The Threat of Pandemic Influenza Are We Ready? Workshop Summary (2005) / Chapter Skim
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6 Beyond Biomedical Response
6 Beyond Biomedical Response
Pages 315-372
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From page 315... ...
The chapter opens with a description of an economic model, based on the notion of preparation as an "insurance policy" against the next influenza pandemic, to calculate the investment necessary to prepare for a range of pandemic scenarios and responses. These calculations indicate the mutual exclusivity of two key goals of pandemic planning, minimizing overall mortality and minimizing economic impact, thus highlighting the need for a system by which to make such difficult choices and explain them to the public.
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From page 316... ...
Legal authority must be brought to bear on nearly every facet of pandemic preparedness, from measures designed to reduce the risk of animalto-human transmission of disease; to surveillance and detection procedures; to medical interventions to prevent or control the spread of infection; to the imposition of voluntary or mandatory quarantine and/or isolation measures; to travel limitations, trade restrictions, and border closures. This chapter continues with an examination of the legal and ethical questions attached to major public health interventions for preventing or ameliorating pandemic influenza; it also summarizes ethical values that can inform public health practice in an emergency.
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From page 317... ...
At $62 per vaccinee and at gross attack rates of 25%, we project net losses if persons not at high risk for complications are vaccinated. Vaccinating 60% of the population would generate the highest economic returns but may not be possible within the time required for vaccine effectiveness, especially if two doses of vaccine are required.
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These rates are based on illness and death rates reported in earlier influenza pandemics and epidemics. The model produces a range of estimated effects rather than a single point estimate.
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From page 319... ...
averaged 15.4 aThe actual number of cases will depend upon the assumed gross attack rate. The distribution of cases was based on lower and upper estimates of age-specific attack rates from the 1918, 192829, and 1957 epidemics and pandemics (Glezen, 1996)
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. Gross Attack Rates In the model, we used gross attack rates (percentage of clinical influenza illness cases per population)
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bFor Monte Carlo simulations, rates are presented as lower and upper for uniform distributions, and lower, most likely, and upper for triangular distributions (Evans et al., 1993)
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. Vaccine Effectiveness The assumed levels of vaccine effectiveness used to estimate the savings gained due to a vaccine-based intervention are described in Appendix I; the equation defining savings from outcomes averted contains the rate of compliance multiplied by the assumed vaccine effectiveness.
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To illustrate the use of the model in estimating the impact of different priorities, we created sample priority lists by using three different criteria: total deaths, risk for death, and maximizing net returns due to vaccination. In choosing the criteria for priorities, society must debate the main goal of a pandemic vaccination plan: prevent deaths, regardless of age and position in society; prevent deaths among those at greatest risk (i.e., 65 years of age)
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324 31 31 31 31 Outcomes 30 Sources Assumed 16, Marketscan Database; Marketscan Database; Marketscan Database; Marketscan Database Marketscan Database Marketscan Database; 30 Health of 3,692 + ±3,200 60 ± 10 5.4 Costs) ± ± 65+ 74 65,837 8,309 74,146 6,856 102 4 41 10 65 7,653 Indirect (yrs)
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325 continued ,5 ,5 Marketscan Database Marketscan Database Marketscan Database Marketscan Database Marketscan Database Marketscan Database 30 30 Assumed 16 22 ± ± 1.52 50 4 36 1.4 3 65 458 65 2 327 12 27 ± ± 1.52 38 4 36 1.8 3 100 330 100 2 202 13 18 ± ± 1.52 49 5 25 0.9 3 3254 65 300 3254 65 2 197 Direct Direct Direct Direct Direct Direct Indirect Indirect Indirect Indirect Direct ($) payment net i ($)
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326 and the (The for for days due The had of from and value point age analysis 30 a lost Database 1993) data pre- any by 1996 ot hospital at patients lizations.
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Option B targets the number of vaccinees as outlined in Option A plus approximately 20 million essential service providers (5 million health-care workers and 15 million providers of other service) (99.2 million vaccinees)
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. The mean numbers of those clinically ill not seeking medical care but still sustaining economic loss ranged from approximately 20 million (gross attack rate of 15%)
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Note that for each gross attack rate, data are totals for all age groups and risk categories. economic losses.
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The results are much less sensitive to increases in gross attack rate than to increases in death rate. For example, assuming a cost of $62.26 per vaccinee and death rates that are half the initial rates, increasing the gross attack rate from 15% to 25% still resulted in negative net returns for all age groups, regardless of assumed level of vaccine effectiveness.
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Because higher costs of vaccination reduce net returns from an intervention, increased vaccination costs reduced the premiums. Conversely, increases in gross attack rates (all other inputs held constant)
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. While Option A would ensure positive mean net returns, Option B would result in greater mean net returns (Figure 6-3)
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333 if Next place separate a the take to can years (103)
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, great uncertainty is associated with any estimate of the pandemic's potential impact. While the results can describe potential impact at gross attack rates from 15% to 35%, no existing data can predict the probability of any of those attack rates actually occurring.
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All other factors being held constant, the net returns due to vaccination are sensitive to the combination of price and gross attack rate, with some scenarios generating negative mean returns (Figure 6-2)
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. The wide range in premiums presents a cautionary tale of the difference between possibility and probability of an influenza pandemic.
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His research interests focus on assessing the economics of public health interventions such as oral raccoon rabies vaccine, Lyme disease vaccine, and hepatitis A vaccine, as well as estimating the economic burden of bioterrorism, dengue, pandemic influenza, and other infectious diseases. His research uses various methods, including Monte Carlo modeling, willingness-to-pay surveys (contingent valuation)
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From page 338... ...
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From page 339... ...
In both cases -- as in most such circumstances -- it is important to recognize that good communication is necessary, but not entirely sufficient, to achieving desired behavioral outcomes. Policies and incentives are also usually necessary to motivate many people to get annual flu shots (e.g., those people who believe influenza vaccination is helpful, but who are not willing to experience much inconvenience to get vaccinated)
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From page 340... ...
However, as the events of 20032004 also illustrate, many of the important ingredients in this recipe are outside the control of health officials and practitioners. For example, one factor that helped to facilitate initial media and public interest in influenza vaccination was the fact that influenza's arrival coincided with the immunization season.
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From page 341... ...
Heading into late November 2003, some medical and public health officials began talking about "pandemic influenza," further heightening media and public interest in both flu and flu vaccination. For those interested in increasing the number of people who receive an annual influenza vaccination, one of the important lessons from the 2003 2004 influenza season is that several of the factors that help generate media attention to, and public demand for, flu shots are ones that cannot be affected or controlled by public health officials or medical professionals.
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From page 342... ...
Public Communication Challenges The efforts and experiences of the past few years in trying to increase annual influenza vaccine uptake in the United States illustrates that a variety of factors must be considered as part of pandemic influenza communication planning. These factors all stem from the situation that (1)
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From page 343... ...
As a result, many "mixed" or "conflicting" messages arise because patients or members of the public see or perceive a contradiction between what is being recommended and the actions of those making the recommendation. In the case of influenza vaccination, for example, one of the mixed messages that exists in the minds of many people for whom annual flu vaccination is recommended is the relatively low uptake among health care professionals (Brunell, 2004)
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From page 344... ...
Their reactions could be summarized as, "There must be some reason(s) that it's now recommended that I receive an annual influenza vaccination-I'd like to know what that reason is" or "something must have changed so that I'm now in a group that is recommended for annual vaccination, what's changed?
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From page 345... ...
Three Population Segments Our experience indicates that Americans broadly fall into three population segments with regard to influenza vaccination. One segment consists of people who routinely receive the annual influenza vaccine, including many of those whom we recommend do so.
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From page 346... ...
This will require a strong investment in research and collaborations to help determine which messages resonate, particularly among people who are not usually inclined to get an influenza vaccination. The use of less nuanced messages and advice should be investigated, coupled with the development and use of portfolios of messages and materials that recognize the cultural and racial diversity that exists in this country.
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Finally, ensuring the effectiveness of public communication during an influenza pandemic will require a greater understanding and use of risk communication principles (Sandman, 1993)
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. Managing Infectious Disease Threats in the Information Age The anthrax letter scare in 2001 revealed the many communication challenges that can arise in an uncertain, evolving, large-scale health crisis that involves infectious disease.7 Briefly reviewed here are select findings from a national, qualitative study of public communication experiences during that event (see Table 6-9)
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In general, communication deficits during the anthrax crisis point to the need for proactive remedies in the precrisis period. Parallels between the anthrax scare and an influenza pandemic make the former case relevant to the larger issue of prevention and response.
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350 THE THREAT OF PANDEMIC INFLUENZA FIGURE 6-4 Communication dilemmas in the Information Age: Lessons learned during 2001 anthrax scare. larly, at the peak of the global SARS outbreak, the New York City Department of Health discovered that some residents were transposing what they were reading and seeing about Hong Kong and other hard-hit areas to conditions in New York, where the impact had been minimal (Roberts, 2003)
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Mainstream Media Have Limited Reach Among Unfamiliar and Untrusting Publics Mass media reach the largest number of people the most quickly, and many research subjects reported that despite the overwhelming amount of information available via news reports, they still found much of what they
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From page 352... ...
Communication as a Means to an End, Not an End in Itself As 2001 demonstrated, open and informative relationships among citizens, government, and public health and safety authorities are fundamental to a population's ability to cope with unconventional health threats. Abundant communication technologies prove both benefit and burden for authorities having to contain an infectious disease threat.
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Governance Dilemmas as Critical Contexts for Public Communication The larger social and political context for public communication practice was the analytic focus of the Working Group on Governance Dilemmas in Bioterrorism Response (2004)
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From page 354... ...
Mutual confidence and obligation among decision makers, citizens and their leaders, and community members are the basis for achieving any and all strategic goals. Breaches of social trust, however, are a common predicament for leaders during outbreaks and are likely to arise during a bioattack (Box 6-2)
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· Restrict civil liberties, if necessary, only in a transparent and equitable way. Protect the economy while using disease controls that disrupt commerce · Be mindful of the goal of long-term financial recovery when controlling dis ease; do not react based solely on the desire to avert short-term economic loss.
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Answering ques tions is not a distraction from managing the crisis; it is managing the crisis. · Confirm that local health agencies and medical facilities are prepared to handle an onslaught of questions from concerned individuals, in person and by phone.
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Influenza pandemics have occurred roughly two to three times per century, causing untold morbidity and mortality (Kolata, 1997)
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has noted three essential prerequisites for an influenza pandemic: (1) the identification of a novel viral subtype in animal populations such as swine or poultry, (2)
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From page 359... ...
Even if strong international health standards did exist, public health authorities would continue to face the problem of when to implement aggressive strategies such as culling. Premature interventions have profound economic implications affecting livelihoods and trade.
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From page 360... ...
Prompt notification of an infectious disease threat can affect a country's tourism, trade, and prestige. Consequently, some governments do not respond promptly to WHO requests for information.
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. Global surveillance could further benefit from "small-world networks" consisting of health professionals, scientists, and nongovernmental organizations continuously monitoring disease threats (Gostin, 2004)
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Mass vaccination to avert an influenza epidemic can go horribly wrong, as occurred with swine flu in 1976: The CDC campaign to immunize the American population cost $134 million and
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One might argue that it is in the richer country's self-interest to do so because infectious disease can and does travel across the globe. Ethical analysis would prove difficult -- do developed countries have an obligation to reduce the burden of disease in developing countries?
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In such instances, the principle of transparency may suggest that public health officials should state honestly the lack of conclusive evidence, leaving the judgment to the individual. Travel and Border Controls One of the first instincts in the face of infectious disease threats is to protect national borders (see Table 6-10)
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When an infectious disease outbreak deeply affects a society's everyday activities, public health authorities will have to cogently explain the justifications for the chosen intervention and gain the public's confidence prior to implementation. Critical legal and logistical questions loom: Which authority has the power to close a venue; what criteria should be used to trigger a closure and when should the restriction be lifted; and how will services be delivered to vulnerable populations who may be at risk in an isolated residence or shelter?
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To what extent would orders for civil confinement dissipate trust and reduce cooperation? Acting Under Conditions of Uncertainty: The Key Scientific and Social Questions Influenza pandemic preparedness requires careful consideration of the public health strategy as well as the legal and ethical implications.
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. Ethical Values Underpinning Public Health Preparedness: The Cross-Cutting Issues Public health authorities have a mandate to protect the population's health.
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People place their trust in political leaders and, in return, deserve due consideration of and respect for their health and human rights. Fair Treatment and Social Justice Justice requires that the benefits and burdens of public health action be fairly distributed, thus precluding the unjustified encumbering of already socially vulnerable populations.
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CME monograph from Infectious Diseases in Children. Selected article: Piedra PA.
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2003. Ethical and legal challenges posed by Severe Acute Respiratory Syndrome: Implications for the control of severe infectious disease threats.
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1997. Influenza pandemic preparedness plan for the United States.
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From page 372... ...
. WHO: Priority Public Health Interventions Before and During Influenza Pandemics.
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