National Strategy for Pandemic Influenza Implementation Plan One Year Summary
Looking Ahead:What have we learned through these efforts and what gaps still need to Be addressed?
Building a Foundation for All-Hazards Preparedness
The threats facing our Nation in the 21st century, from pandemic influenza and the emergence of new diseases such as SARS, to terrorist attacks and naturally occurring disasters such as hurricanes and earthquakes, require an all-hazards approach to emergency planning and preparedness. However, pandemic preparedness is often viewed as separate from or competing with other disaster preparedness efforts. Although there are some unique aspects to pandemic planning, preparing the Nation for the threat of an influenza pandemic has provided a platform to address issues and concerns common to mass casualty disasters. Promoting a culture of individual, family, and community preparedness is the foundation for emergency planning efforts. Strengthening our public health infrastructure by enhancing public health agency coordination with partner State and local agencies, enhancing biosurveillance, and accelerating countermeasure development, production, and distribution, sustaining our Nation's critical infrastructure, and developing strategies for expanding mass casualty care capability and for prioritizing scarce medical resources are important goals for preparing for many of the threats we now face. By investing in pandemic preparedness, our Nation is building a foundation for all-hazards preparedness.
Achieving the goals outlined above and preparing the Nation for a pandemic will not be easy. The Federal Government has made a commitment to transparency and accountability in reporting our progress. While we have made progress over the past year to prepare the Nation for the threat of an influenza pandemic, much important work lies ahead. Critical gaps in pandemic preparedness efforts remain and are outlined below. Despite the waning media interest in avian and pandemic influenza, the potential consequences of a severe pandemic demand that we redouble our efforts to address these critical gaps.
Building Connectivity and Unity of Effort
The National Plan recognized that one of our greatest vulnerabilities was the lack of connectivity and coordination of effort between the various communities responsible for pandemic preparedness. Developing effective strategies and policies to meet the challenge of a pandemic require the engagement of all nations, all levels of government, and all segments of society. Internationally, collaboration and transparency are essential. Here at home, a unified effort that engages all levels of government, as well as the public health community, the medical care community, the private sector, faith-based and community-based organizations, and the public, is critical for an effective response.
One of the most tangible benefits of pandemic planning at a Federal level has been the forging of close working relationships among Federal departments and agencies. This began with the writing of the National Plan. Many of the actions in the National Plan required collaboration, coordination, and cooperation between Federal departments. Recognizing the need for a unified effort across the Federal Government, an interagency group with senior managers representing 16 Federal departments and agencies directly engaged in pandemic preparedness has been meeting weekly since the release of the National Plan in May 2006. This interagency group monitors progress on all actions in the National Plan and reviews pandemic policy issues. To ensure that the Federal Government speaks with one voice on pandemic issues, all pandemic-related information developed by departments is posted on www.pandemicflu.gov and reviewed for consistency prior to release by other departments. The establishment of trusted relationships across the Federal Government as a result of the ongoing work of this interagency group has enhanced connectivity and has improved communication among Federal departments and agencies.
The benefits of a unified effort at the Federal level can also be realized at a State and local levels. It is critical that we establish connectivity and build relationships between various layers of the government, the private sector, and faith-based and community-based organizations. Now is the time, before a pandemic emerges, to establish and test these relationships and partnerships. The Federal Government must take a leadership role in fostering an environment of collaboration and public engagement that will serve our Nation well for any hazard we might face.
Strengthening Disease Detection and Biosurveillance
The strategies associated with pandemic preparedness serve to strengthen the public health infrastructure in the United States and the world. One of the most important areas is disease detection and surveillance.
Although we have realized progress in expanding disease surveillance abroad, critical gaps remain with respect to "real-time" disease detection and clinical surveillance in the United States. As part of its national influenza surveillance effort, the CDC currently receives weekly mortality reports from 122 cities and metropolitan areas in the United States. This information helps the CDC track trends in disease spread, identify severely affected populations, and monitor the impact of influenza on health. One of the limitations of this system, however, is an approximately 2-week lag in obtaining data. BioSense is a national program intended to improve the Nation's capabilities by conducting nearly real-time clinical disease surveillance. Of the nearly 6,000 hospitals in the United States, only 700 hospitals are currently engaged in some stage of implementation for sharing data with the BioSense program.
Given how rapidly a pandemic could spread, it is crucial that we establish this "real-time" surveillance capability at a national, State, and community level. It is imperative to identify outbreaks and implement interventions as quickly as possible, in addition to monitoring the outbreak and evaluating the effectiveness of our interventions.
Another critical gap related to biosurveillance is the availability of rapid diagnostic tests that can quickly discriminate pandemic influenza from non-influenza illnesses. Use of these tests in outpatient clinics and in ambulatory settings will greatly enhance the Nation's capacity to detect pandemic influenza more rapidly. Also, to effectively implement our border measures, it is vital to quickly and correctly identify infected individuals at ports of entry. Moreover, to maximize the utilization of our limited stockpile of antiviral medications (targeting treatment to individuals with confirmed pandemic influenza) and to minimize the disruption of community mitigation measures (limiting isolation and voluntary home quarantine to individuals and households with confirmed pandemic influenza), a field-based test to rapidly diagnose pandemic influenza is essential.
The Federal Government must intensify its efforts for improving biosurveillance to ensure that we are not "blind" during the next pandemic or any other public health crisis. Accelerating the development of rapid diagnostics is key for effectively implementing disease control measures.
Expanding Medical Capacity to Care for Large Numbers of Ill Patients
The projected demand for medical care during a severe pandemic would overwhelm the Nation's present healthcare system. Nationwide, many hospitals and emergency departments are already operating at or near capacity and may not have the capability to treat the surge of patients who will need care during a severe pandemic. Our Nation's current acute inpatient capacity is limited by the number of appropriately staffed and equipped hospital beds. Expanding acute care capacity, by increasing the number of hospital beds and training additional medical staff, would require substantial and recurring investments with long lag times. A severe pandemic will impact all communities nearly simultaneously and at the peak of the outbreak could result in many times the normal demand for acute medical care. There may be little opportunity to shift resources from one part of the country to another. To meet this demand and to ensure delivery of the best quality healthcare possible under such circumstances, individual communities need to plan for dramatic increases in patient care capabilities. Up to this point, contingency planning for pandemics and other disasters has generally attempted to improve medical "surge capacity." However, it is unrealistic for communities to be able to increase the numbers of staffed acute care hospital beds to a level necessary for pandemic preparedness. Clearly, alternative strategies are warranted.
Therefore, many hospitals plan to boost their current capacity to treat ill patients through the use of existing resources for alternative and auxiliary settings for healthcare and by expanding the number of available healthcare providers with retirees and volunteers. Healthcare workers and first responders will be on the front lines during an influenza pandemic. Ensuring the availability of protective measures for these critical workers will be essential to our efforts to protect the health and safety of the public. Community planning efforts will require the coordination of many providers and organizations and must address how healthcare facilities can best share assets in order to assure the greatest benefit for the largest number of people in the most ethical manner. The Federal Government has incorporated both funding and guidance to assist in planning for the strengthening of mass casualty care capacity. Community mitigation measures offer an additional strategy to help narrow the gap between existing acute care capacity in the United States and the projected demand for medical care. The combined efforts of maximizing available surge capacity and reducing the demand for acute care by community mitigation will help, but new strategies are required and much work remains to address our Nation's challenge of mass casualty care.
The stockpiling of critical medical materiel, including a reassessment of antiviral medication stockpile goals, is one area that the Federal Government needs to address in the coming year. Most healthcare facilities have "just-in-time" inventory for medical supplies, which means that hospitals normally have on hand only a few days of basic medical supplies including personal protective equipment and medications. Although the Federal Government has stockpiled medical supplies, the scope and scale of a pandemic in terms of the demand for medical materiel would be unprecedented. Limited global production capacity of antiviral medications was one factor that had constrained antiviral drug stockpile goals. Recent expansion of domestic antiviral drug production capacity -- up to 80 million regimens per year of oseltamivir -- has made increased stockpiling possible. This, in combination with several recent analyses suggesting substantial potential benefits of prophylactic antiviral drug use, has prompted a reassessment of pandemic antiviral drug use, strategies, and potential stockpiling targets. Accordingly, significant work remains at the Federal, State, local, and healthcare facility level to address the projected demand for antiviral medications, personal protective equipment (including surgical masks and respirators), antibiotics, ventilators, and other medical materiel required during a pandemic.
Accelerating Vaccine Development and Production
The Federal Government is investing in the expansion of vaccine manufacturing capacity, the advanced development of new cell-based vaccines, antigen-sparing technologies or adjuvants, and the establishment and maintenance of pre-pandemic vaccine stockpiles.
The challenge of producing enough pandemic vaccine for the U.S. population is significant, but an even greater challenge is producing and providing worldwide access to pandemic vaccine. The global capacity for influenza vaccine production is approximately 350 million doses per year. This could be scaled up to 500 million doses per year in an emergency such as a pandemic. Even with the current investments in expanded capacity, global vaccine production will remain well below projected demand during a pandemic. The U.S. Government is committed to working with the pharmaceutical industry, our international partners, and WHO to address this gap. But commitment alone is not sufficient. We need imaginative solutions to this problem, and we require a unified effort that engages our best scientists in addressing this challenge.
In that spirit, the United States is working in collaboration with WHO and international partners throughout the world to enhance surveillance and pandemic preparedness, including increasing vaccine development and vaccine access. Four important principles guiding our international effort include:(1) transparency; (2) rapid reporting; (3) sharing of data; and (4) scientific cooperation. The United States continues to call on countries everywhere to share influenza samples openly and rapidly, without preconditions. Withholding influenza viruses from the Global Influenza Surveillance Network greatly threatens global public health and is inconsistent with the spirit of the legal obligations member nations have all agreed to undertake through adherence to the International Health Regulations.
The World Health Assembly has recently adopted a resolution on pandemic influenza preparedness that makes clear that member states must continue to share influenza specimens and viruses with WHO's Global Influenza Surveillance Network. The resolution also emphasizes the need for increased vaccine access. The United States has invested more than $1 billion in the development of new vaccine technologies that will benefit the international community. The United States strongly supports and finances WHO's efforts to meet the long-term global need for an influenza vaccine through the Global Pandemic Influenza Action Plan to Increase Vaccine Supply. In addition, the United States is committed to working with member states and WHO to explore other avenues to meet the near-term need for greater access to influenza vaccines, including pre-pandemic vaccines.
Distributing and Tracking Countermeasures
Medical countermeasures have little utility if they cannot be delivered quickly to those in need, yet the logistical challenges of rapidly allocating, distributing, and administering countermeasures to 300 million Americans are substantial. Although we have made significant investments in distribution capacity since 2002 through the Strategic National Stockpile, State and local grant programs, and the Cities Readiness Initiative, much work remains. Guidance and resources have been provided to State, local, tribal, and territorial governments to facilitate completion of distribution plans for medical countermeasure stockpiles. Recipients of pandemic influenza supplemental funding are required to complete and exercise these plans.
Countermeasure allocation and distribution is important for preparing our Nation for pandemic influenza and other naturally occurring infectious diseases, as well as for chemical and nuclear attacks. In the future we may be faced with the need to prioritize scarce medical resources during a major disaster. The pandemic efforts could well serve as a template for allocating and distributing life-saving countermeasures against other threats. The ongoing guidance development process for prioritizing and deploying countermeasures during a pandemic represents our first steps in addressing this complex ethical and logistical challenge.
Implementing Community Mitigation and Building Community Resilience
Although the community mitigation strategy may significantly reduce illness and death, implementing this strategy will not be easy. It is critical that emergency planners better understand the challenges associated with the implementation of the Community Mitigation Guidance. It is also important that they are aware of any potential adverse consequences due to these interventions. Minimizing the negative impact will require communities to undertake appropriate planning and exercises to pre-identify vulnerable populations and persons at risk and to develop population-specific strategies. To enhance individual and community adherence to these community mitigation measures, the Federal Government must continue to work with the private sector, public health, education, and community-based and faith-based organizations to address feasibility concerns, develop clear and appropriate public messaging, and minimize any adverse consequences associated with implementation. Pandemic exercises provide an ongoing opportunity to continually test and refine these plans.
The community mitigation strategy developed by the United States offers hope, especially to countries with limited access to medical countermeasures. The United States is reaching out to partners in the international community by informing them of our approach and assisting them in the adaptation of our strategy.
Translating our Pandemic Preparedness Efforts to Seasonal Influenza
Each year, more than 200,000 Americans are hospitalized and 36,000 die due to seasonal influenza. Increased awareness of available antiviral therapies and advances in vaccine production and point-of-care diagnostics, as a result of pandemic preparedness efforts, could translate to more effective treatment for seasonal influenza. Promoting healthy behaviors, such as hand washing and cough etiquette, could help reduce the spread of seasonal influenza and other respiratory diseases. Seasonal influenza also provides an opportunity to reinforce these behaviors, promote vaccination of nontraditional high-risk groups and healthcare workers, and test workplace policies and practices, such as having ill individuals remain home, so that we are better prepared to respond should a pandemic occur. How our Nation invests today in pandemic preparedness will serve us well when a pandemic does occur and could also prevent illness and death associated with seasonal influenza.
A Year of Progress
Much has been accomplished since the release of the National Plan in May 2006. Over the past year, the United States and the international community have mobilized to confront the threat of an influenza pandemic at its source, bycontaining H5N1 poultry outbreaks and rapidly identifying associated cases of human disease. The United States has made pivotal contributions to control the international spread of H5N1 by working with affected countries and international partners to detect, contain, and prevent animal outbreaks, reduce human exposure to the virus, and enhance planning and preparedness for future outbreaks.
Should a pandemic emerge, the United States is better positioned today to detect an outbreak earlier, to support an international effort to contain the pandemic in its earliest stages, to limit the spread of the pandemic, and to save lives. The Federal Government has developed mitigation strategies and guidelines for controlling influenza outbreaks in communities and has made significant investments in vaccines, antiviral medications, and research, which will safeguard our Nation and benefit the world. The unprecedented efforts to prepare for and respond to the threat of a pandemic underscore the Federal Government's resolve to protect human life.
Resiliency defines us as a Nation. Each American generation has faced and has risen to the challenges of its time. But no prior generation has ever anticipated and prepared for a pandemic. We have the opportunity to be the first generation to use our collective wisdom, determination, and resources to take on this task. The stakes are high, and our greatest enemy is complacency. We remain committed to this effort, not only for generations of Americans alive today, but also for the sake of generations to come.
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