1. Update: H1N1 Pandemic By Ford Rowan National Center for Critical Incident Analysis 17 September 2009 1

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3. Status in Week 35 Decreasing flu activity in Southern Hemisphere Increasing levels of influenza in tropical regions –Bolivia, Ecuador, Venezuela –India, Bangladesh, Cambodia “Variable” activity in Northern Hemisphere. –Moderate or low levels in Europe (beginning to report increases in Eastern Europe) –Increased flu activity in United States, particularly in Southeastern states. 3

4. US Status Estimate 1,000,000 infections have occurred in USA. 40,000 probable/suspected cases (CDC) In early Sept CDC reports increasing flu activity 97% of confirmed cases of influenza A were H1N1. “Efforts to track all cases of influenza … are impractical because of the large number of people infected,” (CDC) 4

5. US Government Response Clinical trials of vaccine to prevent infection – early report are “Encouraging” NIH assumes vaccines will begin shipping in mid October, possibly earlier. Use of Tamilflu is recommended at onset of flu symptoms to reduce severity of respiratory illness. 5

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7. Surveillance Challenges Emergent diseases are a considerable challenge –Epidemiology is evidence-driven and based on statistics. –Data is limited, inherently a lagging indicator, subject to revision. Early on US govt stopped testing all cases –Focused on those hospitalized or who died. Problems include –fragmented and/or incomplete information, –trade-offs between sensitivity and specificity, –certainty and/or context, –timeliness (real-time versus right-time), and –validation (verification). Actionable public health information requires judgment calls and is contextual. 7

8. Other sources of information Online data sources –Various governmental agencies and unofficial sites –Web applications (categorization, filter, visualize). –Blogs and social networking, –Web tools including Google flu-tracker: http://www.google.org/flutrends/ http://www.google.org/flutrends/ Internet sources suffer from concerns about information overload, system failure, false reports, lack of signal specificity, context. News reports are often sensationalistic and superficial. 8

9. Beyond illness: mapping the economic and social consequences Federal government is putting an enormous amount of pandemic money into vaccines. Vaccines will be introduced when the disease is spreading, which may alter their effectiveness and risks. Memories of bad past experience: The swine flu epidemic of 1976. More people died from the vaccine (500 cases of Guillain-Barre Syndrome) than from the flu (25 died) 9

10. Lessons - 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 and decision-makers, particularly about known facts versus un-validated theories.Inadequate communication between technical experts and decision-makers, particularly about known facts 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 observed facts;Decisions made on theoretical possibilities rather than observed facts; Unrealistic expectations of intervention effectiveness, and failure to plan for alternative measures.Unrealistic expectations of intervention effectiveness, and failure to plan for alternative measures. 10

11. Modeling the Psychosocial Impact Primary Secondary Tertiary Time (Not to scale) Psychological Response (Not to scale) Tipping Point (Not to scale) 11

12. Modeling the Psychosocial Impact - Diseases Primary Secondary Tertiary Time Psychological Response Disease management Affected persons Initial description HorizontalVerticalMixed 12

13. Public Health issues have economic and psychosocial impact Attention to the ways earlier cases evolved can help avoid the most serious problems associated with the secondary and tertiary impacts of a pandemic. –Seasonal flu in 2003-04 with media attention to deaths of children –Anthrax attacks of 2001 –SARS in 2003 –Public health consequences of flooding after hurricane Katrina 13

14. Psychosocial Impact – Seasonal Flu Time (Not to scale) Psychological Response (Not to scale) Tipping Point (Not to scale) 2003-4 Media notes “Flu ‘kills’ children” Normal 14

15. 2001 Anthrax Attack  Government officials initially give false reassurance.  Government sources give contradictory information and were slow to provide expert advice.  Rapid treatment provided to Congressional staffers.  Flawed advice and delayed treatment for postal workers.  Media focus on “unfair” treatment for Black postal workers who died.  Uncertainty about what advice to give citizens for handling of mail. 15

16. Anthrax - Who do you trust? 33% trusted homeland security 33% trusted the FBI director 44% trusted the US Surgeon General 48% trusted the director of CDC 52% trusted their local/state health director 53% trusted their local police chief 61% trusted their local fire chief 16

17. 2003 SARS Outbreak In Toronto public health trumped individual freedom of movement o Thousands quarantined o Personal privacy “temporarily suspended” to protect public health o Medical care denied to some ill people o Media attention to extraordinary measures, including disinfection o Large economic losses o Concerns range from “will I catch this?” to “will you infect me?” o Suspicion, avoidance and stigmatization of Asians. 17

18. Aftermath of Hurricane Katrina  Ineffective response by city, state and federal officials.  News of inadequate preparation and evacuation.  Graphic coverage of widespread disaster, deaths and despair.  Reports of looting, attacks on hospitals, shootings.  Focus on plight of the poor, elderly and Blacks.  Police defections; federal troops sent to quell unrest.  Deaths in hospitals; allegations of euthanasia. 18

19. Common Elements: Anthrax, SARS, Katrina Lack of clarity of rules and procedures prior to crisis Second guessing of all major governmental decisions Trust and credibility issues regarding official sources Ethical controversies over who gets care, including medical care Law enforcement was a crucial challenge Allegations of mistreatment of minorities and/or the poor Decisions seemed to be made by the seat of their pants News media challenged. Coverage amplified the risks. 19

20. What is to be done? Learn the lessons from past outbreaks (do not repeat) Act now – tomorrow is too late Plans are good, planning is better, practicing is best of all Communicate, communicate, communicate “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 20