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Non-pharmaceutical Public Health Interventions for Pandemic Influenza: An Evaluation of the Evidence Base


Non-pharmaceutical Public Health Interventions for Pandemic Influenza: An Evaluation of the Evidence Base

Julia E Aledort et al. BMC Public Health.


Background: In an influenza pandemic, the benefit of vaccines and antiviral medications will be constrained by limitations on supplies and effectiveness. Non-pharmaceutical public health interventions will therefore be vital in curtailing disease spread. However, the most comprehensive assessments of the literature to date recognize the generally poor quality of evidence on which to base non-pharmaceutical pandemic planning decisions. In light of the need to prepare for a possible pandemic despite concerns about the poor quality of the literature, combining available evidence with expert opinion about the relative merits of non-pharmaceutical interventions for pandemic influenza may lead to a more informed and widely accepted set of recommendations. We evaluated the evidence base for non-pharmaceutical public health interventions. Then, based on the collective evidence, we identified a set of recommendations for and against interventions that are specific to both the setting in which an intervention may be used and the pandemic phase, and which can be used by policymakers to prepare for a pandemic until scientific evidence can definitively respond to planners' needs.

Methods: Building on reviews of past pandemics and recent historical inquiries, we evaluated the relative merits of non-pharmaceutical interventions by combining available evidence from the literature with qualitative and quantitative expert opinion. Specifically, we reviewed the recent scientific literature regarding the prevention of human-to-human transmission of pandemic influenza, convened a meeting of experts from multiple disciplines, and elicited expert recommendation about the use of non-pharmaceutical public health interventions in a variety of settings (healthcare facilities; community-based institutions; private households) and pandemic phases (no pandemic; no US pandemic; early localized US pandemic; advanced US pandemic).

Results: The literature contained a dearth of evidence on the efficacy or effectiveness of most non-pharmaceutical interventions for influenza. In an effort to inform decision-making in the absence of strong scientific evidence, the experts ultimately endorsed hand hygiene and respiratory etiquette, surveillance and case reporting, and rapid viral diagnosis in all settings and during all pandemic phases. They also encouraged patient and provider use of masks and other personal protective equipment as well as voluntary self-isolation of patients during all pandemic phases. Other non-pharmaceutical interventions including mask-use and other personal protective equipment for the general public, school and workplace closures early in an epidemic, and mandatory travel restrictions were rejected as likely to be ineffective, infeasible, or unacceptable to the public.

Conclusion: The demand for scientific evidence on non-pharmaceutical public health interventions for influenza is pervasive, and present policy recommendations must rely heavily on expert judgment. In the absence of a definitive science base, our assessment of the evidence identified areas for further investigation as well as non-pharmaceutical public health interventions that experts believe are likely to be beneficial, feasible and widely acceptable in an influenza pandemic.


Figure 1
Figure 1
Survey questionnaire results. *Hospital = inpatient acute care hospital, inpatient long-term care facility or any inpatient setting; 'Ambulatory' = emergency departments, ambulatory hospital care, urgent care centers, providers' offices, clinics or other community-based healthcare settings and includes care delivered in the community by first responders; 'Community' = schools workplaces, churches, malls, stadiums, etc,; 'Home' = care delivered in private residences. †None = overseas cases only; Elsewhere = no cases in your state/locality/jurisdiction; Early Localized = cases your state/locality/jurisdiction; Advanced = widespread human-to-human transmission in the US §Since some items were left blank, the indicated results were based on 9, 10, 11 or 12 responses (of out of a possible 13). All remaining results are based on all 13 responses. Green Circle (insert '=') Recommendation for use (46/200 items (23%))Red Circle (insert '=') Recommendation against use (37/200 items (18.5%))(insert space) Clear Circle (insert '=') Disagreement (117/200 items (59%) (insert space) Dash (insert '=') Not Applicable (respondents were instructed to leave blank)

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