Seasonal and Pandemic Influenza Preparedness: A Global Threat
Identifieur interne : 001267 ( Istex/Corpus ); précédent : 001266; suivant : 001268Seasonal and Pandemic Influenza Preparedness: A Global Threat
Auteurs : Richard J. Whitley ; Arnold S. MontoSource :
- The Journal of Infectious Diseases [ 0022-1899 ] ; 2006.
Abstract
The increase in the incidence of avian influenza worldwide in both poultry and humans introduces the potential for another influenza A pandemic that could pose a significant threat to both human health and the global economy. The impact of the next influenza pandemic will be influenced, in part, by how well the medical, government, business, and lay communities are prepared. Despite the additional tools and resources that have become available since prior epidemics, there are limits to the quantity of antiviral drugs that can be manufactured and concerns over the current vaccine production systems. Despite these challenges, there is an opportunity to take action before the emergence of a pandemic influenza strain and, possibly, to prevent its spread or at least mitigate its impact on the world. In February 2006, a group of representatives from federal, state, and local governments; professional bodies; academia; and the pharmaceutical industry met to review the current state of preparedness in the United States for a potential influenza pandemic and its relationship to seasonal influenza. The goal of the meeting was to examine the recently revised US Department of Health and Human Services plan for preparedness and response to an influenza pandemic and to make recommendations to actualize this plan at the state and local levels.
Url:
DOI: 10.1086/507562
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ISTEX:8A3B3B439A299B2223144B0CF561C624534FC1C9Le document en format XML
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Monto</name><affiliation><mods:affiliation>Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j" type="main">The Journal of Infectious Diseases</title><title level="j" type="abbrev">The Journal of Infectious Diseases</title><idno type="ISSN">0022-1899</idno><idno type="eISSN">1537-6613</idno><imprint><publisher>University of Chicago Press</publisher><date when="2006-11-01">2006</date><biblScope unit="vol">194</biblScope><biblScope unit="issue">Supplemet_2</biblScope><biblScope unit="page" from="S65">S65</biblScope><biblScope unit="page" to="S69">S69</biblScope></imprint><idno type="ISSN">0022-1899</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0022-1899</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract">The increase in the incidence of avian influenza worldwide in both poultry and humans introduces the potential for another influenza A pandemic that could pose a significant threat to both human health and the global economy. The impact of the next influenza pandemic will be influenced, in part, by how well the medical, government, business, and lay communities are prepared. Despite the additional tools and resources that have become available since prior epidemics, there are limits to the quantity of antiviral drugs that can be manufactured and concerns over the current vaccine production systems. Despite these challenges, there is an opportunity to take action before the emergence of a pandemic influenza strain and, possibly, to prevent its spread or at least mitigate its impact on the world. In February 2006, a group of representatives from federal, state, and local governments; professional bodies; academia; and the pharmaceutical industry met to review the current state of preparedness in the United States for a potential influenza pandemic and its relationship to seasonal influenza. The goal of the meeting was to examine the recently revised US Department of Health and Human Services plan for preparedness and response to an influenza pandemic and to make recommendations to actualize this plan at the state and local levels.</div></front></TEI><istex><corpusName>oup</corpusName><author><json:item><name>Richard J. Whitley</name><affiliations><json:string>Departments of Pediatrics, Microbiology, Medicine, and Neurosurgery and Center for Biodefense and Emerging Infections, University of Alabama at Birmingham, Birmingham</json:string></affiliations></json:item><json:item><name>Arnold S. 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Despite these challenges, there is an opportunity to take action before the emergence of a pandemic influenza strain and, possibly, to prevent its spread or at least mitigate its impact on the world. In February 2006, a group of representatives from federal, state, and local governments; professional bodies; academia; and the pharmaceutical industry met to review the current state of preparedness in the United States for a potential influenza pandemic and its relationship to seasonal influenza. 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<label>1</label>Departments of Pediatrics, Microbiology, Medicine, and Neurosurgery and Center for Biodefense and Emerging Infections, University of Alabama at Birmingham, Birmingham</aff>
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<corresp>Reprints or correspondence: Dr. Richard J. Whitley, University of Alabama at Birmingham, CHB 303, 1600 7th Ave. S, Birmingham, AL 35233‐1711 (<email>rwhitley@peds.uab.edu</email>).</corresp>
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<p>The increase in the incidence of avian influenza worldwide in both poultry and humans introduces the potential for another influenza A pandemic that could pose a significant threat to both human health and the global economy. The impact of the next influenza pandemic will be influenced, in part, by how well the medical, government, business, and lay communities are prepared. Despite the additional tools and resources that have become available since prior epidemics, there are limits to the quantity of antiviral drugs that can be manufactured and concerns over the current vaccine production systems. Despite these challenges, there is an opportunity to take action before the emergence of a pandemic influenza strain and, possibly, to prevent its spread or at least mitigate its impact on the world. In February 2006, a group of representatives from federal, state, and local governments; professional bodies; academia; and the pharmaceutical industry met to review the current state of preparedness in the United States for a potential influenza pandemic and its relationship to seasonal influenza. The goal of the meeting was to examine the recently revised US Department of Health and Human Services plan for preparedness and response to an influenza pandemic and to make recommendations to actualize this plan at the state and local levels.</p>
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<p>The worldwide increase in the incidence of influenza caused by avian influenza A(H5N1) virus, manifested in poultry outbreaks and sporadic human infections, highlights the concern that another influenza A pandemic is likely to occur soon. Should this happen, there will be significant threats to human health, national and global economies, and, potentially, societies. With the emergence of the H5N1 virus, the threat of a pandemic is higher now than it has been since the last influenza A pandemic, in 1968. Three pandemics occurred during the past century. Of these, the 1918 H1N1 influenza pandemic was by far the worst, resulting in 50–100 million deaths [<xref ref-type="bibr" rid="ref1">1</xref>]. The H1N1 virus that caused the pandemic originated from an avian influenza virus, which adapted to humans by mutation [<xref ref-type="bibr" rid="ref2">2</xref>]. Unlike seasonal influenza, which causes most of its estimated 36,000 annual US deaths among the elderly [<xref ref-type="bibr" rid="ref3">3</xref>], >90% of the deaths caused by pandemic influenza have occurred in healthy people <65 years of age [<xref ref-type="bibr" rid="ref4">4</xref>]. This H1N1 virus was particularly virulent and showed extraordinarily high levels of replication in the lungs of experimentally infected animals [<xref ref-type="bibr" rid="ref5">5</xref>]. Indeed, a conventional human virus containing only the 1918 hemagglutinin caused high viral replication and marked pulmonary damage, in part resulting from activation of a vigorous proinflammatory cytokine cascade that may have contributed to acute respiratory distress syndrome [<xref ref-type="bibr" rid="ref6">6</xref>]. Since the 1918 pandemic, the population of the world has grown 3‐fold; therefore, if a new influenza A virus is as lethal as the 1918 virus, as many as 180–360 million people could die [<xref ref-type="bibr" rid="ref7">7</xref>]. Such a pandemic would overwhelm the health care systems of the world and have a devastating socioeconomic impact. The 1957 H2N2 and 1968 H3N2 pandemics also involved new influenza viruses generated by reassortment events, and, although they were less virulent than the 1918 H1N1 virus, they still caused significant morbidity and mortality.</p>
<p>Recently, several avian influenza A virus subtypes, including H5N1, H9N2, H7N3, and H7N7, have been shown to cross the species barrier from poultry or wild migratory birds to infect humans. The H7N7 and H9N2 viruses largely resulted in mild self‐limiting disease or asymptomatic infection, although 1 lethal infection associated with a mutated H7N7 virus was recognized in a Dutch veterinarian [<xref ref-type="bibr" rid="ref8">8</xref>]. In addition, since the emergence of H5N1 in Hong Kong in 1997, clinically documented H5N1 infections have been associated with a high mortality rate in humans [<xref ref-type="bibr" rid="ref9">9</xref>
<xref ref-type="bibr" rid="ref10">
</xref>–<xref ref-type="bibr" rid="ref11">11</xref>]. Since 2003, 241 laboratory‐confirmed cases have been reported in 10 countries (Azerbaijan, Cambodia, China, Egypt, Indonesia, Iraq, Thailand, Turkey, Vietnam, and Djibouti); as of 23 August 2006, 141 (59%) of these cases have resulted in death [<xref ref-type="bibr" rid="ref11">11</xref>]. Typically, death after infection with the H5N1 virus occurred, on average, 9–10 days after the onset of illness and was usually the result of progressive respiratory failure [<xref ref-type="bibr" rid="ref12">12</xref>]. The high mortality rates may be an overestimate, because limited surveillance studies in Vietnam have reported that several contacts of patients may have developed mild or asymptomatic infection with H5N1 [<xref ref-type="bibr" rid="ref13">13</xref>]. However, recent serologic studies in Southeast Asia have found infrequent H5N1 antibody positivity in apparently healthy contacts, indicating that most infections are clinically manifest. By any standard, H5N1 infection is highly virulent in humans.</p>
<p>The final step required for a pandemic is efficient human‐to‐human transmission of the virus. The H5N1 virus is now endemic in poultry in Asia and parts of Africa and is spreading globally despite active control measures. The greatest current concern is that the H5N1 virus may become more transmissible in humans, either through mutation or through genetic reassortment with a human influenza strain. Fortunately, to date, human‐to‐human transmission of the virus appears to be inefficient, and only a few instances have been documented [<xref ref-type="bibr" rid="ref13">13</xref>, <xref ref-type="bibr" rid="ref14">14</xref>]. However, the H5N1 virus has undergone multiple genetic reassortment events with avian viruses since its emergence in 1997, resulting in a dominant genotype (Z) present in chickens and ducks [<xref ref-type="bibr" rid="ref15">15</xref>], and could potentially mutate further, becoming more transmission efficient. Although genotype Z appears to be dominant in most parts of Asia, there are 2 major clades circulating, as well as a diversity of genotypes in parts of southern China, with observations indicating that the virus continues to evolve. Because different viruses may have altered antigenicity, it would be unwise to rely on a single target virus for vaccine development [<xref ref-type="bibr" rid="ref16">16</xref>]. Indeed, in the United States, the Department of Health and Human Services (HHS) has recently announced its intention to proceed with development of a candidate vaccine based on clade 2 H5N1 virus [<xref ref-type="bibr" rid="ref17">17</xref>].</p>
<p>The impact of the next influenza pandemic on the world’s populations will be influenced, in part, by how well the medical, government, business, and lay communities are prepared. Additional tools and resources are available, such as antiviral drugs, diagnostics, and vaccines, that did not exist during prior pandemics. However, there are limits to the quantity of antiviral drugs that can be manufactured and effectively deployed, as well as uncertainties regarding vaccine effectiveness and concerns regarding the current vaccine production systems. In addition, new challenges exist, such as rapid intercontinental transportation and a larger global population. Despite these challenges, there is an opportunity to take action before the emergence of a pandemic influenza strain and, possibly, to prevent or delay its spread or at least mitigate its impact on the world. In part, this can be achieved by improving the current infrastructure for managing seasonal influenza, an action that would have the additional benefit of reducing morbidity and mortality regardless of the emergence of a pandemic. For example, increased vaccine production can be used to control seasonal disease and ensure more capability to produce vaccine for a pandemic.</p>
<p>Important lessons can be learned from our ability to respond to natural disasters, which can help us to prepare more effectively for pandemic influenza. The recent experience of Hurricane Katrina overwhelmed state and local public health infrastructures in Louisiana and Mississippi, required an unprecedented federal response, and led to international offers of assistance. Although this response was successful in some areas, several important weaknesses were identified [<xref ref-type="bibr" rid="ref18">18</xref>]. The most concerning, in terms of a potential response to pandemic influenza, was the poor coordination of federal assets, within and across agencies, resulting from a fragmented command and response structure. This caused substantial delays in the deployment of federal assets in critical areas. In other cases, assets were deployed inappropriately and were subsequently underutilized. In addition, communication to the public was poorly coordinated among federal, state, and local agencies, which resulted in contradictory and confusing messages being issued [<xref ref-type="bibr" rid="ref18">18</xref>].</p>
<p>
<bold>
<italic>Background. </italic>
</bold>In February 2006, a group of representatives from federal, state, and local governments; professional bodies; academia; and the pharmaceutical industry met to review the current state of preparedness in the United States for a potential influenza pandemic and its relationship to seasonal influenza. The goal of the meeting was to examine the recently revised HHS plan for preparedness and response to an influenza pandemic [<xref ref-type="bibr" rid="ref17">17</xref>] and to make recommendations to actualize this plan at the state and local levels. In addition, the group identified areas for further research and consideration.</p>
<p>The revised HHS plan was designed to provide guidance to national, state, and local policy makers and health departments, to enable them to prepare for the management of an influenza pandemic. It has 2 key components:<list list-type="bullet">
<list-item>
<p>Strategic plan. This section outlines public health care and medical support strategies required to prepare for and respond to an influenza pandemic. In addition to outlining planning assumptions, it also assigns the roles and responsibilities of HHS.</p>
</list-item>
<list-item>
<p>Public health guidance to state and local partners. This section provides guidance to state, local, and tribal governments in 11 areas of preparedness: surveillance, laboratory diagnostics, health care planning, infection control, clinical guidelines, vaccine distribution and use, antiviral drug distribution and use, community disease control and prevention, management of travel‐related risks of disease, public health communication, and work force support.</p>
</list-item>
</list>
</p>
<p>The Seasonal and Pandemic Influenza 2006 meeting was sponsored by the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), the National Institute of Allergy and Infectious Diseases (NIAID), and the Centers for Disease Control and Prevention (CDC). Funding for the meeting was supplied through an unrestricted educational grant from Gilead Sciences, GlaxoSmithKline, Roche Laboratories, MedImmune, Sanofi Pasteur, Biota Holdings, and BioCryst Pharmaceuticals. The content of the meeting was planned and coordinated by an independent planning committee consisting of 6 US infectious diseases experts.</p>
<p>
<bold>
<italic>Meeting overview. </italic>
</bold>The meeting was structured to provide a series of overviews of current knowledge about seasonal and pandemic influenza and the state of preparedness for an influenza pandemic in the United States. Summaries of these presentations are provided in the accompanying articles in this supplement. In addition, panel discussions explored issues relating to state epidemiology, local health care systems, and professional education.</p>
<p>The meeting attendees were assigned to groups to evaluate specific components of the current HHS guidelines (vaccine development and production; education and communication; surveillance and diagnostics; distribution of vaccines, antiviral medications, and medical supplies; containment procedures; and surge capacity for patient care). Each group addressed questions posed by a moderator, and a discussant led each group in constructing a response to the issues highlighted. At the end of the meeting, the recommendations of each group were presented for further discussion. The proceedings of these sessions and the recommendations are detailed in the final article in this supplement [<xref ref-type="bibr" rid="ref19">19</xref>].</p>
<p>The meeting was opened by presentations from Anthony Fauci, NIAID, and Julie Gerberding, CDC, on seasonal and pandemic influenza preparedness, highlighting the existing burden of seasonal influenza and reviewing the current US national plans for pandemic influenza preparedness. Dr. Fauci highlighted the major limitations of the current vaccine production system in the United States and the challenges that need to be overcome in developing a vaccine for the H5N1 influenza virus. Dr. Gerberding presented the CDC’s pandemic influenza plan, which is aimed at preventing or delaying the entry and spread of a pandemic influenza virus in the United States, thus allowing time to develop an effective vaccine.</p>
<p>The next session reviewed the epidemiological profile, surveillance, diagnostics, and treatment of seasonal influenza. Bill Thompson, CDC, opened the session by giving an overview of models used to assess influenza‐associated morbidity and mortality, highlighting the challenges associated with determining the true impact of seasonal influenza. Kristin Nichol, University of Minnesota, reviewed vaccination and prevention strategies for seasonal influenza, emphasizing the underuse of current vaccines, and Andy Pavia, University of Utah, gave an overview of antiviral therapies currently available for treatment of and prophylaxis against seasonal influenza. Lastly, the management of children, immunocompromised hosts, pregnant women, and nursing home residents was reviewed by Richard Whitley, University of Alabama at Birmingham.</p>
<p>The next session focused on planning initiatives for pandemic influenza and was opened with a review of the recently revised US national plan and progress with planning at the state level. Progress made with regard to planning and funding for a national response was addressed by Jay Levi, George Washington University, who also highlighted some of the challenges facing the public and private sectors in pandemic preparedness.</p>
<p>Subsequent presentations addressed lessons learned from past influenza pandemics. Harvey Fineberg, Institute of Medicine, reviewed the experience of the 1976 swine flu episode, sharing 5 key lessons: the importance of (1) building a base for decision making; (2) thinking hard about doing; (3) consideration for the media; (4) maintaining long‐term credibility; (5) and thinking twice about medical knowledge. Arnold Monto, University of Michigan, reviewed the lessons from the 1918, 1957, and 1968 pandemics, highlighting the different aspects of each and the potential impact of future pandemics. Adolfo García‐Sastre, Mount Sinai School of Medicine, presented what was learned from the reconstruction of the 1918 H1N1 virus and the insights that it provided regarding the pandemic potential of other influenza viruses and potential targets for therapeutic and prophylactic interventions.</p>
<p>The current status of H5N1 infections, the spread of the virus from Asia to Europe, and the outcome of the resultant human infections were presented by Tim Uyeki, CDC. John Treanor, University of Rochester Medical Center, reviewed options for producing pandemic vaccines comparing live vaccines, inactivated vaccines, and experimental approaches. Fred Hayden, University of Virginia School of Medicine, tackled the issue of eliminating a pandemic at its source through the use of antiviral therapy. He also reviewed the potential impact of antiviral therapy on mortality during a pandemic. Andrea Morgan, US Department of Agriculture (USDA), outlined the role of USDA in the prevention, surveillance, and response to an outbreak of avian influenza.</p>
<p>The second day of the meeting started with a presentation by Nancy Cox, CDC, regarding the role of the World Health Organization in the prevention and management of an influenza pandemic. This was followed by a session addressing the state and local perspectives on pandemic planning, which was chaired by Michael Osterholm, University of Minnesota. The session was opened by Kathleen Gensheimer, State Epidemiologist, Maine Department of Health and Human Services, who gave her perspective regarding planning for an influenza pandemic. A subsequent panel discussion highlighted the challenges faced at state and local levels. These include distribution of vaccines and antiviral drugs, coordination of a second dose of vaccine, and identifying when and for how long it is appropriate to close down schools and businesses. There was some concern that responsibility for too many decisions was being left to local officials, and a desire was expressed for further national guidance on issues such as rationing health care, use of masks, triage, and alternative standards of care.</p>
<p>The following session, chaired by Michael Tapper, Lenox Hill Hospital and New York University School of Medicine, focused further on local health care issues, with perspectives presented by Isaac Weisfuse, New York City Department of Health and Mental Hygiene; Lawrence Deyton, Department of Veterans Affairs; Dan Hanfling, Inova Health System; and Trish Perl, Johns Hopkins University. A number of areas of concern were identified during these presentations and in the subsequent period of discussion, including (1) the unintended consequences of actions such as school closures, which would leave a large number of children without nutrition; (2) the lack of surge capacity in the health care system, which would result in hospitals and laboratories being overwhelmed; (3) the lack of spare mechanical ventilators that would be required to support critically ill patients; (4) the impact on health care workers and the need for significant numbers of additional staff; (5) the impact of individuals who are infected but are not aware of it; and (6) the lack of rapid sensitive diagnostic tests for use in local facilities.</p>
<p>Henry Masur, IDSA and NIAID, reviewed the professional educational programs for pandemic influenza, presenting the efforts of organizations such as IDSA, highlighting some of the lessons learned from the response to Hurricane Katrina, and raising the issue of how professional society resources could be more effectively utilized by federal, state, and local authorities in the event of a pandemic.</p>
<p>The final session of the meeting consisted of a review of the recommendations generated at each of the break‐out sessions. After presentations made by each of the groups, the meeting participants were invited to make further suggestions or refinements. After the meeting, these recommendations were reviewed and further refined by the Planning Committee. The full details of these recommendations are presented in the final article in this supplement [<xref ref-type="bibr" rid="ref19">19</xref>].</p>
<p>This meeting will not be an isolated event but is a starting point for further preparedness regarding both seasonal and pandemic influenza. Clearly, implementation of these recommendations is beyond the ability of any individual organization and will require fostering collaboration between government agencies, international bodies, academic bodies, professional societies, and the business world. In addition, ongoing review and development of these plans and recommendations are mandatory to ensure that plans are refined in the event of new developments. The authors acknowledge that this initial set of recommendations is focused on the United States. However, there is an intention to broaden the scope of this document in the future, to include additional recommendations for an international audience.</p>
</body>
<back>
<ack>
<title>Acknowledgments</title>
<p>We thank John Fry for his assistance in writing this manuscript. The “Seasonal and Pandemic Influenza 2006: At the Crossroads, a Global Opportunity” conference was sponsored by the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the National Institute of Allergy and Infectious Diseases, and the Centers for Disease Control and Prevention. Funding for the conference was supplied through an unrestricted educational grant from Gilead Sciences, GlaxoSmithKline, Roche Laboratories, MedImmune, Sanofi Pasteur, Biota Holdings, and BioCryst Pharmaceuticals.</p>
<p>
<bold>
<italic>Supplement sponsorship. </italic>
</bold>This article was published as part of a supplement entitled “Seasonal and Pandemic Influenza: At the Crossroads, a Global Opportunity,” sponsored by the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the National Institute of Allergy and Infectious Diseases, and the Centers for Disease Control and Prevention.</p>
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<surname>Monto</surname>
<given-names>AS</given-names>
</name>
</person-group>
<article-title>Seasonal and pandemic influenza: recommendations for preparedness in the United States</article-title>
<source>J Infect Dis</source>
<year>2006</year>
<volume>194</volume>
<supplement>Suppl 2</supplement>
<fpage>S155</fpage>
<lpage>61</lpage>
<comment>(in this supplement)</comment>
</nlm-citation>
</ref>
</ref-list>
<fn-group>
<fn>
<p>Presented in part: Seasonal and Pandemic Influenza 2006: At the Crossroads, a Global Opportunity, Washington, DC, 1–2 February 2006 (for a list of sponsors and funding, see the Acknowledgments). The authors were co‐chairs of the independent committee that planned and coordinated the conference.</p>
<p>Potential conflicts of interest: A.S.M. has received grant support from Roche and Sanofi Pasteur and the National Institutes of Health (grant U01 AI057853) and has served as an ad hoc consultant to Roche, MedImmune, and Chiron. R.J.W. is on the Scientific Advisory Board for Gilead Sciences and is a member of the GlaxoSmithKline and Novartis Speakers Bureaus.</p>
<p>Financial support: supplement sponsorship is detailed in the Acknowledgments.</p>
</fn>
</fn-group>
</back>
</article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo><title>Seasonal and Pandemic Influenza Preparedness: A Global Threat</title></titleInfo><titleInfo type="alternative" contentType="CDATA"><title>Seasonal and Pandemic Influenza Preparedness: A Global Threat</title></titleInfo><name type="personal"><namePart type="given">Richard J. </namePart><namePart type="family">Whitley</namePart><affiliation>Departments of Pediatrics, Microbiology, Medicine, and Neurosurgery and Center for Biodefense and Emerging Infections, University of Alabama at Birmingham, Birmingham</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Arnold S. </namePart><namePart type="family">Monto</namePart><affiliation>Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="article" displayLabel="other" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-6N5SZHKN-D">article</genre><originInfo><publisher>University of Chicago Press</publisher><dateIssued encoding="w3cdtf">2006-11-01</dateIssued><copyrightDate encoding="w3cdtf">2006</copyrightDate></originInfo><abstract>The increase in the incidence of avian influenza worldwide in both poultry and humans introduces the potential for another influenza A pandemic that could pose a significant threat to both human health and the global economy. The impact of the next influenza pandemic will be influenced, in part, by how well the medical, government, business, and lay communities are prepared. Despite the additional tools and resources that have become available since prior epidemics, there are limits to the quantity of antiviral drugs that can be manufactured and concerns over the current vaccine production systems. Despite these challenges, there is an opportunity to take action before the emergence of a pandemic influenza strain and, possibly, to prevent its spread or at least mitigate its impact on the world. In February 2006, a group of representatives from federal, state, and local governments; professional bodies; academia; and the pharmaceutical industry met to review the current state of preparedness in the United States for a potential influenza pandemic and its relationship to seasonal influenza. 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Accessed 24 August 2006</note></relatedItem><relatedItem type="references" displayLabel="b19"><titleInfo><title>Seasonal and pandemic influenza: recommendations for preparedness in the United States</title></titleInfo><name type="personal"><namePart type="given">RJ</namePart><namePart type="family">Whitley</namePart></name><name type="personal"><namePart type="given">J</namePart><namePart type="family">Bartlett</namePart></name><name type="personal"><namePart type="given">FG</namePart><namePart type="family">Hayden</namePart></name><name type="personal"><namePart type="given">AT</namePart><namePart type="family">Pavia</namePart></name><name type="personal"><namePart type="given">M</namePart><namePart type="family">Tapper</namePart></name><name type="personal"><namePart type="given">AS</namePart><namePart type="family">Monto</namePart></name><genre>journal</genre><note>(in this supplement)</note><note>Whitley RJ Bartlett J Hayden FG Pavia AT Tapper M Monto AS Seasonal and pandemic influenza: recommendations for preparedness in the United States J Infect Dis 2006 194 Suppl 2 S155 61 (in this supplement)</note><relatedItem type="host"><titleInfo><title>J Infect Dis</title></titleInfo><part><date>2006</date><detail type="volume"><caption>vol.</caption><number>194</number></detail><extent unit="pages"><start>S155</start><end>61</end></extent></part></relatedItem></relatedItem><identifier type="istex">8A3B3B439A299B2223144B0CF561C624534FC1C9</identifier><identifier type="ark">ark:/67375/HXZ-5ZLMVT72-V</identifier><identifier type="DOI">10.1086/507562</identifier><accessCondition type="use and reproduction" contentType="copyright">© 2006 by the Infectious Diseases Society of America. 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