Knowing pandemics

BackgroundIn view of ongoing pandemic threats such as the recent human cases of novel avian influenza A(H7N9) in China, it is important that all countries continue their preparedness efforts. Since 2006, Central American countries have received donor funding and technical assistance from the U.S. Centers for Disease Control and Prevention (CDC) to build and improve their capacity for influenza surveillance and pandemic preparedness. Our objective was to measure changes in pandemic preparedness in this region, and explore factors associated with these changes, using evaluations conducted between 2008 and 2012.MethodsEight Central American countries scored their pandemic preparedness across 12 capabilities in 2008, 2010 and 2012, using a standardized tool developed by CDC. Scores were calculated by country and capability and compared between evaluation years using the Student’s t-test and Wilcoxon Rank Sum test, respectively. Virological data reported to WHO were used to assess changes in testing capacity between evaluation years. Linear regression was used to examine associations between scores, donor funding, technical assistance and WHO reporting.ResultsAll countries improved their pandemic preparedness between 2008 and 2012 and seven made statistically significant gains (p < 0.05). Increases in median scores were observed for all 12 capabilities over the same period and were statistically significant for eight of these (p < 0.05): country planning, communications, routine influenza surveillance, national respiratory disease surveillance, outbreak response, resources for containment, community interventions and health sector response. We found a positive association between preparedness scores and cumulative funding between 2006 and 2011 (R2 = 0.5, p < 0.01). The number of specimens reported to WHO from participating countries increased significantly from 5,551 (2008) to 18,172 (2012) (p < 0.01).ConclusionsCentral America has made significant improvements in influenza pandemic preparedness between 2008 and 2012. U.S. donor funding and technical assistance provided to the region is likely to have contributed to the improvements we observed, although information on other sources of funding and support was unavailable to study. Gains are also likely the result of countries’ response to the 2009 influenza pandemic. Further research is required to determine the degree to which pandemic improvements are sustainable.

The threat of a human pandemic of influenza has prompted the development of national influenza pandemic preparedness plans over the last 4 years. Analyses have been carried out to assess preparedness in Europe, Asia and Africa. We assessed plans to evaluate the national strategic pandemic influenza preparedness in the countries of Latin America.Published national pandemic influenza preparedness plans from Latin American countries were evaluated against criteria drawn from the World Health Organization checklist. Plans were eligible for inclusion if formally published before 16 November 2007.Fifteen national plans were identified and retrieved from the 17 Latin American countries surveyed. Latin American countries demonstrated different degrees of preparedness, and that a high level of completeness of plans was correlated to a country's wealth to a certain extent. Plans were judged strong in addressing surveillance requirements, and provided appropriate communication strategies directed to the general public and health care personnel. However, gaps remained, including the organization of health care services’ response; planning and maintenance of essential services; and the provision of containment measures such as the stockpiling of necessary medical supplies including vaccines and antiviral medications. In addition, some inconsistencies and variations which may be important, such as in border control measures and the capacity to contain outbreaks, exist between country plans—issues that could result in confusion in the event of a pandemic. A number of plans remain developmental in nature and, as elsewhere, more emphasis should be placed on strengthening the operability of plans, and in testing them. Whilst taking account of resources constraints, plans should be further developed in a coherent manner with both regional and international imperatives.

Preparing to respond: Irish nurses' perceptions of preparedness for an influenza pandemic

Given the enormity of challenges involved in pandemic preparedness, design and implementation of effective and cost-effective public health policies is a major task that requires an integrated approach through engagement of scientific, administrative, and political communities across disciplines. There is ample evidence to suggest that modeling may be a viable approach to accomplish this task. To demonstrate the importance of synergism between modelers, public health experts, and policymakers, the University of Winnipeg organized an interdisciplinary workshop on the role of models in pandemic preparedness in September 2008. The workshop provided an excellent opportunity to present outcomes of recent scientific investigations that thoroughly evaluate the merits of preventive, therapeutic, and social distancing mechanisms, where community structures, priority groups, healthcare providers, and responders to emergency situations are given specific consideration. This interactive workshop was clearly successful in strengthening ties between various disciplines and creating venues for modelers to effectively communicate with policymakers. The importance of modeling in pandemic planning was highlighted, and key parameters that affect policy decision-making were identified. Core assumptions and important activities in Canadian pandemic plans at the provincial and national levels were also discussed. There will be little time for thoughtful and rapid reflection once an influenza pandemic strikes, and therefore preparedness is an unavoidable priority. Modeling and simulations are key resources in pandemic planning to map out interdependencies and support complex decision-making. Models are most effective in formulating strategies for managing public health crises when there are synergies between modelers, planners, and policymakers.

Children in child care centers represent an important population to consider in attempts to mitigate the spread of an influenza pandemic. This national survey, conducted in 2008 and 2016, assessed directors' reports of their child care centers' pandemic influenza preparation before and after the 2009 H1N1 novel influenza pandemic. This was a telephone-based survey of child care center directors randomly selected from a national database of licensed US child care centers who were queried about their preparedness for pandemic influenza. We grouped conceptually related items in 6 domains into indexes: general infection control, communication, seasonal influenza control, use of health consultants, quality of child care, and perceived barriers. These indexes, along with other center and director characteristics, were used to predict pandemic influenza preparedness. Among 1500 and 518 child care center directors surveyed in 2008 and 2016, respectively, preparation for pandemic influenza was low and did not improve. Only 7% of directors had taken concrete actions to prepare their centers. Having served as a center director during the 2009 influenza pandemic did not influence preparedness. After adjusting for covariates, child care health consultation and years of director's experience were positively associated with pandemic influenza preparation, whereas experiencing perceived barriers such as lack of knowing what to do in the event of pandemic influenza, was negatively associated with pandemic influenza preparedness. Pandemic influenza preparedness of child care center's directors needs to improve. Child care health consultants are likely to be important collaborators in addressing this problem.

Improved capacity for influenza surveillance in the WHO Eastern Mediterranean Region: Progress in a challenging setting

In Italy, the arrival of the 2009 pandemic influenza A(H1N1) virus triggered an integrated response that was mainly based on the 2006 National Pandemic Preparedness and Response Plan. In this article we analyse the main activities implemented for epidemiological surveillance, containment and mitigation of the pandemic influenza and the lesson learned from this experience. Overall, from week 31 (27 July – 2 August) of 2009 to week 17 (26 April – 2 May) of 2010, we estimate that there were approximately 5,600,000 cases of influenza-like illness (ILI) who received medical attention (with almost 2,000 laboratory-confirmed cases of pandemic influenza from May to October 2009). A total of 1,106 confirmed cases were admitted to hospital for serious conditions, of whom 532 were admitted to intensive care units. There were 260 reported deaths due to pandemic influenza. Approximately 870,000 first doses of the pandemic vaccine were administered, representing a vaccine coverage of 4% of the target population. One of the possible reasons for the low uptake of the pandemic vaccine in the target population could be the communication strategy adopted, for both the general population and healthcare workers, which turned out to be a major challenge. Active involvement of all health professionals (at local, regional and national level) in influenza pandemic preparedness and response should be encouraged in the future.

Influenza pandemic preparedness has focused on influenza virus H5 and H7 subtypes. However, it is not possible to predict with certainty which subtype of avian influenza virus will cause the next pandemic, and it is prudent to include other avian influenza virus subtypes in pandemic preparedness efforts. An H6 influenza virus was identified as a potential progenitor of the H5N1 viruses that emerged in Hong Kong in 1997. This virus continues to circulate in the bird population in Asia, and other H6 viruses are prevalent in birds in North America and Asia. The high rate of reassortment observed in influenza viruses and the prevalence of H6 viruses in birds suggest that this subtype may pose a pandemic risk. Very little is known about the replicative capacity, immunogenicity, and correlates of protective immunity for low-pathogenicity H6 influenza viruses in mammals. We evaluated the antigenic and genetic relatedness of 14 H6 influenza viruses and their abilities to replicate and induce a cross-reactive immune response in two animal models: mice and ferrets. The different H6 viruses replicated to different levels in the respiratory tracts of mice and ferrets, causing varied degrees of morbidity and mortality in these two models. H6 virus infection induced similar patterns of neutralizing antibody responses in mice and ferrets; however, species-specific differences in the cross-reactivity of the antibody responses were observed. Overall, cross-reactivity of neutralizing antibodies in H6 virus-infected mice did not correlate well with protection against heterologous wild-type H6 viruses. However, we have identified an H6 virus that induces protective immunity against viruses in the North American and Eurasian lineages.

COVID-19, leadership and lessons from physics.

Influenza A virus (IAV) has its natural reservoir in wild waterfowl, and new human IAVs often contain gene segments originating from avian IAVs. Treatment options for severe human influenza are principally restricted to neuraminidase inhibitors (NAIs), among which oseltamivir is stockpiled in preparedness for influenza pandemics. There is evolutionary pressure in the environment for resistance development to oseltamivir in avian IAVs, as the active metabolite oseltamivir carboxylate (OC) passes largely undegraded through sewage treatment to river water where waterfowl reside. In an in vivo mallard (Anas platyrhynchos) model, we tested if low-pathogenic avian influenza A(H7N9) virus might become resistant if the host was exposed to low levels of OC. Ducks were experimentally infected, and OC was added to their water, after which infection and transmission were maintained by successive introductions of uninfected birds. Daily fecal samples were tested for IAV excretion, genotype, and phenotype. Following mallard exposure to 2.5 μg/liter OC, the resistance-related neuraminidase (NA) I222T substitution, was detected within 2 days during the first passage and was found in all viruses sequenced from subsequently introduced ducks. The substitution generated 8-fold and 2.4-fold increases in the 50% inhibitory concentration (IC50) for OC (P < 0.001) and zanamivir (P = 0.016), respectively. We conclude that OC exposure of IAV hosts, in the same concentration magnitude as found in the environment, may result in amino acid substitutions, leading to changed antiviral sensitivity in an IAV subtype that can be highly pathogenic to humans. Prudent use of oseltamivir and resistance surveillance of IAVs in wild birds are warranted.

Stockpile of personal protective equipment in hospital settings: Preparedness for influenza pandemics

Editorial introductions

Editorial introductions

Editorial introductions.

Current Opinion in Pediatrics was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of pediatrics are divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Editor and Section Editors for this issue. EDITOR Philip A. PizzoPhilip A. PizzoPhilip A. Pizzo, MD, is the David and Susan Heckerman Professor and Founding Director of the Stanford Distinguished Careers Institute, USA. Dr Pizzo served as Dean of the Stanford School of Medicine from April 2001 to December 2012, where he was also the Carl and Elizabeth Naumann Professor of Pediatrics and of Microbiology and Immunology. Dr Pizzo has devoted much of his distinguished medical career to the diagnosis, management, prevention and treatment of childhood cancers and the infectious complications that occur in children whose immune systems are compromised by cancer and AIDS. He has also been a leader in academic medicine, championing programs and policies to improve the future of science, education and healthcare in the US and beyond. Dr Pizzo received his MD degree with Honors and Distinction in Research from the University of Rochester, USA in 1970, and completed an internship and residency at Children's Hospital Medical Center in Boston, USA, a teaching fellowship at Harvard Medical School, USA, and a clinical and research fellowship in pediatric oncology at the National Cancer Institute. Pizzo served as Head of the Institute's Infectious Disease Section, Chief of the NCI's Pediatric Department, and Acting Scientific Director for NCI's Division of Clinical Sciences between 1973 and 1996. Before joining Stanford in 2001, he was the Physician-in-Chief of Children's Hospital in Boston and Chair of the Department of Pediatrics at Harvard Medical School, where he was also the Thomas Morgan Rotch Professor of Pediatrics. Dr Pizzo is the author of more than 615 scientific articles and 16 books and monographs, including Principles and Practice of Pediatric Oncology, the Seventh Edition of which was published in 2015. He co-led a multidisciplinary committee for the Institute of Medicine (IOM) that resulted in the 2011 report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research; he also co-chaired the IOM report Dying in America: Improving Quality and Honoring Individual Preferences at the End of Life, which was published in 2015. Dr Pizzo has received numerous awards and honors, among them the Public Health Service Outstanding Service Medal in 1995, the Barbara Bohen Pfiefer Award for Scientific Excellence in 1991, the Elizabeth Kubler-Ross Award in 2008, the Ronald McDonald Charities Award of Excellence in 2009, and the John and Emma Bonica Public Service Award in 2013. He is the 2012 recipient of the John Howland Award, the highest honor for lifetime achievement bestowed by the American Pediatric Society. He has been elected to a number of prestigious organizations and societies, including the Association of American Physicians, the American Society of Clinical Investigation, the American Pediatric Society and the Institute of Medicine of the National Academy of Sciences, where he was also elected to the Governing Council. The IOM became the National Academy of Medicine in 2015. Dr Pizzo has served as Chair of the Association of Academic Health Centers, and Chair of the Council of Deans of the Association of American Medical Colleges, and was elected to the Board of Directors of the American Society for Clinical Oncology and the Infectious Diseases Society of America. He was President of the International Immunocompromised Host Society (1998–2011). He served on the Governing Board for the California Institute of Regenerative Medicine from 2004–2012. In 2009 he was elected to the Board of Trustees of the University of Rochester and the Board of Overseers of Koc University in Istanbul, Turkey. He is also a member of the Board of Directors of MRI Interventions and the Academic Advisory Council for Merritt Hawkins. In 2014 he was elected to the Board of Directors of the Ludwig Institute for Cancer Research and in 2015 he was elected to the Board of Directors of Global Blood Therapeutics. SECTION EDITORS Susan M. BlaneySusan M. BlaneySusan M. Blaney, MD, is a Professor and Executive Vice Chair for the Department of Pediatrics at Baylor College of Medicine, USA and the Director of Texas Children's Cancer Center at Texas Children's Hospital, USA. She is a board-certified pediatric oncologist whose career over the past 25 years has focused on the development of new agents and therapeutic strategies for children with recurrent or refractory cancer, particularly for those with malignancies of the central nervous system. She has extensive experience in clinical translational research and currently serves as the Vice Chair for the Children's Oncology Group (COG), an NCI-funded cooperative effort of 200 leading children's hospitals across North America. Dr Blaney has played a leadership role in the development of numerous early phase clinical trials of novel agents for the treatment of childhood cancer over the course of her career. Dr Blaney has also served as a mentor to many pediatric medical students, residents, fellows and faculty who are current or developing leaders in the field of pediatric oncology. Her influence in the field also extends to numerous advisory roles that she has held including an service on the National Cancer Institute's Clinical Trial Advisory Committee, as a member of the Investigational Drug Steering Committee for the National Cancer Institute, as a regular consultant for the FDA's Pediatric Oncology Drug Advisory Committee, as well as for other leading cancer organizations such as the American Association for Cancer Research and the American Society of Clinical Oncology. She also directs or has served on the scientific advisory boards for many not-for-profit foundations for childhood cancer research. Dr Blaney has published more than 200 articles in peer-reviewed journals, has authored numerous book chapters, and is an editor for Rudolph's Pediatrics as well as an Associate editor for Pizzo and Poplack's Principles and Practice of Pediatric Oncology, the leading textbook in the field of pediatric oncology. Daniel W. GreenDaniel W. GreenDr Daniel W. Green has been practicing at the Hospital for Special Surgery, USA since 1998 and is currently the Director of the Pediatric Sports Program for the Division of Pediatric Orthopedic Surgery. While he thoroughly enjoys caring for patients from birth into early adulthood, he has a special interest in pediatric sports injuries and pediatric knee injuries, in addition to pediatric orthopedic trauma. He provides emergency treatment for pediatric fractures and other orthopedic emergencies at New York Presbyterian Hospital-Manhattan, USA and the Hospital for Special Surgery. His focus is to provide the finest, most advanced orthopedic care available and is devoted to advancing treatments in order to improve patient outcomes and the overall patient experience. His research focuses on pediatric knee surgery, cartilage repair and restoration, pediatric ACL surgery, pediatric growth plate surgery, pediatric fracture care, and osteogenesis imperfecta. He has extensively studied the surgical options for patellar dislocations, evaluating both conservative and surgical approaches to stabilizing the patella. He has also investigated surgical techniques for ACL reconstruction in the skeletally immature. Dr Green is a clinical professor of orthopedic surgery at the Weill Cornell Medical College, USA. Yvonne J. BrysonYvonne J. BrysonDr Yvonne J. Bryson is a Distinguished Professor and recent past Chief of Global Pediatrics Infectious Diseases at David Geffen School of Medicine at UCLA, Mattel Children's, USA. She is a world-renowned leader, researcher, virologist and clinician in the field of HIV pathogenesis, prevention, and treatment of maternal-fetal and pediatric HIV-1, and is an active member of the HIV CURE Scientific Committee of International Maternal Pediatric and Adolescent AIDS Clinical trials network (IMPAACT) and the Adolescent trials network for identification and treatment of HIV acute infection. She is past Chair of the NIH Network IMPAACT PMTCT Committee (Prevention of Mother-to-Child Transmission of HIV) as well as a previous past chair. She has served a national and international leadership role for the past 25 years in studies of prevention and treatment of pediatric HIV. She has served on the HIV Therapeutics Trans NIH panel to set the NIH agenda for the past eleven years. Dr Bryson was influential in the development of CDC and Public Health guidelines for the diagnosis and treatment of HIV-infected pregnant women and has been involved in the planning and execution of national cooperative studies of maternal-fetal HIV transmission. She has made significant contributions to the development of the original studies of the use of Zidovudine and Nevirapine for the prevention of perinatal HIV. She published studies of maternal risk factors for vertical transmission of HIV including viral load and autologous neutralizing antibody, as well as advances in the early diagnosis of HIV in newborns. Her research at UCLA has been funded by NIH for over twenty-five years. She has over 190 original peer-reviewed publications and is a sought-after lecturer and reviewer. She was founding advisor and one of the original health board advisors of the Elizabeth Glaser Pediatric AIDS Foundation, with co-founders Elizabeth Glazer, Susie Zeegan and Susan Delorentis, and colleagues Dr Richard Stiehm and Phil Pizzo. She participated and helped plan the EGPAF thinktanks, the Ariel Project, the Elizabeth Glazer Scientist Award, and fundraising strategies for the foundation and the role of NIH in promoting new investigators in the field. She also was involved in political activism in Washington DC and California with Elizabeth and cofounders to focus attention on children. Dr Bryson has served on numerous NIH study section reviews and panels. She had significant experience in global health issues related to reduction of maternal infant mortality and morbidity and meeting the millennium goals. Dr Bryson has had significant leadership and field experience setting up NIH funded clinical trials, laboratories and infrastructure in Brazil over the past 13 years. She has trained a large number of students and post-doctoral MD, PhD scholars and junior faculty who are now national and international leaders as academic faculty or public health professionals in the US and around the world. Dr Bryson is a strong advocate for mothers and children for the prevention and treatment of infectious disease and is now committed to the CURE for HIV. She still has active NIH RO1 grants for studies of HIV remission and cure in infants and children, collaboration on an infant maque monkey model, and most recently, studies in adolescents in Los Angeles and New Orleans. She is an expert in perinatal infections, pediatric infectious disease, antivirals herpes infections, and other viral, bacterial, and opportunistic infections, and serves as a pediatric infectious disease consultant. Henry H. BernsteinHenry H. BernsteinDr Bernstein is a Professor of Pediatrics at Hofstra Northwell School of Medicine in New York, USA. He taps into his extensive 32-year experience as a general pediatrician in private practice and in academia at urban, suburban, and rural children's hospitals to promote the health and wellbeing of children, their families, and their communities. His private, community-based primary care (generalist) experiences in combination with academic experiences have provided him with a value-added, translational science perspective, unique from many others in academia. This tacit knowledge enables him to fulfill a lifelong passion of communicating, educating, and translating science into clinical settings, educational venues, policy-making, and media interactions to advance the health of children. Research is consistently woven into the fabric of Dr Bernstein's clinical practice, which has served as a “laboratory” for his active studies. His research and quality improvement initiatives focus on issues important to Academic General Pediatrics and community-based practice, including immunizations, postpartum newborn discharge, childhood obesity, breastfeeding, health promotion, preventive health screening in primary care, technology, and medical education. His commitment, innovative spirit, and enthusiasm also encompass many facets of medical education along the continuum, from training and mentoring future physicians to fostering lifelong learning, to supporting the continuous professional development of practicing pediatricians. Hank is an ex-officio member of the American Academy of Pediatrics’ Committee on Infectious Diseases (Red Book Committee), Associate Editor of Red Book Online, and AAP liaison to the CDC Advisory Committee on Immunization Practices’ Influenza Workgroup, spearheading both seasonal and pandemic influenza preparedness and policy for children. In addition, he is Editor-in-Chief Emeritus of PediaLink, the AAP's online home for lifelong learning and chair of the interdisciplinary Bright Futures Health Promotion Workgroup, which has created a distinctive health promotion curriculum, videos, and a companion educational website (www.pediatricsinpractice.org). He regularly shares his knowledge and expertise by educating the public, writing for health information websites, and participating in media interviews on a variety of pediatric health care issues including immunization, diagnosis and treatment of common childhood infectious diseases and illnesses, and practical information for parents, teachers and caregivers. In the spirit of lifelong learning, Hank earned a masters in healthcare management at Harvard School of Public Health, USA, in 2013. He actively maintains his certification by the American Board of Pediatrics. He completed his residency training in pediatrics at St Christopher's Hospital for Children in Philadelphia, USA, after earning his medical degree from the University of Medicine and Dentistry of New Jersey - School of Osteopathic Medicine, USA. Hank and his wife, Sophie, have been married for 36 years and are extremely proud of their 31-year-old daughter, Lauren, and 26-year-old son, David.