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5/12/2011

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Disaster Crisis Outreach Referral Team, Chester County.

DCORT_03

Building Community Resiliency to Bioterrorism and Public Health Emergencies.

Gary Smith, Professor of Population Biology and Epidemiology, Section of Epidemiology and Public Health

School of Veterinary Medicine, University of Pennsylvania

Aim

• To strengthen community resilience and the capacity to respond to the psychosocial and mental health needs of individuals in Pennsylvania affected byPennsylvania affected by

• Bioterrorism, and

• Public Health Emergencies (including a pandemic influenza response)

DCORT_03:

Take home message

The psychosocial and mental health needs of the those that formulate and implement policies for the control infectious disease threats are rarely addressed – but they are

real enough!

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The initial response to a new infectious disease threat…

• Is usually labeled “wrong” by somebody (and often is)

– Nipah virus infections

– Foot and Mouth DiseaseFoot and Mouth Disease

– Mad Cow Disease

– Severe Acute Respiratory Syndrome (SARS)

– H1N1 “Swine ‘flu”

The psychosocial and mental health needs of policy

makers are rarely addressed

The decision makers have several problems

• What disease is it?

– If it truly is a new disease, it is often mistaken for something we already know about

• Hesitation

– Most disease control policies will have adverse consequences for someone and policy makers frequently delay implementation

• Conflicting definitions of success

– Policy makers cannot satisfy everybody!

Possible definitions of Success

• Achieve disease‐free status as quickly as possible

• Minimize overall losses to the population

• Minimize cost of control

• Spatial Containment (eg confine to a given state)

Minimize cost of control

• Minimize “push back” (eg public criticism)

Several of these definitions of success are

mutually exclusive!

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Case Study 1. Nipah Virus infection in Malaysiay

The first known outbreak of Nipa Virus infection in people and pigs (1998‐99) was initially diagnosed as

Japanese encephalitis (wrong)

It was decided the best strategy was to ban the movement of pigs (right) and to slaughter affected

h d ( l i ht)herds (also right).

But the cull was hampered by farmers

who, feeling inadequately

compensated by the government, continued to smuggle pigs from their

properties

Case Study 2. Foot and Mouth Disease in Britain in 2001

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The outbreak was not recognized for about a month

There are several reasons for this:

• The first farmer did not report a disease outbreak.

• Many of the other initial cases were in sheep which don’t seem too ill.

• Many British veterinarians had never seen a case of FMDDead pigs from

a farm near Heddon on the Wall

But even when the authorities knew it was Foot and Mouth Di th h it t d Wh ?Disease they hesitated. Why?

It is estimated that if appropriate measures had been implemented just 3 days earlier the epidemic would have been HALF the size

…Because policy dictated that they shut down and quarantine all infected farms and kill all the animals on those farms and all the

animals on “exposed farms”

Movement bans and quarantine zones are hard to set up and

Threatening a farmer’s livelihood is no easy decision.

enforce?

…and the logistical difficulties are formidable

You inconvenience everybody

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…and who really wants to make the decision to begin a cull?

Round them up

Kill the adults with a captive bolt gun

Kill the lambs “at foot” with a lethal injectionPhotographs courtesy of Dr Helen Aceto

In the USA, the SOP would be to kill cattle with rifles. Pistols, captive bolt guns, and lethal injections are recommended for pigs and sheep…

The grim process of “depopulation”

• “If animals are known to be infected, [or exposed] they mustexposed] they must be depopulated and disposed of by burning, burying or rendering”

And then you have to get rid of the bodies…

• By burial, burning or rendering…– “the individual in charge

building the fire must use ingenuity in acquiring ingenuity in acquiringmaterials and putting them to good use…”

– one cattle carcass requires: 50lbs of kindling wood, 3 hay bales, 3 8x1ft lengths of timber and 5 tires. Under “favorable conditions” it will take 2 days to consume one carcass. (USDA Response Plan)

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Logistical and social difficulties associated with disease control and disposal of

carcasses

Safety issues: this is an accelerant to make sure the fire burns Who is responsible for public safety?

Is it reasonable to assume that animal rights organizations will not become involved?

Slaughter is not a popular policy. Policy makers have to satisfy the contradictory demands of different

consituencies

The public protests the slaughter policy

And the decision to quarantine and cull involves not only famers, vets, and Ag personnel, but law

enforcement too.

• “Checkpoints should be located on all rural roads where they enter the quarantine zone”

• Checkpoints will be manned 24 hours a day and will be maintained for 30 days after the last infected animal is depopulated”days after the last infected animal is depopulated

• “In the high risk area, security will be accomplished primarily by patrols…”

• On affected farms… “A guard should be posted at the one open entrance…addition guards should posted around the premises”

• “Police and other monitoring officials should ensure compliance with established procedures…” (USDA Response Plan)

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Imagine the difficulties of trying to implement the stated policies in Chester County

By Day 3, with just two farms known to have FMD all

the roads intersected by the red circles wouldred circles would have police road

blocks if the policy is followed as

stated!

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Case Study 3. Mad Cow Disease

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Almost 18 months elapsed between recognition and reporting of Mad Cow Disease. Why?

• Clinical signs noted in cattle in 1985 but not reported in the formal

literature in 1987

Wells GA, Scott AC, Johnson CT, Gunning RF, Hancock, Jeffrey M, Dawson, Bradley R (1987) A novel progressive spongiform encephalopathy in cattle. Veterinary record 121: 419-420.

The Central Veterinary Laboratory scientists knew

almost immediately that Mad Cow Disease was a new

disease. But for the first first 12 months or so they were

instructed to say nothing for fear of compromising British

agricultural trade.

Were they right to be worried about the economic risk?

Absolutely.

• In the Financial Year 1996‐1997, the UK losses attributable to BSE were between ₤743 million ‐₤980 million.

http://www.iica.org.ar/Bse/14-%20Atkinson.html,

Obviously then, animal disease is not just a medical issue…take Canada, for example.

• In February, 2010, Canada confirmed its 17th case of Mad Cow Disease in a native born cow.

• This it means CanadaThis it means Canada cannot apply for “negligible risk” status until 2015.1

• Canada’s current “controlled risk” status costs money (extra surveillance, reduced international markets).

1. To apply for negligible risk status for BSE, a country has to have no cases for 11 years after the birth year of the youngest animal diagnosed.

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The decline in cattle cash receipts was immediate and sustained!

• Before the first Canadian case was recognized (2003), Canada was the world’s third largest exporter ofthird largest exporter of meat products (more than 100 markets)

• Now it exports to only 51 markets)

. http://www41.statcan.ca/2006/0920/htm/ceb0920_001_4-eng.htm

Politics, economics, public relations and the law I.

• May 20, 2003– First Canadian case (in Alberta)

– US announces a ban on all imports of Canadian beef (Canada's 90,000‐plus beef producers lose $11 million per day)

• June 8, 2003– Alberta Premier accuses the

federal government of a double standard because Ottawa relaxed employment insurance rules for workers affected by SARS in Ontario but not for Western beef day)

• May 29, 2003– Ontario Agriculture Minister

examines ways the Ontario could prevent Alberta cattle from entering Ontario

industry workers

• Sept. 1, 2003– 450,000 kilograms of beef are

served for free at barbecues across Canada to pull the country's beef industry out of a slump caused by a single case of BSE.

http://www.cbc.ca/news/background/madcow/timeline.html

Politics, economics, public relations and the law 2.

• July 15, 2003– Alberta Premier Ralph Klein says

Canada may have to consider trade sanctions against the USA unless they allow imports of Canadian beef.

• July 18, 2005– The 26‐month USA ban on cattle

imports was lifted.

• Aug. 12, 2004– Canadian cattle producers files a

lawsuit against the U.S. government seeking $150 million under a provision of NAFTA (arguing that producers have suffered because of the U.S. decision to close the border to Canadian beef )

http://www.cbc.ca/news/background/madcow/timeline.html

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The state of play in 1992

• The UK was faced with an apparently new, food‐borne, fatal disease of cattle.

• Meat and Bone meal was clearly implicated as the vehicle.

• The was a plausible (partial) explanation of how the disease had emerged when and where it did.

• The MAFF position was that this was a disease of cattle with no proven health risks for people.

Scrapie in sheep had been around for centuries –It presents no known risk to human health

But despite MAFF’s position people had begun to fear that, they too, could get

“Mad Cow Disease”

• "in the years to come our hospitals will be filled with thousands of people going slowly and painfully mad before dying "and painfully mad before dying."

Today newspaper, March 1, 1990 as referenced in Vol. 6, Chapter 4, (paragraph 4.479) of the BSE Inquiry (Phillips et al., 2000).

Not every one agreed with MAFF’s position that Mad Cow Disease was not

transmissible to people and civil servants have since revealed they were

making tentative plans for huge increases in the number of hospital

beds

It was much later that the UK authorities conceded that Mad Cow Disease and vCJD had the same cause

• People ingest the prion in contaminated processed meat

• The prion has also been transmitted to people by blood‐transfusion.

Charlene Singh, died of vCJD on June 20th, 2004 in Florida (CNN.com)

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Case Study 4. SARS

Severe Acute Respiratory Syndrome

• A viral disease, which, in humans, is characterized by dramatic increases in lung opacity, shortness of breath, and hypoxemia occurred at a median of 6.5 days (range, 3 to 12 days).

Lee, N. et al (2003) A major outbreak of severe acute respiratory syndrome in Hong Kong. New England Journal of Medicine. 348(20):1986-94, 2003 May 15.

Riley S. et al. (2003) Transmission dynamics of the etiological agent of SARS in Hong Kong: impact of public health interventions. Science. 300(5627):1961-6, 2003 Jun 20

SARS epidemic in Hong Kong, 2003

Can SARS be controlled?

VietnamVietnamAnalysis of the epidemic Analysis of the epidemic dynamics suggests that SARS dynamics suggests that SARS coronavirus, if uncontrolled, coronavirus, if uncontrolled, would infect the majority of would infect the majority of people wherever it was people wherever it was introd cedintrod ced Ho e erHo e er

TorontoToronto

introduced.introduced. However, However, straightforward quarantine straightforward quarantine procedures can (and have) procedures can (and have) terminated epidemicsterminated epidemics

Dye C. & Gay N. (2003) Modeling the SARS Epidemic, 20 JUNE 2003 VOL 300 SCIENCE www.sciencemag.org

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The 2003 Toronto SARS ExperienceBiot Report #302: November 27, 2005

• Hospital emergency departments are a point of entry of novel or existing infectious diseases into any hospital system. They employ technologies that invariably aerosolize respiratory tract microorganisms and handle high volumes of patients, often in tight quarters and continue care because in

• The provincial (Ontario) public health authorities were tardy in requiring closure of Scarborough‐Grace Hospital. Although they possessed the authority, they lacked planning, organization, information, manpower, and credibility, and were dealing with an unknown agent whose route ofquarters, and continue care because in

hospital beds are not available

• Hospital administrators at Scarborough‐Grace Hospital delayed closing the hospital, because of the stigma of being unable to cope, eliminating a steady stream of revenues, and removing a facility from providing care to patients who needed care

unknown agent whose route of transmission was also unknown.

• “Denial that an infectious disease threat exists, and delays in implementation of aggressive containment strategies because of medical, economic, or political machinations or ignorance will cost the community, state or province, and country dearly in the long run”

Pamela Varley: “Emergency Response System Under Duress: The Public Health Fight to Contain SARS in Toronto (A)”, John F. Kennedy School of Government Case Program, Harvard University, p. 1. Available at: http://www.ksgcase.harvard.edu/. See also, Implications of the SARS outbreak for Canadian emergency departmentsCAEP Position Statements. CJEM 2003;5(5):343‐347

To be fair, the opening phases of a real outbreak are subtle. They are easy to overlook, and very tempting to dismiss

Dairy Farms Submitting Samples Positive for MDR S . Newport 1999-2003 (01/25/04)

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SARS shuts Taiwan emergency roomCNN World, May 14, 2003|Mike Chinoy, CNN Senior Asia Correspondent

• The hospital has been overwhelmed with patients coming to the emergency room seeking symptoms for fever, which is one of the tell‐tale signs of the disease. Most of them did not have SARS, hospital authorities said.

• Citizens increasingly wear masks, and travelers on the Taipei subway are subject to fines if they aren't wearing them. Taxi drivers also wear masks and drive with their windows down.

• Taipei's mayor said police will now be assigned to check up on people who have been ordered to stay at home in quarantine, and authorities will begin phoning people in the evenings to be sure they are still at home.

• It is increasingly clear that SARS spread more rapidly following an apparent cover‐up at Taipei's municipal Hoping Hospital.

• There have been repeated complaints about disorganization and confusion at the Ministry of Health, the prime minister's office, and the president's office.

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So far we have been talking about infectious disease threats that may see a bit remote for ythose of us that live in the USA.

So let’s talk about ‘flu!

Case Study 5. Avian Influenza and Swine ‘Flu

1918 (H1N1),

1957 (H2N2)

There were four influenza pandemics in the last century

1957 (H2N2),

1968 (H3N2),

1977 (H1N1).

I Capua and DJ Alexander "Avian influenza and human health" National Reference Laboratory for Avian Influenza, Istituto Zooprofilattico Sperimentale delle Venezie, Via Romea 14/A, 35020 Legnaro Padua Italy

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The first was particularly destructive

1918 (H1N1),

1957 (H2N2),

“The Spanish flu of 1918 was particularly destructive, resulting in a higher death total in less than two years than in all of World War I”

“ recent assessments including1957 (H2N2),

1968 (H3N2),

1977 (H1N1).

Daniel J. Barnett, Ran D. Balicer, Daniel R. Lucey, George S. Everly, Jr., Saad B. Omer, Mark C. Steinhoff, Itamar Grotto (2005) A Systematic Analytic Approach to Pandemic Influenza Preparedness PlanningPLoS Medicine | www.plosmedicine.org December 2005 | 2: 1235-1241

…recent assessments, including new estimates from Africa and Asiasuggest that …50–100 million [died]”

Because there was so little immunity, rather

than because it was especially lethal.

1918 (H1N1),

1957 (H2N2),

“The Spanish flu of 1918 was particularly destructive, resulting in a higher death total in less than two years than in all of World War I” “

recent assessments including new1957 (H2N2),

1968 (H3N2),

1977 (H1N1).

Daniel J. Barnett, Ran D. Balicer, Daniel R. Lucey, George S. Everly, Jr., Saad B. Omer, Mark C. Steinhoff, Itamar Grotto (2005) A Systematic Analytic Approach to Pandemic Influenza Preparedness PlanningPLoS Medicine | www.plosmedicine.org December 2005 | 2: 1235-1241

…recent assessments, including new estimates from Africa and Asiasuggest that …50–100 million [died]”

On average, 98.5% of the people that got sick, recovered.

A case fatality rate of 2.5%

The case fatality rate of the subsequent epidemics was much less

• 1918‐1919 pandemic (H1N1)

– 50% of the world’s population was infected

– 25% of the world’s population was sickwas sick

– The mortality in reported cases was 0.6% ‐ 3.0%

• Subsequent pandemics – 1957, H2N2 (0.37%) ;

– 1968, H3N2 (0.15%)

Taubenberger JK, Morens DM. 1918 influenza: the mother of all pandemics. Emerg Infect Dis [serial on the Internet]. 2006 Jan [date cited]. Available from http://www.cdc.gov/ncidod/EID/vol12no01/05-0979.htm. Jonathan S. Nguyen-Van-Tama & Alan W. Hampson (2003) The epidemiology and clinical impact of pandemic influenza. Vaccine 21:1762–1768.

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So, why are we nervous about the next pandemic?

For the last decade, we have focused on the avian influenza outbreak (H5N1)

affecting poultry in

Source: Washington Post, April 2005

SE Asia

So, why are we nervous about the next pandemic?

For the last decade, we have focused on the avian influenza outbreak (H5N1) affecting large

Source: Washington Post, April 2005

numbers of poultry in SE Asia

Very few people have actually caught avian influenza (H5N1) but the case fatality rate may be as high as 61%!

http://www.who.int/csr/disease/avian_influenza/country/cases_table_2009_05_06/en/index.html

Is the 61% case fatality rate real or just an artefact?

The usual argument is that the case fatality

rate is inflated because the mild human cases

do not come to our attention…

However, active searches for people who we can

confirm were infected with H5N1 virus have found

very few additional cases

A very detailed review of the current literature (that takes explicit account of the few inapparent infections that have been found) suggests that the H5N1 case fatality is between 14-33%, which is still 10 times greater that the 1918 H1N1 Influenza.

F C K Li, B C K Choi, T Sly and A W P Pak (2008) Finding the real case-fatality rate of H5N1 Avian Influenza J Epidemiol Community Health 62:555–559.

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So, we were worried about avian influenza (H5N1) because it has a much higher

case fatality rate than other influenza’s.

…and then we had reports about a “swine ‘flu”

(H1N1)in Mexico that seemed to a case fatality rate that was as high as

H5N1

Frequently Asked Questions about H1N1

• How many people will get sick?

• How many people will die?

• Where did it come from?

• Whose is to blame?

– Why isn’t the government doing more?

– Why isn’t the government doing less?

It takes time (6‐12 months) to create a vaccine. So, in the absence of a vaccine, what ,

options do policy makers have?

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Influenza Mitigation Strategies

The goal is to protect life and slow the spread of the

virus (ie keep things manageable) until a

vaccine becomes available.

M. Elizabeth Halloran, Neil M. Ferguson, Stephen Eubank, Ira M. Longini, Jr., Derek A. T. Cummings, Bryan Lewis, Shufu Xu, Christophe Fraser, Anil Vullikanti, Timothy C. Germann, Diane Wagener, Richard Beckman, Kai Kadau, Chris Barrett, Catherine A. Macken, Donald S. Burke, and Philip Cooley (2008) Modeling targeted layered containment of an influenza pandemic in the United States. PNAS 105: 4639–4644


Mitigation strategies that do not involve vaccines are best understood as

holding actions.

This is what happens if we do nothing.


They also necessarily increase the length of the

outbreak without much reducing the overall attack rate (ie approximately the same number of people

get sick)


• School closure (children are infectious for longer)

• Liberal leave policy

• Workplace social distancing (work at home)

• Use antiviral compounds therapeutically and/or prophylactically

• Personal protective measures (eg hand washing(work at home)

• Community social distancing (close movie theaters, cancel large gatherings)

measures (eg hand washing, masks…very little evidence this is beneficial with respect to ‘flu)

• International travel restrictions (buys a couple of weeks)


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So, here is the problem

• Influenza mitigation decisions are based on how bad we think it is going to be. And we usually have to make those decisions before we have any good evidence one way or the other.

• One danger is overreacting to every pandemic and thereby breaking the system

• The other is not reacting rapidly enough

This dilemma leads to actions that have every appearance of ill‐considered haste

Federal officials had recommended that

schools with a confirmed H1N1 case of the flu close for up

The finding: We find that prolonged school closure during a pandemic might reduce the cumulative number of cases by 13–17% (18–23% in children) and peak attack rates by up to 39–45% (47–52% in children). Cauchemez et al (2008)

of the flu close for up to 14 days. More than

400 schools had closed.

Kathleen Sebelius said Tuesday the

government is dropping a

recommendationthat schools close if

they have students with the H1N1

influenza.

Simon Cauchemez, Alain-Jacques Valleron, Pierre-Yves Boëlle, Antoine Flahault & Neil M. Ferguson (2008) Estimating the impact of school closure on influenza transmission from Sentinel data Nature 452, 750-754

Summing up 1.

• In the case of H1N1 ‘flu decision makers “did not appear to expect the level of scientific uncertainty encountered early in the pandemic, and they often expressed significant frustration over changing CDC guidance.”1

• But the stresses on the policy makers involved in creating disease control policies are real and their mental health needs should not be discounted

1. Klaiman et al. BMC Public Health 2011, 11:73

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