UN WHO Ethical Pandemic CDS EPR GIP 2007 2c

8/14/2019 UN WHO Ethical Pandemic CDS EPR GIP 2007 2c

1/33

Ethical considerations indeveloping a public healthresponse to pandemic infuenza

WHO/CDS/EPR/GIP/2007.2

EpidEmic and pandEmic

alErt and rEsponsE Ethics, Equity, tradE and human rights


2/33

Ethical considerations indeveloping a public health response

to pandemic inuena


3/33

World Health Organization 2007

All rights reserved. Publications o the World Health Organiation can be obtained rom WHO Press, World Health Organiation, 20

Avenue Appia, 1211 Geneva 27, Switerland (tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: [email protected]). Requests

or permission to reproduce or translate WHO publications whether or sale or or noncommercial distribution should be ad-

dressed to WHO Press, at the above address (ax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation o the material in this publication do not imply the expression o any opinion what-

soever on the part o the World Health Organiation concerning the legal status o any country, territory, city or area or o its authori-

ties, or concerning the delimitation o its rontiers or boundaries. Dotted lines on maps represent approximate border lines or which

there may not yet be ull agreement.

The mention o specifc companies or o certain manuacturers products does not imply that they are endorsed or recommended by

the World Health Organiation in preerence to others o a similar nature that are not mentioned. Errors and omissions excepted, the

names o proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organiation to veriy the inormation contained in this publication.

However, the published material is being distributed without warranty o any kind, either expressed or implied. The responsibility or

the interpretation and use o the material lies with the reader. In no event shall the World Health Organiation be liable or damages

arising rom its use.

Designed by minimum graphics

Printed in Switerland

EPR publicatios are available at: www.who.it/csr/resources/publicatios/


4/33

Contents

Acknowledgements iv

Glossary v

Glossary reerences vii

1. Itroductio 1

2. Geeral ethical cosideratios 3

Balancing rights, interests and values 3

The evidence base or public health measures 3

Transparency, public engagement and social mobiliation 3

Inormation, education and communication 4

Resource constraints 4

3. Priority settig ad equitable access to therapeutic ad prophylactic measures 5

General considerations 5

Criteria or use in prioritiation 6

Additional considerations related to priority in access to vaccines 7Medical and nursing care 7

4. Isolatio, quaratie, border cotrol ad social-distacig measures 9

Core governmental responsibilities 9

Considerations related to specifc public health strategies 10

5. The role ad obligatios o health-care workers durig a outbreako pademic iueza 13

Establishing the nature and scope o health-care workers obligations 14

Reciprocal obligations o governments and employers 14

Promoting compliance with health-care workers obligations 156. Developig a multilateral respose to a outbreak o pademic iueza 17

The importance o international cooperation 17

Sharing specimens and promoting equitable access to pharmaceutical interventions 17

Assistance to countries in need 18

Issues or countries receiving assistance 18

Attention to the needs o all populations, regardless o their legal status in a country 18

Communication policies 19

Reerences 21

Annex. Additional bibliography and links 23

iii


5/33


6/33

v

Glossary

Confdentiality: The obligation to keep inormation

secret unless its disclosure has been appropriately

authoried by the person concerned or, in extraordi-

nary circumstances, by the appropriate authorities.

Epidemic/pandemic (1): An epidemic is the oc-

currence in a community or a region o cases o an

illness, specifc health-related behaviour or other

health-related events clearly in excess o normal

expectancy. A pandemic is an epidemic occurring

worldwide or over a wide area crossing interna-

tional boundaries, and aecting a large number o

people. The WHO global inuenza preparedness

plan (2) includes six phases in a pandemic scale, di-

vided into three periods: the inter-pandemic period,

the pandemic alert period, and the pandemic pe-

riod. (These phases are defned in order to proposea ramework or pandemic preparedness planning

activities; the proposed phases may not all be de-

tectable in sequence).

Equity: The air distribution o benefts and bur-

dens. In some circumstances, an equal distribution

o benefts and burdens will be considered air. In

others, the distribution o benefts and burdens

according to individual or group need will be con-

sidered air. For example, in some circumstances, it

may be equitable to give preerence to those who

are worst o, such as the poorest, the sickest, or

the most vulnerable (3). Inequities are dierences

in health that are unnecessary, avoidable, and are

considered unair and unjust (4).

Fair innings argument: This argument reects

the idea that everyone is entitled to some nor-

mal span o lie years. According to this argument,

younger persons have stronger claims to lie-

saving interventions than older persons because

they have had ewer opportunities to experience lie

(5). The implication is that saving one year o lie or

a young person is valued more than saving one year

o lie or an older person.

Fair process: Daniels and Sabin (6) propose the

ollowing key elements in a air process or setting

priorities:

Publicity: The process, including the rationale

or setting priorities, must be made public and

transparent; consultations and public hearings

should be held. Publicity and involvement o key

stakeholders are particularly important in con-

texts where policy and programmatic decisions

occur in a multi-actor environment and aect

large parts o the population.

Relevance: The aected stakeholders must

view as relevant the reasons, principles and evi-

dence that orm the basis o the rationale or air

decision-making on priorities.

Revisability and appeals mechanisms: In the

case o new evidence and arguments, the pro-

cess must allow or reconsidering and revising

decisions. It must allow or an appeals process

that protects those who have legitimate reasons

or being an exception to the adopted policies.

Enorcement or regulation: There must be a

mechanism in place that ensures that the previ-

ous three conditions are met.

Human rights: Human rights are universal le-

gal guarantees protecting individuals and groups

against actions that interere with undamental

reedoms and human dignity. Some o the most

important characteristics o human rights are that

they are guaranteed by international standards;

legally protected; ocus on the dignity o the hu-

man being; oblige states and state actors; cannot

be waived or taken away (although the enjoyment

o particular human rights may be limited in excep-

tional circumstances); are interdependent and in-

terrelated; and universal (7).International travel and border controls:

Measures that are designed to limit and/or con-


7/33

Ethical considErations in dEvEloping public hEalth rEsponsE to pandEmic influEnza

trol the spread o inection across entry points to

a country (by road, air, sea, etc). They can include

travel advisories or restrictions, entry or exit screen-

ing, reporting, health alert notices, collection and

dissemination o passenger inormation, etc.Isolation: The separation, or the period o com-

municability, o inected persons (confrmed or sus-

pected) in such places and under such conditions

as to prevent or limit the transmission o the inec-

tious agent rom those inected to those who are

susceptible or who may spread the agent to others

(1).

Necessity: Public health powers are exercised un-

der the theory that they are necessary to prevent

an avoidable harm. Government, in order to justiythe use o compulsion, must thereore act only in

the ace o a demonstrable health threat. The pub-

lic health ofcials must be able to prove that they

had a good aith belie, or which they can give

supportable reasons, that a coercive approach is

necessary (1).

Palliative care: Palliative care is an approach that

improves the quality o lie o patients and their

amilies acing the problems associated with lie-

threatening illness, through the prevention and re-lie o suering by means o early identifcation and

assessment and treatment o pain and other prob-

lems, physical, psychosocial and spiritual (8).

Prophylactic measures: Measures to deend

against or prevent disease.

Proportionality: A requirement or a reasonable

balance between the public good to be achieved

and the degree o personal invasion. I the inter-

vention is gratuitously onerous or unair it will over-

step ethical boundaries.

Quarantine: The restriction o the movement o

healthy persons who have been exposed to a sus-

pected or confrmed case o inection with a highly

communicable disease during the likely inectious

period (1). It is a precaution aimed at preventing

urther spread o inection to other people.

Reciprocity: A relationship between parties char-

acteried by corresponding mutual action. Reci-

procity calls or providing something in return or

contributions that people have made (3). For exam-ple, reciprocity implies that society should support

those who ace disproportionate burdens in pro-

tecting the public good, as well as taking steps to

minimie those burdens as much as possible (9).

Social-distancing measures: A range o commu-

nity-based measures to reduce contact betweenpeople (e.g. closing schools or prohibiting large

gatherings). Community-based measures may also

be complemented by adoption o individual behav-

iours to increase the distance between people in

daily lie at the worksite or in other locations (e.g.

substituting phone calls or ace-to-ace meetings,

avoiding hand-shaking).

Distributive justice/global justice: This ethical

principle requires that the risks, benefts, and bur-

dens o public health action be airly distributed.Beauchamp and Childress (10) view distributive

justice as the air, equitable, and appropriate dis-

tribution in society determined by justifed norms

that structure the terms o social cooperation.

Global justice is social justice on a global scale and

it requires countries, particularly developed coun-

tries, to ensure not only that their own citiens are

protected, but also that other countries, particular-

ly developing countries, have the means to protect

their citiens.

Solidarity: Union or ellowship between members

o a group or between peoples o the world. In-

dividuals in solidarity with one another are frmly

united by common responsibilities and interests,

and undivided in opinion, purpose and action (11).

Therapeutic measures: Measures taken to com-

bat inection or disease.

Triage (1): The process o selecting or care or or

treatment those o highest priority or, when re-

sources are limited, those who are more likely tobeneft (rom the French trier: to sort, choose).

Transparency: An ethical principle that requires

policy-makers to ensure that their decision-

making process is open and accessible to the pub-

lic, through clear and requent communication o

inormation.

Utility/efciency: The principle o utilityrequires

that one acts so as to maximie aggregate welare.

This implies an additional principle o efciency, i.e.

the idea that benefts should be obtained using theewest resources necessary.

vi


8/33


9/33


10/33

1

1Introduction

Although we cannot predict when the next inu-

ena pandemic will occur, since the 16th century,

the world has experienced an average o three

pandemics per century, occurring at intervals o 10

to 50 years (1). Morbidity and mortality have varied

across pandemics, making accurate predictions othe impact o the next pandemic impossible. How-

ever, a new inuena pandemic may result in a sig-

nifcant burden on human health and lead to major

social and economic disruption. In addition, the

implementation o public health measures aimed

at limiting social interaction (such as restrictions on

gatherings and population movements) are likely

to have a major impact on trade and tourism. In

view o these possible consequences, countries and

the international community must prepare to cope

with a pandemic and mitigate its impact.

Many critical ethical questions arise in pan-

demic inuena planning, preparedness and re-

sponse. These include: Who will get priority access

to medications, vaccines and intensive care unit

beds, given the potential shortage o these es-

sential resources? In the ace o a pandemic, what

obligations do health-care workers have to work

notwithstanding risks to their own health and the

health o their amilies? How can surveillance, isola-

tion, quarantine and social-distancing measures beundertaken in a way that respects ethical norms?

What obligations do countries have to one another

with respect to pandemic inuena planning and

response eorts?

I these questions are not properly addressed

in planning, the response eorts in the event o a

pandemic could be seriously hampered. A publicly-

discussed ethical ramework is essential to maintain

public trust, promote compliance, and minimie

social disruption and economic loss. As these ques-

tions are particularly difcult, and there will be in-

sufcient time to address them eectively once a

pandemic occurs, countries must discuss them now

while there is still time or careul deliberations.

Responding to the request by Member States,

WHOs Departments o Epidemic and Pandemic

Alert and Response and o Ethics, Trade, Human

Rights, and Health Law1 launched a joint project onAddressing ethical issues in pandemic inuena

planning. In March 2006, WHO established our

working groups (corresponding to Chapters 36 o

this document) to deliberate on key ethical ques-

tions related to a potential inuena pandemic. On

1819 May 2006 technical meetings o the work-

ing groups took place in Geneva, Switerland.

Based on the discussions at those meetings and

the comments received, our background papers

were written. These papers then ormed the basis

or deliberations at a global consultation that took

place on 2425 October 2006 in Geneva. The con-

sultation was attended by some 100 experts and

representatives rom international organiations,

WHO sta rom regional ofces and headquarters,

and observers rom Permanent Missions in Gene-

va. The main objective was to discuss, on the basis

o the drat background papers, the ethical issues

to be addressed in developing and implementing

a public health response to pandemic inuena,

and to lay the groundwork or the ormulation oWHO guidance in this feld. This document has

been produced rom the insights gained rom the

consultation, urther international meetings, and

other inputs including the report entitled Stand on

guard or thee (2) by the University o Toronto Joint

Centre or Bioethics (WHO Collaborating Centre),

Canada, the discussion orums organied by the

Espace Ethique (Paris, France), and WHO regional

1 Renamed Department o Ethics, Equity, Trade and HumanRights as o 1 November 2007


11/33

2


workshops on rapid containment held in Cambo-

dia, Indonesia, Kaakhstan and Saudi Arabia.

The purpose o this document is to assist social

and political leaders at all levels who inuence policy

decisions about the incorporation o ethical consid-erations into national inuena pandemic prepar-

edness plans (or link to national plans see Annex).

The document ocuses on priority setting and equi-

table access to resources, restriction o individuals

movements as a result o non-pharmaceutical in-

terventions (including isolation o cases, quarantine

o contacts, and limitation o social gatherings), the

respective obligations o health-care workers and

their employers and governments, and the obliga-

tions o countries vis--vis each other. Key ethical

principles emphasied include equity, utility/ef-

ciency, liberty, reciprocity, and solidarity. The docu-

ment also addresses the need or transparent and

timely sharing o inormation to improve evidence-

based policy design and acilitate public engage-ment in the decision-making process.

This document addresses issues related to pub-

lic health, primarily those likely to arise during the

pandemic alert period and the pandemic period

(see Glossary). Since specifc decisions will depend

on local circumstances and cultural values, it will be

necessary to adapt this global guidance to the re-

gional and country-level context, with ull respect

to the principles and laws o international human

rights.


12/33

3

2General ethical considerations

Balacig rights, iterests ad values

Preparedness planning or an inuena pandemic

involves balancing potentially conicting individual

and community interests. In emergency situations,

the enjoyment o individual human rights and civil

liberties may have to be limited in the public inter-

est. However, eorts to protect individual rights

should be part o any policy. Measures that limit

individual rights and civil liberties must be neces-

sary, reasonable, proportional, equitable, non-dis-

criminatory, and in ull compliance with national

and international laws.

In balancing competing interests and values, poli-

cy-makers can draw on ethical principles as tools or

weighing conicting claims and or reaching appro-

priate decisions. Ethics does not provide a prescribedset o policies; rather, ethical considerations will be

shaped by the local context and cultural values. The

principles o equity, utility/efciency, liberty, reci-

procity, and solidarity (see Glossary) are especially

helpul in the context o inuena pandemic prepar-

edness planning. Although these principles oten

give rise to competing claims, they provide a rame-

work or policy-makers to assess and balance the

range o interests that ollow rom them. All ethical

deliberations must take place within the context o

the principles o human rights, and all policies mustbe consistent with applicable human rights laws.

The evidece base or publichealth measures

Public health measures that involve signifcant costs

and/or burdens should be reserved or situations

where they can be reasonably expected to make

a dierence to the consequences o a pandemic.

Because little may be known about the virulence

and transmissibility o the next inuena pandemic

virus until it has started spreading widely, judg-

ments about the likely eectiveness and benefts

o public health measures will oten be difcult and

may change over time. Policy-makers should base

their decisions on the best available evidence at any

given time. To acilitate these eorts, in the event

o a pandemic, WHO will attempt to disseminate

evidence-based guidance as rapidly as possible, asthe pandemic threat evolves. Preparedness plans

should be exible enough to allow timely adapta-

tion as new evidence about the nature o the dis-

ease arises.

Trasparecy, public egagemetad social mobilizatio

Public engagement and involvement o relevant

stakeholders should be part o all aspects o plan-

ning (3). Policy decisions and their justifcations

should be publicied and open to public scrutiny.

This will help to:

increase public awareness about the disease-

related risks and enable people to take steps

at individual, amily, workplace and community

level to prepare or and respond to an inuena

pandemic;

contribute to the development o adequate and

eective plans and increase public confdence

that policies are reasonable, responsive, non-dis-

criminatory, and in line with local circumstancesand values;

secure the agreement o the public and civil so-

ciety on the use o therapeutic and prophylactic

measures and their distribution;

provide useul eedback to planners regarding

both inormation that they may lack (such as on

local conditions) and the acceptability o their

plans to the general public;

maintain public trust, add to the legitimacy o

plans, and ensure the accountability o decision-

makers both in the planning stage and during a

plans implementation;


13/33

4


promote public compliance and mitigate ears

o the unknown and the possibility o social dis-

ruption or panic that can result, particularly in

circumstances where the public is expected to

make sacrifces and possibly incur fnancial lossor inringements o their personal autonomy.

Iormatio, educatio, adcommuicatio

In order or public engagement in preparedness

planning to be meaningul, eective modes o com-

municating with and educating the public about

the issues involved are essential. The principles o

outbreak communication are: trust; transparency;

communicating to the public early, dialogue with

the public; and planning (4). Advance planning willallow the development o strategies that will reach

the entire population and that are linguistically and

culturally appropriate. The ollowing types o inor-

mation should be communicated during all periods,

including the inter-pandemic period:

the initiatives being undertaken to allow citiens

or communities to participate in the develop-

ment o pandemic response policies;

the nature and scope o the threat and related

risks, and the spread o the pandemic; the steps that are being taken to respond to the

pandemic, including new policy developments

and their justifcations;

scientifcally sound, easible and understandable

measures people can take to protect themselves

and/or others rom inection.

The decision-making criteria and procedures that

will be used during an inuena pandemic should

be communicated to the public as ar in advance as

possible. Some o this inormation will inevitably be

uncertain and this uncertainty should also be com-

municated in clear, non-alarmist language. Inorma-

tion available will change continuously throughout

the pandemic, requiring adjustments o response

strategies based on ongoing assessments o therisks and potential benefts o interventions. These

adjustments, and the justifcation or them, should

be communicated to the public.

Resource costraits

While all countries must make reasonable eorts to

prepare or an inuena pandemic, dierences in

access to resources mean that what is reasonable

or one country may not be reasonable or another.

In developing countries, limited resources and im-

mediate health-care needs may make it difcult todevelop and implement comprehensive plans (5,

6). In some cases, it may be possible to generate

resources by using available unds more efciently.

In addition, some measures, such as developing

culturally-sensitive communication strategies, may

be achievable with a relatively modest commitment

o resources. However, at some point countries will

have to make difcult decisions about the relative

weight to be given to pandemic preparedness com-

pared to other important public health priorities,

such as HIV and malaria. These decisions about re-

source allocation should be inormed by a process

o public engagement, and their rationale should

be clearly communicated to the public.

The resource constraints acing developing

countries, as well as the global nature o the threat,

underscore the importance o international coop-

eration in developing a global response to an inu-

ena pandemic (see Chapter 6).


14/33

5

3Priority setting and equitable access totherapeutic and prophylactic measures

An inuena pandemic will require countries to

make difcult decisions regarding the allocation o

limited therapeutic and prophylactic measures (see

Box 1). Many dierent ethical principles can be ap-

plied to rationing and priority-setting in health care.

The principle o utility, or example, suggests thatresources should be used to provide the maximum

possible health benefts, oten understood as sav-

ing most lives. The principle o equity requires that

the distribution o benefts and burdens be air (see

Glossary). When these principles conict, the appro-

priate balance to be struck should be determined in

an open and transparent process that takes into ac-

count local circumstances and cultural values.

Geeral cosideratios

As part o pandemic inuena planning, policy-

makers should establish a process or setting pri-

orities and promoting equitable access that:

involves civil society and other major stakehold-

ers in the decision-making process (see Box 2)

so that decisions about the criteria to be used in

allocating scarce resources are made in an open,

transparent, and inclusive manner;

incorporates clear, pre-established mechanisms

or revising decisions based on new evidence

when appropriate.

Even when access to treatment or prophylaxis is lim-

ited, the public is entitled to timely and accurate

inormation. Communication strategies should en-

sure that the public has access to inormation about:

the availability o drugs or treatment and

prophylaxis;

the availability o other preventive and therapeu-

tic measures;

the standards and procedures that will be used

to guide the allocation o drugs and other pre-

ventive and therapeutic measures;

how individuals can access whatever therapeutic

and prophylactic resources are available or them-

selves, their amilies, and their communities.

Regardless o the criteria selected to govern the al-

location o therapeutic and preventive measures,

certain basic elements will be important in all

plans. These include:

acilitating access to the highest level o treat-

ment possible given available resources, with

careul attention to the needs o all populations

(see also Chapter 6);

providing clinicians with clear and transparent

screening and treatment protocols in line with

the latest guidance rom WHO or relevant na-

tional health authorities;

incorporating mechanisms that

ensure that the guidelines and protocols are

ollowed;

enable clinicians to inorm health authorities

when clinical experience suggests the need

or revisions o the protocols;

enable clinicians to take part in the process

o updating guidelines and protocols as the

pandemic progresses;

proposing prioritiation criteria related to the

maintenance o a unctioning health-care sys-tem as needed in a crisis situation, ensuring

a air balance between treatment o inu-

ena patients and the treatment o patients

with other serious conditions;

among non-inuena patients, the prioriti-

ation o access to the general health-care

inrastructure;

among inuena patients, the identifcation

o those who will receive hospital-based ver-

sus home-based care, and criteria or early

discharge (potentially even i still inectious).


15/33

6


Criteria or use i prioritizatio

Although the principle o utility is not the only rel-

evant ethical consideration, it is an important actor

to take into account when establishing prioritia-

tion policies. Utility considerations include:

or individual beneft

the likelihood that an individual with pan-

demic inuena disease will experience a

medical beneft i provided antiviral and ad-

juvant treatment;

the likelihood that an individual at risk o in-

ection will become inected/ill i inuena-

specifc antiviral prophylaxis is not provided;

or community beneft

the likelihood that an inected individual willinect other persons i not given access to

antivirals (or treatment or prophylaxis) and

inection control measures;

the overall reduction in disease burden ex-

pected to result rom the intervention;

the potential value o giving priority to:

essential health-care workers

other workers who provide lie-saving

services

workers who provide critical services nec-

essary or society to unction as normally

as possible; such policies should be devel-

oped with great care, given the danger

that those which avour certain categorieso workers may be perceived as unair and

undermine public trust.

Another principle, which may sometimes conict

with utility considerations, is equity. Considera-

tions o equity may lead to giving priority to:

the worst-o (in terms o severity o illness)

vulnerable and disabled populations

uninected persons who are at high-risk o de-

veloping severe complications and dying rom

inuena i they become inected.

Dierent views exist on whether it is appropriate to

consider age in making prioritiation decisions.

The air innings argument (see Glossary) sup-

ports giving priority to relatively young persons.

The goal o reducing overall disease burden

might also provide a rationale or avouring

younger persons, even i the air innings argu-

ment is not accepted.

Age-based prioritiation criteria should be adoptedonly ater wide public consultation. Such criteria

Box 1

Allocation o scarce resources Swiss Infuenza Pandemic Plan 2006 (7)

The Swiss National Advisory Commission on Biomedical Ethics drated a document on ethical questions in pandemic

preparedness, which was integrated into the Swiss Inuenza Pandemic Plan. The ollowing tiered model or the alloca-tion o scarce resources is adapted rom the Swiss Inuenza Pandemic Plan:

1. During the frst phase, everyone who needs treatment will receive it. This phase will continue until the number o

those requiring treatment exceeds the capacity o the enhanced treatment acilities. In this phase treatment will be

administered to individuals on a frst come, frst served basis or to those who are already being treated or another

illness.

2. The second phase begins when it is no longer possible to treat everyone because therapeutic capacity is exhausted

and some have to be turned away. In this phase, scarce therapeutic resources will be reserved or those whose condi-

tions are most threatening.

3. Finally, the third phase corresponds to the triage used in war or disaster situations. From the outset o this phase

scarce resources should be reserved or patients with lie-threatening conditions. When all those with lie-threaten-

ing conditions can no longer be treated, priority will be given to those who are expected to have the best chance o

survival as a result o treatment. Conversely, treatment in this phase will, i possible, be withheld only rom those

who are unlikely to beneft rom it. Individuals with a poor prognosis will be given palliative treatment only in this

phase.


16/33

7

should rely on broad lie stages, rather than rank-

ing individuals based on dierences o only a ew

years.

Policy-makers should ensure that criteria or prior-

ity setting do not discriminate against individuals

based on inappropriate characteristics, including

but not limited to

gender

race and ethnicity

religion political afliation

national origin

social or economic status.

Additioal cosideratios related topriority i access to vaccies

The current state o inuena vaccine production

technology used in many countries suggests that

the frst doses o a vaccine against a new pan-

demic inuena virus will not be available until 56

months ater the pandemic has been declared. Pro-

duction o sufcient doses to meet global demand

could take additional months. Thereore, it is criti-

cal that policy-makers at all levels, in consultation

with political and civil society leaders, agree on

how the vaccine will be used as it becomes avail-

able (see Box 3). Many consider that vaccination is

most urgent or persons who are at highest risk o

dying rom inuena i inected. Epidemiological

studies during the pandemic should help to identiy

such high-risk groups, but this inormation may notexist when the vaccine frst becomes available. The

risk o death once inected may dier by country

3. priority sEtting and EquitablE accEss to thErapEutic and prophylactic mEasurEs

Box 2

Inclusion o Maori in pandemic planning New Zealand (8)

The inuenza pandemic in 1918 hit the indigenous Maori population o New Zealand especially hard. Even today, they

have a poorer health status than the general population and oten have a lower socioeconomic status. They are there-ore considered a vulnerable population rom a health perspective. The Ministry o Health included Maori representa-

tives in its pandemic planning process to protect the needs o this vulnerable group in a uture pandemic.

In December 2005, the Ministry o Health convened a meeting with a Maori ocus group o seven members, including

health and disability sector experts as well as District Health Board Maori managers, to identiy key issues or the Maori.

It was decided in this meeting to create a Pandemic Maori Reerence Group. During a second meeting in June 2006,

issues discussed included the development o act sheets or Maori communities and access to other resources, Maori

engagement with District Health Boards and the role o Maori providers, workorce preparedness, and community in-

rastructure and needs. The Pandemic Maori Reerence Group is now part o the health sector branch o New Zealands

pandemic planning process.

and will depend on age, socioeconomic status, un-

derlying health conditions, and availability o health

care including access to antivirals or treatment

or prophylaxis. In addition, a policy o vaccinating

those at highest risk o dying will not necessarily be

consistent with other possible goals, e.g. reducing

spread o inection in the population.

There are thus several reasonable although some-

times competing approaches to prioritiing who

should be vaccinated (9). These include:

prioritiing health-care workers and other essen-

tial service providers to help sustain the health-

care system;

vaccinating groups o people known to be cen-

tral to spreading inection or super-spreaders

(i this strategy is expected to be eective);

vaccinating persons at increased risk o death i

inected.

Additional priority setting criteria may be required;

one approach could be to prioritie children and

young adults based on the air innings argument

(see above).

Medical ad ursig care

Many inuena patients will require basic medical

and nursing care, including treatment directed at

relie o symptoms. Developing and maintaining

health-care inrastructures or primary care is a ma-

jor priority or pandemic preparedness, especially

because such investments will be benefcial at all

times and not only during a pandemic.


17/33

8


In addition, plans should address:

the rules or terminating treatment o patients

suering rom pandemic inuena and other

diseases and conditions, so that other patients

can have access to scarce resources (such asmechanically-assisted ventilation);

Box 3

Community participation in vaccine priority setting Public Engagement Pilot Project onPandemic Infuenza 2005 (10)

The Public Engagement Pilot Project on Pandemic Inuenza (PEPPPI) was launched in 2005 by a consortium o organi-

zations in the United States o America to pilot test a method o engaging the public in vaccine-related policy decisions.

Consultations were conducted with citizens-at-large and a stakeholder group that included representatives rom organi-

zations with an interest in pandemic inuenza and expert consultants. The goal o PEPPPI was to develop an improvedplan or pandemic inuenza that would be likely to receive public support, and to demonstrate that public engagement

can be productive in the policy process or pandemic inuenza preparedness.

A frst consultation was convened with the stakeholder group to rame the issues, secure background inormation and

to raise awareness o the ethical dilemmas related to vaccine prioritization. A second consultation invited citizens-at-

large to select highest priority goals or an inuenza vaccination programme. A ollow-up meeting with the stakeholder

group was held, as was a broader citizen-at-large consultation where citizens were asked or their eedback on the pri-

ority goals established during the initial citizen-at-large consultation. In total the consultations involved approximately

300 participants with diverse backgrounds and points o view.

The groups reached a high level o agreement that the frst immunization goal should be assuring the unctioning o

society, ollowed by the goal o reducing individual deaths and hospitalizations due to inuenza. This project showed

that stakeholder groups and citizens-at-large can be engaged in the policy-making process around pandemic inuenzapreparedness; they can learn about a technical issue, interact respectully, and reach a productive outcome on compli-

cated technical policy issues.

the importance o providing palliative/support-

ive care to all persons who need it.


18/33

9

4Isolation, quarantine, border control

and social-distancing measures

Core govermetal resposibilities

With appropriate international fnancial and tech-

nical assistance, countries should develop core

capacities or public health surveillance and

response that comply with the international legal

obligations in the ramework o the International

Health Regulations (IHR) 2005 (12). They should

also review existing public health laws to en-

sure that they

provide authority or appropriate actions that

might be necessary in the event o a public

health emergency;

clearly delineate the procedures that must be

ollowed to institute particular public health

measures;

recognie the importance o grounding publichealth actions in scientifc evidence;

pay attention to ethical principles o necessity,

proportionality, social justice, liberty, confden-

tiality, reciprocity, air process, efciency, trans-

parency and accountability;

protect the confdentiality and security o per-

sonal inormation and limit the disclosure o

personal health inormation to the minimum

necessary to achieve legitimate public health ob-

jectives; inormation should be shared only or

legitimate public health purposes, and to the

maximum extent possible individuals should be

inormed about third parties access to their per-

sonal inormation, the intended use o the inor-

mation and the reasons the inormation is being

shared.

Countries have an obligation to minimie the bur-

den o disease on individuals and communities, but

they must do so in a way that is respectul o indi-

vidual rights and liberties. The need to balance the

interests o the community and the rights o the in-

dividual is o particular importance in the implemen-

tation o public health measures such as isolation,

quarantine, social distancing and border control.

While all o these measures can legitimately be at-

tempted in order to delay the spread or mitigate

the impact o an inuena pandemic, the burden

they place on individual liberties requires that their

use be careully circumscribed and limited to cir-

cumstances where they are reasonably expected to

provide an important public health beneft.

Internationally-accepted human rights principlesprovide the ramework or evaluating the ethical

acceptability o public health measures that limit

individual reedom, just as human rights provide

the oundation or other pandemic-related policies.

Many o the considerations discussed in this chap-

ter are in act explicitly incorporated into human

rights documents. The Siracusa Principles (11), one

such relevant document, state that any limitations

on human rights must be in accordance with the

law; based on a legitimate objective; strictly nec-

essary in a democratic society; the least restrictiveand intrusive means available; and not arbitrary,

unreasonable, or discriminatory. In addition, princi-

ples o distributive justice require that public health

measures do not place unair burdens on particular

segments o the population. Policy-makers should

pay specifc attention to groups that are the most

vulnerable to discrimination, stigmatiation or iso-

lation, including racial and ethnic minorities, elderly

people, prisoners, disabled persons, migrants and

the homeless.


19/33

10


Countries should develop community-specifc

communication and social mobilization strat-

egies that

are linguistically and culturally appropriate;

are developed with community input; provide comprehensive, timely, and balanced in-

ormation based on the best available scientifc

evidence and expert opinion;

keep communities inormed on the nature and

evolution o the threat and on developments in

governmental policy, including changes in public

health laws;

provide scientifcally sound, easible, and under-

standable measures that people can take to pro-

tect themselves and others rom inection, such

as personal and community hygiene practices.

Cosideratios related to specifc publichealth strategies

The appropriateness o specifc public health strat-

egies cannot be determined in advance o an in-

uena pandemic. The eectiveness o selected

measures will depend on actors that are currently

unknown, especially the pathogenicity and the

transmission pattern o a new inuena virus sub-

type. In considering whether to adopt particularpublic health strategies, countries should rely on

the best available scientifc evidence. Restrictions

on individual liberties should not be adopted un-

less there is a reasonable expectation that they will

have a signifcant impact on containing the spread

or mitigating the impact o the disease, and they

should be terminated when they no longer appear

to oer signifcant benefts. All public health meas-

ures must accord with international human rights

laws and national legal requirements, and govern-

ments should pay special attention to protectingthe interests o vulnerable populations.

In planning or the use o particular public health

measures, countries should take into account the

ollowing actors.

Plans related to social-distancing measures

should

to the extent possible, provide means o miti-

gating adverse cultural, economic, social, emo-

tional, and health eects or individuals and

communities;

provide employment protection or workers who

comply with social-distancing measures against

the wishes o their employers;

incorporate the input o employers, unions, and

other relevant stakeholders, particularly with re-spect to plans or work closure procedures and

the use o alternative work schedules;

be made available in advance to the key actors

who will be charged with implementing these

measures so that they can adapt them to the

local culture and context and prepare or their

implementation.

Plans related to travel restrictions and border

controls should

accord with the WHO recommendations (5, an-nex 1) or each stage o a pandemic and be adapt-

able to evolving international recommendations;

respect, to the extent possible, the individual

right to reedom o movement;

ensure inormed consent o aected travellers

or examinations, prophylaxis, and treatment in

accordance with the IHR (2005) (12).

Plans related to the isolation o symptomatic

individuals and quarantine o their contacts

should be voluntary to the greatest extent possible (see

Box 4); mandatory measures should only be in-

stituted as a last resort, when voluntary meas-

ures cannot reasonably be expected to succeed,

and the ailure to institute mandatory measures

is likely to have a substantial impact on public

health;

provide or inection control measures appropri-

ate to each confnement context (such as hospi-

tals, temporary shelters, or homes) in order to

protect others rom inection;

ensure sae, habitable, and humane conditions

o confnement, including the provision o basic

necessities (ood, water, clothing, medical care,

etc) and, i easible, psychosocial support or

people who are confned;

consider the development o mechanisms to ad-

dress the potential fnancial and employment

consequences o confnement;


20/33

11

4. isolation, quarantinE, bordEr control and socia l-distancing mEasurEs

Box 4

Attitudes towards the use o quarantine a multisite research survey (13)

A telephone survey designed in the USA by the Harvard School o Public Health and the US Centers or Disease Control

and Prevention was conducted in our locations: China, Hong Kong SAR; China, Province o Taiwan; Singapore; and the

USA. Respondents were given inormation on the use o quarantine in the event o an outbreak o a communicable dis-ease and questioned on their attitudes towards this public health measure. These our locations were chosen based on

their past exposure to quarantine measures; the USA being the location where quarantine has not been used in recent

experience.

In all locations, a majority o respondents supported quarantine measures or persons suspected o having been ex-

posed to a communicable disease (China, Hong Kong SAR, 81%; China, Province o Taiwan, 95%; Singapore, 89%;

USA, 76%). Support was lower in all locations i reusal to comply with a quarantine order could lead to arrest (China,

Hong Kong SAR, 54%, China, Province o Taiwan, 70%; Singapore 68%; USA, 42%).

The study showed variations with respect to the approval o measures or monitoring compliance with quarantine poli-

cies. In general, respondents in the USA were less supportive o restrictive monitoring measures than respondents in the

other locations. In all our locations, a majority supported monitoring through periodic telephone calls and daily visits,

but periodic video screening received less support. The majority o respondents in the USA rejected electronic bracelets

and guards positioned in ront o quarantined buildings, whereas these measures were supported by a majority o re-

spondents in China, Hong Kong SAR, China, Province o Taiwan, and in Singapore.

A large majority o USA respondents preerred home quarantine, whereas a smaller number o respondents in the

other locations preerred quarantine at home to institutional quarantine. The main worries about being quarantined in

a health-care acility were being exposed to someone with the contagious disease, overcrowding, and difculty com-

municating with amily members.

The authors concluded that policy-makers need specifc plans to deal with the publics concerns about compulsory

quarantine policies.

protect the interests o household members o

individuals who are isolated and treated at the

household level, including recommending or

providing alternative housing i living with the

isolated patient is likely to put them at signifcantrisk o illness (or example, immunocompromised

amily members);

provide air procedures or making decisions

about aected individuals; in extraordinary cir-

cumstances, exceptions to normal procedural

protections may be appropriate where immedi-

ate action is essential to protect the health oothers, but in all cases legal recourse should be

available to individuals to challenge their isola-

tion or quarantine.


21/33


22/33

13

5The role and obligations o

health-care workers during an outbreako pandemic inuena

The availability o health-care workers will be es-

sential in order to provide an eective response to

an inuena pandemic. Thereore countries should

develop policies that clearly delineate health-care

workers obligations, in order to give them notice

o what will be expected o them (or an example,see Box 5). In developing such policies, countries

should consider that obligations can be recognied

in one or more o the ollowing ways, which are

not mutually exclusive:

Moral obligations Moral obligations are

based on a societys understanding o right

and wrong behaviour and/or appeal to uni-

versal sets o values. They tell people what they

should do, but they are not in themselves le-

gally binding. Policies that address individualsmoral obligations can play an important role

in creating social norms in avour o particular

behaviour.

Proessional obligations Proessional obliga-

tions are based on a particular proessions own

understanding o how members o that proes-

sion should behave. Proessional obligations are

oten set by proessional associations through a

ormal deliberative process and may be set out

in guidelines or codes o ethics. Violations o

proessional obligations can sometimes result in

sanctions within the proession, such as repri-

mands or loss o certain proessional privileges.

Contractual obligations Contractual obliga-

tions are obligations that individuals have vol-

untarily assumed as part o an agreement with

someone else (e.g. employment agreements).

When people do not uphold their contractual ob-

ligations, they may be required to pay money to

the other party to the contract, or they may su-

er other penalties, such as loss o employment. Non-contractual legal obligations Many

laws create binding obligations, the violation o

which can result in civil and/or criminal penal-

ties. Some legal obligations are also moral or

proessional obligations. However, not all moral

or proessional obligations are backed by legal

requirements.

A strong case can be made or recogniing a moral

obligation to provide care during an outbreak o

communicable disease, especially a disease o pan-

demic proportions. The arguments or recogniing

such an obligation are strongest or workers, such

as physicians, respiratory therapists and nurses,

whose specialied training gives them critical skills

that cannot be provided by other persons. How-

ever, even or workers with specialied skills, the

moral obligation to work during an inuena pan-

demic is not unlimited. Judgments about the scopeo any particular workers moral obligations must

take into account actors such as the urgency o

the need or that individuals services and the dif-

culty o replacing him or her, the risks to the worker

and indirectly to his or her amily, the existence o

competing moral obligations, such as amily care-

giving responsibilities, and his or her duties to care

or other (present and uture) patients.

The difculty o establishing clear rules about

the scope o health-care workers moral obligations

suggests the need or caution in translating such

obligations into legally enorceable duties. From an

ethical perspective, the least problematic enorce-

ment mechanisms are those that have been vol-

untarily adopted by those who will be aected by

them. Thus, governments should encourage proes-

sional organiations to develop policies regarding

proessionals obligations to work during epidemics

o communicable diseases. Similarly, employers and

workers should review existing contractual obliga-

tions (such as employment agreements) to ensurethat they contain appropriate requirements or

epidemics. Countries should enact laws requiring


23/33

14


health-care workers to work during a public health

emergency only i they conclude that moral, pro-

essional, and contractual obligations are unlikely

to be sufcient.

Health-care workers assumption o increasedrisks to their health during an inuena pandemic

gives rise to reciprocal obligations on the part o

governments and employers. Preparedness plans

should ensure that mechanisms to satisy these re-

ciprocal obligations are in place (see below).

Establishig the ature ad scope ohealth-care workers obligatios

Policies outlining health-care workers obligations

should

be developed by or in consultation with those

who will be directly aected by these policies,

including proessional organiations, unions,

and other relevant groups;

cover the diverse occupational roles o health-

care workers who may be exposed to increased

risk during an inuena pandemic, including

non-conventional health-care practitioners (e.g.

traditional healers) involved in the response

plan;

consider the appropriateness o assigning health-care workers to unctions not normally within

their scope o responsibilities, including assign-

ing non-proessionals to perorm tasks that are

normally perormed by proessionals, or assign-

ing proessionals to work in areas or which they

are not licensed or trained;

recognie that the duty to work notwithstand-

ing risks to ones own health is not unlimited;

ensure that health-care workers are asked to

assume risks only when their participation can

reasonably be expected to make a dierence tothe consequences o the pandemic (e.g. reduc-

ing morbidity and mortality, alleviating pain and

suering, preventing nosocomial inection, limit-

ing the spread o the pandemic at the commu-

nity level);

seek to distribute risks among individuals and

occupational categories in an equitable manner,

taking into account the act that some catego-

ries o workers may have to be exposed to great-

er risks given the nature o their activities;

accommodate legitimate exceptions regarding

assignment o individuals with ragile health

status to risky situations (e.g. individuals who are

immunodefcient or pregnant);

be discussed in an open and transparent mannerbeore they are implemented.

Reciprocal obligatios o govermetsad employers

In exchange or health-care workers assuming in-

creased risks to their health during an inuena pan-

demic, governments and employers have certain

reciprocal obligations. Governments and employ-

ers should seek to minimize risks to health-care

workers to the extent reasonably possible by

ensuring that adequate inection control systems

are in place in hospitals and other health-care

acilities;

providing preventive measures (e.g. prophylaxis,

personal protective equipment, inection control

protocols) to health-care workers, in line with

technical advice and updated as new epidemio-

logical evidence becomes available;

considering the appropriateness o giving health-

care workers priority access to antiviral drugs

and medical care i they develop inuena; providing health-care workers with access to

psychosocial treatment and support.

These risk reduction methods are important or

the protection both o health-care workers and o

the public. To avoid the urther spread o inection,

workers have an ethical obligation not only to use

the protective measures that are oered to them,

but also to report i they become inected and to

accept temporary exclusion rom work until they

are no longer inectious.

Governments, proessional organiations, and

health-care employers should ensure that health-

care workers receive adequate education and

inormation about

the risks associated with taking care o patients

aected with all communicable diseases, includ-

ing pandemic inuena;

measures they can take to help protect them-

selves and others, and the risks associated with

not using those measures;

expectations regarding their duty to provide careduring an inuena pandemic or other commu-

nicable disease outbreak;


24/33

15

inormation about any social benefts available

to them or their amilies;

inormation about the legal or other conse-

quences o ailing to work.

Governments should use their best eorts to de-velop or strengthen benefts systems that will

provide

medical and social benefts in the case o illness

or disability o health-care workers during an

epidemic;

death benefts to the amily members o health-

care workers who die ater being exposed to the

pandemic inuena virus in the course o their

work.

Promotig compliace with health-careworkers obligatios

Policies setting orth health-care workers obliga-

tions during an epidemic o a communicable dis-

ease can be inuential even i they do not create

any enorceable legal obligations. When such poli-

cies are developed through a transparent, equita-

ble, and accountable process, they are likely to be

accepted as legitimate by those who are aected

by them. As such, they can contribute to a climate

in which workers eel a personal moral responsibil-ity to continue working despite an increased risk to

their health.

Any policies that go beyond moral guidance to

include sanctions or non-compliance whether

adopted by governments, proessional organia-

tions, or individual employers should be tailored

as narrowly as possible. Because excessive sanc-

tions could inringe the human rights o health-

5. thE rolE and obligations of hEalth-carE workErs during an outbrE ak of pandEmic influEnza

care workers, countries should ensure that policies

on sanctions comply with the Siracusa principles

(10) and other applicable human rights standards.

In addition, such policies should

be established in advance by governmentauthorities and/or proessional organiations,

and broadly disseminated to those who will be

governed by the policies;

reect judgments about the level o risk that

health-care workers can reasonably be expected

to assume in ulflling their obligations;

take into account the appropriateness o impos-

ing sanctions i the reciprocal obligations o gov-

ernments and employers have not been met;

take into account the relevance o mitigating ac-

tors, such as individuals competing obligations

to care or sick amily members or others, when

deciding about the imposition o sanctions;

ensure that air procedures are ollowed beore

sanctions are imposed;

provide or an appeals process or health-care

workers who have been sanctioned, either dur-

ing or ater the pandemic period.

The considerations in this chapter relate specif-

cally to health-care workers. In order to minimie

the societal disruption o an inuena pandemic,

countries may also want to consider their relevance

to workers outside the health-care sector who pro-

vide essential services. Such workers include those

in public utilities, workers in actories that provide

indispensable (medical) supplies, and key adminis-

trative decision-makers.


25/33

16


Box 5

Health-care workers the Canadian Pandemic Infuenza Plan or theHealth Sector (14)

Rather than ocussing exclusively on the obligations o health-care workers, the Canadian Pandemic Inuenza Plan or

the Health Sector (CPIP) provides guidance on mitigating the expected health-care worker shortage during an inuenza

pandemic. The CPIP recommends the establishment o a human resource management team to plan and implement the

management o workers during a pandemic. Relevant considerations or such planning and implementation include the

expanded, new or dierent responsibilities that health-care workers may be required to take on, the recruitment o ad-

ditional sta or the pandemic response (e.g. retired physicians, trainees, therapists, technicians, etc), and the provision

o advanced and reresher training or health-care workers and potential recruits regarding pandemic plans, changing

roles and responsibilities, supervising volunteers, crisis management, and emergency planning.

The CPIP also outlines reciprocal obligations to health-care workers. Liability insurance should be provided or workers

and volunteers who may be required to act outside the scope o licensing or other authorization. Additionally, health-

care workers should be considered a high priority or immunization during a pandemic because they are critical to the

pandemic response. Health-care workers should also be provided with personal and emotional support, amily care and

job protection.

The CPIP acknowledges that under emergency legislation, provincial and ederal governments may have the authority

to designate Essential Services workers where an emergency has been declared and to compel such workers time

with due compensation. However, the CPIP also urges that compelling workers should be a last resort and should only

be used ater all other methods o obtaining a sufcient number o health-care workers to respond to a pandemic have

been reviewed. Moreover, the CPIP points out that a state o emergency may not be declared and so system-wide (as

opposed to institution-based) planning should be undertaken to mitigate a health-care worker shortage.


26/33

17

6Developing a multilateral response to an

outbreak o pandemic inuena

in countries with common borders (see example in

Box 6). In addition, cooperation will help to make

plans technically and ethically sound, ensure that

national plans are transparent, and contribute to

their legitimacy. International eorts should include

mechanisms to:

promote cross-border cooperation in surveil-

lance and exchange o inormation at all periods

including pre-pandemic, pandemic alert, pan-

demic and post-pandemic periods;

acilitate countries participation with WHO in

joint rapid containment eorts (15) in order to

stop, or at least slow, the spread o the initial

emergence o pandemic inuena;

avoid disparities in care across borders;

promote the timely and accurate sharing o sci-entifc inormation;

promote international evaluation or peer review

o national inuena pandemic preparedness

plans through a public and transparent process,

taking into account the availability o resources;

promote principles o air process, equity, and

global justice.

Sharig specimes ad promotigequitable access to pharmaceutical

itervetiosBroad international cooperation in the develop-

ment and dissemination o vaccines and treat-

ments is in the interests o all countries as such

cooperation oers the best chance o minimiing

the global impact o an inuena pandemic (16).

According to the principle o reciprocity, each coun-

try should do what it can to contribute to this e-

ort, with the understanding that it can expect the

same rom the rest o the international community.

Thereore, countries should:

There are several reasons or policy-makers to incor-

porate international considerations into inuena

pandemic preparedness planning. First, the ethical

principle o solidarity (see Glossary) suggests that

countries should respond collectively when natural

threats to health are identifed. Second, countrieshave obligations to help one another under inter-

national laws, including human rights laws; many

o these obligations are afrmed and elaborated

upon in IHR (2005) (12). Finally, an inuena pan-

demic is inherently a global crisis; lack o response

to a pandemic threat in one country puts all other

countries at increased risk. It is thereore in each

countrys national interest to contribute to interna-

tional eorts to prevent and respond to an inu-

ena pandemic.

Yet, it is one thing to agree in principle that

countries should assist one another beore and dur-

ing an inuena pandemic and another to work

out the details o what such cooperation actually

entails. Because resources will be limited, countries

are likely to ace difcult choices between the need

to protect their own populations and to support in-

ternational eorts. Advance planning at the inter-

national level can help countries clariy what they

expect o one another during each period (pre-

pandemic, pandemic alert, pandemic and post-pandemic). In addition, international cooperation is

likely to increase the eectiveness o national pre-

paredness plans.

The importace o iteratioalcooperatio

Because o the global impact o an inuena pan-

demic, international and regional cooperation and

coordination in the development and implementa-

tion o inuena pandemic preparedness plans will

be essential to an eective response, particularly


27/33


28/33

19

6. DEVELOPING A MULTILATERAL RESPONSE TO AN OUTBREAK OF PANDEMIC INFLUENzA

displaced persons

reugees

asylum seekers

migrants

travellers.

Commuicatio policies

The International Health Regulations (2005)

are legally binding regulations adopted by most

countries to contain the threat rom diseases that

may spread rapidly rom one country to another.

Under the IHR (2005), States Parties to the Regula-

tions are required to notiy WHO o all events that

may constitute a public health emergency o inter-

national concern (PHEIC). This notifcation obliga-

tion, expanded since IHR (1969) (18), includes novelor evolving public health risks, taking into account

the context in which the event occurs, and includes

human inuena caused by a new virus subtype.

Notifcations must occur within 24 hours o assess-

ment by the country using the decision instrument

provided in Annex 2 o IHR (2005). Notifcations

must be ollowed by ongoing communication o

detailed public health inormation on the event,

including, where possible, case defnition, labora-

tory results, source and type o the risk, number o

cases and deaths, conditions aecting the spreado the disease and the health measures employed.

In addition to international notifcation, in order

to promote public understanding and support or

international collaboration in pandemic response

eorts, governments should establish coherent

and transparent communication policies (4)

that:

promote collaboration between countries, par-

ticularly at the regional level;

explain the importance o international coop-

eration in minimiing the adverse health, social,

industrial, and economic eects o an inuena

pandemic and its atermath;

articulate how such international eorts are

grounded in ethics and human rights.


29/33


30/33

21

Reerences

1. Avian inuenza: assessing the pandemic threat. Geneva, World Health Organiation, 2005 (WHO/

CDS/2005.29) (http://www.who.int/csr/disease/inuena/WHO_CDS_2005_29/en/index.html, accessed

1 October 2007)

2. University o Toronto Joint Centre or Bioethics. Pandemic inuenza and ethics stand on guard or

thee. A Ehical considerations in preparedness planning or pandemic inuenza, 2005 (http://www.

utoronto.ca/jcb/home/documents/pandemic.pd, accessed 1 October 2007).

3. Ethical values or planning or and responding to a pandemic in New Zealand a statement or discus-

sion. National Ethics Advisory Committee, New zealand, 2006 (http://www.neac.health.govt.n/moh.

ns/indexcm/neac-resources-publications-pandemic, accessed 1 October 2007).

4. WHO outbreak communications guidelines. Geneva, World Health Organiation, 2005 (http://www.

who.int/inectious-disease-news/IDdocs/whocds200528/whocds200528en.pd, accessed 1 October

2007).

5. WHO global inuenza preparedness plan. The role o WHO and recommendations or national meas-

ures beore and during pandemics. Geneva, World Health Organiation, 2005 (http://www.who.int/

csr/resources/publications/inuena/WHO_CDS_CSR_GIP_2005_5/en/index.html, accessed 1 October2007).

6. WHO checklist or inuenza pandemic preparedness planning. Geneva, World Health Organiation,

2005. (WHO/CDS/CSR/GIP/2005.4) (http://www.who.int/csr/resources/publications/inuena/WHO_

CDS_CSR_GIP_2005_4/en/, accessed 1 October 2007).

7. Swiss inuenza pandemic plan 2006 (p. 246). Federal Ofce o Public Health, Switerland, 2006 (http://

www.bag.admin.ch/inuena/01120/01134/03058/index.html?lang=en), accessed 1 October 2007).

8. Ministry o Health. New Zealand inuenza pandemic action plan. Wellington, Ministry o Health, 2006

(http:/ /www.moh.govt.n/moh.ns/indexmh/n-inuena-pandemic-action-plan-2006, accessed 1

October 2007).9. Emanuel EJ, Wertheimer A. Public health. Who should get inuena vaccine when not all can? Science,

2006, 312:854855. (http://www.sciencemag.org/cgi/reprint/312/5775/854%20.pd, accessed 1 Octo-

ber 2007)

10. Citien voices on pandemic u choices. A report o the public engagement pilot project on pandemic in-

uena. 2005 (http://www.hhs.gov/nvpo/PEPPPI/PEPPPICompleteFinalReport.pd, accessed 1 October

2007).

11. United Nations Economic and Social Council. Siracusa principles on the limitation and derogation provi-

sions in the international covenant on civil and political rights . Annex, 1985, UN Doc. E/CN.4/1985/4.

12. World Health Assembly. Resolution WHA58.3. Revision o the International Health Regulations (http://www.who.int/gb/ebwha/pd_fles/WHA58/WHA58_3-en.pd, accessed 1 October 2007).


31/33

22


13. Blendon RJ et al. Attitudes toward the use o quarantine in a public health emergency in our countries.

Health Aairs, 2006, 25(2):w1525.

14. The Canadian pandemic inuenza plan or the health sector, Annex H: Resource management guide-

lines or health care acilities during an inuenza pandemic. 2006. Coordinated by Health Canada and

the Public Health Agency o Canada. Available at: http://www.phac-aspc.gc.ca/cpip-pclcpi/pd-e/CPIP-2006_e.pd. (accessed 1 October 2007).

15. WHO Interim Protocol: Rapid operations to contain the initial emergence o pandemic inuenza. Ge-

neva, World Health Organiation, 2007. (http://www.who.int/csr/disease/avian_inuena/guidelines/

dratprotocol/, accessed 1 October 2007)

16. World Health Organiation. Sharing o inuenza viruses and access to vaccines and other benefts: Inter-

disciplinary Working Group on Pandemic Inuenza Preparedness. Report by the Director-General. A/

PIP/IGM/4. 9 October 2007. (http://www.who.int/gb/pip/pd_fles/PIP_IGM_4-en.pd, accessed Octo-

ber 2007)

17. Plan belge durgence pour une pandmie de grippe. Partie 2: Plan oprationnelle. Comit de coordi-nation interministriel Inuena. 2006. Chapter 1, p. 19, and Annex Border problems in case o an

inuenza pandemic(http://www.inuena.be/r/operationeel_plan_r.asp, accessed October 2007, ac-

cessed 1 October 2007).

18. What are the International Health Regulations? Geneva, World Health Organiation, 15 June 2007

(http://www.who.int/eatures/qa/39/en/index.html, accessed 1 October 2007).


32/33

23

AnnEx

Additional bibliography

and links

WHO resources

Addressing Ethical Issues in Pandemic Inuena Planning. Four discussion papers. Geneva, World Health Or-

ganiation, orthcoming. Will be available at: (http://www.who.int/ethics/inuena_project/en/index.html,

accessed 1 October 2007)

Global consultation on addressing ethical issues in pandemic inuenza planning Summary o discussions,2425 October 2006, Geneva, Switzerland. Geneva, World Health Organiations, 2007.(WHO/CDS/EPR/

GIP/2007.1) (http://www.who.int/csr/resources/publications/inuena/WHO_CDS_EPR_GIP_2007_1/, accessed

1 October 2007)

WHO consultation on priority public health interventions beore and during an inuenza pandemic. Geneva,

World Health Organiation, 2004 (WHO/CDS/CSR/RMD/2004.9) (http://www.who.int/csr/disease/avian_

inuena/consultation/en/, accessed 1 October 2007)

WHO guidelines on the use o vaccines and antivirals during inuenza pandemics. Geneva, World Health

Organiation, 2004. (WHO/CDS/CSR/RMD/ 2004.8) (http://www.who.int/csr/resources/publications/

inuena/WHO_CDS_CSR_RMD_2004_8/en/, accessed 1 October 2007)

Avian inuena: WHO Guidelines, recommendations, descriptions, ull list in chronological order at: http://

www.who.int/csr/disease/avian_inuena/ guidelines/en/index.html (accessed 1 October 2007)

WHO web page on inuena http://www.who.int/csr/disease/inuena/en/index.html (accessed 1 October

2007)

WHO web page on the International Health Regulations (2005) http://www.who.int/csr/ihr/en/ (accessed

1 October 2007)

A link to some o the published National Inuena Pandemic Plans can be ound at: http://www.who.int/csr/

disease/inuena/nationalpandemic/en/index.html ( accessed 1 October 2007)

Other key resourcesNew Zealand National Ethics Advisory Committee

Getting through together: ethical values or a pandemic. The National Ethics Advisory Committee Kahui

Matatika o te Motu (NEAC) has completed its work on ethical values or a pandemic. Getting through

togetheremphasies using shared values to help people to care or themselves, their whanau and their

neighbours, and using shared values to make decisions in situations o overwhelming demand. Getting

through togetheralso gives guidance on some key issues in pandemic ethics. (http://www.neac.health.govt.

n, accessed 1 October 2007)

UK Department o Health

The ethical ramework or the response to pandemic inuenza. The ethical ramework is designed to assistplanners and strategic policy-makers with ethical aspects o decisions they ace beore, during, and ater an

inuena pandemic. It may also help clinicians and other health and social-care proessionals with decisions


33/33


they need to make in the same context. (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/

Publications PolicyAndGuidance/DH_073179, accessed 1 October 2007)

CDC USA

Ethical guidelines in pandemic inuenza. As part o its planning or a possible outbreak o pandemic in-uena, the Centers or Disease Control and Prevention (CDC) worked with the Ethics Subcommittee o

the Advisory Committee to the Director, CDC to identiy ethical considerations relevant to public health

decision-making during the planning or and responding to pandemic inuena. (http://www.cdc.gov/od/

science/phec/guidelinesPanFlu.htm, accessed 1 October 2007)

Documents rom the Bellagio meeting

With support rom the Rockeeller Foundation, an international group o experts met in Bellagio, Italy, rom

2428 July 2006 to consider questions o social justice and the threat o avian and human pandemic inu-

ena, with particular ocus on the needs and interests o the worlds disadvantaged. (http://www.hopkins-

medicine.org/bioethics/bellagio, accessed 1 October 2007)

Plate-orme veille et rfexion Pandmie grippale, thique, socit

This site is an initiative by the Espace thique and the Universit Paris-Sud 11 dedicated to the ethical

aspects o a potential u pandemic (in French). (http://www.espace-ethique.org/r/grippe.php, accessed

1 October 2007)

Provincial Health Ethics Network

The Provincial Health Ethics Network (PHEN) is a non-proft, non-partisan organiation which provides re-

sources to people in Alberta, Canada, to support systematic and thoughtul analysis o ethical issues in the

health system.( http://www.phen.ab.ca/pandemicplanning/ accessed 1 October 2007)

Quebec Public Health Ethics Committee (Comit dthique de sant publique, CESP)

Opinion about the public health dimension o the Quebec plan or fghting against pandemic inuena

(in French). (http://msssa4.msss.gouv.qc.ca/r/sujets/ethiqSP.ns/222ea9b71e5846d85256d0a00761591/

35570c61acd975685256ead00636ccc/$FILE/AVIS_PQLPI-MS_v.pd, accessed 1 October 2007)