A historical overview of key milestones in US pandemic planning is provided in the . In 1977, a federal interagency working group on influenza was formed at the request of the deputy assistant secretary for health in the Department of Health, Education, and Welfare, partly in recognition of the need for greater cooperation across government “silos.” The interagency group included representatives from the Center for Disease Control (CDC; renamed Centers for Disease Control and Prevention in 1992), the National Institutes of Health, the Food and Drug Administration (FDA), and the Department of Defense. Under CDC leadership, the work group drafted the first US pandemic plan, which was released in 1978 and included recommendations for annual influenza immunization of persons at high risk, strengthening of surveillance, expanding research, and establishing a planning and policy mechanism (12
Timeline of selected key events in pandemic planning, United States, 1978–2008
The plan was revised in 1983 to include a new recommendation to develop means to distribute and use influenza antiviral drugs (R.A. Strikas, pers. comm.). Even before completion of the pandemic plan, participants of a 1977 conference on influenza, held by the secretary of the Department of Health, Education, and Welfare, recommended continued federal support for influenza vaccination, particularly to increase vaccination levels of persons at high risk, to improve pandemic preparedness. In addition, CDC implemented a federally funded seasonal influenza immunization program, which purchased 3.4 and 2.4 million vaccine doses for the 1978–79 and 1979–80 influenza seasons, respectively, of which ≈1 million and >1.4 million doses, respectively, were administered. Initial plans were to purchase 8–9 million doses of vaccine. However, budget constraints limited vaccine purchases and ended the program after 1980 (13
The next major event leading to further US pandemic planning was 1986 legislation creating the National Vaccine Program Office (NVPO), which was given a mandate to coordinate federal vaccine-related activities. At the Options for the Control of Influenza II meeting held in 1992, a consensus report identified the core components of pandemic preparedness: surveillance, vaccines, antiviral drugs, nonmedical/personal hygiene measures, communications, and enhanced annual seasonal influenza vaccination programs (15
). In 1993, NVPO formed the federal interagency Group on Influenza Pandemic Preparedness and Emergency Response (GrIPPE). The group, which included nonfederal consultants and representatives from CDC, FDA, the National Institutes of Health, and the Department of Defense, drafted a pandemic planning framework that was published in 1997 (16
) and updated by federal staff in 2002 (17
). The GrIPPE-initiated planning documents emphasized the need for enhancements to influenza surveillance, vaccine production and distribution, antiviral drugs, influenza research, and emergency preparedness. Perhaps the most consequential outcome of GrIPPE was the creation of a core group of public health experts dedicated to pandemic planning.
Global events helped accelerate interest in pandemic planning. In 1997, Hong Kong recorded the first outbreak of avian influenza A(H5N1) virus infections in humans. Virus was transmitted from infected chickens directly to humans, and 6 of 18 persons with confirmed infection died. In late 1997, >1.5 million chickens were culled throughout Hong Kong as part of successful efforts to stem the outbreak (18
). This event, combined with the 2003 reemergence of A(H5N1) virus, led to concerns that the next pandemic would be caused by spread of A(H5N1) virus through Asia into Africa and Europe.
In the United States, despite the crucial role of state and local authorities in implementing pandemic plans, a 1995 CSTE survey indicated that <60% of state health departments perceived the need for a state-specific plan (10
). Through a cooperative agreement between CDC and CSTE, a state and local planning effort was begun in the fall of 1995. The state Project Steering Committee included the GrIPPE co-chairs and representatives from CDC, NVPO, CSTE, and the Association of Public Health Laboratories.
A meeting of >40 state and local health officials convened in September 1996 in Atlanta and identified 4 “pillars” deemed most critical for state and local pandemic preparedness efforts: 1) surveillance, 2) vaccine delivery, 3) communication and coordination, and 4) emergency response. From this meeting and subsequent subgroup meetings dedicated to the 4 pillar areas, critical elements of draft state and local guidelines were developed by January 1997. Four states (Connecticut, Missouri, New Mexico, and New York) and 1 local area (East Windsor Township, New Jersey) were selected by the state Project Steering Committee—primarily on the basis of the identification of a key project leader within each jurisdiction—and funded to pilot test the draft guidelines; 1 additional state, Maine, volunteered to test the draft guidelines without CSTE support. These 5 states conducted pilot tests during February and March 1998 and submitted results to CSTE. Findings were discussed on April 7–8, 1998, at a meeting in Atlanta. The major outcomes from pilot testing were the following recommendations: 1) a fifth pillar area, guidance for use of antiviral drugs, should be added to the guide; 2) the format of the guidelines should be more in concert with the national plan (18
); and 3) all states should receive the revised guidelines to enable development of state-specific plans (R.A. Strikas, pers. comm.). These 3 issues were discussed at the Association of State and Territorial Health Officials/NACCHO annual meeting in September 1998 and incorporated into the state and local pandemic influenza planning guidelines (R.A. Strikas, pers. comm.), which were then further revised. California, Maryland, Minnesota, and South Carolina were funded through CSTE to develop state plans and submitted their model plans in April 2000.
A national pandemic influenza steering committee was subsequently formed; it was comprised of immunization program managers, emergency preparedness personnel, and representatives from CDC, CSTE, NACCHO, and the Association of Public Health Laboratories (19
). A national steering committee was a logical extension as the planning process moved from a federal to a national effort.
In 2000, federal funding increased the number of states engaged in pandemic plan development. Florida, Indiana, Massachusetts, New Hampshire, and New Jersey were funded to complete plans by March 2001. In January 2001, Kansas, Washington, Nebraska, Connecticut, and New York were funded to develop plans by March 2002 (11
). Throughout this process, all states received the same nominal level of funding support, which was typically used to convene a statewide stakeholders meeting. Elements critical to the planning process included technical support provided by the national steering committee and the identification of a key public health professional within each state who assumed responsibility for leading and coordinating planning efforts. Arkansas, Arizona, and Oregon concurrently developed plans of their own accord; West Virginia, Tennessee (1999), and Pennsylvania (1999) had already developed plans. Ultimately, funds were sought for every state to develop a plan.
At this early stage in the planning process, the importance of disseminating information to the broader public health community was recognized. On February 25, 1999, and July 13, 2000, CDC presented satellite videoconferences on influenza pandemic preparedness for states and local areas, which were viewed by >7,000 and ≈6,000 participants, respectively. State and local public health staff engaged in development of pandemic plans participated in the broadcasts. At a meeting of state and local planners sponsored by CSTE and CDC in Atlanta on September 12–13, 2000, detailed discussions were held regarding 1) a scenario of how an influenza pandemic might affect states in 2001; 2) how states should enhance surveillance; 3) how vaccination priorities should be determined, and 4) other national and federal pandemic planning issues, such as infection control, patient triage, and antiviral drug usage (R.A. Strikas, pers. comm.).
After the September 11, 2001, terrorist attacks on the United States, public health preparedness emerged as a priority of the federal government. In 2001, bioterrorism emergency funding support was provided to all states to assist in the nation’s response to the anthrax attacks. The 2003 reemergence of avian influenza A(H5N1) infections in humans fundamentally altered the scale of pandemic preparedness. As the A(H5N1) virus spread to more countries in East and Southeast Asia during 2004–2005, concern grew among senior policymakers and public health experts that the world was on the verge of an influenza pandemic. A(H5N1) infection in humans primarily resulted from exposure to ill poultry and had a case–fatality rate of ≈60%. Substantial federal funding was provided for federal-level planning, procurement of countermeasures (e.g., vaccines and antiviral drugs), development of countermeasures, and state and local pandemic preparedness efforts (20
). State health departments eventually received $550 million to prepare for an influenza pandemic. Additional high-level policy engagement by the US federal government included the National Strategy for Pandemic Influenza, which was announced in November 2005 (21
), and the White House’s National Implementation Plan, which was published in May 2006 and addressed federal planning and response strategies: international transport and border control; protection of human and animal health; and security and continuity of operations issues (22
In 2006, the Biomedical Advanced Research and Development Authority (BARDA) was established within the Department of Health and Human Services in response to the growing need for a centralized effort to coordinate research, development, and procurement of countermeasures against potential natural or intentional public health emergencies (23
). BARDA preparations for a possible A(H5N1) pandemic included development of a stockpile of influenza vaccines produced by using strains circulating in poultry and wild birds in Asia (24
). In addition, the US government began to purchase influenza antiviral medications for the Strategic National Stockpile sufficient to treat 25% of the US population. Additional investments were initiated to procure ventilators and personal protective equipment, such as respirators.
The US government also initiated an advanced development agenda for vaccines, therapeutics, and diagnostics. BARDA co-invested with industry to modernize vaccine production methods, with the 5-year aim of creating the capacity to produce sufficient vaccine to protect the entire US population within 6 months of the onset of an influenza pandemic (22
). The US government invested in modernizing diagnostic technologies for public health laboratories. In September 2008, FDA approved specific PCR tests for a panel of influenza diagnostics to be used in CDC reference laboratories in the United States and Department of Defense laboratories around the world. This diagnostic test panel will detect and identify A(H5N1) infections and distinguish novel influenza virus infection from infection with seasonal A, B, and A(H1) and A(H3) influenza viruses. BARDA and CDC awarded contracts in November 2006 for development and evaluation of clinical point-of-care rapid diagnostics to identify seasonal influenza viruses and A(H5N1) viruses (25
Beginning with its first published pandemic plan in 1999 (26
), the World Health Organization globally promoted pandemic planning among member states, with continued planning efforts thereafter (27
). The International Partnership on Avian and Pandemic Influenza was formed to coordinate support for developing countries’ efforts to control the spread of A(H5N1) virus and to prepare for an influenza pandemic. This international body convened a series of meetings beginning in January 2006; these efforts generated hundreds of millions of dollars in pledges to support global pandemic preparedness and promoted a level of visibility and readiness that would not otherwise have been possible. In addition to direct financial assistance, the US government provided technical assistance to help countries develop capacities for rapid response, laboratory diagnosis, and surveillance.
The federal government recognized that the foundation for domestic pandemic response rests with state and local governments; thus, the 2005 Department of Health and Human Services strategy and the White House strategy and implementation plan called for major efforts in planning, exercising, and refining state and local preparedness. The 2006 Pandemic and All-Hazards Preparedness Act called for a review of comprehensive state pandemic preparedness plans. The federal government reviewed and scored the plans and released the results to the public in January 2009 (28
); preparedness levels varied across states and across the domains that were scored. In 2008, as part of its local health profile survey, NACCHO queried local health departments about emergency preparedness and planning activities they had undertaken during the past year (29
): 89% of 2,332 responding health departments said they had developed or updated pandemic influenza preparedness plans, and 86% said they had participated in tabletop drills or exercises. In addition, 76% had updated their written response plan on the basis of a postexercise after-action report, 72% had participated in a functional drill, and 49% had participated in a full-scale drill or exercise. A total of 68% of local health departments had reviewed existing state legal authorities for isolation and quarantine, and 46% had assessed the emergency preparedness competencies of staff. Only 1% of local health departments did none of the above.