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Volume 12, Number 7—July 2006
Peer Reviewed Report Available Online Only

Critical Issues in Responding to Pandemic Influenza

James W. Buehler*Comments to Author , Allen Craig†, Carlos Del Rio‡, Jeffrey P. Koplan§, David S. Stephens‡§, and Walter A. Orenstein‡
Author affiliations: *Emory University Rollins School of Public Health, Atlanta, Georgia, USA; †Tennessee Department of Health; Nashville, Tennessee, USA; ‡Emory University School of Medicine, Atlanta, Georgia, USA; §Emory University Woodruff Health Sciences Center, Atlanta, Georgia, USA

Suggested citation for this article

Pandemic Influenza Planning: The Reality of Implementation in the Southeast
Atlanta, Georgia USA
November 11, 2005

On November 11, 2005, shortly after the US government issued updated pandemic influenza planning guidance (1), the Southeastern Center for Emerging Biologic Threats convened a meeting of public health officials and academic healthcare providers from Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee (2). Participants reflected on pandemic planning efforts to date, sought to identify key challenges and response strategies, and separated into 4 workgroups to address surveillance and containment, vaccination, healthcare and antiviral drugs, and the animal-human health interface. This report summarizes the core issues, solutions, and unmet planning needs that were identified (Table) (a full report is available from

The Surveillance and Containment Workgroup focused on strategies to delay introduction of influenza into a state and slow transmission once cases appear. These measures will be aimed at "buying time" to allow for increased vaccine and antiviral drug availability. The group concluded that individual case reporting, investigations, and mandatory isolation or quarantine are likely to be feasible and effective only at the earliest stages, when few cases have occurred. As infections increase, attention will shift to "social distancing" interventions such as closing schools or canceling public events, despite uncertainties about their effectiveness, costs, and adverse consequences (e.g., if schools close, parents may be unable to work) (3). Similar questions surround the value of using masks in public (3). Strategies for influenza surveillance will evolve over the course of a pandemic, but this is more familiar ground, and planning is largely based on augmenting existing surveillance methods (4).

The Vaccination Workgroup recognized that translating federal guidance into practice will invoke questions of values, fairness, and logistics. The group's consensus was that states should follow federal priority guidelines, with the possible exception of elevating the priority of critical infrastructure workers, and that refinements may be necessary if supply is inadequate to cover the highest priority groups. Procedures for validating priority status will be necessary to avoid tension at vaccination sites. As vaccine availability increases, delivery will shift from administration by public health agencies to involvement of multiple partners, similar to current procedures for seasonal influenza vaccine. Procedures for monitoring vaccine use, efficacy, and side effects should build on existing information systems.

The Healthcare and Antiviral Drugs Workgroup anticipated that healthcare institutions may be unable to meet needs and expectations for care, despite efforts to bolster "surge capacity." To address this concern, health departments and hospitals are developing strategies to maximize space use in hospitals, identify facilities that can be adapted for lower-level inpatient care, and promote home care. This strategy will require triage systems and procedures to transfer patients to higher or lower levels of care when indicated. Staffing will depend on maintaining the current workforce in the face of personal or family illness and "burnout" and on enlisting, training, and credentialing volunteers. A spirit of professional or civic responsibility will motivate many, but the limits of such dedication during a modern pandemic are unknown. Protecting staff will require judicious use of limited antiviral medications, vaccines, or personal protective equipment (PPE), which will require difficult decisions regarding the definition of priority groups among healthcare workers. Participants generally concurred with federal recommendations to prioritize treatment over prophylactic use of antiviral drugs, and they recommended that prophylaxis be reserved for those who care for patients with respiratory illness and those essential for providing urgent care to patients with other severe illnesses. Questions about surge capacity also involve other medications, diagnostics, and supplies. Disparities in the availability of drugs or supplies among institutions will require advance planning for sharing resources.

As capacities are strained, standards of care must be adjusted (5). Plans should ascertain who is responsible for invoking and lifting alternative standards and for coordinating these actions within a region. Managing the healthcare response will require ongoing communication between government agencies and healthcare institutions and within institutions. To this end, the group emphasized the value of exercises to foster relationships and model future crisis interactions.

The Animal-Human Health Interface Workgroup noted several possible routes of introduction of an animal influenza strain with pandemic potential in the United States: migratory birds, illegal importation, or deliberate introduction. Advances in security and surveillance have substantially reduced the potential for distribution of a highly pathogenic avian influenza strain within the commercial poultry industry. Nonetheless, even a limited outbreak would have a dramatic impact, requiring collaboration among animal and human health officials and industry. The group cited examples of successful collaborations in planning for avian influenza and conducting exercises, a trend that merits further development. Such planning is complicated by limitations in the understanding of the health risks for poultry workers, the effectiveness of different forms of PPE for those involved in depopulation and disposal activities, and the role of environmental sampling methods for detecting animal pathogens. The group expressed special concern about the vulnerability of nonindustrial "backyard" flocks or live bird markets. Improving outbreak detection among noncommercial or unregulated facilities will require collaboration among a broad range of groups, such as law enforcement, animal control, natural resource agencies, and agricultural extension services.

The group recommended that heightened attention be given to strengthening surveillance for avian disease among noncommercial birds. It also recommended strengthening the effort to protect the health of poultry industry workers, including programs to expand annual vaccination with trivalent influenza vaccine; preidentifying, training, and PPE fit-testing those who would cull and dispose of birds; developing rapid diagnostic tests that can be used in field settings to detect avian influenza strains; and expanding research on the risk of occupational transmission of influenza from birds to humans.

In conclusion, the public health, healthcare, and veterinary experts who participated in this conference identified and considered responses to a series of major challenges they will face during an influenza pandemic, and participants reported that the conference enhanced their ability to prepare for a pandemic. The conference did not involve the full spectrum of perspectives necessary for planning. Draft state plans extant at the time of the meeting reflected an array of perspectives, and this engagement will expand as states act on federal planning guidance.



We thank Rachel B. Eidex, James Cope, Nina Marano, and Tonya Dixon for their contributions and support of this project.

J.W.B. was supported by a contract with the Southeastern Center for Emerging Biologic Threats.



  1. Department of Health and Human Services. Pandemic influenza plan. 2005 Nov [cited 2006 Feb 20]. Available from
  2. Southeastern Center for Emerging Biologic Threats (SECEBT). [cited 2006 Feb 20]. Available from
  3. World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, national and community measures. Emerg Infect Dis. 2006;12:8894.PubMedGoogle Scholar
  4. Centers for Disease Control and Prevention. Fact sheet: overview of influenza surveillance in the United States. 2006 Jan 11 [cited 2006 Feb 20]. Available from
  5. Agency for Healthcare Research and Quality. Altered standards of care in mass casualty events. Prepared by Health Systems Research Inc. under contract no. 290–04–0010. AHRQ Publication No. 05–0043. Rockville (MD): The Agency; 2005 Apr [cited 2006 Feb 20]. Available from




Suggested citation for this article:Buehler JW, Craig AS, del Rio C, Koplan JP, Stephens DS, Orenstein WA. Critical issues in responding to pandemic influenza [conference summary]. Emerg Infect Dis [serial on the Internet]. 2006 Jul [date cited].

DOI: 10.3201/eid1207.060463

Table of Contents – Volume 12, Number 7—July 2006

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James W. Buehler, Emory University Rollins School of Public Health, 1518 Clifton Rd NE, Room 416, Atlanta, GA 30322, USA

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Page created: December 19, 2011
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The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.