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What interventions may help protect my organization during a pandemic?
The public health and medical communities have identified multiple methods to combat the
spread of pandemic influenza. These countermeasures fall into two broad categories:
medical interventions (both pharmacologic [i.e., pharmaceutical] and nonpharmacologic [i.e., non-pharmaceutical] interventions) and social interventions. 55
Public health interventions include both pharmacologic and nonpharmacologic approaches.
Pharmacologic products include pandemic influenza vaccines and antiviral medications,
whereas non-pharmacologic products include masks, gloves and respirators. The effectiveness of
individual infection control measures (e.g., cough etiquette, hand hygiene) and the role
of surgical masks or respirators in preventing the transmission of influenza are
currently unknown. While cough etiquette and hand hygiene will be recommended universally,
the use of surgical masks and respirators may be appropriate in certain circumstances.56
Social intervention strategies represent voluntary and imposed social constraints that might inhibit the spread of pandemic influenza within a community.
The Centers for Disease Control and Prevention recently developed guidance on the use of
social interventions to limit the spread of disease based upon an early, targeted,
layered mitigation strategy involving the directed application of multiple, partially
effective nonpharmacologic measures initiated early and maintained consistently during
an epidemic wave.56
These interventions include:56
- Isolation and treatment (as appropriate) with influenza antiviral medication of all people with confirmed or probable pandemic influenza. Isolation may occur in the home or healthcare setting, depending on the severity of an individual’s illness and/or the current capacity of the healthcare infrastructure
- Voluntary home quarantine of members of households with confirmed or probable influenza case(s) and consideration of combining this intervention with the prophylactic use of antiviral medications, provided that sufficient quantities of effective medications exist and that a feasible means of distributing them is in place
- Dismissal of students from school (including public and private schools as well as colleges and universities) and school-based activities and closure of childcare programs, coupled with protecting children and teenagers through social distancing in the community to achieve reductions of out-of-school social contacts and community mixing
- Use of social distancing measures to reduce contact among adults in the community and workplace, including, for example, the cancellation of large public gatherings and alteration of workplace environments and schedules to decrease social density and preserve a healthy workplace to the greatest extent possible without disrupting essential services. Enable institution of workplace leave policies that align incentives and facilitate adherence with nonpharmacologic interventions outlined above.
Most likely, these proposed social intervention strategies, along with nonpharmacologic
countermeasures, will be the only disease containment measures available to the public in the
early wave(s) of a pandemic. Whether viewed individually or together, none of these
countermeasures represents a panacea for a pandemic.55 There would be
significant challenges and social costs if the above measures were imposed.56
Based on experience from the 1918 pandemic, there is a great likelihood that some form of the
above social interventions would be implemented in most communities at some point during the
pandemic. The danger exists that uncoordinated, untimely and inconsistent application of
these interventions across our country would impose all of the social and economic costs
with dramatically reduced effectiveness. Only through coordinated efforts across our
organizations and communities will we have the best chance of securing the significant
benefits that these strategies may provide.56
The benefits of these strategies are that none depends on public access to medical care
and all assist in reducing the demand for medical care—important facts given the likelihood
that hospitals, doctors' offices, and health clinics will be overwhelmed during the peak
pandemic waves.55
Pharmacologic Interventions
Pharmacologic interventions for pandemic influenza fall into two major categories:
vaccines and antiviral medications. Each intervention comes with positive and negative
characteristics that define how healthcare providers may most effectively use them before
and during a pandemic. Beyond the characteristics of the interventions themselves, current
vaccine and antiviral medication distribution plans may be overwhelmed in a scenario
demanding swift, nationwide distribution on a scale required to respond to a
pandemic. This is particularly true when trying to reach
public and private sector entities operating across state borders.55
Vaccination
Vaccination is one of the most effective ways to minimize suffering and death due to
seasonal influenza. In fact, vaccination is universally regarded as the most important
medical intervention for preventing seasonal influenza and reducing its health consequences.57,58
Flu Vaccines
Flu vaccination is recommended for people who are at high risk for complications if they
contract flu. It is also recommended for people 50 to 64 years of age, since one third of
individuals in this age range have medical conditions that place them at increased risk for
complications from the flu. Flu vaccination is also recommended for those who will be in
close contact with others at high risk for complications from the flu.57
Flu vaccination is not recommended for the following individuals:57
- People younger than 6 months of age
- Those with severe allergies to chicken eggs
- Those who have had a severe reaction to flu vaccine in the past
- Anyone who has ever developed Guillain-Barré syndrome
Vaccines in a pandemic
Traditionally, influenza vaccine production cannot begin until after researchers identify
and isolate the specific strain of an influenza virus.55 This means that
it is highly unlikely that a well-matched vaccine will be available when a pandemic begins,
unless a vaccine with broad cross-protection is developed in the future. With the current
vaccine technology, pandemic-strain vaccine would not become available for at least 4 to 6
months after the start of a pandemic, although this lag time may be reduced in the future.56
Secondly, standard production restraints constrain the pace and volume of
production. Researchers seek to identify new technologies that would speed vaccine production
and improve the number of vaccinations possible from a given vaccine quantity.55
Production capacity in the United States presents a challenge given that, while five 2006 contracts for domestic plants have been awarded,59 only one US-based influenza vaccine plant with large-scale production capacity currently exists.58 There is also the risk that the continuing mutation of the influenza virus after it becomes transmissible from human to human would render the vaccine ineffective. Unless there is a major scientific breakthrough, it may be many months into the pandemic before adequate doses of vaccine reach the market. Sufficient prepandemic stockpiled vaccine may eventually be available at the start of a pandemic (presently there is only sufficient vaccine to treat 4 million individuals) but there is no guarantee that it will be effective against any emerging pandemic strain.55
For more information about the vaccine development process, visit the National Institutes of
Health Web site: http://www.nih.gov.
Antivirals
In preparation for a pandemic, federal, state, local and private sector officials have been stockpiling two antiviral drugs on the recommendation of the CDC.55
- TAMIFLU® (oseltamivir phosphate)
- Relenza® (zanamivir)
Doctors may use these medications as a treatment option to reduce the duration of
influenza symptoms. Physicians may prescribe TAMIFLU as prophylaxis against influenza.
There are specific uses approved for both TAMIFLU and Relenza, but doctors administer them
to their patients differently depending on age and health condition. The Federal government
and State governments have started stockpiling each of these drugs.55
According to the Centers for Disease Control and Prevention (CDC), the current supply of antiviral medication stockpiled is insufficient to support antiviral prophylaxis of members of households with ill individuals. The feasibility of rapidly--within 48 hours of exposure--providing these medications to ill individuals and those who live in households with ill individuals has not been tested, and the mechanism to support such distribution still needs to be developed.56 It is also important to note that the influenza virus' rapid mutation capacity may render these drugs ineffective.55 Public health agencies recommended against the use of amantadine and rimantadine in the 2006-2007 flu season, as well as in the previous season, due to drug resistance.60,61
Learn what role TAMIFLU could play in a pandemic.
Learn about how much antiviral medicine the government is stockpiling.
Personal Protective Equipment
In addition to stockpiling antiviral medications and vaccines, the government is also
acquiring Personal Protective Equipment (PPE) such as gloves, respirators, and surgical
masks. As of June 2006, the CDC’s Strategic National Stockpile contained 32.5 million masks.
While these stockpiled respirators and masks are similar, there are notable differences:
respirators, such as the N-95 respirator, more effectively filter the air that an individual
breathes, but wearers must have respirators fit-tested to assure maximum performance. Surgical
masks, while less efficient, do not require fit testing.55
Both barriers may serve the same two purposes: limiting the exposure of healthy populations
to the disease and limiting the ability of sick individuals to spread the disease. Similarly,
gloves will likely be used as standard barrier protection between healthy and sick
individuals.55 The FDA has published information on PPE and their use against
influenza outbreaks, including avian influenza.
For more information on PPE, visit www.fda.gov.
HHS is planning to use these physical, non-medical countermeasures in coordination with other
behavioral countermeasures to limit the public’s susceptibility to catching and/or spreading
the influenza virus. Handwashing education and proper cough etiquette are two examples of
highly effective public health recommendations on an individual level. The CDC has published
numerous documents outlining proper etiquette for handwashing and coughing/sneezing.55
Social Interventions
As mentioned above, the federal government is considering a series of social measures
intended to inhibit the spread of disease. These measures vary in their severity and
potential to disrupt day-to-day activities. Federal, state, and local government officials
are developing strategies to respond to a pandemic using these methods. These methods have
a historical precedent; health officials have used them in the past to assist in controlling
previous epidemics, with varying degrees of success. During a pandemic, the goal will be to
slow the transmission of the virus; delaying the spread of the virus will provide more time
for vaccine development while reducing the stress on an already burdened healthcare system. 55
The government retains the authority to limit the public’s movement during an outbreak. In
addition to border closures, isolation, and quarantine generally represent the most widely
known movement control methods. Quarantine is a legally enforceable declaration that a
government body may institute over individuals it considers potentially exposed to a disease,
but who are not yet ill. Isolation refers to the separation of persons who have a specific
infectious illness from those who are healthy and the restriction of their movement to stop
the spread of that illness If enacted, federal quarantine laws will be coordinated between
CDC and state and local public health officials, and, if necessary, law enforcement personnel. 55
During previous pandemics, particularly in 1918, many communities used isolation strategies
and “reverse quarantine strategies” to prevent the disease’s spread to their community from
surrounding populations. The government may also enact travel restrictions to limit the
movement of people and products between geographic areas in an effort to limit disease
transmission and spread. Authorities are currently reviewing possible plans to curtail
international travel upon a pandemic’s emergence overseas. 55
Limiting public assembly opportunities also helps limit the spread of disease. Concert halls,
movie theaters, sports arenas, shopping malls and other large public gathering places might
close indefinitely during a pandemic—whether voluntarily or through government imposed
mandate. Similarly, officials may close schools and nonessential businesses during pandemic
waves in an effort to significantly slow disease transmission rates. These strategies aim to
prevent the close interaction of individuals, the primary condition for spreading the
influenza virus. Even taking steps such as limiting person-to-person interactions within a
distance of three feet or avoiding instances of casual close contact, such as shaking hands,
will help limit disease spread. 55
Recently, the CDC published recommendations in its Interim Pre-Pandemic Community Mitigation
Guidance. In this document, the CDC tied the various nonpharmacologic interventions with 5
different levels of pandemics as shown below. 56
A pandemic will also demand changes in workplace behavior and practices. Businesses may be
encouraged to have employees work from home as a means to limit employee interaction. Other steps, such as instituting shift work and altering business processes to minimize employee
interaction, are likely reactions to a pandemic. DHS' Pandemic Influenza
Preparedness, Response, and Recovery Guide for Critical Infrastructure and Key Resources58
provides more detail on strategies that organizations can use to protect their employees and
their businesses during a pandemic.
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