Pandemic Influenza Preparedness Plans Research Articles

An appraisal of peer-reviewed published literature on Influenza, 2000-2021 from countries in South-East Asia Region.

Influenza poses a major public health challenge in South-East Asia Region (SEAR). To address the challenge, there is a need to generate contextual evidence that could inform policy makers and program managers for response preparedness and impact mitigation. The World Health Organization has identified priority areas across five streams for research evidence generation at a global level (WHO Public Health Research Agenda). Stream 1 focuses on research for reducing the risk of emergence, Stream 2 on limiting the spread, Stream 3 on minimizing the impact, Stream 4 on optimizing the treatment and Stream 5 on promoting public health tools and technologies for Influenza. However, evidence generation from SEAR has been arguably low and needs a relook for alignment with priorities. This study aimed to undertake a bibliometric analysis of medical literature on Influenza over the past 21 years to identify gaps in research evidence and for identifying major areas for focusing with a view to provide recommendations to member states and SEAR office for prioritizing avenues for future research. We searched Scopus, PubMed, Embase, and Cochrane databases in August 2021. We identified studies on influenza published from the 11 countries in WHO SEAR in the date range of 1 January 2000-31 December 2021. Data was retrieved, tagged and analyzed based on the WHO priority streams for Influenza, member states, study design and type of research. Bibliometric analysis was done on Vosviewer. We included a total of 1,641 articles (Stream 1: n = 307; Stream 2: n = 516; Stream 3: n = 470; Stream 4: n = 309; Stream 5: n = 227). Maximum number of publications were seen in Stream 2, i.e., limiting the spread of pandemic, zoonotic, and seasonal epidemic influenza which majorly included transmission, spread of virus at global and local levels and public health measures to limit the transmission. The highest number of publications was from India (n = 524) followed by Thailand (n = 407), Indonesia (n = 214) and Bangladesh (n = 158). Bhutan (n = 10), Maldives (n = 1), Democratic People's Republic of Korea (n = 1), and Timor-Leste (n = 3) had the least contribution in Influenza research. The top-most journal was PloS One which had the maximum number of influenza articles (n = 94) published from SEAR countries. Research that generated actionable evidence, i.e., implementation and intervention related topics were less common. Similarly, research on pharmaceutical interventions and on innovations was low. SEAR member states had inconsistent output across the five priority research streams, and there was a much higher scope and need for collaborative research. Basic science research showed declining trends and needed reprioritization. While a priority research agenda has been set for influenza at the global level through the WHO Global Influenza Program since 2009, and subsequently revisited in 2011 and again in 2016-2017, a structured contextualized approach to guide actionable evidence generation activities in SEAR has been lacking. In the backset of the Global Influenza Strategy 2019-2030 and the COVID-19 pandemic, attuning research endeavors in SEAR could help in improved pandemic influenza preparedness planning. There is a need to prioritize contextually relevant research themes within priority streams. Member states must inculcate a culture of within and inter-country collaboration to produce evidence that has regional as well as global value.

Changed epidemiology of narcolepsy before, during, and after the 2009 H1N1 pandemic: a nationwide narcolepsy surveillance network study in mainland China, 1990-2017.

Increased incidence of narcolepsy was reported in children during the 2009 H1N1 pandemic following Pandemrix, a H1N1 flu vaccine. A link with A(H1N1) pdm09 infections remains controversial. Using nationwide surveillance data from China (1990 to 2017), the epidemiology of narcolepsy was analyzed. Individual records of narcolepsy patients were collected from 15 of 42 hospitals across China known to diagnose cases. Incidence was estimated assuming the representativeness of these hospitals. Age-specific incidence, epidemiological and clinical characteristics of patients were evaluated before, during, and after the 2009 H1N1 pandemic. Sensitivity analyses were conducted by including NT1 cases only and excluding the effect of the 2009 H1N1 vaccination. Average annual incidence was 0.79 per 100 000 person-years (PY) from 1990 to 2017 and 1.08 per 100 000 PY from 2003 to 2017. Incidence increased 4.17 (95% CI 4.12, 4.22) and 1.42 (95% CI 1.41, 1.44) fold during and after the 2009 H1N1 pandemic when compared to baseline. These results were robust in sensitivity analyses. Patients with the onset of narcolepsy during the pandemic period were younger (notably in 5-9-year-old strata), and the age shift toward younger children reversed to baseline following the pandemic. Increased incidence of narcolepsy was observed during the 2009 H1N1 pandemic period. This is likely to be associated with the circulation of the wild type A(H1N1)pdm09 virus. This observation should be considered for future influenza pandemic preparedness plans.

Striving for Health Equity: The Importance of Social Determinants of Health and Ethical Considerations in Pandemic Preparedness Planning.

Since the WHO’s “Influenza Pandemic Preparedness Plan” in 1999, pandemic preparedness plans at the international and national level have been constantly adapted with the common goal to respond early to outbreaks, identify risks, and outline promising interventions for pandemic containment. Two years into the COVID-19 pandemic, public health experts have started to reflect on the extent to which previous preparations have been helpful as well as on the gaps in pandemic preparedness planning. In the present commentary, we advocate for the inclusion of social and ethical factors in future pandemic planning—factors that have been insufficiently considered so far, although social determinants of infection risk and infectious disease severity contribute to aggravated social inequalities in health.

Kanta Subbarao—confronting influenza and COVID-19

Kanta Subbarao—confronting influenza and COVID-19

Leveraging International Influenza Surveillance Systems and Programs during the COVID-19 Pandemic

A network of global respiratory disease surveillance systems and partnerships has been built over decades as a direct response to the persistent threat of seasonal, zoonotic, and pandemic influenza. These efforts have been spearheaded by the World Health Organization, country ministries of health, the US Centers for Disease Control and Prevention, nongovernmental organizations, academic groups, and others. During the COVID-19 pandemic, the US Centers for Disease Control and Prevention worked closely with ministries of health in partner countries and the World Health Organization to leverage influenza surveillance systems and programs to respond to SARS-CoV-2 transmission. Countries used existing surveillance systems for severe acute respiratory infection and influenza-like illness, respiratory virus laboratory resources, pandemic influenza preparedness plans, and ongoing population-based influenza studies to track, study, and respond to SARS-CoV-2 infections. The incorporation of COVID-19 surveillance into existing influenza sentinel surveillance systems can support continued global surveillance for respiratory viruses with pandemic potential.

Turkey’s response to COVID-19 pandemic: strategy and key actions

COVID-19 emerged at the end of 2019 in Wuhan, China, and spread rapidly around the world causing many deaths. Due to the intercontinental escalation in the epidemic, while WHO declared a pandemic on March 11, 2020, our country’s first case was diagnosed. Before this, the MoH established the Operations Center against possible risks regarding the Pandemic Influenza Preparedness Plan on January 10, 2020 and formed the Scientific Committee, which has a critical importance in epidemic management. National and Provincial Pandemic Coordination Boards were established within the scope of this plan. Fast, effective and frequently updated decisions were implemented. The epidemic was kept under control by stopping mutual flights to countries with cases, intermittent curfews, transportation restrictions, closure of schools, filiation, social isolation, use of PPE, social media communication, and intensive work of healthcare workers. Softwares were developed for analysis and data reporting, case and contact tracing. Various mobile applications were developed providing a safe social life in social areas and enabling filiation teams to intervene in the necessary areas in the fastest way and to record data instantly in the system. Prior to normalization process, “COVID-19 Epidemic Management and Working Guide” was prepared including epidemic measures for social life, institutions, organizations, and businesses. Variants of concern, recommended by WHO to be monitored, led to an increase in the number of cases around the world. In our country, the number of laboratories and tests were expanded to monitor variant viruses. Vaccination activities continue in line with the National Vaccine Administration Strategy. In the fight against pandemic, it will be possible to maintain and increase our country’s acquisitions so far, owing to the strong health infrastructure both in terms of manpower and institutions, free health care, success in the production of PPE and medical devices, and finally, rapid acceleration of the vaccination.

The Effectiveness of Table-Top Exercises in Improving Pandemic Crisis Preparedness

The World Health Organization carried out a global survey in 2018 to ascertain the level of preparedness for pandemic influenza. It was discovered that simulation exercises to test national pandemic influenza preparedness plans were carried out in the previous 5 years, by 42 out of the 104 countries that completed the survey. The table-top exercise (TTX) being the preferred format, with 86% of the countries using them. Although no table-top exercise can convey a realistic picture of a pandemic, they can be used to assess plans, policies, and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment. However, table-top exercises are only effective if they are properly designed, carefully conducted, fully evaluated, and most importantly, the results and recommendations identified are actually implemented. TTXs used as part of preparedness for pandemics are not cost free, a failure to implement the lessons learned from them can have both human and economic consequences. To understand the value of TTXs, a sample of national and large scale TTXs are examined in an effort to identify the effectiveness of table-top exercises, as a part of improving pandemic crisis preparedness.

Prophylaxis and treatment of influenza: options, antiviral susceptibility, and existing recommendations.

Influenza viruses of types A and B attack 5–10% of adults and 20–30% of children, thereby causing millions of acute respiratory infections in Germany annually. A significant number of these infections are associated with complications such as pneumonia and bacterial superinfections that need hospitalization and might lead to death. In addition to vaccines, drugs were developed that might support influenza prevention and that can be used to treat influenza patients. The timely application of anti-influenza drugs can inhibit virus replication, help reduce and shorten the symptoms, and prevent death as well as virus transmission.This review concisely describes the mechanism of action, the potential for prophylactic and therapeutic use, and the knowledge on resistance of anti-influenza drugs approved today. However, the main aim is to give an overview on the recommendations available in Germany for the proper use of these drugs. In doing so, the recommendations published in statements and guidelines of medical societies as well as the German influenza pandemic preparedness plan are summarized with the consideration of specific circumstances and groups of patients.

On Pandemic Preparedness: How Well is the Modeling Community Prepared for COVID-19?

On Pandemic Preparedness: How Well is the Modeling Community Prepared for COVID-19?

Country level analysis of COVID-19 policies.

Country level analysis of COVID-19 policies.

Mexico: Lessons learned from the 2009 pandemic that help us fight COVID-19.

In April 2009, Mexican, American, and Canadian authorities announced a novel influenza that became the first pandemic of the century. We report on lessons learned in Mexico. The Mexican Pandemic Influenza Preparedness and Response Plan, developed and implemented since 2005, was a decisive element for the early response. Major lessons-learned were the need for flexible plans that consider different scenarios; the need to continuously strengthen routine surveillance programs and laboratory capacity and strengthen coordination between epidemiological departments, clinicians, and laboratories; maintain strategic stockpiles; establish a fund for public health emergencies; and collaboration among neighboring countries. Mexico responded with immediate reporting and transparency, implemented aggressive control measures and generous sharing of data and samples. Lessons learned induced changes leading to a better response to public health critical events.

Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings-International Travel-Related Measures.

International travel–related nonpharmaceutical interventions (NPIs), which can include traveler screening, travel restrictions, and border closures, often are included in national influenza pandemic preparedness plans. We performed systematic reviews to identify evidence for their effectiveness. We found 15 studies in total. Some studies reported that NPIs could delay the introduction of influenza virus. However, no available evidence indicated that screening of inbound travelers would have a substantial effect on preventing spread of pandemic influenza, and no studies examining exit screening were found. Some studies reported that travel restrictions could delay the start of local transmission and slow international spread, and 1 study indicated that small Pacific islands were able to prevent importation of pandemic influenza during 1918–19 through complete border closure. This limited evidence base indicates that international travel-related NPIs would have limited effectiveness in controlling pandemic influenza and that these measures require considerable resources to implement.

Strengthening emergency preparedness and response systems: experience from Indonesia

Indonesia has made excellent progress on emergency preparedness in compliance with the International Health Regulations, 2005, including a joint external evaluation (JEE) of IHR core capacities in 2017. Development of the National action plan for health security (NAPHS) began soon after the JEE, through multisectoral coordination and collaboration and with the support of a presidential instruction. The logic model approach was used to develop the NAPHS, and provided a robust framework to ensure that activities were linked to indicators at the various capacity levels delineated in the JEE. The NAPHS includes a comprehensive tool within which monitoring and evaluation are completely separated and different indicators applied. Furthermore, development of the NAPHS was done in parallel and in line with that of the National medium-term development plan 2020-2024, which included a focus on health system strengthening based on the primary health-care approach. An innovative approach taken in 2018 was the inclusion of emergency preparedness in the mandatory minimum service standards for provincial and district governments. These standards clearly articulate the importance of local emergency preparedness in Indonesia's decentralized governance through the development of contingency plans and simulation exercises for natural disasters and potential disease outbreaks. Development of the NAPHS has benefited from Indonesia's extensive experience in pandemic influenza preparedness planning and exercises, integrated with a national disaster management system. By signing the Delhi Declaration on Emergency Preparedness in the South-East Asia Region, Indonesia has signalled its commitment to implementing the NAPHS in full, focusing on enhanced emergency preparedness at all administrative levels.

Pandemic influenza preparedness in the WHO South-East Asia Region: a model for planning regional preparedness for other priority high-threat pathogens

Pandemic influenza preparedness has contributed significantly to building, strengthening and maintaining countries' core capacities to prepare for health emergencies. The Pandemic influenza preparedness framework for the sharing of influenza viruses and access to vaccines and other benefits (the PIP framework) was adopted by the World Health Assembly in 2011. The experiences and lessons learnt from the implementation of the PIP framework have provided insights that can be used to strengthen preparedness for epidemics of other priority high-threat pathogens in the World Health Organization (WHO) South-East Asia Region in line with obligations under the International Health Regulations, 2005 (IHR). Implementation has established policies, strategies, action plans, strengthened systems and operational readiness to promptly diagnose influenza virus strains with pandemic potential and ensure timely event notifications and management in compliance with the IHR. WHO collaborating centres and the annual bi-regional meeting of national influenza centres and influenza surveillance have strengthened the influenza laboratory diagnostic knowledge network in the region. After action reviews following influenza outbreaks have documented best practices, strengths, constraints and areas for improvement in pandemic preparedness. The pandemic in 2009 and recent seasonal influenza outbreaks have offered real-life scenarios for testing national pandemic influenza preparedness plans and deploying vaccines. The successful implementation of the PIP framework, along with strengthening of health systems and operational procedures and continued technical collaboration with global centres of excellence, should be tapped into to strengthen preparedness to respond to epidemics of other high-threat pathogens based on the influenza model. The political commitment reflected in the Delhi Declaration on Emergency Preparedness, signed by all ministers of health in September 2019 and supported by the Five-year regional strategic plan to strengthen public health preparedness and response - 2019-2023, should be a catalyst for guidance and support in developing a broad, long-term strategic plan for preparedness and response to high-threat pathogens in the region.

An Evaluation Tool for National-Level Pandemic Influenza Planning.

The historical threat of pandemic influenza and the circulation of novel influenza viruses have led countries to strengthen their efforts in pandemic influenza preparedness planning. A cornerstone of these efforts is the creation of a comprehensive national plan that addresses all of the capacities required to prevent, detect, and respond to novel influenza outbreaks. In 2017 and 2018, the World Health Organization issued updated guidance for national pandemic planning efforts, based on lessons learned from the 2009 influenza A (H1N1) outbreak, the International Health Regulations (World Health Organization, 2005a), and other developments in health security. We have created a tool to assess national‐level plans based on these updated guidelines. This tool will allow for countries to identify both strengths and weaknesses in their national plans, identify capacities and sectors that require improvement, and to help frame the updating or drafting of plans in line with the most updated guidance.

Heterologous prime-boost with A(H5N1) pandemic influenza vaccines induces broader cross-clade antibody responses than homologous prime-boost

Highly pathogenic avian influenza (HPAI) A(H5Nx) viruses continue to pose a pandemic threat. US national vaccine stockpiles are a cornerstone of the influenza pandemic preparedness plans. However, continual genetic and antigenic divergence of A(H5Nx) viruses requires the development of effective vaccination strategies using stockpiled vaccines and adjuvants for pandemic preparedness. Human sera collected from healthy adults who received either homologous (2 doses of a AS03A-adjuvanted A/turkey/Turkey/1/2005, A/Turkey), or heterologous (primed with AS03A-adjuvanted A/Indonesia/5/2005, A/Indo, followed by A/Turkey boost) prime-boost vaccination regimens were analyzed by hemagglutination inhibition and microneutralization assays against 8 wild-type HPAI A(H5Nx) viruses from 6 genetic clades. Molecular, structural and antigenic features of the A(H5Nx) viruses that could influence the cross-clade antibody responses were also explored. Compared with homologous prime-boost vaccinations, priming with a clade 2.1.3.2 antigen (A/Indo) followed by one booster dose of a clade 2.2.1 antigen (A/Turkey) administered 18 months apart did not compromise the antibody responses to the booster vaccine (A/Turkey), it also broadened the cross-clade antibody responses to several antigenically drifted variants from 6 heterologous clades, including an antigenically distant A(H5N8) virus (A/gyrfalcon/Washington/410886/2014, clade 2.3.4.4) that caused recent outbreaks in US poultry. The magnitude and breadth of the cross-clade antibody responses against emerging HPAI A(H5Nx) viruses are associated with genetic, structural and antigenic differences from the vaccine viruses and enhanced by the inclusion of an adjuvant. Heterologous prime-boost vaccination with AS03A adjuvanted vaccine offers a vaccination strategy to use existing stockpiled vaccines for pandemic preparedness against new emerging HPAI A(H5Nx) viruses.

Risk modelling the mortality impact of antimicrobial resistance in secondary pneumococcal pneumonia infections during the 2009 influenza pandemic

ObjectivesThe aim of this study was to estimate the impact of antimicrobial resistance (AMR) in secondary pneumococcal pneumonia infections on global mortality during the 2009 influenza pandemic, to estimate future pandemic mortality risk and to inform pandemic preparedness. MethodsRisk analysis modelling was conducted using a multivariate risk formula. Literature reviews were conducted to generate global central estimates for each of the parameters of the risk formula in relation to the 2009 influenza pandemic, secondary pneumococcal pneumonia, rates of AMR, and pneumococcal vaccine efficacy as a component of pandemic preparedness. ResultsGlobal Streptococcus pneumoniae AMR was estimated at 21.8% to 27.6%, and contributed to 1.8% to 2.3% of deaths during the 2009 influenza pandemic. When directly applied to mortality due to multidrug resistance, pneumococcal vaccination could potentially prevent 1277 to 3754 deaths and could have reduced mortality from multidrug-resistant S. pneumoniae to 1% to 1.2%. ConclusionsAMR in secondary pneumococcal infections contributed towards a small percentage of the global mortality during the 2009 influenza pandemic. Increased S. pneumoniae AMR could result in a three- to four-fold rise in mortality due to secondary pneumococcal infections in future influenza pandemics. Pneumococcal vaccination has an important role in preventing pneumococcal co-infections and combating AMR in all populations, and should be considered a key component of influenza pandemic preparedness or early action plans.

European Pandemic Influenza Preparedness Planning: A Review of National Plans, July 2016.

Pandemic influenza A (H1N1) commenced in April 2009. Robust planning and preparedness are needed to minimize the impact of a pandemic. This study aims to review if key elements of pandemic preparedness are included in national plans of European countries. Key elements were identified before and during the evaluations of the 2009 pandemic and are defined in this study by 42 items. These items are used to score a total of 28 publicly available national pandemic influenza plans. We found that plans published before the 2009 influenza pandemic score lower than plans published after the pandemic. Plans from countries with a small population size score significantly lower compared to national plans from countries with a big population (P <.05). We stress that the review of written plans does not reflect the actual preparedness level, as the level of preparedness entails much more than the existence of a plan. However, we do identify areas of improvement for the written plans, such as including aspects on the recovery and transition phase and several opportunities to improve coordination and communication, including a description of the handover of leadership from health to wider sector management and communication activities during the pre-pandemic phase. (Disaster Med Public Health Preparedness. 2019;13:582-592).

PanStop: a decade of rapid containment exercises for pandemic preparedness in the WHO Western Pacific Region.

Member States in the Western Pacific Region (WPR) of the World Health Organization (WHO), are highly vulnerable to emerging influenza viruses that have the potential to cause global pandemics. A well-coordinated strategy for preparedness is required at national and international levels for a robust response and to mitigate the potentially dire consequences of the next influenza pandemic. Of 37 countries and areas in the region, 23 have publically available national pandemic influenza preparedness and response plans; of these, only 17% have been updated in the last five years. However, many plans are pending update and may benefit from integrating some components of the 2017 WHO pandemic influenza risk management guide. Additionally, many plans need to be operationalized to test their functionality. Since 2007, WPRO has conducted annual PanStop exercises to test pandemic containment plans and RC mechanisms in a simulated environment that imitates pandemic events as they unfold. PanStop exercises provide an opportunity for countries to validate policies, protocols and procedures involved in implementing rapid containment (RC) operations, and to identify strengths and opportunities for improvement in planning activities for pandemic influenza. By participating in exercises such as PanStop and the annual regional International Health Regulation (IHR) Crystal Exercise, and subsequently adapting national preparedness plans based on exercise outcomes, WPR continues to improve readiness for the next influenza pandemic.

A review on the preparedness plans on influenza pandemics, by WHO and China: the current status and development

Every influenza pandemic in history would end up with disastrous outcomes on mankind, of which the most notorious one was the "Spanish flu" pandemic in 1918. In the past century, with advanced knowledge on influenza viruses, laboratory technologies and surveillance methods, human beings were not as helpless when facing the influenza pandemic. In order to control the outbreaks and reducing the negative impacts, programs as: setting up and improving the influenza pandemic preparedness and response plan were recognized as important issues on early detection or prompt warning of any influenza virus strain that might lead to potential pandemics. The scheduled and planned control measures towards the pandemic preparedness and response plan had been considered of key importance in mitigating the peak of pandemic or controlling the transmission of virus. Since the "1918 influenza pandemic" , we had reviewed the evolution and development of plans regarding the preparedness and response on influenza pandemic issued by both WHO and China. We also emphasized on the variety of strategies which were linked to the preparedness and response at different historical stages, to provide reference for the pandemic preparedness of the disease, in the future.