homeland security council

J U L Y 2 0 0 7

National Strategy for 

pandemic 

influenza

ONE YEAR SUMMARY

implementation plan

NATIONAL STRATEGY FOR PANDEMIC INFLUENZA 

IMPLEMENTATION PLAN

ONE YEAR SUMMARY

Table of Contents

Executive Summary...................................................................................................................1

Introduction...............................................................................................................................5

Limiting the International Spread of a Pandemic .................................................................6 

Limiting the Domestic Spread of a Pandemic and Mitigating Disease, 

Suffering, and Death ...............................................................................................................14

Sustaining Infrastructure and Mitigating Impact to the Economy and the 

Functioning of Society During a Pandemic.........................................................................21

Looking Ahead: What Have We Learned Through These Efforts and 

What Gaps Still Need to Be Addressed?...............................................................................26

Acknowledgements.................................................................................................................33

National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 1

National Strategy for Pandemic Influenza 

Implementation Plan 

One Year Summary 

Executive Summary

Since the release of the National Strategy for Pandemic Influenza Implementation Plan one year ago, 

much has been accomplished to realize the U.S. Government’s pandemic preparedness and response 

goals of: (1) stopping, slowing, or otherwise limiting the spread of a pandemic to the United States; 

(2) limiting the domestic spread of a pandemic and mitigating disease, suffering, and death; and (3) 

sustaining infrastructure and mitigating impact to the economy and the functioning of society.

Although the visibility of avian influenza and pandemic preparedness has waned in the media, the 

threat of avian influenza and the potential for an influenza pandemic has not. A pandemic occurs 

when a novel strain of influenza virus emerges that has the ability to infect humans and to cause 

severe disease, and where efficient and sustained transmission between humans occurs. Though we 

cannot be certain that highly pathogenic avian influenza A H5N1 (H5N1) will spark a pandemic, we 

can be sure that a pandemic will occur at some point in the future. It is everyone’s responsibility to 

remain vigilant. We cannot become complacent and must continue to take the threat of a pandemic 

very seriously.

Over the past year, through the International Partnership on Avian and Pandemic Influenza, the 

United States and the international community have mobilized to confront the threat of an influenza 

pandemic at its source, by containing H5N1 poultry outbreaks and rapidly identifying associated 

cases of human disease. The United States is supporting efforts to improve laboratory diagnosis and 

early warning networks in more than 75 countries and is working with its partners to expand on-theground surveillance capacity, enhance national and regional laboratories, and improve knowledge 

about the movement and changes in H5N1 on a global scale to ensure that countries are able to 

quickly confirm outbreaks in animals or people. In cooperation with the World Health Organization 

(WHO) and the United Nations Food and Agriculture Organization (FAO), U.S. experts have 

investigated outbreaks of H5N1 in countries on three continents and provided technical assistance, 

commodities, and logistical or financial support to 39 of the 60 countries and jurisdictions affected 

by H5N1. As a result of the efforts of the United States and the support of our international partners, 

the international community becomes aware of outbreaks sooner and is able to launch more effective 

and timely responses.

Although a pandemic virus has not yet emerged, the appearance of limited human clusters of H5N1 

cases has tested our international surveillance and response capabilities. Should a pandemic emerge, 

whether from the current H5N1 subtype of concern or from another influenza virus with pandemic 

potential, the United States is better positioned today to detect an outbreak earlier, to support an 

international effort to contain the pandemic in its earliest stages, to limit the spread of the pandemic, 

and to save lives. 
2 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

The United States has developed 

protocols and trained personnel 

to support an international 

effort to contain the pandemic 

in its earliest stages. The U.S. 

Government procured and prepositioned overseas stockpiles of 

personal protective equipment, 

decontamination kits, and antiviral 

medications to complement 

global efforts to contain pandemic 

outbreaks. Today, our Federal and 

State stockpiles contain enough 

antiviral medications to treat nearly 

50 million people, with up to 6 

million courses now reserved for 

containment efforts. If a pandemic 

begins outside the United States, 

and our international containment 

efforts fail, the U.S. Government 

is planning to implement border 

measures during a severe pandemic 

to slow the entry of a pandemic 

virus into the United States while 

allowing the flow of goods and 

people. 

Once an influenza pandemic 

reaches the United States, the 

primary focus is safeguarding the 

health of Americans. The U.S. 

Government is working to enhance 

the Nation’s ability to detect and respond early and effectively to a pandemic. To better identify 

the first cases of pandemic influenza in a community, the U.S. Government has provided resources 

to State and local health departments to increase the number of sentinel providers and improve 

laboratory detection at public health laboratories. The U.S. Laboratory Response Network (LRN), 

which includes State public health laboratories, is prepared to conduct initial testing of suspected 

human infection with H5N1 within 24 hours of receipt. To ensure that suspected cases can be 

promptly confirmed and treated, the Federal Government is working with industry partners to 

develop rapid diagnostic tests to quickly discriminate pandemic influenza from seasonal influenza or 

other illnesses.

The Federal Government is investing in the expansion of vaccine manufacturing capacity, the 

advanced development of new cell-based vaccines, antigen-sparing technologies to stretch our 

vaccine supply, and the establishment and maintenance of pre-pandemic vaccine stockpiles. In 

	 •	 Encourage hand hygiene and cough etiquette

	 •	 Promote use of facemasks and respirators,

	 	 as appropriate

	 •	 Prepare to implementcommunity

	 	 mitigation measures

	 •	 Expand vaccine production capacity

	 	 and technology

	 •	 Stockpile pre-pandemic vaccine

	 •	 Develop waysto stretch our vaccine supply 		

	 	 (adjuvants)

	 •	 Stockpile antiviral medications

	 •	 Educate and inform the public about

	 	 measuresto reduce disease transmission

Reduce

Disease

Transmission

Improve 

Detection

and 

Response

•	 Enhance global and domestic

	 biosurveillance capability

•	 Coordinate internationalcontainment

	 and rapid response

•	 Prepare to implement layered border	 	 	

	 measures

•	 Develop rapid diagnostictests

•	 Create ability to care forlarge numbers of ill

•	 Stockpile critical medical materiel

•	 Maintain essential governmentservices

•	 Sustain critical infrastructure and

	 businesscontinuity

•	 Communicate accurate and timely

	 information to the public

Safeguarding Our Health
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 3

April 2007, the Federal Government approved the first pre-pandemic vaccine for humans against 

the H5N1 virus. We currently have enough of this pre-pandemic H5N1 vaccine for approximately 

6 million people, with plans to stockpile enough pre-pandemic vaccine for 20 million people. In 

addition, antiviral medications are an important element of pandemic influenza preparedness. As 

of June 2007, the Strategic National Stockpile contains more than 35 million regimens of antiviral 

drugs with an additional 2 million regimens on order. So far, individual States have stockpiled more 

than 13 million regimens of antiviral drugs. The Government’s antiviral strategy includes not only 

stockpiling existing antiviral drugs, but also developing new antiviral medications to further broaden 

our capabilities to treat and prevent influenza. 

In February 2007, the U.S. Government released groundbreaking Federal guidance for nonpharmaceutical interventions for mitigating the impact of a pandemic. This community mitigation 

strategy is important because the best protection against pandemic influenza, a matched pandemic 

vaccine, is not likely to be available at the outset of a pandemic. Recent scientific modeling and 

historical reviews of the 1918 pandemic suggest that non-pharmaceutical interventions (such as 

school closures, social distancing, and cancellation of large public gatherings) could be very effective 

at slowing the spread of disease and mitigating the outbreak, but only if they are implemented early 

and maintained consistently across communities affected by a pandemic. These interventions, 

coupled with the use of antiviral medications, could dramatically reduce the number of people who 

become infected, potentially preventing illness and death in millions of Americans. 

The U.S. Government has invested in health system preparedness of hospitals and medical facilities 

across the country, has produced tools to assist in planning for expansion in hospital capacity during 

a pandemic, and is stockpiling medical supplies for distribution to individual States in the event of a 

pandemic. 

Each Federal department and agency is developing its own department- or agency-specific pandemic 

preparedness plan to ensure the continuation of Federal Government essential functions. Over the 

past year, the Federal Government has produced tools for businesses and other employers to assist 

them in pandemic planning and has conducted an extensive outreach effort to the private sector. 

Through these efforts, businesses operating at home and abroad have been provided practical 

action-oriented information to identify essential functions and critical planning elements, to protect 

the health of employees, to maintain continuity of business operations, and to sustain community 

function during a pandemic. 

Preparing the Nation for the threat of an influenza pandemic has provided a platform to address 

issues and concerns common to all types of mass casualty disasters. Promoting a culture of 

individual, family, and community preparedness is the foundation for all emergency planning efforts. 

Though we have made significant progress over the past year to prepare the Nation and the 

international community for the threat of an influenza pandemic, much important work lies ahead. 

One of the most tangible benefits of planning and preparing at a Federal level has been the forging 

of close working relationships and unity of effort among Federal departments and agencies. It is 

important that we enhance connectivity and collaboration between all levels of government and 

all segments of society. Now is the time, before a pandemic emerges, to establish and test these 

relationships and partnerships. The Federal Government must continue playing a leadership role in 

fostering an environment of collaboration and public engagement. 
4 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

Although we have realized progress in enhancing disease surveillance, critical gaps remain with 

respect to “real-time” disease detection and clinical surveillance in the United States. The Federal 

Government must redouble its efforts for developing “real-time” surveillance to ensure that we are 

not “blind” during the next pandemic. Real-time surveillance is needed to provide broad situational 

awareness, including the ability to detect, integrate, analyze, and operationally respond to pandemic 

influenza. The Federal Government must accelerate the development of rapid diagnostic tests 

and screening tests to ensure that our efforts to detect disease, treat ill people, and limit disease 

transmission can be appropriately and effectively implemented. 

Many hospitals and emergency departments nationwide are already operating at or near capacity and 

may not have the capability to treat the large numbers of patients who may need care during a severe 

pandemic. Healthcare workers and first responders will be on the front lines during an influenza 

pandemic. Ensuring the availability of protective measures for these critical workers will be essential 

to our efforts to protect the health and safety of the public. Community planning efforts will require 

the coordination of many providers and organizations and must address how healthcare facilities 

can best share medical response assets of personnel, materiel, and infrastructure in order to assure 

the greatest benefit for the largest number of people in the most ethical manner with the highest 

standard of medical care. The Federal Government has incorporated both funding and guidance 

to assist in planning for the strengthening of mass casualty care capacity. The stockpiling of critical 

medical materiel, including a reassessment of antiviral medication stockpile goals, is one area the 

Federal Government needs to address in the coming year. However, medical countermeasures, such 

as antiviral medications, have little utility if they cannot be delivered quickly to those in need. The 

Federal Government is working with State and local public health officials to strengthen plans to 

swiftly distribute needed medical countermeasures. 

Although the community mitigation strategy may significantly reduce illness and death, 

implementing this strategy will not be easy. To enhance individual and community adherence 

to these community mitigation measures, the Federal Government must continue to work with 

non-Federal stakeholders to address practical implementation considerations, including legal and 

feasibility concerns, at the State, local, and tribal levels and minimize any adverse consequences 

associated with implementation. 

Our Nation’s investment in pandemic preparedness could translate to a reduction in the number of 

deaths each year related to seasonal influenza. Improving disease detection and surveillance, utilizing 

antiviral medications, and promoting healthy behaviors such as hand washing and cough etiquette 

could help reduce the spread of seasonal influenza and other respiratory diseases. 

The unprecedented efforts to prepare for and respond to the threat of a pandemic underscore our 

resolve to protect human life and safeguard our Nation. No prior generation has ever anticipated and 

prepared for a pandemic. We have the opportunity to be the first generation to use our collective 

knowledge, determination, and resources to take on this task. The stakes are high, and our greatest 

enemy is complacency. We remain committed to this effort, not only for generations of Americans 

alive today, but also for the sake of generations to come.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 5

 National Strategy for Pandemic Influenza 

Implementation Plan

One Year Summary

Introduction

Although the visibility of avian influenza and pandemic preparedness has waned in the media, the 

threat of avian influenza and the potential for an influenza pandemic has not. A pandemic occurs 

when a novel strain of influenza virus emerges that has the ability to infect humans and to cause 

severe disease, and where efficient and sustained transmission between humans occurs. If humans 

have little or no immunity to a new virus, a worldwide epidemic, or pandemic, could ensue. Three 

influenza pandemics occurred during the 20th century. The most lethal of these was the 1918 

pandemic, which killed more than 500,000 Americans and 20 million people worldwide. A 

1918-like pandemic today would exact a terrible toll. In the United States alone, we could face 90 

million persons ill and nearly two million deaths.

Scientists believe that avian (bird) influenza viruses played a role in all three of the pandemics of 

the 20th century. This is the reason for the concern over the recent spread of the highly pathogenic 

avian influenza A H5N1 (H5N1) virus. Since the beginning of 2006, the number of countries 

with documented outbreaks of H5N1 in birds has increased from 16 to 60. Although H5N1 avian 

influenza is rarely transmitted to humans, it produces severe illness when such infections occur. As 

of June 2007, there have been more than 300 confirmed human cases and almost 200 deaths. Every 

human case represents an opportunity for the H5N1 virus to adapt itself to the human host or to 

exchange genetic material with a human influenza virus in a way that may increase its transmissibility 

among humans. If this occurs, the H5N1 virus could lead to the first pandemic of the 21st century.

In November 2005, President Bush mobilized the Nation to prepare for an influenza pandemic 

with the announcement of the National Strategy for Pandemic Influenza (National Strategy). The 

National Strategy outlines the Federal Government’s pandemic preparedness and response goals: 

(1) stopping, slowing, or otherwise limiting the spread of a pandemic to the United States; 

(2) limiting the domestic spread of a pandemic and mitigating disease, suffering, and death; and 

(3) sustaining infrastructure and mitigating impact to the economy and the functioning of society.

One year ago, in May 2006, the U.S. Government issued the National Strategy for Pandemic 

Influenza Implementation Plan (National Plan). The National Plan provides a roadmap to achieve 

the pandemic preparedness and response goals laid out in the National Strategy. To accomplish 

these goals, the National Plan contains more than 300 specific actions for Federal departments and 

agencies. Every one of the Federal actions included in the National Plan includes a measure of 

performance and a timeline for implementation of that action. The U.S. Government committed 

to this level of transparency and accountability in order to demonstrate to the rest of the world, our 

international partners, State and local governments, businesses, and the general public, just how 

seriously we take this threat.
6 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

One year after the release of the National Plan, we have an opportunity to review the tremendous 

progress that has been made, redirect our efforts as necessary, and focus on the highest priority 

gaps in our capabilities that remain. Approximately two-thirds of the 324 actions in the National 

Plan were targeted for completion within one year of the National Plan’s release. Of these “one year” 

actions, nearly 90 percent have been completed. While the completion of these actions attests to the 

level of effort dedicated to pandemic preparedness, it is important to examine how much progress we 

have made in addressing the three goals of our National Strategy.

It is everyone’s responsibility to remain vigilant. Though we cannot be certain that highly pathogenic 

avian influenza A H5N1 will spark a pandemic, we can be sure that at some point in the future a 

pandemic will occur. We cannot become complacent and must continue to take the threat of a 

pandemic very seriously. The ongoing efforts to plan and prepare for a pandemic will serve us well in 

the future, irrespective of the manner in which the current H5N1 outbreak unfolds. 

Limiting the International Spread of a Pandemic

At present, scientists believe that the likelihood of an avian virus changing into a virus that ultimately 

leads to the next influenza pandemic is greatest in places with widespread outbreaks in birds and with 

significant contact between infected animals and people. Reducing the opportunities for the virus to 

mutate, improving global disease monitoring, and helping other nations to prepare for and respond 

to outbreaks are key components of our risk mitigation strategy and a shared global responsibility. 

The United States has made pivotal contributions to control the international spread of H5N1 by 

working with affected countries and international partners to detect, contain, and prevent animal 

outbreaks, reduce human exposure to the virus, and enhance planning and preparedness for future 

outbreaks.

Leading the International Effort

In September 2005, President Bush announced the International Partnership on Avian and Pandemic 

Influenza (IPAPI) at the United Nations General Assembly. The Partnership was developed in 

concert with the World Health Organization (WHO) to align nations around a series of key goals 

including: elevating the issue of avian influenza on national agendas; coordinating efforts among 

donors and affected nations; mobilizing and leveraging resources; increasing transparency in disease 

reporting; improving surveillance; and building local capacity to identify, contain, and respond to an 

influenza pandemic. The challenge of avian influenza and the threat of a pandemic have required, 

and have produced, a coordinated international response, and the Partnership has mobilized the 

international community. The first meeting of the Partnership took place in Washington, DC in 

October 2005. In June 2006, 93 countries and 20 international organizations attended the IPAPI 

meeting in Vienna, Austria. Major international conferences have also taken place in Beijing, China 

in January 2006 and in Bamako, Mali in December 2006.

The United States is working on avian influenza issues in more than 100 countries, in collaboration 

with WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the World 

Organization for Animal Health (OIE), and regional organizations, as well as with other international 

and in-country partners, including national governments and non-governmental organizations. The 

U.S. Government is supporting communications and public education activities in more than 

50 countries to generate awareness about avian influenza and promote healthy behaviors and 
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 7

practices to reduce the risk of disease transmission. To help achieve this goal, the United States 

has supported the training of more than 113,000 people in the delivery of avian influenza 

communications messages. 

U.S. Government agencies have deployed scientists, veterinarians, public health and communications 

experts, physicians, and emergency response teams to affected and high-risk countries to assist in 

the development and implementation of emergency preparedness plans and procedures for response 

to avian and pandemic influenza. As a result of these efforts, the United States and its global 

partners have made much progress across the spectrum of animal health protection, public health 

preparedness, information sharing, and public communication and awareness. 

Establishing Surveillance Capability 

Worldwide

Constant vigilance is the key to combating 

avian influenza and preventing pandemic 

influenza. By detecting avian influenza 

outbreaks early, with improved surveillance 

and laboratory diagnostic capacity, the world 

community has the opportunity to contain 

outbreaks in birds and intensify surveillance 

for human H5N1 cases that may accompany 

those outbreaks. When human cases occur, 

U.S. scientists are working with international 

partners to help determine whether the 

infecting virus is developing the capacity 

for efficient, sustained human-to-human 

transmission. The United States is supporting 

efforts to improve laboratory diagnosis and 

early warning networks in 75 countries and is 

working with its partners to expand on-theground surveillance capacity and improve 

knowledge about the movement and changes 

in H5N1 on a global scale. This includes 

support for improving national and regional 

laboratories to ensure that countries are able 

to quickly confirm the presence of H5N1 

virus in people or animals so that a timely 

response is possible. 

In 2004, the United States launched the Influenza Genome Sequencing Project to track genetic 

changes in viral strains. As a result, genome sequences of more than 2,250 human and avian 

influenza isolates have been made publicly available. Scientists around the world can now use 

the public sequence data to compare different strains of the virus, identify the genetic factors that 

determine their virulence, and develop new countermeasures. In 2006, the U.S. Government 

supported the creation of the Wild Bird Global Avian Influenza Network for Surveillance project 

The United States Provides Assistance for 

Laboratories Overseas

The Lao People’s Democratic Republic (Laos), a 

high-risk Southeast Asian country, has become a 

full participant in the Global Influenza Surveillance 

Network. The new Lao National Influenza 

Laboratory was established in 2006 with on-site 

U.S. Government assistance. In March 2007, the 

Lao laboratory identified a human case of H5N1 and 

sent the specimen to a WHO Collaborating Center 

for confirmatory testing. In 2006, the U.S. Naval 

Medical Research Unit in Egypt (NAMRU-3) assisted 

the Ukrainian Ministry of Health in establishing 

a national influenza laboratory that conducts 

molecular diagnostic testing for both seasonal and 

pandemic influenza. The United States provided 

equipment and reagents and provides ongoing 

confirmatory diagnostic testing. With technical and 

financial support from the United States, the Pacific 

Public Health Surveillance Network laboratory 

consortium in New Caledonia began routine testing 

of influenza viruses in 2006, and identified a new 

influenza A (H1N1) strain from the Solomon Islands 

that was recommended by WHO as a vaccine 

strain for vaccines to be used in the 2007-8 season. 

These examples represent major milestones in the 

development of capacity for pandemic influenza 

detection and response in priority countries.
8 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

in order to share information, increase 

the availability of scientific information 

for detection and containment, and track 

changes in virus isolates in wild birds. 

The U.S. Department of Defense’s Global 

Emerging Infections Surveillance and 

Response System (GEIS) supports 

surveillance activities in the military health 

system worldwide. Overseas, there are five 

laboratories located in Peru, Egypt, Kenya, 

Thailand, and Indonesia. These laboratories 

represent a global network of expertise 

in emerging infectious disease detection. 

The U.S. Navy’s laboratory in Lima, Peru, 

expanded the number of sites from which 

it receives specimens from 12 sites in three 

countries to a total of 35 clinic/hospital 

sentinel sites in six countries of Central and 

South America, with plans for expansion 

to another four countries in 2007. The U.S. 

Naval Medical Research Unit in Cairo, Egypt 

(NAMRU-3) provides influenza surveillance 

including human and animal sampling in 19 

countries in Africa, East Europe, the Middle 

East, and the former Soviet Union. Additional surveillance sites are being established in 2007 in six 

countries. Previously there was no consistent surveillance in sub-Saharan Africa. The U.S. Army 

Medical Research Unit (USAMRU) in Kenya now provides ongoing human influenza surveillance in 

the region. The U.S. Naval Medical Research Unit in Jakarta, Indonesia (NAMRU-2) has probably 

had the largest expansion in influenza surveillance efforts this past year because it is located in the 

epicenter of the H5N1 epidemic in the region. Syndromic surveillance has been expanded in 2006 to 

ten hospitals in the Lao People’s Democratic Republic (Laos) and two in Cambodia. 

Supporting a Coordinated International Response to H5N1 Avian (Bird) Influenza

Once an influenza virus with pandemic potential, such as highly pathogenic avian influenza A H5N1, 

is found in domestic birds, swine, or other domestic animals, it is necessary to eradicate the disease 

as quickly as possible and to take public health measures to minimize human exposure to the virus. 

If such a virus is found in wild birds or other wildlife, efforts should be directed at preventing it from 

being introduced into domestic birds or other susceptible animals. 

The U.S. Government provided funding to strengthen WHO’s Global Outbreak Alert and Response 

Network (GOARN), which supports public health surveillance and response in nations worldwide. 

The United States, with international partners, is providing training for thousands of individuals 

who will lead efforts to detect, contain, and mitigate the impact of animal outbreaks and take steps 

The United States Helps Enhance Surveillance 

in High-Risk Areas

Due in large part to support from the United States, 

countries particularly vulnerable to avian influenza 

outbreaks have made significant developments 

in surveillance and response capacity at national 

and local levels. In Indonesia, an increasing 

number of high-risk areas are now able to provide 

weekly outbreak updates and launch outbreak 

response efforts within 24 hours. Contributing to 

this improvement are U.S. Government efforts to 

work with FAO and the Ministries of Agriculture 

and Health to develop participatory disease 

surveillance and response teams in all 154 avian 

influenza-endemic districts. The United States is 

also helping to expand local capacity for active 

surveillance across 27,000 villages in Java, 

Bali, and Sumatra through two Indonesian nongovernmental organizations. In addition, increased 

surveillance and detection capacity in Laos allowed 

for rapid and accurate diagnosis of the July 2006 

outbreak in poultry as an H5 avian influenza virus. 

These enhancements in surveillance resulted in 

more rapid response to outbreaks and improved 

containment to limit the spread of the virus.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 9

to prevent future outbreaks from occurring. Over 

the past year, the U.S. Government has supported 

the training of more than 129,000 animal health 

workers and 17,000 human health workers in 

H5N1 surveillance and outbreak response. Since 

January 2006, the United States has deployed more 

than 300,000 personal protective equipment kits to 

over 70 countries for use by surveillance workers 

and outbreak-response teams. In cooperation 

with WHO and the United Nations Food and 

Agriculture Organization (FAO), U.S. experts 

have provided vital technical expertise to national 

investigations of actual outbreaks of H5N1 in 

countries on three continents and provided 

technical assistance, commodities, and logistical 

or financial support to 39 of the 60 countries and 

jurisdictions affected by H5N1 to date. As a result 

of the efforts of the United States and the support 

of our international partners, the international 

community is aware of outbreaks sooner and is 

able to launch more effective and timely responses. 

The U.S. Government has expanded the HHS/

CDC network of Global Disease Detection (GDD) Centers, which works closely with WHOGeneva and WHO Regional and Country Offices. This program is a network of international 

centers of excellence dedicated to the surveillance of emerging infectious diseases, outbreak 

detection, identification, tracking, and response, as well as the provision of training programs for 

field epidemiology and laboratory scientists. New GDD Centers have been established in China, 

Egypt, and Guatemala, and GDD Centers in Thailand and Kenya have been strengthened. The GDD 

Centers in Thailand and Kenya have fully trained rapid response teams and stockpiles of protective 

equipment available for deployment internationally within 24 hours. Work is underway to establish 

regional rapid response teams and stockpiles at GDD Centers in China and Egypt. 

The United States Prepares for H5N1 Avian Influenza Spread to North America

Although the H5N1 avian influenza virus has not yet spread to North America, the United States is 

collaborating closely with Canada and Mexico through the Security and Prosperity Partnership to 

coordinate surveillance efforts for the early detection of the virus in wild birds migrating within and 

across North America. In the United States, a joint Federal/State program for the early detection of 

highly pathogenic avian influenza virus in wild birds has collected more than 145,000 samples from 

birds in all 50 States and territories since April 1, 2006. None of these U.S. samples tested positive for 

highly pathogenic avian influenza A H5N1. 

The U.S. Government has completed acquisition of 140 million doses of avian vaccine. The National 

Veterinary Stockpile has entered into a contract for delivery of up to 500 million doses of an 

additional vaccine that can be used in young poultry. These avian vaccines can be acquired more 

The United States Helps Reduce H5N1 

Outbreaks in Southeast Asia 

Between 2003 and 2005, Thailand and Vietnam 

accounted for 88 percent of the world’s H5N1 

avian influenza outbreaks in animals. In 2005, 

there were at least 1,500 reported poultry 

outbreaks; however, the number fell to just 209 

in 2006, and human cases fell from 75 to 3 over 

the same period of time. While many factors 

likely contributed to this shift, a substantial 

portion of this dramatic reduction in outbreaks 

can be attributed to the aggressive measures 

these countries, with U.S. Government 

support, have taken to combat avian influenza. 

As a result, countries across the region are 

more prepared and better able to mount 

effective outbreak response. In Cambodia and 

Laos, for instance, the time between onset 

of outbreaks and reporting has shortened 

from up to 5 weeks to 48 hours, significantly 

improving the opportunity for an effective 

outbreak response and containment.

National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 11 U.

S. Assistance to Countries 

Affected by H5

N1
12 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

rapidly than human vaccines because they, or similar vaccines, have already been tested and approved 

for use in poultry, in some cases long before highly pathogenic avian influenza H5N1 was a subtype 

of concern. Since May 2006, Federal veterinary specialists have participated in more than 50 Stateand county-level exercises for highly contagious animal diseases, including avian influenza. The 

U.S. Government also held a national exercise that focused on the roles of Federal, State, and local 

government agencies, industry (primarily poultry), and consumer groups in collectively responding 

to an outbreak. More exercises are planned for 2007, with a focus on State- and tribal-level response 

planning and on mobilizing the National Veterinary Stockpile. 

In addition, the U.S. Government has in place a process that provides real-time technical information 

and policy guidance to prevent the spread of avian influenza in commercial and other domestic 

birds and animals during a disease outbreak. This guidance includes biosecurity practices to help 

prevent disease from being introduced into a bird or flock, including restricting access to outside 

persons; preventing contact with wild birds; cleaning equipment, footwear, and vehicles; and 

separating new or returning birds from others in the flock for a period of time. Nearly one million 

copies of “Biosecurity for Birds” campaign materials have been distributed to all 50 States and more 

than 50 countries, and bilingual biosecurity information has been placed on more than 1.7 million 

poultry feed sacks. This guidance has also reached nearly 30 million readers through newspaper 

and magazine ads and 23 million listeners in 29 States through 30-second radio ads on national and 

regional agricultural radio networks.

International Response to Pandemic Influenza

By its very nature, a pandemic respects no borders. An outbreak of pandemic influenza anywhere 

poses a risk to populations everywhere. Our international effort to contain and mitigate the effects 

of an outbreak of pandemic influenza 

beyond our borders is a central 

component of our strategy. 

The United States is working to enhance 

the ability of international organizations 

and individual countries to detect 

and respond to a pandemic. We are 

supporting many countries in their 

efforts to strengthen their laboratory 

diagnostic capacity, improve public 

communication, and develop national 

preparedness plans.

Although a pandemic virus has not 

yet emerged, the appearance of limited 

human clusters of H5N1 cases has 

tested our international surveillance 

and response capabilities. Since 

January 2006, U.S. Government 

scientists have assisted with on-site 

H5N1 investigations in Turkey, Nigeria, 

The United States Responds to Human H5N1 Cluster 

In May 2006, a cluster of human cases in Indonesia 

raised alarms that the disease may have spread between 

humans. Through prior preparedness planning and 

through coordination centered in the State Department 

with the U.S. Naval Medical Research Unit (NAMRU-2), the 

CDC, and the U.S. Agency for International Development, 

U.S. scientists, as part of a WHO team, were able to 

provide emergency support to the Indonesian Government. 

The international team investigated the outbreak, quickly 

analyzed samples through NAMRU-2 in Jakarta, and 

performed additional analyses and H5N1 confirmation 

through the CDC in Atlanta. This coordinated international 

response allowed WHO to quickly provide updates and 

reduce alarm as the cases were confirmed to be isolated 

incidents of inefficient human-to-human transmission 

and that the virus was not widely circulating among 

humans. The outbreak of avian influenza was not the start 

of a human pandemic, but the coordinated international 

response was an opportunity to practice what we intend to 

do if a pandemic arises.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 13

Romania, Djibouti, Indonesia, China, Laos, Vietnam, and southern Sudan. Investigative assistance 

included laboratory diagnosis, identification of disease risk factors, and analysis of clusters of disease 

to establish whether human-to-human (second generation) or human-to-human-to-human (third 

generation) transmission was occurring. U.S. Government scientists helped investigate several 

clusters of suspected human-to-human transmission including: a three-person family cluster in 

Thailand in 2004, in which limited second generation transmission was documented; three family 

clusters of H5N1 cases in South Sumatra, Indonesia, in 2005, in which the possibility of limited 

second generation H5N1 transmission could not be excluded for two of the clusters; and a large 

family cluster of H5N1 cases in North Sumatra, Indonesia (eight cases, seven deaths) in 2006, in 

which limited, non-sustained third generation transmission of H5N1 viruses likely occurred.

If, despite our efforts, a pandemic virus does emerge (i.e., the virus develops easy and ongoing 

transmission among humans), the United States and our global partners are preparing to mount an 

international rapid containment effort wherever the virus emerges in order to contain it or to slow its 

spread.

The United States has developed protocols and trained personnel to support an international effort 

to contain the pandemic in its earliest stages. The U.S. Government procured and pre-positioned 

overseas stockpiles of personal protective equipment, decontamination kits, and antiviral medications 

to complement global containment efforts. 

National Border Measures: One Layer of Protection Against the Pandemic Virus

If a pandemic begins outside the United States, and international containment efforts fail, the U.S. 

Government has planned a series of layered border measures that may be implemented incrementally 

during a severe pandemic to slow the entry of a pandemic virus into the United States while allowing 

the flow of goods and people. These border measures during the early stages of a severe pandemic 

may include flight restrictions from affected regions, issuance of health guidance to travelers 

intending to enter the United States, health screening of travelers before departure, en route, and on 

arrival to the United States, as well as public health measures to limit onward transmission of the 

disease.

We are working closely with our neighbors Canada and Mexico to establish a common North 

American approach to delay the arrival and impact of a pandemic. One of the objectives of the 

pandemic planning efforts in the Security and Prosperity Partnership is the development of the 

North American Plan for Avian and Pandemic Influenza. This trilateral plan, now being finalized, 

establishes a framework for coordinated, trilateral actions regarding communication, responses to 

avian and pandemic influenza, border monitoring, and critical infrastructure protection. Developed 

as part of the Plan is a concept of operations for responding to aircraft inbound to North America 

that are carrying passengers potentially infected with the pandemic virus. This approach is currently 

being shared with other aviation partners around the world. U.S. Quarantine Stations, located at 

ports of entry and land-border crossings where international travelers arrive, will play an important 

role in delaying the introduction of pandemic influenza into the United States and helping to limit its 

spread. The number of quarantine stations in the United States has more than doubled since 2004, 

expanding from 8 to 20 locations, with quarantine stations in Dallas and Philadelphia added this 

past year.
14 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

Limiting the Domestic Spread of a Pandemic and Mitigating 

Disease, Suffering, and Death

Should an influenza pandemic reach the United States, our primary focus will be to safeguard 

the health of the U.S. population. Our ability to accomplish this goal will require: (1) effective 

surveillance for influenza outbreaks, including improved diagnostic tests; (2) the rapid development, 

production, and distribution of vaccine; (3) the targeted and effective use of antiviral medications; 

(4) the application of community mitigation measures; (5) the expansion of hospital and medical care 

capability; and (6) effective communication of risk reduction strategies. Although we still have much 

to do in these areas, progress has been made on each of these fronts over the past year. 

Enhancing Clinical Surveillance and Response

The U.S. Government is working to enhance the Nation’s ability to detect and respond early and 

effectively to a pandemic, particularly through partnerships with State and local governments. 

To better detect first cases of pandemic influenza in a community, the U.S. Government has provided 

resources to State and local health departments to increase the number of sentinel providers, to 

improve laboratory detection at public health laboratories, to support an influenza coordinator in 

each jurisdiction, and to educate clinicians to increase testing for and detection of influenza infection. 

The Sentinel Provider Network includes approximately 2,300 healthcare providers nationwide who 

report the number of weekly outpatient visits for influenza-like illness and submit specimens to 

State public health laboratories for influenza virus testing. This information helps identify emerging 

influenza strains and monitor disease patterns.

Since 2003, the Federal Government had designated $5 million per year for the States bordering 

Canada and Mexico to create and maintain an Early Warning Infectious Disease Surveillance System. 

This system is a unique collaboration of State, Federal, and international partners who work together 

to provide rapid and effective laboratory confirmation of urgent infectious disease case reports in 

the border regions of the United States, Canada, and Mexico. More recently, the border surveillance 

system has expanded to include, among other activities, 11 border pandemic influenza tabletop 

exercises, which included testing response by local personnel to the arrival of inbound flights with ill 

passengers. 

In partnership with the Council of State and Territorial Epidemiologists (CSTE), the Federal 

Government operates the National Notifiable Disease Surveillance System. Through this system, 

public health practitioners at local, State, and national levels provide weekly information about 

specific diseases occurring in the 50 States, 5 territories, New York City, and the District of Columbia. 

In January 2007, the CSTE adopted an interim position statement that added “novel influenza A 

virus infections” to its list of reportable diseases. This action will help activate timely and appropriate 

health responses to human infections that might have pandemic potential and meets WHO’s 

International Health Regulations 2005 revision that member states report human infections with new 

human influenza viruses. 

The U.S. Laboratory Response Network (LRN), which includes State public health laboratories, has 

the capacity to perform tests using the real-time reverse transcriptase-polymerase chain reaction 

(RT-PCR) technique. All 50 States are prepared to conduct initial testing of suspected human 

infection with H5N1 within 24 hours of receipt, using RT-PCR primers and probes developed 
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 15

and validated at the CDC. Reagents and 

protocols for testing for H5 influenza have 

been distributed to 99 LRN laboratories 

throughout the country.

The U.S. Government is also working to 

create a test that would, within 30 minutes, 

detect and differentiate seasonal influenza 

from highly pathogenic avian influenza 

H5N1. In November 2006, the Federal 

Government awarded contracts to four 

companies to develop new diagnostic tests 

that doctors and field epidemiologists could 

eventually use to quickly and accurately test 

patients for avian-origin H5N1 and other 

emerging influenza viruses, as well as more 

common influenza viruses.

The Federal Government has been working to ensure that both Emergency Medical Services (EMS) 

and 9-1-1 public safety answering points are well integrated into the Nation’s pandemic influenza 

planning and response, as both are essential to the Nation’s health and safety in the event of a 

pandemic. To accomplish this integration new guidelines and protocols for both EMS and 9-1-1 have 

been developed. Representatives from Federal agencies and national EMS, 9-1-1, and public health 

organizations jointly developed these new guidelines. Taken together, the two documents provide 

general guidance, considerations, and ideas that can enhance the optimal delivery of emergency care 

and 9-1-1 services during an influenza pandemic. 

Expanding Vaccine Supply

If our containment efforts fail, a well-matched pandemic vaccine will be our most effective 

countermeasure during an influenza pandemic. However, the current global capacity to produce 

a vaccine to respond to an influenza pandemic is insufficient to meet global needs. Developing 

improved vaccines and novel vaccine technologies and enhancing vaccine production is a top 

priority. The U.S. Government is providing direct financial support to WHO to expand the 

development and manufacturing infrastructure for influenza vaccine in six key developing countries, 

which will give them the capability to manufacture safe and effective influenza vaccines for seasonal 

influenza, and for their own, and possibly regional, needs in the event of a pandemic. 

It is the goal of the Federal Government to be able to vaccinate every American as rapidly as possible 

during a pandemic. To help accomplish this, the Federal Government is investing in the expansion 

of both egg- and cell-based vaccine manufacturing capacity, the advanced development of new 

cell-based vaccines, antigen-sparing technologies, and the establishment and maintenance of prepandemic vaccine stockpiles. 

Licensed influenza vaccines are currently produced in special chicken eggs, in a technique that has 

changed little in over 50 years. In contrast, cell-based vaccine manufacturing, a technology that 

is used to produce other modern vaccines, holds the promise of a reliable, flexible, and scalable 

Online Training for Public Health Response 

To improve domestic response efforts, the CDC has 

released an online version of its three-day training 

course that provides a standardized curriculum 

to State and local public health responders about 

how to identify and control human infections and 

illness associated with avian influenza A H5N1. 

The course, entitled “CDC/CSTE Rapid Response 

Training: The Role of Public Health in a MultiAgency Response to Avian Influenza in the United 

States” is the result of a partnership between 

the Centers for Disease Control and Prevention 

(CDC) and the Council of State and Territorial 

Epidemiologists (CSTE). The course is available at 

<www.cste.org/influenza/avian.asp>.
16 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

method of producing influenza vaccines. To 

help achieve this goal, the U.S. Government 

awarded over $1 billion in May 2006 to major 

influenza vaccine manufacturers to enable 

them, over the next 5 years, to produce at 

least 300 million courses of egg- and cellbased pandemic vaccine within 6 months 

of the emergence of a pandemic virus. This 

year, the U.S. Government will request 

proposals from commercial manufacturers 

for the advanced development of other 

technologies such as recombinant DNA 

vaccines that may be made more rapidly at 

the time of a pandemic. Not only will such 

vaccines further diversify our vaccine arsenal, 

these vaccine technologies have the potential 

to be manufactured faster than traditional 

vaccines.

In April 2007, the Federal Government 

approved the first vaccine for humans against 

the H5N1 avian-origin influenza virus. We 

currently have enough of this pre-pandemic H5N1 vaccine for approximately 6 million people, with 

plans to stockpile enough pre-pandemic vaccine for 20 million people. The approval and availability 

of this vaccine will enhance national readiness and the Nation’s ability to protect those at increased 

risk of exposure. This vaccine could be used if the current H5N1 avian virus were to develop the 

capability for efficient, sustained spread among humans, resulting in the spread of the disease 

across the globe. Should the H5N1 virus lead to a pandemic, this vaccine may provide early limited 

protection in the months before a vaccine tailored to the pandemic strain of the virus could be 

developed and produced. 

We are also investing heavily in the evaluation of adjuvants, which could allow us to greatly increase 

the number of people vaccinated with a limited supply of vaccine material. An adjuvant is a 

substance that may be added to a vaccine to increase the body’s immune response to the vaccine’s 

active ingredient, called antigen. Adjuvants are one of the most promising technologies, given that 

they could dramatically extend the reach of a limited supply of the pre-pandemic vaccine and expand 

the production of a well-matched pandemic vaccine when it becomes available. Contracts totaling 

$132.5 million were awarded in January 2007 to three vaccine makers for the advanced development 

of H5N1 influenza vaccines for humans using antigen-sparing techniques. Initial clinical studies 

from two of the vaccine manufacturers have shown that the addition of their adjuvants to 

H5N1 vaccines may increase the vaccine’s efficacy 10- to 20-fold and may provide cross-protection 

against variants of virus subtypes. Additional clinical studies are planned in 2007 for the H5N1 

vaccine products with each of the three new adjuvants. If these results are confirmed, then these 

adjuvants offer hope that we will be able to stretch our pre-pandemic vaccine supplies and, in effect, 

increase our pandemic vaccine manufacturing capacity 10- to 20-fold. 

DARPA Challenge—Accelerated Manufacture 

of Vaccines

Our best scientists are racing to develop new 

vaccine production technologies now. The 

Department of Defense’s Defense Advanced 

Research Projects Agency (DARPA) is working 

with scientists on radical technologies to create 

new vaccines, at a fraction of the cost of traditional 

vaccines, in much less time. The DARPA Challenge: 

to create a scalable system that makes 3 million 

doses of vaccine within 12 weeks of an outbreak 

of a new disease -- enough to protect our fighting 

men and women. Because of the goal, scientists 

are exploring novel and innovative production 

techniques. The principal aim of the DARPA 

projects is to remove technological barriers to 

imaginative solutions. This project, like other 

DARPA Challenges, taps the talent and ingenuity of 

our Nation’s scientists. If any of the technologies 

under development prove feasible, they will further 

revolutionize our vaccine production capability.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 17

At the beginning of a pandemic, the scarcity 

of vaccine will require the limited supply 

to be prioritized for distribution and 

administration. The Federal Government has 

begun a process to revise previous interim 

guidance for Federal, State, local, tribal, and 

territorial planners on groups to target for 

earlier access to pandemic vaccines. The U.S. 

Government has sought input from influenza 

experts, State and local public health officials, 

homeland security experts, ethicists, private 

sector stakeholders, and the public in 

developing this guidance.

Stockpiling Antiviral Medications

Antiviral medications are an important 

element of pandemic influenza preparedness. 

Our current national goal is to have 

81 million courses of antiviral drugs in 

Federal and State stockpiles by 2008, of which 

50 million regimens will be purchased and 

managed in Federal stockpiles and 31 million 

in State stockpiles. As of June 2007, the 

Strategic National Stockpile contains more 

than 35 million regimens of antiviral drugs 

with an additional 2 million regimens on order. Thus far, States have stockpiled over 13 million 

regimens of antiviral drugs. At this time all State and Federal stockpiles of antiviral medications 

should be reserved for treatment of symptomatic patients. As stockpiles of antiviral drugs increase, 

the strategies for use may be expanded to include prophylaxis. Additional guidance on prophylaxis 

strategies is being developed.

The Government’s antiviral strategy includes not only stockpiling existing antiviral drugs, but 

also developing new antiviral medications to further broaden our capabilities to treat and prevent 

influenza. In January 2007, the Federal Government awarded a 4-year contract of over $100 million 

for advanced development of a new influenza antiviral drug that can be given by injection to rapidly 

treat persons with severe influenza.

Limiting the Spread and Impact of a Pandemic: Community Mitigation 

There is no question that the United States and the world stand to benefit from the unprecedented 

investments in influenza vaccine production, but the reality is that it will be years before we have 

enough capacity to quickly produce enough pandemic vaccine for the entire population. Even then, 

the time required to produce a vaccine may exceed the duration of the first wave of a pandemic. 

This means that we must have a plan to deal with a pandemic that does not rely upon the immediate 

availability of a vaccine.

U.S. Scientists Identify Harmful Genes 

in 1918 Virus

Groundbreaking research efforts are helping 

us understand what makes an influenza virus 

into a virulent pandemic virus. U.S. scientists 

have reconstructed the influenza virus strain 

responsible for the 1918 pandemic, a project that 

greatly advances preparedness efforts for the next 

pandemic. U.S. Government researchers have 

also analyzed one of the proteins that covers the 

surface of the 1918 influenza virus and discovered 

a molecular property that may help to explain the 

virus’s ability to spread easily from human to human. 

They found that the hemagglutinin protein, which 

is found on the surface of influenza viruses and 

binds to host cells, plays an important role in the 

transmission efficiency of the virus. By changing 

two amino acids (the basic building blocks of 

proteins) in the hemagglutinin of the 1918 virus, the 

researchers were able to create a version of the 

1918 virus that was incapable of transmission in an 

animal model. This knowledge will help scientists 

develop new drugs and vaccines that act on the 

proteins encoded by these genes.
18 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

In February 2007, the U.S. Government 

released groundbreaking Federal guidance 

for non-pharmaceutical interventions for 

mitigating the impact of a pandemic. This 

community mitigation strategy is important 

because the best protection against 

pandemic influenza, a matched pandemic 

vaccine, is not likely to be available at the 

outset of a pandemic. 

The impact of a poorly mitigated 1918-like 

pandemic today would be staggering. In the 

United States alone, we could face 90 million 

ill persons and nearly two million deaths. 

Recent scientific modeling and historical 

reviews of the 1918 pandemic suggest that 

non-pharmaceutical interventions could 

be very effective at slowing the spread of 

disease and mitigating the outbreak, but 

only if they are implemented early and 

maintained consistently across communities 

affected by a pandemic. We estimate that 

these interventions could dramatically 

reduce the number of people who become 

infected, potentially preventing illness and 

death in millions of Americans. Therefore, 

community mitigation measures will serve 

as a first line of defense to help delay or 

mitigate the spread of influenza. 

These interventions include:

• Staying home if one is ill;

• Staying home if someone in one’s household is ill;

• Dismissing students from school, closing childcare facilities, and keeping children home; and

• Reducing close contacts in the community and at work (i.e., social distancing). 

These interventions are strengthened by the combining of these non-pharmaceutical interventions 

with antiviral medications and the layering of other infection control measures to reduce disease 

transmission, such as hand hygiene (frequent hand washing), respiratory etiquette (covering coughs 

and sneezes), and the use of facemasks. 

The Community Mitigation Guidance also introduces a Pandemic Severity Index (PSI) for assessing 

the health threat posed by a pandemic virus. The index will allow us to tailor community mitigation 

interventions and balance the need to protect the public’s health while minimizing societal and 

economic disruptions. The community mitigation strategy was designed with input from many 

Lessons from the 1918 Pandemic Can Help 

Communities Today

Researchers studying the outcomes of the 1918 

pandemic in dozens of U.S. cities have concluded 

that the speed of the public health response 

matters tremendously. Implementing multiple nonpharmaceutical interventions early in a local epidemic 

can save lives. As an example, the contrast of 

mortality outcomes in 1918 between Philadelphia and 

St. Louis is particularly striking. The first cases of 

disease among civilians in Philadelphia were reported 

on September 17, 1918, but authorities allowed large 

public gatherings, most notably a citywide parade on 

September 28, 1918, to continue. School closures, 

bans on public gatherings, and other social distancing 

interventions that reduce contacts between people 

were not implemented until October 3, when disease 

spread had already begun to overwhelm the city. In 

contrast, the first cases of disease among civilians in 

St. Louis were reported on October 5, and authorities 

introduced interventions essentially identical to 

those introduced in Philadelphia on October 7. The 

difference in response times between the two cities 

was approximately 14 days, when measured from the 

first reported cases. The costs of this delay were 

enormous. Philadelphia ultimately experienced a 

cumulative excess pneumonia and influenza death 

rate during the fall of 1918, more than twice that of 

St. Louis.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 19

Federal agencies, State and local public health officials, researchers and mathematical modelers, 

healthcare and influenza experts, private sector entities, faith-based and community organizations, 

labor unions, educational stakeholders, and members of the public. The development from inception 

to adoption of a Federal policy on community mitigation within 9 months of the release of the 

National Plan underscores the level of commitment and coordination among government agencies 

with responsibility for emergency response. 

Expanding Medical Capacity to Care for Large Numbers of Ill Patients

A severe influenza pandemic would place a tremendous burden on the U.S. healthcare system. 

Estimates based on extrapolation of a severe 1918-like pandemic project that 45 million Americans 

would seek medical care with 10 million of those requiring hospitalization. The projected demand 

for inpatient and intensive care unit beds and mechanical ventilation services would overwhelm the 

Nation’s healthcare system. Pre-pandemic planning by healthcare facilities is essential to prepare for 

the surge in medical care associated with a pandemic. 

Coordinated community-wide and regional planning is needed for an optimal medical care response 

to a pandemic. An essential part of community and regional planning is the development and 

implementation of electronic systems that exchange information among hospitals and public health 

agencies to provide the needed situational awareness to manage patients, medical supplies, and staff 

during an influenza pandemic. The Federal Government has produced tools to assist in planning 

for improvements in hospital capacity during a pandemic. The Community Planning Guide for 

Providing Mass Medical Care with Scarce 

Resources offers specific recommendations 

for providing the highest possible standard of 

care where resources are limited. This guide 

addresses ethical and legal issues and offers 

recommendations across the spectrum of care, 

including pre-hospital, hospital, alternative 

care sites, and palliative care. Implementing 

these recommendations will help prevent 

degradation of care if large numbers of patients 

are seeking care in healthcare facilities.

Pre-hospital care and emergency response is a 

critical component of medical surge planning. 

EMS responders are a respected, well-trained, 

mobile healthcare workforce that exists in 

every community in the country and can be 

quickly dispatched when the public calls 9-1-1 

for assistance. Because the Nation will rely on 

this workforce during an influenza pandemic, 

the Federal Government has developed new 

guidelines and protocols to enhance the 

delivery of EMS and 9-1-1 services during an 

influenza pandemic.

Federal Healthcare Systems Prepare 

for a Pandemic 

The Department of Veterans Affairs, one of the 

largest integrated national healthcare systems 

in the United States, consisting of 150 hospitals 

and more than 700 outpatient clinics, has taken 

steps to ensure that medical care services can be 

sustained during a pandemic. The VA healthcare 

system has a fully functional electronic medical 

record system that automatically provides critical 

surveillance data from all sites of care to the 

CDC. Through its Consolidated Mail Outpatient 

Pharmacy program, more than three-fourths of 

all prescriptions are delivered to patients, thus 

avoiding the need for patient visits to pharmacies, 

clinics, or hospitals for medications. The 

organization has made a commitment to protect 

patient care staff during a pandemic by providing 

them with the best available personal protective 

equipment and access to antiviral medications. 

A system-wide retired clinician volunteer corps 

is being organized to enhance staffing during a 

pandemic.
20 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

The Federal Government has incorporated both funding and guidance to ensure that public health 

and healthcare delivery partners throughout the country work together to strengthen public health 

and health system preparedness. Awardees of Federal Pandemic Influenza funding were required 

to hold exercises in the areas critical to expanding mass casualty care capability and health system 

preparedness, including: use of the Emergency System for Advanced Registration of Volunteer 

Health Professionals (ESAR-VHP), mass-fatality plans, communications systems, triage and 

admission plans, alternate care sites, and healthcare facility-level infection control. These activities 

support both pandemic and all-hazards preparedness. 

As part of the joint effort to strengthen capacity within the healthcare and medical communities, 

funding has been directed to the purchase and storage of pharmaceutical caches, personal protective 

equipment, ventilators, and other critical medical materiel. In addition to these stockpiles, the 

Department of Veterans Affairs has more than 150 emergency pharmaceutical and medical caches 

around the Nation.

By reducing disease transmission and decreasing the number of Americans becoming ill, and 

therefore the number requiring hospitalization, community mitigation measures offer an additional 

strategy to help narrow the gap between existing acute care capacity in the United States and the 

surge demand for medical care. The community mitigation measures, as well as infection control 

practices such as hand hygiene and respiratory etiquette, can help lessen the strain on healthcare 

systems by focusing on the goal of reducing disease transmission. 

Risk Communication 

Effective risk and crisis communications will help guide the public, the news media, healthcare 

providers, and other groups to respond appropriately in outbreak situations and to adhere to public 

health measures. The website <www.pandemicflu.gov>, available in English, Spanish, Chinese, and 

Vietnamese, provides one-stop access to all Federal avian and pandemic influenza information. More 

than 1,700 websites around the world link to the PandemicFlu.gov homepage. 

In early 2007, the U.S. Government sponsored tabletop exercises with key media leaders and 

senior government officials in Atlanta, Chicago, Los Angeles, Miami, New York, and Washington, 

DC. These exercises facilitated effective two-way communication between the media and senior 

government officials about the challenges of delivering timely, accurate information to the public 

during a pandemic. In addition, the U.S. Government has delivered 10 Crisis and Emergency-Risk 

Communications courses to State and local officials, presenting and applying proven tools and 

approaches to the communication of crisis information.

In February 2007, the Federal Government launched a series of television and radio public service 

announcements (PSAs) to raise awareness of pandemic influenza and to educate members of the 

public about the steps they can take now to prepare. The PSAs, released under the brand “Know 

What to do About Pandemic Flu,” were distributed to 300 television and 1,000 radio stations across 

the country. Basic collateral materials were developed to support the PSA campaign and have been 

posted on PandemicFlu.gov. As of May 21, 2007, the PSAs have been aired more than 20,000 times. 
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 21

Overseas, the U.S. Government has reached out to the estimated 4 to 5 million private U.S. citizens 

abroad through a variety of methods to provide information on individual pandemic preparedness 

measures. The Department of State, through its website <www.travel.state.gov>, American 

community newsletters, warden messages, and town hall meetings, has conducted an aggressive 

outreach campaign to private U.S. citizens traveling and residing abroad. 

In the event of a pandemic, the Federal Government will communicate to the public through both 

traditional and new media channels and will work with partners including the business community, 

faith-based and civic organizations, and healthcare providers to reach the general public with critical 

information on how to protect themselves and their loved ones. 

Sustaining Infrastructure and Mitigating Impact to the 

Economy and the Functioning of Society During a Pandemic

Although social distancing is critical for helping to limit the spread of the pandemic, it will be 

difficult to maintain if people feel that they do not have access to the resources, information, and 

support systems necessary to keep them safe. A severe pandemic could dramatically reduce the 

number of available workers and significantly disrupt the movement of people and goods, which 

could in turn threaten essential services and operations across our Nation. 

The scale and scope of a pandemic necessitate a dedicated effort and investment beyond typical 

business continuity planning. The effort to sustain our critical infrastructure and the functioning 

of society will require the engagement of all levels of government and all segments of society. 

Ultimately, the effectiveness of our response depends upon individual, family, and community 

preparedness.

Strengthening Community Resiliency

A major U.S. university, partnering with leading businesses, public health officials, and public schools, is 

developing and testing innovative approaches to increase local community and neighborhood resiliency. 

To provide local and timely information during a pandemic, they have engaged major technology 

companies to help deliver community-specific information for pandemic preparedness over the web 

and to increase the capacity for providing local information to the public by phone. Using existing 

technologies, large numbers of toll-free calls could be routed to informed community volunteers able 

to answer phones from their homes. Local schools would also play an important role. Through a new 

classroom curriculum, students will help their families develop pandemic disaster plans. This model 

program would also build upon and leverage the existing relationships among students attending K-12 

schools and their parents to serve as a nucleus for strengthening community cohesion. 
22 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

Ensuring Continuity of Federal Government Operations

Over the past year, Federal departments and agencies, including Federal healthcare systems, have 

been developing and exercising preparedness and response plans that take into account the potential 

impact of a pandemic on the Federal workforce and are configured to support State, local, and private 

sector efforts where appropriate. 

Pandemic planning summits were 

conducted in all States to start the 

process of community-level planning 

for a pandemic. Congress appropriated 

$600 million over the past year for State 

and local preparedness efforts, including 

the exercising of community mitigation 

measures, medical surge plans, and mass 

inoculation plans. As a follow-on to the 

2006 planning summits, the National 

Governors Association, with Federal 

funding, has launched a series of 10 

regional pandemic influenza workshops 

to enhance intergovernmental and 

interstate coordination.

The National Plan highlighted the 

importance of having in place a 

comprehensive and effective program to 

ensure the uninterrupted continuation of 

Federal Government essential functions. 

The Federal Government has been 

refining and strengthening continuity 

plans to account for the 

unique challenges associated with a 

pandemic. All Federal departments and agencies are addressing their own pandemic preparedness 

by completing all elements of a comprehensive checklist. The “meta-checklist” guiding their efforts is 

available for any institution to use, at <www.pandemicflu.gov>. In addition, comprehensive guidance 

on Human Capital Planning for Pandemic Influenza, available to Federal agencies and employees, 

includes a series of helpful planning guides for managers and supervisors, frequently asked questions 

and answers, and a newly revised telework guide to assist the Government in continuing operations.

Preparing and Engaging the Private Sector

The private sector has an important role to play in preparing for, responding to, and recovering 

from a pandemic. The private sector owns and operates over 85 percent of the critical infrastructure 

in the United States, and therefore represents an integral part of our society because of the critical 

goods and services that it provides. Moreover, it touches the majority of our population on a daily 

Streamlining Access to Essential Government 

Services

With the complete conversion of food benefits delivery 

from paper coupons to electronic benefit transfer (EBT) 

cards, the Federal Government’s Disaster Food Stamp 

Program is better positioned to reinforce the public 

health response during a pandemic. This program 

allows maximum benefits for low-income families 

with children to help compensate for the loss of free 

and reduced price school and childcare meals due to 

school dismissal. This new technology also facilitates 

the purchasing of food from supermarkets through 

self-checkout or drive-through and could minimize 

the risk of face-to-face contact with others. Current 

participants of the Food Stamp Program would continue 

to receive benefits automatically as they are deposited 

into the client’s food stamp account on a monthly basis. 

Because of the EBT card, extra or extended benefits 

to current participants can be electronically added to 

the EBT card. Since the certification process is more 

flexible and can be completed by mail, telephone, or 

internet, rapid food assistance to newly eligible families 

experiencing financial hardships would be possible 

during a pandemic, including the possibility of offering 

them pre-loaded EBT cards. 
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 23

basis, through employer-employee or 

vendor-customer relationships. For these 

reasons, it is essential that the U.S. private 

sector be engaged in preparedness and 

response activities for a pandemic. In the 

event of an influenza pandemic, businesses 

and other employers will play a key role in 

protecting employees’ health and safety as 

well as limiting the negative impact to the 

community, economy, and society.

Over the past year, the Federal Government 

has produced numerous tools for businesses 

of all types and sizes to assist them in 

planning for a pandemic. Several checklists 

have been produced that include information 

for businesses in general (Business Pandemic 

Influenza Planning Checklist), as well as 

Planning for U.S. Businesses with Overseas Operations, Health Insurer Pandemic Influenza Planning 

Checklist, and Travel Industry Pandemic Influenza Planning Checklist. State governments, local 

governments, and thousands of businesses and employers in this country and worldwide have used 

the checklists to improve their pandemic planning efforts. Federal agencies have also developed and 

distributed other tools for businesses to use, including:

• Guidance on Preparing Workplaces for an Influenza Pandemic: guidance and 

recommendations on infection control in the workplace, including information on 

engineering controls, work practices, and personal protective equipment, such as respirators 

and surgical masks.

• Guidance for Protecting Workers Against Avian Flu: information for protecting employees 

who may have been exposed to avian influenza. 

• Cover Your Cough: flyers and posters showing ways to reduce transmission of 

respiratory illnesses. 

• Stopping the Spread of Germs at Work: basic precautions for protecting employee health. 

• Quick Cards for Employees to Protect Yourself from Avian Flu: general precautions and 

specific information for poultry employees, laboratory employees, animal handlers, 

food handlers, and healthcare workers.

• Pandemic Influenza Preparedness and Response Guidance for Healthcare Workers and 

Healthcare Employers: information and tools helpful to healthcare planners.

In addition, the recently released Community Mitigation Guidance includes specific planning 

recommendations for aligning business practices with public health protection interventions. The 

document provides clear steps an employer can take to potentially slow the spread of pandemic 

influenza, help keep workplaces safe, and reduce the number of people who become sick. All of these 

tools are posted on <www.pandemicflu.gov>.

Building a “Chain of Preparedness”

Businesses realize that their ability to cope with 

a pandemic depends both on steps that they take 

and on the preparedness levels of the businesses 

that make up their critical supply chain. One 

large business recently invited more than 300 of 

their top suppliers to a pandemic preparedness 

workshop, so they could pass along pandemic 

planning information and encourage each one of 

the attending companies to start to prepare. By 

sharing information and encouraging planning along 

their supply chain, this large business enhances its 

readiness and mentors other smaller businesses 

to do the same. This “chain of preparedness” 

improves overall business preparedness and 

resiliency and enables communities to be better 

prepared to face a pandemic.
24 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

Protecting and Sustaining Critical Infrastructure

Critical infrastructure entities that provide essential services, such as food, water, healthcare, power, 

and telecommunications, have a special responsibility to prepare and plan for continued operation 

during a pandemic. Efforts that focus on both protecting health and maintaining continuity of 

operations are vital parts of pandemic preparedness for critical infrastructure businesses.

Protecting the Nation’s critical infrastructure, and the businesses both large and small within these 

sectors, requires the full cooperation and coordinated actions of the public and private sectors. In 

the Fall of 2006, the Federal Government, working collaboratively with partners in the public and 

private sectors, released its Pandemic Influenza Preparedness, Response, and Recovery Guide for 

Critical Infrastructure and Key Resources (Guide). Tailored to national goals and capabilities, and to 

the specific needs identified by the private sector, this business continuity guidance represented an 

important first step in working with the owners and operators of critical infrastructure to prepare for 

a potentially severe pandemic outbreak. The Guide has served to support private sector pandemic 

planning by complementing and enhancing, not replacing, their existing continuity planning efforts. 

With that in mind, the Federal Government developed the Guide to assist businesses whose existing 

continuity plans generally do not include strategies to protect human health during emergencies such 

as those caused by pandemic influenza or other diverse natural and manmade disasters. 

Over the last year, the Federal Government has conducted an extensive outreach effort to the private 

sector, particularly critical infrastructure businesses. In the last year, more than 150 presentations, 

workshops, and fora have been conducted and attended by thousands of key stakeholders from 

critical infrastructure entities (e.g., healthcare operations, banking and finance entities, operations 

centers, retail operations, transportation and trucking operations, supply warehousing operations, 

grocery and food suppliers, and supply distributors) as well as businesses of all types. These 

information sharing sessions have provided practical action-oriented information to identify 

essential functions and critical planning elements and to assist businesses in protecting the health of 

employees and in maintaining continuity of 

business operations during a pandemic. 

Sustaining the Economy

Sustaining infrastructure and mitigating the 

pandemic influenza-related impacts to the 

economy and society require vigilance that 

extends beyond the workplace. Policymakers 

and interagency subject matter experts have 

developed border policies and protocols 

that aim to slow the spread of disease while 

limiting, to the extent possible, disruptions 

to trade and passenger flows. Minimizing 

economic impacts while limiting disease 

entry is the primary goal of this approach. 

The Federal Government has conducted a 

number of pandemic preparedness exercises 

that include financial institutions, public 

Preserving and Protecting Financial Services

A large retail financial institution has 

institutionalized a good health awareness program 

to improve employees’ understanding of how 

to protect themselves during a pandemic. This 

program includes a website with guidance 

information by health officials and models to inform 

employees on the progression of H5N1 globally. 

They have modified their human resources policies 

to support employees during a pandemic outbreak 

whether they are home due to illness, taking care 

of a loved one, or because of social distancing 

advice from local authorities. Furthermore, this 

financial institution is assessing all of its vendors to 

determine whether or not they have pandemic plans 

that can support the organization’s supply chain 

during a pandemic.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 25

health officials, and other relevant Federal, State, and local officials. Additionally, both the Financial 

and Banking Information Infrastructure Committee (FBIIC) and the Financial Services Sector 

Coordinating Council (FSSCC) have established working groups that identify and address issues 

related to the resilience of the financial services sector during a pandemic. The FSSCC established 

the Infectious Disease Forum and convenes regular meetings with the FBICC and other stakeholders 

to discuss preparations and to identify interdependencies in other critical sectors. 

Maintaining Society and Civil Order

Hurricane Katrina highlighted the necessity for the uninterrupted continuity of the justice system. 

States must know what the procedures are for requesting Federal law enforcement assistance in the 

event of an emergency, such as a pandemic outbreak. On May 31, 2006, the Attorney General sent 

a letter to each Governor outlining the procedures for obtaining assistance under the Emergency 

Federal Law Enforcement Assistance provisions of the Justice Assistance Act of 1984. The letter 

recognized that pre-event collaborative 

planning would have improved the Katrina 

response and stressed that the goal was “to 

ensure that any future response, whether 

to a natural disaster, a pandemic influenza 

outbreak, or an act of terrorism occurs as 

expeditiously as possible.”

The Federal Government has also engaged 

in extensive outreach efforts to criminal 

justice stakeholder groups stressing the 

importance of pandemic preparedness and 

encouraging agencies to begin planning 

now. In May 2006, the Federal Government 

convened a forum for more than 200 

professionals representing a cross-section 

of all components of the justice system, 

including police, probation, corrections, 

and court personnel. Officials shared 

information on the challenges these 

stakeholders may face, and the participants discussed and shared “best practices.” Furthermore, 

representatives from each of the 94 U.S. Attorney’s Offices met with Federal court representatives to 

coordinate continuity planning efforts in the event of a pandemic or other emergency.

An influenza pandemic would also present significant challenges to public service response 

organizations and the communities they serve. Earlier this year, a 3-day forum brought together 

partners from Federal, State, local, territorial, and tribal emergency medical services, fire, emergency 

management, law enforcement, and public works in order to develop best practices and model 

protocols, to coordinate pandemic preparedness activities, and to standardize all-hazards training 

and exercises. 

Keeping Courts Open to Ensure Justice for All

Building on lessons learned from existing “allhazards” emergency planning efforts initiated 

after 9/11, and incorporating lessons learned from 

their experience planning for and responding to 

hurricanes, the Supreme Court in Florida developed 

a strategy for Pandemic Influenza with the goals of 

protecting the health and safety of everyone at the 

court facilities and “keeping the courts open” to 

ensure justice for the people. A detailed planning 

template was produced to assist local courts 

in developing their own pandemic plans. Court 

Emergency Management Teams, consisting of judges, 

attorneys, deputy clerks, deputy sheriffs, information 

technology staff, and others, are exploring a 

number of innovative ideas including holding court 

proceedings via videoconference, and assembling 

and managing juries while adhering to social 

distancing measures.
26 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

In the coming months, the Federal Government will work with the private sector to develop and 

release sector-specific guidelines that will complement and enhance these activities. These efforts by 

the Federal Government, in partnership with the private sector, are crucial for sustaining society, and 

for ensuring the continued availability of essential goods and services such as food, water, healthcare, 

power, transportation, and communications during a pandemic. 

One final question deserves to be asked as we review the progress over the past year. 

Looking Ahead: What Have We Learned Through These Efforts 

and What Gaps Still Need to Be Addressed?

Building a Foundation for All-Hazards Preparedness

The threats facing our Nation in the 21st century, from pandemic influenza and the emergence of 

new diseases such as SARS, to terrorist attacks and naturally occurring disasters such as hurricanes 

and earthquakes, require an all-hazards approach to emergency planning and preparedness. 

However, pandemic preparedness is often viewed as separate from or competing with other disaster 

preparedness efforts. Although there are some unique aspects to pandemic planning, preparing 

the Nation for the threat of an influenza pandemic has provided a platform to address issues 

and concerns common to mass casualty disasters. Promoting a culture of individual, family, and 

community preparedness is the foundation for emergency planning efforts. Strengthening our public 

health infrastructure by enhancing public health agency coordination with partner State and local 

agencies, enhancing biosurveillance, and accelerating countermeasure development, production, and 

distribution, sustaining our Nation’s critical infrastructure, and developing strategies for expanding 

mass casualty care capability and for prioritizing scarce medical resources are important goals for 

preparing for many of the threats we now face. By investing in pandemic preparedness, our Nation is 

building a foundation for all-hazards preparedness.

Achieving the goals outlined above and preparing the Nation for a pandemic will not be easy. 

The Federal Government has made a commitment to transparency and accountability in reporting 

our progress. While we have made progress over the past year to prepare the Nation for the threat 

of an influenza pandemic, much important work lies ahead. Critical gaps in pandemic preparedness 

efforts remain and are outlined below. Despite the waning media interest in avian and pandemic 

influenza, the potential consequences of a severe pandemic demand that we redouble our efforts to 

address these critical gaps.

Building Connectivity and Unity of Effort

The National Plan recognized that one of our greatest vulnerabilities was the lack of connectivity 

and coordination of effort between the various communities responsible for pandemic preparedness. 

Developing effective strategies and policies to meet the challenge of a pandemic require the 

engagement of all nations, all levels of government, and all segments of society. Internationally, 

collaboration and transparency are essential. Here at home, a unified effort that engages all levels of 

government, as well as the public health community, the medical care community, the private sector, 

faith-based and community-based organizations, and the public, is critical for an effective response. 
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 27

One of the most tangible benefits of pandemic planning at a Federal level has been the forging of 

close working relationships among Federal departments and agencies. This began with the writing 

of the National Plan. Many of the actions in the National Plan required collaboration, coordination, 

and cooperation between Federal departments. Recognizing the need for a unified effort across 

the Federal Government, an interagency group with senior managers representing 16 Federal 

departments and agencies directly engaged in pandemic preparedness has been meeting weekly 

since the release of the National Plan in May 2006. This interagency group monitors progress on 

all actions in the National Plan and reviews pandemic policy issues. To ensure that the Federal 

Government speaks with one voice on pandemic issues, all pandemic-related information developed 

by departments is posted on <www.pandemicflu.gov> and reviewed for consistency prior to release 

by other departments. The establishment of trusted relationships across the Federal Government as 

a result of the ongoing work of this interagency group has enhanced connectivity and has improved 

communication among Federal departments and agencies. 

The benefits of a unified effort at the Federal level can also be realized at a State and local levels. 

It is critical that we establish connectivity and build relationships between various layers of the 

government, the private sector, and faith-based and community-based organizations. Now is the 

time, before a pandemic emerges, to establish and test these relationships and partnerships. The 

Federal Government must take a leadership role in fostering an environment of collaboration and 

public engagement that will serve our Nation well for any hazard we might face. 

Strengthening Disease Detection and Biosurveillance

The strategies associated with pandemic preparedness serve to strengthen the public health 

infrastructure in the United States and the world. One of the most important areas is disease 

detection and surveillance. 

Although we have realized progress in expanding disease surveillance abroad, critical gaps remain 

with respect to “real-time” disease detection and clinical surveillance in the United States. As part of 

its national influenza surveillance effort, the CDC currently receives weekly mortality reports from 

122 cities and metropolitan areas in the United States. This information helps the CDC track trends 

in disease spread, identify severely affected populations, and monitor the impact of influenza on 

health. One of the limitations of this system, however, is an approximately 2-week lag in obtaining 

data. BioSense is a national program intended to improve the Nation’s capabilities by conducting 

nearly real-time clinical disease surveillance. Of the nearly 6,000 hospitals in the United States, 

only 700 hospitals are currently engaged in some stage of implementation for sharing data with the 

BioSense program. 

Given how rapidly a pandemic could spread, it is crucial that we establish this “real-time” surveillance 

capability at a national, State, and community level. It is imperative to identify outbreaks and 

implement interventions as quickly as possible, in addition to monitoring the outbreak and 

evaluating the effectiveness of our interventions. 

Another critical gap related to biosurveillance is the availability of rapid diagnostic tests that 

can quickly discriminate pandemic influenza from non-influenza illnesses. Use of these tests in 

outpatient clinics and in ambulatory settings will greatly enhance the Nation’s capacity to detect 

pandemic influenza more rapidly. Also, to effectively implement our border measures, it is vital 
28 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

to quickly and correctly identify infected individuals at ports of entry. Moreover, to maximize the 

utilization of our limited stockpile of antiviral medications (targeting treatment to individuals with 

confirmed pandemic influenza) and to minimize the disruption of community mitigation measures 

(limiting isolation and voluntary home quarantine to individuals and households with confirmed 

pandemic influenza), a field-based test to rapidly diagnose pandemic influenza is essential. 

The Federal Government must intensify its efforts for improving biosurveillance to ensure that we are 

not “blind” during the next pandemic or any other public health crisis. Accelerating the development 

of rapid diagnostics is key for effectively implementing disease control measures. 

Expanding Medical Capacity to Care for Large Numbers of Ill Patients

The projected demand for medical care during a severe pandemic would overwhelm the Nation’s 

present healthcare system. Nationwide, many hospitals and emergency departments are already 

operating at or near capacity and may not have the capability to treat the surge of patients who will 

need care during a severe pandemic. Our Nation’s current acute inpatient capacity is limited by 

the number of appropriately staffed and equipped hospital beds. Expanding acute care capacity, 

by increasing the number of hospital beds and training additional medical staff, would require 

substantial and recurring investments with long lag times. A severe pandemic will impact all 

communities nearly simultaneously and at the peak of the outbreak could result in many times the 

normal demand for acute medical care. There may be little opportunity to shift resources from 

one part of the country to another. To meet this demand and to ensure delivery of the best quality 

healthcare possible under such circumstances, individual communities need to plan for dramatic 

increases in patient care capabilities. Up to this point, contingency planning for pandemics and other 

disasters has generally attempted to improve medical “surge capacity.” However, it is unrealistic for 

communities to be able to increase the numbers of staffed acute care hospital beds to a level necessary 

for pandemic preparedness. Clearly, alternative strategies are warranted. 

Therefore, many hospitals plan to boost their current capacity to treat ill patients through the use 

of existing resources for alternative and auxiliary settings for healthcare and by expanding the 

number of available healthcare providers with retirees and volunteers. Healthcare workers and first 

responders will be on the front lines during an influenza pandemic. Ensuring the availability of 

protective measures for these critical workers will be essential to our efforts to protect the health and 

safety of the public. Community planning efforts will require the coordination of many providers 

and organizations and must address how healthcare facilities can best share assets in order to assure 

the greatest benefit for the largest number of people in the most ethical manner. The Federal 

Government has incorporated both funding and guidance to assist in planning for the strengthening 

of mass casualty care capacity. Community mitigation measures offer an additional strategy to help 

narrow the gap between existing acute care capacity in the United States and the projected demand 

for medical care. The combined efforts of maximizing available surge capacity and reducing the 

demand for acute care by community mitigation will help, but new strategies are required and much 

work remains to address our Nation’s challenge of mass casualty care.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 29

The stockpiling of critical medical materiel, including a reassessment of antiviral medication stockpile 

goals, is one area that the Federal Government needs to address in the coming year. Most healthcare 

facilities have “just-in-time” inventory for medical supplies, which means that hospitals normally 

have on hand only a few days of basic medical supplies including personal protective equipment 

and medications. Although the Federal Government has stockpiled medical supplies, the scope and 

scale of a pandemic in terms of the demand for medical materiel would be unprecedented. Limited 

global production capacity of antiviral medications was one factor that had constrained antiviral drug 

stockpile goals. Recent expansion of domestic antiviral drug production capacity—up to 80 million 

regimens per year of oseltamivir—has made increased stockpiling possible. This, in combination 

with several recent analyses suggesting substantial potential benefits of prophylactic antiviral drug 

use, has prompted a reassessment of pandemic antiviral drug use, strategies, and potential stockpiling 

targets. Accordingly, significant work remains at the Federal, State, local, and healthcare facility level 

to address the projected demand for antiviral medications, personal protective equipment (including 

surgical masks and respirators), antibiotics, ventilators, and other medical materiel required during a 

pandemic. 

Accelerating Vaccine Development and Production 

The Federal Government is investing in the expansion of vaccine manufacturing capacity, the 

advanced development of new cell-based vaccines, antigen-sparing technologies or adjuvants, and the 

establishment and maintenance of pre-pandemic vaccine stockpiles. 

The challenge of producing enough pandemic vaccine for the U.S. population is significant, but an 

even greater challenge is producing and providing worldwide access to pandemic vaccine. The global 

capacity for influenza vaccine production is approximately 350 million doses per year. This could be 

scaled up to 500 million doses per year in an emergency such as a pandemic. Even with the current 

investments in expanded capacity, global vaccine production will remain well below projected 

demand during a pandemic. The U.S. Government is committed to working with the pharmaceutical 

industry, our international partners, and WHO to address this gap. But commitment alone is not 

sufficient. We need imaginative solutions to this problem, and we require a unified effort that 

engages our best scientists in addressing this challenge.

In that spirit, the United States is working in collaboration with WHO and international partners 

throughout the world to enhance surveillance and pandemic preparedness, including increasing 

vaccine development and vaccine access. Four important principles guiding our international effort 

include: (1) transparency; (2) rapid reporting; (3) sharing of data; and (4) scientific cooperation. 

The United States continues to call on countries everywhere to share influenza samples openly 

and rapidly, without preconditions. Withholding influenza viruses from the Global Influenza 

Surveillance Network greatly threatens global public health and is inconsistent with the spirit of the 

legal obligations member nations have all agreed to undertake through adherence to the International 

Health Regulations.
30 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

The World Health Assembly has recently adopted a resolution on pandemic influenza preparedness 

that makes clear that member states must continue to share influenza specimens and viruses with 

WHO’s Global Influenza Surveillance Network. The resolution also emphasizes the need for 

increased vaccine access. The United States has invested more than $1 billion in the development of 

new vaccine technologies that will benefit the international community. The United States strongly 

supports and finances WHO’s efforts to meet the long-term global need for an influenza vaccine 

through the Global Pandemic Influenza Action Plan to Increase Vaccine Supply. In addition, the 

United States is committed to working with member states and WHO to explore other avenues to 

meet the near-term need for greater access to influenza vaccines, including pre-pandemic vaccines. 

Distributing and Tracking Countermeasures

Medical countermeasures have little utility if they cannot be delivered quickly to those in need, yet 

the logistical challenges of rapidly allocating, distributing, and administering countermeasures to 

300 million Americans are substantial. Although we have made significant investments in 

distribution capacity since 2002 through the Strategic National Stockpile, State and local grant 

programs, and the Cities Readiness Initiative, much work remains. Guidance and resources 

have been provided to State, local, tribal, and territorial governments to facilitate completion 

of distribution plans for medical countermeasure stockpiles. Recipients of pandemic influenza 

supplemental funding are required to complete and exercise these plans. 

Countermeasure allocation and distribution is important for preparing our Nation for pandemic 

influenza and other naturally occurring infectious diseases, as well as for chemical and nuclear 

attacks. In the future we may be faced with the need to prioritize scarce medical resources during a 

major disaster. The pandemic efforts could well serve as a template for allocating and distributing 

life-saving countermeasures against other threats. The ongoing guidance development process 

for prioritizing and deploying countermeasures during a pandemic represents our first steps in 

addressing this complex ethical and logistical challenge. 

Implementing Community Mitigation and Building Community Resilience

Although the community mitigation strategy may significantly reduce illness and death, 

implementing this strategy will not be easy. It is critical that emergency planners better understand 

the challenges associated with the implementation of the Community Mitigation Guidance. It is also 

important that they are aware of any potential adverse consequences due to these interventions. 

Minimizing the negative impact will require communities to undertake appropriate planning and 

exercises to pre-identify vulnerable populations and persons at risk and to develop populationspecific strategies. To enhance individual and community adherence to these community mitigation 

measures, the Federal Government must continue to work with the private sector, public health, 

education, and community-based and faith-based organizations to address feasibility concerns, 

develop clear and appropriate public messaging, and minimize any adverse consequences associated 

with implementation. Pandemic exercises provide an ongoing opportunity to continually test and 

refine these plans.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 31

The community mitigation strategy developed by the United States offers hope, especially to 

countries with limited access to medical countermeasures. The United States is reaching out to 

partners in the international community by informing them of our approach and assisting them in 

the adaptation of our strategy. 

Translating our Pandemic Preparedness Efforts to Seasonal Influenza

Each year, more than 200,000 Americans are hospitalized and 36,000 die due to seasonal influenza. 

Increased awareness of available antiviral therapies and advances in vaccine production and pointof-care diagnostics, as a result of pandemic preparedness efforts, could translate to more effective 

treatment for seasonal influenza. Promoting healthy behaviors, such as hand washing and cough 

etiquette, could help reduce the spread of seasonal influenza and other respiratory diseases. Seasonal 

influenza also provides an opportunity to reinforce these behaviors, promote vaccination of 

nontraditional high-risk groups and healthcare workers, and test workplace policies and practices, 

such as having ill individuals remain home, so that we are better prepared to respond should a 

pandemic occur. How our Nation invests today in pandemic preparedness will serve us well when a 

pandemic does occur and could also prevent illness and death associated with seasonal influenza. 

A Year of Progress

Much has been accomplished since the release of the National Plan in May 2006. Over the past 

year, the United States and the international community have mobilized to confront the threat of 

an influenza pandemic at its source, by containing H5N1 poultry outbreaks and rapidly identifying 

associated cases of human disease. The United States has made pivotal contributions to control the 

international spread of H5N1 by working with affected countries and international partners to detect, 

contain, and prevent animal outbreaks, reduce human exposure to the virus, and enhance planning 

and preparedness for future outbreaks.

Should a pandemic emerge, the United States is better positioned today to detect an outbreak earlier, 

to support an international effort to contain the pandemic in its earliest stages, to limit the spread of 

the pandemic, and to save lives. The Federal Government has developed mitigation strategies and 

guidelines for controlling influenza outbreaks in communities and has made significant investments 

in vaccines, antiviral medications, and research, which will safeguard our Nation and benefit the 

world. The unprecedented efforts to prepare for and respond to the threat of a pandemic underscore 

the Federal Government’s resolve to protect human life. 

Resiliency defines us as a Nation. Each American generation has faced and has risen to the 

challenges of its time. But no prior generation has ever anticipated and prepared for a pandemic. 

We have the opportunity to be the first generation to use our collective wisdom, determination, 

and resources to take on this task. The stakes are high, and our greatest enemy is complacency. We 

remain committed to this effort, not only for generations of Americans alive today, but also for the 

sake of generations to come. 

National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 33

ACKNOWLEDGEMENTS

This One Year Summary provides an overview of the steps that Federal Government has taken to 

prepare the Nation for an influenza pandemic. While these accomplishments are credited to the 

U.S. Government, they result from the coordinated efforts of many Federal departments and 

agencies. It is not possible to capture the full depth and breadth of those activities in a report of this 

nature, but the following provides a very brief summary of some of them. 

The Department of Agriculture (USDA) is conducting surveillance for influenza in domestic 

animals and animal products, monitoring wildlife in coordination with the Department of the 

Interior (DOI), and working to ensure an effective veterinary response to a domestic animal 

outbreak of highly pathogenic avian influenza. As part of an international effort, USDA has provided 

education, research, monitoring, and eradication assistance to affected countries to slow the spread 

of highly pathogenic avian influenza H5N1 overseas. USDA, in coordination with other key Federal 

and State departments and agencies as well as industry partners, has developed a detailed response 

plan to contain and eliminate a domestic outbreak of highly pathogenic avian influenza.

The Department of Commerce (DOC) is promoting pandemic preparedness across the private 

sector, both domestically and internationally, by creating guidance and executing outreach. DOC, 

in coordination with the Department of Health and Human Services (HHS), is playing a key role 

in pandemic preparedness in the Pacific Rim through leadership in the Asia Pacific Economic 

Cooperation (APEC) forum. Over the past year, DOC, in coordination with the Department of 

Homeland Security (DHS), has worked with private sector, academic, and government organizations 

to promote critical infrastructure preparedness. In addition, DOC has been actively involved, in 

coordination with the Department of the Treasury and other economic agencies, in evaluating 

the economic effects of proposed government policies meant to minimize the spread of pandemic 

influenza. 

The Department of Defense (DOD) is working to protect American interests at home and abroad in 

the event of a pandemic. DOD supports the Department of State (DOS) in international engagement 

to promote global capacity to address an influenza pandemic and provides up-to-date information 

and pandemic risk-level assessments as an integral part of the global surveillance network for 

pandemic influenza. Domestically, DOD supports DHS and HHS in developing, planning, and 

exercising national and regional response efforts. In order to maintain readiness and to promote 

international efforts, geographic combatant commands continue to exercise, refine, and review their 

existing plans with Federal departments and agencies and international partners.
34 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

The Department of Education (ED) is working with schools to ensure that they have the proper 

tools to assist in mitigating the spread of a pandemic by preparing students, families, and staff. ED 

has convened expert roundtables, created guidance, provided resources, conducted outreach, and 

produced information campaigns for education stakeholders.

The Department of Health and Human Services is responsible for the overall coordination of the 

public health and medical emergency response during a pandemic. HHS, in coordination with other 

Federal departments and agencies, has provided guidance, conducted training and outreach, and 

developed tools critical to pandemic preparedness and response, at home and abroad. International 

efforts include establishment of regionally deployable response teams and provision of technical 

assistance with investigation of human H5N1 outbreaks. HHS has led initiatives to strengthen 

disease detection and surveillance, provide guidance on community mitigation measures to reduce 

the spread and impact of a pandemic, enhance medical capacity to care for large numbers of infected 

people, and acquire and accelerate distribution of countermeasures from the Strategic National 

Stockpile. HHS continues to support the establishment of a robust domestic capacity to manufacture 

influenza vaccine, foster the incorporation of modern vaccine production methods, support 

advanced development of dose-sparing technologies, and acquire a stockpile of pre-pandemic 

vaccine.

The Department of Homeland Security is responsible for the coordination of the overall Federal 

response during an influenza pandemic. DHS has pre-designated the Pandemic Influenza 

Principal Federal Official (PFO) and Regional PFOs for coordinating this response. DHS is 

ensuring continuity of government operations, the integrity of the Nation’s critical infrastructure, 

and domestic security and is working with HHS to implement scalable border measures during 

a pandemic. Initiatives include outreach to governmental organizations, the private sector, and 

critical infrastructure entities, through education and guidance development as well as continued 

development of an integrated biosurveillance system. In coordination with other Federal 

departments and agencies, DHS is developing a coordinated government-wide concept of operations 

plan for response to a severe pandemic.

The Department of the Interior is enhancing surveillance systems for identifying wildlife that may 

be carrying highly pathogenic avian influenza H5N1. In coordination with USDA, DOI has trained 

hundreds of biologists over the past year in sample and data collection and entry techniques for wild 

birds and effective monitoring of wild bird mortality. In addition, DOI continues to work with other 

Federal departments and agencies, academic institutions, non-governmental organizations, private 

citizens, and the media to raise awareness and enhance our understanding of and response to avian 

influenza.
National Strategy for Pandemic Influenza Implementation Plan: One Year Summary 35

The Department of Justice (DOJ) is enhancing pandemic preparedness across the justice system 

to ensure continuity of public safety and the justice system during a pandemic. Over the past year, 

DOJ has developed best-practices guidance, held a number of pandemic preparedness seminars, and 

worked in coordination with DHS and the Department of Transportation (DOT) to ensure the safety 

and functioning of the first responder community in the event of a pandemic. 

The Department of Labor (DOL) is promoting employer preparedness to protect the health, safety, 

and welfare of the Nation’s workforce as an essential component of maintaining critical infrastructure 

and economic security during a pandemic. Over the past year, DOL has issued guidance, developed 

in consultation with HHS, to help America’s employers meet their responsibility to protect their 

employees during a pandemic. DOL has also issued guidance targeted to employers and employees 

in the healthcare industry, a workforce that is indispensable to the Nation’s pandemic response.

The Department of State is leading and coordinating international efforts including U.S. engagement 

in a broad range of bilateral and multilateral initiatives that build cooperation and capacity to fight 

the spread of avian influenza and to prepare for a possible pandemic. These initiatives include the 

International Partnership on Avian and Pandemic Influenza, which has elevated pandemic influenza 

on national agendas and mobilized resources for the global effort, the North American Plan for Avian 

and Pandemic Influenza, and information on pandemic preparedness to American citizens overseas. 

DOS has also carried out public diplomacy activities through training foreign journalists, and 

sending experts abroad to speak to medical and veterinary health professionals, government officials, 

and the media.

The Department of Transportation is working to ensure that coordinated actions are taken by the 

transportation sector to limit spread of infection while preserving the movement of essential goods 

and services and limiting the impact of the pandemic on the economy. Over the last year, DOT has 

worked with the Emergency Medical Services (EMS) and 9-1-1 community to develop protocols 

and guidelines, conducted outreach and education campaigns for transportation stakeholders, 

and worked closely with DHS and other border stakeholders to plan for transportation and border 

measures.

The Department of the Treasury (Treasury) is working to ensure that the financial sector is prepared 

for a pandemic by communicating guidance, conducting outreach and education campaigns, and 

executing exercises with financial sector stakeholders. In addition, Treasury is preparing policy 

responses to pandemic-related international economic developments; for example, the Department 

is leading the Federal Government’s engagement with the multilateral development banks (MDB) 

and international financial institutions (IFI), including encouraging MDB and IFI efforts to assist 

countries to address the threat of pandemic influenza.
36 National Strategy for Pandemic Influenza Implementation Plan: One Year Summary

The Department of Veterans Affairs (VA) operates the largest Federal integrated healthcare system 

and has increased pandemic preparedness by enhancing surveillance, stockpiling scarce resources, 

contributing to Federal Government efforts to develop critical guidance for healthcare facilities and 

healthcare workers, and participating in State and community-level preparedness activities. VA 

organized and exercised a leadership and incident command structure and created an advisory panel 

of experts in pandemic influenza and VA operations. 

The Environmental Protection Agency (EPA) is assisting DHS and HHS in preparing the Nation’s 

water sector (drinking water and wastewater) utilities by working to increase preparedness and 

maintain essential services in the event of an avian influenza or human pandemic influenza outbreak. 

EPA has engaged Federal, State, and local partners in order to develop and promote the establishment 

of mutual aid and assistance agreements so that water sector utilities can appropriately assist each 

other in time of need.

The Office of Personnel Management (OPM) is working to ensure that Federal departments and 

agencies have the workforce needed to complete critical missions during a pandemic. OPM has 

conducted outreach to Federal human capital stakeholders, created guidance for and provided 

technical assistance to human resources offices within Federal agencies, and designed pandemicrelated educational materials and programs, including a new telework guide, specifically for Federal 

employees.

The United States Agency for International Development (USAID), in partnership with HHS and 

USDA, is assisting countries at risk, including those experiencing outbreaks of highly pathogenic 

avian influenza H5N1, in increasing public awareness and developing surveillance and diagnostic 

capacity at national, regional, and local levels toward timely notification of suspected cases of 

avian influenza. USAID has developed a stockpile of essential commodities for use by surveillance 

and response workers for effective disease containment during outbreaks and has shipped these 

commodities to over 70 countries to date.