|
 |
|
|||||||
|
|||||||||
© 2009 American Public Health Association
DOI: 10.2105/AJPH.2008.153056
RESEARCH AND PRACTICE |
At the time of the study, Helen Marshall and Don Roberton were with the Paediatric Trials Unit, Women's and Children's Hospital, Adelaide, Australia. Helen Marshall, Philip Ryan, and Jackie Street were with the Discipline of Public Health, University of Adelaide, Adelaide. Helen Marshall and Don Roberton were with the Discipline of Paediatrics, University of Adelaide, Adelaide. Maureen Watson is with the South Australian Immunisation Co-ordination Unit, Department of Health, South Australia, Adelaide.
Correspondence: Correspondence should be sent to Dr Helen Marshall, Paediatric Trials Unit, Women's and Children's Hospital, 72 King William Rd, North Adelaide, South Australia (e-mail: helen.marshall{at}adelaide.edu.au). Reprints can be ordered at http://www.ajph.org by clicking on the "Reprints/Eprints" link.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONHuman Paticipation ProtectionReferences |
|---|
Objectives. We aimed to examine community knowledge about and attitudes toward the threat of pandemic influenza and assess the community acceptability of strategies to reduce its effect.
Methods. We conducted computer-aided telephone interviews in 2007 with a cross-sectional sample of rural and metropolitan residents of South Australia.
Results. Of 1975 households interviewed, half (50.2%) had never heard of pandemic influenza or were unaware of its meaning. Only 10% of respondents were extremely concerned about the threat of pandemic influenza. Respondents identified children as the highest priority for vaccination, if supplies were limited; they ranked politicians and teachers as the lowest priority. Although only 61.7% of respondents agreed with a policy of home isolation, 98.2% agreed if it was part of a national strategy. Respondents considered television to be the best means of educating the community.
Conclusions. Community knowledge about pandemic influenza is poor despite widespread concern. Public education about pandemic influenza is essential if strategies to reduce the impact of the disease are to be effective.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONHuman Paticipation ProtectionReferences |
|---|
The latest outbreaks of avian influenza A(H5N1) and novel H1N1 influenza have heightened concerns that an influenza pandemic is imminent.1–4 In response, many governments have prepared protocols for rapid response and containment of infection to minimize the heavy burden of morbidity and mortality associated with previous pandemics.
Although epidemic influenza kills thousands of people worldwide each year, the emergence of influenza viruses with novel surface antigens poses a greater threat with increased economic and social consequences. The occasional crossover of the highly pathogenic but poorly transmissible avian influenza virus H5N1 into humans has placed governments on high alert for an influenza pandemic.
The United States began preparing pandemic influenza response plans in 1993 after the emergence of H5N1, closely followed by the European Union.5,6 A worldwide response to emerging diseases coalesced in the World Health Organization (WHO) Global Outbreak Alert and Response Network, established in 2000.7 Since then, a steady flow of WHO resource documents has encouraged the development of national pandemic influenza response plans and rapid action where outbreaks have occurred.8
Australia developed its own pandemic influenza management plan in 2005 in response to new cases of H5N1 in Asia; this was revised in 2006.9 Each state has developed a plan that is consistent with the national plan but includes additional details relating to local circumstances.10 The Australian federal government has invested more than AU $600 million in influenza pandemic preparedness,11 including stockpiling antiviral drugs and personal protective equipment and developing a vaccine that is effective against H5N1.
In 2006 a national pandemic influenza exercise, Exercise Cumpston, carried out at sites across Australia, highlighted several gaps in existing plans, including poor communication with the general public and a lack of information targeted to indigenous and culturally diverse groups. The Exercise Cumpston report led to an emphasis on improved communication, including government engagement in increasing public knowledge, with the aim of building a base level of awareness and understanding across the community and among primary care providers about the threat of an influenza pandemic.11
Although many government and public health agencies have been involved in pandemic influenza planning, the wider population (including community and hospital health care workers) has generally not been included in decision-making on issues that will require community compliance. Public health control measures that are inadequately understood or supported by communities may fail to be implemented.12 Poorly understood control measures caused confusion and fear during the SARS (severe acute respiratory syndrome) outbreak.13 Pandemic influenza planning in North America has included a US–Canada summit,14 the Public Engagement Pilot Project on Pandemic Influenza,15 and local initiatives such as the Baltimore program B'More Prepared,16 but citizen consultation and engagement have been limited. In New Zealand, consideration of ethical issues in pandemic influenza planning included elements of community consultation.17
Engagement of the community as active participants in pandemic flu preparedness is considered essential if a successful prevention program is to be established.17,18 We aimed to assess community knowledge regarding pandemic influenza preparedness and acceptance of government strategies to reduce the impact of pandemic influenza in South Australia.
|
METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONHuman Paticipation ProtectionReferences |
|---|
We conducted a cross-sectional telephone survey of randomly selected households in South Australia (population 1.5 million). The study was part of the Health Monitor program of the Population Research and Outcomes Studies Unit, Department of Health, South Australia.19 We based the random sampling process on the South Australian electronic white pages household telephone listings, both city and rural. The household contact identified the adult in the household (aged
18 years) who most recently had a birthday; up to 10 callbacks were made to interview the identified individual. The interviews were conducted by the computer-assisted telephone interviewing method. In South Australia, 97% of households have a telephone listed in the white pages. Phone calls were made at different times of the day and evening and on different days of the week. A pilot study of 50 randomly selected households was conducted in March 2007 to test question formats and sequence prior to commencement of the main study, which took place in April and May 2007. The method was similar to that employed in previous community surveys.20,21 Questions were intended to determine the level of knowledge and community acceptance of government strategies for pandemic influenza control. The complete list of survey questions is available from the corresponding author on request.
The survey data were weighted to the age, gender, and geographical area profile of the population of South Australia and the probability of selection within a household. Individual data were weighted by the inverse of the individual's probability of selection and then reweighted to benchmarks derived from the Australian Bureau of Statistics' estimated resident population for June 30, 2005 (age, gender data, and geographical area profile), for South Australia.19 For questions regarding households, records were weighted by the inverse probability of the selection of the household, then reweighted to benchmarks derived from the Australian Bureau of Statistics' 2001 Census of Population and Housing. We used the Socioeconomic Index for Areas Index of Relative Socioeconomic Disadvantage as a measure of socioeconomic status.22
We used Stata software for statistical analyses, with routines specifically designed to analyze clustered, weighted survey data.23 Statistical tests were 2-tailed, with a significance level of 5%.
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONHuman Paticipation ProtectionReferences |
|---|
Of 3900 telephone numbers selected, 960 could not be contacted or were not household numbers. From the remaining 2940 numbers, 1975 interviews were conducted, a participation rate of 67.2%.
The mean age of the household interviewees was 53.4 years, with a median of 53 years (95% confidence interval [CI] = 52, 54) and a range of 18 to 94 years. We weighted the raw data collected from the 1975 randomly selected households in the Health Monitor Survey for both numbers and proportions (Table 1). Within weighted households the mean age of the interviewee was 47.2 years (95% CI = 46.2, 48.2), with a nearly equal proportion of men (49.1%) and women (50.9%; Table 1). Our results were therefore based on a weighted survey sample of 969 men and 1006 women. Children younger than 18 years resided in 686 (34.7%) of the households interviewed.
|
Knowledge of Pandemic Influenza and Prevention
Of 1975 households interviewed, 50.2% of the respondents had either never heard of pandemic influenza (8.4%; 95% CI = 7.0, 10.1) or were unaware of its meaning (41.8%; 39.1, 44.5). When asked an open-ended question about the meaning of pandemic influenza, 34% were able to provide the meaning.
A correct response (WHO definition24) included recognition of a global spread of influenza with potential to cause a large number of deaths. A statement based on the WHO definition of pandemic influenza was read to all respondents after they answered the question on knowledge of pandemic influenza to facilitate further discussion. Age was a statistically significant correlate of knowledge of pandemic influenza (
26 = 49.543; P < .001): respondents aged 45 to 64 years were likeliest to know of pandemic influenza, and those aged 18 to 24 years or older than 75 years were least likely to possess such knowledge.
Participants with a higher level of educational attainment were more likely to know the meaning of pandemic influenza (23 = 91.817; P < .001). Those with secondary school education were less likely to know the meaning of pandemic influenza (29.7%; 95% CI = 26.6, 33.1) than were respondents who had learned a trade or served an apprenticeship (35.0%; 95% CI = 27.7, 43.1) or who had completed a bachelor's or higher degree (56.7%; 95% CI = 50.3, 62.9).
The test for trend showed that the proportion of respondents who provided the correct meaning of pandemic influenza increased by 4.3% (95% CI = 2.0, 6.5) with each quartile of socioeconomic status (P < .001). Almost one third of respondents (31.5%; 95% CI = 27.1, 36.2) in the lowest socioeconomic quartile knew the meaning of pandemic influenza; 46.5% (95% CI = 41.7, 51.5) of those in the highest socioeconomic quartile answered this question correctly.
The mean level of concern regarding pandemic influenza (on a scale of 1–10) was 5.8 (95% CI = 5.7, 6.0; Figure 1). Thirty percent of respondents had a score of 7 or higher, suggesting a high level of concern in the community, with 10% of respondents indicating extreme concern about the threat of pandemic influenza with a score of 10. A test for trend showed that women were more likely than men to report high concern about the threat of pandemic influenza (P < .001). The mean score for concern among men was 5.5 (95% CI = 5.3, 5.7); for women it was 6.1 (95% CI = 6.0, 6.3). The gender difference in means was 0.65 (95% CI = 0.36, 0.93).
|
As age increased and household income decreased, the proportion of respondents concerned about pandemic influenza increased. A test for trend (P < .001) showed that as age increased (by 10-year categories), the level-of-concern score increased by 0.39 (95% CI = 0.31, 0.47). Similarly, as household income decreased (household income categories shown in Table 1), the score for concern increased by 0.37 (95% CI = 0.45, 0.29). Among lower-income households (< AU $20 000), 78.9% (95% CI = 73.9, 83.1) were concerned about pandemic influenza (scores of 5–10); among respondents with higher household incomes (> AU $80 000), 56.0% (95% CI = 50.0, 61.9) were similarly concerned.
The majority of respondents believed that the routine influenza vaccination would give sufficient protection against a pandemic influenza strain. This was considered true by 52.4% (95% CI = 49.7, 55.1) of respondents; 27.5% (95% CI = 25.2, 29.9) were aware that the influenza vaccine would not provide protection, and 20.0% (95% CI = 17.9, 22.3) were unsure. Respondents with higher educational attainment were less likely to believe that the annual influenza vaccine would protect against a pandemic strain (45.3%; 95% CI = 38.9, 51.8); 56.6% of those with lower educational attainment held this opinion (95% CI = 53.0, 60.2). A test for trend was significant (P < .001): 10.1% fewer respondents (95% CI = 6.4, 13.8) believed in the efficacy of the annual influenza vaccine for each increase in educational attainment (categories described in Table 1).
Preparation for Pandemic Influenza
Use of antiviral drugs.
If antiviral drugs were available, 49.3% (95% CI = 46.6, 52.0) of respondents said that they would not buy and store them in preparation for an influenza pandemic, 35.0% (95% CI = 32.5, 37.6) stated that they would store antiviral drugs, and 15.7% (95% CI = 13.8, 17.7) were unsure. Women, households with lower income, respondents with a lower level of educational attainment and of lower socioeconomic status, and residents of rural areas were all significantly more likely to buy and store antiviral medication in preparation for an influenza pandemic (Table 2).
|
Acceptance of a pandemic influenza vaccine. Of all households interviewed, 81.4% (95% CI = 79.2, 83.5) said that once a licensed vaccine to prevent pandemic influenza was available, they would agree to be vaccinated; 11.7% (95% CI = 10.0, 13.5) reported that they would not agree to be vaccinated; and 6.9% (95% CI = 5.6, 8.6) were unsure. Similarly, when parents (n = 578) were asked if they would have their children vaccinated with a licensed vaccine to prevent pandemic influenza, the majority agreed that their children should receive the vaccine (78.6%; 95% CI = 74.3, 82.4). Some parents (8.1%; 95% CI = 5.7, 11.3) would refuse vaccination for their children, and others (8.1%; 95% CI = 6.1, 10.7) were unsure.
The highest-priority recipients of vaccine suggested by respondents if supplies were limited were children (49.7%; Table 3). We observed a gender difference in this response (21 = 25.062; P < .001): men were more supportive of emergency service workers receiving priority for vaccination (63.0%; 95% CI = 56.1, 69.4) than were women (37.0%; 95% CI = 30.6, 43.8). Women were more likely to consider vulnerable groups such as children, the elderly, or sick people as needing a priority for vaccination (53.9%; 95% CI = 50.9, 56.9) than were men (46.1%; 95% CI = 43.1, 49.1).
|
Wearing a mask to prevent spread of infection. A high proportion of respondents (83.5%; 95% CI = 81.3, 85.5) would agree to wear a mask to prevent spread of infection in pandemic influenza. Women, older adults (aged > 50 years), part-time employees, and adults with home duties were most willing to wear a mask (Table 4). The responses provided by indigenous participants were similar, with 19 of 20 agreeing to wear a mask.
|
Reduction of virus transmission. Of adult employees interviewed, 61.7% (95% CI = 58.4, 64.9) said they would stay home from work if they had symptoms suggestive of influenza. A small proportion of respondents (3.6%; 95% CI = 2.7, 4.8; n = 52) worked from home and were not included in any further analysis of home isolation. The proportion of respondents who would miss work if they were ill rose substantially (98.2%; 95% CI = 97.1, 98.9) if this was recommended as part of a national strategy to prevent the spread of infection. Men were less likely than women to stay at home if unwell (
21 = 36.842; P < .001): 56.0% (95% CI = 51.0, 60.9) and 72.6% (95% CI = 68.4, 76.4), respectively.
Full-time employees were less likely to stay at home with influenza-like symptoms (56.9%; 95% CI = 52.2, 61.4) than were part-time employees (74.4%; 95% CI = 68.5, 79.5; 21 = 27.337; P < .001). When home isolation was presented as a component of a national strategy, we observed no significant gender difference. Employees with a higher income (> AU $80 000) were less likely to stay at home with an influenza-like illness (55.0%; 95% CI = 48.5, 61.3) than were those with an income under AU $20 000 (74.3%; 95% CI = 64.0, 82.5). A test for trend was significant (P < .001): as income increased by multiples of AU $20 000, the proportion of respondents who said they would stay home decreased by 4.9% (95% CI = 2.5, 7.3).
Community Attitudes Toward Preparedness
Fewer than one third of respondents (32.0%; 95% CI = 29.5, 34.6) believed that enough was being done to prepare for pandemic influenza; 44.7% (95% CI = 42.1, 47.4) were unsure.
Respondents with higher educational attainment were more concerned that not enough was being done, with 66.5% (95% CI = 58.4, 73.8) suggesting that more should be done; 59.3% (95% CI = 54.3, 64.2) of participants with secondary schooling shared this concern. More than 40% of respondents agreed that further information and education needs to be provided to the public. Other priorities suggested were vaccination (18.3%; 95% CI = 16.4, 20.4), including compulsory vaccination, and increased funding for vaccine research (7.1%; 95% CI = 5.3, 9.5).
More than one third of respondents (36.6%; 95% CI = 34.1, 39.3) received most of their information from television, and 16.9% (95% CI = 15.1, 18.8) from newspapers. Doctors' waiting rooms provided most information for 4.4% of respondents (95% CI = 3.5, 5.6); only 1.2% (95% CI = 0.8, 1.9) cited the Internet as the most important source of information.
Most respondents (69.6%; 95% CI = 67.1, 72.0) considered television the best means of communication about pandemic influenza; 12.4% (95% CI = 10.7, 14.2) cited radio. An information pack from the government was considered a priority by 2.8% of participants (95% CI = 2.1, 3.8), and another 1.6% (95% CI = 1.1, 2.4) suggested pamphlets should be sent by mail (n = 1975). Almost all (97.4%; 95% CI = 87.3, 99.5) younger adults (< 55 years of age) cited the Internet as the best means of communication. In addition, 67.9% (95% CI = 65.1, 70.5) of respondents who identified television as the best means of communication were younger than 55 years. Older adults ( 55 years) were more likely to cite their doctor's office: 81.7% of respondents who relied on this information source were in this age group. Men were more likely to suggest the Internet as a source of information (75.0%; 95% CI = 43.3, 92.2), and women were more likely to cite the doctor's office as the best source (82.7%; 95% CI = 57.0, 94.5). Women preferred information packs (62.6%; 95% CI = 47.0, 75.9) and letters (75.5%; 95% CI = 53.5, 89.1).
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONHuman Paticipation ProtectionReferences |
|---|
Despite initial widespread publicity regarding pandemic influenza and advocacy to build a base level of awareness and understanding among the population,26 we found that the majority of adults in the community we surveyed were completely unaware of the possibility of pandemic influenza and harbored misconceptions about protection against a pandemic influenza strain. This was especially true for young adults and the elderly, which is noteworthy because the elderly are at increased risk of complications and mortality from influenza. We observed a high level of concern within the community, particularly among elderly women and adults in low-income households, possibly reflecting perceived vulnerability to potential loss of income and concern for dependents. Community knowledge about pandemic influenza is deficient, and exploration of the most effective methods for providing information to the general public is urgently needed.
Knowledge of Pandemic Influenza Preparedness
Socioeconomically disadvantaged and low-income respondents expressed a higher level of concern, which may reflect perceived lack of resources in times of stress. This concern may relate to the potential for loss of income or job if they comply with government recommendations, such as home isolation or quarantine, as shown by Blendon et al.27 Our findings and those of other studies suggest that educational interventions are required to improve trust in the community and to promote effective coping mechanisms that could support implementation of government strategies.28,29
As a component of a pandemic influenza education campaign, the community must be made aware that the routine influenza vaccine will not provide protection against a novel strain and that an effective vaccine will need to be developed.30,31 In addition, the community will need to be aware that because of delays in the provision of a vaccine, other preventive measures will be required to minimize the spread of infection, many of which could be promoted for use during seasonal outbreaks.
Acceptance of Government Preparedness Strategies
Support for development of a vaccine to prevent pandemic influenza is strong.18 H5N1 vaccines are licensed in several countries, and policymakers are considering vaccinating their communities with a prepandemic influenza vaccine in the near future, followed by a booster pandemic vaccine when it becomes available. A vaccine uptake of 80% in the community is likely necessary to provide herd immunity during an outbreak. Our results indicate that most citizens would agree to be vaccinated, but almost 12% would refuse vaccination, meaning that 2.4 million adults would remain unprotected and would be able to spread infection.
Compulsory vaccination was supported by a small proportion of our respondents. It has been debated and rejected in Australia for routine immunizations but has been accepted in some states in the United States.32 The community may consider that some circumstances warrant compulsory immunization, such as a global threat of disease with high morbidity and mortality. The most vulnerable groups within society, selected by our respondents as a priority for vaccination, included children, the elderly, and the ill. Children are also an important priority for vaccination in government plans, to control the spread of infection, particularly to the elderly.33–35
Rationing of antivirals and vaccines is controversial.36 The Australian government places the highest priority on the protection of providers of health and emergency services.18,37 The difference in government and community priorities will need to be addressed to encourage community participation in strategies to prevent pandemic influenza. The mechanism by which rationing of vaccines is communicated and implemented will be vital in determining public trust and reaction.
A majority of our respondents indicated a willingness to stay home from work with symptoms of influenza-like illness if required as part of a national strategy to stop the spread of infection. During an influenza pandemic, home isolation may be required for up to a week,37 and our data suggest that this strategy would be supported by the community. Wearing masks is considered a high priority by the Australian government, which has designated significant funding in its pandemic influenza preparedness plans for fitting masks to all health care workers. Our study showed robust community acceptance of wearing masks, although no further details, such as how long masks would need to be worn or their efficacy in preventing transmission, were discussed during our interviews.
Our respondents expressed a need for more pandemic influenza preparedness. This included providing more information, and they designated television as the most appropriate medium for communication. Most available information is provided on the Internet by government agencies, but only a small proportion of our participants had accessed this information; it may therefore not be the optimal way to inform the community. Our respondents also identified funding for pandemic influenza research and development of a vaccine as high priorities. Informing and engaging the community could lead to community lobbying of government or to community funding for vital pandemic influenza research.
Limitations
Although our results may be used to inform pandemic policy, the community may respond differently when the threat of a pandemic is imminent. The community's response is also likely to be affected by the perceived effectiveness of government strategies during a pandemic and by a clear and consistent release of information to the public, neither of which was measured during our study.
Nonresponse in telephone surveys may result in underrepresentation of subgroups within the population. This may be important because of the high mortality in younger age groups in previous pandemics.25 Weighting the survey data may compensate for this bias because it helps ensure that the age and gender structure of the sample better represents that of the general population. This type of survey does not provide an opportunity to give participants a detailed explanation of the measures presented, including risks and benefits, which might evoke a different response.
Conclusions
Accurate information must be provided to the public both before and during a pandemic on how to care for those infected and how to protect against the spread of infection. Provision of information in a clear, accessible, and engaging way is required to optimize community acceptance of public health actions to prevent or respond to a pandemic.38 Strategies to restrict the spread of disease will be ineffective if communication is not improved. Although the Exercise Cumption report acknowledged that communication to the public was inadequate, little has been done to raise community awareness.
Community and government need to work as partners in planning for a pandemic. The needs of vulnerable groups within the community who may be severely affected should be considered. Clarity and transparency of decision-making, along with thorough and efficient communication of information to the public, are essential to the mission of pandemic influenza preparedness—prevention of a global catastrophe.
|
Human Paticipation Protection |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONHuman Paticipation ProtectionReferences |
|---|
The study was approved by the Children, Youth and Women's Health Service research ethics committee.
|
Footnotes |
|---|
Peer Reviewed
H. Marshall and P. Ryan designed and conducted the study, analyzed the results, and are joint authors of this article. H. Marshall is the primary author and assumed the primary role for preparation of the article. D. Roberton, J. Street, and M. Watson helped interpret the results. All authors contributed substantially to writing and reviewing drafts of the article and approved the final version.
Accepted for publication May 30, 2009.
|
References |
|---|
|
TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONHuman Paticipation ProtectionReferences |
|---|
1. Subbarao K, Klimov A, Katz J, et al.. Characterization of an avian influenza A (H5N1) virus isolated from a child with a fatal respiratory illness. Science. 1998;279:393–396.
2. Claas EC, Osterhaus AD, van Beek R, et al.. Human influenza A H5N1 virus related to a highly pathogenic avian influenza virus. Lancet. 1998;351:472–477.[CrossRef][Web of Science][Medline]
3. Peiris JS, Yu WC, Leung CW, et al.. Re-emergence of fatal human influenza A subtype H5N1 disease. Lancet. 2004;363:617–619.[CrossRef][Web of Science][Medline]
4. Tran TH, Nguyen TL, Nguyen TD, et al.. Avian influenza A (H5N1) in 10 patients in Vietnam. N Engl J Med. 2004;350:1179–1188.
5. Gensheimer KF, Fukuda K, Brammer L, Cox N, Patriarca PA, Strikas RA. Preparing for pandemic influenza: the need for enhanced surveillance. Emerg Infect Dis. 1999;5(2):297–299.[Web of Science][Medline]
6. Desenclos JC, Manigat R. The European Union faces up to the threat of a pandemic: meeting at the DGV on the influenza A (H5N1) of the ad hoc group on communicable diseases Luxembourg 14 January 1998. Euro Surveill. 1998;3(3):25–26.[Medline]
7. World Health Organization. Global outbreak alert and response network. Available at: http://www.who.int/csr/outbreaknetwork/en/. Accessed August 16, 2007.
8. World Health Organization. Epidemic and pandemic alert and response: guidelines, recommendations, descriptions. Available at: http://www.who.int/csr/disease/avian_influenza/guidelines/en/index.html. Accessed August 16, 2007.
9. Australian Government, Department of Health and Ageing. Australian health management plan for pandemic influenza. 2006. Available at: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pandemic-plan.htm. Accessed August 16, 2007.
10. Australian Homeland Security Research Centre. Australian pandemic plans. Available at: http://www.pandemic.net.au/resources.html. Accessed August 16, 2007.
11. Australian Government, Department of Health and Ageing. National pandemic influenza exercise. Exercise Cumpston 06 report. 2007. Available at: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/ohp-cumpston-report.htm. Accessed August 16, 2007.
12. Schoch-Spana M. Lessons from the 1918 pandemic influenza: psychosocial consequences of a catastrophic outbreak of disease. In: Fullerton C, ed. Bioterrorism: Psychological and Public Health Interventions . Cambridge, England: Cambridge University Press; 2004.
13. Cava MA, Fay KE, Beanlands HJ, McCay EA, Wignall R. Risk perception and compliance with quarantine during the SARS outbreak. J Nurs Scholarsh. 2005;37(4):343–347.[CrossRef][Web of Science][Medline]
14. Centre for Biosecurity. Disease, disaster and democracy: the public's stake in health emergency planning. Available at: http://www.upmc-biosecurity.org/website/resources/publications/2006_orig-articles/2006-09-15-diseasedisasterdemocracy.html. Accessed August 16, 2007.
15. US Department of Health and Human Services. Citizen voices on pandemic flu choices—a report of the public engagement pilot project on pandemic influenza (PEPPPI): preface & executive summary. Available at: http://www.pandemicflu.gov/plan/federal/citizenvoices.html. Accessed August 16, 2007.
16. Baltimore City Health Department. While city residents are encouraged to B'More Prepared Baltimore City Health Department is selected for project public health ready, B'More Prepared program [press release]. Available at: http://www.ci.baltimore.md.us/government/health//press/051011.html Accessed October 11, 2005.
17. National Ethics Advisory Committee. Getting through together: ethical values for a pandemic. Available at: http://www.neac.health.govt.nz/moh.nsf/indexcm/neac-resources-publications-gettingthroughtogether. Accessed August 16, 2007.
18. Australian Government, Department of Health and Ageing. The Australian health management plan for pandemic influenza. 2008. Available at: http://www.flupandemic.gov.au/internet/panflu/publishing.nsf/Content/ahmppi. Accessed April 20, 2009.
19. Population Research and Outcome Studies Unit. The Health Monitor Survey methodology. Brief report 2002–12. Available at: http://www.health.sa.gov.au/pros/portals. Accessed October 17, 2007.
20. Marshall H, Ryan P, Roberton D. Uptake of varicella vaccine—a cross sectional survey of parental attitudes to nationally recommended but unfunded varicella immunisation. Vaccine. 2005;23:5389–5397.[CrossRef][Web of Science][Medline]
21. Marshall H, Ryan P, Roberton D, Baghurst P. A cross sectional survey to assess community attitudes to introduction of HPV vaccine. Aust N Z J Public Health. 2007;31(3):235–242.[CrossRef][Web of Science][Medline]
22. Australian Bureau of Statistics. Census of population and housing: socioeconomic index for areas (SEIFA) 2001. Available at: http://www.ausstats.abs.gov.au/Ausstats/free.nsf/0/A5561C69BF600637CA256E20007B5DF1/$File/2039055001_2001.pdf. Accessed October 17, 2007.
23. Stata, Release 9 [computer program]. College Station, TX: Stata Corporation, 2005.
24. World Health Organization. Epidemic and pandemic alert and response: pandemic preparedness. Available at: http://www.who.int/csr/disease/influenza/pandemic/en/#pandemic. Accessed June 01, 2008.
25. Johnson NP, Mueller J. Updating the accounts: global mortality of the 1918–1920 "Spanish" influenza pandemic. Bull Hist Med. 2002;76:105–115.[Web of Science][Medline]
26. Australian Department of Health and Ageing. Communication strategy overview: annex to the Australian health management plan for pandemic influenza. 2006. Available at: http://www.health.gov.au/internet/panflu/publishing.nsf/Content/comms-strategy-1. Accessed February 2, 2009.
27. Blendon RJ, Koonin LM, Benson JM, et al.. Public response to community mitigation measures for pandemic influenza. Emerg Infect Dis. 2008;14(5):778–786.[CrossRef][Web of Science][Medline]
28. Watkins RE, Cooke FC, Donovan RJ, MacIntyre CR, Itzwerth R, Plant A. Influenza pandemic preparedness: motivation for protection amongst medium businesses in Australia. BMC Public Health. 2007;7:157–167.[CrossRef][Medline]
29. Anikeeva O, Braunack-Mayer A, Street J. What will Australian general practitioners do in a pandemic and why? A qualitative study of ethical values. Med J Aust. 2008;189(3):148–150.[Web of Science][Medline]
30. Nicolson C, Major D, Wood JM, Robertson JS. Generation of influenza vaccine viruses on Vero cells by reverse genetics: an H5N1 candidate vaccine strain produced under a quality system. Vaccine. 2005;23:2943–2952.[CrossRef][Web of Science][Medline]
31. Chen H, Matsuoka Y, Swayne D, et al.. Generation and characterization of a cold-adapted influenza A H9N2 reassortant as a live pandemic influenza virus vaccine candidate. Vaccine. 2003;21:4430–4436.[CrossRef][Web of Science][Medline]
32. Isaacs D, Kilham H, Marshall H. Should routine childhood immunisations be compulsory? J Paediatr Child Health. 2004;40:392–396.[CrossRef][Web of Science][Medline]
33. Piedra PA, Gaglani MJ, Kozinetz CA, et al.. Herd immunity in adults against influenza-related illnesses with use of the trivalent-live attenuated influenza vaccine (CAIV-T) in children. Vaccine. 2005;23(13):1540–1548.[CrossRef][Web of Science][Medline]
34. Reichert TA, Sugaya N, Fedson DS, Glezen WP, Simonsen L, Tashiro M. The Japanese experience with vaccinating schoolchildren against influenza. N Engl J Med. 2001;344(12):889–896.
35. Longini IM, Halloran ME, Nizam A, Yang Y. Containing pandemic influenza with antiviral agents. Am J Epidemiol. 2004;159(7):623–633.
36. World Health Organization. Addressing ethical issues in pandemic influenza planning. 2008. Available at: www.who.int/csr/resources/publications/WHO_HSE_EPR_GIP_2008-2/en/index.html. Accessed February 2, 2009.
37. Horvath JS, McKinnon M, Roberts L. The Australian response: pandemic influenza preparedness. Med J Aust. 2006;185(10 suppl):S35–S38.[Web of Science][Medline]
38. Torda A. Ethical issues in pandemic planning. Med J Aust. 2006;185(10 suppl):S73–S76.[Web of Science][Medline]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |