Tracking progress toward global polio eradication--worldwide, 2009-2010

Since the Global Polio Eradication Initiative (GPEI) began in 1988, progress has been tracked by 1) surveillance comprised of detection and investigation of cases of acute flaccid paralysis (AFP), coupled with environmental surveillance (sewage testing) in selected areas, and 2) timely testing of fecal specimens in accredited laboratories to identify polioviruses. The sensitivity of AFP case detection and the timeliness of AFP investigations are monitored with performance indicators. Polioviruses are isolated and characterized by the Global Polio Laboratory Network (GPLN). This report assesses the quality of polio surveillance and the timeliness of poliovirus isolation reporting and characterization worldwide during 2009--2010. During that period, 77% of countries affected by wild poliovirus (WPV) met national performance standards for AFP surveillance; underperforming subnational areas were identified in two of four countries with reestablished WPV transmission and in 13 of 22 countries with WPV outbreaks. Targets for timely GPLN reporting of poliovirus isolation results were met in five World Health Organization (WHO) regions in 2009 and in four of six regions in 2010; targets for timely poliovirus characterization were met in four WHO regions in 2009 and in five regions in 2010. Monitoring of surveillance performance indicators at subnational levels continues to be critical to identifying surveillance gaps that might allow WPV circulation to be missed in certain areas or subpopulations. To achieve polio eradication, efforts are needed to further strengthen AFP surveillance, implement targeted environmental surveillance, and ensure that GPLN quality is maintained.     

Challenges of global surveillance during an influenza pandemic

Surveillance is an essential foundation for monitoring and evaluating any disease process, and is especially critical when new disease agents appear. The H1N1 influenza pandemic of 2009 tested the capacities of countries to detect, assess, notify and report events as required by the 2005 International Health Regulations (IHR). As detailed in the IHR, the World Health Organization drew on official reports from Member States as well as unofficial sources (e.g., media alerts) to quickly report and disseminate information about the appearance of the novel influenza virus. The pre-existing Global Influenza Surveillance Network for virological surveillance also provided crucial information for rapid development of a vaccine and for detection of changes in the virus. However, the pandemic also highlighted a number of shortcomings in global epidemiological surveillance for respiratory disease. These included the lack of standards for reporting illness, risk factor and mortality data, and a mechanism for systematic reporting of epidemiological data. Such measures would have facilitated direct comparison of data between countries and improved timely understanding of the characteristics and impact of the pandemic. This paper describes the surveillance strategies in place before the pandemic and the methods that were used at global level to monitor the pandemic. Enhancements of global surveillance are proposed to improve preparedness and response for similar events in the future.     

Enhanced Influenza Surveillance using Telephone Triage Data in the VA ESSENCE Biosurveillance System

Objective

To evaluate the utility and timeliness of telephone triage (TT) for influenza surveillance in the Department of Veterans Affairs (VA).

Introduction

Telephone triage is a relatively new data source available to biosurveillance systems.1–2 Because early detection and warning is a high priority, many biosurveillance systems have begun to collect and analyze data from non-traditional sources [absenteeism records, over-the-counter drug sales, electronic laboratory reporting, internet searches (e.g. Google Flu Trends) and TT]. These sources may provide disease activity alerts earlier than conventional sources. Little is known about whether VA telephone program influenza data correlates with established influenza biosurveillance.

Methods

Veterans phoning VA’s TT system, and those admitted or seen at a VA facility with influenza or influenza-like-illness (ILI) diagnosis were included in this analysis. Influenza-specific ICD-9-CM coded emergency department (ED) and urgent care (UC) visits, hospitalizations, TT calls, and ILI outpatient visits were analyzed covering 2010–2011 and 2011–2012 influenza seasons (July 11, 2010–April 14, 2012). Data came from 80 VA Medical Centers and over 500 outpatient clinics with complete reporting data for the time period of interest. We calculated Spearman rank-order coefficients, 95% confidence intervals and p-values using Fisher’s z transformation to describe correlation between TT data and other influenza healthcare measures. For comparison of time trends, we plotted data for hospitalizations, ED/UC visits and outpatient ILI syndrome visits against TT encounters. We applied ESSENCE detection algorithms to identify high-level alerts for influenza activity. ESSENCE aberration detection was restricted to the 2011–2012 season because limited historical TT and outpatient data from 2009–2010 was available to accurately predict aberrancy in the 2010–2011 season. We then calculated the peak measure of healthcare utilization during both influenza seasons (2010–2011 and 2011–2012) for each data source and compared timing of peaks and alerts between TT and other healthcare encounters to assess maximum healthcare system usage and timeliness of surveillance.

Results

There were 7,044 influenza-coded calls, 564 hospitalizations, 1,849 emergency/urgent visits, and 416,613 ILI-coded outpatient visits. Spearman rank correlation coefficients were calculated for influenza-coded calls with hospitalizations (0.77); ED/UC visits (0.85); and ILI-outpatient visits (0.88), respectively (P< 0.0001 for all correlations). Peak influenza activity occurred on the same week or within 1 week across all settings for both seasons. For the 2011–2012 season, TT alerted with increased influenza activity before all other settings.

Conclusions

Data from VA telephone care correlates well with other VA data sources for influenza activity. TT may serve to augment these existing clinical data sources and provide earlier alerts of influenza activity. As a national health care system with a large patient population, VA could provide a robust early-warning system for influenza if ongoing biosurveillance activities are combined with TT data. Additional analyses are needed to understand and correlate TT with healthcare utilization and severity of illness.     

Scales of governance: The role of surveillance in facilitating new diplomacy during the 2009–2010 H1N1 pandemic

The 2009–2010 H1N1 influenza pandemic has highlighted the importance of global health surveillance. Increasingly, global alerts are based on 'unexpected’ 'events’ detected by surveillance systems grounded in particular places. An emerging global governance literature investigates the supposedly disruptive impact of public health emergencies on mobilities in an interdependent world. Little consideration has been given to the varied scales of governance – local, national and global – that operate at different stages in the unfolding of an 'event', together with the interactions and tensions between them. By tracking the chronology of the H1N1 pandemic, this paper highlights an emergent dialogue between local and global scales. It also draws attention to moments of national autonomy across the global North and South which undermined the WHO drive for transnational cooperation.     

Epidemiological surveillance activities during the 2009 influenza pandemic in Spain: lessons learnt one year after

In this article the actions taken in the area of epidemiological surveillance in Spain during the influenza pandemic and the recommendations drawn from them during the progression of the pandemic are reviewed. The performance of the Surveillance Subcommittee established in the National Influenza Preparedness and Response Plan was central to the coordination of these activities. The Surveillance Subcommittee was immediately activated when the alert was issued. Its role is also described in this review. The existence of a National Plan allowed a rapid and coordinated response after the alert declaration. The epidemiological and virological surveillance of the influenza pandemic was adapted to an evolving situation. In addition to routine influenza monitoring systems, new surveillance systems were put in place such as a case-based surveillance for community influenza cases and a case-based surveillance for severe cases and deaths due to the pandemic. Among the lessons learned from this pandemic, we would highlight the need to strengthen the timely analysis of data collected during an alert, the need to promote the exchange of information among public health and health care professionals, and to strengthen the response capacity in order to have resilient and consolidated public health structures for future health alerts.     

Absenteeism in schools during the 2009 influenza A(H1N1) pandemic: a useful tool for early detection of influenza activity in the community?

Certain influenza outbreaks, including the 2009 influenza A(H1N1) pandemic, can predominantly affect school-age children. Therefore the use of school absenteeism data has been considered as a potential tool for providing early warning of increasing influenza activity in the community. This study retrospectively evaluates the usefulness of these data by comparing them with existing syndromic surveillance systems and laboratory data. Weekly mean percentages of absenteeism in 373 state schools (children aged 4-18 years) in Birmingham, UK, from September 2006 to September 2009, were compared with established syndromic surveillance systems including a telephone health helpline, a general practitioner sentinel network and laboratory data for influenza. Correlation coefficients were used to examine the relationship between each syndromic system. In June 2009, school absenteeism generally peaked concomitantly with the existing influenza surveillance systems in England. Weekly school absenteeism surveillance would not have detected pandemic influenza A(H1N1) earlier but daily absenteeism data and the development of baselines could improve the timeliness of the system.     

Estimating and comparing case fatality rates of pandemic influenza A (H1N1) 2009 in its early stage in different countries

Aim

The case fatality rate (CFR) of the novel influenza A (H1N1) 2009 was estimated to gain an understanding of the virulence at the early stage of the pandemic, and it was interpreted and reported primarily as a point estimate without an accompanying measure of precision. To allow proper interpretation of the estimated CFR, the uncertainty inherited from the data sample should be reflected in an inferential conclusion. The aim of this article is to construct confidence limits around the estimates from the sample and then compare the CFR of pandemic influenza A (H1N1) 2009 in its early stage to that in different areas.

Methods

Data were extracted from published papers and WHO pandemic surveillance reports. Statistical method such as the bootstrap approach is used to obtain estimates of confidence intervals.

Results

The estimates of CFR and their confidence intervals in the initial stage of the pandemic are provided for 28 countries (or areas) in this article. The comparison of CFR for 28 countries (or areas) is shown and it is found that the pandemic in South American countries such as Argentina, Uruguay, Costa Rica, Colombia, Paraguay, Dominican Republic, Jamaica, Puerto Rico, were more severe than other countries which had reported cases to corresponding organizations. The analysis shows that the severity of the disease in the USA and Canada has no significant difference.

Conclusion

The CFRs of pandemic influenza A (H1N1) 2009 for 28 countries (or areas) with an accompanying measure of precision are estimated. Therefore, it is possible to compare the severity of pandemic influenza between different countries and to know whether a difference between the severities is significant.     

Report of the international forum on pandemic influenza 2010 Qingdao, China, 24-25 July 2010

The 2009 H1N1 influenza pandemic is the first pandemic to hit the world in the 21st century. According to World Health Organization (WHO) reports, as of 18 July 2010, more than 214 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, and over 18,336 people have died as a result of the disease [1]. In an effort to facilitate the exchange of strategic and operational experience in the fight against the pandemic, the Chinese Center for Disease Control and Prevention (China CDC), supported by the China Ministry of Health, in collaboration with WHO, the World Bank, the U.S. CDC, and co-organised with the Elsevier Publishing Group, hosted the International Forum on Pandemic Influenza 2010 in July. The two-day meeting, attended by over 600 international delegates, saw human health and animal health professionals discuss the current situation of the pandemic, the global response and vaccination strategies, pandemic surveillance and preparedness, and the animal-human interface in influenza and other emerging infectious diseases. A summary of the discussions is presented here.     

Implementing integrated disease surveillance and response: Four African countries' experience, 1998–2005

Abstract

The Integrated Disease Surveillance and Response (IDSR) strategy was developed by the Africa Regional Office (AFRO) of the World Health Organisation (WHO) and proposed for adoption by member states in 1998. The goal was to build WHO/AFRO countries' capacity to detect, report and effectively respond to priority infectious diseases. This evaluation focuses on the outcomes in four countries that implemented this strategy.

Major successes included: integration of the surveillance function of most of the categorical disease control programmes; implementation of standard surveillance, laboratory and response guidelines; improved timeliness and completeness of surveillance data and increased national-level review and use of surveillance data for response.

The most challenging aspects were: strengthening laboratory networks; providing regular feedback and supervision on surveillance and response activities; routine monitoring of IDSR activities and extending the strategy to sub-national levels.     

Does having a seasonal influenza program facilitate pandemic preparedness? An analysis of vaccine deployment during the 2009 pandemic

BackgroundNational seasonal influenza programs have been recommended as a foundation for pandemic preparedness. During the 2009 pandemic, WHO aimed to increase Member States’ equitable access to influenza vaccines through pandemic vaccine donation.MethodsThis analysis explores whether the presence of a seasonal influenza program contributed to more rapid national submission of requirements to receive vaccine during the 2009 influenza pandemic. Data from 2009 influenza vaccine donation, deployment, and surveillance initiatives were collected during May-September 2018 from WHO archival material. Data about the presence of seasonal influenza vaccine programs prior to 2009 were gathered from the WHO-UNICEF Joint Reporting Form. Cox proportional hazards models were used to assess the relationship between presence of a seasonal influenza program and time to submission of a national deployment and vaccination plan and to vaccine delivery.FindingOf 97 countries eligible to receive WHO-donated vaccine, 83 (86%) submitted national deployment and vaccination plans and 77 (79%) received vaccine. Countries with a seasonal influenza vaccine program were more likely to submit a national deployment and vaccination plan (hazards ratio [HR] 2.1; 95% confidence interval [CI]. Countries with regulatory delays were less likely to receive vaccine than those without these delays (HR 0.4, 95% CI: 0.2–0.6).InterpretationDuring the 2009 pandemic, eligible countries with a seasonal influenza vaccine program were more ready to receive and use donated vaccines than those without a program. Our findings suggest that robust seasonal influenza vaccine programs increase national familiarity with the management of influenza vaccines and therefore enhance pandemic preparedness.FundingN/A.     

Assessment of ESSENCE performance for influenza-like illness surveillance after an influenza outbreak--U.S. Air Force Academy, Colorado, 2009

The Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE), version II, designed by the Johns Hopkins University Applied Physics Laboratory and the U.S. Department of Defense (DoD), is an Internet-based syndromic disease surveillance system used by civilian and military health departments. ESSENCE was designed to increase the timeliness of outbreak detection, serving as an early warning system and providing opportunities to prevent and control the spread of infection. After a 2009 pandemic influenza A (H1N1) outbreak at the U.S. Air Force (USAF) Academy in Colorado, CDC was invited to conduct an evaluation of the ESSENCE influenza-like illness (ILI) surveillance system to assess its performance during the outbreak. Medical records at the USAF Academy clinics from June 25 through July 8, 2009, the period of the outbreak, were reviewed. This report summarizes the results of the evaluation, which demonstrated strengths in data quality, flexibility, and representativeness; however, ESSENCE was not useful for detecting or monitoring the H1N1 outbreak because of its lack of timeliness (1-3 day delay), inadequate sensitivity (71.4%), and poor predictive value positive (PVP) (31.8%) for identifying ILI cases. In this localized, single-source outbreak, ESSENCE did not serve as an early warning system for an emerging infectious disease and did not detect the outbreak soon enough to institute prevention and control measures that might have slowed the spread of infection. More frequent Internet data transmissions from the clinics to the ESSENCE server could improve timeliness, and PVP could be enhanced by including measured body temperature in the ESSENCE ILI case definition.     

Early-warning health and process indicators for sentinel surveillance in Madagascar 2007-2011

Background: Epidemics pose major threats in resource-poor countries, and surveillance tools for their early detection and response are often inadequate. In 2007, a sentinel surveillance system was established in Madagascar, with the aim of rapidly identifying potential epidemics of febrile or diarrhoeal syndromes and issuing alerts. We present the health and process indicators for the five years during which this system was constructed, showing the spatiotemporal trends, early-warning sign detection capability and process evaluation through timely analyses of high-quality data.Methods: The Malagasy sentinel surveillance network is currently based on data for fever and diarrhoeal syndromes collected from 34 primary health centres and reported daily via the transmission of short messages from mobile telephones. Data are analysed daily at the Institut Pasteur de Madagascar to make it possible to issue alerts more rapidly, and integrated process indicators (timeliness, data quality) are used to monitor the system.Results: From 2007 to 2011, 917,798 visits were reported. Febrile syndromes accounted for about 11% of visits annually, but the trends observed differed between years and sentinel sites. From 2007 to 2011, 21 epidemic alerts were confirmed. However, delays in data transmission were observed (88% transmitted within 24 hours in 2008; 67% in 2011) and the percentage of forms transmitted each week for validity control decreased from 99.9% in 2007 to 63.5% in 2011.Conclusion: A sentinel surveillance scheme should take into account both epidemiological and process indicators. It must also be governed by the main purpose of the surveillance and by local factors, such as the motivation of healthcare workers and telecommunication infrastructure. Permanent evaluation indicators are required for regular improvement of the system.Key words: Sentinel surveillance, Madagascar, early warning, mobile phone     

The Biosurveillance Resource Directory - A One-Stop Shop for Systems,Sources, and Tools

Objective

The goal of this project is to identify systems and data streams relevant for infectious disease biosurveillance. This effort is part of a larger project evaluating existing and potential data streams for use in local, national, and international infectious disease surveillance systems with the intent of developing tools to provide decision-makers with timely information to predict, prepare for, and mitigate the spread of disease.

Introduction

Local, national, and global infectious disease surveillance systems have been implemented to meet the demands of monitoring, detecting, and reporting disease outbreaks and prevalence. Varying surveillance goals and geographic reach have led to multiple and disparate systems, each using unique combinations of data streams to meet surveillance criteria. In order to assess the utility and effectiveness of different data streams for global disease surveillance, a comprehensive survey of current human, animal, plant, and marine surveillance systems and data streams was undertaken. Information regarding surveillance systems and data streams has been (and continues to be) systematically culled from websites, peer-reviewed literature, government documents, and subject-matter expert consultations.

Methods

A relational database has been developed and refined to allow for detailed analyses of data streams and surveillance systems. To maximize the utility of the database and facilitate one-stop-shopping for biosurveillance system information, we have expanded our scope to include not only biosurveillance systems, but also data sources, tools, and biosurveillance collectives. Captured in the information collected about the resource (if available) is the name and acronym of the resource, the date the resource became available, the accessibility of the resource (is it open to all, or are there limitations to access), the primary sponsors, if the resource is associated with GIS functionality, and if the focus is health. Also collected is contact information, information regarding the scope and domain of the resource, the pertinent diseases or disease categories, and the geographic and population coverage of the resource. Websites associated with the resource are directly accessible from the database. Data stream information is also captured based on our developed data stream framework. If the resource uses other specified systems/sources/tools for data gathering or analysis, then that is also captured and directly linked within the database.

Results

The Biosurveillance Resource Directory (BRD) is in the process of being tested by multiple potential end users in the public health, biosecurity, and biosurveillance communities. Feedback from these testers is being used to refine the database to maximize functionality and utility. Additionally, methods for dynamically updating and maintaining the database are being evaluated. Automated and semi-automated queriable reports have been developed and are integral to demonstrating specific use-case scenarios in which the BRD would be beneficial for end-users.

Conclusions

A need for a biosurveillance one-stop shop has been increasingly called for to help in evaluating what data streams and systems are available and relevant for many different biosurveillance needs and goals. The prototype Biosurveillance Resource Directory is a search-able, dynamic database for biosurveillance systems, sources, and tools information.     

Development and evaluation of a data‐adaptive alerting algorithm for univariate temporal biosurveillance data

This paper discusses further advances in making robust predictions with the Holt–Winters forecasts for a variety of syndromic time series behaviors and introduces a control‐chart detection approach based on these forecasts. Using three collections of time series data, we compare biosurveillance alerting methods with quantified measures of forecast agreement, signal sensitivity, and time‐to‐detect. The study presents practical rules for initialization and parameterization of biosurveillance time series. Several outbreak scenarios are used for detection comparison. We derive an alerting algorithm from forecasts using Holt–Winters‐generalized smoothing for prospective application to daily syndromic time series. The derived algorithm is compared with simple control‐chart adaptations and to more computationally intensive regression modeling methods. The comparisons are conducted on background data from both authentic and simulated data streams. Both types of background data include time series that vary widely by both mean value and cyclic or seasonal behavior. Plausible, simulated signals are added to the background data for detection performance testing at signal strengths calculated to be neither too easy nor too hard to separate the compared methods. Results show that both the sensitivity and the timeliness of the Holt–Winters‐based algorithm proved to be comparable or superior to that of the more traditional prediction methods used for syndromic surveillance. Copyright © 2009 John Wiley & Sons, Ltd.     

A decade of adaptation: Regulatory contributions of the World Health Organization to the Global Action Plan for Influenza Vaccines (2006–2016)

The Global Action Plan (GAP) for Influenza Vaccines is a decade-long initiative that brings together a diverse range of stakeholders to work towards reducing anticipated global shortage of influenza vaccines and ensuring more equitable access to vaccines during the next influenza pandemic. Since its inception in 2006, significant progress has been made towards all the main objectives of GAP, namely: (1) an increase in seasonal vaccine use, (2) an increase in vaccine production, and (3) progress in research and development of more effective vaccines. The Technology Transfer Initiative (TTI), conceived and managed by WHO under the GAP, contributed to increasing regional influenza vaccine production capacity. This was achieved by facilitating technology transfer in 14 low- and middle-income countries, through grants to manufacturers to establish or strengthen influenza vaccine production capacity and support to their national regulatory authorities. Five of the countries subsequently licensed locally produced influenza vaccines; two pandemic and three seasonal vaccines received WHO prequalification. The success of GAP can be largely attributed to the regulatory support provided by WHO to both manufacturers and regulators. This support had two components: (1) direct regulatory support to GAP/TTI, and (2) support to GAP-related WHO programmes, such as the Pandemic Influenza Vaccine Deployment Initiative in 2010 and the Pandemic Influenza Preparedness Framework since 2013, especially in non-vaccine-producing countries. Temporary adaptation of the assessment process for influenza vaccines in the WHO Vaccine Prequalification Programme to the A(H1N1) pandemic situation in 2009 was instrumental to the success of the WHO Pandemic Influenza Vaccine Deployment Initiative in its attempt to meet the demand for pandemic vaccines in countries that received donated vaccines.     

Developing pandemic preparedness in Europe in the 21st century: experience, evolution and next steps

Problem

Improving pandemic planning and preparedness is a challenge in Europe, a diverse region whose regional bodies (the Regional Office for Europe of the World Health Organization [WHO], the European Commission and the European Centre for Disease Prevention and Control) have overlapping roles and responsibilities.

Approach

European pandemic preparedness indicators were used to develop an assessment tool and procedure based on the 2005 global WHO checklist for pandemic preparedness. These were then applied to Member States of WHO’s European Region, initially as part of structured national assessments conducted during short visits by external teams.

Local setting

Countries in WHO’s European Region.

Relevant changes

From 2005 to 2008, 43 countries underwent a pandemic preparedness assessment that included a short external assessment visit by an expert team. These short visits developed into a longer self-assessment procedure involving an external team but “owned” by the countries, which identified gaps and developed plans for improving preparedness. The assessment tool and procedure became more sophisticated as national and local pandemic preparedness became more complex. The 2009 pandemic revealed new gaps in planning, surveillance communications and immunization.

Lessons learnt

Structured national self-assessments with support from external teams allow individual countries to identify gaps in their pandemic preparedness plans and enable regional bodies to assess the regional and global resources that such plans require. The 2009 pandemic revealed additional problems with surveillance, pandemic severity estimates, the flexibility of the response, vaccination, involvement of health-care workers and communication. European national plans are being upgraded and global leadership is required to ensure that these plans are uniformly applied across the region.     

Rotavirus surveillance --- worldwide, 2009

Rotavirus is the leading cause of severe diarrhea worldwide among children aged <5 years (1). An estimated 527,000 children in this age group died from rotavirus in 2004, and approximately 85% of those deaths occurred in South Asia and sub-Saharan Africa (2). In 2009, the World Health Organization (WHO) recommended inclusion of rotavirus vaccination in all national immunization programs (3). Disease burden data generated from surveillance are important for making decisions regarding whether to introduce rotavirus vaccine into a country, and establishing surveillance platforms is essential to enable monitoring of vaccine impact. WHO coordinates a global surveillance network for rotavirus that uses standardized case definitions and laboratory methods at sentinel hospitals to identify cases of rotavirus in children with diarrhea. This report summarizes an assessment of data from the global surveillance network for 2009, which found that, among 43 participating countries that tested ≥ 100 stool specimens and reported results for all 12 months in 2009, a median of 36% of enrolled and tested children aged < 5 years hospitalized with diarrhea (range: 25%-47% among the six WHO regions) tested positive for rotavirus. These data illustrate the important etiologic role of rotavirus in hospitalizations for diarrhea in children worldwide, which can be prevented by rotavirus vaccination.     

Pandemic risk prevention in European countries: role of the ECDC in preparing for pandemics. Development and experience with a national self-assessment procedure, 2005-2008

To be effective risk prevention work takes place well before pandemics through the three Ps: Planning, Preparedness and Practise. Between 2005 and 2008 the European Centre for Disease Prevention and Control (ECDC) worked with the European Commission (EC) and the WHO Regional Office for Europe (WHO-Euro) to assist European countries in preparing themselves for a future influenza pandemic. All eligible countries in the European Union and European Economic Area participated with energy and commitment. Indicators of preparedness were developed based on WHO planning guidance and these were set within a simple assessment which included a formal country visit. The procedure evolved considerably with field experience. As the complexity of pandemic preparedness was appreciated it changed from being a classical short external assessment to longer national self-assessments with demonstrable impact, especially when self-assessments were published. There were essential supporting activities undertaken including a series of pan-European pandemic preparedness workshops organised by EC, WHO-Euro, ECDC and countries holding the European Union Presidency. The self-assessments highlighted additional work and documentation that was needed by national authorities from the ECDC. This work was undertaken and the document produced. The benefits of the self-assessments were seen in the 2009 pandemic in that EU/EEA countries performed better than some others. A number of the guidance documents were updated to fit the specific features of the pandemic. However the pandemic revealed many weaknesses and brought new challenges for European countries, notably over communication and vaccines, the need to prepare for a variety of scenarios and to factor severity estimates into preparedness, to improve surveillance for severe disease and to deliver seroepidemiology. Any revised self-assessment procedure will need to respond to these challenges.     

A pandemic influenza vaccine in India: from strain to sale within 12 months

In the event of a highly pathogenic influenza pandemic, the Indian subcontinent would need 1.2 billion doses of vaccine to immunize its entire population, double if two doses were required to assure immunity. Serum Institute of India Limited (SII) thus became one of six initial grantees of the World Health Organization (WHO) technology transfer initiative to create capacity in developing countries to manufacture H5N1 pandemic influenza vaccine. At the outbreak of the A(H1N1) 2009 influenza pandemic, experience gained from the H5N1 project was used to develop a live attenuated influenza vaccine (LAIV), since this was the only option for the level of surge capacity required for a large-scale immunization campaign in India. SII took <12 months to develop and market its LAIV intranasal vaccine from receipt of the seed strain from WHO. As of November 2010, over 2.5 million persons have been vaccinated with Nasovac(?) with no serious adverse reactions or vaccine failure after 3 months' post-marketing surveillance. The product has been submitted for prequalification by WHO for purchase by United Nations agencies. In parallel, SII also developed an inactivated influenza vaccine, and is currently looking to ensure the sustainability of its influenza vaccine manufacturing capacity.