Posted: May 16, 2013
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Article SummaryThis is a sequel to my April 8, 2013 column, “H7N9: A Tale of Two CDCs.” My focus then was on the ways the U.S. CDC was over-reassuring the public about the possibility of an H7N9 pandemic – even avoiding the word “pandemic” as much as possible. As this follow-up column documents, the CDC has become much more candid about the pandemic risk posed by this newly discovered influenza virus; other officials and experts around the world are being similarly candid. The column then discusses two remaining concerns about H7N9 risk communication: the failure to be candid about the likelihood that we’ll face the pandemic, if it comes, without vaccine; and – more important still – the failure to make any attempt to involve the public in pandemic preparedness. The column also documents that public interest in H7N9 has already declined from its (modest) peak in early April.

H7N9 Risk Communication:
Candor but No Push to Prepare

H7N9 was a newly discovered influenza virus in early April 2013, when I reported in “H7N9: A Tale of Two CDCs” that officials of the U.S. Centers for Disease Control and Prevention were being too reassuring about the risk of an H7N9 pandemic – potentially the most severe flu pandemic in history, given the 29% case fatality rate of H7N9 up to then.

I concluded my April 8 column with these words:

A fundamental goal of risk communication is to replicate in your audience the level of concern that you yourself are experiencing. If you’re less concerned than your audience is, it’s appropriate to try to reassure. If you’re more concerned than your audience is, you should try to warn. I’d lay odds that right now the experts at the U.S. CDC are more concerned about H7N9 than the U.S. public is. They nonetheless decided to conduct a reassuring press briefing. Maybe – maybe – that’s okay in Week One. If the U.S. CDC is still concerned a few weeks from now, I hope it won’t still be hiding its concern.

Now, more than a month later, I can report that the CDC has become much more candid about the pandemic risk. Others have been candid as well, including experts at the World Health Organization and even in China (ground zero for the outbreak).

But candor about the risk of an H7N9 pandemic has not been accompanied by candor about the reality that we are likely to face such a pandemic, if it comes, without any vaccine. Nor has the CDC – or governments elsewhere – done anything to urge the public to prepare.

Introduction and Overview

link up to indexOfficial communication about H7N9 has focused mostly on six messages:

  1. There hasn’t been any confirmed human-to-human transmission yet.
  2. There probably will be sooner or later, and that won’t be terribly frightening; only sustained human-to-human transmission portends a pandemic.
  3. H7N9 could mutate at any time in a way that would permit sustained human-to-human transmission and launch a pandemic, potentially a very severe pandemic.
  4. The Chinese are taking steps to minimize the likelihood of that happening, such as shutting down live bird markets.
  5. Governments elsewhere are monitoring the situation carefully, and the Chinese are being open, so we will know quickly if the situation worsens.
  6. Work is moving fast to develop an H7N9 vaccine that can be deployed if a pandemic materializes.

A not-quite-explicit seventh message: Governments are doing everything that ought to be done about H7N9, and there’s no need for the public to do anything at all. It’s a message of passivity.

In this column I will document both officials’ increased candor about H7N9 pandemic risk and what I see as their two principal H7N9 risk communication failures: failure to warn about vaccine realities and failure to urge any sort of public preparedness.

I will also document that, for the most part, the public isn’t paying attention anyway. Like H5N1 before it, H7N9 has morphed in the public’s mind from an emerging crisis to just one chronic risk among many – from a news story that was big enough that the CDC had no choice but to schedule a press briefing to a news story that you’re unlikely to run across unless you’re searching for it (and fewer and fewer people are searching for it). H5N1 took several years to make that transition. H7N9 has done it in a matter of weeks.

I will end this column with a brief discussion of an even newer pandemic threat (newer in the public’s awareness, that is, though the first known case came earlier), a novel coronavirus now emerging in Saudi Arabia.

Before we get to my main risk communication points, here’s a brief technical update on H7N9. From a virology and epidemiology perspective, not much is new over the past month:

  • Except for one Taiwanese who had traveled on the mainland, cases are so far confined to China, mostly eastern China.
  • The case fatality rate of confirmed cases has declined to roughly 20%, still a terrifyingly high number.
  • The number of cases is climbing much more slowly than it was in the early weeks. The lull might be attributable to China’s closing its live bird markets in cities where the virus seemed to be concentrated; it might be attributable to the onset of warmer weather; it might be attributable to some unknown cause; it might be random variation. Or the lull might mean that H7N9 is declining and will soon disappear. One thing is sure: The justifiably feared explosion of human cases hasn’t happened so far.
  • There are no signs yet that the virus is changing in a direction that would facilitate efficient human-to-human transmission.
  • The experts still don’t really know how the disease spreads. Evidence of even limited human-to-human transmission is very weak. Many but by no means all the human cases reported some direct or indirect exposure to live poultry – but then again many people in China are exposed to live poultry. Massive testing of apparently healthy birds has found only a few that were H7N9-positive. Among humans, too, very few mild or asymptomatic cases have been found. Assuming the Chinese tests are accurate (which not all experts believe), it’s a major mystery how the cases got infected.

“No news is good news” isn’t a scientific principle. Nobody credible is claiming that the H7N9 threat has passed. Still, the longer the outbreak continues without an alarming increase in the frequency of new human cases, the greater the optimism (even among experts) that maybe we’ll get lucky again and nothing horrific will happen.

If something horrific does happen, we will be less prepared than we might have been if the public had been encouraged to play a role in preparedness.

Four Milestones of Increasing Risk Candor in the U.S.

link up to indexThe U.S. CDC and the rest of the U.S. government continue to come further and further out of the closet about how scary H7N9 is … or at least how scary it might become.

Among the milestones of the past month, four stand out:

The first milestone came on April 12, when the CDC launched a webpage devoted to H7N9. The lede paragraph noted: “While there are no reported cases of H7N9 in the United States or anywhere else outside of China, the Centers for Disease Control and Prevention (CDC) is taking standard pandemic preparedness precautions…” Putting the word “pandemic” in the first paragraph of the new webpage signaled that H7N9 was to be taken seriously. (Putting the reassuring information in a subordinate clause link is to a PDF file was an excellent way to add some reassuring content to the webpage without sounding over-reassuring.)

A later paragraph reiterated the risk: “Since this H7N9 virus is a novel influenza virus with pandemic potential, the situation in China is being carefully investigated.” This is a far cry from the CDC’s April 5 press briefing, when CDC Director Tom Frieden and CDC flu epidemiologist Joe Bresee (the two presenters) never once used the P word.

The bulk of the webpage carefully explained that sustained human-to-human transmission would presage a likely pandemic; that there had been no sustained human-to-human transmission of H7N9 so far; and that limited (“dead-end”) human-to-human transmission had occurred several times with H5N1, was likely to occur with H7N9 as well, and wouldn’t constitute an increase in pandemic risk since “sustained (ongoing) transmission in the community is needed for an influenza pandemic to begin.” This is spectacular anticipatory guidance link is to a PDF file: Limited h2h transmission won’t be a serious danger sign, but sustained h2h transmission will.

The second milestone came on April 28, when Anthony Fauci, head of U.S. National Institute of Allergy and Infectious Diseases, spoke out on the risk of H7N9. “It’s unpredictable as are all the influenza,” Fauci told Agence France-Presse. “One of the things we need to be concerned about is this might gain the capability of going human-to-human which up to this point has not happened and is somewhat encouraging news.” He added: “But we still need to be very prepared for the eventuality of that happening.”

As far as I know Fauci didn’t use the word “pandemic” in his AFP interview. But he worried aloud about the prospect of human-to-human transmission and said it was important to start developing an H7N9 vaccine, although “[h]opefully, we will never have to use it.” Media that ran the Fauci story rightly interpreted the interview as a warning: It’s “encouraging” that there hasn’t been h2h transmission so far and “hopefully” we won’t need a new vaccine … but H7N9 is something “we need to be concerned about.”

The third milestone came on May 1, when the CDC posted an article soon to be published in its Morbidity and Mortality Weekly Report (MMWR). Entitled “Emergence of Avian Influenza A(H7N9) Virus Causing Severe Human Illness – China, February-April 2013,” the article ended with this paragraph:

Given the number and severity of human H7N9 illnesses in China, CDC and its partners are taking steps to develop a H7N9 candidate vaccine virus…. Although no decision has been made to initiate an H7N9 vaccination program in the United States, CDC recommends that local authorities and preparedness programs take time to review and update their pandemic influenza vaccine preparedness plans because it could take several months to ready a vaccination program, if one becomes necessary. CDC also recommends that public health agencies review their overall pandemic influenza plans to identify operational gaps and to ensure administrative readiness for an influenza pandemic….

I have some criticisms of this paragraph that I’ll get to later. But whatever its deficiencies, it couldn’t have been clearer that an H7N9 pandemic is a possibility worth worrying about and preparing for.

The fourth and most explicit milestone came on May 6, when Reuters published an “exclusive interview” with CDC head Frieden. Compare the two paragraphs from the Reuters story below with Frieden’s April 5 press briefing, which I criticized for over-reassurance a month ago.

“This particular virus is not going to cause a pandemic because it doesn’t spread person-to-person,” Frieden said. “But all it takes is a bit of mutation for it to be able to go person-to-person.”

“I cannot say with certainty whether that will happen tomorrow, within 10 years or never.”

Frieden told Reuters that the CDC had activated its Emergency Operations Center for H7N9 and had assigned 193 staff to the new flu virus. Later in the story came this passage:

Frieden said there are several factors that make this particular virus especially worrisome.

An analysis of the genetic code of the virus shows that it has receptors that bind to the lower respiratory tract of people, much like the more familiar bird flu strain known as H5N1. “That is why it’s causing severe disease,” Frieden said.

But it also has receptors that bind to the upper respiratory tract of people, which may explain why it is more transmissible from birds to people than H5 appears to be, he said.

And unlike H5N1, which caused severe disease in poultry, this new virus does not, which may make it more difficult to control because researchers will not be able to cull poultry flocks.

Frieden said even with H5, it took 18 months from the emergence of the virus until the 100th case. By comparison, it took only about one month from the emergence of H7 until the 100th case….

“If there is evolution in the virus, it could go person-to-person, and that could cause severe pandemic.”

Frieden’s May 6 Reuters interview is orders of magnitude more candidly alarming than his April 5 press briefing. At the same time, it’s worth noting that there has been no second press briefing on H7N9. Reporters’ questions necessitated the April 5 briefing. When the questions died down, so did the CDC’s media effort. Candor, yes. Outreach, no.

Risk Candor at WHO and in China

link up to indexThe World Health Organization has also become more open about its H7N9 worries. On April 12, WHO Assistant Director Keiji Fukuda told Helen Branswell of the Canadian Press: “I think we are genuinely in new territory here in which the situation of having something that is low path in birds (yet) appears to be so pathogenic in people.”

Fukuda continued: “And then to have those genetic changes … I simply don’t know what that combination is going to lead to…. Almost everything you can imagine is possible. And then what’s likely to happen are the things which you can't imagine.”

Fukuda’s bottom line: “[W]hen you put it all together, this is a quite serious signal for us…. And there’s nothing which has lessened the seriousness of that signal over the last few weeks.”

Two weeks later, on April 24, Fukuda held a news conference in Beijing, where he sounded even more alarming. Here’s how the CNN website covered it:

“This is an unusually dangerous virus for humans,” Keiji Fukuda, WHO’s assistant director-general for health, security and the environment told a news conference in Beijing Wednesday.

“We think this virus is more easily transmitted from poultry to humans than H5N1,” he added, referring to the bird flu outbreak between 2004 and 2007 that claimed 332 lives.
[I can’t resist interpolating here that H5N1 didn’t disappear in 2007. Only the coverage disappeared, or nearly so.]

“This is definitely one of the most lethal influenza viruses that we have seen so far.”

The most alarmist mainstream official or semi-official statement I have seen so far came from China itself – a “risk assessmentlink is to a PDF file published on April 29 in the Chinese Science Bulletin by a team of eleven scientists, all but one from the China National Avian Influenza Professional Laboratory. They wrote: “We think that the H7N9 influenza outbreak is of enormous risk for the following reasons.” There followed a list of eight reasons to worry. Number eight was the key one:

Eighthly, the probable long existence of the H7N9 virus in humans will provide the driving force to the virus to adapt to humans through mutations. The virus may thus obtain human-to-human transmission, and may spark a pandemic influenza thereafter. The possible pandemic should likely be very dangerous with the consideration that the virus has showed highly pathogenicity in the first 91 cases.

Based on their risk assessment, the authors recommended a number of precautionary measures, including “building enough stockpile of H7N9 vaccine for human use in case the pandemic really occurs.” So far, no Western government has said it plans to take this advice. As far as anyone knows, the Chinese government isn’t taking it either.

The authors acknowledged that H7N9 might not go pandemic – that it might “disappear naturally” or remain a minor problem that doesn’t make birds sick and doesn’t spread easily to humans or from human to human. Then they wrote this amazing sentence: “However, such a mild scenario of the outbreak evolution is of less possibility than the very or extremely severe scenario describe above.” Conventional opinion among Western flu experts and public health officials ranges from “a severe H7N9 pandemic is possible but unlikely” to “there’s no way to assess its likelihood.” Here’s a team of Chinese experts who seem to be saying it’s likelier than not!

I am not trying to determine who’s right; that’s way, way outside my field. At the very least it is clear that the Chinese government isn’t suppressing alarming commentary.

Inevitably, there have also been some less-than-exemplary examples of H7N9 risk communication coming out of WHO and China. April 19 was a good day for bad examples. Attempting to buoy China’s poultry market, WHO China chief Michael O’Leary boasted: “I eat chicken every day, or almost every day, and I haven’t changed that at all…. Eating chicken is of no concern to me.” O’Leary, based in Beijing, didn’t mention who cooks his chicken, or who shops for it, or whether the shopping takes place at a live bird market. And a top Chinese agriculture official pointed out that no H7N9-infected fowl had been found in poultry farms or slaughterhouses, only in live markets, and claimed (in a Xinhua paraphrase) these test results proved that the H7N9 virus “can be controlled.”

But imperfections aside, experts and official sources around the world are being admirably candid about the risk of an H7N9 pandemic.

Low Levels of Public Interest

link up to indexExperts and officials speaking out about the risk of an H7N9 pandemic might have hoped to arouse increased public concern. They might have worried about overshooting the mark and arousing excessive public concern, even panic. Or, more realistically in my judgment, they might have worried about arousing public skepticism and even public ridicule instead, and getting accused of hype.

As far as I can tell, none of those things happened. Expert and official H7N9 communications may or may not have had some impact on local public health officials. But in terms of impact on the public, they have aroused, basically, nothing.

According to Google Trends, public interest in H7N9 peaked sharply on April 5–6, less than a week after its existence was first announced on March 31, and immediately started declining. It doesn’t matter whether you look at the number of Google searches worldwide or in the U.S. Both charts show a secondary peak on April 24–25, probably connected to WHO’s justifiably alarming April 24 news conference in Beijing. But the trend from April 6 on is steadfastly downward. Even in China, where people continued to get infected and die, the trend is downward from April 5–6.

More interesting still: The number of daily searches for the term “pandemic” since March 31 is indistinguishable from the number before March 31, both worldwide and in the U.S. (In China, there have been too few searches for “pandemic” or its Chinese translation for Google Trends to track.) Here’s the Google Trends U.S. graph for “pandemic” searches since 2004. The peak is April–May 2009, when swine flu was new. There’s isn’t even a blip for April–May 2013.

So the U.S. public’s very modest interest in the H7N9 outbreak hasn’t provoked additional U.S. interest in the threat of an influenza pandemic. That was true in early April, when U.S. officials shied away from the word “pandemic.” And it’s still true, even though officials have come out of the closet.

Little Focus on Vaccine and Antiviral Dilemmas

link up to indexFlu experts and public health officials have talked more about the risk of an H7N9 pandemic than about preparedness for such a pandemic. And when they do address preparedness, their focus is almost entirely on vaccination.

More precisely, their focus is almost entirely on vaccine seed stock. The U.S. CDC and comparable government agencies in other countries have explained in details what they are doing to develop an H7N9 vaccine. They have not usually emphasized that developing a vaccine is just a necessary first step toward mass-manufacturing and stockpiling a vaccine – a measure no government has announced plans to implement. Nor have they emphasized the substantial logistical problems of mass-manufacturing an H7N9 vaccine, problems that virtually guarantee a delay of many months, maybe a year or more. Unless H7N9 vaccine is stockpiled in advance, as the Chinese risk assessment I mentioned earlier recommended, even affluent countries like the U.S. will almost certainly face the first wave of an H7N9 pandemic without vaccine. That has been the case in all previous flu pandemics in the age of vaccines.

It’s not clear whether mass-manufacturing a pre-pandemic stockpile of H7N9 vaccine makes sense. The investment could easily turn out worthless, not just if the virus never goes pandemic but also if it mutates before going pandemic in a way that undermines vaccine effectiveness. At best, flu vaccines in general and H7 vaccines in particular have never been terribly effective.

So my point isn’t that the CDC should champion building a national stockpile of H7N9 vaccine. My point is that it should point out more aggressively than it has that without such a stockpile, its efforts to develop vaccine seed stock probably won’t give us a usable vaccine in time to deploy against the first pandemic wave.

Ideally, I believe, the CDC would see the vaccine stockpiling dilemma as a political decision to be made after public debate, not a technical decision to be made quietly inside the CDC’s Atlanta headquarters. Sharing the dilemma about vaccine stockpiling would yield a more democratic decision. It would teach the public something crucial about the uncertainties of emergency preparedness. It would build the case for a new generation of universal flu vaccines. And it would give the CDC some partial immunity against recriminations if we end up facing a severe H7N9 pandemic without vaccine.

Perhaps most important, sharing the vaccine dilemma could help drive some attention to non-pharmaceutical interventions such as increasing the distance between people when one of them might be infected (“social distancing”). Though far from a panacea, social distancing can help at least a little in a flu pandemic, especially when there’s no vaccine available. And it can help a little more if there has been a comparatively inexpensive social distancing preparedness effort before the pandemic. More about that below.

Another possibility that has received even less attention than stockpiling is priming – adding H7 antigen to the seasonal flu vaccine in the hope that this would give vaccinees partial immunity against a pandemic H7N9 virus. (Priming could also be accomplished via a monovalent H7 vaccine, separate from the seasonal flu vaccine, that people could choose to get or not get as they preferred.)

Both stockpiling and priming received a fair amount of official and expert attention when concern about H5N1 was highest in 2004-2007 – provoking, among other things, a vigorous debate over the ethics and practicalities of pandemic vaccine triage: who should get vaccinated first while vaccine was scarce. Neither stockpiling nor priming has received much attention (at least in public) with regard to H7N9. The simple fact that an H7N9 pandemic (if one materializes) will otherwise catch us flatfooted hasn’t received much attention either.

One exception is an article on “Major Challenges in Providing an Effective and Timely Pandemic Vaccine for Influenza A(H7N9)” by Michael Osterholm and colleagues, first posted on May 9 on the Journal of the American Medical Association website. On the same day, Osterholm also published a New York Times op-ed entitled “The Next Contagion: Closer Than You Think,” referencing the JAMA article and warning that “we won’t be saved by vaccines if a pandemic emerges.” Neither the JAMA article nor the Times op-ed mentions stockpiling or priming, but Osterholm is among the few to stress that if we face an H7N9 pandemic at all, we will probably face it without vaccine.

What I have said here about vaccine is also true of Tamiflu and other antiviral drugs. If a pandemic materializes, there will be an immediate shortage of antivirals, and it won’t be feasible to manufacture as much as we’ll need while the pandemic rages. So the time to manufacture and stockpile is now, pre-pandemic. But Tamiflu stockpiling has the same downsides as vaccine stockpiling: If there’s no pandemic we won’t have any need for all that Tamiflu, and if a mutation makes the virus Tamiflu-resistant we won’t have any use for all that Tamiflu.

There’s one difference: Whereas only governments can stockpile vaccine against a possible pandemic, individuals can stockpile Tamiflu. (Antivirals work best if taken immediately after the onset of symptoms. So you should want them in your medicine cabinet. Even if there isn’t an actual shortage, you don’t want to be waiting on line at your doctor’s office and then at the pharmacy.) I have mine. I’ve had it since I started taking H5N1 seriously almost a decade ago. I make sure my loved ones have theirs too.

But even at the height of H5N1 concern, officials and experts (and most doctors) were leery and contemptuous of individual antiviral stockpiling. (In 2009 the Department of Health and Human Services did issue guidance for businesses link is to a PDF file regarding antiviral stockpiling and usage.) Jody Lanard and I wrote about their leeriness and contempt – and their specious anti-stockpiling arguments – in a 2006 column entitled “The Dilemma of Personal Tamiflu Stockpiling.” This time around the personal antiviral stockpiling option hasn’t even come up, so they haven’t needed to argue against it. Certainly they haven’t urged it.

Zero Focus on Public Preparedness

link up to indexTamiflu is the tip of the iceberg.

Look again at the MMWR article I quoted earlier. Here’s the key paragraph again:

Given the number and severity of human H7N9 illnesses in China, CDC and its partners are taking steps to develop a H7N9 candidate vaccine virus…. Although no decision has been made to initiate an H7N9 vaccination program in the United States, CDC recommends that local authorities and preparedness programs take time to review and update their pandemic influenza vaccine preparedness plans because it could take several months to ready a vaccination program, if one becomes necessary. CDC also recommends that public health agencies review their overall pandemic influenza plans to identify operational gaps and to ensure administrative readiness for an influenza pandemic….

After acknowledging that the CDC doesn’t plan to stockpile vaccine, this paragraph advises local officials to dust off their vaccine preparedness plans “because it could take several months to ready a vaccination program.” Jody has drafted a few possible revisions of that clause to make it more realistic:

  • because it could – with some kind of miracle – take several months to ready a vaccination program, though most likely it would take a year or more
  • because it could take several months to ready a vaccination program, but if the pandemic is severe, millions of Americans could be dead by then
  • because it could take several months to ready a vaccination program, but only small amounts would likely be available at first, so your preparedness plans should include riot control and extreme measures to protect your vaccine supply
  • because it could take several months to ready a vaccination program, but the program might not have any vaccine to distribute

Although the focus of the paragraph is on readying local vaccine preparedness plans, the CDC “also” recommends reviewing local “overall” plans to “ensure administrative readiness” for a pandemic. I love the use of “ensure” here. If the CDC is sure of anything, it is sure that we are not ready for a pandemic with a case fatality rate higher – possibly much higher – than that of the 1918 pandemic. As used in this paragraph, ensuring readiness is a fanciful concept. (Of course pandemic H7N9 might turn out far less deadly than H7N9 is so far. Maybe we’ll be blessed with a mild pandemic like the swine flu pandemic of 2009–2010. We’re arguably pretty ready for that, though even with regard to a mild pandemic we could do much better preparedness for social distancing during peak waves in specific locations.)

But over-optimism about vaccine preparedness and government preparedness isn’t my most severe criticism of the CDC paragraph, and of the MMWR article in its entirety – and of H7N9 risk communication overall. My most severe criticism is the absence of any sense that the public, too, should prepare for a possible (and possibly severe) pandemic.

Public preparedness was a major theme in H5N1 risk communication during the 2004–2007 period when H5N1 concern was at its height. That didn’t keep me from complaining in an October 2005 column on “The Flu Pandemic Preparedness Snowball” that there was too much focus on “the pharmaceutical fix” and too little on non-medical preparedness and non-governmental and local preparedness. But the imbalance was far less severe in 2004–2007 than it is today. By 2007, in fact, U.S. Secretary of Health and Human Services Michael Leavitt was crisscrossing the country urging people to stock up on food, water, prescription medicines, and other key supplies to have on hand in advance of a possible pandemic.

It is almost impossible to imagine an official barnstorming trip with that key message today.

Assume that you are in charge of a public health agency that is seriously worried about a possible (and possibly severe) influenza pandemic. Assume that you have already decided not to urge – or even discuss – vaccine stockpiling, priming, or personal antiviral stockpiling. You know that for quite a while after the start of any pandemic, your country will be relying mostly on social distancing and other non-pharmaceutical interventions. What preparedness measures might you recommend?

Here’s my partial list of non-pharmaceutical preparedness measures your public health agency might recommend:

  • Individuals should stockpile food, medications, and other supplies. This is partly because there’s likely to be a run on the stores when it’s clear a severe pandemic is on its way. It’s partly because there might be supply chain disruptions impeding the flow of goods. And it’s partly because people should try to avoid going out into public places while the pandemic is hot locally. The more people have stocked up before the pandemic is imminent, the easier it’ll be on them, as well as on the laggards and on people who can’t afford to stockpile.
  • Everyone who can – individuals, hospitals, businesses, etc. – should stockpile masks. Both surgical masks and the more effective but more expensive (and harder to use) N95 masks will instantly be in short supply once it’s clear that a severe pandemic is imminent. Better to increase the demand now, gradually, so manufacturers can cope with it. I am not claiming that masks are any more or less effective than an eventual vaccine would be. I am suggesting only that masks have a role to play in social distancing efforts. Like vaccines and antivirals and hand-washing, they are a “harm reduction” strategy, not a “prevention” strategy.
  • Schools should figure out now under what circumstances they will probably decide to close. Parents should figure out now how they will take care of their children when the schools are closed.
  • Businesses, local governments, and other organizations should make cross-training for irreplaceable jobs a top priority. When a severe pandemic wave passes through a community, many people will be sick at the same time, and others may be reluctant to come to work. Now is the time to decide who will cover for your key people if they are unavailable, making sure the backups know what their emergency job is and know how to do it.
  • For similar reasons, hospitals need to look more closely at surge capacity issues.
  • Everyone should plan now to stay home as much as possible when a pandemic wave is locally intense (to reduce your chances of getting infected) and especially when you feel sick (to reduce your chances of infecting others). And organizations need to rethink their sick leave policies. People who come to work because they can’t afford an unpaid sick day are endangering themselves, their fellow workers, and your business.
  • Influenza viruses are mostly transmitted person-to-person, when people cough or sneeze near other people; but sometimes they are transmitted when people cough or sneeze on objects that other people touch … and then infect themselves by touching their mouth, nose, or eyes. Like masks, social distancing can help, although some unknown percentage of influenza viruses can travel farther than the usual “six feet apart” social distancing recommendation. Covering your cough or sneeze can also help. So can hand-washing and antiseptic gels. So can wiping or washing surfaces that are likeliest to harbor the virus. None of these is a panacea, but together they can reduce how bad the pandemic gets at its worst, in various locations. Now is the time to plan for these tools of pandemic mitigation.
  • Even in 1918, the historically worst pandemic, most of the people who got sick got better after a week or two. Once recovered, they were at least partially immune for some period of time. To make optimum use of these individuals – there will be millions of them! – communities and organizations should consider creating a “Pandemic Survivor Volunteer Corps.” (A similar recommendation was included in the 2005 WHO checklist for influenza pandemic preparedness planning.) link is to a PDF file If there are liability issues, labor relations issues, etc., it is important to raise them and resolve them before the pandemic starts.

The CDC included many of these strategies, though not all, in its recommendations for the 2009 swine flu pandemic. Why isn’t it, or any other U.S. government agency, or any agency of any government I am aware of, recommending any of them now?

And why aren’t local public health and emergency preparedness officials recommending them? I have seen one – just one – local story on local pandemic preparedness. Entitled “It could happen: King County prepares for possible bird virus pandemic,” it was published in the Puget Sound Business Journal on April 16, 2013. It focuses on the business continuity recommendations of Michael Loehr, preparedness manager for Public Health King County. Loehr’s challenge to the article’s readers: “How would they maintain their businesses if a quarter to a third of staff could not show up for work?”

One day after this exemplary article, on April 17, a New York Times editorial captured the sadly misguided consensus. Here’s its final sentence: “There is plenty of reason for health authorities to remain hypervigilant but no reason for anyone other than travelers to China to take precautions.”

In fairness, numerous recent articles, both in top medical journals and in the mainstream media, very briefly mention social distancing, while focusing intensely on vaccine issues.

I don’t know why the CDC has avoided talking about public pandemic preparedness, preferring to imply that as long as public health officials are preparing the rest of us can go about our business. And I don’t know why it has avoided talking about non-pharmaceutical pandemic preparedness, preferring to imply that vaccines and antivirals are the whole story.

Among the possibilities:

  • Maybe that’s actually what Frieden and his staff believe.
  • Maybe they’re afraid to raise the issue of public non-pharmaceutical preparedness for fear that it will provoke panic (highly unlikely) or ridicule (likelier).
  • Maybe they wanted to raise the issue but political higher-ups at HHS or the White House said no.
  • Maybe they knew from experience that political higher-ups would say no, so they didn’t even make the recommendation.

I’d have thought that at the very least the CDC could use H7N9 news as a teachable moment for talking about all-hazards preparedness. We urge the public to prepare for hurricanes; for earthquakes; for fictional zombie attacks, for heaven’s sake. Why don’t we urge the public to prepare for pandemics too?

Would sounding the alarm about public preparedness have increased the level of public concern about H7N9? Would it still?

I suspect the answer depends largely on the extent to which preparedness messaging is yoked to institutional changes that would make preparedness more feasible. Telling people to stockpile 90 days worth of their medications, for example, would sound a lot more serious if insurance companies were told to pay for their customers’ pandemic drug stockpiles. Telling people to stay home when they feel sick would sound a lot more serious if employers were told to adjust their paid sick leave policies accordingly.

Some (though not all) public preparedness recommendations are unduly difficult to implement because of these sorts of institutional barriers. It’s not just that people won’t follow the recommendations if they’re too hard to follow. It’s also that people won’t believe the recommendations are serious if the organizations making them aren’t also taking steps to make implementing them more feasible.

Obviously the CDC doesn’t have enough clout to take on insurance company prescription payment plans or corporate sick leave policies. That may have something to do with its failure to make personal pandemic preparedness a major theme.

So here’s where H7N9 risk communication stands as of mid-May 2013. We (the public) are being told by top officials and experts that there’s a serious risk of a pandemic, possibly a very severe pandemic. With only occasional exceptions, we’re not being told that we’re likely to face the pandemic, if it comes, without vaccine. We’re not being asked to do any serious preparing. And we’re not listening anyway.

And As If H7N9 Weren’t Enough….

link up to indexMeanwhile, another pandemic threat is percolating in Saudi Arabia. It’s not a flu virus at all, but rather a coronavirus, from the same family that gave us SARS and the common cold. So far it goes under the accurate but not very catchy name “novel coronavirus” or nCoV.

Novel coronavirus was discovered in September 2012 in a Qatari man who had recently traveled in Saudi Arabia. Since then 40 cases have been counted, mostly in Saudi Arabia, with 20 deaths so far. The Saudi government has been much less candid and much more over-reassuring about nCoV than the Chinese government has been about H7N9 – becoming, in effect, the new China.

Novel coronavirus is arguably even scarier than H7N9, for several reasons:

  • Its apparent case fatality rate is even higher, 50% (though the true fatality rate of these emerging infectious diseases is anybody’s guess).
  • It is even more mysterious – nobody knows yet what animals carry and transmit the virus, though bats are high on the list of suspects.
  • Nobody has ever invented a successful vaccine against any human coronavirus.
  • The number of cases increased dramatically in recent weeks.
  • It has already been found in several Middle Eastern countries, and people infected in the Middle East have already carried it to three European countries, the U.K., France, and Germany.
  • It has already demonstrated limited human-to-human transmission several times in several different countries, with clusters of cases in both family and healthcare settings.

So far, obviously, nCoV hasn’t acquired the ability to transmit efficiently from human to human in a continuing chain; all the clusters have burnt out. Otherwise the world would be worrying about an imminent coronavirus pandemic, wondering whether good public health measures (plus good luck) would manage to halt the spread of nCoV as they halted the spread of SARS.

Until just a few days ago, nCoV had received even less public attention than H7N9. But the worldwide and U.S. Google Trends graphs show a sharp surge in “coronavirus” searches starting May 8 in the worldwide graph and May 12 in the U.S. graph. (May 8 is the day France confirmed the first of its two cases.) For the U.S., the coronavirus peak right now as I write is roughly equivalent to the H7N9 peak back in early April. For the world, the coronavirus peak is substantially higher than the H7N9 peak ever got.

Unfortunately, there are no comparable peaks for the word “pandemic.” So far, at least, the public’s growing interest in nCoV isn’t matched by a growing interest in pandemic risk.

Assuming nCoV doesn’t actually go pandemic in the coming weeks, will the Google Trends coronavirus graphs decline the way the H7N9 graphs declined? That is, will people lose interest in that pandemic threat too if it continues for a couple of months without actually launching a pandemic? That would be my bet.

This is a huge risk communication conundrum. How do you keep people interested, concerned, and willing to take precautions with regard to a chronic risk of a devastating crisis?

And especially: How do you keep people interested, concerned, and willing to take precautions with regard to yet another pandemic threat. A decade ago, public interest in H5N1 was sustained for several years at a fairly high level. (At least it feels now like a fairly high level.) But H5N1 never went pandemic. And then in 2009 we finally got a real pandemic, H1N1 (swine flu), and it was anticlimactically mild. Now experts and public health officials are worried about two new viruses that might prove capable of launching a severe pandemic, H7N9 and nCoV. How can they sustain the public’s interest, concern, and willingness to take precautions with regard to both … or either?

Maybe that’s too ambitious a goal. Maybe we should settle for occasional teachable moments when some new development gets people temporarily interested, and thus temporarily open to warnings that they ought to be concerned and instruction about appropriate precautions they might want to take.

If so, we already missed a few H7N9 teachable moments, and probably need to wait for another one to roll around. But right now looks like a novel coronavirus teachable moment. We will see if, and how, it gets exploited in the service of pandemic preparedness.

My wife and colleague Jody Lanard contributed to this column.

Copyright © 2013 by Peter M. Sandman

For more on infectious diseases risk communication:    link to Pandemic and Other Infectious Diseases index
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