W John Paget ¹ and Jean-François Aguilera ^2,3 on behalf of the European Influenza Surveillance Scheme (EISS)*

1 European Influenza Surveillance Scheme coordination centre, Netherlands Institute for Health Services Research (Nivel), Utrecht, Netherlands
2 Public Health Laboratory Service, Communicable Disease Surveillance Centre, London, England
3 European Programme for Intervention Epidemiology Training (EPIET)

The World Health Organization strongly recommends that all countries prepare in advance multidisciplinary pandemic plans to prevent and control the next influenza pandemic. We carried out a survey of influenza surveil-lance methods among members of the European Influenza Surveillance Schemes, EISS, which included a set of questions on pandemic planning. All but one of the countries have a pandemic plan or are in the process of producing one. A coordination of these different national plans at a European level would probably contribute to their improved impact and efficiency. 

Introduction

Influenza epidemics are associated with increased general practice consultations, hospital admissions, and excess deaths (1). Their socioeconomic burden must also be considered as influenza epidemics result in an increased number of days lost because of absence from work and may cause the disruption of health and other services. In the 20th century, major worldwide influenza epidemics – pandemics – occurred in 1918-9, 1957-8, and 1968-9. It is estimated that, by the end of winter 1918-9, 2 billion people in the world had become infected with influenza, and between 20 million and 40 million people died from influenza (2). The total number of deaths in Europe during the 1918-9 pandemic was estimated to be around 2.3 million (3).

The World Health Organization (WHO) strongly recommends that all countries establish multidisciplinary national pandemic planning committees, responsible for developing strategies appropriate for their countries in advance of the next influenza pandemic (4). The United States established its first pandemic plan in 1978 (5), and the first country to do so in Europe was the United Kingdom in 1993 (6). Under WHO guidance (4), other countries in Europe established, or are in the process of establishing, pandemic plans.

The aims of pandemic planning are (2):

1. To recognise promptly the emergence of a potential pandemic strain of virus and monitor its course;

2. To establish a formal mechanism to declare and manage

a pandemic;

3. To reduce morbidity, mortality, and hospital admissions from influenza illness;

4. To be able to cope if necessary with large numbers of people who are ill and dying, both in the community and in hospital;

5. To ensure that essential services are maintained and reduce the disruption of normal daily life; and

6. To provide appropriate, timely, authoritative, and up to date information for all those who require it, including health-care and other professionals, managers of public or private institutions, military, police, shops, the public, and the media, at all stages of the pandemic.

This paper presents the results of an inventory on influenza pandemic planning in Europe carried out among countries that are members of the European Influenza Surveillance Scheme (EISS). The results are considered within the context of each individual country, and the coordination of pandemic planning at a European level is then discussed.

Methods

In November 2000, we sent a questionnaire to all EISS members concerning the methods they used for the surveillance of influenza. The questionnaire was developed in collaboration with all of the EISS members and sent to 16 influenza surveillance networks in Belgium, the Czech Republic, Denmark, England, France, Germany, Ireland, Italy, the Netherlands, Portugal, Scotland, Slovenia, Spain, Sweden, Switzerland, and Wales. More than one person could complete the questionnaire (the coordinators of sentinel surveillance systems, national reference laboratories, and national communicable disease centres), and a contact person was responsible for collecting the different responses. By the end of January 2001, all EISS members had responded to the questionnaire.

The main objective of the survey was to make an inventory of methods used for the surveillance of influenza in Europe. The questionnaire (63 questions) included sections on the collection of clinical and virological data, indicators used to define an epidemic threshold, and the timeliness of reporting. In addition, there were sections on data available for action (ten questions) and preparations for an influenza pandemic (five questions). This paper only presents findings concerning national preparations for an influenza pandemic. They represent responses from those responsible for the national surveillance of influenza and not those directly responsible for the pandemic plans. Since the pandemic plans are national projects, we present the findings in terms of countries and not surveillance networks.

Results

All countries completed the questionnaire. Eight countries (50%) had pandemic plans that the authorities (e.g. health ministries) had rendered official (table 1). Seven countries (44%) had pandemic plans in preparation (advanced or draft plans) at the time of the survey. Slovenia was the only country that reported no pandemic plan.

Table 1. Pandemic planning in Europe, November 2000

*There is a vaccine manufacturer in Switzerland but influenza vaccines are no longer produced in Switzerland.

Planning at a regional level was reported in England and Scotland, two of the eight countries with a pandemic plan, and the Netherlands, one of the seven countries currently preparing a pandemic plan. Six countries reported having an influenza vaccine manufacturer (England, France, Germany, Italy, the Nether-lands, and Switzerland), although influenza vaccines are no longer produced in one of these countries (Switzerland). Six countries reported arrangements for the supply of an appropriate vaccine in the event of a pandemic. France, Ireland, Italy, Portugal, and Switzerland have no such arrangements.

Eleven countries reported that priority vaccination groups are identified in their pandemic plans, and in one country (Ireland) this question is under review. No priority groups have been identified in Italy. Countries with priority groups for vaccination generally listed the specific target population groups and, with the exception of the Czech Republic, had similar priority groups (table 2). Some countries provided groups that would be immunised in descending order of priority, according to vaccine availability (for example, the Netherlands and England).

Table 2: Priority groups for vaccination in the case of an influenza pandemic (countries which reported this information), November 2000

¹ Le plan pandémique est en phase avancée de préparation / Pandemic plan is in advanced preparation
² Le plan pandémique est en cours de préparation / Pandemic plan is in preparation
³ Une liste des groupes possibles existe, mais les niveaux de priorité n'ont pas encore été définis (à l'exception du personnel soignant). La liste finale, avec les niveaux de priorité spécifiques par groupes, sera établie dès que l'OMS signalera une alerte pandémique / A list of possible groups exists but the levels of priority have not yet been defined (with the exception of healthcare staff). The final list, including group-specific priority levels, will be established as soon as WHO issues a pandemic alert.

Discussion

Western Europe is in the process of preparing itself for an influenza pandemic. Our survey found that some countries in Europe are better prepared for an influenza pandemic than others: some countries have established pandemic plans whereas others are still in the process of developing them. Only one country reported that it did not have a pandemic plan.

Faced with a major influenza pandemic, Europe would need a coordinated response to adequately address the health threat to its population (7). In our survey, the comparatively small number of countries that declared having arrangements for vaccine supply could complicate the coordination at a national and European level. The WHO has stressed the necessity for countries to ensure in advance the availability of vaccines for a pandemic (4), and the absence of arrangements could be worsened by the fact that most European countries surveyed do not have a national vaccine manufacturer and would therefore have to rely on other countries for their vaccine supply. A coordinated distribution would also be needed for antiviral drugs as few or no antiviral drugs are produced in Europe (7).

Surprisingly, not all of the countries in our survey reported having a planned priority list of population groups that would be targeted for vaccination in the event of a pandemic. This is an important component of pandemic planning, as there would be a limited supply of influenza vaccines and it would be impossible to vaccinate the entire population (8). This point was stressed in a European meeting in Berlin in 1993 (8), and the 1999 WHO guidelines for national and regional planning state that the extent of the vaccination intervention must be planned in advance, depending on national resource availability (4).

An outbreak of influenza A(H5N1) – a new and highly virulent influenza strain that had a case fatality rate of 33% – in Hong Kong in 1997 has been used as a case study to evaluate the response of European Union member states to the potential threat of an influenza pandemic (9). The study found very dif-ferent levels of preparedness for a potential influenza pandemic in the member states and little evidence of information sharing between countries (9). The results of our inventory are consistent with these findings: we found different levels of preparedness and little evidence to suggest that European states have adopted a common set of guidelines to establish their pandemic plans.

Currently, Europe is probably not in the position to respond to an influenza pandemic in a coordinated manner. Progress is being made at a national level, but an initiative to introduce a European coordination is now needed. The establishment of a working group or task force, possibly under the auspices of the European Commission, including representatives from concerned parties (vaccine manufacturers, antiviral drugs manufacturers, national influenza coordinators, surveillance coordinators, WHO, EU, etc…), seems necessary. Particular attention needs to be paid to the availability of vaccines in Europe, priority groups for vaccination, the availability of antiviral drugs (including the creation of stockpiles in preparation for a pandemic (10) and the production of timely and authoritative information during a pandemic.

EISS Participants

1. Goddard NL, Joseph CA, Zambon M, Nunn M, Fleming DM, Watson JM. Influenza surveillance in England and Wales: October 1999 to May 2000. Commun Dis Pub Health 2000; 3(4): 261-6.

2. Leese J, Tamblyn SE. Pandemic planning. In: Textbook of influenza, Blackwell Science, London, 1998.

3. Patterson KD, Pyle GF. The geography and mortality of the 1918 influenza pandemic. Bull Hist Med 1991; 65: 4-21.

4. World Health Organization. Influenza pandemic plan. The role of WHO and guidelines for national and regional planning. Geneva: WHO, 1999. (WHO/CDS/CSR/EDC/99.1.)

5. Marwick C. Readiness is all: public health experts draft plan outlining pandemic influenza response. JAMA 1996; 275(3): 179-80.

6. Ward R, Fleming D, Oxford JS. Pandemic influenza: is Europe prepared? Eurohealth 1997; 3(3): 18-20.

7. Desenclos JC, Manigat R. The European Union faces up to the threat of a pandemic: meeting at the DGV on influenza A(H5N1) of the ad hoc group on communicable diseases, Luxembourg, 14 January 1998. Eurosurveillance 1998; 3(3): 25-6.

8. Chippaux I. Populations of persons who must be vaccinated with priority. Eur J Epidemiol 1994; 10: 511-2.

9. MacLehose L, Schaefer O, Camaroni I, Reintjes R, Fulop N, Brand H, et al. European response to the potential threat of the influenza A (H5N1) outbreak in Hong Kong 1997/1998. In Health inequalities in Europe, European Public Health Association Congress, December 2000. Congress abstract book, p. 93. Bialec, Nancy, France, 2000.

10. Das P. Flu experts fear countries are unprepared for a future epidemic. Lancet 2001; 357: 1419.