who global influenza · acknowledgements who is grateful to participants in the who consultation on...

WHO global influenzapreparedness planThe role of WHO and recommendations fornational measures before and during pandemics

EPIDEMICA L E R T &RESPONSE

WHO/CDS/CSR/GIP/2005.5

Department of Communicable DiseaseSurveillance and ResponseGlobal Influenza Programme

© World Health Organization 2005

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All reasonable precautions have been taken by World Health Organization to verify the information contained in thispublication. However, the published material is being distributed without warranty of any kind, either express or implied.The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World HealthOrganization be liable for damages arising from its use.

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Contents

Executive summary 1

1. Introduction 4

2. Overview of new pandemic phases 6

3. Overarching goals, objectives and actions for each phase 10

Annex 1 Recommendations for nonpharmaceutical public healthinterventions 42

Annex 2 List of participants 47

Bibliography 49

EXECUTIVE SUMMARY iii

Acknowledgements

WHO is grateful to participants in the WHO consultation on WHO-recommended national andinternational measures before and during influenza pandemics, held in December 2004. Their workformed the basis of this document. Special thanks go to the chairs and rapporteurs for their helpduring and after the meeting. The team of the WHO Global Influenza Programme, supported bystaff of the Department of Communicable Disease Surveillance and Response, organized the con-sultation. David Bell , Marja Esveld and Brian Wertschnig were instrumental in initiating andcoordinating the work on this document, and finalized the text with assistance from Jonathan VanTam. The consultation was made possible with financial support from the governments of Aus-tralia, Germany, the Netherlands and the United States of America. A list of participants in theconsultation appears in Annex 2.

WHO GLOBAL INFLUENZA PREPAREDNESS PLANiv

1

Executive summary

* Available at: http://www.who.int/csr/disease/influenza/inforesources/en/

The present WHO global influenza preparednessplan has been prepared to assist WHO MemberStates and those responsible for public health,medical and emergency preparedness to respondto threats and occurrences of pandemic influ-enza.* It updates, significantly revises andreplaces the Influenza pandemic plan. The roleof WHO and guidelines for national andregional planning published by WHO in 1999.This new plan addresses the possibility of aprolonged existence of an influenza virus of pan-demic potential, such as the H5N1 influenzavirus subtype in poultry flocks in Asia whichpersisted from 2003 onwards. It also makesprovision for the possibility of simultaneousoccurrence of events with pandemic potentialwith different threat levels in different countries,as was the case in 2004 with poultry outbreaksof H7N3 in Canada and H5N1 in Asia.

This new plan redefines the phases of increas-ing public health risk associated with the emer-gence of a new influenza virus subtype that maypose a pandemic threat, recommends actions fornational authorities, and outlines measures tobe taken by WHO during each phase. Thisshould result in greater predictability of themeasures to be taken by the various partnersinvolved, including WHO, during the differentphases of the pandemic, and should improveinternational coordination and transparency inrecommended national measures. Guidance isalso provided to national authorities for devel-oping their own pandemic plans in line withthese phases.

The responsibility for management of the na-tional risk of pandemic influenza rests prima-rily with the relevant national authorities. Everycountry is strongly urged to develop or update anational influenza preparedness plan according

to the recommendations contained in thisdocument. Each national authority should playits part towards achieving the internationalharmonization of preparedness measures, as thisis the key to success in reducing the risk ofspread of an influenza pandemic.

Redefinition of the phases was needed to addressthe public health risks of influenza infection inanimals, link phase changes more directly withchanges in public health response, and focus onearly events during a “pandemic alert” periodwhen rapid, coordinated global and national ac-tions might help to possibly contain or delaythe spread of a new human influenza strain.Even if not successful in containing spread, thisapproach should gain time to develop vaccinesagainst the new strain, and to implement otherpandemic preparedness measures that had beenplanned in advance. Success will depend on sev-eral factors, including surveillance to provideglobal early warning of human infections withnew influenza subtypes. The new phases and theoverarching public health goals for each phaseare summarized on page 2.

This document also contains suggestions fornational authorities to subdivide certain phasesat the national level to reflect the national situ-ation. It is suggested to subdivide phases 2–5according to whether a country is affected (orhas extensive trade or travel links with anaffected country), or is not affected. It is alsosuggested to subdivide phase 6, the pandemicphase, according to whether a country is not yetaffected, is affected (or has extensive trade ortravel links with an affected country), whetherits wave of infection has subsided, or whetherit is experiencing a subsequent wave.

In order to accomplish the public health goalsfor each phase, the specific objectives andactions to be taken by WHO, and those recom-mended for national authorities, are divided into

EXECUTIVE SUMMARY

2 WHO GLOBAL INFLUENZA PREPAREDNESS PLAN

five categories: (1) planning and coordination;(2) situation monitoring and assessment; (3) pre-vention and containment; (4) health systemresponse; and (5) communications. Certain ob-jectives and actions are specific to influenza,whereas others address preparedness for andresponse to many health emergencies thataffect large numbers of people. Although manycountries already have contingency plans for dis-asters or other health emergencies, some suchmeasures are included to ensure completenessin pandemic influenza planning. The extent ofimplementation will depend on available re-sources.

Of critical importance in pandemic preparednessis intersectoral planning involving partners out-

NEW PHASES OVERARCHING PUBLIC HEALTH GOALS

Interpandemic periodPhase 1. No new influenza virus subtypes have been detected Strengthen influenza pandemic preparednessin humans. An influenza virus subtype that has caused human at the global, regional, national andinfection may be present in animals. If present in animals, the subnational levels.riska of human infection or disease is considered to be low.

Phase 2. No new influenza virus subtypes have been detected Minimize the risk of transmission to humans;in humans. However, a circulating animal influenza virus detect and report such transmission rapidlysubtype poses a substantial riska of human disease. if it occurs.

Pandemic alert periodPhase 3. Human infection(s) with a new subtype, but no Ensure rapid characterization of the new virushuman-to-human spread, or at most rare instances of spread subtype and early detection, notificationto a close contact.b and response to additional cases.

Phase 4. Small cluster(s) with limited human-to-human Contain the new virus within limited foci ortransmission but spread is highly localized, suggesting that delay spread to gain time to implementthe virus is not well adapted to humans.b preparedness measures, including vaccine

development.

Phase 5. Larger cluster(s) but human-to-human spread still Maximize efforts to contain or delay spread,localized, suggesting that the virus is becoming increasingly to possibly avert a pandemic, and to gainbetter adapted to humans, but may not yet be fully time to implement pandemic responsetransmissible (substantial pandemic risk). measures.

Pandemic periodPhase 6. Pandemic: increased and sustained transmission in Minimize the impact of the pandemic.general population.b

a The distinction between phase 1 and phase 2 is based on the risk of human infection or disease resulting from circulating strains inanimals. The distinction is based on various factors and their relative importance according to current scientific knowledge. Factorsmay include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife, whether thevirus is enzootic or epizootic, geographically localized or widespread, and/or other scientific parameters.

b The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors and theirrelative importance according to current scientific knowledge may be considered. Factors may include rate of transmission, geo-graphical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain), and/orother scientific parameters.

side the health sector. These partners includeother government departments (e.g. agriculture,transport, trade, labour, defence, education, thejudiciary) at multiple levels of government, aswell as partners in the private sector, includingindustry and nongovernmental organizations.

It is impossible to anticipate when the next pan-demic might occur or how severe its conse-quences might be. On average, three pandemicsper century have been documented since the16th century, occurring at intervals of 10–50years. In the 20th century, pandemics occurredin 1918, 1957 and 1968. The pandemic of 1918is estimated to have killed more than 40 mil-lion people in less than one year, with peakmortality rates occurring in people aged 20–45

3EXECUTIVE SUMMARY

years. The pandemics of 1957 and 1968 weremilder (1–4 million estimated deaths, primarilyin traditional risk groups such as the elderly),but many countries nevertheless experiencedstrains on health-care resources. If an influenzapandemic virus were to appear again similar tothe one that struck in 1918, even taking intoaccount the advances in medicine since then,unparalleled tolls of illness and death could be

expected. Air travel might hasten the spread ofa new virus, and decrease the time available forpreparing interventions. Health-care systemscould be rapidly overburdened, economiesstrained, and social order disrupted. Althoughit is not considered feasible to halt the spread ofa pandemic virus, it should be possible to mini-mize its consequences through advance prepa-ration to meet the challenge.

1. Introduction

– if not in containing a pandemic, then possiblyin delaying its emergence to “buy time” for theimplementation of preparations made in ad-vance. A new appreciation of infectious diseasesas threats to global and national security offersthe prospect that high-level political leadershipcould be enlisted in support of the necessaryintersectoral planning. Finally, while severalcountries have made important progress inpandemic influenza planning in recent years,others have asked WHO for more specific rec-ommendations regarding national objectives andactions during different phases. This has led torecognition of the need for more detailed meas-ures providing for harmonized global andnational actions.

In December 2004, WHO held a consultationon WHO-recommended national and interna-tional measures before and during influenzapandemics. The present document is based onthe results of the consultation.

Summary of the major changes to the1999 WHO plan

This document:

1. Redefines pandemic phases based on the needfor changes in public health action, by:

(a) addressing human health risks posed byinfection in animals (“animal” as usedherein includes all non-human animalspecies, including birds);

(b) using a risk assessment considering mul-tiple factors as the basis for movingbetween phases;

(c) providing for downscaling of phases toreflect decreased public health risks.

2. Focuses greater attention on early phaseswhen rapid intervention might contain ordelay the spread of a new influenza virussubtype in humans. Such measures would

Why revise the pandemicpreparedness plan?

In 1999, the World Health Organization pub-lished the Influenza pandemic plan. The role ofWHO and guidelines for national and regionalplanning.1 This plan defined phases of diseaseprogression that could be expected after humaninfection with a new human influenza virussubtype, outlined measures that would be takenby WHO during these phases, suggested issuesthat should be considered by national authori-ties, and provided background information. Ithas proved useful in guiding pandemic planningand in addressing several subsequent events in-volving limited human infections with new in-fluenza subtypes.

The 1999 WHO plan now requires updating andrevision in light of several recent developments.One is the recognition of endemic animal in-fection with an influenza virus subtype (H5N1)that has been repeatedly transmitted to humans,causing fatal human disease. Other recent de-velopments include advances in the understand-ing of the evolutionary biology of influenzaviruses, new techniques for vaccine develop-ment and laboratory diagnosis, improvedantivirals, and the ongoing revision of theInternational Health Regulations. A promisingnew paradigm for management of epidemics wasillustrated by the successful control of severeacute respiratory syndrome (SARS) in 2003,facilitated by the rapid implementation of glo-bal and national actions coordinated by WHOthat depended upon early disease recognition,high-level political support for interventions,and transparent communication involving manypartners and the public. The SARS experiencesuggests that coordinated global and nationalefforts could also be successful in addressing theemergence of a new human subtype of influenza

1 Document WHO/CDS/CSR/EDC/99.1.


include enhanced surveillance and use ofnonpharmaceutical public health interven-tions and consideration of deployment of apossible global early intervention stockpile.

3. Provides more specific objectives and activi-ties at each phase for WHO and nationalauthorities.

4. Provides for the harmonization of the recom-mended measures with the ongoing revisionof the International Health Regulations.

How to use this document

• It should be used as a guide to inform andharmonize national and international prepar-edness and response before and during influ-enza pandemics.

• Its primary audience is public health officialswith responsibility for influenza preparednessand response. The executive summary hasbeen developed for senior policy-makers andofficials in other sectors of government whomay not necessarily have a public healthbackground.

• Countries should develop or update nationalinfluenza preparedness plans that address therecommendations made here. This documentis not designed to replace national plans,which every country should develop. More de-tailed information on why recommended ac-tions are needed and how to implement themcan be found in further documents, such asthose mentioned in the bibliography.

• Table 1 provides a comparison of the old andnew phases.

• Table 2 provides an overview of actions to betaken by WHO and recommended for consid-eration by each country during each phase,classified into five categories: (1) planning andcoordination; (2) situation monitoring and as-sessment; (3) prevention and containment;(4) health system response; and (5) commu-nications. The extent of implementation willdepend on available resources.

• Certain measures outlined in Table 2 are spe-cific to influenza, whereas others address pre-paredness for and response to many healthemergencies that may affect large numbersof people. Although many countries alreadyhave contingency plans for disasters or otherhealth emergencies, some such measures areincluded to ensure completeness in pandemicinfluenza planning.

• The recommendations made herein apply tonaturally occurring influenza. In the event ofunintentional or intentional release of an in-fluenza virus with pandemic potential (e.g.related to a laboratory accident or the delib-erate release of biological agents), most ofthem may also be suitable however. Addi-tional guidance should nevertheless be ob-tained from WHO and other appropriateauthorities.

1. INTRODUCTION 5

2. Overview of new pandemic phases

New phases

Table 1 provides a summary of new phases be-fore and during an influenza pandemic. To pro-mote harmonization with existing national andinternational documents, the new phases are (asmuch as possible) related to the phases in the1999 WHO Global influenza pandemic prepar-edness plan.

Additional national subdivisions

Each phase is associated with international andnational public health actions. National actionsduring each phase are further subdivided accord-ing to the national epidemiological situation. Forconvenience, the term “not affected” is used forcountries without cases/outbreaks. However,these countries should also take certain actionsas indicated, in order to strengthen preparedness.National authorities are free to adjust the sug-gested additional national subdivisions of phasesgiven here. However, WHO strongly recom-mends that countries consider the national ac-tions proposed in this document whendeveloping or updating a national plan.

Sequence of declaration of phases

As the species of origin and sequence of progres-sion of the next pandemic strain may vary andthus be difficult to predict, WHO may declare,upscale and downscale phases in a non-sequen-tial order. If an upscaling designation skips aphase, actions in the skipped phase should alsobe implemented, unless they are specificallysuperseded by actions in the new phase.

Rationale for phases

Interpandemic period

Phase 1. No new1 influenza virus subtypes havebeen detected in humans. An influenza virussubtype that has caused human infection or dis-ease may or may not be present in animals. If

present in animals, the risk of human infectionor disease is considered to be low.2

Rationale. It is likely that influenza subtypesthat have caused human infection and/or dis-ease will always be present in wild birds or otheranimal species. Lack of recognized animal orhuman infections does not mean that no actionis needed. Preparedness requires planning andaction in advance.

Phase 2. No new1 influenza virus subtypes havebeen detected in humans. However, a circulat-ing animal influenza virus subtype poses a sub-stantial risk2 of human disease.

Rationale. The presence of animal infectioncaused by a virus of known human pathogenic-ity may pose a substantial risk to human healthand justify public health measures to protectpersons at risk.

Pandemic alert period

Phase 3. Human infection(s) with a new subtype,but no human-to-human spread, or at most rareinstances of spread to a close contact.3

Rationale. The occurrence of cases of humandisease increases the chance that the virus may

1 Definition of new: a subtype that has not circulated inhumans for at least several decades and to which the greatmajority of the human population therefore lacks immu-nity.

2 The distinction between phase 1 and phase 2 is based onthe risk of human infection or disease resulting from cir-culating strains in animals. The distinction is based onvarious factors and their relative importance accordingto current scientific knowledge. Factors may includepathogenicity in animals and humans, occurrence in do-mesticated animals and livestock or only in wildlife,whether the virus is enzootic or epizootic, geographicallylocalized or widespread, and/or other scientific param-eters.

3 The distinction between phase 3, phase 4 and phase 5 isbased on an assessment of the risk of a pandemic. Vari-ous factors and their relative importance according tocurrent scientific knowledge may be considered. Factorsmay include rate of transmission, geographical locationand spread, severity of illness, presence of genes fromhuman strains (if derived from an animal strain), and/orother scientific parameters.


2. OVERVIEW OF NEW PANDEMIC PHASES 7

Table 1 Comparison of phases published by WHO in 1999 and thosein the present document

PHASES AS PUBLISHED NEW PANDEMIC PHASES ADDITIONAL NATIONALBY WHO IN 1999 SUBDIVISIONS OF NEW PHASES

Interpandemic period Interpandemic periodPhase 0 Phase 1. No new influenza virus subtypes

have been detected in humans. An influenzavirus subtype that has caused humaninfection may be present in animals. Ifpresent in animals, the riska of humaninfection or disease is considered to be low.

Phase 2. No new influenza virus subtypes Affected or extensive travel/tradehave been detected in humans. However, links with affected country.a circulating animal influenza virus subtypeposes a substantial riska of human disease. Not affected.

Pandemic alert periodPhase 0. Preparedness Phase 3. Human infection(s) with a new Affected or extensive travel/tradelevel 1: human case. subtype, but no human-to-human spread, or links with affected country.

at most rare instances of spread to a closecontact. Not affected.

Phase 0. Preparedness Phase 4. Small cluster(s) with limited human- Affected or extensive travel/tradelevel 2: limited human to-human transmission but spread is highly links with affected country.transmission. localized, suggesting that the virus is not well

adapted to humans.b Not affected.

Phase 0. Preparedness Phase 5. Larger cluster(s) but human-to- Affected or extensive travel/tradelevel 3: spread in general human spread still localized, suggesting that links with affected country.population. the virus is becoming increasingly better

adapted to humans, but may not yet be fully Not affected.transmissible (substantial pandemic risk).b

Pandemic period Pandemic periodPhase 1. Multiple countries. Phase 6. Pandemic phase: increased and Not yet affected.

sustained transmission in generalPhase 2. Multiple regions. population.b Affected or extensive travel/trade

links with affected country.

Phase 3. Subsiding in initially Subsided.affected countries but not inother countries.

Phase 4. Next wave. Next wave.

Postpandemic period Postpandemic periodPhase 5. Return to phase 0. Return to interpandemic period. Return to interpandemic period.

a The distinction between phase 1 and phase 2 is based on the risk of human infection or disease resulting from circulating strains inanimals. The distinction would be based on various factors and their relative importance according to current scientific knowledge.Factors may include: pathogenicity in animals and humans; occurrence in domesticated animals and livestock or only in wildlife;whether the virus is enzootic or epizootic, geographically localized or widespread; other information from the viral genome; and/orother scientific information.

b The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors and theirrelative importance according to current scientific knowledge may be considered. Factors may include: rate of transmission; geo-graphical location and spread; severity of illness; presence of genes from human strains (if derived from an animal strain); other infor-mation from the viral genome; and/or other scientific information.


adapt or reassort to become transmissible fromhuman to human, especially if coinciding witha seasonal outbreak of influenza. Measures areneeded to detect and prevent spread of disease.Rare instances of transmission to a close con-tact – for example, in a household or health-caresetting – may occur, but do not alter the mainattribute of this phase, i.e. that the virus isessentially not transmissible from human tohuman.

Examples:

• One or more unlinked human cases with aclear history of exposure to an animal source/non-human source (with laboratory confirma-tion in a WHO-designated reference labora-tory).

• Rare instances of spread from a case to closehousehold or unprotected health-care con-tacts without evidence of sustained human-to-human transmission.

• One or more small independent clusters1 ofhuman cases (such as family members) whomay have acquired infection from a commonsource or the environment, but for whomhuman-to-human transmission cannot beexcluded.

• Persons whose source of exposure cannot bedetermined, but are not associated with clus-ters1 or outbreaks of human cases.

Phase 4. Small cluster(s) with limited human-to-human transmission but spread is highlylocalized, suggesting that the virus is not welladapted to humans.2

Rationale. Virus has increased human-to-humantransmissibility but is not well adapted tohumans and remains highly localized, so thatits spread may possibly be delayed or contained.

Examples:

• One or more clusters1 involving a smallnumber of human cases, e.g. a cluster of <25cases lasting <2 weeks.3

• Appearance of a small number of human casesin one or several geographically linked areaswithout a clear history of a non-human sourceof exposure, for which the most likely expla-

nation is considered to be human-to-humantransmission.

Phase 5. Larger cluster(s) but human-to-humanspread still localized, suggesting that the virusis becoming increasingly better adapted tohumans, but may not yet be fully transmissible(substantial pandemic risk).2

Rationale. Virus is more adapted to humans, andtherefore more easily transmissible amonghumans. It spreads in larger clusters, but spreadis localized. This is likely to be the last chancefor massive coordinated global intervention, tar-geted to one or more foci, to delay or containspread. In view of possible delays in document-ing spread of infection during pandemic phase4, it is anticipated that there would be a lowthreshold for progressing to phase 5.

Examples:

• Ongoing cluster-related transmission, buttotal number of cases is not rapidly increas-ing, e.g. a cluster of 25–50 cases and lastingfrom 2 to 4 weeks.4

• Ongoing transmission, but cases appear to belocalized (remote village, university, militarybase, island).

1 An unusual cluster of cases or deaths from influenza-likeillnesses can be defined as a group of cases (suspected,probable and/or confirmed) of individuals with diseaseonset within a period of two weeks in a same definedgeographical area, presenting with similar clinical featuresincluding respiratory symptoms, and for which the epi-demiological pattern or clinical features do not correspondto usual observation in cases of infection with seasonalinfluenza. These unusual observations may include: (i)unusual distribution by age group; (ii) severity of illnessin adults in the absence of chronic disease; (iii) diseaseaffecting special risk groups such as individuals exposedto potentially infective live or dead animals, or health-care workers.


3 Ro = Basic reproduction rate (average number of new in-fections acquired from one case). It will not be possibleto calculate Ro in the early stages of a cluster; howevermodelling suggests that for a cluster with thesecharacterististics, 0< Ro≤0.5.

4 It will not be possible to calculate Ro in the early stagesof a cluster; however modelling suggests that for a clus-ter with these characteristics, 0.5<Ro≤1.0.

9

• In a community known to have a cluster, ap-pearance of a small number of cases whosesource of exposure is not readily apparent (e.g.beginning of more extensive spread).

• Appearance of clusters caused by same orclosely related virus strains in one or moregeographical areas without rapidly increasingnumbers of cases.

Pandemic period

Phase 6. Increased and sustained transmissionin the general population.

Rationale. Major change in global surveillanceand response strategy, since pandemic risk isimminent for all countries. The nationalresponse is determined primarily by the diseaseimpact within the country.

Postpandemic period

A return to the interpandemic period (the ex-pected levels of disease with a seasonal strain)follows, with continued need to maintain sur-veillance and regularly update planning. An in-tensive phase of recovery and evaluation maybe required.

Simultaneous occurrence of situationsposing different levels of pandemic risk

In the event of simultaneous situations posingdifferent levels of risk, e.g. different new influ-enza subtypes or different extent of spread indifferent areas, the phase will be determined bythe highest applicable level of risk.

Criteria for downscaling of phases

All phases except phase 1 are anticipated to betemporary. With every announcement of a newphase, WHO will set a time period at which thedesignation will be reviewed. In considerationof downscaling, the following criteria will beused:

• Lack of ongoing disease activity meeting thecriteria for the current phase.

• Adequate national surveillance and interna-tional reporting as assessed by WHO and, forissues relating to infection in animals, in part-nership with other organizations such as the

2. OVERVIEW OF NEW PANDEMIC PHASES

Food and Agriculture Organization of theUnited Nations (FAO) and the World Organi-sation for Animal Health (OIE).

• Adequate, if necessary on-site, risk assess-ment by WHO in partnership with affectedcountries, and for issues relating to infectionin animals, in partnership with other organi-zations such as FAO and OIE.

• A risk assessment considering the factors thatled to designation of the phase,1,2 as well asother potential factors. For example, if therespiratory illness season is in progress in theregion, downscaling might sometimes be de-layed because of the increased risk that newstrains might reassort with seasonal strains,and that surveillance to detect new strainsco-circulating with seasonal strains might bemore difficult.

Procedure for decision-making

• Designation of phases, including decisions onupscaling and downscaling, will be made bythe Director-General of WHO. The designa-tion will be made in harmony with existingregulations governing human disease report-ing and control (e.g. the International HealthRegulations), and in consultation with otherorganizations and institutions, as necessary.

• The national subdivisions of phases will bedesignated by national authorities.

1 The distinction between phase 1 and phase 2 is based onthe risk of human infection or disease resulting from cir-culating strains in animals. The distinction is based onvarious factors and their relative importance accordingto current scientific knowledge. Factors may includepathogenicity in animals and humans, occurrence in do-mesticated animals and livestock or only in wildlife,whether the virus is enzootic or epizootic, geographicallylocalized or widespread, and/or other scientific param-eters.


3. Overarching goals, objectivesand actions for each phase

Table 2 provides an overview of objectives andactions that WHO will take and recommend tonational authorities to address the overarchingpriority goals. Objectives and actions are dividedinto five categories:

1. Planning and coordination

2. Situation monitoring and assessment

3. Prevention and containment (nonpharma-ceutical public health interventions, vaccines,and antivirals)

4. Health system response

5. Communications

The extent of implementation will depend onavailable resources.

The proposed measures are based upon currentknowledge of outbreaks of seasonal influenzaand past pandemics. Recommendations may beadjusted based on new evidence and experience.

Actions are intended to continue afterupscaling to higher phases unless they aresuperseded by actions in the higher phase.If an upscaling designation skips a phase,actions in the skipped phase should alsobe implemented, unless they are super-seded by actions in the higher phase.


3. OVERARCHING GOALS, OBJECTIVES AND ACTIONS FOR EACH PHASE 11

Table 2 Overarching goals, objectives and actions for WHOand national authorities, by phase

INTERPANDEMIC PERIODInterpandemic period, phase 1 – Overarching goalStrengthen influenza pandemic preparedness at the global, regional, national and subnational levels.

Interpandemic period, phase 1 – Planning and coordination

WHO OBJECTIVES NATIONAL OBJECTIVES

1. To promote the development of harmonizedglobal, regional and national influenza pandemicpreparedness plans.

2. To promote the development of global andnational capacity to detect and respond to earlyreports of new strains.

3. To develop strategies and procedures tocoordinate the rapid mobilization anddeployment of global resources to foci of infectionduring a pandemic alert period.

4. To improve international response to pandemicinfluenza (and other health emergencies) bydeveloping mechanisms for rapid decision-making and action, establishing intersectoralcollaboration, and promoting correspondingmeasures at the national level.

1. To develop and maintain national influenzapandemic contingency plans which are inharmony with international plans.

2. To promote national and global capacity torespond to early reports of new influenza virusstrains.

3. To develop effective mechanisms for mobilizationand rapid deployment of resources to areas ofneed.

4. To develop effective mechanisms for decision-making and subsequent actions regardingnational and international responses to influenza-related health emergencies, by strengtheningintersectoral and intergovernmental cooperativearrangements that will identify and minimize therisk of human infection with a new influenza virus.

WHO ACTIONS NATIONAL ACTIONS

1. Form a panel of experts (WHO Influenza Task Force)to monitor and evaluate available information andadvise WHO on influenza-related issues, includingrecommendation of appropriate phases.

2. Encourage and assist comprehensive nationalpandemic influenza planning.

3. Develop tools to estimate influenza seasonal andpandemic disease burden, and the public healthvalue and cost-effectiveness of interventions,including seasonal vaccination.

4. Facilitate implementation of pandemic plans throughpreparedness activities, including exercises.

5. Facilitate/negotiate agreements among partners, e.g.Member States, other international organizations,nongovernmental organizations and the privatesector, to facilitate implementation of the global plan.

6. Promote agreements to develop, manage and deploya global stockpile (e.g. of antivirals, personalprotective equipment, vaccines, laboratorydiagnostics), other resources and technical assistanceduring pandemic alert periods to resource-poorcountries with foci of influenza activity.

1. Establish a national pandemic planning committee.

2. Advocate the importance of pandemic planning torelevant decision-makers.

3. Develop and periodically update national plans inclose collaboration with relevant partners, includingthose outside the health sector, and with reference tocurrent WHO guidance.

4. Ensure implementation of plans and preparednessactivities at all levels of public authorities.

5. Exercise pandemic plans and use the results toimprove and refine plans and preparedness.

6. Identify, brief regularly and train key personnel to bemobilized in case of emergence of a new influenzavirus strain.

7. Consider the development of a domestic stockpile(antivirals, personal protective equipment, vaccines,laboratory diagnostics, other technical support) forrapid deployment when needed.

8. Consider providing resources and technicalassistance during pandemic alert periods toresource-poor countries with foci of influenzaactivity.

PHASE

1


7. Harmonize pandemic planning with otherinternational legal and policy instruments, e.g. theInternational Health Regulations.

8. Develop surge-capacity contingency plans for theinternal management of WHO resources and staffduring a pandemic.

9. Establish international guidance to address foodsafety and other public health issues related toinfected animals.

9. Ensure procedures for rapid sharing of specimens orisolates for virus characterization and developmentof diagnostics and vaccine.

10. Develop surge-capacity contingency plans for theinternal management of domestic resources andessential workers during a pandemic.

11. Establish national guidance to address food safety,safe agricultural practices and other public healthissues related to infected animals.

Interpandemic period, phase 1 – Situation monitoring and assessment


1. To coordinate global surveillance networks thatmonitor trends of human infection with seasonalstrains, and provide early warning of new strains inhumans and animals (in collaboration with otherpartners and organizations, e.g. FAO and OIE ).

2. To promote the development of global andnational capacity to assess risks to humans fromanimals and other possible sources of humaninfection with new strains.

3. To promote the development of national plans forongoing assessment of impact and resourceneeds during the pandemic period.

1. To have available up-to-date information ontrends in human infection with seasonal strains ofinfluenza.

2. To be able to detect animal and human infectionswith new influenza virus strains, identify potentialanimal sources of human infection and assess therisk of transmission to humans.

3. To develop plans for ongoing assessment ofimpact and resource needs during the pandemicperiod.


1. Strengthen the global influenza surveillance networkand other laboratories to increase national capacityfor influenza surveillance.

2. Work with national authorities and other partners(e.g. FAO and OIE) to coordinate a research andmonitoring programme for the human–animalinterface, and use data collected to assess the risk ofhuman infection with animal influenza viruses.

3. Facilitate sharing of influenza virus strains forreagents development and subtyping of new viruses.

4. Encourage relevant national authorities, such asanimal and public health authorities, to establishintersectoral and interinstitutional collaboration ininfluenza surveillance.

5. Develop or review interpandemic and pandemicguidelines and tools for detection, investigation,rapid risk assessment, reporting and ongoingevaluation (e.g. monitoring outcome of containmentmeasures), of clusters of influenza-like illness.

6. Develop guidelines and tools to assist countries inongoing monitoring of information, for assessment ofimpact and resource needs during the pandemicphase.

1. Develop robust national generic surveillance systemsfor the detection, characterization and assessment ofclusters of influenza-like illness or respiratory deaths,with provision for surge capacity and intersectoraland interinstitutional collaboration.

2. Develop or strengthen national systems for influenzasurveillance in both humans and animals, based onWHO, FAO and OIE guidance.

3. Report routine and unusual surveillance findings torelevant national and international authorities.

4. Characterize and share influenza virus isolates andinformation on circulating strains with relevantinternational agencies, such as WHO, FAO and OIE.

5. Assess burden of seasonal influenza to help estimateadditional needs during a pandemic.

6. Develop contingency plan for ongoing monitoring ofinformation, for assessment of impact and resourceneeds during the pandemic phase (e.g. morbidity,mortality, workplace absenteeism, regions affected,risk groups affected, health-care workers and otheressential workers’ availability, health-care supplies,bed occupancy/availability, admission pressures, useof alternative health facilities, mortuary capacity).

Interpandemic period, phase 1 – Planning and coordination (continued)

PHASE

1

133. OVERARCHING GOALS, OBJECTIVES AND ACTIONS FOR EACH PHASE

Interpandemic period, phase 1 – Prevention and containment


1. To ensure the availability of up-to-date, evidence-based recommendations on potentialinterventions.

2. To promote the increased use of seasonalinfluenza vaccine, consistent with WHOrecommendations.

3. To coordinate efforts to resolve impediments tothe development, production and access topandemic vaccines.

4. To assess the needs and develop strategies andguidelines for development, deployment and useof global stockpiles.

1. To agree in advance a range of containmentstrategies based on nonpharmaceutical publichealth actions.

2. To develop a strategy regarding stockpiling ofantivirals and criteria for deployment.

3. To increase availability of vaccine in the event of apandemic.

4. To develop national strategies and criteria for useof seasonal and pandemic vaccines.

5. To anticipate the possible need to develop afuture pandemic vaccine.


Public health interventions

1. Periodically reassess recommended interventions(Annex 1) in consultation with appropriate partners,including those not in the health-care sector,regarding acceptability, effectiveness and feasibility.Modify as appropriate.

2. Facilitate development of models to assess impact ofmeasures, conduct/observe table-top exercises anduse the results to improve planning.

Antivirals

1. Assess the potential usefulness of a global stockpileduring the pandemic alert period, and if appropriatebased on such assessment, develop criteria for itsdeployment and use.

2. Develop procedures to coordinate rapid antiviralsusceptibility testing of new strains.

Vaccines

1. Provide tools for countries on methods of assessingthe annual burden of influenza as a means toincrease vaccine use during interpandemic period.

2. Develop a prioritized global research anddevelopment agenda for producing innovative andmore efficient vaccines.

3. Explore ways to shorten the time needed for vaccineprototype preparation and to increase vaccine use inWHO-recommended risk groups, by working withpharmaceutical companies, national authorities andresearch institutes.

4. Explore ways to increase availability of pandemicvaccines during pandemic alert and pandemicperiods.

1. Develop national guidance for use of public healthinterventions, considering WHO recommendations(Annex 1).

2. Ensure that proposed interventions are discussedwith responsible decision-makers in and outside thehealth sector (transport, education, etc.); ensure legalauthority for proposed interventions; anticipate andaddress resource implications for implementation.

3. Conduct/observe table-top exercises and use theresults to improve planning.

4. Develop a strategy to ensure access to antivirals fornational use (e.g. stockpiling); ensure availability ofdata to project likely needs during higher phases.

5. Consider setting priorities and criteria fordeployment and use of antivirals during pandemicalert and pandemic periods.

6. Consider participation in research projects to assesssafety and antiviral drug resistance to current drugsand promote development of affordablealternatives.

7. Using national data on burden of influenza disease,develop or adapt a national vaccination policy toachieve the targets recommended by the WorldHealth Assembly for uptake of seasonal influenzavaccine.

8. Define national objectives for the use of pandemicvaccines; develop preliminary priorities for pandemicvaccine use, based on expected availability.

9. Explore possible ways to increase access to pandemicvaccines; address regulatory issues, liability,intellectual property rights.

PHASE

1


5. Provide mechanism for vaccine manufacturers toaccess vaccine prototype strains.

6. Develop principles to guide nationalrecommendations for use of seasonal and pandemicvaccines.

(a) Countries with vaccine manufacturing capacity.Define how to ensure access to vaccines, and fairand effective distribution to target population;consider supporting initiatives to increase globalproduction by contributing to global vaccineresearch and/or by strengthening infrastructure.

(b) Countries without vaccine manufacturing capacity.Explore strategies to allow access to vaccinesthrough bilateral agreements with manufacturersor manufacturing countries.

10. Review logistic and operational needs forimplementation of pandemic vaccine strategy(vaccine storage, distribution capacity, cold-chainavailability. vaccination centres, staffing requirementsfor vaccine administration).

Interpandemic period, phase 1 – Health system response


1. To promote contingency planning by health-caresystems for response to an influenza pandemic.

1. To ensure that up-to-date contingency plans andstrategies are in place for pandemic response inthe health-care sector.


1. Assist national health-care delivery authorities inidentifying priority needs and response strategies,and assessing preparedness (e.g. through developingchecklists, model pandemic preparedness plans,training and table-top exercises).

2. Provide guidance for appropriate infection andclinical control in health-care and social settings, andin care facilities.

3. Coordinate international response planning withother international organizations.

4. Collect pandemic preparedness plans from countriesand make them available to other countries.

5. Develop/strengthen laboratory and clinical networksfor diagnostics and development of clinicalguidelines.

6. Keep a global inventory of key manufacturers of keyproducts.

7. Provide guidance for technical support and trainingof health-care workers on risk factors for infectionwith emerging influenza virus strains.

8. Develop guidelines for self-care.

9. Develop and maintain WHO guidelines on biosafetyand biosecurity in handling and shipping specimensand isolates.

1. Benchmark health system preparedness with thehelp of the WHO checklist for influenza pandemicpreparedness planning,* and address deficienciesaccording to national resources.

2. Ensure that authorities, responsibilities and pathwaysare clearly identified for command and control ofhealth systems in the event of a pandemic.

3. Identify priorities and response strategies for publicand private health-care systems for each stageincluding where relevant: triage systems, surgecapacity, human and material resource management.

4. Produce interim: case-finding, treatment andmanagement protocols and algorithms; infectioncontrol guidelines; guidance on triaging; surge-capacity management and staffing strategies.

5. Ensure implementation of routine laboratorybiosafety, safe specimen handling, and hospitalinfection control policies.

6. Estimate pharmaceutical and other materiel supplyneeds; commence arrangements to secure supply.

7. Increase awareness and strengthen training ofhealth-care workers on pandemic influenza.

8. Exercise contingency plans regularly, includingcommand-and-control pathways.

* Available at http://www.who.int/csr/disease/influenza/inforesources/en/

Interpandemic period, phase 1 – Prevention and containment (continued)

PHASE

1


Interpandemic period, phase 1 – Communications


1. To promote the establishment of mechanisms forroutine and emergency communications withinand among health authorities and otherappropriate partners at the international, nationaland subnational levels, and with the public.

2. To promote the establishment of national risk-communication strategies and capabilitiesappropriate to each phase.

3. To establish a collaborative working relationshipwith news media regarding epidemic response.

1. To ensure that mechanisms exist for routine andemergency communications between healthauthorities, within and between governmentagencies, with other organizations likely to beinvolved in a pandemic response, and with thepublic.

2. To maintain an appropriate level of awarenessamong government and other essential partners.

3. To ensure collaborative working relationships withthe media regarding epidemics, including theroles, responsibilities and operating practices ofpublic health authorities.


1. Provide information to facilitate risk communicationrelated to influenza.

2. Plan and test capacity for meeting current andexpected future international information demands,among others by maintaining a web site.

3. Facilitate training workshops to strengthen thecapacity of national authorities for best practices inrisk communication related to influenza and otherepidemic diseases.

4. Include risk communicators in senior managementgroups.

5. Increase the familiarity of news media with WHOactivities, operations and decision-making related toinfluenza and other epidemic diseases.

6. Establish formal communication channels among keyresponse stakeholders, including WHO Membercountries, other international organizations (e.g.United Nations, European Union, nongovernmentalorganizations, etc.), and technical/professionalassociations for facilitating outbreak-informationsharing and communications-strategy coordination.

7. Develop feedback mechanisms to identify emergingpublic concerns, address rumours, and correctmisinformation.

1. Establish phased national communications strategyfor pandemic influenza.

2. Strengthen risk communication related to influenza,taking into consideration existing WHO guidance foroutbreak communication and correspondingnational contingency plans.

3. Plan and test capacity for meeting expecteddomestic information demands for diverse audiences,including professional/technical groups, the newsmedia and general public.

4. Ensure communications infrastructure is adequate forpandemic needs.

5. Establish and maintain a web site with relevantinformation.

6. Establish networks among key response stakeholders,including risk communicators, non-healthgovernment departments, and professional andtechnical groups.

7. Include risk communicators in senior managementgroups.

8. Familiarize news media with national plans,preparedness activities and decision-making relatedto seasonal and pandemic influenza.

9. Establish formal communications channels with WHOand other partners for sharing of outbreakinformation and coordination of communicationsstrategy related to influenza.

10. Develop feedback mechanisms to identify publiclevel of knowledge about pandemic influenza andemerging public concerns. Address rumoursproactively, and correct misinformation.

PHASE

1


Interpandemic period, phase 2 – Overarching goalMinimize the risk of transmission to humans; detect and report such transmission rapidly if it occurs.

Interpandemic period, phase 2 – Planning and coordination


1. To promote strengthened response capacity todeal with possible human cases.

2. To coordinate development of strategies andguidelines to reduce the risk of human infection.

1. To ensure a heightened response capacity toaddress possible human cases.

2. To coordinate implementation of measures inclose collaboration with animal health authoritiesin order to limit the risks of human infection.


1. Activate joint mechanisms for actions with otherorganizations (e.g. FAO, OIE) to control disease inanimals and to implement prevention measures.

2. Coordinate measures to ensure that appropriatecomponents of a possible stockpile and otherresources and technical assistance are available andcould be deployed to affected areas if necessary.

Affected countries and countries with extensivetravel/trade links with affected countries

1. Activate joint mechanisms for actions with animalhealth authorities and other relevant organizations.

2. Assess preparedness status and identify immediateactions needed to fill gaps (e.g. with the help of theWHO checklist for influenza pandemic preparednessplanning).*

3. Ensure ability to mobilize and rapidly deploy amultisectoral expert response team.

4. Ensure ability to rapidly deploy stockpile resources(national or from global pool) to field locations.

5. Decide whether to deploy part of the stockpilecomponents according to risk assessment.

6. Establish a policy on compensation for loss ofanimals through culling, in order to improvecompliance with emergency measures.

Interpandemic period, phase 2 – Situation monitoring and assessment


1. To obtain and disseminate information on spreadin animals and interspecies transfers.

2. To support early detection of human infection.

3. To collaborate in assessment of the risk oftransmission from animals to humans.

4. To facilitate the availability of diagnostic reagentsto diagnose human infections.

1. To identify interspecies transmission at an earlystage and transmit this information to WHO andother appropriate partners.

2. To provide ongoing risk assessment fortransmission of viruses with pandemic potential tohumans.


PHASE

2



1. Collaborate with national authorities and appropriateinternational organizations, e.g. FAO and OIE, toconfirm the presence of a new strain, assess theepidemiology and coordinate strain characterization.

2. Encourage dissemination of information on spread inanimals and interspecies transfers.

3. Provide guidance on human risk assessment tonational authorities in affected countries, and assistwith on-site assessment if requested and feasible.

4. Assist national authorities in enhancing surveillanceand investigating suspect cases of transmission tohumans, if possible.

5. Continue to support the collection of strains andinformation needed to develop diagnostic reagents.

6. Coordinate development and provision of diagnosticreagents to WHO national influenza centres, asnecessary.

7. Work with countries to monitor and report onongoing national surveillance and investigation.

Affected countries and countries with close travel/trade links with affected countries

1. Implement enhanced animal and human surveillancebased on WHO, FAO and OIE recommendations;report results rapidly and regularly to the above-mentioned international bodies.

2. Urgently transmit representative isolates frominfected animals to WHO- and OIE-designatedreference laboratories for confirmation, detailedcharacterization, development of diagnostic reagentsand consideration of suitability for use to developcandidate vaccine viruses/prototype vaccine strains.

3. Urgently transmit representative isolates fromsuspected human cases of infection with an animalinfluenza virus strain to the national influenza centreor other designated national laboratory for influenza.

4. Conduct field investigations (epidemiological,laboratory) in affected area to assess spread of thedisease in animals and threat to human health.

5. Participate actively in assessment of the risk oftransmission (e.g. animal models for pathogenicitytesting).

6. Ensure expertise and capacity for virologicalsurveillance in national laboratories according tostandard procedures and using reagents provided byWHO- and OIE- designated reference laboratories.

7. Continue to collect and exchange virus isolates andother scientific information with partnerorganizations.

8. Conduct serological surveillance of farmers(including their families) and animal workers involvedin containment of outbreaks of animal influenza.

Interpandemic period, phase 2 – Prevention and containment


1. To reduce the risk of human infection throughexposure to animal viruses.

2. To assess the susceptibility of animal strains toantiviral drugs.

3. To reduce the risk of coinfection in humans andthereby minimize the opportunities for virusreassortment.

4. To consider the development of a human vaccineagainst the new strain.

1. To minimize the risk of human infection fromcontact with infected animals.

2. To assess the national availability of antiviraldrugs.

3. To reduce the risk of coinfection in humans andthereby minimize the opportunities for virusreassortment.

Interpandemic period, phase 2 – Situation monitoring and assessment (continued)

PHASE

2



Affected countries

1. Ensure optimal response to the animal outbreak,including measures to reduce infection risk in thoseinvolved in the response (education and trainingregarding potential threat; correct use of personalprotective equipment; deployment of antivirals if riskassessment indicates).

2. Recommend measures to reduce human contact withpotentially infected animals (e.g. advice for travellers).

3. Prepare for use of further interventions if humaninfection is detected.

4. Update information on available national supplies ofantivirals.

5. Update recommendations for prophylaxis andtreatment with antivirals; consider implementationafter formal risk assessment.

6. Ensure that antivirals component of a national orglobal stockpile could be deployed rapidly from acentral location to the affected district(s), and thatappropriate staff are familiar with guidance fordeployment and use.

7. Review strategy for the use of interpandemicvaccines to prevent dual infection with human andanimal viruses, and promote their use in defined riskgroups.

8. Develop contingency plans for procuring seasonalvaccine (or specific vaccine if available) and fordistribution once available.

Unaffected countries

1. Establish or enhance mechanisms for exchange ofepidemiological and virological data, and of infectioncontrol expertise/guidance with affected countries.

Countries with vaccine production capacity

1. Review strategies for emergency production,licensing and testing of pandemic vaccine.

Interpandemic period, phase 2 – Prevention and containment (continued)


1. Maintain close liaison with international agriculturalauthorities having the primary responsibility for thecontrol of the disease in animals, and provideappropriate assistance as needed.

2. Recommend measures to reduce human exposure(e.g. persons living, working or travelling in affectedareas).

Antivirals

1. Coordinate testing of the new strains for antiviralsusceptibility.

2. Provide information to national authorities onprinciples for antiviral drug use needed for thedevelopment of prophylaxis and treatmentrecommendations.

3. Encourage national authorities and companies toprovide current data on national inventories andinternational availability of antiviral agents effectiveagainst the new strain.

4. Ensure that the antivirals component of a possibleglobal stockpile could be deployed to the affectedcountries if necessary, and review indications fordeployment and use.

Vaccines

1. Characterize the virus and decide on need to developand distribute vaccine prototype strain for possiblevaccine production.

2. Communicate with vaccine manufacturers regardingpossible planning for investigatory vaccine lots andclinical trials (especially if this phase was downscaledfrom the pandemic alert period).

3. Support establishment of mechanisms forproducing/obtaining seasonal and pandemicprototype vaccines for possible targeted use as ameasure to reduce pandemic risk during prolongedpandemic alert periods.

PHASE

2

19

Interpandemic period, phase 2 – Health system response


1. To promote national efforts to ensure earlydiagnosis of human cases and appropriate healthsystem response.

1. To ensure that if human infections occur, they willbe quickly recognized and that health system willrespond appropriately.


1. Provide guidance to countries in assessing healthsystem preparedness and needs if not already done.

2. Coordinate the availability of diagnostic reagents toaffected countries as appropriate.

3. Ensure readiness of diagnostic capacity in WHO-designated reference laboratories.

4. Develop guidelines for health-care workers to assistin case-finding and investigation.


1. Alert local health-care providers to: consider newinfluenza infection in ill patients withepidemiological link to affected animal species;implement infection control measures; report casesimmediately to public health authorities; providealgorithms to assist in case-finding and management.

2. Verify availability and distribution procedures forpersonal protective equipment and antivirals and forvaccine for the protection of persons at occupationalrisk; consider measures to implement.

3. Ensure rapid deployment of diagnostic tests whenavailable.

All countries

1. Alert health system to review preparedness plans andbe ready to receive presumably small numbers ofpatients with new influenza subtype infectionrequiring isolation and clinical care.

2. Assess health system capacity to detect and containoutbreaks of human disease in hospital settings.

3. Alert local health-care providers to consider influenzainfection in ill patients with travel or epidemiologicallink to an affected country, and to recognize the needfor immediate reporting to national authorities;provide algorithms to assist in case-finding andinvestigation.

Interpandemic period, phase 2 – Communications


1. To ensure rapid global sharing of appropriatetechnical information.

2. To ensure that mechanisms exist for coordinatingcommunications with FAO and OIE, and otherinternational partners.

1. To ensure that appropriate information is sharedrapidly among health authorities, other partnersand the public.

2. To ensure that mechanisms exist for coordinatingcommunications with the animal-health sector.


PHASE

2



1. Update national and international authorities, otherpartners and stakeholders, including at-risk groupsand the public, with current information on virusspread and risks to humans.

2. Work with partners to promote consistent messagesin the interest of personal safety and public health.


1. Establish rapid communications to answer questionsfrom health-care providers and the public.

2. Communicate information on risk and prevention(risk of infection; safe food; animal handling) basedon WHO recommendations.

3. Address possible stigmatization of individuals/populations in contact with the animal strain.

All countries

1. Update national authorities, other partners andstakeholders, including at-risk groups and the public,with current information on virus spread and risks tohumans.

Interpandemic period, phase 2 – Communications (continued)

PHASE

2

21

PANDEMIC ALERT PERIODPandemic alert period, phase 3 – Overarching goalEnsure rapid characterization of the new virus subtype and early detection, notification and response toadditional cases.

Pandemic alert period, phase 3 – Planning and coordination


1. To provide guidance to national authoritiesregarding interventions to detect and respond tohuman cases.

1. To ensure that mechanisms exist so that imminentpotential human health threats can be recognizedand dealt with.

2. To coordinate timely interventions that will reducethe risk of a pandemic.


1. Mobilize response by providing guidance to nationalauthorities in reviewing and updating nationalcontingency plans, based on evolving scientificinformation about the human case(s).

2. Provide international oversight and support tocountries with initial human cases, to assist inestablishing facts and fully characterizing cases

3. Review WHO internal contingency plan.

Affected countries

1. Activate national pandemic contingency planningarrangements.

2. Implement interventions to reduce disease burden inthe initial foci and contain or delay the spread ofinfection.

3. Mobilize national response and provide guidance torelevant authorities in reviewing, updating andimplementing contingency plans.

4. Brief appropriate officials in all relevant governmentdepartments (e.g. health, agriculture, executive,legislative/judicial) at national and subnational levels,regarding the status of the incident and the potentialneed for additional resources, interventions and theuse of emergency powers.

5. Provide assistance to regional, district and localauthorities (including private essential services) inimplementing interventions.

Pandemic alert period, phase 3 – Situation monitoring and assessment


1. To coordinate confirmation of human infection(s).

2. To provide assistance to national authorities ifneeded in describing the epidemiological,virological and clinical features of infection andpossible sources, and in assessing the extent ofhuman-to-human transmission.

3. To enhance alertness for additional cases.

4. To enhance development or adjustment ofdiagnostic reagents and vaccines.

1. To be able to exclude wider human-to-humantransmission, and to detect this as soon as itoccurs.

2. To be able to detect and characterize additionalcases (including risk factors for transmission).

PHASE

3




1. Facilitate laboratory confirmation of humaninfections through the WHO network of referencelaboratories.

2. Establish global case definition for reporting bycountries.

3. Collaborate with national authorities to ensure rapidreporting of human infections with a new influenzavirus strain by appropriate means.

4. Collect, synthesize and disseminate information onthe global situation in collaboration with partners.

5. Provide appropriate support to national authorities ininvestigating the case(s), and the epidemiologicalcircumstances of infection, and in identifying riskgroups.

6. Provide guidance to national authorities in assessingthe pathogenicity, and clinical and virological aspectsof human infection.

7. Encourage countries to publicize data and informWHO on ongoing case investigations.

8. Update, if needed, and provide diagnostic reagents tonational influenza reference centres for identificationof the new strain.

9. Continue to collaborate with national andinternational organizations to collect strains andinformation needed to develop or adjust diagnosticreagents and vaccines.

10. Decide on need to develop or update prototypevaccine strain.

11. Enhance alertness for additional cases and encourageactive human case-finding.


1. Confirm and report cases promptly using appropriatechannels (e.g. International Health Regulations).

2. Exclude laboratory accident or intentional release asthe cause of the human cases.

3. Determine the epidemiology of human cases (sourceof exposure; incubation period; infection of contacts(clinical and subclinical); period of communicability).

4. Establish national case definition (or review/modifyexisting definition) based on WHO guidance.

5. Assess clinical characteristics of infections in humansand share with relevant international partners.

6. Ensure rapid virological characterization of the virusresponsible for human infection, in collaboration withWHO collaborating centres.

7. Enhance human and animal surveillance, includingcluster detection.

8. Collaborate with international efforts to assess viruspathogenicity in humans.

9. Identify priority geographical areas and risk groupsfor targeting with preventive measures.

10. Assess effectiveness of treatment protocols andinfection control measures and revise if necessary.

11. Conduct seroprevalence studies in risk groups, andthen expand to the general population, to assessprevalence/incidence of infection (symptomatic andasymptomatic).

12. Continue to collect and share virus isolates and otherinformation needed to develop or adjust diagnosticreagents and develop candidate vaccine viruses/prototype vaccine strains, and monitor any emergingantiviral resistance.

Pandemic alert period, phase 3 – Situation monitoring and assessment (continued)

Pandemic alert period, phase 3 – Prevention and containment


1. To provide guidance in implementing measures toprevent or reduce human-to-human spread.

2. To assess the potential for use of antivirals incurrent and later phases.

3. To facilitate planning for pandemic vaccinedevelopment.

1. To contain or reduce human-to-human virustransmission.

2. To limit morbidity and mortality associated withcurrent human infections.

3. To assess the potential for use of antivirals incurrent and later phases.

4. To increase readiness for possible pandemicvaccine development.

PHASE

3


Pandemic alert period, phase 3 – Prevention and containment (continued)



1. Reiterate appropriate and inappropriate measures foraffected and unaffected countries (Annex 1).

2. Request affected countries to inform WHO onimplementation and effectiveness of containmentmeasures, to inform national and internationalplanning.

3. Advocate that appropriate internationalorganizations and associations and transportationcompanies develop and prepare to implementstandard measures for travellers on boardinternational conveyances.

Antivirals

1. Coordinate assessment of effectiveness and safety ofantiviral therapy in treated patients usingstandardized research protocols when possible.

2. Work with national authorities to coordinatepositioning of components of a possible globalstockpile so that they could be swiftly deployed.

3. Coordinate collection and testing of strains forantiviral susceptibility.

Vaccine

1. Support strain characterization and decide on needto develop and distribute vaccine prototype strain forpossible vaccine production.

2. Communicate with vaccine manufacturers regardingplanning for production of investigatory vaccine lotsand clinical trials.

3. Assist national authorities in affected countries toassess the possible benefits and disadvantages ofvaccinating persons with occupational and otherexposures with seasonal vaccines, and to planvaccination programmes if appropriate.

4. Review and update WHO recommendations forpandemic vaccine use strategies with partners,including national authorities. Assess the advisabilityand feasibility of use of pandemic vaccines duringpandemic alert periods.

Countries with case(s)

1. Implement appropriate interventions as identifiedduring contingency planning, in consultation withrelevant partners.

2. Share virus isolates with WHO in a timely fashion toallow for potential pandemic vaccine developmentand updating of reagents.

3. If associated with animal outbreak(s):

(a) consider deploying supplies of antivirals for post-exposure (and possibly pre-exposure) prophylaxisof individuals who are most likely to be exposedto the animal virus;

(b) continue promoting vaccination with seasonalinfluenza vaccine to limit risk of dual infection inthose most likely to be exposed to the animalvirus, and potentially decrease concurrentcirculation of human strains in the outbreak-affected area.

All countries

1. Assess/reassess availability of antivirals.

2. Review evidence base for effectiveness and safety ofantivirals and if necessary reassess and reviewstrategies, guidelines and priorities for use withpartner organizations.

3. Reassess emergency methods to increase supply ofantivirals, e.g. additional production facilities,investigatory new drugs.

4. Review vaccine use strategies with partnerorganizations.

5. Resolve liability and other legal issues linked to use ofthe pandemic vaccine for mass or targetedemergency vaccination campaigns, if not yet done.

6. Assess inventories of vaccines and other materialresources needed to carry out vaccinations (e.g.syringes).

7. Consider supporting development of prototypevaccines.

PHASE

3


Pandemic alert period, phase 3 – Health system response



1. Encourage national authorities to review and updatehealth system response strategies at national andsubnational levels.

2. Review and update guidelines for clinical care,diagnostics, treatment, infection control and safespecimen handling.

3. Activate existing clinical networks to review clinicalinformation, advise on knowledge gaps and developclinical research protocols.

Affected countries

1. Activate emergency coordinating committees(national, regional and local) and pre-establishedcoordination between the health-care sector andrelevant partner organizations.

2. Explore ways to provide drugs and medical care freeof charge (or covered by insurance) to the patientand the health-care delivery system, in order toencourage prompt reporting of new cases.

3. Review contingency plans at all levels, with specialattention to surge capacity.

4. Test decision-making procedures and chains ofcommand.

5. Train health-care workers to detect/identify clustersof cases.

6. Ensure implementation of infection-controlprocedures to prevent nosocomial transmission.

7. Ensure compliance with standards for biosafety inlaboratories, and for safe specimen-handling andshipment.

All countries

1. Provide public and private health-care providers withupdated case definitions, protocols and algorithms toassist with case-finding, management, infectioncontrol and surveillance.

2. Assess capability/capacity for implementing infectioncontrol procedures for ill patients; implementinfection control consistent with existing WHOguidance.

1. To promote increased national efforts inrecognition and diagnosis of cases and inimplementing contingency plans for use ofhealth-care resources.

2. To provide guidance for clinical care and infectioncontrol.

3. To provide guidance on appropriate handling ofspecimens, including biosafety and security issues.

1. To prevent nosocomial transmission andlaboratory infections.

2. To ensure heightened awareness among health-care workers regarding the possibility of casesand/or clusters of cases.

PHASE

3

25

Pandemic alert period, phase 3 – Communications


1. To communicate transparently with the publicregarding possible outbreak progression andcontingencies to be expected.

2. To ensure rapid sharing of appropriateinformation among health authorities, otherpartners and the public, including what is knownand what is unknown.

Affected countries

1. Provide regular updates to WHO and otherinternational and domestic partners on the evolvingnational situation.

All countries

1. Identify target groups for delivery of key messages;develop appropriate materials, formats and languageoptions.

2. Work with partners to ensure consistent messagesare delivered.

3. Address the issue of stigmatization of individuals/families/communities affected by human infectionwith the animal strain.

4. Review and update information materials for newsmedia, general public, health workers and policy-makers.

5. Review communications systems and facilities toensure that they are functioning optimally, and thatcontact lists are up to date.


1. To communicate transparently with the publicregarding possible outbreak progression andcontingencies to be expected.

2. To ensure rapid sharing of appropriateinformation among health authorities, otherrelevant government departments and otherpartners, including what is known and what isunknown.


1. Update national and international authorities, otherpartners and stakeholders, and the public on theglobal epidemiological situation and diseasecharacteristics.

2. Work with partners to promote consistent messages.

3. Provide background information regarding theeffectiveness of recommended measures.

4. Upon request, dispatch communications experts toaffected areas.

Pandemic alert period, phase 4 – Overarching goalContain the new virus within limited foci or delay spread to gain time to implement preparednessmeasures, including vaccine development.



1. To coordinate global and national efforts to delayor contain the spread of human infection withinlimited foci.

2. To coordinate assessment of national needs andresource mobilization among affected andunaffected countries.

1. To ensure that systems exist to detect andcharacterize outbreaks, and assess the risk ofescalation into a pandemic.

2. To coordinate the implementation of proceduresthat will delay or contain the spread of humaninfection within limited foci.

PHASE

4



1. Facilitate deployment of a possible global stockpileor other resources, as well as of technical assistance.

2. Coordinate global interventions and assist in theirimplementation and evaluation.

3. Consider activating internal WHO contingency plan.

4. Identify needs and encourage the provision ofinternational assistance to resource-poor countries.

Affected countries

1. Ensure highest levels of political commitment forongoing and potential interventions/countermeasures.

2. Activate procedures to obtain additional resources;consider invoking emergency powers.

3. Activate overarching national command and controlof response activities, either by formal means or defacto (close oversight of district and local activities).

4. Deploy operational response teams across allrelevant sectors.

5. Ensure cross-border collaboration with surroundingcountries for information-sharing and coordination ofemergency responses.

6. Identify needs for international assistance.


1. Activate national pandemic contingency planningarrangements.

2. Reassess current state of preparedness using theWHO checklist for influenza pandemic preparednessplanning* and national tools; implement actionsrequired to close priority gaps.

3. Identify ability to respond to requests forinternational assistance.


Pandemic alert period, phase 4 – Planning and coordination (continued)

Pandemic alert period, phase 4 – Situation assessment and monitoring


1. To coordinate assessment of the extent of human-to-human transmission.

2. To describe the epidemiological, virological andclinical features of infection and possible source,and disseminate this information as needed forsurveillance and control measures.

3. To enhance development or adjustment ofdiagnostic reagents and vaccines.

1. To assess the extent of human-to-humantransmission

2. To detect, notify and characterize additionalclusters (including the identification of risk factorsand other data concerning transmission asrequested by WHO).

3. To assess the threat to human health and theimpact of any control measures, and identifyresources required for enhanced control.

PHASE

4



1. Facilitate assessment of the extent of human-to-human transmission, if necessary with on-siteevaluation.

2. Adjust case definition for global reporting.

3. Facilitate reporting of human-to-human transmissionof infection with a new influenza virus strain bynational authorities by appropriate means, e.g. theInternational Health Regulations.

4. Recommend strategies for national authorities toenhance surveillance in risk groups in affected areas.

5. Coordinate with national authorities the monitoringof national actions on containment and control.

6. Provide appropriate support to national authorities ininvestigating cases and contacts, enhancing diseasesurveillance to identify additional cases, and theepidemiological circumstances of infection (e.g.source of exposure, infection of contacts, and spreadin the general population), and in identifying riskgroups.

7. Enhance active case-finding for early detection ofassociated clusters.

Affected countries

1. Describe and (re)assess the epidemiological,virological and clinical features of infection; identifypossible source(s).

2. Report this information on cases and clustersthrough appropriate mechanisms, e.g. InternationalHealth Regulations, to WHO and other appropriatebodies.

3. Expand activities already under way in

phase 3 ; adjust case definition if

necessary.

4. Assess sustainability of human-to-humantransmission.

5. Conduct clinical research to optimize treatmentprotocols, if resources available.

6. Collect and share strains and information needed todevelop or adjust diagnostic reagents and prototypevaccines.

7. Forecast likely impact of the spread of infection.

8. Attempt to assess the impact of containmentmeasures to allow for adjustment ofrecommendations; share findings urgently with theinternational community (including WHO) to allowupdating of national and international policies.

9. Enhance surge capacity for surveillance.


1. Enhance surveillance, especially in countries withextensive travel/trade links to affected areas.

Pandemic alert period, phase 4 – Situation assessment and monitoring (continued)



1. To support and evaluate global and nationalefforts to delay or contain the spread of humaninfection within limited foci.

2. To assess susceptibility of new strain andavailability of antivirals, and deploy from globalstockpile when appropriate.

3. To promote development and prepare forproduction of pandemic vaccine.

4. To deploy pandemic vaccine to foci of disease, ifappropriate and available.

1. To contain or delay human-to-human virustransmission.


3. To assess the potential for wider usage of antiviralsin later phases.

4. To increase readiness for pandemic vaccineproduction and deployment.

5. To gain early experience in pandemic vaccine useunder field conditions (if clinical trial lots areavailable).

PHASE

4





2. Request affected countries to report onimplementation of enhanced surveillance andcontainment measures, assist in evaluating theeffectiveness of such measures, and transmitappropriate information to all Member States toinform national and international planning.

3. Advocate that appropriate internationalorganizations and associations, and transportationcompanies, implement standard measures fortravellers on board international conveyances,consistent with the new phase.

4. Assess needs for recommending additionalcontainment measures, e.g at international borders.

Antivirals

1. Same as in phase 3.

2. Collaborate with national authorities in support oftargeted antiviral prophylaxis to close contacts ofcases, if appropriate.

Vaccines

1. Develop up-to-date vaccine prototype strains.

2. Coordinate the planning of clinical trials.

3. Collaborate with national authorities in vaccinatingpersons at occupational or other risk of infection, ifappropriate.

4. Update guidance for optimal use of seasonal andpandemic vaccines when available.

Countries with cases

1. Implement appropriate interventions identifiedduring contingency planning, and consider any newguidance provided by WHO.

2. Evaluate the effectiveness of these measures incollaboration with WHO.

3. Use antivirals for early treatment of cases, andconsider antiviral prophylaxis for close contacts ofcases based on risk assessment and severity of illnessin humans.

4. Assess likely effectiveness and feasibility ofprophylaxis for the purpose of attempting to containoutbreaks. Determine target population; ifintervention agreed, implement as an emergencymeasure; assess impact.

5. Consider deploying prototype pandemic vaccine ifavailable.

Countries without cases

1. Assess need to deploy current antiviral stock to local/regional level to facilitate rapid implementation ofantiviral strategy (if this becomes necessary).

2. Consider supporting development or increasedproduction of prototype vaccines.


PHASE

4




1. To promote efforts by national authorities to usehealth-care capacity optimally if additional casesoccur.

2. To provide guidance on clinical triage andtreatment.

3. To enhance appropriate infection control andbiosafety procedures in community primary andsecondary care.

1. To prevent nosocomial transmission.

2. To maintain biosafety.

3. To ensure capacity is available and used optimallyin affected countries.


1. Coordinate international response with otherinternational organizations.

2. Reassess guidelines for clinical management andinfection control in health care (including long-termcare facilities).

3. Review guidelines for biosafety in laboratories.

4. Encourage national systems to prepare for the nexthigher phase, including a mobilization plan forhealth-care workers.

5. Coordinate and support clinical research to increaseevidence for recommended guidelines and protocols.

Affected countries

1. Update and reinforce messages to local health-careproviders to consider influenza infection in illpatients, and report findings to public healthauthorities.

2. Update case definition, protocols and algorithms forcase-finding, management (antivirals and otherrequired drugs), infection control and surveillance asrequired.

3. Activate contingency plans for response to overloadof health facilities with influenza patients, andidentify alternative strategies for case isolation andmanagement.

4. Implement surge-capacity arrangements andcontingency plans for staff shortages in health-carefacilities and in all other key activity sectors.

5. Re-emphasize infection-control measures and issuestockpiles of personal protective equipment.


1. Activate pandemic contingency planningarrangements.



1. To ensure rapid sharing of appropriateinformation among health authorities, otherinternational agencies and other partners,including what is known and what is unknown.

2. To prepare the public and partners for a possiblerapid progression of events and possiblecontingency measures.


2. To prepare the public and partners for a possiblerapid progression of events and possiblecontingency measures.

PHASE

4




1. Coordinate global interventions to reduce diseaseburden in the initial foci, and thereby contain or delaythe spread of infection.

2. Coordinate the ongoing evaluation of interventions.

3. Finalize preparations for imminent pandemic,including internal organization and staffing surgecapacity.

4. Identify needs and encourage internationalassistance to resource-poor countries.

5. Activate WHO contingency plan.

Affected countries

1. As needed, designate special status to affected areain order to facilitate interventions (e.g. state ofemergency).

2. Assist in the ongoing evaluation of interventions.

3. Finalize preparations for imminent pandemic,including activation of internal organizationalarrangements (within command-and-control system)and staffing surge capacity.

4. Adjust and maximize efforts and resources to reducedisease burden and contain or delay the spread ofinfection.

Pandemic alert period, phase 4 – Communications (continued)

1. Update national and international authorities, otherpartners and stakeholders, and the public on globalepidemiological situation and disease characteristics.


3. Provide templates for general health educationmaterials.

4. Ensure regular updating of information regarding theeffectiveness of recommended measures.

Affected countries

1. Reinforce and intensify key messages on preventionof human-to-human spread.

2. Explain rationale and update public on all aspects ofoutbreak response and likely next steps.

3. Provide instruction in self-protection.

All countries

1. Update national authorities, other partnerorganizations/stakeholders and the public on thedomestic and international epidemiological situationand known disease characteristics.

2. Activate emergency communications plans.

3. In conjunction with partner organizations, updatecommunications messages.

4. Develop general health protection educationmaterials, e.g. templates, for national and localapplications.

5. Re-emphasize infection-control measures in thecommunity, health-care settings, and long-term carefacilities.

Pandemic alert period, phase 5 – Overarching goalMaximize efforts to contain or delay spread, to possibly avert a pandemic, and to gain time to implementpandemic response measures.



1. To coordinate maximum global efforts to delay orpossibly avert a pandemic.

1. To coordinate and ensure maximum efforts todelay or possibly avert a pandemic.

PHASE

5


Pandemic alert period, phase 5 – Situation monitoring and assessment


1. To determine pandemic risk and spread of disease.

2. To update description of the epidemiological,virological and clinical features of infection andpossible source, and disseminate this informationas needed for surveillance and control measures.

3. To provide guidance on national monitoring ofhealth-care system needs.

1. To determine pandemic risk and exclude spread toother countries/regions and to identify this assoon as it occurs.

2. To determine and monitor public health resourcesrequired for pandemic response.


1. Coordinate assessment of the extent of human-to-human transmissibility in collaboration with partners.

2. Promote intensification of disease surveillance incountries not yet affected, to the maximum extentpossible.

3. Support affected Member States as much as possiblein confirming the spread of human infections andassessing the epidemiological situation.

4. Review and adjust case definition and guidelines ifneeded.

5. Facilitate reporting of increased spread and otherepidemiological features by national authoritiesthrough appropriate means.

6. Accelerate and enhance situation monitoring andassessment activities in pandemic alert period,phase 4, to a maximum.

7. Promote monitoring of health-care needs andfacilities in affected countries.

8. Forecast trends for the first pandemic wave (affectedregions, risk groups, health-care resource needs,impact, etc.).

Affected countries

1. Expand and adjust activities in phase 4,to maximum intensity.

2. Report increased spread through appropriate means,including the revised International HealthRegulations, as a public health emergency ofinternational concern (PHEIC).

3. Implement real-time monitoring of essentialresources (medical supplies, pharmaceuticals,infrastructure, vaccines, hospital capacity, humanresources, etc.).

4. Conduct enhanced surveillance for respiratorydisease through surveys (telephone orquestionnaires).

5. Adjust forecasts of the likely impact of both infectionspread and control measures.

6. Assess impact of containment measures to date inorder to allow for readjustment if necessary; sharefindings with the international community to allowupdating of national and international guidance/recommendations.

7. Monitor the development of antiviral resistance.


1. Enhance surveillance measures to maximumintensity.

PHASE

5




1. To mobilize and focus global resources to contain/control outbreak

2. To coordinate efforts to limit morbidity andmortality.

3. To assess impact of control measures.

1. To make massive efforts to contain or delayhuman-to-human virus transmission and theonset of a pandemic.


3. To assess the potential for usage of antivirals inthe pandemic period.

4. To support preparations for large-scale pandemicvaccine production and licensing, and prepare fordeployment as supplies become available.

5. To gain early experience in pandemic vaccine useunder field conditions (if clinical trial lots areavailable).



1. Same as phase 4.

2. Collaborate to the extent possible with nationalauthorities in distributing infection-control suppliesto health-care settings providing care to humancases, especially if these supplies are from the globalstockpile.

Antivirals

1. Same as in phase 4.

2. Collaborate with national authorities to the extentpossible in administering and evaluating targetedantiviral prophylaxis to close contacts of cases,especially if the global stockpile is used.

Vaccines

1. Promote vaccine prototype development, e.g. bycoordinating clinical trials, if not done in phase 2.

2. Establish ongoing information exchange with vaccinemanufacturers to prepare for full-scale pandemicvaccine production.

3. Provide guidance to national authorities in preparingand conducting a targeted vaccine campaigninvolving persons in the affected community, ifpandemic vaccine is available.

Countries with cases

1. Implement interventions identified during contin-gency planning and new guidance provided by WHO.

2. Consider/reconsider use of antivirals for earlytreatment of cases (prioritization may need to bechanged).

3. Assess/reassess efficacy and feasibility of prophylaxisfor the purpose of attempting to contain outbreaks.Determine target population; if intervention agreed,implement as an emergency measure; assess impact.

4. Consider deploying prototype pandemic vaccine ifavailable.

Countries without cases

1. Reassess need to deploy current antiviral stock tolocal/regional level to facilitate rapid implementationof antiviral strategy (if this becomes necessary).

2. Consider results and lessons learned from use incountries with cases and modify antiviral strategy (ifapplicable).

3. If agreements already in place with manufacturer(s),consider recommending cessation of seasonalvaccine production and initiation of full-scalepandemic vaccine production.

4. Plan for vaccine distribution and acceleratepreparations for mass vaccination campaigns (e.g.education, legal/liability issues) for when pandemicvaccine becomes available.

5. Adjust priority lists of persons to be vaccinated (ifapplicable).

PHASE

5


If pandemic vaccine has already been developed

1. Activate emergency procedures for rapid licensingand use of pandemic vaccines (all countries).

2. Consider allocating vaccine for population-basedintervention aimed at containing infection withincurrently affected areas.

3. Consider implementing pandemic vaccinestrategy as indicated in pandemic period.




1. To promote efforts by national authorities to usehealth-care capacity optimally if additional casesoccur, including providing guidance on clinicaltriage, treatment and infection-controlprocedures.

2. To provide guidance on appropriate handling ofspecimens, including biosafety and security issues.

1. To ensure that health systems are ready to scaleup response and implement changes in triage andtreatment priorities, and that these actions occuras soon as a country becomes affected.

2. To prevent nosocomial transmission and maintainbiosafety.



2. Provide guidance to national authorities in assistingclinicians in recognition, diagnosis and reporting ofcases.

3. Provide guidance to national authorities to optimizeuse of scarce facilities (triage, modified clinicalguidelines, modified hospital infection guidelines,etc.).

4. Provide countries with updated models foralternative care and protection of non-influenzahealth-care service.

Affected countries

1. Full mobilization of health services and fullimplementation of emergency/contingency plans inaffected areas, including coordination with otheremergency sectors.

2. Commence triage arrangements and otheremergency procedures for efficient use of health-carefacilities.

3. Fully implement emergency plans for deployment ofhealth-care workers.

4. Ensure attention to the health and other needs ofpersons in quarantine.

5. Arrange for additional human and material resources,and alternative means of health-care delivery, basedon forecasted needs and contingency plans.

6. Implement corpse-management procedures.

7. Prepare health-care workers for potential change inpolicy regarding antivirals for occupational exposures(switch from prophylaxis to early treatment).


1. Activate emergency coordinating committees(national, regional or other) for health system.

2. Provide public and private health-care providers withupdated case definition, protocols and algorithms forcase-finding, management, infection control andsurveillance.

PHASE

5


3. Explore ways to provide drugs and medical care freeof charge (or covered by insurance) to the patientand the health-care delivery system, to encourageprompt reporting and enrolment.

4. Assess capability/capacity for infection control for illpatients, and implement infection control consistentwith WHO guidelines.

5. Review contingency plans relevant to health systemresponse at all levels, with special attention to surge-capacity arrangements.

6. Test decision procedures and chains of command,and other pandemic working arrangements toensure that they are functioning.

7. Train health-care workers to detect/identify cases andclusters.

Pandemic alert period, phase 5 – Health system response (continued)



1. To prepare national authorities, other partners,and the public for a likely rapid progression ofevents, additional contingency measures, anddisruptions to normal life.

2. To ensure rapid sharing of appropriateinformation among health authorities, otherpartners and the public, including what is knownand what is unknown.

1. To prepare the public and other partners for alikely rapid progression of events, additionalcontingency measures, and disruptions to normallife.



1. Update national authorities, other partners andstakeholders, and the public on global situation,trends, epidemiological characteristics andrecommended measures.

2. Continue to work with partners to promoteconsistent messages.

3. Explain importance of complying with recommendedmeasures despite their possible limitations, andabout interventions that may be modified orimplemented during a pandemic.

1. Redefine key messages; set reasonable publicexpectations; emphasize need to comply with publichealth measures despite their possible limitations.

2. Utilize last “window of opportunity” to refinecommunications strategies and systems inanticipation of imminent pandemic.

3. Inform public about interventions that may bemodified or implemented during a pandemic, e.g.prioritization of health-care services and supplies,travel restrictions, shortages of basic commodities,etc.

PHASE

5


PANDEMIC PERIOD■ The intensity of activities in a country will depend largely on whether there are cases in the country. The eventual

appearance of cases in all countries is considered virtually inevitable.

■ Affected countries should follow the recommendations below. Unaffected countries should prepare to implementthese recommendations rapidly, especially if they have extensive trade/travel links with affected countries.

Pandemic period, phase 6 – Overarching goalMinimize the impact of the pandemic.

Pandemic period, phase 6 – Planning and coordination


1. To provide global leadership and coordination tominimize morbidity and mortality; preservehealth-care system effectiveness; minimizesocietal disruption; and minimize the economicimpact of a pandemic.

2. To promote rational access to finite resources,including vaccines and other pharmaceuticalsupplies (when available).

3. To support evaluation of the effectiveness ofspecific responses and interventions.

4. To establish and maintain trust across all agenciesand organizations and with the public, through acommitment to transparency and credible actions.

5. To draw lessons from the ongoing pandemicresponse in order to improve response strategyand inform future planning.

1. To provide leadership and coordination ofmultisectoral resources that will: minimizemorbidity and mortality; preserve health-caresystem effectiveness; minimize societal disruption;and minimize the economic impact of a pandemic.

2. To ensure rational access to finite nationalresources, including pharmaceutical supplies and(when available) vaccine.

3. To evaluate the effectiveness of specific responsesand interventions.

4. To establish and maintain trust across all agenciesand organizations and with the public, through acommitment to transparency and credible actions.

5. To draw lessons from the ongoing pandemicresponse in order to improve response strategyand inform future planning.


1. Establish WHO influenza pandemic information andcoordination centre.

2. Interact with international organizations andagencies inside and outside of the health sector tocoordinate interventions.

3. Coordinate ongoing development of guidelines.

4. Provide guidance to national authorities onimplementing and evaluating interventions andassessing their impact.

5. Identify need for and promote provision of resourcesand other support as may be required in severelyaffected countries.

6. Facilitate development of consensus on lessonslearned for immediate application, as well as forfuture needs.

Countries not yet affected

1. Activate crisis committee(s) and national commandand control of emergency operations (if not alreadydone).

2. Finalize adjustment of official guidelines andrecommendations.

3. Provide guidance to local authorities in all sectors onimplementation and evaluation of proposedinterventions.

Affected countries

1. Implement all relevant elements of nationalpandemic plan, including coordination of responseand implementation of specific interventions.

2. Assess and publicize the current and cumulativenational impact.

3. Consider applying emergency powers.

PHASE

6


Subsided (end of pandemic or between waves)

1. Determine need for additional resources and powersduring subsequent pandemic waves.

2. Declare end of emergency command-and-controloperations, states of emergency, etc.

3. Support rebuilding of essential services, includingrotating rest and recuperation for staff.

4. Review national plan based on experiences.

5. Address psychological impacts.

6. Acknowledge contributions of all stakeholders(including the public) and essential staff towardsfighting the disease.

7. Consider offering assistance to remaining countrieswith ongoing widespread activity.

Pandemic period, phase 6 – Planning and coordination (continued)

Pandemic period, phase 6 – Situation monitoring and assessment


1. To monitor the epidemiological, virological andclinical features, and the course and impact of thepandemic at the global level, in order to forecasttrends and optimize the use of finite resources.

2. To assess the effectiveness of interventions usedto date in order to guide future actions.

1. To monitor the epidemiological, virological andclinical features, and the course and impact of thepandemic at the national level, in order to forecasttrends and optimize the use of finite resources.

2. To assess the effectiveness of interventions usedto date in order to guide future actions.


1. Coordinate global strain surveillance.

2. Monitor spread of disease and adjust case definitions.

3. Coordinate monitoring for possible changes inepidemiological, clinical and virological aspects ofinfection, including antiviral drug resistance.

4. Coordinate and/or facilitate assessment of globalimpact (morbidity, mortality).

5. Assist national reporting of estimated nationalimpact and facilitate global situation monitoring(global spread, national trends).

6. Encourage preparation of forecasts for the next wave(new affected regions, risk groups, health-careresources, etc.).

7. Review lessons learnt and make adjustments insurveillance guidelines and tools for countries.


1. Continue enhanced surveillance measures as forphase 5 (unaffected country).

2. Monitor global situation (vaccine/antiviral availability,recommendations for best practices, etc.).

3. Estimate the impact of vaccination and antiviralprogrammes used elsewhere (safety, efficacy andantiviral resistance).

Affected countries

1. Monitor geographical spread of disease from point(s)of introduction/first detection.

2. Use enhanced surveillance and case-managementdatabase to identify initial cases/contacts and trackinitial geographical spread.

3. Monitor for possible changes in epidemiology, clinicalpresentation and virological features.

PHASE

6


4. Monitor and assess national impact (morbidity,mortality, workplace absenteeism, regions affected,risk groups affected, health-care worker availability,essential worker availability, health-care supplies, bedoccupancy/availability, admission pressures, use ofalternative health facilities, mortuary capacity, etc.).

5. Assess need for emergency measures, e.g. emergencyburial procedures, use of legal powers to maintainessential services.

6. If sufficient resources, forecast trends (course ofpandemic) and economic impact.

7. Assess uptake and impact of: treatments andcountermeasures, including vaccine/antiviral efficacyand safety and emergence of antiviral resistance;nonpharmaceutical interventions; etc.

8. As disease activity intensifies and becomes morewidespread, adjust surveillance (e.g., reducevirological surveillance, discontinue case-management database) and adjust case definition toreflect increasing certainty of clinical diagnoses inabsence of virological confirmation; switch toaggregate data collection on morbidity, mortality.Maintain sufficient virological surveillance to detectantigenic drift.


1. Evaluate resource needs for subsequent waves if theyoccur.

2. Identify the most effective surveillance and controlmeasures for subsequent pandemic waves.

3. Report current status through appropriateinternational mechanisms.

4. Review lessons learned.

5. Reinstate enhanced surveillance for early detectionof subsequent wave.

6. Share experience gained with internationalcommunity (lessons learned).

Pandemic period, phase 6 – Situation monitoring and assessment (continued)

Pandemic period, phase 6 – Prevention and containment


1. To mitigate impact in affected countries.

2. To evaluate and update recommendedinterventions.

3. To promote maximum production and rational useof pharmaceuticals, e.g. vaccines and antivirals.

1. To contain or delay spread using public healthinterventions, while limiting societal disruption.

2. To minimize morbidity and mortality through therational use of available pharmaceuticals, e.g.vaccines and antivirals.

PHASE

6





2. Advocate that appropriate internationalorganizations and associations and transportationcompanies implement standard measures fortravellers on board international conveyances,consistent with the new phase.

3. Coordinate and facilitate assessment of interventionsand update recommendations if needed.

Antivirals

1. Coordinate assessment of antiviral susceptibility,effectiveness, and safety.

2. Update guidance on the optimal use of availableagents.

Vaccines

1. Recommend /update composition of pandemicvaccine.

2. Encourage emergency pandemic vaccine production.

3. Provide updated guidelines for national authorities toconduct targeted vaccination campaigns.

4. Recommend which strains should be included invaccines, especially if nonpandemic strains are stillcirculating.

As soon as possible (regardless of extent of diseaseactivity)

1. Implement pandemic vaccine procurement plans;update vaccine recommendations; re-evaluatedosage and schedule based on available new dataand WHO recommendations; plan logistics ofdelivery.

2. As soon as available, implement pandemic vaccineprogramme as availability/resources permit; evaluatesafety and efficacy; monitor supply.


1. Implement appropriate public health interventions asidentified during contingency planning and considernew guidance provided by WHO.

2. Review/update recommendations for use of antiviralsbased on: emerging data from affected countries;clinical studies; evidence of resistance; changes toWHO recommendations; availability and resources.

3. Implement distribution plan; monitor supply; beprepared to contribute to evaluation of safety andeffectiveness.

Affected countries

1. Implement appropriate public health interventionsidentified during contingency planning, and considernew guidance provided by WHO.

2. When possible, evaluate the effectiveness of suchmeasures.

3. Re-evaluate use of antivirals based on clinical studies,evidence of resistance, changes to WHOrecommendations and availability.


1. Review effectiveness of treatments andcountermeasures; update guidelines, protocols andalgorithms.

2. Evaluate antiviral efficacy, safety and resistance data;review/update guidelines as necessary; assess supplyfor subsequent wave(s).

3. Assess vaccine coverage to date, efficacy and safety;review/update guidelines as necessary; beginvaccination of persons not yet immunized in line withplans, priority status and availability; considerincorporation of pandemic strain into seasonalvaccine.

Pandemic period, phase 6 – Prevention and containment (continued)

PHASE

6


Pandemic period, phase 6 – Health system response


1. To provide guidance on ways to optimize patientcare with limited resources.

1. To optimize patient care with limited resources.

2. To reduce overall impact of the pandemic(morbidity and mortality).

3. To manage demand on health systems in order tomaximize sustainability of response.



2. Provide guidelines and (updated) model algorithmsfor the triage of influenza and non-influenza cases.

3. Update guidelines on self-care.

4. Facilitate mutual aid arrangements betweencountries according to the phasing of the pandemic,including mobilization of immune health-careworkers.

5. Utilize existing clinical networks to review clinicalinformation and effectiveness, and safety of clinicalinterventions; advise on knowledge gaps, researchneeds.


1. Keep emergency coordinating arrangements andchains of command for health systems fullyfunctional.

2. Keep case definition, protocols and algorithms forcase-finding, management (including appropriateuse of antibiotics to treat suspected bacterialinfections), infection control and surveillanceupdated in line with latest WHO guidance.

3. Maintain health-care worker vigilance for the onset ofcases and clusters.

4. Explore ways to provide drugs and medical care freeof charge (or covered by insurance) to the patientand the health-care delivery system, to encourageprompt reporting and recognition of the start ofpandemic activity.

5. Maintain capability/capacity for infection control forill patients, and implement infection controlconsistent with latest WHO guidelines; maintain staffcompetency in use of personal protective equipment(conduct drills).

6. Keep under review plans relevant to health systemresponse at all levels down to the smallestfunctioning health unit; maintain surge-capacityarrangements; prepare for imminent switch topandemic working arrangements.

Affected countries

1. Implement in full pandemic contingency plans forhealth systems and essential services, at national andlocal levels where affected; monitor health systemstatus; adjust triage system if necessary; deployadditional workforce and volunteers; ensure staffsupport; provide medical and non-medical supportfor ill people in alternative (non-health-care) facilitiesif needed; provide social/psychological support forhealth-care workers, victims and communities.

2. If resources permit, collect available data oneffectiveness and safety of clinical interventions andshare these with areas not yet affected and WHO.

3. Implement vaccination campaign according topriority status, in line with plans and availability.

PHASE

6


4. If resources permit, collect available data oneffectiveness of clinical interventions and share thesewith WHO.


1. Ensure that overworked staff have opportunities forrest and recuperation.

2. Restock medications and supplies; service and renewessential equipment.

3. Review/revise plans in anticipation of subsequentwave(s).

4. Support rebuilding of essential services.

5. Adjust case definitions, protocols and algorithms.

6. Continue with vaccination programme in line withplans, priority order and availability.

Pandemic period, phase 6 – Health system response (continued)

Pandemic period, phase 6 – Communications


1. To share appropriate information rapidly amonghealth authorities, other partners and the public.

2. To serve as official global source and focal pointfor credible information related to the pandemic.

1. To ensure public access to regularly-updatedofficial national sources and focal points forcredible, consistent information related to thepandemic.

2. To maintain open and accessible channels foradvice to the public on specific subjects (e.g.travel, social gatherings, etc.).

3. To achieve public acceptance and support fornational responses and contingency measures.

4. To ensure rapid sharing of information regardingprogress of the pandemic among healthauthorities, other relevant governmentdepartments and other partners.


1. Regularly brief international organizations, nationalauthorities, other partners and stakeholders, and thepublic on the situation.

2. Implement and maintain capacity for meetingexpected international information demands.


4. Evaluate communications response during previousphases; review lessons learned.


1. Keep news media, public, professional partners andother stakeholders informed about progress ofpandemic in affected countries; prepare audiencesfor imminent onset of pandemic activity.

2. Redefine key messages; set reasonable publicexpectations; emphasize need to comply with publichealth measures despite their possible limitations.

3. Utilize last “window of opportunity” to refinecommunications strategies and systems inanticipation of imminent pandemic.

PHASE

6


4. Inform public about interventions that may bemodified or implemented during a pandemic, e.g.prioritization of health-care services and supplies,travel restrictions, shortages of basic commodities,etc.

Affected countries

1. Maintain capacity for meeting expected domesticand international information demands.

2. Activate all elements of communications plan.

3. Acknowledge public anxiety, grief and distressassociated with pandemic.

4. Audit outcomes of communications activities torefine current response and inform future pandemicplanning.


1. Evaluate communications response during previousphases; review lessons learned.

2. Publicly address community emotions after thepandemic.

3. Make people aware of uncertainties associated withsubsequent waves.

Pandemic period, phase 6 – Communications (continued)

PHASE

6

ANNEX 1

Recommendations for nonpharmaceuticalpublic health interventions

Source: WHO consultation on priority public health interventions before and during an influenza pandemic. Geneva, World HealthOrganization, 2004. (Document WHO/CDS/CSR/RMD/2004.9. )

MEASURES AT THE NATIONAL LEVEL(for persons living or travelling within an affected country)

Pandemic alert Pandemicperioda perioda

Phase Phases PhaseMeasures 3 4 and 5 6 Comments

Public health information, communication

Information for public on risks and risk avoidance(tailored to target population). Y Y Y

Information for professionals. Y Y Y

Advice on universal hygiene behaviour. Y Y Y

Preparatory information on next phase. Y Y Y

Measures to reduce risk that cases transmit infection

Confinement:— Confine cases (mild and severe) as Y Y Y Need to plan for large

appropriate to local situation; provide medical numbers of severe cases.and social care.

Face masks:b

— Symptomatic persons. Y Y Y Logistics need to be considered.

— Exposed persons: undertake risk assessment C C C Consider recommending masksconsidering: evidence of human-to-human based on risk assessment.transmission; closeness of contact; frequencyof exposure.

— Persons seeking care (respiratory illness) in Y Y Y Need more data, especiallyrisk area (waiting room). on use by well persons.

Measures to reduce risk that contacts transmit infection

Tracing and follow-up of contacts. Y Y N Not feasible once pandemicstarts.

Voluntary quarantine (such as home confinement) N Y N Voluntary quarantine shouldof healthy contacts with health monitoring; also apply to contacts of knownprovide medical and social care. cases undergoing antiviral

prophylaxis, as efficacy notknown.

Self-health monitoring and reporting if ill but no Y C N Not relevant for contacts inrestrictions on movement. quarantine.

ANNEX 142 WHO GLOBAL INFLUENZA PREPAREDNESS PLAN



Advise contacts to reduce social interaction. N NR N Not relevant for contacts inquarantine; see also measuresto increase social distance.

Advise contacts to defer travel to unaffected N NR Y Not relevant for contacts inareas. quarantine. Precautionary

principle when unclear whetherhuman-to-human transmissionis occurring; see also travelmeasures.

Provide contacts with antiviral prophylaxis.c Y Y N Principle of early aggressivemeasures to avert pandemic.

Measures to increase social distance

Voluntary home confinement of symptomatic Y Y Y Measures needed to reducepersons. risk of transmission to other

household members.

Closure of schools (including preschool, higher N C C Depends on epidemiologicaleducation) in conjunction with other measures context – extent to which these(limiting after-school activities) to reduce mixing settings contribute toof children. transmission.

Population-wide measures to reduce mixing of N C C Consider in certain circum-adults (furlough non-essential workers, close stances – extent to whichworkplaces, discourage mass gatherings).d unlinked community trans-

mission and transmission inworkplaces occurs.

Masks in public places. N N N Not known to be effective;permitted but not encouraged.

Measures to decrease interval between symptom onset and patient isolation

Public campaign to encourage prompt self- Y Y Ydiagnosis.

Urge entire population (affected area) to check N N Nfor fever at least once daily.

Set up fever telephone hotlines with ambulance N C Nresponse.

Set up fever clinics with appropriate infection N C Ncontrol.

Introduce thermal scanning in public places. N N N Not effective based on ex-perience; also requires individualand public health action foridentified febrile persons.

ANNEX 1 43




Disinfection measures

Hand-washing. Y Y Y

Household disinfection of potentially Y Y Ycontaminated surfaces.

Widespread environmental disinfection. N N N

Air disinfection. N N N

Measures for persons entering or exiting an infected area within the country

Advise to avoid contact with high-risk Y Y Yenvironments (such as infected poultry farms,live-poultry markets).

Recommended deferral of non-essential travel N Y Y If significant areas of countryto affected areas. remain unaffected.

Restrict travel to and from affected areas. N Ne N Enforcement of travel restric-tions considered impractical inmost countries but likely tooccur voluntarily when riskappreciated by the public.

Cordon sanitaire. N N N Enforcement consideredimpractical.

Disinfection of clothing, shoes or other objects N N N Not recommended for publicof persons exiting affected areas. health purposes, but may be

required by veterinaryauthorities to prevent spread ofinfection in animals.

MEASURES AT THE INTERNATIONAL LEVEL

Measures at borders for persons entering or exiting a country

Information to travellers:— Outbreak notice. Y Y Y Message must be tailored to

phase. While travel would— Recommend that travellers to areas Y Y C remain a matter of personal

experiencing outbreaks of highly pathogenic choice, transparency must beavian influenza avoid contact with poultry ensured in order to allow forfarms and live animal markets. informed decision-making.

Consequences for the traveller— Recommend deferral of non-essential N Y Y may include personal risk to

international travel to affected areas. health and economic harm.

— Recommend deferral of non-essential See screening measures.international travel from affected areas.

45



Measures at borders for international travellers coming from or going to affected areas

Health alert notices to travellers to and from N Y Y WHO negotiates with appro-affected areas. priate organizations (e.g,

International Air TransportAssociation) to ensure thathealth alert notices aredistributed; WHO facilitatesshared notice formats amongcountries.

Medical surveillance:— Daily self-checking for fever,

travellers from affected area; N Y Ytravellers to affected area. N N Y

— Self-reporting if symptoms appear in Y Y Y Contacts of confirmed casestravellers from affected areas. should be encouraged to

monitor health. Quarantine may— Advice on how to behave if ill after travel in Y Y Y be indicated. Persons on

affected areas (seek health care, give travel affected conveyance should behistory, receive influenza laboratory test); if traced and similarly advised.pandemic virus detected, patient should beisolated and public health officials, includingWHO, notified.

Entry screening for travellers coming from Due to lack of proven healthaffected areas. benefit, practice should be per-

mitted (for political reasons, topromote public confidence) butnot encouraged. Travellersshould receive health alertnotices instead.

— Screening for symptoms (visual detection of N N N Entry screening may be consid-symptoms). ered where host country

suspects that exit screening (seebelow) at traveller’s point ofembarkation is suboptimal.

— Screening for at-risk travellers (health N N Ndeclaration, questionnaire).

— Thermal screening. N N N

— Medical examination. N N N

Entry screening for geographically isolated N Y Y Feasible, may prevent entranceinfection-free areas (islands), using the options of pandemic virus. May also beabove. relevant where country’s

internal surveillance capacity islimited.

Exit screening for all travellers from areas with More feasible than entry screen-human infection. ing for detecting early cases.

— Screening for symptoms (visual detection of N N N Not feasible due to passengersymptoms). volume.

ANNEX 1




— Screening for at-risk travellers (health N Y Ydeclaration, questionnaire).

— Thermal scanning or ear-temperature N Y Y Thermal scanning less sensitivemeasurement. and specific but may be more

practical than ear-temperaturescanning.

— Stop-list of isolated or quarantined persons. N N N May be feasible in certaincountries, but generally notencouraged.

— Recommend that ill persons postpone travel. Y Y Y

— Medical examination for travellers at risk or N N N Not feasible to implement atwith fever. borders.

Measures for countries with porous borders (including informal or illegal crossing points) adjoiningaffected areas

Raise awareness among health-care providers N Y Y WHO to post relevant guidelinesand general public to facilitate surveillance and on web for use by countries inresponse measures, such as social distancing, developing posters, mass-mediaquarantine or isolation. messages and similar measures.

Possible benefits includerumour control.

Measures for travellers on board international conveyances from affected areas

Recommend self-reporting if influenza-like N Y Ysymptoms appear.

Separate sick travellers (if possible) on board. N Y Y On flights from affected areas,masks should be offered to allpassengers upon boarding.

Advise health authority at countries of traveller’s Y Y Y Established requirement forembarkation, destination and transit that a destination, but not uniformlyperson on board is ill (airline is responsible to observed in practice.notify destination only).

Share epidemiological information for contact N Y Y Countries to share this infor-tracing with national public health authorities. mation directly with others, as

appropriate.

a Y = yes, should be done at this phase; N = no, not necessary at this phase; C = should be considered; NR = not relevant.

b Quality and type of mask depend on risk group. Cases: surgical mask; health-care workers: N95 or equivalent; others: depends on risk.

c Implementation depends on adequate supplies and may require a global stockpile with a prenegotiated targeting and delivery strat-egy to ensure availability in the area where a potential pandemic virus emerges. Prophylactic use will depend on evidence of effec-tiveness. Targeted use is required because of potential for drug resistance, side-effects and limited supplies. Targeted use might consider:public prevention; protection of health-care workers; protection of other essential service providers; individual treatment.

d Given a pandemic strain causing significant morbidity and mortality in all age groups and the absence of a vaccine, authorities shouldseriously consider introducing population-wide measures to reduce the number of cases and deaths. Decisions can be guided bymathematical and economic modelling. If modelling indicates a reduction in the absolute numbers of cases and deaths, decisions tointroduce measures involving multiple government sectors will then need to balance the protection of priority functions against therisk of social and economic disruption.

e Could be considered as an emergency measure to avert or delay a pandemic.

47

ANNEX 2

List of participants

WHO consultation on WHO-recommended national and international measuresbefore and during influenza pandemicsWHO headquarters, Geneva, Switzerland, 13–15 December 2004

Dr P.Y. Leung (Breakout Group Moderator), Control-ler, Centre for Health Protection, Department ofHealth, Hong Kong Special Administrative Regionof China.

Dr Woraya Luang-on, Medical Epidemiologist, Bureauof General Communicable Diseases, Departmentof Disease Control, Ministry of Public Health,Nonthaburi, Thailand.

Dr Arnold Monto, Director of the Center forBioterrorism and Health Preparedness, Universityof Michigan School of Public Health, Ann Arbor,United States of America.

Professor Peter M. Ndumbe,* Director, Centre for theStudy and Control of Communicable Diseases,Faculty of Medicine and Biomedical Sciences, Uni-versity of Yaoundé, Yaoundé, Cameroon.

Dr Angus Nicoll (Breakout Group Moderator),Director, Communicable Disease SurveillanceCentre, Health Protection Agency Centre for In-fections, London, United Kingdom.

Dr Darina O’Flanagan, Director, National DiseaseSurveillance Centre, Dublin, Ireland.

Dr Preecha Prempree, ASEAN+3 Coordinator, Bureauof Epidemiology, Department of Disease Control,Ministry of Public Health, Nonthaburi, Thailand.

Mr Daniel Rutz (Breakout Group Rapporteur),Special Assistant for Communications, NationalCenter for Infectious Diseases, Centers for Dis-ease Control and Prevention, Atlanta, UnitedStates of America.

Dr David Salisbury, Principal Medical Officer, De-partment of Health, London, United Kingdom.

Dr Vilma Savy, Director, National Influenza Centre,National Institute for Infectious Diseases, BuenosAires, Argentina.

Dr Lars Schaade, Specialist Advisor, German FederalMinistry of Health and Social Security, Bonn,Germany.

* Invited but unable to attend.

Dr Isabelle Bonmarin, Project Coordinator, Institutde veille sanitaire, Saint-Maurice, France.

Dr Supamit Chunsuttiwat, Senior Medical Officer,Department of Disease Control, Ministry of Pub-lic Health, Nonthaburi, Thailand.

Dr Nancy Cox (Breakout Group Moderator), Chief,Influenza Branch, Centers for Disease Control andPrevention, Atlanta, United States of America.

Dr Philip van Dalen (Breakout Group Rapporteur),Senior Policy Officer, Department of PublicHealth, Ministry of Health, Welfare and Sport, TheHague, Netherlands.

Mr Nigel Gay, Communicable Disease SurveillanceCentre, Modelling and Economics Unit, HealthProtection Agency Centre for Infections, London,United Kingdom.

Dr Ian Gust (Consultation Chair), University of Mel-bourne Parkville, Victoria, Australia.

Dr Walter Haas (Breakout Group Rapporteur), Headof Respiratory Diseases and Immunization Unit,Department for Infectious Disease Epidemiology,Robert-Koch Institute, Berlin, Germany.

Dr Martina Havlickova, Head of National ReferenceLaboratory for Influenza, National Institute ofPublic Health, Prague, Czech Republic.

Dr Lance Jennings, Clinical Virologist, CanterburyHealth Laboratories, Christchurch Hospital,Christchurch, New Zealand.

Dr Zhang Jing, Associate Professor, Office of DiseaseControl and Emergency Response Chinese CDC,Xuanwu District, Beijing, China.

Dr Olivier Laurens-Bernard, Head, Département dessituations d’urgence sanitaire, Direction généralede la santé, Ministère de la santé, Paris, France.

Dr Duk-Hyoung Lee, Director-General, KoreanCentre for Disease Control and Prevention, Seoul,Republic of Korea.

ANNEX 1


Dr Benjamin Schwartz, Senior Advisor for Science,National Vaccine Program Office, Department ofHealth and Human Services, Atlanta, UnitedStates of America.

Ms Jill Sciberras (Breakout Group Rapporteur),Senior Epidemiologist, Centre for Infectious Dis-ease Prevention and Control, Public HealthAgency Canada, Ottowa, Canada.

Dr Theresa Tam (Consultation Co-rapporteur), As-sociate director, Division of Respiratory Diseases,Public Health Agency Canada, Ottowa, Canada.

Dr Masato Tashiro, Director, Department of ViralDiseases and Vaccine Control, National Instituteof Infectious Diseases, Tokyo, Japan.

Dr Thomas Ho Fai Tsang (Breakout Group Modera-tor), Consultant, Community Medicine, Depart-ment of Health, Hong Kong Special AdministrativeRegion of China.

Dr Jonathan Van-Tam (Consultation Co-rapporteur),Consultant Epidemiologist, Respiratory Depart-ment, Health Protection Agency Centre for Infec-tions, London, United Kingdom.

Dr Luningning Villa,* Medical Specialist IV, NationalCentre for Disease Prevention and Control,Department of Health, Manila, Philippines.

Dr Clare Wylks, Medical Officer, Scientific and Clini-cal Advisory Unit, Biosecurity and DiseaseControl Branch, Department of Health and Age-ing, Woden, Australia.

Dr Donglou Xiao, Deputy Director-General, Depart-ment of Disease Control, Beijing, China.

Dr Weigong Zhou, Medical Epidemiologist, InfluenzaBranch, Centers for Disease Control and Preven-tion, Atlanta, United States of America.

United Nations Children’s Fund (UNICEF)

Dr Agostino Panganini, Principal Health Advisor,Health Programme Division, New York, UnitedStates of America.

Food and Agriculture Organization of theUnited Nations (FAO)

Dr Juan Lubroth,* Senior Officer, Infectious DiseaseGroup-EMPRES, Animal Production and HealthDivision, Rome, Italy.

European Commission

Dr Franz Karcher, Directorate-General Health andConsumer Protection, Luxembourg.

Dr Massimo Ciotti, WHO/EC Liaison Officer, Lux-embourg.

International Federation of Red Cross and RedCrescent Societies (IFRC)

Dr Adelheid Marschang, Senior Officer, Health inEmergencies, Health and Care Department, Ge-neva, Switzerland.

World Organisation for Animal Health (OIE)

Dr Alejandro Thiermann, President, Terrestrial Ani-mal Health Code Commission, Paris, France.

WHO regional offices

Dr Marlo Libel, Regional Adviser in CommunicableDiseases, Division of Disease Prevention and Con-trol, Pan American Sanitary Bureau/RegionalOffice for the Americas, Washington, UnitedStates of America.

Dr Jai Narain, Coordinator, HIV/AIDS, TB and otherCommunicable Diseases, Health Systems andCommunity Health, Community Health Services,Regional Office for South-East Asia, New Delhi,India.

Dr Peet Tüll, Medical Officer, Communicable Dis-ease Surveillance and Response, WHO RegionalOffice for Europe, Copenhagen, Denmark.

Dr Hitoshi Oshitani, Regional Adviser in Commu-nicable Diseas Surveillance and Response, Re-gional Office for the Western Pacific, Manila,Philippines.

WHO country offices

Dr William Aldis, WHO Representative to Thailand.

Dr Julie Hall, CSR Coordinator, Beijing, China.

Dr Peter Horby, Medical Epidemiologist, Hanoi, VietNam.

WHO headquarters (secretariat)

Dr Jonathan Abrahams, Dr David Bell, Dr Peter BenEmbarek, Ms Maria Cheng, Ms Peggy Creese, DrAlice Croisier, Dr Marja Esveld, Dr Helge Hollmeyer,Dr François Meslin, Dr Gunnar Nylen, Dr GenevièvePinet, Dr Guénaël Rodier, Dr Klaus Stöhr, Mr DickThompson, Dr Denise Werker, Mr Brian Wertschnig,Dr Wenqing Zhang

* Invited but unable to attend.

49

Bibliography

• WHO checklist for influenza pandemic preparedness planning. Geneva, World Health Organi-zation, 2005. (Document WHO/CDS/CSR/GIP/2005.4.)http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_4/en/

• WHO consultation on priority public health interventions before and during an influenza pan-demic. Geneva, World Health Organization, 2004. (Document WHO/CDS/CSR/RMD/2004.9.)http://www.who.int/csr/disease/avian_influenza/consultation/en/

• WHO guidelines on the use of vaccines and antivirals during influenza pandemics. Geneva,World Health Organization, 2004. ( Document WHO/CDS/CSR/RMD/2004.8.)http://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_RMD_2004_8/en/

• WHO outbreak communications guidelines. Singapore, September 2004.http://www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdf

• Selected WHO guidelines on influenza H5N1.http://www.who.int/csr/disease/avian_influenza/guidelines/en/

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