Friday, March 7, 2014

Re-thinking Containment Stategies for Outbreaks of Highly Pathogenic Disease


"At its peak, the 1918-1919 influenza pandemic (Spanish Flu), incapacitated American cities and paralyzed the health care system. A 20th Century outbreak of disease with calamitous effects in this country, Spanish flu is an apt case to influence current bioterrorism  planning efforts.  Throughout human history, global influenza outbreaks have sickened large number of people, claiming many lives, and dramatically disrupted social and economic relations (1,2). The most infamous episode is the 1918-1919 influenza pandemic, which altered World War 1 battle plans and peace talks and made almost 1 billion people (one-half of the world's population) ill, killing from 21 to 40 million  (3,4). In interpandemic years, flu still exacts a harsh told: excess deaths, in the aggregate, approach pandemic levels (2,5,6). see: http://cid.oxfordjournals.org/content/31/6/1409.full

The history of pandemic disease and containment efforts is one of evolving methodologies. The Spanish flu was by far not the only grave pandemic to ravage global populations. Smallpox (variola major) is estimated to have killed between 300 to 500 million in the Twentieth Century alone. The last European outbreak occurred in Yugoslavia in 1972. That outbreak was contained in three weeks, under draconian measures and Martial Law imposed under Tito. Today, such practices would face legal challenges in most Western democratic nations.

Today, containment strategies vary significantly from one nation to the next, even from one region to the next. Public health infrastructures, economic resources and medical counter-measure all play a role in containment strategy selection, with most Western nations opting for a combination. However, in nations with poor public health infrastructures, options are severely limited. Containment strategy can mean anything from martial law to ring vaccination or mass vaccination. "Given limited supplies of vaccines, antiviral drugs, and ventilators, non-pharmaceutical interventions are likely to dominate the public health response to any pandemic". see http://www.ncbi.nlm.nih.gov/books/NBK54163/#ch3.s31 "Isolation and quarantine are two of the oldest disease control methods in existence and would likely be used in at least some instances during a pandemic. While the terms "quarantine," "isolation," and "compulsory hospitalization" are often used interchangeably, they are in fact, distinct. The modern definition of quarantine is the restriction of the activities of asymptomatic persons who have been exposed to a communicable disease, during or immediately prior to the period of communicability, to prevent disease transmission (Reich, 2003). In contrast, isolation is the separation, for the period of communicability, of known infected persons in such places and under such conditions as to prevent or limit the transmission of the infectious agent (Benenson, 1995). Quarantine and isolation are the most complex and controversial public health powers. Given that they involve a significant deprivation of an individual's liberty in the name of public health, quarantine and isolation expose the tension between society in protecting the health of its citizens and the civil liberties of individuals, such as privacy, non-discrimination, freedom of movement and freedom from arbitrary detention.See:  http://www.ncbi.nlm.nih.gov/books/NBK54163/#ch3.s31

Should we face a deliberate outbreak of disease, the impact would likely result in higher mortality than a natural outbreak of disease. It is likely that our efforts to manufacture and stockpile vaccines and medical counter-measures would be rapidly outstripped. It is essential to consider manufacturing processes which close the time gap in vaccine availability, delivery, stockpiling and distribution. While this is an increasingly technically viable objective, we must consider, largely in areas of the world with little or no health infrastructure, that quarantine and isolation may again be the best option in the short term to prevent further spread of disease.

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