Notes |
WHO Library Cataloguing-in-Publication Data
Pandemic influenza preparedness and response: a WHO guidance document.
1.Influenza, Human - epidemiology. 2.Influenza, Human - prevention and
control. 3.Disease outbreaks - prevention and control. 4.Epidemiologic
surveillance. 5.Health planning. 6.Guidelines. I.WHO Global Influenza
Programme. II.World Health Organization.
ISBN 978 92 4 154768 0 (NLM classification: WC 515)
© World Health Organization 2009. Reprinted 2010.
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Printed in France
02
These guidelines were edited by Jum Kanokporn Coninx, Keiji Fukuda, Hande Harmanci, Kidong
Park, Mary Chamberland, Tamara Curtin Niemi, Elisabeth (Isis) Pluut and Claudia Vivas of the Global
Influenza Programme in the Health Security and Environment Cluster of the World Health Organization.
This guidance is an update of WHO global influenza preparedness plan, the role of WHO and
recommendations for national measures before and during pandemics, published by WHO in March
2005.1
The information and recommendations contained in this guidance document are the product of expert
opinion obtained in the course of international consultations which began in 2007. During the
meeting held between 27 and 29 November 2007, five task forces were created to prepare draft
guidance documents which were discussed in subsequent meetings. All task force members and
other experts invited to participate in the subsequent meetings were asked to complete, sign and
submit the Declaration of Interest for WHO Experts form.
During the revision process, the task forces reviewed and consolidated existing WHO guidance;
examined available information and modeling studies; sought input from public health experts on
lessons learned from SARS; and reviewed studies and analyses of both animal and human influenza
responses. All the external experts that participated in the substantive elaboration of this guidance
document are listed and acknowledged in the following section. In accordance with WHO policy,
participating experts were requested to submit a duly completed and signed Declaration of Interest
for WHO Experts form. Representatives of industry attending the meeting of 5-9 May 2008 participated
as observers and, in accordance with WHO rules, were not therefore required to submit a Declaration
of Interest. Further information on the declarations of interests by individual experts is summarized
in Annex 2.
The Global Influenza Programme will revise this guidance in 2014, or sooner in the event of significant
developments which impact pandemic preparedness and response planning.
FOREWORD
03
1. WHO Global Influenza Preparedness Plan. The role of WHO and recommendations for national measures before and during pandemics, World Health Organization. 2005
(WHO/CDS/CSR/GIP/2005.5)
This guidance is an update of WHO global influenza preparedness
plan, the role of WHO and recommendations for national measures
before and during pandemics, published by WHO March 2005.1
04
WHO wishes to acknowledge the contributions of experts from all over the world who participated
in the process of developing this guidance:
P Abi-Hanna (Lebanon), L Ahadzie (Ghana), S Al Awaidy (Oman), T Asikainen (ECDC), Azimal
(Indonesia), N Bakirci (Turkey), D Bell (USA), Y Berhane (Ethiopia), M Betancourt-Cravioto (Mexico),
F Binam (Cameroon), D Boakye (Ghana), M Bökkerink (Netherlands), S Borroto-Gutierrez (Cuba),
H Branswell (Canada), JS Bresee (USA), P Calvi-Parisetti (IFRC), D Camus (France), O Carlino
(Argentina), E Carmo (Brazil), M de Carvalho (Brazil), M Cetron (USA), P Chappe (France),
É Chatigny (Canada), P-H Chung (China), S Chunsuttiwat (Thailand), E Coker (Nigeria), T Colgate
(IFPMA), J Cutter (Singapore), J Dabanch (Chile), V Davidyants (Armenia), B Duncan (ECDC),
P Duplessis (IFRC), R El-Aouad (Morroco), O Ergonul (Turkey), B Eshaya-Chauvin (IFRC), M Esveld
(Netherlands), R Fasce (Chile), M Fawzi (Egypt), N Fergusson (UK), L Finelli (USA), A Fiore (USA),
G Foliot (WFP), A Fry (USA), J Gale (Singapore), M Gastellu-Etchegorry (France), N Gay (UK),
U Go (Republic of Korea), P Grove (UK), MM Gouya (Iran), W Haas (Germany), J Hall (Australia),
N Hehme (IFPMA), M Henkens (Belgium), N-T Hien (Vietnam), P Hung (Vietnam), P Imnadze
(Georgia), M Jacobs (New Zealand), S Jadhav (DCVMN), A Kandeel (Egypt), M Kaku (Japan),
G Kamenov (Bulgaria), F Karcher (EC), R Kirby (UK), O Kiselev (Russia), P Kreidl (ECDC), J-W Kwon
(Republic of Korea), H-S Lee (Republic of Korea), W Lum (Panama), J Macey (Canada), J Mackenzie
(Australia), H Mambu-ma-Disu (Congo), O Mansoor (UNICEF), M Mapatano (DR Congo), A Marx
(OCHA), M Meltzer (USA), Z Memish (Saudi Arabia), Z Mohamed (Sudan), A Monto (USA), J Moran
(Kazakhstan), M Mosselmans (OCHA), A Mounts (USA), Y Ndao (Senegal), H Needham (ECDC),
J Newstead (UK), J Nguyen van Tam (UK), A Nicoll (ECDC), T Omori (Japan), H Oshitani (Japan),
J O'Toole (ECDC), J Paget (Netherlands), E Palacios-Zavala (Mexico), B Paton (OCHA), C Patterson
(Australia), W Peerapatanapokin (Thailand), E Perez (France), N Phin (UK), S Plotkin (USA),
N Pshenichnaya (Russia), G Ramirez-Prada (Peru), P Ravindran (India), B Rawal (IFPMA),
S Redd (USA), A Reynolds (UK), A Ricol-Solernou (EC), B Rodriques (UNICEF), C Russell (UK),
G Saour (France), C Schuyler (NATO), J Sciberras (Canada), P Scott-Bowden (WFP), P Seukap
(Cameroon), H Shirley-Quirk (UK), Y Shu (China), L Simonssen (USA), M Smolinski (USA),
R Snacken (Belgium), S Strickland (UK), N Sunderland (USA), K Taniguchi (Japan), M Tashiro
(Japan), J Toessi (Benin), B Toussaint (EC), P Tull (Sweden), M Vanderford (USA),
M Van der Sande (Netherlands), S Vaux (France), L Vedrasco (OCHA), S Venkatesh (India),
R Vivarie (UNHCR), S Vong (Cambodia), R Waldman (USA), W Wang (China), J Watson (UK),
D Xiao (China), P Yosephine (Indonesia), H Yu (China), S Zaidi (Pakistan), H Zhao (UK),
D Zoutman (Canada).
ACKNOWLEDGEMENTS
05
The following WHO staff were involved in the development and review of this document and their
contribution is gratefully acknowledged:
B Abela-Ridder, W Alemu, C Alfonso, M Almiron, R Andraghetti, P Andrea, N Asgari, J Azé,
M Barbeschi, P Ben-Embarek, I Bott, B Brennan, S Briand, C Brown, R Brown, P Carrasco,
L Castellanos, M Chamberland, C Chauvin, M Chu, S Chungong, M Coly, P Cox, A Croisier,
T Curtin-Niemi, A Dabbagh, T dos Santos, H El Bushra, N Eltantawys, N Emiroglu, S Eremin, D
Featherstone, J Fitzner, M Friede, K Fukuda, B Ganter, M Gayer, P Ghimire, A Gilsdorf,
T Grein, M Guardo, P Gully, M Hardiman, H Harmanci, G Hartl, F Hayden,
M Hegermann-Lindencrone, D Heymann, H Hollmeyer, A Huvos, J Kanokporn Coninx, T Kasai, S
Kirori, D Lavanchy, R Lee, D Legros, A Li, K Limpakarnjanarat, J Lopez-Macedo, Q Lui, C Maher,
S Martin, D Menucci, A Merianos, C Mukoya, L Mumford, A Odugleh-Kolev, K O'Neill, S Otsu, L
Palkonyay, K Park, C Pessoa Da Silva, O Pinheiro de Oliva, B Plotkin, S Pooransingh,
G Poumerol, E Pluut, K Prosenc, J Rainford, A Reis, G Rodier, J Rovira, M Ryan, D Scales,
N Shindo, C Toscano, K Vandemaele, C Vivas, J Watson, S Westman, E Whelan, S Wilburn,
L Wolfson, A Yada, A Yeneabat, W Zhang, W Zhou, P Zuber.
CONTENTS
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08
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24
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FOREWORD
ACKNOWLEDGEMENTS
EXECUTIVE SUMMARY
1. INTRODUCTION
2. BACKGROUND
2.1 How influenza viruses with pandemic potential develop
2.2 Ensuring ethical pandemic preparedness and response
2.3 Integrating pandemic preparedness and response into general emergency
preparedness
3. ROLES AND RESPONSIBILITIES IN PREPAREDNESS AND RESPONSE
3.1 National preparedness and response as a whole-of-society responsibility
3.1.1 Government leadership
3.1.2 Health sector
3.1.3 Non-health sectors
3.1.4 Communities, individuals, and families
3.2 WHO
3.2.1 Coordination under International Health Regulations (IHR 2005)
3.2.2 The designation of the global pandemic phase
3.2.3. Switching to pandemic vaccine production
3.2.4 Rapid containment of the initial emergence of pandemic influenza
3.2.5 Providing an early assessment of pandemic severity on health
4. THE WHO PANDEMIC PHASES
4.1 Definition of the phases
4.2 Phase changes
5. RECOMMENDED ACTIONS BEFORE, DURING AND AFTER A PANDEMIC
A. Phases 1-3
B. Phase 4
C. Phases 5-6
D. The post-peak period
E. The post-pandemic period
07
ANNEX 1 - PLANNING ASSUMPTIONS
1. Modes of transmission
Suggested assumptions
Implications
Scientific basis
Selected references
2. Incubation period and infectiousness of pandemic influenza
Suggested assumptions
Implications
Scientific basis
Selected references
3. Symptom development and clinical attack rate
Suggested assumptions
Implications
Scientific basis
Selected references
4. Dynamics of the pandemic and its impact
Suggested assumptions
Implications
Scientific basis
Selected references
ANNEX 2 REVISION PROCESS
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51
51
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EXECUTIVE SUMMARY
08
2. Global pandemic influenza action plan to increase vaccine supply (WHO/CDS/EPR/GIP/2006.1) World Health Organization, 2006.
(http://www.who.int/csr/resources/publications/influenza/WHO_CDS_EPR_GIP_2006_1/en/index.html, accessed 23 March 2009).
Influenza pandemics are unpredictable but recurring events that can have severe consequences on
human health and economic well being worldwide. Advance planning and preparedness are critical
to help mitigate the impact of a global pandemic. This WHO Guidance document Pandemic influenza
preparedness and response significantly updates and replaces WHO global influenza preparedness
plan: the role of WHO and recommendations for national measures before and during pandemics
which was published in 2005.
Why update the 2005 guidance?
The global response to the spread of avian influenza A (H5N1) that began in 2003 has helped shape
a number of significant public health advances. First, avian and pandemic influenza initiatives have
led to substantial gains in strengthening national and global capacities and building partnerships
between animal and human health sectors. Extensive practical experience in dealing with outbreaks
of avian influenza (H5N1) virus in poultry and humans, in addition to pandemic preparedness and
response exercises carried out in various countries, has led to a greater understanding of the issues
that need to be addressed in pandemic preparedness. Second, there is increased understanding of
past pandemics, strengthened outbreak communications, greater insight into disease spread and
approaches to control, and development of increasingly sophisticated statistical modeling techniques.
Third, there has been growing attention to global health security following the adoption of the revised
International Health Regulations (IHR) in 2005, which provide a framework to address international
public health concerns. Finally, stockpiles of antiviral drugs and other essential supplies are now a
reality, new approaches to influenza vaccine development are under way and a Global Vaccine Action
Plan2 has been devised to increase the supply of pandemic vaccine.
Overview of the major changes
The revised guidance:
1. retains the six-phase structure but regroups and redefines the phases to more accurately reflect
pandemic risk and the epidemiological situation based upon observable phenomena
2. highlights key principles when undertaking pandemic planning including:
a) application of ethical principles to assist policymakers in balancing a range of interests and
protecting human rights;
b) integration of pandemic preparedness and response into national emergency frameworks to
encourage sustainable preparedness;
c) incorporation of a “whole of society” approach that emphasizes not only the central
role played by the health sector, but also the significant roles of other sectors such as
businesses, families, communities and individuals;
3. harmonizes the recommended measures with the IHR 2005 and the concurrent
development/revision of WHO guidance in related areas such as pandemic influenza surveillance,
disease control measures, rapid containment and communications;
4. includes suggested planning assumptions, their implications and a selected evidence base to
aide planning efforts on a national level.
09
How to use this guidance
This document should be used as a guide to inform and harmonize national and international
preparedness and response before, during and after an influenza pandemic. Countries should develop
or update national influenza preparedness and response plans that address the recommendations
in this guidance. This document is not intended to replace national plans which should be developed
by each country.
This guidance serves as the core strategic document in a suite of materials. It is supported by a
complement of pandemic preparedness materials and tools (Figure 1). These documents and tools
provide detailed information on a broad range of specific recommendations and activities, as well
as clear guidance on their implementation. The individual elements of the guidance package will
be made available as they are finalized.
THE WHO GUIDANCE PACKAGE FOR PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE
FIGURE 1
Communications
Reducing the
spread of disease
Self Assesment
Checklist for
Preparedness
Planning and
Executing
a Preparedness
Exercise Training
CD-ROMs for
Trainers
Sample
Preparedness
Plans
THE
THEMATIC AREAS OF SUPPORTING DOCUMENTS
TOOLS
Situation
monitoring and
assessment
Continuity
of health care
provision
Planning and
coordination
Handbook
for the Public
Rapid
Containment
Training
Package
10
Roles and responsibilities in preparedness and response
A “whole-of-society” approach to pandemic influenza preparedness emphasizes the significant roles
played by all sectors of society.
• The national government is the natural leader for communication and overall coordination
efforts. Central governments should work to put in place the necessary legislation, policies
and resources for pandemic preparedness, capacity development and anticipated response
efforts across all sectors.
• The health sector (including public health and health-care services) provides critical
epidemiological, clinical and virological information which, in turn, informs measures to
reduce spread of the pandemic virus and its attendant morbidity and mortality.
• The diverse array of non-health sectors must provide essential operations and services
during a pandemic to mitigate health, economic and social impacts.
• Civil society organizations are often well placed to raise awareness, communicate accurate
information, counter rumours, provide needed services, and liaise with the government
during an emergency.
• Families and individuals can help reduce the spread of pandemic influenza through adoption
of measures such as covering coughs and sneezes, hand washing, and the voluntary isolation
of persons with respiratory illness.
WHO will work with Member States across a range of activities, including:
• coordination of the international public health response under IHR 2005;
• designation of the current global pandemic phase;
• selection of the pandemic vaccine strain and recommendation of timing to start pandemic
vaccine production;
• assistance to national pandemic rapid containment efforts;
• assessment of pandemic severity;
• global aggregation of key epidemiologic, virologic, and clinical information about the pandemic
virus to help national authorities in deciding the optimal response;
• provision of guidance and technical assistance.
The WHO pandemic phases
The phases are applicable globally and provide a framework to aid countries in pandemic preparedness
and response planning. The use of a six-phased approach has been retained to facilitate incorporation
of new recommendations into existing national plans. However, the pandemic phases have been
re-defined (Table 1). To facilitate planning at national and global levels, Phases 1-3 and 5-6 have
been grouped to include common action points. In addition, the time after the first pandemic wave
has been elaborated into post peak and post pandemic periods. When making a change to the global
phase, WHO will carefully consider all available information to assess if the criteria for a new phase
have been met.
Recommended actions before, during and after a pandemic
Recommended actions to be taken by WHO and national authorities are presented for Phases 1-3,
Phase 4, Phases 5-6, a post-peak period and a post-pandemic period. These actions are organized
into the five basic components of preparedness and response:
1. planning and coordination
2. situation monitoring and assessment
3. reducing the spread of disease
4. continuity of health care provision
5. communications.
Actions taken during Phases1-3 are aimed at strengthening pandemic preparedness and response
capacities at global, regional, national and sub-national levels. The overarching goal of actions taken
during Phase 4 is containment of the new virus within a limited area or the delay of its spread. If
successful, valuable time could be gained to implement interventions including the use of vaccines.
During Phases 5-6, actions shift from preparedness to response at a global level to reduce the impact
of the pandemic. Actions during the post-peak period focus on addressing the health and social
impact of the pandemic as well as preparation for a possible future pandemic wave(s). The focus
of the post-pandemic period is restoration of normal health and social functions while addressing
the long-term health and social impact of the pandemic.
Effectively meeting the challenges of the next influenza pandemic will require robust and extraordinary
advance planning on the part of WHO and countries worldwide. WHO encourages countries to use
this guidance and the associated tools and supporting documents to build and strengthen national
plans for pandemic influenza preparedness and response.
PANDEMIC PHASE DESCRIPTIONS
TABLE 1
No animal influenza virus circulating among animals has been reported to cause infection
in humans.
An animal influenza virus circulating in domesticated or wild animals is known to have
caused infection in humans and is therefore considered a specific potential pandemic
threat.
An animal or human-animal influenza reassortant virus has caused sporadic cases or
small clusters of disease in people, but has not resulted in human-to-human transmission
sufficient to sustain community-level outbreaks.
Human-to-human transmission (H2H) of an animal or human-animal influenza reassortant
virus able to sustain community-level outbreaks has been verified.
The same identified virus has caused sustained community level outbreaks in two or more
countries in one WHO region.
In addition to the criteria defined in Phase 5, the same virus has caused sustained
community level outbreaks in at least one other country in another WHO region.
Levels of pandemic influenza in most countries with adequate surveillance have dropped
below peak levels.
Level of pandemic influenza activity in most countries with adequate surveillance rising
again.
Levels of influenza activity have returned to the levels seen for seasonal influenza in most
countries with adequate surveillance.
PHASE 1
PHASE 2
PHASE 3
PHASE 4
PHASE 5
PHASE 6
POST-PEAK PERIOD
POSSIBLE NEW WAVE
POST-PANDEMIC
PERIOD
DESCRIPTION
11
12
There is greater understanding that pandemic preparedness requires the
involvement of not only the health sector, but also the whole of society.
1. INTRODUCTION
WHO previously published pandemic preparedness guidance in 1999 and a revision of that guidance
in 2005. Since 2005, there have been advances in many areas of preparedness and response
planning. For example, stockpiles of antiviral drugs are now a reality and a WHO guideline3 has been
developed to attempt to stop or delay pandemic influenza at its initial emergence. There is increased
understanding of past pandemics, strengthened outbreak communications, greater insight on disease
spread and approaches to control, and increasingly sophisticated statistical modeling of various
aspects of influenza. Extensive practical experience has been gained from responding to outbreaks
of highly pathogenic avian influenza A (H5N1) virus infection in poultry and humans, and from
conducting pandemic preparedness and response exercises in many countries. There is greater
understanding that pandemic preparedness requires the involvement of not only the health sector,
but the whole of society. In 2007, the International Health Regulations (2005) or IHR (2005) entered
into force providing the international community with a framework to address international public
health concerns.
In light of these developments, WHO decided to update its guidance to enable countries to be better
prepared for the next pandemic. This guidance serves as the core strategic document in a suite of
materials. It is supported by a complement of pandemic preparedness materials and tools
(Figure 1). These documents and tools provide detailed information on a broad range of specific
recommendations and activities, as well as clear guidance on their implementation. The individual
elements of the guidance package will be made available as they are finalized.
3. WHO Interim Protocol: Rapid operations to contain the initial emergence of pandemic influenza. World Health Organization,
(http://www.who.int/csr/disease/avian_influenza/guidelines/draftprotocol/en/index.html, accessed 10 February, 2009).
4. Avian influenza: assessing the pandemic threat. Geneva, World Health Organization, 2005 (WHO/CDS/2005.29).
5. Adapted from European Centre for Disease Prevention and Control, Pandemics of the 20th Century (http://ecdc.europa.eu/Health_topics/Pandemic_Influenza/stats.aspx,
accessed 6 October 2008).
6. McKibbin WJ, Sidorenko AA. Global Macroeconomic Consequences of pandemic influenza. Lowy Institute for International Policy. Analysis paper. Feb 2006.
(http://www.acerh.edu.au/publications/McKibbin_PandemicFlu%20Report_2006.pdf accessed January 7, 2009).
7. McKibbin WJ, Sidorenko AA. The global cost of an influenza pandemic. The Milken Institute Review. Third Quarter 2007.
(http://www.acerh.edu.au/publications/McKibbin_MilkenInstRev_2007.pdf accessed January 7, 2009).
2. BACKGROUND
Influenza pandemics are unpredictable but recurring events that can have severe consequences on
societies worldwide. Since the 16th century, influenza pandemics have been described at intervals
ranging between 10 and 50 years4 with varying severity and impact (Table 2).
13
Developing and sustaining a country’s preparedness is challenging,
and carries a risk of complacency.
CHARACTERISTICS OF THE THREE PANDEMICS OF THE 20th CENTURY5
TABLE 2
PANDEMIC
(DATE AND
COMMON NAME)
AREA OF
EMERGENCE
INFLUENZA
A VIRUS
SUBTYPE
ESTIMATED
REPRODUCTIVE
NUMBER
ESTIMATED
CASE FATALITY
RATE
ESTIMATED
ATTRIBUTABLE
EXCESS
MORTALITY
WORLDWIDE
AGE GROUPS
MOST
AFFECTED
(SIMULATED
ATTACK RATES)
GDP LOSS
(PERCENTAGE
CHANGE)6,7
1918-1919 Unclear
“Spanish Flu”
H1N1 1.5-1.8 2-3% 20-50
million
Young
adults
-16.9 to 2.4
Southern
China
1957-1958
“Asian Flu”
H2N2 1.5 <0.2% 1-4
million
Children -3.5 to 0.4
Southern
China
1968-1969
“Hong Kong Flu”
H3N2 1.3-1.6 <0.2% 1-4
million
All age
groups
-0.4 to (-1.5)
The precise timing and impact of a future influenza pandemic remains unknown. Developing and
sustaining a country’s preparedness is challenging, and carries a risk of complacency.
Pandemic preparedness in most, if not all countries, remains incomplete - even though an influenza
pandemic could occur at any time resulting in:
• rapid spread of pandemic disease leaving little time to implement ad hoc mitigation
measures;
• medical facilities struggling to cope with a possible large surge in demand;
• potentially serious shortages of personnel and products resulting in disruption
of key infrastructure and services, and continuity of all sectors of business and government;
• delayed and limited availability of pandemic influenza vaccines, antivirals and antibiotics,
as well as common medical supplies for treatment of other illnesses;
• negative impact on social and economic activities of communities which could last long
after the end of the pandemic period;
• intense scrutiny from the public, government agencies, and the media on the state of
national preparedness; and
• a global emergency limiting the potential for international assistance.
14
2.1.1 The highly pathogenic avian influenza A (H5N1) virus and an influenza
pandemic
In 1997, an avian influenza A virus of subtype H5N1 first demonstrated its capacity to infect humans
after causing disease outbreaks in poultry in Hong Kong SAR, China. Since its widespread reemergence in 2003-2004, this avian virus has resulted in millions of poultry infections and over
four hundred human cases. An unusually high percentage of human H5N1 infections result in severe
illness and death compared to other influenza viruses and far exceed the proportion of deaths caused
by the 1918 pandemic virus. On rare occasions, H5N1 has spread from an infected person to another
person - most often a family or other household member acting as a caregiver. However, none of
these events has so far resulted in sustained community-level outbreaks.
The primary risk factor for a human to acquire a zoonotic H5N1 infection is direct contact or close
exposure to infected poultry, although the virus remains difficult to transmit to humans. Five years
after the widespread emergence and spread of H5N1, the virus is now entrenched in domestic birds
in several countries. Controlling H5N1 among poultry is essential in reducing the risk of human
infection and in preventing or reducing the severe economic burden of such outbreaks. Given the
persistence of the H5N1 virus, successfully meeting this challenge will require long-term commitment
from countries and strong coordination between animal and human health authorities.
While the H5N1 virus is currently the most visible influenza virus with pandemic potential, it is not
the only candidate. Wild birds form a reservoir for a large number of other influenza viruses and
influenza viruses are found in other animal species as well. Any one of these other viruses, which
normally do not infect people, could transform into a pandemic virus. In addition to H5N1, other
examples of animal influenza viruses previously known to infect people include avian H7 and H9
subtypes and swine influenza viruses. The H2 subtype, which was responsible for the 1957 pandemic
(but has not circulated for decades), could also have the potential to cause a pandemic should it
return. The uncertainty of the next pandemic virus means that planning for pandemic influenza
should not exclusively focus on H5N1, but should be based on active and robust surveillance and
science-based risk assessment.
2.1 How influenza viruses with pandemic potential develop
Many animal influenza viruses naturally infect and circulate among a variety of avian and mammalian
species. Most of these animal influenza viruses do not normally infect humans. However, on occasion,
certain animal viruses do infect humans. Such infections have most often occurred as sporadic or
isolated infections or sometimes resulted in small clusters of human infections.
An influenza pandemic occurs when an animal influenza virus to which most humans have no
immunity acquires the ability to cause sustained chains of human-to-human transmission leading
to community-wide outbreaks. Such a virus has the potential to spread worldwide, causing a pandemic.
The development of an influenza pandemic can be considered the result of the transformation of
an animal influenza virus into a human influenza virus. At the genetic level, pandemic influenza
viruses may arise through:
• genetic reassortment: a process in which genes from animal and human influenza viruses
mix together to create a human-animal influenza reassortant virus;
• genetic mutation: a process in which genes in an animal influenza virus change allowing
the virus to infect humans and transmit easily among them.
8. 25 Questions and Answers on Health and Human Rights. Health and Human Rights Publication Series Issue No.1, July 2002. World Health Organization. ISBN 92 4
154569 0, p 18.
9. Ethical considerations in developing a public health response to pandemic influenza (WHO/CDS/EPR/GIP/2007.2), World Health Organization, 2007.
2.2 Ensuring ethical pandemic preparedness and response
An influenza pandemic, like any urgent public health situation, calls for making certain decisions
that will require balancing potentially conflicting individual interests with community interests.
Policymakers can draw on ethical principles as tools to assess and balance these competing interests
and values. An ethical approach does not provide a prescribed set of policies. Instead, it applies
principles such as equity, utility/efficiency, liberty, reciprocity, and solidarity in light of local context
and cultural values. While application of these principles sometimes results in competing claims,
policymakers can use these principles as a framework to assess and balance a range of interests and
to ensure that overarching concerns (such as protecting human rights and the special needs of
vulnerable and minority groups) are addressed in pandemic influenza planning and response. Any
measures that limit individual rights and civil liberties must be necessary, reasonable, proportional,
equitable, non-discriminatory, and not in violation of national and international laws.8
WHO has developed9 detailed ethical considerations on priority setting, disease control measures,
the role and obligations of health-care workers, and a multilateral response to pandemic influenza.
2.3 Integrating pandemic preparedness and response into
general emergency preparedness
Pandemic preparedness activities take place within the context of national and international priorities,
competing activities, and limited resources. Given the fundamental uncertainties surrounding the
timing of the next influenza pandemic, steps to ensure the long-term sustainability of pandemic
preparedness are crucial and should involve:
• integration of pandemic influenza preparedness into national emergency preparedness plans,
frameworks, and activities;
• use of pandemic preparedness activities to strengthen basic and emergency health-related
capacities (such as the primary health-care system, respiratory disease surveillance, and
laboratory diagnostic capacities);
• use of preparedness activities to actively build communication channels between sectors
and communities;
• development or modification of business continuity plans specifically tailored to pandemic
influenza; and
• periodic reassessment and updating of current plans based on new developments and
information gained from exercises.
Through the use of these and other approaches, governments, public health agencies, and others
have an opportunity to strengthen preparedness for the next influenza pandemic while building the
capacity to address a range of local, national, and international emergencies.
15
PLANNING AND COORDINATION
• Develop guidance
and implement
actions needed to
minimize the
adverse effects of
a pandemic on
non-health sectors.
•
•
•
Provide leadership
and guidance
Take actions to
reduce
health consequences
Raise awareness
about risk and
potential health
consequences
HEALTH SECTOR
OTHER SECTORS
• Take actions needed
to minimize the
adverse effects of a
pandemic on families
and individuals
INDIVIDUALS /
FAMILIES /
COMMUNITIES
COMMUNICATION
WHOLE OF SOCIETY APPROACH TO PANDEMIC PREPAREDNESS
FIGURE 2
3. ROLES AND RESPONSIBILITIES IN PREPAREDNESS
AND RESPONSE
A whole-of-society approach to pandemic influenza preparedness emphasizes the significant roles
played not only by the health sector, but also by all other sectors, individuals, families, and
communities, in mitigating the effects of a pandemic. Developing capacities for mitigating the effects
of a pandemic, including robust contingency and business continuity plans is at the heart of preparing
the whole of society for a pandemic. Activities such as capacity development, planning, coordination,
and communication are cross-cutting and require action by all parties (Figure 2).
3.1 National preparedness and response as a whole-of-society responsibility
While all sectors of society are involved in pandemic preparedness
and response, the national government is the natural leader for overall
coordination and communication efforts.
16
While all sectors of society are involved in pandemic preparedness and response, the national
government is the natural leader for overall coordination and communication efforts. In its leadership
role, the central government should:
3.1.1 Government leadership
The health sector (including public health and both public and private health-care services), has a
natural leadership and advocacy role in pandemic influenza preparedness and response efforts. In
cooperation with other sectors and in support of national intersectoral leadership, the health sector
must provide leadership and guidance on the actions needed, in addition to raising awareness of the
risk and potential health consequences of an influenza pandemic. To fulfil this role, the health sector
should be ready to:
• provide reliable information on the risk, severity, and progression of a pandemic and the
effectiveness of interventions used during a pandemic;
• prioritize and continue the provision of health-care during an influenza pandemic;
• enact steps to reduce the spread of influenza in the community and in health-care facilities;
and
• protect and support health-care workers during a pandemic.
3.1.2 Health sector
In the absence of early and effective preparedness, societies may experience social and economic
disruption, threats to the continuity of essential services, reduced production, distribution difficulties,
and shortages of essential commodities. Disruption of organizations may also have an impact on other
businesses and services. For example, if electrical or water services are disrupted or fail, the health
sector will be unable to maintain normal care. The failure of businesses would add significantly to
the eventual economic consequences of a pandemic. Some business sectors will be especially
vulnerable and certain groups in society are likely to suffer more than others. Developing robust
preparedness and business continuity plans may enable essential operations to continue during a
pandemic and significantly mitigate economic and social impacts. In order to minimize the adverse
effects of a pandemic, all sectors should:
• establish continuity policies to be implemented during a pandemic;
• plan for the likely impact on businesses, essential services, educational institutions, and
other organizations;
• establish pandemic preparedness plans;
3.1.3 Non-health sectors
17
• identify, appoint, and lead the coordinating body for pandemic preparedness and response;
enact or modify legislation and policies required to sustain and optimize pandemic
preparedness, capacity development, and response efforts across all sectors;
• prioritize and guide the allocation and targeting of resources to achieve the goals as
outlined in a country’s Pandemic Influenza Preparedness Plan;
• provide additional resources for national pandemic preparedness, capacity development,
and response measures; and
• consider providing resources and technical assistance to countries experiencing outbreaks
of influenza with pandemic potential.
10. Whole of Society Pandemic Readiness, World Health Organization 2009 (http://www.who.int/csr/disease/influenza/CP045_2009-0808_WOS_Pandemic_Readiness-FINAL.pdf).
3.2 WHO
WHO has been mandated by a series of World Health Assembly resolutions to provide Member States
with guidance and technical support regarding influenza. These are listed below:
• WHA 56.19: Prevention and control of influenza pandemics and annual epidemics;
• WHA 58.5: Strengthening pandemic influenza preparedness and response;
• WHA 60.28: Pandemic influenza preparedness: sharing of influenza viruses and access to vaccines
and other benefits.
During a pandemic, it is important that households take measures to ensure they have access to accurate
information, food, water, and medicines. For families, access to reliable information from sources such
as WHO and local and national governments will be essential. Individuals, especially those who have
recovered from pandemic influenza, may consider volunteering with an organized group to assist others
in the community.
Because influenza is transmitted from one person to another, the adoption of individual and household
measures such as covering coughs and sneezes, hand washing, and the voluntary isolation of persons
with respiratory illness may prevent additional infections.
Individuals and families
Civil society organizations, families, individuals, and traditional leaders all have essential roles to
play in mitigating the effects of an influenza pandemic. Non-governmental groups should be involved
in preparedness efforts and their expertise and capabilities harnessed to help communities prepare
for and respond to a pandemic. The supporting document ‘ Whole-of-society pandemic readiness’
explores the roles of each of these groups in greater detail.10
3.1.4 Communities, individuals, and families
Groups that have a close and direct relationship with communities are often well placed to raise
awareness, communicate accurate information, counter rumours, provide needed services, and liaise
with the government during an emergency. Such groups should identify their strengths and potential
roles and, in partnership with local governments and other local organizations, plan for the actions
they will take during a pandemic. These groups may be able to augment the efforts of organizations
in other sectors, such as hospitals or clinics. For example, if large numbers of ill people are being
cared for at home, community and faith-based organizations could provide support to households.
Civil society organizations
18
• develop capacity and plan for pandemic response;
• plan the allocation of resources to protect employees and customers;
• communicate with and educate employees on how to protect themselves and on measures
that will be implemented; and
• contribute to cross-cutting planning and response efforts to support the continued
functioning of the society.
19
11. World Health Organization. International Health Regulations (2005). ISBN 978 92 4 158041 0.
12. Resolution WHA 58.3 Revision of the International Health Regulations. In: Fifty-eighth World Health Assembly, Geneva 16-25 May, 2005 (WHA58/2005/REC/3).
13. World Health Organization. International Health Regulations (2005). ISBN 978 92 4 158041 0.
14. Plotkin, Hardiman, Gonzalez-Martin and Rodier, "Infectious disease surveillance and the International Health Regulations, Chapter 2. In: Infectious Disease Surveillance.
Blackwell Publishing 2007.
3.2.1 Coordination under International Health Regulations (IHR 2005)
The International Health Regulations (2005) also referred to as IHR (2005),11 are an international
legal instrument adopted by the World Health Assembly in 2005.12 They are legally binding upon
194 States Parties around the world and provide a global legal framework to prevent, control, or
respond to public health risks that may spread between countries.
Under the IHR (2005), a number of reporting requirements obligate States Parties to promptly inform
WHO of cases or events involving a range of diseases and public health risks. These include the
obligation to notify WHO of all cases of “human influenza caused by a new subtype” in their territories
within 24 hours of assessment in accordance with the case definition established by WHO for this
specific purpose.
These requirements, with related guidance on their application, are provided in Annex 2 of the IHR
(2005). Notification must be followed by ongoing communication of detailed public health information
on the event, including, where possible, case definitions, laboratory results, source and type of risk,
number of cases and deaths, conditions affecting the spread of the disease, and the public health
interventions employed. Even if there are no notifiable cases or events involving an influenza virus
of pandemic potential occurring within a State, States Parties have additional obligations to report
to WHO evidence of serious public health risks in other States, to the extent that they have evidence
of related imported or exported human cases. Finally, WHO has the mandate under the IHR (2005)
to collect reports (including from unofficial sources) of potentially serious international public health
risks and, after preliminarily assessment, to obtain verification of such reports from States.
If verification is sought, including in the context of potential pandemic influenza, States are required
to respond to WHO within a prescribed time period and include available relevant public health
information.13,14
• All cases of human influenza of a new subtype, as further defined by WHO,
are notifiable to WHO under the IHR (2005).
• In addition, all public health events, including those which may involve an influenza
virus of pandemic potential (even if not yet confirmed) are notifiable under the IHR
(2005) if they fulfil at least two of the contextual risk assessment criteria in the
Regulations:
• if the public health impact is serious;
• if the event is unusual or unexpected;
• if there is a significant risk of international spread; or
• if there is a significant risk of international travel or trade restrictions.
WHO will work with Member States across a range of activities, including coordination under the IHR
(2005), designation of global pandemic phases, switching to pandemic vaccine production, coordination
of a rapid containment operation, and providing early assessments of pandemic severity.
15. World Health Organization. International Health Regulations (2005). ISBN 978 92 4 158041 0. Articles 5.1, 13.1 and Annex 1.
16. World Health Organization. International Health Regulations (2005). ISBN 978 92 4 158041 0. Articles 23.32, 37-8 and Annexes 8-9.
17. World Health Organization. International Health Regulations (2005). ISBN 978 92 4 158041 0. Articles 12, 15, 17-18, 48-49.
18. WHO Collaborating Centres and Reference Laboratories involved in annual influenza vaccine composition recommendations
(http://www.who.int/csr/disease/influenza/collabcentres/en/index.html accessed 10 February 2009).
19. Recommendations for influenza vaccines (http://www.who.int/csr/disease/influenza/vaccinerecommendations, accessed 3 December 2008).
3.2.2 The designation of the global pandemic phase
The designation of the global pandemic phase will be made by the Director-General of WHO. The
designation of a phase will be made consistent with applicable provisions of the IHR (2005) and
in consultation with other organizations, institutions, and affected Member States.
3.2.3. Switching to pandemic vaccine production
One of WHO's critical actions during an emerging pandemic will be selection of the pandemic vaccine
strain and determining the time to begin production of a pandemic vaccine instead of a seasonal
influenza vaccine.
WHO issues bi-annual recommendations on the composition of seasonal influenza vaccines and, in
addition, has been reviewing vaccine candidate viruses for A (H5N1) and other influenza subtypes
with pandemic potential since 2004. This process is undertaken in consultation with WHO Collaborating
Centres (CCs)18 for influenza, National Influenza Centres, WHO H5 Reference Laboratories, and key
national regulatory reference laboratories based on surveillance conducted by the WHO Global Influenza
Surveillance Network (GISN). The recommendations and availability of vaccine viruses are announced
in a public meeting and simultaneously on the WHO website,19 and are also communicated to
influenza vaccine manufacturers via the International Federation of Pharmaceutical Manufacturers
and Associations and the Developing Country Vaccine Manufacturers Network.
The IHR (2005) also obligates States Parties to develop national public health capacities to detect,
assess and respond to events, and to report to WHO as necessary, as well as capacities to address
risks of international spread of disease at designated ports and airports (and potentially, at designated
ground crossings).15 If a potential pandemic or related public health risk should arise, the IHR also
provides extensive options for national authorities to obtain information from incoming aircraft, ships,
and other vehicles and travellers, and includes the potential use of medical or public health
interventions subject to various safeguards and other requirements. Regarding international travellers,
for example, there are human rights and other protections, such as prior informed consent for
examinations, prophylaxis or other measures (subject to exceptions in exigent circumstances). There
are also obligations to provide adequate food, water, medical care, and other essentials to international
travellers who are isolated or quarantined.16
The IHR (2005) also provides a mandate to WHO to perform public health surveillance, support
States, and coordinate international response to international public health risks. In extraordinary
circumstances, including an influenza pandemic, the Regulations provide that the WHO DirectorGeneral can determine that a “public health emergency of international concern” is occurring. In
such a case, the Director-General will, after taking advice from a committee of outside experts,
determine and issue specific IHR “Temporary Recommendations” to governments on the appropriate
actions to prevent or reduce the international spread and minimize unnecessary interference with
international traffic and trade. Both the determination that a Public Health Emergency of International
Concern (PHEIC) is occurring (which may also require outside expert advice) and the issuance of
Temporary Recommendations are based upon specific procedures and criteria in the IHR (2005).17
20
3.2.4 Rapid containment of the initial emergence of pandemic influenza
The intention of a pandemic influenza rapid containment operation is for national authorities, with
the assistance of WHO and international partners to prevent or delay the widespread transmission
of an influenza virus with pandemic potential as soon as possible following its initial detection. Rapid
pandemic containment is an extraordinary public health action, which builds upon, but goes beyond,
routine outbreak response and disease control measures.
The WHO pandemic rapid containment guidance,20 which is periodically reviewed and updated,
outlines what should be done, provides information on how to do it, and serves as the foundation
for the development of more detailed operational plans. Rapid containment poses a number of
planning, resource, and organizational challenges. The exercising of operational components of
pandemic preparedness and response plans, including elements related to pandemic rapid containment
operations is strongly encouraged.
If a rapid containment operation is being considered, national authorities and WHO will need to
jointly and rapidly assess all the relevant technical, operational, and political factors to determine
if:
• compelling evidence is present to suggest that an influenza virus with pandemic potential
has gained the ability to transmit efficiently from human-to-human at a level that can sustain
community-level outbreaks; and
• there are compelling reasons why a containment operation should not be attempted.
A recommendation whether to proceed will depend on expert assessment of the situation and related
scientific and operational feasibility factors. A rapid containment operation would likely not be
attempted if evidence suggests that the virus with pandemic potential has already spread too widely
to make containment feasible or if it was considered not operationally possible to rapidly implement
the necessary measures. Should a decision be made to proceed, WHO will provide ongoing advice
and support to the affected country on management and technical aspects of the containment
operation. WHO will also support the coordination and implementation of international responses,
20. WHO Interim planning guidance for rapid containment of the initial emergence of pandemic influenza.
(http://www.who.int/csr/disease/avian_influenza/guidelines/draftprotocol/en/index.html accessed 10 February 2009).
21
As soon as there is credible evidence to suggest that an influenza virus with pandemic potential has
acquired the ability to sustain human-to-human transmission, WHO will expedite the process of
review, selection, development, and distribution of vaccine viruses for pandemic vaccine production,
as well as vaccine potency testing reagents and preparations involving all stakeholders as necessary.
The efficiency of this process depends on the timely sharing of viruses/clinical specimens with WHO
via GISN/WHO CCs.
If the situation involves parallel determination of a PHEIC by the Director-General, then the decision
to recommend a vaccine switch in production will be taken with due consideration to applicable
requirements under the IHR (2005), including potentially, advice from an IHR Emergency Committee
as appropriate. WHO will then announce its recommendations on whether and when to switch
production to pandemic vaccine and the virus strain that should be used in the pandemic vaccine.
Given the possible rapid spread of the pandemic virus and the potential consequences of a pandemic,
as well as the time needed for vaccine production, the process to decide whether to switch to pandemic
vaccine will be started independently from the formal declaration of a pandemic phase change.
3.2.5 Providing an early assessment of pandemic severity on health
As soon as possible, WHO will provide an assessment of pandemic severity to help governments
determine the level of interventions required as part of their response. As outlined in section 2, past
influenza pandemics have been associated with varying levels of illness and death.
Although making an informed assessment of severity early in the course of a pandemic will be
challenging, such an assessment will assist countries in:
• deciding whether or not to implement mitigation measures that may be potentially
disruptive;
• prioritizing the use of antivirals, vaccines, and other medical interventions;
• managing continuity of health care; and
• communicating with the media and the public and answering queries.
Pandemic severity may be assessed in many ways. One fundamental distinction is an assessment
based on direct health effects as opposed to one based upon societal and economic effects. While
societal and economic effects may be highly variable from country to country and dependent upon
multiple factors (including the effects of the media and the underlying state of preparedness), WHO
plans to assess pandemic severity based primarily on observable effects on health.21
Available quantitative and qualitative data on health impacts will be used to estimate severity using
the three-point scale of Mild-Intermediate-Severe. As more information becomes available, WHO will
update the severity assessment. Since national circumstances will vary in terms of disease activity
and capacity to respond, caution should be exercised in directly linking severity assessment at a
global level to actions at the national level.
It is likely that information will be limited early in the pandemic while the demand for information
simultaneously escalates. If pandemic surveillance is to provide sufficient information and data to
assess severity, countries need to review their existing surveillance capacity to address the weaknesses
to be prepared for pandemic surveillance. Essential components of an effective pandemic influenza
surveillance system will include:
22
21. Human infection with pandemic (H1N1) 2009 virus: updated interim WHO guidance on global surveillance, World Health Organization 2009
(http://www.who.int/csr/disease/swineflu/guidance/surveillance/WHO_case_definition_swine_flu_2009_04_29.pdf).
such as the deployment of international field teams, if requested; mobilizing and dispatching necessary
resources (e.g. antivirals and other materials); and developing or refining guidance in consultation
with the affected country and external experts. Ultimately the decision to launch a rapid containment
operation rests with the national authority. The announcement of Phase 4 is not required for rapid
pandemic containment efforts as the decision to mount an operation could be made before or after
a phase change.
Launching a containment operation will require time to mobilize and deploy equipment, people, and
supplies. Before a formal decision has been made to initiate rapid containment, the affected country
and WHO may need to initiate response activities if available information is highly suggestive, but
not yet definitive, that an influenza virus capable of causing a pandemic has emerged.
National authorities and WHO will need to be in continuous communication and maintain a flexible
and agile approach to the developing situation.
23
Potential health indicators of severity
• case fatality rate
• unusually severe morbidity
• unexpected mortality patterns
• unusual complications.
22. WHO Global Surveillance for Pandemic Influenza, World Health Organization 2009 (to be published 2009 http://www.who.int/csr/disease/influenza/ ).
• early detection and investigation;
• comprehensive assessment; and
• monitoring.22
4. THE WHO PANDEMIC PHASES
The WHO pandemic phases were developed in 1999 and revised in 2005. The phases are applicable
to the entire world and provide a global framework to aid countries in pandemic preparedness and
response planning. In this revision, WHO has retained the use of a six-phased approach for easy
incorporation of new recommendations and approaches into existing national preparedness and
response plans. The grouping and description of pandemic phases have been revised to make them
easier to understand, more precise, and based upon observable phenomena. Phases 1-3 correlate
with preparedness, including capacity development and response planning activities, while Phases
4-6 clearly signal the need for response and mitigation efforts. Furthermore, periods after the first
pandemic wave are elaborated to facilitate post pandemic recovery activities.(see Figure 3)
The grouping and description of pandemic phases have been revised
to make them easier to understand, more precise, and based upon
observable phenomena.
24
TIME
PREDOMINANTLY
ANIMAL
INFECTIONS;
FEW HUMAN
INFECTIONS
PHASES 1-3
SUSTAINED
HUMAN-TO-HUMAN
TRANSMISSION
PHASE 4
WIDESPREAD
HUMAN
INFECTION
PHASES 5-6 /
PANDEMIC
POSSIBILITY
OF RECURRENT
EVENTS
POST PEAK
DISEASE
ACTIVITY AT
SEASONAL
LEVELS
POST
PANDEMIC
PANDEMIC INFLUENZA PHASES (2009)
FIGURE 3
The 2009 pandemic phases:
• are a planning tool;
• are simpler, more precise, and based on verifiable phenomena;
• will be declared in accordance with the IHR (2005);
• only loosely correspond to pandemic risk;
• identify sustained human-to-human transmission as a key event;
• better distinguish between time for preparedness and response; and
• include the post-peak and post-pandemic periods for recovery activities.
The new phases are NOT:
• designed to predict what will happen during a pandemic; and
• always going to proceed in numerical order.
25
In nature, influenza viruses circulate continuously among animals, especially birds. Even though
such viruses might theoretically develop into pandemic viruses, in Phase 1 no viruses circulating
among animals have been reported to cause infections in humans.
In Phase 2, an animal influenza virus circulating among domesticated or wild animals is known to
have caused infection in humans, and is therefore considered a potential pandemic threat.
In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or
small clusters of disease in people, but has not resulted in human-to-human transmission sufficient
to sustain community-level outbreaks. Limited human-to-human transmission may occur under some
circumstances, for example, when there is close contact between an infected person and an unprotected
caregiver. However, limited transmission under such restricted circumstances does not indicate that
the virus has gained the level of transmissibility among humans necessary to cause a pandemic.
Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal
influenza reassortant virus able to cause “community-level outbreaks”. The ability to cause sustained
disease outbreaks in a community marks a significant upwards shift in the risk of a pandemic. Any
country that suspects or has verified such an event should urgently consult with WHO so that the
situation can be jointly assessed and a decision made by the affected country if implementation of a
rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk
of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion.
Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO
region (Figure 4)23. While most countries will not be affected at this stage, the declaration of Phase 5
is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication,
and implementation of the planned mitigation measures is short.
4.1 Definition of the phases
WHO REGIONS
FIGURE 4
© WHO 2008. All rights reserved
The boundaries and names shown and the designations used on this map do not imply the expression of
any opinion whatsoever on the part of the World Health Organization concerning the legal status of any
country, territory, city or area of its authorities, or concerning the delimination of its frontiers or boundaries.
Dotted lines on maps represent approximate lines for which there may not yet be full agreement.
Data Source: World Health Organization
Map Production: Public Health Information
and Geographic Information Systems (GIS)
World Health Organization.
WHO REGION FOR THE AMERICAS
WHO AFRICA REGION
WHO EASTERN MEDITERRANEAN REGION
WHO SOUTH-EAST ASIA REGION
WHO EUROPEAN REGION
WHO WESTERN PACIFIC REGION 0 1.500 3.000 6.000 Kilometres
23. WHO - its people and offices (http://www.who.int/about/structure/en/index.html, accessed 10 February 2009).
26
Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other
country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this
phase will indicate that a global pandemic is under way.
During the post-peak period, pandemic disease levels in most countries with adequate surveillance
will have dropped below peak observed levels. The post-peak period signifies that pandemic activity
appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need
to be prepared for a second wave.
Previous pandemics have been characterized by waves of activity spread over months. Once the level
of disease activity drops, a critical communications task will be to balance this information with the
possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease”
signal may be premature.
In the post-pandemic period, influenza disease activity will have returned to levels normally seen for
seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus.
At this stage, it is important to maintain surveillance and update pandemic preparedness and response
plans accordingly. An intensive phase of recovery and evaluation may be required.
This phased approach is intended to help countries and other stakeholders to anticipate when certain
situations will require decisions and decide at which point main actions should be implemented (see
Table 3). As in the 2005 guidance, each of the phases applies worldwide once announced. However,
individual countries will be affected at different times. In addition to the globally announced pandemic
phase, countries may want to make further national distinctions based upon their specific situations.
For example, countries may wish to consider whether the potential pandemic virus is causing disease
within their own borders, in neighbouring countries, or countries in close proximity.
It is important to stress that the phases were not developed as an epidemiological prediction, but
to provide guidance to countries on the implementation of activities. While later phases may loosely
correlate with increasing levels of pandemic risk, this risk in the first three phases is simply unknown.
It is therefore possible to have situations which pose an increased pandemic risk, but do not result
in a pandemic.
Alternatively, although global influenza surveillance and monitoring systems are much improved, it
is also possible that the first outbreaks of a pandemic will not be detected or recognized. For example,
if symptoms are mild and not very specific, an influenza virus with pandemic potential may attain
relatively widespread circulation before being detected; thus, the global phase may jump from Phase
3 to Phases 5 or 6. If the rapid containment operations are successful, Phase 4 may revert back to
Phase 3.
When making a change to the global phase, WHO will carefully consider whether the criteria for a
new phase have been met. This decision will be based upon all credible information from global
surveillance and from other organizations.24
4.2 Phase changes
24. Such as UN Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE).
27
WHO PANDEMIC PHASE DESCRIPTIONS AND MAIN ACTIONS BY PHASE
TABLE 3
ESTIMATED
PROBABILITY
OF PANDEMIC
Uncertain
PHASE 1
DESCRIPTION
MAIN ACTIONS
IN AFFECTED
COUNTRIES
MAIN ACTIONS
IN NOT-YET-AFFECTED
COUNTRIES
No animal influenza virus
circulating among animals has
been reported to cause infection
in humans.
Producing, implementing, exercising,
and harmonizing national pandemic
influenza preparedness and response
plans with national emergency
preparedness and response plans.
An animal influenza virus
circulating in domesticated or wild
animals is known to have caused
infection in humans and is
therefore considered a specific
potential pandemic threat.
An animal or human-animal
influenza reassortant virus has
caused sporadic cases or small
clusters of disease in people, but
has not resulted in human-to-human
transmission sufficient to sustain
community-level outbreaks.
Human-to-human transmission of
an animal or human-animal
influenza reassortant virus able to
sustain community-level outbreaks
has been verified.
The same identified virus has caused
sustained community-level
outbreaks in at least two countries
in one WHO region.
In addition to the criteria defined in
Phase 5, the same virus has caused
sustained community-level outbreaks
in at least one other country in
another WHO region.
Levels of pandemic influenza in
most countries with adequate
surveillance have dropped below
peak levels.
Level of pandemic influenza activity
in most countries with adequate
surveillance is rising again.
Levels of influenza have returned
to the levels seen for seasonal
influenza in most countries with
adequate surveillance.
PHASE 2
PHASE 3
PHASE 4
PHASE 5
PHASE 6
POST-PEAK
PERIOD
POSSIBLE
NEW WAVE
POST-PANDEMIC
PERIOD
Medium
to high
High to
certain
Pandemic in
progress
Rapid
containment.
Readiness for
pandemic
response.
Pandemic
response: each
country to
implement actions
as called for in their
national plans.
Readiness for
imminent
response.
Evaluation of
response; recovery;
preparation for
possible second wave.
Response
Evaluation of
response;
revision of plans;
recovery.
-
28
5. RECOMMENDED ACTIONS BEFORE, DURING AND
AFTER A PANDEMIC
This section provides specific actions to be taken by national authorities and WHO. The new WHO
pandemic phases and a summary of recommended actions for each phase are presented in Table
4. Recommendations are grouped by pandemic phases and the five components of preparedness
and response which are the following:
1. planning and coordination
2. situation monitoring and assessment
3. reducing the spread of disease
4. continuity of health care provision
5. communications.
The goal of planning and coordination efforts is to provide leadership and coordination across sectors.
One important aspect is to integrate pandemic preparedness into national emergency preparedness
frameworks.
The goal of situation monitoring and assessment is to collect, interpret, and disseminate information
on the risk of a pandemic before it occurs and, once under way, to monitor pandemic activity and
characteristics. To assess if the risk of a pandemic is increasing, it will be important to monitor the
infectious agent, its capacity to cause disease in humans, and the patterns of disease spread in
communities. It is important to collect data on influenza viruses, the genetic changes taking place
and consequent changes in biological characteristics, and to rapidly investigate and evaluate outbreaks.
Once a pandemic influenza virus begins to circulate, it will be vital to assess the effectiveness of
the response measures.
Reducing the spread of disease will depend significantly upon increasing the “social distance”
between people. Measures such as individual/household level measures, societal-level measures and
international travel measures, and the use of antivirals, other pharmaceuticals, and vaccines will be
important.
Individual/household level measures include risk communication, individual hygiene and personal
protection, and home care of the ill and quarantine of contacts. Societal-level measures are applied
to societies or communities rather than individuals or families. These measures require a behavioural
change in the population, multiple sector involvement, mobilization of resources, strong communication,
and media support.
International travel measures aim to delay the entry of pandemic disease into not-yet-affected
countries and will have an impact on international traffic and trade. Countries should balance reducing
the risks to public health and avoiding unnecessary interference with international traffic and trade.
The use of pharmaceutical interventions to prevent or treat influenza encompasses a range of
approaches. Additionally, the successful prevention and treatment of secondary or pre-existing
conditions will be a key factor in many settings for reducing the overall burden of illness and death.
During a pandemic, health systems will need to provide health-care services while attending to the
influx of patients with influenza illness. Planning for surge capacity in health-care facilities will help
The goal of planning and coordination efforts is to provide leadership
and coordination across sectors.
29
25. World Health Organization Outbreak Communication Planning Guide. World Health Organization 2008. ISBN 978 92 4 159744 9.
determine the extent to which the existing health system can expand to manage the additional patient
load. Health-care facilities will need to maintain adequate triage and infection control measures to
protect health-care workers, patients, and visitors.
The goal of communications before and during a pandemic is to provide and exchange relevant
information with the public, partners, and stakeholders to allow them to make well informed decisions
and take appropriate actions to protect health and safety and response and is a fundamental part
of effective risk management. Communications should be based on the five principles outlined in
WHO's outbreak communications planning guide:25 planning; trust; transparency; announcing early;
and listening. Given the complex risks and perceptions associated with an influenza pandemic,
communication strategies that simply disseminate outbreak information and recommendations will
be insufficient. The scope and complexity of the task demands frequent, transparent, and proactive
communication and information exchange with the public, partners, and other stakeholders about
decision making, health recommendations, and related information. In addition to the suggested
actions which follow below, countries are encouraged to develop core risk communication capacities
such as those described in the WHO outbreak communication planning guide. By developing a solid
foundation for pandemic influenza communications, Member States would also strengthen communication
response systems for any public health emergency that may arise.
Core elements of pandemic influenza communication are:
• to maintain and build public trust in public health authorities before, during and after
an influenza pandemic;
• to support coordination and the efficient use of limited resources among local, national,
regional and international public health partners;
• to provide relevant public health information to the public; to support vulnerable populations
having the information they need to make well-informed decisions;
• to take appropriate actions to protect their health and safety; and
• to minimize social and economic disruption.
30
SUMMARY TABLE OF RECOMMENDED ACTIONS
TABLE 4
PREPAREDNESS
COMPONENTS
PLANNING
AND
COORDINATION
PHASES
Develop, exercise, and
periodically
revise national
influenza
pandemic
preparedness
and response
plans.
1-3 4 5-6 POST PEAK POST PANDEMIC
SITUATION
MONITORING
AND
ASSESSMENT
COMMUNICATIONS
REDUCING
THE SPREAD
OF DISEASE
CONTINUITY OF
HEALTH CARE
PROVISION
Direct and
coordinate rapid
pandemic
containment
activities in
collaboration
with WHO to limit
or delay the
spread of
infection.
Provide
leadership and
coordination to
multisectoral
resources to
mitigate the
societal and
economic
impacts.
Plan and
coordinate for
additional
resources and
capacities
during possible
future waves.
Review lessons
learned and
share
experiences with
the international
community.
Replenish
resources.
Develop robust
national
surveillance
systems in
collaboration
with national
animal health
authorities, and
other relevant
sectors.
Increase
surveillance.
Monitor
containment
operations.
Share findings
with WHO and
the international
community.
Actively
monitor and
assess the
evolving
pandemic and
its impacts and
mitigation
measures.
Continue
surveillance to
detect
subsequent
waves.
Evaluate the
pandemic
characteristics
and situation
monitoring and
assessment tools
for the next
pandemic and
other public
health
emergencies.
Complete
communications
planning and
initiate
communications
activities to
communicate real
and potential risks.
Promote and
communicate
recommended
interventions to
prevent and
reduce
population and
individual risk.
Continue
providing
updates to
general public
and all
stakeholders on
the state of the
pandemic and
measures to
mitigate risk.
Regularly
update the
public and other
stakeholders on
any changes to
the status of the
pandemic.
Publicly
acknowledge
contributions of
all communities
and sectors and
communicate the
lessons learned;
incorporate
lessons learned
into
communications
activities and
planning for the
next major public
health crisis.
Promote
beneficial
behaviours in
individuals for self
protection.
Plan for use of
pharmaceuticals
and vaccines.
Implement rapid
pandemic
containment
operations and
other activities;
collaborate with
WHO and the
international
community as
necessary.
Implement
individual,
societal, and
pharmaceutical measures.
Evaluate the
effectiveness of
the measures
used to update
guidelines,
protocols, and
algorithms.
Conduct a
thorough
evaluation of all
interventions
implemented.
Prepare the health
system to
scale up.
Activate
contingency
plans.
Implement
contingency
plans for health
systems at all
levels.
Rest, restock
resources,
revise plans,
and rebuild
essential
services.
Evaluate the
response of the
health system to
the pandemic
and share the
lessons learned.
PHASES 1-3
26. Resolution WHA 56.19 Prevention and
control of influenza pandemics and annual
epidemics. In: Fifty-sixth World Health
Assembly, Geneva 19-28 May, 2003
27. Resolution WHA 56.19 Prevention and
control of influenza pandemics and annual
epidemics. In: Fifty-sixth World Health
Assembly, Geneva 19-28 May, 2003.
28. Resolution WHA 56.19 Prevention and
control of influenza pandemics and annual
epidemics. In: Fifty-sixth World Health
Assembly, Geneva 19-28 May, 2003.
29. Ethical considerations in developing
a public health response to pandemic
influenza (WHO/CDS/EPR/GIP/2007.2),
World Health Organization, 2007.
31
A. PHASES 1-3
Actions taken during pandemic Phases 1-3 are aimed at strengthening pandemic influenza preparedness
and response capacities at global, regional, national and sub-national levels.
• Provide technical support to Member States in the preparation
of national pandemic preparedness plans.26
• Provide leadership in coordinating the prioritized activities
for epidemic and pandemic preparedness.27
• Advocate new partnerships with organizations of the United
Nations system, bilateral development agencies,
nongovernmental organizations, and the private sector.28
• Facilitate and encourage the operability of national pandemic
plans through preparedness activities, including exercises.
WHO ACTIONS
• Establish and activate a cross-governmental, multi-agency
national pandemic preparedness committee that meets
regularly.
• Assess capacities and identify priorities for pandemic
preparedness planning and response at national and subnational levels.
• Advise sub-national governments on best practices in pandemic
planning; monitor and evaluate the operability and quality of
their plans.
• Develop, exercise, and periodically revise national and subnational influenza pandemic preparedness and response plans
in close collaboration with human and animal health sectors
and other relevant public and private partners with reference
to current WHO guidance.
• Establish, as needed, full legal authority and legislation for all
proposed interventions.
• Anticipate and address the resources required to implement
proposed interventions at national and sub-national levels
including working with humanitarian, community-based, and
non-governmental organizations.
• Develop an ethical framework to govern pandemic policy
development and implementation.29
• Integrate pandemic preparedness and response plans into
existing national emergency preparedness and response
programmes.
• Provide to public and private sectors the key assumptions,
guidance and relevant information to facilitate their pandemic
business continuity planning.
• Identify and address trans-border issues, including
interoperability of plans across borders.
• Consider providing resources and technical assistance to
resource-poor countries with foci of influenza activity.
• Participate, when possible, in regional and international
pandemic preparedness planning initiatives and exercises.
NATIONAL ACTIONS
PLANNING AND COORDINATION
PHASES 1-3
32
PREDOMINANTLY
ANIMAL INFECTIONS;
FEW HUMAN 1-3 INFECTIONS
• Collect, synthesize, and disseminate information on the global
human influenza situation in collaboration with partners.
• Provide guidance and tools for detection, investigation, rapid
risk assessment, reporting and ongoing evaluation of clusters
of influenza-like illness.
• Provide support to countries with human cases of influenza
caused by viruses with pandemic potential to assist in
establishing facts and fully characterizing cases.
• Develop tools to estimate seasonal and pandemic influenza
disease burden.30
• Establish joint initiatives for closer collaboration with national
and international partners, including FAO and OIE in the early
detection, reporting and investigation of influenza outbreaks of
pandemic potential, and in coordinating research on the
human-animal interface.31
• Establish global case definitions for reporting by countries of
human cases of influenza caused by viruses with pandemic
potential.
• Strengthen the Global Influenza Surveillance Network and
other laboratories to increase capacity for influenza
surveillance.32
• Provide diagnostic reagents to national influenza reference
centres for identification of the new strain.
• Coordinate collection and testing of strains for possible vaccine
production and antiviral susceptibility.
• Develop national surveillance systems to collect up-to-date
clinical, virological, and epidemiological information on trends
in human infection with seasonal influenza viruses, which will
also help to estimate additional needs during a pandemic.
• Detect animal31,33 and human infections with animal influenza
viruses, identify potential animal sources of human infection,
assess the risk of transmission to humans, and communicate
this information to WHO and relevant partners.
• Detect and investigate unusual clusters of influenza-like
respiratory illness or deaths and assess for human-to-human
transmission.
• Characterize and share both animal and human influenza virus
isolates and associated information with relevant international
agencies, such as WHO, FAO and OIE, to develop diagnostic
reagents, candidate vaccine viruses, and monitor antiviral
resistance.
• Strengthen the national laboratories in influenza diagnostic
capabilities.
WHO ACTIONS NATIONAL ACTIONS
SITUATION MONITORING AND ASSESSMENT
PHASES 1-3 30. Resolution WHA 56.19 Prevention and
control of influenza pandemics and annual
epidemics. In: Fifty-sixth World Health
Assembly, Geneva 19-28 May, 2003.
31. Resolution WHA 58.5 Strengthening
pandemic influenza preparedness and
response. In: Fifty-eighth World Health
Assembly, Geneva 16-25 May, 2005
(WHA58/2005/REC/1).
32. Resolution WHA 58.5 Strengthening
pandemic influenza preparedness and
response. In: Fifty-eighth World Health
Assembly, Geneva 16-25 May, 2005.
(WHA58/2005/REC/1).
33. Using current FAO and OIE guidelines:
Avian influenza and the virus that causes
it(ftp://ftp.fao.org/docrep/fao/010/a063
2e/a0632e02.pdf accessed 8 October
2008), Terrestrial Animal Health Code
2008, Article 10.4.29, Surveillance
strategies
(http://www.oie.int/eng/normes/mcode/e
n_index.htm accessed 8 October 2008).
33
PHASES 1-3 34. Resolution WHA 58.5 Strengthening
pandemic influenza preparedness and
response. In: Fifty-eighth World Health
Assembly, Geneva 16-25 May, 2005
(WHA58/2005/REC/1).
35. Prequalification. World Health
Organization
(http://www.who.int/hiv/amds/prequalifi
cation/en/ accessed 11 February, 2009).
36. Essential medicines list and WHO model formulary. World Health
Organization
(http://www.who.int/selection_medicine
s/list/en/ accessed 11 February 2009).
37. Resolution WHA 58.5 Prevention and
control of influenza pandemics and annual
epidemics. In: Fifty-eighth World Health
Assembly, Geneva 16-25 May, 2005
(WHA58/2005/REC/1).
38. Resolution WHA 60.28 Pandemic influenza preparedness: sharing of
influenza viruses and
access to vaccines and other benefits In:
Sixtieth World Health Assembly, Geneva
14-23 May, 2007 (WHASS1/2006-
WHA60/2007/REC/1)
39. Avian influenza: guidelines,
recommendations, descriptions. World
Health Organiztion
(http://www.who.int/csr/disease/avian_i
nfluenza/guidelinestopics/en/index.html
accessed 11 February, 2009).
40. Infection prevention and control of
epidemic- and pandemic-prone acute
respiratory diseases in health care, WHO
Interim Guidelines. Geneva, World Health
Organization 2007. (
WHO/CDS/EPR/2007.6).
41. Infection prevention and control of
epidemic- and pandemic-prone acute
respiratory diseases in health care, WHO
Interim Guidelines. Geneva, World Health
Organization 2007. (
WHO/CDS/EPR/2007.6).
42. Communicable disease alert and response for mass gatherings. Geneva,
World Health Organization, 2008
(WHO/HSE/EPR/2008.8).
43. Resolution WHA 56.19 Prevention and control of influenza pandemics and annual
epidemics. In: Fifty-sixth World Health
Assembly, Geneva 19-28 May, 2003.
44. Resolution WHA 56.19 Prevention and control of influenza pandemics and annual
epidemics. In: Fifty-sixth World Health
Assembly, Geneva 19-28 May, 2003.
45. Currently there are no WHO
recommendations either supporting or
opposing the stockpiling of new influenza
vaccines for use either prior to a pandemic
or during its early stages.
46. Guidelines for the deployment of a
pandemic influenza vaccine (to be
published in 2009). World Health
Organization 2009.
47. Pneumococcal conjugate vaccine for
childhood immunization - WHO position
paper. Weekly Epidemiological Record, No.
12, 2007, 82:93-104.
• Promote agreements for international technical assistance
and resource mobilization to resource-poor countries with
foci of influenza activity.
Preventing human influenza infection from animals
• Activate joint mechanisms for actions with other organizations
(e.g. FAO, OIE) to control disease in animals and to implement
prevention measures.
• Encourage dissemination of information on spread in animals
and interspecies transfers.
Individual/societal level measures
• Provide guidance on measures to reduce the spread of influenza
disease (social distancing and use of pharmaceuticals) and
develop tools to estimate their public health value.34
• Periodically reassess and modify recommended interventions
in consultation with appropriate partners, including those not
in the health-care sector, regarding acceptability, effectiveness
and feasibility.
Antivirals
• Develop principles to guide national recommendations for use
of antivirals (for prophylaxis and treatment).
• Manage WHO strategic global stockpile of antivirals and develop
standard operating procedures for rapid deployment.
• Increase global antiviral availability by using UN/WHO
mechanisms such as the prequalification programme35 and
the Essential Medicines List.36
Vaccines
• Develop principles to guide national recommendations for use
of seasonal and pandemic vaccines.
• Support strain characterization and development and
distribution of vaccine prototype strains for possible vaccine
production.
• Review and update WHO recommendations for pandemic
vaccine use.
• Provide technical support, capacity building and technology
transfer for influenza vaccines and diagnostics to developing
countries.37
• Formulate mechanisms and guidelines to promote fair and
equitable distribution of pandemic influenza vaccines.38
• Manage an international stockpile of H5N1 vaccine for use in
countries in need.
WHO ACTIONS
• Identify, regularly brief, and train key personnel to be mobilized
as part of a multisectoral expert response team for animal or
human influenza outbreaks of pandemic potential.
Preventing human influenza infection from animals39
• Reduce infection risk in those involved in responding to animal
outbreaks (education and training regarding the potential risk
of transmission; correct use of personal protective equipment;
making antivirals available if indicated by the risk assessment).
• Recommend measures to reduce human contact with potentially
infected animals.
• Control potentially contaminated environments such as wet
markets and ponds with free grazing ducks.
• In conjunction with animal health authorities, establish national
guidance on food safety, safe agricultural practices, and public
health issues related to influenza infection among animals.
Individual / household level measures
• Promote hand and respiratory hygiene.40
• Develop infection control guidance for household settings.41
• Develop plans to provide necessary support for ill persons isolated
at home and their household contacts.
Societal level measures
• Establish protocols to suspend classes, especially in the event
of a severe pandemic or if there is disproportionate or severe
disease in children.
• Promote development of mitigation strategies for public and
private sector workplaces (such as adjusting working patterns
and practices).
• Promote reduction of unnecessary travel and overcrowding of
mass transport systems.
• Develop a framework to facilitate decision-making for cancellation
/restriction of mass gatherings at the time of the pandemic.42
International travel measures
• Develop capacities for emergency public health actions at
designated points of entry in accordance with IHR (2005) Annex
1 B.2.
Antivirals and other pharmaceuticals
• Estimate and prioritize antiviral requirements for treatment and
prophylaxis during a pandemic.
• Develop mechanisms and procedures to select, procure, stockpile,
distribute, and deliver antivirals based on national goals and
resources.
• Plan for the increased need for antibiotics, antipyretics, hydration,
oxygen, and ventilation support within the context of national
clinical management strategies.
• Assess effectiveness and safety of antiviral therapy using
standardized protocols when possible.
Vaccines
• For countries not using seasonal influenza vaccine, document
the disease burden and economic impact of seasonal influenza
and develop a national vaccine, policy if indicated.43
• For countries using seasonal influenza vaccine, work to increase
seasonal influenza vaccine coverage levels of all high risk
people. 44
• Establish goals and priorities for the use of pandemic influenza
vaccines.45
• Develop a deployment plan to deliver pandemic influenza
vaccines to national distribution points within seven days from
when the vaccine is available to the national government.46
• Consider the feasibility of using pneumococcal vaccines as
part of the routine immunization program in accordance with
WHO guidelines.47
NATIONAL ACTIONS
REDUCING THE SPREAD OF DISEASE
PHASES 1-3
34
• Provide guidance for appropriate infection control, laboratory
biosafety and clinical management in health care and social
settings, and in care facilities.
• Establish regional clinical advisory network for timely
distribution and collection of important clinical information,
identify knowledge gaps, and develop standardized clinical
protocols.
• Assist national health care delivery authorities in identifying
priority needs and response strategies, and assessing
preparedness (e.g. through developing checklists, model
pandemic preparedness plans, training and table-top exercises).
• Develop guidance for remote, resource-poor communities on
home-based care of patients during an influenza pandemic.
• Identify priorities and response strategies for public and private
health care systems for triage, surge capacity, and human and
material resource management.
• Review and update continuity of health care provision strategies
at national and sub national levels.
• Develop strategies, plans, and training to enable all health
care workers, including community level workers, to respond
during animal outbreaks and a pandemic.
• Develop case-finding, treatment, and management protocols,
and algorithms.
• Develop national infection control guidance.48
• Estimate and plan for procurement and distribution of personal
protective equipment for protection of workers.49
• Develop and implement routine laboratory biosafety and safe
specimen-handling and shipping policies and procedures.50
• Explore ways to provide drugs and medical care free of charge
(or cover by insurance) to encourage prompt reporting and
treatment of human cases caused by an animal influenza virus
or virus with pandemic potential.
• Develop the capacity for the rapid deployment of diagnostic
tests once available.
• Assess health system capacity to detect and contain outbreaks
of human influenza disease in hospital settings.
WHO ACTIONS NATIONAL ACTIONS
CONTINIUITY OF HEALTH CARE PROVISION
PHASES 1-3 48.Infection prevention and control of
epidemic- and pandemic-prone acute
respiratory diseases in health care, WHO
Interim Guidelines. Geneva, World Health
Organization 2007.
(WHO/CDS/EPR/2007.6).
49.Infection prevention and control of
epidemic- and pandemic-prone acute
respiratory diseases in health care, WHO
Interim Guidelines. Geneva, World Health
Organization 2007.
(WHO/CDS/EPR/2007.6).
50.Collecting, preserving and shipping
specimens for the diagnosis of avian
influenza A(H5N1) virus infection, Guide
for field operations. World Health
Organization 2006
(WHO/CDS/EPR/ARO/2006.1) .
PREDOMINANTLY
ANIMAL INFECTIONS;
FEW HUMAN 1-3 INFECTIONS
35
• Update national and international authorities, other partners
/stakeholders, and the public, with current information on risks,
sources, personal safety, and ways of mitigation of influenza
pandemics.
• Maintain formal communication channels among Member States,
other international organizations, key stakeholders, and
technical/professional associations to facilitate information
sharing and coordination.
• Increase the familiarity of news media with WHO activities,
operations, and decision-making related to influenza and other
epidemic-prone diseases.
• Develop feedback mechanisms to identify emerging public
concerns, address rumours, and correct misinformation.
• Support Member States' communication efforts during a pandemic
by providing material and technical guidance.51
WHO ACTIONS
• Establish an emergency communications committee with all
necessary standard operating procedures to ensure a streamlined,
expedited dissemination of communications products.
• Update leadership and other relevant sectors regarding global
and national pandemic influenza risk status.
• Build effective relations with key journalists and other
communications channels to familiarize them with influenza and
pandemic related issues.
• Develop effective dialogue and listening mechanisms with the
general public.
• Develop effective communication strategies and messages to
inform, educate, and communicate with individuals and families
so they are better able to take appropriate actions before, during,
and after a pandemic.
• Initiate public health education campaigns in coordination with
other relevant authorities on individual-level infection control
measures.
• Increase public awareness of measures that may be available
to reduce the spread of pandemic influenza.
• Create messages and feedback mechanisms targeted towards
hard-to-reach, disadvantaged, or minority groups.
• Test communications procedures through exercises.
• Update communications strategies as feedback from the general
public and stakeholder organizations is collected and analysed.
NATIONAL ACTIONS
COMMUNICATIONS
PHASES 1-3 51. World Health Organization Outbreak
Communication Planning Guide. World
Health Organization 2008. ISBN 978 92 4
159744 9.
PHASES 1-3
36
SUSTAINED
HUMAN-TO-HUMAN 4 TRANSMISSION
• Consult with the affected country and external experts on the
decision to launch a rapid containment operation.
• Provide ongoing advice to the affected country on the
management of the containment operation.
• Coordinate the international response to rapid containment,
including the deployment of international field teams as
requested and necessary.
• Mobilize and dispatch resources (e.g. antivirals from the global
stockpile, other materials and logistics) for rapid containment.
• Mobilize financial resources for a rapid containment operation
as needed and encourage the provision of international
assistance to resource-poor countries.
• Initiate planning and actions to switch from seasonal to
pandemic vaccine production.
FOR AFFECTED COUNTRIES
• Direct and coordinate rapid pandemic containment activities
in collaboration with WHO to limit the spread of human infection.
• Activate national emergency and crisis committee(s) and
national command, control, and coordination mechanisms for
emergency operations.
• Activate procedures to access and mobilize additional human
and material resources.
• Deploy operational and logistics response teams.
• Identify needs for international assistance.
• Designate special status as needed (such as declaring a state
of emergency) to facilitate rapid containment interventions.
• Provide regular updates on the evolving situation to WHO as
required under IHR (2005) and to other partners to facilitate
coordination of response.
• Encourage cross-border collaboration with surrounding
countries through information sharing and coordination of
responses.
• Activate pandemic contingency plans for all sectors as deemed
critical for the provision of essential services.
• Finalize preparations for a possible pandemic including
procurement plans for essential pharmaceuticals.
COUNTRIES NOT YET AFFECTED
• Finalize preparations for a possible pandemic by activating
internal organizational arrangements within the commandand-control mechanism and mobilizing staffing surge capacity
in critical services.
• Respond, if possible, to requests for international assistance
organized by WHO.
WHO ACTIONS NATIONAL ACTIONS
PLANNING AND COORDINATION
PHASE 4
B. PHASE 4
An important goal during WHO pandemic Phase 4 is to contain the new virus within a limited area
or delay its spread to gain time to implement interventions, including the use of vaccines.
37
PHASE 4
• Provide support to national authorities and facilitate assessment
of the extent of human-to human transmission with on-site
evaluation.
• Refine case definition for global reporting.
• Recommend strategies for national authorities to enhance
surveillance in affected areas.
• Coordinate collection and testing of specimens and/or strains
to develop diagnostic reagents, prototype vaccines, and for
antiviral susceptibility.
• Coordinate with national authorities to monitor containment
measures.
WHO ACTIONS
FOR AFFECTED COUNTRIES
• Enhance surveillance to rapidly detect, investigate, and report
new cases and clusters.52
• Collect specimens for testing and virological characterization
using protocols and procedures developed in collaboration
with WHO.
• Share specimens and/or strains to develop diagnostic reagents
and prototype vaccines and for antiviral susceptibility.
• Collect more detailed epidemiological and clinical data as
time and resources permit.53
• To the extent possible, monitor compliance, safety, and
effectiveness of mitigation measures and share findings with
the international community and WHO.
FOR COUNTRIES NOT YET AFFECTED
• Enhance virological and epidemiological surveillance to detect
possible cases and clusters, especially if sharing extensive
travel or trade links with affected areas.
• Report any suspect cases to national authorities and WHO.
NATIONAL ACTIONS
SITUATION MONITORING AND ASSESSMENT
PHASE 4 52. WHO Interim planning guidance for
rapid containment of the initial emergence
of pandemic influenza.
(http://www.who.int/csr/disease/avian_
influenza/guidelines/draftprotocol/en/
index.html accessed 10 February 2009).
53. WHO Interim planning guidance for
rapid containment of the initial emergence
of pandemic influenza.
(http://www.who.int/csr/disease/avian_
influenza/guidelines/draftprotocol/en/
index.html accessed 10 February 2009)
and WHO Global Surveillance for Pandemic
Influenza, World Health Organization 2009
(to be published 2009
http://www.who.int/csr/disease/
influenza/ ).
PHASE 4
38
• Assist the affected country in undertaking rapid pandemic
containment operations coordinating international
collaboration.
• Dispatch antivirals from the WHO stockpile to the affected
country, to be used in rapid containment operations.
• Develop up-to-date vaccine prototype strains.
• Collaborate with national authorities in determining possible
use of a potentially effective vaccine during rapid containment
operations.
• Update guidance for optimal use of pandemic vaccines when
available.
ALL COUNTRIES
International travel measures
• Consider implementing exit screening as part of the early
global response (i.e. first few affected countries).54
• Provide advice to travellers.
AFFECTED COUNTRIES
• Undertake rapid pandemic containment55 operations in
collaboration with WHO and the international community.
• Request and distribute antivirals from the WHO global stockpile
and/or other national or regional stockpiles for treatment of
cases and prophylaxis of all persons in the designated areas.
• Consider deploying pandemic vaccine if available.
• Implement individual/household and societal-level disease
control measures.56
• Limit all non-essential movement of persons in and out of the
designated containment area(s) and implement screening
procedures at transit points.
COUNTRIES NOT YET AFFECTED
• Reassess the capacity to implement mitigation measures to
reduce the spread of pandemic influenza.
• Distribute stockpiles of pharmaceuticals and other materials
according to national plans.
• Use appropriate individual/household disease control measures
for suspect cases and their contacts.57
WHO ACTIONS NATIONAL ACTIONS
REDUCING THE SPREAD OF DIEASE
PHASE 4 54. If exit screening is implemented, it
should be considered as a time-limited
intervention and the isolation and
treatment of cases and quarantine of
contacts resulting from screening must
be carried out in accordance with IHR
(2005).
55. WHO Interim Protocol: Rapid
operations to contain the initial emergence
of pandemic influenza.
(http://www.who.int/csr/disease/avian_
influenza/guidelines/draftprotocol/en/in
dex.html accessed 8 October 2008).
56. Recommended interventions to reduce the spread of disease during pandemic
influenza. World Health Organization 2009
(to be published 2009
http://www.who.int/csr/disease/
influenza/).
57. Infection prevention and control of
epidemic- and pandemic-prone acute
respiratory diseases in health care, WHO
Interim Guidelines. Geneva, World Health
Organization
2007.(WHO/CDS/EPR/2007.6).
SUSTAINED
HUMAN-TO-HUMAN 4 TRANSMISSION
39
• Coordinate and support collection of clinical data to reassess
clinical management guidelines and protocols.
• Update guidelines for clinical management and infection
control as necessary.
• Update guidelines for biosafety in laboratories as necessary.
WHO ACTIONS
AFFECTED COUNTRIES
• Provide guidance to health-care workers to consider influenza
infection in patients with respiratory illness and to test and
report suspect cases.
• Implement appropriate infection control measures and issue
personal protective equipment as needed.
• Activate contingency plans for responding to the possible
overload of health and laboratory facilities to deal with potential
staff shortages.
• Activate alternative strategies for case isolation and
management as needed.
COUNTRIES NOT YET AFFECTED
• Activate pandemic contingency planning arrangements for the
health sector.
• Advise health-care workers to consider the possibility of
influenza infection in patients with respiratory illness, especially
those with travel or other contact with persons in the affected
country(ies).
NATIONAL ACTIONS
CONTINUITY OF HEALTH CARE PROVISION
PHASE 4
PHASE 4
40
• Update national and international authorities, other partners,
stakeholders, and the public on global epidemiological situation,
disease characteristics, and the containment efforts.
• Issue updates on the effectiveness of various public health
measures as data become available.
• Coordinate and disseminate relevant public health messages
using various channels (WHO website, published material,
press conferences, and the media).
• Work with partners to promote consistent messages.
FOR ALL COUNTRIES
• Activate communications mechanisms to ensure widest possible
dissemination of information.
• Update and disseminate “Talking Points” so that all
spokespeople convey consistent information.
• Conduct frequent and pre-announced public briefings through
popular media outlets such as the web, television, radio, and
press conferences to counter panic and dispel rumours.
FOR AFFECTED COUNTRIES
• Regularly communicate via established mechanisms:
• what is known and not known about the virus, the state of
the outbreak, use and effectiveness of measures and likely
next steps;
• the importance of limiting all non-essential movement of
persons in and out of the designated containment area(s) and
relevant screening procedures at transit points;
• the importance of compliance with recommended measures
to stop further spread of the disease;
• how to obtain medicines, essential services and supplies in
the containment area(s).
• Gather feedback from the general public, vulnerable populations
and at-risk groups on attitudes towards the recommended
measures and barriers affecting their willingness or ability to
comply. Incorporate the findings into communication and
health education campaigns targeted to the specific groups.
• Collaborate with surrounding countries on information sharing.
WHO ACTIONS NATIONAL ACTIONS
COMMUNICATIONS
PHASE 4
SUSTAINED
HUMAN-TO-HUMAN 4 TRANSMISSION
41
PHASES 5-6
C. PHASES 5-6
During Phases 5-6 (pandemic), actions shift from preparedness to response at a global level. The
goal of recommended actions during these phases is to reduce the impact of the pandemic on society.
• Encourage international assistance to resource-poor countries
and/or seriously affected countries.
• Interact with international organizations and agencies inside
and outside of the health sector to coordinate interventions.
WHO ACTIONS
AFFECTED COUNTRIES
• Maintain trust across all agencies and organizations and with
the public through a commitment to transparency and credible
actions.
• Designate special status as needed, such as declaring a state
of emergency.
• Provide leadership and coordination to multisectoral resources
to mitigate the societal and economic impact of a pandemic.
• Work for rational, ethical, and transparent access to resources.
• Assess if external assistance is required to meet humanitarian
needs.
COUNTRIES NOT YET AFFECTED
• Finalize preparations for an imminent pandemic, including
activation of crisis committee(s) and national command and
control systems.
• Update, if necessary, national guidance and recommendations
taking into account information from affected countries.
NATIONAL ACTIONS
PLANNING AND COORDINATION
PHASES 5-6
PHASES 5-6
42
• Coordinate the assessment and monitoring of the disease
characteristics and severity, and provide guidance accordingly.
• Monitor the global spread of disease and possible changes in
epidemiological, clinical, and virological aspects of infection,
including antiviral drug resistance.
• Support affected Member States as much as possible in
confirming the spread of human infections and assessing the
epidemiological situation.
AFFECTED COUNTRIES
Pandemic disease surveillance58
• Undertake a comprehensive assessment of the earliest cases
of pandemic influenza.
• Document the evolving pandemic including geographical spread,
trends, and impact.
• Document any changes in epidemiological and clinical features
of the pandemic virus.
• Maintain adequate virological surveillance to detect antigenic
and genetic changes, as well as changes in antiviral
susceptibility and pathogenicity.
• Modify national case definitions and update clinical and
laboratory algorithms for diagnosis, as necessary.
Monitoring and assessment of the impact of the pandemic
• Monitor essential health-related resources such as: medical
supplies; antivirals, vaccines and other pharmaceuticals; health
care worker availability, hospital occupancy/availability; use
of alternative health facilities, laboratory material stocks; and
mortuary capacity.
• Monitor and assess national impact using criteria such as
workplace and school absenteeism, regions affected, groups
most affected, and essential worker availability.
• Assess the uptake and impact of implemented mitigation
measures.
• Forecast economic impact of the pandemic, if possible.
WHO ACTIONS NATIONAL ACTIONS
SITUATION MONITORING AND ASSESSMENT
PHASES 5-6 58. Global surveillance during an influenza
pandemic, World Health Organization 2009
(http://www.who.int/csr/disease/swinefl
u/guidance/surveillance/WHO_case_def
inition_swine_flu_2009_04_29.pdf).
5-6PANDEMIC
WIDESPREAD HUMAN
INFECTION
43
PHASES 5-6
• Consider and issue any new or revised Temporary
Recommendations under IHR (2005), including advice from
Emergency Committee as appropriate.59
• Facilitate assessment of interventions and update
recommendations if needed.
• Facilitate assessment of antiviral susceptibility, effectiveness,
and safety.
• Make recommendations for pandemic vaccine composition60
and switch to pandemic vaccine production if not previously
done.
• Facilitate development of national guidelines for national
authorities to conduct targeted vaccination campaigns if
pandemic vaccine is available.
WHO ACTIONS
ALL COUNTRIES
International travel measures
• Take into account WHO guidance and information when issuing
international travel advisories and health alerts.
AFFECTED COUNTRIES
Individual/household level measures
• Advise people with acute respiratory illness to stay at home
and to minimize their contact with household members and
others.
• Advise household contacts to minimize their level of interaction
outside the home and to isolate themselves at the first sign of
any symptoms of influenza.
• Provide infection control guidance for household caregivers61
taking into account the WHO guidance.62
Societal level measures
• Implement social distancing measures as indicated in national
plans, such as class suspensions and adjusting working patterns.
• Encourage reduction in travel and crowding of the mass
transport system.63
• Assess and determine if cancellation, restriction, or modification
of mass gatherings is indicated.64
International travel measures
• Consider implementing exit screening as part of the early
global response (i.e. first few affected countries).65
• Provide advice to travellers.
Pharmaceutical measures
• Distribute antivirals, and other medical supplies in accordance
with national plans.
• Implement vaccine procurement plans.
• Plan for vaccine distribution and accelerate preparations for
mass vaccination campaigns.
• Modify/adapt antiviral and vaccine strategies based on
monitoring and surveillance information.
• Implement medical prophylaxis campaigns for antivirals and/or
vaccines according to priority status and availability in
accordance with national plans.
• Monitor safety and efficacy of pharmaceutical interventions
to the extent possible and monitor supply.
COUNTRIES NOT YET AFFECTED
• Be prepared to implement planned interventions to reduce the
spread of pandemic disease.
• Update recommendations on the use of planned interventions
based on experience and information from affected countries.
• Implement distribution and deployment plans for
pharmaceuticals, and other resources as required.
• Consider implementing entry screening at international borders.66
NATIONAL ACTIONS
REDUCING THE SPREAD OF DISEASE
PHASES 5-6 59. Assuming a PHEIC has been
determined to be occurring as defined by
IHR (2005)
60. Especially if non-pandemic strains
are still circulating.
61. If medical masks are available and the training on their correct use is feasible,
they may be considered for symptomatic
persons and susceptible caregivers in
household settings when close contact
can not be avoided.
62. Infection prevention and control of
epidemic- and pandemic-prone acute
respiratory diseases in health care, WHO
Interim Guidelines. Geneva, World Health
Organization 2007.
(WHO/CDS/EPR/2007.6)
63. Symptomatic people should self-isolate
and avoid using public transport. There
is, however, insufficient evidence to date
to either support or oppose the closure or
restriction of mass transport systems as
a measure to reduce disease transmission
in the community.
64. If a country decides to cancel, restrict
or modify all or certain mass gatherings,
this decision should be based on the
nature of the gathering and on local
disease levels, and should only be
implemented once the disease is present
in the community.
65. If exit screening is implemented, it should be considered as a time-limited
intervention and the isolation and
treatment of cases and quarantine of
contacts resulting from screening must
be carried out in accordance with IHR
(2005).
66. If entry screening is implemented, it should be considered as a time-limited
intervention and the isolation and
treatment of cases and quarantine of
contacts resulting from screening must
be carried out in accordance with IHR
(2005).
WHO recognizes individual country considerations will affect national decisions, but, in general, does
not encourage:
• pandemic-related international border closures for people and/or cargo;
• general disinfection of the environment during a pandemic;
• the use of masks in the community by well persons;
• the restriction of travel within national borders during a pandemic, with the exception
of a globally led rapid response and containment operation, or in rare instances where
clear geographical and other barriers exist;
44
• Coordinate response with other international organizations.
• Provide guidance to national authorities in assisting clinicians
in recognition, diagnosis, and reporting of cases and other
critical issues as needed.
• Implement pandemic contingency plans for full mobilization
of health systems, facilities, and workers at national and subnational levels.
• Implement and adjust the triage system as necessary.
• Enhance infection control practices in healthcare and laboratory
settings and distribute personal protective equipment in
accordance with national plans.
• Provide medical and non-medical support for patients and
their contacts in households and alternative facilities if needed.
• Provide social and psychological support for health-care
workers, patients, and communities.
• Implement corpse management procedures as necessary.
FOR COUNTRIES NOT YET AFFECTED
• Prepare to switch to pandemic working arrangements.
WHO ACTIONS NATIONAL ACTIONS
CONTINUITY OF HEALTH CARE PROVISION
PHASES 5-6
• Update national authorities, other partners and stakeholders,
and the public on global situation, trends, epidemiological
characteristics, and recommended measures.
• Continue to work with partners to promote consistent messages.
• Regularly update the public on what is known and unknown
about the pandemic disease, including transmission patterns,
clinical severity, treatment, and prophylaxis options.
• Provide regular communications to address societal concerns,
such as the disruption to travel, border closures, schools, or
the economy or society in general.
• Regularly update the public on sources of emergency medical
care, resources for dealing with urgent non-pandemic health
care needs, and resources for self-care of medical conditions.
WHO ACTIONS NATIONAL ACTIONS
COMMUNICATIONS
PHASES 5-6
5-6PANDEMIC
WIDESPREAD HUMAN
INFECTION
45
THE POST-PEAK
PERIOD
• Identify lessons learned for immediate application, as well as
for future needs. • Determine the need for additional resources and capacities
during possible future pandemic waves.
• Begin rebuilding of essential services.
• Address the psychological impacts of the pandemic, especially
on the health workforce.
• Consider offering assistance to countries with ongoing pandemic
activity.
• Review the status of and replenish national, local, and household
stockpiles and supplies.
• Review and revise national plans.
WHO ACTIONS NATIONAL ACTIONS
PLANNING AND COORDINATION
THE POST-PEAK PERIOD
D. THE POST-PEAK PERIOD
The overall goal of actions during the post-peak period is to address the health and social impact
of the pandemic, as well as to prepare for possible future pandemic waves.
• Assist countries in estimating national impact.
• Continue global situation monitoring for global spread and
national trends.
• Review lessons learned and make adjustments in surveillance
guidelines and tools for countries.
• Assess and monitor the type and pathogenicity of circulating
influenza viruses.
• Activate the surveillance activities required to detect subsequent
pandemic waves.
• Evaluate the resources needed to monitor subsequent waves.
WHO ACTIONS NATIONAL ACTIONS
SITUATION MONITORING AND ASSESSMENT
THE POST-PEAK PERIOD
THE POST-PEAK PERIOD
46
• Facilitate evaluation of interventions. • Evaluate the effectiveness of the measures used and update
guidelines, protocols, and algorithms accordingly.
• Continue with vaccination programmes in accordance with
national plans, priorities, and vaccine availability.
WHO ACTIONS NATIONAL ACTIONS
REDUCING THE SPREAD OF DISEASE
THE POST-PEAK PERIOD
• Update guidance to national authorities to optimize use of
scarce facilities.
• Ensure that health-care personnel have the opportunity for
rest and recuperation.
• Restock medications and supplies and service and renew
essential equipment.
• Review and, if necessary, revise pandemic preparedness and
response plans in anticipation of possible future pandemic
wave(s).
• Revise case definitions, treatment protocols, and algorithms
as required.
WHO ACTIONS NATIONAL ACTIONS
CONTINUITY OF HEALTH CARE PROVISION
THE POST-PEAK PERIOD
• Regularly update the public and other stakeholders on any
changes to the status of the pandemic.
• Urge Member States, partners, and other stakeholders to make
adjustments to their communications plans and systems.
• Regularly update the public and other stakeholders on any
changes to the status of the pandemic.
• Communicate to the public the ongoing need for vigilance and
disease-prevention efforts to prevent any upswing in disease
levels.
• Continue to update the health sector on new information or
other changes that affect disease status, signs and symptoms,
or case definitions, protocols and algorithms.
WHO ACTIONS NATIONAL ACTIONS
COMMUNICATIONS
THE POST-PEAK PERIOD
THE POST-PEAK
PERIOD
POSSIBILITY OF
RECURRENT EVENTS
47
• Facilitate implementation of lessons learned for immediate
application, as well as for future needs. • Evaluate the effectiveness of specific responses and
interventions and share findings with the international
community.
• Review the lessons learned and apply to national emergency
preparedness and response programmes.
• Revise national and sub-national pandemic preparedness and
response plans.
WHO ACTIONS NATIONAL ACTIONS
PLANNING AND COORDINATION
THE POST-PANDEMIC PERIOD
E. THE POST-PANDEMIC PERIOD
The goal of activities during the post-pandemic period is to address the long-term health and social
impact of the pandemic, as well as to restore normal health and social functions.
• Report on the global situation.
• Review lessons learned and make adjustments in surveillance
guidelines and tools for countries.
• Collect and analyse available data to evaluate the
epidemiological, clinical, and virological characteristics of
the pandemic.
• Review and revise situation monitoring and assessment tools
for the next pandemic and other public health emergencies.
• Resume seasonal influenza surveillance incorporating the
pandemic virus subtype as part of routine surveillance.
WHO ACTIONS NATIONAL ACTIONS
SITUATION MONITORING AND ASSESSMENT
THE POST-PANDEMIC PERIOD
• Provide technical support to Member States, as requested, to
evaluate the impact of the pandemic on the country and the
effectiveness and impact of interventions utilized during the
pandemic.
• Conduct a thorough evaluation of individual, household, and
societal interventions implemented.
• Conduct a thorough evaluation of all the pharmaceutical
interventions used, including:
• antiviral effectiveness, safety, and resistance; and
• vaccine coverage, effectiveness, and safety.
• Review and update relevant guidelines as necessary.
• Continue with vaccination programmes in accordance with
national plans, priorities, and vaccine availability.
WHO ACTIONS NATIONAL ACTIONS
REDUCING THE SPREAD OF DISEASE
THE POST-PANDEMIC PERIOD
THE POSTPANDEMIC PERIOD
THE POST-PANDEMIC PERIOD
48
• Utilize existing clinical networks to review clinical information
and effectiveness and safety of clinical interventions; advise
on knowledge gaps and research needs.
• Review and revise relevant guidance.
• Collect and analyse available data to evaluate the response
of the health system to the pandemic.
• Review the lessons learned and share experiences with the
international community.
• Amend plans and procedures to include lessons learned.
• As needed, provide psychosocial services to facilitate individual
and community-level recovery.
WHO ACTIONS NATIONAL ACTIONS
CONTINUITY OF HEALTH CARE PROVISION
THE POST-PANDEMIC PERIOD
• Evaluate communications response during previous phases;
review lessons learned.
• Ensure that lessons learned are incorporated into revised and
improved communications plans of all stakeholders, ready for
use in the next pandemic/major public health event.
• Continue to work with Member States to increase the
effectiveness of national communications activities.
• Publicly acknowledge the contributions of all communities and
sectors.
• Communicate to the public and other stakeholders the lessons
learned about the effectiveness of responses during the
pandemic and how the gaps that were discovered will be
addressed.
• Encourage stakeholders across all sectors, public and private,
to revise their pandemic and emergency plans based upon the
lessons learned.
• Extend communications planning and activities to cover other
epidemic diseases and use the principles of risk
communications to build the capacity to dialogue with the
public on all health matters of potential concern to them.
• Improve and adjust communications plan in readiness for the
next major public health event.
WHO ACTIONS NATIONAL ACTIONS
COMMUNICATIONS
THE POST-PANDEMIC PERIOD
THE POSTPANDEMIC PERIOD
DISEASE ACTIVITY AT
SEASONAL LEVELS
49
1. Modes of transmission
ANNEX 1 - PLANNING ASSUMPTIONS
This annex provides some parameters to be
considered by national authorities in planning
for pandemic influenza.
GENERAL GUIDANCE IN PANDEMIC INFLUENZA PREPAREDNESS
PLANNING ASSUMPTIONS
Planning for a future influenza pandemic is difficult in part because many important features of the
next pandemic are not known. In this situation, assumptions relating to the epidemiology of influenza
are needed to make decisions in public health planning, as well as estimating required resources.
This annex provides some parameters to be considered by national authorities in planning for pandemic
influenza. These assumptions are based on information known at the time of publication about
seasonal influenza, avian influenza, and past influenza pandemics.
These data should not be taken as predictions of how the next influenza pandemic will spread and
its resulting impact. Features of the next pandemic will not be uniform worldwide. The characteristics
and impacts of past pandemics have varied between countries and within an individual country.
These differences are most likely attributable to both the characteristics of the pandemic virus and
the ability of the country to respond to the disease.
It is beyond the scope of this Annex to provide a comprehensive review of the epidemiology of
influenza. It will be updated as new scientific data become available that significantly change these
assumptions. Key references are provided for readers to review the existing literature.
Suggested assumptions
• Modes of virus transmission of pandemic influenza are expected to be similar to those of
seasonal influenza: via the large droplet or contact (either direct or indirect) route, with a
contribution by particle airborne route, or a combination of both.
• The relative contribution and clinical importance of potentially different modes of transmission
of influenza are unknown. However, epidemiological patterns suggest that the spread of the
virus is mostly through close contact via the droplet or contact route.
Implications
• Good hand hygiene, isolation of ill persons, and the use of personal protective equipment are
important measures when caring for persons with influenza to decrease viral transmission.
• An airborne precaution room is not indicated for routine care. However, health care workers
should wear eye protection, a gown, clean non-sterile gloves, and particulate respirators during
the performance of aerosol generating procedures.
50
Scientific basis
• Droplet and contact transmission appear to be major routes of transmission for seasonal
influenza (Brankston G et al, 2007; Bridges CB et al, 2003).
• However, data are insufficient to determine the relative importance of the different modes
of transmission. In addition, there is lack of standardization and consensus about the technical
definition (i.e., particle size) of an aerosol versus a droplet (Tellier R, 2006; Lemieux, C et
al, 2007).
• Relative heat and humidity impact the efficiency of transmission of influenza via aerosol.
Some have reported the lack of aerosol transmission at 30oC, while transmission via the
contact route was equally efficient at 30oC and 20oC (Lowen AC et al. 2007; Lowen AC et
al. 2008).
• Certain procedures performed in health care settings can create aerosols. Some of these
procedures have been associated with a significant increase in the risk of disease transmission
and have been termed “aerosol-generating procedures associated with pathogen transmission”
(WHO, 2007). These procedures include intubation, cardiopulmonary resuscitation, bronchoscopy,
autopsy, and surgery where high-speed devices are used (WHO, 2007).
Selected references
• Brankston G, Gitterman L, Hirji Z et al. Transmission of influenza A in human beings. Lancet
Infect Dis. 2007;7(4):257-65.
• Bridges CB, Kuehnert MJ, Hal CB. Transmission of influenza: implications for control in
health care settings. Clinl Infect Dis 2003;37:1094-1101.
• Lemieux C, Brankston G, Gitterman L et al. Questioning aerosol transmission of influenza.
Emerg Inf Dis, 2007;13(1):173-174.
• Lowen AC, Mubareka S, Steel J et al. Influenza virus transmission is dependent on relative
humidity and temperature. PLoS Pathog. 2007 Oct 19;3(10):1470-6.
• Lowen AC, Steel J, Mubareka S et al. High temperature (30 degrees C) blocks aerosol but not
contact transmission of influenza virus. J Virol. 2008;82(11):5650-2.
• Tang JW, Li Y, Eames I et al. Factors involved in the aerosol transmission of infection and
control of ventilation in healthcare premises J Hosp Infect. 2006 Oct;64(2):100-14.
• Tellier R. Review of aerosol transmission of influenza A virus. Emerg Inf Dis, 2006;12(11):1657-
1662.
2. Incubation period and infectiousness of pandemic influenza
Suggested assumptions
• Incubation period: 1 - 3 days.
• Latent period: 0.5 - 2 days.
• Duration of infectiousness: About five days in adults and could be longer in children
• Basic reproduction number (R0): 1.5 - 2.0.
51
Implications
• The incubation period and the duration of infectiousness are useful for planning purposes
regarding: length of isolation for cases; development of a definition for contacts of cases; and
the length of quarantining contacts.
• A relatively short incubation period would make it difficult to stop the spread of pandemic
influenza by contact tracing and quarantine.
• Viral shedding before symptoms develop would make it difficult to stop the spread of pandemic
influenza solely by screening and isolating clinically ill persons.
• Once the pandemic begins, it will be important for countries to undertake surveillance and
special studies to assess the incubation period and the duration of infectiousness of the
pandemic virus.
Scientific basis
• An early study using Australian maritime statistics suggested that the mean incubation period
of the 1918 pandemic influenza was 32.71 hours (1.4 days). (McKendrick and Morison as
reviewed by Nishiura, 2007).
• A meta-analysis of 56 volunteer studies (Carrat et al, 2008) found that:
• an increase in the average total symptoms score was noted by day 1 after inoculation, total
scores peaked by day 2 and returned to baseline values by day 8;
• viral shedding increased sharply between 0.5 and 1 days after challenge and consistently
peaked on day 2 (mean generation time 2.5 days); the average duration of viral shedding
was 4.8 days;
• viral shedding curves and total symptom score curves showed similar shapes, although
viral shedding preceded illness by 1 day.
• Longer durations of viral shedding are not rare. As reviewed by Carrat et al., in one study
subgroup, five participants (20 percent) shed influenza B virus eight days after inoculation,
while another study also reported nine days of shedding for influenza A/H3N2.
• Reasonable estimates of the basic reproduction number (R0) for past pandemic viruses as
well as seasonal influenza viruses converge between 1.5 and 2.0 (Ferguson NM et al., 2005;
Ferguson NM et al., 2006; Colliza V et al., 2007; Vynnycky E et al. 2007).
• The incubation period of H5N1 human cases (7 days or less; mostly 2 - 5 days) appears to
be longer than that of seasonal influenza. In clusters in which limited human-to-human
transmission has probably occurred, the incubation period appears to be approximately 3 -
5 days, although in one cluster it was estimated to be 8 - 9 days (WHO writing committee,
2008).
• Patients with influenza A (H5N1) disease may have detectable viral RNA in the respiratory
tract for up to three weeks; data, however, are limited. (reviewed by WHO writing committee,
2008; and Gambotto et al., 2007).
Selected references
• Carrat F, Vergu E, Ferguson NM et al. Time lines of infection and disease in human influenza:
a review of volunteer challenge studies. Am. J. Epidemiol., 2008;167:775-785.
• Colliza V, Barrat A, Barthelemy M et al. Modelling the worldwide spread of pandemic influenza:
baseline case and containment interventions. PLoS Medicine, 2007;4(1):95-110.
52
• Ferguson NM, Cummings DAT, Cauchemez S et al. Strategies for containing an emerging
influenza pandemic in Southeast Asia. Nature, 2005;437(8):209-214.
• Ferguson NM, Cummings DAT, Fraser C et al. Strategies for mitigating an influenza pandemic.
Nature 2006;442:448-452.
• Gambotto A, Barratt-Boyes SM, de Jong MD et al. Human infection with highly pathogenic
H5N1 influenza virus. Lancet 2007;371:1464-75.
• Nishiura H. Early efforts in modeling the incubation period of infectious diseases with an
acute course of illness. Emerging Themes in Epidemiology, 2007;4:2.
• Vynnycky E, Trindall A, Mangtani P. Estimates of the reproduction numbers of Spanish influenza
using morbidity data. International Journal of Epidemiology. 2007;36:881-889.
• Writing committee of the second WHO consultation on clinical aspect of human infection with
avian influenza A(H5N1) virus. Update on avian influenza A (H5N1) virus infection in humans.
N Engl J Med 2008;358:261-73.
3. Symptom development and clinical attack rate
Suggested assumptions
• About two-thirds of people with pandemic influenza are expected to develop clinical symptoms.
• Uncomplicated clinical symptoms of pandemic influenza are expected to be similar to those
of seasonal influenza: respiratory symptoms, fever and abrupt onset of muscle ache, and
headache or backache.
• Averaged overall (across all age groups), population clinical attack rates are expected to be
25% to 45%.
Implications
• Existing clinical criteria for influenza-like illness can serve as the basis for pandemic disease
surveillance. However, countries are encouraged to closely monitor the evolution of clinical
characteristics of pandemic influenza and to facilitate refinement of a clinical case definition.
• Given influenza's usual nonspecific clinical presentations, pandemic surveillance should be
supported by laboratory diagnosis. This is critical to confirm and comprehensively describe
the first cases in each country.
• Because the number of ill persons may overwhelm the existing health care capacities, countries
should plan for rapid scaling up of health care capacity and prioritization of limited resources.
• Wide variations in clinical attack rates among different age groups and localities have been
observed with previous pandemics. Countries are encouraged to estimate clinical attack rates
based on their own data and experiences.
Scientific basis
• A pooled analysis of 522 persons who were voluntarily infected with influenza reported the
proportion of symptomatic infection (any symptoms) as 66.9% (95% CI: 58.3, 74.5). No
significant differences were noted according to the virus type or the initial infectious dose
(Carrat et al, 2008).
53
• A modelling study using 1957 pandemic data from the United Kingdom estimated that 60 - 65%
of infected individuals experienced clinical symptoms (Vynnycky E et al., 2008).
• An analysis of an influenza outbreak experience in an isolated island, Tristina da Cunha, in 1971
suggested that almost all susceptible persons developed symptomatic illness (Mathews JD
et al., 2007).
• During the 1918 pandemic in the United States of America, influenza-like illness rates averaged
28%, with a low of 15% and a high of 50% (Frost WH, 1919). These data were based on houseto-house surveys.
• In one report, age-specific serological attack rates for the 1957 pandemic averaged 40%,
with a low of 5% and a high of 70%. In contrast, a 20% serological attack rate was reported
for the 1968 pandemic (Stuart-Harris CH, 1970).
• A retrospective questionnaire survey from one US city revealed the overall clinical attack rate
during the 1968 pandemic was 39%; and it was similar among all age groups (Davis LE et
al., 1970). Another serological survey found that about 25% (range of 21% to 27%) of children
tested positive for antibodies to the influenza strain that circulated in 1968 (Chin J et al.,
1974).
• Clinical attack rates calculated from an estimated basic reproduction number (R0) between
1.5 and 2.0 range from approximately 25% to 45% (Ferguson NM et al., 2005; Ferguson
NM et al., 2006; Germann TC et al., 2006; Colliza V et al., 2007; Halloran ME et al., 2008).
• Gastrointestinal symptoms have been observed among patients with influenza A (H5N1), but
have varied by clades (WHO writing committee, 2008).
Selected references
• Frost WH. The epidemiology of influenza. Pub Health Reports; 1919;34(33) (republished
in Pub Health Report, 2006;121(S1):149-158).
• Stuart-Harris CH. Pandemic influenza: an unresolved problem in prevention. J Infect Dis,
1970;122:108-115.
• Davis LE, Caldwell GG, Lynch RE. Hong Kong influenza: the epidemiologic features of a high
school family study analyzed and compared with a similar study during the 1957 Asian
influenza epidemic. Amer J Epid, 1970;92:240-247.
• Chin J, Magoffin RL, Lennette EH. The epidemiology of influenza in California, 1968-1973.
West J Med. 1974;121:94-99.
• Germann TC, Kadau K, Longini, IM Jr. et al. Mitigation strategies for pandemic influenza in
the United States. PNAS, 2006;103(15):5935-5940.
• Halloran ME, Ferguson NM, Eubank S et al. Modeling targeted layered containment of an
influenza pandemic in the United States. PNAS, 2008;105(12):4639-4644.
• Mathews JD, McCaw CT, McVernon et al. A biological model for influenza transmission:
pandemic planning implication of asymptomatic infection and immunity. PLoS ONE,
2007;2(11):e1220.
• Vynnycky E, Edmunds WJ. Analyses of the 1957 (Asian) influenza pandemic in the United
Kingdom and the impact of school closures. Epidemiol Infect. 2008;136(2):166-79.
54
4. Dynamics of the pandemic and its impact
Suggested assumptions
• An influenza pandemic can begin at any time of the year and any place in the world; it is
expected to spread to the rest of the world within several weeks or months.
• Duration of a pandemic wave is expected to be from several weeks to a few months, but will
likely vary from country to country; within a single country variations may be seen by community.
• Most communities are expected to experience multiple waves of a pandemic.
• Increased hospitalizations, excess mortality, and secondary complications are expected to vary
widely among countries and communities. Vulnerable populations are expected to be affected
more severely.
• Workplace absenteeism is expected to be higher than the estimated clinical attack rate.
Implications
• Each county should develop and strengthen its capacity to detect the early emergence of a
potential pandemic event and to respond rapidly.
• Countries should guide their local governments and communities to develop their own pandemic
influenza preparedness and response plans.
• Actions during the post-peak periods between pandemic waves should be considered in overall
pandemic preparedness and response plans.
• Countries are encouraged to further estimate and prepare health care needs based on their
own resources and experiences, with particular concern to vulnerable populations.
• A series of waves as experienced with 20th century pandemics, may lead to depletion of stocks
of consumables, such as personal protective equipment and pharmaceuticals, before a second
wave.
• Countries are encouraged to further estimate excess workplace absenteeism during a pandemic
based on their own context and to guide all sectors to develop business continuity plans for
high and possibly fluctuating levels of absenteeism throughout the pandemic.
Scientific basis
• Early reports and later analysis of epidemiological evidence suggest that milder epidemic
waves (in Europe in April and May, 1918 and in the USA in the spring of 1918) preceded the
most severe pandemic wave in autumn 1918 (Frost WH, 1919; Olson SR et al., 2005).
• An influenza virus A(H1N1) resistant to oseltamivir was first reported from Norway in January
2008 and then spread throughout much of the Northern Hemisphere during the next couple
of months (WHO, 2008). It subsequently was detected in the Southern Hemisphere during
the summer of 2008.
• Excess mortality data from 1918 to 1920 show that population mortality varied more than 30-
fold across countries (Murray CL et al., 2006).
• Variation among countries ranged from a low of 0.20% (Denmark) to a high of 4.39%
(India).
• Variation within countries ranged from 2.12% to 7.82% in India and from 0.25% to 1.00%
in USA.
• In the US during the 1918 pandemic, there were marked and consistent differences in
55
morbidity and mortality among persons of different economic status: the lower the economic
level, the higher the attack rate. This relationship persisted even after adjustments were made
for factors such as colour, sex, age, and other conditions (Sydenstricker E, 1931).
• A multinational analysis of the 1968 pandemic showed very different epidemic patterns in
the six countries studied (Viboud C et al., 2005).
• In the USA, a large epidemic was observed in 1968/1969, followed by a milder one in
1969/1970, late in the winter season.
• In Canada, the two epidemic patterns were similar in amplitude and timing.
• In other countries (Australia, France, Japan and the United Kingdom), the first
epidemic was mild, followed by a much more intense epidemic in the next season.
• A simulation study in the United Kingdom estimated that, overall, about 16% of the workforce
is likely to be absent due to school closures during a pandemic. This estimate
rises for sectors with a high proportion of female employees, such as health and social care
(Sadique MZ et al., 2008).
Selected references
• Cockburn WC, Delon PJ, Ferreira W. Origin and progress of the 1968-69 Hong Kong influenza
epidemic. Bull World Health Organ 1969;41:345-8.
• Murray CL, Lopez AD, Chin B et al. Estimation of potential global pandemic influenza mortality
on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis. Lancet
2006;368:2211-18.
• Olson DR, Simonson L, Edelson PJ et al. Epidemiological evidence of an early wave of the
1918 influenza pandemic in New York City. PNAS 2005;102(31):11059-11063.
• Sadique MZ, Adams EJ, Edmunds WJ. Estimating the costs of school closure for mitigating
an influenza pandemic. Public Health 2008, 8:135.
• Sydenstricker E. The incidence of influenza among persons of different economic status during
the epidemic of 1918. Pub Health Report 1931;46(4) (republished in Pub Health Report,
2006;121(S1):191-204).
• Viboud C, Grais RF, Lafont BAP et al. Multinational impact of the 1968 Hong Kong influenza
pandemic: evidence for a smoldering pandemic. JID 2005;192:233-48.
• WHO Expert committee on respiratory virus diseases. First Report. World Health Organization
Technical Report Series No 170. Geneva, 1959.
• WHO. Influenza A (H1N1) virus resistance to Oseltamivir: preliminary summary and future
plans. WHO, Geneva, 2008 (at http://www.who.int/csr/disease/influenza/oseltamivir_
summary/en/index.html, accessed on 3 December 2008).
56
ANNEX 2 - REVISION PROCESS
WHO convened the first meeting of the Pandemic Preparedness and
Response Guidance Revision Working Group in Geneva, Switzerland,
on 27-29 November 2007
On 27-29 November 2007, WHO convened the first meeting of the Pandemic Preparedness and
Response Guidance Revision Working Group in Geneva, Switzerland. Experts in the field of
communicable diseases and influenza, emergency and pandemic planning, and communications
from national and international technical institutions, UN/international organizations and WHO staff
from headquarters, regional and country offices convened to identify areas requiring updating.
The working group created five task forces with specific focus on developing a strategic policy
document as well as recommendations on public health interventions, medical interventions, the
“whole-of-society” approach to pandemic preparedness and communications.
In advance of an actual pandemic, the precise symptoms, epidemiology, virology and diseasetransmission patterns can not be known. Assumptions based on past epidemics and seasonal influenza
can, however, be used in order to facilitate pandemic preparedness planning activities - and identify
disease control approaches likely to be effective. The assumptions upon which this guidance is based,
outlined in Annex 1, were derived from available PubMed, Cochrane Library and secondary papers
identified from existing relevant guidelines.
A second meeting of the Working Group was held on 5-7 March 2008 in Lyon, France. In order to
support the discussions of Public Health Interventions and Medical Interventions Task Forces, WHO
also hosted consultations in Geneva, Switzerland.
A final WHO consultation was convened on 5-9 May 2008 in Geneva, Switzerland, to consolidate
the results of these meetings to produce a draft of the strategic document.
The revised draft of the WHO Pandemic Preparedness Guidelines was made available for public
review through the WHO web-site for four weeks. Over 600 comments from Member States, healthrelated organizations, universities, the private sector and individuals were received. All input from
this review were considered and evaluated by members of the task forces and the WHO Secretariat.
Declaration of interest
As indicated in the Foreword, all external experts acknowledged herein, submitted a WHO Declaration
of Interest for WHO Experts form. The experts who declared interests are listed below, along with a
short description of the interests concerned. The chairs and focal points of the five task forces, and
the chairs of the subsequent meetings, formally declared that they had no interests.
Taskforce Chairs and Focal Points
Task Force 1: Focusing on Policy Guidelines and Overarching documents
Chair: Ms Jill Sciberras, Canada
Focal point: Dr Helge Hollmeyer, WHO
57
Task Force 2: Focusing on Communications and Social Mobilization
Chair: Mr John Rainford, WHO
Focal point: Ms Sarah Galbraith, WHO
Task Force 3: Focusing on Public Health Interventions
Chair: Dr Hitoshi Oshitani, Japan
Focal point: Dr Nima Asgari, WHO
Task Force 4: Focusing on Medical Interventions
Chair: Dr Salah Al-Awaidy, Oman
Focal point: Dr Hongxin Zhao, the United Kingdom
Task Force 5: Focusing on Non-health Sector Preparedness
Chair: Dr Michael Mosslemans, UNOCHA
Focal point: Dr Liviu Vedrasco, UNOCHA,
Focal point 2: Dr Arthur Marx, UNOCHA
The following meetings were held and contributed to the revision process:
Working Group Meetings of Task Forces, November 2007, March 2008
Consultations on Pandemic Surveillance, December 2007, March 2008
Consultation on Pandemic Influenza Disease Control Strategies, April 2008
The Global Consultation for Revision of WHO Guidance, May 2008.
Experts with declared interests
Of the 139 experts who participated in the substantive elaboration of this guidance document,
declared interests. The names of the experts concerned, the meetings they attended and their possible
membership of a task force are indicated along with their declared interest(s). No interests were
declared by the Chairs and Focal Points of the five task forces, nor by the chairs of any subsequent
meetings.
Professor Ziad Memish
Professor Memish's institute had conducted contract research on meningococcal vaccine and PCV7
for GSK and Wyeth. Professor Memish attended the second WHO Consultation on Pandemic Influenza
Disease Control Strategies in April 2008, and the Global Consultation on the Preparation of the
Pandemic Preparedness Guidelines in May 2008.
Professor Arnold Monto
Professor Monto has been an ad-hoc consultant for Roche, GSK, Novartis, Solvay and Aventis Pasteur.
in December 2007 and April 2008, and the Global Consultation on the Preparation of the Pandemic
Preparedness Guidelines in May 2008.
seven
He attended the first and second WHO Consultations on Pandemic Influenza Disease Control Strategies
58
Professor Jonathan Nguyen van Tam
Professor van Tam is a former employee of GSK, Roche, MSD and Sanofi Pasteur. In addition, he has
received financial support from Roche, Sanofi Pasteur and MSD to attend symposia. Finally, he has
received consulting fees from Roche, Baxter and Novartis, and honoraria to speak at meetings
sponsored by GSK, Novartis, Solvay and Roche. Professor Nguyen van Tam attended the first and
second working group meetings in November 2007 and March 2008. He also attended the second
Consultation on Pandemic Disease Control Strategies in April 2008 and the Global Consultation on
Preparation of the Pandemic Preparedness Guidelines in May 2008. Professor Nguyen van Tam was
a member of Task Force 1 focusing on Policy Guidelines and Overarching documents and Task Force
3 focusing on Public Health Interventions.
Dr Nick Phin
Dr Phin has participated in scientific discussion panels sponsored by pharmaceutical companies,
including for example MSD and Sanofi Pasteur in relation to public acceptance of influenza vaccines.
Global Consultation on the Preparation of the Pandemic Preparedness Guidelines in May 2008. Dr
Phin participated in Task Force Four Focusing on Medical Interventions
Dr Stanley Plotkin
Dr Plotkin is a former employee of Sanofi Pasteur and jointly holds patents with Merck. He attended
the second Consultation on Pandemic Disease Control Strategies in April 2008.
Simon Strickland
Mr Strickland declared owning shares in GSK. He attended the first and second working group
meetings in November 2007 and March 2008 and the Global Consultation on the Preparation of
the Pandemic Preparedness Guidelines in May 2008. Mr Strickland participated in Task Force Five
Dr Neil Fergusson
Dr Fergusson has spoken at sponsored symposia (Roche, Novartis) and has been paid honoraria for scientific
(Swiss Re and Risk Management Solutions). He has also acted as an adviser to the United States
and United Kingdom governments. He attended the first Consultation on Pandemic Surveillance in
December 2007.
focusing on Non-Health Sector Preparedness.
advisory board meetings (GSK, Roche, Novartis), and has acted as a scientific adviser to insurance companies
Dr Phin attended the first and second working group meetings in November 2007 and March 2008. He
also attended the second Consultation on Pandemic Disease Control Strategies in April 2008 and the
59
Commenting process
Following the last meeting in May 2008, the draft guidance document prepared by the five task
forces, was opened for public comment. The month-long commenting period began on 15 October
and ended on 15 November 2008.
The process adopted for receiving comments was as follows: A message was posted on the WHO
website indicating that those wishing to comment on the guidance should contact the Global Influenza
Programme. Following receipt of a request, interested parties were asked to complete the WHO
Declaration of Interest Form, after which they were granted access to the draft guidance document.
Declarations of Interest were reviewed and assessed by the Secretariat upon receipt of comments.
If the declared interests were deemed to constitute a conflict, the comments were not taken into
consideration during the process to finalize the guidance document.
• A total of 428 individuals from 66 countries submitted a request to review the guidance document
and provided 488 comments in the electronic forum.
• Over 150 written comments were also received from WHO Member States and other institutions
via e-mail.
The comments received were analysed to check that they did not duplicate other comments, categorized
according to the subject matter, and any remarks on non-health related issues, for example on
linguistic points, were acted upon.
The remaining comments were reviewed in a series of four meetings with working group members
and the WHO Secretariat in November 2008. During these meetings, the comments received were
examined against, and analysed for, their added value and feasibility. None of the public comments
that were discussed during these meetings had any significant impact on the recommendations. Over
300 comments were accepted and integrated into the guidance document, while the remaining
comments were partially or completely rejected, either because they were construed as political
commentaries; or because the cost implications of the suggestion outweighed the benefit of the
change; or because the person who submitted the comment had a declared conflict of interest.
Comments from members of the pharmaceutical industry with a vested interest in influenza vaccines
were rejected when not substantiated by existing evidence.
60
OVERVIEW OF STEPS FOR THE DEVELOPMENT OF PANDEMIC INFLUENZA PREPAREDNESS AND RESPONSE GUIDANCE REVISION
1st Working Group Meeting
Drafting
1st Disease Control Strategies
Task Force Meeting
2nd Working Group Meeting
Pandemic Surveillance
Task Force Meeting
2nd Disease Control Strategies
Task Force Meeting
Drafting
Global Consultation
for WHO Pandemic
Preparedness Guidelines
Revision, editing, visual elements
Web-based public review
Processing of web-based
review comments
Internal WHO Clearance
STEPS
November 2007, Geneva
Nov.'07-Mar.'08, virtual space
January 2008, Geneva
March 2008, Lyon
March 2008, Geneva
April 2008, Geneva
Jan-May 2008, virtual space
May 2008, Geneva
May-Oct 2008
Oct-Nov 2008
Dec. '08 - Jan '09
February - April 2009
DATE, PLACE OUTCOME
5 task forces to focus on various
aspects of the guideline.
1st draft of the guidelines.
2nd draft: revised section on
disease control strategies.
3rd draft of the guidelines.
4th draft: revised section on
pandemic surveillance.
5th draft: revised section on
disease control strategies.
6th draft: collation of various
sections.
7th draft: general consensus
reached on main
recommendations.
8th draft.
Over 600 comments received.
9th draft: comments incorporated
into the document.
Official document ready for
publication.
World Health Organization
Global Influenza Programme
Avenue Appia 20
1211 Geneva 21
Switzerland
E-mail: whoinfluenza@who.int
www.who.int/csr/diseases/influenza
ISBN 978 92 4 154768 0 |