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Social inequality – a forgotten forgotten factor in pandemic influenza preparedness.

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Svenn-Erik Mamelund at OsloMet - Oslo Metropolitan University
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Abstract

Reducing social inequality in health is at the core of international health work, but does not form part of the discussionon international preparedness plans for pandemic influenza. This is surprising given that influenza pandemic mortality rates are highest among those with the lowest socioeconomic status. This is not conducive to achieving the international goals of reducing social inequality in health and ensuring good health for all by 2030.
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28.6.2017 | Social inequality – a forgotten factor in pandemic influenza preparedness | Tidsskrift for Den norske legeforening
Social inequality – a forgotten factor in pandemic
influenza preparedness
GLOBAL HELSE
SVENN-ERIK MAMELUND
E-post: Svenn-Erik.Mamelund@afi.hioa.no
Svenn-Erik Mamelund (born 1969), PhD and research professor at the Work Research Institute, Oslo and Akershus University College
of Applied Sciences. He was previously employed at the Norwegian Institute of Public Health, and has conducted research on
historical influenza pandemics, with a particular focus on the Spanish influenza.
The author has complete the ICMJE form and reports no conflicts of interest.
Reducing social inequality in health is at the core of international health work, but does not form part of the discussion
on international preparedness plans for pandemic influenza. This is surprising given that influenza pandemic mortality
rates are highest among those with the lowest socioeconomic status. This is not conducive to achieving the
international goals of reducing social inequality in health and ensuring good health for all by 2030.
The World Bank’s latest ‘Global Crisis Response Platform’ report claims that the most serious threats to human life and
economic security are climate change, conflicts and pandemics (1). In recent years, several infectious diseases, such as
Middle East respiratory syndrome coronavirus (MERS-CoV), Zika and Ebola, have been characterized as pandemic
threats.
The Ebola epidemic in West Africa killed more than 11 000 people in the period 2014–15, and exposed failings in the
global epidemic preparedness. In response, the Coalition for Epidemic Preparedness Innovations (CEPI) was formed
recently (2). The aim is to produce vaccines, initially against the three aforementioned viruses, and then to conquer new
local epidemic outbreaks. During the launch of CEPI at the World Economic Forum in January 2017, the head of CEPI, Bill
Gates, argued that the pandemic threat with the greatest potential to harm society and the economy was a new
influenza pandemic (3).
The World Bank suggests that the annual cost of a new, less serious pandemic is USD 570 billion, which represents 0.7% of
the global gross domestic product (GDP). A serious pandemic like the Spanish influenza of 1918–19 can cost as much as
5% of the global GDP, or almost USD 4 trillion (1). The Spanish influenza killed 50–100 million people (4); 5–10 times more
than the number who perished during World War I.
Influenza pandemics past and present
Influenza pandemics have occurred 3–4 times every century since the 16th century, and have not been linked to
fluctuations in the economy or conflicts (5). In the last century, in addition to the Spanish influenza, we also had the
Asian influenza in the period 1957–58 and the Hong Kong influenza from 1968 to 1970. The last pandemic, in 2009–10,
killed 200 000 people globally (6). The number of pandemic-related deaths per 1 000 inhabitants has fallen over time:
1918–19 (27– 54), 1957–1958 (0.7), 1968–1970 (0.3) and 2009–10 (0.03) (4–6).
Who will be most at risk in a new influenza pandemic? A natural answer is young children, the elderly and people who
are already sick, as is the case during the annual influenza epidemics. During pandemics, people who are already ill are
vulnerable, but it is young adults who are affected the most (6–8). What about the socioeconomically disadvantaged?
During the Spanish influenza pandemic, mortality rates differed considerably between high and low-income countries
(9) and between the rich and the poor in towns with a large degree of social inequality. In Oslo, the highest mortality
rate was among the working classes, those living in small flats and people on the east side of the city (10). In Chicago, it
28.6.2017 | Social inequality – a forgotten factor in pandemic influenza preparedness | Tidsskrift for Den norske legeforening
was the illiterate, the unemployed and those with the most cramped living conditions who suffered the highest
mortality rates (11). During the 2009 pandemic, the mortality rate was 20 times higher in some South American
countries than in Europe (6), and three times higher in the poorer parts of England compared to the affluent parts (12).
There is not much we can do to reduce the likelihood of a new pandemic. However, we can draw on historical experience
to prevent social inequality in mortality rates during future pandemics.
Social inequality and global pandemic response plans
The European Union (EU), Norway, the World Health Organization (WHO) and the USA aim to reduce social inequality
in health in a generation (13–17). The World Bank, the EU and the Centers for Disease Control and Prevention in the USA
have adopted a ‘One Health’ strategy with a view to improving the preparedness for pandemic threats, with a particular
focus on lowincome countries (18–20). The strategy is a transdisciplinary approach for the early identification,
prevention and reduction of health threats to humans, animals and the environment. In addition to the aforementioned
CEPI, the World Bank also launched a pioneering funding scheme – the Pandemic Emergency Financing Facility (PEF) in
2016 – aimed at the rapid prevention of the spread of pandemic threats in low-income countries (21). These measures can
play an important role in the UN’s goal to eradicate poverty and ensure good health for all by 2030 (22).
In view of the international objectives of reducing social inequality in health and implementing measures to conquer
pandemic threats that arise in low-income countries, it is striking that international documents do not address the
question of how social disparities in mortality rates are to be reduced during the next influenza pandemic. This applies
to the preparedness plans by WHO, the USA, Canada, Australia, the EU and its 28 member countries, Iceland, Norway,
Switzerland, Turkey, Macedonia, policy documents by the World Bank, general sociodemographic projections, and
plans to reduce the impact of pandemics on indigenous populations (23–30). The complete absence of discussion on
social inequality in the pandemic response plan for England (12) has already been pointed out, but the failing in
international pandemic plans is something that is only now coming to light.
Internationally, the biomedical target groups for pandemic vaccines are health workers, high-risk age groups, pregnant
women and people with underlying diseases, while target groups defined on the basis of socioeconomic status are not
mentioned (23, 27, 29–31). However, indigenous populations are covered in pandemic plans for the USA, Canada and
Australia in the same way as the biomedical target groups (29–31).
It is unclear why those who devise plans do not discuss how to avoid social inequality in mortality rates in the event of a
new pandemic. Have the rich countries – who have prepared such plans – been most concerned about reducing social
inequality in diseases that take the most lives in rich parts of the world, such as cardiovascular disease and cancer? Has
this been at the expense of the interest in social inequality in infectious diseases that are rare or have little prestige, or
which have been eradicated or have a low mortality rate in our part of the world? Could it be that those who devise
pandemic plans consider influenza to be a disease which, beyond the biomedically defined risk groups, is random, and
therefore socially blind? Is that the reason why there is little emphasis on research showing that social conditions have a
bearing on who dies during a pandemic?
Need for transdisciplinary pandemic research and pandemic preparedness
plans
Although several studies have shown social inequalities in pandemic mortality rates both 100 years ago and in 2009 (6,
9–12), more studies are needed on the biological and social mechanisms that drive the inequality. These may relate to
poor nutritional status, concurrent illnesses, cramped living conditions and a lack of understanding of or access to
health advice/vaccination recommendations due to poor reading and writing skills. There is also a lack of studies that
can reveal whether the mortality rate for the socially disadvantaged was higher due to a greater incidence of influenza or
a higher mortality rate – or a combination of these.
The influenza models used in the pandemic plans often study the effects of earlier immunity, use of antiviral drugs,
vaccination strategies and non-pharmaceutical measures such as the closure of schools and the isolation of infected
persons. The pandemic outcome measures are usually incidence of infection, hospitalization, intensive care and death
(27). However, international and national preparedness plans should be expanded such that these models also illustrate
how nonpharmaceutical and pharmaceutical interventions can prevent social inequality in morbidity and mortality in
new pandemics, thus saving lives and limiting social and economic losses. In this way, international health institutions
and national public health institutes will also work to put social inequality in infectious diseases such as influenza on
28.6.2017 | Social inequality – a forgotten factor in pandemic influenza preparedness | Tidsskrift for Den norske legeforening
the agenda along with non-infectious diseases.
As part of the initiative, influenza researchers and pandemic groups at the international health institutions and national
public health institutes – which normally consist of doctors or professionals with backgrounds in other health
disciplines and science disciplines – should collaborate with or recruit pandemic historians and social scientists who
research influenza pandemics. If medical and natural scientists, social scientists and historians work together to develop
common issues, theories, frameworks and languages – including joint analyses and publications – this will generate
more robust and tenable empirical and theoretical results than when they work individually (32). In order to conduct
high-quality epidemiological research on the Spanish influenza, for example, it is not enough just to have a good
understanding of the influenza virus, immunity and virulence; researchers also need to be aware of the historical
context in which data was collected and produced, and take into account that the events of the time, such as World War
I, may have affected the pandemic outcomes (33, 34). For example, the refugee camps in Europe, the Middle East and
North Africa that sprang up during the recent migration and refugee crisis are at a high risk of becoming a breeding
ground for the spread of disease if a new influenza pandemic were to break out today. A holistic research approach to
historical influenza pandemics and transdisciplinary collaboration in the development of pandemic plans will mean
more robust research and will have a long-term influence on the formulation of influenza pandemic preparedness
policy.
Social conditions as an indicator for pandemic vaccines?
Based on the research showing that there are clear social disparities in the pandemic mortality rate (6, 9–12), it is natural
to recommend changes in the vaccination policy on the basis of social conditions in addition to biomedical priorities
for pandemic vaccination. This requires the development of good social indicators. For Norway’s part, the following
groups are assumed to be at risk: those on long-term sick leave, disability benefit claimants and those with a reduced
ability to work, i.e. people with complex social and/or health challenges. Other examples are people with a low level of
education and low income (16). The health authorities in most countries currently translate the international
biomedical recommendations for influenza vaccination into their own national context. The social conditions for
recommending vaccination therefore need to be investigated and determined nationally. Globally, there is no doubt
that prioritizing poor countries in relation to the distribution of scarce pandemic vaccines will have the greatest impact
on reducing social and economic consequences.
Towards a paradigm shift in vaccination strategies against influenza?
In order to aid the international goals of reducing social inequality in health and ensuring good health for all by 2030,
preparedness plans should be revised to reflect the need to avoid the socially unjust burden of disease in future
influenza pandemics. A broader indication of influenza vaccination, based on both social and biomedical conditions,
will have greater potential to reduce the risk of death than if only the biomedical indications are used. Such a change,
where social conditions have implications for vaccination recommendations, would be a paradigm shift in the policy to
combat influenza.
A transdisciplinary approach to the study of influenza pandemics and the preparation of preparedness plans, in which
social and biomedical conditions are taken into account simultaneously, can also inspire research and formulation of
policy that can help reduce social inequality in pandemic threats that are not related to influenza, thereby lessening the
social and economic consequences.
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Publisert: 29. mai 2017, Nr. , 29. mai 2017, Tidsskr Nor Legeforen2017; :911-913
DOI: 10.4045/tidsskr.17.0273
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Full-text available
  • Jun 2024
Introduction: The COVID-19 pandemic has accentuated a health-wealth gradient, reminiscent of patterns observed in previous influenza pandemics. This systematic review, employing a population-based approach, aims to delve into the etiological and prognostic roles of socio-economic factors on COVID-19 outcomes during the pandemic's initial phase. Methods: Our search spanned PubMed, Embase, WHO COVID-19 Global literature, and PsycINFO databases from January 2020 to April 7, 2021, focusing on English peer-reviewed articles. We examined the impact of socio-economic determinants on SARS-CoV-2 infection, COVID-19 related hospitalization, ICU admission, mechanical ventilation, mortality, and a range of prognostic outcomes including quality of life and mental health. Results: The initial search resulted in 9,701 records after removal of duplicates. Out of hundred articles that met our review criteria, 67 discussed the etiological role of socio-economic factors, 25 addressed the prognostic role, and 8 covered both. Fifty-nine percent of the studies were from the United States of America and the United Kingdom, highlighting an increased risk of infection and severity among their Black, Asian, and Hispanic populations. Lower-income groups, crowded households, and, higher socio-economic deprivation were associated with higher COVID-19 incidence and severity. Results regarding educational status varied across different waves. Conclusion: Populations groups with disadvantaged socio-economic positions and certain ethnic and racial backgrounds face a higher risk of SARS-CoV-2 infection and poorer COVID-19 outcomes. Our findings underscore the need for incorporating social determinants into routine health surveillance and monitoring, suggesting an avenue for targeted interventions.
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The Role and Value of Professional Rapid Testing of Acute Respiratory Infections (ARIs) in Europe: A Special Focus on the Czech Republic, Poland, and Romania
Article
Full-text available
  • Mar 2024
This review aims to explore the role of professional diagnostic rapid testing of acute respiratory infections (ARIs), especially COVID-19 and influenza, ensuring proper disease management and treatment in Europe, and particularly in Czech Republic, Poland, and Romania. The paper was constructed based on a review of scientific evidence and national and international policies and recommendations, as well as a process of validation by four experts. The development of new testing technologies, treatment options, and increased awareness of the negative multidimensional impact of ARI profiles transformed differential diagnosis into a tangible and desirable reality. This review covers the following topics: (1) the multidimensional impact of ARIs, (2) ARI rapid diagnostic testing platforms and their value, (3) the policy landscape, (4) challenges and barriers to implementation, and (5) a set of recommendations illustrating a path forward. The findings indicate that rapid diagnostic testing, including at the point of care (POC), can have a positive impact on case management, antimicrobial and antibiotic stewardship, epidemiological surveillance, and decision making. Integrating this strategy will require the commitment of governments and the international and academic communities, especially as we identified room for improvement in the access and expansion of POC rapid testing in the focus countries and the inclusion of rapid testing in relevant policies.
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Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices-United States 2016-17 influenza season
Article
Full-text available
  • Jan 2016
This report updates the 2016–17 recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding the use of seasonal influenza vaccines (MMWR Recomm Rep 2016;65[No. RR-5]). Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. A licensed, recommended, and age-appropriate vaccine should be used. For the 2017–18 season, quadrivalent and trivalent influenza vaccines will be available. Inactivated influenza vaccines (IIVs) will be available in trivalent (IIV3) and quadrivalent (IIV4) formulations. Recombinant influenza vaccine (RIV) will be available in trivalent (RIV3) and quadrivalent (RIV4) formulations. Live attenuated influenza vaccine (LAIV4) is not recommended for use during the 2017–18 season due to concerns about its effectiveness against (H1N1)pdm09 viruses during the 2013–14 and 2015–16 seasons. Recommendations for different vaccine types and specific populations are discussed. No preferential recommendation is made for one influenza vaccine product over another for persons for whom more than one licensed, recommended product is available. Updates to the recommendations described in this report reflect discussions during public meetings of ACIP held on October 20, 2016; February 22, 2017; and June 21, 2017. New and updated information in this report includes the following: •Vaccine viruses included in the 2017–18 U.S. trivalent influenza vaccines will be an A/Michigan/45/2015 (H1N1)pdm09–like virus, an A/Hong Kong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008–like virus (Victoria lineage). Quadrivalent influenza vaccines will contain these three viruses and an additional influenza B vaccine virus, a B/Phuket/3073/2013–like virus (Yamagata lineage). • Information on recent licensures and labelling changes is discussed, including licensure of Afluria Quadrivalent (IIV4; Seqirus, Parkville, Victoria, Australia); Flublok Quadrivalent (RIV4; Protein Sciences, Meriden, Connecticut); and expansion of the age indication for FluLaval Quadrivalent (IIV4; ID Biomedical Corporation of Quebec, Quebec City, Quebec, Canada), previously licensed for ≥3 years, to ≥6 months. • Pregnant women may receive any licensed, recommended, age-appropriate influenza vaccine. • Afluria (IIV3; Seqirus, Parkville, Victoria, Australia) may be used for persons aged ≥5 years, consistent with Food and Drug Administration–approved labeling. • FluMist Quadrivalent (LAIV4; MedImmune, Gaithersburg, Maryland) should not be used during the 2017–18 season due to concerns about its effectiveness against influenza A(H1N1)pdm09 viruses in the United States during the 2013–14 and 2015–16 influenza seasons. This report focuses on the recommendations for use of vaccines for the prevention and control of influenza during the 2017–18 season in the United States. A Background Document containing further information and a summary of these recommendations are available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html. These recommendations apply to licensed influenza vaccines used within Food and Drug Administration–licensed indications, including those licensed after the publication date of this report. Updates and other information are available at CDC’s influenza website (https://www.cdc.gov/flu). Vaccination and health care providers should check CDC’s influenza website periodically for additional information.
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Disparities in influenza mortality and transmission related to sociodemographic factors within Chicago in the pandemic of 1918
Article
Full-text available
  • Nov 2016
Significance The pervasiveness of influenza among humans and its rapid spread during pandemics create a false sense that all humans are affected equally. In this work, we show that neighborhood-level social determinants were associated with greater burdens of pandemic influenza in 1918 and several other diseases in a major US city. We show that literacy, homeownership, and unemployment were associated with cumulative influenza mortality as well as measures of the speed of transmission using a unique dataset describing the home location and week of death of individuals who died during the influenza pandemic in 1918. Our results suggest that, similar to other infectious diseases, social disparities should be a focus of research and public health response in future pandemics.
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The ghost of pandemics past: Revisiting two centuries of influenza in Sweden
Article
Full-text available
  • Nov 2016
Previous influenza pandemics are usually invoked in pandemic preparedness planning without a thorough analysis of the events surrounding them, what has been called the ‘configuration’ of epidemics. Historic pandemics are instead used to contrast them to the novelty of the coming imagined plague or as fear of a ghost-like repetition of the past. This view of pandemics is guided by a biomedical framework that is ahistorical and reductionist. The meaning of ‘pandemic’ influenza is in fact highly ambiguous in its partitioning of pandemic and seasonal influenza. The past 200 years of influenza epidemics in Sweden are examined with a special focus on key social structures—households, schools, transportations and the military. These are shown to have influenced the progression of influenza pandemics. Prevailing beliefs around influenza pandemics have also profoundly influenced intervention strategies. Measuring long-term trends in pandemic severity is problematic because pandemics are non-linear events where the conditions surrounding them constantly change. However, in a linearised view, the Spanish flu can be seen to represent a historical turning point and the H1N1 2009 pandemic not as an outlier, but following a 100-year trend of decreasing severity. Integrating seasonal and pandemic influenza, and adopting an ecosocial stance can deepen our understanding and bring the ghost-like pandemic past to life.
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Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2016–17 Influenza Season
Article
Full-text available
  • Aug 2016
This report updates the 2015-16 recommendations ofthe Advisoiy Committee on Immunization Practices (ACIP) regarding the use of seasonal influenza vaccines (Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season. MMWR Morb Mortal Wkly Rep 2015;64:818-25). Routine annual influenza vaccination is recommended for all persons aged months who do not have contraindications. For the 2016-17 influenza season, inactivated influenza vaccines (IIVs) will be available in both trivalent (IIV3) and quadrivalent (IIV4) formulations. Recombinant influenza vaccine (RIV) will be available in a trivalent formulation (RIV3). In light of concerns regarding low effectiveness against influenza A(H1N1)pdm09 in the United States during the 2013-14 and 2015-16 seasons, for the 2016-17 season, ACIP makes the interim recommendation that live attenuated influenza vaccine (LAIV4) should not be used. Vaccine virus strains included in the 2016-17 U.S. trivalent influenza vaccines will be an A/California/7/2009 (H1N1) like virus, an A/Hong Kong/4801/2014 (H3N2) like virus, and a B/Brisbane/60/2008 like virus (Victoria lineage). Quadrivalent vaccines will include an additional influenza B virus strain, a B/Phuket/3073/2013 like virus (Yamagata lineage). Recommendations for use of different vaccine types and specific populations are discussed. A licensed, age -appropriate vaccine should be used. No preferential recommendation is made for one influenza vaccine product over another for persons for whom more than one licensed, recommended product is otherwise appropriate. This information is intended for vaccination providers, immunization program personnel, and public health personnel. Information in this report reflects discussions during public meetings ofACIP held on October 21, 2015; February 24, 2016; andJune 22, 2016 These recommendations apply to all licensed influenza vaccines used within Food and DrugAdministration licensed indications, including those licensed after the publication of this report. Updates and other information are available at CDC's influenza website (http://www.cdc.govfflit). Vaccination and health care providers should check CDC's influenza website periodically for additional information.
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Influenza, Historical
Article
Full-text available
  • Dec 2008
The history of influenza spans 2500 years from Egypt and Ancient Greece to the present. However, there is little evidence of influenza epidemics in the historical literature before the period from 1173 to 1387, thus the first generally agreed pandemic occurred in 1580. This article reviews the history of the naming of influenza and the discovery of its cause from a social science perspective, giving a chronicle of the epidemics and pandemics described in the literature, and addressing the demographic, economic, and public health concerns and consequences of the disease. The historical role of disease prevention, antiviral drugs, and vaccines is also discussed.
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Recommended Mitigation Measures for an Influenza Pandemic in Remote and Isolated First Nations Communities of Ontario, Canada: A Community-Based Participatory Research Approach
Article
Full-text available
  • Jun 2014
Influenza pandemics disproportionately impact remote and/or isolated Indigenous communities worldwide. The differential risk experienced by such communities warrants the recommendation of specific mitigation measures. Interviewer-administered questionnaires were conducted with adult key health care informants from three remote and isolated Canadian First Nations communities of sub-Arctic Ontario. Forty-eight mitigation measures (including the setting, pandemic period, trigger, and duration) were questioned. Participants’ responses were summarized and collected data were deductively and inductively coded. The participants recommended 41 of the questioned mitigation measures, and often differed from previous literature and national recommendations. Results revealed that barriers, such as overcrowded housing, limited supplies, and health care infrastructure, impacted the feasibility of implementing mitigation measures. These findings suggest that pandemic plans should recommend control strategies for remote and isolated Canadian First Nations communities that may not be supported in other communities. These findings highlight the importance of engaging locally impacted populations using participatory approaches in policy decision-making processes. Other countries with remote and/or isolated Indigenous communities are encouraged to include recommendations for mitigation measures that specifically address the unique needs of such communities in an effort to improve their health outcomes during the next influenza pandemic.
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Updated Preparedness and Response Framework for Influenza Pandemics
Article
Full-text available
  • Sep 2014
The complexities of planning for and responding to the emergence of novel influenza viruses emphasize the need for systematic frameworks to describe the progression of the event; weigh the risk of emergence and potential public health impact; evaluate transmissibility, antiviral resistance, and severity; and make decisions about interventions. On the basis of experience from recent influenza responses, CDC has updated its framework to describe influenza pandemic progression using six intervals (two prepandemic and four pandemic intervals) and eight domains. This updated framework can be used for influenza pandemic planning and serves as recommendations for risk assessment, decision-making, and action in the United States. The updated framework replaces the U.S. federal government stages from the 2006 implementation plan for the National Strategy for Pandemic Influenza (US Homeland Security Council. National strategy for pandemic influenza: implementation plan. Washington, DC: US Homeland Security Council; 2006. Available at http://www.flu.gov/planning-preparedness/federal/pandemic-influenza-implementation.pdf). The six intervals of the updated framework are as follows: 1) investigation of cases of novel influenza, 2) recognition of increased potential for ongoing transmission, 3) initiation of a pandemic wave, 4) acceleration of a pandemic wave, 5) deceleration of a pandemic wave, and 6) preparation for future pandemic waves. The following eight domains are used to organize response efforts within each interval: incident management, surveillance and epidemiology, laboratory, community mitigation, medical care and countermeasures, vaccine, risk communications, and state/local coordination. Compared with the previous U.S. government stages, this updated framework provides greater detail and clarity regarding the potential timing of key decisions and actions aimed at slowing the spread and mitigating the impact of an emerging pandemic. Use of this updated framework is anticipated to improve pandemic preparedness and response in the United States. Activities and decisions during a response are event-specific. These intervals serve as a reference for public health decision-making by federal, state, and local health authorities in the United States during an influenza pandemic and are not meant to be prescriptive or comprehensive. This framework incorporates information from newly developed tools for pandemic planning and response, including the Influenza Risk Assessment Tool and the Pandemic Severity Assessment Framework, and has been aligned with the pandemic phases restructured in 2013 by the World Health Organization.
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International encyclopedia of public health
Book
  • Jan 2008
An authoritative and comprehensive guide to the major issues, challenges, methods, and approaches of global public health. This encyclopedia will cover all dimensions of the field, from details of specific diseases to the organization of social insurance agencies. A significant percentage of the articles will cover public health aspects of diseases and conditions. Other articles will survey aging, diet, injuries, ethical and legal subjects in public health, measurement and modeling, consumerism, anthropology and sociology, economics, the history of public health, and global issues.
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