Gaps are seen in pandemic containment plans
Gaps are seen in pandemic containment plans
Research reported by the Centers for Disease Control and Prevention says the lack of unified national direction for states to follow in developing pandemic flu plans is leading to disparate and confused state efforts and could result in "a patchwork of plans that will not adequately detect and control this or other respiratory disease pandemics."
The survey of publicly posted plans for 49 states covered vaccination strategies, surveillance and detection, and containment strategies.
Research Triangle Institute International senior infectious disease epidemiologist Scott Holmberg, MD, MPH, the lead study author, said that despite the lack of clear guidance, and the fact that no one can say with any certainty when a flu pandemic will strike, what its characteristics will be, or the effectiveness and quantity of any strain-specific vaccine, still the evolving state plans are in agreement in adhering generally to Advisory Committee on Immunization Practices and Department of Health and Human Services guidelines for prioritizing vaccination.
"In general, the elderly, those with chronic diseases, and health care and infrastructure personnel will be prioritized to receive vaccination," Dr. Holmberg said, "and in approximately one-third of the states, young children will be prioritized to be vaccinated. We believe the estimate that such persons make up 15% to 20% of the population in any state is reasonable. However, the vaccination strategy is predicated on preventing deaths from influenza, not stopping or retarding an epidemic or pandemic. Given that vaccine adequate to cover the entire U.S. population will not be available for several more years, the goal of reducing transmission would require much more vaccination than is available."
Looking at surveillance and detection, the report notes, state plans are even more variable than they are about strategizing vaccinations. Systems states are planning to use have unavoidable delays built into them, it said, and thus some state are looking into the possibility of moving to a different type of program.
"However," the researchers wrote, "to our knowledge no health authority feels confident that earlier detection of influenza by one to three weeks would necessarily lead to better control or substantial retardation of an outbreak."
In terms of proposing practical containment measures in the community, there is confusion and lack of specificity in the posted state plans, the researchers found. They noted that the national Department of Health and Human Services plan has several recommendations for infection control in hospitals, but is weaker and nonspecific in other areas such as control of influenza in the community.
"For example," they wrote, "there is no agreed-upon definition of geographic clustering of cases or number of persons infected that will trigger the declaration of a pandemic. Much of the national plan suggests social distancing and respiratory (cough) etiquette and devotes much of its discussion to mask use. Accordingly, states are comparably nonspecific about community control plans."
Dr. Holmberg said several practical, nonpharmaceutical steps should be under consideration. For example, he said, only one-third of state plans are explicitly considering recommending self-isolation of adults with influenza-like symptoms and keeping children with such symptoms home from school and day care. Even in an increasingly computer-based economy, in which a considerable percentage of people can work from home most of the time, the strategy has not been addressed in most state plans. And other simple recommendations for use in the community such as avoiding mass gatherings, shopping on off-hours, and household and workplace strategies such as frequent hand washing, avoiding handshaking, and keeping towels separate, often are neglected in state plans.
The report blames the lack of uniformity and consistency in state plans on weak federal direction, but also on the fact that answers are lacking to several epidemiologic questions necessary for national planning.
Questions that need answering
Questions the report raises include:
- What is the typical intrahousehold or institutional attack rate, and would vaccination or chemoprophylaxis of contacts retard or stem outbreaks?
- How well do masks work for pandemic influenza in the community, and where and for how long should they be used?
- Does closing a school or other institution actually reduce community-level illness and death?
- Does earlier detection of influenza in a community lead to behavior changes that could stem an outbreak?
The researchers said they know of no studies designed to address those and several other issues, and several state plans have expressed frustration about such lack of information.
They argue for revisions to the national pandemic influenza plan to provide more uniform, specific, and practical influenza protection, avoidance, and containment practices, and also call for studies and expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.
The research report is available on-line at www.cdc.gov/ncidod/eid/vol12no09/06-0369.htm. E-mail Dr. Holmberg at [email protected].
Research reported by the CDC says the lack of unified national direction for states to follow in developing pandemic flu plans is leading to disparate and confused state efforts and could result in "a patchwork of plans that will not adequately detect and control this or other respiratory disease pandemics."Subscribe Now for Access
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