1. 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

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. Goals of Community Mitigation1
Delay outbreak peak
Decompress peak burden on hospitals/infrastructure
Pandemic Outbreak:
No Intervention 2
Diminish overall cases and health impacts 3
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
Public health response time
Outcome
Early (<7 d)
Late (>7 d)
P-value
Time to peak
18 d
11 d
<0.001
Magnitude of peak (weekly EDR)
67.6
125.8
Excess P & I mortality (total EDR)
451.2
580.3
Total days of NPIs
Longer (>65 d)
Shorter (<65 d)
559.3
Markel, JAMA 2007

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

9. Public Health Response Time by Mortality Burden
Spearman’s r = p =
Markel, JAMA 2007

10. 1918 Outcomes by City City First Cases Death Rate Boston 8/27/18 5.7
Philadelphia
By 9/11/18
7.4
New Haven
Week of 9/11/18
5.1
Chicago
9/11/18
3.5
New York
Before 9/15/18
4.1
Pittsburgh
Mid-9/18
6.3
Baltimore
9/17/18
6.4
San Francisco
9/24/18
4.7
Los Angeles
“Last days 9/18”
3.3
Milwaukee
9/26/18
1.8
Minneapolis
9/27/18
St. Louis
Before 10/3/18
2.2
Toledo
“First week 10/18”
2.0
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 *
This is death curve—deaths is thing that we know for certain. What we know median time to death is 9 deaths, 24 hrs to 3weeks death curve lags case curve about 9 days so this is back extrapolation from death to incidence the second line
* 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 sick person to stay home (voluntary quarantine)
Dismissing children from schools and closing childcare and keeping kids and teens from re-congregating and mixing in 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 Feb

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. Willingness to Follow Recommendations
Poll results from representative national sample of 1,697 adults
conducted in September-October, 2006
Stay at home for days if sick 94%
All members of HH stay at home for 85% 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 – 93%
Avoid church services 82%
Postpone family events 79%
Blendon, Emerg Inf Dis 2008

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

19. Community Mitigation by PSI
Interventions by Setting
Pandemic Severity Index 1
2 and 3
4 and 5
Home
Voluntary isolation
Recommend
Voluntary quarantine
Generally not recommend
Consider
School
Dismissal of students from schools and closure of child care programs
Consider:
≤ 4 weeks
Recommend:
≤ 12 weeks
Reduce out-of-school contacts and community mixing

20. Community Mitigation by PSI
Interventions by Setting
Pandemic Severity Index 1
2 and 3
4 and 5
Workplace/Community
Adult social distancing
Decrease number of social contacts (e.g., encourage teleconferences, alternatives to face-to-face meetings)
Generally not recommend
Consider
Recommend
Increase distance between persons (e.g., reduce density in public transit, workplace)
Modify, postpone, or cancel selected public gatherings to promote social distance (e.g., stadium events, theater performances)
Modify workplace schedules and practices (e.g., telework, staggered shifts)

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. and community-based organizations
Identifying at risk populations
Collaboration and engagement in planning 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

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
A lot/some
Only a little/None
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
12 million single parent households
28 million couple households with children
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
Households with children and no non-working adults (millions)
Children <18
Only Children <15
Only Children <14
Only Children <13
Single adult in HH
5.1
3.5
3.2
2.8
Two adults
14.3
10.6
9.6
8.7
Multiple adults
2.5
1.3
1.1
0.9
Total
22.0
15.4
13.8
12.4
%Absenteeism
16%
11%
10% 9%
Age Threshold
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 to protect workers
Support planning for child minding
Plan to maintain essential 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
Public engagement both from community representatives and what we are actually talking about, for how long, and why