial effort to develop following capabilities: Facilities: A multitiered, multpartner approach will be required to stretch existing hospital and clinic resources, identify alternative care sites for those who require an intermediate level of care, and encourage and support home healthcare. Staff: Assuring sustainability of currently licensed healthcare workforce and support personnel will require attention to personal and family health concerns, redirection of staff resources to care of influenza patients, and appeals to professional values. Volunteers: Developing, maintaining, and credentialing a ready volunteer workforce will require collaboration with volunteer and community-based organizations and businesses. Medications/supplies: Variations among facilities in availability of stockpiled medications and supplies will raise complex ethical questions that were identified but not resolved.
Current standards of care will not be sustainable	Guidelines for relaxing standards of care, such as those developed by the Agency for Healthcare Quality and Research, will be necessary, including procedures for defining responsibility within a region for enacting altered care standards. These standards should be accompanied by triage policies to ensure that patients are directed to appropriate levels of care based on need.
Communication between public health and healthcare providers will be critical.	Channels of communication and necessary relationships should be established in advance of crises. Panel recommended joint participation of public health officials and healthcare providers in tabletop exercises and drills, including exercising incident command procedures.

Animal-Human Health Interface Workgroup
Responding to outbreak of avian influenza in commercial poultry will require unprecedented collaboration between animal and human health officials	Relationships among animal health agencies, public health agencies, and industry must be strengthened, and models of successful collaboration in planning and conducting exercises must be expanded.
Birds outside the commercial poultry industry (e.g., backyard flocks, smuggled birds) may be at risk for exposure to avian influenza, but capacity is limited to detect outbreaks among birds in these less visible settings.	Provide training on recognition of avian disease as part of preparedness training provided to community service workers (e.g., police, fire, social services, agricultural extension services); include natural resource or wildlife agencies in public health and agricultural emergency planning.
Veterinary research and research into the animal-human interface of infectious disease is under-developed, leading to critical gaps in information relevant to prevention and control of zoonotic diseases.	Avian influenza research should address Prevalence and risk for occupational exposure to "low-pathogenic" avian influenza strains among poultry workers For those involved in depopulation and other outbreak response: Risk for occupational exposure to avian pathogens Effectiveness of various forms of personal protective equipment Effectiveness and role of environmental sampling for animal pathogens for surveillance and outbreak management Development of rapid tests for animal pathogens, including tests that can be used in field settings
Additional attention to the health of poultry industry workers and avian outbreak response workers is warranted.	Improve interventions for poultry industry workers and outbreak response workers Improve use of seasonal influenza vaccination among poultry industry workers Improve training of outbreak response workers, including pre-event fit testing and training in use of personal protective equipment Increase consideration of poultry industry workers in defining priority groups for pandemic strain vaccination and antiviral use

*DHHS, Department of Health and Human Services.

Suggested citation for this article:
Buehler JW, Craig AS, del Rio C, Koplan JP, Stephens DS, Orenstein WA. Critical issues in responding to pandemic influenza [conference summary]. Emerg Infect Dis [serial on the Internet]. 2006 Jul [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol12no07/06-0463.htm

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James W. Buehler, Emory University Rollins School of Public Health, 1518 Clifton Rd NE, Room 416, Atlanta, GA 30322, USA; email: james.buehler@emory.edu

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