Update: H1N1 Update: H1N1 PandemicPandemic

ByBy

Ford RowanFord Rowan

National Center for Critical Incident AnalysisNational Center for Critical Incident Analysis

17 September 200917 September 2009

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Status in Week 35Status in Week 35

Decreasing flu activity in Southern HemisphereDecreasing flu activity in Southern Hemisphere

Increasing levels of influenza in tropical regionsIncreasing levels of influenza in tropical regions– Bolivia, Ecuador, VenezuelaBolivia, Ecuador, Venezuela– India, Bangladesh, CambodiaIndia, Bangladesh, Cambodia

““Variable” activity in Northern Hemisphere.Variable” activity in Northern Hemisphere.– Moderate or low levels in Europe (beginning to report increases Moderate or low levels in Europe (beginning to report increases

in Eastern Europe)in Eastern Europe)– Increased flu activity in United States, particularly in Increased flu activity in United States, particularly in

Southeastern states.Southeastern states.

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US StatusUS Status

Estimate 1,000,000 infections have occurred in USA.Estimate 1,000,000 infections have occurred in USA.

40,000 probable/suspected cases (CDC)40,000 probable/suspected cases (CDC)

In early Sept CDC reports increasing flu activity In early Sept CDC reports increasing flu activity

97% of confirmed cases of influenza A were H1N1.97% of confirmed cases of influenza A were H1N1.

““Efforts to track all cases of influenza … are impractical Efforts to track all cases of influenza … are impractical because of the large number of people infected,” (CDC)because of the large number of people infected,” (CDC)

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US Government ResponseUS Government Response

Clinical trials of vaccine to prevent infection – early Clinical trials of vaccine to prevent infection – early report are “Encouraging”report are “Encouraging”

NIH assumes vaccines will begin shipping in mid NIH assumes vaccines will begin shipping in mid October, possibly earlier.October, possibly earlier.

Use of Tamilflu is recommended at onset of flu Use of Tamilflu is recommended at onset of flu symptoms to reduce severity of respiratory illness. symptoms to reduce severity of respiratory illness.

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Surveillance ChallengesSurveillance ChallengesEmergent diseases are a considerable challenge Emergent diseases are a considerable challenge – Epidemiology is evidence-driven and based on statistics.Epidemiology is evidence-driven and based on statistics.– Data is limited, inherently a lagging indicator, subject to revision.Data is limited, inherently a lagging indicator, subject to revision.

Early on US govt Early on US govt stoppedstopped testing all cases testing all cases – Focused on those hospitalized or who died.Focused on those hospitalized or who died.

Problems includeProblems include– fragmented and/or incomplete information, fragmented and/or incomplete information, – trade-offs between sensitivity and specificity, trade-offs between sensitivity and specificity, – certainty and/or context, certainty and/or context, – timeliness (real-time versus right-time), and timeliness (real-time versus right-time), and – validation (verification).validation (verification).

Actionable public health information requires judgment Actionable public health information requires judgment calls and is contextual.calls and is contextual.

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Other sources of informationOther sources of information

Online data sources Online data sources – Various governmental agencies and unofficial sitesVarious governmental agencies and unofficial sites– Web applications (categorization, filter, visualize).Web applications (categorization, filter, visualize).– Blogs and social networking,Blogs and social networking,– Web tools including Google flu-tracker: Web tools including Google flu-tracker:

http://www.google.org/flutrends/

Internet sources suffer from concerns about information Internet sources suffer from concerns about information overload, system failure, false reports, lack of signal overload, system failure, false reports, lack of signal specificity, context. specificity, context.

News reports are often sensationalistic and superficial. News reports are often sensationalistic and superficial.

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Beyond illness: mapping the Beyond illness: mapping the economic and social consequenceseconomic and social consequences

Federal government is putting an enormous amount Federal government is putting an enormous amount of pandemic money into vaccines.of pandemic money into vaccines.

Vaccines will be introduced when the disease is Vaccines will be introduced when the disease is spreading, which may alter their effectiveness and spreading, which may alter their effectiveness and risks.risks.

Memories of bad past experience: Memories of bad past experience: The swine flu epidemic of 1976. The swine flu epidemic of 1976. More people died from the vaccine More people died from the vaccine (500 cases of Guillain-Barre Syndrome)(500 cases of Guillain-Barre Syndrome)than from the flu (25 died) than from the flu (25 died)

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Lessons - 1976 Swine Flu DebacleLessons - 1976 Swine Flu Debacle

• Decision-making without reconsidering new data.Decision-making without reconsidering new data.• Inability to communicate real-time data and updates.Inability to communicate real-time data and updates.• Inadequate communication between technical experts Inadequate communication between technical experts

and decision-makers, particularly about known facts and decision-makers, particularly about known facts versus un-validated theories.versus un-validated theories.

• Insufficient public risk communication.Insufficient public risk communication.• Inadequate and non-credible media relations.Inadequate and non-credible media relations.• Decisions made on theoretical possibilities rather than Decisions made on theoretical possibilities rather than

observed facts;observed facts;• Unrealistic expectations of intervention effectiveness, Unrealistic expectations of intervention effectiveness,

and failure to plan for alternative measures.and failure to plan for alternative measures.

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Modeling the Psychosocial Impact

Primary

Secondary

Tertiary

Time (Not to scale)

Psychological

Response

(Not to scale)

Tipping Point (Not to scale)

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Modeling the Psychosocial Impact - Diseases

Primary

Secondary

Tertiary

Time

Psychological

Response

Disease management

Affected persons

Initial description

Horizontal Vertical Mixed1212

Public Health issues have economic Public Health issues have economic and psychosocial impactand psychosocial impact

Attention to the ways earlier cases evolved can help avoid Attention to the ways earlier cases evolved can help avoid the most serious problems associated with the secondary the most serious problems associated with the secondary and tertiary impacts of a pandemic.and tertiary impacts of a pandemic.

– Seasonal flu in 2003-04 with media attention to Seasonal flu in 2003-04 with media attention to deaths of childrendeaths of children

– Anthrax attacks of 2001Anthrax attacks of 2001

– SARS in 2003SARS in 2003

– Public health consequences of flooding after Public health consequences of flooding after hurricane Katrinahurricane Katrina

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Psychosocial Impact – Seasonal Flu

Time (Not to scale)

Psychological

Response

(Not to scale)

Tipping Point (Not to scale)

2003-4Media notes “Flu ‘kills’ children”

Normal

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2001 Anthrax Attack2001 Anthrax Attack Government officials initially give false reassurance. Government officials initially give false reassurance.

Government sources give contradictory information and Government sources give contradictory information and were slow to provide expert advice.were slow to provide expert advice.

Rapid treatment provided to Congressional staffers.Rapid treatment provided to Congressional staffers.

Flawed advice and delayed treatment for postal workers. Flawed advice and delayed treatment for postal workers.

Media focus on “unfair” treatment for Black postal Media focus on “unfair” treatment for Black postal workers who died.workers who died.

Uncertainty about what advice to give citizens for Uncertainty about what advice to give citizens for handling of mail.handling of mail.

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Anthrax - Who do you trust?Anthrax - Who do you trust?

33% trusted homeland security33% trusted homeland security

33% trusted the FBI director33% trusted the FBI director

44% trusted the US Surgeon General44% trusted the US Surgeon General

48% trusted the director of CDC48% trusted the director of CDC

52% trusted their local/state health director52% trusted their local/state health director

53% trusted their local police chief53% trusted their local police chief

61% trusted their local fire chief61% trusted their local fire chief

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2003 SARS Outbreak2003 SARS Outbreak

In Toronto public health trumped individual freedom of In Toronto public health trumped individual freedom of movementmovementoThousands quarantinedThousands quarantinedoPersonal privacy “temporarily suspended” to protect public Personal privacy “temporarily suspended” to protect public healthhealthoMedical care denied to some ill peopleMedical care denied to some ill peopleoMedia attention to extraordinary measures, including Media attention to extraordinary measures, including disinfectiondisinfectionoLarge economic lossesLarge economic lossesoConcerns range from “will I catch this?” to “will you infect Concerns range from “will I catch this?” to “will you infect me?”me?”oSuspicion, avoidance and stigmatization of Asians.Suspicion, avoidance and stigmatization of Asians.

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Aftermath of Hurricane KatrinaAftermath of Hurricane Katrina

Ineffective response by city, state and federal officials.Ineffective response by city, state and federal officials.

News of inadequate preparation and evacuation.News of inadequate preparation and evacuation.

Graphic coverage of widespread disaster, deaths and Graphic coverage of widespread disaster, deaths and despair.despair.

Reports of looting, attacks on hospitals, shootings. Reports of looting, attacks on hospitals, shootings.

Focus on plight of the poor, elderly and Blacks.Focus on plight of the poor, elderly and Blacks.

Police defections; federal troops sent to quell unrest.Police defections; federal troops sent to quell unrest.

Deaths in hospitals; allegations of euthanasia.Deaths in hospitals; allegations of euthanasia.

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Common Elements: Common Elements: Anthrax, SARS, KatrinaAnthrax, SARS, Katrina

Lack of clarity of rules and procedures prior to crisisLack of clarity of rules and procedures prior to crisis

Second guessing of all major governmental decisionsSecond guessing of all major governmental decisions

Trust and credibility issues regarding official sourcesTrust and credibility issues regarding official sources

Ethical controversies over who gets care, including Ethical controversies over who gets care, including medical caremedical care

Law enforcement was a crucial challengeLaw enforcement was a crucial challenge

Allegations of mistreatment of minorities and/or the poorAllegations of mistreatment of minorities and/or the poor

Decisions seemed to be made by the seat of their pantsDecisions seemed to be made by the seat of their pants

News media challenged. Coverage amplified the risksNews media challenged. Coverage amplified the risks..

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What is to be done?

“In a crisis, the condition most likely to induce panic isn’t bad news, it’s conflicting information from those in authority.”

Barbara Johnson, CDC

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