A revision of the national pandemic influenza plan could help to remedy the current patchwork of state plans “that will not adequately detect and control” an influenza pandemic, according to a review by Scott D. Holmberg, Ph.D., and his colleagues at Research Triangle Institute International, Atlanta.
“The control of future pandemic and interpandemic influenza will necessarily rely on each individual state's plan to vaccinate persons and detect and contain this disease,” the investigators wrote (Emerg. Infect. Dis. 2006;12:1414–7). “The current national [Health and Human Services] pandemic influenza plan presents only a categorization and listing of steps rather than explicit direction for the states.”
The authors cite a “lack of clear guidance” at the federal level as one of the reasons for the considerable disparity among the 49 states that have posted their plans for vaccination, early epidemic surveillance and detection, and containment of pandemic influenza (available online at www.cdc.gov/ncidod/EID/vol12no09/06/0369_appT1.htm
According to the review, all states agree on vaccination priority strategies as recommended by the Advisory Committee on Immunization Practices and the U.S. Department of Health and Human Services. “General agreement exists, explicit or implicit, to provide vaccination during a pandemic that is prioritized by those most likely to acquire, become ill, or die from pandemic influenza,” they noted.
In general, this means that the elderly, those with chronic diseases, and health care and infrastructure personnel will be vaccinated first; some states will include young children in this list. “We believe the estimate that such persons make up [about] 15%–20% of the population in any state is reasonable,” the researchers wrote.
State plans are more variable regarding surveillance and detection, although they all plan to use the National Sentinel Physician Surveillance and the nationwide 122 Cities Mortality Reporting System. Neither system would likely detect a local outbreak of influenza within 2 weeks, the authors noted, but “to our knowledge, no health authority feels confident that earlier detection of influenza by 1–3 weeks would necessarily lead to better control or substantial retardation of an outbreak.”
Syndromic surveillance aimed at detecting influenzalike illness in emergency departments and clinics is being used in several cities, and the Centers for Disease Control plans to expand the use of syndromic surveillance to 300 clinical sites by the end of 2006.
State plans are “markedly heterogenous” in their recommendation of personal contact avoidance and prophylactic measures, with few states discussing nonpharmaceutical strategies. “Even in this computer-based economy, in which a considerable percentage of persons can work from home most of the time, this simple stratagem is not addressed in most state plans,” Dr. Holmberg and his associates noted.
Specifically, 35% of states mention voluntary self-isolation; 37% discuss closing schools, institutions, or businesses; 31% talk about quarantining institutions, persons, or households; and 25% mention contact vaccination or chemoprophylaxis. Other simple recommendations that are often neglected in the plans include avoidance of mass gatherings; shopping on off-hours; and home and work strategies such as handwashing, keeping towels separate, and avoidance of handshaking, the investigators wrote.
Although the authors point to weak federal direction as one of the reasons for the patchwork of state plans, they also acknowledge gaps in epidemiologic knowledge.
“We also believe it would be prudent to begin studies and, in the interim, create expert panels to determine if masks, school closings, social isolation, and several other nonpharmaceutical strategies would be useful in reducing the illness and death caused by pandemic influenza and its spread in the community.”