CDC Community Flu Planning Guide

Catching up on an old item here. The CDC recently released interim guidelines for a community strategy to mitigate the effects of pandemic flu mitigation. The guidelines focus on "early, targeted, and layered use of nonpharmaceutical interventions":

This document provides interim planning guidance for State, territorial, tribal, and local communities that focuses on several measures other than vaccination and drug treatment that might be useful during an influenza pandemic to reduce its harm.

The guide points out that:

It is highly unlikely that the most effective tool for mitigating a pandemic (i.e., a well-matched pandemic strain vaccine) will be available when a pandemic begins. This means that we must be prepared to face the first wave of the next pandemic without vaccine and potentially without sufficient quantities of influenza antiviral medications.

As a result, the guide focuses on four nonpharmaceutical interventions that can mitigate the effects of a flu pandemic:

1. Isolation and treatment (as appropriate) with influenza antiviral medications of all persons with confirmed or probable pandemic influenza. Isolation may occur in the home or healthcare setting, depending on the severity of an individual’s illness and /or the current capacity of the healthcare infrastructure.

2. Voluntary home quarantine of members of households with confirmed or probable influenza case(s) and consideration of combining this intervention with the prophylactic use of antiviral medications, providing sufficient quantities of effective medications exist and that a feasible means of distributing them is in place.

3. Dismissal of students from school (including public and private schools as well as colleges and universities) and school-based activities and closure of childcare programs, coupled with protecting children and teenagers through social distancing in the community to achieve reductions of out-of-school social contacts and community mixing.

4. Use of social distancing measures to reduce contact between adults in the community and workplace, including, for example, cancellation of large public gatherings and alteration of workplace environments and schedules to decrease social density and preserve a healthy workplace to the greatest extent possible without disrupting essential services. Enable institution of workplace leave policies that align incentives and facilitate adherence with the nonpharmaceutical interventions (NPIs) outlined above.

One innovation in the guide is the "Pandemic Severity Index," which categorizes the severity of pandemics based on the case fatality ratio:

Future pandemics will be assigned to one of five discrete categories of increasing severity (Category 1 to Category 5).

As the severity of a pandemic increases, the suggested interventions increase. For Category 1 pandemics, the only recommended community-wide intervention is the voluntary isolation of ill persons. For Category 2 and 3 pandemics, other measures such as school closures and other social distancing interventions may be appropriate. For Category 4 and 5 pandemics, it is recommended that community leaders implement all nonpharmeceutical interventions.

The guide points out that timing is critical:

Implementing these measures prior to the pandemic may result in economic and social hardship without public health benefit and over time, may result in “intervention fatigue” and erosion of public adherence. Conversely, implementing these interventions after extensive spread of pandemic influenza illness in a community may limit the public health benefits of employing these measures.

But the guide suggests an appropriate epidemiological trigger for implementing interventions:

This guidance suggests that 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).

There is a special caution about cascading effects of any intervention:

Communities must be prepared for the cascading second- and third-order consequences of the interventions, such as increased workplace absenteeism related to child-minding responsibilities if schools dismiss students and childcare programs close.

For example, according to a 2006 poll conducted by the Harvard School for Public Health:

Nearly three-fourths (73 percent) said they would have someone to take care of them at home if they became ill with pandemic influenza and had to remain at home for seven to ten days. However, about one in four (24 percent) said they would not have someone to take care of them.

More than four in ten respondents living in one-adult households (45 percent) and about one-third of low-income (36 percent), African-American (34 percent), disabled (33 percent), or chronically ill (32 percent) adults said they would not have anyone to take care of them if they were ill and had to remain at home.

While most employed people (74 percent) believed they could miss 7-10 days of work without having serious financial problems, one in four (25 percent) said they would face such problems. A majority (57 percent) think they would have serious financial problems if they had to miss work for 1 month, and three-fourths of respondents (76 percent) thought they would have such problems if they were away from work for 3 months.

These findings suggest that, while a vast majority of people say they are willing to adhere to community-wide interventions in the early stages of a pandemic, "adherence fatigue" may set in after a period of time. In addition, a community must have plans in place for their at-risk populations.

To minimize the adverse effects of both pandemics and their cascading effects, the guide emphasizes that planning is critical:

Communities should undertake appropriate planning to address both the consequences of these interventions and direct effects of the pandemic.

Communication is absolutely critical, to mitigate both the effects of the disease itself and the fear that the disease may cause (which could have cascading effects on the healthcare system, as the "worried well" could overload a community's healthcare resources):

It is also critical for communities to begin planning their risk communication strategies. This includes public engagement and messages to help individuals, families, employers, and many other stakeholders to prepare.

For any community, it is important to test the plan:

Since few communities have experienced disasters on the scale of a severe pandemic, drills and exercises are critical in testing the efficacy of plans.

Of course, just about everything in this document is common sense. Other recent flu guides have said much the same thing (see this post). Given the ever-present risk of a flu pandemic - which may or may not turn out to be bird flu - it is simply irresponsible not to develop plans. Human history tells us that a pandemic flu will eventually strike. The only question is how well we have planned for it.

Within the local community, early collaboration and planning are critical. Local leaders, business people, school administrators, public health professionals, and healthcare providers need to ask themselves who would be affected by a change in their operations resulting from a flu pandemic. Early collaboration and information sharing will be critical to developing plans that mitigate the effects of a pandemic for all.