BMJ: Was the public health response to swine flu alarmist?

Was the public health response to swine flu alarmist?
http://www.bmj.com/cgi/doi/10.1136/bmj.b3471

The public health measures taken in response to swine flu may be seen as alarmist, overly restrictive, or even unjustified, says a US expert in a paper published on bmj.com today.

Peter Doshi, a doctoral student at the Massachusetts Institute of Technology, argues that our plans for pandemics need to take into account more than the worst case scenarios, and calls for a new framework for thinking about epidemic disease.

Over the past four years, pandemic preparations have focused on responding to worst case scenarios. As a result, we responded to the H1N1 outbreak as an unfolding disaster. Some countries erected port of entry quarantines. Others advised against non-essential travel to affected areas and some closed schools and businesses.

Pandemic A/H1N1 is significantly different than the pandemic that was predicted, says Doshi. Pandemic A/H1N1 virus is not a new subtype but the same subtype as seasonal H1N1 that has been circulating since 1977. Furthermore, a substantial portion of the population may have immunity.

Actions in response to the early H1N1 outbreak were taken in an environment of high public attention and low scientific certainty, he argues. The sudden emphasis on laboratory testing for H1N1 in the first weeks of the outbreak helped to amplify the perceived risk.

He also points out that, since the emergence of A/H1N1, the World Health Organisation has revised its definition of pandemic flu.

The wisdom of many of these responses to pandemic A/H1N1 will undoubtedly be debated in the future, he writes. What the early response to the pandemic has shown, however, is that the public health response to, as well as impact and social experience of a pandemic, is heavily influenced by longstanding planning assumptions about the nature of pandemics as disaster scenarios.

If the 2009 influenza pandemic turns severe, early and enhanced surveillance may prove to have bought critical time to prepare a vaccine that could reduce morbidity and mortality, says Doshi. But if this pandemic does not increase in severity, it may signal the need to reassess both the risk assessment and risk management strategies towards emerging infectious diseases.

He suggests that future responses to infectious diseases may benefit from a risk assessment that broadly conceives of four types of threat based on the disease’s distribution and clinical severity.

For example,

• the 1918 pandemic was a type 1 epidemic (severe disease affecting many people),
• while SARS was a type 2 epidemic (infecting few, mostly severe disease), and
• the H1N1 pandemic may prove to be type 3 (affecting many, mostly mild).

Public health responses not calibrated to the threat may be perceived as alarmist, eroding the public trust and resulting in the public ignoring important warnings when serious epidemics do occur, he warns.

The success of public health strategies today depends as much on technical expertise as it does on media relations and communications. Strategies that anticipate only type 1 epidemics carry the risk of doing more harm than they prevent when epidemiologically limited or clinically mild epidemics or pandemics occur, he concludes.

Contact:
Peter Doshi, Doctoral Student, Program in History, Anthropology, and Science, Technology and Society, Massachusetts Institute of Technology, Cambridge, MA, USA
Email: pnd@mit.edu

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My Comments:

1. There is no doubt that there have been vigorous debates regarding this A/H1N1 flu pandemic, with many claiming that the overall official responses had been alarmist and over the top, starting with the WHO, and most national health authorities.
   
2. However, it is clearly mainly due to "hindsight wisdom", that one finds this highly infectious disease, so much more benign than it was feared to be, thus far. At least this seems to be the case in most Western countries, where antiviral medications have been generously dished out to anyone having ILI (flu-like illness).
3. That it is very contagious cannot be denied, but it is also becoming increasingly clear that most people exposed to this infection appear to have quite mild symptoms with some having none at all.
   
4. The difficult question is who amongst us have such supposedly natural immunity or who would have very mild subclinical infections at all. According to some, the similarity of the viral genome to the 1987 flu pandemic might have given immunity to many people already previously exposed--thus the milder uptake.
5. However, it cannot be denied that in other countries where flu outbreaks are less than perennial or seasonal in their occurrence, the outbreak has been experienced with greater ferocity of more severe ailments. Pneumonia and multi-organ breakdown appear to have afflicted more Malaysians than ever before... so this is certainly new.
   
6. The number of cases still being admitted to ICUs for critical care and mechanical respiratory support, and even dying, attest to the more virulent nature among some of our patients who have contracted this disease.
7. Thus, for Malaysia at least, we have much to learn about this enigmatic flu outbreak, but we do know that among the sickest patients, we have to marshal in even more appropriate and urgent life support care, so as to save more lives.
8. My contention is still that what we have done is appropriate and necessary, and we did modify our stance repeatedly as we learn more about the ailment.
   
9. One possible criticism may be that we had perhaps erred on the side of extreme caution and possibly some delay in dissemination of changing urgent decision pathways, including use of definitive treatment a little too late sometimes--but we have done as best can be under the circumstances.
   
10. Our weaknesses and shortcomings have been exposed, and as someone cynically had said: "that this is a timely stress test for checking the capacity and effectiveness of our entire health care system!"
    

Managing schools during the current pandemic (H1N1) 2009

Managing schools during the current pandemic (H1N1) 2009 – Reactive and proactive school closures in Europe (European Centre for Disease Prevention & Control, ECDC)

Proactive school closures, that is, closing schools ahead of a pandemic arriving in an area, is a public health measure that has been commonly suggested for mitigating the impact of pandemics. It has been suggested that they could help because children are considered to be more infectious and susceptible to seasonal influenza than adults and can therefore be important vectors of transmission. Similarly, the high contact rates among children in schools favour transmission.[1,2] This is an area that is addressed with other public health measures in the ECDC ‘Menu’ on Public Health Measures.

Here it is important to distinguish between proactive closures of schools (which means closing schools just as, or even before, they are affected by a pandemic) and reactive closures, which occur simply because many students or staff are sick and the schools cannot function for a while (Table 1).

It was hoped by some that closing schools proactively during a pandemic may break some chains of transmission and so reduce the total number of cases. This would, to some extent, slow the epidemic, giving a little more time for final preparations and vaccine development and production, as well as reducing the incidence of cases at the peak of the epidemic. The latter effect in particular, would limit both the stress on healthcare systems and peak absenteeism in the general population.

However, though some health benefits can be expected, there is still considerable debate about if, when and how, proactive school closure policy should be implemented.[3]

There is no consensus on the scale of the benefits to be expected but the most recent scientific review addressing the general issue, conducted by a European group of authors from the UK, France, Sweden and ECDC, concluded that proactive school closures could indeed be beneficial in the ways described above, but only if the children do not simply mix elsewhere outside the schools.[4]

Any benefits, however substantial, must be weighed against the potential high economic and social costs of proactively closing schools.[3,4] Particularly critical may be the negative impact of unplanned school closures on key health workers since, for example, many doctors and nurses are also parents with dependent children.[4]

There are also many important operational issues related to school closures which, though not insuperable, need careful preparation. It is also important to remember the many educational and social functions that schools deliver which would be lost, especially by prolonged closures (Table 2).

The current pandemic (H1N1) 2009 is proving especially challenging when considering school closures. The heterogeneous and unpredictable distribution of outbreaks and the mild nature of the illness in most people means that, by the time it becomes clear that the infection is in a school, it is too late for a proactive closure.

For example, the Centers for Disease Control and Prevention (CDC) in North America, has moved away from recommending that authorities consider proactive closures. The CDC is also emphasising the importance of local flexibility and local decisions.[2,5]

Within Europe there are different traditions with regard to school closures, and schools and school systems are often administratively complex bodies not necessarily under a single national authority. Communication of the policies to the public presents particular challenges in a European context where some countries (or even regions within a country) may close schools proactively, others perhaps only reactively and some not close them at all. In their paper published in The Lancet, the authors point out that historical experience shows that some schools close during pandemics just because of high levels of illness-related absenteeism. That has been the experience to date in North America.[4,6] It therefore seems sensible for countries and schools to at least have plans for reactive closures.

Table 1: Definitions and types of school closure

School closure: Closing a school and sending all the children and staff home.
Class dismissal: A school remains open with administrative staff but most children stay home.
Reactive closure: Closing a school when many children and/or staff are experiencing illness.
Proactive closure: School closure or class dismissal before significant transmission among the school children occurs.

Table 2: Operational questions concerning school closure to be considered during pandemic (H1N1) 2009

• The need for local sensitivity in timing in larger countries as the pandemic spreads; even if proactive school closures are considered desirable, it will not be necessary for all schools to close in all parts of a country at once, despite the communication and administrative advantages of doing so.
• What should be the trigger for proactive closures? Some suggested triggers are:
  • The first case/outbreak involving the pandemic strain confirmed in a child or teacher.
  • Outbreaks in neighbouring/nearby schools.
• What should be the trigger for re-opening? Low levels of transmission in surrounding community?
• What should be the recommended length of time of closure?
• How to sustain teaching and learning over prolonged periods of closure, especially for pupils approaching examinations.
• How to maintain contact between the schools and families and teachers; the advantages of ‘class dismissal’ over ‘school closures’.
• Anticipate group childcare arrangements so that any healthcare benefits are not undermined; consider organised approaches to alternative childcare.
• How to sustain vital social functions of some schools, especially with regard to disadvantaged and vulnerable families.
• Consider the major complexities of school systems that comprise state schools, independent schools, faith-based schools and the fact that decisions on school closures are often a matter for local not central government, i.e. some European countries find it much harder than others to have command and control relations with schools.
• Consider the potential loss of earning of parents who have to take time off work.
• Establish agreements between sectors (such as education and health) so that one does not undermine the other.
• Consider the communication issues inherent in explaining different policies in neighbouring countries or even adjoining administrations.

• Consider early warning mechanisms so that adjoining administrations are aware of imminent decisions.
• Should Tertiary (Higher) Education and pre-school care be included?

References

1. Glass RJ, Glass LM, Beyeler WE, Min HJ. Targeted social distancing design for pandemic influenza. Emerging Infectious Diseases 2006;12(11):1671-1681.
2. CDC United States Department of Health and Human Services and Centers for Disease Prevention and Control. Interim pre-pandemic planning guidance: Community strategy for pandemic influenza Mitigation in the United States. Dec 2006
3. Inglesby TV, Nuzzo JB, O'Toole T, Henderson DA. Disease mitigation measures in the control of pandemic influenza. Biosecur Bioterror 2006;4(4):366-75
4. Cauchemez S, Ferguson NM, Wachtel C, Tegnell A, Saour G, Duncan B, et al. Closure of schools during an influenza pandemic. Lancet Infect Dis 2009; 9: 473–81.
5. CDC Update on School (K – 12) and Child Care Programs: Interim CDC Guidance in Response to Human Infections with the Novel Influenza A (H1N1) Virus
6. Weisfuse I. Presentation to ECDC on Outbreak of Influenza A(H1N1)v in New York

H1N1 update: EU health authorities agree on common approach

EU health authorities agree on common approach to H1N1 flu

BRUSSELS, Aug 13 — The European Union (EU) Health Security Committee has agreed on a coordinated EU approach to the Influenza A/H1N1, the European Commission said Thursday.

China's Xinhua news agency reported that the committee has adopted two policy statements on public health measures, which set out a common approach on what kind of school closures may be most appropriate to protect public health, and how to balance freedom of movement and public health protection for travellers with flu symptoms.

The European Commission, the executive body of the EU, proposed the statements as part of the broader strategic planning for coordinated efforts in the EU in fighting the A/H1N1 flu.

In the statement on school closures, the committee says there is no need to enact preemptive mass school closures at present.

Decisions on school closures are the sole responsibility of each EU member state based on the epidemiological situation in each country, it says.

In the statement concerning travel, the committee provides a set of options on what to do in a situation where a traveller falls ill before or during travel, adding that the overriding public health recommendation to symptomatic individuals remains to delay travel and stay at home.

However, this public health recommendation should not lead to restriction of movement at the EU borders and travel restrictions between EU member states, it says.

The EU Health Security Committee, established in 2001, was given the responsibility to exchange information on health-related threats and to share information and experience on preparedness and response plans and crisis management strategies.

The committee is chaired by the European Commission and consists of officials from EU member states. – Bernama