International pandemic influenza preparedness plans lack prioritization

One-third of countries engaged in pandemic influenza planning have not prioritized who should get vaccinations and antiviral medications, according to researchers from the Johns Hopkins Bloomberg School of Public Health and the Ben-Gurion University of the Negev, Israel.

The study authors performed the largest pandemic-plan review to date, a targeted review of 45 national pandemic influenza plans from developed and developing countries. The study is published in the October 2006 issue of the journal PLoS Medicine.

“Because of costs and the time delay of manufacturing strain-specific vaccines, critical medical resources are likely to be scarce in a pandemic and will require rationing. However, we learned that individual countries have not consistently prioritized population groups for vaccines and antivirals. No countries prioritized population groups to receive ventilators, face masks and other critical resources,” said Lori Uscher-Pines, lead author of the study and a doctoral candidate in the Bloomberg School of Public Health's Department of Health Policy and Management.

The study authors included 45 national pandemic influenza plans in their study–19 from developed and 26 from developing nations. In total, the plans would affect 3.8 billion individuals, or two-thirds of the world population. The study found that 28 countries prioritized individual population groups to receive vaccines in a pandemic; 22 prioritized groups to receive antiviral medications during a pandemic.

The failure to prioritize antivirals is an unexpected finding since they may be the first–and perhaps the only–pharmaceutical intervention available to many countries in a pandemic, the authors explain in the study.

Of the 28 nations that prioritized medical resources, health care workers were most frequently ranked at the top of vaccine and antiviral priority lists. After that, countries differed greatly on who should receive top priority–high-risk individuals, such as the elderly and children, or essential service workers, such as communications/telecommunications workers, fire fighters, key government decision makers and energy/power supply workers.

The authors also learned that some countries made children a top priority, despite mixed epidemiological support of this practice and a previous World Health Organization recommendation against it. None of these countries cited sociocultural values in reference to this prioritization decision.

“Prioritization can play a significant role in international preparedness against pandemic influenza. In the absence of explicit WHO guidelines, nations should be encouraged and supported in priority-setting based on individualized pandemic-impact estimates, and should be guided in balancing evidence and ethical considerations,” said Ran D. Balicer, MD, MPH, of the Ben-Gurion University, senior co-author of the study.