SoAP-Oct2006

Handbook of WMA Policies
World Medical Association ⏐ S-2006-02-2006

WMA STATEMENT
ON
AVIAN AND PANDEMIC INFLUENZA
Adopted by the 57th
WMA General Assembly, Pilanesberg, South Africa, October 2006
1. This statement provides guidance to National Medical Associations and physicians
on how they should be involved in their respective country’s pandemic planning
process. It also encourages governments to involve their National Medical
Associations when planning for pandemic influenza. Finally, it provides broadly
stated recommendations about activities that physicians should consider in preparing
themselves for pandemic influenza.
AVIAN INFLUENZA VERSUS PANDEMIC INFLUENZA

1. Avian influenza (bird flu) is a contagious common viral infection of birds and, less
commonly, pigs. Two forms have been identified: less pathogenic avian influenza
(LPAI) and highly pathogenic avian influenza (HPAI), which is extremely
contagious and has nearly a 100% mortality rate in birds. Avian influenza viruses
differ from human influenza viruses. While avian influenza viruses do not normally
infect hu-mans, since 1997 several cases of human infection have been documented.
2. The current H5N1 HPAI virus is a subtype of influenza type A viruses and was first
isolated from South African terns in 1961. The current outbreak started in late 2003
and early 2004 in eight countries in Asia. While originally reported as controlled,
since June 2004 new outbreaks of H5N1 have reappeared. Migratory and smuggled
birds are likely to be responsible for the spread of H5N1. The infected birds shed
large quantities of virus in their feces, and exposure to infected droppings or to en-
vironments contaminated by the virus is common. It is anticipated that H5N1 will
continue to spread along the migratory pathways of wild birds. Most human
infections have occurred in rural areas where freely-roaming small poultry flocks are
kept.
3. HPAI is controlled by rapidly destroying all infected and/or exposed birds, by proper
disposal of the carcasses, and by quarantining and rigorous disinfection of farms. In
order to contain an outbreak, aggressive measures are needed immediately after the
outbreak is detected.
4. Human pandemic influenza occurs three to four times a century and can take place in
any season, not just winter. Pandemic influenza results from the emergence of a new
human influenza strain to which no human immunity exists. This new human pan-
demic strain can arise from either avian influenza strains or from influenza viruses
infecting swine and potentially other mammalian species. It is usually associated
with a higher severity of illness and, consequently, a higher risk of death. All age
groups may be at risk, and experts predict an infection rate of 25-50% of the
S-2006-02-2006⏐ Pilanesberg
Avian and Pandemic Influenza

population, depending on the severity of the strain. Since the virus strain cannot be
accurately predicted, a vaccine against pandemic flu may not be available until
several months after the pandemic begins. A major factor in protecting populations
will be the time from emergence of a new strain to the development and manufacture
of vaccine. It is hypothesized that use of anti-virals may control the progression of a
pandemic fol-lowing its emergence, so adequate supplies of anti-virals are important.
At all phases of a pandemic outbreak, but especially during the period when vaccine
is unavailable, infection control is critical.
5. Health officials are concerned that avian influenza, if given the right opportunities,
could mutate to form a new strain of human influenza virus against which humans
have no immunity or existing vaccine – a pandemic strain. It is apparent that H5N1
has the capacity to directly jump the species barrier and cause serious disease in
humans but thus far, H5N1 has demonstrated very limited, if any, human
transmission potential. A new pandemic virus could develop if a human became
simultaneously infected with H5N1 and a human influenza virus, resulting in gene
swapping. Also, the H5N1 virus could mutate on its own. With this new virus strain,
direct human-to-human transmission could result, and if the virus remains highly
pathogenic, a pandemic with high mortality rates could occur. This is believed to
have happened in the worst pandemic of the 20th century, the “Spanish Flu” of 1918,
that killed 50 million people worldwide.
6. Even though the H5N1 virus is not easily transmitted to humans, any H5N1 human
infection provides an opportunity for co-existence with a human influenza virus.
Consequently, the World Health Organization (WHO) and other health organizations
recommend that any person coming in contact with infected poultry receive the cur-
rent annual flu vaccine. Since it is not yet known whether residual immunity to the
N1 component of the annual vaccine provides any immunity to H5N1, there is no
way to accurately predict the severity of the next pandemic. It is important to
recognize that while there is current concern surrounding H5N1, a pandemic
influenza strain may not arise from H5N1 but may come from another HPAI strain.
Regardless, the odds are great that another pandemic will occur.
PRINCIPLES OF PANDEMIC INFLUENZA PLANNING

The Role of Governments

1. The WHO has responsibility for co-ordinating the international response to an in-
fluenza pandemic. It has defined phases in the evolution of a pandemic that allow an
escalating approach to preparedness planning and response leading up to a
declaration of onset of a pandemic.
2. The development of a national pandemic plan, will, by necessity, be led by the na-
tional government, but physicians should be involved at all stages. While each nation
will have unique situations to address, the following pandemic preparedness princi-
ples apply:
a. Define key preparedness issues, needs, and goals.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-02-2006

• The prioritization of one or two goals for the nation’s pandemic planning is
essential. Depending on these goals, the prioritization and use of vaccines and
antivirals will vary. For example, a goal of reducing morbidity and mor-tality
due to influenza will have very different planning criteria from a goal of
preserving societal infrastructure.
• Defining the nation’s needs in the event of a pandemic will require making
some basic assumptions about the severity of the pandemic in the nation.
Based upon that assumption, it will then be possible to make some predic-
tions about the issues and needs facing the country. It will be useful to con-
sult with other nations that have prepared pandemic plans to see what
challenges they faced in identifying their needs and issues.
b. In countries where there is a substantial presence of healthcare professionals in
the private sector, involve those in the private sector, who will be managing the
pandemic on the ground, particularly physicians, in the decision-making
process.
The administration of millions of doses of antivirals and vaccine to the manage-
ment of surge capacity and hospital beds will all require specific participation of
those most knowledgeable and involved in the process.
c. Prepare risk communication and crisis communication strategies and messages
in anticipation of public and media fear and anxiety.
d. Provide guidance and timely information to regional health departments, health
care organizations, and physicians. Utilize physicians as spokespeople to explain
the medical and ethical issues to the public. Ensure that communications mecha-
nisms and infrastructure continue to function efficiently.
• As planning proceeds, timely and clear information not only of the plan, but
also of the rationale behind decisions, needs to be made available to public
health authorities and the medical establishment as well as to the public.
Physician leaders in a community are well-respected and frequently can
serve as excellent spokespersons to educate the public about the issues sur-
rounding pandemic planning. Public feedback into important decisions that
may have moral and ethical implications will help secure public acceptance
of the plan. For example, holding a public engagement process to assess the
public’s opinion about rationing of vaccine during a pandemic can be useful.
• It is important that government representatives and physicians speak with
one voice in order to avoid confusion and panic during a pandemic event.
e. Identify the legal issues and authorities for pandemic responses, e.g. liability,
quarantine, closing borders.
Authorities will need to make decisions that range in complexity from local
deci-sions to close public areas to national decisions regarding border closings
and/or quarantine/isolation of exposed/infected citizens. The legal and ethical
issues sur-rounding these decisions need to be in place prior to a pandemic.
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Avian and Pandemic Influenza

f. Determine the order of importance for use of scarce resources such as vaccines
and antivirals based on pandemic response goals. Priority groups chosen for vac-
cine should be those that help maintain essential community services and those
at highest risk.
g. Do not put physicians in the position of being responsible for decisions
regarding the rationing of vaccine, antivirals and other scarce resources during a
pandemic. Those decisions must be made by the government.
h. Outline coordination and implementation of a response by stages of the pande-
mic.
Depending on the size of a country, this response may be at a national level or at
a regional level. Large countries may see the pandemic occur in waves in which
case affected regions will need to have their own response ready to be imple-
mented.
i. Consider the surge capacity of hospitals, laboratories, and the public health infra-
structure and improve them if necessary. Prepare for absences of key staff and
the need to maintain health services for conditions other than influenza.
j. Prepare for the psychosocial impact on health care workers in managing the
waves of a pandemic.
k. Consider whether the safety of those in facilities managing the pandemic must be
ensured, such as police protection of the supply chain for vaccines and antivirals.
Address what might be needed to control a pandemic in the absence of a vaccine.
l. Assess whether there is sufficient funding available to adequately prepare for
pandemic influenza.
Political will to fund public health preparedness is essential. Resources spent on
pandemic planning should be framed in the context of general preparedness; pan-
demic preparedness and public health preparedness share many of the same
issues.
m. Identify key issues that remain to be resolved, which may include management
of patients in the community, triage in hospitals, ventilation management, safe
handling of bodies, and death investigations and reports.
The Role of the National Medical Association (NMA)

1. In any disaster situation or infectious disease outbreak, physicians and their pro-
fessional organisations will be challenged to continue to provide needed care to the
vulnerable and sick, as well as to aid in the emergency response called for in the spe-
cific situation. The following issues should be considered in this regard:
a. NMAs should have their own organization-specific business contingency plan in
place to ensure continued support of their members.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-02-2006

Many existing plans anticipate disruptions such as fires, earthquakes, and floods
that are geographically restricted and have fairly well defined timeframes. How-
ever, pandemic influenza planning requires assumptions that the influenza will
be widely dispersed geographically and will potentially last many months.
b. NMAs should clearly identify their responsibilities during a pandemic.
The NMA should actively seek participation in the nation’s pandemic planning
process. If this is achieved, the NMA’s responsibilities will also be clearly de-
fined to its physicians as well as to the government.
c. For effective global pandemic influenza planning, NMAs should collaborate and
network with NMAs from other countries.
Many NMAs have already been involved in their countries’ pandemic planning
process. Challenges and key roles for the NMA that have been identified should
be shared.
d. NMAs should have an essential role in communicating vital information:
• To the public. As the authoritative medical voice, an NMA engenders public
trust and should use that trust to communicate accurate and timely informa-
tion regarding pandemic planning and the current state of the pandemic to the
public;
• Between authorities and physicians, and between physicians in affected
areas and their colleagues elsewhere;
• Between health care professionals. NMAs should work with other health
care provider organizations (e.g., nurses, hospital groups) to identify common
issues and congruent policies and messages regarding pandemic prepared-ness
and response.
e. NMAs should offer training seminars and clinical support tools, such as online
and e-published self-help training materials, for physicians and regional medical
associations.
Such training/tools should consider how, in a worst-case pandemic scenario,
physicians will manage respiratory crises without intensive or critical care
facili-ties. Training should also be given in triage strategies and how infected
patients should be counselled.
f. NMAs should consider what new programs and services they might offer during
a pandemic, such as coordination or provision of mental health crisis support
programs for affected members and their families, facilitation of health emer-
gency response teams, emergency locum relief, and facilitation of equipment
supply lines.
g. NMAs should be involved in and support the development and implementation
of government plans while still considering their own professional code of
ethics. They should monitor and assess the implementation of said plans to
ensure that as pandemic outbreaks cycle through their natural history, health
interests remain paramount.
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Avian and Pandemic Influenza

h. NMAs should advocate for adequate government funding to prepare for
pandemic influenza.
i. NMAs should anticipate the different practice environments that may evolve
during pandemic conditions and be prepared to discuss liability and related
issues with health authorities and advise members on such issues.
j. NMAs should be prepared to advocate on behalf of members who, during a pan-
demic, will have rapidly emerging professional needs that must be met, and on
behalf of patients and the public who will be affected by the unfolding events.
The Role of the Physician

1. Physicians will be the first point of contact and source for advice for many as a
pandemic evolves. The following are broad issues that physicians should consider in
the event of a pandemic:
a. Be sufficiently educated about pandemic influenza and transmission risks.
Communication about the actual risks of pandemic influenza is important to
impart a sense of urgency without creating undue public alarm. Consider active
physician participation in the media response to a pandemic.
b. Be vigilant for the possibility of severe or emerging respiratory diseases, espe-
cially in patients who have recently travelled internationally.
As with any emerging infection, the astute physician is one of the important sur-
veillance tools for detecting and managing an outbreak.
c. Plan for how to manage high-risk patients in the office/clinic setting and com-
municate the plan to clinic staff.
Isolation and infection control plans must be available and staff should be well-
versed in them. Be aware of what regional public health authorities are
requesting be done with potential patients and their exposed contacts.
d. Plan how to concurrently manage patients with chronic illnesses who require
routine medical management.
e. Plan accordingly for possible interruptions of essential services like sanitation,
water, power, and disruptions to the food supply. Plan for the possibility of staff
shortages because of personal illness and/or the care of next-of-kin who are ill.
It is vital to have contingency plans in place to deal with possible societal
disrup-tion. Recognize that usual sources of these essential services may not be
function-ing so identifying alternative sources for these essentials may be
necessary.
f. Prepare educational materials for patients and staff, including recommendations
for proper infection control.
An educated patient/public that recognizes the necessity for stringent measures
such as quarantine and isolation will make a physician’s job easier should s/he
have to utilize such procedures when a pandemic occurs.
Handbook of WMA Policies
World Medical Association ⏐ S-2006-02-2006

g. Remain involved in local pandemic planning efforts and understand how the
plan will affect the physician. Participate in local simulation exercises.
Since physicians will be on the frontlines of monitoring, reporting, and event-
ually managing pandemic influenza patients, they must be closely involved in
the planning process. They must continuously provide feedback as to what is
logisti-cally possible regarding physicians’ efforts on the ground when a pandemic
arrives.
h. Physicians have an ethical responsibility to provide services to the injured or ill.
They should have resources in place in the event they and/or their own families
become infected.
• A physician will have a strong public health duty in the time of a pandemic
and his/her services will be critical at a time when surge capacity will be
stressed. Physicians should make arrangements for the care of their families
and dependents in the event of a pandemic.
• Physicians should take all measures necessary to protect their own health and
the health of their staff.
• Physicians can also consult the WMA Statement on Medical Ethics in the
Event of Disasters for additional guidance.
i. Develop a clinic plan to decrease potential for contact including isolation areas
for infected patients, use of close-fitting surgical masks, designating separate
blocks of time for non-influenza-related patient care, and postponing non-
essential medical visits.
j. Review staff infection control procedures and train staff in the use of personal
protective equipment. Provide signage in the office instructing patients on respi-
ratory hygiene practices; provide tissues, receptacles for their disposal, and hand
hygiene materials in waiting areas and examination rooms.
k. Get vaccinated against annual influenza each year and urge all staff to be vac-
cinated.
Annual influenza readiness goes a long way for pandemic preparedness. Addi-
tionally, it is possible that components in the annual vaccine (e.g., N1) may pro-
vide some immunity against H5N1.
l. Work to ensure that the office/clinic has access to adequate supplies of antibiotic
and antiviral medications as well as commonly prescribed drugs like insulin or
warfarin, in case the pharmaceutical supply line is disrupted.
RECOMMENDATIONS

1. That the WMA increase its collaboration with the WHO on pandemic planning and
commit to becoming an important participant in the decision-making process.
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Avian and Pandemic Influenza

2. That the WMA communicate to the WHO its capabilities and the capabilities of its
NMA members to provide a credible voice that can efficiently reach many practising
physicians.
3. That the WMA acknowledge that although pandemic planning is a country-specific
task, it can provide general principles for guidance. Additionally, the WMA can pro-
vide basic advice that can be given by its member NMAs to practising physicians.
4. That the WMA establish an operational capacity to develop and maintain emergency
communication channels between the WMA and NMAs during a pandemic.
5. That the WMA provide timely evidence-based control measures to countries with no
or limited up-dated information about pandemics.
6. That NMAs be actively involved in the national pandemic planning process.
7. That physicians participate in local pandemic planning efforts and be involved in
communicating vital information to the public.