Bulletin of the World Health Organization

Developing pandemic preparedness in Europe in the 21st century: experience, evolution and next steps

Angus Nicoll, Caroline Brown, Franz Karcher, Pasi Penttinen, Michala Hegermann-Lindencrone, Silvia Villanueva, Massimo Ciotti, Lucie Jean-Gilles, Sybille Rehmet & Jonathan S Nguyen-Van-Tam

Volume 90, Number 4, April 2012, 311-315B

Table 1. Weaknesses in the response to the 2009 pandemic and suggested improvements

Weaknesses revealed in 2009 pandemic response Ways to improve pandemic preparedness
Preparedness and planning
– General weaknesses in core preparedness capacities – Assess core capacities by WHO and EU Member States as required by the IHR and facilitate this through coordinated approaches by WHO and the ECDC
– Define the roles of key personnel during crisis management
– See pandemic preparedness as part of wider general preparedness and develop both
– Inadequate regional coordination, preparedness and cooperation
– Differing and sometimes conflicting national responses
– Adopt a serious cross border threats initiative to improve coordination between Member States, WHO and EU structures
– National plans and preparedness not always carried through to the local level and front line services – Use ECDC local tests to assess local preparedness and update these in light of the 2009 pandemic
– Difficulties in adjusting general pandemic plans and preparedness to the specific requirements of a particular pandemic
– Planning assumptions not fit to the specific pandemic
– Develop structures for describing and defining pandemics based on the appreciation that pandemics differ, that they have to be characterized as they emerge, that they can change over time and that countermeasures have to be flexible
– Develop a range of planning assumptions and of pandemic patterns and severities and the ability to refine default planning assumptions in light of early surveillance data
– Confusion over WHO’s pandemic definition and phases and their relation to disease severity – Review WHO’s definition of a pandemic and explain how severity fits within it
– Sub-optimal information sharing during the pandemic – Share preliminary evaluations early, as soon as the first countries are affected, as required under EU legislation and the IHR
– Specific gaps in national plans and preparedness – Collect all international and national evaluations of the response to the pandemic and analyse them to extract key lessons
– Improve national plans and preparedness following international guidance from WHO, the EC and the ECDC
– Lack of structures for cross-sectoral work during a pandemic in some settingsa – Identify the sectors that could be most seriously affected during a severe pandemic
– Integrate more cross-sectoral aspects into pandemic influenza preparedness
– Confusion between containment (responding to outbreaks of A(H5N1)) and mitigation (pandemic response) – Provide clearer guidance on the roles of different entities in the early assessment of a pandemic in Europe versus containment
– Lack of effectiveness of new interventions introduced in the pandemic for the first time – As far as possible, introduce the potential tools and mechanisms needed during a pandemic and seasonal influenza, such as surveillance for severe influenza, studies of field vaccine effectiveness and monitoring of vaccine safety
Surveillance in a pandemic
– Excessive concern over numbers of cases and deaths to the neglect of more important indices – Start with the information needed to inform key decisions
– Adopt the “known unknowns approach of the ECDC and rolling risk assessments
– Improving access to appropriate epidemiological and surveillance information at an early stage – Adopt pre-defined protocols for information gathering and sharing
– Apply Decision 2 119/98 and IHR(2005) for information sharing
– Difficulty defining pandemic severity – Develop criteria to define pandemic severity in Europe
– Select candidate set of appropriate severity indicators
– Apply the indicators to seasonal influenza each year in an annual risk assessment
– Weaknesses in rapidly identifying risk factors, clinical problems and the spectrum of infection and disease (asymptomatic infections) – Develop severe disease surveillance (hospital cases and deaths), clinical surveillance and a plan for undertaking seroepidemiology in a pandemic
– Poor sharing of information on clinical presentation, treatment effectiveness and other clinical parameters – Share clinical experience in treating patients among Member States (e.g. through ICU networks)
– Develop channels of communication with and among clinicians, especially intensivists
Communications
– Poor relationship with the media at times – Work more closely with the media during each influenza season
– Inexperience of some official communicators – Conduct workshops with communicators
– Provide guidance for communicators in EU countries on how to communicate health information
– Organize workshops for key journalists
– Failure to monitor the beliefs and attitudes of the public and specifically health-care workers (HCWs)
– Failure to detect the early loss of confidence in countermeasures and the authorities
– Have standard European models for monitoring public attitudes and beliefs of HCWs to be used by Member States
– Keep the relevant professional associations of health professionals informed and involved
– Create communication channels for advocacy concerning influenza immunization and the risks of influenza infection in health-care workers
– Occasional lack of targeted messages for different risk and vulnerable groups – Develop EU guidelines on how to reach specific risk groups
– Have core, tested information for the public and health-care workers that can be adapted by Member States into appropriate languages
– Difficulties in disseminating early reports on vaccine and antiviral safety and effectiveness, and in dealing with questions over whether those providing information and advice were independent of commercial influences – Develop protocol for circulating and disseminating the independent reports of various agencies
– Improve communication flow between different institutions
– Difficulty working with the new social media – Assess the use and influence of new social media with respect to public health messages
– Include new social media in communication campaigns known to be effective
– Poor coordination of the timing and content of some health messages – Improve the coordination, consistency, timing and content of health messages
Vaccines, vaccination and other medical countermeasures
– Poor seasonal influenza vaccine uptake – Develop EU guidance on successful vaccination strategies
– Improve monitoring of seasonal influenza vaccination coverage
– Implement the 2009 EU Council recommendation on seasonal influenza immunization
– Loss of confidence by health-care staff in vaccination in some countries
– Failure to reach some vulnerable risk and marginal groups;
– Develop EU guidance on how to reach vulnerable and risk groups
– Develop methods to monitor the views and attitudes of the public and health-care workers concerning immunization
– Inequitable access to vaccines across Europe
– Lack of flexibility of vaccine procurement contracts, especially concerning the liability of manufacturing vaccines
– Make advance purchase agreements more flexible
– Develop a system for the joint procurement of vaccines in the EU
– Suboptimal effectiveness of influenza vaccines – Continue to support research on influenza vaccines, including adjuvants
– Poor use of antivirals to treat pandemic and seasonal influenza – Review guidance, policies and practices surrounding the prescription of antivirals against seasonal and pandemic influenza
– Lack of surge capacity in some key aspects of health care, notably intensive care and paediatric services – Plan for improving surge capacity in intensive care, paediatrics and develop plans for triage
– Late detection of potential adverse events following vaccination and use of antivirals – Improve routine mechanisms for detecting adverse events and subsequent rapid evaluation and independent scientific investigation of these reports

EC, European Commission; ECDC, European Centre for Disease Prevention and Control; EU, European Union; ICU, intensive care unit; IHR, International Health Regulations; WHO, World Health Organization.

a Although the 2009 pandemic was not severe enough to stress sectors other than health, inter-sectoral work remains important.