Adopted by the WMA General Assembly, Pilanesberg, South Africa, October 2006

1. This statement provides guidance to National Medical Associations and physicians on how they should be involved in their respective country's pandemic planning process. It also encourages governments to involve their National Medical Associations when planning for pandemic influenza. Finally, it provides broadly stated recommendations about activities that physicians should consider in preparing themselves for pandemic influenza.

Avian Influenza versus Pandemic Influenza

2. Avian influenza (bird flu) is a contagious common viral infection of birds and, less commonly, pigs. Two forms have been identified: less pathogenic avian influenza (LPAI) and highly pathogenic avian influenza (HPAI), which is extremely contagious and has nearly a 100% mortality rate in birds. Avian influenza viruses differ from human influenza viruses. While avian influenza viruses do not normally infect humans, since 1997 several cases of human infection have been documented.
3. The current H5N1 HPAI virus is a subtype of influenza type A viruses and was first isolated from South African terns in 1961. The current outbreak started in late 2003 and early 2004 in eight countries in Asia. While originally reported as controlled, since June 2004 new outbreaks of H5N1 have reappeared. Migratory and smuggled birds are likely to be responsible for the spread of H5N1. The infected birds shed large quantities of virus in their feces, and exposure to infected droppings or to environments contaminated by the virus is common. It is anticipated that H5N1 will continue to spread along the migratory pathways of wild birds. Most human infections have occurred in rural areas where freely-roaming small poultry flocks are kept.
4. HPAI is controlled by rapidly destroying all infected and/or exposed birds, by proper disposal of the carcasses, and by quarantining and rigorous disinfection of farms. In order to contain an outbreak, aggressive measures are needed immediately after the outbreak is detected.
5. Human pandemic influenza occurs three to four times a century and can take place in any season, not just winter. Pandemic influenza results from the emergence of a new human influenza strain to which no human immunity exists. This new human pandemic strain can arise from either avian influenza strains or from influenza viruses infecting swine and potentially other mammalian species. It is usually associated with a higher severity of illness and, consequently, a higher risk of death. All age groups may be at risk, and experts predict an infection rate of 25-50% of the population, depending on the severity of the strain. Since the virus strain cannot be accurately predicted, a vaccine against pandemic flu may not be available until several months after the pandemic begins. A major factor in protecting populations will be the time from emergence of a new strain to the development and manufacture of vaccine. It is hypothesized that use of anti-virals may control the progression of a pandemic following its emergence, so adequate supplies of anti-virals are important. At all phases of a pandemic outbreak, but especially during the period when vaccine is unavailable, infection control is critical.
6. Health officials are concerned that avian influenza, if given the right opportunities, could mutate to form a new strain of human influenza virus against which humans have no immunity or existing vaccine - a pandemic strain. It is apparent that H5N1 has the capacity to directly jump the species barrier and cause serious disease in humans but thus far, H5N1 has demonstrated very limited, if any, human transmission potential. A new pandemic virus could develop if a human became simultaneously infected with H5N1 and a human influenza virus, resulting in gene swapping. Also, the H5N1 virus could mutate on its own. With this new virus strain, direct human-to-human transmission could result, and if the virus remains highly pathogenic, a pandemic with high mortality rates could occur. This is believed to have happened in the worst pandemic of the 20th century, the "Spanish Flu" of 1918, that killed 50 million people worldwide.
7. Even though the H5N1 virus is not easily transmitted to humans, any H5N1 human infection provides an opportunity for co-existence with a human influenza virus. Consequently, the World Health Organization (WHO) and other health organizations recommend that any person coming in contact with infected poultry receive the current annual flu vaccine. Since it is not yet known whether residual immunity to the N1 component of the annual vaccine provides any immunity to H5N1, there is no way to accurately predict the severity of the next pandemic. It is important to recognize that while there is current concern surrounding H5N1, a pandemic influenza strain may not arise from H5N1 but may come from another HPAI strain. Regardless, the odds are great that another pandemic will occur.

8. The WHO has responsibility for co-ordinating the international response to an influenza pandemic. It has defined phases in the evolution of a pandemic that allow an escalating approach to preparedness planning and response leading up to a declaration of onset of a pandemic.
9. The development of a national pandemic plan, will, by necessity, be led by the national government, but physicians should be involved at all stages. While each nation will have unique situations to address, the following pandemic preparedness principles apply:
   
   1. Define key preparedness issues, needs, and goals.
      
      1. The prioritization of one or two goals for the nation's pandemic planning is essential. Depending on these goals, the prioritization and use of vaccines and antivirals will vary. For example, a goal of reducing morbidity and mortality due to influenza will have very different planning criteria from a goal of preserving societal infrastructure.
         
      2. Defining the nation's needs in the event of a pandemic will require making some basic assumptions about the severity of the pandemic in the nation. Based upon that assumption, it will then be possible to make some predictions about the issues and needs facing the country. It will be useful to consult with other nations that have prepared pandemic plans to see what challenges they faced in identifying their needs and issues.
         
   2. In countries where there is a substantial presence of healthcare professionals in the private sector, involve those in the private sector, who will be managing the pandemic on the ground, particularly physicians, in the decision-making process.
   The administration of millions of doses of antivirals and vaccine to the management of surge capacity and hospital beds will all require specific participation of those most knowledgeable and involved in the process.
   3. Prepare risk communication and crisis communication strategies and messages in anticipation of public and media fear and anxiety.
   4. Provide guidance and timely information to regional health departments, health care organizations, and physicians. Utilize physicians as spokespeople to explain the medical and ethical issues to the public. Ensure that communications mechanisms and infrastructure continue to function efficiently.
      
      1. As planning proceeds, timely and clear information not only of the plan, but also of the rationale behind decisions, needs to be made available to public health authorities and the medical establishment as well as to the public. Physician leaders in a community are well-respected and frequently can serve as excellent spokespersons to educate the public about the issues surrounding pandemic planning. Public feedback into important decisions that may have moral and ethical implications will help secure public acceptance of the plan. For example, holding a public engagement process to assess the public's opinion about rationing of vaccine during a pandemic can be useful.
         
      2. It is important that government representatives and physicians speak with one voice in order to avoid confusion and panic during a pandemic event.
         
   5. Identify the legal issues and authorities for pandemic responses, e.g. liability, quarantine, closing borders.
   Authorities will need to make decisions that range in complexity from local decisions to close public areas to national decisions regarding border closings and/or quarantine/isolation of exposed/infected citizens. The legal and ethical issues surrounding these decisions need to be in place prior to a pandemic.
   6. Determine the order of importance for use of scarce resources such as vaccines and antivirals based on pandemic response goals. Priority groups chosen for vaccine should be those that help maintain essential community services and those at highest risk.
   7. Do not put physicians in the position of being responsible for decisions regarding the rationing of vaccine, antivirals and other scarce resources during a pandemic. Those decisions must be made by the government.
   8. Outline coordination and implementation of a response by stages of the pandemic.
   Depending on the size of a country, this response may be at a national level or at a regional level. Large countries may see the pandemic occur in waves in which case affected regions will need to have their own response ready to be implemented.
   9. Consider the surge capacity of hospitals, laboratories, and the public health infrastructure and improve them if necessary. Prepare for absences of key staff and the need to maintain health services for conditions other than influenza.
   10. Prepare for the psychosocial impact on health care workers in managing the waves of a pandemic.
       
   11. Consider whether the safety of those in facilities managing the pandemic must be ensured, such as police protection of the supply chain for vaccines and antivirals. Address what might be needed to control a pandemic in the absence of a vaccine.
   12. Assess whether there is sufficient funding available to adequately prepare for pandemic influenza.
       
   Political will to fund public health preparedness is essential. Resources spent on pandemic planning should be framed in the context of general preparedness; pandemic preparedness and public health preparedness share many of the same issues.
   
   13. Identify key issues that remain to be resolved, which may include management of patients in the community, triage in hospitals, ventilation management, safe handling of bodies, and death investigations and reports.

10. In any disaster situation or infectious disease outbreak, physicians and their professional organisations will be challenged to continue to provide needed care to the vulnerable and sick, as well as to aid in the emergency response called for in the specific situation. The following issues should be considered in this regard:
    
    1. NMAs should have their own organization-specific business contingency plan in place to ensure continued support of their members.
       Many existing plans anticipate disruptions such as fires, earthquakes, and floods that are geographically restricted and have fairly well defined timeframes. However, pandemic influenza planning requires assumptions that the influenza will be widely dispersed geographically and will potentially last many months.
    2. NMAs should clearly identify their responsibilities during a pandemic.
       The NMA should actively seek participation in the nation's pandemic planning process. If this is achieved, the NMA's responsibilities will also be clearly defined to its physicians as well as to the government.
    3. For effective global pandemic influenza planning, NMAs should collaborate and network with NMAs from other countries.
       Many NMAs have already been involved in their countries' pandemic planning process. Challenges and key roles for the NMA that have been identified should be shared.
    4. NMAs should have an essential role in communicating vital information:
       
       1. To the public. As the authoritative medical voice, an NMA engenders public trust and should use that trust to communicate accurate and timely information regarding pandemic planning and the current state of the pandemic to the public;
          
       2. Between authorities and physicians, and between physicians in affected areas and their colleagues elsewhere;
          
       3. Between health care professionals. NMAs should work with other health care provider organizations (e.g., nurses, hospital groups) to identify common issues and congruent policies and messages regarding pandemic preparedness and response.
          
    5. NMAs should offer training seminars and clinical support tools, such as online and e-published self-help training materials, for physicians and regional medical associations.
    Such training/tools should consider how, in a worst-case pandemic scenario, physicians will manage respiratory crises without intensive or critical care facilities. Training should also be given in triage strategies and how infected patients should be counselled.
    6. NMAs should consider what new programs and services they might offer during a pandemic, such as coordination or provision of mental health crisis support programs for affected members and their families, facilitation of health emergency response teams, emergency locum relief, and facilitation of equipment supply lines.
    7. NMAs should be involved in and support the development and implementation of government plans while still considering their own professional code of ethics. They should monitor and assess the implementation of said plans to ensure that as pandemic outbreaks cycle through their natural history, health interests remain paramount.
    8. NMAs should advocate for adequate government funding to prepare for pandemic influenza.
    9. NMAs should anticipate the different practice environments that may evolve during pandemic conditions and be prepared to discuss liability and related issues with health authorities and advise members on such issues.
    10. NMAs should be prepared to advocate on behalf of members who, during a pandemic, will have rapidly emerging professional needs that must be met, and on behalf of patients and the public who will be affected by the unfolding events.

11. Physicians will be the first point of contact and source for advice for many as a pandemic evolves. The following are broad issues that physicians should consider in the event of a pandemic:
    
    1. Be sufficiently educated about pandemic influenza and transmission risks.
       Communication about the actual risks of pandemic influenza is important to impart a sense of urgency without creating undue public alarm. Consider active physician participation in the media response to a pandemic.
    2. Be vigilant for the possibility of severe or emerging respiratory diseases, especially in patients who have recently travelled internationally.
    As with any emerging infection, the astute physician is one of the important surveillance tools for detecting and managing an outbreak.
    3. Plan for how to manage high-risk patients in the office/clinic setting and communicate the plan to clinic staff.
    Isolation and infection control plans must be available and staff should be well-versed in them. Be aware of what regional public health authorities are requesting be done with potential patients and their exposed contacts.
    4. Plan how to concurrently manage patients with chronic illnesses who require routine medical management.
    5. Plan accordingly for possible interruptions of essential services like sanitation, water, power, and disruptions to the food supply. Plan for the possibility of staff shortages because of personal illness and/or the care of next-of-kin who are ill.
    It is vital to have contingency plans in place to deal with possible societal disruption. Recognize that usual sources of these essential services may not be functioning so identifying alternative sources for these essentials may be necessary.
    6. Prepare educational materials for patients and staff, including recommendations for proper infection control.
    An educated patient/public that recognizes the necessity for stringent measures such as quarantine and isolation will make a physician's job easier should s/he have to utilize such procedures when a pandemic occurs.
    7. Remain involved in local pandemic planning efforts and understand how the plan will affect the physician. Participate in local simulation exercises.
    Since physicians will be on the frontlines of monitoring, reporting, and eventually managing pandemic influenza patients, they must be closely involved in the planning process. They must continuously provide feedback as to what is logistically possible regarding physicians' efforts on the ground when a pandemic arrives.
    8. Physicians have an ethical responsibility to provide services to the injured or ill. They should have resources in place in the event they and/or their own families become infected.
       
       1. A physician will have a strong public health duty in the time of a pandemic and his/her services will be critical at a time when surge capacity will be stressed. Physicians should make arrangements for the care of their families and dependents in the event of a pandemic.
          
       2. Physicians should take all measures necessary to protect their own health and the health of their staff.
       3. Physicians can also consult the WMA Statement on Medical Ethics in the Event of Disasters for additional guidance.
    9. Develop a clinic plan to decrease potential for contact including isolation areas for infected patients, use of close-fitting surgical masks, designating separate blocks of time for non-influenza-related patient care, and postponing non-essential medical visits.
    10. Review staff infection control procedures and train staff in the use of personal protective equipment. Provide signage in the office instructing patients on respiratory hygiene practices; provide tissues, receptacles for their disposal, and hand hygiene materials in waiting areas and examination rooms.
    11. Get vaccinated against annual influenza each year and urge all staff to be vaccinated.
        Annual influenza readiness goes a long way for pandemic preparedness. Additionally, it is possible that components in the annual vaccine (e.g., N1) may provide some immunity against H5N1.
    12. Work to ensure that the office/clinic has access to adequate supplies of antibiotic and antiviral medications as well as commonly prescribed drugs like insulin or warfarin, in case the pharmaceutical supply line is disrupted.

12. That the WMA increase its collaboration with the WHO on pandemic planning and commit to becoming an important participant in the decision-making process.
13. That the WMA communicate to the WHO its capabilities and the capabilities of its NMA members to provide a credible voice that can efficiently reach many practising physicians.
14. That the WMA acknowledge that although pandemic planning is a country-specific task, it can provide general principles for guidance. Additionally, the WMA can provide basic advice that can be given by its member NMAs to practising physicians.
15. That the WMA establish an operational capacity to develop and maintain emergency communication channels between the WMA and NMAs during a pandemic.
16. That the WMA provide timely evidence-based control measures to countries with no or limited up-dated information about pandemics.
17. That NMAs be actively involved in the national pandemic planning process.
18. That physicians participate in local pandemic planning efforts and be involved in communicating vital information to the public.