Pandemic Influenza Preparedness and Community Resiliency

Weathering a future pandemic of influenza will be a challenge unlike anything experienced in the United States since 1918. A unique strength of the country has been the sharing of common goals and aspirations. Drawing on strong ethnic identities that celebrate diversity and respect for heritage, when faced with crises, individuals throughout the United States have protected each other because of this common bond.

Responding to a future influenza pandemic will test loyalties to families, friends, neighborhoods, and communities. As planning for the national response to pandemic influenza continues, it is essential to protect against adverse, unintended consequences that could seriously threaten the fabric of US society. There has been a major shift in public health advice regarding influenza,^{1 - 7} and current national pandemic influenza planning advocates that individuals will be able to prevent influenza infection by modifying personal behaviors. Decreased person-to-person contact is recommended as an effective strategy to prevent infection.^{4 ,6 - 7} This new advice is based on limited current scientific evidence and could have serious adverse unintended consequences for the social fabric of society and community resiliency.^{4 - 9}

Consensus exists on some aspects of the science of influenza transmission and prevention: individuals can spread influenza for 1 to 2 days before they develop any symptoms,^{2 - 4} and some infected individuals are able to transmit influenza to others even though they never develop any symptoms.^{2 - 4}

Because of the short incubation period and asymptomatic transmission of influenza, it is unlikely that the spread of influenza can be prevented without vaccinating entire populations. Public health strategies have focused on increasing the supply of influenza vaccine and on vaccinating individuals who are at higher risk of serious morbidity and mortality or providing antiviral medications to these individuals.

Despite the lack of scientific evidence on which to change past recommendations, public health messages about influenza have changed considerably.^{4 - 7} Current thought is that (1) although influenza virus can be recovered from individuals for 1 to 2 days before onset of symptoms, influenza is not transmitted, or is only rarely transmitted, before symptoms occur; (2) members of the general public can protect themselves from becoming infected during a pandemic by reducing contact with others, wearing respirators or face masks, and by taking antiviral medications (although these medications likely will be scarce); and (3) communities can stop, reduce, or delay the spread of influenza by having members of the community wear respirators or face masks, take antiviral agents, and keep socially distant, and social distancing will delay the progress of a pandemic, reduce the number of cases, and enable time for the preparation and deployment of an effective vaccine.

These messages raise hope and expectations that each individual, through personal actions, can prevent exposure to and infection by the influenza virus during a pandemic, and these actions will significantly reduce the effect of pandemic influenza on the population. Because adequate antiviral agents and vaccine probably will not be available, the success of current preparedness planning is to rely on isolation, reduced person-to-person interaction, and increased social distancing. But these measures threaten the ability to maintain social contact, interpersonal support, and community resiliency.

Attempts to increase influenza vaccine production capacity and use of the vaccine have also brought unintended adverse consequences for societal cohesiveness. If the United States is to have adequate vaccine production capability to protect all its 300 million residents, vaccine production and delivery capacity would have to expand substantially.

Despite considerable efforts, acceptance of seasonal influenza vaccine has been far from optimal, even among those at high risk for infection and for whom the vaccine is strongly recommended. When there was wide publicity over the influenza vaccine shortage in 2004, the public was asked to forgo vaccination unless they were among those in the high-risk groups. To the surprise of many, large numbers of individuals in high-risk groups chose not to get vaccinated. When vaccine became available later in the influenza season, demand was less than anticipated and the companies producing the vaccine were left with millions of doses of unused vaccine.¹⁰

To stimulate more public demand for and use of seasonal influenza vaccine, industry leaders and public health officials have generated substantial publicity over the threat of disease from seasonal influenza as part of an explicit agenda to create increased demand for seasonal influenza vaccination.¹¹ Coincident with these marketing efforts is the continued pressure to expand vaccination recommendations to the entire population of the United States annually for seasonal influenza. The campaign to increase use of influenza vaccination for seasonal influenza adds to the fear of this disease and fuels separation and isolation.

These 2 major components of the current national program of influenza preparedness that emphasize social distancing and the threat of seasonal influenza have combined to produce the possibility of significant, unintended consequences on community resiliency by causing societal estrangement.^{4 ,9 ,12} The successful frightening of the public about germs has also frightened health care workers, first responders, law enforcement officers, and workers who have frequent contact with the public. Surveys have documented that up to 30% of the workforce will not report for work if a pandemic begins because of fear that they will become infected by continuing to work and that they will carry the infection home to their families and friends.¹³

Adoption of current social distancing recommendations evolved from computer models and historical analysis of community responses in 1918.^{14 - 18} The goals of the recommended community mitigation standards are to delay the outbreak peak, decompress the peak burden on hospitals and the health care infrastructure, and diminish overall cases and health effects.³ Yet, there is no evidence that these recommended measures will have the desired beneficial outcomes.

A report by Markel and colleagues¹⁸ provides the most robust historical analysis of the experience in the United States during the 1918 pandemic of influenza. Even though this study is cited as providing strong support for implementing community measures, it is important to acknowledge that Markel et al found no cities in which the peak of the outbreak was delayed by 4 to 6 months—the projected time for production and distribution of a new vaccine against a novel pandemic strain. However, if current public health messages result in individuals' refusing to work, the burden on hospitals and infrastructure might increase.

Although continuing to invest in diverse aspects of the national pandemic preparedness effort, new resources and attention should be devoted to societal values and cohesiveness. The question, “What if all the planning for social distancing and nonpharmaceutical interventions does not work?” should be addressed. How will individuals be able to work together to support each other and maintain the functions of communities and society in the face of catastrophic illness, morbidity, and death? How can educational efforts teach individuals to fear what is appropriate and not to fear what is not appropriate? For example, past public health interventions did not rely on individuals' acting to prevent becoming infected. The thought was that if influenza could be spread by asymptomatic individuals, an individual would likely become infected no matter where he or she works or plays. Therefore, there is no reason to avoid contact with others or to avoid offering care and support to those in need, and there is every reason to continue life as normally as possible. Furthermore, how can community-based planning for a surge of ill and dying persons, for individuals who cannot care for themselves, and for each other be supported?

Historical evidence and current science suggest that a new pandemic due to influenza will rapidly sweep the globe. The 1918 pandemic influenza swept across the United States in 6 to 8 weeks, and most large cities experienced a rapid rise and fall of cases, with the peak of illness lasting from 4 to 6 weeks.^{18 - 19} With the vastly increased population and travel, members of society should expect and must prepare for a similar, rapid course of a new pandemic. Given the complexity of modern society, the “just-in-time economy,” the current dependence on rapid and widespread travel, and the great increase in human population, the highest priority for preparedness needs to ensure social cohesiveness, interpersonal bonds, human compassion, and social order.

Physicians, other health care professionals, and public health policy makers must recognize that a pandemic will sweep through a community very quickly, and that most individuals will have mild disease, fully recover, be immune, able to help others, and continue to work. In 1918, citizens throughout the United States rallied to help each other in face of the catastrophic pandemic.¹⁹

Considering that the current national approach is based on limited evidence, care should be taken to ensure that current policies will not cause more harm than good. Has the current synthesis of scientific evidence and practical experience led to plans that will provide communities with the greatest opportunity to survive the next pandemic of influenza? Investing in maintaining interpersonal bonds and social discourse in the midst of overwhelming tragedy may prove to be the most effective preparedness planning for the next influenza pandemic.