PDF How to Prepare For a Pandemic: How to Plan for a Natural Disaster or a State of Emergency

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Although making an informed assessment of severity early in the course of a pandemic will be challenging, such an assessment will assist countries in:.

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Pandemic severity may be assessed in many ways. One fundamental distinction is an assessment based on direct health effects as opposed to one based upon societal and economic effects. While societal and economic effects may be highly variable from country to country and dependent upon multiple factors including the effects of the media and the underlying state of preparedness , WHO plans to assess pandemic severity based primarily on observable effects on health.

Available quantitative and qualitative data on health impacts will be used to estimate severity using the three-point scale of Mild-Intermediate-Severe. As more information becomes available, WHO will update the severity assessment. Since national circumstances will vary in terms of disease activity and capacity to respond, caution should be exercised in directly linking severity assessment at a global level to actions at the national level. It is likely that information will be limited early in the pandemic while the demand for information simultaneously escalates.

If pandemic surveillance is to provide sufficient information and data to assess severity, countries need to review their existing surveillance capacity to address the weaknesses to be prepared for pandemic surveillance. Essential components of an effective pandemic influenza surveillance system will include:. World Health Organization. International Health Regulations ISBN 92 4 0. Resolution WHA In: Infectious Disease Surveillance. Blackwell Publishing Articles 5. Articles Articles 12, 15, , WHO Interim planning guidance for rapid containment of the initial emergence of pandemic influenza.

All rights reserved. Turn recording back on. National Center for Biotechnology Information , U. Show details Geneva: World Health Organization ; Search term. National preparedness and response as a whole-of-society responsibility A whole-of-society approach to pandemic influenza preparedness emphasizes the significant roles played not only by the health sector, but also by all other sectors, individuals, families, and communities, in mitigating the effects of a pandemic.

Government leadership While all sectors of society are involved in pandemic preparedness and response, the national government is the natural leader for overall coordination and communication efforts. In its leadership role, the central government should: identify, appoint, and lead the coordinating body for pandemic preparedness and response; enact or modify legislation and policies required to sustain and optimize pandemic preparedness, capacity development, and response efforts across all sectors;.

Health sector The health sector including public health and both public and private health-care services , has a natural leadership and advocacy role in pandemic influenza preparedness and response efforts. To fulfil this role, the health sector should be ready to: provide reliable information on the risk, severity, and progression of a pandemic and the effectiveness of interventions used during a pandemic;. Non-health sectors In the absence of early and effective preparedness, societies may experience social and economic disruption, threats to the continuity of essential services, reduced production, distribution difficulties, and shortages of essential commodities.

In order to minimize the adverse effects of a pandemic, all sectors should: establish continuity policies to be implemented during a pandemic;. Communities, individuals, and families Civil society organizations, families, individuals, and traditional leaders all have essential roles to play in mitigating the effects of an influenza pandemic.

Individuals and families During a pandemic, it is important that households take measures to ensure they have access to accurate information, food, water, and medicines. These are listed below: WHA WHA In addition, all public health events, including those which may involve an influenza virus of pandemic potential even if not yet confirmed are notifiable under the IHR if they fulfil at least two of the contextual risk assessment criteria in the Regulations:.

The designation of the global pandemic phase The designation of the global pandemic phase will be made by the Director-General of WHO. Switching to pandemic vaccine production One of WHO's critical actions during an emerging pandemic will be selection of the pandemic vaccine strain and determining the time to begin production of a pandemic vaccine instead of a seasonal influenza vaccine.

Anticipate and address the resources required to implement proposed interventions at national and sub-national levels including working with humanitarian, community-based, and non-governmental organizations. Develop an ethical framework to govern pandemic policy development and implementation. Integrate pandemic preparedness and response plans into existing national emergency preparedness and response programmes. Provide to public and private sectors the key assumptions, guidance and relevant information to facilitate their pandemic business continuity planning.

Consider providing resources and technical assistance to resource-poor countries with foci of influenza activity. Participate, when possible, in regional and international pandemic preparedness planning initiatives and exercises. Provide guidance and tools for detection, investigation, rapid risk assessment, reporting and ongoing evaluation of clusters of influenza-like illness. Provide support to countries with human cases of influenza caused by viruses with pandemic potential to assist in establishing facts and fully characterizing cases. Develop tools to estimate seasonal and pandemic influenza disease burden.

Establish joint initiatives for closer collaboration with national and international partners, including FAO and OIE in the early detection, reporting and investigation of influenza outbreaks of pandemic potential, and in coordinating research on the human-animal interface. Establish global case definitions for reporting by countries of human cases of influenza caused by viruses with pandemic potential. Strengthen the Global Influenza Surveillance Network and other laboratories to increase capacity for influenza surveillance. Provide diagnostic reagents to national influenza reference centres for identification of the new strain.

Coordinate collection and testing of strains for possible vaccine production and antiviral susceptibility. Develop national surveillance systems to collect up-to-date clinical, virological, and epidemiological information on trends in human infection with seasonal influenza viruses, which will also help to estimate additional needs during a pandemic. Detect animal 31 , 33 and human infections with animal influenza viruses, identify potential animal sources of human infection, assess the risk of transmission to humans, and communicate this information to WHO and relevant partners.

Detect and investigate unusual clusters of influenza-like respiratory illness or deaths and assess for human-to-human transmission. Characterize and share both animal and human influenza virus isolates and associated information with relevant international agencies, such as WHO, FAO and OIE, to develop diagnostic reagents, candidate vaccine viruses, and monitor antiviral resistance. Activate joint mechanisms for actions with other organizations e.

Provide guidance on measures to reduce the spread of influenza disease social distancing and use of pharmaceuticals and develop tools to estimate their public health value. Periodically reassess and modify recommended interventions in consultation with appropriate partners, including those not in the health-care sector, regarding acceptability, effectiveness and feasibility. Develop principles to guide national recommendations for use of antivirals for prophylaxis and treatment. Manage WHO strategic global stockpile of antivirals and develop standard operating procedures for rapid deployment.

Develop principles to guide national recommendations for use of seasonal and pandemic vaccines. Support strain characterization and development and distribution of vaccine prototype strains for possible vaccine production. Provide technical support, capacity building and technology transfer for influenza vaccines and diagnostics to developing countries. Formulate mechanisms and guidelines to promote fair and equitable distribution of pandemic influenza vaccines. Identify, regularly brief, and train key personnel to be mobilized as part of a multisectoral expert response team for animal or human influenza outbreaks of pandemic potential.

Reduce infection risk in those involved in responding to animal outbreaks education and training regarding the potential risk of transmission; correct use of personal protective equipment; making antivirals available if indicated by the risk assessment. Control potentially contaminated environments such as wet markets and ponds with free grazing ducks. In conjunction with animal health authorities, establish national guidance on food safety, safe agricultural practices, and public health issues related to influenza infection among animals.

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Develop infection control guidance for household settings. Develop plans to provide necessary support for ill persons isolated at home and their household contacts. Establish protocols to suspend classes, especially in the event of a severe pandemic or if there is disproportionate or severe. Promote development of mitigation strategies for public and private sector workplaces such as adjusting working patterns and practices.

Develop capacities for emergency public health actions at designated points of entry in accordance with IHR Annex 1 B. Estimate and prioritize antiviral requirements for treatment and prophylaxis during a pandemic. Develop mechanisms and procedures to select, procure, stockpile, distribute, and deliver antivirals based on national goals and resources. Plan for the increased need for antibiotics, antipyretics, hydration, oxygen, and ventilation support within the context of national clinical management strategies.

Assess effectiveness and safety of antiviral therapy using standardized protocols when possible. For countries not using seasonal influenza vaccine, document the disease burden and economic impact of seasonal influenza and develop a national vaccine, policy if indicated.

For countries using seasonal influenza vaccine, work to increase seasonal influenza vaccine coverage levels of all high risk people. Establish goals and priorities for the use of pandemic influenza vaccines. Develop a deployment plan to deliver pandemic influenza vaccines to national distribution points within seven days from when the vaccine is available to the national government. Consider the feasibility of using pneumococcal vaccines as part of the routine immunization program in accordance with WHO guidelines. Establish regional clinical advisory network for timely distribution and collection of important clinical information, identify knowledge gaps, and develop standardized clinical protocols.

Assist national health care delivery authorities in identifying priority needs and response strategies, and assessing preparedness e. Develop guidance for remote, resource-poor communities on home-based care of patients during an influenza pandemic. Identify priorities and response strategies for public and private health care systems for triage, surge capacity, and human and material resource management.

Review and update continuity of health care provision strategies at national and sub national levels. Develop strategies, plans, and training to enable all health care workers, including community level workers, to respond during animal outbreaks and a pandemic. Develop national infection control guidance. Estimate and plan for procurement and distribution of personal protective equipment for protection of workers. Develop and implement routine laboratory biosafety and safe specimen-handling and shipping policies and procedures. Explore ways to provide drugs and medical care free of charge or cover by insurance to encourage prompt reporting and treatment of human cases caused by an animal influenza virus or virus with pandemic potential.

Assess health system capacity to detect and contain outbreaks of human influenza disease in hospital settings.

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  8. Increase the familiarity of news media with WHO activities, operations, and decision-making related to influenza and other epidemic-prone diseases. Develop feedback mechanisms to identify emerging public concerns, address rumours, and correct misinformation. Support Member States' communication efforts during a pandemic by providing material and technical guidance. Establish an emergency communications committee with all necessary standard operating procedures to ensure a streamlined, expedited dissemination of communications products.

    Update leadership and other relevant sectors regarding global and national pandemic influenza risk status. Build effective relations with key journalists and other communications channels to familiarize them with influenza and pandemic related issues. Develop effective communication strategies and messages to inform, educate, and communicate with individuals and families so they are better able to take appropriate actions before, during, and after a pandemic.

    Initiate public health education campaigns in coordination with other relevant authorities on individual-level infection control measures. Increase public awareness of measures that may be available to reduce the spread of pandemic influenza. Create messages and feedback mechanisms targeted towards hard-to-reach, disadvantaged, or minority groups. Update communications strategies as feedback from the general public and stakeholder organizations is collected and analysed.

    PHASE 4 An important goal during WHO pandemic Phase 4 is to contain the new virus within a limited area or delay its spread to gain time to implement interventions, including the use of vaccines. Coordinate the international response to rapid containment, including the deployment of international field teams as requested and necessary. Mobilize and dispatch resources e. Mobilize financial resources for a rapid containment operation as needed and encourage the provision of international assistance to resource-poor countries.

    Direct and coordinate rapid pandemic containment activities in collaboration with WHO to limit the spread of human infection. Activate national emergency and crisis committee s and national command, control, and coordination mechanisms for emergency operations. Designate special status as needed such as declaring a state of emergency to facilitate rapid containment interventions. Provide regular updates on the evolving situation to WHO as required under IHR and to other partners to facilitate coordination of response.

    Encourage cross-border collaboration with surrounding countries through information sharing and coordination of responses. Activate pandemic contingency plans for all sectors as deemed critical for the provision of essential services. Finalize preparations for a possible pandemic including procurement plans for essential pharmaceuticals. Finalize preparations for a possible pandemic by activating internal organizational arrangements within the command-and-control mechanism and mobilizing staffing surge capacity in critical services.

    Enhance surveillance to rapidly detect, investigate, and report new cases and clusters. Collect specimens for testing and virological characterization using protocols and procedures developed in collaboration with WHO. Collect more detailed epidemiological and clinical data as time and resources permit. To the extent possible, monitor compliance, safety, and effectiveness of mitigation measures and share findings with the international community and WHO. Enhance virological and epidemiological surveillance to detect possible cases and clusters, especially if sharing extensive travel or trade links with affected areas.

    Dispatch antivirals from the WHO stockpile to the affected country, to be used in rapid containment operations. Collaborate with national authorities in determining possible use of a potentially effective vaccine during rapid containment operations. Consider implementing exit screening as part of the early global response i. Undertake rapid pandemic containment 55 operations in collaboration with WHO and the international community. Limit all non-essential movement of persons in and out of the designated containment area s and implement screening procedures at transit points.

    Reassess the capacity to implement mitigation measures to reduce the spread of pandemic influenza. Provide guidance to health-care workers to consider influenza infection in patients with respiratory illness and to test and report suspect cases. Implement appropriate infection control measures and issue personal protective equipment as needed.

    Activate contingency plans for responding to the possible overload of health and laboratory facilities to deal with potential staff shortages. Advise health-care workers to consider the possibility of influenza infection in patients with respiratory illness, especially those with travel or other contact with persons in the affected country ies. Coordinate and disseminate relevant public health messages using various channels WHO website, published material, press conferences, and the media. Conduct frequent and pre-announced public briefings through popular media outlets such as the web, television, radio, and press conferences to counter panic and dispel rumours.

    Gather feedback from the general public, vulnerable populations and at-risk groups on attitudes towards the recommended measures and barriers affecting their willingness or ability to comply. Incorporate the findings into communication and health education campaigns targeted to the specific groups. Interact with international organizations and agencies inside and outside of the health sector to coordinate interventions. Maintain trust across all agencies and organizations and with the public through a commitment to transparency and credible actions.

    Provide leadership and coordination to multisectoral resources to mitigate the societal and economic impact of a pandemic. Finalize preparations for an imminent pandemic, including activation of crisis committee s and national command and control systems. Update, if necessary, national guidance and recommendations taking into account information from affected countries.

    Monitor the global spread of disease and possible changes in epidemiological, clinical, and virological aspects of infection, including antiviral drug resistance. Support affected Member States as much as possible in confirming the spread of human infections and assessing the epidemiological situation. Maintain adequate virological surveillance to detect antigenic and genetic changes, as well as changes in antiviral susceptibility and pathogenicity. The goal of phase 3 is to ensure rapid characterization of the new virus subtype and early detection, notification and response to additional human cases.

    During phase 4, there are small cluster s with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. The goal of this phase is contain the new virus or delay its spread in order to gain time to implement such preparedness measures as developing a vaccine. Phase 5 is an intensification of phase 4, in that there are large cluster s , but human-to-human spread is still localized.

    This suggests that the virus is becoming increasingly better adapted to humans, but may not yet pose a substantial pandemic risk. Therefore, the goal of this phase is to maximize efforts to contain or delay spread of the virus to possibly avert a pandemic. However, once there is increased and sustained transmission in the general population, the pandemic period phase 6 has commenced.

    The goal during the pandemic period is to minimize its impact. The United States utilizes the WHO pandemic phases to gauge, plan for and implement the appropriate national response. Nationally, operational phases can be divided into preparedness, response, recovery, and mitigation, based on the framework of the National Response Plan NRP.

    In November , the U. Department of Health and Human Services issued a Pandemic Influenza Plan describing national as well as state and local responses to pandemic influenza. Although many important facets are addressed, there are areas that APHA believes require additional attention, as described below. The HHS Pandemic Influenza Plan states that the framework of the NRP would be followed in the multi-party response needed in the event of pandemic influenza, which includes all federal agencies.

    In the implementation of this response effort, the HHS is named the primary federal agency. The federal, state and local responses to the hurricanes of illustrated the problems that can arise during an emergency response when government agencies are unclear about and do not effectively implement their respective roles. State and local governments were not familiar with the National Response Plan and the National Incident Management System, which resulted in these actors operating without an integrated response. Although most states have pandemic plans, many of these have not been tested.

    Localities and communities are generally unprepared for pandemic flu in this regard. Local and State Preparedness and Response. Federal, state, and local governments are responsible for assuring that the capacity of State Health Departments SHDs and Local Health Departments LHDs is sufficiently robust to respond to pandemic influenza once it affects a community. LHDs, which have always formed the basis of the public health emergency response system, have been vigorously working to improve their capacity to respond to a global emergency since September 11, Such capacity depends on the public health training of their respective public health workforces and is presently in jeopardy as a result of a long under-funded public health system, an aging work force, low salaries that impede recruitment, and inconsistencies in preparation in public health.

    3.1. National preparedness and response as a whole-of-society responsibility

    This is consistent with the National Association of City and County Health Officials statement that state and local agencies are not adequately funded to address pandemic influenza. As minority health professionals are more likely to serve minority and under-served communities, the shortage of minority health professionals has led to poorer health outcomes for minorities due to a lack of health literacy and access to health care. The ability to respond effectively to a pandemic is further compromised by a system that does not foster ongoing collaboration and communication among partners at national, state and local levels.

    Current local public health efforts in preparedness have already strained an over-burdened work force that must balance the day-to-day needs of communities with the labor-intensive activities of pandemic flu planning. Planning efforts need to include the collaboration of administrators, information technology and health educators amongst other professionals. The realities of local public health activities include using the same staff for all of the demands of public health. Cross-training of existing staff in issues related to planning, training and evaluation for pandemic flu as well as other possible epidemics is necessary, but will not adequately cover the anticipated surge in demands during a pandemic.

    Federal funding restrictions that prohibit states and localities from using federal dollars to supplant other state and local funds, as is the case with the Preventive Health and Health Services Block Grant and bioterrorism funding, do not take into consideration that it is the traditional public health functions such as disease surveillance and vaccination in addition to antiviral therapy and other public health activities that hold the key to adequately responding to a flu pandemic.

    During this time of state and local budgetary restraint, positions may be lost, seriously compromising local ability to meet these demands. Without an adequate, well-prepared work force, our hopes of reducing the impact of a pandemic are severely impaired. In addition, projections estimate that 30 percent of the active work force may be seriously ill and therefore unable to work during some portion of a pandemic. Therefore, if staffing levels remain stagnant, expectations of adequate staffing during the response phase are unrealistic.

    Lastly, while multiple attempts have been made to enumerate the public health work force, we do not have a national standard for defining what constitutes an adequate work force in non-pandemic times. Pandemic times will require more personnel, but there will be a drop-off in the personnel due to illness and fears. Because the antigenic properties of influenza viruses are constantly changing, strong laboratory-based surveillance will be critical through all stages of the pandemic to monitor both for disease activity and changes in virus strain.

    Timely identification of viral strains is equally important for pandemic detection and vaccine preparation. During the earliest stages of the pandemic, public health and hospital laboratories are likely to receive a large number of specimens for testing. Planning for laboratory surge capacity and the availability of diagnostic reagents will be essential for timely and effective testing. State health departments should provide financial, human and material resources, and necessary leadership and guidance to state and local public health laboratories.

    It is essential to build strong, statewide laboratory-based surveillance capacity in the interpandemic phase, including strengthening partnerships between state laboratories and local public health laboratories to enhance the ability to monitor for disease activity and strengthening control measures.

    Furthermore, university and private or other public laboratories may have the requisite facilities and expertise to be of assistance, especially at times when surge capacity is needed, so that relationships with these non-governmental institutions should be expanded and strengthened. Ultimately, state-level public health laboratory networks should be able to:. Public health interventions. APHA agrees with the HHS plan on the need to implement enhanced surveillance activities at the local, state and federal levels during a pandemic to accurately monitor disease spread, which will complement the activities occurring at the international level by the International Partnership on Avian and Pandemic Influenza.

    Monitoring disease spread among vulnerable populations, including pregnant women, children, the elderly, individuals in under-served areas, persons with chronic conditions and those who are immune-compromised is essential. A stronger focus on international surveillance and containment could assist in delaying the entry of a pandemic virus into the United States. This investment internationally is especially vital as most developing countries have minimal public health resources and, in the event of a pandemic, do not have the ability to increase their efforts to mount a significant response.

    At the same time, an investment in determining the environmental linkages to avian influenza spread is key in order to accurate assess risks of transmission and identify optimal mitigation measures. When human-to-human transmission of pandemic influenza occurs in the United States, new cases must be reported to the CDC as frequently as it recommends. However, before this occurs, there is a need to clarify which types of influenza illness will be officially reportable. In addition, further clarification is needed about which and what proportion of viral isolates at different pandemic stages will be sent to public health laboratories for confirmation.

    It is inappropriate to suggest that local authorities should make the decisions about closure of airports or other large transportation hubs independently. Clear federal guidance is needed on issues that have implications for other parts of the nation. Powers to implement containment measures are found predominantly in state and to a limited extent federal emergency powers laws, but many containment measures can be achieved without an emergency declaration. Voluntary containment measures can be quite effective, especially in smaller towns and rural areas where group contacts are less numerous.

    Emergency website

    However, the onset of an influenza pandemic may necessitate the invocation of extraordinary legal powers. State emergency powers laws often provide these exceptional powers once an emergency has been declared, which may include the ability to more rapidly implement containment measures, control the movement of people, and seize or destroy property to facilitate a public health response. Community restrictions raise profound questions of faith religious worship , family funeral attendance , and protection of the vulnerable food, water, clothing, medical care.

    The constitutional questions are equally complex, as the Supreme Court finds travel and free association to be fundamental rights. The courts would uphold reasonable community restrictions. Ports of Entry found that there were gaps in the current quarantine system, the most severe being the inability of personnel to identify persons carrying a virus but who are asymptomatic, and the difficulty in quickly locating airline passengers who may have been exposed to a high-risk infectious agent.

    Legal authority for isolation and quarantine must be clear and constitutionally acceptable, with criteria based on risk and fair procedures. Containment powers principally are exercised at the state level. While some state isolation and quarantine powers derive from old and outdated statutes, at least 27 states have modernized their laws based on the Model State Emergency Health Powers Act.

    In , novel influenza viruses with pandemic potential were added as a quarantinable federal disease. Federal and state statutes rarely specify where quarantine should take place, and there are myriad options, as evidenced by the SARS outbreaks: home, hospital, school, workplace, or other institutional setting such as a military base, prison, nursing home, or stadium.

    Perimeter quarantines may restrict movement to and from designated geographic areas, sometimes coupled with medical prophylaxis. Public concerns with quarantine include overcrowding, exposure to infection, and inability to work, shop, or contact family. Authorities often enforced SARS quarantines by intrusive surveillance such as thermal scanners, electronic bracelets, web cameras, or placards. Isolation and quarantine are extreme measures that require rigorous safeguards: scientific assessment of risk and effectiveness, safe and habitable environment, procedural due process, and the least restrictive alternative to other forms of containing an outbreak.

    Such safeguards should take the health needs of certain populations into consideration, such as mothers who are breastfeeding and their babies. Above all, state power must be exercised fairly, and never as a subterfuge for discrimination. Containment, as with all public health interventions, requires public trust and acceptance in accordance with the principles of justice.

    This recommendation for children to stay at home can also be applied to children in day care. Schools also must work with public health officials, community leaders and partners to determine whether school facilities will be used as alternative sites of care. Most businesses do not have pandemic preparedness plans in place. There are no federal legal requirements for paid sick leave.

    Although companies subject to the Family and Medical Leave Act are required to offer unpaid sick leave, 40 most employees without a paid sick leave benefit do not have the financial security necessary to stay home from work when they are sick. This problem could be especially problematic in the event of pandemic flu. Over 15 million first responder personnel, including health care and law enforcement workers, may be required to protect the public from and manage a pandemic outbreak in the United States.

    Other workers will be occupationally exposed prior to awareness of an epidemic, including poultry and agricultural workers, laboratory workers, and transportation workers. Finally, workers who provide essential services will be needed to continue working throughout an epidemic, including those in health care, laboratories, transportation, public infrastructure, institutions such as prisons and group homes, child and elder care professionals, and mortuary workers. Protecting them goes beyond a moral obligation; the U. Several applicable workplace safety standards describe minimum governmental expectations.

    Further, in past times of crisis, OSHA has sometimes suspended enforcement of regulations, leaving exposed workers even more vulnerable. There is no program in place assuring governmental resources to address increased workplace expenses for pandemic preparedness and for providing exposure controls, mental health support, and assistance with family and outside commitments. In addition, many health care workers tend to continue to come to work, especially in prodromal phases of illness. A coalition of labor organizations petitioned OSHA to issue an Emergency Temporary Standard applying to health care workers, emergency responders, essential personnel, and those having close contact with birds and other potentially contagious animals.

    The National Pandemic Influenza Plan 9 does not provide adequate worker protection, as noted by the labor organizations. The plan does not recommend comprehensive infection control plans, as have been required for other agents.

    Introduction to the Public Health Preparedness Capabilities (101)

    CDC has issued guidance on mask use by healthcare workers. The HHS Pandemic Influenza Plan stresses that the success of containment measures, ranging from isolation to hand washing, depends on the level of understanding of the community of the importance of such measures. Such education must begin before a pandemic influenza outbreak or other public health emergency.

    Ultimately, public information and key messages must work to garner public cooperation, help multiple populations understand federal, state and local response efforts, educate and motivate vigilant adherence to self-protective prevention behaviors, and prepare communities for lifestyle, mental, and emotional issues related to response and containment measures. To this end, the media must be included in creating national, state and local education campaigns to ensure that accurate messages get consistently communicated.

    The field of risk communication focuses on how to communicate with the public during an emergency. However, there is a need to communicate effective messages to the public before a pandemic occurs so that they are ready and have accurate expectations. Communication challenges are frequently the greatest issue faced in any emergency response.

    In the pre-pandemic, pandemic alert and pandemic states, there must be consistent messages from local, state and federal public health partners. The HHS Pandemic Influenza Plan, in annex 10, provides guidance regarding public health communications and contains recommendations for communications during the interpandemic, pandemic alert and pandemic stages. During a pandemic, the plan outlines steps that need to be taken to provide timely, accurate information; coordinate communications leadership across all tiers of jurisdiction and promptly address rumors, misperceptions, stigmatization, and any unrealistic expectations about public and private health provider response capacity.

    Medical Countermeasures. As such, our national strategy must not be dominated by or solely rely on antivirals. Vaccine development, research and purchase should be priority activities in planning for pandemic influenza on the federal level, as pandemic viruses might be resistant to antivirals or develop drug resistance due to widespread use. Ultimately, vaccine use should prevent mortality and severe morbidity associated with pandemic influenza. If two doses of vaccine are required, then the education of the public will be a key component, as they are accustomed to the one-dose seasonal influenza vaccine.

    Scientists face several challenges in developing a pandemic flu vaccine especially since the exact viral strain that will result in an outbreak will be unknown until the incident begins unfolding. If the pandemic influenza strain is avian, mechanisms other than requiring two doses of vaccine may need to be developed to enhance the immunogenicity of the avian hemagglutinin HA to achieve a protective level of immunity. Also, researchers will not know what level of cross-protection a vaccine matched to an earlier virus strain would provide to the pandemic strain in circulation.

    Finally, considering there will not be enough vaccine supply in the early months to vaccinate the population at risk, researchers will have to explore different ways to maximize the number of doses available. This would include reducing the amount of HA antigen required to reach a protective level of immunity; alternative means to administer the vaccine; and use of known and novel adjuvants to enhance immunogenicity.

    Widespread vaccination of the population against the pandemic virus depends on the capacity to manufacture vaccines in an expedited and effective manner. APHA supports the significant investment in cell-based vaccine technology, which will not only facilitate mass, expedited manufacturing of millions of doses of influenza vaccine, but has the potential to create vaccines for other diseases and to make current vaccines more effective. However, APHA is concerned that the HHS plan did not clearly outline whether federal purchase of influenza vaccine and centralized distribution will continue beyond the onset of a pandemic.

    Our current system of private purchase, reliant on supply and demand, will not give vaccine manufacturers ample incentive to produce all the necessary pandemic influenza vaccine, as there is no guarantee that they will be left with leftover vaccine due to insufficient purchasing levels. Also of concern is that the distribution of pandemic vaccine to health departments and providers may occur through private-sector vaccine distributors or directly from the manufacturer s , without adequate federal oversight, and state and local public health input.

    Pandemic Influenza Preparedness and Response: A WHO Guidance Document.

    Thus, the vaccine may not be available to those at highest risk. The HHS plan also calls for the creation of a vaccine database by CDC, which should build on existing systems and be able to import relevant information from state immunization registries to help us more efficiently track the immunization of priority populations — including children, pregnant women, health care workers and the elderly — in an equitable fashion. However, without federally led vaccine distribution efforts, this database will not provide timely information regarding vaccine distribution, as manufacturers and private vaccine distributors will be relied on to provide the necessary information.

    Preparing Child Care Programs for Pandemic Influenza

    This potential information gap on vaccine distribution and tracking of vaccines could be a significant obstacle in ensuring that priority individuals receive pandemic vaccine in proper order. In addition, such tracking will assist in ensuring equitable vaccine use across racial and ethnic populations.

    Existing immunization information systems IIS, immunization registries can be of great assistance in this tracking. Also, the HHS plan does not outline a process for how the priority vaccination guidelines may be altered or reviewed at the time of the pandemic to adapt to the epidemiology of the disease. However, regardless of the epidemiology of disease, it is imperative that health care workers and first responders, as priority populations, get vaccinated in the event of a flu pandemic.

    Vaccination of such populations will not only protect their colleagues, but their patients and communities as well. Antiviral medications such as oseltamivir and zanamivir have been shown to reduce the severity and duration of seasonal influenza, typically reducing the duration of illness by one or two days. The HHS plan, considering that an effective pandemic vaccine will not be in general circulation during the first months of an influenza pandemic, calls for the purchase of enough antivirals — oseltamivir and zanamivir — to treat 25 percent of the population.

    Efforts center on the federal purchase of 44 million courses of antiviral drugs for treatment, with another 6 million courses for containment. However, the federal plan contains a strategy to leverage state tax dollars to purchase the remaining 31 million courses of antiviral drugs with a 25 percent federal subsidy.