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Pandemic Influenza Preparedness and Response: A WHO Guidance Document. Geneva: World Health Organization; 2009.

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Pandemic Influenza Preparedness and Response: A WHO Guidance Document.

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4THE WHO PANDEMIC PHASES

The grouping and description of pandemic phases have been revised to make them easier to understand, more precise, and based upon observable phenomena.

The WHO pandemic phases were developed in 1999 and revised in 2005. The phases are applicable to the entire world and provide a global framework to aid countries in pandemic preparedness and response planning. In this revision, WHO has retained the use of a six-phased approach for easy incorporation of new recommendations and approaches into existing national preparedness and response plans. The grouping and description of pandemic phases have been revised to make them easier to understand, more precise, and based upon observable phenomena. Phases 1-3 correlate with preparedness, including capacity development and response planning activities, while Phases 4-6 clearly signal the need for response and mitigation efforts. Furthermore, periods after the first pandemic wave are elaborated to facilitate post pandemic recovery activities.(see Figure 3)

FIGURE 3. PANDEMIC INFLUENZA PHASES (2009).

FIGURE 3

PANDEMIC INFLUENZA PHASES (2009).

The 2009 pandemic phases:

  • are a planning tool;
  • are simpler, more precise, and based on verifiable phenomena;
  • will be declared in accordance with the IHR (2005);
  • only loosely correspond to pandemic risk;
  • identify sustained human-to-human transmission as a key event;
  • better distinguish between time for preparedness and response; and
  • include the post-peak and post-pandemic periods for recovery activities.

The new phases are NOT:

  • designed to predict what will happen during a pandemic; and
  • always going to proceed in numerical order.

4.1. Definition of the phases

In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1 no viruses circulating among animals have been reported to cause infections in humans.

In Phase 2, an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat.

In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. Limited human-to-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained the level of transmissibility among humans necessary to cause a pandemic.

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks”. The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk of a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion.

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region (Figure 4)23. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

FIGURE 4. WHO REGIONS.

FIGURE 4

WHO REGIONS. The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area of (more...)

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave.

Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature.

In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required.

This phased approach is intended to help countries and other stakeholders to anticipate when certain situations will require decisions and decide at which point main actions should be implemented (see Table 3). As in the 2005 guidance, each of the phases applies worldwide once announced. However, individual countries will be affected at different times. In addition to the globally announced pandemic phase, countries may want to make further national distinctions based upon their specific situations. For example, countries may wish to consider whether the potential pandemic virus is causing disease within their own borders, in neighbouring countries, or countries in close proximity.

TABLE 3. WHO PANDEMIC PHASE DESCRIPTIONS AND MAIN ACTIONS BY PHASE.

TABLE 3

WHO PANDEMIC PHASE DESCRIPTIONS AND MAIN ACTIONS BY PHASE.

4.2. Phase changes

It is important to stress that the phases were not developed as an epidemiological prediction, but to provide guidance to countries on the implementation of activities. While later phases may loosely correlate with increasing levels of pandemic risk, this risk in the first three phases is simply unknown. It is therefore possible to have situations which pose an increased pandemic risk, but do not result in a pandemic.

Alternatively, although global influenza surveillance and monitoring systems are much improved, it is also possible that the first outbreaks of a pandemic will not be detected or recognized. For example, if symptoms are mild and not very specific, an influenza virus with pandemic potential may attain relatively widespread circulation before being detected; thus, the global phase may jump from Phase 3 to Phases 5 or 6. If the rapid containment operations are successful, Phase 4 may revert back to Phase 3.

When making a change to the global phase, WHO will carefully consider whether the criteria for a new phase have been met. This decision will be based upon all credible information from global surveillance and from other organizations.24

Footnotes

23

WHO - its people and offices (http://www​.who.int/about​/structure/en/index.html, accessed 10 February 2009).

24

Such as UN Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE).

Copyright © 2009, World Health Organization.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications - whether for sale or for noncommercial distribution - should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e- mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK143061

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