paredness and Strategic National Stockpile (SNS) guidance documents to grantees (states, territories, and three cities) require them to practice their plans in table-top exercises and subsequent full-scale exercises. However, pandemic preparedness plans or parts of these plans, such as antiviral dispensing plans, also are used by some grantees to respond to disease outbreaks and other public health emergencies, and may help them test and improve the implementation of a wide range of distribution and dispensing sites and mechanisms, in addition to the well-known and exercised SNS point-of-dispensing. The committee understands that aspects of such activities may be used to meet the performance measures requirement in CDC guidance, but not the exercise requirement.

Implementation of an antivirals program for pandemic influenza, whether it occurs in the near or distant future will need to take into account multiple factors, many of which are evolving or will only become apparent in a pandemic (supply of antivirals, shelf-life, resistance, vaccine technology, roles of stakeholders). The epidemiologic characteristics of the pandemic strain—for example, age of greatest impact and/or mortality, mode of spread, rapidity of development of resistance—constitute large unknowns that will affect when, how, and which individuals are provided antiviral medication. Regardless of the final shape of the pandemic, it is clear to the committee that many of these issues need to be prepared for in advance and provide a basis for all decisions. Several overarching goals need to be kept in the forefront: developing in advance an ethical framework, communication and education of the public with clear and consistent messages, the need to reconcile actual supply and antiviral program goals, and flexibility to on the one hand react to the changes in the course of the pandemic and on the other hand, address the diverse needs of localities.