2 Strengthening Preparedness for Pandemic Influenza Flashcards
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Overview Summary
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This session provides an overview of preparedness for pandemic influenza. In the introductory session, you learned about what constitutes a global health policy issue. In this session, you will apply the concepts learned in the previous session to the issue of pandemic influenza.
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Overview Aims
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The aim of this session is to provide students with an understanding of the global dimensions of pandemic influenza; why combating this particular disease is important; the contemporary governance mechanisms aimed at preventing and controlling this disease; and the key issues inhibiting and/or facilitating collective action to strengthen preparedness.
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Overview Learning outcomes
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By the end of this session, you should be able to: 1 Understand the nature, epidemiology and history of the influenza virus; 2 Analyse the various factors that contribute to and/or mitigate the risk of pandemic influenza; 3 Identify the key actors and institutions in global efforts to control and mitigate the threat of pandemic influenza; 4 Assess national measures to enhance pandemic influenza preparedness; and 5 Explain the contemporary debates/issues inhibiting effective governance of pandemic influenza.
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Key Terms Antigenic drift
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This occurs when there is a minor change (mutation) during virus replication in the same sub-type of the influenza virus, resulting in a new strain of the virus emerging.
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Key Terms Antigenic shift
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This occurs when there is a major change during virus replication resulting in an entirely new sub-type of the influenza virus emerging that may or may not be capable of crossing the species barrier, but which has pandemic potential.
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Key Terms Antiviral medication
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A category of medication that is used to treat viral infections (such as influenza) by inhibiting viral replication. This is usually accomplished through preventing the virus from entering and infecting cells.
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Key Terms Case Fatality Rate (CFR)
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The ratio of the number of deaths caused by a specific disease divided by the number of confirmed diagnoses of that disease.
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Key Terms Influenza
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A viral infection of the nose, throat and lungs (respiratory infection) caused by one of three sub-types of an RNA virus (Type A, B or C).
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Key Terms Influenza vaccines
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Biological preparations developed using deactivated or partially live influenza viruses for the purpose of conferring immunity against influenza by stimulating the human immune system to identify the virus as a foreign entity.
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Key Terms Pandemic influenza
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A pandemic is the worldwide spread of a new disease. An influenza pandemic occurs when a new subtype of the influenza virus emerges to which humans have little to no immunity, that is easily transmissible between humans and causes serious illness.
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Key Terms Social distancing measures
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Non-pharmaceutical infection control measures. These can include quarantine, isolation, school closures, face masks, cancellation of mass public gatherings.
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- Background
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An influenza pandemic occurs when a new strain of influenza virus spreads around the world to which most people do not have immunity. Viruses that have caused past pandemics typically originated from animal influenza viruses. Although rare, influenza pandemics are a regular feature of human existence and are likely to remain so until the elusive (and perhaps impossible) goal of a universal flu vaccine is achieved. Every year, millions of people are exposed to seasonal influenza viruses, but in most cases these viruses only cause mild to moderate illness. For an influenza pandemic to happen, a new sub-type of the virus must emerge to which humans have little or no immunity, and which has the potential to cause severe illness. A pandemic can occur when this virus then achieves effective human-to-human transmission, meaning that it can spread easily amongst people.
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- Background
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The World Health Organisation (WHO) has been at the forefront of efforts to prepare the international community for another influenza pandemic. The WHO’s Global Influenza Surveillance and Response System (GISRS) is the foundation of the contemporary global influenza governance system. The GISRS brings together scientists and public health professionals based in laboratories and influenza research institutions around the world to share information and data, isolate viruses, and determine which strains of the virus are circulating. The information generated by this network is then used to inform the development of influenza vaccines, which offer the best protection against becoming infected with influenza.
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- Background
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Influenza vaccines provide the best protection against infection so the WHO has encouraged governments to secure access to influenza vaccines as part of their contingency planning. The core problem, however, is that global production capacity of influenza vaccines is limited, and it currently takes months to develop vaccines against specific virus strains (such as a new pandemic strain). Anti-viral medications may help to reduce the severity of illness, and non-pharmaceutical measures can assist in preventing infection, but vaccines continue to offer the best protection. Every government around the world has been encouraged to develop, and then exercise, a national pandemic influenza preparedness plan in order to limit the social disruption and loss of human life that may occur from an influenza pandemic. In this section we will give a brief explanation of the history and epidemiology of influenza to show why it is such an important threat to global health. The following sections will then discuss the efforts being made to prepare and respond to this threat at international and national levels.
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1.1 Brief history of influenza
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Influenza is one of the oldest diseases known to humans. The first documented influenza epidemic in Europe occurred in 1173 CE. There were many other epidemics over the next 400 years, but it is generally accepted that the first influenza pandemic took place in 1580 [Potter 2001]. Since then, documentary evidence reveals that pandemics have occurred with regular frequency. In the 20th century there were three major influenza pandemics, the worst in 1918 which killed tens of millions of people. For centuries, medical practitioners did not know how influenza spread. Early theories suggested that the disease was spread through foul-smelling air, or miasma, or that it was caused by meteorological or telluric conditions such as solar flares, rainfall, or even volcanoes and earthquakes. In the late 19th century, a new theory emerged that the disease was actually spread by microscopic agents that were too small to be seen by the human eye but the debate was not truly concluded until 1933 when a group of scientists isolated the influenza virus from pigs. An effective vaccine to protect humans from influenza was not developed until the 1940s.
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1.2 Basic epidemiology of the influenza virus
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As you may be aware, influenza is a respiratory infection of the upper respiratory tract – usually affecting the nose, throat and lungs. Importantly, influenza is a disease common to humans, but it is also frequently found in both pigs and birds. Less well known is that it is a disease that also affects whales, horses and seals.
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1.2 Basic epidemiology of the influenza virus
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Transmission of the influenza virus in humans most commonly occurs when there is direct contact with respiratory secretions from an infected person, usually in the form of coughing or sneezing. The influenza virus is a fairly hardy virus and is capable of surviving outside the human body for up to 48 hours. This means it can live for a period on inanimate items such as door handles, tables, and so on. Another name for these inanimate objects is fomites.
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1.2 Basic epidemiology of the influenza virus
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Symptoms usually start to appear between one to four days post exposure and commonly include coughing and sneezing accompanied by a fever. Lethargy or tiredness, muscle pains and headaches are also commonly experienced. Individuals with the influenza virus will usually be infectious for one to two days before symptoms appear, and up to five days after symptoms appear. Most people usually recover within one to two weeks. Although influenza is often confused with other illnesses such as the common cold, influenza is far more serious, as it has the potential to overwhelm the body’s immune system which can lead to more life-threatening conditions.
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1.2 Basic epidemiology of the influenza virus Subtypes of Influenza
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Following the isolation and identification of the influenza virus in 1933, scientists identified three main types of the virus (and numerous sub-types), which have been named A, B and C.
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1.2 Basic epidemiology of the influenza virus Subtypes of Influenza
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Type A - Type A influenza is known to be the most dangerous for humans. It is also found in pigs, birds and other mammals. This ability to infect a wide range of animal hosts as well as humans means that the virus has ample opportunity to mutate and change. Type A virus is often the virus that is responsible for causing epidemics and pandemics.
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1.2 Basic epidemiology of the influenza virus Subtypes of Influenza
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Type B - Type B influenza has been found in seals but is otherwise believed to be exclusive to humans. The limited number of hosts means that the virus has less opportunity to change. Type B has been identified as being responsible for occasional epidemics in humans, but historically these have been relatively mild.
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1.2 Basic epidemiology of the influenza virus Subtypes of Influenza
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Type C - Type C influenza is the rarest. It is believed to be found in pigs and dogs as well as humans, but generally will only cause mild respiratory illness.
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1.2 Basic epidemiology of the influenza virus Subtypes of Influenza
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Most viruses are DNA based, so that every time these viruses copy themselves, the new virus is identical to the first. But influenza is an RNA-based virus, which means that it is much more prone to mutation when it replicates.
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1.2 Basic epidemiology of the influenza virus Structure of Influenza A virus
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Figure 1 shows a simplified image of the influenza A virus as if it has been cut in half through the middle. The pink and purple stripes that surround the virus represent the proteins on the surface of the virus: neurominidase (NA) and hemagglutinin (HA) which the virus uses to attach itself to another cell so it can then invade that cell.
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1.2 Basic epidemiology of the influenza virus Antigenic drift
When a minor change in the composition of the virus occurs, but the virus remains of the same subtype, this is described as antigenic drift. Antigenic drift is quite common, and in the case of influenza, will result in a new strain emerging. Antigenic drift is the reason why people can become sick from influenza again and again, even though they may have been exposed to the virus in the past. It is also why new influenza vaccines need to be developed each year, as the antigenic drift results in small changes to the structure of the virus that means the vaccines are less effective against the new strain.
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1.2 Basic epidemiology of the influenza virus Antigenic shift
Occasionally, two or more viruses will combine to create an entirely new subtype of the virus. The process is known as antigenic shift. In the context of influenza, antigenic shift only occurs in type A, as influenza A is found in (and can infect) many different species. When two viruses combine within the same host cell, it can create a new hybrid virus, or sub-type, to which humans have little or no acquired immunity. If the new virus then acquires the ability to transmit effectively between humans, the virus has what we refer to as “pandemic potential.” In Figure 2, we see antigenic drift and antigenic shift represented visually. In figure 2, the image on the left represents antigenic drift, which is the phenomenon where only small changes or mutations occur. Antigenic drift may result in a new strain of influenza emerging, whereas antigenic shift (represented on the right) is when different influenza A viruses combine to create an entirely new subtype. It is this antigenic shift that raises the chance of a pandemic emerging, as humans may have little to no immunity to the new subtype.
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1.2 Basic epidemiology of the influenza virus Summary
In this section, you have learned that throughout human history outbreaks of influenza have regularly killed millions of people. Influenza is especially dangerous because of its ability to cross species and to mutate (antigenic drift and antigenic shift), so humans may have little immunity. This creates a particular challenge for public health professionals and policy-makers. The next section will discuss what happens when antigenic shift occurs, and an influenza outbreak develops into a pandemic.
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2.1 Seasonal Influenza
Because of antigenic drift, every year multiple strains of the influenza virus circulate around the world causing illness. Influenza is often confused with the common cold due to the similarity in symptoms. While getting colds can certainly be inconvenient, exposure to influenza will usually cause much more severe symptoms and can be life threatening. Influenza is most prevalent in the winter months. This is because lower temperatures allow the virus to survive longer outside the human body, and because people are often more likely to be found in confined spaces together where the virus can spread much more easily between people.
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2.1 Seasonal Influenza
Vaccines are developed twice a year to counter the effects of influenza, one for the northern hemisphere and a second for the southern hemisphere. In the northern hemisphere, the influenza season extends from October-February/March, whereas in the southern hemisphere the influenza season extends from March/April-September. Seasonal influenza is one of the diseases that we have, by and large, learned to live with, and which we consider relatively harmless. Yet while most of us who contract influenza will go on to make a full recovery within about two weeks, according to WHO, annual epidemics of seasonal influenza result in about 3 to 5 million cases of severe illness and about 290,000 to 650,000 deaths. Far from being a harmless disease, influenza adds a considerable burden to healthcare systems.
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2.2 Influenza Pandemics
A pandemic is, by definition, something much more serious and very different from the seasonal influenza that circulates around the world every year. An influenza pandemic may occur when a new subtype of the Influenza A virus emerges to which humans have little or no immunity. It is a virus that causes serious disease in humans, and it is capable of human-to-human transmission, meaning that it can spread very easily. Thus, there are three requirements for an influenza pandemic: 1 The existence of a novel virus, and 2 The ability of the novel virus to infect humans, and 3 Efficient human-to-human transmission of the novel virus
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2.2 Influenza Pandemics
Influenza pandemics are acknowledged to be fairly rare events, and yet billions of dollars have been spent over the past decade to strengthen pandemic preparedness. It can legitimately be asked why this money is not instead invested on treating the many other infectious diseases, such as malaria, HIV/AIDS, cholera and tuberculosis which kill millions of people every year? While it is true that influenza pandemics are fortunately very rare events, when they occur, they can be catastrophic. In 1918 at the end of World War 1, an influenza pandemic began that killed an estimated 40-50 million people worldwide - more deaths than in both world wars combined. Whereas influenza usually affects only the very young or the very old, the 1918 virus killed people in the prime of their lives. The majority of victims were young healthy adults between the ages 25-35.
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2.2 Influenza Pandemics
Smaller pandemics in 1957 and 1968 each killed around one million people. Some controversy arose over WHO declaring a pandemic in 2009 following the global spread of the H1N1 virus. Even though this virus had achieved effective human-to-human transmission, it was not known to cause serious illness in humans, except for pregnant women and people with pre-existing medical conditions. As a consequence, WHO was criticised for calling it a pandemic. We will discuss more about the work of WHO in the next section. Human cases of avian influenza are still an ongoing problem in many countries throughout Asia, the Middle East, and certain parts of Africa. The case fatality rate for avian influenza is approximately 60%. In other words, almost two out of every three people who contract the avian flu virus die as a result of their exposure.
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2.2 Influenza Pandemics
Most natural disasters have a clearly defined beginning and end, but influenza pandemics are non-linear events, as there can be several waves of infection. In 1918, the virus that caused so many deaths it is believed to have circulated the globe up to five times in 18 months. This was before the age of commercial aircraft. The virus was transported around the world by people on ships. Today, we live in a very different environment where people are able to get on a plane and be virtually anywhere in the world within 24 hours. Influenza viruses can therefore spread much more rapidly than ever before, and it is very likely that if a new sub-type of Influenza A emerges that meets the criteria of a pandemic, then there will be multiple waves of the pandemic. This makes it very difficult for people to enter a recovery phase, as they simply don’t know if and when another wave of the virus will emerge. A pandemic “event” will usually last a minimum of two years. Aside from the risk of a massive loss of human life, therefore, a pandemic will likely cause prolonged social and economic disruption that will last not just for a few weeks, but in all likelihood for a number of years.
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2.3 Pharmaceutical and Non-Pharmaceutical Response Measures
There are two main types measures that governments can take to strengthen a country’s pandemic preparedness. They are broadly classified into pharmaceutical measures and non-pharmaceutical measures.
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2.3 Pharmaceutical and Non-Pharmaceutical Response Measures Pharmaceutical Measures
Pharmaceutical measures are drug-based interventions. Vaccines remain by far the most effective means of protecting human populations from influenza. Influenza vaccines are developed using deactivated or partially live viruses to stimulate the immune system into recognising the virus as a foreign threat, thereby provoking an immune response.
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2.3 Pharmaceutical and Non-Pharmaceutical Response Measures Pharmaceutical Measures
Ideally, for an individual to achieve immunity, they should be vaccinated prior to infection, as this provides the immune system with sufficient time to develop an immune response to fight off the infection. Vaccines can still be effective, however, if they are administered soon after infection, as they will stimulate the immune system to respond much more rapidly. In contrast, antiviral medications work on the basis of inhibiting viral replication. Antiviral medications are usually only effective if administered prior to infection
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2.3 Pharmaceutical and Non-Pharmaceutical Response Measures Pharmaceutical Measures
Therefore, vaccines are a key weapon in the battle against influenza. A crucial problem however, is that vaccines take time to develop. Because antigenic drift and antigenic shift mean that the influenza virus is changing all the time, the first step in developing an effective vaccine is to identify the strain or subtype that is causing illness. This means that we have to wait for the virus to appear and spread a little to make sure that we have isolated and identified the correct virus. On average it takes around 3- 6 months to develop an effective influenza vaccine and produce it in a sufficient quantity to begin a vaccination campaign. Although efforts are being made to speed up this process, this delay is obviously a problem if a pandemic has started.
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2.3 Pharmaceutical and Non-Pharmaceutical Response Measures Non-Pharmaceutical Measures
Governments have a variety of non-pharmaceutical measures that they might implement during the delay while an effective vaccination is being developed. For example, children are known to be highly susceptible to influenza and therefore often suffer higher morbidity and mortality. They are more likely to have poor personal hygiene and can therefore spread the virus very easily to others. To counteract the possibility that children may become what in epidemiological terms is described as “super spreaders”, governments may close schools and child care centres to try and prevent further transmission.
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2.3 Pharmaceutical and Non-Pharmaceutical Response Measures Non-Pharmaceutical Measures
Similarly, because the virus is spread via droplet form, any large gathering of people can help to further disseminate the virus. Governments may decide to cancel mass gatherings such as football matches, or public forums, in an attempt to limit the spread of the virus. They may also encourage voluntary isolation and quarantine or pass laws to allow them to compel isolation and quarantine for people who do not agree to enter into quarantine voluntarily. These types of measures are commonly referred to as social distancing measures, and are designed to encourage physical distance between people to prevent transmission of the virus.
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2.3 Pharmaceutical and Non-Pharmaceutical Response Measures Non-Pharmaceutical Measures
Individuals can also take a number of personal measures to try and reduce their exposure. Regular handwashing may help to reduce transmission of the virus. The use of facemasks has also been proven to reduce the transmission of the virus in clinical settings. Both pharmaceutical and non-pharmaceutical measures have social and economic costs associated with them. We will be considering some of the implications later in this session.
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2 Influenza Pandemics Summary
In this section, you’ve learned the key distinction between seasonal influenza and the more serious pandemic influenza, as well as some of the reasons for why this disease continues to remain a threat to humanity. We have discussed some of the measures that governments and individuals can take to try and protect themselves against influenza. In the next section, we’re going to discuss some of the international institutions and networks involved in strengthening pandemic preparedness. Before then, try the following activities to test your understanding.
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Activity 1 What conditions must be met for an influenza pandemic to occur?
1. When a minor change occurs during virus replication resulting in a new strain emerging that can infect humans and cause illness. False - this is antigenic drift
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Activity 2 What conditions must be met for an influenza pandemic to occur?
2. When a new sub-type of the virus emerges to which humans have little to no immunity, that causes severe illness and which is easily transmissible. True - this is antigenic shift. An influenza pandemic is defined as an event where a new sub-type of the virus emerges to which humans have little to no immunity, that causes severe illness which is easily transmissible.
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Activity 3 What conditions must be met for an influenza pandemic to occur?
3. Whenever a new strain of Type C emerges. False - type C is rare and it is type A that is associated with pandemics
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3.1 The World Health Organization
The lead actor in global efforts to prepare and respond to the threat of pandemic influenza, is the World Health Organization (WHO). In this work it often works with other bodies, such as the Food and Agriculture Organisation (FAO), the World Organisation for Animal Health (OIE), the World Bank and private stakeholders. The WHO was officially established in 1948 as the United Nations specialised agency for human health. An interim commission was established in 1946 to help bring the new health organisation into being, and one of its first actions was to establish the World Influenza Centre (WIC), in London in 1947. Influenza was greatly feared at that time and considered by many to be a “war disease”. There was concern that in the wake of the Second World War another influenza pandemic of similar severity to the 1918 pandemic would occur. The decision to establish the WIC, even before the WHO came into being, reflected the importance which the international scientific community gave to the threat of influenza. This initiative was strengthened came in 1952 when WHO launched the Global Influenza Programme.
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3.1 The World Health Organization WHO: The Global Influenza Programme: GIP
The GIP provides Member States with strategic guidance, technical support and coordination of activities to make their health systems better prepared against seasonal, zoonotic and pandemic influenza threats. The goals of the Global Influenza Programme are to: 1. Monitor and track influenza outbreaks; 2 Generate and transfer knowledge and technical guidance about influenza; 3 Guide and support countries to develop and strengthen influenza control programmes; 4 Identify gaps in knowledge about the disease and foster research to fill these gaps; 5 Facilitate more equitable access to vaccines and antiviral medicines; and 6 Provide global health leadership to prevent and control influenza.
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3.1 The World Health Organization WHO: The Global Influenza Surveillance and Response System (GISRS)
The WHO maintains and coordinates the Global Influenza Surveillance and Response System, or GISRS. Established in 1952 and formerly known as the Global Influenza Surveillance Network (GISN), the WHO GISRS: Monitors the evolution of influenza viruses and provides recommendations and risk assessment; and Acts as a global alert mechanism for the emergence of influenza viruses with pandemic potential.
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3.1 The World Health Organization WHO: The Global Influenza Surveillance and Response System (GISRS)
The WHO encouraged its Member States to establish influenza research centres around the world. There are currently 153 National Influenza Centres (NICs) based in 114 countries. These NICs collect data and samples and forward this information to one of six Collaborating Centres (CCs) or four Essential Regulatory Laboratories (ERLs) for influenza, based in five countries: the UK, the US, China, Australia and Japan.
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3.1 The World Health Organization WHO: The Global Influenza Surveillance and Response System (GISRS)
There are also four WHO H5 Reference Laboratories which deal specifically with public health needs arising from avian influenza A (H5N1) infection in humans. The CCs and ERLs have responsibility for isolating and identifying which strains of the influenza virus are currently circulating and which are the most prevalent. They then make a recommendation to national licensing authorities and pharmaceutical manufacturers on which strains should be contained in the vaccines for seasonal influenza. Based on the WHO recommendation, which is made twice a year, each vaccine is developed to contain the three most dominant strains. This information is then used to inform the development of vaccines, which National Licensing Agencies have responsibility for authorising prior to any national vaccination campaign being launched.
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3.1 The World Health Organization WHO: The Global Influenza Surveillance and Response System (GISRS)
In the event of a pandemic, the WHO CCs play a critically important role in isolating and identifying the new subtype of Influenza A. The information is then passed to pharmaceutical manufacturers to begin producing the vaccines that will help to protect populations. Here, the primary function of the GISRS is to share information and virus samples for research purposes.
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3.1 The World Health Organization WHO: The Global Influenza Surveillance and Response System (GISRS)
Figure 3 outlines the functions of the GISRS. The NICs gather the epidemiological data and help to gather clinical specimens that are then passed to the WHO CCs and ERLs to identify the extent of antigenic drift and/or antigenic shift, and the genetic composition of the virus.
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3.1 The World Health Organization WHO: Global Outbreak Alert and Response Network: GOARN
The Global Outbreak Alert and Response Network (GOARN) was created by WHO in April 2000. GOARN’s role is to bring together technical expertise from around the world to rapidly respond to disease outbreaks as they are occurring. Since 2000 GOARN has responded to over 50 events worldwide, helping to deploy numerous Rapid Response Teams or RRTs, to assist national health authorities in containing outbreaks within their territories by sending technical experts to advise on the implementation of public health measures. While GOARN provides support for all types of disease outbreaks (such as Ebola), it has been involved in several influenza-related events, assisting a number of southeast Asian countries in 2003 and 2004 following multiple outbreaks of H5N1. GOARN was also mobilised to respond to the 2009 H1N1 influenza pandemic and most recently the COVID-19 pandemic. It is, in many senses, the practical “hands on” side of WHO’s work.
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3.1 The World Health Organization WHO: FluNet
FluNet is a global web-based tool for influenza virological surveillance. The virological data entered into FluNet are critical for tracking the movement of viruses globally and interpreting the epidemiological data. The data at country level are publicly available and updated weekly. The results are presented in various formats including tables, maps and graphs.
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3.1 The World Health Organization WHO: International Health Regulations (2005)
WHO’s mandate to protect human health against influenza, is reinforced by the organisation’s authority under the International Health Regulations (2005) – or IHR. The IHR were originally developed in 1952 to help strike the balance between preventing the spread of infectious diseases, while minimising disruption to international traffic and trade. Although originally only covering a limited number of diseases, in 2005 the IHR underwent substantial revision and the scope of the Regulations was expanded to include any disease that may cause a “public health emergency of international concern”, or PHEIC.
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3.1 The World Health Organization WHO: International Health Regulations (2005)
Pandemic influenza now falls under the scope of the IHR 2005 framework, and this gives both WHO and all member states certain roles and responsibilities. The IHR sets guidelines for preparedness and response measures for a public health emergency of international concern and it is intended to be binding on all WHO member states. The most recent influenza pandemic was the H1N1 outbreak in 2009, which was declared a PHEIC. Subsequent epidemics of Ebola, Zika, COVID-19 and the Monkeypox virus were also declared PHEICs.
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3.1 The World Health Organization WHO: International Health Regulations (2005)
An obligation imposed by the IHR is the need for national pandemic preparedness plans to be in place. Virtually every member state of WHO now has a national pandemic plan, and we have also seen the emergence of regional pandemic plans such as the North American Plan for Avian and Pandemic Influenza, that seeks to encourage close collaboration between Mexico, the United States and Canada. We will discuss national plans later on in the session.
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3.1 The World Health Organization WHO: The Pandemic Influenza Preparedness (“PIP”) Framework
The Pandemic Influenza Preparedness (“PIP”) Framework was endorsed by the World Health Assembly in 2011 and is considered an important step forward in global pandemic preparedness. Its goals are (1) to improve and strengthen the sharing of influenza viruses with human pandemic potential; and (2) to increase the access of developing countries to vaccines and other pandemic related supplies. The WHO and its Member States commit to virus sharing obligations, in return for benefits in vaccine access. It is innovative in involving the private sector which is required to provide benefits to low-income countries (via the WHO) in exchange for access to biological materials which support industry research and development. The PIP Framework aims to regain the trust of developing countries such as Indonesia. In 2005 Indonesia had been particularly badly hit by the H5N1 avian flu outbreak in South East Asia. Indonesia stopped sharing A (H5N1) viruses with WHO collaborating centres because the resulting vaccines produced by commercial companies were likely to be unavailable to developing countries such as itself.
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3.1 The World Health Organization WHO: The Pandemic Influenza Preparedness (“PIP”) Framework
Although Indonesia was criticised, the controversy exposed the inequitable position of lower income countries which tend to be more vulnerable to infectious disease outbreaks, while being least able to purchase vaccines or compete with high income countries for medications in an influenza pandemic when supplies will be limited. The PIP framework enables cash benefits to be channelled through WHO to countries most in need and there are in-kind contributions, including pledges of pandemic vaccine and antivirals in real time in the event of a pandemic and capacity building.
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3.1 The World Health Organization WHO: The Pandemic Influenza Preparedness (“PIP”) Framework
Weaknesses of the framework are that it applies only to H5N1 and other influenza viruses with human pandemic potential, so seasonal influenza outbreaks are excluded. It is also non-binding so it does not impose a legal obligation to share virus samples, although it should encourage state cooperation. Furthermore, Gostin has pointed out that while a step in the right direction, “The PIP Framework will likely fall short in meeting vaccine demand during a pandemic, and it provides no guidance on equitable rationing during scarcity” [Gostin 2014]. The framework is not set up to cover total demand for pandemic vaccine in a pandemic, but rather to enable developing countries to receive an early supply of donated vaccine.
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3.2 Other Institutions/Programmes
There are many institutions and initiatives which play a role in global efforts to prepare and respond to cross border threats, including pandemic influenza. Many of these work with WHO and some examples are given below:
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3.2 Other Institutions/Programmes Food and Agriculture Organisation: FAO; World Organisation for Animal Health: OIE
The FAO and the OIE have focused on assisting countries to strengthen their animal disease surveillance capacity for highly pathogenic avian influenza (HPAI), and have established the OFFLU network, which fulfils a similar function to GISRS but in terms of animal health.
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3.2 Other Institutions/Programmes The World Bank
The World Bank makes funds available for pandemic influenza-related initiatives by means of: 1 The Global Program (GPAI), and 2 Trust funds, notably the multidonor Avian and Human Influenza Facility (AHIF). The GPAI permits countries to access loans, credit or grants from the Bank to strengthen pandemic preparedness for both animal and human health. Countries can apply to the Bank for funding to strengthen their veterinary and health services to deal with avian flu outbreaks among animals, to minimise the threat to people, as well as initiating projects that prepare for and respond to any potential human flu pandemic. The AHIF was established to help developing countries meet financing gaps in their integrated county programmes, to minimise the risk and socioeconomic impact of avian and potential human pandemic influenza.
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3.2 Other Institutions/Programmes North American Plan for Animal and Pandemic Influenza (NAPAPI)
Launched in 2012 as a joint initiative of the USA, Canada and Mexico, NAPAPI is a regional and cross-sectoral health-security framework to strengthen these countries’ emergency response capacities and to ensure a quick and coordinated response to outbreaks of pandemic influenza or animal influenza.
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3.2 Other Institutions/Programmes Global Health Security Initiative (GHSI)
Established in November 2001, the GHSI is an informal partnership of eight countries (France, Germany, Italy, Japan, Mexico, the UK and the US) and the European Union to strengthen global preparedness and response to threats to health security, including pandemic influenza. With WHO acting as technical advisor, the GHSI is intended to work with, rather than replace or duplicate the work of other groups. The GHSI has five working groups including a Pandemic Influenza Working Group which “is responsible for sharing and comparing respective national approaches to pandemic preparedness, including vaccine and anti-viral stockpiling and use, surveillance and epidemiology, diagnostics, and public health measures” [GHSI website].
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3.3 The Challenge of Vaccine Production
Vaccines remain the best defence to an influenza pandemic and although the PIP Framework was a positive step forward, there remain what Gostin [2014] has identified as the five “factors at play in pandemic vaccine shortages”, namely:
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3.3 The Challenge of Vaccine Production Vaccine design, production and registration:
the time lag between identifying a pandemic strain and designing a vaccine which has been tested for safety and effectiveness will allow the virus to spread, and lead to increased demand and cost when the vaccine is available. This will disadvantage the poor and increase inequity.
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3.3 The Challenge of Vaccine Production Intellectual property rights:
Any point in vaccine production where pharmaceutical companies can exert IP rights (e.g. by patenting viral genetic sequences) will restrict access to the vaccine to those able to afford the increased cost.
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3.3 The Challenge of Vaccine Production Production capacity:
Despite an increase in vaccine production capacity, it remains below pandemic demand. The largest vaccine companies are located in wealthy countries. Even if lower-income countries can obtain IP rights, they may be unable to produce vaccines domestically.
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3.3 The Challenge of Vaccine Production Prepurchase agreements:
High income countries often have contracts with industry to secure pandemic vaccine supplies, exacerbating shortages for countries without such agreements.
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3.3 The Challenge of Vaccine Production Multiple stakeholders:
Vaccine production requires the coordination of diverse stakeholders with varied interests and motivations. This requires improved global governance.
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3.3 The Challenge of Vaccine Production
Although vaccines are considered the “gold standard” for pandemic response, there has been criticism that the focus on vaccine production has taken away attention from other possible strategies such as social distancing methods or anti-virals. Unfortunately, there remains little evidence base for the effectiveness of these treatments. Research has been ongoing for many years into a universal flu vaccine, but to date this remains elusive.
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3. The International Response to Influenza Summary
In this section, you have learned that the WHO has taken the lead on coordinating efforts to strengthen global preparedness for pandemic influenza. Important initiatives include The Global Influenza Surveillance and Response System (GISRS), FluNet, the Global Outbreak Alert and Response Network (GOARN), and for animal health, the OFFLU network. The WHO also works with other institutions such as the FAO, the OIE and the World Bank. WHO’s authority has been reinforced by The International Health Regulations (IHR) 2005 which sets guidelines and gives both WHO and all member states certain roles and responsibilities. Difficult challenges remain, particularly in ensuring sufficient vaccine production and avoiding inequities between rich and poor countries. The PIP framework 2011 is an attempt to tackle these challenges. In the next section we will look at some of the challenges that national governments face in strengthening preparedness. But for now, please take a few minutes to answer some questions to test your knowledge of what we’ve just covered.
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Activity 2 Choose either the GISRS or GOARN and write a few paragraphs on the Moodle discussion forum giving an example of its activities during a recent outbreak.
Respond to at least one other classmate’s post.
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4. National Influenza Preparedness
Although international efforts are obviously important, what is really crucial is what happens at national level, and what countries are doing individually, internally, to strengthen pandemic preparedness. A serious pandemic would be an event of such magnitude that it could not only wipe out large numbers of the population, but also disrupt social functioning and destroy economies. Governments have recognised the need to be better prepared to deal with such an event but the extent of pandemic preparedness differs considerably between countries. As we saw in the previous section, the IHR (2005), which sets standards for pandemic preparedness, includes the obligation that member states should develop national influenza preparedness plans, supported by national laws in place so that these plans can be legally enforceable at country level.
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4.1 National Pandemic Preparedness Plans
To support the obligations of the IHR, the WHO issued guidance, advising national governments to plan for issues such as public communication, surveillance, infection control measures and maintaining essential services. This guidance was updated following the 2009 H1N1 pandemic and again in 2013. Countries are encouraged to focus on “intersectoral cooperation, collaboration and leadership” and “strategies for exchanging information and communicating risk”. Under the terms of the IHR (2005), countries are obliged to designate a national focal point to liaise with their WHO regional office and WHO headquarters in Geneva, Switzerland. The purpose of the focal point is to share information and updates on the situation, and to act as the main point of contact.
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4.1 National Pandemic Preparedness Plans
Countries are advised to designate a national pandemic planning committee, to develop national emergency structures, and to clearly delineate a coherent chain of command to identify who takes charge and how decisions taken will be implemented. WHO member states are then encouraged to test those plans to identify any areas in need of improvement. Governments have also been encouraged to strengthen links with neighbouring countries, to ensure that the actions and activities taken by one government will not adversely affect neighbouring countries and vice versa. A majority of member states have now developed national plans, but surveys of these plans indicate considerable inconsistency in the different approaches taken. It is not clear if some countries have simply missed some elements of pandemic planning, or if they had reviewed the various options and decided they were inappropriate or did not fit with their national arrangements.
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4.2 Challenges in National Pandemic Preparedness Planning
There are a number of challenges in planning for a pandemic. These include: Ethical considerations; Lack of cross-border consistency; Lack of testing of plans; Variation in health system structures and public health arrangements; Need for a “whole-of-society” approach; Capacity building; and Legislative authority
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4.2 Challenges in National Pandemic Preparedness Planning Ethical Considerations
Responding to a pandemic requires many difficult decisions to be made, often very quickly. There may be conflict in the need to protect the general population while also respecting individual human rights. Typical issues which may be faced include: Rationing of limited medical resources among the population; Enforcement of quarantine or isolation; Seizure of property; Information privacy – e.g. medical records; Information sharing – how (and how much) to communicate to the public; and Border controls
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4.2 Challenges in National Pandemic Preparedness Planning Ethical Considerations
It is important that decisions are made not only on the basis of the latest, scientific evidence, but that they are also legal and ethical. In 2007 the WHO issued guidance titled: “Ethical Considerations in Developing a Public Health Response to Pandemic Influenza”. This sets out some of these potential ethical issues and advises that countries should consider these factors when planning for an emergency. It may sometimes be necessary to limit individual rights in order to protect the general population, for example in enforced isolation of infected individuals, or governments may have to prioritise certain groups of people, such as emergency workers, to receive scarce medical resources. These decisions must be transparent, justifiable and non-discriminatory. Nevertheless, many national plans do not include any reference to ethical considerations or protection of individual rights.
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4.2 Challenges in National Pandemic Preparedness Planning Lack of Cross-Border Consistency
The IHR and WHO guidance aims for countries to take a consistent approach in order to achieve “international harmonization of preparedness measures, as this is the key to success in reducing the risk of spread of an influenza pandemic” [WHO global influenza preparedness plan 2005]. Yet it is unclear to what extent many plans have been developed in consultation with neighbouring countries. This is not an obligation but problems can arise when one country announces that they are doing one thing, and other countries say they are doing something else. If Country A announces, for instance, that healthcare workers will be given priority access to antiviral medications as a prophylaxis measure, but Country B declares that priority access will only be given to people if they suspect they have been exposed to the virus, it can create tensions.
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4.2 Challenges in National Pandemic Preparedness Planning Lack of Testing of Plans
Another concern is the extent to which countries have tested their pandemic plans. A study by Kamradt-Scott in 2009 of the Asia-Pacific region revealed that while the majority of countries in Asia and the Pacific have developed national contingency plans for pandemic influenza, few have tested those plans through national exercise programmes. Without such activities being conducted, it is often impossible to identify gaps in contingency planning.
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4.2 Challenges in National Pandemic Preparedness Planning Variation in Health System Structures and Public Health Arrangements
A further complication is the variation in health system structures and public health arrangements. In some countries like Canada, Australia, Norway and the UK, healthcare services are paid for through taxation revenue and are accessible to all citizens. Other countries, such as the United States and Ghana, require citizens to pay costs directly to the service providers or pay into an insurance scheme that covers the costs. Yet other countries maintain a mix of services, covering the costs of some services through taxation where other healthcare costs must be borne by the individual.
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4.2 Challenges in National Pandemic Preparedness Planning Variation in Health System Structures and Public Health Arrangements
In some countries healthcare services are seen as the responsibility of central government, whereas in other countries they are the responsibility of provincial or even local authorities. Added to this, countries also differ in the types of healthcare on offer, with some maintaining a strong preference for traditional or folk medicine, while others have chosen to pursue Western biomedical models. All of these factors can have a direct bearing on how countries seek to strengthen their pandemic preparedness, the interventions they deem appropriate and are prepared to implement, and the extent to which they amend domestic laws and invest in building capacity
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4.2 Challenges in National Pandemic Preparedness Planning Need For a “Whole of Society” Approach
As a pandemic can disrupt social and economic functioning, pandemic plans need to take into account not only how the healthcare system will respond and maintain operations, but also how the transport, education, emergency service, food and agriculture, banking and finance, IT services, and so on, will continue to function. This is what is referred to as a “whole-of-society” approach, and it is the hallmark of sound contingency planning.
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4.2 Challenges in National Pandemic Preparedness Planning Need For a “Whole of Society” Approach
For example, a government may decide to implement school and childcare closures, a sensible public health measure as it reduces the risk of children being exposed to the virus and it decreases the likelihood that they will spread infection. However, this step may have an adverse impact on family incomes (since one parent will have to stay home to look after the children) and can also put a strain on the parent’s employer who has to cover the absence. Governments may be expected to pay compensation. If a pandemic occurs in multiple waves, extending over 18 months to two years, schooling, businesses and the national economy would be seriously impacted, and it is questionable how feasible such a policy could be on a long-term basis.
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4.2 Challenges in National Pandemic Preparedness Planning Need For a “Whole of Society” Approach
Thus, while the decision to close schools and child care centres may seem sound from a public health perspective, it raises complications that governments must take into account. Intersectoral pandemic planning is essential if governments are to think through the consequences of just one policy decision to try and limit the spread of influenza. Plans need to establish chains of command to ensure the continuation of government and basic social functions. They need to outline decision-making processes and lines of responsibility between various government agencies. Plans also need to be practical, addressing matters such as how to deal with potentially large numbers of human fatalities; where to store bodies to prevent creating additional public health hazards; how to establish communication networks to disseminate information; and how to implement social distancing measures such as school closures and the cancellation of mass gatherings.
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4.2 Challenges in National Pandemic Preparedness Planning Need For a “Whole of Society” Approach
Ideally, plans should also outline strategies for how societies will begin to recover, and who will lead recovery efforts once the pandemic has been declared over. Therefore, pandemic preparedness plans need to be comprehensive and should preferably adopt a whole-of-society approach. This means that in the planning stage, governments should consult with a variety of stakeholders. For example: Civil society and non-governmental organisations including volunteer services; Business groups and industry; Critical infrastructure, specifically healthcare providers (both public and private), the banking and finance industry, water, energy, transport; and Food suppliers such as supermarket distributors, and emergency services such as police, fire brigade and the military.
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4.2 Challenges in National Pandemic Preparedness Planning Capacity Building
Arguably, one of the largest challenges is capacity building. Under the IHR, the governments of every WHO member state are obliged to “build, strengthen and maintain” certain core capacities in disease surveillance and outbreak response in order to detect, verify and respond to any public health emergency of international concern. This has proven to be a particularly large challenge for many low-income countries, many of which struggle to provide even basic primary healthcare services. To have these core capacities in place requires advanced healthcare infrastructure. It requires scientific laboratories that are capable of isolating virus and bacteria strains. It requires surveillance systems, with professionals trained at detecting disease outbreaks, and it requires medical facilities that are well stocked with supplies and equipment to treat patients. Human resources are a critical component. Developing a suitably qualified and competent workforce to conduct disease surveillance and mount an effective outbreak response takes time and years of training.
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4.2 Challenges in National Pandemic Preparedness Planning Capacity Building
Developing and nurturing a culture of reporting is another essential element to effective disease outbreak control. which takes considerable time and effort, and a commitment at the highest levels of political decision-making to instil. Some societies and their governments still view disease outbreaks as something to be hidden, not spoken about, and certainly not something to talk to outsiders about. Countries have been reluctant to report disease outbreaks, particularly when examining the economic consequences of past events. The costs to the tourism and international trade for Asia in the wake of the 2003 SARS outbreak has been estimated to be between US$30 and $100 billion.
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4.2 Challenges in National Pandemic Preparedness Planning Capacity Building
All member states were required to have these “core capacities” in place by July 2012. WHO granted a 2-year extension for achieving core capacity to 2014 and then “final 2-year extensions (for exceptional circumstances)” to 2016. These deadlines have passed yet many countries are still far from achieving core capacity. In the aftermath of the 2014-15 Ebola outbreak, in 2016 the WHO established the Joint External Evaluation (JEE) tool to test national capacity and compliance with the IHR. This is a voluntary exercise which combines national self-assessment with evaluation by a team of experts appointed by WHO. Core capacities required by the IHR such as surveillance, human resources and laboratory facilities are measured and scored, and a report is published on the WHO website.
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4.2 Challenges in National Pandemic Preparedness Planning Legislative Authority
Although the IHR is described as “legally binding”, there is no enforcement mechanism at the international level. Therefore, national laws need to be in place to provide the legislative authority to do what needs to be done. For example, issues surrounding quarantine and isolation, or compulsory vaccination may run counter to civil liberties and personal freedoms. Therefore, governments need to carefully review their legal systems and ensure that they contain the necessary legal provisions to underpin their public health response and also protect civil rights.
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4. National Influenza Preparedness
In this section, you have learned about the various challenges associated with developing an effective and comprehensive national pandemic influenza preparedness plan. These include ethical considerations, the variation in health systems and structures, lack of cross-border consistency, legal considerations, and the very real challenge of capacity building. Hopefully, you’ve gained an appreciation of what is involved in strengthening pandemic preparedness, both at the domestic and international levels. You will now be asked to complete a series of questions and some self-evaluation exercises to test your knowledge and understanding of the issues.
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Activity 3 Using a copy of your own country’s pandemic influenza preparedness plan, identify at least three (3) examples of non-pharmaceutical measures that can be deployed to prevent human-to-human transmission of the influenza virus.
Post your response on the discussion board.
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5. Integrating Activity Imagine you are the health minister in the following scenario: The World Health Organization has announced that the health authorities in Country x (a country in your same continent) have confirmed that a novel strain of an Influenza A virus has been identified and is believed to be spreading easily amongst the population. Your country’s national news station (Channel 15) has already aired several news reports on the situation and have suggested that you, as health minister, should raise the pandemic alert level within your own country and deploy healthcare personnel at all major border entry points to screen incoming arrivals. What sort of issues would you take into consideration before agreeing to such a course of action?
Feedback: Your answer should have included some of the following points: Consult with your country’s chief medical officer on appropriate next steps and which health measures are most beneficial at this early stage; Review your country’s pandemic plan to familiarise yourself with the planning and preparation objectives; Issue a memorandum to all hospitals and GP clinics to conduct additional surveillance for Influenza A; Contact the health minister in Country X to enquire if they need any assistance in containing the virus before it spreads further; Issue a press statement that your office is closely monitoring the situation and is in contact with WHO; Convene your country’s national pandemic emergency committee; and Contact WHO’s country office in your country to verify the reports and seek new information.
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6. Summary
During this session, you learned about the long history of influenza in human society. You learned of the three types of the influenza virus (A, B and C), but that only Type A has the potential to cause a pandemic. The influenza virus is an organism that is prone to easily mutate, making long-term immunity difficult to achieve. Periodically, an entire new strain of the virus to which humans have little to no immunity, which causes severe illness, and which is easily transmissible between humans can appear. This has the potential to cause a pandemic. There are a number of United Nations organisations and other actors engaged in assisting countries to strengthen their pandemic influenza preparedness through providing advice and assisting in capacity building.
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6. Summary
Internationally, WHO is the lead agency for responding to a human influenza pandemic. WHO maintains several networks, including the GISRS, FluNet and the Global Outbreak Alert and Response Network (GOARN) to gather information, and use this data to provide advice and recommendations to governments. Upon request, WHO can also send teams to assist countries with containing disease outbreaks. Many countries struggle to gain access to affordable influenza vaccines and antiviral medications in sufficient quantity to protect their populations. Access has been made difficult by limited supply, costs and disagreements about intellectual property.
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6. Summary
National governments ultimately have responsibility for developing pandemic preparedness plans that are comprehensive and plan for the potential loss of human life as well as taking into account the wider social and economic impacts of a pandemic. Yet many countries have yet to test their plans and even fewer have adopted a whole-of-society approach to pandemic planning. Other ongoing challenges include differences in healthcare systems and structures, varying levels of technical capacity and legal issues.
