Pandemic Influenza Preparedness Plans Research Articles

Pandemic influenza A (H1N1) 2009 in Madrid, Spain: incidence and characteristics in immigrant and native population

Some immigrants and refugees might be more vulnerable than other groups to pandemic influenza because of pre-existing health and social disparities, migration history and living conditions. The objective of this study was to compare, between the immigrant and autochtonous population, the incidence and characteristics of influenza cases consulting in primary care (PC) and severe influenza cases. Descriptive cross-sectional study of influenza episodes registered in PC and severe influenza cases reported between 1 May 2009 and 22 May 2010, by gender and origin. Age-adjusted rates were calculated and the association between origin and chronic pathology, pregnancy, delay in admission to hospital and admission to intensive care units (ICU) was analyzed by logistic regression and generalized linear models. The influenza rate in PC, adjusted by age, was lower for immigrant population (2396.3, 95% confidence interval (95% CI) 2362.5-2430.0 vs. 2795.9, 95% CI 2780.4-2811.5 per 100, 000). The difference between severe influenza rates by origin was not statistically significant. Chronic conditions were less common in immigrant population. In severe influenza cases, pregnancy was more common in immigrant women, and the probability of admission to ICU was higher in men from Central and Eastern Europe (prevalence ratio (PR) 8.44, 95% CI 2.81-25.40) and North African women (PR 3.30, 95% CI 1.09-10.05). Differences in influenza rates were detected by origin. This information could be useful for new pandemic wave management purposes, in addition to targetting future investigations. Pandemic influenza preparedness and response plans should incorporate specific actions to improve immigrants' access to health services and to decrease cultural barriers.

From Lessons Learned After 2009 H1N1 Pandemic to TEPIK's Preparedness and Response Plan

In response to the global spread of the H1N1 influenza virus after first being detected in North America in April 2009, WHO declared the first influenza pandemic in more than four decades on June 11 of the same year. In Korea, the arrival of the 2009 H1N1 pandemic influenza triggered an integrated response that was mainly based on the 2006 Pandemic Influenza Preparedness and Response Plan. At least 270 fatal cases, 764 laboratory-thousand confirmed cases, and 3.6 million courses of antiviral agent use were reported to the end of August 2010 in this country. Even if government tried to control and mitigate the impact of pandemic by using public health and medical countermeasures, there were several issues found during the H1N1 pandemic responses. The main difficulty was the delayed and insufficient supply of pandemic vaccine. Therefore the mass vaccination campaign was begun after the peak of pandemic and its mitigation effect on the pandemic disease burden was diminished. The amount of stockpiled antiviral agents by government was not enough in the early phase of pandemic. The rapid antigen test for the H1N1 influenza showed low sensitivity, about 50%. Many infected people were seeking to be diagnosed with rRT-PCR test, which is expensive and not useful for the decision of antiviral use because of late test report. The communications among government, medical societies, general people and mass media were also not satisfactory. Lessons learned from the national response to the H1N1 pandemic made the government to launch the TEPIK in October 2010. TEPIK will incorporate those lessons into the future pandemic preparedness planning. The mission of TEPIK is to ensure the safety of the nation and people from the threat of pandemic influenza. TEPIK focuses to establish government-academic-institute-industry collaborative system with three main strategies; to expedite sharing of RD to establish the preparedness and response of RD and to secure the innovative and leading response technology against pandemic influenza. TEPIK has 34 research projects in eight research areas, which include vaccine; therapeutics; diagnostics; basic/mechanism; clinical/ policy; surveillance/epidemiology; innovative researches; and infrastructures. Research subjects in each research area will be stated in this presentation.

Sensitivity Analysis of the Parameters of Korea’s Pandemic Influenza Preparedness Plan

ObjectivesOur aim was to evaluate Korea’s Pandemic Influenza Preparedness Plan. MethodsWe conducted a sensitivity analysis on the expected number of outpatients and hospital bed occupancy, with 1,000,000 parameter combinations, in a situation of pandemic influenza, using the mathematical simulation program InfluSim. ResultsGiven the available resources in Korea, antiviral treatment and social distancing must be combined to reduce the number of outpatients and hospitalizations sufficiently; any single intervention is not enough. The antiviral stockpile of 4–6% is sufficient for the expected eligible number of cases to be treated. However, the eligible number assumed (30% for severe cases and 26% for extremely severe cases) is very low compared to the corresponding number in European countries, where up to 90% of the population are assumed to be eligible for antiviral treatment. ConclusionsA combination of antiviral treatment and social distancing can mitigate a pandemic, but will only bring it under control for the most optimistic parameter combinations.

Challenges and opportunities in the Israeli 2009 Pandemic Influenza Vaccination Program

Vaccines are a cornerstone in any pandemic influenza preparedness plan. Successful supplementary mass vaccination programs require proper advance planning. We aimed to identify general, and Israeli specific, challenges and opportunities before initiating the Israeli pandemic influenza vaccination program in order to better plan implementation of the program. Following the vaccination campaign the analysis was retrospectively examined in order to determine whether the challenges were properly identified and whether the opportunities were indeed realized. The major challenges identified were prioritization; ongoing communication with the public; balancing between central management and accessibility; and preventing vaccination errors. The major opportunity was expected to be the chance to enhance cooperation and communication between different organizations both within and outside of the health system at local, national and international levels. The vaccination program was planned based on this analysis. In retrospect, the analysis identified the key challenges and opportunities and appropriate measures were taken. However, the criticalness of acceptance of the vaccine among health care practitioners was not given sufficient attention and should be addressed in future vaccination programs. Analysis of global and local challenges and opportunities served as a useful tool for planning a pandemic influenza vaccination program. Lessons learned from this analysis could serve to foster cooperation and communication between various agencies in the event of planning rapid mass vaccination programs as well as for more routine public health vaccination campaigns.

Lars R. Haaheim PhD (1945–2011)

Lars R. Haaheim PhD (1945–2011)

Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries

The aim of this study was to identify the common barriers and facilitators for acceptance of pandemic influenza vaccination across different countries. This study utilized a standardized, anonymous, self-completed questionnaire-based survey recording the demographics and professional practice, previous experience and perceived risk and severity of influenza, infection control practices, information of H1N1 vaccination, acceptance of the H1N1 vaccination and reasons of their choices and opinions on mandatory vaccination. Hospital-based doctors, nurses and allied healthcare workers in Hong Kong (HK), Singapore (SG) and Leicester, United Kingdom (UK) were recruited. A total of 6318 (HK: 5743, SG: 300, UK: 275) questionnaires were distributed, with response rates of 27.1% (HK), 94.7% (SG) and 94.5% (UK). The uptake rates for monovalent 2009 pandemic H1N1 vaccine were 13.5% (HK), 36.2% (SG) and 41.3% (UK). The single common factor associated with vaccine acceptance across all sites was having seasonal influenza vaccination in 2009. In UK and HK, overestimation of side effect reduced vaccination acceptance; and fear of side effect was a significant barrier in all sites. In HK, healthcare workers with more patient contact were more reluctant to accept vaccination. Drivers for vaccination in UK and HK were concern about catching the infection and following advice from health authority. Only a small proportion of respondents agreed with mandatory pandemic influenza vaccination (HK: 25% and UK: 42%), except in Singapore where 75.3% were in agreement. Few respondents (<5%) chose scientific publications as their primary source of information, but this group was more likely to receive vaccination.The acceptance of pandemic vaccine among healthcare workers was poor (13–41% of respondents). Breaking barriers to accept seasonal influenza vaccination should be part of the influenza pandemic preparedness plan. Mandatory vaccination even during pandemic is likely to arouse substantial discontent.

Epidemiological Characteristics of 2009 (H1N1) Pandemic Influenza Based on Paired Sera from a Longitudinal Community Cohort Study

While patterns of incidence of clinical influenza have been well described, much uncertainty remains over patterns of incidence of infection. The 2009 pandemic provided both the motivation and opportunity to investigate patterns of mild and asymptomatic infection using serological techniques. However, to date, only broad epidemiological patterns have been defined, based on largely cross-sectional study designs with convenience sampling frameworks. We conducted a paired serological survey of a cohort of households in Hong Kong, recruited using random digit dialing, and gathered data on severe confirmed cases from the public hospital system (>90% inpatient days). Paired sera were obtained from 770 individuals, aged 3 to 103, along with detailed individual-level and household-level risk factors for infection. Also, we extrapolated beyond the period of our study using time series of severe cases and we simulated alternate study designs using epidemiological parameters obtained from our data. Rates of infection during the period of our study decreased substantially with age: for 3-19 years, the attack rate was 39% (31%-49%); 20-39 years, 8.9% (5.3%-14.7%); 40-59 years, 5.3% (3.5%-8.0%); and 60 years or older, 0.77% (0.18%-4.2%). We estimated parameters for a parsimonious model of infection in which a linear age term and the presence of a child in the household were used to predict the log odds of infection. Patterns of symptom reporting suggested that children experienced symptoms more often than adults. The overall rate of confirmed pandemic (H1N1) 2009 influenza (H1N1pdm) deaths was 7.6 (6.2-9.5) per 100,000 infections. However, there was substantial and progressive increase in deaths per 100,000 infections with increasing age from 0.66 (0.65-0.86) for 3-19 years up to 220 (50-4,000) for 60 years and older. Extrapolating beyond the period of our study using rates of severe disease, we estimated that 56% (43%-69%) of 3-19 year olds and 16% (13%-18%) of people overall were infected by the pandemic strain up to the end of January 2010. Using simulation, we found that, during 2009, larger cohorts with shorter follow-up times could have rapidly provided similar data to those presented here. Should H1N1pdm evolve to be more infectious in older adults, average rates of severe disease per infection could be higher in future waves: measuring such changes in severity requires studies similar to that described here. The benefit of effective vaccination against H1N1pdm infection is likely to be substantial for older individuals. Revised pandemic influenza preparedness plans should include prospective serological cohort studies. Many individuals, of all ages, remained susceptible to H1N1pdm after the main 2009 wave in Hong Kong. Please see later in the article for the Editors' Summary.

The Vaccine Formulation Laboratory: A platform for access to adjuvants

Adjuvants are increasingly used by the vaccine research and development community, particularly for their ability to enhance immune responses and for their dose-sparing properties. However, they are not readily available to the majority of public sector vaccine research groups, and even those with access to suitable adjuvants may still fail in the development of their vaccines because of lack of knowledge on how to correctly formulate the adjuvants. This shortcoming led the World Health Organization to advocate for the establishment of the Vaccine Formulation Laboratory at the University of Lausanne, Switzerland. The primary mission of the laboratory is to transfer adjuvants and formulation technology free of intellectual property rights to academic institutions, small biotechnology companies and developing countries vaccine manufacturers. In this context, the transfer of an oil-in-water emulsion to Bio Farma, an Indonesian vaccine manufacturer, was initiated to increase domestic pandemic influenza vaccine production capacity as part of the national pandemic influenza preparedness plan.

A simulation model for policy decision analysis: a case of pandemic influenza on a university campus

Pandemic influenza preparedness plans strongly focus on efficient mitigation strategies including social distancing, logistics and medical response. These strategies are formed by multiple decision makers before a pandemic outbreak and during the pandemic in local communities, states and nation-wide. In this paper, we model the spread of pandemic influenza in a local community, a university, and evaluate the mitigation policies. Since the development of an appropriate vaccine requires a significant amount of time and available antiviral quantities can only cover a relatively small proportion of the population, university decision makers will first focus on non-pharmaceutical interventions. These interventions include social distancing and isolation. The disease spread is modelled as differential equations-based compartmental model. The system is simulated for multiple non-pharmaceutical interventions such as social distancing including suspending university operations, evacuating dorms and isolation of infected individuals on campus. Although the model is built based on the preparedness plan of one of the biggest universities in the world, Arizona State University, it can easily be generalized for other colleges and universities. The policies and the decisions are tested by several simulation runs and evaluations of the mitigation strategies are presented in the paper.

A novel methodological approach to systematically analyse pandemic influenza response programs within health systems

Background: Pandemic influenza preparedness plans exist in most countries yet the health systems operational capacity to actually implement these is a challenge. Diverse approaches to evaluate pandemic influenza programmes like guidelines, checklists or table top exercises exist yet they do not see the broader health system context in which programs have to function. Here we present an evaluation framework which helps to systematically determine how health systems and pandemic programmes interact, whether, where and which weak points exist; and how and where pandemic response programmes can be improved effectively. Method: The applied evaluation framework draws upon two existing approaches, the Systemic Rapid Assessment Toolkit (SYSRA) and the Hazard Analysis of Critical Control Points (HACCP) modified to systematically assess pandemic preparedness programmes in context. The assessment process can be divided into four basic phases i) data collection, ii) data synthesis, iii) hazard analysis and iv) generating recommendations. Results: The SYSRA is a systematic approach to analyse the interplay between pandemic control programmes and the broader health systems context within which they operate i.e. the meso level. Program functionality is for e.g. influenced by the political, economical, social and legal background of the health system environment. The HACCP methodology extends this to the micro level (service delivery) and builds upon a systematic analysis of predefined successive process steps within a pandemic programme to identify and localise likely hazards and to develop control measures to address them. Discussion: The combination of a systematic data collection tool with an analytical evaluation method provides a simple and rapid means for developing a contextual understanding and for identifying frailties in programmes that need to be responded to. Data collection from different sources (interviews, documents and guidelines) and data triangulation aims to display programme and system functionality as accurately as possible yet as with all models it can only represent reality.

Usefulness of simulated cases for assessing pandemic influenza preparedness plans

To evaluate compliance with preparedness plans, actors simulating avian influenza attended various hospital emergency departments and public health centres during the last quarter of 2007. Most centres (89%) did not respond correctly. The useful information obtained was sent to the medical and administrative staff who were responsible for the preparedness plans. Awareness of these errors and their rectification can lead to improvements in the response to any case of influenza with pandemic potential and in the capacity to combat any other emergent or re-emergent community infection.

Pandemic influenza preparedness and health systems challenges in Asia: results from rapid analyses in 6 Asian countries

BackgroundSince 2003, Asia-Pacific, particularly Southeast Asia, has received substantial attention because of the anticipation that it could be the epicentre of the next pandemic. There has been active investment but earlier review of pandemic preparedness plans in the region reveals that the translation of these strategic plans into operational plans is still lacking in some countries particularly those with low resources. The objective of this study is to understand the pandemic preparedness programmes, the health systems context, and challenges and constraints specific to the six Asian countries namely Cambodia, Indonesia, Lao PDR, Taiwan, Thailand, and Viet Nam in the prepandemic phase before the start of H1N1/2009.MethodsThe study relied on the Systemic Rapid Assessment (SYSRA) toolkit, which evaluates priority disease programmes by taking into account the programmes, the general health system, and the wider socio-cultural and political context. The components under review were: external context; stewardship and organisational arrangements; financing, resource generation and allocation; healthcare provision; and information systems. Qualitative and quantitative data were collected in the second half of 2008 based on a review of published data and interviews with key informants, exploring past and current patterns of health programme and pandemic response.ResultsThe study shows that health systems in the six countries varied in regard to the epidemiological context, health care financing, and health service provision patterns. For pandemic preparation, all six countries have developed national governance on pandemic preparedness as well as national pandemic influenza preparedness plans and Avian and Human Influenza (AHI) response plans. However, the governance arrangements and the nature of the plans differed. In the five developing countries, the focus was on surveillance and rapid containment of poultry related transmission while preparation for later pandemic stages was limited. The interfaces and linkages between health system contexts and pandemic preparedness programmes in these countries were explored.ConclusionHealth system context influences how the six countries have been preparing themselves for a pandemic. At the same time, investment in pandemic preparation in the six Asian countries has contributed to improvement in health system surveillance, laboratory capacity, monitoring and evaluation and public communications. A number of suggestions for improvement were presented to strengthen the pandemic preparation and mitigation as well as to overcome some of the underlying health system constraints.

Evaluation of Replication and Cross-Reactive Antibody Responses of H2 Subtype Influenza Viruses in Mice and Ferrets

H2 influenza viruses have not circulated in humans since 1968, and therefore a large segment of the population would likely be susceptible to infection should H2 influenza viruses reemerge. The development of an H2 pandemic influenza virus vaccine candidate should therefore be considered a priority in pandemic influenza preparedness planning. We selected a group of geographically and temporally diverse wild-type H2 influenza viruses and evaluated the kinetics of replication and compared the ability of these viruses to induce a broadly cross-reactive antibody response in mice and ferrets. In both mice and ferrets, A/Japan/305/1957 (H2N2), A/mallard/NY/1978 (H2N2), and A/swine/MO/2006 (H2N3) elicited the broadest cross-reactive antibody responses against heterologous H2 influenza viruses as measured by hemagglutination inhibition and microneutralization assays. These data suggested that these three viruses may be suitable candidates for development as live attenuated H2 pandemic influenza virus vaccines.

The 1918 influenza pandemic: lessons for 2009 and the future.

The 1918 to 1919 H1N1 influenza pandemic is among the most deadly events in recorded human history, having killed an estimated 50 to 100 million persons. Recent H5N1 avian influenza epizootics associated with sporadic human fatalities have heightened concern that a new influenza pandemic, one at least as lethal as that of 1918, could be developing. In early 2009, a novel pandemic H1N1 influenza virus appeared, but it has not exhibited unusually high pathogenicity. Nevertheless, because this virus spreads globally, some scientists predict that mutations will increase its lethality. Therefore, to accurately predict, plan, and respond to current and future influenza pandemics, we must first better-understand the events and experiences of 1918. Although the entire genome of the 1918 influenza virus has been sequenced, many questions about the pandemic it caused remain unanswered. In this review, we discuss the origin of the 1918 pandemic influenza virus, the pandemic's unusual epidemiologic features and the causes and demographic patterns of fatality, and how this information should impact our response to the current 2009 H1N1 pandemic and future pandemics. After 92 yrs of research, fundamental questions about influenza pandemics remain unanswered. Thus, we must remain vigilant and use the knowledge we have gained from 1918 and other influenza pandemics to direct targeted research and pandemic influenza preparedness planning, emphasizing prevention, containment, and treatment.

Pandemic influenza planning by videoconference

Collaboration between nations and sectors is crucial to improve regional preparedness against pandemic influenza. In 2008, a Virtual Symposium was organized in the Asia-Pacific region by the Asia-Pacific Economic Cooperation Emerging Infections Network (APEC EINet) to discuss pandemic preparedness. The multipoint videoconference lasted approximately 4.5 hours and was attended by 16 APEC members who shared best practices in public-private partnerships for pandemic influenza preparedness planning. Twelve of the 16 APEC members who participated responded to a post-event survey. The overall experience of the event was rated highly. Partnering public health, technology and business communities to discuss best practices in preparedness using videoconferencing may be an effective way to improve regional preparedness. Utilization of videoconferencing on a routine basis should be considered to improve preparedness among APEC members and enhance its usability during a pandemic.

Pandemic Influenza Preparedness Planning in the Home Care Environment

Pandemic Influenza Preparedness Planning in the Home Care Environment

National pandemic influenza preparedness planning.

The recent outbreaks of influenza A/H5N1 and 'swine influenza' A/H1N1 have caused global concern over the potential for a new influenza pandemic. Although it is impossible to predict when the next pandemic will occur, appropriate planning is still needed to maximize efficient use of resources and to minimize loss of life and productivity. Many tools now exist to assist countries in evaluating their plans but there is little to aid in writing of the plans. This study discusses the process of drafting a pandemic influenza preparedness plan for developing countries that conforms to the International Health Regulations of 2005 and recommendations of the World Health Organization. Stakeholders from many sectors should be involved in drafting a comprehensive pandemic influenza plan that addresses all levels of preparedness.

Protecting home health care workers: a challenge to pandemic influenza preparedness planning.

The home health care sector is a critical element in a pandemic influenza emergency response. Roughly 85% of the 1.5 million workers delivering in-home care to 7.6 million clients are low-wage paraprofessionals, mostly women, and disproportionately members of racial and ethnic minorities. Home health care workers' ability and willingness to respond during a pandemic depends on appropriate communication, training, and adequate protections, including influenza vaccination and respiratory protection. Preparedness planning should also include support for child care and transportation and help home health care workers protect their income and access to health care. We summarize findings from a national stakeholder meeting, which highlighted the need to integrate home health care employers, workers, community advocates, and labor unions into the planning process.

Pandemic influenza preparedness in Latin America: analysis of national strategic plans

The threat of a human pandemic of influenza has prompted the development of national influenza pandemic preparedness plans over the last 4 years. Analyses have been carried out to assess preparedness in Europe, Asia and Africa. We assessed plans to evaluate the national strategic pandemic influenza preparedness in the countries of Latin America.Published national pandemic influenza preparedness plans from Latin American countries were evaluated against criteria drawn from the World Health Organization checklist. Plans were eligible for inclusion if formally published before 16 November 2007.Fifteen national plans were identified and retrieved from the 17 Latin American countries surveyed. Latin American countries demonstrated different degrees of preparedness, and that a high level of completeness of plans was correlated to a country's wealth to a certain extent. Plans were judged strong in addressing surveillance requirements, and provided appropriate communication strategies directed to the general public and health care personnel. However, gaps remained, including the organization of health care services’ response; planning and maintenance of essential services; and the provision of containment measures such as the stockpiling of necessary medical supplies including vaccines and antiviral medications. In addition, some inconsistencies and variations which may be important, such as in border control measures and the capacity to contain outbreaks, exist between country plans—issues that could result in confusion in the event of a pandemic. A number of plans remain developmental in nature and, as elsewhere, more emphasis should be placed on strengthening the operability of plans, and in testing them. Whilst taking account of resources constraints, plans should be further developed in a coherent manner with both regional and international imperatives.

Simulation suggests that rapid activation of social distancing can arrest epidemic development due to a novel strain of influenza

BackgroundSocial distancing interventions such as school closure and prohibition of public gatherings are present in pandemic influenza preparedness plans. Predicting the effectiveness of intervention strategies in a pandemic is difficult. In the absence of other evidence, computer simulation can be used to help policy makers plan for a potential future influenza pandemic. We conducted simulations of a small community to determine the magnitude and timing of activation that would be necessary for social distancing interventions to arrest a future pandemic.MethodsWe used a detailed, individual-based model of a real community with a population of approximately 30,000. We simulated the effect of four social distancing interventions: school closure, increased isolation of symptomatic individuals in their household, workplace nonattendance, and reduction of contact in the wider community. We simulated each of the intervention measures in isolation and in several combinations; and examined the effect of delays in the activation of interventions on the final and daily attack rates.ResultsFor an epidemic with an R0 value of 1.5, a combination of all four social distancing measures could reduce the final attack rate from 33% to below 10% if introduced within 6 weeks from the introduction of the first case. In contrast, for an R0 of 2.5 these measures must be introduced within 2 weeks of the first case to achieve a similar reduction; delays of 2, 3 and 4 weeks resulted in final attack rates of 7%, 21% and 45% respectively. For an R0 of 3.5 the combination of all four measures could reduce the final attack rate from 73% to 16%, but only if introduced without delay; delays of 1, 2 or 3 weeks resulted in final attack rates of 19%, 35% or 63% respectively. For the higher R0 values no single measure has a significant impact on attack rates.ConclusionOur results suggest a critical role of social distancing in the potential control of a future pandemic and indicate that such interventions are capable of arresting influenza epidemic development, but only if they are used in combination, activated without delay and maintained for a relatively long period.