In the list of potential bioterrorist agents, influenza would be classified
as a category C agent (1). While previous influenza pandemics were naturally
occurring events, an influenza pandemic could be started with an intentional
release of a deliberately altered influenza strain. Even if a deliberately
altered strain is not released, an influenza pandemic originating from natural
origins will inevitably
occur (2) and will likely cause substantial illness, death, social disruption,
and widespread panic. Globally, the 1918 pandemic killed at least 20 million
people (3). This figure is approximately double the number killed on the
battlefields of Europe during World War I (4). In the United States alone, the
next pandemic could cause an estimated 89,000–207,000 deaths, 314,000–734,000
hospitalizations, 18–42 million outpatient visits, and 20–47 million additional
illnesses (5). These predictions equal or surpass many published casualty
estimates for a bioterrorism event (6–8). In addition to the potential for a
large number of casualties, a bioterrorism incident and an influenza pandemic
have similarities that allow public health planners to simultaneously plan and
prepare for
both types of emergencies (Table). Preparing for both the
next influenza pandemic and the
next bioterrorist attack requires support and collaboration from multiple
partners at the state, local, and federal level. Potential partners include the
medical community, law enforcement, emergency management, and public health
agencies. To help foster these crucial cross-discipline relationships, the
Centers for Disease Control and Prevention CDC) and the Council of State and
Territorial Epidemiologists (CSTE), in collaboration with the National Emergency
Management Association, the Association of State and Territorial Health
Officials, the Federal Emergency Management Agency, and the Association of
Public Health Laboratories, hosted a 2-day meeting on state and local pandemic
influenza planning in May 2002. Over 125 officials representing
epidemiology, communicable disease, laboratory, immunization, and emergency
management programs from 46 states registered for this meeting. The objectives
of the meeting were to enhance collaboration between state and local public
health and emergency management agencies, establish
mechanisms for integrating bioterrorism and pandemic influenza preparedness and
response planning, and develop policy and strategy options for influenza
pandemic preparedness and response at the state and local level. We report the
results of a questionnaire distributed to the attendees;
it was designed to elicit their views on the most important issues that must be
addressed by a plan to
respond to a catastrophic disease event.
All plans for any catastrophic infectious disease event such as
pandemic influenza or a bioterrorist attack must address five topics:
surveillance and laboratory issues; communications; maintenance of community
services; medical care; and supply and delivery of vaccines and drugs. After
presentations providing background information, conference attendees were
divided into breakout groups to discuss these topics. The groups did not discuss
particular scenarios, but the presentations given before the breakout groups did
include details of estimates of the potential impact of the next influenza
pandemic (5). Attendees completed short (<5 questions), anonymous
questionnaires at both the beginning and end of the breakout session. Each
breakout group had a different set of questions relevant to the topic of that
group.1 However, all groups addressed a common question, which asked persons to
pick their top priority for a pandemic influenza response from one of the
following options: reduce mortality, reduce morbidity, ensure continuation of
essential services, reduce economic impact, and ensure equitable distribution of
resources. As explained to the attendees before the breakout session,
differences by age and risk group in rates of mortality and morbidity could mean
that public health officials with limited resources might not be able to
simultaneously maximize reductions in mortality and morbidity (5). The first
three options were chosen most frequently (Figure). Even
after discussion, no option was chosen by >50% of attendees, indicating that
this group of professionals did not have a unified opinion regarding what the
top priority should be to guide planning and response measures. Conference
attendees did, however, agree that global
and domestic laboratory and disease surveillance must be strengthened to
increase the likelihood of early detection and tracking of either pandemic
influenza or a bioterrorist event. A rise beyond the baseline number of
influenza-like illnesses (ILIs) could indicate a severe influenza season,
arrival of pandemic influenza, or early warning of a bioterrorist attack with a
pathogen that causes ILIs (e.g.,
anthrax). Thus, the number and accuracy of reports of ILI, ILI outbreaks, and
laboratory-confirmed reports of influenza need to be increased. In addition,
ensuring that adequate laboratory and disease surveillance systems are in place
will benefit the public health response during yearly influenza epidemics.
Conference attendees identified two critical gaps in infectious disease
surveillance systems: 1) less than ideal or nonexistent systems to monitor
outpatient and hospital-based ILI cases and 2) insufficient numbers of
laboratory personnel and epidemiologists to
monitor, provide diagnostic support, and respond to events.
Another critical component of any catastrophic infectious disease plan is
communications. The anthrax attacks in 2001 demonstrated that the public, media,
and healthcare professionals will demand accurate information, with frequent
updates throughout the emergency. To minimize the potential for confusion,
states and localities need to identify a recognized and trusted leader who will
be the primary spokesperson to disseminate accurate information. Among attendees
in the communications breakout group, 40% felt that the state governor would be
the best spokesperson, 40% chose the state health officer, and 20% chose the
state epidemiologist. In the initial stages of, and potentially throughout, an
influenza pandemic or a bioterrorist attack, there will be a shortage of many
essential resources, including medical equipment and supplies, personnel,
vaccines, and drugs.
Prioritizing medical resources will therefore be necessary. The medical
care breakout group unanimously chose state and local government as the
authority that should prioritize and distribute healthcare resources. In the
breakout group that discussed vaccine and antimicrobial agent issues, 73% chose
essential workers and physicians as those who should be the first to receive
vaccine and antiviral drugs. Only 27% chose those at high risk for adverse
influenza related health outcomes to be early recipients of vaccine.
Conclusions: Maximizing Resources and Planning Efforts
Conference attendees were well aware of the need to simultaneously plan and
prepare for the next influenza pandemic and the next bioterrorist event.
However, much work remains to be done. Without agreement regarding the top
priority for allocating scarce resources, planning and implementing an optimal
response to either pandemic influenza or a bioterrorist event will be difficult,
if not impossible. Illustrating potential planning problems was the incongruity
between the inability of most attendees to agree on the goal of planning and
response measures (Figure) while 75% of a subgroup stated
that essential workers and physicians should be the first to receive vaccines
and antiviral drugs. In a situation with limited resources, usually only one
goal can be optimized (either maximized or minimized) (9). Therefore, before
accepting any of the initially limited supplies of vaccine and antiviral drugs,
physicians and first responders will have to explain how such an allocation will
help achieve the chosen top priority. Unprecedented resources for
enhancing the public health preparedness and response infrastructure have been
recently provided to all states by congressional appropriations in the form of
bioterrorism cooperative agreements. The request for proposals stated that
planning moneys may be used “…to upgrade state and local public health
jurisdictions’ preparedness for and response to bioterrorism, other outbreaks of
infectious disease, and other public health threats and emergencies…” (10).
Using such resources and reflecting upon the lessons learned from previous
influenza pandemics and the 2001 terrorist events, public health, medical, and
emergency management communities must work together to develop an effective plan
to strengthen our national readiness to respond to any catastrophic infectious
disease situation. If our public health planning efforts are too narrowly
focused on preparing responses to a few select bioterrorism- related scenarios,
a new opportunity for planning responses to a broad spectrum of infectious
disease-related catastrophes will be lost. Any plans made for responding to
either pandemic influenza or bioterrorism events must include an explicit
mechanism for making difficult decisions regarding the prioritization of scarce
resources. The conference highlighted the need for all states to continue their
discussions and public debates regarding the setting of priorities and methods
for allocating scarce resources. Obviously, each state or local government
will chose its
own specific method for drawing up a plan to deal with catastrophic infectious
disease events such as an influenza pandemic. To help aid the planning process,
materials such as a planning guide are available from agencies such as CDC and
CSTE. Ideally, such planning and prioritization activities should take place
well in advance of any catastrophic infectious disease event.
