HSPH Contributes Quickly to H1N1 Flu Global Control Efforts

Shortly after H1N1 flu hit the public health radar in April, HSPH researchers were consulting with the Mexican and U.S. governments, fielding dozens of international media calls, polling Americans, and identifying research projects to help the world better understand how to control and prevent the spread of the virus.

Communicating Quickly

As former Minister of Health of Mexico, the viewpoints of HSPH Dean Julio Frenk were sought by the global media. After consulting with the Mexican government, which welcomed his help in communicating about H1N1 flu, Dean Frenk was intensively engaged in communications activities in the days after the outbreak. He was interviewed by major media organizations such as CNN and NPR, and he swiftly published an Op-Ed in the April 30 issue of The New York Times commenting on the Mexican government response. He wrote: "As a former minister of health for Mexico, I met with Mexican officials this week to consult with them on their response to the influenza, and I was impressed by how medical scientists in the country quickly perceived the unusual trend of illness against a background of standard flu and then analyzed the virus and alerted global health authorities. Their fast action gave other countries the warning they needed to screen for the new virus, which is why cases of swine flu have already been discovered in a dozen other countries -- cases that might otherwise have long gone unnoticed."

Modeling an Emerging Epidemic

Marc Lipsitch, professor of epidemiology in the Department of Epidemiology, was on a plane to Atlanta the last week in April to lend his services to the Centers for Disease Control and Prevention (CDC). He was there to develop statistical modeling to support estimates of the severity and transmission of the virus in collaboration with colleagues at HSPH (who remained onsite in Boston), Hong Kong University, the Netherlands National Institute for Public Health and the Environment, and Imperial College London.

In a nearly prescient development, Lipsitch had co-authored a draft paper on delaying drug resistance to flu medications -- before the epidemic emerged. Understanding the importance of the paper, PLoS Medicine fast-tracked its publication, making it available online on April 30. Using a mathematical model to represent the global spread of pandemic influenza, the international team of researchers found that treating as few as only the first one percent of the population in a local epidemic with a secondary drug rather than with oseltamivir (Tamiflu), could substantially delay the development of resistance to oseltamivir. In the context of the H1N1 flu, the secondary drug could be zanamivir (Relenza), the only other approved drug to which the new H1N1 flu strain has been found to be susceptible. Lipsitch conducted a telephone press conference while in Atlanta to communicate the paper's findings and has continued to field media calls.

Building Checklists for Hospitals

Building on a model he developed to reduce surgical errors, HSPH Associate Professor and 2009 Commencement Speaker Atul Gawande helped lead a World Health Organization (WHO) team to rapidly produce an "Influenza A(H1N1) patient care checklist" for hospitals managing suspected or confirmed cases. The concept is based on a previous collaboration with the WHO that produced a simple surgical checklist that was demonstrated to reduce the incidence of surgical deaths and complications by more than one-third.

The H1N1 checklist required facilitating clinical consensus from infectious disease experts on the behavior and management of the new virus as information developed, followed by swift feedback on practicability from 12 hospitals trying the checklist around the world. The hospitals included a Mexican hospital, arranged with the help of Robin Herman, assistant dean for communications at HSPH. Herman has coordinated a slew of media requests in the wake of the H1N1 epidemic to interview School experts on infectious disease and created messaging from the HSPH emergency management team when our own Longwood Campus was faced with cases. In the course of the news requests, she tapped HSPH doctoral student Martin Lajous for help with the Spanish-language media and also asked him to assist Gawande. A trained MD from Mexico, Lajous was able to help Gawande identify the appropriate hospital contacts in Mexico to pilot the flu checklists.

Using Text Messaging to Survey Mexicans

Lajous played a key role in an inventive public health response, reaching out to a large cell phone company in Mexico to help survey Mexican residents in an effort to gauge the earliest course of the outbreak. He was inspired to do so after learning that companies had used text messaging about hygiene practices and H1N1 flu. Lajous pitched an idea to the Mexican Ministry of Health to conduct a random survey of cell phone customers to get a better idea of if/when they started to feel ill with flu-like symptoms and the severity of the symptoms.

Working with Marc Lipsitch's group -- including Christina Astley, Leon Danon, Ted Cohen, Justin O'Hagan, and Joel Miller -- and with input from the CDC, Lajous developed a menu of six questions. "The idea is that this could be a ‘proof of concept' whether we can use cell phone technology for public health response and public health surveillance," he said. "The primary question we want to know is, ‘When did the symptoms start?' This could give us an idea of the epidemic curve."

The cell phone company, Telefónica, agreed to participate, Lajous explained, as it had the right technology to send the menu of questions to customers -- preceded by a message from Mexico's Ministry of Health asking for their participation. In all, a random sample of a million cell phone users received the health questions, and four key cities were of particular focus: two with apparently high prevalence of the disease, Mexico City and San Luis de Potosi, and two where very few cases had been reported, Monterrey and Cancun, but where American visitors could have provided the avenue to spread the virus in the United States. Lajous and his colleagues expect to analyze the resulting data starting the week of May 18.

Urging a Gradual Roll-Back of Social-Distancing Measures

Meanwhile another member of the Lipsitch group, research scientist Edward Goldstein, was concerned about the Mexican government's plans to precipitously end its social distancing policies now that the virus seems to be receding. In collaboration with other members of the Lipsitch group, he drafted a memo explaining the factors affecting population dynamics of influenza and historical precedence of the untimely lifting of control measures that resulted in the resurgence of an epidemic. This memo, translated by Lajous, was forwarded to Mexican health officials and was raised during the deliberations that led to their decision to implement a gradual roll-back of control measures.

Polling Americans

In the U.S., rapid formal polling was undertaken by Robert Blendon, professor of health policy and political analysis, as part of the Harvard Opinion Research Program at HSPH. In the span of one week, he and his colleagues conducted two overnight surveys, polling Americans on whether they have taken steps to protect themselves against H1N1 flu (many have done so), and whether Americans are concerned that they or their family may get sick from swine flu (nearly half of those polled are concerned.) More polls in the series are planned as needed by the CDC.

Convening a Panel Discussion

Staff from the HSPH Center for Public Health Preparedness and the Division of Public Health Practice gathered useful and interesting links to government case-tracking sites, the CDC swine flu information site, WHO statements, and other sites for gathering the facts about the outbreak and posted them on the Center's website on April 28. The Center also co-arranged with the Division of Public Health Practice a panel and discussion for the HSPH community on "Type A Influenza H1N1: Science and the Public Health."

Training Leaders

Graduates of the National Preparedness Leadership Initiative (NPLI), a joint program of HSPH and the Harvard Kennedy School, were also at the forefront of the response to the H1N1 flu. NPLI graduates include Richard Besser, acting director of the CDC, as well as officials at the Department of Defense, the various agencies that comprise the Departments of Health and Human Services and Homeland Security, and the White House. NPLI alumni could also be found leading the response in Alaska, Canada, Colorado, Hawaii, and Massachusetts in organizations such as public health agencies, public health laboratories, and frontline responder organizations. NPLI is co-directed by Leonard Marcus, lecturer on public health practice at HSPH.

-- Eric McNulty contributed to this article.