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Non-pharmaceutical Interventions for an Influenza Pandemic:

September 2008. Non-pharmaceutical Interventions for an Influenza Pandemic: U.S. Approach to Community Mitigation and Prevention of Secondary Effects. Benjamin Schwartz, MD National Vaccine Program Office U.S. Department of Health and Human Services. Presentation Outline.

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Non-pharmaceutical Interventions for an Influenza Pandemic:

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  1. September 2008 Non-pharmaceutical Interventions for an Influenza Pandemic: U.S. Approach to Community Mitigation and Prevention of Secondary Effects Benjamin Schwartz, MD National Vaccine Program Office U.S. Department of Health and Human Services

  2. Presentation Outline • U.S. non-pharmaceutical intervention (NPI) strategy and rationale • Hygiene and respiratory protection interventions not included in this presentation • Potential secondary (adverse) consequences of NPI strategies and approaches to mitigation • Applicability of NPIs globally

  3. 2 1 3 Goals of Community Mitigation Delay outbreak peak Decompress peak burden on hospitals/infrastructure Pandemic Outbreak: No Intervention Diminish overall cases and health impacts Daily Cases Pandemic Outbreak: With Intervention Days Since First Case

  4. Scientific Basis for NPI Strategy • Person-to-person transmission of influenza • Primary role for respiratory droplets • Epidemiological data support need for close contact • Transmission may occur before symptoms • Pandemic and seasonal influenza data on role of children in spreading infection in communities • Mathematical modeling results on the impacts of single and combined interventions • Historical analysis of interventions in U.S. cities during the 1918 pandemic

  5. Historical Analysis of NPIs During the 1918-19 Pandemic • Objective – determine whether city to city variation in mortality was related to timing, duration, or combination of NPIs • Data and analysis • Mortality data from 43 urban areas, Sept 1918 – Feb 1919 • Information on interventions from public health, newspapers, and other sources (n = 1143) • NPIs considered included gathering bans, closing schools, and mandatory isolation and quarantine • Excess death rate analyzed as a function of type and timing of interventions Markel, JAMA 2008

  6. NPIs Implemented in U.S. Cities, 1918-19 Markel et al. JAMA 2007

  7. Associations of NPIs and Excess P & I Mortality, 1918-19 Markel, JAMA 2007

  8. Public Health Response Time by Time to Peak Spearman’s r = -0.74 p < 0.0001 Markel, JAMA 2007

  9. Public Health Response Timeby Mortality Burden Spearman’s r = 0.37 p = 0.0080 Markel, JAMA 2007

  10. 1918 Outcomes by City Death rate from influenza and pneumonia / 1000 population: "Causes of Geographical Variation in the Influenza Epidemic of 1918 in the Cities of the United States," Bulletin of the National Research Council, July, 1923, p.29.

  11. Excess P&I Mortality in Philadelphia and St. Louis, 1918 Source: Hatchett, Mecher, & Lipsitch. Public health interventions and epidemic intensity during the 1918 influenza pandemic. PNAS Early Edition. April 6, 2007

  12. Excess P&I Mortality in Philadelphia and St. Louis, 1918 Timing of NPIs * * Estimate based on back extrapolation of death to incidence curves Source: Hatchett, Mecher, & Lipsitch. Public health interventions and epidemic intensity during the 1918 influenza pandemic. PNAS Early Edition. April 6, 2007

  13. U.S. Community Mitigation Interventions • Asking sick people to stay home(voluntary isolation) • Asking household members of a sickperson to stay home (voluntary quarantine) • Dismissing children from schools and closing childcare and keeping kids and teens from re-congregating and mixingin the community • Social distancing at work and in the community Implementing measures in a uniform way as early as possible during community outbreaks CDC. Interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the United States. 2007 Feb http://www.pandemicflu.gov/plan/community/commitigation.html

  14. Layered Solutions

  15. Potential Secondary Effects of Community Mitigation • Isolation & quarantine • Income & job security • Ability to access support and essential services • Dismissal of children from school & closing childcare • Child minding responsibilities and absenteeism • Educational continuity • School breakfast and lunch programs • Social distancing at work and in communities • Business continuity and sustaining essential services

  16. Public & Stakeholder Engagement on Community Mitigation • Acceptability of interventions assessed in public and stakeholder meetings • Concern expressed on the ability to apply and effectiveness of interventions • In a severe pandemic, where a high mortality rate is anticipated, participants were willing to “risk” undertaking interventions of unclear effectiveness to mitigate disease & death • Planners should work to reduce secondary adverse effects of intervention

  17. Stay at home for 7 -10 days if sick 94% All members of HH stay at home for 85% 7 -10 days if one member of HH sick Could arrange care for children if 93% schools/daycare closed 1 month Could arrange care for children if 86% schools/daycare closed 3 months Keep children from gathering outside 85% home while schools closed for 3 months Would avoid mass gatherings for 1 month 79 – 93% Willingness to Follow Recommendations Poll results from representative national sample of 1,697 adults conducted in September-October, 2006 Blendon, Emerg Inf Dis 2008

  18. U.S. Pandemic Severity Index 1918 1957, 1968

  19. Community Mitigation by PSI

  20. Community Mitigation by PSI

  21. CDC’s Proposed Pandemic Intervals

  22. Caregiving for Ill Persons % saying they have no one to take care of them at home if they were sick for 7-10 days Blendon, Emerg Inf Dis 2008

  23. Caregiving for Ill Persons % saying they have no one to take care of them at home if they were sick for 7-10 days Blendon, Emerg Inf Dis 2008

  24. Planning to Address Needs of At-risk Populations • Guidance for health depts. andcommunity-based organizations • Identifying at risk populations • Collaboration and engagement inplanning for a pandemic • Communications and education • Existing activities and best practices – links to materials • Recommendations for planning • Guidance on vaccine prioritization targets community support service providers

  25. Examples of Community Planning • New Jersey • Special Needs Advisory Panel – representatives of 30 organizations – advises the Office of Emergency Management • Identifies critical issues affecting at risk populations • Educates emergency management personnel • Makes recommendations for planning and liaison with community groups • Drafts proposed legislation • Mississippi – 4 rural counties • Developed operations plan creating neighborhood networks • Local fire departments and churches monitor neighborhoods to identify and assist at risk populations http://www.astho.org/pubs/ASTHO_ARPP_Guidance_June3008.pdf

  26. Dismissing Children from Schools: Child Minding Needs If recommended by health officials, could keep children from going to public events and gathering outside home while schools closed for 3 months Would need help with problems of having children at home Only a little/None A lot/some Among those who would need a lot or some help, would rely most on… Family Friends Outside agencies Blendon, Emerg Inf Dis 2008

  27. U.S. Household Survey Data, 2006 45 million 31 million 7 million 33 million Source: Department of Labor, Office of the Assistant Secretary for Policy calculations from Current Population Survey microdata.

  28. Absenteeism Related to Child Minding:Impact of Age Threshold Age Threshold 18 15 14 13 Source: Department of Labor, Office of the Assistant Secretary for Policy calculations from Current Population Survey microdata.

  29. Household Response to School Closure during a Seasonal Influenza Outbreak • Influenza B outbreak in Yancey County, NC • Schools closed. Nov 2 to 12 • Parents surveyed on child minding and absenteeism • Results • In 54% of households, all adults worked • 18% had occupations allowing them to work from home • 24% of adults missed >1 day of work; of these only 18% missed work because of school closure • 76% of parents had existing childcare arrangements • 10% made arrangements with family or friends • 91% agreed with the decision to close schools Johnson, Emerg Inf Dis 2008

  30. Business Planning to Maintain Essential Services and Support Employees • Reduce absenteeism • Implement measures toprotect workers • Support planning forchild minding • Plan to maintainessential functions • Teleworking, cross-training for essential functions • Support employee families • Modify leave policies for a pandemic & other emergencies

  31. Global Issues in Implementation of NPIs • Community strategies may be especially important in settings where vaccine and antiviral drugs are not initially available • Evidence base for community measures in developing countries is limited • Strategies are based on influenza transmission • Relative importance of different measures may differ from industrialized countries • Secondary (adverse) impacts also may differ • Ethical and societal considerations • Balance pandemic response with rights and values • Recognize other threats to health

  32. Community Mitigation Strategies: International Pandemic Planning Issues Socio-cultural attitudes (individualism vs. community) Health care delivery systems Socio-economic structure and workforce Housing structure and density Urban vs. rural populations Access to sustainable nutrition and clean water Sanitation and hygiene Educational infrastructure Legal authorities, enforcement & ethical construct Political / Governmental framework

  33. Asia Pacific Economic Cooperation (APEC) Business Planning • Focus on business continuity, worker protection, and family/ community preparedness • Planning materials and strategies for business outreach being developed

  34. Conclusions: Planning and Implementing Community Mitigation • Proposed strategies based on current science • Early implementation of multiple interventions most effective • Duration of implementation important • Match intervention with pandemic severity • Planning requires action of government, private sector, and communities • Plan for second-order effects • Consider at-risk populations

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