Ethical Issues in National Pandemic Influenza Plans


Influenza pandemics are unpredictable but recurring events that can have severe consequences on human health and socio-economic life to global level. For this reason, the World Health Organization (WHO) has recommended all countries to prepare a pandemic influenza plan and to keep them constantly updated, following its own guidelines. The WHO guidance – revised in 2009 to help policymakers to balance individual and community interests when dealing with national influenza preparedness plans – stresses the importance of ethical principles such as equity, utility/efficiency, liberty, reciprocity and solidarity. Any measure that limits the individual rights and the civil liberties (such as isolation and quarantine) must be necessary, reasonable, proportional, equitable, not discriminatory, and not in violation of the national and international laws. For such purposes, WHO has developed a framework of detailed ethical considerations, in order to ensure that overall concerns (such as protecting human rights and the special needs of vulnerable and minority groups) are addressed in pandemic influenza planning and response.

In 2008, WHO has published another document aimed at providing a more comprehensive analysis of the ethical and policy issues, and emphasizing that every public health interventions must be implemented within the context of internationally recognized human rights, according to the Siracusa Principles.

WHO has highlighted that guidelines included in these documents should be used from all countries to develop or update national influenza preparedness and response plans, in conjunction with the WHO checklist for influenza preparedness planning published by WHO in 2005.

Experts from the ASSET project conducted a study on this issue, performing a semantic analysis of national pandemic plans developed by ten European Union/European Economic Area (EU/EEA) countries and by Switzerland, member of European Free Trade Association (EFTA), including EU and WHO documents. All documents were taken from the ECDC official website (, whenever a translation in English was available.

The analysis has been based on two keyword lists: in a first, generic, list, keywords represent areas of possible ethical interest; in a second, more specific, list, keywords are more precisely related to ethical issues actually addressed in each national pandemic plan.

Aim of the research was to assess and compare the occurrence rates of each keyword within both lists, in order to evaluate the relevance of ethical issues and the application of ethical principles in the development of national preparedness and response plans.

The semantic analysis showed little concern for ethical aspects and a lack of discussion on ethical issues in most pandemic plans developed from European countries, except for Switzerland, United Kingdom, Czech Republic and France.

Data Visualization

The following graphs show the results of the semantic analysis on ethical issues in national pandemic plans.

These two graphs show the flow of the keywords in national pandemic plans. The left side show the list of keywords ordered by occurrence rates, while the right side show the documents ordered by number of keywords found. The flow shows the distribution of the keywords in these documents.
* We used a stemming process to reduce derived words to their word stem, base or root form. E.g. to reduce words "ethical", "ethically", "ethics" to the root word, "ethic". We used Raw to make alluvial diagrams.

Generic keywords

Specific keywords

Analysing doc by doc

Histograms show where the keywords occur in every document.

For each document, you can scroll the cursor along the histogram. On the bottom, you will see generic and specific keywords from the two lists and, on the top, the page number where they are mentioned. The greater or lesser intensity of red areas is related to higher or lower occurrence rates for each keyword, namely the number of times that each keyword occurs in each document. The first row concerns the list of keywords generically connected to ethic, while the second row refers to the list of keywords more specifically related with the ethical issues (see the two lists).


ASSET analysis shows that ethical issues have not been addressed in most national pandemic plans. They are just mentioned in some of them, like in the Italian and Spanish ones, while ethical concerns have been discussed more extensively in Swiss, English, Czech and French pandemic plans. Only Swiss, UK and France dedicated a specific section – also included in the index – to ethical questions.

In all national pandemic plans examined there are contents which could be related to ethical issues, with different distribution. For instance, the words isolation and quarantine are mentioned in all documents examined, but mostly as measures aimed at limiting the spread of the diseases. Only some plans consider the ethical implications of these measures which limit personal freedom, such as the necessity of a transparent communication and the respect of personal needs and human rights.

Similarly, the word "borders" would require ethical observations too, especially when a document states that an individual coming from a country at risk should be subjected to screening procedures, facing, for example, the risk of stigmatisation. Although the enjoyment of particular human rights may be limited in exceptional circumstances, the focus on the dignity of the human being must always be a priority.

Final Considerations

Ethical issues have great impact also on the spread of diseases. Despite awareness of this relevance, this analysis clearly shows that they are still underestimated in pandemic plans. Some of them – like the Italian and Spanish ones – just mentioned them while others discussed them more in details. Only 4 plans (Switzerland, United Kingdom, Czech Republic and France) among those available in English on the ECDC website, have a dedicated section to this topic, including ethical issues among the main principles of a pandemic plan. This is even more relevant since the analysis revealed multiple areas of possible ethical interest within the different plans, like graphs above show.

This analysis has some limits, such as the lack of pandemic plans in English for some EU/EEA countries and the fact that not all pandemic plans examined are updated in accordance with WHO guidelines revised in 2009. Also, this semantic analysis has used some keywords that are not always matching with the context in which the same keywords occur in documents examined.

Despite these limits, however, this work may represent a useful tool to guide future drafters of pandemic plans. It aims at encouraging debate on the necessity to update all national pandemic plans including ethical and other SiS issues, such as gender and participatory governance, which have proved to be of great relevance in case of epidemics and pandemics.


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