Salvador Borges-Neto, MD

• Professor of Radiology
• Professor of Medicine
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/salvador-borges-neto-md

A the presence of weight loss and jaundice androgen hormone of happiness rogaine 5 60 ml without prescription, and the facility conducting the meta-analysis including 20 studies and 2761 patients showed sensitivity imaging evaluation prostate cancer prevalence discount rogaine 5 60 ml overnight delivery. Some of the most common somatic mutations in disease man health tonic purchase rogaine 5 visa, other acceptable methods of biopsy exist prostate cancer 4049 discount 60 ml rogaine 5 overnight delivery. The panel recognizes the importance of identifying high-volume center is preferred, though new methods are being developed biomarkers for early detection of this difficult disease, and they for diagnosis of pancreatobiliary malignancies (eg, emphasize the need for collection and sharing of tissue to help cholangiopancreatoscopy) when repeat biopsy is needed. Differential Diagnoses Chronic pancreatitis and other benign conditions are possible differential Autoimmune pancreatitis can, however, be negative for IgG4, thus closely diagnoses of patients suspected of having pancreatic cancer. For patients with borderline resectable disease and cancer not as lymphoplasmacytic sclerosing pancreatitis, is a heterogeneous disease confirmed after 2 or 3 biopsies, a second opinion is recommended. In addition, gemcitabine plus sorafenib is not with advanced pancreatic cancer, median survival was increased in the recommended. Gemcitabine combinations are currently being used and to the standard infusion of gemcitabine over 30 minutes (category 2B). Adverse events, such as rash of patients from that arm were alive at 42 months, whereas no patients and diarrhea, were increased in the group receiving erlotinib, but most were alive from the control arm at that time. A retrospective study from Johns Hopkins University School of capecitabine had a greater overall response rate, compared to patients Medicine of patients with metastatic pancreatic cancer and a family history who received gemcitabine only (43. Although there are concerns large survival advantage when treated with platinum-based chemotherapy about dosing and toxicity of capecitabine in a U. Angiogenesis inhibitors may be more useful after more effective first-line treatments. Clearly, additional trials are Fluoropyrimidine Plus Oxaliplatin needed in this important area. With the success of more effective regimens in patients with advanced Second-line systemic therapy should be administered to patients with disease, questions have been raised about how best to manage the good performance status only. Final results of the trial were without evidence of progression after 6 months of initial therapy (n = 55; 317 published in 2014. Options for patients with good antibodies that inhibit the interactions between immune cells and antigen performance status and previously treated with fluoropyrimidine-based presenting cells, including tumor cells. Adverse events were experienced by 74% of all patients receiving pembrolizumab; most were Radiation and Chemoradiation Approaches low grade (20% experienced grade 3 or 4 adverse events, such as In patients with pancreatic cancer, radiation is usually given concurrently diarrhea/colitis, pancreatitis/hyperamylasemia, fatigue, arthritis/arthralgias, with gemcitabine or fluoropyrimidine-based chemotherapy. Although the mechanism of radiosensitization is Immunotherapy-Related Toxicities, available at It also treatment-related toxicity, particularly in patients with unresectable may be used to enhance local control and prevent disease progression, disease. Studies are presently investigating the from adjuvant chemoradiation than those with negative nodes. Chemoradiation is a conventional option for the management of locoregional pancreatic cancer, although the utility of chemoradiation in Studies that have looked at R0 or R1 subsets of patients have found this population of patients is controversial. One retrospective review compared 370-374 radiation sensitizer in the locally advanced setting. A retrospective of upfront chemotherapy followed by chemoradiation in locally advanced analysis of 77 patients with unresectable disease demonstrated that while disease have been discussed. Hypofractionated dosing patients with locally advanced pancreatic cancer, was closed early due to 387 may also be used in these patients, with acceptable toxicity. Employing an initial course of chemotherapy may improve local disease progression. In addition, the natural history of chemotherapy regimens than gemcitabine monotherapy, additional studies the disease can become apparent during the initial chemotherapy, thus are planned to assess the role of radiation after more active allowing the selection of patients most likely to benefit from subsequent chemotherapy. Moreover, clinically meaningful tumor should only be performed at specialized centers. For instance, patients who complain of intractable nausea and vomiting may have the primary goals of treatment for metastatic pancreatic cancer are gastric outlet obstruction rather than chemotherapy-induced emesis. However, have noted that the opportunity for curative intent resection occasionally patients may demonstrate progressive disease clinically without objective arises. Following resection, these patients Management of Locally Advanced Disease have similar survival rates as those initially determined to be resectable. This technique has been used in patients with locally advanced the role of modern, more active regimens in locoregionally advanced pancreatic cancer. Five patients (23%) were able to undergo R0 resections, although Management of Resectable and Borderline Resectable 3 of these patients experienced distant recurrence by 5 months. The goals of surgery for adenocarcinoma of the pancreas include an oncologic resection of the primary tumor and regional lymph nodes. However, more than 80% of patients present with Based on their clinical experience with the primary management of disease that cannot be cured with surgical resection. Early concerns about tumor resectability so as to improve patient selection for surgery and high mortality associated with various pancreatic resection procedures428 increase the likelihood of an R0 resection. A review of 4 studies with 2580 patients management and resectability always involve multidisciplinary consultation showed that additional resection to achieve a negative surgical margin at high-volume centers with use of appropriate high-quality imaging was not associated with improved survival. Although it is clear that patients taken approximately 5 mm from the transection margin, with the clean-cut with visceral, peritoneal, or pleural metastases or with metastases to side facing down, to avoid cautery artifact that may confound analysis and nodes beyond the field of resection derive no benefit from resection, result in false negatives. If tumor is located within 5 mm of margins, further institutions differ in their approaches to patients with locoregional disease excision of the pancreas should be considered to ensure at least 5 mm of involvement (pancreas and peripancreatic lymph nodes). Careful intraoperative staging should rule out peritoneal, liver, and distant For cancers of the pancreas head and uncinate, a lymph node metastases, and resection of the primary tumor should only pancreatoduodenectomy (Whipple procedure) is done. The surgical procedure pancreas body and tail, a distal pancreatectomy with en-bloc splenectomy required is based on the location of the primary tumor and relationship to is done. The panel has adapted the criteria put forth by other groups and lists its recommended criteria for defining resectability status in the guidelines. Overall, the likelihood of attaining recommends biopsy confirmation of adenocarcinoma at this time, if a negative margins is the key criterion for consideration when determining biopsy was not previously performed. If a patient with jaundice is found to whether a patient is a potential candidate for resection. If a stent has been previously placed, then surgical there is a higher likelihood of an incomplete resection. In addition, gastrojejunostomy can be for positive surgical margins are not considered to be good candidates for considered if appropriate regardless of jaundice (category 2B for an upfront resection but may be potentially downstaged and safely prophylactic gastrojejunostomy). Celiac plexus neurolysis can also be resected following neoadjuvant therapy [see Preoperative (Neoadjuvant) performed, especially when indicated by pain in a patient with jaundice Therapy below]. See Severe Tumor-Associated Abdominal Pain, be considered when deciding whether a patient is a surgical candidate. Comorbidities, performance status, and frailty are all things to be In patients with suspected borderline resectable disease for whom cancer discussed during the multidisciplinary review. If resectable disease is found in further discussion of the treatment of older patients. If unresectable disease is found, then recommendations the nature and extent of the surgery for resectable tumors depend on the for management of locally advanced or metastatic disease should be location and size of the tumor. If these patients present with jaundice, surgical tail cause symptoms late in their development, they are usually advanced biliary bypass and gastrojejunostomy (category 2B for prophylactic at diagnosis and are rarely resectable. When tumors in the pancreatic tail gastrojejunostomy) should be considered, as well as celiac plexus are resectable, distal pancreatectomy, in which the surgeon removes the neurolysis for pain (category 2B if no pain). If the cancer diffusely involves the pancreas or is present at Pancreatoduodenectomy (Whipple Procedure) multiple sites within the pancreas, a total pancreatectomy may be required Achievement of a margin-negative dissection must focus on meticulous where the surgeon removes the entire pancreas, part of the small perivascular dissection of the lesion in resectional procedures, recognition intestine, a portion of the stomach, the common bile duct, the gallbladder, of the need for vascular resection and/or reconstruction, and the potential the spleen, and nearby lymph nodes. Of course, the biology of the the pancreas, who usually present because of jaundice, are treated with cancer might not allow for an R0 resection even with the most meticulous open or minimally invasive pancreaticoduodenectomy (ie, the Whipple surgery. Plane of dissection anterior to adrenal gland or en bloc and requires careful dissection to free the vein from the pancreatic head if resection of left adrenal gland with plane of dissection posterior to it is possible to do so. The preservation is not indicated in distal pancreatectomy for adenocarcinoma, liberal use of partial or complete vein resection when vein infiltration is and an R0 distal pancreatectomy for adenocarcinoma mandates en bloc suspected during Whipple procedures has been studied. However, if an R0 resection is obtained with vein excision, longevity appears similar to those with R0 resections without resections is associated with an increase in blood loss, transfusion venous involvement, with no significant increase in morbidity and mortality.

Computational Characterization of Transient Strain Transcending Immunity against Inuenza A prostate and masurbation purchase rogaine 5 with a visa. The impact of cross-immunity prostate urine flow order 60ml rogaine 5 with amex, mutation and stochastic extinction on pathogen diversity mens health lean muscle x generic 60ml rogaine 5 overnight delivery. Essential epidemiological mechanisms underpinning the transmission dynamics of seasonal inuenza prostate operations for enlarged prostate cheap rogaine 5 60 ml online. Estimating inuenza attack rates in the United States using a participatory cohort. Estimating the im pact of school closure on inuenza transmission from Sentinel data. The roles of competition and muta tion in shaping antigenic and genetic diversity in inuenza. Primary inuenza A virus infection induces cross-protective immu nity against a lethal infection with a heterosubtypic virus strain in mice. Infection of mice with a human inuenza A/H3N2 virus induces protective immunity against lethal infection with inuenza A/H5N1 virus. Evaluation of the humoral and cellular immune responses elicited by the live attenuated and inactivated in uenza vaccines and their roles in heterologous protection in ferrets. Neutralization escape mutants of type A inuenza virus are readily selected by antisera from mice immunized with whole virus: a possible mechanism for antigenic drift. Understanding the dynamics of rapidly evolving pathogens through modeling the tempo of antigenic change: inuenza as a case study. Estimating the Life Course of Inuenza A(H3N2) Antibody Responses from Cross Sectional Data. Assessing Google u trends performance in the United States during the 2009 inuenza virus A (H1N1) pandemic. Improving Google u trends estimates for the United States through transformation. In: Proceedings of the conference on empirical methods in natural language processing. Nonparametric Stein-type shrinkage covariance matrix estimators in high dimensional settings. Center for Advanced Engineering Study, Massachusetts Institute of Technology; 1961. Algorithm aversion: People erroneously avoid 126 algorithms after seeing them err. The generation of inuenza outbreaks by a network of host immune responses against a limited set of antigenic types. Although the format of each document is slightly different, the stakeholders worked hard to ensure that the two are closely related and interconnected. Both documents are intended to provide guidance to State and local agencies in developing their pandemic influenza plans and operational protocols. They provide general guidance, considerations, references and ideas that can enhance the optimal delivery of emergency care and 9-1-1 services during an influenza pandemic. Coordination among the 9-1-1 Public Safety Answering Point, the Emergency Medical Services System and the Public Health System is of paramount importance. Sufficient legal authority must be in place while still allowing the system to be responsive to the exigencies of the situation. It is impossible to establish one set of protocols/procedures that works for every single jurisdiction. The effectiveness of patient care will require responsive medical direction, training and coordinated system oversight. Their early involvement in community mitigation strategies such as Targeted Layered Containment may help to control the spread of the virus and reduce the subsequent use of health care resources. PandemicFlu Calls this chart is for illustrative purposes only, to be modified to locally adopted protocols as need. Provision of antiviral prophylaxis Consider provision of antiviral if effective, feasible and prophylaxis if effective, feasible and quantities sufficient. Non-urgent and ambulatory Emergency medical services may Only severe cases transported victims may have to walk or self transport victims to specific via ambulance Transportation transport to the nearest facility quarantine or isolation locations and or hospital. Alternate care sites will be used Ambulatory and some non Emergency department access Destination for triage and distribution of ambulatory patients may be diverted may be reserved for immediate vaccines or other prophylactic to alternate care sites (including non need patients. Measure of performance: model protocols developed and disseminated to 9-1-1 call centers and public safety answering points. While two separate documents were developed to address each task, the documents are intended to be used in tandem. How the document was developed the document was developed based on existing Federal guidelines; international, national, State and regional pandemic influenza and disaster response plans; and relevant research, publications and expert interviews. In addition, Federal agency representation and expertise was involved from the Department of Health and Human Services, Department of Homeland Security, Department of Commerce, Department of Transportation, Department of Justice and others. A list of the participating stakeholder organizations, as well as a list of participants in the development process, may be found in Appendix S. Because there is little natural immunity, the disease spreads easily and sustainably from person to person. Avian influenza viruses played a role in the development of the human influenza viruses associated with the last three influenza pandemics. Two of these viruses remain in circulation among humans today and are responsible for the majority of seasonal influenza cases each year. There will be very little discussion of specifics regarding avian influenza in this document as it is impossible to predict whether an avian influenza virus will in fact be the cause of a future pandemic. The last three pandemics, in 1918, 1957 and 1968, killed approximately 50 million, 1-2 million and 700, 000 people worldwide, respectively. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but would not be able to stop it. Nations are unlikely to have the staff, facilities, equipment and hospital beds needed to cope with large numbers of people who suddenly fall ill. Death rates may be high, depending on four factors: the number of people who become infected, the virulence of the virus, the underlying characteristics and vulnerability of affected populations and the effectiveness of preventive measures. Surge capacity at non-traditional sites such as schools may be created to cope with demand. FluAid is a test version of software designed to assist State and local level planners by providing estimates of potential impact specific to their locality. The software cannot describe when or how people will become ill, or how a pandemic may spread through a society over time. An inuenza virus subtype 1 that has caused human infection may be present in animals. Suspected human outbreak overseas 1 Small cluster(s) with limited human-to-human transmission but spread is highly localized, 4 suggesting that the virus is not well adapted to humans. The index is designed to estimate the severity of a pandemic on a population level, allow better forecasting of the impact of a pandemic and enable recommendations on the use of mitigation interventions matched to the severity of influenza pandemics. Pandemics will be assigned to one of five discrete categories of increasing severity (Category 1 to Category 5). Accordingly, communities facing the imminent arrival of pandemic disease will be able to use the pandemic severity assessment to define which pandemic mitigation 5 interventions are indicated for implementation. This document uses the Pandemic Severity Index to guide planning of protocol development and alteration of response mechanisms.

Medicare periodically updates the list of covered procedures and related payment amounts through release of regulations and change requests prostate otc generic rogaine 5 60ml on-line. Facility services are items and services furnished in connection with listed covered procedures prostate 5x cheap 60 ml rogaine 5 with amex, which are covered if furnished in a hospital operating suite or hospital outpatient department in connection with such procedures prostate cancer tattoo order cheapest rogaine 5 and rogaine 5. Administrative prostate kidney problems order 60ml rogaine 5 overnight delivery, Recordkeeping, and Housekeeping Items and Services these include the general administrative functions necessary to run the facility. Usually the blood deductible results in no expenses for blood or blood products being included under this provision. Materials for Anesthesia these include the anesthetic itself, and any materials, whether disposable or reusable, necessary for its administration. The fact that they are covered under Medicare is an exception to the general policy not to cover experimental or investigational items or services. If it determines the item or service does fall into one of those categories, it makes payment following the applicable rules for such items and services found elsewhere in this chapter. The facility may obtain approval as an ambulance supplier to bill covered ambulance services. The updates will be proposed and finalized in the Federal Register concurrent with updates to the hospital outpatient prospective payment system. Also, surgical procedures are commonly thought of as those involving an incision of some type, whether done with a scalpel or (more recently) a laser, followed by removal or repair of an organ or other tissue. In recent years, the development of fiber optics technology, together with new surgical instruments utilizing that technology, has resulted in surgical procedures that, while invasive and manipulative, do not require incisions. Instead, the procedures are performed without an incision through various body openings. Medicare will pay for glaucoma screening examinations where they are furnished by or under the direct supervision in the office setting of an ophthalmologist or optometrist, who is legally authorized to perform the services under State law. Payment may be made for a glaucoma screening examination that is performed on an eligible beneficiary after at least 11 months have passed following the month in which the last covered glaucoma screening examination was performed. To determine the 11-month period, start the count beginning with the month after the month in which the previous covered screening procedure was performed. Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable. Payment should not be made for a screening glaucoma service unless the claim also contains a visit code for the service. Therefore, the contractor installs an edit in its system to assure payment is not made for revenue code 770 unless the claim also contains a visit revenue code (520 or 521). Effective for Services Furnished On or After July 1, 2001: G0121 Colorectal Cancer Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk C. Effective for Services Furnished On or After January 1, 2004: G0328 Colorectal cancer screening; fecal-occult blood test, immunoassay, 1-3 simultaneous determinations. For claims with dates of service prior to January 1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy. For services furnished from January 1, 1998, through June 30, 2001, inclusive Once every 48 months. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121). Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer (Code G0121) Effective for services furnished on or after July 1, 2001, screening colonoscopies (code G0121) are covered when performed under the following conditions: 1. Screening Barium Enema Examinations (codes G0106 and G0120) Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters for screening sigmoidoscopies and screening colonoscopies above apply. In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1999. In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 2000. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2002. The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The beneficiary is eligible to receive another blood test in January 2001 (the month after 11 full months have passed). This service should be denied as noncovered because it fails to meet the requirements of the benefit for these dates of service. Note that this code is a covered service for dates of service on or after July 1, 2001. This service should be denied as noncovered because it fails to meet the requirements of the benefit. Unlike diagnostic mammographies, there do not need to be signs, symptoms, or history of breast disease in order for the exam to be covered. Coverage applies as follows: Age Screening Period Less than 35 No payment may be made for a screening mammography performed on years old a woman under 35 years of age. Pay for only one screening mammography performed on a woman between her 35th and 40th birthday.

Syndromes

• Cognitive tests (psychometric tests)
• Incontinence
• Pelvic laparoscopy
• Family history
• Flank pain
• Rotator cuff tendinitis
• Skin rash

Whilst the latter has relatively less impact on transmission than other age groups prostate revive reviews generic rogaine 5 60 ml amex, reducing morbidity and mortality in the highest risk groups reduces both demand on critical care and overall mortality prostate cancer images order rogaine 5 american express. In combination mens health ebook download free generic rogaine 5 60 ml without prescription, this intervention strategy is predicted to reduce peak critical care demand by two-thirds and halve the number of deaths androgen hormone values buy rogaine 5 60ml on line. Stopping mass gatherings is predicted to have relatively little impact (results not shown) because the contact-time at such events is relatively small compared to the time spent at home, in schools or workplaces and in other community locations such as bars and restaurants. Overall, we find that the relative effectiveness of different policies is insensitive to the choice of local trigger (absolute numbers of cases compared to per-capita incidence), R0 (in the range 2. Our projections show that to be able to reduce R to close to 1 or below, a combination of case isolation, social distancing of the entire population and either household quarantine or school and university closure are required (Figure 3, Table 4). All four interventions combined are predicted to have the largest effect on transmission (Table 4). Such an intensive policy is predicted to result in a reduction in critical care requirements from a peak approximately 3 weeks after the interventions are introduced and a decline thereafter while the intervention policies remain in place. While there are many uncertainties in policy effectiveness, such a combined strategy is the most likely one to ensure that critical care bed requirements would remain within surge capacity. The orange line shows a containment strategy incorporating case isolation, household quarantine and population-wide social distancing. The blue shading shows the 5-month period in which these interventions are assumed to remain in place. Combining all four interventions (social distancing of the entire population, case isolation, household quarantine and school and university closure) is predicted to have the largest impact, short of a complete lockdown which additionally prevents people going to work. Once interventions are relaxed (in the example in Figure 3, from September onwards), infections begin to rise, resulting in a predicted peak epidemic later in the year. The more successful a strategy is at temporary suppression, the larger the later epidemic is predicted to be in the absence of vaccination, due to lesser build-up of herd immunity. Case-based policies of home isolation of symptomatic cases and household quarantine (if adopted) are continued throughout. Such policies are robust to uncertainty in both the reproduction number, R0 (Table 4) and in the severity of the virus. Expected total deaths are also reduced for lower triggers, though deaths for all the policies considered are much lower than for an uncontrolled epidemic. The right panel of Table 4 shows that social distancing (plus school and university closure, if used) need to be in force for the majority of the 2 years of the simulation, but that the proportion of time these measures are in force is reduced for more effective interventions and for lower values of R0. Only social distancing and school/university closure are triggered; other policies remain in force throughout. The right panel shows the proportion of time after policy start that social distancing is in place. Our results demonstrate that it will be necessary to layer multiple interventions, regardless of whether suppression or mitigation is the overarching policy goal. However, suppression will require the layering of more intensive and socially disruptive measures than mitigation. The choice of interventions ultimately depends on the relative feasibility of their implementation and their likely effectiveness in different social contexts. Disentangling the relative effectiveness of different interventions from the experience of countries to date is challenging because many have implemented multiple (or all) of these measures with varying degrees of success. Through the hospitalisation of all cases (not just those requiring hospital care), China in effect initiated a form of case isolation, reducing onward transmission from cases in the household and in other settings. At the same time, by implementing population-wide social distancing, the opportunity for onward transmission in all locations was rapidly reduced. Close monitoring of the situation in China in the coming weeks will therefore help to inform strategies in other countries. Adaptive hospital surveillance-based triggers for switching on and off population-wide social distancing and school closure offer greater robustness to uncertainty than fixed duration interventions and can be adapted for regional use. Given local epidemics are not perfectly synchronised, local policies are also more efficient and can achieve comparable levels of suppression to national policies while being in force for a slightly smaller proportion of the time. However, there are very large uncertainties around the transmission of this virus, the likely effectiveness of different policies and the extent to which the population spontaneously adopts risk reducing behaviours. This means it is difficult to be definitive about the likely initial duration of measures which will be required, except that it will be several months. Future decisions on when and for how long to relax policies will need to be informed by ongoing surveillance. As case numbers fall, it becomes more feasible to adopt intensive testing, contact tracing and quarantine measures akin to the strategies being employed in South Korea today. Our results show that the alternative relatively short-term (3-month) mitigation policy option might reduce deaths seen in the epidemic by up to half, and peak healthcare demand by two-thirds. The combination of case isolation, household quarantine and social distancing of those at higher risk of severe outcomes (older individuals and those with other underlying health conditions) are the most effective policy combination for epidemic mitigation. Both case isolation and household quarantine are core epidemiological interventions for infectious disease mitigation and act by reducing the potential for onward transmission through reducing the contact rates of those that are known to be infectious (cases) or may be harbouring infection (household contacts). Social distancing of high-risk groups is predicted to be particularly effective at reducing severe outcomes given the strong evidence of an increased risk with age12, 16 though we predict it would have less effect in reducing population transmission. We predict that school and university closure will have an impact on the epidemic, under the assumption that children do transmit as much as adults, even if they rarely experience severe disease12, 16. However, school closure is predicted to be insufficient to mitigate (never mind supress) an epidemic in isolation; this contrasts with the situation in seasonal influenza epidemics, where children are the key drivers of transmission due to adults having higher immunity levels17, 18. The optimal timing of interventions differs between suppression and mitigation strategies, as well as depending on the definition of optimal. However, for mitigation, the majority of the effect of such a strategy can be achieved by targeting interventions in a three-month window around the peak of the epidemic. For suppression, early action is important, and interventions need to be in place well before healthcare capacity is overwhelmed. Given the most systematic surveillance occurs in the hospital context, the typical delay from infection to hospitalisation means there is a 2 to 3-week lag between interventions being introduced and the impact being seen in hospitalised case numbers, depending on whether all hospital admissions are tested or only those entering critical care units. We therefore conclude that epidemic suppression is the only viable strategy at the current time. The social and economic effects of the measures which are needed to achieve this policy goal will be profound. However, we emphasise that is not at all certain that suppression will succeed long term; no public health intervention with such disruptive effects on society has been previously attempted for such a long duration of time. Modeling targeted layered containment of an influenza pandemic in the United States. Social contacts and mixing patterns relevant to the spread of infectious diseases. Epidemiological characteristics of novel coronavirus infection: A statistical analysis of publicly available case data. Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019 to January 2020. Estimating the impact of school closure on influenza transmission from Sentinel data. Model-Based Comprehensive Analysis of School Closure Policies for Mitigating Influenza Epidemics and Pandemics. Green shows a suppression strategy incorporating closure of schools and universities, case isolation and population-wide social distancing beginning in late March 2020. As a reminder, the situation is rapidly evolving and for the latest numbers and/or guidance, please reference the links within this guidance. Quarantine, restricted movement, and monitoring should only be directed by local departments of health at the direction of the State Health Department.

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References

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