2
Planning for Pandemic Influenza

OVERVIEW

Turning from the past to the worrisome present, workshop participants representing the U.S. Department of Health and Human Services (HHS) and the Pan American Health Organization (PAHO) discussed current efforts to prepare for a potential influenza pandemic. Both of these agencies have provided considerable leadership in assessing the possible effects of pandemic influenza on individuals, communities, health-care systems, and economies.

In the United States, just as the potential consequences of pandemic influenza are many and various, so are the plans being made by the U.S. government to address these contingencies, said speaker Bruce Gellin, director of the National Vaccine Program Office of HHS. In order to illustrate both the breadth and depth of national pandemic planning, Gellin discussed the overall national strategy, the role of the HHS within that framework, and several specific initiatives undertaken by the National Vaccine Program Office to fulfill that role.

In his workshop presentation, Gellin described the National Strategy for Pandemic Influenza (NSPI) created by the Homeland Security Council (HSC) as well as the detailed NSPI implementation plan released in May 2006 (HSC, 2005, 2006). The NSPI provides an integrated framework for national planning efforts across all levels of government and in all sectors of society outside of government. The integrated response should be based on the following principles, Gellin said:

  • The federal government will use all instruments of national power to address the pandemic threat.



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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary 2 Planning for Pandemic Influenza OVERVIEW Turning from the past to the worrisome present, workshop participants representing the U.S. Department of Health and Human Services (HHS) and the Pan American Health Organization (PAHO) discussed current efforts to prepare for a potential influenza pandemic. Both of these agencies have provided considerable leadership in assessing the possible effects of pandemic influenza on individuals, communities, health-care systems, and economies. In the United States, just as the potential consequences of pandemic influenza are many and various, so are the plans being made by the U.S. government to address these contingencies, said speaker Bruce Gellin, director of the National Vaccine Program Office of HHS. In order to illustrate both the breadth and depth of national pandemic planning, Gellin discussed the overall national strategy, the role of the HHS within that framework, and several specific initiatives undertaken by the National Vaccine Program Office to fulfill that role. In his workshop presentation, Gellin described the National Strategy for Pandemic Influenza (NSPI) created by the Homeland Security Council (HSC) as well as the detailed NSPI implementation plan released in May 2006 (HSC, 2005, 2006). The NSPI provides an integrated framework for national planning efforts across all levels of government and in all sectors of society outside of government. The integrated response should be based on the following principles, Gellin said: The federal government will use all instruments of national power to address the pandemic threat.

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary States and communities should have credible pandemic preparedness plans to respond to an outbreak within their jurisdictions. The private sector should play an integral role in preparedness before a pandemic begins and should be part of the national response. Individual citizens should be prepared for an influenza pandemic and be educated about individual responsibility to limit the spread of infection if they or their family members become ill. Global partnerships will be leveraged to address the pandemic threat. The NSPI implementation plan (see Figure 2-1), organized in stages that correspond to the pandemic phases in the World Health Organization (WHO) global framework for pandemic influenza (WHO, 2005b), provides a detailed prescription for how the government should plan and respond to a pandemic, Gellin said. The NSPI assigns responsibilities to various government agencies and departments in the areas of international efforts, transportation and borders, human and animal health, public safety, and government continuity. The implementation plan also outlines expectations for state and local governments, the private sector, and groups and individuals deemed critical to the nation’s infrastructure. The core of the NSPI implementation plan is the specification of more than 300 actions to be taken by federal departments and agencies, Gellin explained. For each such item, the plan identifies lead and supporting agencies, outcome measures, and timelines for action. Within the area of human health, these actions include the enhancement of domestic and international disease surveillance, the procurement and distribution of countermeasures, the acceleration of research and development of vaccines, drugs, and diagnostics, and the development of international cooperation, capacity, and preparedness. In order to demonstrate how this scheme translates into specific actions by government departments and agencies, Gellin focused on HHS and one of its areas of responsibility: pandemic vaccine development programs. He noted that HHS planning for pandemic vaccine production is governed by several assumptions. First, it is assumed that the entire global manufacturing capacity for influenza vaccine, currently estimated to be approximately 300 million doses per year, would be devoted to the production of vaccine against a pandemic strain. Second, the first trial of pre-pandemic H5N1 vaccine is assumed to require two doses per person at 90 micrograms per dose—as compared with the seasonal influenza vaccine, which requires 15 micrograms per dose—although it is possible that still-unproven antigen-sparing strategies could reduce this dosage. Third, it is assumed that the U.S. cannot rely on other countries to supply vaccine in a pandemic; the nation must therefore depend upon its sole domestic vaccine manufacturer, Sanofi-Pasteur, to supply all of its pandemic vaccine. If a pandemic commenced today and these assumptions proved correct, Sanofi-Pasteur could produce enough vaccine to immunize approximately 15 million people, or about five percent of the U.S. population. In 2005, in response to these calculations,

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary FIGURE 2-1 Stages of federal government response. SOURCE: Gellin (2006).

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary the President requested $7 billion to increase domestic influenza vaccine manufacturing capacity. One way to increase the domestic production of pandemic vaccine is to develop cell-culture influenza vaccine technology. Gellin noted that the federal government is funding an effort to license a cell-culture influenza vaccine in the United States for seasonal use, with the ultimate goal of developing domestic cell-culture facilities. While it will not hasten strain identification or speed the initial stages of vaccine development, cell-culture technology will be able to produce a far greater volume of vaccine once production begins. Moreover, Gellin said, cell-culture technology is only one of a broad spectrum of strategies being advanced by the HHS pandemic vaccine influenza program. Other goals of the agency include ensuring egg security, building pre-pandemic vaccine stockpiles, increasing vaccine production capacity, employing dose-sparing technologies, and developing broad-spectrum vaccines that could be used indefinitely against evolving strains of H5N1 influenza or other future pandemic influenza viruses. As noted in the Summary and Assessment, workshop participants engaged in extended discussions concerning priorities for influenza vaccination, opportunities for boosting domestic vaccine production capacity, and the use of antiviral drugs for either prophylaxis or as a secondary measure when vaccines are in short supply. Gellin noted HHS Secretary Leavitt’s May 2006 announcement that stocks of Tamiflu© would be pre-deployed to Asia as a first defense against a possible pandemic; the U.S. will control deployment of the stockpile and, if foreign containment efforts are not feasible, plans to return it to this country. Reflecting on the process of developing a national pandemic strategy, workshop participants applauded the efforts that have been made to date but voiced concerns regarding the translation of national policies into local action. Steven Bice, an infectious disease specialist at Battelle Science and Technology International, noted that all responses to pandemic disease are local and advised planners that they should therefore consult with those public health officials “who will have the fight on their shoulders” in a pandemic. Rather than taking part in “a lot of top-down planning and not a lot of listening up,” Bice advised the federal government to “start listening very, very carefully to the states and the locals.” If they do listen, he said, they will hear that state and local officials would like guidance from the federal government on pandemic planning, including such things as feedback on the results of tabletop exercises or drills to test state and local preparedness. Conversely, he noted, the state and local perspective is lacking in the evaluation of such exercises at the federal level. In addition, Bice said, pandemic planning has been further undermined by a lack of coordination at the federal level, resulting, for instance, in turf wars between the Department of Homeland Security and HHS. While it is widely acknowledged that an infectious disease pandemic is likely to overwhelm the U.S. medical system, workshop participants noted that the federal government has given scant attention—and even less money—to

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary addressing this situation. D.A. Henderson projected that a pandemic would force hospitals to handle an additional 30 to 40 percent more patients than normal, a “Katrina scenario” that demands emergency planning by communities and the hospitals that serve them. The emergency plans will need to include provisions for such things as triage, the credentialing of non-physicians to provide care in an emergency, and relief from liability under such circumstances. “There is a great gaping gap here,” said Henderson, who criticized government planners for focusing on the stockpiling and delivery of countermeasures of questionable efficacy rather than concentrating their efforts on “a problem which we know we are going to have.” Workshop participants also expressed concern that the U.S. pandemic influenza strategy fails to recognize our nation’s dependence on and interdependence with fast-moving global markets. As noted in the Summary and Assessment, Gellin responded that the federal government’s efforts to promote pandemic planning with and by the private sector—a proxy for the global economy—have begun to address this issue. In addition to describing preparations for pandemic influenza in the United States, the session also examined such preparations in Latin America and the Caribbean under the aegis of PAHO. In their contribution to this chapter, presenter Oscar Mujica and colleagues discuss how PAHO, along with partners that include the U.S. Agency for International Development, the Centers for Disease Control and Prevention (CDC), the World Bank, the Food and Agriculture Organization of the United Nations (FAO), and the United Nations Children’s Fund, has worked to encourage pandemic influenza planning in the region. In particular, they describe a key element in this process, a series of planning workshops and self-assessment exercises conducted by PAHO for national representatives of its member states and guided by the World Health Organization (WHO) Global Influenza Preparedness Plan (WHO, 2005b). The authors also report on the progress made by member states in developing national influenza pandemic preparedness plans and mechanisms for their implementation at both national and local levels.

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary PANDEMIC INFLUENZA PREPAREDNESS: REGIONAL PLANNING EFFORTS1 Oscar J. Mujica, M.D.2 Pan American Health Organization Otavio Oliva, M.D.2 Pan American Health Organization Thais dos Santos, B.Sc.2 Pan American Health Organization John P. Ehrenberg, M.D.2 Pan American Health Organization “Ver después no vale; lo que vale es ver antes … y estar preparados.”3 —José Martí In 2003 the 56th World Health Assembly and the 44th PAHO Directing Council issued resolutions urging countries to strengthen their capacity to prevent, detect, and diagnose influenza virus infection and to be prepared to respond to a pandemic situation (WHO, 2003; PAHO, 2003). To avoid the catastrophic consequences that would accompany a worldwide influenza pandemic, these contingency plans should be put in place now, during the inter-pandemic period, instead of waiting for the next one to strike. In 2006 around 130 million people, or 23 percent of the total population, lived in rural areas of Latin America and the Caribbean (UN, 2006), most of them in direct contact with chickens and pigs. The FAO reports that poultry accounts for approximately 70 percent of the animal protein consumed in Latin America and the Caribbean (FAO, 2006). Also, the expanding poultry industry has become a major source of income and employment in these countries, contributing greatly to their urban and peri-urban development. A pandemic in the Region would be not only a public health problem but also a threat to food security and an 1 Corresponding author: Oscar J Mujica, M.D., Epidemiologist, Communicable Diseases Unit, Health Surveillance & Disease Management, Pan American Health Organization, World Health Organization, 525 23rd St., NW, Washington, DC 20037. Telephone (202) 974-3974; Fax (202) 974-3656; E-mail: mujicaos@paho.org 2 Pandemic Influenza Team of the Communicable Diseases Control Unit. 3 Translation: “It is worthless to analyze after the fact; what counts is to anticipate what may happen … and be prepared.”

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary economic disaster for the poorest populations in the rural areas and for entire national economies. Considering the threat posed by a possible influenza pandemic, PAHO has been supporting its member states in preparing for a pandemic, as mandated by its governing bodies as well as by the 2005 Presidential Summit of the Americas. In 2005 the PAHO director created a multidisciplinary Task Force on Epidemic Alert and Response (the EAR task force) to advise, coordinate, and monitor all activities of the organization related to the planning and implementation of influenza pandemic preparedness and response. All activities of the EAR task force are guided by the revised International Health Regulations (IHR) adopted in May 2005 (WHO, 2005a). These regulations stipulate that countries develop and maintain core capacities to detect, assess, and control events of international public health importance. The inter-programmatic nature of the task force allows it to deal better with the complex process involved in IHR implementation and planning for an influenza pandemic, which requires highly coordinated efforts from a variety of sectors. So far, PAHO’s focus has been to assist member states in drafting National Influenza Pandemic Preparedness Plans (NIPPPs), taking into account the recommendations that the WHO Global Influenza Preparedness Plan offers for national measures before and during pandemics (WHO, 2005b). Box 2-1 summarizes key steps in the development and assessment of NIPPPs. These multisectoral plans should take into account both human and veterinary health and be flexible enough to take into account various possible outcomes of a pandemic, depending on levels of viral pathogenicity and availability of resources. Subregional workshops have been carried out to train those charged with preparing NIPPPs in the use of modeling software. These modeling tools have been developed by the CDC to estimate the potential impact of a pandemic (Meltzer et al., 2000; Zhang et al., 2005; Praveen et al., 2006). The availability of such estimates helps countries keep their national plans flexible by providing them with a variety of contingencies to plan for, including a worst-case scenario where there are neither available vaccines nor antiviral medications. Table 2-1 shows a summary of estimates of potential pandemic impact in Latin America and the Caribbean for 1968-like and 1918-like scenarios which were prepared by country teams during those subregional workshops. After member countries provided draft plans, PAHO carried out a series of self-assessment exercises where NIPPPs were evaluated using a PAHO-developed tool based on WHO’s checklist for influenza pandemic preparedness planning (WHO, 2005c). The tool covers the seven core components on the WHO checklist: emergency preparedness; surveillance; case investigation and treatment; preventing spread of the disease in the community; maintaining essential services; research and evaluation; and implementation, testing and revision of the national plan. These core components are further divided into 44 main categories containing a total of 368 checkpoints for assessment.

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary BOX 2-1 PAHO Strategy in Supporting Member States in the Development and Assessment of National Influenza Pandemic Preparedness Plans (NIPPPs) Development of draft NIPPPs Introduction of WHO guidelines for pandemic preparedness planning Introduction and application of modeling tools such as FluAid, FluSurge and FluWorkloss in order to estimate the potential impact of a pandemic Development of national action plans which include adequate development of draft NIPPPs Assessment and testing of draft NIPPPs Self-assessment of NIPPPS Tabletop exercises to highlight issues of chain of command and need for multi-sectoral integration and coordination Development of action plans to address remaining gaps identified during the self-assessment and simulation exercises Local implementation of NIPPPs Development of simulation drills and tabletop exercises to test local preparedness and put local contingency plans into practice Promote subnational, multisectoral training to promote the development of local contingency plans for a pandemic which adequately incorporate all pertinent areas, including surveillance, health services, disasters management, and social communication. Carrying out of tabletop exercises to test the completeness of local plans, taking into account subnational realities. Monitoring and strengthening of NIPPPs Promote the use of subnational drills to assist in the monitoring of suitability of local contingency plans Promote any necessary changes in order to keep plans updated SOURCE: PAHO (in press). All countries in Latin America and the Caribbean participated in such self-assessment exercises. Each country delegation had participants from the areas of epidemiology, health services, laboratory diagnosis, immunization, disaster management, emergency preparedness, social communication, veterinary public health, agriculture, and international relations. The main goal of the exercises was for countries to work together in a collective, multidisciplinary, and intersectoral way to improve the preparation and implementation of their various national plans. For many of these professionals this exercise was the first time that they had sat at the same table with their peers to discuss pandemic preparedness. One of the major achievements of this interaction was the multisectoral discussion that took place about the steps required to complete the national plans of the different

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary TABLE 2-1 Potential Impact of a 25 Percent Clinical Attack Rate Influenza Pandemic in Latin America and the Caribbean, by Main Health Outcome and Severity Scenario, Mid-2006   Pandemic Scenario Potential Health Impact 1968 Moderate 1918 Severe Deaths 334,163 [131,630–654,960] 2,418,469 [627,367–5,401,035] Hospitalizations 1,461,401 [459,051–1,937,503 11,798,613 [3,189,747–16,418,254] Outpatient visits 76,187,593 [59,738,730–109,207,769] 68,470,386 [58,114,124–92,27,761] SOURCE: PAHO (in press). countries. In particular, the discussion highlighted the importance of joint work and integration in the contingency-planning process. The participating countries’ national plans showed varying levels of compliance with the WHO checklist, and different subregions tended to have different patterns of strengths and weaknesses in their levels of compliance.4 In the Andean subregion, for example, national plans seemed to be most comprehensive in the areas pertaining to the management of cases, while they were not so well done in the area of research and evaluation. Caribbean countries also had difficulties with research and evaluation, but they were strong in the area of emergency preparedness. National plans for countries in Central America appear to be strongest in implementation and weakest in essential services continuity. For Southern Cone countries, development was a strength and essential services continuity a weakness. Table 2-2 presents the average compliance with WHO guidelines for each of the seven NIPPP core components in the four geographical subregions. Emergency preparedness, the first core component in the pandemic influenza preparedness planning, is broken down into six main categories, one of which is devoted to a number of specific and fundamental legal and ethical issues as described in Box 2-2. 4 Four sub-regions were assessed: the Andean Area, comprising Bolivia, Colombia, Ecuador, Peru, and Venezuela; the Southern Cone, comprising Argentina, Brazil, Chile, Paraguay, and Uruguay; Central America, comprising Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama (plus Cuba, Dominican Republic, and Haiti); and the Caribbean, comprising Anguilla, Antigua and Barbuda, Aruba, Barbados, Belize, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Martinique, Montserrat, St. Kitts and Nevis, St. Lucia, St. Maarten, St. Vincent and The Grenadines, Suriname, The Bahamas, Trinidad and Tobago, and the Turks and Caicos Islands.

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary TABLE 2-2 Pandemic Preparedness Readiness in Latin America and the Caribbean. Current Compliance (percentage) with WHO Guidelines, by Core Components and PAHO Sub-Regions, Mid-2006 NIPPP core component Andean Area Central America The Caribbean Southern Cone 1 Emergency preparedness 38.6 34.6 56.7 58.5 2 Epidemiological surveillance 37.0 34.8 56.5 54.4 3 Case management 52.3 54.5 48.9 60.9 4 Population containment 20.0 38.0 37.0 64.0 5 Essential services continuity 24.5 33.3 45.2 41.9 6 Research and evaluation 10.0 40.0 15.0 30.2 7 Implementation of the national plan 40.0 60.0 30.0 50.0 SOURCE: PAHO (in press). Among all the categories of emergency preparedness, the area of legal and ethical issues is where Latin American countries need the most work in satisfying the WHO checklist. As can be seen in Table 2-3, it is by far among the least developed areas for the countries of the Andean Area and Central America and is the second-least developed area for the other two subregions. The workshops called attention to the need for intersectoral coordination in the development of NIPPPs. Since February 2006, when the workshops started, many countries have been engaging in intersectoral dialogue in addition to carrying out the necessary activities for the local implementation of NIPPPs. Using the momentum created by the subregional self-assessment meeting, professionals in charge of preparedness planning have strengthened their interaction with those professionals who will be responsible for implementing the plans. The discussion resulted in the roles and responsibilities for all the actors in the response becoming better defined. It was also extremely beneficial to have representatives from the legal departments of the ministries of health participate in the process, as they were able to point out amendments to health legislation that will be necessary in order to implement the NIPPP. In addition to promoting the development of national plans, PAHO is helping its member states strengthen the mechanisms and capacities necessary to implement these plans fully. The necessary capacities include surveillance capabilities, health services, vaccine and antiviral technologies, and communication, among others. In particular, PAHO is supporting its member states in making national influenza preparedness plans operational at the local level, since National Influenza Preparedness Plans are only as effective as their local contingency plans. One important goal will be to strengthen the core competencies of member states and communities to respond to any public health emergency, as identified through the new IHR.

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary BOX 2-2 Core Legal and Ethical Issues to Be Considered and Assessed in the NIPPPs Legal Issues Evidence of a legislative framework in place for the national response plan Legal dispositions for contingencies (maintenance of essential services and other crisis management measures) Legal basis for travel and movement restrictions assessed Legal basis for closure of educational institutions assessed Legal basis for isolation and quarantine of infected persons or of persons suspected of being infected assessed Legal basis for prohibition of mass gatherings assessed Standing policy and legal basis for influenza vaccination of essential personnel assessed Legal issues (liability, insurance, licensing) related to the mobilization of temporary workers assessed Liability for unforeseen adverse events attributed to antipandemic strain vaccine and antiviral use considered Legislative framework for compliance with the International Health Regulations in effect Inclusion of pandemic influenza in national legislation for the prevention of occupational diseases considered Ethical Issues Ethical review on the limitation/restriction of access to scarce resources Ethical review on the compulsory nature of vaccination of essential personnel Ethical review on limiting personal freedom and movement, such as may occur with isolation and quarantine Establishment of an ethical framework for research, especially when this involves human subjects SOURCE: WHO (2005c). Influenza pandemics have historically taken the world by surprise, leaving minimal time for health services to prepare for the surge in cases and deaths that characterize these events and that make them so disruptive (Glezen, 1996). The current situation is markedly different, however, as the world has been warned in advance. This advance warning has brought an unprecedented opportunity, especially in the Americas, to prepare for a pandemic and develop ways to mitigate its effects even in areas with problems of access to basic health services. Evidence suggests that an influenza pandemic will be most intensely felt at the community level, especially among the young, the poor, and other vulner-

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary TABLE 2-3 Assessment of the Emergency Preparedness NIPPP Component, Including Legal and Ethical Issues, in Latin America and the Caribbean. Current Compliance (percentage) with WHO Guidelines, by Main Areas and PAHO Sub-Regions, Mid-2006 Emergency Preparedness Andean Area Central America The Caribbean Southern Cone Political mobilization 58.3 55.6 66.7 88.9 Command and control 37.5 22.2 58.3 66.7 Risk assessment 40.0 50.0 37.5 40.0 Risk communication 38.5 41.7 62.5 75.0 Legal and ethical issues 11.1 13.3 40.0 60.0 Phased-response plan 33.3 33.3 66.7 100.0 SOURCE: PAHO (in press). able groups (IOM, 2005). Despite the tremendous strides that have been made in increasing influenza pandemic preparedness at the national level, a significant challenge remains in bringing preparedness down to the subnational level—to the policy makers, practitioners, and concerned citizens who will be charged with actually implementing the national plans. As national strategies are put in place, PAHO’s focus is shifting from planning and awareness-raising to increasing the local acceptance and adoption of these strategies and also to ensuring their effective implementation. In order to bridge the existing gap between planning and implementation, those who will be implementing the plans at the local level must be encouraged to take part in the national planning process. The local implementation of NIPPPs should be tested though simulation drills and tabletop exercises that test local preparedness and contingency plans. Furthermore, local-level contingency planning should be promoted and supported by the broader measure of improving the ability of member states and communities to respond to all types of public health emergencies and not just pandemic influenza. The Region of the Americas is in the fortunate position of having the opportunity to get ready for an influenza pandemic before the virus is introduced in this part of the world. However, the fact that the region is as yet unaffected creates a false sense of security and causes pandemic preparedness to not seem so urgent. The result is that pandemic preparedness seems less important in comparison to many other competing priorities and thus falls short on the political agendas of many of the countries. All preparations for a pandemic must be carried out under the framework provided by the revised IHR, which set a baseline level of core competencies that countries must have in order to detect and respond to any public health emergency of international concern. Similarly, existing structures and mechanisms, such as contingency plans for mitigation of emergencies and national disasters, should

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary BOX 2-3 Achievements of PAHO’s Member States in theMember States in the Development and Assessment of NIPPPs Professionals from varied sectors working together, often for the first time, on building national capacity to cope with a pandemic Countries are creating, analyzing, and refining their NIPPPs in an integrated and coordinated fashion Inclusion of pandemic influenza preparedness in the Health Agendas of the Regional Integration Systems (MercoSur, CariCom, CAN, SISCA) Basic bolstering of public health infrastructure, targeted to a possible influenza pandemic, but applicable to a varied array of public health emergencies Regional cadre of professionals trained in multiple aspects of influenza preparedness—health services delivery, surveillance, risk and social communication, and disasters and emergency management Professionals who are able to replicate training to associates and colleagues at the sub-national levels Commitment from trained professionals to continue influenza preparedness activities SOURCE: PAHO (in press). be used in preparations for pandemic influenza in order to avoid duplication of efforts and to maximize available resources. PAHO, with its 105-year history of working with the countries in the Americas, has laid a solid foundation that can be put to work in preparing for a potential influenza pandemic. By building on its experience of supporting member states in Latin America and the Caribbean, PAHO can be an effective partner in helping them to develop and revise their NIPPPs as well as to consolidate their current achievements (see Box 2-3). Current global threats, including influenza pandemic, require a concerted effort by all those capable of effective action. PAHO recognizes the paramount importance of partnerships in such an effort and is collaborating closely with several stakeholders. It will also continue to encourage multisectoral and multicountry approaches, such as those used during the planning exercises, to strengthen cooperation, surveillance, and communication. Clearly, additional resources will be needed to reach a number of goals, such as stimulating counterpart support by the various countries, piggybacking on existing surveillance systems and expanding them to become population-based, and scaling up preparedness and rapid-response capabilities at the local level. And access to drugs, vaccines, and other supplies is still an unresolved issue.

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Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary Nonetheless, we believe the region has the potential to be self-sufficient. One final challenge will be to extend intersectoral involvement and commitment to the private sector, to nongovernmental organizations (NGOs), and to the academic sectors. Mechanisms for this to take place remain to be devised. In conclusion, the threat of an influenza pandemic has revealed the weaknesses of some systems in the Americas, but it also has once again demonstrated the strong determination among the countries of the region to work together, to work fast, to overcome disparities, and to share information. Technical cooperation has served to strengthen public health in these countries. This constitutes an important global contribution and ultimately could save many lives. REFERENCES FAO (Food and Agriculture Organization of the United Nations). 2006. Helping prevent avian influenza in Latin America and the Caribbean. FAONewsRoom. [Online]. Available: http://www.fao.org/newsroom/en/news/2006/1000381/index.html [accessed January 11, 2007]. Gellin B. 2006 (September 19). Session II: Domestic, Regional and International Preparedness Planning. Institute of Medicine’s Forum on Microbial Threats public workshop entitled “Ethical and Legal Considerations in Mitigating Pandemic Disease,” Washington, DC. Glezen WP. 1996. Emerging infections: Pandemic influenza. Epidemiologic Reviews 18(1):64-76. HSC (Homeland Security Council). 2005 (November). National Strategy for Pandemic Influenza. [Online]. Available: http://www.whitehouse.gov/homeland/nspi.pdf [accessed January 3, 2007]. HSC. 2006 (May). National Strategy for Pandemic Influenza Implementation Plan. [Online]. Available: http://www.whitehouse.gov/homeland/nspi_implementation.pdf [accessed January 3, 2007]. IOM (Institute of Medicine). 2005. The Threat of Pandemic Influenza: Are We Ready? Washington, DC: The National Academies Press. Meltzer MI, Shoemake HA, Kownaski M, Crosby R. 2000. FluAid 2.0: Software and Manual to aid State and Local-Level Health Officials Plan, Prepare and Practice for the Next Influenza Pandemic (Beta Test Version). Centers for Disease Control and Prevention. [Online]. Available: http://www.cdc.gov/flu/tools/fluaid/ [accessed May 1, 2007]. PAHO (Pan American Health Organization). 2003. Resolution CD44.R8: Influenza Pandemic: Preparation in the Hemisphere. Forty-fourth Directing Council: Washington, DC. [Online]. Available: http://www.paho.org/english/gov/cd/cd44index-e.htm#resolutions. [accessed January 15, 2007]. PAHO. (In Press). Health in the Americas: 2007 Edition. Pan American Health Organization: Washington, DC. Praveen D, Zhang X, Meltzer MI, Bridges CB. 2006. FluWorkLoss 1.0: Software and Manual to Aid State and Local Public Health Officials Estimating the Impact of an Influenza Pandemic on Work Day Loss (Beta Test Version). Centers for Disease Control and Prevention. [Online]. Available: http://www.cdc.gov/flu/tools/fluworkloss/ [accessed May 1, 2007]. UN (United Nations). 2006. World Urbanization Prospects: The 2005 Revision. ESA/P/WP/200. Department of Economic and Social Affairs: New York. [Online]. Available: http://www.un.org/esa/population/publications/WUP2005/2005wup.htm. [accessed January 17, 2007]. WHO (World Health Organization). 2003. Resolution WHA56.19: Prevention and Control of Influenza Pandemics and Annual Epidemics. Fifty-sixth World Health Asembly, Geneva. [Online]. Available: http://www.who.int/gb/e/e_wha56.html/#Resolutions [accessed January 15, 2007]. WHO. 2005a. Resolution WHA58.3: Revision of the International Health Regulations. Fifty-eighth World Health Assembly: Geneva. [Online]. Available: http://www.who.int/gb/e/e_wha58.html/#Resolutions [accessed January 15, 2007].

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