Engineering Effective Response to Outbreaks of Influenza AAAS National Meeting, San Jose, California Richard C. Larson Massachusetts Institute of Technology Cambridge, Massachusetts February 13, 2015 Status: MERS Flu H5N1 Flu H9N7 Each a Major Threat to the World And now, Ebola

We Often Plan Based on Past “Anchored Events” 1918 ‘Spanish’ Flu

And, about 60 months ago, we found ourselves living with Novel H1N1 “Swine Flu”

Supported by the CDC, the Sloan Foundation & IBM “Decision-Oriented Analysis of Pandemic Flu Preparedness & Response.” Our focus: Social distancing, hygienic responses and other NPI’s, Non- Pharmaceutical Interventions. Vaccine allocation. Educational outreach.

Our Team Dr. Stan Finkelstein, Co-PI, ESD and Harvard Medical School faculty member. Richard C. Larson, PI, ESD. John M. Barry, Historian James McDevitt, Ph.D., Faculty, Harvard School of Public Health Karima Nigmatulina, OR Ph.D. Student Anna Teytelman, OR Ph.D. student Dr. Sahar Hashmi, MD and ESD Ph.D. student Shiva Prakash, Sloan Masters student Kallie Hedberg, MIT CEE Undergraduate student Julia A. Hopkins, MIT CEE Undergraduate student (now MIT PhD student in environmental science)

SARS, 2003 NPI’s: We Learned from SARS

A simple law----

Flu Fundamentals: R 0 = p  frequency of daily contacts (“lambda”) p=probability of transmitting infection, given contact

Let’s talk about

Let’s talk about p

Let’s talk about The probability distribution whose mean is R 0

Karima Nigmatulina’s Ph.D. Thesis: Modeling and Responding to Pandemic Influenza: Importance of Population Distributional Attributes and Non-Pharmaceutical Interventions

Vaccine distribution --- Large

Vaccine Distribution in the US > 4 weeks after peak between 2 and 4 weeks after peak > 4 weeks before peak 1 week before peak 1 week after peak between 2 and 4 weeks before peak at peak First vaccines delivered with respect to peak of infection The CDC started shipping vaccines in early October 2009 Measure: Number of Weeks Before Peak that Vaccines are Shipped

H1N1 Vaccine Administration # Of States Peaking… Week 39 or earlier Week 40 or earlier Week 41 or earlier Week 42 or earlier Week 43 or earlier Week 44 or earlier Week Ending October 10 Paper published: Vaccine availability in the United States during the 2009 H1N1 outbreak. American Journal of Disaster Medicine.

Typical Example: Indiana Administration of vaccine lags shipment Vaccine effectiveness lags administration  Few are protected in time to affect epidemic

Vaccine Distribution Model Goal: To estimate numbers of flu cases averted by delivery of the vaccine according to reported data. Goal: To estimate the beneficial effects of delivering the vaccine earlier than actual. Key metrics: Numbers of infections averted; number of deaths averted.

Example: Oklahoma

Vaccine Model: Results Effect of single vaccine depends on timing Vaccinating early avoids infection for more than the vaccinated person Needs to be taken into account

Best Paper of the Year Award, Value in Health

Think of Fire Fighting Is it better to pour lots of water on a fire already blazing and out of control? OR To focus the limited water on at-risk structures that are not yet burning, and save them entirely?

Finally, Two More Items:

Article designated for AMA PRA Category 1 Credit™. Physicians and other health professionals earn credit by reading the article in the online issue of DMPHP and taking a quiz online. The CDC is now undertaking a trial implementation of requiring this article and its approach for all CDC employees.

Discussion…

HealthMap tracks Ebola’s footprints online ESD Ph.D. Student -- Maia Majumder african-ebola-outbreak-91014http://healthmap.org/site/diseasedaily/article/estimating-fatality-2014-west- african-ebola-outbreak-91014