An influenza pandemic is a large scale epidemic of the influenza virus, such as the 1918 Spanish flu. The World Health Organization (WHO) warns that there is a substantial risk of an influenza pandemic within the next few years. One of the strongest candidates is a highly pathogenic variation of the H5N1 subtype of avian influenza which is rapidly mutating and could mutate into a variation that transmits easily human to human causing a pandemic. If such a mutation occurs, it might remain an H5N1 subtype or could shift subtypes as did H2N2 when it evolved into the Hong Kong Flu strain of H3N2.

Nature of a pandemic

In a bad pandemic, some communities cut themselves off totally while others have half their population die. People try every remedy they can think of. [1] There are not enough doctors, hospital rooms, or medical supplies for the living and dead bodies pile up faster than they can be dealt with. There is great social disruption and efforts to deal with the pandemic always leave a great deal to be desired due to selfishness, lack of trust, illegal behavior, and ignorance. For example in the 1918 pandemic "This horrific disconnect between reassurances and reality destroyed the credibility of those in authority. People felt they had no one to turn to, no one to rely on, no one to trust." [2]

A letter from a physician at one U.S. Army camp in the 1918 pandemic said:

It is only a matter of a few hours then until death comes [...]. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies [...]. We have been averaging about 100 deaths per day [...]. Pneumonia means in about all cases death [...]. We have lost an outrageous number of Nurses and Drs. It takes special trains to carry away the dead. For several days there were no coffins and the bodies piled up something fierce [...]. [3]

Comes in waves

Flu pandemics typically come in waves. The 1889–1890 and the 1918-1919 flu pandemics each came in three or four waves of increasing lethality. [4] But within a wave, mortality was greater at the beginning of the wave. [5]

Variable mortality

Mortality varies widely in a pandemic. In the 1918 pandemic:

In U.S. Army camps where reasonably reliable statistics were kept, case mortality often exceeded 5 percent, and in some circumstances exceeded 10 percent. In the British Army in India, case mortality for white troops was 9.6 percent, for Indian troops 21.9 percent. In isolated human populations, the virus killed at even higher rates. In the Fiji islands, it killed 14 percent of the entire population in 16 days. In Labrador and Alaska, it killed at least one-third of the entire native population. [6]

If avian influenza remains an animal problem with limited human-to-human transmission it is not a pandemic, though it continues to pose a risk.

To prevent the situation from progressing to a pandemic, the following short-term strategies have been put forward:

• Culling and vaccinating livestock
• Vaccinating poultry workers against common flu
• Limiting travel in areas where the virus is found

The rationale for vaccinating poultry workers against common flu is that it reduces the probability of common influenza virus recombining with Avian H5N1 virus in the bloodstream of poultry workers to form a pandemic strain.

Longer term strategies proposed for regions where highly pathogenic H5N1 is endemic in wild birds have included:

• changing local farming practices to increase farm hygiene and reduce contact between livestock and wild birds.
• altering farming practices in regions where animals live in close, often unsanitary quarters with people, and changing the practices of open-air "wet markets" where birds are slaughtered in unsanitary conditions near fruits and vegetables. Cock fighting also has played a role in spreading the disease by bringing humans into contact with fowl, and this practice will also continue to contribute to infection if it is not curbed. A challenge to implementing these measures is widespread poverty, frequently in rural areas, coupled with a reliance upon raising fowl for purposes of subsistence farming or income without measures to prevent propagation of the disease.
• changing local shopping practices from purchase of live fowl to purchase of slaughtered, pre-packaged fowl.
• improving veterinary vaccine availability and cost. [7]

Vaccines

A vaccine probably would not be available in the initial stages of population infection [8]. Once a potential virus is identified, it normally takes at least several months before a vaccine becomes widely available, as it must be developed, tested and authorized. The capability to produce vaccines varies widely from country to country; in fact, only 15 countries are listed as "Influenza vaccine manufacturers" according to the World Health Organization [9]. It is estimated that, in a best scenario situation, 750 million doses could be produced each year, whereas it is likely that each individual would need two doses of the vaccine in order to become inmuno-competent. Distribution to and inside countries would probably be problematic [10]. Several countries, however, have well-developed plans for producing large quantities of vaccine. For example, Canadian health authorities say that they are developing the capacity to produce 32 million doses within four months, enough vaccine to inoculate every person in the country. [11]

United States

According to the US HHS (United States Department of Health & Human Services) Pandemic Influenza Plan Appendix F: Current HHS Activities last revised on November 8, 2005 and located here:

Currently, influenza vaccine for the annual, seasonal influenza program comes from four manufacturers. However, only a single manufacturer produces the annual vaccine entirely within the U.S. Thus, if a pandemic occurred and existing U.S.-based influenza vaccine manufacturing capacity was completely diverted to producing a pandemic vaccine, supply would be severely limited. Moreover, because the annual influenza manufacturing process takes place during most of the year, the time and capacity to produce vaccine against potential pandemic viruses for a stockpile, while continuing annual influenza vaccine production, is limited. Since supply will be limited, it is critical for HHS to be able to direct vaccine distribution in accordance with predefined groups (see Appendix D); HHS will ensure the building of capacity and will engage states in a discussion about the purchase and distribution of pandemic influenza vaccine.

Vaccine production capacity: The protective immune response generated by current influenza vaccines is largely based on viral hemagglutinin (HA) and neuraminidase (NA) antigens in the vaccine. As a consequence, the basis of influenza vaccine manufacturing is growing massive quantities of virus in order to have sufficient amounts of these protein antigens to stimulate immune responses. Influenza vaccines used in the United States and around world are manufactured by growing virus in fertilized hens’ eggs, a commercial process that has been in place for decades. To achieve current vaccine production targets millions of 11-day old fertilized eggs must be available every day of production.

In the near term, further expansion of these systems will provide additional capacity for the U.S.-based production of both seasonal and pandemic vaccines, however, the surge capacity that will be needed for a pandemic response cannot be met by egg-based vaccine production alone, as it is impractical to develop a system that depends on hundreds of millions of 11-day old specialized eggs on a standby basis. In addition, because a pandemic could result from an avian influenza strain that is lethal to chickens, it is impossible to ensure that eggs will be available to produce vaccine when needed.

In contrast, cell culture manufacturing technology can be applied to influenza vaccines as they are with most viral vaccines (e.g., polio vaccine, measles-mumps-rubella vaccine, chickenpox vaccine). In this system, viruses are grown in closed systems such as bioreactors containing large numbers of cells in growth media rather than eggs. The surge capacity afforded by cell-based technology is insensitive to seasons and can be adjusted to vaccine demand, as capacity can be increased or decreased by the number of bioreactors or the volume used within a bioreactor. In addition to supporting basic research on cell-based influenza vaccine development, HHS is currently supporting a number of vaccine manufacturers in the advanced development of cell-based influenza vaccines with the goal of developing U.S.-licensed cell-based influenza vaccines produced in the United States.

Dose-sparing technologies. Current U.S.-licensed vaccines stimulate an immune response based on the quantity of HA (hemagglutinin) antigen included in the dose. Methods to stimulate a strong immune response using less HA antigen are being studied in H5N1 and H9N2 vaccine trials. These include changing the mode of delivery from intramuscular to intradermal and the addition of immune-enhancing adjuvant to the vaccine formulation. Additionally, HHS is soliciting contract proposals from manufacturers of vaccines, adjuvants, and medical devices for the development and licensure of influenza vaccines that will provide dose-sparing alternative strategies.

Anti-viral drugs

Many nations, as well as the World Health Organization, are working to stockpile anti-viral drugs in preparation for a possible pandemic. Oseltamivir (trade name Tamiflu) is the most commonly sought drug, since it is available in pill form. Zanamivir (trade name Relenza) is also considered for use, but it must be inhaled. Other anti-viral drugs are less likely to be effective against pandemic influenza.

Both Tamiflu and Relenza are in short supply, and production capabilities are limited in the medium term. Some doctors say that co-administration of Tamiflu with probenecid could double supplies[12].

There also is the potential of viruses to evolve drug resistance. Some H5N1-infected persons treated with oseltamivir have developed resistant strains of that virus.

Tamiflu was originally discovered by Gilead Sciences and licensed to Roche for late-phase development and marketing.

Donald Rumsfeld, the major shareholder in Gilead Sciences, has profited from the US government stockpiling of oseltamivir in case of an influenza pandemic. [13] Critics have used this fact to question both government stockpiling policies and the H5N1 potential pandemic itself.

Other

(The World Health Organization published a compendium of non-pharmaceutical interventions in November 2005. The following list is not identical to the WHO recommendations.)

• Social distance. By travelling less, working from home or closing schools there is less opportunity for the virus to spread.
• Respiratory etiquette. Placing one's hand in front of the mouth when coughing or sneezing can somewhat limit the dispersal of droplets. However It has been suggested recently that covering one's mouth and nose with one's hand is not very effective in stopping the spread of germs as these germs are retained in the hand, and are then deposited on doorknobs, on to others through handshakes, etc. Current thinking suggests coughing or sneezing into the crook of one's arm would be preferable to limit germ spread.
• Masks. No mask can provide a perfect barrier but products that meet or exceed the NIOSH N95 standard recommended by the World Health Organization are thought to provide good protection. WHO recommends that health-care workers wear N95 masks and that patients wear surgical masks (which may prevent respiratory secretions from becoming airborne) [14]. Any mask may be useful to remind the wearer not to touch his face. This can reduce infection due to contact with contaminated surfaces, especially in crowded public places where coughing or sneezing people have no way of washing their hands. The mask itself can become contaminated and must be handled as medical waste when removed.
• Hygiene. Frequent handwashing, especially when there has been contact with other people or with potentially contaminated surfaces can be very helpful. Alcohol-based hand sanitizers also kill both bacteria and viruses.[15]

In the case of a flu pandemic, to avoid the risk of contracting H5N1 (or indeed, any other strain of the flu virus) people may have to take certain precautions, and make changes to their routine, to minimise the risk of infection. They may also have to prepare for the possibility of their lives being disrupted in a significant way, even if they do not actually become ill.

Social disruption

A flu pandemic could cause major disruption to everyday life, with footpaths and the countryside being partially or even totally off-limits, and even restrictions on public gatherings (such as public meetings, parties, services at places of worship), quarantine, and bans on individuals travelling to certain locations. However, there are a number of things people could do to prepare themselves:

• Plan for the possibility that usual services may be disrupted. These could include services provided by hospitals and other health care facilities, banks, stores, restaurants, government offices, and post offices. Think of a back-up plan - what would you do, for example, if you could not buy food from the supermarket, because it was closed?
• Think about the possibility of having to grow your own food, and if it is possible, "stock up" on essentials.
• Prepare backup plans in case public gatherings are cancelled - keep in touch via telephone, for instance.
• Consider how to care for people with special needs or with severe illnesses or disabilities in case the services they rely on are not available - could medicine be delivered to the house, for instance?

Work

• Find out if you can work from home.
• Ask your employer about how business will continue during a pandemic. (A Business Pandemic Influenza Planning Checklist is available at this US government website.)
• Plan for the possible reduction or loss of income if you are unable to work or your place of employment is closed.
• Check with your employer or union about sick leave policies.

Education

• Help your child's school plan for pandemic influenza. Talk to the school nurse or the health center. Talk to your teachers, administrators, and parent-teacher organizations, and help them put together a strategy if they have not already done so.
• Be prepared for the idea that you might have to teach your kids at home. Have textbooks, audiotapes etc on hand, and prepare some exercises for the children to do so that their education doesn't suffer. Also plan recreational activities that your children can do at home, so that they do not begin to suffer from boredom.
• Be prepared for the possibility of your child's school being closed for a prolonged period of time, meaning that your child, and probably you, will be stuck at home.

Transport

• Think about how you can rely less on public transport during a pandemic. For example, store or grow food and other essential supplies so you can make fewer trips to the store. Stock up on petrol so that you don't have to use the bus or train.
• Prepare backup plans for taking care of loved ones who are far away. Make sure you keep in touch with these people on a regular basis.
• Consider other ways to get to work, such as lift sharing or using your own car, or, if you can, work at home.

Organizing

• Think about what information the people in your workplace will need if you are a manager. This may include information about insurance, leave policies, working from home, possible loss of income, and when not to come to work if sick. (A Business Pandemic Influenza Planning Checklist is available at this US Government website.)
• Meet with your colleagues and make lists of things that you will need to know and what actions can be taken. For example, does everyone have access to a computer or a fax machine in the event that the business has to close?
• Find volunteers who want to help people in need, such as elderly neighbors, single parents of small children, or people without the resources to get the medical help they will need. You could become a volunteer yourself as there are plenty of people who will need your help.
• Make sure that those close to you know the risks and are safe and sensible, not putting themselves in danger of infection.
• Provide support to friends, family and others in your community who need it.

Food storage

Keep a supply of water and food. During a pandemic you may not be able to get to a store. Even if you can get to a store, it may be out of supplies or it may not be safe to enter it. Public waterworks services may also be interrupted. Stocking supplies can be useful in other types of emergencies. Store foods that:

• are nonperishable (will keep for a long time) and don’t require refrigeration - such as tinned fruit, condensed milk, etc
• are easy to prepare in case you are unable to cook
• require little or no water, so you can conserve water for drinking

Personal health and hygiene

Will the seasonal flu shot protect me against pandemic influenza?

• No, it won't protect you against pandemic influenza. But flu shots can help you to stay healthy.
• Get a flu shot to help protect yourself from seasonal flu.
• Get a pneumonia shot to prevent secondary infection if you are over the age of 65 or have a chronic illness such as diabetes or asthma.
• For specific guidelines, talk to your GP or another healthcare provider.
• Make sure that your family's immunizations are up-to-date.

Take common-sense steps to limit the spread of germs. Make good hygiene a habit.

• Wash hands frequently. Touching your face with contaminated hands can infect you with human-adapted flu viruses.
• Cover your mouth and nose with a tissue when you cough or sneeze. Put used tissues in a waste basket. Do not use cloth or other reuseable methods. Reuseables spread flu.
• Clean your hands after coughing or sneezing. Use soap and water or an alcohol-based hand cleaner.
• Stay at home if you are sick.

It is always a good idea to practice good health habits.

• Eat a balanced diet. Be sure to eat a variety of foods, including plenty of vegetables, fruits, and whole grain products. Also include low-fat dairy products, lean meats, poultry, fish, and beans. Drink lots of water and go easy on salt, sugar, alcohol, and saturated fat.
• Exercise on a regular basis and get plenty of rest.

Being informed during a pandemic

Knowing the facts is the best preparation. Identify sources you can count on for reliable information. If a pandemic occurs, having accurate and reliable information will be critical. Listen to local and national radio, watch news reports on television, and read your newspaper and other sources of printed and Web-based information. Talk to your local health care providers and public health officials. Read your government Web sites. As you begin your individual or family planning, you may want to review your state's planning efforts and those of your local public health and emergency preparedness officials.

Australia

• http://www.health.gov.au
• 1 800 004 599 - national avian influenza helpline, available Monday to Friday, 8.30 am to 5.00 pm EST

Brazil

• http://dtr2001.saude.gov.br/influenza/principal_gripe.htm
• gripe@saude.gov.br
• (61) 3315-3676, (61) 3315-3678, (61) 9696-3628 - Assessoria de Imprensa da Secretaria de Vigilância em Saúde

Canada

• http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/avian-aviare_e.html
• You can also call toll free at 1-866-225-0709 or TTY at 1-800-267-1245*

France (FR)

• http://www.grippeaviaire.gouv.fr
• Info'Grippe Aviaire on 0 825 302 302 (from France) from 7 am to 8pm

Germany

• http://www.verbraucherschutzministerium.de/index-272804D294E247F1BEF4F4F9D9C2BC4C.html
• The German ministry of agriculture has hotlines on numbers 01888-529-4601 through to 4609.

Hong Kong

• http://www.info.gov.hk/info/flu/eng
• Central Notification Office: 2477 2772
• 24-hour Health Education Hotline: 2833 0111

India

• Information and action plans
• NATIONAL INSTITUTE OF COMMUNICABLE DISEASES, DELHI Control room: 23921401 or 23913028 (FAX)
• List of contact numbers

Ireland

• The Department of Agriculture and Food has a bird flu helpline at 01-6072512
• http://www.agriculture.gov.ie/index.jsp?file=animal_health/avian_influenza/wildbirdadvice.xml

New Zealand (NZ)

• The government has spent NZ$26 million on a preparedness program.[16]
• http://www.moh.govt.nz/pandemicinfluenza
• Healthline on 0800 611 116

Singapore

• http://www.flu.gov.sg
• General AVA helpline: 1800-2262250
• For Pet Owners: 1800-4761600
• Ministry of Health: 1800-3339999

South Africa

• National Health System Ethics Line - 0800 20 14 144 14
• Department of Health bird flu page

Spain

• http://www.gripeaviar.es (Also includes information in Basque, Catalan and Galician)
• 901 400 100 (for Spanish health ministry)
• http://www.mapya.es/es/ganaderia/pags/influenza_aviar/influenza.htm

Switzerland

• Swiss H5N1 hotline - ++41 (0)31 322 21 00 or email at epi@bag.admin.ch
• Bird flu website of the federal health authorities
• For local information and regulations, see also the websites of the cantonal health authorities: AG, AI, AR, BE, BL, BS, FR, GE, GL, GR, JU, LU, NE, NW, OW, SG, SH, SO, SZ, TG, TI, UR, VD, VS, ZG, ZH

United Kingdom (UK)

• Talk to NHS Direct on 0845 4647.
• Department of Health information page
• The Defra helpline for reporting dead/sick birds is 08459 33 55 77

United States (US)

• http://www.pandemicflu.gov
• Centers for Disease Control and Prevention (CDC) Hotline at: 1-800-CDC-INFO (1-800-232-4636). This line is available in English and Spanish, 24 hours a day, 7 days a week. TTY: 1-888-232-6348. Questions can be e-mailed to inquiry@cdc.gov.

Stocks / Investments

Experts agree that a lethal pandemic will have a negative effect on the world and local economies.

• Review your portofilo for vulnerabilities. While some sectors of the economy might benefit, most will suffer from absenteeism and lost productivity, lost sales and potentially higher prices for some commodities. Some businesses may be forced to cut hours or close.
• Travel, tourism and the hospitality industry will be directly impacted as people avoid unneccessary contact with strangers.
• Modern just-in-time inventory management makes manufacturers and retailers more vulnerable to disruptions in the supply chain. Even companies whose products and services are in demand during a pandemic (hospitals, supermarkets) could suffer supply shortfalls.
• You may not have the option of waiting out a downturn. You or family members may suffer loss of income and be forced to liquidate investments at a disadvantageous time. Cash-equivilant investments such as money market funds or treasury bills offer relatively higher safety and liquidity.
• Bear market mutual funds offer a hedge or an investment strategy in down markets.
• Have some cash on hand for emergencies. Banks may not maintain normal hours and ATMs may not be restocked.

The World Health Organization announces the current phase of the pandemic alert here.

See "Assessing the pandemic threat" at [17]. WHO published a first edition of the Global Influenza Preparedness Plan in 1999, and updated it in April 2005. See [18] and [19] which define the responsibilities of WHO and national authorities in case of an influenza pandemic. This is the first time a pandemic has been anticipated and is being prepared for.

The aims of such plans are, broadly speaking, the following:

• Before a pandemic, attempt to prevent it and prepare for it in case prevention fails.
• If a pandemic does occur, to slow its spread and allow societies to function as normally as possible.

The World Health Organization (WHO) has developed a global influenza preparedness plan, which defines the stages of a pandemic, outlines WHO's role and makes recommendations for national measures before and during a pandemic.

Investigations of small clusters of cases are currently ongoing in southeast Asia, particularly Vietnam, to rule out limited human-to-human spread (which would signify Phase 4). The phases are defined as:

Interpandemic period

Phase 1: Low risk No new influenza virus subtypes dangerous to humans detected in humans or animals.

Phase 2: New virus A new circulating animal influenza virus subtype poses a substantial risk of human disease but no new influenza virus subtypes have been detected in humans.

Pandemic alert period

Phase 3: Self limiting Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact. Even without human intervention it would be self limiting among humans.

Phase 4: Person to person: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. An epidemic is possible but has not yet happened.

Phase 5: Epidemic: Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly well adapted to humans, but may not yet be fully transmissible (substantial pandemic risk).

Pandemic period

Phase 6: Pandemic: increased and sustained transmission in general population.

Notes

The distinction between phase 1 and phase 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The distinction is based on various factors and their relative importance according to current scientific knowledge. Factors may include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife, whether the virus is enzootic or epizootic, geographically localized or widespread, and/or other scientific parameters.

The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include rate of transmission, geographical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain), and/or other scientific parameters.

The pandemic stage 6 may be marked by two or more waves. For example, the initial wave of the Spanish Influenza pandemic in the spring of 1918 was so mild in its effects that it received the dismissive nickname of the "three day flu." But when the second wave hit North America a few months later in the summer of 1918, it was lethal. Apparently in the interim the novel H1N1 pandemic strain had added the gene or genes that made the final wave a killer. Perhaps the effects of the lethal second wave would have been even more devastating if the innocuous first wave had not already passed through the population, leaving in its wake at least some immune response to the surface antigens presented by the H1N1 in both waves.

CIDRAP provides a thoroughgoing overview, Pandemic Influenza, which has its roots in materials from the U.S. HHS National Vaccine Program Office. CIDRAP's overview originally set forth a model listing five numbered stages for the pandemic itself, preceded by four additional pre-pandemic stages, each numbered as zero, that overlapped the WHO's first five stages of a pandemic. CIDRAP's overview has since adopted the WHO's 6-stage model.

"[T]he United States is collaborating closely with eight international organizations, including the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health (OIE), and 88 foreign governments to address the situation through planning, greater monitoring, and full transparency in reporting and investigating avian influenza occurrences. The United States and these international partners have led global efforts to encourage countries to heighten surveillance for outbreaks in poultry and significant numbers of deaths in migratory birds and to rapidly introduce containment measures. The U.S. Agency for International Development (USAID) and the U.S. Department of State, the U.S. Department of Health and Human Services (HHS), and Agriculture (USDA) are coordinating future international response measures on behalf of the White House with departments and agencies across the federal government." [20]

Together steps are being taken to "minimize the risk of further spread in animal populations", "reduce the risk of human infections", and "further support pandemic planning and preparedness". [21]

Ongoing detailed mutually coordinated onsite surveillance and analysis of human and animal H5N1 avian flu outbreaks are being conducted and reported by the USGS National Wildlife Health Center, the Centers for Disease Control and Prevention, the World Health Organization, the European Commission, the National Influenza Centers, and others. [22]

United Nations

In September 2005, David Nabarro, a lead UN health official warned that a bird flu outbreak could happen anytime and had the potential to kill 5-150 million people. [23]

United States

"[E]fforts by the federal government to prepare for pandemic influenza at the national level include a $100 million DHHS initiative in 2003 to build U.S. vaccine production. Several agencies within Department of Health and Human Services (DHHS) — including the Office of the Secretary, the Food and Drug Administration (FDA), CDC, and the National Institute of Allergy and Infectious Diseases (NIAID) — are in the process of working with vaccine manufacturers to facilitate production of pilot vaccine lots for both H5N1 and H9N2 strains as well as contracting for the manufacturing of 2 million doses of an H5N1 vaccine. This H5N1 vaccine production will provide a critical pilot test of the pandemic vaccine system; it will also be used for clinical trials to evaluate dose and immunogenicity and can provide initial vaccine for early use in the event of an emerging pandemic." [24]

On August 26, 2004, Secretary of Health and Human Services, Tommy Thompson released a draft Pandemic Influenza Response and Preparedness Plan [25], which outlined a coordinated national strategy to prepare for and respond to an influenza pandemic. Public comments were accepted for 60 days.

In a speech before the United Nations General Assembly on September 14, 2005, President George W. Bush announced the creation of the International Partnership on Avian and Pandemic Influenza. The Partnership brings together nations and international organizations to improve global readiness by:

• elevating the issue on national agendas;
• coordinating efforts among donor and affected nations;
• mobilizing and leveraging resources;
• increasing transparency in disease reporting and surveillance; and
• building capacity to identify, contain and respond to a pandemic influenza.

On October 5, 2005, Democratic Senators Harry Reid, Evan Bayh, Dick Durbin, Ted Kennedy, Barack Obama, and Tom Harkin introduced the Pandemic Preparedness and Response Act as a proposal to deal with a possible outbreak. ([26])

On October 27, 2005, the Department of Health and Human Serviced awarded a $62.5 million contract to Chiron Corporation to manufacture an avian influenza vaccine designed to protect against the H5N1 influenza virus strain. This followed a previous awarded $100 million contract to sanofi pasteur, the vaccines business of the sanofi-aventis Group, for avian flu vaccine.

In October 2005, President Bush urged bird flu vaccine manufacturers to increase their production. [27] .

On November 1, 2005 President Bush unveiled the National Strategy To Safeguard Against The Danger of Pandemic Influenza [28]. He also submited a request to Congress for $7.1 billion to begin implementing the plan. The request includes $251 million to detect and contain outbreaks before they spread around the world; $2.8 billion to accelerate development of cell-culture technology; $800 million for development of new treatments and vaccines; $1.519 billion for the Departments of Health and Human Services (HHS) and Defense to purchase influenza vaccines; $1.029 billion to stockpile antiviral medications; and $644 million to ensure that all levels of government are prepared to respond to a pandemic outbreak.

On 06 March 2006, Mike Leavitt, Secretary of Health and Human Services, said U.S. health agencies are continuing to develop vaccine alternatives that will protect against the evolving avian influenza virus. [29] .

The U.S. government, bracing for the possibility that migrating birds could carry a deadly strain of bird flu to North America, plans to test nearly eight times as many wild birds starting in April 2006 as have been tested in the past decade. [30] .

On 08 March 2006, Dr. David Nabarro, senior U.N. coordinator for avian and human influenza, said that given the flight patterns of wild birds that have been spreading avian influenza (bird flu) from Asia to Europe and Africa, birds infected with the H5N1 virus could reach the Americas within the next six to 12 months. [31]

• United States Draft 2004 Final 2005
• European Commission

• Nature Magazine: Avian flu special: The flu pandemic: were we ready? Fictional account of flu epidemic from Nature magazine
• Worldwide Disasters - Pandemics
• Pandemic Influenza Risk Communication: The Teachable Moment, by Sandman and Lanard
• Latest Bird Flu and global pandemic advice
• Information about the next pandemic
• World Health Organisation pandemic alert page
• Pandemic Plan blog - Practical commentary explaining why one should prepare for a possible influenza pandemic, with creative suggestions about how to prepare.
• Public Healthy.com - Flu pandemic planning Regularly updated information on flu pandemic preparedness