half of the U.S. vaccine supply—the product of a single manufacturer, Chiron, Inc.—unusable.

This chapter discusses challenges to pandemic preparedness at international, national, and state levels. It begins with the executive summary of a technical consultation convened by the World Health Organization (WHO) in March 2004 in response to the threat posed by H5N1 avian influenza, and in particular to the evidence that this virus had been transmitted to humans in Vietnam and Thailand, with deadly results. More than 100 experts from 33 countries discussed a broad range of measures that could be introduced by WHO and national authorities to forestall emerging pandemics, slow their spread, and reduce their potential toll of morbidity, mortality, and social disruption. The executive summary presents the recommendations and conclusions of four working groups (surveillance, public health interventions, antivirals, and vaccines) regarding key issues in pandemic preparedness.

In the United States, the Department of Health and Human Services released a draft Pandemic Preparedness and Response Plan for a 60-day period of public comment on August 26, 2004. This chapter includes an executive summary and a synopsis of this plan, which describes coordination and decision making at the national level; provides an overview of key issues; and outlines steps that should be taken at the national, state, and local levels before and during a pandemic. It is followed by two contributions that further discuss pandemic planning from the perspective of state and local public health officials, who will be largely responsible for implementing pandemic prevention and control actions in the United States. The first essay discusses pandemic planning as a collaborative process that involves officials at all levels of government and that is guided by federal priorities. The second essay highlights the importance of strengthening influenza surveillance at the state and local levels, both as a means to early detection of an emerging pandemic and to inform the public health response to interpandemic influenza.

The chapter continues with a consideration of pharmaceutical defenses against pandemic influenza. Vaccines significantly reduce morbidity and mortality during annual (interpandemic) flu seasons, but as this chapter demonstrates, considerable obstacles currently hinder the production of a vaccine against a pandemic strain of influenza. The critical role of vaccine manufacturers in addressing a pandemic is described, accompanied by a review of methods and logistics for the development and production of a pandemic vaccine.

Demand for vaccine during a pandemic will likely far exceed supply. These considerations are subsequently explored first in a discussion of the challenges to equitable and effective vaccine distribution, and then in a description of the potential use of antiviral drugs to fill unmet need for



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