By: Eric S. Starbuck, DrPH, MPH
Abstract: Although the risk of onset in the next year, or in the next decade, cannot be quantified, a severe pandemic involving person-to-person transmission of a novel respiratory virus is considered by leading organizations to be a substantial global threat. The ongoing threat posed by the H5N1 and H7N9 avian influenza viruses, and by the MERS coronavirus, should serve to remind us of the continuing importance of pandemic preparedness. In a severe pandemic from a rapidly spreading novel respiratory virus, when all countries and all responding organizations will themselves be struck, most low-resource populations will fail to receive adequate medical supplies, and their health services will be more stressed than they are today. However, these populations could, by employing well-planned, evidence-based measures, reduce disease transmission and care for those not severely ill, without substantial outside resources. Authoritative guidance must be developed, and support provided for country adaptation, planning for rapid roll-out, and testing of these plans.
Source: Adapted from: CDC. Interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the United States—early, targeted, layered use of nonpharmaceutical interventions. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. https://stacks.cdc.gov/view/cdc/11425.
The US CDC recently noted that China is experiencing its largest epidemic to date of human cases of Asian lineage H7N9 avian influenza, bringing the total cumulative number of cases to over 1,300. During the previous four annual epidemics, about 40 percent of people confirmed with H7N9 virus infection died. The CDC also noted that, while the current risk to the public’s health posed by Asian H7N9 virus is low, the pandemic potential of this virus is concerning. Influenza viruses constantly change and it is possible that this virus could gain the ability to spread easily among people, triggering a global pandemic. In fact, of the novel influenza viruses that are of special concern to public health, the Asian lineage H7N9 virus is rated by the CDC as having the greatest potential to cause a pandemic, as well as potentially posing the greatest risk to severely impact public health.(1) The Asian H5N1 avian influenza virus also continues to pose a similar pandemic threat,(2,3) and the MERS coronavirus represents another example of an evolving zoonotic virus which has killed hundreds of humans, and which may further evolve into a highly lethal pandemic virus rapidly spread among humans by respiratory means.(4,5)
In 2014, the US Director of National Intelligence stated to the US Senate Select Committee on Intelligence, that “If H7N9 influenza or any other novel respiratory pathogen that kills or incapacitates more than 1 percent of its victims were to become easily transmissible, the outcome would be among the most disruptive events possible. Uncontrolled, such an outbreak would result in a global pandemic with suffering and death spreading globally in fewer than six months and would persist for approximately two years.”(6) The following year, the UK Cabinet Office noted that pandemic influenza “continues to represent the most significant civil emergency risk” to the United Kingdom, and that the consequences may include “half the UK population potentially being infected, with between 20,000 and 750,000 additional deaths potentially by its end,” with “significant social and economic disruption, significant threats to the continuity of essential services, lower production levels, and shortages and distribution difficulties.” …… “The UK Government plans to maintain a stockpile of antivirals sufficient to treat 50% of the population,” and although arrangements are in place for vaccines to be developed, “delivery of the first batch of vaccine will not take place until four to six months after the pandemic’s start.”(7)
Kamradt-Scott has noted that the focus of governments to protect their populations against the threat of influenza has been to ensure adequate access to supplies of vaccines and antiviral medications.(8) This focus has shaped the global governance structures around pandemic influenza, with collective efforts centered on facilitating virus sharing, maintaining and increasing vaccine production, and ensuring access to pharmaceuticals – responses that remain unattainable for many low- and middle-income countries in the short to medium term. He also noted that this emphasis on pharmacological responses reflects a particular view of biomedicine that pays inadequate attention to the weak capacity of many health systems, and that the intense focus on specific pharmaceutical measures has structured the allocation of billions of dollars in public funding on interventions that debatably benefit a comparatively small proportion of humankind located primarily in high-income countries. In 2008, Oshitani, Kamigaki, and Suzuki noted that since the availability of pharmaceutical interventions in developing countries is less likely, nonpharmaceutical interventions, such as social distancing and personal hygiene, may be the only available interventions.(9) They also noted that WHO had developed several tools, including a checklist for national preparedness. However, these tools described the general approaches to pandemic preparedness and were not specifically designed for countries with limited resources. They noted that more practical tools were needed for developing countries.
In many low-resource populations with which we currently work around the world, health services remain frail, and shortages of skilled health workers, medical supplies, and other resources mean that many mothers and children are not effectively reached with lifesaving services. In a severe pandemic scenario, when all countries around the world and all responding organizations are themselves struck or preparing to be struck, most of these populations will fail to receive adequate medical supplies, and their health services will be more stressed than they are today. However, these populations, and families, could, by following well-directed and evidence-based measures, play an important role in slowing transmission and caring for those not severely ill, without substantial outside resources.(10) Furthermore, most people in these settings do have access to local volunteers, community health workers, radio, or mobile phones, from which they could receive guidance about such measures.
In 2015, Bill Gates warned that “the Ebola epidemic showed me that we are not ready for a serious epidemic, an epidemic that would be more infectious and would spread faster than Ebola did. This is the greatest risk of a huge tragedy. This is the most likely thing by far to kill over 10 million excess people in a year.”(11) He also noted the importance of a “plan for effective public communications, including coordination of the messages conveyed by all the different voices people will hear, from governments, to United Nations agencies, to news media, to bloggers. Digital communication can be used to great advantage, but unless a plan is in place, it will only spread confusion and panic faster.”(12)
Taubenberger and Morens have noted that, in spite of the extraordinary number of global deaths in the 1918 pandemic, most influenza cases (over 95% in most locales in industrialized nations) were mild, and essentially indistinguishable from seasonal influenza today.(13) Thus, even in a severe pandemic, appropriate care for most of those ill may potentially be provided in the home, if families receive appropriate guidance. Home-based care can address hydration, fever, nutrition, safe use of available medications, and when to seek outside help.(14) However, accounts of the 1918 pandemic in Alaska, Connecticut, and Philadelphia include reports of substantial challenges and increased mortality when all caretakers in families were ill at the same time and unable to care for other family members.(15-17) As in 1918, such households will need help from others in the community.
Nonpharmaceutical interventions (NPIs) to reduce influenza transmission at the household level may include keeping a distance from others, washing hands, covering one’s cough, and isolation of the ill.(18) However, experience during the comparatively mild 2009 H1N1 pandemic indicates that communication materials, such as those encouraging the practice of these NPIs, need to be adapted, tested, and approved for local use ahead of time. The absence of standardized, pretested messages was a challenge in 2009.(19) At the community level, NPIs may include dismissal of students from schools and colleges, along with social distancing to reduce out-of-school mixing of children, closure of childcare programs, cancelation of large public gatherings, measures to reduce crowding on public transportation, and alteration of workplace environments and schedules to decrease social density without disrupting essential services.(20) These community-level NPIs go beyond the health sector and may involve legal issues.(21)
These nonpharmaceutical interventions can decrease influenza transmission and illness by reducing contact between infectious and susceptible individuals, thereby reducing the burden on health services and the impact of a pandemic on society. In 1918, with little or no time to prepare, and a lack of expert consensus on what to do, cities in the United States made very different decisions about which NPIs to implement and when to do so. Analyses of data from over 40 of these US cities show statistically significant associations between the early use of multiple NPIs and substantial reductions in peak death rates, and modest reductions in overall death rates.(22-24) There is now a substantial evidence base on NPIs for influenza. The April 2017 US CDC guidance on community mitigation is based on approximately 191 journal articles written in English and published from 1990 through September 2016, including 14 systematic literature reviews and meta-analyses composed of approximately 475 individual studies.(25) Although convincing and consistent evidence of the effectiveness of some individual interventions is limited, intervention studies and mathematical modeling indicate that pandemic mitigation strategies utilizing multiple NPIs can decrease transmission substantially.(26,27) Thus, WHO,(28) the European Center for Disease Prevention and Control (ECDC),(29) the US CDC,(20) and the UK Department of Health (26) all recommend using a combination of these partially effective measures to help mitigate a severe influenza pandemic. The 2007 document on community mitigation from the CDC and fifteen other US federal agencies,(30) and the eight guidance documents on community mitigation for pandemic influenza posted by the US CDC in April 2017,(31) are examples of detailed guidance, with recommended interventions based on the severity of the pandemic wave.
Some measures, such as travel restrictions and quarantine of communities, are not recommended in most situations (28) because of their likely ineffectiveness or substantial negative consequences. However, even appropriate community-level measures may have negative social consequences, such as increased absenteeism from work related to child-minding if schools dismiss students (for as long as six months) and childcare programs close.(32) The feasibility, effectiveness, and negative effects of different NPIs will partly depend on local social and economic conditions. While some measures appropriate for rural districts may not work in densely populated areas, even crowded urban populations would likely benefit from planning to focus on feasible interventions, including selected family-level measures, and to avoid detrimental approaches. Thus, implementing locally appropriate interventions, requiring specific actions by individuals, employers, schools, local government, and civil society organizations, in a timely and coordinated fashion, will require advance planning.
In a severe pandemic scenario, the imperative to respond may lead many communities to attempt mitigation measures without prior planning or expert guidance on the best choice of interventions, how and when to implement them, and how to limit any negative consequences. The effectiveness of these efforts will likely be less – and negative effects greater – than if plans had been made in advance. In a severe pandemic, many communities may also be challenged by contradictory guidance, as in Connecticut in October 1918, when communities received precisely the opposite recommendations from federal and state health officials on closing schools, theaters, and other places of public gathering.(33) Planning for public health measures before pandemic onset may reduce the risk of such contradictory guidance. Thus, we believe in preparing in advance so leaders in low-resource populations, supported by the organizations working with them, can take appropriate actions to mitigate the effects of a severe influenza pandemic in the absence of substantial outside resources.(34) Similar preparedness work may also aid in responding to other kinds of severe outbreaks.(35)
Some of the necessary global guidance has been completed and country-level planning commenced, but much remains to be carried out. The US Agency for International Development supported preparation of detailed guidance for municipalities in Latin America and the Caribbean,(36) while the Humanitarian Pandemic Preparedness (H2P) initiative engaged civil society and United Nations agencies with governments on country and district planning for mitigation measures to be rolled out during the weeks most populations would have before being struck.(37,38) Preparing for rapid roll-out requires advance planning at country level, and testing in selected districts and communities, but may not require advance planning in numerous jurisdictions throughout a country.
In late 2009, WHO issued detailed guidance specific to the ongoing comparatively mild H1N1 pandemic, on reducing influenza transmission in schools (39) and on considerations for mass gatherings.(40) In 2011, WHO published detailed guidance appropriate for low-resource settings in a severe pandemic on home-based care and reducing transmission at household level.(41) In its 2011 Comparative Analysis of National Pandemic Influenza Plans, WHO concluded that NPIs are crucial to an effective overall response and may in some cases be the only means of delaying the spread of a pandemic. Although approximately two-thirds of all national plans had considered NPIs, most plans did not outline practical operational considerations, such as triggers for undertaking and ceasing such measures.(42) One reason for inadequate preparedness for community mitigation may be the continuing lack of detailed authoritative guidance.
A decade ago WHO warned that “all concerned should keep in mind that no health emergency on the scale of a severe influenza pandemic has confronted the international community for several decades.” They also noted that, while “neither the timing nor the severity of the next pandemic can be predicted with any certainty” ……. “the present threat to international public health is sufficiently serious to call for emergency actions calculated to provide the greatest level of protection and preparedness as quickly as possible.”(43) We agree. Detailed authoritative guidance for low-resource settings on NPIs to reduce influenza transmission at community level in a severe pandemic must be developed. In addition, support should be provided to developing countries to adapt this and related guidance (44) to their settings, plan for rapid roll-out, and test these plans. We are concerned about this gap in the most basic kind of preparedness for a severe pandemic.
Acknowledgments: The author thanks Ms. Heike Sommer for her review of the draft and for her valuable suggestions.
Author: Eric Starbuck, DrPH, MPH, is the Advisor for Child Health & Pandemic Preparedness at the Department of Global Health, Save the Children, in Fairfield, Connecticut. Eric has been working on pandemic preparedness since early 2006. He served as Public Health Advisor to the Humanitarian Pandemic Preparedness (H2P) initiative from 2007 through 2010, contributing to several WHO guidance documents. Eric is the lead author of “Are we prepared to help low-resource communities cope with a severe influenza pandemic?” in Influenza and Other Respiratory Viruses, November 2012.
- Asian Lineage Avian Influenza A (H7N9) Virus, US CDC, March 2017 (https://www.cdc.gov/flu/avianflu/h7n9-virus.htm).
- Public Health Threat of Highly Pathogenic Asian Avian Influenza A (H5N1) Virus, US CDC, June 2015, paragraph 2 (https://www.cdc.gov/flu/avianflu/h5n1-virus.htm).
- Warning signals from the volatile world of influenza viruses, WHO, February 2015 (http://www.who.int/influenza/publications/warningsignals201502/en/).
- MERS-CoV Emergency Use Authorizations, U.S. Food & Drug Administration, May 2013 (http://www.phe.gov/emergency/news/healthactions/phe/Pages/mers-cov.aspx).
- Frequently Asked Questions on Middle East Respiratory Syndrome Coronavirus (MERS‐CoV), WHO, July 2015 (http://www.who.int/csr/disease/coronavirus_infections/faq/en/).
- Statement for the Record: Worldwide Threat Assessment of the US Intelligence Community, Senate Select Committee on Intelligence, January 2014, page 12 (http://www.dni.gov/files/documents/Intelligence%20Reports/2014%20WWTA%20%20SFR_SSCI_29_Jan.pdf).
- National Risk Register of Civil Emergencies, UK Cabinet Office, March 2015 (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419549/20150331_2015-NRR-WA_Final.pdf).
- Kamradt-Scott, A. Evidence-based medicine and the governance of pandemic influenza. Global Public Health, 2012;7:sup2, S111-S126 (https://www.researchgate.net/publication/231817075_Evidence-based_medicine_and_the_governance_of_pandemic_influenza).
- Oshitani H, Kamigaki T, Suzuki A. Major issues and challenges of influenza pandemic preparedness in developing countries. Emerg Infect Dis, June 2008 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600290/).
- Alonso WJ, Schuck-Paim C. Public preparedness guidance for a severe influenza pandemic in different countries: a qualitative assessment and critical overview. PLoS Curr2009, revised April 2010 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775164/?tool=pubmed).
- What Bill Gates is afraid of, Vox, May 27, 2015 (4 ½ minute video) (http://www.news.com.au/finance/work/bill-gates-has-revealed-what-frightens-him-most-an-epidemic-so-great-it-would-rapidly-wipe-out-millions-worldwide/story-fn5tas5k-1227372407389 & https://www.youtube.com/watch?v=9AEMKudv5p0).
- Gates B. The Next Epidemic — Lessons from Ebola. N Engl J Med, April 2015;372:1381-1384 (http://www.nejm.org/doi/full/10.1056/NEJMp1502918).
- Taubenberger JK, Morens DM. 1918 Influenza: the mother of all pandemics. Emerg Infect Dis2006;12:20 (http://wwwnc.cdc.gov/eid/article/12/1/pdfs/05-0979.pdf).
- The Flu: Caring for Someone Sick at Home, US CDC, Feb. 2013 (http://www.savethechildren.org/publications/technical-resources/avian-flu/).
- Crosby AW. America’s Forgotten Pandemic, 2nd edn. Cambridge, UK: Cambridge University Press, 1989: pages 80, 246, 250, & 257.
- Barry JM. The Great Influenza. London: Penguin Books, 2005: pages 330–331.
- Starbuck ES. The “Spanish” Influenza Pandemic in Bethel & Danbury Connecticut, as Reported in the Danbury News & Danbury Evening News: Selected Headlines & Accounts of the Second Wave, September 12, 1918 through January 29, 1919. April 2007 (http://www.savethechildren.org/publications/technical-resources/avian-flu/).
- Pandemic Influenza: Community Planning and Response Curriculum for Community Responders, Volunteers, and Staff. Humanitarian Pandemic Preparedness (H2P) initiative, July 2009 (http://www.coregroup.org/our-technical-work/initiatives/h2p).
- Public health measures during the influenza A(H1N1) 2009 pandemic: Meeting report. WHO Technical Consultation. WHO, 2011, page 23 (http://whqlibdoc.who.int/hq/2011/WHO_HSE_GIP_ITP_2011.3_eng.pdf).
- Nonpharmaceutical Interventions (NPIs), US CDC webpages, updated April 2017 (https://www.cdc.gov/nonpharmaceutical-interventions/index.html & https://www.cdc.gov/nonpharmaceutical-interventions/tools-resources/published-research.html).
- Regulations and Laws That May Apply During a Pandemic, US CDC, page last updated November 2016 (https://www.cdc.gov/flu/pandemic-resources/planning-preparedness/regulations-laws-during-pandemic.htm)
- Markel H, Lipman HB, Navarro JA et al. Nonpharmaceutical interventions implemented by US cities during the 1918–1919 influenza pandemic. JAMA2007;298:644–654 (http://jama.ama-assn.org/cgi/reprint/298/6/644.pdf).
- Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci USA2007;104:7582–7587 (http://www.pnas.org/content/104/18/7582.full.pdf).
- Bootsma CJ, Ferguson NM. The effect of public health measures on the 1918 influenza pandemic in US cities. Proc Natl Acad Sci USA2007;104:7588–7593 (http://www.pnas.org/content/104/18/7588.full.pdf).
- Community mitigation guidelines to prevent pandemic influenza — United States, 2017 : Technical report 2: Supplemental chapters 1-7, US CDC, April 2017, page 12 (https://stacks.cdc.gov/view/cdc/44314)
- Review of evidence base underpinning the UK influenza pandemic preparedness strategy, Scientific summary of pandemic influenza & its mitigation. London: UK Department of Health, 2011:7–8 (https://www.gov.uk/government/publications/review-of-the-evidence-base-underpinning-the-uk-influenza-pandemic-preparedness-strategy).
- Qualls N, Levitt A, Kanade N, et al. Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017. MMWR Recomm Rep 2017;66(No. RR-1):1–34. DOI: http://dx.doi.org/10.15585/mmwr.rr6601a1
- Pandemic influenza preparedness and response: a WHO guidance document. WHO, 2009, page 43 (http://whqlibdoc.who.int/publications/2009/9789241547680_eng.pdf).
- Guide to public health measures to reduce the impact of influenza pandemics in Europe –”The ECDC Menu.” European Centre for Disease Prevention and Control, 2009 (http://ecdc.europa.eu/en/publications/Publications/0906_TER_Public_Health_Measures_for_Influenza_Pandemics.pdf).
- Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States – Early, Targeted, Layered Use of Nonpharmaceutical Interventions. US CDC, 2007 (https://www.cdc.gov/flu/pandemic-resources/pdf/community_mitigation-sm.pdf ).
- Rashid H, Ridda I, King C, Begun M, Tekin H, Wood JG, Booy R. Evidence compendium and advice on social distancing and other related measures for response to an influenza pandemic. Paediatr Respir Rev. 2015 Mar;16(2):119-26. doi: 10.1016/j.prrv.2014.01.003 (https://www.ncbi.nlm.nih.gov/pubmed/24630149 & https://www.health.gov.au/internet/main/publishing.nsf/Content/519F9392797E2DDCCA257D47001B9948/$File/Social.pdf).
- Many Cases of Influenza, Health Authorities Differ. Danbury Evening News, Saturday, October 5, 1918. (Quoted in: Starbuck ES. The “Spanish” Influenza Pandemic in Bethel & Danbury Connecticut, as Reported in the Danbury News & Danbury Evening News: Selected Headlines & Accounts of the Second Wave, September 12, 1918 through January 29, 1919. April 2007 http://www.savethechildren.org/publications/technical-resources/avian-flu/).
- Pandemic Influenza: Community Planning and Response Curriculum for District and Community Leaders. Humanitarian Pandemic Preparedness (H2P) initiative, July 2009 (http://www.coregroup.org/our-technical-work/initiatives/h2p).
- For example, the report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola noted that “field staff often reinvented strategies for community mobilisation and contact tracing because relevant lessons from previous Ebola outbreaks in Uganda and the Democratic Republic of Congo were not effectively transferred.” Moon S, Sridhar D, Pate MA, et. al. Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola. thelancet.com published online November 2015, page 4 (http://globalhealth.harvard.edu/files/hghi/files/will_ebola_change_the_game._ten_essential_reforms_before_the_next_pandemic.pdf?m=1461703757). (Thus, along with the pre-existing guidance on Ebola treatment units, authoritative pre-existing guidance on community mobilisation and contact tracing for Ebola, preferably adapted and tested in countries, and ready for use by responding organizations, may have been very helpful for the response.)
- Leadership During A Pandemic: What Your Municipality Can Do. Washington, DC: USAID, 2011 (http://www.paho.org/disasters/index.php?option=com_content&view=article&id=1053:leadership-during-a-pandemic-what-your-municipality-can-do&Itemid=937&lang=en).
- Pandemic Influenza Preparedness & Response: Guidance & Template for Country Planning by Humanitarian Organizations on Overarching Actions & Public Health Interventions. Humanitarian Pandemic Preparedness (H2P) Initiative. Sep. 2010 (http://www.savethechildren.org/publications/technical-resources/avian-flu/ see Pandemic Flu Program Response).
- Humanitarian Pandemic Preparedness (H2P) Program Review 2010, Executive Summary. Geneva: International Federation of Red Cross and Red Crescent Societies, 2010 (http://www.ifrc.org/docs/evaluations/Evaluations2010/Geneva/Report%20H2P.zip).
- Reducing transmission of pandemic (H1N1) 2009 in school settings: a framework for national and local planning and response. WHO, 2009 (http://www.who.int/csr/resources/publications/swineflu/reducing_transmission_h1n1_2009/en/index.html).
- Interim planning considerations for mass gatherings in the context of pandemic (H1N1) 2009 influenza. WHO, 2009 (http://www.who.int/csr/resources/publications/swineflu/h1n1_mass_gatherings/en/index.html).
- Community case management during an influenza outbreak: a training package for community health workers. WHO, 2011 (http://www.who.int/influenza/resources/documents/community_case_management_flipbook/en/index.html).
- Comparative Analysis of National Pandemic Influenza Plans. WHO, 2011, page 36 (http://www.who.int/influenza/resources/documents/comparative_analysis_php_2011_en/en/index.html).
- WHO Strategic Action Plan for Pandemic Influenza, WHO, 2007, page 4 (http://www.who.int/csr/resources/publications/influenza/StregPlanEPR_GIP_2006_2.pdf?ua=1).
- See 2X3 table in: Starbuck ES, von Bernuth R, Bolles K, Koepsell J. Are we prepared to help low-resource communities cope with a severe inﬂuenza pandemic? Inﬂuenza Other Respiratory Viruses 2013;7(6):909–913 (http://onlinelibrary.wiley.com/doi/10.1111/irv.12040/epdf).