Community Mitigation of Pandemic Influenza

Community Mitigation of Pandemic Influenza

What Key Stakeholders Need to Know

Poudre School DistrictBoard of EducationNovember 13, 2007

What is a flu pandemic?Influenza pandemics occur when an animal flu virususually a bird flu virusthat has never infected people alive today changes in ways that it can Infect humans

Spreads easily between them, causing illness throughout the world.

What is a flu pandemic?Pandemics are natural events that happen about 3 times per century (in 1918, 1957, and 1968)They can be mild (not much worse than a bad seasonal flu outbreak) or severe (killing millions all over the world)

Infectious Disease Deaths in the 20th century191819571968Deaths per 100,000 per yearUnited States, 1900-1996JAMA.1999; 281: 61-66.

Currently we cant stop a pandemicWe cant stop a pandemic, but we can lessen the harm through control measuresImpactWeeksWithout control measuresWith control measures

What actions should we take in a pandemic?Mandatory or voluntary?Which combinations of actions?At what point in the outbreak?What evidence is there that these actions will work?

Potential Tools in Our ToolboxOur best countermeasure vaccine will probably be unavailable during the first wave of a pandemicAntiviral treatment may not be available in sufficient quantities.The effectiveness of antiviral treatment is not clear.

Recent CDC guidanceCommunity strategies recommended for pandemic flu when vaccines and antivirals are not availablehttp://www.pandemicflu.gov/plan/community/community_mitigation.pdf

4 Key Community toolsAsking those who are ill to remain at homeAsking household members of ill persons to remain at homeChild social distancing closure of schools and places children gatherWorkplace/community Adult social distancing

Control measures will be based on pandemic severity

Severity measured by case-fatality rate (# that die / # that become ill) as determined in region where a pandemic begins (likely not CO, nor even USA) Pandemic Severity Index created to help communicate level of danger to the public, similar to the well-known hurricane index.

For comparison,

the case-fatality rate of the 1918 pandemic was 2.5% in the U.S.

the case-fatality rate of H5N1 in 2006 was 69%

Severity Index will drive actions

Why are these measures recommended?

Two approaches to look at effectivenessof control measures

Looking back at data from 1918 to look for evidence that certain interventions workedModeling influenza outbreak using mathematical tools

Looking at 1918 to see what worked

Weekly mortality data provided by Marc Lipsitch (personal communication)

Public gathering ban

School closure

Business regulations

Total Excess Death Rate748 vs. 1040

partial ?

total

total

partial

Public gathering ban

total

partial

Schools closed

total

total

partial

Business hours altered

total

Total Excess Death Rate358 vs. 1180

Timing is everythingNot just what was done but when it was done made a big difference

Trigger to implement school closure in current guidance is when first cases occur anywhere in state

Could be very controversial decision

Purpose of Community-Based Interventions1. Delay outbreak peak2. Decrease peak burden on hospitals/ infrastructure3. Diminish overall cases and health impactsHealth care capacity

What models tell usabout actions to reducepandemic flu spread

Value of combining strategies Glass model

Why does closing schools (dismissing students) make such a difference?

Evidence to Support Dismissing StudentsChildren are more susceptible to flu and more contagious than adultsChildren are believed to be the main introducers of influenza into households.School closure during influenza epidemics has resulted in significant decreases in the diagnoses of respiratory infections, visits to physicians, and emergency departments.Reducing infection in children (via vaccines) has reduced flu rates in all ages in community

Children are in close contact at school

Workplace / Classroom Social Densityhttp://buildingsdatabook.eren.doe.gov/docs/7.4.4.xls11.7 feet3.9 feet7.8 feetElementary SchoolsHospitalsOffices16.2 feetResidences

Spacing of people: If homes were like schools

*Based on avg. 2,600 sq. ft. per single family home

Extrapolation of social density data to a household

What can be done to reduce adverse impacts of dismissing students?

Adverse impactsDifficulties of working parents with no child care provider for younger students; impact on other workplaces.Loss of childrens learningLoss of school meal programs for low-income childrenLoss of state funding for school districts

66 million No children18 million >= age129 millionNon-workingadult8 million5 millionLabor Status of Households (U.S.)Source: U.S. Census Bureau, Population Division, Current Population Survey, 2003 Annual Social and Economic Supplementhttp://www.census.gov/population/www/socdemo/hh-fam/cps2003.html

Chart4

0.6202547193

0.1655297519

0.0892273389

0.0796092289

0.0453789611

Raw Data

Multiunit

Total1, detached1, attachedTotal2 to 45 to 910 to 1920 to 4950 or moreManu-

factured/

%Multiunitmobile homes

24%Total10584267753627224963847451354468329435926854

8748358746462818075623636333230246425116035

Race and Origin

21%White alone

18%Non-Hispanic7735853623400314136498027252531187120295596

39%Hispanic10125512362439391256908699593482438

39%Black alone1300461041220501317051154869549736667

38%Non-Hispanic1254859541166476616531101835498678663

54%Hispanic4561515424751533451584

22%American Indian or Alaska Native alone6644283514574193191156

39%Asian alone31831641283124429722024820927014

33%Pacific Islander alone@99295167279623301311194

32%Two or more races1215668793901387977524578

40%Hispanic or Latino (of any race)@2111038551171743641357996774676560447

55832424482847556925036

Cooperatives and Condominiums

80%Cooperatives

63%Condominiums4722282148129566306376214925753

52283435439818151136221187122537

Year Structure Built@14

16%2000 to 2004

15%1995 to 19997922480846911933062463351881191452

15%1990 to 199463444077481948243230223149103837

29%1985 to 1989793642496962289437606659292296702

29%1980 to 1984664133455821954548479429229268761

26%1975 to 19791087664197052811765715545324462940

31%1970 to 1974959851195652953729640571396617961

25%1960 to 19691378193744853396911647686535617526

15%1950 to 1959119339634385183673833922322930778

21%1940 to 194970985252341148972026215515319917

25%1930 to 19395432372830913517372269614914344

30%1920 to 1929475029923271431768196911921840

30%1919 or earlier83045321488249514204122352711560

Median1970196719761970195819731976197119711985

344161631231524786960

Rooms

91%1 room

89%2 rooms984604387116315311816826810

83%3 rooms8617792487714915621414140713071458189

51%4 rooms18558536815149511334521101818110111352166

21%5 rooms244151512516515020214110878544774622619

7%6 rooms2255418463144315989282311881221291049

2%7 rooms138351241065029919850191021476

1%8 rooms79437477199785084314188

1%9 rooms374935578339154214270

2%10 rooms or more48444484186874023115787

8113446729901201001812393

Bedrooms

90%None

80%1115571324652929620681794185216301951286

41%22859511534259211704453925942154125311642765

6%344592360952393283515505683122071993269

2%4 or more202861876659039922858512340531

64231135247405644703749

Complete Bathrooms

38%None

44%14081418509216117902632335132943242926942243

14%1 1/2162401182114512317897509426205280651

9%2 or more4814737112262644971214105710565905813912

746076775300000006854

Square Footage of Unit

Single detached and

manufactured/mobile homes

0%Less than 5006864600000000226

0%500 to 749204612790000000767

0%750 to 9995248362100000001627

0%1,000 to 1,499180571588900000002168

0%1,500 to 1,999174911642900000001062

0%2,000 to 2,49911827115370000000290

0%2,500 to 2,99960475971000000076

0%3,000 to 3,99954345374000000059

0%4,000 or more31453086000000060

0%Not reported462641080000000518

Median17551821500-500-500-500-500-500-500-1126

7453748945450416572552533102986215725954516

Persons per Room

22%0.50 or less

25%0.51 to 1.002874317734161972662564155313109598812123

41%1.01 to 1.50209791212186531022413611580198

56%1.51 or more46516228259754836633716

0%746076775300000006854

Square Feet Per Person

Single detached and

manufactured/mobile homes

0%Less than 200168712640000000423

0%200 to 299422834140000000814

0%300 to 399635454800000000874

0%400 to 499724563860000000860

0%500 to 599672261060000000616

0%600 to 699685862740000000584

0%700 to 799565851320000000526

0%800 to 899446641120000000355

0%900 to 999423738690000000369

0%1,000 to 1,49912436117940000000642

0%1,500 or more1009098160000000274

0%Not reported462641080000000518

Median733756200-200-200-200-200-200-200-532

155318532131442529126618714423

Equipment@1

85%Lacking complete kitchen facilities

With complete kitchen (sink,10428967568624123649804948444202310634486831

23%refrigerator, and oven or burners)

23%Kitchen sink10563567707625824816846651124432324835586854

24%Refrigerator10566767680625724882846251144461326435816848

23%Cooking stove or range10505467413620324632838950774408322435336806

37%Burners, no stove or range14353205326984817

40%Microwave oven only34016822135392320322215

18%Dishwasher6377645168412311415278826132805156316463070

11%Washing machine8602965102520795084418184316689086726211

10%Clothes dryer8253863178487685773961174216037655065907

25%Disposal in kitchen sink496243245237931238228082891304818151820996

16%Trash compactor3913298220263412011410212117895

6188042452387411439286926722731153116364115

Air conditioning:

18%Central

11%Additional central4133336415344911484887490166

38%1 room unit1434671276285448199310738087548211144

27%2 room units8004481750021281002285212243387559

16%3 room units or more40142844354628340544971114189

6538044713388511552402525692325130613275230

Main Heating Equipment

18%Warm-air furnace

42%Steam or hot water system13257683785155531978797611925124217

23%Electric heat pump1134771018012587557651662385332858

48%Built-in electric units47602133254229863449843737535575

39%Floor, wall, or other built-in hot-air532227723102098792445361242258143

39%units without ducts

20%Room heaters with flue143210044228616653202224100

7%Room heaters without flue15091220141098415271166

19%Portable electric heaters731428391399424939126

1%Stoves10409261366000094

4%Fireplaces with inserts13913215200040

4%Fireplaces without inserts524302110007

36%Other2851432410254141710716

44%Cooking stove1496866532205259

36%None43923432160474718182913

10448767086617724428832050234377321534946796

Plumbing

23%With all plumbing facilities

Lacking some or all plumbing13556679653515311291799858

39%facilities@1

24%No hot piped water22512112551061617637

45%No bathtub and no shower166821074191540100

46%No flush toilet13965106419153270

42%No exclusive use10635138244814310373438621

9232456559613824820834051314468329435874806

Primary Source of Water

27%Public system or private company

1%Well serving 1 to 5 units130971086412412512230001983

1%Drilled11276940585878330001699

2%Dug9197321119190000157

2%Not reported9027272720200000128

4%Other422330111712000664

10575767692626424953846951324467329135926847

Units Using Each Fuel@1

24%Electricity

24%Piped gas6513043529421815330585529192202205023042053

4%Bottled gas91886844121400234644816381823

32%Fuel oil157109310809498115066185728771409610

3%Kerosene or other liquid fuel13769443344295037356

2%Coal or coke18917883300000

4%Wood96018394214417174105982515575

12%Solar energy159133519412662

23%Other69246527162281242404038

34%All electric units260791270118048839212121602179120311772735

8956262359522516121607135083131176816435858

Selected Amenities@1

18%Porch, deck, balcony, or patio

23%Telephone available10287366293607023937814149174281314534536574

7%Usable fireplace3545830290171123797585815762931721079

12%Separate dining room5069039583296863342602118410936478081804

With 2 or more living rooms or302542721111948584411441147485991

3%recreation rooms, etc.

10%Garage or carport included with home652515369431276417259511649587529482013

46%Not included4041513964312818484585639673498252626374838

43%Off-street parking included3310112222225514130430133083056178816774494

76%Off-street parking not reported46453503412152

35%Garage or carport not reported176941762233131672

82946453234704617554678

Selected Deficiencies@1

28%Signs of rats in last 3 months

23%Signs of mice in last 3 months630438523651460553261153260232628

Signs of rodents, not sure which kind3452122089272215151024

26%in last 3 months

34%Holes in floors9784516533710078446549126

31%Open cracks or holes (interior)523228763351646633324252213225374

35%Broken plaster or peeling paint23401252155811285165126113122122

(interior)

18%No electrical wiring74401513203456

26%Exposed wiring64340444167662332281828

30%Rooms without electric outlets14868341224471547795586383

1970921126820239176121133151103

Selected Physical Problems

42%Severe physical problems@1

39%Plumbing13556679653515311291799858

51%Heating49518428250835520504234

11%Electric9368810421207

39%Upkeep87378345964118

100%Hallways7007133000

44%Moderate physical problems@1432020051331918714412340241211265

43%Plumbing19585188331121313149

7%Heating14471183131038112271149

34%Upkeep13036708644915910457616898

100%Hallways148001485933311780

87%Kitchen141013919123242027624916012819

2817113101206111154319922042004162221251855

Persons

40%1 person575111154

20%2 persons344242325120226914249514211317863818223729986914

20%3 persons173261188492633901263725629438334112614013389

13%4 persons153191157673620568624653112351819537272054

13%5 persons684651593468833852021249874458296883

16%6 persons2414177212137816587602739144126378

14%7 persons or more1343101162189105302211218154189

81703509494960205987156449239852667229951951135324961

Persons 65 Years Old and Over

25%None

22%1 person1623010560924360710525643905031099113919923608

10%2 persons or more791062443897572667994124194520412757

6087161844736811165891858470297341

Age of Householder

60%Under 25 years

43%25 to 297805328261533841191755664478295524

30%30 to 3410575598080331351030710624440331656

20%35 to 4422516151921291456116559568685545281472

17%45 to 5421828156511084374513318216284655011347

16%55 to 64154041106989824119074113932874121026

16%65 to 741078277195461742531290247259416775

21%75 years and over1084572415882304663300187341812713

Median47494440403736395148

7767254652421213809527529312464167214674999

Household Composition by Age of

Householder

18%2-or-more-person households

Married-couple families,5354242012238458512202118010127477113294

11%no nonrelatives

42%Under 25 years13105341055451951461185036126

28%25 to 29 years3245188119590432019421211067266

17%30 to 34 years5491388832992031323217611880354

10%35 to 44 years13046104685061280491263215179132791

7%45 to 64 years212221784880914316132511881692111133

8%65 years and over9228739343977226994103121185624

32%Other male householder850145795752728982578548354266619

40%Under 45 years551625254212202780473452289209369

17%45 to 64 years2275157212339414488824831186

19%65 years and over71048232132581714172664

33%Other female householder15629806112535230209111739055714901085

42%Under 45 years8881372078337651485906696401277614

24%45 to 64 years479829473751156477221181134143320

16%65 years and over194913959430912946283669151

40%1-person households2817113101206111154319922042004162221251855

42%Male householder122495441783511215081030970794810912

51%Under 45 years552119664142808828562607478333333

36%45 to 64 years423020272491540480344274183258415

31%65 years and over2497144812076519912588133219164

38%Female householder159227660127760411691117410348281315943

59%Under 45 year397310914042339630536538318317140

35%45 to 64 years470723274261635524328297217270319

29%65 years and over724342424482068538310200293728485

3815826363207871192856166612197985792598

Adults and Single Children Under

18 Years Old

19%Total households with children25967118

11%Married couples2593420205109929561184668499351253167411032955

21%One child under 6 only3695243121878625616518611068260364785

13%One under 6, one or more 6 to 1744033331170565239150706739337

15%Two or more under 6 only2397177013136915683614721128

Two or more under 6, one or more1313950681797337381614115

14%6 to 17

7%One or more 6 to 17 only14125117235121056460233143110111834

27%Other households with two or more540930784051463538351252182140462

adults




19%Two or more under 6, one or more2841603755271361932

6 to 17


40%Households with one adult or none68163080574270011346474682651864629192700




50%Two or more under 6, one or more22063231115339141523

6 to 17


26%Total households with no children6768441390419517844561834693249249630134256875817845

11%Married couples28385223341322300710665355284084711722

34%Other households with two or more11457605186338511389793737482451691

adults

39%Households with one adult2784313004201010986316321411984160720911842568210986

530725173912057622478339287330342

Household Income

39%Less than $5,000

42%$5,000 to $9,99958412501298245080048232032852059211682450

35%$10,000 to $14,99967583269372238179047043230638373711212381

34%$15,000 to $19,999663132594032276817470422298269693

32%$20,000 to $24,999691535784062215816529417257197716

29%$25,000 to $29,999685138513942005672418391250275601

27%$30,000 to $34,999719141754731957663418368270238586

26%$35,000 to $39,999571234233131472459336302174202503

24%$40,000 to $49,999966360586172310772508457327247679

20%$50,000 to $59,999840857475291660599306304218233472

15%$60,000 to $79,9991300296148611983690378373238304544

11%$80,000 to $99,99980936536466899328159146130136192

9%$100,000 to $119,999511743422514481507780687377

8%$120,000 or more103538884498850296108117143185121

Median41774521704137527749279102666728891284342675627884

626930014322383791542404299347454

As percent of poverty level:

38%Less than 50 percent

40%50 to 99769133504253081104869345338250483413393080

32%100 to 1499984513559531861073636541425511106814773186

28%150 to 199945153215062682949579511327316941

19%200 percent or more7244850946431513631461326852559186019143557

602228124382359733535409328354413

Income of Families and Primary

Individuals

39%Less than $5,000

43%$5,000 to $9,999626726133272670896528362346539656

36%$10,000 to $14,999715034614022541845530453322391746

35%$15,000 to $19,999701233944062481877530475303296732

32%$20,000 to $24,999725837344232357886568401296205744

29%$25,000 to $29,999713040014312098695418445260281599

27%$30,000 to $34,999738143085152002670420385277250556

24%$35,000 to $39,999571034763391394445303276168202500

23%$40,000 to $49,999937460495772141734455414299239607

18%$50,000 to $59,999793755785081427488271248217203424

13%$60,000 to $79,9991231493557821656563318312194269521

10%$80,000 to $99,99975486225429723266111121103122172

8%$100,000 to $119,999490642162333831215961707175

7%$120,000 or more9833853146173125390106109172110

Median39116500513785625173249932391426511259872519826137

1283578253337687633572347

Monthly Housing Costs

26%Less than $100

16%$100 to $1997211461526511843192151361483661147

15%$200 to $2495000360117276826514510471182460

13%$250 to $299475534301986342221318366132494

17%$300 to $3494558319221176232013599101109393

23%$350 to $39941782614205981441208109104119379

27%$400 to $449446726082501213475270189175105396

33%$450 to $499444922712711464554315273179144443

36%$500 to $5998780431751831771226689597359306768

38%$600 to $6998471418155132061004777680444301533

36%$700 to $799788241065292856798598675434351392

29%$800 to $99912010718789534511013772698516452477

21%$1,000 to $1,2491016871127302100632389411296372226

13%$1,250 to $1,4996629523445889433614613911016343

10%$1,500 or more13783115388031339530133151196329103

27%No cash rent22181169193601263126626288254

Median (excludes no cash rent)684745770651620639681685671410

5287419419940312272654599491

Monthly Housing Costs as Percent of

Current Income@3

8%Less than 5 percent

9%5 to 9 percent1230997225151087410176171133198985

14%10 to 14 percent144591055374920527253913692513151105

18%15 to 19 percent14686103758132649905585433349376849

25%20 to 24 percent12506797670431381070635629447356688

29%25 to 29 percent969357416272800924596485366428525

30%30 to 34 percent708140245142159651473429309298384

33%35 to 39 percent486026613411597532389290196190261

35%40 to 49 percent622032514412171703430403329305356

37%50 to 59 percent342417182451257465259222148163203

36%60 to 69 percent210810421757692901481607398121

39%70 to 99 percent324715972141266429285241157154171

39%100 percent or more@4517724993752018675356341274372285

39%Zero or negative income25681231168994308214167153152175

27%No cash rent22181169193601263126626288254

Median (excludes 2 previous lines)21.518.924.829.228.829.529.629.228.818.7

Median (excludes 3 lines before medians)20.418.323.427.4272827.927.426.717.8

10575767692626424953846951324467329135926847

Monthly Cost Paid for Electricity

24%Electricity used

55%Less than $25539718424052948907707489478368203

29%$25 to $49292211687219148610301617791552123310301825

19%$50 to $742850819461176353221839124411496064831962

12%$75 to $99158081194880119107863753671991831149

8%$100 to $1491279610102599106446721318898981031

7%$150 to $1993741303813325812349352327312

11%$200 or more2154175675228894048351795

73%Median62675745474647424266

Included in rent, other fee,81312673574461312437256406191387271

57%or obtained free

Sheet1

Occupied

TotalOwnerRenterTotal

Total105842722383360411369

677535964281115129

Units in Structure

1, detached0.7641484477

1, attached627236792593750

2 to 484741426704813900.080062735

5 to 9513550146348030.0485157121

10 to 19446848539838870.042213866

20 to 49329438929055540.0650592392

50 or more35926012991568

Manufactured/mobile home or trailer6854551413401288

55837818075

Cooperatives and Condominiums

Cooperatives

Condominiums472234161305867

105842722373360511369

Sheet11

TotalU.S. Households Labor 2003 data#Households

Married Couple total57,320,000

31,406,000Married Couple with children

Possible solutions for working parentsFamily or friends to provide careVolunteers to provide care to small numbers of children (no more than 6)Teleworking option for parentsShift changes allowing parents to be home at different times

Possible solutions for child instructionUse email, web lessons, mailed assignments, cable TV, phone calls to continue learning

Provide parents with home- schooling materials appropriate for their child

Possible solutions of loss of school mealsWeekly parent pick-up or home delivery of food items for child

Other community food providers

Possible solutions for state funding of schoolsGovernor has the power to waive state statutes and regulations in emergency

School districts should work now with legislators and governor to ensure funding of school operations if severe pandemic sends children home

Community Mitigation Summary

Ill persons should be isolated Voluntary home quarantine for household contactsSocial distancing measuresDismissing students may have profound impactWorkplace social distancing and liberal leave NOT closure (for most)Cancellation of public events, closure of entertainment venues (movies, sports,etc.), even church services may be cancelled

Key Stakeholders mustUnderstand reasons for public health recommendationsParticipate in discussions about such interventions with a goal of reaching consensusWork together to do what need to be done to save lives.

Charlie, 45Jessie, 40Florence, 19Tommy, 16Harry, 10Bobbie, 8Davie, 6Willie, 4

A Larimer County family -- all 8 died in a 10-day period, Oct Nov. 1918

With H5N1, children have high mortality

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The pandemic of 1918 was a very severe pandemic as you can see by the huge spike in the graph. During the course of the epidemic,47% of all deaths in the US resulted from influenza and its complications. Influenza killed enough people during this time to depress the average life expectancy in the US by more than 10 years.

This spike represents about a 2.5% mortality rate among people who became ill, or about 0.6% (less than 1%) of the total population--since not everyone got infected or became ill.*****Focus on #3, with some discussion of #4.********Comparison of two cities on opposite ends of the cumulative mortality curve in the previous slide. This provides a clearer picture of the differences in experience between cities in 1918 differences that can be obscured if an analysis is limited to cumulative mortality.Note that Philadelphia implemented community-wide interventions relatively late in the outbreak, relative to St. Louis, and likely suffered from the decision to continue with certain activities such as the Liberty Loan Parade.The St. Louis experience approximates the objectives outlined on slide (Community Based Interventions): delay the peak, lower the peak, and reduce the total area under the curve.*********Viboud C, et al. Risk factors of influenza transmission in households. British Journal of General Practice 2004;54:684-689.

Heymann, A, et al. Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization. Ped Infect Dis J 2004;23:675-677.******The use of community containment interventions, particularly school closure, inevitably leads to questions about the impact on the workforce. This data from the U.S. census shows that 8% of households have a working couple with children < 12, and 5% of households have a single parent with children < 12. The U.S. Census used the age threshold of 12 years in its statistics, hence the above segregation of the data. This should not be interpreted as guidance on the minimum age for children to be left at home without adult supervision.

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Documents

Community Mitigation of Pandemic Influenza