J Alexander Navarro’s research while affiliated with University of Michigan and other places

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Publications (9)


Politics, Pushback, and Pandemics: Challenges to Public Health Orders in the 1918 Influenza Pandemic
  • Article

January 2021

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141 Reads

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15 Citations

American Journal of Public Health

J. Alexander Navarro

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Howard Markel

During the first wave of the COVID-19 pandemic in the United States, many state governors faced an increasing number of acts of defiance as well as political and legal challenges to their public health emergency orders. Less well studied are the similar acts of protest that occurred during the 1918–1919 influenza pandemic, when residents, business owners, clergy, and even local politicians grew increasingly restless by the ongoing public health measures, defied public health edicts, and agitated to have them rescinded. We explore several of the themes that emerged during the late fall of 1918 and conclude that, although the nation seems to be following the same path as it did in 1918, the motivations for pushback to the 2020 pandemic are decidedly more political than they were a century ago. (Am J Public Health. Published online ahead of print January 21, 2021: e1–e7. https://doi.org/10.2105/AJPH.2020.305958 )




A Tale of Many Cities: A Contemporary Historical Study of the Implementation of School Closures during the 2009 pA(H1N1) Influenza Pandemic

February 2016

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139 Reads

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26 Citations

Journal of Health Politics Policy and Law

Applying qualitative historical methods, we examined the consideration and implementation of school closures as a nonpharmaceutical intervention (NPI) in thirty US cities during the spring 2009 wave of the pA(H1N1) influenza pandemic. We gathered and performed close textual readings of official federal, state, and municipal government documents; media coverage; and academic publications. Lastly, we conducted oral history interviews with public health and education officials in our selected cities. We found that several local health departments pursued school closure plans independent of CDC guidance, that uncertainty of action and the rapidly evolving understanding of pA(H1N1) contributed to tension and pushback from the public, that the media and public perception played a significant role in the response to school closure decisions, and that there were some notable instances of interdepartmental communication breakdown. We conclude that health departments should continue to develop and fine-tune their action plans while also working to develop better communication methods with the public, and work more closely with education officials to better understand the complexities involved in closing schools. Lastly, state and local governments should work to resolve lingering issues of legal authority for school closures in times of public health crises.


Findings, Gaps, and Future Direction for Research in Nonpharmaceutical Interventions for Pandemic Influenza
  • Article
  • Full-text available

April 2010

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94 Reads

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14 Citations

Emerging Infectious Diseases

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Rebecca M Coulborn

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Tomas J Aragon

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[...]

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Scott F Wetterhall

In June 2006, the Centers for Disease Control and Prevention (CDC) released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs) to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010) (1). Eleven studies (Table 1) were funded to identify optimal, discrete, or combined NPIs for implementation during an influenza pandemic. During March 4-6, 2009, the principal investigators met to share results, identify research gaps, and define future research needs in 9 areas as described here. A total of 16 research gaps were identified (Table 2).

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Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research

March 2010

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131 Reads

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73 Citations

American Journal of Infection Control

In June 2006, the Centers for Disease Control and Prevention released a request for applications to identify, improve, and evaluate the effectiveness of nonpharmaceutical interventions (NPIs)-strategies other than vaccines and antiviral medications-to mitigate the spread of pandemic influenza within communities and across international borders (RFA-CI06-010). These studies have provided major contributions to seasonal and pandemic influenza knowledge. Nonetheless, key concerns were identified related to the acceptability and protective efficacy of NPIs. Large-scale intervention studies conducted over multiple influenza epidemics, as well as smaller studies in controlled laboratory settings, are needed to address the gaps in the research on transmission and mitigation of influenza in the community setting. The current novel influenza A (H1N1) pandemic underscores the importance of influenza research.



Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic

August 2007

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803 Reads

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809 Citations

JAMA The Journal of the American Medical Association

A critical question in pandemic influenza planning is the role nonpharmaceutical interventions might play in delaying the temporal effects of a pandemic, reducing the overall and peak attack rate, and reducing the number of cumulative deaths. Such measures could potentially provide valuable time for pandemic-strain vaccine and antiviral medication production and distribution. Optimally, appropriate implementation of nonpharmaceutical interventions would decrease the burden on health care services and critical infrastructure. To examine the implementation of nonpharmaceutical interventions for epidemic mitigation in 43 cities in the continental United States from September 8, 1918, through February 22, 1919, and to determine whether city-to-city variation in mortality was associated with the timing, duration, and combination of nonpharmaceutical interventions; altered population susceptibility associated with prior pandemic waves; age and sex distribution; and population size and density. Historical archival research, and statistical and epidemiological analyses. Nonpharmaceutical interventions were grouped into 3 major categories: school closure; cancellation of public gatherings; and isolation and quarantine. Weekly excess death rate (EDR); time from the activation of nonpharmaceutical interventions to the first peak EDR; the first peak weekly EDR; and cumulative EDR during the entire 24-week study period. There were 115,340 excess pneumonia and influenza deaths (EDR, 500/100,000 population) in the 43 cities during the 24 weeks analyzed. Every city adopted at least 1 of the 3 major categories of nonpharmaceutical interventions. School closure and public gathering bans activated concurrently represented the most common combination implemented in 34 cities (79%); this combination had a median duration of 4 weeks (range, 1-10 weeks) and was significantly associated with reductions in weekly EDR. The cities that implemented nonpharmaceutical interventions earlier had greater delays in reaching peak mortality (Spearman r = -0.74, P < .001), lower peak mortality rates (Spearman r = 0.31, P = .02), and lower total mortality (Spearman r = 0.37, P = .008). There was a statistically significant association between increased duration of nonpharmaceutical interventions and a reduced total mortality burden (Spearman r = -0.39, P = .005). These findings demonstrate a strong association between early, sustained, and layered application of nonpharmaceutical interventions and mitigating the consequences of the 1918-1919 influenza pandemic in the United States. In planning for future severe influenza pandemics, nonpharmaceutical interventions should be considered for inclusion as companion measures to developing effective vaccines and medications for prophylaxis and treatment.


Nonpharmaceutical Influenza Mitigation Strategies, US Communities, 1918–1920 Pandemic

January 2007

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263 Reads

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99 Citations

Emerging Infectious Diseases

We studied nonpharmaceutical interventions used to mitigate the second, and most deadly, wave of the 1918-1920 influenza pandemic in the United States. We conclude that several small communities implemented potentially successful attempts at preventing the introduction of influenza.

Citations (7)


... The effect of this social distancing was obvious when it was broken in Denver, the USA with its double-humped mortality curve of the Spanish flu pandemic in 1918. [3] The geography and mortality of the 1918 influenza pandemic were similar to that of COVID-19 with high severity and mortality in Europe and the USA, low in Asia, and very low in Africa. [4][5][6] Nowadays the technology allowed us to detect possible mutations and formulate a vaccine for the virus. ...

Reference:

What should be learned from the COVID-19 pandemic for the next coronavirus pandemics?
To Save Lives, Social Distancing Must Continue Longer Than We Expect
  • Citing Article
  • April 2020

... A century later, COVID-19 was known to be a respiratory pathogen, and masks were again recommended by public health authorities and resisted by many citizens. Both the 1918 influenza and COVID-19 pandemics saw citizen resistance to public health mandates, although in the case of COVID-19, some of the resistance was political (16). Even the development of safe and effective vaccines found resistance, and in the United States alone, vaccine hesitancy cost over 200,000 lives (17). ...

Politics, Pushback, and Pandemics: Challenges to Public Health Orders in the 1918 Influenza Pandemic
  • Citing Article
  • January 2021

American Journal of Public Health

... While school closures have proven to be an important means for delaying or reducing outbreaks, 40,41 they come with large economic and societal costs, with generally an outsized impact on disadvantaged, and vulnerable populations. 42 In light of this analysis, the approach of keeping schools open in a safe manner (i.e., if teachers can be protected from getting infected by their students) for as long as feasible was the better approach. School closures preferentially reduce infections in low risk groups, 40,43 thus possibly shifting infections that occur on the way to population immunity towards higher risk groups. ...

A Tale of Many Cities: A Contemporary Historical Study of the Implementation of School Closures during the 2009 pA(H1N1) Influenza Pandemic
  • Citing Article
  • February 2016

Journal of Health Politics Policy and Law

... Studies evaluating the effect of programs to improve immunization uptake in LMICs are very limited. Programs that create awareness, provide health education to the community, and teach preventive behaviours are found to help increase knowledge and change attitudes and behaviours of the community [20][21][22][23]. Specifically, targeted interventions such as community or facility-based educational programs to caregivers, providing reminder cards to mothers, home visits by ASHAs or ANMs, and integrating immunization with other primary health care services have been found to be somewhat effective in increasing immunization uptake in LMICs [24]. ...

Findings, Gaps, and Future Direction for Research in Nonpharmaceutical Interventions for Pandemic Influenza

Emerging Infectious Diseases

... They include hygiene measures like washing hands with soap or alcohol-based sanitizers or covering the mouth when sneezing or coughing (Center For Disease Control and Prevention, 2020). Wearing a mask is another NPI, as it can constrain the creation of droplets greater or equal to 5.00 mm (i.e., 5.00 3 10 26 ) in size containing an influenza virus (Aiello et al., 2010). ...

Research findings from nonpharmaceutical intervention studies for pandemic influenza and current gaps in the research
  • Citing Article
  • March 2010

American Journal of Infection Control

... Generalized lockdowns form part of so-called "preparedness policies" (David and Le Dévédec 2019), which began in the 1990s and flourished in the wake of the 11 September 2001 attacks and the 2003 severe acute respiratory syndrome (SARS) epidemic as a result of an obsession with security that combined two fears: of terrorism and the use of biological weapons. What preparedness means in the context of a potential pandemic is the introduction of "physical distancing" measures that have worked in the past, notably during the 1918-1919 H1N1 influenza pandemic (Markel et al. 2006). These measures aim to contain the disease until "pharmaceutical solutions," such as drugs or vaccines, are developed. ...

Nonpharmaceutical Influenza Mitigation Strategies, US Communities, 1918–1920 Pandemic

Emerging Infectious Diseases

... NPIs such as quarantine and isolation have a long history of use in public health (1). Large-scale use of NPIs in the 1918/1919 influenza pandemic likely saved many lives in some U.S. cities, while the late application of NPIs in other cities had the opposite impact (2)(3). There was a renewed interest in NPIs following the emergence of highly pathogenic avian influenza A(H5N1) in 1997, with the goal of improving the evidence base for influenza pandemic planning. ...

Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic
  • Citing Article
  • August 2007

JAMA The Journal of the American Medical Association