2 nd and 3 rd Order Impacts of Community Mitigation Strategies

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1 2 nd and 3 rd Order Impacts of Community Mitigation Strategies Institute of Medicine October 26, 2006 Carter Mecher, MD Department of Veterans Affairs

2 Pneumonia and Influenza Death Rates per 100,000 Infants, Children, and Young Adults , , Age <1 Ages 1-4 Ages 5-14 Ages Source: U.S. Vital Statistics

3 Pneumonia and Influenza Death Rates per 100,000 Ages 25 and Older , , Ages Ages Ages Ages Ages Ages Ages Source: U.S. Vital Statistics

4 All Cause Death Rates per 100,000: Children and Teenagers by Age Group 2,000 1,500 1,000 Ages 1-4 Ages 5-9 Ages Ages Source: U.S. Vital Statistics

5 1900-Present All Cause Death Rates per 100,000 with a 1918-like Pandemic Today 1918 Age-specific Attack Rates and CFRs Applied to Current Population 2,000 1, years 5-9 years years 1, years

6 Community Mitigation Strategies Closing schools Keeping children and teens at home Social distancing at work and in the community Encouraging voluntary home isolation by ill individuals and voluntary home quarantine by the household contacts Treating the ill and providing targeted antiviral prophylaxis to household contacts

7 Impact on Individuals and Families at Home Underscores preparedness of individuals and families Tests the resiliency of all families and individuals but particularly vulnerable populations Hinders access to essential goods and services (meds, food, medical care) Alters the nature of services schools provide Shifts medical care from community to home Disease transmission at home

8 Impact on Economy and Critical Infrastructure Individuals and Families Loss of income/job related to absenteeism especially related to school closure and child minding Financial insecurity, fear, worry Community Delivery of goods and services Business, supply-chain Critical infrastructure

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10 School Absenteeism Chicago 1918

11 School Closure, Child Minding and Workplace Absenteeism

12 Baseline Information Workforce Dynamics Household Demographics Schools and School Services

13 Baseline Workplace Absenteeism Normal February All-Cause Absenteeism by Industry % Absenteeism All Goods Agriculture Forestry Utilities Manufacturing Services Trade Transportation Finance Scientific Education Health Care Recreation Accomodation/Food Other Services Public Administration 0.0 Source: The Economic Impact of an Influenza Pandemic. James, S., and Sargent, T. October 5, 2006.

14 Job Separations Rate, July Total Natural Resources / Mining Construction Manufacturing Trade, Transportation, and Utilities Information Financial Activities Professional Services Education and Health Leisure and Hospitality Other Government Quits Layoffs and Discharges Other Source: Bureau of Labor Statistics, Job Openings and Labor Turnover Survey. Percent

15 Baseline Workplace Dynamics 54.5 million people separated from their jobs in million quit 19.9 million were laid off 3.7 million retired, died, transferred, or developed disability 10% of businesses fail every year (600,000 bankruptcies or terminations) ftp://ftp.bls.gov/pub/news.release/history/jolts news

16 Household Survey Data 2006 Single adult with no children<18 Two or more adults with no children<18 Single Adult with children<18 Two or more adults with children<18 45 million 38.8% 26.9% 31 million 7 million 33 million 6.1% 28.2% Source: Department of Labor, Office of the Assistant Secretary for Policy calculations from Current Population Survey microdata.

17 Household Survey Data August 2006 Household Survey Households (millions) Households: All Employed (millions) Households: Some Employed (millions) Households: None Employed (millions) No children<18 Single adult in HH Two adults Multiple adults Total Children under 18 years Single adult in HH Two adults Multiple adults Total Total Source: Department of Labor, Office of the Assistant Secretary for Policy calculations from Current Population Survey microdata.

18 Absenteeism Related to Child Minding Impact of Age Threshold Households with children and no non-working adults (millions) Children <18 Only Children<15 Only Children<14 Only Children<13 Single adult in HH Two adults Multiple adults Total %Absenteeism 16% 11% 10% 9% Age Threshold Source: Department of Labor, Office of the Assistant Secretary for Policy calculations from Current Population Survey microdata.

19 Parents Who is Minding the Kids? SIPP Survey 2002 Part-time employment, staggered shifts, working from home, bringing children to work, parents sharing responsibilities including divorced/separated parents Other family members Grandparents, siblings, other relatives Non-relative child care in the home Non-relative child care outside the home Child self-care ( Latchkey kids ) Source:

20 Workforce Distribution by Presence of Children and Non-Working Adults Children<18 Two or more adults working; No non-working Adult present 25.8% Children<18 Single working adult 3.6% 13.9% Children<18 One or more adults Working; Non-working Adult present 56.2% Without children<18 12% Single households 37% Multi-worker households 7% Single worker with non-working adult at home Source: Department of Labor, Office of the Assistant Secretary for Policy calculations from Current Population Survey microdata.

21 Added Impact of Illness and Quarantine Effect of Reducing Attack Rate Workplace Absenteeism Related to Illness, Quarantine, and Child Minding Attack Rates 50%-1% Millions Absent Illness Absenteeism (millions) Quarantine Absenteeism (millions) Child Minding Absenteeism (millions) % Attack Rate 40% Attack Rate 30% Attack Rate 20% Attack Rate 10% Attack Rate 5% Attack Rate 2% Attack Rate 1% Attack Rate Assumption: Children <18 would require adult supervision (22 M working adults needed for child minding)

22 Schools A Community Resource

23 Schools in 1918 and Today

24 Education Resources Preschool/Day Care: 1 million wage and salary, self-employed, and unpaid workers $40 billion Schools K-12: 7 million employees $500 billion Colleges and Universities: 3 million employees $300 billion National Child Care Association, 2002 U.S. Department of Education, National Center for Education Statistics, August 2005

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26 Feeding our Children School Meal Programs

27 School Meal Programs FY million Participants (millions) National School Lunch Program 9.3 million School Breakfast Program 2.0 million Summer Meal Program Source:

28 School Meals Sep-05 to Jul-06 Full Price Meals Free or Reduced Price Meals 600 Millions of Meals Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Source:

29 Summer Meal Program

30 Other Food Programs Food Stamp Program 26 million participants $31 billion WIC 8 million participants $5 billion Child Care Food Program 3 million participants 1.8 billion meals $2.1 billion Source:

31 Keeping Children and Teens from Re-Congregating in the Community Retail Shopping $2 trillion in sales (teens $158 billion) April 2006 Business Week report, Kick Out The Kids, Bring In The Sales Teenage employment 168, year-olds FT 2.16 million year-olds PT

32 Source: OJJDP Statistical Briefing Book, Juvenile Offenders and Victims: 2006 National Report

33 Source: OJJDP Statistical Briefing Book, Juvenile Offenders and Victims: 2006 National Report

34 Vulnerable Populations Poor 37 million, 13 million children, 7.7 million families New Immigrants 7.9 million since 2000 Homeless 600, million Disabled 22.8 million (13.6 M physical; 8.4 M mental disability) Institutionalized 1.6 million NH; 1 million Assisted Living Incarcerated Prisons (State and Federal) 1.5 million Jails (City, County multiple jurisdictions) 750,000 Juvenile detention 100,000

35 Children with Disabilities Individuals with Disabilities Education Act (IDEA) Children served under IDEA Infants and Toddlers (age<3) 300,000 Preschool (ages 3-5) 700,000 School Age (ages 6-21) 6,100,000 Source:

36 Macroeconomic Analysis Supply-Side Impact vs. Lives Saved (Impact of Deaths Excluded) Base Case (unmitigated) and Mitigated Scenarios, Ro=2.1 $600 3,000,000 $500 $400 Meltzer CBO CEA Low -Work Loss CEA High-Work Loss Lives Saved 2,500,000 2,000,000 $Billions $300 1,500,000 Lives Saved $200 1,000,000 $ ,000 $0 Base Case Ro=2.1 30%-60%-10% 30%-60%-1% 30%-60%-0.1% 60%-60%-0.1% 90%-80%-0.001% 0

37 Premium of Life Private Life Insurance Insurance Coverage Ages Ages Group Life 46% 42-51% 20% Individual Life 27% 43-52% Annual life insurance premiums $138 billion Annual death benefits $50 billion (2005) Severe Pandemic $155 billion Social Security survivor benefits 6.7 M beneficiaries $66 billion (2004) 51% Source: Pandemic: Can the Life Insurance Industry Survive the Avian Flu? Steven Weisbart, PhD.

38 Community Mitigation Strategies Carry Consequences That Should Be Anticipated and Incorporated into Pandemic Planning Economic impact and potential disruption of services due to absenteeism Issues associated with closure of schools and sequestration of children Home-based care Disproportionate impact on certain populations These and other consequences may occur in the absence of community-wide interventions, as a result of spontaneous action by the public.

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