Progress and shortcomings in European national strategic plans for pandemic influenza

923Bulletin of the World Health Organization | December 2007, 85 (12) Objective To repeat and update our previous evaluation (2005) of Europe’s national pandemic influenza preparedness plans and assess the progress that has been made. Methods We assessed published national pandemic influenza preparedness plans from the European Union countries, from the two acceding countries (Bulgaria and Romania) and from Norway, Switzerland and Turkey. Plans were eligible for inclusion if formally published before 30 September 2006. We referred to WHO guidelines and used a systematically applied data extraction form. We considered plans in relation to border control measures, antiviral drugs and vaccines. Findings Twenty-nine countries had plans that were included in the analysis, compared with 21 countries in 2005. Substantial differences existed in countries’ plans for border control measures, and many plans diverged from WHO guidelines. Likewise, countries’ plans on antiviral drugs and vaccines varied and operational planning remained weak. Conclusion Although progress has been made in the completeness of plans, problems remain unsolved regarding national plans’ divergence from international recommendations, persisting strategic incoherence and operational limitations in relation to potentially scarce resources. Border control plans also show gaps and inconsistencies, and these are likely to be politically volatile during a pandemic. Bulletin of the World Health Organization 2007;85:923–929. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا Progress and shortcomings in European national strategic plans for pandemic influenza Sandra Mounier-Jack,a Ria Jas a & Richard Coker a a Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England. Correspondence to Richard Coker (e-mail: richard.coker@lshtm.ac.uk). doi: 10.2471/BLT.06.039834 (Submitted: 21 December 2006 – Final revised version received: 5 March 2007 – Accepted: 14 March 2007 – Published online: 21 September 2007) Introduction With the emergence of the H5N1 avian influenza virus in Asia and outbreaks on the European continent and elsewhere, concerns about a human influenza pandemic are growing. In April 2005, WHO expressed concern about the general lack of global preparedness for pandemic influenza,1 and updated its 1999 global influenza preparedness plan to outline the components that each country’s plan should include to ensure an effective response.2 The Ministerial Meeting and Donor Conference that took place on 6–8 December 2006 in Bamako, Mali, drew attention to the urgent need for international organiza- tions and the donor community to share emerging good practices, notably those coming from Europe, in order to guide the global response.3 In 2005, WHO published a check- list to facilitate preparedness planning. Its aim was to maintain essential ser- vices, to reduce disease transmission and the socioeconomic consequences of a pandemic and to minimize cases, hos- pitalizations and deaths.4 The European Commission (EC) updated its planning in line with the revised WHO defini- tions of pandemic phases and the cre- ation of the European Centre for Disease Prevention and Control (ECDC). A subsequent WHO document 2 urged every country “to develop or update a national influenza preparedness plan” and suggested that “each national author- ity should play its part towards achiev- ing the international harmonization of preparedness measures”. We previously analysed European national strategic preparedness plans for pandemic human influenza published before November 2005. This study’s findings showed considerable variation between different countries’ plans, and important gaps in many.5 These differ- ences and gaps included border control issues, antiviral drugs and vaccines – all issues that are likely to test health systems’ responses because of scarce resources or the need for international coordination, coherence and coopera- tion. During the Austrian Presidency of the European Union (EU), January to June 2006, these issues were predicted to be particularly politically sensitive by policy-makers. We repeated our evalu- ation of national preparedness plans in Europe to assess progress made between November 2005 and November 2006, and analyse these three important stra- tegic planning elements. Methods We sought plans from the 25 EU coun- tries, the two acceding countries (Bul- garia and Romania), and three non-EU countries (Norway, Switzerland and Turkey). We evaluated each plan by methods similar to those described above, using the WHO checklist4–6 but expanding our assessment of the three areas of strategic interest.2,7,8 Plans in the public domain were identified and sourced through the ECDC, WHO, internet-based searches and countries’ health ministries. Plans were eligible for inclusion if formally published before 30 September 2006. All plans not avail- able in either English or French were translated into English by public health specialists fluent in the original language. 924 Bulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenza Sandra Mounier-Jack et al. We assessed national strategic plans and, where clear links were documented, national operational plans. A data extraction tool was designed, piloted, modified and finalized. We selected variables with particular refer- ence to WHO guidelines on vaccines, antiviral drugs and border control, and used 142 criteria to assess plans. We also recorded priority populations for antiviral drugs and vaccines, whether the sizes of populations were defined (and if so, what these sizes were) and whether certain populations were ranked more highly than others in terms of favoured access. We recorded antiviral stockpile sizes if mentioned. Preparedness plans were scored independently by two researchers; where differences arose, agreement was reached through review and discussion. Results We identified 29 plans from a range of sources (Table 1, available at: http://www. who.int/bulletin/volumes/85/12/06- 039834/en/index.html). We translated 12 plans into English. Overall scores for key pandemic preparedness criteria concerned with border control, vaccine policies and antiviral policies are presented in Figs. 1, 2 and 3. Border control Strategic planning in relation to border control varied in terms of completeness of issues considered and approaches discussed (Fig. 1). Travel restrictions, for example, were anticipated by 16 coun- tries, whereas two countries explicitly advised against such measures. Notably, five countries envisaged an absolute ban on cross-border travel, while 16 coun- tries expressed an intention to follow WHO travel advice. Only a minority of plans detailed the legal foundation for possible restriction of cross-border population movements. The need for information and guid- ance on travel was widely acknowledged. However, planning for implementation of travel-related public health measures was less coherent. Many countries diverged from WHO guidance; for ex- ample, 17 countries favoured the intro- duction of specific entry screening mea- sures.9 Two countries planned to use thermal screening, and four planned to screen for symptoms. Although WHO Absolute ban on the entry of people arriving from affected areas Selective restrictions on the entry of people arriving from affected areas Mentions following WHO recommendations on travel Information for travellers Measures at borders for international travellers coming from or going to affected areas Entry screening anticipated Exit screening anticipated Quarantine of passengers coming from suspected areas anticipated Measures for travellers on board international conveyances from affected areas International cooperation with neighbouring countries explicit Restrictions anticipated on importing goods from affected countries considered 0 5 10 15 20 25 No. of countries Fig. 1. Border control measures mentioned in European national preparedness plans, by number of countries guidance favours exit screening over en- try screening, only 10 countries planned to implement exit screening. Only nine countries had plans that addressed how travellers on board international conveyances from af- fected areas would be managed. Eight recommended separating sick travellers from others, and four aimed to provide masks to passengers, crew members or both. Border quarantine was advocated by 11 countries, mostly for travellers en route from an affected area, but most acknowledged that this strategy would be limited in scope. Thirteen countries addressed the issue of imported goods during a pandemic, with most referring to restrictions on poultry imports. Only about half of the countries explicitly planned to coordinate their strategies with those of neighbouring countries. Vaccines All but one country had plans for pan- demic vaccination; Fig. 2 highlights the key issues of these plans. Broadly, plans included details on sourcing vaccines, on which populations should be vaccinated first and on provisions to distribute and administer vaccine. Eighteen countries stated explicitly that they planned to 925Bulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenzaSandra Mounier-Jack et al. vaccinate their whole population. Only three countries did not stipulate groups to be given priority when vaccine is in short supply. The definition of priority groups was broadly consistent, with health-care workers named as a priority group in 26 countries. “Essential” workers were given priority in 23 countries, and 19 countries prioritized older people and populations at risk of serious complica- tions. In practice the groups given high- est priority were health-care workers in 16 countries, essential workers in four countries and people at risk of serious complications in three countries. Eight countries that defined priority groups for vaccination did not rank them explicitly. Sixteen countries estimated the size of priority groups. Some plans specifically prioritized vaccination of children, employees and people thought likely to pose a risk to vulnerable groups. Most plans explicitly prioritized groups in order to maintain health-care services and societal functions and to protect those at highest risk of death, yet the ethical reasoning for priority-setting was rarely explicit (Box 1). Vaccination strategies revealed im- portant gaps. A minority of plans referred to or included operational guidelines for factors such as provisions for vaccine stor- age, distribution mechanisms and vaccine administration. Only three countries referred to existing generic plans for mass vaccination. Nine countries described how vaccine will be delivered to priority groups, including four that stated the need for local administrations to deter- mine in advance which individuals should be vaccinated first. Few details were provided on who would be responsible for vaccination and where it would be done. The plans of Belgium, France, Ger- many, Hungary, Italy, the Netherlands, Romania and the United Kingdom stated that these countries are capable of manufacturing vaccine. Four coun- tries (Denmark, Norway, Sweden and Switzerland) intended to develop vac- cine production capacity. Twenty-one countries planned to secure vaccine pre- purchase agreements, and four countries said such agreements were already in place. Five explicitly indicated that they have arranged to buy H5N1 vaccine; two countries, Finland and Switzerland, had placed orders for vaccine to cover their entire population. Fig. 2. Vaccine strategy measures mentioned in European national preparedness plans, by number of countries 0 A strategic plan for pandemic vaccination 5 10 15 20 25 A strategic plan to vaccinate the whole population Defined priority groups for influenza vaccination Sizes of priority groups given or referenced Provision of storage for vaccines described Operational plan for the distribution of vaccines Specifies which health-care workers will administer vaccine Provisions of medical equipment (needles, syringes) to support vaccine administration Tender for H5N1 vaccine procurement Plans to secure pre-purchase agreement with vaccine companies for the supply of pandemic strain vaccine Secured pre-purchase agreement with vaccine companies for the supply of pandemic strain vaccine A strategic plan for pneumoccocal vaccination in pandemic phase No. of countries 30 Antiviral drugs Although most countries had antiviral strategies, these varied considerably (Fig. 3). All countries but one advocated the use of antiviral drugs for treatment. Although treatment was generally clearly defined, use of antivirals for prophylaxis was less so. For some plans, distinctions between pre-exposure and post-exposure prophylaxis often were not clear. Just over half of the countries planned to supply antivirals for early containment, and 20 recommended specific treatment and prophylaxis strategies for animal workers. Five countries anticipated a need to supply antiviral drugs to their citizens abroad. Plans for dosage and duration for treatment and prophylaxis were gener- ally consistent with manufacturers’ rec- ommendations. Twenty-two countries specified which antivirals they intended to use, with half advising the possible use of M2-membrane protein inhibi- tors (amantadine and rimantadine) in addition to neuraminidase inhibitors (oseltamivir and zanamivir) for prophy- laxis or as a second-line drug. Treatment was explicitly given pri- ority over prophylaxis by 15 countries, which mostly outlined plans for antiviral use according to WHO pandemic phase. They noted that in phase 6, prophylaxis probably will not be feasible and might 926 Bulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenza Sandra Mounier-Jack et al. Box 1. Ethics and priority-setting An influenza pandemic will raise many ethical challenges, including allocation of scarce resources and the needs to balance individual freedom against the common good, economic losses against the need to contain the disease, and health workers’ duty to provide care against self-interest.a,b Although national preparedness plans provide an important opportunity for transparent communication with the public, most of those examined for this analysis failed to discuss these issues. Plans usually stated that their goal was to decrease morbidity and mortality and ensure that society still functions. However, the lack of ethical reasoning, especially regarding resource allocation, might cause confusion when policies and practices need to be justified to an anxious population. Finland and Norway discussed ethical concerns and expressed differing views. The Finnish plan suggested that beyond early containment of the disease, “long-term preventative medication with antivirals of essential personnel would not be justifiable and would create a feeling of unfairness within the population”. The Norwegian plan stated that “health care personnel who are continually exposed to the disease [should] receive the highest priority because they are crucial in providing care for a greater number of patients and because they have a higher risk of being infected.” a University of Toronto Joint Centre for Bioethics. Ethical considerations in preparedness planning for pandemic influenza. Toronto: University of Toronto; 2005. b Singer PA, Benatar SR, Bernstein M, Daar AS, Dickens BM, MacRae SK, et al. Ethics and SARS: lessons from Toronto. BMJ 2003;327:1342-4. result in drug resistance. The other countries did not distinguish between use of antivirals for treatment and pro- phylaxis. Priority groups for antiviral treat- ment were stated by 19 countries, 16 of which indicated the size of these groups. Seventeen countries planned to treat patients at the greatest risk of complica- tions. Patients with severe disease and complications were top-priority in eight countries, while health-care workers were top-priority in two countries. France and Switzerland suggested that they had sufficient stockpiles to treat all patients. Twenty-two plans advised offer- ing pre-exposure prophylaxis; of these, 21 suggested health-care workers as recipients, and 17 suggested essential workers. Only 12 countries explicitly ranked priority groups for prophylaxis. Some plans discouraged seasonal use of antivirals because this would rapidly deplete stockpiles. Norway prioritized prophylaxis for continuously exposed health-care workers over treatment of sick patients in order to maintain a functioning health service. Twenty-five plans recommended post-exposure prophylaxis. Thirteen stated that this strategy should be used only in the early phases for contacts of cases and exposed animal workers. Only one country estimated the number of contacts who might need antiviral drugs. The operational management of antiviral storage, distribution and ad- ministration remained underdeveloped in most plans. Sixteen countries planned to devolve all or parts of these respon- sibilities to local administrations. Only 13 mentioned distribution centres such as influenza pandemic centres, hospital pharmacies and community pharmacies, but these were not discussed in detail. Few plans mentioned the need for prescriptions. Eight plans addressed the need for security measures at antiviral drug distribution centres. Most plans stated an intention to stockpile antiviral drugs, with 14 plans noting that a stockpile had been secured. Eleven plans quantified their existing stockpile and nine defined a target stock- pile, usually assuming an attack rate of 25–30% of the population. Discussion Europe became better prepared for pandemic human influenza than it was before the study period.5,6,10,11 Between November 2005 and November 2006, more countries published national strategic plans, and many countries and international agencies (such as the ECDC) have made considerable efforts to support planning through regional workshops, country visits and analyses of preparedness status.12 An increased number of plans consider an early con- tainment strategy that offers prophy- laxis to contacts and discuss the need to protect people who work with animals. Clarity and links to operational imple- mentation also have improved. More countries prioritize the use of antivirals for treatment and prophylaxis, enhanc- ing strategic clarity. A recent World Bank report empha- sizes the need for clear procedures and systems to manage rapid reporting and responses to human influenza, notably to ensure a rapid containment response. Our findings show that even in Europe, which may be better prepared than some regions,3 considerable gaps and inconsistencies persist and several areas of operational planning have not been addressed. For example, only half the countries have developed storage, distri- bution and administration strategies for vaccines and antivirals. The issue of how to deliver antivirals within 48 hours to individual patients remains largely un- resolved. The recent increase in national antiviral stockpiles by many countries perhaps highlights this gap. Many countries are devolving responsibility to local administrations but providing little guidance. Consequently, they risk inconsistencies in practice, inequalities in provision of goods, chaotic service responses and public anxiety during a pandemic. Likewise, although most countries have prioritized groups for vaccination and antivirals, details of how these poli- cies would be put into action are still scarce. Plans do not always specify types of antiviral drugs to be used, and drug resistance is a concern with monother- apy.13 If international policies change in response to this risk, delivery systems need to be even more robust. The size of priority groups is often unclear because their scope is not clearly defined. Ad- ditionally, groups are often much larger than the actual (or intended) stockpile could accommodate. Some countries attempt to resolve this issue by building stockpiles large enough that priority- setting is not an issue, but use of antiviral prophylaxis is likely to deplete stocks quickly. For example, our analysis of whether four countries have sufficient publicly acknowledged antiviral stock- piles to meet the needs stated in their plans suggest that shortfalls will occur (Fig. 4), despite assumptions that prob- ably underestimate demand. Governments need to balance pol- icy in the face of uncertainty. Although considerable funds have been com- mitted to stockpiling antivirals, many 927Bulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenzaSandra Mounier-Jack et al. Fig. 3. Antiviral drug strategy measures mentioned in European national preparedness plans, by number of countries Strategic plan for the use of antivirals Specifies which antivirals will be used Doses and duration of treatment recommended in the plan Strategy for antiviral use in early containment Plans to use antivirals in people working with animals/birds during animal outbreak Antivirals planned for treatment Antivirals planned for pre-exposure prophylaxis during a pandemic Antivirals planned for pre-exposure prophylaxis Antiviral use for treatment explicitly prioritized over that for prophylaxis Priority groups for treatment defined Priority groups for prophylaxis defined Sizes of priority groups given or referenced Provisions for storage described Operational distribution plan for antivirals described Provisions to package API in capsule described Named centres for local distribution Requirement for prescription for antivirals Country planning to stockpile antivirals Country documents existing stockpile of antivirals There is antiviral stockpile reserved specifically for early containment 0 5 10 15 20 25 No. of countries 30 countries may have insufficient sup- plies. Moreover, if resistance emerges rapidly, then the expected public health benefits might not accrue. The ability of combination therapy to prevent resis- tance remains debatable,14 although the ineffectiveness of adamantanes in pre- venting transmission, the rapid devel- opment of resistance to these drugs and probable associated harms imply that neuraminidase inhibitors will require supplementation with other drugs.15 However, combination treatment would further stretch resources and compound logistical challenges. If vaccine development cannot take advantage of the window of opportu- nity offered by antiviral drugs, further concerns arise. An effective vaccine is unlikely to be available for 3–6 months after a pandemic begins. Even if it can be made quickly enough,16 demand will outstrip supply. Six billion people worldwide could benefit from protec- tion, but manufacturing capacity is cur- rently about 300 million doses. Recent findings showing cross-protection with influenza virus from avian to human strains17,18 have led some countries to stockpile H5N1 vaccine in the hope that it could offer protection against an emergent pandemic strain. Across Europe, plans for border control measures are inconsistent, espe- cially in relation to screening practices and travel restrictions; such plans fre- quently diverge from WHO guidelines. These inconsistencies might reflect a lack of evidence. Recent research suggest- ing that very strict travel measures might delay a country’s exposure to a pandemic may also have affected plans.19,20 In view of the political volatility attached to differences in national approaches, in- creased coherence is advisable. In preparing for the next pandemic, governments face challenges that are beyond their purview and over which they have little control. Important les- sons have been learned from SARS, and the international governance structure of public health has improved, particularly in surveillance capacity, coordination and cooperation. However, response capacity and coherence remain relatively weak. These problems arise because risk management, even more than risk assessment, remains under sovereign states’ control 21 despite the authority provided through the new International Health Regulations.22 For example, Indonesia recently stopped sharing human genetic samples of H5N1 with foreign laboratories because its govern- ment wanted to retain control of the intellectual property rights of the virus strain23 and secure early public health protection for its citizens. The potential delays in vaccine production that could result from such unilateral action could have far-reaching implications testing assumptions about global solidarity.24 Our evaluation’s l imitations are similar to those of our previous study.5,6,25 Although our survey pro- vides only a snapshot, it is based on a similar analysis from a year earlier so that changes and advances can be documented. Our results, as with earlier findings, agree largely with analyses done by other investigators using differ- ent methods.12,15,26 A second limitation is that plans are only one element in a preparedness strategy, albeit an im- portant one. By revisiting plans after a year, we have at least shown that policy- makers have addressed some previously neglected issues. A further limitation is the subjective nature of our assessment. We have tried, through independent review, to address this issue. However, variations in format, terminology and API, active pharmaceutical ingredient. 928 Bulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenza Sandra Mounier-Jack et al. Fig. 4. Potential demand and stockpiles for antiviral drugs for four European Union countries 1 000 000 In di vi du al d os es o f o se lt am iv ir (t ho us an ds ) 10 100 Bulgaria Publicly acknowledged stocks Stocks required if pre-exposure demand met 1000 10 000 100 000 Cyprus Norway United Kingdom Stocks required if treatment-only demand met Assumptions: stockpiles have been made public,a attack rate of 25%, treatment needed for 50% infected. Estimates for pre-exposure prophylaxis requirements are for health care workers only, and do not include other groups mentioned in the plans.b Norway has committed to procuring an additional 12 million doses of rimantadin/amantadin for prophyaxis alone; this is not included here. a Stockpile size sources: Bulgaria, BBC Monitoring International Reports, 12 January 2006; Cyprus, Cyprus Mail, 25 January 2006; Norway, Norway National Pandemic Preparedness Plan, 2006; United Kingdom, Reuters, March 2006. b Population data taken from Eurostat website (available at: http://epp.eurostat.ec.europa.eu/portal/page?_ pageid=1996,39140985&_dad=portal&_schema=PORTAL&screen=detailref&language=en&product=Yearlies_new_ population&root=Yearlies_new_population/C/C1/C11/caa10000). Health-care worker figures taken from WHO, World health statistics 2006 (Geneva: WHO; 2006). language mean that any evaluation of plans must be subjective. Governmental commitment across Europe in preparing for a pandemic seems strong, and Europe has strength- ened its plans since our last evaluation. However, the remaining gaps and inconsistencies need urgent attention. Although pandemic influenza will test health systems in many unforeseen ways, coherent regional planning should ensure that responses are coordinated, evidence-based and coherent in order to effectively protect public health. ■ Funding: This work was undertaken through an unrestricted educational grant from F Hoffmann-La Roche. Competing interests: Richard Coker has received funding and reimburse- ments on pandemic influenza prepared- ness research from F Hoffmann-La Roche, and from several European Union institutions and national govern- ments. Résumé Améliorations et insuffisances des plans stratégiques nationaux européens pour faire face à la grippe pandémique Objectif Renouveler et mettre à jour notre précédente évaluation (2005) des plans nationaux européens de préparation à la grippe pandémique et évaluer les progrès réalisés. Méthodes Nous avons évalué les plans nationaux de préparation à la grippe pandémique publiés par les pays de l’Union européenne, par deux pays en voie d’accession à l’UE (Bulgarie et Roumanie) et par la Norvège, la Suisse et la Turquie. Pour être inclus dans l’étude, les plans devaient avoir été formellement publiés avant le 30 septembre 2006. Nous nous sommes référés aux recommandations de l’OMS et nous avons utilisé un formulaire d’extraction des données systématiquement appliqué. Nous avons examiné le contenu des plans en ce qui concerne les contrôles aux frontières, les antiviraux et les vaccins. Résultats Les plans de vingt-neuf pays ont été inclus dans l’analyse contre vint-et-un en 2005. Ces plans présentaient des différences substantielles à propos des mesures de contrôle aux frontières et beaucoup d’entre eux s’écartaient des recommandations de l’OMS. De même, le volet médicaments antiviraux et vaccins des plans était traité de manière variable et le volet planification opérationnelle restait peu développé. Conclusion Malgré les progrès réalisés en matière de complétude, il reste à résoudre des problèmes de divergence des plans avec les recommandations internationales, d’incohérence persistante sur le plan stratégique et de limitation de la planification opérationnelle, en relation éventuellement avec un manque de moyens. En ce qui concerne les contrôles aux frontières, les plans présentent aussi des lacunes et des incohérences et sont susceptibles d’être modifiés en fonction de considérations politiques pendant une pandémie. Objetivo Repetir y actualizar nuestra evaluación anterior (2005) de los planes nacionales de preparación para una gripe pandémica elaborados en Europa y determinar los avances conseguidos. Métodos Se evaluaron los planes nacionales de preparación para una gripe pandémica publicados en los países de la Unión Europea, en los dos países en fase de adhesión (Bulgaria y Rumania) y en Noruega, Suiza y Turquía. El requisito para incluir los planes era que hubiesen sido publicados oficialmente antes del 30 de septiembre de 2006. Empleamos como referencia Resumen Progresos y deficiencias de los planes estratégicos nacionales europeos para afrontar una gripe pandémica directrices de la OMS y utilizamos un formulario de obtención de datos que se aplicó sistemáticamente. Los planes fueron analizados en relación con las medidas de control fronterizo, los medicamentos antivirales y las vacunas. Resultados Veintinueve países disponían de planes que fueron incluidos en el análisis, en comparación con 21 países en 2005. Se observaron diferencias sustanciales entre los planes de los países en lo relativo a las medidas de control fronterizo, y muchos de los planes se apartaban de las directrices de la OMS. Diferían 929Bulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenzaSandra Mounier-Jack et al. también entre los países los planes referentes a los antivirales y las vacunas, y la planificación operacional seguía siendo deficiente. Conclusión Aunque los planes son ahora más completos, siguen sin resolver los problemas que entrañan la divergencia de los planes nacionales respecto a las recomendaciones internacionales, la persistente incoherencia estratégica y las limitaciones operacionales asociadas a unos recursos potencialmente escasos. Los planes de control fronterizo muestran también lagunas e incongruencias, y probablemente serán políticamente volátiles en caso de pandemia. صخلم ةيحئاجلا ازنولفنلأل ةيبورولأا ةينطولا ةيجيتارـتسلاا ططخلا في روصقلا هجوأو زرْحُمـلا م ُّدقتلا ططخلل 2005 ماع نوثحابلا هارجأ يذلا ميـيقتلا ثيدحتو ةداعإ :فدهلا .زرْحُمـلا م ُّدقتلا ميـيقتلو ةيحئاجلا ازنولفنلأل ب ُّهأتلل ةيبورولأا ةينطولا ازنولفنلأل ب ُّهأتلاب ةصاخلا ةروشنلما ةينطولا ططخلا نوثحابلا مَّيق :ةقيرطلا داحتلال ًاثيدح ين َّمضنلما نْيَدلبلا نم ،بيورولأا داحتلاا نادلب نم ةيحئاجلا ةلباق ططخلا تناك دقو .ايكرـتو اسريوسو جيونرلا نمو ،)اينامورو ايراغلب( .2006 برمتبس/لوليأ 30 لبق ًايمسر تشرن دق تناك اذإ ةساردلا في جامدلإل اومدختساو ةيلماعلا ةحصلا ةمظنلم ةيداشرلإا لئلادلا لىإ نوثحابلا عجر دقو ةقلعتلما ططخلا نابسحلا في اوذخأ دقو .تايطعلما صلاختسلا ةيجهنم ةقيرط .تاحاقللاو تاسويرفلل ةداضلما ةيودلأاو دودحلا لىع ةحفاكلما تاءارجإب عم ةنراقلماب ،ليلحتلا في تجمدأ ططخ ًادلب 29 ىدل ناك دقل :تادوجولما نادلبلا ططخ ينب ةيرهوج تافلاتخا كانه تناك دقو .2005 ماع في ًادلب 21 لئلادلا نع اديعب ططخلا نم يرثكلا ناكو ،دودحلا لىع ةحفاكلما تاءارجلإ ةقلعتلما نادلبلا ططخ نإف ،لثلمابو .ةيلماعلا ةحصلا ةمظنلم ةيداشرلإا طيطختلا ناكو ةتوافتم تناك تاحاقللابو تاسويرفلل ةداضلما ةيودلأاب .ًافيعض لازيلا نياديلما كانه لازتلاف ،ططخلا لماكتسا في زرُحأ دق ًام ُّدقت كانه نأ مغر :جاتنتسلاا تايصوتلا نع ةينطولا ططخلا داعتباب قلعتي مايف لحلل جاتحت تلاكشم قلعتي ام في ةيليغشتلا دويقلاو تايجيتارـتسلاا في رفانتلا رارمتساو ،ةيلودلا نم نياعت دودحلا لىع ةحفاكلما ططخ نأ حضتا ماك .ةلمتحلما دراولما ةردنب .ةحئاجلا ءانثأ سيايس رـتوت ثودحب ددهت دق اهنأو ،تاضقانتلاو تارغثلا References 1. 58th World Health Assembly, 7 April 2005. Geneva: WHO; 2005. 2. WHO global influenza preparedness plan, the role of WHO and recommendations for national measures before and during pandemics. Geneva: WHO; 2005 (WHO/CDS/CSR/GIP/2005.5). 3. Responses to avian and human influenza threats (draft report), July-December 2006. New York: UN System Influenza Coordinator & World Bank; 2006. 4. Checklist for influenza epidemic preparedness. Geneva: WHO; 2005 (WHO/ CDS/CSR/GIP/2005.4). 5. Mounier-Jack S, Coker RJ. How prepared is Europe for pandemic influenza? Analysis of national plans. Lancet 2006;367:1405-11. 6. Mounier-Jack S, Coker R. How prepared is Europe for pandemic influenza? An analysis of national plans. London: London School of Hygiene and Tropical Medicine; 2006. 7. Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO. Geneva: WHO; 2006. Available at: http://www.who.int/csr/ disease/avian_influenza/country/cases_table_2006_04_12/en/index.html 8. Guidelines on the use of vaccines and antivirals during influenza pandemic. Geneva: WHO; 2004 (WHO/CDS/RMD/2004.8). 9. World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, international measures. Emerg Infect Dis 2006;12. 10. Pandemic influenza preparedness in the EU. Stockholm: European Centre for Disease Prevention and Control (ECDC); 2007. Available at: http://www. ecdc.eu.int/pdf/Pandemic_preparedness.pdf 11. 3rd Joint EC/ECDC/WHO Workshop on Pandemic Influenza Preparedness in Uppsala Castle, Sweden, 15-17 May 2006. Stockholm: ECDC; 2006. Available at: http://www.ecdc.eu.int/documents/Uppsala060516/index.html 12. Technical report: pandemic influenza preparedness in the EU. Status report as of Autumn 2006. Stockholm: ECDC; 2007. 13. Pandemic influenza: science to policy. London: Royal Society; 2006. Available at: http://www.royalsoc.ac.uk/document.asp?id=5574 14. Tsiodras S, Mooney JD, Hatzakis A. Role of combination antiviral therapy in pandemic influenza and stockpiling implications. BMJ 2007;334:293-4. 15. Jefferson T, Demicheli V, Di Pietrantonj C, Rivetti D. Amantadine and rimantadine for influenza A in adults. Cochrane Database Syst Rev 2006;2: CD001169. 16. Jefferson T. Influenza vaccination: policy versus evidence. BMJ 2006; 333:912-5. 17. Suguitan AL, McAuliffe J, Mills KL, Jin H, Duke G, Lu B et al. Live, attenuated influenza A H5N1 candidate vaccines provide broad cross-protection in mice and ferrets. PLoS Med 2006;3:e360. 18. Gillim-Ross L, Subbarao K. Can immunity induced by the human influenza virus N1 neuraminidase provide some protection from avian influenza H5N1 viruses? PLoS Med 2007;4:e91. 19. Brownstein JS, Wolfe CJ, Mandl KD. Empirical evidence for the effect of airline travel on inter-regional influenza spread in the United States. PLoS Med 2006;3:e401. 20. Ferguson NM, Cummings DA, Fraser C, Cajka JC, Cooley PC, Burke DS. Strategies for mitigating an influenza pandemic. Nature 2006;442:448-52. 21. Lee K, Fidler DP. Avian and pandemic influenza: progress and problems with global health governance. Global Public Health. 2007; 2: 215–34. 22. Fidler DP. Germs, governance, and global public health in the wake of SARS. J Clin Invest 2004;113:799-804. 23. Aglionby J, Jack A. Indonesia withholds genetic samples of bird flu virus. London: Financial Times; 5 February 2007. Available at: http://www.ft.com/ cms/s/bd900a94-b55d-11db-a5a5-0000779e2340.html 24. Coker R, Mounier-Jack S. Pandemic influenza preparedness in the Asia- Pacific region. Lancet 2006;368:886-9. 25. Nicoll A, Kaiser R. Limitations of recently published review of national influenza pandemic plans in Europe. Euro Surveill 2006;11:E060427 3. 26. Coker R, Mounier-Jack S. Further thoughts on the limitations of a recently published review of national influenza pandemic plans in Europe. Euro Surveill 2006;11:E060504 3. ABulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenzaSandra Mounier-Jack et al. Table 1. European national preparedness plans for pandemic human influenza Country Date of plan Length (pages) Original language Source Websites Documents Strategic plan Operational plan Plan with elements of both Austria September 2005 76 German ECDC website (direct link) http://www.bmgf.gv.at/cms/site/attachments/3/6/8/CH0019/CMS1126084167391/ pandemieplanh3neu.pdf – – Yes Belgium July 2006 52 French ECDC website (via MoH website) http://www.influenza.be – – Yes Bulgaria October 2006 100 English UNDG website (direct link) http://www.undg.org/documents/7926-Bulgaria_National_Influenza_Plan.pdf – – Yes Cyprus September 2005 96 + 11 (tabulated appendices) Greek ECDC website (via MoH website) http://www.moh.gov.cy/moh/moh.nsf/All/ 4CCD90ECED95DD174225718800218F00?OpenDocument – – Yes Czech Republic April 2004 53 English WHO web (direct link) http://www.who.int/csr/disease/influenza/nationalpandemic/en/index.html – – Yes Denmark April 2006 57 + 97 (appendix) Danish ECDC website (via MoH website) http://www.sst.dk/Forebyggelse/Sygdomsforebyggelse_og_vaccination/Smitsomme_ sygd/Influenza/Pandemiberedskab.aspx?lang=da – Yes (appendix) Yes Estonia March 2006 55 Estonian ECDC website (direct link) http://www.sm.ee/est/HtmlPages/ Sotsiaalministeeriumigripipandeemiaksvalmisolekuplaanaprill2006a/$file/Sotsiaalminist eeriumi%20gripipandeemiaks%20valmisoleku%20plaan%20aprill%202006%20a.doc – – Yes Finland 2006 202 Finnish WHO Regional Office for Europe Website (direct link) http://www.euro.who.int/flu/related/20060822_1 (WHO web page) http://www.stm.fi/Resource.phx/publishing/documents/6425/index.htx (plan location) – – Yes France January 2006 68 French ECDC website (direct link) http://www.grippeaviaire.gouv.fr/IMG/pdf/Plan_pandemie_grippale_janvier_2006.pdf http://www.sante.gouv.fr/dossiers/grippe_aviaire/fiches_techniques.htm (Appendices, accessed 31/08/06) – Yes (appendices) Yes Germany March 2005 90 (in 3 parts) German ECDC (via MoH website) http://www.rki.de/cln_011/nn_879788/DE/Content/InfAZ/I/Influenza/ Influenzapandemieplan.html – – Yes Greece October 2005 44 English ECDC website (via MoH website) http://www.keel.org.gr/keelpno/National_plan.pdf – – Yes Hungary October 2005 22 English MoH website http://www.eum.hu/index.php?akt_menu=2652&hir_reszlet=8 – – Yes Ireland 2002 119 English Fluwiki (via MoH website) http://www.fluwikie.com/pmwiki.php?n=Geographic.Ireland (Fluwiki web page) http://www.dohc.ie/publications/influenza_pandemic.html (MoH web page) – – Yes Italy 2006 32 English ECDC (direct link) http://www.ccm.ministerosalute.it/imgs/C_17_pubblicazioni_511_allegato.pdf – – Yes B Bulletin of the World Health Organization | December 2007, 85 (12) Research European national strategic plans for pandemic influenza Sandra Mounier-Jack et al. Country Date of plan Length (pages) Original language Source Websites Documents Strategic plan Operational plan Plan with elements of both Latvia October 2005 16 Latvian ECDC (direct link) http://phoebe.vm.gov.lv/faili/gripa/info_20051018.pdf – – Yes Lithuania September 2005 7 English ECDC (direct link) http://www.vvspt.lt/aktai/gripas/2005%2009%2020%20GRIPO%20PLANO%20VERT. doc – – Yes Luxembourg July 2006 24 (in 2 parts) French ECDC (via MoH website) http://www.grippeaviaire.public.lu/ – Yes – Netherlands October 2005 59 + 246 (appendices) Dutch WHO Regional Office for Europe Website (via MoH website) http://www.euro.who.int/flu/related/20060822_1 (WHO web page) http://www.infectieziekten.info/index.php3?lokatie=http%3A//www.infectieziekten. info/protocol.php3%3Fpagid%3D142 (MoH web page) Yes Yes Yes Norway February 2006 145 + appendices Norwegian Fluwiki (direct link) http://www.fluwikie.com/pmwiki.php?n=Geographic.Norway Yes Yes – Poland August 2005 80 English UNDG website (direct link) http://www.undg.org/content.cfm?id=1575 – – Yes Portugal January 2006 23 Portuguese ECDC (direct link) http://www.dgs.pt/upload/membro.id/ficheiros/i007770.pdf – – Yes Romania October 2005 23 Romanian MoH contacted in person Not applicable (paper copy obtained) – – Yes Slovakia November 2005 103 English ECDC (via MoH website) http://www.health.gov.sk/redsys/rsi.nsf/0/D2869A65B5F83280C12570EC00517352? OpenDocument – – Yes Slovenia July 2006 66 Slovenian Ministry of Health, Slovenia Yes Spain May 2005 43 English ECDC (direct link) http://www.msc.es/ciudadanos/enfLesiones/enfTransmisibles/docs/PlanGripeIngles.pdf Yes – – Sweden November 2005 23 + 32 Swedish ECDC (via MoH website) http://www.socialstyrelsen.se/Publicerat/2005/8972/2005-130-7.htm http://www.socialstyrelsen.se/Publicerat/2005/8660/2005-131-7.htm http://www.socialstyrelsen.se/Publicerat/2005/8662/2005-130-2.htm – – Yes Switzerland May 2006 249 (in 3 parts) French MoHweb http://www.bag.admin.ch/influenza/01120/01134/index.html?lang=fr Yes (parts 1 and 2) Yes (part 3) – Turkey June 2006 184 English ECDC (direct link) http://www.grip.saglik.gov.tr/eng/index.html – – Yes United Kingdom October 2005 177 English ECDC (direct link) http://www.dh.gov.uk/assetRoot/04/12/17/44/04121744.pdf (Department of Health plan); http://www.hpa.org.uk/infections/topics_az/influenza/pandemic/documents/ HPAPanFluContPlanSept06.pdf (UK Health Protection Agency Plan) – – Yes MoH, Ministry of Health; ECDC, European Centre for Disease Prevention and Control; UNDG, United Nations Development Group. (Table 1, cont.)