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1. alakoff Says:
   April 28th, 2009 at 12:47 pm

   CDC has a guidance document on “non-pharmaceutical interventions” (eg. school closures, banning public gathering, isolating cases) called “Community Strategy for Pandemic Influenza Mitigation in the United States.”

   http://www.pandemicflu.gov/plan/community/commitigation.html

   My understanding this strategy is at least in part based on a study of the comparative efficacy of responses by US cities to the 1918 pandemic conducted by Howard Markel and colleagues. Just looking at it quickly, the document emphasizes the importance of engaging in these interventions *early.* One would guess that public health departments are now on either “alert” or “standby”.

   Here is the section from the document on “triggers”:

   VI. Triggers for Initiating Use of Nonpharmaceutical Interventions

   The timing of initiation of various NPIs will influence their effectiveness. Implementing these measures prior to the pandemic may result in economic and social hardship without public health benefit and may result in compliance fatigue. Conversely, implementing these interventions after extensive spread of a pandemic influenza strain may limit the public health benefits of an early, targeted, and layered mitigation strategy. Identifying the optimal time for initiation of these interventions will be challenging, as implementation likely needs to be early enough to preclude the initial steep upslope in case numbers and long enough to cover the peak of the anticipated epidemic curve while avoiding intervention fatigue. In this document, the use of these measures is aligned with declaration by WHO of having entered the Pandemic Period Phase 6 and a U.S. Government declaration of Stage 3, 4, or 5.

   Case fatality ratio and excess mortality rates may be used as a measure of the potential severity of a pandemic and, thus, suggest the appropriate nonpharmaceutical tools; however, mortality estimates alone are not suitable trigger points for action. This guidance suggests the primary activation trigger for initiating interventions be the arrival and transmission of pandemic virus. This trigger is best defined by a laboratory-confirmed cluster of infection with a novel influenza virus and evidence of community transmission (i.e., epidemiologically linked cases from more than one household). Other factors that will inform decision-making by public health officials include the average number of new infections that a typical infectious person will produce during the course of his/her infection (R0) and the illness rate. For the recommendations in this interim guidance, trigger points for action assume an R0 of 1.5-2.0 and an illness rate of 20 percent for adults and 40 percent for children. In this context, in all categories of pandemic severity, it is recommended that State health authorities activate appropriate interventions (as described in Table 2) when a laboratory-confirmed human pandemic influenza case cluster is reported in their State or region (as appropriate) and there is evidence of community transmission.

   Defining the proper geospatial-temporal boundary for this cluster is complex and should recognize that our connectedness as communities goes beyond spatial proximity and includes ease, speed, and volume of travel between geopolitical jurisdictions (e.g., despite the physical distance, Hong Kong, London, and New York City may be more epidemiologically linked to each other than they are to their proximate rural provinces/areas). In this document in order to balance connectedness and the optimal timing referenced above, it is proposed that the geopolitical trigger be defined as the cluster of cases occurring within a U.S. State or proximate epidemiological region (e.g., a metropolitan area that spans more than one State’s boundary). It is acknowledged this definition of region is open to interpretation; however, it offers flexibility to State and local decision-makers while underscoring the need for regional coordination in pre-pandemic planning.

   From a pre-pandemic planning perspective, the steps between recognition of pandemic threat and the decision to activate a response are critical to successful implementation. Thus, a key component is the development of scenario-specific contingency plans for pandemic response that identify key personnel, critical resources, and processes. To emphasize the importance of this concept, this guidance section on triggers introduces the terminology of Alert, Standby, and Activate, which reflect key steps in escalation of response action. Alert includes notification of critical systems and personnel of their impending activation, Standby includes initiation of decision-making processes for imminent activation, including mobilization of resources and personnel, and Activate refers to implementation of the specified pandemic mitigation measures. Pre-pandemic planning for use of these interventions should be directed to lessening the transition time between Alert, Standby, and Activate. The speed of transmission may drive the amount of time decision-makers are allotted in each mode, as does the amount of time it takes to truly implement the intervention once a decision is made to activate.

   These triggers for implementation of NPIs will be most useful early in a pandemic and are summarized in Table 3. This table provides recommendations arrayed by Pandemic Severity Index and U.S. Government Stage for step-wise escalation of action from Alert, to Standby, to Activate.

   For the most severe pandemics (Categories 4 and 5), Alert is implemented during WHO Phase 5/U.S. Government Stage 2 (confirmed human outbreak overseas), and Standby is initiated during WHO Phase 6/U.S. Government Stage 3 (widespread human outbreaks in multiple locations overseas). Standby is maintained through Stage 4 (first human case in North America), with the exception of the State or region in which a laboratory-confirmed human pandemic influenza case cluster with evidence of community transmission is identified. The recommendation for that State or region is to Activate the appropriate NPIs as defined in Table 2 when identification of a cluster and community transmission is made. Other States or regions Activate appropriate interventions when they identify laboratory-confirmed human pandemic influenza case clusters with evidence of community transmission in their jurisdictions.

   For Category 1, 2, and 3 pandemics, Alert is declared during U.S. Government Stage 3, with step-wise progression by States and regions to Standby based on U.S. Government declaration of Stage 4 and the identification of the first human pandemic influenza case(s) in the United States. Progression to Activate by a given State or region occurs when that State or region identifies a laboratory-confirmed human pandemic influenza case cluster with evidence of community transmission.

   Determining the likely time frames for progression through Alert, Standby, and Activate postures is difficult. Predicting this progression would involve knowing 1) the speed at which the pandemic is progressing and 2) the segments of the population most likely to have severe illness. These two factors are dependent on a complex interaction of multiple factors, including but not limited to the novelty of the virus, efficiency of transmission, seasonal effects, and the use of countermeasures. Thus it is not possible to use these two factors to forecast progression prior to recognition and characterization of a pandemic outbreak, and predictions within the context of an initial outbreak investigation are subject to significant limitations. Therefore, from a pre-pandemic planning perspective and given the potential for exponential spread of pandemic disease, it is prudent to plan for a process of rapid implementation of the recommended measures.

   Once the pandemic strain is established in the United States, it may not be necessary for States to wait for documented pandemic strain infections in their jurisdictions to guide their implementation of interventions, especially for a strain that is associated with a high case fatality ratio or excess mortality rate. When a pandemic has demonstrated spread to several regions within the United States, less direct measures of influenza circulation (e.g., increases in influenza-like illness, hospitalization rates, or other locally available data demonstrating an increase above expected rates of respiratory illness) may be used to trigger implementation; however, such indirect measures may play a more prominent role in pandemics within the lower Pandemic Severity Index categories.

   Once WHO has declared that the world has entered Pandemic Phase 5 (substantial pandemic risk), CDC will frequently provide guidance on the Pandemic Severity Index. These assessments of pandemic severity will be based on the most recent data available, whether obtained from the United States or from other countries, and may use case fatality ratio data, excess mortality data, or other data, whether available from outbreak investigations or from existing surveillance.

2. alakoff Says:
   April 28th, 2009 at 12:58 pm

   A quick follow-up: so the “trigger” points are based on a combination of three numerical indicators: WHO pandemic phase (the 1 – 6 scale we’ve been following); US government Stage (I don’t know where this is now); and Pandemic Severity Index (categories 1 – 5; as soon as Phase 5 is declared – which may happen shortly – CDC provides guidance on PSI).

3. scollier Says:
   April 28th, 2009 at 1:04 pm

   There is quite a bit of wiggle room in there as to how drastically one acts when. If you expect that there will be flu deaths, can you justify not taking more aggressive measures?

   CDC Chief Expects More U.S. Swine Flu Cases, Deaths (Update2)
   Share | Email | Print | A A A

   By Alex Nussbaum and Peter Cook

   April 28 (Bloomberg) — Swine flu will kill people in the U.S., and businesses and citizens should plan in case the outbreak worsens, the acting head of the Centers for Disease Control and Prevention said.

   It’s too soon to say whether the virus will spark a pandemic, a global outbreak that spreads easily and causes serious illness, Richard Besser, the Atlanta-based agency’s acting head, said in an interview today. Businesses should review plans and be ready to act, he said.

   The CDC today raised the number of confirmed cases in the U.S. to 64, with 45 of them in New York. No deaths have been confirmed in the U.S. That will change, Besser said.

   “Given the situation in Mexico, where they’re seeing much more severe disease, I would expect that as we continue to look we’re going to find hospitalized individuals and, unfortunately, I expect that we will see deaths in this country,” Besser said.

4. alakoff Says:
   April 28th, 2009 at 1:10 pm

   This seems like a kind of strange thing to say at this stage, no? Does he know something we don’t? Note Besser’s bio: “He began his career at CDC in the Epidemic Intelligence Service working on the epidemiology of food–borne diseases.”

5. scollier Says:
   April 28th, 2009 at 1:25 pm

   Pretty strange to me, yes. My question is: how can you say that and not order more aggressive measures?

6. scollier Says:
   April 28th, 2009 at 1:26 pm

   Ie, “People are probably going to die. But we have done a cost-benefit analysis and determined that it is not worthwhile to close schools…” etc.

7. tmacphail Says:
   April 28th, 2009 at 1:33 pm

   I’ve been following this from a variety of sources – both public and in relation to the project I’m working on here at Berkeley in epi/public health. Margaret Chan has announced to the WHO and its affiliates that containment (and thus, detailed contact tracing and quarantine) is no longer feasible; all efforts should be directed toward “mitigation measures”.

   I do know that the CDC and the WHO have been battling it out on this one – with the WHO initially wanting to raise the alert level and the CDC maintaining that there is no real trouble since little is known about the virus strain at this point and deaths are concentrated only in Mexico. The CDC had been arguing that since cases were mild, there was no need for an all-out response. Obviously, all that changed this morning, but I find the tension between levels and institutions both interesting and troubling.

8. scollier Says:
   April 28th, 2009 at 1:46 pm

   Troubling indeed. I am curious about the phrase “abundance of caution” — which is being repeated constantly. It isn’t clear that what is going on in the US now is evidence of an “abundance of caution”….

9. mstalcup Says:
   April 28th, 2009 at 4:37 pm

   Governor Schwarzenegger declared that California is now in a a state of emergency (http://gov.ca.gov/press-release/12149). In relation to Stephen’s question- what are public health officials actually spending their time doing? – although not really answering it, the release states that the government of California has been “deploying public health experts across the state, increasing surveillance of patients with flu-like illness and activating the joint emergency operations center and health alert network.” Today’s proclamation is basically intended to make it possible to give flu-related activities priority. Given the reality of finite resources, that does seem significant. Personnel, equipment and facilities will go to this, instead of something else.

   “This proclamation cuts government red tape by:

   * Ordering all state agencies and departments to utilize and employ state personnel, equipment and facilities to assist the Department of Public Health (DPH) and the State Emergency Plan as coordinated by the California Emergency Management Agency

   * Ordering DPH and the Emergency Medical Services Authority to enter into any and all necessary contracts for providing services, materials, personnel and equipment to supplement extraordinary preventive measures being taken across the state

   * Suspending non-competitive bid contracts for services, material, personnel and equipment needed to respond to this outbreak

   * Waiving select certification requirements for public health laboratories to help in the state’s expansion of our testing capabilities”

   On to what the public is urged to do:

   “*Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
   * Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
   * Try to avoid close contact with sick people.
   * If you get sick with flu, it is recommended that you stay home from work or school and limit contact with others to keep from infecting them. Avoid touching your eyes, nose or mouth. Germs spread this way.”

   So on the level of the individual, not “an abundance of caution” but the advice to take basic precautions, for a cold or flu. On the level of the state, yes, maybe. Actions have been authorized, for when they need to be taken. There’s also something interesting in the “waiving select certification requirements for public health laboratories to help in the state’s expansion of our testing capabilities”. California can now confirm swine flu without the CDC. One, it is an act of faith in the state’s public health laboratories. Two, does it signal a lack of faith in the federal response?

10. Dale A. Rose Says:
    April 28th, 2009 at 5:12 pm

    Outbreaks are currently focal in the US, meaning largely localized by geography, e.g., five states for two days now. Moreover, “community” spread of illness is largely proscribed – although this can certainly change on a dime. Therefore, mitigation measures are being implemented in a tiered manner according to the level of “involvement” of a given state. Should Idaho close its schools because of what’s happening in NYC? Which NYC public schools should close? All of them? Affected ones? Adjacent cities or states?

    The CDC is issuing massive amounts of interim guidance to states (and communities, and vulnerable populations, and occupational groups, and… etc etc) on the basis of what it knows *now* and what it can reasonably predict *now.* It can, apparently, reasonably predict deaths from this, just as it can for any seasonal flu (so why has that become so remarkable in this context?). But if the CFR is exceedingly low – i.e., virulence is mild – then what additional aggressive measures would one suggest? I’d say releasing one quarter of the SNS seems like it is an attempt to align itself to known information, including info about severity, today. Where should the other three-quarters go? On top of all this: Public health has a perennial problem with risk communication, insofar as messaging can sound either trite or overblown. Because of the uneven spread of illness, coupled with – at the moment – a fairly low PSI score, it is therefore a tricky proposition to communicate targeted behavior modification or policy prescription messages to specific locales or jurisdictions. Other jurisdictions might just do the same thing needlessly. Thus the seemingly odd balance between universal precautionary measures for individuals (shown to reduce community transmission) and judicious messaging in other respects.

    On the question of what public health folks are doing, everyone here has really answered the question already. I’ll just say that, at the very least, this is what’s going on: (1) Increased epi and contact tracing as appropriate; (2) extensive active surveillance throughout the healthcare system; (3) laboratory ramp up; (4) receipt of SNS stockpiles; (5) planning for mass meds distribution; (6) regional, state, federal collaboration/planning, conference calls, etc.

    As everything here is all my personal opinion, I’ll just take this moment to say I’m glad the US now has a Secretary of Health and Human Services.

11. alakoff Says:
    April 28th, 2009 at 5:50 pm

    Dale – thanks, this is extremely helpful. A question: do you have any idea how PSI is being evaluated?

12. Dale A. Rose Says:
    April 28th, 2009 at 6:54 pm

    Directly correlated to the CFR, is my understanding, which in the US is presumably zero as of today. Developed and published as part of interim community mitigation guidance for pre-pandemic stage. CDC acknowledged the challenge associated with prior categorization schemes, including PSI, for present circumstances, in updated guidance released today. See: http://cdc.gov/swineflu/mitigation.htm for relevant para as well as specific recommendations for communities with a lab-confirmed case.

13. Carlo Caduff Says:
    April 29th, 2009 at 2:01 am

    Theresa and Dale, thanks, this is very helpful. I have a question regarding the CDC. Obviously, it is a complex institution with a complex power structure and I was wondering if there have been some tensions between the health/influenza people, i.e. Cox and her team and the security/preparedness people.

    One of the problems lies with the WHO alert scheme. On the basis of the definitions of the different phases, we are clearly in phase 5. However, given the relative slow but steady spread of a relatively mild disease, the type of interventions prescribed by phase 5 seem over the top. So there is a problem here, which is an effect of anticipatory planning itself.

    Finally, there is not much you can do anyway, except producing a protective vaccine, caring for the sick, and trying to avoid contact with other people. The rest is largely and almost entirely political.

    As you know, the impact of currently available forms of intervention on the pathological effects of regular seasonal influenza are very limited.

14. Carlo Caduff Says:
    April 29th, 2009 at 2:05 am

    Just one more thing. Every single year, 36 000 people die in the United States due to regular seasonal flu. That’s considered normal.

15. scollier Says:
    April 29th, 2009 at 3:56 am

    Carlo — The issue you point to about the bad fit with the stages indicated in the classificatory system is exactly the problem I had in mind. It is obvious that we are stage 5, and yet health authorities do not yet want to do what is implied by stage 5.

    I am also very interested in the other issue you hint at: much of what is being done is meaningless, and the things that could really make a difference are not being done. The New York Times ran a story today which reports that ten countries have now banned pork imports from affected countries, despite the fact that WHO and CDC say that it is impossible for the virus to be transmitted to someone consuming pork. I suppose it simply must just be politics. And good for the domestic pork industry.

    On the other hand — back to my old example — they aren’t closing schools in New York. This seems to me like a basic precautionary measure, though I guess it is potentially very disruptive.

16. Carlo Caduff Says:
    April 29th, 2009 at 5:08 am

    Yes, the banning of pork is totally meaningless from a scientific point of view. There are now efforts to re-name “swine flu.” Some now call it the “Mexican flu,” others the “North-American flu,” and – beyond the emerging geography of blame – and definitely my favourite: the “new flu!”

    The closing of schools in the case of a pandemic has been discussed extensively in the public health community in the past few years. It’s a very disruptive kind of intervention. Not many working parents can look after their kids over several weeks. Also, a lot of these kids are getting their daily meals in their schools. So that creates a whole range of new problems. As long as we don’t see a lot of people dying in the US, I don’t think the experts are going to recommend the closing of schools.

17. Carlo Caduff Says:
    April 29th, 2009 at 5:10 am

    By the way, it has not even been proved that this strain is actually circulating in swine today. It’s just that some (but not all) genetic sequences are very similar to sequences currently found in swine flu viruses.

18. Carlo Says:
    April 30th, 2009 at 9:44 am

    Here is a quote from Peter Palese from Mount Sinai School of Medicine: “If this virus keeps going through the summer, I would be very concerned.”

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