Influenza pandemic preparedness.

In the list of potential bioterrorist agents, influenza would be classified as a category C agent (1). While previous influenza pandemics were naturally occurring events, an influenza pandemic could be started with an intentional release of a deliberately altered influenza strain. Even if a deliberately altered strain is not released, an influenza pandemic originating from natural origins will inevitably occur (2) and will likely cause substantial illness, death, social disruption, and widespread panic. Globally, the 1918 pandemic killed at least 20 million people (3). This figure is approximately double the number killed on the battlefields of Europe during World War I (4). In the United States alone, the next pandemic could cause an estimated 89,000-207,000 deaths, 314,000-734,000 hospitalizations, 18-42 million outpatient visits, and 20-47 million additional illnesses (5). These predictions equal or surpass many published casualty estimates for a bioterrorism event (6-8). In addition to the potential for a large number of casualties, a bioterrorism incident and an influenza pandemic have similarities that allow public health planners to simultaneously plan and prepare for both types of emergencies (Table).

Preparing for both the next influenza pandemic and the next bioterrorist attack requires support and collaboration from multiple partners at the state, local, and federal level. Potential partners include the medical community, law enforcement, emergency management, and public health agencies. To help foster these crucial cross-discipline relationships, the Centers for Disease Control and Prevention (CDC) and the Council of State and Territorial Epidemiologists (CSTE), in collaboration with the National Emergency Management Association, the Association of State and Territorial Health Officials, the Federal Emergency Management Agency, and the Association of Public Health Laboratories, hosted a 2-day meeting on state and local pandemic influenza planning in May 2002. Over 125 officials representing epidemiology, communicable disease, laboratory, immunization, and emergency management programs from 46 states registered for this meeting. The objectives of the meeting were to enhance collaboration between state and local public health and emergency management agencies, establish mechanisms for integrating bioterrorism and pandemic influenza preparedness and response planning, and develop policy and strategy options for influenza pandemic preparedness and response at the state and local level. We report the results of a questionnaire distributed to the attendees; it was designed to elicit their views on the most important issues that must be addressed by a plan to respond to a catastrophic disease event.

Priorities for Pandemic Influenza Planning

All plans for any catastrophic infectious disease event such as pandemic influenza or a bioterrorist attack must address five topics: surveillance and laboratory issues; communications; maintenance of community services; medical care; and supply and delivery of vaccines and drugs. After presentations providing background information, conference attendees were divided into breakout groups to discuss these topics. The groups did not discuss particular scenarios, but the presentations given before the breakout groups did include details of estimates of the potential impact of the next influenza pandemic (5). Attendees completed short ([less than or equal to] 5 questions), anonymous questionnaires at both the beginning and end of the breakout session. Each breakout group had a different set of questions relevant to the topic of that group. (1) However, all groups addressed a common question, which asked persons to pick their top priority for a pandemic influenza response from one of the following options: reduce mortality, reduce morbidity, ensure continuation of essential services, reduce economic impact, and ensure equitable distribution of resources. As explained to the attendees before the breakout session, differences by age and risk group in rates of mortality and morbidity could mean that public health officials with limited resources might not be able to simultaneously maximize reductions in mortality and morbidity (5). The first three options were chosen most frequently (Figure). Even after discussion, no option was chosen by >50% of attendees, indicating that this group of professionals did not have a unified opinion regarding what the top priority should be to guide planning and response measures.

[FIGURE OMITTED]

Conference attendees did, however, agree that global and domestic laboratory and disease surveillance must be strengthened to increase the likelihood of early detection and tracking of either pandemic influenza or a bioterrorist event. A rise beyond the baseline number of influenza-like illnesses (ILIs) could indicate a severe influenza season, arrival of pandemic influenza, or early warning of a bioterrorist attack with a pathogen that causes ILIs (e.g., anthrax). Thus, the number and accuracy of reports of ILI, ILI outbreaks, and laboratory-confirmed reports of influenza need to be increased. In addition, ensuring that adequate laboratory and disease surveillance systems are in place will benefit the public health response during yearly influenza epidemics. Conference attendees identified two critical gaps in infectious disease surveillance systems: 1) less than ideal or nonexistent systems to monitor outpatient and hospital-based ILI cases and 2) insufficient numbers of laboratory personnel and epidemiologists to monitor, provide diagnostic support, and respond to events.

Another critical component of any catastrophic infectious disease plan is communications. The anthrax attacks in 2001 demonstrated that the public, media, and healthcare professionals will demand accurate information, with frequent updates throughout the emergency. To minimize the potential for confusion, states and localities need to identify a recognized and trusted leader who will be the primary spokesperson to disseminate accurate information. Among attendees in the communications breakout group, 40% felt that the state governor would be the best spokesperson, 40% chose the state health officer, and 20% chose the state epidemiologist.

In the initial stages of, and potentially throughout, an influenza pandemic or a bioterrorist attack, there will be a shortage of many essential resources, including medical equipment and supplies, personnel, vaccines, and drugs. Prioritizing medical resources will therefore be necessary. The medical care breakout group unanimously chose state and local government as the authority that should prioritize and distribute healthcare resources. In the breakout group that discussed vaccine and antimicrobial agent issues, 73% chose essential workers and physicians as those who should be the first to receive vaccine and antiviral drugs. Only 27% chose those at high risk for adverse influenza-related health outcomes to be early recipients of vaccine.

Conclusions: Maximizing Resources and Planning Efforts

Conference attendees were well aware of the need to simultaneously plan and prepare for the next influenza pandemic and the next bioterrorist event. However, much work remains to be done. Without agreement regarding the top priority for allocating scarce resources, planning and implementing an optimal response to either pandemic influenza or a bioterrorist event will be difficult, if not impossible. Illustrating potential planning problems was the incongruity between the inability of most attendees to agree on the goal of planning and response measures (Figure) while 75% of a subgroup stated that essential workers and physicians should be the first to receive vaccines and antiviral drugs. In a situation with limited resources, usually only one goal can be optimized (either maximized or minimized) (9). Therefore, before accepting any of the initially limited supplies of vaccine and antiviral drugs, physicians and first responders will have to explain how such an allocation will help achieve the chosen top priority.

Unprecedented resources for enhancing the public health preparedness and response infrastructure have been recently provided to all states by congressional appropriations in the form of bioterrorism cooperative agreements. The request for proposals stated that planning moneys may be used "... to upgrade state and local public health jurisdictions' preparedness for and response to bioterrorism, other outbreaks of infectious disease, and other public health threats and emergencies ..." (10). Using such resources and reflecting upon the lessons learned from previous influenza pandemics and the 2001 terrorist events, public health, medical, and emergency management communities must work together to develop an effective plan to strengthen our national readiness to respond to any catastrophic infectious disease situation.

If our public health planning efforts are too narrowly focused on preparing responses to a few select bioterrorism-related scenarios, a new opportunity for planning responses to a broad spectrum of infectious disease-related catastrophes will be lost. Any plans made for responding to either pandemic influenza or bioterrorism events must include an explicit mechanism for making difficult decisions regarding the prioritization of scarce resources. The conference highlighted the need for all states to continue their discussions and public debates regarding the setting of priorities and methods for allocating scarce resources. Obviously, each state or local government will chose its own specific method for drawing up a plan to deal with catastrophic infections disease events such as an influenza pandemic. To help aid the planning process, materials such as a planning guide are available from agencies such as CDC and CSTE. Ideally, such planning and prioritization activities should take place well in advance of any catastrophic infectious disease event.

Table. Planning for pandemic influenza and
bioterrorism: similarities and differences (a,b)

Issue                      Bioteirorist event      Pandemic influenza

Likelihood                        High                    High
Wanting                       None to days           Days to months
Occurrence                Focal or multifocal          Nationwide
Transmission/duration    Point source; limited;    Person-to-person,
  of exposure               person-to-person            6-8 wks
Casualties               Hundreds to thousands   Hundreds of thousands
                                                      to millions
First responders
  susceptible?                    Yes                     Yes
Disaster medical team
  support/response                Yes             No (too widespread)
Main site for
  preparedness,
  response, recovery,
  and mitigation         State and local areas   State and local areas
Essential preparedness
  components
  Surveillance                    Yes                     Yes
  Law enforcement
    intelligence                  Yes                      No
  Investigation                   Yes                     Yes
  Research                        Yes                     Yes
  Liability programs              Yes                     Yes
  Communication systems           Yes                     Yes
  Medical triage and
    treatment plans               Yes                     Yes
  Vaccine supply issues      Yes (for most                Yes
                            likely threats)
  Drug supply issues              Yes                     Yes
  Training/
    tabletop exercises            Yes                     Yes
  Maintenance
    of essential
    community services            Yes                     Yes
Essential response
  components
  Rapid deployment
    teams                         Yes                      No
  Effective
    communications/
    media
    relations strategy            Yes                     Yes
  Vaccine delivery           Yes (for some)               Yes
  Drug delivery              Yes (for most)               Yes
  Hospital/public
    health coordination           Yes                     Yes
  Global assistance             Possibly                  Yes
  Medical care                    Yes                     Yes
  Mental health support           Yes                     Yes
  Mortuary services               Yes                     Yes
  Supplies and
    equipment                     Yes                     Yes
Essential mitigation
  components
  Enhanced surveillance           Yes                     Yes
  Enhanced
    law enforcement
    intelligence                  Yes                      No
  Vaccine stockpile      Yes (selected agents)     Prototype vaccines
                                                          only
  Drug stockpile                  Yes                     Yes
  Pre-event vaccination      Vaccination of      Vaccination of groups
                            selected groups'     at medical high risk
                                                   with pneumococcal
                                                        vaccine

(a) During a catastrophic infectious disease event, such as an
influenza pandemic, there maybe critical shortages of vaccines
and drugs. Thus, clinics set up to administer vaccines and
distribute antimicrobial drugs may require the services of a
range of personnel whose fields of expertise are nonclinical.
Examples of additional personnel that may be needed include law
enforcement, translators, social workers, psychologists, and legal
experts.

(b) Source: Adapted from: National Vaccine Program Office. Pandemic
influenza: a planning guide for state and local officials
(Draft 2.1). Atlanta: Centers for Disease Control and
Prevention: 2000.

(c) At the time of writing, the smallpox vaccination program was
just beginning. For other bioterrorist agents for which vaccines
are available (e.g., anthrax), limited supplies and concerns about
safety profiles have, up to this point, effectively prevented the
widespread use of these vaccines.

(d) It may eventually be possible to vaccinate high-priority groups
and the general population with a yet-to-be-developed "common
epitope" vaccine, which might provide for a broader spectrum
of protection against a variety of influenza A subtypes.

Acknowledgments

We thank Kakoli Roy and Margaret Coleman for their help in administering and analyzing the questionnaires; Pascale Wortley for valuable comments on an earlier draft of the manuscript; and the Council of State and Territorial Epidemiologists for its support. The following members of the ad-hoc Influenza Pandemic Conference Planning and Steering Committee significantly contributed to organizing the conference in May 2002: Lynnette Brammer, Ron Burger, Nancy Cox, Zygmunt Dembek, Kristine Ehresmann, Keiji Fukuda, John Iskander, Deva Joseph, Donna Lazorik, Ann Moen, Mack Sewell, and Gregory Wallace.

(1) A complete copy of each questionnaire and a complete set of the results are available from the corresponding author.

References

(1.) Rotz LD, Khan AS, Lilibridge SR, Ostroff SM, Hughes JM. Public health assessment of potential biological terrorism agents. Emerg Infect Dis 2002;8:225-30.

(2.) Patriarca PA, Cox NJ. Influenza pandemic preparedness plan for the United States. J Infect Dis 1997;176(Suppl 1):S4-7.

(3.) Crosby AW. America's forgotten pandemic: the influenza of 1918. Cambridge, U.K.: Cambridge University Press; 1989.

(4.) Keegan J. The first world war. New York: Alfred A. Knopf; 1999.

(5.) Meltzer MI, Cox NJ, Fukuda K. The economic impact of pandemic influenza in the United States: implications for setting priorities for interventions. Emerg Infect Dis 1999;5:659-71.

(6.) Kaufmann AF, Meltzer MI, Schmid GP. The economic impact of a bioterrorist attack: are prevention and postattack intervention programs justifiable? Emerg Infect Dis 1997;3:83-94.

(7.) Meltzer MI, Damon I, LeDuc JW, Millar JD. Modeling potential responses to smallpox as a bioterrorist weapon. Emerg Infect Dis 2001 ;7:959-69.

(8.) Kaplan EH, Craft DL, Wein LM. Emergency response to a smallpox attack: the case for mass vaccination. Proc Natl Acad Sci U S A 2002;99:10935-40.

(9.) Giordano FR, Weir MD, Fox WE A first course in mathematical modeling. 2nd edition. Pacific Grove (CA): Brooks/Cole Publishing; 1997.

(10.) Centers for Disease Control and Prevention. Notice of Cooperative Agreement Award: guidance for fiscal year 2002 supplemental funds for public health preparedness and response for bioterrorism [announcement number 99051--emergency supplemental]: Feb. 15, 2002. Atlanta: Centers for Disease Control and Development; 2002.

Kathleen F. Gensheimer, * Martin I. Meltzer, ([dagger]) Alicia S. Postema, ([dagger]) and Raymond A. Strikas ([dagger])

* Department of Human Services, Augusta, Maine, USA; and ([dagger]) Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Dr. Gensheimer is the state epidemiologist and the director of the Medical Epidemiology Section, Maine Bureau of Health. She helps coordinate responses to outbreaks of disease as well as working on existing programs to promote the welfare and safety of the citizens of Maine. She has taken a leading role in influenza pandemic planning.

Address for correspondence: Martin I. Meltzer, Mailstop D59, 1600 Clifton Rd., Atlanta, GA 30333, USA; fax: [phone]; email: [e-mail]