The Role of CommunityWide Mitigation Strategies in Pandemic Planning

1
The Role of Community-Wide Mitigation Strategies
in Pandemic Planning
Education Association Outreach Meetings 21
September 2006

• Marty Cetron, MD
• Centers for Disease Control
• Carter Mecher, MD
• U.S. Department of Veterans Affairs

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Update

• Insert current map of H5N1 outbreaks or current
  WHO statistics

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(No Transcript)
4
A 1918-Like Pandemic Would Take a Significant
Toll Today

• Congressional Budget Office estimates 4.75
  reduction in U.S. GDP, not including years of
  productivity lost

5
Implementation Plan for the National Strategy

• Strategy released on Nov 1, 2005
• Plan released on May 3, 2006
• Contains over 300 actions for Federal Departments
  and Agencies
• Provides guidance on implementation of the
  Strategy, the development of Department plans,
  and outlines specific roles and responsibilities
  of Departments and Agencies in pandemic
  preparedness and response
• Communicates expectations of non-Federal entities
  (State and local governments, private sector,
  critical infrastructure entities, individuals)

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Vaccine Production AfterA Pandemic Begins
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Potential Tools in Our Toolbox

• Our best countermeasure vaccine will probably
  be unavailable during the first wave of a
  pandemic
• Antiviral treatment may improve outcomes but will
  have only modest effects on transmission
• Antiviral prophylaxis will have more substantial
  effects on reducing transmission
• Infection control and social distancing should
  reduce transmission, but strategy requires
  clarification

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Questions

• During a severe pandemic, how can communities use
  the resources at their disposal to limit illness,
  hospitalization and death?
• Based upon the available evidence, what planning
  should be done now?

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Community-Based Interventions
1. Delay outbreak peak 2. Decompress peak
burden on hospitals / infrastructure 3. Diminish
overall cases and health impacts
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Liberty Loan Parade - Philadelphia September 28,
1918
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Cumulative Excess Mortality by Location
McLaughlin AJ. Epidemiology and Etiology of
Influenza. Boston Medical and Surgical Journal,
July 1920.
12
Weekly mortality data provided by Marc Lipsitch
(personal communication)
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What do the Modeling Results Mean?

• Not Proof of efficacy or effectiveness, BUT offer
  reason for optimism re NPIs
• Suggest that maximal effectiveness will be
  achieved by appropriate layering and timing
• Need to be evaluated based upon assumptions and
  validated against experience

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A Targeted and Layered Approach
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Modeling Suggests that Community Actions May
Significantly Reduce Illness and Death Before
Vaccine is Available

• Early and Uniform Implementation of
• Closing schools
• Keeping kids and teens at home
• Social distancing at work and in the community
• Encouraging voluntary home isolation by ill
  individuals and voluntary home quarantine by the
  household contacts
• Implementing measures early and in a coordinated
  way
• Treating the ill and providing targeted antiviral
  prophylaxis to household contacts enhances the
  effect

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A Layered Approach
Individual / Household Hand hygiene Cough
etiquette Infection control Living space
control Isolation of ill Designated care
provider Facemasks
Community Isolation of ill Treatment of
ill Quarantine of exposed Prophylaxis of
exposed School closure Protective sequestration
of children Social distancing - Community -
Workplace Liberal leave policies
International Containment-at-source Support
efforts to reduce transmission Travel
advisories Layered screening of travelers Health
advisories Limited points of entry
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Epidemiology Drives Approach
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Community Mitigation Strategies Carry
Consequences That Should Be Anticipated and
Incorporated into Pandemic Planning

• Economic impact and potential disruption of
  services due to absenteeism
• Issues associated with sequestration of children
• Home-based care
• Disproportionate impact on certain populations
• Administration of antiviral medications
• As treatment without rapid diagnostics
• As prophylaxis to household contacts of ill
  persons
• These and other consequences may occur in the
  absence of community-wide interventions, as a
  result of spontaneous action by the public.

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Workplace / Classroom Social Density
Residences
Offices
Hospitals
7.8 feet
Elementary Schools
16.2 feet
11.7 feet
3.9 feet
http//buildingsdatabook.eren.doe.gov/docs/7.4.4.x
ls
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Spacing of people If homes were like schools
Based on avg. 2,600 sq. ft. per single family
home
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Spacing of people If homes were like schools
Based on avg. 2,600 sq. ft. per single family
home
22
Households in the United States
37 million
28 million
28 million
12 million
Source U.S. Census Bureau, Population Division,
Current Population Survey, 2003 Annual Social and
Economic Supplement http//www.census.gov/populati
on/www/socdemo/hh-fam/cps2003.html
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Labor Status of Parents
66 million
18 million
5 million
9 million
8 million
Source U.S. Census Bureau, Population Division,
Current Population Survey, 2003 Annual Social and
Economic Supplement http//www.census.gov/populati
on/www/socdemo/hh-fam/cps2003.html
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Consultation and Analysis Before Policy Decision
and Guidance
Current Activities
December 2006

• Outreach to Key Stakeholders
• Scientific Community
• Private Sector
• Education
• Faith Based and Community Based Organizations
• The Public
• State and Local Elected Officials
• Community-based table-top exercises
• Policy Analysis
• Feasibility
• Necessary Authorities/Legislation
• Economic Impacts
• Impact on Underserved Communities
• Communication Strategy
• Alignment of Incentives
• Community-based table-top exercises

• Community Guidance Developed, Informed By
• Institute of Medicine Workshop and Letter Report
• Inputs from the Private Sector, Education, Faith
  Community Based Organizations and State Local
  Officials
• Comprehensive Policy Analysis

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What Can Be Done Now?

• Education of leadership in State and local
  government about the need for cross-sectoral
  planning
• Engagement of non-health communities education,
  private sector, labor, NGOs
• Examination of relevant authorities, and
  scenario-based discussions of implementation

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Leadership
Closing Thoughts
Empowerment
Resilience
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Acknowledgements

• Carter Mecher (VA)
• Rajeev Venkayya (HSC)
• Richard Hatchett (NIH)
• Camille Welborn (DoEd)
• CDC
• Tony Marfin
• David Bell
• Rachel Eidex
• Martin Meltzer
• Lisa Koonin

• Midas Network (NIH)
• Ira Longini et. al. (UW)
• Neil Ferguson et. al. (Imperial College)
• Don Burke et. al. (JHU)
• Tim Germanm et. al. (Los Alamos)
• Marc Lipsitch (Harvard)
• Howard Markel et. al.(UMI)
• SARS
• Singapore MOH
• Beijing MOH
• Taiwan MOH
• Hong Kong MOH
• Robert Blendon et. al.