Non-pharmaceutical public health interventions for pandemic influenza: An evaluation of the evidence base

RAND Center for Domestic and International Health Security, 1776 Main Street, Santa Monica, California, USA.
BMC Public Health (Impact Factor: 2.26). 02/2007; 7(1):208. DOI: 10.1186/1471-2458-7-208
Source: PubMed


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.
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).
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.
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.

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    • "The mitigating effect of the weekend on influenza transmission has been widely reported [37,38]. For example, the study by Hens et al. in eight European countries estimated a 10 ~ 20% reduction in influenza infections during weekend when compared to weekdays [37]. "
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    • "In the face of pH1N1, prevention strategies including vaccination, wearing face masks when having influenzalike symptoms, and frequent handwashing have been recommended by Taiwan officials (Taiwan CDC 2009). Among them, handwashing is more readily accepted and less constrained by limitations on supplies and effectiveness (Aiello et al. 2010; Aledort et al. 2007). Handwashing is also effective in impeding the spread of influenza virus in household and school settings (Cowling et al. 2009; Jefferson et al. 2009), as it can significantly reduce *These authors contributed equally to this work. "
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    • "Since we have based our analysis on the winter wave of the pandemic and we have excluded the ILI or ARI rates observed during the summer wave, when the consultation rates were most likely to be affected by media bias or panic [42], we expect less influence on health seeking behavior during the winter wave of the pandemic. On the other hand, a variety of prevention measures had been undertaken by countries during the pandemic influenza season, including vaccination, social distancing, school closures, antiviral treatment and prophylaxis that might have reduced the attack rates [43-45], and subsequently the outpatient consultation rates due to ILI or ARI. If these measures had not been undertaken, we might have observed a greater difference between pandemic and seasonal ILI/ARI rates in the countries of the Region. "
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