1. Comparison of Private vs. Public Interventions for Controlling Influenza Epidemics Joint work with Chris Barrett, Jiangzhuo Chen, Stephen Eubank, Bryan Lewis, Yifei Ma and Madhav Marathe Achla Marathe Virginia Bioinformatics Institute and Dept. of Agricultural and Applied Economics

2. This work has been funded in part by the following grants: NIH-MIDAS, NIH-R01, DoD CNIMS, NSF-ICES and NSF-NetSe. Acknowledgment

3. Goal: – Design effective intervention strategies to control the spread of Influenza. Challenges: – Lack of compliance for public health directives. – Lack of accurate knowledge about the global prevalence and the severity of the disease. Introduction

4. This research considers two sets of interventions strategies, private and public. Evaluates the performance of each intervention strategy under a variety of scenarios through agent based simulations. Uses a synthetic social network of a large urban city as the area of study. Offers guidance to public health policy makers. Introduction

5. Standard Evaluation Measures Effectiveness of intervention: – Reduce attack rate/peak – Delay outbreak/peak Cost – Number of antivirals or vaccines consumed. These are often available in limited supply – Other costs: e.g. administration of a mass vaccination campaign (not considered here)

6. Individuals observe the health state of distance-1 (or immediate) contacts in the social network. After a threshold number of contacts become sick, individual intervenes with an antiviral or a vaccine. Private Strategy AA Distance 1 neighbors of AInfected neighbors of A

7. Public Strategy Block intervention: take action on all people residing in a census block group if an outbreak is observed in the block group School intervention: take action on all students in a school if an outbreak is observed in the school

8. Private Individuals observe the health state of local contacts. High accuracy on prevalence Self motivated to intervene when encounter sickness. Compliance is high No delay Private vs. Public Intervention Strategies Public Public health officials use global incidence data Low accuracy on prevalence Interventions are imposed top-down on individuals. Compliance is low Delay in implementation

9. Experimental Settings Disease propagation through social contact network on a synthetic population – Miami network: 2 million people, 100 million people-people contacts Assume unlimited supply of antiviral and vaccine – One course of antiviral is effective immediately for 10 days: reduce incoming transmissibility by 80% and outgoing by 87% – Vaccine is effective after 2 weeks but remains effective for the season. Vaccine efficacy is 100%. Simulation tool used: Indemics Indemics is an interactive epidemic simulation and modeling environment that was developed in our group.

10. Within Host Disease Model Individuals move through disease states Incubation period: mean 1.9 days Infectious period: mean 4.1 days Symptomatic rate: 0.67 Asymptomatic are 50% less likely to transmit the disease.

11. Experiment: A Factorial Design 3 different intervention strategies: D1, Block, School 2 flu models: 20% (moderate) and 40% (catastrophic) attack rate Diagnosis rate: 2 values 1 and 0.3 2 threshold values for taking actions:.01 and.05 – Fraction of direct contacts found to be sick: D1 intervention – Fraction of block group (school) subpopulation found to be sick: block (school) intervention 2 compliance rates: 1 and 0.5. 2 pharmaceutical actions: Antiviral and Vaccination (VAX) Delay in implementing interventions: 2 values for Block and School, 1 day and 5 days; no delay for D1 2 x 2 x 2 x 2 x 2 x ( 2 + 2 + 1) = 160 cells 25 replicates per cell (4000 simulation runs!)

12. Experimental Results

13. Attack Rate: Moderate Flu with Various Interventions

14. Intervention Coverage: Moderate Flu with Various Interventions

15. Attack Rate: Catastrophic Flu with Various Interventions

16. Intervention Coverage: Catastrophic Flu with Various Interventions

17. Experiment Results: Effectiveness of Actions Antiviral is very effective under D1; almost no effect under two public strategies No efficacy delay; protect people from sick contacts immediately Efficacy expires after 10 days; hard to avoid transmissions from farther-away nodes in the neighborhood If only antiviral is available, should motivate people to take antiviral by themselves Vaccine performs best under Block, worst under School Two weeks efficacy delay; sick contacts become less relevant Form larger “ring” around “hot-spots” Large consumption under Block; little consumed under school (school students <25% of whole population) If sufficient vaccines are available, should apply Block intervention strategy

18. Experiment Results Compliance: limited impact on attack rate; almost linearly determine drug consumption – Higher compliance  more consumption – Double consumption !  twice reduction in attack rate Implementation delay: little difference between 1 day or 5 days Nothing is useful under low diagnosis + high threshold – Campaign to raise concern on epidemic and early action – Increase diagnosis accuracy and enhance public health surveillance

19. Antiviral or Vaccine D1 intervention is effective with antiviral; Block intervention is effective with vaccine School intervention consumes little: may be most cost-effective when drugs are available in limited quantity

20. Closer look at an interesting setting… (catastrophic flu, high diagnosis rate, low threshold, only vaccines available)

22. Comparative Performance under Vaccination

23. Summary An interesting comparison study – Individual behavioral vs. public health level interventions – Use simulations to guide policy Unique capability to run such complex, realistic studies – No other tool can apply interventions based on social network based relationships because it requires Detailed social network Network relationship based dynamic intervention capability An efficient simulation environment

24. Summary Vaccine intervention: Block strategy performs better than D1. Given the 2 week delay in vaccine efficacy, block strategy is able to form a larger ring around hot-spots. The immediate contacts become less relevant. However a lot more vaccines are needed. If the transmissibility is high and vaccines are available in abundant supply, the Block strategy is likely to be the best choice. Antiviral Intervention: If antivirals are available in limited supply, it may be best to distribute them to people over the counter to make them easily accessible.

25. Thanks!

26. Indemics: Interactive Simulation Indemics: Interactive Epidemic Simulation and Modeling Environment Data Models: – Relational Data about individuals (P) – Social Contact Network (N) – Transmission Network/Dendrogram (D) Queries on a single data type – (P) Find all school-ages in area – (N) Find all neighbors of person – (D) Find all infected persons at day Queries across multiple data types – Count number of infected persons in zip code 24060 (Blacksburg, VA) – Find all infectious students on day 20 in Blacksburg high school and their family members

27. Dynamic Queries and Interventions Users interact with the system using well-defined languages – Indemics commands: count infected persons : group = seniors, infected day = between 20 and 22 – SQL statements: select * from social_network SN and infections INF where SN.pid_a = INF.transmitee_pid and time = 20 (find all neighbors of all infections at day 20) – Libraries of queries can be pre-defined by expert users Indemics Interventions – apply interventions: type = antiviral, duration = 10, group = school age, infected_day = between 24 and 30 – apply interventions: type=work closure, duration = 5, group = adults, infected day = between 20 and 21; type = school closure, duration = 5, group = school age