How to survive the next big pandemic

The New Zealand Ministry of Health has recently published its 2017 pandemic action plan. Flicking through it I noted that it tends to cite other governmental publications rather than academic sources.

Of course, many of the publications cited may well cite the academic literature themselves, but I decided to take a quick independent look at what has been published since the 2009 H1N1 pandemic.

So this afternoon I searched PubMed for ‘pandemic, public health, virus’ and limited the results to the last five years, and review articles only. This turned up 354 results. I read the titles and selected 45 for abstract review. Please note, this is a quick look, so I have not read any full-texts.

The findings of these recent reviews can be collated under the following seven headings:

Travel Restrictions

• Travel restrictions delay pandemics if implemented within 6 weeks, but only reduce case numbers by 3%.

Although note a modelling study by Adapt Research Ltd, which suggests good cost-benefit for border closure in island nations.

Vaccines

• Vaccines are effective but there are cognitive facilitators and barriers to vaccination
• Some cross-protection occurs between strains, so any vaccination might be better than no vaccination
• There are attempts around the world to develop a universal vaccine effective against all pandemic influenza
• The Influenza Risk Assessment Tool (IRAT) can be used to prioritize vaccine development for those strains with most pandemic potential

A problem with vaccines is the clear difficulty in changing knowledge, attitudes and behaviours related to influenza and influenza vaccination, particularly on the scope and scale needed to greatly improve uptake.

Modeling the spread

• Modelling is potentially useful in real time, but its effectiveness still needs evaluating in real pandemic situations
• During the 2009 influenza pandemic modeling work struck problems with data availability, dissemination, heterogeneity, and unclear assumptions
• Modelling might be able to be used to identify higher risk populations on whom to target interventions
• Modeling can provide a quantitative estimate of the impact of various interventions

The challenges that modelling faced in 2009 were: (i) expectations of modelling were not clearly defined; (ii) appropriate real-time data were not readily available; (iii) modelling results were not generated, shared, or disseminated in time; (iv) decision-makers could not always decipher the structure and assumptions of the models; (v) modelling studies varied in intervention representations and reported results; and (vi) modelling studies did not always present the results or outcomes that are useful to decision-makers.

Behaviour

• Precautionary behaviours are less frequent than expected or intended given the threat during a pandemic
• Difference in behavior between populations within countries is marked (this suggests targeting interventions might be done better, and a one-size-fits-all response may not be appropriate)
• Misconceptions about risk are common and vaccination uptake is low
• Risk communication needs to be tailored to the perceptions/behavior being seen in real time, monitoring social media might help
• Hand washing has modest efficacy, and dental hygiene may be useful, but other interventions have not been fully assessed
• Healthcare workers’ willingness to work in a pandemic is variable (this will need to be accounted for in any planning/workforce assumptions)
• Effectiveness of school closures was unclear in a Japanese review

It seems that a comprehensive, longitudinal study is needed to clarify the effects of school closure and other public distancing measures during pandemics.

Communication

• Emergency response planners should consider leveraging social media to track population beliefs and behavious in real time, and consider individually tailored engagement and communication
• There are a number of potential predictors of behavioral compliance with preventive recommendations, these might help focus interventions

Cost-effectiveness

• Cost-effective are: hospital quarantine, vaccination, antiviral stockpile usage
• Not cost-effective are: school closures, antiviral treatments, social distancing (at $45,000 willingness to pay per QALY)
• These interventions are potentially more cost-effective the more severe the pandemic
• However, cost-effectiveness modeling in the local context is needed.

Ethics

• Pandemic plans need ethics frameworks that can be used in unique infectious disease pandemic situations, yet most pandemic plans copy and paste ethical approaches from previous influenza plans.

To summarize: How ought we prepare for the inevitable next pandemic?

Before the pandemic hits:

• Seasonal influenza vaccine
• Personal protective gear stockpiles
• Strategic drug stockpiles
• Risk communication strategy in place
• Plan for modelling and data needs
• Regional cooperation plan
• Plan to research during pandemic (to inform future plans)

During the pandemic

• Real time PCR for diagnosis (recommended by the CDC)
• Case surveillance
• Surge capacity ensured
• Antiviral drug delivery
• Risk communication implemented
• Adherence to strict sanitary and hygienic measures
• Regional collaboration and cooperation
• Focus on high-risk groups
• Data collection and research to inform future response

The above information is consistent with research published in the last five years, and ought to be considered for further research or evaluation, or inclusion in any local, national or international pandemic plan.