Pandemic Influenza Preparedness Research Articles

65years of influenza surveillance by a World Health Organization-coordinated global network.

The 1918 devastating influenza pandemic left a lasting impact on influenza experts and the public, and the importance of global influenza surveillance was soon recognized. The World Health Organization (WHO) Global Influenza Surveillance Network (GISN) was founded in 1952 and renamed to Global Influenza Surveillance and Response System in 2011 upon the adoption by the World Health Assembly, of the Pandemic Influenza Preparedness Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits (“PIP Framework”). The importance of influenza surveillance had been recognized and promoted by experts prior to the years leading up to the establishment of WHO. In the 65 years of its existence, the Network has grown to comprise 143 National Influenza Centers recognized by WHO, 6 WHO Collaborating Centers, 4 Essential Regulatory Laboratories, and 13 H5 Reference Laboratories. The Network has proven its excellence throughout these 65 years, providing detailed information on circulating seasonal influenza viruses, as well as immediate response to the influenza pandemics in 1957, 1968, and 2009, and to threats caused by animal influenza viruses and by zoonotic transmission of coronaviruses. For its central role in global public health, the Network has been highly recognized by its many partners and by international bodies. Several generations of world‐renowned influenza scientists have brought the Network to where it is now and they will take it forward to the future, as influenza will remain a preeminent threat to humans and to animals.

Canadian Pandemic Influenza Preparedness: Communications strategy.

When faced with uncertainty and unpredictability, early and transparent communication during a pandemic is critical to build trust and to ensure the credibility of public health advice. The responsibility for communicating with Canadians during a pandemic is shared by federal, provincial, territorial and local governments. A common plan is needed to ensure consistent, coordinated and appropriate communication. Canada's diversity in terms of its size, geography, languages and culture also requires a multifaceted approach so that the right message is delivered at the right time to the right person in the right format. The Communications and Stakeholder Liaison Annex is a recently updated communication strategy in the Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP). The Annex emphasizes the importance of communicating with both the public and key stakeholders (e.g., health care providers, professional organizations and policymakers) before, during and after a pandemic. This strategy is grounded in several communications guiding principles: putting the health of Canadians first; providing timely and sound information; communicating in a coordinated fashion from across all levels of government; protecting confidentiality; and monitoring and adapting to the public's perception of risk. The Annex outlines a risk communications approach, proposes triggers for action based on pandemics of varying impact, and includes a Communication Protocol that will be used countrywide in the event of a pandemic.

Canadian Pandemic Influenza Preparedness: Communications strategy

Canadian Pandemic Influenza Preparedness: Communications strategy

Editorial introductions

Editorial introductions

Pharmacist Views on Alternative Methods for Antiviral Distribution and Dispensing During an Influenza Pandemic.

Antiviral drugs are likely to be a frontline countermeasure needed to minimize disease impact during an influenza pandemic. As part of pandemic influenza preparedness efforts, the Centers for Disease Control and Prevention, in coordination with state health departments, has plans in place to distribute and dispense antiviral drugs from public stockpiles. These plans are currently under review and include evaluation of the benefits of commercial distribution and dispensing through community pharmacies. To ensure this alternative distribution and dispensing system is viable, it is critical to assess pharmacist acceptability and to understand the pharmacist perspective on dispensing these antivirals during a response. In this study, we examine community pharmacist reactions to the proposed alternative antiviral distribution and dispensing system using a nationally representative survey of pharmacists. Overall, pharmacists were highly receptive to this alternative system and voiced a willingness to participate personally, and most thought their own pharmacy would participate in such an effort. This was true across pharmacists with different personal and professional backgrounds, as well as those in different pharmacy settings. However, sizable shares of pharmacists said they were worried about facing shortages of the antivirals, the risk of exposure to disease for themselves and their families, managing their usual patients who need their prescriptions filled for medications other than antivirals, keeping order in the pharmacy, and potential liability concerns. These findings should be interpreted as an indication of acceptability of the concept, encouragement for the next steps in alternative distribution and dispensing system design, and a guide to potential barriers that may need to be addressed proactively.

Editorial introductions

Editorial introductions

Canada's Pandemic Influenza Preparedness: Laboratory strategy.

The Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP) is a guidance document that outlines key health sector preparedness activities designed to ensure Canada is ready to respond to the next influenza pandemic. This article outlines Canada's pandemic influenza laboratory strategy as described in the CPIP Laboratory Annex. Laboratory identification and characterization of an influenza pandemic virus is critical to detect the pandemic, develop a vaccine, detect antiviral resistance and inform surveillance functions such as monitoring the geographic spread of the disease. Key elements of the laboratory response will include ensuring there are adequate resources for all activities. Pre-analytical activities include the appropriate collection, transport to the laboratory, triaging and preparation of specimens. Analytical activities refer to the different testing methods for the detection of influenza, including maintaining the ability to culture influenza virus for genetic and antigenic characterization. Post-analytic activities include ensuring front-line and provincial public health laboratories work together to make data and specimens available for surveillance purposes. In the inter-pandemic period, it is important to develop the infrastructure, protocols and processes to enable rapid-response research during a pandemic. This is an evergreen document that will be updated regularly.

Canada’s Pandemic Influenza Preparedness: Laboratory strategy

Canada’s Pandemic Influenza Preparedness: Laboratory strategy

Canadian Pandemic Influenza Preparedness: Health sector planning guidance

Canadian Pandemic Influenza Preparedness: Health sector planning guidance

Canada's Pandemic Influenza Preparedness: Surveillance strategy.

The Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP) is a guidance document that outlines key health sector preparedness activities designed to ensure Canada is ready to respond to the next influenza pandemic. This article outlines Canada's pandemic influenza surveillance strategy as described in the CPIP Surveillance Annex. The strategy builds on the surveillance activities used for seasonal influenza and incorporates lessons learned from the 2009 H1N1 pandemic, including improved information sharing, improved electronic links among federal, provincial and territorial (FPT) partners and improved surveillance for Indigenous communities. Key elements of the surveillance strategy include early detection and investigation of a novel influenza virus through the reporting of cases or clusters of severe acute respiratory infections and laboratory detections of novel influenza viruses. Community-based surveillance will provide information on clinical severity, age groups affected and risk factors associated with severe disease. Severe outcome surveillance will capture data on hospitalizations and deaths. Laboratory surveillance will include weekly reports of respiratory virus detections. The response activities are adaptable to the demands of different levels of pandemic activity and impact, supported by a set of triggers for the activation and deactivation. Surveillance will be linked with other response components, such as communications, research, assessment and evaluation. This is an evergreen document that will be updated regularly.

Canadian Pandemic Influenza Preparedness: Health sector planning guidance.

Pandemic preparedness requires a multifaceted approach with collaboration from all levels of government. The Canadian Pandemic Influenza Preparedness: Planning Guidance for the Health Sector (CPIP) is a guidance document that outlines key health sector preparedness activities designed to ensure Canada is ready to respond to the next influenza pandemic. This article outlines Canada's approach to pandemic influenza preparedness as described in the CPIP Main Body. Canada's pandemic influenza preparedness planning takes place within a network of legislated requirements and emergency frameworks at provincial/territorial, federal and international levels. The plan includes several guiding principles, including collaboration among governments and stakeholders, evidence-based decision-making, proportionality and flexibility in tailoring responses to the situation, the adoption of a precautionary approach, the use of established practices and systems and the explicit incorporation of ethical principles in all decisions and decision-making processes. The roles and responsibilities of the federal and provincial/territorial governments is identified and three planning tools are provided: planning assumptions rooted in evidence; multiple scenarios to support decision-making; and descriptive terms such as the start, peak and end of pandemic wave rather than phase terminology to provide triggers for action. Overall, the CPIP Main Body sets out a scalable, coordinated risk management approach to an influenza pandemic. This is an evergreen document that will be updated regularly.

Emergence, Epidemiology, and Transmission Dynamics of 2009 Pandemic A/H1N1 Influenza in Kampala, Uganda, 2009-2015.

In sub-Saharan Africa, little is known about the epidemiology of pandemic-prone influenza viruses in urban settings. Using data from a prospective sentinel surveillance network, we characterized the emergence, epidemiology, and transmission dynamics of 2009 pandemic A/H1N1 influenza (H1N1pdm09) in Kampala, Uganda. After virus introduction via international air travel from England in June 2009, we estimated the basic reproductive number in Kampala to be 1.06-1.13, corresponding to attack rates of 12-22%. We subsequently identified 613 cases of influenza in Kampala from 2009 to 2015, of which 191 (31.2%) were infected with H1N1pdm09. Patients infected with H1N1pdm09 were more likely to be older adult (ages 35-64) males with illness onset during rainy season months. Urban settings in sub-Saharan Africa are vulnerable to importation and intense transmission of pandemic-prone influenza viruses. Enhanced surveillance and influenza pandemic preparedness in these settings is needed.

In vivo mallard experiments indicate that zanamivir has less potential for environmental influenza A virus resistance development than oseltamivir.

Neuraminidase inhibitors are a cornerstone of influenza pandemic preparedness before vaccines can be mass-produced and thus a neuraminidase inhibitor-resistant pandemic is a serious threat to public health. Earlier work has demonstrated the potential for development and persistence of oseltamivir resistance in influenza A viruses exposed to environmentally relevant water concentrations of the drug when infecting mallards, the natural influenza reservoir that serves as the genetic base for human pandemics. As zanamivir is the major second-line neuraminidase inhibitor treatment, this study aimed to assess the potential for development and persistence of zanamivir resistance in an in vivo mallard model; especially important as zanamivir will probably be increasingly used. Our results indicate less potential for development and persistence of resistance due to zanamivir than oseltamivir in an environmental setting. This conclusion is based on: (1) the lower increase in zanamivir IC50 conferred by the mutations caused by zanamivir exposure (2-17-fold); (2) the higher zanamivir water concentration needed to induce resistance (at least 10 µg l-1); (3) the lack of zanamivir resistance persistence without drug pressure; and (4) the multiple resistance-related substitutions seen during zanamivir exposure (V116A, A138V, R152K, T157I and D199G) suggesting lack of one straight-forward evolutionary path to resistance. Our study also adds further evidence regarding the stability of the oseltamivir-induced substitution H275Y without drug pressure, and demonstrates the ability of a H275Y-carrying virus to acquire secondary mutations, further boosting oseltamivir resistance when exposed to zanamivir. Similar studies using influenza A viruses of the N2-phylogenetic group of neuraminidases are recommended.

Seasonal and pandemic influenza: global fatigue versus global preparedness

Seasonal and pandemic influenza: global fatigue versus global preparedness

A Qualitative Stakeholder Analysis of Avian Influenza Policy in Bangladesh

Avian influenza is a major animal and public health concern in Bangladesh. A decade after development and implementation of the first national avian influenza and human pandemic influenza preparedness and response plan in Bangladesh, a two-stage qualitative stakeholder analysis was performed in relation to the policy development process and the actual policy. This study specifically aimed to identify the future policy options to prevent and control avian influenza and other poultry-related zoonotic diseases in Bangladesh. It was recommended that the policy should be based on the One Health concept, be evidence-based, sustainable, reviewed and updated as necessary. The future policy environment that is suitable for developing and implementing these policies should take into account the following points: the need to formally engage multiple sectors, the need for clear and acceptable leadership, roles and responsibilities and the need for a common pool of resources and provision for transferring resources. Most of these recommendations are directed towards the Government of Bangladesh. However, other sectors, including research and poultry production stakeholders, also have a major role to play to inform policy making and actively participate in the multi-sectoral approach.

A multi-site feasibility study to assess fever and wheezing in children after influenza vaccines using text messaging.

Using text messaging for vaccine safety monitoring, particularly for non-medically attended events, would be valuable for pandemic influenza and emergency vaccination program preparedness. We assessed the feasibility and acceptability of text messaging to evaluate fever and wheezing post-influenza vaccination in a prospective, observational, multi-site pediatric study. Children aged 2-11 years old, with an emphasis on children with asthma, were recruited during the 2014-2015 influenza season from three community-based clinics in New York City, and during the 2014-2015 and 2015-2016 seasons from a private practice in Fall River, Massachusetts. Parents of enrolled children receiving quadrivalent live attenuated (LAIV4) or inactivated influenza vaccine (IIV4) replied to text messages assessing respiratory symptoms (day 3 and 7, then weekly through day 42), and temperature on the night of vaccination and the next seven nights (day 0-7). Missing data were collected via diary (day 0-7 only) and phone. Phone confirmation was obtained for both presence and absence of respiratory symptoms. Reporting rates, fever (T≥100.4 °F) frequency, proportion of wheezing and/or chest tightness reports captured via text message versus all sources (text, phone, diary, electronic health record) and parental satisfaction were assessed. Across both seasons, 266 children were analyzed; 49.2% with asthma. Parental text message response rates were high (>70%) across sites. Overall, fever frequency was low (day 0-2: 4.1% [95% confidence interval (CI) 2.3-7.4%]; d3-7: 6.7% [95% CI 4.1-10.8%]). A third (39.2%) of parents reported a respiratory problem in their child, primarily cough. Most (88.2%) of the 52 wheezing and/or chest tightness reports were by text message. Most (88.1%) participants preferred text messaging over paper reporting. Text messaging can provide information about pediatric post-vaccination fever and wheezing and was viewed positively by parents. It could be a helpful tool for rapid vaccine safety monitoring during a pandemic or other emergency vaccination program. clinicaltrials.gov Identifier: NCT02295007.

Distressed setting and profound challenges: Pandemic influenza preparedness plans in the Eastern Mediterranean Region.

Influenza pandemics are unpredictable and can have severe health and economic implications. Preparedness for pandemic influenza as advised by the World Health Organization (WHO) is key in minimizing the potential impacts. Pandemic Influenza Preparedness (PIP) Framework is a global public-private initiative to strengthen the preparedness. A total of 43 countries receive funds through Partnership Contribution (PC) component of PIP Framework to enhance preparedness; seven of these fall in the WHO's Eastern Mediterranean Region. We report findings of a desk review of preparedness plans of six such countries from the Region. The assessment was done using a standardized checklist containing five criteria and 68 indicators. The checklist was developed using the latest WHO guidelines, in consultation with influenza experts from the Region. The criteria included preparation, surveillance, prevention and containment, case investigation and treatment, and risk communication. Two evaluators independently examined and scored the plans. Pandemic preparedness plan of only one country scored above 70% on aggregate and above 50% on all individual criteria. Plans from rest of the countries scored below satisfactory on aggregate, as well as on individual preparedness criteria. Among the individual criteria, prevention and containment scored highest while case investigation and treatment, the lowest for majority of the countries. In general, surveillance also scored low while it was absent altogether, in one of the plans. This was a desk review of the plans and not the actual assessment of the influenza preparedness. Moreover, only plans of countries facilitated through funds provided under the PC implementation plan were included. The preparedness scores of majority of reviewed plans were not satisfactory. This warrants a larger study of a representative sample from the Region and also calls for immediate policy action to improve the pandemic influenza preparedness plans and thereby enhance pandemic preparedness in the Region.

Knowing pandemics

How does microbial emergence become a local area of medical, political, and technological intervention in cities such as London or Frankfurt? Through a multi-sited ethnography of urban health authorities, hospitals, blue light services, and epidemiologists, this article examines the achievement of pandemic order in times of crisis. Its specific focus is on pandemic influenza preparedness. By tracing the complex spatiotemporal, technological, and administrative dimensions required for the articulation of a local pandemic threat, this paper will look at how public health experts know about the arrival of an influenza pandemic, how sociotechnical networks are assembled in the decision-making process, and how single cases of illness are drawn into spaces of pandemic potential. Integrating concepts from science and technology studies and critical global health, the article highlights how disease emergence entails hard work and administrative, technological, political, and biomedical skills in order to be made present and tangible. In consequence, it will be argued that local pandemic preparedness does not result from a linear adaption of internationally circulating standards, but from rather precarious modes and modalities of ordering.

The Pandemic Influenza Preparedness Framework: A viable procurement option for developing states?

In this article, I argue that the Pandemic Influenza Preparedness (PIP) Framework is unlikely to have a significant impact on procurement of pandemic influenza vaccines by developing states during the next pandemic. I argue this on the basis that the vaccine stockpile that the Framework has created is not sufficiently large to meet the demand from developing states. I also argue that the fact that so few pandemic influenza vaccine manufacturers have committed to supply the PIP stockpile, and those that have, have given commitments lower than those initially proposed by the World Health Organization in the Framework, implies that the overall impact the PIP stockpile will have on procurement of pandemic influenza vaccines is even lower than initially anticipated within the literature.

Survey of distribution of seasonal influenza vaccine doses in 201 countries (2004-2015): The 2003 World Health Assembly resolution on seasonal influenza vaccination coverage and the 2009 influenza pandemic have had very little impact on improving influenza control and pandemic preparedness.

There is no global monitoring system for influenza vaccination coverage, making it difficult to assess progress towards the 2003 World Health Assembly (WHA) vaccination coverage target. In 2008, the IFPMA Influenza Vaccine Supply International Task Force (IVS) developed a survey method to assess the global distribution of influenza vaccine doses as a proxy for vaccination coverage rates. The latest dose distribution data for 2014 and 2015 was used to update previous analyses. Data were confidentially collected and aggregated by the IFPMA Secretariat, and combined with previous IFPMA IVS survey data (2004-2013). Data were available from 201 countries over the 2004-2015 period. A "hurdle" rate was defined as the number of doses required to reach 15.9% of the population in 2008. Overall, the number of distributed doses progressively increased between 2004 and 2011, driven by a 150% increase in AMRO, then plateaued. One percent fewer doses were distributed in 2015 than in 2011. Twenty-three countries were above the hurdle rate in 2015, compared to 15 in 2004, but distribution was highly uneven in and across all WHO regions. Three WHO regions (AMRO, EURO and WPRO) accounted for about 95% of doses distributed. But in EURO and WPRO, distribution rates in 2015 were only marginally higher than in 2004, and in EURO there was an overall downward trend in dose distribution. The vast majority of countries cannot meet the 2003WHA coverage targets and are inadequately prepared for a global influenza pandemic. With only 5% of influenza vaccine doses being distributed to 50% of the world's population, there is urgency to redress the gross inequities in disease prevention and in pandemic preparedness. The 2003WHA resolution must be reviewed and revised and a call issued for the renewed commitment of Member States to influenza vaccination coverage targets.