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  • Influenza pandemic preparedness: gauging from EU plans

    The Lancet 2006; 367:1374-1375 April 17, 2006
    DOI:10.1016/S0140-6736(06)68512-7
    Influenza pandemic preparedness: gauging from EU plans Kennedy F Shortridge a b

    See Articles

    The world is on an influenza knife-edge. The possibility of avian influenza H5N1 virus converting into a pandemic form in human beings is an imminent threat. Then again it might not assume pandemicity for some time, or not at all. A vexing problem, all the more so since this is the first time the world has had the opportunity for real preparedness for an influenza pandemic?9 years in fact. It was in 1997 in Hong Kong that an early avian H5N1 relative signalled the virus's pandemic capabilities.1 So, how is the world shaping up for influenza pandemic preparedness?
    In today's Lancet, Sandra Mounier-Jack and Richard Coker2 review preparedness plans of a group of technologically advanced countries?25 European Union (EU) countries, two EU accession countries, and two non-EU European countries. Importantly they also give a guide as to how countries outside this arena are faring.
    Not surprisingly ?governmental commitment?is high and preparedness?broadly good.?2 That is fine. Although most countries have an immunisation strategy for a pandemic H5N1 vaccine, the hard reality is that plans have been drawn up without a commercially available vaccine. Recently reported vaccine trial studies highlight immunogenicity problems.3 Moreover, multiple genetic and antigenic lineages of H5N1 complicate vaccine candidacy.4 Because immunisation is the most effective mechanism for blunting a pandemic, it would seem wise to reconsider plans as there may not be a vaccine available at whatever time a pandemic might arise.
    There is also concern that antiviral drugs?the use of which is advised in all countries' plans?may not necessarily be the magic medicine to stop the virus once human-to-human transmission is underway. Only 13 countries acknowledge starting stockpiling?and their approaches are a mixed bag (besides the problem of availability). In southeast Asian cases, high-level resistance to oseltamivir, a neuraminidase inhibitor and antiviral front-runner,5 probably contributes to planning uncertainty even though delays in starting treatment might have been an important factor. The optimistic question is whether this pattern of antiviral behaviour will change for the better in the conversion of H5N1 from avian to human pandemic form. The antiviral area needs maximum concentration of effort.
    The maxim that ?each man is his own safety officer? could tip the scales in the overall effect of a pandemic. Early adoption of preventive and hygiene measures recommended by governments for every individual are paramount. Avoidance of crowds and social distancing are key elements here. But how might one manage this in large cities where supermarket shopping for food is the norm? There is a compelling need for governments to get these safety messages across to all levels of the public.
    Unforeseen problems lie ahead. There are many ?what ifs?. Earlier promiscuous genetic behaviour6,7 raises the possibility of H5N1 presenting as pandemic virus HxNy with different surface antigens, perhaps at a point way distant from the southern China epicentre, or two pandemic viruses could arise in the same time frame in widely different locations. Way out? My mantra on pandemicity remains?expect the unexpected. Indeed another virus, say H9N2, could usurp H5N1 for pandemicity.8
    Other problems?medical, distribution of medical supplies, essential services, quarantine, civil order?may be listed under the broad umbrella of confidence. These are grey areas in countries' plans, yet it is here that the public's confidence in governments and agencies can be easily eroded, particularly in a rapidly evolving situation. Failure to have financial contingencies in place, or appearance of counterfeit medicines, will exacerbate any such erosion. The mass media has an essential role in conveying information responsibly.6 Neither they nor the public can cope with uncertainty, preferring news in tidy understandable bundles, which is not always possible. Official spokespeople need a thorough understanding of the problem and must display tact, particularly in this era of internet communication.
    Mounier-Jack and Coker are to be congratulated for taking stock of the EU's plans. Much has happened since Belshe's Comment on the need to beef up the research infrastructure in readiness for a future pandemic,9 but still more needs to be done, both scientifically and in the spirit of cooperation for the common good. The H5N1 virus has exposed human vulnerability. A tricky fellow indeed.
    I declare that I have no conflict of interest.


    <!--start simple-tail=-->References

    1. Claas ECJ, Osterhaus ADME, van Beek R, et al. Human influenza A H5N1 virus related to a highly pathogenic avian influenza virus. Lancet 1998; 351: 472-477. Abstract | Full Text | PDF (87 KB) | MEDLINE | CrossRef
    2. Mounier-Jack S, Coker RJ. How prepared is Europe for pandemic influenza? Analysis of national plans. Lancet 2006; 367: 1405-1411. Abstract | Full Text | PDF (91 KB) | CrossRef
    3. Treanor JJ, Campbell JD, Zangwill KM, et al. Safety and immunogenicity of an inactivated subvirion influenza A (H5N1) vaccine. N Engl J Med 2006; 354: 1343-1351. CrossRef
    4. Chen H, Smith GJD, Li KS, et al. Establishment of multiple sublineages of H5N1 influenza viruses in Asia: implications for pandemic control. Proc Natl Acad Sci USA 2006; 103: 2845-2850. MEDLINE | CrossRef
    5. de Jong MD, Tranh TT, Khanh TH, et al. Oseltamivir resistance during treatment of influenza A (H5N1) infection. N Engl J Med 2005; 353: 2667-2672. CrossRef
    6. Shortridge KF, Peiris JSM, Guan Y. The next influenza pandemic: lessons from Hong Kong. J Appl Microbiol 2003; 94: 70S-79S.
    7. Li KS, Guan Y, Wang J, et al. Genesis of a highly pathogenic and potentially pandemic H5N1 influenza virus in eastern Asia. Nature 2004; 430: 209-213. CrossRef
    8. Peiris JSM, Yuen KY, Leung CW, et al. Human infection with influenza H9N2. Lancet 1999; 354: 916-917. Abstract | Full Text | PDF (26 KB) | MEDLINE | CrossRef
    9. Belshe RB. Influenza as a zoonosis: how likely is a pandemic?. Lancet 1998; 351: 460-461. Full Text | PDF (51 KB) | MEDLINE | CrossRef
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  • #2
    Re: Influenza pandemic preparedness: gauging from EU plans

    Summary

    Background The threat of a human pandemic of influenza has prompted urgent development of national preparedness plans. We assessed these plans, to judge Europe's preparedness for pandemic influenza.

    Methods Published national pandemic influenza preparedness plans from the European Union countries, the two acceding countries (Bulgaria and Romania), Norway, and Switzerland, were evaluated against criteria taken from a WHO checklist. Plans were eligible for inclusion if formally published between Jan 1, 2002, and Nov 30, 2005.

    Findings 21 national plans were eligible for inclusion for analysis. Although preparation for surveillance, planning and coordination, and communication were good, maintenance of essential services, putting plans into action, and public-health interventions were probably inadequate. Few countries have addressed in their plans the need for collaboration with adjacent countries, despite this being an acknowledged imperative. Similarly, plans for the timely distribution of available medical supplies are notably absent.

    Interpretation Governmental commitment in most European countries is strong, and levels of preparedness are broadly good. However, gaps in preparedness planning remain, and substantial variations exist between countries, with important implications for the region and nation states. Improved cooperation between countries may be needed to share experience, and to ensure coherence of approaches.
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    Introduction

    The emergence of avian influenza H5N1 and the threat of a new human influenza pandemic have prompted European governments, the European Commission, and WHO to plan and prepare an appropriate response. The past 18 months have seen much planning for a potential pandemic, and most European countries have now published national preparedness plans.
    In its 2004 report on the use of vaccines and antivirals during influenza pandemics, WHO noted: ?Once a pandemic begins it will be too late to accomplish the many activities required to minimize its impact. Therefore, planning and implementation of preparations must start now.?1
    In 2005, WHO published a checklist to facilitate preparedness planning, with the aims of reducing transmission, decreasing cases, hospital admissions, and deaths, maintaining essential services, and reducing the socioeconomic consequences of a pandemic.2 The European Commission updated their planning in line with the revised WHO definitions of pandemic phases and the opening of the European Centre for Disease Prevention and Control (ECDC). WHO issued further guidance following its checklist to assist national authorities in the preparedness planning.3 This document urged every country ?to develop or update a national influenza preparedness plan? and suggested that ?each national authority should play its part towards achieving the international harmonization of preparedness measures?. Moreover, throughout 2005, WHO and the European Commission jointly organised workshops at the European regional level to strengthen and coordinate country preparedness, surveyed the state of preparedness,4,5 and undertook a regional simulation exercise.6
    We examined Europe's national preparedness plans in an attempt to judge Europe's preparedness for pandemic influenza.
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    Methods

    We surveyed the 25 European Union (EU) countries, the two acceding countries (Bulgaria and Romania), and two non-EU countries (Norway and Switzerland), and evaluated each plan against criteria taken from the WHO checklist.2 Published plans in the public domain were identified and sourced through WHO, through internet-based searches, and through countries' ministry of health representatives. Plans were eligible for inclusion if formally published between Jan 1, 2002, and Nov 30, 2005. All plans that were not available in either English or French were translated into English by public-health specialists who were fluent in the original language. We evaluated main plans and, where clear links were documented, references or annexes that were made to other formal and accessible documents.
    A data extraction system, based on the WHO checklist for influenza epidemic preparedness,2 was designed in consultation with pandemic influenza planning experts, and piloted. 169 criteria were identified from plans and scored as either present or absent, to give an indication of the completeness of each plan. We also attributed a weighted score against the same criteria, according to their perceived importance in preparedness planning, after discussions with experts from two member states, to give a measure of quality. Of these 169 criteria, 47 were designated essential and were given additional weight in scoring. Subset analysis of only these essential criteria was also done; detailed findings can be found in the full report online.7 Preparedness plans were scored independently by two researchers, and where differences arose agreement was reached through review and discussion.
    Countries' preparedness plans were assessed in their entirety and by seven thematic areas drawn from the WHO guidelines:2,3 planning and coordination; surveillance; public-health interventions; health-system response; maintenance of essential services; communication; and putting plans into action. Countries were ranked in three groups, each containing seven countries in aggregate and for each of the seven themes.
    Role of the funding source

    The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
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    Results

    21 national plans were eligible for inclusion for analysis, representing coverage of 93% of the population (panel). Of those not included in our analysis, only Hungary had a publicly available plan, but it was published before 2002. The average score for completeness was 54%, ranging from 24% to 80% (figure 1). For quality, the average score was 58%, ranging from 27% to 86%. There was a very close correlation between completeness and quality scores. For purposes of brevity, we report here mainly findings on completeness.
    Panel: Countries included and not included in analysis Included
    Austria, Czech Republic, Denmark, Estonia, France, Germany, Greece, Ireland, Italy, Latvia, Lithuania, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Spain, Sweden, Switzerland, UK
    Not included
    Belgium, Bulgaria, Cyprus, Finland, Hungary, Luxembourg, Malta, Slovenia





    Click to enlarge image


    Figure 1. Aggregate completeness scores of preparedness plans by country group


    Although completeness scores for surveillance, planning, and coordination, and for communication scored quite highly, maintenance of essential services, putting plans into practice, and public-health interventions were less well planned (figure 2).


    Click to enlarge image


    Figure 2. Completeness of preparedness plans by country group and thematic area


    A national planning committee had been established in 18 of the countries surveyed. Veterinary services were mentioned as part of the planning committee in only 14 plans. Public-health agencies assumed a lead role in all plans, and 14 noted participation of governmental institutions other than those responsible for health, such as ministries of defence and the interior.
    For most plans, goals included a reduction of mortality and morbidity, the need to ensure care for a large number of patients, and the need to keep social disruption and economic loss to a minimum. However, the target audience for all the plans remained unclear.
    Only seven countries envisaged an outbreak originating within their territory, whereas all countries indicated that an influenza outbreak was most likely to be caused by infected people coming from abroad. Planning according to different phases of the pandemic will be essential to enable countries to provide an effective response at each stage of the pandemic and to draw effectively on their capacity in different spheres; 20 countries' plans organised their response by pandemic phases, although only seven countries had updated their plans in accord with WHO's 2005 revised definition (table).3

    Click to view table


    Table. WHO pandemic influenza phases3


    16 countries had included some assessment of the epidemiological effects of the pandemic. Most plans indicated preparation based on estimates of attack rates ranging between 15% and 50% of the population, showing the uncertainty that surrounds the transmission dynamics of any future pandemic. Estimated death rates varied from 14 to 1685 per 100000 population. Most countries' plans estimated death rates between 230 and 465 per 100000. Expected hospital admission rates varied between 40 and 2707 per 100000.
    In plans from all but four countries, roles and responsibilities of the main national stakeholders were well described, most notably those in the health sector. For most of the plans, the ministry of health was the coordinating body responsible for the response; in a minority, a crisis coordination body led the process.
    15 plans noted the need to consider the legislative framework. Of these, 12 stated that specific legislative changes might be needed to implement the pandemic response plan. Among the legal issues most frequently mentioned were enforcement of quarantine, compulsory immunisation, and responses to adverse effects from vaccines.
    Collaboration with EU institutions was planned, notably through the European Influenza Surveillance System (EISS), the EU Early Warning and Response System (EWRS), and the licensing of vaccines. Plans rarely stated the need for collaboration with neighbouring states or other member states, including direct neighbours?the exception, broadly, was eastern European countries. Despite a communication from the European Commission stating that ?it will be important to coordinate clinical care and health service plans with bordering jurisdictions to avoid patients migrating across borders in expectation of better health care?,6 this coordinating function was not addressed in national plans.
    All surveyed countries had systems for influenza surveillance. All assess the burden of seasonal influenza with the support of sentinel surveillance networks that report data to the EISS. Of the 21 countries with available plans, 19 had a reference laboratory approved by WHO as a national influenza centre. Only seven countries clearly indicated in their plans that they had the capacity to test for antiviral drug resistance.
    Links with animal surveillance networks were described in 17 plans, although these associations were rarely detailed, and were not given particular prominence for early pandemic phases (when such surveillance should assume greater importance). 11 plans mentioned the need to take specific public-health measures in relation to the handling of infected animals. Ten countries targeted people working with animals; strategies included recourse to chemoprophylaxis (seven countries), seasonal influenza immunisation to reduce the risk of virus reassortment (four countries), and use of protective equipment (three countries).
    During the initial stages of a pandemic (table), most countries indicated that they would reinforce surveillance, increasing the number of samples processed and increasing reporting frequency. Indicators (deaths, hospital admissions, complications) of pandemic surveillance were included in most plans. However, only seven countries addressed the issue of modifying approaches to surveillance as the pandemic unfolds, and envisaged a necessary reduction in the scope of surveillance. In particular, prioritisation of testing capacity was poorly addressed.
    The implementation of public-health interventions by pandemic phase was unclear in many plans. All but two countries, Italy and Lithuania, advised at least one measure of non-medical public-health control. School closures were expected by 19 countries, and restriction of public gatherings by 18. Nine plans encouraged voluntary quarantine, and 14 noted the possible use of mandatory isolation or quarantine.
    Although WHO has suggested that travel restrictions are unlikely to have much effect on the spread of the epidemic and in most countries are probably not practicable,3,8 15 plans recommended at least one measure regulating international travel. Nine countries advised travel restrictions, and eight expected to implement some kind of entry screening policy. One country acknowledged explicitly that the benefit of travel restrictions would be mainly political.
    20 countries had developed an antiviral-drug strategy, although the amount of detail varied substantially between countries. Only Portugal had left the development of a strategy to a later stage. 13 countries had issued guidelines for the use of antiviral drugs, again with wide variation in the amount of detail provided.
    All countries advised treatment with antiviral medicines. 18 plans recommended that individuals should be given antiviral drugs prophylactically after exposure to the virus. 13 advised giving antiviral drugs before potential exposure to the virus. The distinction within the plans between prophylactic use of drugs after exposure and precautionary administration to individuals at greatest risk of exposure was not always clear. Some countries noted that during a pandemic outbreak this distinction will prove difficult, especially if the number of people affected is high. Only five countries (the Netherlands, the UK, France, Latvia, and Romania) were clear in determining the priority of treatment over prophylaxis.
    16 countries have guidance on which groups of people should be given priority for the prophylactic use of antiviral drugs. Health-care workers were a clear concern, with 11 plans making them top priority. Four countries identifed high-risk groups as their first priority group, and one reserved prophylactic treatment for poultry workers and close contacts. Other key workers were generally mentioned as a second priority. Several countries advised that people who cannot be immunised should also be prime candidates for prophylaxis.
    13 countries had guidance on priority groups for treatment with antiviral drugs. Patients with severe disease and complications were most frequently mentioned as the first priority group. People at high risk of serious complications and those who cannot be immunised were a second priority group; key workers were mentioned third. Only 11 countries gave some indication of the size of these groups in each country.
    Seven countries provided some details of their policies on storage and distribution of antiviral drugs. The plans did not make clear the mechanisms of delivery to patients or the mechanisms and personnel for the writing and filling of prescriptions, if needed. Distribution channels cited included routine pharmacies, public-health agencies, occupational-health groups, and hospitals.
    20 countries had an immunisation strategy for a pandemic vaccine. Portugal stated that the immunisation strategy would be developed at a later stage. 14 countries aimed to immunise their entire population if vaccine supply was sufficient. 14 countries also specified that they had a policy recommending pneumoccocal vaccination for at-risk groups.
    In 19 plans, priority groups for recipients of the pandemic strain vaccine were defined. Most (15) plans ranked health-care workers as their first priority; essential services workers were ranked second (13 plans), and the third priority group (11 plans) was people at risk of serious medical complications associated with influenza. In two national plans, populations at risk of medical complications had a higher priority than essential workers or health-care workers. Other plans specifically included children, working people, and people thought likely to pose a risk to vulnerable groups.
    Few countries, however, set out their principles of prioritisation. Only nine plans detailed vaccine distribution mechanisms, six plans outlined storage mechanisms, and three provided details of transportation procedures.
    Only a small minority of countries specified clearly which institutions would operate the health-care triage system. In other cases, triage policy was mooted as the responsibility of local health-care groups, but details of organisational responsibility and duties were not given.
    Health-care supplies such as protective equipment, antibiotics, reagents, and medical equipment were mentioned in 19 (90%) of plans. However, none gave estimates of the magnitude of need. In many cases, decisions about what to purchase and stockpile were designated to local authorities.
    Seven plans did not address the need to prepare for the maintenance of essential services during a pandemic. Only eight plans noted that a contingency plan had been developed for the maintenance of essential services. A basic list of essential personnel was described in 11 plans, and replacement personnel were identified in seven.
    Close communication and collaboration between country agencies, WHO, and EU institutions was a feature of most plans, yet only seven countries addressed the need for collaboration with directly neighbouring countries, although this is an acknowledged imperative.9
    Development of a comprehensive national communication strategy was mentioned in 14 plans, although all 21 noted the need to communicate specifically with the general public and with health professionals. In most plans, the strategy was developed on a phase-by-phase basis, and included some materials designed especially for the general public and for health professionals. The potential role of the media was not discussed in most plans. Some countries suggest in their plans that they will develop a targeted communication strategy at later stages of the pandemic. The Netherlands has in place a dedicated public announcement channel that can be used to relay information to the public. Only Latvia stated an intention to target communication specifically to high-risk groups. In 15 plans, the agency responsible for communication was stated; in most it was the ministry of health spokesman.
    12 plans described operational action plans, often set out phase-by-phase, that detail roles and responsibilities of the different governmental agencies involved in the pandemic response.
    Instructions to regions were available through 11 plans only, and these, in general, lacked detail, despite the federal nature of health systems in many countries. There was no discernible association between the type of health system (federal or unitary) and the presence of instructions to districts. Many federal systems offered only general guidance, with the implication that districts need to produce their own plans. Others had instructions, but they were not detailed or were unclear. Mechanisms for monitoring the development and completion of district plans within the national plan were not addressed.
    11 plans mentioned the need for capacity building, primarily of health-care staff, and 19 have developed awareness materials targeted at health-care workers.
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    Discussion

    Although many European countries have detailed preparedness plans for pandemic influenza, gaps remain, many of which are common to most of the plans. Furthermore, potentially important variations in planning exist. Some differences are the result of uncertainties in the evidence base that informs policy. Others might be related to sociopolitical and cultural differences.
    With the spread of avian influenza H5N1 to Europe in 2005, countries should consider the possibility that the pandemic could originate in Europe. Surveillance of animals and of people working with them should be closely aligned, with effective cooperation and coordination between systems.10 However, health and veterinary authorities currently have no joint standard procedures.11 National plans must be explicitly coherent with veterinary contingency plans.
    Management of scarce resources and travel restrictions are likely to assume substantial political and possibly public-health importance in the event of a pandemic. In an area where freedom to travel without hindrance is a pivotal principle of regional policy, and where patients increasingly travel across national borders to access care, national policies need to be coherent and harmonised rather than different. Countries within the region need to be informed and to inform others of their respective strategies to ensure policy coherence and mitigate the public-health consequences where differences exist. In December, 2005, the ECDC indicated that the EU's preparedness for a possible influenza pandemic would be ?more or less? complete by 2007 and noted ?Europe will be much better prepared than any other part of the world?.12
    The challenge for the EU and its institutions is, while acknowledging that decisions should be made at the national level where possible, to provide during an emergency the robust and coherent structures and procedures necessary to coordinate and lead regional surveillance and response efforts effectively and efficiently. The EU must play its part in ensuring consistency in operability for specific areas such as border control. Yet serious questions remain about how, in practice, the EU agencies and national institutions will function in a time of emergency.13
    Planning for an influenza pandemic is the responsibility of central government in all national plans. To be effective, preparedness planning must be coherent with national governance structures and health-care systems. Clearly, states must each balance central direction with respect for district authority, while acknowledging current frameworks of health-system governance and how they might need to be modified in a time of emergency.14 District planning is essential to ensure the availability of care and the coordination of demand in health care and other support services, to coordinate sampling and testing priorities, and to deploy locally needed public-health interventions. The effectiveness of planning will depend on the federal or unitary nature of health-care systems. When operational planning and response are largely the responsibility of local districts, implementation of plans and coordination of responses could be challenging without central direction.
    Apart from the general exercise led by the European Commission in November, 2005,6 to our knowledge only three countries (the UK, the Netherlands, and France) have plans that have been tested nationally in simulation exercises, although the lessons learnt from these exercises have generally not been communicated to the public.
    If available in sufficient quantities, antiviral drugs could potentially be valuable in the initial response to the pandemic, especially if no effective vaccine is available.1 Although prioritisation is an essential exercise that needs to be communicated transparently to the public, no plans describe the processes by which individuals belonging to priority groups will be identified, or describe mechanisms to ensure that those identified as priority recipients actually receive drug treatment and take it. The uncertain nature of these processes could lead to individual claims of unfairness and potential concerns over the equitable distribution of scarce resources. In view of the strategies for the use of antiviral drugs (treatment only; blanket prophylaxis; treatment plus restricted prophylaxis?eg, household contacts; and treatment plus restricted prophylaxis combined with implementation of social distancing measures such as closure of schools), the lack of clarity in most plans is surprising, with only a handful clearly focusing provision of drugs to the sick, a recommendation of the European Commission.6
    Stockpiling of antiviral drugs has attracted great attention. By November, 2005, for example, 13 countries had publicly acknowledged stockpiling. Estimates at that time, derived from publicly available stockpiling figures, suggested that about 18% of the population of these 13 countries would be covered. However, provision for individual countries varied greatly, ranging from 2% to 53% population coverage. Furthermore, new purchase agreements are reached frequently, and many agreements are not made public until months have passed. The true position for Europe in relation to antiviral coverage remains unclear and is constantly changing. Additionally, estimates of coverage might be misleading, since most calculations are based on treatment of infected individuals, whereas many plans also include prophylaxis for essential-services workers and specified high-risk groups.
    Although the constraints on securing and manufacturing pandemic vaccine are well defined, many preparedness plans do not offer a specific procurement strategy. Possible production shortages are being addressed by expansion of interpandemic vaccine (by 16 countries, although new targets are rarely mentioned). Six European countries noted that they have the capacity to manufacture vaccine (France, Germany, the Netherlands, the UK, Italy, and Romania). Four further countries indicated in their plans that they are considering development of local production capacity (Norway, Sweden, Denmark, and Switzerland). Additionally, a few countries have negotiated advance purchase agreements.
    Traditional plans for health-care facilities, such as emergency or sectorwide contingency plans, are unlikely to be sufficient, relying as they do on often informal cooperation and support between hospitals.11 Health-care facilities need plans that specify clinical management, infection control, human resources management, admission criteria, and provision of necessary medical supplies. Strategic choices made by different countries on the organisational response to the pandemic raise diverse issues and challenges, but choices should be made ahead of an emerging pandemic. In particular, triage policy will be crucial to management of patients, and needs to be addressed by national authorities. Likewise, planning the distribution of medical supplies (such as antiviral drugs, vaccines, and masks) will need to be specific, yet details are currently absent from national plans.
    Countries with national insurance systems might need to formalise arrangements with health insurance providers to address issues of financial coverage for vaccination and antiviral medications.
    Our study has several limitations. The fluidity of the environment means that plans are being drafted and modified constantly. Our survey provides only a snapshot in time, and the timeframe we chose means that older plans, which might not have been subjected to the same urgency and predated WHO and EU initiatives (such as the Hungarian plan) have been excluded. To subject such plans to the same rigorous scrutiny as those produced more recently when guidance from international public-health agencies could be drawn upon readily would not, we believe, have been reasonable. Several high-profile initiatives urging the development and publication of preparedness plans occurred in 2005. For this reason, all data collection was censored at Nov 30, 2005, allowing a reasonable period for plans to enter the public domain.
    A second limitation concerns the difference between appraisal of plans and actual preparedness for an influenza pandemic. The completeness and quality of national preparedness plans might be an important indicator of countries' preparedness, but plans are only one element. The test of countries' preparedness will be the effectiveness of their response, which can be supported by a robust plan, but will also be affected by many other factors, foreseen and unknown. Moreover, the completeness of plans could show simply the attention paid to drafting rather than preparedness. Countries may be prepared in areas that are not mentioned in their plans. Robust, generic emergency plans that are not specifically targeted at an influenza pandemic, but would facilitate an effective response to such a problem, would not surface in this analysis. Our analysis of plans describes, therefore, an incomplete but important assessment of preparedness. Plans show not only strategic and tactical policy choices that are made by governments, but also countries' ability to involve and coordinate transparently a large range of stakeholders. A further limitation is the subjective nature of our assessment. Because of the nature of plans, and the variations in language and format, any determination of inclusion criteria must be somewhat subjective.
    Europe has the resources to prepare for pandemic influenza. Governmental commitment in most European countries is strong, preparedness levels are broadly good, surveillance and monitoring capacities allied to laboratory capacity are well developed, and the public-health infrastructure is robust. However, gaps in preparedness planning seem to remain, and variations exist between countries, with important implications for the region and nation states. Improved cooperation between countries is needed, to share experience and to ensure coherence of approaches. Planning must respond explicitly to probable scenarios. European institutions and WHO have a role to play in supporting cooperative arrangements, and the European Commission must continue to ensure that knowledge of pandemic responses is shared among EU members, support equitable provision of services, and coordinate the response across the region.
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    Comment


    • #3
      Figure 1

      <TABLE class=popupAreaContainer cellSpacing=0 cellPadding=0 width="100%" border=0><TBODY><TR><TD class=popupPaneBody>

      Figure 1. Aggregate completeness scores of preparedness plans by country group

      </TD></TR></TBODY></TABLE>

      Comment


      • #4
        Figure 2


        Figure 2. Completeness of preparedness plans by country group and thematic area

        Comment


        • #5
          Re: Influenza pandemic preparedness: gauging from EU plans

          From post #1

          "The world is on an influenza knife-edge. The possibility of avian influenza H5N1 virus converting into a pandemic form in human beings is an imminent threat."

          It doesn't get any clearer than that.
          Please do not ask me for medical advice, I am not a medical doctor.

          Avatar is a painting by Alan Pollack, titled, "Plague". I'm sure it was an accident that the plague girl happened to look almost like my twin.
          Thank you,
          Shannon Bennett

          Comment


          • #6
            Table


            Table. WHO pandemic influenza phases<!--start ce:cross-ref=--><!--start ce:sup=-->3<!--end ce:sup--><!--end ce:cross-ref-->

            Comment

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