A report to be published in an upcoming issue of the World Health Organisation (WHO) Bulletin will call for urgent attention to the politically sensitive issue of border control, and the need for coherent and robust national plans in the face of a catastrophic flu pandemic .
The report comes after the recent confirmation of person-to-person transmission of a strain of avian influenza A (HN51) in Northern Sumatra: although the outbreak was contained by voluntary quarantine and rapid administration of antiviral medication, scientists admitted that the world had ‘dodged a bullet’ and ‘may not be so lucky next time.
“Governments need to work with their neighbours, sharing best practices and strategic thinking openly. The European Centre for Disease Prevention and Control (ECDC) might have successfully established pan-European surveillance procedures but the current significant differences in countries’ pandemic plans are likely to test any notion of global solidarity or security,” said study author, Dr Richard Coker, Reader in Public Health at the London School of Hygiene and Tropical Medicine, in the United Kingdom.
The report surveyed EU and bordering countries and found that:
- Europe is broadly better prepared than a year ago, with most countries having drafted a preparedness plan
- Fewer than half provide defined plans for distribution of antivirals or specific guidance on where vaccines would be stored, how they would be distributed, and who would administer them
- Two thirds of national plans depart from WHO guidelines on the crucial step of limiting people’s movement from affected to unaffected areas
Concerns about the lack of restrictions on imported goods, and potential chaos caused by uncertainty about how to deal with travellers on board plane or ships from affected areas were also highlighted. Only eight countries of the thirty surveyed recommend separating sick travellers from others, and just four aim to provide masks to either passengers or crew.
“A year on from the previous review, many nations remain ill prepared for the on-the-ground realities of an imminent flu pandemic” commented Dr Richard Coker. “Critically, the who, what, when and where is not defined for antiviral medications which are the first line of defence before vaccine supplies can be manufactured and distributed.”
The report notes the recent increase in stockpiles of antivirals by many countries. However, the issue of how to deliver antivirals to individual patients is not addressed with the majority of plans: basic medical supplies that would be required (syringes, antibiotics and protective clothing) have not necessarily been taken into account, and would inevitably be affected by disruptions to transportation.
“In the event of pandemic, initial demand for antivirals may outstrip the medical community’s ability to administer them. Although many countries in Europe have stockpiles, rigorously thought through plans for storage, distribution and administration are now an urgent requirement, as panic and ultimately chaos will result unless the operational procedures are defined and tested in advance of a pandemic,” commented Dr Coker. He added: “The absence of international cooperation on border control is alarming, and raises the ugly spectre of people detained without warning, and possibly against their will, when they are travelling from one country to another.”
Overall Report Findings
The report was published one year on from the previous review of EU countries’ plans for pandemic control and found that the majority of countries (29 / 30) now have strategic plans in place. Authors noted international surveillance has been strengthened, but warned that:
- On-the-ground response capacity remains weak - particularly in the critical areas of antiviral and vaccine supply and distribution
- Pandemic influenza is likely to test notions of global solidarity, with only half of plans explicitly saying that border control measures will be coordinated with neighbouring countries
Key Issues: Border Control
The need for information and advice about travel was widely acknowledged, but concerns were raised about the significant inconsistency between countries:
- Travel restrictions are anticipated by 16 / 30 countries, but two countries explicitly advise against these measures
- Five countries envisage applying an absolute ban on cross-border travel, but sixteen countries intend to follow WHO advice
- The majority of plans (20 / 30) depart from the explicit WHO recommendations for exit screening, and 17 of these favour introducing specific entry screening measures, which is in contrast to WHO advice
Key Issues: Antivirals
The majority of countries have strategic plans for antiviral drugs but substantial weaknesses are highlighted in the operational management of storage, distribution and administration:
- 16 / 30 countries plan to devolve all or part of these responsibilities to local administrations – yet provide few details as to how this will occur
- Only eight countries address the need for security measures at antiviral drug distribution centres
- There was significant confusion between countries as to whether antivirals should be used for treatment or prophylaxis: where guidance prophylactic use existed, it was often unclear as to whether drugs should be used pre- or post-exposure
Key Issues: Vaccination
All but one country had plans for pandemic vaccination, but:
- The lead time on vaccination development (3-6 months) and the manufacturing capacity (300 million doses), means that demand will outstrip supply
- Ranking of priority groups is currently not included in nearly one in three plans
- Less than half the plans detail storage, provision and distribution mechanisms, and few details are provided relating to who will be responsible for administering vaccines and where this will occur
About the Report
The report follows a similar assessment, conducted in 2006, which identified considerable variation between the plans of different countries in these critical areas that are likely to test health system responses because of scarcity or the need for international coordination, coherence and cooperation. It evaluated national plans for pandemic preparedness from 25 EU countries, two accession countries and three non-EU countries that border the EU (Norway, Switzerland and Turkey).
The initial survey of plans identified 29 for inclusion in the report, and the evaluation cross-checked each plan against WHO guidelines in three key areas of preparedness: national planning border control measures and antiviral drugs and vaccine strategies.
Progress and shortcomings in European national strategic plans for pandemic influenza is available online at: http://www.who.int/bulletin/volumes/85/06-039834.pdf
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