Front Matter i-xviii
Summary and Assessment 1-56
1 The Story of Influenza 57-114
2 Today 115-140
3 Toward Preparedness: Opportunities and Obstacles 141-221
4 Strategies for Controlling Avian Influenza Birds and Mammals 222-253
5 Emerging Technical Tools 254-314
6 Beyond Biomedical Response 315-372
Appendix A: Pandemic Influenza: Assessing Capabilities for Prevention and Response 373-380
Appendix B: Selected Bibliography 381-387
Appendix C: The Critical Path to New Medical Products 388-389
Appendix D: Forum Members, Speakers, and Staff Biographies
Read this extract from Chapter 6
Beyond the Biomedical Response
OVERVIEW
An influenza pandemic will likely spawn a plethora of legal and ethical dilemmas and political and economic consequences, and its impact will depend to a large extent on the public’s perception of and reaction to the crisis. This chapter presents a variety of social perspectives on the coming pandemic: economic, legal, and ethical implications of various response options; opportunities for collaboration between public and private sectors; and public communication strategies to address both interpandemic and pandemic influenza.The chapter opens with a description of an economic model, based on the notion of preparation as an “insurance policy” against the next influenza pandemic, to calculate the investment necessary to prepare for a range of pandemic scenarios and responses. These calculations indicate the mutual exclusivity of two key goals of pandemic planning, minimizing overall mortality and minimizing economic impact, thus highlighting the need for a system by which to make such difficult choices and explain them to the public.
Focusing on the important role in mitigating pandemic influenza of both annual immunization (to build demand for flu vaccine, and therefore supply in the event of a crisis) and prompt vaccination against a pandemic strain, the chapter continues with a consideration of strategies to increase immunization uptake before and during a pandemic. In a pandemic—or even a severe annual flu season, as occurred in late 2003—public health officials face the difficult task of encouraging people with high priority to receive vaccine while persuading others to wait calmly and use nonmedical measures to reduce their exposure to infection. Limited research indicates that public officials can avoid losing their credibility in such situations by sharing the dilemmas of disease control with the public in a productive and effective way.
Current understanding about the influence and causes of panic in public crises and how to remedy its effects has been advanced through recent efforts to prepare society to deal productively with terrorism. Both the September 11, 2001, terrorist attacks and subsequent anthrax assaults in the United States demonstrated that open and informative relationships among citizens, government, and public health and safety authorities are fundamental to a population’s ability to cope with unconventional health threats. In her contribution to this chapter, Monica Schoch-Spana describes a series of findings by study and research focus groups convened by the Center for Biosecurity of the University of Pittsburgh Medical Center in collaboration with Johns Hopkins University to examine governance dilemmas in bioterrorism response. These groups characterized the unique governing dilemmas posed by a major infectious outbreak and produced guidelines by which decision makers can identify opportunities to enlist public trust and cooperation in such emergencies.
Legal authority must be brought to bear on nearly every facet of pandemic preparedness, from measures designed to reduce the risk of animal-to-human transmission of disease; to surveillance and detection procedures; to medical interventions to prevent or control the spread of infection; to the imposition of voluntary or mandatory quarantine and/or isolation measures; to travel limitations, trade restrictions, and border closures. This chapter continues with an examination of the legal and ethical questions attached to major public health interventions for preventing or ameliorating pandemic influenza; it also summarizes ethical values that can inform public health practice in an emergency.
THE ECONOMIC IMPACT OF PANDEMIC INFLUENZA IN THE UNITED STATES:
PRIORITIES FOR INTERVENTIONMartin I. Meltzer, Nancy J. Cox, and Keiji Fukuda
Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Reprinted from Emerging Infectious Diseases, CDC, 2003
(Address for correspondence: Martin Meltzer, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Clifton Road, Mail Stop C12, Atlanta, GA 30333; fax: 404–639–3039; e-mail: qzm4@cdc.gov)
We estimated the possible effects of the next influenza pandemic in the United States and analyzed the economic impact of vaccine-based interventions. Using death rates, hospitalization data, and outpatient visits, we estimated 89,000 to 207,000 deaths; 314,000 to 734,000 hospitalizations; 18 to 42 million outpatient visits; and 20 to 47 million additional illnesses. Patients at high risk (15% of the population) would account for approximately 84% of all deaths. The estimated economic impact would be US$71.3 to $166.5 billion, excluding disruptions to commerce and society. At $21 per vaccinee, we project a net savings to society if persons in all age groups are vaccinated. At $62 per vaccinee and at gross attack rates of 25%, we project net losses if persons not at high risk for complications are vaccinated. Vaccinating 60% of the population would generate the highest economic returns but may not be possible within the time required for vaccine effectiveness, especially if two doses of vaccine are required.
Influenza pandemics have occurred for centuries, three times (1918, 1957, and 1968) in the 20th century alone. Another pandemic is highly likely, if not inevitable (Patriarca and Cox, 1997). In the 1918 influenza pandemic, more than 20 million people died (Simonsen et al., 1998). Improvements in medical care and technology since the last pandemic may reduce the impact of the next. When planning for the next pandemic, however, decision makers need to examine the following questions: Would it make economic sense to vaccinate the entire U.S. population if 15% were to become clinically ill? What if 25% were to become ill? To answer such questions, we conducted economic analyses of potential intervention scenarios.
Although many studies have examined or reviewed the economics of influenza vaccination (Campbell and Rumley, 1997; Carrat and Valleron, 1995; Jefferson and Demicheli, 1998; Kavet, 1977; Office of Technology Assessment, 1981; Patriarca et al., 1987; Riddiough et al., 1983; Schoenbaum, 1987), only one study (Schoenbaum et al., 1976), published in 1976, examined the economics of a vaccine-based intervention aimed at reducing the impact of an influenza epidemic in the United States. Our study examines the possible economic effects of the next influenza pandemic in the United States, analyzes these effects, and uses the results to estimate the costs, benefits, and policy implications of several possible vaccine-based interventions. These estimates can be used in developing national and state plans to respond to an influenza pandemic. (Footnote: complete plan detailing a response to an influenza pandemic should include definition of a pandemic, points that will initiate various steps in the response plan, and details about deploying the intervention. While a U.S. federal influenza pandemic plan is being developed, a guide to aid state and territorial health officials in developing plans for their jurisdictions is available at http://www.cdc.gov/od/nvpo/pandemicflu.htm. Printed copies can be obtained from the author.) Unlike the 1976 study, ours examined the effect of varying the values of a number of key input variables. Specific objectives were to provide a range of estimates regarding the number of deaths, hospitalizations, outpatient visits, and those ill persons not seeking medical care in the next influenza pandemic; provide a cost estimate of health outcomes; estimate the potential net value of possible vaccination strategies;3 evaluate the effect of using different criteria (e.g., death rates, economic returns due to vaccination) to set vaccination priorities; assess the economic impact of administering various doses of vaccine and of administering vaccine to different age groups and groups at risk; and calculate an insurance premium that could reasonably be spent each year for planning, preparedness, and practice. (article continues in book)
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Front Matter i-xvi
Summary and Assessment 1-40
1. SARS: Emergence, Detection, and Response 41-90
2. Political Influences on the Response to SARS and Economic Impacts of the Disease 91-136 (skim)
3. Microbiology, Ecology, and Natural History of Coronaviruses 137-172
4. Diagnostics, Therapeutics, and Other Technologies to Control SARS 173-205
5. Preparing for the Next Disease Outbreak 206-276
Appendix A: Agenda: Learning from SARS: Preparing for the Next Disease Outbreak 277-280
Appendix B: Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease Among Persons Presenting with Community-Acquired Illness 281-291
Appendix C: In the Absence of SARS-CoV Transmission Worldwide: 292-302
Appendix D: Selected Bibliography 303-323
Appendix E: Glossary and Acronyms 324-338
Appendix F: Forum Member, Speaker, and Staff Biographies
Description
"The emergence of severe acute respiratory syndrome (SARS) in late 2002 and 2003 challenged the global public health community to confront a novel epidemic that spread rapidly from its origins in southern China until it had reached more than 25 other countries within a matter of months. In addition to the number of patients infected with the SARS virus, the disease had profound economic and political repercussions in many of the affected regions. Recent reports of isolated new SARS cases and a fear that the disease could reemerge and spread have put public health officials on high alert for any indications of possible new outbreaks. This report examines the response to SARS by public health systems in individual countries, the biology of the SARS coronavirus and related coronaviruses in animals, the economic and political fallout of the SARS epidemic, quarantine law and other public health measures that apply to combating infectious diseases, and the role of international organizations and scientific cooperation in halting the spread of SARS. The report provides an illuminating survey of findings from the epidemic, along with an assessment of what might be needed in order to contain any future outbreaks of SARS or other emerging infections."Stacey Knobler, Adel Mahmoud, Stanley Lemon, Alison Mack, Laura Sivitz, and Katherine Oberholtzer, Editors, Forum on Microbial Threats
376 pages, 6 x 9, 2004
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Front Matter i-xviii
Summary and Assessment 1-12
1 Defining the Relationship: An Examination of Infectious Agents Associated with Chronic Disease 13-80
2 Endemic Infectious Diseases Linked to Chronic Diseases: Implications for Developing Countries 81-134
3 Obstacles and Opportunities for Framing Future Research 135-173
4 Opportunities to Prevent and Mitigate the Impact of Chronic Diseases Caused by Infectious Agents 174-186
Appendix A: Workshop Agenda 187-191
Appendix B: Information Resources 192-193
Appendix C: Biosketches 194-216
Stacey L. Knobler, Siobhan O'Connor, Stanley M. Lemon, Marjan Najafi, Editors, Forum on Microbial Threats
236 pages, 6 x 9, 2004
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