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Commentary
Influenza Pandemic Preparedness
Kathleen F. Gensheimer,* Martin I. Meltzer,† Alicia S. Postema,† and
Raymond A. Strikas†
*Department of Human Services, Augusta, Maine, USA; and †Centers for Disease
Control and Prevention, Atlanta, Georgia, USA
Suggested citation
for this article:
Gensheimer KF, Meltzer MI, Postema AS, Strikas
RA. Influenza pandemic preparedness. Emerg Infect Dis [serial online]
2003 Dec [date cited]. Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no12/03-0289.htm
In the list of potential bioterrorist agents, influenza would be classified
as a category C agent (1). While previous influenza pandemics
were naturally occurring events, an influenza pandemic could be started
with an intentional release of a deliberately altered influenza strain.
Even if a deliberately altered strain is not released, an influenza pandemic
originating from natural origins will inevitably occur (2)
and will likely cause substantial illness, death, social disruption, and
widespread panic. Globally, the 1918 pandemic killed at least 20 million
people (3). This figure is approximately double the number
killed on the battlefields of Europe during World War I (4).
In the United States alone, the next pandemic could cause an estimated
89,000–207,000 deaths, 314,000–734,000 hospitalizations, 18–42 million
outpatient visits, and 20–47 million additional illnesses (5).
These predictions equal or surpass many published casualty estimates for
a bioterrorism event (6–8). In addition to the potential
for a large number of casualties, a bioterrorism incident and an influenza
pandemic have similarities that allow public health planners to simultaneously
plan and prepare for both types of emergencies (Table).
Preparing for both the next influenza pandemic and the next bioterrorist
attack requires support and collaboration from multiple partners at the
state, local, and federal level. Potential partners include the medical
community, law enforcement, emergency management, and public health agencies.
To help foster these crucial cross-discipline relationships, the Centers
for Disease Control and Prevention (CDC) and the Council of State and
Territorial Epidemiologists (CSTE), in collaboration with the National
Emergency Management Association, the Association of State and Territorial
Health Officials, the Federal Emergency Management Agency, and the Association
of Public Health Laboratories, hosted a 2-day meeting on state and local
pandemic influenza planning in May 2002. Over 125 officials representing
epidemiology, communicable disease, laboratory, immunization, and emergency
management programs from 46 states registered for this meeting. The objectives
of the meeting were to enhance collaboration between state and local public
health and emergency management agencies, establish mechanisms for integrating
bioterrorism and pandemic influenza preparedness and response planning,
and develop policy and strategy options for influenza pandemic preparedness
and response at the state and local level. We report the results of a
questionnaire distributed to the attendees; it was designed to elicit
their views on the most important issues that must be addressed by a plan
to respond to a catastrophic disease event.
Priorities
for Pandemic Influenza Planning
All plans for any catastrophic infectious disease event
such as pandemic influenza or a bioterrorist attack must address five
topics: surveillance and laboratory issues; communications; maintenance
of community services; medical care; and supply and delivery of vaccines
and drugs. After presentations providing background information, conference
attendees were divided into breakout groups to discuss these topics. The
groups did not discuss particular scenarios, but the presentations given
before the breakout groups did include details of estimates of the potential
impact of the next influenza pandemic (5). Attendees
completed short (<5 questions), anonymous questionnaires at
both the beginning and end of the breakout session. Each breakout group
had a different set of questions relevant to the topic of that group.1
However, all groups addressed a common question, which asked persons to
pick their top priority for a pandemic influenza response from one of
the following options: reduce mortality, reduce morbidity, ensure continuation
of essential services, reduce economic impact, and ensure equitable distribution
of resources. As explained to the attendees before the breakout session,
differences by age and risk group in rates of mortality and morbidity
could mean that public health officials with limited resources might not
be able to simultaneously maximize reductions in mortality and morbidity
(5). The first three options were chosen most frequently
(Figure). Even after discussion, no option was chosen
by >50% of attendees, indicating that this group of professionals did
not have a unified opinion regarding what the top priority should be to
guide planning and response measures.
Conference attendees did, however, agree that global
and domestic laboratory and disease surveillance must be strengthened
to increase the likelihood of early detection and tracking of either pandemic
influenza or a bioterrorist event. A rise beyond the baseline number of
influenza-like illnesses (ILIs) could indicate a severe influenza season,
arrival of pandemic influenza, or early warning of a bioterrorist attack
with a pathogen that causes ILIs (e.g., anthrax). Thus, the number and
accuracy of reports of ILI, ILI outbreaks, and laboratory-confirmed reports
of influenza need to be increased. In addition, ensuring that adequate
laboratory and disease surveillance systems are in place will benefit
the public health response during yearly influenza epidemics. Conference
attendees identified two critical gaps in infectious disease surveillance
systems: 1) less than ideal or nonexistent systems to monitor outpatient
and hospital-based ILI cases and 2) insufficient numbers of laboratory
personnel and epidemiologists to monitor, provide diagnostic support,
and respond to events.
Another critical component of any catastrophic infectious disease plan
is communications. The anthrax attacks in 2001 demonstrated that the public,
media, and healthcare professionals will demand accurate information,
with frequent updates throughout the emergency. To minimize the potential
for confusion, states and localities need to identify a recognized and
trusted leader who will be the primary spokesperson to disseminate accurate
information. Among attendees in the communications breakout group, 40%
felt that the state governor would be the best spokesperson, 40% chose
the state health officer, and 20% chose the state epidemiologist.
In the initial stages of, and potentially throughout, an influenza pandemic
or a bioterrorist attack, there will be a shortage of many essential resources,
including medical equipment and supplies, personnel, vaccines, and drugs.
Prioritizing medical resources will therefore be necessary. The medical
care breakout group unanimously chose state and local government as the
authority that should prioritize and distribute healthcare resources.
In the breakout group that discussed vaccine and antimicrobial agent issues,
73% chose essential workers and physicians as those who should be the
first to receive vaccine and antiviral drugs. Only 27% chose those at
high risk for adverse influenza-related health outcomes to be early recipients
of vaccine.
Conclusions:
Maximizing Resources and Planning Efforts
Conference attendees were well aware of the need to simultaneously plan
and prepare for the next influenza pandemic and the next bioterrorist
event. However, much work remains to be done. Without agreement regarding
the top priority for allocating scarce resources, planning and implementing
an optimal response to either pandemic influenza or a bioterrorist event
will be difficult, if not impossible. Illustrating potential planning
problems was the incongruity between the inability of most attendees to
agree on the goal of planning and response measures (Figure)
while 75% of a subgroup stated that essential workers and physicians should
be the first to receive vaccines and antiviral drugs. In a situation with
limited resources, usually only one goal can be optimized (either maximized
or minimized) (9). Therefore, before accepting any of
the initially limited supplies of vaccine and antiviral drugs, physicians
and first responders will have to explain how such an allocation will
help achieve the chosen top priority.
Unprecedented resources for enhancing the public health preparedness
and response infrastructure have been recently provided to all states
by congressional appropriations in the form of bioterrorism cooperative
agreements. The request for proposals stated that planning moneys may
be used “…to upgrade state and local public health jurisdictions’ preparedness
for and response to bioterrorism, other outbreaks of infectious disease,
and other public health threats and emergencies…” (10).
Using such resources and reflecting upon the lessons learned from previous
influenza pandemics and the 2001 terrorist events, public health, medical,
and emergency management communities must work together to develop an
effective plan to strengthen our national readiness to respond to any
catastrophic infectious disease situation.
If our public health planning efforts are too narrowly focused on preparing
responses to a few select bioterrorism-related scenarios, a new opportunity
for planning responses to a broad spectrum of infectious disease-related
catastrophes will be lost. Any plans made for responding to either pandemic
influenza or bioterrorism events must include an explicit mechanism for
making difficult decisions regarding the prioritization of scarce resources.
The conference highlighted the need for all states to continue their discussions
and public debates regarding the setting of priorities and methods for
allocating scarce resources. Obviously, each state or local government
will chose its own specific method for drawing up a plan to deal with
catastrophic infectious disease events such as an influenza pandemic.
To help aid the planning process, materials such as a planning guide are
available from agencies such as CDC and CSTE. Ideally, such planning and
prioritization activities should take place well in advance of any catastrophic
infectious disease event.
Acknowledgments
We thank Kakoli
Roy and Margaret Coleman for their help in administering and analyzing
the questionnaires; Pascale Wortley for valuable comments on an earlier
draft of the manuscript; and the Council of State and Territorial Epidemiologists
for its support. The following members of the ad-hoc Influenza Pandemic
Conference Planning and Steering Committee significantly contributed
to organizing the conference in May 2002: Lynnette Brammer, Ron Burger,
Nancy Cox, Zygmunt Dembek, Kristine Ehresmann, Keiji Fukuda, John Iskander,
Deva Joseph, Donna Lazorik, Ann Moen, Mack Sewell, and Gregory Wallace.
Dr. Gensheimer is
the state epidemiologist and the director of the Medical Epidemiology
Section, Maine Bureau of Health. She helps coordinate responses to outbreaks
of disease as well as working on existing programs to promote the welfare
and safety of the citizens of Maine. She has taken a leading role in
influenza pandemic planning.
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potential responses to smallpox as a bioterrorist weapon. Emerg
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response to a smallpox attack: the case for mass vaccination. Proc
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2nd edition. Pacific Grove (CA): Brooks/Cole Publishing; 1997.
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| Table.
Planning for pandemic influenza and bioterrorism: similarities and
differencesa,b |
|
| Issue |
Bioterrorist event
|
Pandemic influenza
|
|
| Likelihood |
High
|
High
|
| Warning |
None to days
|
Days to months
|
| Occurrence |
Focal or multifocal
|
Nationwide
|
| Transmission/duration
of exposure |
Point source; limited; person-to-person
|
Person-to-person, 6–8 wks
|
| Casualties |
Hundreds to thousands
|
Hundreds of thousands to millions
|
| First responders susceptible? |
Yes
|
Yes
|
| Disaster medical team
support/response |
Yes
|
No (too widespread)
|
| Main site for preparedness,
response, recovery, and mitigation |
State and local
areas
|
State and local areas
|
|
Essential preparedness components
|
|
|
Surveillance
|
Yes
|
Yes
|
Law enforcement intelligence
|
Yes
|
No
|
Investigation
|
Yes
|
Yes
|
Research
|
Yes
|
Yes
|
Liability programs
|
Yes
|
Yes
|
Communication systems
|
Yes
|
Yes
|
Medical triage and treatment plans
|
Yes
|
Yes
|
Vaccine supply issues
|
Yes (for most likely threats)
|
Yes
|
Drug supply issues
|
Yes
|
Yes
|
Training/tabletop exercises
|
Yes
|
Yes
|
Maintenance of essential community services
|
Yes
|
Yes
|
| Essential response
components |
|
|
Rapid deployment teams
|
Yes
|
No
|
Effective communications/media relations
strategy
|
Yes
|
Yes
|
Vaccine delivery
|
Yes (for some)
|
Yes
|
Drug delivery
|
Yes (for most)
|
Yes
|
Hospital/public health coordination
|
Yes
|
Yes
|
Global assistance
|
Possibly
|
Yes
|
Medical care
|
Yes
|
Yes
|
Mental health support
|
Yes
|
Yes
|
Mortuary services
|
Yes
|
Yes
|
Supplies and equipment
|
Yes
|
Yes
|
| Essential mitigation
components |
|
|
Enhanced surveillance
|
Yes
|
Yes
|
Enhanced law enforcement intelligence
|
Yes
|
No
|
Vaccine stockpile
|
Yes (selected agents)
|
Prototype vaccines only
|
Drug stockpile
|
Yes
|
Yes
|
Pre-event vaccination
|
Vaccination of selected groupsc
|
Vaccination of groups at medical
high risk with pneumococcal vaccined
|
|
| aDuring
a catastrophic infectious disease event, such as an influenza pandemic,
there may be critical shortages of vaccines and drugs. Thus, clinics
set up to administer vaccines and distribute antimicrobial drugs may
require the services of a range of personnel whose fields of expertise
are nonclinical. Examples of additional personnel that may be needed
include law enforcement, translators, social workers, psychologists,
and legal experts. |
| bSource:
Adapted from: National Vaccine Program Office. Pandemic influenza:
a planning guide for state and local officials (Draft 2.1). Atlanta:
Centers for Disease Control and Prevention; 2000. |
cAt
the time of writing, the smallpox vaccination program was just beginning.
For other bioterrorist agents for which vaccines are available (e.g.,
anthrax), limited supplies and concerns about safety profiles have,
up to this point, effectively prevented the widespread use of these
vaccines.
dIt may eventually be possible to vaccinate high-priority
groups and the general population with a yet-to-be-developed “common
epitope” vaccine, which might provide for a broader spectrum of protection
against a variety of influenza A subtypes. |
1A complete copy of each questionnaire and
a complete set of the results are available from the corresponding author.
|
