In April 2009 a new strain of influenza A virus was detected, H1N1, an unsubtypable strain with a genetic combination never before identified in humans or animals. From the first confirmed cases in La Gloria, Mexico, and San Diego, California, in mid-April to more than 15 000 identified cases in 53 countries by late May 2009,1 transmission of the novel virus rapidly emerged from regional concern to global threat. The need for international cooperation was articulated by US health officials early in the H1N1 story. Addressing the World Health Assembly in May 2009, US Department of Health and Human Services (HHS) Secretary Kathleen Sebelius emphasized that “viruses know no borders,” and successful containment of H1N1 is not possible without “an unprecedented level of international preparation and cooperation.”2
Immediately after identification of the novel H1N1 virus, the World Health Organization (WHO) took a lead role in coordinating worldwide influenza detection, reporting, and management. By late May, nearly 30 000 cases in 74 countries were confirmed,Reference Chan3 and WHO Director-General Margaret Chan raised the level of influenza alert from phase 5 to the highest phase, 6, declaring that transmission had reached pandemic proportions. The alert fueled efforts toward large-scale production and distribution of H1N1 vaccine and reinforced the urgency for national, regional, and community-based pandemic preparedness.
More than 1 year after Dr Chan's declaration, epidemiologists, virologists, clinicians, and disaster managers are engaged in post hoc examination of the handling by the international community (including WHO) of the 2009 pandemic influenza response. With the overall loss of life totaling far fewer than anticipated, and millions of doses of costly vaccine discarded, criticism of WHO's response to what some consider a “damp squib” continues to reverberate through professional and public discourse.Reference Godlee4Reference Flynn5 WHO spokesperson Fadela Chaib acknowledged that “criticism is part of an outbreak cycle. We expect and indeed welcome criticism and the chance to discuss it.”Reference Lynn6 Although critical discussion can be productive in fine-tuning policy and planning for future pandemic response, it is also important to underscore the positive outcomes and innovations spurred by WHO's actions and their valuable application now and in the future.
WHO/EUROPE HOSPITAL CHECKLIST
One important innovation to emerge from the 2009 H1N1 pandemic is the WHO Hospital Preparedness Checklist for Pandemic Influenza.7 Originating from the WHO Regional Office for Europe (WHO/Europe), the checklist developed amid a flurry of WHO surveillance reports correlating rise in H1N1 disease burden with disruption of health care services in the European Region.8 In response to these reports and country office requests for clearly defined pandemic preparedness guidelines, WHO/Europe designed a concise, practical tool to assist hospital administrators and disaster managers to prepare for and effectively respond to the influenza pandemic. Based on accepted emergency management principles and best practices in triage and surge capacity, the checklist built upon existing WHO recommendations and novel H1N1–specific management applications. WHO/Europe covers a remarkably large geographic region comprising 53 nations in Europe, the Baltic States and Caucasuses, and central and western Asia. To provide uniform technical support to member states with such varied health system infrastructures against a backdrop of diverse political, economic, and cultural influences was a lofty goal indeed.
Although differences in health system organization and management strategy exist within the European Region, outcome benefits of effective hospital-based pandemic planning are generic, and according to WHO/Europe, broadly deliverable. These include continuity of essential services, effective implementation of priority actions at all levels, clear and accurate internal and external communication, swift adaptation to increased demands, effective use of scarce resources, and establishment of a safe environment for health workers.7 The checklist tool was designed to help hospitals achieve these goals.
After 6 months of intensive development, the checklist was finalized in November 2009. The document consists of the following 11 key components of hospital-based pandemic management:
1. Incident Command System
2. Communication
3. Continuity of essential health services and patient care
4. Surge capacity
5. Human resources
6. Logistics and management of supplies, including pharmaceuticals
7. Essential support services
8. Infection prevention and control
9. Case management
10. Surveillance: early warning and monitoring
11. Laboratory services
Within each component section is a list of specific recommended actions. WHO/Europe encourages hospitals that are experiencing an excessive demand for health services due to pandemic-prone disease to implement each action. Hospitals at risk of increased health service demand are advised to prepare to initiate each action. A recommended reading section is also provided that lists supplementary tools, guidelines, and strategies relevant to each component. English and Russian editions of the checklist have been distributed throughout the WHO European Region and an electronic version is available (http://www.euro.who.int/en/what-we-do/health-topics/emergencies).
FUTURE PREPAREDNESS
As worldwide pandemic influenza activity and related health system burden continue to decline,9 most agree that true disaster has, at least for the time being, been circumvented. Will we see a rise in H1N1 influenza activity again in the near future? The unpredictability of H1N1 virulence and spread has left many experts uncertain. “We can't be sure of what will happen in the future,” Dr Thomas Frieden, Director of the Centers for Disease Control and Prevention, told reporters after the initial pandemic wave. “If you’ve seen one flu pandemic, you’ve seen one flu pandemic. And each pandemic is different. Each pandemic occurs at a different time [and] has a different pattern.”10 As health officials prepare for possible future influenza outbreaks, there is a new generation of tools and guidelines to assist in pandemic planning and response.
Several resources have been developed by WHO, HHS, and other leading health agencies to assist in pandemic preparedness for a variety of organizations including hospitals, clinics, emergency medical services organizations, home health care services, and long-term care and residential facilities.11 A number of these resources, including WHO's Pandemic Influenza Preparedness and Response12 and the HHS Pandemic Influenza Plan,13 were consulted in the development of the WHO Hospital Preparedness Checklist for Pandemic Influenza. The checklist incorporates best principles and practices from these resources and tailors them to a response-oriented format. Rather than simply providing guidelines for pandemic planning, the checklist identifies actions that can be implemented at the moment hospitals experience excessive demand, making it a valuable tool at any stage of a pandemic event. Its potential for rapid utilization, in conjunction with the checklist's broadly adaptable format, makes the document valuable among pandemic management resources and ideal for international application.
Within WHO/Europe, the checklist has been widely distributed, accepted, and integrated into regional and subregional pandemic training models. Positive feedback from country health officials and hospital administrators has led to preliminary plans for future editions as pandemic management options, recommendations, and health system needs evolve. As an offshoot of the pandemic checklist, WHO/Europe is in the process of developing a new all-hazards tool to provide hospitals with critical action steps to effectively respond to the most common types of disaster. Among the innovative deliverables to emerge from the 2009 H1N1 pandemic, the Hospital Preparedness Checklist for Pandemic Influenza is a valuable resource in ongoing efforts to “ramp up preparedness . . . [and] look for responses and solutions that benefit all countries.”Reference Chan14
Author's Disclosures: The author provides consultative expertise to the WHO Regional Office for Europe Disaster Preparedness and Response Programme and was a contributing author to the WHO Hospital Preparedness Checklist for Pandemic Influenza.
