. - Paper Answers

Requirements: Identify the question you decide to answer at the top of your post. Prompt responses should answer the question and elaborate in a meaningful way using 2 of the weekly class readings (250 words of original content). Do not quote the readings, paraphrase and cite them using APA style in text citations. You can only use ONE multimedia source for your minimum 2 sources each week. The readings must be from the current week. The more sources you use, the more convincing your argument. Include a reference list in APA style at the end of your post, does not count towards minimum word content.

Select ONE of the following:

1) Why is influenza such a complex virus to deal with? How do agencies deal with this challenge? What are the lessons learned from the H1N1 US experience?

2) Compare the Mitigation, Preparedness and Response actions of the H1N1 pandemic and the Coronavirus Pandemic in the US. Use class readings for the H1N1 and ONLY academic and official sources about the coronavirus. No news outlets or blogs or non academic sources allowed.

Commentar

CDC’s Evolving Approach to Emergency Respon

Stephen C. Redd and Thomas R. Friede

The Centers for Disease Control and Prevention (CDC) transformed its approach to preparing for and responding to

public health emergencies following the anthrax attacks of 2001. The Office of Public Health Preparedness and Re-

sponse, an organizational home for emergency response at CDC, was established, and 4 programs were created or greatly

expanded after the anthrax attacks: (1) an emergency management program, including an Emergency Operations Center;

(2) increased support of state and local health department efforts to prepare for emergencies; (3) a greatly enlarg

Strategic National Stockpile of medicines, vaccines, and medical equipment; and (4) a regulatory program to assure that

work done on the most dangerous pathogens and toxins is done as safely and securely as possible. Following these

changes, CDC led responses to 3 major public health emergencies: the 2009-10 H1N1 influenza pandemic, the 2014-1

Ebola epidemic in West Africa, and the ongoing Zika epidemic. This article reviews the programs of CDC’s Office of

Public Health Preparedness, the major responses, and how these responses have resulted in changes in CDC’s approach

to responding to public health emergencies

The Centers for Disease Control and Prevention(CDC) was established in 1946 with the primary
purpose of supporting state and local public health agen-
cies, particularly in responding to disasters and infectiou

disease outbreaks.1 The capacity to respond to health
emergencies in order to protect the public has remained an
essential function of CDC. Over the decades, disease out-
break investigations have evolved to include larger and
more complex events, and CDC’s role has remained that of
providing support to state and local health departmen

while sometimes taking a leadership or coordination role
with complex or interstate investigations. For international
investigations, CDC has worked with ministries of health
that requested assistance as well as with the World Health
Organization.

Within weeks of the 9/11 World Trade Center attack,
CDC responded to a biological attack with anthrax in-
volving numerous domestic jurisdictions. The anthrax at-
tack required CDC to provide the public with frequent
updates on the progress of the investigation. The volume of
information and the expectations of the public created a
need for CDC to operate at an unprecedented scale and
tempo.3 To meet the challenges identified in the response
to the anthrax attacks, CDC created a new organizational
unit and approach to respond to large, complex public
health emergencies, whether naturally occurring, inten-
tional, or accidental. CDC’s approach to emergency re-
sponse continues to evolv

In addition to the potential for bioterror attacks, such as
the anthrax attack, 2 global trends required that CDC

Stephen C. Redd, MD, is Director, Office of Public Health Preparedness and Response, and Thomas R. Frieden, MD, MPH, is CDC
Director, both at the Centers for Disease Control and Prevention, Atlanta, Georgia. The findings and conclusions in this report are
those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the
Department of Health and Human Services.

Health Security
Volume 15, Number 1, 2017 ª Mary Ann Liebert, Inc.
DOI: 10.1089/hs.2017.0006

develop an expanded capability to respond at speed and
scale to future emergencies.4 First, the speed and volume of
long-distance travel have increased substantially. Over the
past 75 years, the widespread availability of air travel has
reduced the time for intercontinental travel from weeks to
hours.5 Along with shorter travel times, the volume of in-
tercontinental travel has increased exponentially. With in-
creased and faster global travel, the opportunity for a person
infected with a pathogen to travel to another part of the
world within hours has become increasingly likely.6 Sec-
ond, global population increases concentrated in Africa, the
Indian subcontinent, and East Asia have resulted in a dra-
matic increase in the number of cities with populations over
10 million.7 Ease of travel and urbanization, particularly
the concentration of poverty in urban areas, is creating the
opportunity for an increasing number of large infectious
disease epidemics affecting multiple urban areas.

Technological advances in medicine and public health
have created new tools to diagnose and quickly respond to
public health emergencies. Rapid and specific diagnostic
methods, vastly improved communication systems, and
evolving therapeutic and vaccine technologies create oppor-
tunities to detect and respond to health emergencies that
were unimaginable in the past. Unfortunately, these same
scientific and technologic advances allow the possibility to
create more deadly or transmissible pathogens that could be
released, intentionally or not, into the community.8

In this article we describe how CDC’s emergency re-
sponse preparations and execution have evolved with these
changing realities and expectations, with a particular focus
on changes beginning with the 2009 H1N1 pandemic.

Creation of the Office of Public

Health Preparedness and Response

After the 2001 anthrax attacks, the nation readied itself
for additional bioterror attacks. Government policy-
makers and public health officials created lists of mi-
croorganisms and chemical and biological toxins that
could be used as terror agents. Government funding
created a scientific-medical-production enterprise to de-
velop medical countermeasures—diagnostics, vaccines,
and therapeutics—to address these threats.9

The concerns and activities following the 2001 attacks
were similar to those that led to the 1951 creation of the
CDC Epidemic Intelligence Service, a 2-year training
program in field epidemiology, as part of a response to fea

of an attack with bioweapons during the Cold War.1 In
2002 CDC created a new organization—the Office of
Terrorism Preparedness and Emergency Response, later the
Coordinating Office for Terrorism Preparedness and
Emergency Response, predecessors to the current Office of
Public Health Preparedness and Response (OPHPR)—
with responsibility for preparing for large-scale emergen-
cies, including terrorism attacks. The office combined

smaller existing programs: support of state and local emer-
gency preparedness activities, the Strategic National Stock-
pile, and the regulatory program for select agents and toxins.
In addition, the Bernie Marcus Foundation, through the
CDC Foundation, funded renovations and equipment pro-
curement for CDC’s first Emergency Operations Center.10

Each division or program in the Office of Public Health
Preparedness and Response has specific responsibilities to as-
sure that CDC and the nation’s public health system is as
ready as possible to respond to future health threats (Table 1).

Regulatory Program on Select
Agents and Toxins
The mission of the Division of Select Agents and Toxins
(DSAT) is to assure that work done with dangerous path-
ogens and toxins in the United States is done as safely and
securely as possible (Table 1). The Federal Select Agent
Program consists of CDC’s DSAT and the US Department
of Agriculture’s Agriculture Select Agent Services Program.
Examples of select agents and toxins include the organisms
that cause anthrax, smallpox, and bubonic plague, as well as
the toxins ricin and botulinum neurotoxin. The progr

has an enabling mission: to assure that laboratories working
with select agents and toxins are able to do their work, to
create new knowledge to detect and respond to the threats
these pathogens and toxins could cause.11 As of November
2016, 279 laboratories were registered with the Federal
Select Agent Program (a decrease from a high of 336 lab-
oratories in 2006); 241 are registered with CDC’s Select
Agent and Toxins program and 38 with USDA’s Agri-
culture Select Agent Services Program. The CDC Select
Agent Program conducted 183 inspections in 2015, in-
cluding 72 unannounced inspections. Since its inception,
the program has denied 361 individuals access to select
agent laboratories through the Security Risk Assessment
process, which includes background investigations con-
ducted by the FBI.

The underlying challenge for the Federal Select Agent
Program is to balance competing priorities: (1) transpar-
ency to the public regarding the work and safety of the
laboratories registered with the program with the need to
protect information about the work from those that might
use such information to cause harm; (2) the regulatory
burden necessary to assure safety and security with fostering
an environment where the greatest scientific output is
possible; and (3) ultimately, assuring that the benefits of the
research justify its inherent risks. Even the most stringent
regulations cannot ensure that work with select agents and
toxins has zero risk; the program works to keep risk to the
minimum possible. Determining whether potential benefit
outweighs irreducible risks is complex and requires recon-
ciling numerous points of view.

Within the purview of the regulatory program, work
continues to improve in the following areas: (1

)

CDC’S EVOLVING APPROACH TO EMERGENCY RESPONSE

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Volume 15, Number 1, 2017 43

T
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1

.
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)
D
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(1

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44 Health Security

standardizing the inspection process through ongoing ef-
forts to improve training of inspectors, (2) improving the
science of biosafety and biosecurity, and (3) preparing for
biosafety and biosecurity risks of the future as a result of the
ongoing revolution in biology. These ongoing advances in
biology, including sequencing technologies and synthetic
biology, will make regulation and oversight in these areas
increasingly complex.

Emergency Operations at CDC
The Division of Emergency Operations manages CDC’s
Emergency Operations Center (EOC). The division’s mission is
to serve as a hub for communication, decision making, and
operations during emergency activations and to plan and train
for that function. When activated, the EOC serves as a tempo-
rary home for responders: scientists, communication specialists,
laboratory experts, and program managers from throughout
CDC who are deployed to respond to a specific emergency.
Since April 2009, the start of the H1N1 pandemic response,
CDC’s EOC has been activated over 91% of the time.12

By activating the EOC, CDC is able to perform many of the
functions it was not able to carry out during the 2001 anthrax
attack: managing a scalable system for travel and shipping of
equipment; recruiting and managing volunteer responders;
assuring a uniform system of deployment, including pre-
deployment, during deployment, and postdeployment activi-
ties; and providing software tools to visualize data, thereby
improving situational awareness. Although the health and
safety of deployed staff have always been of concern during
responses, the risks in the Ebola response led to the creation of a
Deployment Risk Mitigation Unit, which provided a focal
point for assuring a standard approach to safety and security
training for staff deployed in responses.

The division has taken on an important new activity:
training future incident commanders to lead CDC emer-
gency responses. The training is based on the real-world
experiences of large emergency responses in which CDC
has played a leading role. The intent is to provide a setting
for experiential learning in initiating a response, making
recommendations or decisions, and understanding the
needs of senior leaders during a large emergency response
and how to meet those needs.

Improving emergency response capacity globally is a sec-
ond, related function the division has undertaken as part of
the Global Health Security Agenda.13 CDC staff have led
emergency management training sessions in 40 countries
since 2014. This training has been put to use in 6 countries in
2015 and 2016, where ministry of health officials have acti-
vated their emergency operations centers 11 times to respond
to emergencies ranging from cholera and influenza outbreaks
to a train derailment. The training sessions and establishment
of emergency operations centers have resulted in earlier and
more effective responses to health emergencies. For those
emergencies that have the potential to spread, more effective
responses overseas protect Americans.

The Strategic National Stockpile
The Strategic National Stockpile’s purpose is to assure that
medical material needed to respond to a public health
emergency is available when, where, and in the quantity
needed to respond effectively. The stockpile’s inventory
includes vaccines, medications, chemical antidotes, ancillary
supplies needed to administer the countermeasures, me-
chanical ventilators, respirators, and other medical equip-
ment. The stockpile is a part of the Public Health Emergency
Medical Countermeasure Enterprise, an interagency com-
mittee led by the Department of Health and Human Ser-
vices’ (HHS) Assistant Secretary of Preparedness and
Response. The Public Health Emergency Management
Countermeasure Enterprise is charged with developing and
implementing the medical countermeasure strategy from
basic science, to product development, licensing, stock-
piling, distribution, and dispensing.14 As of November
2016, the stockpile contains material worth approximately
$7 billion, with annual funding of $575 million in 2016.

State and Local Readiness
The Division of State and Local Readiness is responsible for
assuring that state, local, tribal, and territorial health de-
partments are as ready as possible to respond to any health
emergency. The division manages the Public Health and
Emergency Preparedness cooperative agreement and pro-
gram, with annual funding of $660 million in 2016. This
cooperative agreement funds personnel in state and local
jurisdictions responsible for emergency response, planning
and exercising, and costs associated with small-scale re-
sponses (as a means of testing and improving systems that
would be needed in larger responses). Through this pro-
gram, state and local health departments have become part
of the emergency response structure in their jurisdictions.
This functionality includes the ability to rapidly mobilize
for an event that requires a large-scale response. The co-
operative agreement also supports the Laboratory Response
Network, which has the capability to detect pathogens that
might be used in a bioterror attack. The network has
proved adaptable in quickly adding diagnostic tests to de-
tect novel infectious diseases. Risk communication staff are
now available in state and local health departments to assure
that the public is informed about emerging health threats.

Experience in Responding

to Large-Scale Emergencies

In the years since the restructuring of emergency response
at CDC, public health emergencies have become in-
creasingly frequent. Since 2001, CDC has mounted
major responses to the SARS epidemic, Hurricane Ka-
trina, and more recently to the H1N1 influenza pan-
demic and Ebola and Zika virus epidemics (Table 2).15

REDD AND FRIEDEN

Volume 15, Number 1, 2017 45

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46 Health Security

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Volume 15, Number 1, 2017 47

Since 2009, CDC has activated its Emergency Opera-
tions Center 17 times (Tables 2 and 3). The median
duration of activation has been 85 days, and most have
been for infectious disease emergencies, frequently be-
ginning overseas but with the potential to spread to the
United States.15 Natural threats, rather than accidental or
intentional events, have predominated. Brief summaries
help to understand the results and lessons of these re-
sponses (Tables 2 and 3).

2009 H1N1 Pandemic
In mid-April 2009, CDC confirmed several human in-
fections with a novel H1N1 influenza virus. When cases
of severe respiratory illness in Mexico, including deaths,
were confirmed to be caused by the same virus, CDC
activated its Emergency Operations Center to the highest
response level.16 Within weeks, CDC had developed and
distributed a PCR diagnostic test to state health depart-
ment laboratories and influenza laboratories throughout
the world. The Biomedical Advanced Research and De-
velopment Authority (BARDA), operating in the HHS
Office of the Assistant Secretary of Health for Pre-
paredness and Response, worked with vaccine manufac-
turers to produce monovalent H1N1 vaccine. CDC
coordinated the distribution of 126.9 million doses of
monovalent H1N1 vaccine in 330,000 separate ship-
ments to more than 72,000 providers using the same
system that is used to distribute childhood vaccines
through the Vaccines for Children’s Program. Even-
tually, an estimated 81 million US residents were vacci-
nated against the pandemic strain of H1N1 influenza.17

CDC distributed 12 million treatment courses of anti-
viral drugs to treat influenza, approximately one-quarter
of the quantity stockpiled. To keep the public informed,
CDC conducted 39 press conferences and 21 telebrief-
ings and convened a pandemic influenza ‘‘boot camp’’ for
media in August 2009. CDC coordinated closely with
state and local health departments, other federal depart-
ments, and clinician organizations.

In a public opinion poll conducted in January 2010 re-
garding the federal government response to H1N1, 59% of
respondents rated the government response as good or ex-
cellent.18 Despite delayed production of vaccine, produced
and procured through contracts managed by BARDA,
CDC’s work to rapidly distribute vaccine as soon as it be-
came available and encourage use of antiviral medications
prevented at least 1 million cases of influenza, 18,000
hospitalizations, and 600 deaths.19,20 Public Health
Emergency Preparedness grantees were able to track cases of
H1N1 disease and mobilize planning and communication
efforts for the vaccination campaign because of investments
in these capabilities before the pandemic. Similarly, the
investments and training in CDC’s Emergency Operations
Center facilitated CDC’s uniform and prioritized approach
to the response.

The West African Ebola Epidemic
In March 2014, the global public health community was
alerted to an outbreak of Ebola in West Africa. First
identified in a remote area of Guinea bordering Liberia and
Sierra Leone, this was the first Ebola outbreak in West
Africa.21 Over the next 8 weeks, cases were identified in
Conakry, Guinea’s capital, and in Liberia. When measures
to identify suspect cases, isolate them to prevent transmis-
sion, and conduct laboratory testing to distinguish cases
from non-cases were implemented in March and April
2014, initial reports indicated a fall in incidence. The global
public health response largely demobilized, allowing
transmission to continue and leading to the world’s first
Ebola epidemic.21 The epidemic ultimately involved more
than 28,000 cases and more than 11,000 deaths in Guinea,
Sierra Leone, and Liberia—the 3 most highly affected
countries—with imported cases and limited transmission in
3 neighboring countries (Nigeria, Mali, and Senegal) and
more than a dozen medical evacuations and single genera-
tions of transmission in developed countries (Spain and the
United States). The outbreak was not brought fully under
control until March 2016.22

Severe as the epidemic was, rapid response to a cluster of
cases in Lagos, Nigeria, as well as effective work to end the
epidemic in West Africa prevented a catastrophe that could
have resulted in hundreds of thousands of deaths and wide-
spread dissemination of Ebola.23,24 Two cases were diagnosed
in the United States in returning travelers; Public Health
Emergency Preparedness grantees implemented a system to
track returning travelers from Guinea, Sierra Leone, and Li-
beria to quickly identify people with possible Ebola.

The epidemic serves as a vivid example of the conse-
quences of the ease of travel to and from any location in the
world and has spurred efforts to assure that every country has
the ability to detect and respond to disease outbreaks, the
goal of the Global Health Security Agenda.25 In addition to
local capability, the West Africa Ebola epidemic showed the
need for the global community to have the resources and
training in place to be able to support local response efforts
rapidly anywhere in the world when the need arises.

The Zika Epidemic
Even before the response to the Ebola epidemic was over, a
new disease had emerged requiring a global response. Zika
virus was little more than an arboviral curiosity until the fall
of 2015.26 The mosquito-transmitted virus was first iden-
tified in the late 1940s and was recognized as causing only
mild symptoms among the 1 in 5 human infections who
had any symptoms.26,27 In May 2015, a large outbreak was
reported in Brazil, similar epidemiologically to outbreaks
that had occurred in the Western Pacific in the preceding
decade.28 In November 2015, investigators in Brazil re-
ported an unexpected finding: an association between the
Zika virus epidemic and large numbers of babies born with

48 Health Security

CDC’S EVOLVING APPROACH TO EMERGENCY RESPONSE

microcephaly.29 Over the next several months, epidemio-
logic and pathologic evidence mounted that Zika virus was
the cause of this severe and previously extremely rare birth
defect.30 Protecting pregnant women from Zika virus in-
fection became a high priority. In addition to mosquito-
borne transmission and the association with birth defects,
the Zika virus epidemic differed from the Ebola epidemic
or H1N1 pandemic; in those earlier events, there was a
good understanding of the pathophysiology of the disease
and the effectiveness of control measures. In the case of
Zika virus, new knowledge continues to emerge. For ex-
ample, sexual transmission of Zika virus infection, though
documented previously, is not a characteristic known to be
shared with other arboviruses.31

The public health community in the continental United
States has little recent experience in controlling diseases
spread by Aedes mosquitoes. In addition, the eventual
public health burden of the epidemic has been challenging
to communicate because the disease is most often asymp-
tomatic and the severe consequences occur in babies,
months after infection of pregnant women.

The Zika virus epidemic has required an unprecedented
scientific, operational, and communication response.
Above all, the outbreak has shown the need to be able to
respond rapidly to an event that was unpredictable. The
response has required expertise in reproductive health,
vector biology, arbovirology, birth defects, sexually trans-
mitted diseases, laboratory test development, risk commu-
nication, and community engagement.

Major Observations from Responses

Several observations emerge from the experience over the
past 15 years using the CDC Emergency Operations
Center to respond to large, complex health events. The first
is that experience, whether acquired through plans and
exercises or through real-life response, pays dividends.
CDC’s response to the H1N1 pandemic was based on plans
and exercises to prepare for a severe influenza pandemic
emerging overseas.32 The rapid spread of H5N1 in wild
birds and poultry and the high mortality rate among hu-
man H5N1 cases in 2005 and 2006 provided an urgency to
this preparation.33 The work to plan and exercise for a
response to H5N1 was put to the test in the 2009 H1N1
influenza pandemic response. The plans and exercises to
prepare for a severe influenza pandemic established a
framework to understand and respond to the H1N1 pan-
demic, even though it was less severe than assumptions in
H5N1 planning scenarios. The involvement of state and
local public health and emergency response staff, many
federal agencies, and the private sector in planning for an
influenza pandemic also helped create a shared sense of
expectations for what was important in the response. The
Ebola and Zika responses benefited from the experience
gained during the H1N1 response.T

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Volume 15, Number 1, 2017 49

REDD AND FRIEDEN

The second observation is that public health systems
used routinely—everyday systems—form the basis for
emergency response; these systems are easier to scale than
systems not in everyday use. CDC adapted the Vaccines for
Children system, the system that ships more than half of all
childhood vaccines in the United States to providers, to
distribute monovalent H1N1 vaccine in the H1N1 pan-
demic. CDC also scaled up routine vaccine coverage sur-
veys to measure vaccine uptake weekly.34 In contrast, CDC
shipped antiviral drugs to state health departments, where
distribution plans differed widely. It remains unclear how
many patients with influenza received antiviral drugs from
the Strategic National Stockpile, but treatment of more
patients could have led to improved outcomes.

The third observation is that naturally occurring emer-
gencies are more frequent than bioterror attacks.35 This has
implications for ensuring that these more frequent re-
sponses, especially aspects of the response that need to be
improved, are used to plan for scenarios that require near
instantaneous response—such as low-likelihood, high-
consequence terrorist attacks. Large-scale natural disasters,
such as hurricanes, earthquakes, and tornadoes, will con-
tinue to occur, and these events require dedicated plans and
exercises. However, of the 3 major emergency responses in
the past 10 years, only the H1N1 influenza pandemic was
anticipated. Plans and the experience from exercises and
real-life events have to be adapted to respond to un-
predicted and unexpected emergencies.

The fourth major observation, evident in all large emergency
responses, is that the best responses adapt quickly to changing
circumstances. Unlike responses to natural disasters, in which
the course of events is somewhat predictable based on the
magnitude and location of the event, an effective response to a
public health emergency depends on rapid collection and
analysis of complex information and adaptive response based
on both epidemiologic trends and the documented impact of
program interventions. The ability to receive new, sometimes
unexpected, information and to change the objectives and
operations of the response is critical. Effective emergency re-
sponse is similar to effective public health action generally—
using data to improve performance rapidly. In both emergency
responses and in public health programs, policymakers need to
use all available facts and base decisions on scientifically valid
principles in order to optimally protect the public. As the full
extent of the Ebola epidemic in Liberia became apparent in the
summer of 2014, it became clear that resources were insuffi-
cient to implement all control measures widely. Efforts to es-
tablish clinical care for Ebola patients that met established
minimal standards and assuring safe and dignified burial for
people who died of Ebola took priority. Later, when action to
reduce transmission from burials and ill patients led to a de-
crease in cases, the emphasis shifted to rapid laboratory con-
firmation of cases, case isolation, and contract tracing.

Another example of this adaptation occurred during the
Ebola response following the domestic diagnosis of the first
case of Ebola virus disease and the subsequent confirmation

of the disease in 2 nurses who had cared for the initial
patient. Within days, CDC and DHS’s Customs and
Border Protection established procedures for screening at 5
airports where almost all travelers from the highly affected
countries entered the United States; CDC revised and re-
leased more specific guidance for personal protective
equipment and established a system to track travelers from
highly affected countries through their potential incubation
period.36 This tracking system used data collected during
airport screening and relied on state and local health de-
partments to make contact with travelers on a daily basis.

The fifth observation is that public communication is a
crucial response function. The need for a massive communi-
cation response—the need to respond to media and public
inquiries orders of magnitude greater than baseline—might
serve as the definition of a public health emergency. Ef-
fective risk communication cannot change bad outcomes or
decisions, but poor communication can lead to confusion
or lack of confidence and erosion of trust. Basic risk com-
mination principles include explaining what is known and
not known, what is being done to better understand the
situation and to intervene, and what individuals can do to
reduce their health risks.37 Setting realistic expectations is
key but may be difficult, depending on the situation. For
large emergencies, the media act as an amplifier of public
opinion, but also offer a platform to assure that people have
the most up-to-date information and are sufficiently in-
formed so that they can take action. This spotlight of at-
tention is linked with the next finding.

Sixth, large emergency responses require the ability to co-
ordinate response actions with many groups external to CDC.
CDC has a close relationship with state and local health de-
partments, but events frequently require a broader set of
partners. Providing timely and essential information, not only
to the public, but also to political leaders, is important in order
to avoid misunderstanding and unproductive work and to
identify areas where higher level intervention and assistance is
necessary. For example, during the Ebola response, the dis-
position of medical waste in the United States became a major
challenge. The Pipeline and Hazardous Materials Safety Ad-
ministration with the Department of Transportation has the
responsibility to regulate the transportation of medical waste.38

Within 48 hours of becoming involved, that office had issued
guidance to hospitals for contracts with medical waste trans-
porters on how to package and transport medical waste.

The final observation, perhaps also implicit in the defi-
nition of an emergency, is that a sense of urgency is inherent
in the event. Unlike public health programs that address
diseases in which the disease burden changes slowly, in an
emergency, events can and do change quickly. Response
leaders need to remember that every decision and im-
plementation action has to be accomplished within a
timeframe—often a very short timeframe. Understanding
that timeframe, when a decision or action has to be initiated
or completed, means that some decisions have to be made
with incomplete information or analysis.

CDC’S EVOLVING APPROACH TO EMERGENCY RESPONSE

50 Health Security

Recurrent Issues and Next Steps

Since 2001, CDC and the nation’s public health system
have continued to improve capabilities to respond to
emergencies. We have accomplished this improvement
through ongoing adjustments and refinements to internal
procedures and guidance to state and local health depart-
ments. Despite this progress, more work remains. The
current preparedness and response program represents ef-
forts to develop, improve, and sustain response capabilities.
Without sustained funding and leadership support, these
gains would quickly erode.

Resources are always scarce at the beginning of a large-
scale public health response, and at the outset the ultimate
scale of an emergency and response cannot be known. An
emergency public health response fund, set up along the
same lines as FEMA’s Disaster Relief Fund, could alleviate
much of this challenge. Such a response fund would include
established triggers, authorities, and reporting require-
ments. Because the scale of public health emergencies varies
by orders of magnitude, the resources needed to respond
also vary. Even with a response fund, large responses would
require a supplemental appropriation or replenishment to a
response fund to assure the best response, as is done to fund
response and recovery efforts to large-scale natural disasters.
Congress appropriated $2.1 billion to CDC for the 2009
H1N1 response and $1.8 billion for the Ebola response.
Even when funds are available, public health programs
(federal, state, and local) need to have expedited means of
contracting, hiring, and otherwise bringing available re-
sources to bear quickly. For CDC, emergency authorities to
distribute funds to states quickly would alleviate delays
associated with usual grant procedures.

Assuring that trained and experienced staff are available
is a further challenge. At CDC, a system of identifying
personnel needs and requesting staff with specific skills and
training has been established. Being able to recruit retired
staff and staff from other agencies and rapidly hire are
additional means of shoring up the workforce.

Every emergency CDC has responded to since 2001 has
been a natural event—either an emerging infectious disease
or natural disaster.39 Although the strategies and structures
put in place after the attacks of September 2001 have shown
their value in responding to these natural events, the orig-
inal motivation for these systems was to be better prepared
for bioterror attacks. By their nature, bioterror attacks will
be unannounced and will require responders to mobilize
countermeasures quickly; resources have to be in place
before the attack. A difficult policy decision for the future
requires balancing the resources devoted to everyday, nat-
urally occurring emergencies with resources to procure
countermeasures and plan and train for their distribution
and dispensing in a bioterror attack.

Emergency response—protecting the public from health
emergencies—has always been a bedrock function of public
health. The planning, training, staffing, and experience of

the past 15 years to prepare for and respond to public health
emergencies has expanded the scope of emergency pre-
paredness and response as a discipline in public health.

Acknowledgments

The authors thank the following people for their review,
editorial assistance, and advice: Dan M. Sosin, Jeffery
Bryant, Christine A. Kosmos, Samuel S. Edwin, Roberto
Henry, and Cara Rivera.

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32. Singleton CM, DeBastiani S, Rose D, Kahn EB. An analysis
of root cause identification and continuous quality im-

provement in public health H1N1 after-action reports. J
Public Health Manag Pract 2014;20(2):197-204.

33. World Health Organization. Cumulative number of confirmed
human cases for avian influenza A(H5N1) reported to WHO,
2003-2011. Geneva: World Health Organization; 2011. http://
www.who.int/influenza/human_animal_interface/EN_GIP_
LatestCumulativeNumberH5N1cases . Accessed January
12, 2017.

34. H1N1 Preparedness: An Overview of Vaccine Production and
Distribution: Hearing before the Committee on Energy and
Commerce, U.S. House of Representatives, November 18,
2009. https://www.gpo.gov/fdsys/pkg/CHRG-111hhrg74853/
pdf/CHRG-111hhrg74853 . Accessed January 12, 2017.

35. Centers for Disease Control and Prevention. CDC’s emer-
gency management program activities—worldwide, 2003-
2012. MMWR Morb Mortal Wkly Rep 2013;62(35):709-713.

36. Brown CM, Aranas AE, Benenson GA, et al. Airport exit and
entry screening for Ebola—August-November 10, 2014.
MMWR Morb Mortal Wkly Rep 2014;63(49):1163-1167.

37. Reynolds B, Crawford S, Deitch S, et al. Crisis and emer-
gency risk communication: pandemic influenza. Reynolds B,
Crawford S, Deitch S, et al., eds. Atlanta, GA: Centers for
Disease Control and Prevention; 2007.

38. Corse T, Thomas K, Broderick J, et al. Using Ebola as a lens
to examine medical waste sterilization. World Medical &
Health Policy 2015;7(4):402-411.

39. Centers for Disease Control and Prevention. Public Health
Preparedness: Strengthening CDC’s Emergency Response.
Atlanta, GA: Centers for Disease Control and Prevention;
2009. https://www.cdc.gov/phpr/publications/2009/phprep_
report_2009 . Accessed January 12, 2017.

40. Dawood FS, Iuliano AD, Reed C, et al. Estimated global
mortality associated with the first 12 months of 2009 pan-
demic influenza A H1N1 virus circulation: a modelling
study. Lancet Infect Dis 2012;12(9):687-695.

41. ArboNET. Centers for Disease Control and Prevention. 2016.
https://www.cdc.gov/westnile/resourcepages/survresources.
html. Accessed January 12, 2017.

42. Cronberg S, Cronberg E. First description of a small epi-
demic of poliomyelitis (1808) with an extensive case report
from 1807. J Hist Med Allied Sci 1965;20(1):33-37.

43. Global Polio Eradication Initiative. Polio this week as of 2
November 2016. Geneva: World Health Organization;
2016. http://polioeradication.org/polio-today/polio-now/
this-week/. Accessed January 12, 2017.

44. Centers for Disease Control and Prevention. Updates on
CDC’s polio eradication efforts. CDC website. Updated
March 18, 2016. http://www.cdc.gov/polio/updates/. Accessed
January 12, 2017.

Address correspondence to:
Stephen C. Redd, MD

Centers for Disease Control and Prevention
1600 Clifton Rd., MS A48

Atlanta, GA 30329

E-mail: scr1@cdc.gov

CDC’S EVOLVING APPROACH TO EMERGENCY RESPONSE

52 Health Security

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n engl j med 370;14 nejm.org april 3, 2014 1335

review article

global health

Pandemic Preparedness and Response —
Lessons from the H1N1 Influenza of 2009

Harvey V. Fineberg, M.D., Ph.D.

From the Institute of Medicine, Washing-
ton, DC. Address reprint requests to Dr.
Fineberg at the Institute of Medicine, 500
Fifth St. NW, Washington, DC 20001-2721,
or at fineberg@nas.edu.

This article was updated on December
22, 2014, at NEJM.org.

A number of viruses have pandemic potential. For example, the coronavirus responsible for the severe acute respiratory syndrome (SARS), which first appeared in southern China in November 2002, caused 8096
cases and 774 deaths in 26 countries before coming to a halt by July 2003 mainly
owing to isolation and quarantine.1 In terms of persistence, versatility, potential
severity, and speed of spread, however, few viruses rival influenza virus. Endemic
in a number of species, including humans, birds, and pigs, influenza virus causes
annual outbreaks punctuated by occasional worldwide pandemics, which are char-
acterized by sustained community spread in multiple regions of the world.

Beyond spread, the degree to which a pandemic is defined according to the
severity of the disease, or whether it may be simply described as often producing
many illnesses and deaths, remains ambiguous.2 At its worst, pandemic influenza
can be catastrophic: the great influenza pandemic of 1918–1919 is estimated to
have infected 500 million persons worldwide and to have killed 50 to 100 million
persons.3 In a typical year of seasonal outbreaks in the Northern and Southern
Hemispheres, influenza virus causes as many as 5 million cases of severe illness
in humans and 500,000 deaths.4

Over the past decade, sporadic cases of severe influenza and deaths in humans
have been caused by a number of avian influenza A viruses, including the H5N1
virus, first detected in 1997, and the H7N9 and H10N8 viruses, first reported in
2013. Such sporadic cases may be harbingers of a gathering pandemic, but the
likelihood is difficult to judge because it is not known how frequently similar zoo-
notic episodes occurred silently in the past, when surveillance was more limited,
and did not cause pandemics.

The most recent global pandemic was caused by the influenza A (H1N1) strain,
which was first detected in North America in 2009 (influenza A[H1N1]pdm09).
This event prompted the first activation of provisions under the 2005 Interna-
tional Health Regulations (IHR), which went into effect in 2007.5 Deliberations
that led to the 2005 IHR revisions were shaped by experience in the SARS outbreak
of 2003. The regulations delineate the responsibilities of individual countries and
the leadership role of the World Health Organization (WHO) in declaring and
managing a public health emergency of international concern.

The 2009 H1N1 pandemic presented a public health emergency of uncertain
scope, duration, and effect. The experience exposed strengths of the newly imple-
mented IHR as well as a number of deficiencies and defects, including vulnerabil-
ities in global, national, and local public health capacities; limitations of scien-
tific knowledge; difficulties in decision making under conditions of uncertainty;
complexities in international cooperation; and challenges in communication
among experts, policymakers, and the public.

The New England Journal of Medicine
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T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e

n engl j med 370;14 nejm.org april 3, 20141336

At the request of the WHO, an international
committee, which I chaired, reviewed the experi-
ence of the pandemic, with special attention
given to the function of the 2005 IHR and the
performance of the WHO.6 Since this was the
first time that the 2005 IHR was tested in a real-
world situation, it was inevitable that aspects of
the response to the series of outbreaks and sub-
sequent pandemic could have been improved.
Even though there were areas of outstanding
performance, such as the timely identification of
the pathogen, the development of sensitive and
specific diagnostics, and the creation of highly
interactive networks of public health officials, the
most fundamental conclusion of the committee,
which applies today, is not reassuring: “The world
is ill prepared to respond to a severe influenza
pandemic or to any similarly global, sustained
and threatening public-health emergency.”6

In this article, I focus on lessons from the
global response to the 2009 H1N1 pandemic. I
identify some of the key successes and short-
comings in the global response, on the basis of
the findings and conclusions of the review com-
mittee. The article concludes by pointing to steps
that can improve global readiness to deal with
future pandemics.

T I M E C O U R S E O F T H E 2 0 0 9 H 1 N1
PA N D E M I C

The first laboratory-confirmed cases of H1N1
influenza appeared in Mexico in February and
March of 2009. Cases that were detected in Cali-
fornia in late March were laboratory-confirmed
by mid-April. By the end of April, cases had been
reported in a number of U.S. states and in coun-
tries on various continents, including Canada,
Spain, the United Kingdom, New Zealand, Israel,
and Germany. On April 25, invoking its authority
under the 2005 IHR, the WHO declared a public
health emergency of international concern and
convened the emergency committee called for in
the regulations. The WHO also established a
dedicated internal group to coordinate the re-
sponse to the widening outbreaks. As of June 9,
2009, a total of 73 countries had reported more
than 26,000 laboratory-confirmed cases, and the
WHO declared on June 11 that the situation met
the criteria for phase 6 — that is, a full-fledged
pandemic (Table 1). By the time the pandemic
had waned, in August 2010, virtually all coun-
tries had reported laboratory-confirmed cases

(Fig. 1). An interactive graphic showing the time-
line of the 2009 H1N1 pandemic is available with
the full text of this article at NEJM.org.

Evidence from the first outbreak in Mexico
was alarming. An observational study of 899
hospitalized patients showed that 58 (6.5%) be-
came critically ill, and of those, 41% died.7 Dur-
ing the course of the pandemic, mortality among
children, young adults, and pregnant women
was much higher than in a typical inf luenza
season, and there was substantial variation in
severity among different regions of the world.8
In general, older adults fared relatively well, and
the total number of inf luenza-related deaths
worldwide (estimated ranges of 123,000 to
203,000 deaths8 and 105,700 to 395,600 deaths9)
proved similar to the number in a relatively mild
year of seasonal influenza. However, because of
the proportionately higher mortality among chil-
dren and young adults, the severity in terms of
years of life lost was greater than in a typical
year of seasonal influenza.10

2005 INTERNATIONAL HEALTH REGULATIONS

A number of provisions of the 2005 IHR proved
helpful in dealing with the 2009 H1N1 pandemic.
For example, the 2005 IHR established system-
atic approaches to surveillance, early-warning
systems, and response in member states and pro-
moted technical cooperation and sharing of logis-
tic support. Communication among countries and
the WHO was strengthened by the establishment
in each member state of National Focal Points
— national offices that would be responsible for
rapid collection and dissemination of emerging
data and guidance.

A static and potentially outdated list of notifi-
able diseases in previous regulations was replaced
by a more flexible flow diagram and decision
tool that identified conditions warranting public
health action. The 2005 IHR required, for the
first time, that member states implementing uni-
lateral measures that interfere with international
traffic and trade inform the WHO and that they
also provide a public health rationale and scien-
tific justification for those measures. Most im-
portant, the 2005 IHR formally assigned to the
WHO the authority to declare a public health
emergency of international concern and take a
leading role in the global response.

Despite these positive features, many member
states did not have in place the capacities called
for in the IHR, nor were they on a path to meet

An interactive
timeline of the

2009 H1N1
influenza
pandemic

is available
at NEJM.org

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Copyright © 2014 Massachusetts Medical Society. All rights reserved.

gl ob a l he a lth

n engl j med 370;14 nejm.org april 3, 2014 1337

their obligations by the 2012 deadline specified
in the document. Of the 194 eligible states, 128
(66%) responded to a WHO questionnaire on
their state of progress in 2011. Only 58% of the
responding member states reported having de-
veloped national plans to meet their core capac-
ity requirements, and only 10% claimed to have
fully established the capacities called for in
the IHR.6

The IHR fails to specify a basis for virus shar-
ing and vaccine sharing. This has been partially
ameliorated in a framework for pandemic-influ-
enza preparedness, adopted in 2011, that calls
on member states to encourage vaccine manu-
facturers to set aside a fraction of their pandem-
ic-vaccine production for donation and for dis-
counted pricing in developing countries.11 A
glaring gap in the IHR, which has not been
remedied, is its lack of enforceable sanctions.
For example, if a country fails to explain why it
restricted trade or travel, no financial penalties

or punitive trade sanctions are called for under
the 2005 IHR.

WORLD HEALTH ORGANIZATION

The WHO is an indispensable global resource for
leading and coordinating the response to a pan-
demic. In the 2009 H1N1 pandemic, the WHO
had many notable achievements. The organization
provided guidance to inform national influenza-
preparedness plans, which were in place in 74%
of countries at the time of the first outbreak in
North America, and helped countries monitor
their development of IHR core capacities. The
WHO Global Influenza Surveillance Network de-
tected, identified, and characterized the virus in
a timely manner and monitored the course of the
pandemic.

Within 48 hours after the activation of provi-
sions in the 2005 IHR, the WHO convened the
first meeting of the emergency committee of ex-
perts who would advise the WHO on the status

Table 1. World Health Organization (WHO) Pandemic-Phase Descriptions and Main Actions According to Phase.

Phase
Estimated Probability

of Pandemic Description
Main Actions in Affected

Countries

Main Actions in Nonaffected

Countries

1 Uncertain No animal influenza virus circulating
among animals has been reported
to cause infection in humans

Developing and implementing na-
tional pandemic-influenza pre-
paredness and response plans
and harmonizing them with
national emergency prepared-
ness and response plans

Same as in affected countries

2 Uncertain An animal influenza virus circulating
in domesticated or wild animals is
known to have caused infection in
humans and is therefore considered
a specific potential pandemic threat

Same as phase 1 Same as phase 1

3 Uncertain An animal or human–animal influenza
reassortant virus has caused spo-
radic cases or small clusters of dis-
ease in people but has not resulted
in a level of human-to-human
transmission sufficient to sustain
community-level outbreaks

Same as phase 1 Same as phase 1

4 Medium to high Human-to-human transmission of an
animal or human–animal influenza
reassortant virus that is able to sus-
tain community-level outbreaks
has been verified

Rapid containment Readiness for pandemic
response

5 High to certain The same identified virus has caused
sustained community-level out-
breaks in at least two countries in
one WHO region

Pandemic response: each country
implements the actions called
for in its national plans

Readiness for imminent
pandemic response

6 Pandemic in
progress

In addition to the criteria for phase 5,
the same virus has caused sus-
tained community-level outbreaks
in at least one other country in an-
other WHO region

Same as phase 5 Same as phase 5

T h e n e w e n g l a n d j o u r n a l o f m e d i c i n e

n engl j med 370;14 nejm.org april 3, 20141338

of the pandemic. Within 32 days after the WHO
had declared a public health emergency of inter-
national concern, the first candidate reassortant
vaccine viruses were developed, and vaccine seed

strains and control reagents were made available
within a few weeks. The Strategic Advisory Group
of Experts on immunization at the WHO provided
early recommendations on vaccine target groups

Extent of H1N1 Influenza Worldwide by Late April 2009 A

Extent of H1N1 Influenza by Late July 2010B

Number of cumulative positive H1N1 samples by country

0
1–24,999
25,000–49,999

50,000–74,999
75,000–99,999
≥100,000

Not available

Figure 1. H1N1 Inf luenza Pandemic.

Data are from the World Health Organization and http://fluNet.org.

gl ob a l he a lth

n engl j med 370;14 nejm.org april 3, 2014 1339

and dose. The WHO provided prompt and valu-
able field assistance to affected countries and
efficiently distributed more than 3 million cours-
es of antiviral drugs to 72 countries.

Against this backdrop of accomplishment,
the WHO confronted systemic difficulties and
made a number of missteps in the course of cop-
ing with the unfolding pandemic. Although the
WHO is the only global agency with legitimate
authority to lead the response to a pandemic, it is
burdened by a number of structural impediments.
First, the WHO is simultaneously the moral voice
for health in the world and the servant of its
member states, which authorize the overall pro-
gram and budget. National interests may con-
flict with a mandate to equitably protect the
health of every person on the planet. Second,
the budget of the WHO is incommensurate with
the scope of its responsibilities. Only approxi-
mately one quarter of the budget comes from
member-state assessments, and the rest depends
on specific project support from countries and
foundations. These budget realities and the per-
sonnel-management requirements inherent in be-
ing a United Nations agency constrain flexibility.

Third, the WHO is better designed to respond
to focal, short-term emergencies, such as investi-
gating an outbreak of hemorrhagic fever in sub-
Saharan Africa, or to manage a multiyear, steady-
state disease-control program than to mount and
sustain the kind of intensive, global response
that is required to deal with a rapidly unfolding
pandemic. Finally, the regional WHO offices are
autonomous, with member states of the region
responsible for the election of the regional direc-
tor, budget, and program. Although this system
allows for regional variation to suit local condi-
tions, the arrangement limits the ability of the
WHO to direct a globally coherent and coordi-
nated response during a global health emergency.

In anticipation of a possible pandemic before
2009, public health authorities had focused on
the threat of avian H5N1 influenza, and a signal
feature among recognized cases of H5N1 influ-
enza in humans was mortality exceeding 50%.12
Hence, it was expected that a newly emerging
pandemic virus would cause many deaths as well
as widespread disease, and the WHO said as
much on its website on pandemic preparedness
in advance of the 2009 H1N1 pandemic.

The prospects of a pandemic depend on the
transmissibility and virulence of the virus and
on the susceptibility of the population, which

may vary according to age and past exposure to
influenza viruses. Although a catastrophic pan-
demic probably depends on the emergence of a
new antigenic type of influenza virus, it does
not follow that every newly emerging influenza
virus will produce an especially severe burden of
influenza. For example, in the 40 years between
the mid-1930s and mid-1970s, the 5 years of
greatest excess mortality from influenza in the
United States were 1937, 1943, 1953, 1957, and
1960, but among these years, only 1957 was
marked by a new antigenic type (H2N2), and
1968 (the year when H3N2 appeared) did not
rank in the top five for severity.13 The expecta-
tion of a very severe pandemic was understand-
able in the context of H5N1 but not necessarily
for every new antigenic type.

Since the formal criteria for advancing from
one phase to the next higher phase in an emerg-
ing pandemic were based entirely on the extent
of spread and not on severity, this led to public
confusion about exactly what the WHO meant by
a pandemic. The WHO lacked a consistent, mea-
surable, and understandable depiction of the
severity of a pandemic. This situation was prob-
lematic because, regardless of the definition of
a pandemic, the decisions about response logi-
cally depend on both spread and severity. In
addition, the defining phase structure that was
based on spread was needlessly complex in that
it defined more stages than there were differen-
tiated responses, and the structure that seemed
suitable for planning proved less suited to op-
erational management.

The weekly requests by the WHO for data
were overwhelming for some countries, particu-
larly those with limited epidemiologic and labo-
ratory capacity. As the epidemic progressed, it
was not always evident to country officials that
the data they submitted were being analyzed and
used. Rather than focus on laboratory-confirmed
cases, a surveillance model that relied on syn-
dromic surveillance and selective, systematic viro-
logic testing might have been more revealing.14
Public health officials in some countries, such
as the U.K. Health Protection Agency, produced
weekly summaries that tracked domestic indica-
tors of influenza spread and severity while not-
ing pertinent global influenza activity, and this
approach could hold lessons for other countries
as well as for the WHO.15

When the WHO convened an expert group,
typically for a 1- or 2-day consultation, the prac-

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n engl j med 370;14 nejm.org april 3, 20141340

tice of the organization was not to disclose the
identities of the experts until the consultation
was concluded. Similarly, the WHO kept confi-
dential the identities of emergency-committee
members convened under the provisions of the
IHR, who would advise the WHO on the status
of the emerging pandemic. Although the intent
was to shield the experts from commercial or
political influences, the effect was to stoke sus-
picions about the potential links between indi-
vidual members of the emergency committee
and industry.16 Although the review committee
uncovered no evidence of inappropriate influence
on the emergency committee, the decision to
keep the members’ identities secret fostered sus-
picions about WHO decision making, which were
exacerbated by the failure to apply systematic
and open procedures for disclosing, recognizing,
and managing conflicts of interest. A practice of
confidentiality that was arguably fitting for a
1-day consultation was ill-suited to an advisory
function that extended over a period of months.

The failure to acknowledge legitimate criti-
cisms, such as inconsistent descriptions of the
meaning of a pandemic and the lack of timely
and open disclosure of potential conflicts of
interest, undermined the ability of the WHO to
respond effectively to unfounded criticisms. For
example, the WHO was wrongly accused of
rushing to declare phase 6, or a full-fledged
pandemic, because such action would trigger
vaccine orders sought by manufacturers. This
kind of suspicion proved hard for the WHO to
dispel, despite the fact that the declaration of
phase 6 was delayed until the sustained com-
munity spread in multiple countries in multiple
WHO regions was incontrovertible.

The WHO made a number of operational mis-
steps, including conferring with only a subset of
the emergency committee, rather than inviting
input from the full group, at a crucial point of
deciding to declare progression from phase 4 to
phase 5. Throughout the pandemic period, the
WHO generated an unmanageable number of
documents from multiple technical units within
the organization and lacked a cohesive, over-
arching set of procedures and priorities for pro-
ducing consistent and timely technical guidance.
In addition, after the declaration of phase 6, a
time when public awareness of the evolving pan-
demic was especially important, the WHO chose
to diminish proactive communication with the

media by discontinuing routine press conferences
on the pandemic.

The most serious operational shortcoming,
however, was the failure to distribute enough
inf luenza vaccine in a timely way. Ultimately,
78 million doses of vaccine were sent to 77 coun-
tries, but mainly long after they would have done
the most good. At its root, this reflected a short-
fall in global vaccine-production capacity and
technical delays due to reliance on viral egg
cultures for production, as well as distributional
problems. Among the latter were variation among
wealthier countries and manufacturers in their
willingness to donate vaccine, concerns about
liability, complex negotiations over legal agree-
ments with both manufacturers and recipient
countries, a lack of procedures to bypass national
regulatory requirements for imported vaccine,
and limited national and local capacities to trans-
port, store, and administer vaccines. Some re-
cipient countries thought that the WHO did not
adequately explain that the liability provisions
included in their recipient agreements were the
same as the provisions accepted by purchasing
countries.

L O O K I N G A H E A D

In light of these structural impediments and op-
erational deficiencies, the world was very fortu-
nate that the 2009 H1N1 influenza pandemic
was not more severe. On the basis of its analysis,
the review committee offered 15 recommenda-
tions to the WHO and the member states (Table 2).
The report and recommendations were endorsed
by the member states at the 64th World Health
Assembly in May 2011, and the relevant WHO
departments incorporated the recommendations
into their biennial work plans.17 Some recom-
mendations, such as improved protocols for vac-
cine sharing, have been carried out, some are
within the power of the WHO to implement, and
others depend on the actions and resources of
the member states, which have yet to be commit-
ted to this purpose.

Beyond institutional, political, and manage-
rial difficulties, the most fundamental con-
straints on pandemic preparedness are the lim-
its of scientific understanding and technical
capacity. Perhaps because only three or four in-
fluenza pandemics tend to occur each century,
at least in recent centuries, the annals of influ-

gl ob a l he a lth

n engl j med 370;14 nejm.org april 3, 2014 1341

enza are filled with overly confident predictions
based on insufficient evidence.18 Studies de-
signed to select for avian-origin viruses that can
be transmitted more readily than the original
virus in mammalian species (gain-of-function
studies) may arguably help predict the pandemic
potential of naturally occurring viruses but have
raised concerns about the possibilities of inten-
tional misuse and unintended consequences.19,20
In the current state of scientific knowledge,
however, no one can predict with confidence
which influenza virus will become dangerous to
human health and to what degree. The only way,
potentially, to reduce this uncertainty is through a
deeper biologic and epidemiologic understanding.

Disease detection, surveillance, and labora-
tory capacity are improving in many countries.
The new techniques of Web-based field reports
and analysis of Web-based search patterns can
yield valuable intelligence that can give the world
a head start on the next emerging pandemic.21

In addition to superior surveillance and agree-
ments on virus and vaccine sharing, the world
needs better antiviral agents and more effective
influenza vaccines, greater production capacity,
and faster throughput. One comprehensive as-
sessment showed that the effectiveness of cur-
rent influenza vaccines in practice is lower than
is typically asserted, especially among elderly
persons.22 The traditional methods of influenza-
vaccine production, which rely on egg cultures,
are often too slow to keep up with a first wave
of pandemic spread, and in total, the annual
capacity of influenza-vaccine production covers
less than one third of the global population.

In early 2013, the Food and Drug Administra-
tion approved the first trivalent influenza vac-
cine produced with the use of recombinant
technology,23 and other production methods are
under active research and development. At least
four lower-income countries have their own
influenza-vaccine manufacturing facilities, and
more are on the way. Most important, if research
could yield a universal (non–strain-specific),
long-lasting, safe, and effective vaccine against
inf luenza, the annual frenzy of action against
inf luenza would be transformed into a proac-
tive, long-term prevention program.24,25

In the meantime, influenza outbreaks and
pandemics will continue to challenge policy-
makers and public health leaders to make deci-
sions under conditions of stress and uncertainty.

Pandemics will challenge national authorities
and the WHO to function more efficiently and
effectively with insufficient resources. Prepara-
tion beyond planning, with advance protocols and
agreements, the commitment of ready reserves
of public health experts and a financial line of
credit, and the fulfillment of the IHR require-
ments can all help. Whenever the next influenza
pandemic arises, many more lives may be at risk.
By heeding the lessons from the 2009 H1N1
pandemic, the international community will be
able to cope more successfully the next time.

The views expressed in this article are those of the author and
do not necessarily represent the views of the Institute of Medicine.

Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.

Members of the World Health Organization committee for the
review of the 2009 H1N1 pandemic and 2005 International Health
Regulations, on whose work this article is largely based, include
Preben Aavitsland (Norway), Tjandra Y. Aditama (Indonesia), Sil-
via Bino (Albania), Eduardo Hage Carmo (Brazil), Martin Cetron
(United States), Omar El Menzhi (Morocco), Yuri Fedorov (Russia),
Andrew Forsyth (New Zealand), Claudia Gonzalez (Chile), Moham-
mad Mehdi Gouya (Iran), Amr Mohamed Kandeel (Egypt), Arlene
King (Canada), Abdulsalami Nasidi (Nigeria), Paul Odehouri-
Koudou (Ivory Coast), Nobuhiko Okabe (Japan), Mahmudur
Rahman (Bangladesh), Palliri Ravindran (India), José Ignacio

Table 2. Recommendations of the WHO Review Committee on the Functioning
of the 2005 International Health Regulations (IHR) in Relation to the 2009
H1N1 Influenza Pandemic.

Accelerate the implementation of the core capacities required by the IHR

Enhance the WHO Event Information Site*

Reinforce evidence-based decisions on international travel and trade

Ensure necessary authority and resources for all National Focal Points†

Strengthen the internal capacity of the WHO for sustained response

Improve practices for the appointment of an emergency committee

Revise pandemic-preparedness guidance

Develop and apply measures to assess the severity of a pandemic

Streamline the management of guidance documents

Develop and implement a strategic, organization-wide communications policy

Encourage advance agreements for vaccine distribution and delivery

Establish a more extensive public health reserve workforce globally

Create a contingency fund for public health emergencies

Reach an agreement on the sharing of viruses, access to vaccines, and other
benefits

Pursue a comprehensive influenza research and evaluation program

* The Event Information Site is a WHO website that, in the event of a pandemic,
would serve as an authoritative resource to disseminate reliable, up-to-date,
and readily accessible information related to the pandemic.

† National Focal Points are national offices that are responsible for the rapid
collection and dissemination of emerging data and guidance.

n engl j med 370;14 nejm.org april 3, 20141342

gl ob a l he a lth

Santos (Mexico), Palanitina Tupuimatagi Toelupe (Samoa), Patri-
cia Ann Troop (United Kingdom), Kumnuan Ungchusak (Thai-
land), Kuku Voyi (South Africa), Yu Wang (China), and Sam
Zaramba (Uganda). The committee secretariat was led by Nick
Drager and included Dominique Metais, Faith McLellan, Mary

Chamberland, Nadia Day, Alice Ghent, Sue Horsfall, Janet Kin-
caid, Phillip Lambach, Linda Larsson, Fabienne Maertens, Joan
Ntabadde, Les Olson, Magdalena Rabini, Sarah Ramsay, Mick
Reid, Chastine Rodriguez, Alexandra Rosado-Miguel, and Na-
tasha Shapovalova.

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Video lecture

Welcome to disasters from shock to recovery. The past disasters that we have studied in this class had mostly to do with atmospheric disturbances are natural processes. This week we’ll look into an entirely different hazard. Pandemic influenza are case study focuses on the response in the US during the 2009 H1N1 influenza pandemic. But let’s take a couple of steps back in time to understand how the Center for Disease Control prepare for the event in 2009. The first human case of H5 N1 or avian influenza was detected in China in 1997. At the time there was an alarm as to how it was transmitted and how to stop it spread.Scientists discovered that it wasn’t very efficient at at transmitting from person to person. And thus direct animal exposure was to be blamed for most infections. At the time avian influenza did not turn into our world wall pandemic but scientists and policymakers were willing to invest time money and effort to prepare for such an eventuality. H5 N1 made its appearance again in 20052006. Spreading rapidly not only in South East Asia but also in Africa Europe and the Middle East. Public health officials officials in the US were aware of the potential threat of this virus and we’re preparing for the worst think something like the great influenza pandemic of 1918 that cost nearly a 100 million deaths and 500 million infections worldwide. Us public health officials also use experiences from the Severe Acute Respiratory Syndrome. Sars outbreak of 2003 to prepare for the pandemic in 2009. This was a potential worldwide pandemic. So the World Health Organization on several member countries created international health regulations in 2005 as well. Officials were fearful and willing to prepare because of the uncertainty associated with the scope duration and effects of this kind of outbreaks. So a lot of the planning in the US and the world was based on the H5N1 outbreak the sars outbreak among other small ones. But H1 N1 in the US will bring its own challenges to the CDC. The H1N1 outbreak in the US was different than anything they had planned for before. The initial outbreak started in Mexico and rapidly arrive in the US. Most scenarios where a plan for overseas outbreaks that slowly spread. They had planned for a specific strings like i stronger strain of avian influenza or sars Influenza common but ever changing virus which makes Korean vaccines less effective. People will not take-the initial symptoms seriously. It’s just a call right. Other viruses like Ebola had much more noticeable an alarming symptoms.Finally H1N1 is efficiently transmitted from human to human but also from animals to humans because this was a type a string. So there was a higher chance of contamination and the virus could mutate easily. Think about a commons needs that reaches six feet away from the infected person. On April 2009 the first two cases of H1N1 where identify all thanks to good timing from the CDC who had just developed a testing kit that included this one string h one. The two children infected had initially tested positive for influenza type a but it wasn’t clear what strain. The CDC test came just in time but he brought more questions that identify strain was swine H1 type a but they couldn’t find a connection between patients and any contact with peaks or among themselves. With any Type a influenza the CDC was already on high alert launching investigations on warnings as more and more cases started to show up. The CDC immediately activated its emergency operation center and was quick to identify priority areas to be vaccinated while more vaccines were produced. They also provided guidelines that reduce chaos or more infections They had to act quickly with constantly flowing information whatever new information they had was communicated to keep local state and federal officials and other nations as well. By June 2009 H1N1 pandemic affecting 73 countries. The CDC in the US coordinate the distribution of almost 126.9 million doses of H1N1 vaccine manufacturer only weeks after the first cases. 81 million of those were for US citizens at risk. And the rest for foreign countries suffering outbreaks. Some of the most important lessons learn during the H1N1 pandemic are the following. This need to plan for more general outbreak scenarios. Partnerships between public health officials local state health departments school and businesses are crucial for speedy response. Preparedness pays off existence seasonal influenza surveillance systems were useful as they just needed to be scaled up for a larger event but the knowledge was there Surveillance systems help information gathering decision-making on forecasting. Pandemic exercises are a pain in the neck but they provide a helpful information with processes and procedures regardless of the type of the virus. Moving forward the CDC is also focusing on developing more efficient impact assessment frameworks that looks at measures of transmission and measures of severity. This means that the health officials will have these estimates available earlier than previous measures-and is designed to accept multiple inputs. Better ways to visualize data using military inspire mapping and communications in the flu view website. And management of data for better understanding and compiling of lessons learned.Even though the US has a well-funded and efficient systemH1N1 brought its own challenges and the people in charge of the emergency. We’re capable of using existing resources to service communities affected. Novel influenza strains keep scientists and public health officials on the move constantly updating and reviewing systems. But how do you think other countries Less resources may have fair. Could some of these practices be replicated abroad.

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