The Experience of 2 Independent Schools With In-Person Learning During the COVID-19 Pandemic.

BACKGROUND: In 2020, US schools closed due to SARS-CoV-2 but their role in transmission was unknown. In fall 2020, national guidance for reopening omitted testing or screening recommendations. We report the experience of 2 large independent K-12 schools (School-A and School-B) that implemented an array of SARS-CoV-2 mitigation strategies that included periodic universal testing. METHODS: SARS-CoV-2 was identified through periodic universal PCR testing, self-reporting of tests conducted outside school, and contact tracing. Schools implemented behavioral and structural mitigation measures, including mandatory masks, classroom disinfecting, and social distancing. RESULTS: Over the fall semester, School-A identified 112 cases in 2320 students and staff; School-B identified 25 cases (2.0%) in 1400 students and staff. Most cases were asymptomatic and none required hospitalization. Of 69 traceable introductions, 63 (91%) were not associated with school-based transmission, 59 cases (54%) occurred in the 2 weeks post-thanksgiving. In 6/7 clusters, clear noncompliance with mitigation protocols was found. The largest outbreak had 28 identified cases and was traced to an off-campus party. There was no transmission from students to staff. CONCLUSIONS: Although school-age children can contract and transmit SARS-CoV-2, rates of COVID-19 infection related to in-person education were significantly lower than those in the surrounding community. However, social activities among students outside of school undermined those measures and should be discouraged, perhaps with behavioral contracts, to ensure the safety of school communities. In addition, introduction risks were highest following extended school breaks. These risks may be mitigated with voluntary quarantines and surveillance testing prior to reopening.

Evolution of the Public Health Preparedness and Response Capability Standards to Support Public Health Emergency Management Practices and Processes.

In spring 2011, the Centers for Disease Control and Prevention (CDC) released Public Health Preparedness Capabilities: National Standards for State and Local Planning. The capability standards provide a framework that supports state, local, tribal, and territorial public health agency preparedness planning and response to public health threats and emergencies. In 2017, a project team at the CDC Division of State and Local Readiness incorporated input from subject matter experts, national partners, and stakeholders to update the 2011 capability standards. As a result, CDC released the updated capability standards in October 2018, which were amended in January 2019. The original structure of the 15 capability standards remained unchanged, but updates were made to capability functions, tasks, and resource elements to reflect advances in public health emergency preparedness and response practices since 2011. When the number of functions and tasks in the 2018 capability standards were compared to those in the 2011 capabilities, only 20% (3/15) of the capabilities had a decrease in function number. The majority of changes were at the task level (task numbers changed in 80%, or 12/15, capabilities) in the 2018 version. The capability standards provide public health agencies with a practical framework, informed by updated science and tools, which can guide prioritization of limited resources to strengthen public health agency emergency preparedness and response capacities.

CDC's Evolving Approach to Emergency Response.

The Centers for Disease Control and Prevention (CDC) transformed its approach to preparing for and responding to public health emergencies following the anthrax attacks of 2001. The Office of Public Health Preparedness and Response, an organizational home for emergency response at CDC, was established, and 4 programs were created or greatly expanded after the anthrax attacks: (1) an emergency management program, including an Emergency Operations Center; (2) increased support of state and local health department efforts to prepare for emergencies; (3) a greatly enlarged Strategic National Stockpile of medicines, vaccines, and medical equipment; and (4) a regulatory program to assure that work done on the most dangerous pathogens and toxins is done as safely and securely as possible. Following these changes, CDC led responses to 3 major public health emergencies: the 2009-10 H1N1 influenza pandemic, the 2014-16 Ebola epidemic in West Africa, and the ongoing Zika epidemic. This article reviews the programs of CDC's Office of Public Health Preparedness, the major responses, and how these responses have resulted in changes in CDC's approach to responding to public health emergencies.

Zika Virus -10 Public Health Achievements in 2016 and Future Priorities.

The introduction of Zika virus into the Region of the Americas (Americas) and the subsequent increase in cases of congenital microcephaly resulted in activation of CDC's Emergency Operations Center on January 22, 2016, to ensure a coordinated response and timely dissemination of information, and led the World Health Organization to declare a Public Health Emergency of International Concern on February 1, 2016. During the past year, public health agencies and researchers worldwide have collaborated to protect pregnant women, inform clinicians and the public, and advance knowledge about Zika virus (Figure 1). This report summarizes 10 important contributions toward addressing the threat posed by Zika virus in 2016. To protect pregnant women and their fetuses and infants from the effects of Zika virus infection during pregnancy, public health activities must focus on preventing mosquito-borne transmission through vector control and personal protective practices, preventing sexual transmission by advising abstention from sex or consistent and correct use of condoms, and preventing unintended pregnancies by reducing barriers to access to highly effective reversible contraception.

Using results from infectious disease modeling to improve the response to a potential H7N9 influenza pandemic.

As the Centers for Disease Control and Prevention (CDC) and other government agencies prepared for a possible H7N9 pandemic, many questions arose about the virus's expected burden and the effectiveness of key interventions. Public health decision makers need information to compare interventions so that efforts can be focused on interventions most likely to have the greatest impact on morbidity and mortality. To guide decision making, CDC's pandemic response leadership turned to experts in modeling for assistance. H7N9 modeling results provided a quantitative estimate of the impact of different interventions and emphasized the importance of key assumptions. In addition, these H7N9 modeling efforts highlighted the need for modelers to work closely with investigators collecting data so that model assumptions can be adjusted as new information becomes available and with decision makers to ensure that the results of modeling impact policy decisions.

Pandemic influenza planning, United States, 1978-2008.

During the past century, 4 influenza pandemics occurred. After the emergence of a novel influenza virus of swine origin in 1976, national, state, and local US public health authorities began planning efforts to respond to future pandemics. Several events have since stimulated progress in public health emergency planning: the 1997 avian influenza A(H5N1) outbreak in Hong Kong, China; the 2001 anthrax attacks in the United States; the 2003 outbreak of severe acute respiratory syndrome; and the 2003 reemergence of influenza A(H5N1) virus infection in humans. We outline the evolution of US pandemic planning since the late 1970s, summarize planning accomplishments, and explain their ongoing importance. The public health community's response to the 2009 influenza A(H1N1)pdm09 pandemic demonstrated the value of planning and provided insights into improving future plans and response efforts. Preparedness planning will enhance the collective, multilevel response to future public health crises.

Novel framework for assessing epidemiologic effects of influenza epidemics and pandemics.

The effects of influenza on a population are attributable to the clinical severity of illness and the number of persons infected, which can vary greatly between seasons or pandemics. To create a systematic framework for assessing the public health effects of an emerging pandemic, we reviewed data from past influenza seasons and pandemics to characterize severity and transmissibility (based on ranges of these measures in the United States) and outlined a formal assessment of the potential effects of a novel virus. The assessment was divided into 2 periods. Because early in a pandemic, measurement of severity and transmissibility is uncertain, we used a broad dichotomous scale in the initial assessment to divide the range of historic values. In the refined assessment, as more data became available, we categorized those values more precisely. By organizing and prioritizing data collection, this approach may inform an evidence-based assessment of pandemic effects and guide decision making.

Peramivir use for treatment of hospitalized patients with influenza A(H1N1)pdm09 under emergency use authorization, October 2009-June 2010.

BACKGROUND: In response to the influenza A(H1N1)pdm09 (pH1N1) pandemic, peramivir, an investigational intravenous neuraminidase inhibitor, was made available for treatment of hospitalized patients with pH1N1 in the United States under an Emergency Use Authorization (EUA). The Centers for Disease Control and Prevention (CDC) implemented a program to manage peramivir distribution to requesting clinicians under EUA. We describe results of the CDC's peramivir program and 3 related surveys. METHODS: We analyzed data on peramivir requests made by clinicians to the CDC through an electronic request system. Three surveys were administered to enhance clinician compliance with adverse event reporting, to conduct product accountability, and to collect data on peramivir-treated patients. Descriptive analyses were performed, and 2-source capture-recapture analysis based on the 3 surveys was used to estimate the number of patients who received peramivir through the EUA. RESULTS: From 23 October 2009 to 23 June 2010, CDC received 1371 clinician requests for peramivir and delivered 2129 five-day adult treatment course equivalents of peramivir to 563 hospitals. Based on survey responses, at least 1274 patients (median age, 43 years; range, 0-92 years; 49% male) received ≥1 doses of peramivir (median duration, 6 days). Capture-recapture analysis yielded estimates for the potential total number of peramivir recipients ranging from 1185 (95% confidence interval [CI], 1076-1293) to 1490 (95% CI, 1321-1659). CONCLUSIONS: Approximately 1274 hospitalized patients received peramivir through EUA program during the pH1N1 pandemic. Further analyses are needed to assess the clinical effectiveness of peramivir treatment of hospitalized patients with pH1N1.

Improving the evidence base for decision making during a pandemic: the example of 2009 influenza A/H1N1.

This article synthesizes and extends discussions held during an international meeting on "Surveillance for Decision Making: The Example of 2009 Pandemic Influenza A/H1N1," held at the Center for Communicable Disease Dynamics (CCDD), Harvard School of Public Health, on June 14 and 15, 2010. The meeting involved local, national, and global health authorities and academics representing 7 countries on 4 continents. We define the needs for surveillance in terms of the key decisions that must be made in response to a pandemic: how large a response to mount and which control measures to implement, for whom, and when. In doing so, we specify the quantitative evidence required to make informed decisions. We then describe the sources of surveillance and other population-based data that can presently--or in the future--form the basis for such evidence, and the interpretive tools needed to process raw surveillance data. We describe other inputs to decision making besides epidemiologic and surveillance data, and we conclude with key lessons of the 2009 pandemic for designing and planning surveillance in the future.

Estimating the burden of 2009 pandemic influenza A (H1N1) in the United States (April 2009-April 2010).

To calculate the burden of 2009 pandemic influenza A (pH1N1) in the United States, we extrapolated from the Centers for Disease Control and Prevention's Emerging Infections Program laboratory-confirmed hospitalizations across the entire United States, and then corrected for underreporting. From 12 April 2009 to 10 April 2010, we estimate that approximately 60.8 million cases (range: 43.3-89.3 million), 274,304 hospitalizations (195,086-402,719), and 12,469 deaths (8868-18,306) occurred in the United States due to pH1N1. Eighty-seven percent of deaths occurred in those under 65 years of age with children and working adults having risks of hospitalization and death 4 to 7 times and 8 to 12 times greater, respectively, than estimates of impact due to seasonal influenza covering the years 1976-2001. In our study, adults 65 years of age or older were found to have rates of hospitalization and death that were up to 75% and 81%, respectively, lower than seasonal influenza. These results confirm the necessity of a concerted public health response to pH1N1.

The science behind preparing and responding to pandemic influenza: the lessons and limits of science.

A strong evidence base provides the foundation for planning and response strategies. Investments in pandemic preparedness included support for research that aided early detection, response, and control of the 2009 influenza A (H1N1) (pH1N1) pandemic. Scientific investigations conducted during the pandemic guided understanding of the virus, disease severity, and epidemiologic risk factors. Field investigations also produced information that strengthened guidance for the use of antivirals, identification of target populations for monovalent pH1N1 vaccine, and refinement of recommendations for social distancing measures. Communication of this evolving evidence base was important to sustaining credibility of public health. Areas where substantial controversy emerged, such as the optimal approach to respiratory protection of healthcare workers, often suffered from gaps in the evidence base. Many aspects of the 2009-2010 pandemic influenza experience provide ongoing opportunities for additional study, which will strengthen plans for future pandemic response as well as control of seasonal influenza.

A primer on strategies for prevention and control of seasonal and pandemic influenza.

The United States has made considerable progress in pandemic preparedness. Limited attention, however, has been given to the challenges faced by populations that will be at increased risk of the consequences of the pandemic, including challenges caused by societal, economic, and health-related factors. This supplement to the American Journal of Public Health focuses on the challenges faced by at-risk and vulnerable populations in preparing for and responding to an influenza pandemic. Here, we provide background information for subsequent articles throughout the supplement. We summarize (1) seasonal influenza epidemiology, transmission, clinical illness, diagnosis, vaccines, and antiviral medications; (2) H5N1 avian influenza; and (3) pandemic influenza vaccines, antiviral medications, and nonpharmaceutical interventions.

Protecting vulnerable populations from pandemic influenza in the United States: a strategic imperative.

Protecting vulnerable populations from pandemic influenza is a strategic imperative. The US national strategy for pandemic influenza preparedness and response assigns roles to governments, businesses, civic and community-based organizations, individuals, and families. Because influenza is highly contagious, inadequate preparedness or untimely response in vulnerable populations increases the risk of infection for the general population. Recent public health emergencies have reinforced the importance of preparedness and the challenges of effective response among vulnerable populations. We explore definitions and determinants of vulnerable, at-risk, and special populations and highlight approaches for ensuring that pandemic influenza preparedness includes these populations and enables them to respond appropriately. We also provide an overview of population-specific and cross-cutting articles in this theme issue on influenza preparedness for vulnerable populations.

Prevalence of viral respiratory tract infections in children with asthma.

BACKGROUND: Previous studies support a strong association between viral respiratory tract infections and asthma exacerbations. The effect of newly discovered viruses on asthma control is less well defined. OBJECTIVE: We sought to determine the contribution of respiratory viruses to asthma exacerbations in children with a panel of PCR assays for common and newly discovered respiratory viruses. METHODS: Respiratory specimens from children aged 2 to 17 years with asthma exacerbations (case patients, n = 65) and with well-controlled asthma (control subjects, n = 77), frequency matched by age and season of enrollment, were tested for rhinoviruses, enteroviruses, respiratory syncytial virus, human metapneumovirus, coronaviruses 229E and OC43, parainfluenza viruses 1 to 3, influenza viruses, adenoviruses, and human bocavirus. RESULTS: Infection with respiratory viruses was associated with asthma exacerbations (63.1% in case patients vs 23.4% in control subjects; odds ratio, 5.6; 95% CI, 2.7- 11.6). Rhinovirus was by far the most prevalent virus (60% among case patients vs 18.2% among control subjects) and the only virus significantly associated with exacerbations (odds ratio, 6.8; 95% CI, 3.2-14.5). However, in children without clinically manifested viral respiratory tract illness, the prevalence of rhinovirus infection was similar in case patients (29.2%) versus control subjects (23.4%, P > .05). Other viruses detected included human metapneumovirus (4.6% in patients with acute asthma vs 2.6% in control subjects), enteroviruses (4.6% vs 0%), coronavirus 229E (0% vs 1.3%), and respiratory syncytial virus (1.5% vs 0%). CONCLUSION: Symptomatic rhinovirus infections are an important contributor to asthma exacerbations in children. CLINICAL IMPLICATIONS: These results support the need for therapies effective against rhinovirus as a means to decrease asthma exacerbations.

From research to reality: from the National Cooperative Inner-City Asthma Study to the inner-city asthma implementation.

Several themes emerged from the information provided in this supplement. 1. Implementation of the protocol was feasible, although retention of participants was challenging and customization at each site was essential. 2. Master's degree level social workers were well suited to partnering with health care professionals to address the many issues involved in caring for children with asthma and their families. 3. Collaboration between team members and community partners was critical to successful implementation. 4. Sustainability beyond external funding is attainable if local funding is sought and outcome measures that are considered important to the community are measured and reported.

The Inner-City Asthma Intervention: description of a community-based implementation of an evidence-based approach to asthma management.

BACKGROUND: In 2000, the Centers for Disease Control and Prevention funded a 4-year project to implement the Inner-City Asthma Intervention (ICAI)-an asthma treatment and management project based on the protocol developed for the National Cooperative Inner-City Asthma Study (NCICAS) funded by the National Institutes of Health, National Institute of Allergy and Infectious Disease. OBJECTIVE: To describe the ICAI's major components and implementation issues. METHODS: Information contained in this article is based on project activity and management reports, site client tracking and data collection reports, site visit and other program oversight activity, and general subject matter knowledge. The site client tracking data collection process varied among sites during the intervention. Common definitions and processes were developed and implemented as needed. RESULTS: Three of the 24 original sites discontinued participation. The remaining sites enrolled 4,174 children into the intervention. Although the project ended earlier than originally scheduled, 1,035 children completed the entire intervention. Of the 3,139 children who did not complete the entire protocol, 1,355 children and their families completed the core activities or the core activities plus one or more follow-up activities. CONCLUSION: The ICAI project demonstrated that although there were a number of implementation issues to overcome, it is possible to implement effectively a proven National Institutes of Health protocol in the community setting.