Experts give qualified praise to new pandemic guidance

Feb 2, 2007 (CIDRAP News) – New federal recommendations on nonpharmaceutical measures communities can use to fight an influenza pandemic are drawing generally high marks from public health officials and others, but they say the plan spells a massive workload for local planners.

Yesterday the Centers for Disease Control and Prevention (CDC) released guidance about community measures such as isolating patients, closing schools, canceling public gatherings, and changing work schedules. The steps were tied to a new, five-level Pandemic Severity Index (PSI), with the more disruptive measures reserved for moderate or severe pandemics.

The CDC recommendations "will buy us time if they're implemented uniformly across the US," Dr. Poki Namkung, president of the National Association of City and County Health Officials (NACCHO), told CIDRAP News today. "They really are the only thing we can do, those tried-and-true public health measures that worked in 1918 and hopefully will work again."

The community measures will pose "extraordinary challenges because they will totally alter people's lives, and no one in the United States has lived with those kinds of changes for nearly a century now," added Namkung, who is health officer for Santa Cruz County in California.

She said implementing the steps will be difficult because people may not understand the need. "If people do understand and agree with their necessity, then we stand a chance of actually being successful in lowering the number of people affected and the death rate."

Jeffrey Duchin, MD, chief of communicable disease control for Seattle King County Public Health in Washington, praised the new guidance, while stressing that it means a lot of work not only for local public health but also for businesses, local organizations, families, and individuals.

"This is a big improvement over the previous guidance," said Duchin, who represented NACCHO and the Infectious Diseases Society of America on a work group that advised the CDC on the project. "It includes many of the criteria that we asked for at the IOM [Institute of Medicine] meeting in December."

The work group asked the CDC to spell out the rationale and evidence for the guidance along with the limitations of the data, and to offer recommendations flexible and specific enough to be useful at the local level, Duchin reported.

"I would give passing marks on all those fronts," he said. "I don't think it's definitive but I think it's a tremendous improvement."

But implementing the guidance, which includes voluntary quarantine of people in flu patients' households in a severe pandemic, will cause tremendous dislocations, including high levels of work absenteeism, Duchin added. Consequently, careful planning is needed.

"A huge amount of work needs to be done to survive the guidance, basically," he said. "I think this is necessary advice. But this is not a cakewalk. It's going to cause hardship, so people need to look at this guidance now and start planning for how they can do this."

In particular, the measures will require a lot of local preparation for supporting vulnerable populations, including low-income people and non-English speakers, Duchin said. He added that business people, government agencies, schools, faith-based organizations, and individuals should know the implications of the measures.

Jeff Levi, PhD, executive director of Trust for America's Health, a public health advocacy group, offered a similar message in a news release yesterday. He said the new document should launch "an important national conversation about how to better prepare the country for a possible outbreak."

Levi said the document raises "important practical and policy issues." Examples include how to provide sick leave for patients and family leave for caregivers, how to deliver food and medicine to people in quarantine, and, in the case of school closings, how to care for children and feed those who depend on school meal programs.

Also offering qualified praise for the CDC report was an expert on the 1918 flu pandemic: John M. Barry, author of the 2004 book The Great Influenza.

"My gut instinct is that a lot of these interventions will have some positive impact," Barry told CIDRAP News. "But I'd feel a lot more comfortable with a lot more research [supporting them]."

He added that personal hygiene measures such as "cough etiquette," handwashing, and not shaking hands may have at least as much impact as community measures. "These things were mentioned but not emphasized," he said.

The CDC has cited research indicating that in 1918, communities that took preventive measures early fared better than those that didn't. Barry has suggested an alternative explanation: that some cities fared better in the fall of 1918, the second wave of the pandemic, because they had been struck by the milder first wave in the spring, leaving people with some immunity.

"Another alternative explanation [for some cities doing better than others] is that the virus was gradually losing virulence," Barry said today. He said most of the cities that seemed to use community interventions effectively were hit by the virus a little later than others.

Barry said he has urged the CDC to consider the effect of the pandemic waves in studying the effects of community interventions in 1918, but the agency hasn't done so yet.

Michael T. Osterholm, PhD, MPH, praised the CDC for devising a simple, clear approach to an extremely difficult public health problem.

"Now how do we take it to the next level? This is a work in progress and process," said Osterholm, director of the University of Minnesota Center for infectious Disease Research and Policy, publisher of the CIDRAP Web site. The onus is now on states and cities, which must take the plan and assess how they would make it work in their localities, he said.

Osterholm says he's not worried that officials would be reluctant to close schools in the event of an influenza pandemic, because parents will probably force the issue by keeping children home. But when to reopen schools may be a tricky question, he said. "How do you unring the bell? How do you make the school decisions if there are multiple waves?" he asked.

The community mitigation strategies such as school closures and social distancing for adults will have a big impact on businesses, Osterholm said. He added that it's positive that the CDC guidance does not mention closing borders. Closing borders is unlikely to slow a pandemic, and keeping them open will ease some of the supply-chain concerns that corporations will have, in his view.

Marc Siegel, MD, associate professor of medicine at New York University, said the CDC did a good job of delivering the pandemic planning guidance calmly. Siegel, an internist and author of Bird Flu: Everything You Need to Know About the Next Pandemic, said he worries about the counterproductive effects of fear and panic surrounding a pandemic. "I'm always concerned the worst case scenario is prematurely considered," he said.

Closing schools during a pandemic is backed by good rationale, but closing schools too soon could create undue public fear, said Siegel.

Modeling pandemic severity levels after hurricane classifications is probably useful, he said. "We don't want to sound an alarm too soon," he said. "We need a consistent mode of public response to all disasters."

Rob Fulton, director of St Paul–Ramsey County Public Health in Minnesota, said the CDC guidance is helpful for making decisions about closing schools. Though it's useful to have a five-level severity system, "I think we still have to prepare for a category 5 pandemic," he said.

Closing colleges, discussed in the CDC report, is a problem that continues to vex pandemic planners, Fulton said. Health officials are struggling with questions like how to transport students home, how to quarantine them if needed, and even whether it would be useful, from an infection control perspective, to encourage students to return home, he noted.

See also:

CDC community mitigation guidance document
http://www.pandemicflu.gov/professional/community/community_mitigation.pdf

Feb 1 CIDRAP News story "HHS ties pandemic mitigation advice to severity"

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