Although there is rapid progress in vaccine research regarding influenza pandemic vaccines it is expected that pandemic influenza vaccine production can only start once the pandemic virus has been recognized. Therefore, pandemic vaccine capacity will be limited at least during the first phase of an influenza pandemic, requiring vaccine prioritization strategies. WHO recommends developing preliminary priorities for pandemic vaccine use. The goal of this review is to provide a thorough overview of pandemic vaccine prioritization concepts in the 27 European Union (EU) member states and the four non-EU countries of the Global Health Security Action Group.
Between September and December 2006 data was collected for each country through two data sources: (i) the national influenza pandemic plan; (ii) contacting key persons involved in pandemic planning by email and/or phone and/or fax
Twenty-six (84%) countries had established at least one vaccine priority group. Most common reported vaccine priority groups were health care workers (HCW) (100%), essential service providers (ESP) (92%) and high risk individuals (HRI) (92%). Ranking of at least one vaccine priority group was done by 17 (65%) of 26 countries. Fifteen (88%) of these 17 countries including a ranking strategy, decided that HCW with close contact to influenza patients should be vaccinated first; in most countries followed and/or ranked equally by ESP and subsequently HRI. Rationales for prioritization were provided by 22 (85%) of 26 countries that established vaccine priority groups. There was large variation in the phrasing and level of detailed specification of rationales. Seven (32%) of 22 countries providing rationales clearly associated each vaccine priority group with the specific rationale. Ten (32% of the 31 countries studied) countries have consulted and involved ethical experts to guide decisions related to vaccine prioritization.
In the majority of the countries the establishment of vaccine priority groups, ranking and underlying rationales are in line with WHO recommendations. In most public plans the criteria by which prioritized groups are identified are not easily recognizable. Clarity however, may be necessary to assure public acceptability of the prioritization. Ethical experts, results of modelling exercises could play an increasing role in the future decision making process.
In 2005, WHO has strongly recommended to its member states to develop or update their national influenza pandemic preparedness plan . Mitigating the potential impact of an influenza pandemic may be accomplished by non-pharmaceutical (e.g. closing schools, using facemasks, social distancing) and pharmaceutical interventions such as use of antiviral drugs and pandemic vaccines . WHO coordinates global scientific research and development to ensure that antiviral drugs and pandemic vaccines are rapidly and widely available and that scientific understanding of the virus evolves quickly . While pandemic vaccine production can only start once the pandemic virus has been recognized, pandemic vaccine capacity will be limited at least during the first phase of the pandemic . The distribution of limited and progressively available vaccine supply will require strategies for vaccine prioritization, i.e. a concept defining which group(s) of people shall receive the pandemic vaccine first .
Considerations for vaccine prioritization will be different for each country, not only because of differences in vaccine availability and resources for administration of vaccine, but also because of differences in population structure and the organization of essential services . However, differences in vaccine priority groups between neighbouring countries may lead to difficulties in implementation, especially when rationales underlying the concepts are not clearly communicated. Germany in particular has not less than 9 bordering countries. While the federal public health institute in Germany, the Robert Koch Institute (RKI) was approaching the neighbouring countries to learn about their strategies for vaccine prioritization, other countries also expressed their interest to have an overview of pandemic vaccine priorities internationally.
Recent reviews of pandemic preparedness assessments have been published that either briefly highlighted vaccine prioritization among several aspects of pandemic preparedness or provided aggregated data on vaccine prioritization in multiple developed and developing countries [7-9]. The goal of this review is to provide a thorough overview of pandemic vaccine prioritization concepts in the 27 European Union (EU) member states and the four non-EU countries of the Global Health Security Action Group (GHSAG).
We explored the status of establishing pandemic influenza vaccine prioritization concepts in the 27 EU countries as of January 1st 2007 and the remaining non-EU countries belonging to the GHSAG (Canada, Japan, Mexico, United States). Between September and December 2006 we obtained information through the two following data sources: (i) for each country we first identified the national influenza pandemic plan available in the public domain. If the original or translated version was published in English, Danish, Dutch, French, German, or Swedish we extracted data directly. Otherwise we only obtained information through the second data source; (ii) for every country we contacted key persons involved in pandemic planning by either email and/or phone and/or fax.
We investigated the following questions:
(1) Does the country has a list of pandemic vaccine priority groups?
(2) Are pandemic vaccine priority groups ranked?
(3) What is the rationale for the pandemic vaccine prioritization concept?
(4) Were ethical committees involved in the establishment of the vaccine prioritization concept?
(5) Which types of institutions were involved in the development of vaccine priority groups?
Reported vaccine priority groups were first assigned to the following main categories that were similar to those in the guidelines from WHO : 1) Health care workers (HCW); 2) Persons employed in positions that are essential for the maintenance of the infrastructure and public safety ("essential service providers"; ESP); 3) Individuals with high risk of death and severe complications ("high risk individuals"; HRI); 4) Healthy adults and children. We also categorized listed subgroups into these four main categories when applicable. Other groups that could not be assigned to one of these four main categories were listed in a separate table.
Similarly, the rationales for the vaccine prioritization concept chosen, were grouped into four categories which were again compatible with guidelines provided by the WHO : 1) To reduce morbidity and mortality; 2) To maintain infrastructure, including functioning of the health care system; 3) To limit social disruption; 4) To limit economic losses. There was large variation in the phrasing and level of detailed specification of rationales. However, we attempted to put the reported rationales in the most appropriate category.
In December 2006 all identified key persons received a draft version of the tables included in this review and were able to comment on correct representation of their country and permission to publish the country specific data. Abbreviations can be found at the end of the manuscript.
Vaccine priority groups
Except for Malta, the countries included in this review had a National Pandemic Influenza Plan published on the internet [see Additional file 1]. The language of the pandemic plans of all but seven countries (CY, FI, LV, MX, PT, RO, SI) were available in English, Danish, Dutch, French, German or Swedish and allowed direct extraction of the information.
Additional file 1. Pandemic influenza plans and relevant appendixes. This file provides references to the pandemic influenza plans and relevant appendixes and/or governmental acts of those countries included in the review.
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Representatives from all 31 (100%) countries responded to our request for either updated or additional information on the information reported in the National Pandemic Influenza Plans available in public domain during the study period. Furthermore, representatives of 30 (98%) countries either confirmed the correctness or provided changes to the representation of their countries' data on the draft tables and the US referred to the information available in the public domain.
At least 19 (61%) countries (AT, BG, CA, CY, DE, DK, EE, FI, HU, IE, IT, JP, LT, MT, NL, PT, SE, UK, US) reported that ultimately the whole population shall be immunized with the pandemic vaccine. For countries that included "healthy adults and children" in their vaccine priority groups it was inferred that they are also planning to finally immunize the entire population. However, because vaccine will likely become progressively available while the pandemic has already started all but one (PT) of these 19 countries have already defined vaccine priority groups. A general statement frequently reported by the countries' representatives was that vaccine priority groups had been established to stimulate planning prior to a pandemic, but that these will be continually revised in light of new information that will be learnt once the pandemic virus is identified.
Except for Belgium, Latvia, Luxembourg, Mexico and Portugal twenty-six (84%) countries had established at least one vaccine priority group. Denmark and Greece did not list vaccine priority groups as such, but mentioned them as groups reflecting a discussion part in the National Pandemic Plan (DK) or as "suggested" (GR). We included information from these two countries in the description of vaccine priority groups in the 26 countries. Four of the five countries without defined vaccine priority groups may still do so as discussion about determining them was still ongoing (BE, PT), or may be established in the updated National Plan (LV) or when more information about vaccine production and availability is accessible (MX). (Table 1) Only Luxembourg will not determine any vaccine priority groups in advance of the pandemic. The number of vaccine priority groups as categorized by the countries varied from one to eight. This wide range is mainly due to differences in the level of detail in the definition of the specific vaccine priority groups. However, most of these vaccine priority groups could be categorized into HCW, ESP, HRI and "healthy adults and children". Among the 26 countries that defined vaccine priority groups 23 (88%) agreed to prioritize HCW, ESP and HRI (Table 1). There were three exceptions: Finland (HCW only), Germany (HCW and ESP) and the Netherlands (HCW and HRI).
Table 1. Establishment of Vaccine Priority Groups in EUA and GSHAGB countries
Thus, HCW were included as vaccine priority group in all these 26 countries. Cyprus specified "individuals involved with the distribution of vaccines and antivirals" as one vaccine priority group and "people working in essential services" as another vaccine priority group. This latter group may by definition include HCW but specific information about subgroups was not available (Table 1). The most common subgroups specifically listed under HCW included paramedics, ambulance and emergency services as well as in-patient health care workers (Table 2).
Table 2. Common reported subgroups within three main vaccine priority groups as listed in National Influenza Pandemic Plans A
Except for Finland and the Netherlands, ESP were included as vaccine priority group by 24 (92%) of 26 countries that had established at least one vaccine priority group. Identified subgroups belonging to this category were e.g. key persons in government, emergency response, defence and security as well as in the public sector (for example utility workers, Table 2).
Only Finland and Germany did not include HRI as vaccine priority group, thus HRI were included by 24 (92%) of the 26 countries. In many countries the definition of this group is very similar to the one used for seasonal influenza recommendations, but not all countries specifically listed all subgroups in this context. Of note, six countries (BG, CA, DK, IE, NL, UK) report specifically that the exact types of risk group will need to be identified during the pandemic (through investigations, studies or surveillance).
Healthy adults and children were included as one or two vaccine priority groups by 13 (50%) countries (BG, CA, CY, DK, ES, IE, IT, JP, MT, NL, SE, UK, US), including 3 countries (DK, IE, UK) that intend to "offer vaccination to all individuals not belonging to any other vaccine priority group". Estonia, Poland, Romania and Slovenia reported to vaccinate children (and not healthy adults) as they considered them to belong to HRI.
Other vaccine priority groups have been established in 11 (42%) of 26 countries (EE, GR, IE, IT, JP, MT, RO, SE, SK, UK, US). However, partially they represent just an extension of the above named first three main groups (HCW, ESP, HRI) for example long term care facility residents (RO) may overlap with HRI and selected industries may overlap with ESP (IE, UK). Other groups defined were e.g. staff of workplaces where many people gather (SK), household contacts of immunocomprised persons (SK, US), pandemic vaccine manufacturers (RO, US) and a 'wild card' selected age groups based on National or WHO recommendations as reported by three countries (IE, MT, UK) (Table 3).
Table 3. List of vaccine priority groups other than health care workers, essential service providers, high risk individuals and healthy adults/children
Ranking of at least one vaccine priority group was done by 17 (65%) of 26 countries (BG, CA, CY, DE, DK, EE, IE, FI, HU, IT, MT, NL, RO, SI, ES, UK, US) which had established at least one vaccine priority group.
Fifteen (88%) (BG, CA, DE, DK, EE, ES, FI, HU, IE, IT, MT, RO, SI, UK, US) of these 17 countries decided that HCW with close contact to influenza patients should be vaccinated first; in most countries (BG, CA, EE, ES, DE, HU, IE, IT, MT, UK) followed and/or ranked equally by ESP and subsequently HRI (BG, CA, EE, ES, IE, IT, UK) (Table 4). Except for the very young children which might receive vaccination because they belong to the seasonal influenza vaccination group, children and healthy adults are not ranked at the top in any of the countries. However, in Japan, a discussion on the ranking of children is ongoing and will depend on the chosen rationale being either to prevent severe cases from dying or "to save people considering future life" (email communication). At the time of writing, ranking was either under discussion (GR, LT, JP); information unavailable (CZ); or not done (AT, FR, PL, SE, SK) by 9 (35%) of 26 countries that had established vaccine priority group(s). These, and also other, countries reported that establishment and ranking of vaccine priority groups is constantly under discussion and final decision will depend on the specific epidemiological characteristics of the new pandemic virus and the pandemic vaccine availability.
Table 4. Ranking of vaccine priority groups A
Except for the Czech Republic, Japan, Poland and the Slovak Republic rationales for prioritization were provided by 22 (85%) of 26 countries that established vaccine priority groups (Table 5). There was large variation in the phrasing and level of detailed specification of rationales. However, we attempted to put the reported rationales in the most appropriate category.
Table 5. Overview of rationales considered in EU and GSHAG countries to define vaccine priority groups A
The category "To reduce morbidity and mortality" included rationales reported by 21 (95%) of 22 countries that reported any rationale, only Cyprus did not report this rationale. The general non-specific rationale "to reduce morbidity and mortality" was reported by 10 (45%) of 22 countries (AT, BG, CA, DK, DE, ES, IE, RO, SI, UK); and the rationale "to prevent illness in the general population" was also reported by 4 (AT, CA, DK, UK) of these 10 countries and by 3 other countries (FI, NL, US) not specifically reporting the general rationale. We included the rationale "to save years of life" as reported by Finland also under this general category. We further dichotomized this category into "directly" and "indirectly" as morbidity and mortality can be reduced through vaccinating the respective group of persons (direct protection) or by vaccinating those who could transmit the virus to them (indirect protection). For example 10 countries (BG, CA, DK, FR, LT, MT, NL, SE, UK, US) gave direct protection as (one of) the underlying rationale(s) for their prioritization of persons considered to be most vulnerable to severe illness. Three countries (CA, SI, UK) intend to prevent transmission to the general population and minimal four countries (DK, DE; SI, UK) to high risk individuals by vaccinating those individuals most likely to transmit the virus to them.
The category "To maintain infrastructure and health care system" includes rationales reported by all 22 countries that provided rationales (AT, BG, CA, CY, DE, DK, EE, ES, FI, FR, GR, HU, IE, IT, LT, MT, NL, RO, SI, SE, UK, US). These were divided into two broad categories: maintenance of the work force and maintenance of essential community services. The latter was specified by overall 19 countries and compromised for example maintenance of the essential health service response (14 countries: CA, DK, EE, FI, FR, GR, HU, IT, MT, NL, RO, SE, UK, US) and maintenance of the infrastructure to implement the pandemic response (5 countries: CY, EE, FR, SI, US). Maintenance of the work force was named explicitly only by Canada.
Only seven countries (BG, CA, DE, DK, IE, UK, US) clearly associated each vaccine priority group with the specific rationale underlying the inclusion of the specific group. At least five countries (CY, EE, HU, RO, IT) did not specify rationales for all established vaccine priority groups. The inclusion of a specific vaccine priority group may be rationalized different by countries. E.g. in Estonia and Poland children are included under the rationale to protect high risk individuals and at least three countries (CA, NL, US,) specifically reported that children are only vaccinated when sufficient vaccine is available to vaccinate the entire population anyway. Canada intends to vaccinate children specifically to limit spread of infection.
Decision making process
Coordination of the pandemic preparedness is in most countries under the responsibility of the Ministry of Health. Frequently working groups of experts or advisory committees for vaccination advised the government in the development of the pandemic preparedness plans. Six countries (19%) (DE, FR, IE, NL, UK, US) have included references to pre-pandemic modelling in their pandemic plan and/or referred to ongoing (or, when the pandemic has begun: real time) mathematical modelling that might result in future changes of vaccine priority groups. Ten (32%) of 31 countries have consulted and involved ethical experts (AT, CY, FI, GR, MX, PT, RO, SE, UK, US) to guide decisions related to vaccine prioritization, five further countries (16%) (BG, CA, EE, IE, SI) reported the intent to include ethical aspects in future discussions.
The objective of this review was to provide an overview of pandemic vaccine priority groups in 27 EU member states and the 4 non-EU countries that are members of the GSHAG. We included these countries as they are part of organized structures (e.g. Health Security Committee, European Union) with the goal to strengthen public health preparedness and response globally to not only threats of biological, chemical, radio-nuclear terrorism but also pandemic influenza [11,12]. A multinational comparison between countries may be useful to e.g. identify large differences in prioritization between cross bordering countries which may result in either harmonisation or proactively explaining the potential differences. For example we found a large difference in ranking priority between the neighbouring countries Germany and the Netherlands. The Netherlands is the only country that has not top ranked health care workers but the "highest complication individuals"; this latter group is in Germany's National Pandemic Plan, but not included as one of the two established vaccine priority groups. However, we do not aim to provide the most suitable prioritization concept. We rather wish to provide an overview of approaches in the wider European perspective and want to discuss some general aspects in more detail. This might help countries to put themselves into the international context and/or to assist them should they be in the process to formulate or overhaul pandemic vaccine prioritizations concepts.
Nineteen (61%) of the countries state that they intend to finally vaccinate the whole population, but most admit that progressive vaccine availability will make some form of prioritization unavoidable. Twenty six (84%) of the 31 surveyed countries had defined vaccine priority groups which were fairly similar. Commonly defined vaccine priority groups included HCW, ESP and HRI and are thus consistent with WHO guidelines . Approximately half of these countries have defined subgroups among those three main groups, some, e.g. Canada, Czech Republic and Denmark specified many groups in great detail. This may reflect their intention to respond to two of the major challenges in pandemic vaccine prioritization: logistical administration and acceptability. It seems likely that the better priority groups are defined in advance of the pandemic the easier it is to identify eligible individuals or conversely, ask those who are not or not yet eligible to hold out to the point of time when it is their turn. Identifying HCW and ESP might be possible through personal registers. However, identification of HRI might be more complex. While in e.g. the Netherlands those individuals belonging to the high risk influenza complication group are yearly invited by their general practitioner to receive seasonal influenza vaccination, such a register has not been established in Germany. Owing to difficulties in prioritization on the basis of chronic diseases, age is often a surrogate for identifying those at greatest risk of complications . Therefore, a pragmatic solution might include simple criteria by e.g. grouping HRI by year of birth. In addition, early communication and transparency of prioritization may aid greatly in the acceptability of concepts within the population. We did not observe a clear association between population size and the number of established vaccine priority groups. Austria and Germany, the only two EU countries with a federal government, state that the National Pandemic Plan serves as a framework to guide the pandemic preparedness in each of the individual states. Both federal EU-countries leave the specification of subgroups to the responsibility of the individual states. This is in contrast to two of the three non-EU GSHAG countries with a federal structure included in this review. Both Canada and the USA have included extensive lists of subgroups to guide the state health departments. Thirteen (93%) of 14 countries that foresee prioritization of HRI and have reported subgroups, have defined them similarly or identically to those for whom seasonal influenza vaccination is recommended, but 6 (43%) also want to keep their flexibility to give groups priority who will be identified in the pandemic as being at increased risk for complications. In this context children or subgroups of children are only covered within the HRI group. Two-thirds (65%) of the countries having established vaccine priority groups ranked at least one of these groups, but also kept the flexibility to change ranking when more information about risk groups and vaccine availability will be accessible
Broad agreement exists among countries regarding ranking of the vaccine priority groups with HCW as the first priority, ESP as second and HRI as third, in line with WHO recommendations . None of the 14 countries that included children as priority (sub)group, and ranked priority groups, prioritized the vaccination of children above the previously mentioned three groups unless they are regarded as HRI.
Apparent discrepancies exist between WHO recommendations as well as the low priority given to vaccination of children on one hand with published results from mathematical modelling on the other hand that rather favour prioritization of children [13-15]. Ferguson et al. modelled the effect of a staged vaccination programme at the beginning of a pandemic in the USA and showed a maximum effect on the reduction of transmission if children are vaccinated first . Similarly, Germann et al. concluded that schoolchildren should receive high priority for vaccination, unless other strategies, such as closing schools, are implemented to limit the contact rates among children . Longini et al. estimated that vaccinating 80% of the children aged less than 19 years will be almost as effective as vaccinating 80% of the population, and this strategy would be the most efficient use of the vaccine  The 2004 publication from WHO and likely also the working process of most pandemic plans reviewed here preceded these publications . WHO stated that there is an absence of evidence that use of inactivated vaccine in children will reduce the spread of a pandemic in the community. It is unclear however, if recommendations were drastically different since a substantial reduction of transmission among and from children might be achieved through social distancing measures of children, such as closure of schools . While 6 countries (19%) have included references to pre-pandemic modelling and/or referred to ongoing mathematical modelling, we cannot conclude that pre-pandemic modelling has not played a role in the decision making in other countries because we did not systematically ask this specific question.
Rationales for prioritization were provided by 85% of the countries that had established vaccine priority groups. Yet again, clearly stating the objectives and rationales of vaccine prioritisation will be important for acceptance in the general population. Of note, prioritization of HCW may be justified by three rationales: (1) to protect them directly because they are at increased risk (reducing morbidity and mortality), (2) to prevent or minimise transmission to HRI (indirect reduction of morbidity and mortality), and (3) by maintaining infrastructure and health care system.
Ideally the goals of prioritization need to be stated clearly and unambiguously. Meltzer et al showed that differences in prioritization goals or rationales can result in completely different prioritization ranking . E.g. if preventing the greatest number of deaths is the most important goal, adults in the working age (20–64 years old) with the highest risk for severe illness should be vaccinated first. However, if maximizing economic returns is the highest priority HRI aged 0 to 64 years should be vaccinated first. Also the importance of the specificity of goals was shown by Meltzer. For example, the commonly formulated goal to 'prevent deaths', is not precise enough because different priority lists can be drawn up by using death rates (elderly HRI) versus the total number of deaths (working age HRI) . Thus, criteria for prioritization should be clear and defensible. Several countries have only partly (or not at all) specified the rationales for prioritization. In addition, it was not always obvious to make the link between rationales and priority groups, or differently stated which rationales were underlying the prioritisation of which specific group. For example, Bulgaria specified the rationale "to limit economic losses" but it was not clear which priority group was prioritized because of this.
Apart from epidemiological deliberations the allocation of scarce resources also requires ethical considerations. The importance of including ethics in pandemic preparedness was addressed during a recent WHO workshop . Only 32% of the countries included in this review reported to have involved an ethic committee or consultant, and 16% reported the intention to include ethical aspects in future discussions. While for 13% of the countries information is unavailable the remaining 30% has not reported to have involved ethical consultants, it is unknown if these countries consider including ethics in the future.
A final note concerns the dynamic process of developing vaccine prioritization strategies as this might be influenced by e.g. availability of antivirals and developments in vaccine technology (e.g. the stockpiling of pre-pandemic H5N1 vaccines). These developments may change the perception of policy makers with respect to the need of defining or updating prioritization strategies.
In the majority of the countries the establishment of vaccine priority groups, ranking and underlying rationales are in line with WHO recommendations. The first challenge in the prioritization of pandemic vaccines is public acceptability, which can be first addressed by involving ethical experts or an ethics committee in the decision making process. In this regard the result may even be less important than the process. In most public plans the criteria by which prioritized groups are identified are not easily recognizable. Goals of prioritization need to be stated clearly and criteria need to be linked with the groups that are to be prioritized. The resulting concept should then be communicated as clearly and precisely as possible including a detailed and unambiguous set of defined groups that will be prioritized and in which order. This approach should also aid in the management of the second major challenge: how prioritized individuals can be identified and how the vaccine can be administered to them. Registers may help to easily and rapidly identify and keep track of HCW and ESP. HRI could be simply grouped by year of birth, although there may be some HRI that are not captured adequately by this procedure.
Results of modelling exercises may and perhaps should play an increasing role in vaccine prioritization. Lastly, there is a need to build in flexibility and to be able to change policy intermittently (in the prepandemic phase) or perhaps even rapidly (in the pandemic) should information arise that supports modification of prioritization strategies. But for this purpose the rationales for prioritization ought to be clearly defined.
AT, Austria; BE, Belgium; BG, Bulgaria; CA, Canada; CZ, Czech Republic; CY, Cyprus; DE, Germany; DK, Denmark; EE, Estonia; ES, Spain; ESP, Essential Service Providers; EU, European Union; FI, Finland; FR, France; GHSAG, Global Health Security Action Group; GR, Greece; HCW, Health Care Workers; HRI, High Risk Individuals; HU, Hungary; IE, Ireland; IT, Italy; JP, Japan; LT, Lithuania; LV, Latvia; LU, Luxembourg; MT, Malta; MX, Mexico; NL, the Netherlands; PL, Poland; PT, Portugal; RO, Romania; SE, Sweden; SI, Slovenia; SK, Slovak Republic; UK, United Kingdom; US, United States.
The author(s) declare that they have no competing interests.
MS, UB, GK participated in the design of the study. MS collected the data. MS served as lead author of this report, UB contributed substantially to drafting and redrafting the report. WH, SR and GK contributed to redrafting the final version of the manuscript and have approved the final manuscript. All authors read and approved the final manuscript.
We are grateful to all country key persons who provided additional information and explanations related to their countries pandemic vaccine priority strategies and who reviewed the concept tables included in this manuscript: In alphabetical order of country we want to thank:
Austria: Dr. Hubert Hrabcik, Generaldirektor für öffentliche Gesundheit, Vorsitzender des Bundesamtes für Sicherheit im Gesundheitswesen, Bundesministerium für Gesundheit und Frauen; Belgium: Dr. Sophie Maes, Scientific Institute of Public Health Belgium; Bulgaria: Mira Kojouharova, MD, PhD, National Consultant on Epidemiology, National Center of Infectious Disease and Parasitic Diseases; Canada: Public Health Agency of Canada; Cyprus: Dr. Chrystalla Hadjianastassiou, Chief Medical Officer, Medical and Public Health Services, Ministry of Health Cyprus; Czech Republic: Dr. Michael Vít, Chief Hygienist of the Czech Republic and Deputy Minister of Health; Denmark: Sigrid Poulsen, MD MPH, Senior Medical Officer, Communicable Diseases, National Board of Health; Finland: Merja Saarinen, Ministerial Counsellor, Health/Medical Affairs, Ministry of Social Affairs and Health; France: Dr. Isabelle Bonmarin, medical epidemiologist, Institut de veille sanitaire; Germany: Dr. Walter Haas, Robert Koch Institute; Greece: Dr. Pierroutsakos and Dr. Efstathiou, KE.EL.P.NO, Hellenic Center for Infectious Disease Control; Hungary: Ministry of Health; Ireland: Dr. Derval Igoe, MB, MPH, FRCPI, FFPHMI, Health Protection Surveillance Centre; Japan: Dr. Nobuhiko Okabe, Director of Infectious Disease Surveillance Center, National Institute of Infectious Diseases; Latvia: Dace Viluma, Head of the division of Epidemiological Safety of the Department of Public Health, Lithuania: Nerija Kupreviciene, Centre for Communicable Diseases Prevention and Control, Luxembourg: Mr Roland Bombardella, Haut-Commissaire a la Protection Nationale; Malta: Dr. Tanya Melillo Fenech, Public Health PMO, Disease Surveillance Unit, Department of Public Health; Poland: Prof. Lidia B. Brydak, PhD, Magdalena Romanowska, PhD, National Influenza Center; Portugal: Teresa M. Alves Fernandes, Operative Group for the Structure of the National Influenza Pandemic Preparedness Plan, Director General of Health; Romania: Dr. Viorel Alexandrescu, Head of National Influenza Center, Cantacuzino Institute; Slovak Republic: Dr. Jan Mikas, MD, Head of Department of Epidemiology, Public Health Authority of the; Slovenia: Dr. Alenka Kraigher, Head of Communicable Diseases Center, Institute for Public Health Slovenia; Spain: Dr. Jose Sierra, Direccion General de Salud Publica, Ministerio de Sanidad y Consumo; Sweden: Dr. A. Tegnell, Director, Communicable Disease Prevention and Control, National Board of Health and Welfare; the Netherlands: Mr Andre Jacobi, Policy advisor preparedness & response, National Coordination Centre for Outbreak Management, RIVM.
Furthermore we would like to thank the key persons involved with pandemic influenza preparedness of the following countries: Estonia, Italy, Mexico, United Kingdom and United States.
We also like to thank Prof. Angus Nicoll, Influenza coordination, European Centre for Disease Prevention and Control, for his thoughtful critics of the draft of the manuscript and his suggestions.
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The pre-publication history for this paper can be accessed here: