About
About Flu Wiki
How To Navigate
New? Start Here!
Search FW Forum
Forum Rules
Simple HTML I
Simple HTML II
Forum Shorthand
Recent Active Diaries
RSS Feed

Search




Advanced Search


Flu Wiki Forum
Welcome to the conversation Forum of Flu Wiki

This is an international website intended to remain accessible to as many people as possible. The opinions expressed here are those of the individual posters who remain solely responsible for the content of their messages.
The use of good judgement during the discussion of controversial issues would be greatly appreciated.

Re-considering School Closure

by: SusanC

Mon May 04, 2009 at 17:55:25 PM EDT


The great economist John Maynard Keynes, when challenged on changing his policy during the Great Depression, said "When the facts change, I change my mind. What do you do, sir?"
SusanC :: Re-considering School Closure
With this current outbreak, it's surprising how quickly the sum total of information you receive, can cause you to change your mind completely.  Only 5 days ago, I was making the case for nationwide school closure.  In the past 48 hours, I have gradually come to the conclusion that maybe we will get more longer term benefits by being more conservative in activating community mitigation.  

The problem with public health, and interventions like community mitigation and school closure, is that you really need to act before you have real solid information (here's why), cos often by the time you know for sure, the window of opportunity for interventions to have significant effect would have closed.  Thus, last week, as news of the first fatality AND 2 additional critically ill cases in the same state (Texas) came, it was entirely possible that we were seeing the beginning of a trend, of significant numbers of severe cases and ultimately deaths in all the other states that were just beginning to have outbreaks.  In that scenario, if we had not acted fast enough, we would have had many dead kids by the time this wave is over.

In any case, the CDC were going on a more cautious path, giving guidance for state and local PH on school closure that seem to be gradually ramping up to more aggressive closures.  Then King County, Seattle, where some of the most clued-up PH folks have done remarkable work on pandemic preparedness, announces that they are easing their response and will not be closing schools if cases are confirmed.  The CDC also appears to be re-thinking their approach.

I can't speak for anyone else, but let me explain why I'm coming to different assessment than several days ago.  

It's pretty clear to me that even though we may not call it that (yet) this has all the hallmarks of a pandemic virus.  Apart from being a novel virus that has acquired the ability to transmit H2H, additional features being reported include

  • efficient transmission within households with AR of 25-30%
  • the flu activity is rising instead of falling, even though this should be the end of the flu season, ie the virus is now transmitted based on 'its own steam', regardless of seasonality.
  • the age distribution for confirmed cases is atypical, with a median age of 17
  • the age distribution of hospitalized cases is also atypical, mostly affecting older children and young adults

In previous pandemics, the virus tended to subside and come back later.  In 1918 particularly, the first wave was mild, but the second and third waves were very deadly.  

With all that in mind, we are faced with some tough choices in the current situation.  Yes, there are outbreaks all over the US, but they mostly appear to be mild (35 hospitalizations reported).  The bigger picture is, if this is a pandemic, then this virus is not going to go away.  It's going to come back again and again, until all of us develop immunity, either from infection or vaccination.  That is the hard fact we are up against, and not something we can prevent.

The biggest fear therefore, is not so much with the current outbreak, but what will happen in the fall.  If it comes back in say September, and start a second wave with much higher lethality, is there anything we can do now to reduce mortality for the second wave?

We have been lucky, in being able to identify this outbreak, and observe it realtime.  Although work on creating a vaccine has started, there are many uncertainties as to when we will see substantial quantities of vaccines being made available to the general public.  Most estimates would say the first doses may be available in 4-6 months, ie maybe August to October.  But that's just first doses, probably only enough for critical personnel or whatever.  It will take more time to have enough vaccine for most people.  Plus we may need 2 doses before there's enough immunity.  We just don't know.

So if we start planning for what's going to happen in the fall, there's a significant chance that we will see a more severe outbreak but with no vaccine available for most people.  What's more, the age distribution of having the most severe cases in young and healthy people, has been consistent in both Mexico and in the limited number of cases in the US and Canada.  There's no reason to expect that pattern to change in the fall, which means teenagers and young adults will be at much higher risk if they catch the virus for the first time in the second wave in the fall, than if they have already been infected in this first wave.  

Which means there may be a case to not damp down transmission so much, in this first wave, and let more people particularly school-aged youngsters, acquire some immunity by natural infection.

It's a tough choice, but I'm increasingly inclined to think it is the right one.

Tags: (All Tags)
Print Friendly View Send As Email

there is some historical data
from 1918, that suggests infection in the first wave did not protect against re-infection in the second wave, but protected against death.  http://www.newfluwiki2.com/sho...



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


Interesting...
In one way, there's an argument here for allowing some natural movement of the the current bug...

I'd liken it to "control fires" often set in an attempt to prevent widescale and uncontrollable fires later.

I won't get into why it is we have seen such bad fires, but one may argue that it's because we have become so efficient at extinguishing them.  Huh?  Well, most forest fires are fed by the dead limbs and natural tree debris.  Up to a hundred years ago - these layers of material would be consumed my natural fires sparked by lightning or an errant native fire.

But once we came in with firefighting gear and determined this process interferes with our desire to protect life and property... well we started to stop the process.  At some point forest conservationists figured out the above process and now we have "control fires".

Alas...

Folks in Cali and other Western states know it isn't perfect.

Perhaps, this revelation you are making is a similar idea?


[ Parent ]
I don't disagree with your basic assessment
except to add the caveat that this applies to THIS pandemic and not a potential H5N1. Yes, no?

"may need 2 doses before there's enough immunity" I wondered about this. Doesn't one dose of any H5N1 vaccine pre prime people for the second tailored vaccine? Might not human H1N1 do the same thing or is A(H1N1) too different?

Is the age breakdown for victims purely from Brazil? I wonder if the stats from tourists to Mexico are skewed because of the demographics of those who would be visiting right now. Spring break, Easter holidays, lots of families and young adults.


agree
except to add the caveat that this applies to THIS pandemic and not a potential H5N1. Yes, no?

Every outbreak, every pandemic, needs to be assessed individually.  That's why all plans are only approximate models.

"may need 2 doses before there's enough immunity" I wondered about this. Doesn't one dose of any H5N1 vaccine pre prime people for the second tailored vaccine? Might not human H1N1 do the same thing or is A(H1N1) too different?

We won't know till we test it.  That's always the case, unfortunately.

Is the age breakdown for victims purely from Brazil? I wonder if the stats from tourists to Mexico are skewed because of the demographics of those who would be visiting right now. Spring break, Easter holidays, lots of families and young adults.

I didn't look at tourists.  I'm just looking at what they say about severe and fatal cases in Mexico, and the age of hospitalized cases in the US.  Check out today's CDC press briefing.  http://www.cdc.gov/media/trans...



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Ahhh, that question was asked.
"Your other question had to do with the age distribution.  And you know, we look at the age distribution and we asked some of the same questions you were asking, and that's, is the age distribution having to do with how the virus was introduced, with more young people going to Mexico, a lot of spring break travel, and then coming back?  Is it a delay?  Could we see this going into an older population later as this spreads through the community?  And we're watching for that.  Other possibilities are that, perhaps, older people have some protection, because each year we're all exposed to flu viruses and you develop some immunity.  If there were some cross protection, that's another thing that might explain why we're seeing more in younger people and less in the older folks.  But that question isn't -- don't have a firm answer on that yet."

[ Parent ]
with H5N1
the current CFR is so extremely high, that any 'milder' first wave is likely to be a matter of semantics.  Like 20% CFR is less than 60%, but would you call it mild?  I wouldn't.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Nope, I'd shut schools first, ask questions later n/t


[ Parent ]
ditto n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Agree. Now we need to work the messaging
The critical challenge now is a communication we have not done much planning for. How do we back away from the high social distancing brink, without losing appropriate attention, vigilance and preparation at the "unit of cohabitation" level?

We've written extensively here about skilled risk communication, and now we need to craft careful messages so that we do not lose the ground we've gained.

The preparation that will not be well attended to without steady coaching, will be a the unit of cohabitation. Read some thinking about that here:
"Unit of cohabitation?" see here:
http://www.newfluwiki2.com/dia...

Then the message of the moment needs to be something like:

"While this A-H1N1 strain looks like it might not be much more deadly than seasonal flu in most cases, it has offered a couple of important lessons. First, we got to see just how rapidly a new strain of influenza spread planet wide, and how unable to contain it we were. Second, we learned that as a new strain initially emerges, we'll be unclear about what it's true danger will be. So, we need to continue to support and pay attention to surveillance of influenza. We've now clearly seen that if we get a virus with the virulence of what we got in 1918, we'll have some very serious problems."

Read more of that thinking here: http://www.newfluwiki2.com/dia...

Honest dialogue, and an openness to learning will lead to the best possible solution to any problem.
http://www.newandimproved.com/...


I think CDC is doing the right thing
Just keep the same messaging about washing hands, staying home if sick etc, but just go more conservative on the guidance to schools.  

Of course they also need to tell people to prepare for the next wave, so they have to gradually shift people's attention towards that.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Well all the pandemic personnel are getting one helluva practice.
Between the countries with flu there should be a load of new data on what works and what doesn't.

In terms of getting the message out to the public, everything's out there, the trouble is for every good message there's a bad one. The public will be at flu overload by now.

If it dies down, the summer will be the time to feed best practice to schools and parents.

Time for the CDC to back ReadyMoms country wide.


[ Parent ]
If it were up to a vote
I'd vote no.  I think too many ifs have to be correct.

To calm the wife buy cases of chocolate, to calm the husband buy cases of booze, and to calm the children...... heck the booze and chocolate should work.

Oops didn't finish
IF this has more than one wave.

IF this becomes more severe.

IF exposure decreases mortality to a more severe wave.

IF the amount of deaths caused by X exposure is less than the deaths in hypothetical severe second wave minus the deaths in hypothetical severe second wave where X people were exposed in the first wave.

IF other thing

Now if you feel confident with this hypothesis, feel free to take all your loved ones on a tour of the ERs in Mexico City.

To calm the wife buy cases of chocolate, to calm the husband buy cases of booze, and to calm the children...... heck the booze and chocolate should work.


[ Parent ]
yeah there are too many ifs
But the problem that I see, the only unchanging and unchangeable if, is that unless the virus magically disappears, which looks increasingly unlikely, then every person on this planet will eventually either get infected or they need to be protected by effective vaccination before they become exposed.

That is an unchanging law, of pandemic flu science.

There are times when all options are unpalatable.  And nature does not bargain with our sensitivities.  The virus is what it is.  Our only option is to make the best of the situation.

Now if you feel confident with this hypothesis, feel free to take all your loved ones on a tour of the ERs in Mexico City.

No, I don't feel confident about this hypothesis.  I don't dare to feel confident around a pandemic flu virus, cos it will only lead to complacency.  I have the utmost respect for its ability to destroy and kill.

But no, I wouldn't take anybody to any ER's in Mexico City either.  This diary was written only with the US situation in mind.  The situation from Mexico is both different and unclear.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
That last line
wasn't meant for you personally. I hope you didn't take it that way.

To calm the wife buy cases of chocolate, to calm the husband buy cases of booze, and to calm the children...... heck the booze and chocolate should work.

[ Parent ]
no, I didn't ;-)
but it was a good opportunity to address a couple of issues.  Thanks anyway.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
I agree
My thoughts exactly.  The numbers are just ramping up.  We haven't reached the critical mass that Mexico had.  We have no idea what the fatality rate is yet.   We don't even know how many cases are in serious condition or in ICU to say how "mild" this is.  I've read story after story and what these people are experiencing is nothing like "regular" flu.  HEALTHY young people coughing up blood? In May?  

While my kids are at home right now, my heart aches for my friends who want to bring their kids home but are waiting for some direction from the schools, who are looking for direction based on cases.   Most of them don't appear to have been infected but there seem to be areas in my part of the country that aren't endemic yet.

And now we're finding out, health departments are moving to not test each case anymore.  They'll just be sampling areas.

There are just as valid arguments against the first wave offering some protection against death in the 2nd wave.  First, we don't know the immunological makeup of the person who survived the first and perhaps it's that same makeup that helped them the second time.  Also data didn't show that catching the 2nd helped in the 3rd wave.  Finally, there is evidence the first wave wasn't even the same virus.

The arguments in the other threads FOR school closure are so rock solid that I sent several school officials here to help with their decision.   Now they will think it's all find and "mild" and my son's friends will be put in harms way.  I am shocked and saddened by the 180 degree turn.  The facts really haven't changed.  The facts aren't even all in yet.


[ Parent ]
I think the key question for me is
say we keep the kids safe, uninfected, through this wave.  What is the endgame?  

Keeping in mind that they have to get immunity one way or the other, how do you propose making that happen?
 You have a choice of either natural infection or vaccination.  You also have a choice of getting infected now or later.  The risk in waiting lies in not being able to get vaccinated soon enough, and not being able to SIP sufficiently well and getting infected with a severe second wave virus to which the kids have zero immunity.

It isn't an easy question to answer.  I've been thinking about it non-stop for a good 48 hours.  And I don't know that I have the right answer either, just that on balance this seems to make more sense.  Of course, other people may come to different conclusions and choices.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Keeping in mind...
It has been here only a week. Or two.  

[B]No one[/b] knows yet what this thing is going to do.   I find it absolutely incredulous that anyone would suggest putting children at risk to "immunize them" based on controversial data. There are people in ICUs, on ventilators RIGHT NOW.  Many of them will die. THese aren't old, weak people or immune compromised people who have other risk factors.  These are your healthy children, grandchildren, neices, nephews, spouses, younger brothers and sisters.

How can anyone suggest putting children on the front lines?   What you are suggesting is equivalent to making children lab rats.  If you have to risk something to immunize them, take the lesser risk.  Immunizations are not failproof, but are at least tested.  People will know the risk by the time they line up to get their shot and they can CHOOSE.  

But the kids - they don't get a choice.  That is wrong on SO MANY levels.

But let's be clear about one thing - essential workers will get theirs.  TPTB and their cronies will be just fine.  The rest, well guess what folks, we're all lab rats now.  As long the mice to run the economic wheel, everything's just fine.  I think people are waking up, more and more that I talk to.  They aren't as stupid as the "experts" think.

   


[ Parent ]
It's too early to tell.
This is just the beginning of the first wave of this pandemic, which may have several waves, or may not; we may see a steady continuum of cases from now until the fall, when we may see a large surge. Or we may not.  Nobody knows.  Or if they do they haven't spoken to me yet!
(wish they would!)

Nobody knows what new genetic information this virus will pick up, or when.

Nobody can truthfully say how much, if any, protection an early 'Wave 1' infection would provide to subsequent mutations of this strain.

Nobody knows when it will acquire Tamiflu resistance, which would change the clinical picture substantially.

Nobody  can yet explain why apparently identical viruses in Mexico and the US have very different clinical outcomes.

Nobody can document how many people have already died from this disease in Mexico, and likely the real answer will never be known.

There are a great many things that we do not know.
We are doing far too much speculation on far too few facts, IMO, to rush to judgement on any of them.

We do know that this strain has killed over 2 dozen people in Mexico.
We do know that if this outbreak becomes tamiflu resistant we will have a much bigger problem than we have now.

We do know that the more people are exposed, the greater the likelihood that we'll get a Tamiflu reistant strain, unless we prohibit Tamiflu use, and maybe not even then.

We do know that most people are not prepared for an outbreak.

With that in mind, it seems to me that the prudent course requires us to do several things:

-TELL THE TRUTH about what we know AND WHAT WE DO NOT KNOW;

-Act prudently to limit the opportunities this virus has to spread and adapt. This means continuing to close schools to limit spread.  The Mexican NPI of closing down public events and schools actually worked as intended.  New cases appear to be slowing.

-Continue to advocate preparedness in the event that this bug does evolve into something worse.

I do not think we hav enough data yet to conclude with confidence that abandoning school closings is a bad strategy.  On the contrary, we have already seen that this NPI actually works.

It's too soon to rush to judgement, Susan.

I think you are wrong to say this at this time.
Wait a week or two and see what happens; let's be prudent, not hasty.



KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
100% agree, LMWatBullRun, and absolutely nothing to add. You said it all, and you said it perfectly imo. n/t


Always have a plan B.

[ Parent ]
some additional thoughts on the 'facts'
Paradoxically, what prompts this diary is a combination of apparent mildness (35 hospitalizations) plus an age pattern that resembles 1918.

The age pattern of hospitalized patients in the US, (and of fatal cases in Mexico) worries me a great deal.  It looks like the W-curve is back.  The reason for suggesting maybe we shouldn't damp down the current wave so much, is because this virus looks more, not less scary.  If the age distribution is more suggestive of a 1957 or 68 virus, then I would be less worried.  But this really looks 1918-like.  It may or may not be as severe as 1918, we really can't tell till it happens, but it sure looks like it's headed that way.  

In some ways, you can look at this milder wave in the US as a God-given opportunity.  Our ancestors did not have the luxury of such knowledge and forewarning.  They had no control over their destiny.  Now, in the 21st century, for the first time, we can see it coming.  It looks to me this is a chance, a window of opportunity, to save some lives.  

It may not work.  But as long as the current wave stays mild, the downside risk is low compared to the risk of massive deaths from severe second wave infections.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Some things to consider
The situation is changing so fast.  On the one hand the number of cases is rising at epidemic levels but because the CFR remains low, even stalwarts like Dr. Osterholm are now saying that school closure may not be needed.

Dr. Osterholm is one of my "Flu Heroes" as are Dr. Garrett and John Barry.  

Influenza is a true shape shifter.  Not only can it change the way it looks to our immune system it can and regularly does pick up deadly little gene segments from other influenza strains when co-infecting the same host cell.  The H1N1 Spanish Flu had many of the deadly gene segments called lethal polymorphisms. The H5N1 Bird Flu has acquired many of the same LPs found in the Spanish Flu.  These LPs allow the virus to infect the brain, liver, kidneys and disrupt the body's blood coagulation system, which together with cytokine storm was the cause of many of the deaths during the Spanish Flu and the persistently high (60%) CFR of H5N1 Bird Flu.

While the newly emergent N1H1 Mexican Flu does appear to be pretty benign outside of Mexico so far, what the immediate future holds for the US and Canada is not known.  What's more, this virus has spread around the globe about as expected; real fast.  We have no clue as to what will happen in the 18 other countries where it has now been confirmed.  As far as we can tell, it started in Mexico sometime in January or February and spread rapidly accross the country before the first deaths became apparent in mid-March.  It took another month for the PH authorities to confirm that the Mexican Flu was a unique virus never before seen in humans.

Since the Mexican Flu is new and has good H2H, it is not going away.  Over the next few months it will have a very good chance of reassorting and/or recombining with H5N1 Bird Flu as well as the human adapted seasonal flu strains currently circulating. What this means is that as a result of this congress with its fellow travelers the Mexican Flu is very likely to acquire some of H5N1's lethal polymorphisms as well as H1N1's and H5N1's Tamiflu resistance.

This is by no means a certainty, just a possibility that we should all keep in mind, especially if the virus dies out in the Northern Hemisphere but returns here after a devastating visit to Southern during their winter.  This is
something that we will be able to observe.  If what we see becomes progressively worse as their flu season advances, it will be a real horror show since we will know that we will be next.  

Grattan Woodson, MD


Our large urban district (LBUSD)
has decided today not to close schools despite both a high school and a middle school now having 1 confirmed case each.  I had doubted that they would close even if a confirmed case was found -- now is not a good time with AP tests and Star Testing going on -- but it still made me uneasy to have my gut feeling confirmed.

However, after reading the growing sense that school closures may not be as useful/necessary as thought at first, I'm feeling a bit better.  It's tough, because both my kids have asthma, so it's an issue I've been wrestling with a lot, but your post came at the right time to offer me some comfort.  Thanks, SusanC.  


school closures are useful
However, after reading the growing sense that school closures may not be as useful/necessary as thought at first

If done right, ie early and proactively, they are very powerful public health tools to reduce infections and save communities.  In this instance, I look at the features of this virus and I'm concerned about it coming back later at a much higher severity.  We don't know for sure it's going to happen, but because pandemic flu spreads very quickly and it's very difficult for most people especially kids to avoid infection, I believe it may be safer (in a relative sense) for them to catch some immunity before the virus turns deadlier.

If it stays mild, all they've done is get their first exposure earlier.  If it turns nasty, we may have protected a proportion of kids.  That's the rationale.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
New CDC guidance may undermine future school closures attempts
As a local health officer in the U.S., I'm concerned about the guidance that came out today.  I would have been happier with guidance that allowed more local decision-making about this issue.  

With the current CDC position, no health officer anywhere in the country is going to implement a school closure, as that would be contrary to CDC guidance.

If things go bad in the next few weeks, there will be no "St. Louis" to compare to "Philadelphia."  The option to be a Saint Louis is basically gone. Dr. Besser justified this decision in part on the basis that the virus has basically spread throughout the U.S., and once that happens, school closures won't stop the spread.  (I agree there's no point once the virus is widespread, but that does not appear to be true in most of our communities, and the goal was never to "stop" the spread with school closures, only to "slow" the spread.)

HHS Secretary Sebelius said we would only close schools for seasonal influenza if the abseentee rate was very high.  But the reason for doing that in a seasonal flu outbreak is very different than the reason when dealing with a novel virus.

There are lots of unanswered questions. We still don't know the case-fatality rate of this virus.  Is it less than 0.1%?  Is it 0.5%? Is it 1%?  We don't have this information.  The Community Mitigation guidance becomes unclear, perhaps unusable.  We likely will never have the CFR information at the time a decision to implement it needs to be made.

Can the U.S. health care system handle even a mild pandemic? Though the illness for a single individual may not be much worse than seasonal flu, a lot more people could become ill. We have little or no excess capacity in our health care system, and health care workers will get sick, too, aggravating the shortages.  While it's true that fewer people are likely to die than in a more severe pandemic, the absenteeism issue is still a problem  whether the infection is fatal or not. It would have been nice to at least have the option of considering school closures to dampen the peak of this initial wave of spread.

I hope the arrival of spring weather, warmer and more humid, may slow the spread of the virus in the next few weeks, and not closing schools may well be the right option.  But we've lost our chance if it wasn't.
I'm still more inclined to agree with the guidance that CDC put out one week ago ("It is prudent for communities to act in the absence of sufficient data to protect their citizens and take advantage of a narrow window of opportunity for intervention.") than with what came out today.

I think some of the CDC decision was based on political pressure, rather than science, and that the reluctance on the part of state/local officials to close schools may have been as much an effort to avoid such a controversial decision as it was concern for the impact on the parents and students.

I seriously question whether the early interventions encouraged in the 2007 Community Mitigation Guidance will ever be implemented when they need to be in the future.

And I think we may have lost a teachable moment for the public in what Revere calls the "overreaction overreaction."


[ Parent ]
difficult decision
we do expect positive cases in our own community, and having seen that, it makes school closing less helpful. I tend to agree with the Seattle group... if you have one case noted, you likely have 1000 cases around, some mild, some in non-closed schools.

I also think all it would take is demonstration of higher CFR for schools to close. Without that, why should they? With that, why wouldn't they?

What I would love is for table tops all summer by school admins/local PH so they know when and how to close schools.


[ Parent ]
Thanks Big Critter and Dem
Look, lets face it, with this pandemic the cat was out of the bag before we knew it.  This is not what we planned for.  Most thought this pandemic like most of the prior ones would begin in Asia or possibly Africa, be detected by our beefed up surveillance system and give us at least a few weeks to implement NPIs before the bug arrived in the US and EU.  Well, what did someone say about the best laid plans....

OK, what we need to do is deal with the situation we have not the one we wished for.  

The next month or two will probably provide us with a lot of insight for what is going on and what we can expect to happen in the Northern Hemispheric fall.

No plan is written in stone.  When the facts change the most intelligent among us adjust and by doing so survive.

The public has no clue what plans and assumptions were in place before this pandemic outbreak.  They don't know that we were caught with our pants down and in fact don't need to know not that I would object to their learning the we are human and err.

What is critically important for the public, those we serve, is for our colleagues within the PH, scientific, political, and medical community to take into consideration what is happening now and adjust our response accordingly.

To do this requires us to forget what we think we know and out best laid plans and look afresh at the facts.  When the facts get in the way of our opinions, then our response to them is likely to be sub-optimal. So, we need to readjust our planned response to a pandemic as our perception of the facts change.  Otherwise we run the risk of failing in our duty to those we serve.

Grattan Woodson, MD


[ Parent ]
I continue to think-
that reducing peak case load and reducing total case count, even by a small amount, could help keep a hospital from the tipping point, and significantly reduce the overall effects.  Moreover, the fewer cases the less likely we are to get unwelcome changes in the virus.

I would recommend that school boards continue to be relatively aggressive in closing schools.

Suppose that we stop closing schools.  And suppose the virus changes, for the worse.  

A) how will we know ahead of time?

B) once we know, what kind of compliance will we get?

BTW, BigCritter, I agree that these policy shifts are not science driven.  CDC has continued to say that there is no way to know yet what the severity of this virus is, or will remain.  

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
The problem is, Dem,
by the time you know you are facing a higher CFR,
YOU'VE ALREADY GOT IT loose in your community and it's all over the place!

After all, this thing has been floating around Mexico for 2 months and we still don't know the CFR there, and likely we never will.

Even here in the US, we are seeing an increasing number of ICU cases and more deaths.  It's 2 weeks in; do we know the CFR with the current virus and the present treatment standards?  Well, we know the data so far, but there are cases that are hospitalized that have not resolved yet.

If we wait for a 'higher' CFR to start closing schools again, it will be too late.  The horse has been saddled;  ride it!

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
from what I see both in the news
and in my community and state, I think this really is mild right now, and the issue is in the fall. From what I read and hear, the virus has been relatively stable from fist cases until now.

The (again relatively) small number of hospitalizations and deaths, while they will grow, are still reassuring. i don't really expect higher CFR in the near future.


[ Parent ]
how much of this do you think is Tamiflu?
and how much the viral strain?  The word I get is that the strains are very much alike from Mexico to here.  If that's true, then it seems to me the major difference is Tamiflu.

I have no idea how long it will take for resistance to be acquired, but I'll guess that happens by the end of this year, maybe much faster.  that's just a guess, of course, but I'd like to know, what do you think?

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
There does seem to be a lot of reports about a slow burn
People are only mildly sick for a number of days (up to 5) and then it takes a turn for the worst. Unfortunately that's only hearsay. I think it would be an inportant area for study.

[ Parent ]
it already is loose in the community
by the time you know you are facing a higher CFR,
YOU'VE ALREADY GOT IT loose in your community and it's all over the place!

and all over the place.  The time for proactive and effective school closure was last week.  We've missed the window of opportunity.

As for more deaths, one is the one we already knew about, the 3 year old from Brownsville, the other is a pregnant woman who would have been at high risk even during seasonal flu.  In fact, these 2 and a 3rd case in ICU last week, was the reason why I called for widespread and sustained school closure then, not knowing whether the pattern would be repeated elsewhere.  

As it turns out, the pattern is not being repeated elsewhere.  Sure, there are hospitalizations,  Sure, there's a time-lag from onset to deterioration and death.  But the earliest cases in the US started in mid April.  This is the 3rd week.  Surely if this is a high CFR virus we'd be seeing lots more hospitalizations by now (remember that there'd be a lot more hospitalizations than deaths, in general)



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
"table tops all summer"
A couple of major problems with that---

1) It would cost money;
2) It would infringe on the 'right' of teachers/school admins to have a couple of months off from work;
3) The teacher's unions would want to be involved, and probably impose their own will on the outcome...

Unfortunately, I don't see the two sides getting together during the summer because of union rules. Unless, of course, a high-CFR pandemic comes to pass in the next couple of months...but then again, if that happens, table-top excercises will be moot.


[ Parent ]
table tops are not new
and there's this and this.

[ Parent ]
Agreed...but there would be a lot of resentment...
...from the school personnel who have to "work" during their summer break. JMHO, of course. I knew a lot teachers/school admins out in CA who traveled during the summer months, and said they wanted nothing to do with work until next year's school season started.

The unions backed them up, and told the school districts that they had no right to ask teachers or admins to attend any meetings between July and August...


[ Parent ]
I have to think
that there is a significant amount of learning going on right now at the state and local level, Dept of Health, Dept of Education...etc.  The warning concerning this fall might be falling on deaf ears in the general public, but I doubt it is for public officials.  They have just had a significant scare (haven't we all), and the warning that things could be much worse will set many off onto a learning curve.  Of course there will be some who will remain ignorant, but I believe there will be enough who get the heads-up that they will make a difference if this think turns more deadly.

[ Parent ]
When and how to close the schools
Our county-wide table top focused exactly on this issue a year ago, and everyone, including the school board and administration, understood the importance of closing schools early, when few cases had occurred.

Now they don't know what to do.  Heck, I don't even know any more.

How do we know if the CFR is higher if we can't measure it?  The situation in Mexico two weeks ago may well represent a CFR of <.1% for all we know.  Perhaps they took all their extreme social distancing measures "unnecessarily."

I guess we all should have realized that the number we were using to trigger these interventions would not be knowable in the midst of an outbreak.

It will be interesting to see, as Mexico relaxes its mandatory social distancing measures, whether the cases rebound or not.  


[ Parent ]
I share your concern, Big Critter.
I teach high school.  I'm the parent of an 18 year old and a 20 year old. There is nothing abstract about this issue for me. I'm not ready for all the ways letting a highly mutable virus burn through school populations could turn out.  I have no crystal ball and no recommendations except that we be extraordinarily careful with the health and the lives of our children and youth.

For me the litmus test is not whether the virus has already established inroads into the wider community.  The litmus test is whether we put students day in and day out in an environment where they run a high risk of being infected with a virus that could take any turn (indeed a risk far higher than most of us adults face, perhaps with the exception of younger teachers and healthcare workers).  


[ Parent ]
for me the litmus test
The litmus test is whether we put students day in and day out in an environment where they run a high risk of being infected with a virus that could take any turn (indeed a risk far higher than most of us adults face, perhaps with the exception of younger teachers and healthcare workers).  

is whether you (or anyone else) has an alternate endgame, that takes into account how you can protect not just one, but all or most of our young people should it come back in the fall in a more virulent form and vaccines are not ready (for all the reasons I gave here http://www.newfluwiki2.com/pos...

Let me ask everyone again, what is the endgame?

The kids are going to get either infected, vaccinated, or dead.  Those are the 3 options available, nothing else..  How do you solve this problem, given current and historical information?




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
let me repeat
look at this chart

The kids are going to get either infected, vaccinated, or dead.

What is your endgame?



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Maybe the best option is exactly what is happening now
with a mixture of school closures and openings.

Try not to let the virus free reign but at the same time not trying to stamp it out altogether. Save full closure if it looks like it's getting out of control.

The decision is not always in the hands of local authorities anyway. Some schools in the UK have closed on the decision of the govenors or parents. Some areas will take a different view and want their kids at school if possible.

Events like graduation and leavers balls are another matter. I don't think there is justification for mass social gatherings.



[ Parent ]
that is exactly what I'm saying
Try not to let the virus free reign but at the same time not trying to stamp it out altogether. Save full closure if it looks like it's getting out of control.

I'm not saying we shouldn't close schools.  I'm saying let's not damp it down too much.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
I think people might have missed that.
And just be dwelling on not shutting schools.

The problems with shutting/not shutting schools as a tool:-

From a distance it's hard to know what is being done in each area. The worry is that it's 'random' and not the result of a specific management decision.

If there isn't some sort of management of the policy you run the risk that too many schools make the decision to stay open at once.

There's also the back lash from 'mild' hysteria. If too many assume that there is no problem they'll stop taking the care that is currently putting the brakes on.

People will get exasperated at what seems to be inconsistant actions.

Is there anyone who can successfully manage this?


[ Parent ]
Surge capacity
There are some severe cases - I worry about surge capacity if schools are open and many kids are sick at once.  Some cases are severe and do require hospitalization.  It is better to let this flu percolate through a population more slowly than it will if schools remain open?  

Ask yourself how many students a school system serves.  If 1/3 of the student population falls ill in within a fairly short time frame (as happened at St. Francis in Queens) and, say, 10% of those children or teenagers require hospitalization, can area hospitals serve them all along with their usual case loads?  

Jefferson County Public Schools, for instance is a district serving 97,000 students, according to Wikipedia. If 32,300 of those kids get sick in fairly short order, and 3230 of them need to be hospitalized within a 6-8 week period, can the Louisville hospitals handle them all, along cases resulting from transmission through families into the community?  Louisville has, according to one source, approximately 5200 hospital beds.

I suggest running the numbers - school districts in consultation with hospitals serving their populations.  Then factor in the student populations of area colleges.

Controlling novel H1N1 flu in concentrated populations of kids will be like controlling wildfire.  We'll be prudent to moderate their level of exposure and transmission rates so as not to overwhelm our ablity to care for them.



Hospitalization rates
Key will be the percentage of patients requiring hospitalization - currently significantly less than 10% (in the U.S.) according to today's CDC report, though 10% is offered as a planning guideline for communities by the WHO.

[ Parent ]
Yes, and surge
You make an excellent point.

The lack of Tamiflu is extremely important.  We have no idea what a true CFR is because of the Tamiflu.  But there is NOT ENOUGH.  I recommend everyone look up their state and county Tami stockpiles and compare that against a 30% infection rate.  More and more folks are struggling to find it.  

No one is saying closing schools will eliminate risk, but it will reduce risk.  If that is after all what you're goal is.  I believe for most of us, it is.


[ Parent ]
This is analogous to managing a fire.
You don't give the fire too much dry fuel at once or burn on a windy day if you want a controlled burn.

[ Parent ]
Since the fire has started
why in the world would our PH officials wish to add more fodder to it.  Not closing schools where there have been probable or confirmed cases or re-opening those with these conditions when there is obviously an epidemic rise in new cases seems to me to have the potential to be a terrible mistake.

OTHO I do see the wisdom in Susan's argument regarding the potential benefit of having as many people as possible infected with this "mild" version of Mexican Flu assuming of course that this provides them with immunity to this virus in its future manifestations.  When I was 7 years old, my grandmother took me to visit a child that lived nearby with measles so that I could contract the virus at an age when the infection was generally regarded as "mild" rather than as an adult when it was often severe.  Ditto for the mumps.  So, exposing children to a virus in the hopes that they experience a "mild" from of the disease rather than a severe one later is a well established medical practice.  

Another example of this relates to Dr. Edward Jenner's observation that milk maid's who contracted cow pox as an occupational hazard experienced significantly less illness and death from infection with small pox.  This led to Dr. Jenner experimentally infecting his patients with cow pox and his finding that those so infected were afforded protection from natural small pox infection similar to that seen in the milk maids.  This observation was the first step in the chain of events that eventually resulted in vaccine science and ultimately the erradication of small pox and the control of a host of other terrible viral and bacterial infections that have plagued humankind for countless millennia.

As pointed out by Susan though there are well documented reports from 1918 than some infected in the first wave in the spring succumb to the virus in its second that started the following September.  These reports were what led John Barry to postulate that between the spring and fall of 1918 the Spanish Flu underwent a malignant mutation that caused it to become much more lethal during the second wave.  

However, Dr. Tautenberg etal's work, which was published after Mr. Barry's book, The Great Influenza, reveals that the virus that caused the first wave was the same as that causing the second and third US waves.  This is an interesting finding that begs the question how could the Spanish Flu be so relatively "mild" in the spring only to return 5 months later as a man killer the likes of which had never been seen before or since?

Of course, we will soon see whether the choices made by our current PH and school officials regarding school closures during the opening innings of this pandemic were wise or not.  Personally, I will keep my eye on St. Francis in NY to see what happens.  

Lets hope for the best but be ready for the worst.

Grattan Woodson, MD


[ Parent ]
exactly!
When I was 7 years old, my grandmother took me to visit a child that lived nearby with measles so that I could contract the virus at an age when the infection was generally regarded as "mild" rather than as an adult when it was often severe.  Ditto for the mumps.  So, exposing children to a virus in the hopes that they experience a "mild" from of the disease rather than a severe one later is a well established medical practice.  

That would be traditional practice.  Your grandmother sure knew what she was doing.  With modern medicine, people have forgotten the simple old ways.

However, Dr. Tautenberg etal's work, which was published after Mr. Barry's book, The Great Influenza, reveals that the virus that caused the first wave was the same as that causing the second and third US waves.  This is an interesting finding that begs the question how could the Spanish Flu be so relatively "mild" in the spring only to return 5 months later as a man killer the likes of which had never been seen before or since?

Actually, they do not have the sequence for the first wave.  The comparisons were across 3 different cases in the second wave - one soldier in NYC, one in South Carolina, and one Inuit woman in Alaska.  They have fragments of RNA from first wave samples from London, but since the first wave was mild, there were very few deaths and so very few autopsy specimens to choose from, and only tiny fragments of RNA to work with.  They are still working on them.

Even from the second wave, they went through lots of samples from army archives before they found 2 that had enough fragments to discern some of the sequences, but it was only after they had the Alaska sample (which was freshly cut from frozen lung, not just paraffin-fixed blocks) that they had a lot more viral material to work with.  

Remember that the people in Brevig mission (where the Alaskan sample was obtained) died rapidly, while there was still large amount of virus in the lungs.  72 of 80 adults died in a 5-day period.  When the missionaries from outside arrived after the pandemic, they found the survivors too weak to bury the dead, which was why there was a big mass grave.  (more on that story here http://www.newfluwiki2.com/dia... )

Which is another reason why I take this flu virus with great respect!



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
hospitalization rates
Your estimate of currently significantly less than 10% begs the question, how much less?  For me, the hospitalization rate has to be <1% to justify what I'm saying.

Right now we're seeing 35 hospitalizations.  Since all hospitals are on the lookout of cases of severe respiratory illness of unknown cause, the true no of hospitalizations, especially in the young, is likely to be not much higher than that.  But let's suppose we are missing half the cases, say there are actually 70 people in hospital cos of this swine flu.  For that to make up <1% of cases, we'd need >7000 cases in the US.  Are there >7000 cases in the US by now?  I think so.

We know that the confirmed cases are just the tip of the iceberg.  They are not testing mild cases, cases within already known clusters (eg only testing 1 case in a family whereas the AR is 30%), cases who never come on anybody's radar cos they got well on their own or never even suspected they had the flu, or that hospitals and docs refuse to test cos they are in overload, or cos the docs think all this is overhype.  

Let's just take one example, the outbreak in St Francis school in NYC.  Although they did test some 40+ students at the school, they stopped testing because ALL cases came back positive for swine flu.  I don't know how many students eventually got infected, but I do know that before the school closed, >200 students were already out sick, and that was only 2-3 days after the first cases appeared, and > 1 week ago now.  In addition, there'll be community spread as well.

They say that the AR within families is similar to that of seasonal flu.  That gives us an R0 in the range of maybe 2.  Which means that in NYC alone, from those 200 KNOWN cases, by now there would be some 2000, just from the St Francis outbreak spilling out to community and family and other schools.  

Do you think there are more than 3.5 times the no of such clusters like St Francis (which would give us 7000 cases), in all of the US?  I think so.  Or, even if some schools manage to close early and they never got to 200 cases in a school, there are MANY school districts with cases up and down the country.  And that's just from schools. There will be other community clusters where the index case is not connected to schools.

We don't know the true no of cases.  But America is a big country.  My estimate is, by now, there's a LOT more than 7000 cases.  Hence the hospitalization rate is very low, favoring that this is indeed a mild outbreak.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
In order to make some rational assessments, you have to work the numbers... n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Numbers would be useful.


[ Parent ]
also, since the vast majority of school districts
have NOT followed the CDC guidance to close all schools within a district on confirmation of cases in the district, there hasn't been significant mitigation so far.  The closure of one school after identification of one case is not enough for mitigation, cos by then you would have passed the critical threshold of 1%.  See explanation in the Yancey County example, and in Dem's post, especially this chart.





All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Is "I think so" considered valid solid data to "work the numbers" with? I think not.
Alot of presumptions are made about the fact that this "has to have infected large numbers of mild cases" that we never hear about. Why is that presumption made? In Mexico perhaps, early on when it wasn't recognized. But with the whole world on the alert for anything resembling swine flu in anyone who could remotely have been exposed, then I don't think the number of missed cases is as high as you presume. But again that is just what "I think" versus what you "think."  

I would just like the solid rationale behind the think before I take comfort in your numbers.

Always have a plan B.


[ Parent ]
I agree. Too little data yet.
I've heard a lot of talk here and elsewhere about exposing yourself and your family early as the best of three options.
(get sick and recover, get vaccinated, or die.)

There is a fourth option.

Don't get it.  I like that one a lot better.
That is the option my maternal grandparents took during the Great Pandemic, and they both RAN A HOSPITAL during the pandemic.  My mother was conceived during the tail end of that pandemic.  Don't tell ME that we're all going to get sick from this virus; every epidemiology text I  have read says that epidemic infectious diseases don't infect EVERYONE even during the worst outbreaks.  Even before N-95 masks and Tamiflu, a significant percentage avoided exposure.

There are some other options I don't see listed-
get sick early, then get sick again later, maybe die;
get vaccinated, then get sick anyway;  ( done that already!)

There is no way to know if or when the Tamiflu will stop working, or run out, but the more people that get sick, the more likely we are to confront those two unpleasant possibilities. SO until I see some FACTS, some DATA, to tell me how likely ALL the options are, I'm sticking with option 4.  Don't get me wrong, I'd take a vaccine if available and if I was satisfied with the safety and efficacy data, but my primary plan is not to get sick.

DON'T GET SICK!  

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
the 'don't get it' option does not exist.
You may see people who are infected but asymptomatic, and you may see people who do not get infected till a year or so later, but in general, for influenza, over time everyone gets infected.

Whether you get sick, and how sick, is a different story.  Not getting infected as an option does not exist, at least according to current scientific data.  




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
really?
Why don't you tell that to the people in Samoa in 1918? I think they'd disagree.  SO would some folks in Colorado.  

It may not be an easy option to implement, but it IS an option.  You have to decide what the price is for implementing it and whether or not it's worth the price, but it is an option.

YOU may decide not to select it, but just because YOU make that decision doesn't mean others have the same imperatives driving them.

Rural farm folks in the Midwest US would find it easy to implement;  Doctors living in NYC find it very difficult.

You pay for the choices you make, but just because you don't like the price doesn't mean others will not pay it, or even that the price is the same for everyone.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
I'm inclined to agree with you
I noticed the last time we went to town that people were really staying away from each other, keeping 6 feet apart was relatively easy because pretty much everyone was doing it, even in line at Wal Mart. Most of the children were doing it too, except in family clusters and the younger ones. There have been no cases reported in my state, so I imagine in states where it has been reported people would be being even more cautious.

That, along with hand washing hands and staying home if sick, may make a big difference in how many contract it.

In fact, the lady at the door saw my husband rubbing sanitizer on the shopping cart, asked if we wanted a towel thinking it was wet, then agreed wholeheartedly that it was a good idea when we explained that he was putting sanitizer on the cart.

The younger woman at the checkout had a big bottle of hand sanitizer and was using it often. We talked a bit about it - she was pretty spooked by it all and was doing everything she could to prevent it.


[ Parent ]
check out this report
http://blogs.sciencemag.org/sc...

especially this (bolding mine):

the United States had more than 600 confirmed and 800 probable, and testing was showing that more than 99% of the probable cases were proving to be positive for the A (H1N1) virus.

What does this mean?  Doctors are seeing patients and figuring out which are the most likely cases, to be tested.  We know that no doctor can make a correct diagnosis 100% of the time, there is always some error.  But if >99% of such 'probable' cases are positive, that means those who are tested are only the tip of the iceberg, and that the actual number of infections is far far higher than the confirmed and probable numbers suggest.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
this is sounding more like 1918 by the minute...
What I did not like is the part about "Mexico as of 6 May had nearly 12,000 suspected cases, more than 1000 others confirmed; the United States had more than 600 confirmed and 800 probable, and testing was showing that more than 99% of the probable cases were proving to be positive for the A (H1N1) virus."

That means that if the case count doubles every 3 days, that in a week we'll have over 50,000 cases in Mexico, and over 6000 in the US, and those are only the suspect ones, and the real doubling rate is probably more like a day or less.  This thing must be wickedly infectious.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
looks like it
This thing must be wickedly infectious.

the classic description of pandemic flu is 'explosive' spread



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
reading it in a book is one thing
and watching it happen is something else again.

definitions in a textbook don't sicken the people you know.

This probably will.

There is also the fascination of watching what you know will be one of the few truly defining historical moments of the 21st century unfold in front of your eyes.  This is somewhat akin to what I imagine watching a train bearing down on a stalled school bus full of 6 year old children stalled on the tracks, through a pair of binoculars from a long way away, would be like.

You aren't able to do much about it, and you know yelling won't help, but you do it anyway, you scream yourself hoarse, you make as much noise as you can, just on the offchance that it might help.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
thinking out loud
This situation is keeping us on our toes, isn't it?

Just as it should. :-)

Now's the time to engage the public in "pandemic thinking", which means entering a cycle of insufficient data, uncomfortable projections, tough decisions, and back to insufficient data.

Nobody said this would be easy.

I think we need to keep shifting from close-up to wide-angle and back again.  No way to make sense of things at one level only!

So, here's my current thinking, and please correct me if I'm wrong:

1)  Mexican data is biased because so far we've been looking mostly at hospitalised cases, which tend to be more severe, while I don't think we have a complete picture of what's going on there "at street level".  How many mild cases are there?  What's their age distribution?  Are we having seroprevalence studies yet?

2)  Out of Mexico data, both USA and Europe, are also biased right now because so far we've been looking mostly at re-patriated tourists, most of them young and previously healthy, with no idea of what happens when this virus hits the elderly, the very young, and the already chronically ill.  What if we start seeing that this virus does nasty things to a substantial fraction of, say, pregnant women?  Not saying it's the case, just that some data will clarify itself only gradually.

Both #1 and #2 leave us with quite important unknowns, I'd say.  And yet we need to take action, which can be all or nothing, or the more fine-grained, flexible path that seems to have been taken.

That's not soft leadership, in my book.  Quite the contrary!

3) We don't know how protective this "first wave" is.  I hope they are meassuring antibody levels and coming up with whatever fine viro-epidemio-immunological assessment then can come up with.

I think #1, #2 and #3 are just part of what we don't know.

Until then, it's not a matter of wait and see, but a matter of wait and learn.  We need to actively learn, and I hope that's what we're doing.

Now, how does that translate into "thinking out loud"?  I think the public needs to learn how we all do the "assess, act and back again" dance.

They need to be on their toes too.

No easy answers when it comes to thinking about what looks too much like an unfolding pandemic.

Finally, one fear with this situation is that people will get lost in thinking, and not prepare for a likely enough more severe second wave.

So, while we think out loud, we need to look into how to act prudently.  Just as one example, maybe now is the time to talk about 2 weeks of food for every home.  If done right, some will be able to do it at their own leisure.  If done just a tad too strongly there will be some ocassional shortages which will be rapidly filled up by a supply network that so far is in good shape, and that will add up to our collective learning.

So, to summarise my own thinking, I think we're learning fast.  We need to do our thinking out in the open, and encourage people to realise this is not simple.  We need to look at the wider picture: not just today, not just one country, not just one age group.  We need to act now, just in case.  We need to learn from each and every thing we do.

Cognitive overload, I know, but what's the alternative?  Not thinking?

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


also, could this wave turn uglier _in midwave_?


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
Of course -
Viral mutations can occur with such rapidity that this wave could have turned uglier in the time it took you to ask the question . . .

[ Parent ]
Thinking Out Loud
I think it may be too late for those unprepard to prepare because they are the vast majority of every country's population.  That said, there is still plenty of food in the local stores around me so for some, there may still be a little time remaining to www.getpandemicready.com

What Lugon says is exactly what I think.  If the unprepared public suddenly becomes alarmed enough to prepare, the store shelves will become bare and quickly.  Empty shelves will result in more panic.

Those of us who have studied these issues for a while understand that while in fact food and every other commodity is being produced, processed, and shipped to retail outlets, if consumers decide to hoard them shortages will occur. This is due to the now globalized business practice known as "Just in Time Inventory Management".  

For years now those of us posting here and elsewhere about this issue have begged the unprepared to do so rather than wait.  Why?  If you wait until you can see the eye of the pandemic before you as now, it will be too late to properly prepare.  Too late because if you can see it so can the multitude of the other unprepared.  

Lugon has always been interested in trying to find ways to help the hopeless.  Those unprepared who find themselves face to face with a pandemic who have no clue what to do.  So, here we are.  The unprepared remain so and our governments continue to play the odds.  Specifically they are hoping for the best and preparing for the best; a sketchy strategy that may pay off for a while but one that will ultimately result in catastrophe.  

Grattan Woodson, MD


early data from NYC
H1N1 (SO) Cases Continue to Be Mild in New York City

Latest findings suggest that "swine flu" is not causing unexpectedly severe illness

May 4, 2009 - Intensive investigation of the newly identified H1N1 virus shows that the illness continues to be mild in New York City so far. "We have looked daily at every hospital and every intensive care unit in the city within the past 10 days," said Dr. Thomas R. Frieden, New York City Health Department Commissioner, "and we have yet to find a single patient with severe illness from H1N1 (SO)." The Health Department also reported that testing at the Centers for Disease Control and Prevention (CDC) have confirmed 11 more cases of H1N1 (SO) infection in New York City. The new results bring the number of confirmed cases to 73. The CDC is currently testing six more probable cases from New York City.

http://www.nyc.gov/html/doh/ht...



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


Good to see that. n/t


[ Parent ]
Experimenting on an uninformed public
I am Soooooo Glad that they feel so confident in their data that they can experiment on the public.

In fact, their scientists are so much smarter than the rest of us, that we should all just do what they want, without the usual and customary standard in science of publishing the data and allowing others to check the data, methodology, theory, and conclusions.

I am so glad I no longer live in a free republic, but in a society controlled by a select, chosen few, who can make decisions about my general welfare better than I. After all, the vast majority of Americans and the people of the world are uneducated, superstitious, prone to panic, children.

While I agree with Susans conclusion based upon available facts, I am so pissed off that I not only don't trust the facts we've been able to glean from the web, I don't trust the decision makers.

TBTB are gambling they are right.  If they are, fine.  If they are not, then the repercussions will be more horrific than the flu, IMHO.


Just rolling along, making waves and causing trouble...


well they sure are tough choices
and no winners.  Except maybe the virus.  

But your comment on experimenting part is also so true.  There is simply no data, no previous experiment that tells us what works, to any degree of certainty.  But the virus is not going to hang around and wait for us to get that data.  So decisions have to be made based on limited information.  These are really tough choices, and no clear answers.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Surveillance
We have a short time frame in which we need to drastically shore up our surveillance capabilities nationwide.

[ Parent ]
Unsubstantiated
Which means there may be a case to not damp down transmission so much, in this first wave, and let more people particularly school-aged youngsters, acquire some immunity by natural infection.

Susan, to me this statement is a very dangerous and unsubstantiated theory.  It is like playing Russian roulette with our children's lives.  One could also argue that school closure has slowed the spread of the virus in America.  We truly don't have enough hard data to make either case.

In addition, if this assumption is true, then why did Hong Kong and mainland China quarantine so many foreigners in their hotels?  Why didn't they follow the premise that their population should get infected now and have immunity?  

"I am opposed to any form of tyranny over the mind of man."  Thomas Jefferson


Folks
We are all, including the world's governments, operating on limited information.  Limited in the present, and limited as to what could occur in the future.  What I understand SusanC doing is opening dialog and debate concerning the merits of allowing this first wave to run it's course.  This is worthy of debate in my opinion.  Debate is good.

Each of us, government officials and individuals each have to make some difficult decisions based upon incomplete information.  I don't envy the government officials.  They've got a tough job.  There are a lot of variables involved, the disease itself being the most important, but only one among many.  Individuals/families must also make some difficult decisions.  To shelter in place or not during the first wave is one, and this with incomplete information.  Judge the risk yourself with what info. you have and act (or not act).  It's your decision, not the governments or mine or Susan's.  Decide for yourself.  If you are hacked at the government for not providing all the information available, and I have been, then use what you've got and decide from that.  Did you really ever believe that the government would lay everything out in the open during a pandemic?  I have not thought so.  I might do the same if I were in their position, I just don't know.  We in flublogia are not representative of the general population.  Face it, we are very different.  How we react is and has been different from most everyone else.  I accept that and move on.  I also accept that I am not privy to all the information available.  I take what I can get, make my decisions and act based upon the best available info.  It is this way in all aspects of life.

It is worthwhile to debate difficult issues.  I realize that such debates have the potential to influence national policy, eventually impacting individuals and families.  We may not like those policies.  What's new there?  Decide for yourself what is best for you and yours and act upon it.  What you decide may be different from what I decide, or SusanC, or your neighbor down the road, but it is your decision to make.  For better or worse.


two key factors
that IMO differentiate Mexico's results from the USA

1) we knew this was happening sooner than Mexico did;
2)We got Tamiflu to the infected persons sooner than Mexico did.

Both of these things make a huge difference.

If we squander these advantages by promoting widespread infection by not closing schools, then we allow the virus the most opportune environment to spread and evolve, and we hasten the day that this virus becomes Tamiflu resistant.

That would be a mistake. Rushing to judgement would be an error.  Prudent caution is called for here.



KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


I agree LMWatBullRun.
If we squander these advantages by promoting widespread infection by not closing schools, then we allow the virus the most opportune environment to spread and evolve, and we hasten the day that this virus becomes Tamiflu resistant.

Some people on this forum have been proactive in pulling their children out of school, or have begun to homeschool them, or have been relieved when school districts closed campuses. Susan even sent her college-age daughter out of the country, a decision I applauded.  We do not know how virulent this virus can become, because America and Europe have not reached their peak with the infection.  We don't know what will happen in the future, but we do know that right now this virus, even if not yet deadly in the United States, can be horrible in some cases.  

"I am opposed to any form of tyranny over the mind of man."  Thomas Jefferson


[ Parent ]
in fact, my DD is going back tomorrow
I pulled her out because I was worried about border closures or flight stoppages.  Also, as many of you may be doing, to assess the situation.  She has just handed in her thesis but she's going back for the last week of the semester and her commencement.  She is also going to spend a year in NYC doing internships.

I'll be lying if I say I'm not scared.  I'm not so scared about now, I'm scared about the fall.  We're having ongoing discussions about contingency plans.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
what I'm most worried about
but we do know that right now this virus, even if not yet deadly in the United States, can be horrible in some cases.  

is that it will get even more horrible in the fall, and we'd be caught out.  I wish this virus is not around.  I wish we don't have to tackle such subjects.  But the prospect of severe second wave is supported by history.  See this chart from Morens & Fauci

I can make decisions for my kids, and share my opinions.  Each of us need to make up our own minds.  I just want to share what I think in case it's useful to stimulate people's thoughts.  I also know of a couple of people who have come to the same conclusion as I and are now acting accordingly.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
look at this chart
Everyone should sit and look at the 1st and 2nd peak and not take your eyes away until you have a solution.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
i agree that school closure is not for now
thoughts posted here:

http://www.dailykos.com/storyo...


by now, I expect the virus to be in most communities,.
 And the low hospitalization rate, is encouraging.

[ Parent ]
that is exactly my assessment n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Facts? what data do we have?
'The great economist John Maynard Keynes, when challenged on changing his policy during the Great Depression, said "When the facts change, I change my mind. What do you do, sir?"'

When I have enough facts to make a judgement, then I make one.  Right now facts are pretty scanty.

This is too soon to rush to judgment.

Let's see what happens next week.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


Instead of responding to individual comments
let me just add a few points here:

I agree with Okieman.  There's insufficient information, and difficult decisions need to be made.  We all need to make up our own minds, and we'll all have different opinions.  That's as it should be.  Only time will tell what would have been the best option.

For those of you who are saying, too soon to tell, wait a couple of weeks, here's my question.  Too soon to do WHAT, precisely?  

Last week I advocated for school closures to happen IMMEDIATELY, which was what was needed to make a difference to transmission.  Up to now, we have seen maybe a handful of school districts that have closed schools by district (ie not just close 1 school per case, but entire districts).  This was the MINIMUM required in order to damp down transmission before the 1% threshold is reached. (see Dem's diary for why)  All other districts that closed schools one at a time, were NOT doing significant mitigation.  They only pushed transmission to the community instead of schools.  So irrespective of our individual opinions, most districts had NOT used school closure to properly mitigate this outbreak, ie they haven't pulled the trigger, and they have now gone beyond the time when pulling the trigger would have been effective.

So, would you advocate them pulling the trigger NOW?  Widespread and prolonged closures after we've already gone beyond the 1% threshold?  

Yes, it may make some difference to the outcome, but we can't tell till it's all over.  More importantly, it's likely to fail, there will still be people infected, but if the disease is mild, as all current indicators suggest, then the public will be up in arms for having to deal with the consequences of school closure when the outbreak is mild.

We will then have totally lost the argument for community mitigation, next time round if the second wave is severe, and a LOT more kids will die because of it.  

Finally, for those of you who keep saying protect our kids, let me ask this question again.  What is your endgame?  They will have to gain immunity either by natural infection or by vaccination.  Are you placing your faith in being able to get vaccinated with a safe efficacious vaccine (remembering 1976 and the hazards of novel vaccines) before a more severe fall wave comes around?

If you let kids become infected now, they get sick.  There's tamiflu around, and the illness to the vast majority is not serious enough to require hospital care nor is it life-threatening.

If you wait, you'll have to place your faith on getting sufficient immunity from vaccination, bearing in mind that with novel viruses, you may need 2 doses over 4 weeks to get enough immunity.

Let me ask one more logistical question.  Suppose we are in the second wave, and a vaccine is available.  How are they going to vaccinate the kids without exposing them to the virus?  If the vaccine takes 2-4 weeks minimum to induce immunity (assuming single dose is effective), how are you going to make sure your kids don't catch the virus while standing in line to get the vaccine?  

Nobody has worked out how to do mass vaccination AND social distancing at the same time.  All mass vaccination plans require people to congregate in specific locations.

Think about it.  Do you have a solution?  Please share it here.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


and if they use an adjuvant
NOBODY has any data on the effect of an adjuvant administered just as the kid becomes infected with a virus.  An adjuvant is used for the specific purpose of enhancing immune responses.  But would it enhance host response to the virus and not just the vaccine? Would this enhanced host response cause severe or even fatal disease?

No one has done any work on this.  No one has any answers.  I just know that adjuvants are powerful stuff, and enhanced host immune response may be a key factor in the development of severe or fatal disease.

Would you take that risk?

I don't know the answer.  The specter of having millions of kids being given an adjuvant just as they are also exposed to a deadly virus really scares me.  It's the stuff that nightmares are made of.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
but if they don't use an adjuvant
It may be a whole year before your kids will actually get vaccinated.  It most definitely won't be 6 months.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
What the future holds?
As Susan states in her introduction to this diary, when the facts change, the wise adjust to them.

It has been pointed out by many over the years that our scientific ability to "see" what is happening within the influenza world has never been so acute.  Virtually all the information we are provided with today are new compared to what was available during past pandemics.  

What this means is that we don't really know how to interpret this data. It is possible that in the future, what we have learned during these times will make us better predictors of what is to come but for now we really don't have a clue what is going on.

Despite these conditions, it is still possible to speculate or make educated guesses on what may come.  This is the best we can do and is what we should do given the fact the potential for great harm do to this or future influenza pandemics is real.

Grattan Woodson, MD


Speculation on the present outbreak
My evaluation of the outbreak of Mexican Flu suggests that this epidemic probably began in mid-February in that country.  It was mild at the start but after a month or so there was a significant and sustained rise in atypical pneumonia, hospitalizations, and death in Mexico.  

When these more serious cases were noticed, the Mexican PH officials began investigating, collected samples and sent them to Canada for testing.  The findings were anomilus and caused confusion among PH officials since the H1N1 virus was one not previously encountered.  In early April, there was enough data available for North American PH officials to become very concerned.  Then in mid-April, the CDC isolated several specimens from TX and CA patients with ILI that were positive for the same virus causing the Mexican outbreak.

On about April 25th, the Mexican authorities went public with their findings.  Paradoxically that appears to be at about the peak of the current pandemic.  They took appropriate action but it was too late to change much of anything.

One observation regarding the above narative is the fact that it took a while, about 2 months from initial outbreak to the peak in severe cases and deaths in Mexico.

Does the 2 month time from outbreak to peak have any significance for the the other countries with cases of Mexican Flu? It so, then this may mean that since the outbreak in the US date back to April 12th or so, if the disease pattern seen in Mexico repeats itself here, it will not be long before we see the case severity of those ill with flu along with the CFR will rise dramatically.

Of course this is just one possible view of where we currently are.  It appears to me that we could be in a race between the Mexican Flu's transmission rate and the heat of summer that could terminate the pandemic in the Northern Hemisphere.  But this is simply speculation, nothing more.

Grattan Woodson, MD


This is exactly my thought
Currently my children are still in school. Currently there are no cases of flu (of any kind) reported in our small town.

BUT...I think about the estimate that in that village in Mexico (Edgar's village) 60% ended up getting the flu. 60%!! We simply don't have the resources to deal with even 1% of the town being sick enough to need medical help; much less a higher number (which this flu seems to instigate).

We won't see the real impact of this wave for at least two more weeks to come. Of course, we are leaving flu season behind. I don't think we can count on the weather to drive away this already unseasonal flu.

I'm going to watch and wait; remain vigilant. At some point I'm probably going to keep the kids home and limit social contact. I do NOT want to get this flu now, and most especially I don't want to get it in two to three weeks when it might be "peaking" and medical help is rare or unavailable.


[ Parent ]
Susan, I have a question for you.
What numbers will be drawn in the Powerball lottery drawing at 11:00 PM EST on May 9, 2009?

Do you get my meaning? You can't see into the future! You are doing a lot of guessing in all of this. Even the virologists/expert flu scientists say they don't know what is going to happen with this novel virus. So I am pretty sure you don't know. We can all sit around and guess what it's behavior will be but that is all it will be....a guess.

The first wave is just gathering steam. There could be mutations, recombination, antigen drift, before we see a second wave. There is a very small chance this could die out. There is a much, much greater chance of a change in the virus before a second wave. That can go either way....less virulent or more deadly. The change could be to the extent that the immune system doesn't even recognize it anymore so there still will be no immunity. The schools stayed open, the kids got sick, a few died, all for nothing so for parents to promote exposure to this specific virus strain in hopes it will give their children immunity to a second wave is nuts, IMO.

Let's not forget.....closing schools interrupts transmission throughout the community. That is a good thing for all of us.

Life is not measured by the number of breaths we take, but by the moments that take our breath away. --Unknown

     


sure you can't see into the future
I'm doing a lot of guessing, but so are you.  I've laid out my thoughts and my rationale, including when I changed my mind.  I don't expect everyone to agree.  

We can all sit around and make guesses, but I suspect the reason why you and so many people are interested, is because we know that the consequences of those guesses can make a significant difference to the outcome for our kids.  Otherwise why should anyone care?  

So, guess away.  That's the best we can do.  Ain't much, but that's all we've got.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
what we know and what we guess
What we know is that a lot more people have been confirmed to have died so far in Mexico than in the US from this outbreak.

There are many possible explanations of this difference:
-The virus may be different (although early sequences indicate this is not so, it is still a possibility)
-the treatment may have been different(early vs. late tamiflu, more alertness in USA, etc.)
-The people may be different(USA more exposed to more strains and less likely to get severe illness, etc.)

We do not know which of these hypotheses are correct.  It's possible that any one, or a combination, of these explanations are correct, or that some other reason not listed is the explanation for this difference.

We.
Don't.
Know.

It is also possible for this situation to change, and change quickly.  If the virus changes, prior exposure may no longer protect Norte Americanos.  If the virus acquires the seasonal flu resistance gene, then any advantage we may have enjoyed from early use of Tamiflu  will be gone. If there is a difference in viral strains from the US to Mexico, the nasty one will get here sooner or later.
We don't know when or if such changes will happen, either.  It is possible we will never see any such change during the entire course of this pandemic.  We don't know.

There is something else we DO know.  Reducing the packing density of humans reduces the spread of the disease.  While it is true that complete district by district closure is better, reduction in exposure does dampen out the disease spread to some extent. How much is debateable; we don't have enough data to know.

It is possible, possible, that this virus replicates slower than typical seasonal flu, with a longer incubation period, although we do not know that, and if it does, then school closures will be more effective, as will social distancing.

Another thing we do not know is whether infection now will provide any partial immunity for future mutations of this virus.  While it is true that it appears that it has in the past,  the recent history of influenza is replete with influenza doing things that all the experts confidently stated it could not do, or not doing the things we thought it would do.  I doubt that the propensity to surprise and confound is a trait restricted to H5N1; I suspect this new H1N1 has some surprises in store, too.  BUT WE DON'T KNOW WHAT THEY ARE; that's why they are SURPRISES.

I think every flu strain has things to teach us, and most of the lessons will be painful ones, bought with the agony and tears of those we hold precious.  

I will not play infection chess, a game whose rules I do not know, with the lives of my family on a board whose size and shape I do not know, with pieces I cannot locate, in the hope that I can outwit the viral computer running the game.  Whenever I can, I refuse to play, and I don't want to drag others into the game.  I would rather not be the 'lab rat' in this experiment, and I WON't be a Judas goat.  There is too much I don't know, and until I know more, I will assiduously avoid getting this bug, and so will my family.  If I can, I will avoid getting it at all.
I promise, I won't feel left out if I NEVER get it.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
you're making my case
If the virus acquires the seasonal flu resistance gene, then any advantage we may have enjoyed from early use of Tamiflu  will be gone.

THAT is one major reason kids should get 'immunized' now, when tamiflu still works and stocks are still available, cos they can be treated if necessary.  Imagine the CFR when they are infected when it's resistant, severe, and the kids have zero immunity.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
But how do you know that prior infection will confer immunity?
You don't know that.

It's speculation, Susan.

It's an 'expert opinion', and how many times have the experts been proven wrong over the last few years?

It's a GUESS, based on more guesses about PAST pandemics.

If the virus changes, (and I AM sure that will happen) how do you know that the mutated strain will not infect those previously infected?

You don't.  You cannot know that.  You don't even know whether it will get the traits by mutation, recombination or reassortment, or some combination of all three.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
speculation, educated guesses, and freewill
It is a well-established observation in immunology, that in general prior infection confers some protection.  How much protection there is depends on many variables.

It's a little like saying October tends to be cooler than August (in the Northern hemisphere), but whether that is true in a particular year or in a particular location, that is harder to predict.  But is the statement that October tends to be cooler than August a speculation?  I don't think so.  I consider it an educated guess.  

We make a lot of educated guesses every day.  How cold is it going to be?  Is it going to rain?  What's the traffic like today?  Would I be better off taking the freeway or taking another route?  These are all educated guesses we make on a daily basis

How much anyone wants to rely on educated guesses, is a matter of personal choice and free will.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
You are right, we guess a lot, every day.
BUT WE GUESS ON THE BASIS OF ABUNDANT HISTORICAL DATA.

I don't know that the sun will rise tomorrow morning, but since I haven't heard of any potential supernovas, or large alien spacecraft closing in on our SOlar system, I'm fairly sure that the Sun will indeed herald the dawn for the foreseeable future.  I know the relevant physical laws and I am comfortable with that judgement.

Your weather example is a good one.

I agree that the trend is for October to be cooler than August, but I would not bet my life or the lives of my family on the high temperature on the 10th of October 2009 being lower than the high temperature on the 15th of August 2009.  There is a great deal of stochastic variability in the weather; it's extremely hard to predict.  Now, if I were planning a trip, I'd pack clothes suitable for the expected weather, but I'd also pack a few clothes in case I saw some departure from the norms;  I'd have a raincoat with maybe a warm liner even if I were going to Arizona in August, just in case.

Similarly, in immunology, while we know the general trend is for prior infection to confer immunity to subsequent infections of the same virus that does not always happen.  Especially with influenza, and one of the reasons that it does not is that influenza is so mutable that the second time around it is NOT the same virus.  If the virus changes significantly, there may be little to no immunity conferred.

While I can prepare to some extent for unusual weather, because I have an idea, based on past data, of what the range of conditions I can expect might be, how do I do that for the ongoing influenza pandemic?

How do I prepare for the possibility that I may get infected during this pandemic by two versions of this virus, the second much worse than the first?  What is the prudent course to take to mitigate that risk?  What data do I use to justify my decision?

The logical course of action is to reduce the likelihood of this occurring in the first place, by limiting the spread of the virus as much as can be done, and to reduce the likelihood that my family will be exposed.  No exposure, no infection.

NO EXPOSURE =
NO INFECTION


KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
I can imagine that,
which is why my family is not going out to public places, and why if I do see an increase in hospitalizations, any children I am responsible for WILL be kept isolated by whatever means neccessary.  If you don't get exposed you WON'T get infected.  
Everyone has to set their own priorities and there is a price for the choices you make.

My number one priority is the safety and well being of my family.  Others may choose convenience, or avoiding social embarrassment, or pandering to TPTB.  I choose to be very, very, careful, and I will pay the price for that choice.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
you may be able to protect your family
but the vast majority of the public do not have the knowledge or ability to do so.  Which means if we care about the wellbeing of their kids (and not just our own) then we should put our minds to considering what might be the best approach, on balance.  Would it be to protect all kids as much as possible during this mild early phase, or would it be better to have some of them gain some natural immunity?

It's a public policy question, not just a question for individual parents.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
so it's 'Public Policy' versus individual prudence?
It's a public policy question, not just a question for individual parents.  

That bears repeating.

It's a public policy question, not just a question for individual parents.  

So, if the "ignorant" parents decide that they want to avoid exposing their children to a potentially deadly disease, are you saying that they should be forced to subordinate their judgment about what's best for their families to the supposed needs of the State?  Did I read that correctly?  I hope not................

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
you are distorting my words
I'm saying that most parents are ignorant and don't have the options that you have.  Whether we like it or not, in essence they ARE already subordinating their judgement to the recommendations in public policy.  They do not have the knowledge to make a determination of what is best for their kids.  If we all shut up here, then they WILL have to only take whatever the government gives them.

I'm opposed to that.  I believe people should be informed and prepared.  My actions for the past few years support my words.  I do not believe the government is always right.  I cannot count the no of times when I've taken them to task (and still do) when I think what they are doing are not in the public interest.

But the virus is not upon us.  With the best will in the world, neither myself nor the small group who works with RMA can overturn the tide of ignorance in time for the second wave.  It would have been better if there were more people out there spreading the word, but what's done is done.  We can only focus on the present.

The current situation is we are already in the first wave of a pandemic.  I have some suggestions for everyone's consideration.  I don't expect everyone to agree.  But I would again, for the fourth time on this thread, throw down the gauntlet and ask, what is the endgame that you propose, for the vast majority of kids whose parents are ignorant and whose families are unprepared?

I respect your view.  Please do not distort mine.  Thank you.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
typo - the virus is NOW upon us. n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
vaccination by the fall?
SusanC: I respect the way you wrestle with very difficult issues. It looks as if this wave will be "mild" unless things change in the southern hemisphere. But a parent might hope in the US or EU that normal seasonality will damp down the virus in the next few months and vaccines will help out by the fall? It seems likely that some sort of vaccine will be made, though that is not certain. There is also the issue of vaccine capacity, a topic on which you have written a lot. If there were a probability of an effective vaccine for H1N1 by the fall for children, surely that is a plausible endgame? Or do you think that capacity will be constrained by producing normal seasonal flu shots and only a limited # will have access to an H1N1 shot before 2010?  

[ Parent ]
this may answer your question
http://www.newfluwiki2.com/sho...  although the vaccine issue is complex and really deserves a whole diary, or more than one, in itself.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
I agree people should be informed and prepared
Susan, I do respect you, and I respect still more what you have accomplished.  I vividly recall your frustration at the 2008 Pandemic conference.

That is why I was so thunderstruck at this apparent reversal regarding NPIs and school closure in particular.  Closing schools to limit spread made sense to me.

It still does.  The fact that I (correctly) thought that a snowball had a better chance in hell than that the USA would pre-emptively close the schools did not change my opinion of that strategy. Even with very poor implementation, I think that this has made a difference, based on anecdotal evidence from media reports and case numbers, and will continue to do so.

So, to answer the question you asked, to be blunt, I foresee poor outcomes for the families that have not prepared.  I see no assurance of any difference in that assessment if more children get a 'mild' version early than if they do not, and I do see several significant risks associated with that strategy, ESPECIALLY since this is NOT 1918.  The likelihood that an evolved version of this virus could fly in from 'down under' or elsewhere in the Southern Hemisphere or the world pretty much any time at all is MUCH higher than in 1918.  In 1918 it took weeks to get from there to here and you had to go through the tropics.  Today it takes 12 hours, and the environmental conditions on the way are ideal for conserving virus.  We could easily see one continuously evolving wave 18 months long, with each Hemisphere continuously reinfecting the other;  we just do not know.

The best way to cope with this bad situation is to push HARD on three things-
-getting safe and effective vaccines out the door as quickly as we possibly can;
Agggressively increasing the stockpile of antiviral drugs, especially RELEMZA;
-Aggressively planting the preparedness meme via PSAs.

The cure for ignorance is education.

The cure for unpreparedness is to PREPARE.

The cure for a flu pandemic is a vaccinated population.

But trying to avoid the effort inherent in proceeding with these things is grasping at straws, and carries significant risk.  TANSTAAFL.  There are no shortcuts, and the fact that we are now in a pandemic does not change that. In particular, suggesting to TPTB that they might be able to avoid the needed effort by letting everybody get sick is a recipe for catastrophe, in my judgment, and whoever suggested it ought to be strangled with his own guts, since he doesn't need them.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
LMWatBullRun, I appreciate all your comments.
And I am in total agreement with everything you say.  It is clearly a frightening idea that a number of children should be purposely exposed to infection and then of course spread that infection to those whose parents are trying to shield them from the disease.  I am thinking specifically of special needs and medically fragile children.  If this sort of behavior is coupled with non-closure of schools, then it could be a truly frightening scenario.  While some may gain immunity, the most vulnerable will quite possibly pay the ultimate price.

"I am opposed to any form of tyranny over the mind of man."  Thomas Jefferson

[ Parent ]
children with special needs
and anyone at higher risk of complications from influenza should continue to be protected.   I don't think anyone is suggesting that any child be purposely exposed to infection.  I certainly am not suggesting that.  I'm suggesting that blanket and aggressive school closure irrespective of circumstances may not produce the best public health outcomes.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
another thought on relative risk and risk perception
There's no such thing as zero risk.  All our decisions carry some consequences.  As Carol said, we are just making guesses based on inadequate information.  But there's something else that may be instructive as lesson, and that is the accuracy of our perception of risk.

After 911, many Americans stopped flying and chose to drive instead.  The increase in driving lasted one year and then went back to normal.  In that one year, an additional 1,500 people died from road accidents (ref Gigerenzer 2006 )

For me, the lesson lies in careful detached analysis of pros and cons of the choices that we make.  There are no perfect solutions, and certainly no one solution that fits all.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


Everybody makes different decisions
I'm sure it must seem strange to some people that I couldn't wait to get on a plane post 9/11.  I flew to Anguilla in the Caribbean exactly one month after 9/11.  So - when most people were driving, I was doing my best to get on a plane and go far, far away - where I stayed until the end of the following January.

It was a Twilight Zone experience, flying so soon after, when even the small airports were full of large men with large weapons.  Funny, though - I traveled with my little black dog, and as soon as all those big serious looking men got a look at that dog they ignored me totally and just wanted to hold the dog. They'd even hand their weapons to a buddy to hold so they could get their turn at holding the dog.  

Point is, though - we all make different choices based on different reasons.  I felt safer once I was out of the US, even though I had to endure the anxiety of flying to get there.  Most people felt safer not flying, but I made travel arrangements as soon as possible.


[ Parent ]
You were very smart Clawdia...
to get on a plane at that time. It was probably the safest time ever. ALL eyes were on the airlines and preventing more terrioist attacks during that period. Those big fellows with guns did a hell of a good job! I did the same thing as you. Had a great time scuba diving for a week.

Life is not measured by the number of breaths we take, but by the moments that take our breath away. --Unknown

     


[ Parent ]
yes, that is classic
Reminds me of my experience with skiing.  Coming from Hong Kong, it's a bit unusual to be a skier.  I only started in my 40s, and many of my friends used to warn me about the dangers.  

Anyhow, one year I broke my shoulder in a skiing accident (more accurately a chairlift accident, as in being pushed off one) in August in New Zealand.  I immediately went back to the slopes that December, even though one arm was still weak and painful, and I couldn't pull myself up if I fell.  My friends thought I was crazy, but I told them the sooner I went back to it, the sooner I'd be able to overcome my fears and enjoy myself.  I've never regretted that choice.  It was good to learn that I could enjoy myself while still recovering from a recent injury.  

I ski at fairly high speeds but I (and my whole family) always wear helmets and follow all safety rules.  I think of how the actress Natasha Richardson died slipping on a beginners' slope (most likely without a helmet).  The lesson there for me is never underestimate the risks, take all precautions, but find ways of enjoying life while being (relatively) safe.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
probably case in our school system
In our town (Newton MA), we got a phone call from the school system that a probably case was detected in a student at one of the schools.

The new policy here is to not close the schools but just to have sick people stay home for at least seven days. They based this policy on the recent information indicating that the severity was no worse than seasonal flu.

My kids are still in school. We're reminding them to do hand washing , and I have been keeping them from going to large events such as dances when possible.

I'm not so worried given the lack of serious hospitalizations reported so far in the US, and the downgrading of fatality numbers from Mexico.



letter from school system
This is the letter the school superintendent  put up today

http://www.newton.k12.ma.us/pd...


[ Parent ]
It is very strange
It is very strange for me to be going from contemplating pulling my daughter from college just a week ago to thinking it might be best if she caught this flu now.  I, too, have great concerns about it coming back much stronger this fall and the strong possibility of Tamiflu resistance.   Here are some of the questions I am struggling with-and I am not asking for a crystal ball-just the best information that we have at this time....  :~)

• Is it pretty much for sure that this flu will come back again?  It seems to me that is the case but I am curious what some of you who understand this better believe.  SusanC, I believe you are saying that it will come back again and again if it is a pandemic (which it seems to be whether or not we have the official rating from WHO yet).  Is there any reasonable chance to believe that it might just die out and go away-or is that more wishful thinking?
• What are the chances of it coming back less severe?  It seems to me that if it is pretty mild now, that the most probably change is to become more severe, not less.  Is this the general thought?  Is it just as likely that could come back less severe?
• It seems like there really will be no vaccines for regular folks anytime soon.   Looking at Dr. Woodson's book, he estimates that the U.S. would be able to vaccinate 120 million American out of a population of 300 million over the 18 month estimated duration of a pandemic.  I assume that the first batch that is done about 6 months from now will be for health and safety workers plus other "essential" people.  That puts the next round out about a year from now, after we have gone through the fall and winter flu season.  Is it feasible that higher risk patients like those with severe asthma, heart conditions, diabetes, etc. would get their vaccines in the first round or more likely in the second round or perhaps not even until the third round?  And even if they do get their vaccines, do the rest of their family members?  I am guessing not, but please correct me if I am wrong...  SO is it fair to say that most people will not be vaccinated even 18 months from now?  Or will so many people be infected earlier in the first or second wave that if you SIP that you could reasonably assume that you could get a vaccine at that point?
• Lastly, how does the idea of catching this flu now relate to children who ARE more high risk?  Yes, I understand it is more of a gamble.  But then again, is it?  Because if they are higher risk now, then they would probably benefit from Tamiflu and a hospital bed now, which may not be available during a more severe outbreak....  Perhaps it is even more important for them to get the flu now while it is mild.  Thoughts?    Please don't flame me-- I love my children more than anything.  This is such an important decision and I want to understand the variables as much as I can...

I really do understand that no one knows for sure and that each of us have to make our own decisions with what we feel comfortable with.  I really appreciate the fact that you brought this subject up, SusanC as I had already been thinking along these lines as well and it was nice to know someone else might be as crazy as me!  ;~)


same here ;-)
It is very strange for me to be going from contemplating pulling my daughter from college just a week ago to thinking it might be best if she caught this flu now.

I pulled my daughter out of college and today she's going back.

Is it pretty much for sure that this flu will come back again?  It seems to me that is the case but I am curious what some of you who understand this better believe.  SusanC, I believe you are saying that it will come back again and again if it is a pandemic (which it seems to be whether or not we have the official rating from WHO yet).  

Nobody knows anything for sure.  But historically pandemic flu did come back in waves and infect everyone and then becomes the 'seasonal' flu.  That's how flu viruses behave.

Is there any reasonable chance to believe that it might just die out and go away-or is that more wishful thinking?

The 1976 swine flu infected a number of people, killed one, then died out.  But that was highly localized, to one army camp, and I believe seroprevalence studies found some other cases that were asymptomatic in the community, but that was it.  What is happening now is different in that this virus has seeded in many countries in the world in a short time, and in Mexico and US has become widespread in communities.  It would be highly atypical for a flu virus that has successfully established itself in humans in this way, to die out for no reason.  

What are the chances of it coming back less severe?  It seems to me that if it is pretty mild now, that the most probably change is to become more severe, not less.  Is this the general thought?  Is it just as likely that could come back less severe?

Let me pose the question in a different way.  If it is pretty mild now, similar to seasonal flu (which is not mild for everyone), why would a virus become even milder than current seasonal flu and still dominate as the circulating strain?  Remember viruses compete against each other.  Assuming similar levels of transmissibility (which we are seeing) the competition happens within the cells of a host.  Suppose you get infected with several strains of virus at the same time, which one would win?  At the cellular level, the competition is driven by viral replication.  The virus that replicates most efficiently, will crowd out the competition.  But efficient viral replication is also associated with severe disease.  Of course our knowledge is incomplete, but other things being equal, the more virulent strains would win and become the dominant circulating virus.

Sorry, gotta go.  More later



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
pathogen evolution and virulence
Whether a pathogen tends to evolve towards virulence or become milder is the subject of great debate and a lot of literature.  The older notion that pathogens tend to become milder cos there's a downside to killing off the host, is considered too simplistic and not borne out by observations by many scholars (I can write more with references some other time).  Here's one interesting experiment that is illuminative for what we are contemplating.

Timing of transmission and the evolution of virulence of an insect virus.

This experiment was done to test a hypothesis, that the timing of transmission (ie whether the pathogen is transmitted early or late in the infection process) makes a difference to the virulence of the strain selected.  

We used the nuclear polyhedrosis virus of the gypsy moth, Lymantria dispar, to investigate whether the timing of transmission influences the evolution of virulence. In theory, early transmission should favour rapid replication and increase virulence, while late transmission should favour slower replication and reduce virulence. We tested this prediction by subjecting one set of 10 virus lineages to early transmission (Early viruses) and another set to late transmission (Late viruses). Each lineage of virus underwent nine cycles of transmission. Virulence assays on these lineages indicated that viruses transmitted early were significantly more lethal than those transmitted late. Increased exploitation of the host appears to come at a cost, however. While Early viruses initially produced more progeny, Late viruses were ultimately more productive over the entire duration of the infection. These results illustrate fitness trade-offs associated with the evolution of virulence and indicate that milder viruses can obtain a numerical advantage when mild and harmful strains tend to infect separate hosts.

Influenza as a disease is most transmissible at the onset of symptoms.  Would the findings of this paper apply?  I don't know, but it's certainly food for thought.  

Another example of disease where the more virulent strain has selection advantage is dengue fever http://www.pubmedcentral.nih.g...

These are just snippets of a huge topic, just to say, increasing virulence with adaptation (at least shortly after host switching) would not be unusual in evolutionary terms



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
vaccines etc
It seems like there really will be no vaccines for regular folks anytime soon.   Looking at Dr. Woodson's book, he estimates that the U.S. would be able to vaccinate 120 million American out of a population of 300 million over the 18 month estimated duration of a pandemic.  I assume that the first batch that is done about 6 months from now will be for health and safety workers plus other "essential" people.  That puts the next round out about a year from now, after we have gone through the fall and winter flu season.  Is it feasible that higher risk patients like those with severe asthma, heart conditions, diabetes, etc. would get their vaccines in the first round or more likely in the second round or perhaps not even until the third round?  And even if they do get their vaccines, do the rest of their family members?  I am guessing not, but please correct me if I am wrong...  SO is it fair to say that most people will not be vaccinated even 18 months from now?  Or will so many people be infected earlier in the first or second wave that if you SIP that you could reasonably assume that you could get a vaccine at that point?

That's a whole long discussion in itself.  Suffice it to say that with current capacity, using existing licensed capacity, the US only produces enough vaccine for <20% of the population per year.  The prioritization of pandemic vaccines was the subject of public consultation a while ago, and HHS has some interim guidance on this.  http://www.pandemicflu.gov/vac...  How exactly they plan on implementing it I'm not sure.  It's hard to predict when you will get vaccinated.  There are many variables, eg would tptb decide to use an adjuvant for dose sparing?  That seems a little dicey given this is swine flu and the 1976 experience of Guillan- Barre syndrome, an autoimmune disease which may be enhanced by the use of adjuvants.

They may use newer technology, especially the recombinant hemagglutinin vaccine FluBlok.  With this technology they may be able to make a vaccine much faster and in greater quantities, but it's not clear which way the government is inclined.

• Lastly, how does the idea of catching this flu now relate to children who ARE more high risk?  Yes, I understand it is more of a gamble.  But then again, is it?  Because if they are higher risk now, then they would probably benefit from Tamiflu and a hospital bed now, which may not be available during a more severe outbreak....  Perhaps it is even more important for them to get the flu now while it is mild.  Thoughts?    Please don't flame me-- I love my children more than anything.  This is such an important decision and I want to understand the variables as much as I can...

I wouldn't encourage anyone to expose high risk individuals even if this virus is 'mild'.  Look at the pregnant woman who died in Texas.  She was in the high risk group.  We need to be very careful about protecting them.





All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Did the 1958 and 1968 pandemics
have multiple waves? If so were the subsequent waves more severe?  Asking because I can't remember. I know I read of them but not in depth.

To calm the wife buy cases of chocolate, to calm the husband buy cases of booze, and to calm the children...... heck the booze and chocolate should work.

[ Parent ]
here are 2 slides from Arnold Monto

I don't know whether the actual CFR differed between waves for these 2 pandemics.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
but the fundamental mechanism
of formation of the pandemic virus was different.  Both 1957 and 68 were the result of reassortment between the circulating seasonal flu virus with avian viruses.  The pandemic viruses retained most (5 for 57, 6 for 68) of the genes from the previous seasonal virus.

1918 was an entirely novel virus, with no genes from human-adapted viruses.  This current 2009 one is also almost entirely novel.  There is only 1 gene that came originally from a human-adapted virus, but it had gone into swine 20-something years ago.  It's not clear that there is any immunological memory for such a gene.

Which is why this pandemic is more likely to resemble 1918 than 1957 or 68. We are already seeing the fatalities in young healthy adults, a characteristic feature from 1918.  It's also the same subtype, ie H1N1.  Which is why IMO we should consider a 1918-like pandemic more likely than not, although the overall CFR may be less than 1918 cos it isn't entirely novel.  But this last bit is REALLY speculative, cos it could be more severe as well.  Just no way to tell right now.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
the virus doesn't have 1918 virulence factors
 - at this time -  and the truth is we have no idea what fall will look like. I think it's fairer to say that than anything else.

[ Parent ]
that was only in comparison
to the 1918 second wave virus.  We don't know whether the first wave virus in 1918 had those mutations.  http://www.newfluwiki2.com/dia...



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
no, we don't
add it to the long list of what we do not know.

[ Parent ]
virulence factors
The CDC report stated that this Novel (A)H1N1 virus did not shwo the virulence factors seen in the 1918 virus.  Are we sure that the missing factors are the only genetic markers for virulence?

In the absence of Tamiflu, it would appear to be adequately lethal. (early cases in Mexico)  Is there any explanation of these deaths in the context of the genetics of the virus?

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
no we are not
The CDC report stated that this Novel (A)H1N1 virus did not shwo the virulence factors seen in the 1918 virus.  Are we sure that the missing factors are the only genetic markers for virulence?

They only compared it with the second wave of 1918, plus a recent study shows that flu viruses do not necessarily use the same set of mutations for virulence.  More in this diary http://www.newfluwiki2.com/sho...

In the absence of Tamiflu, it would appear to be adequately lethal. (early cases in Mexico)  Is there any explanation of these deaths in the context of the genetics of the virus?

There can be a wide range of severity, with flu.  The problem is, the only viruses that we've been able to study for human disease, are all direct descendants of the 1918 pandemic virus.  Other viruses (or parts of viruses) that don't have the same ancestry may depend on other mutations that we don't know about.  Again, see above link for more.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
OK, so what the CDC report means is
"this is not the same virus as the 1918 panflu virus, and we do not know why it is killing people".

What was the point in publishing such a report?

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
a negative finding is still useful to know
It would have been a lot worse if they found the same mutations as in 1918, don't you think?  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
It's true, science is largely a compilation of things we know are not so
But there is a big difference between doing the research that was done in this instance, and broadcasting the results in a manner apparently intended to deceive the public.

I am willing to believe that every word in that report was true, but the conclusions that have been drawn from it by the media and even some health care professionals are absolutely false, and whoever published these results damned well knew what would happen before he did it.

That is just plain wrong.  It is evil, and people may die as a result.  Whoever was behind that ought to be tarred and feathered and ridden out of town on a rail.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"


[ Parent ]
the biggest wrong that I see
is removing the recommendation for 2-weeks preps.  It was up as a PSA for all of 2 days, then it was gone.  Clearly the work of Sebelius, given what she said on the HHS webcast. http://www.newfluwiki2.com/sho...

Let's still up on pandemicflu.gov.  http://pandemicflu.gov/plan/in...  Let's see how long it stays there.  And let's see how they justify that change.

Unfortunately, I don't think any of the media noticed.  Early on, a couple of journalists (I think one from Washington Post) were asking questions about personal prep, but even they shut up after a while, cos they didn't get anywhere with the questions.

If you can't rake up anything, it ain't a story.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
it's none of the above
not wrong, not evil, not deceiving.

This virus at this time is relatively benign, but has unclear potential. We don't know why younger people are affected, for example. But this idea of "they must know something they're keeping from us", or that "they are lying"  (deceiving?) or "it's delibererate" is just not so.


[ Parent ]
But why so little attention given to preps at the start?
Before the virus was designated as mild, it seemed prudent to me to remind the public of what HHS has been saying for several years about stocking up. But as has been pointed out in many other places on the wiki, CDC / HHS spokespersons seem to go out of their way NOT to suggest prepping. I found that to be strange until someone pointed out what should have been obvious to me: Had officials given such guidelines, the store shelves would likely have emptied fast, feeding a "panic" that governments abhor.

Don't you think that a fear of panic played a role in the decision not to promote stocking up?  


[ Parent ]
i think you're right on all counts
today, CDC/Besser sent everyone to pandemicflu.gov re preps. Better late than never. And better now than in the fall.

[ Parent ]
Thanks, glad to hear of the change. n/t


[ Parent ]
How did Besser "send everyone" to preps info?
I haven't found that yet.  Thanks!  

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

[ Parent ]
transcript now available
There are all kinds of information sources on what you can do to plan.  I would refer you to a website called pandemicflu.gov, that has great information for individual, it has information for businesses, community group, things that you need to be thinking about because as we as a government are thinking about the fall, as we've talked about vaccines and whether that's something that's going to be done, the response to a potential pandemic is not just about vaccines, it's been all of the things we've been talking about over the past two weeks.  During this period of time, between now and at fall is critically important to individual preparedness, the community preparedness and how the impact of this could be on our communities should this virus come back in a severe form.

http://www.cdc.gov/media/trans...


[ Parent ]
Readability of Transcripts
It would be dandy if a careful writer were deployed to proofread those transcripts for accuracy and to determine sensible punctuation and paragraphing. Editing would significantly enhance readability.

I know this is a very small point.


[ Parent ]
Hope the message filters into media reports.
I get to make the case for preparedness at a disaster preparedness fair in Louisville on Tuesday - help from above is always useful.

[ Parent ]
Link was on another diary here; hat tip to hornblower.
http://www.cdc.gov/media/trans...

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

[ Parent ]
here's a chart from the first wave of 1918
from Crosby's book, America's Forgotten Pandemic

The pattern was already discernible in April 1918, even though the overall mortality was not very high.  We are in April/May 2009 and seeing the same pattern.  Does that give you pause?  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
I don't know who said it
If you've seen one pandemic, you've seen one pandemic.

To calm the wife buy cases of chocolate, to calm the husband buy cases of booze, and to calm the children...... heck the booze and chocolate should work.

[ Parent ]
Jeffery Taubenberger n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
To ask your question--what is the endgame?
Thank you so much, SusanC for taking the time to give me so much information.  I truly appreciate it!  The draft the govt. has for vaccine distribution was extremely interesting and pretty much what I was suspecting.  When I first started to follow H5N1 a few years ago, I had pretty much written off the idea of a vaccine to "save" us.  I still feel that is probably true.

So looking at their charts, I could expect my higher risk children to get a vaccine about 1 year or so from now, well after the second wave and perhaps even after the third wave, if there is one.   So I guess, I would like to ask your question: what is the endgame?  :~)  If it is likely the flu will come back again, if it is probable that it will mutate to a stronger strain, if we will not have vaccinations available to us, why would exposing higher risk children be any different?  If the hospitals are not overflowing, if Tamiflu is still working, why would taking the chance of them getting it later, be better?

I am not asking for anyone's recommendation-that is a personal choice each family must make-- with as much information that is available.  I just want to look at all of the angles of this to make my choices and these are questions that have not been resolved in my mind yet. I need to know for my own piece of mind that I have explored this as fully as possible regardless of what decisions my family makes.  This is serious stuff and talking about different ideas is the best way to look at different possibilities.  So thank you!  


[ Parent ]
NWmom, you have captured the spirit of this discussion
Really no one has the 'correct' answer, but more discussion and exploration is useful, and everyone needs to make their own decisions about their kids.  It ain't easy, but then we knew that when we became parents, didn't we?



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
To ask your question--what is the endgame?
I have seriously thought about this as well. The similarity to the 1918 pandemic pattern has struck me from the beginning. I'm not sure if getting it now is better or not, but with a 6 and 11 year old, I'm seriously worried about next fall. It's a crap-shot without a doubt, with everyone having to hedge what they consider their best bet.

And really, who says hiding out for a year is going to save anyone either. So little statistical information is actually available on the 1918 (reports of anywhere from 20 to 100 million deaths), that we really can't know the full extent of the thing.

At this point it seems we can only watch and wait. Really, if we opt to get it now, where exactly do we sign up?


[ Parent ]
Physician/mother blogger comments on school reopenings and parent's lack of knowledge
This afternoon, in an interview, Richard Besser, MD, from the CDC in Atlanta, shed some light on the puzzling about-face on behalf of the government and the CDC when he said the school closures weren't working as anticipated because parents were dropping their children off at the public library and the mall, instead of leaving them at home, thereby defeating the purpose and possibly even increasing potential exposures....

...Second: We scrap the school closures, but how do we get from that to saying that this flu is no worse than "seasonal influenza"? That part is still beyond me. Couldn't we just have said that as the situation unfolded, school closures no longer seemed needed or effective in preventing the spread of the illness? Because without school closures, handwashing and covering for coughs/sneezes become even more important, and so does staying home at the slightest hint of illness. Stopping this outbreak is going to require a cooperative effort, and giving up on all our measures because one measure wasn't successful isn't the way to go about it.

Really, I blame this on the lack of honest information shared early on. If our leaders had come out and explained, clearly and concisely, WHY we feared this outbreak even though it didn't look like much, if they'd given voice to what they were thinking instead of simply reminding us of 1918, I think you'd have an American public far more willing to get behind them to do what was required.


http://gaymwalker.blogspot.com...

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

2nd case in Metro ATL but school plans to open
If this information is correct, here's an example of a 2nd case but the school plans to open, anyway.  Maybe they'll change their mind in ... an hour?

2nd case at Metro Atlanta school:
http://www.wsbtv.com/news/1938...

School plans to reopen, anyway:
http://www.nbcaugusta.com/news...


Menu

Make a New Account

Username:

Password:



Forget your username or password?



Active Users
Currently 2 user(s) logged on.

Contact
  DemFromCT
  pogge (In Memorium)
  Bronco Bill
  SusanC (emeritus)
  Melanie (In Memoriam)

  Flu Wiki (active wiki resource)
  How To Add To Flu Wiki
  Get Pandemic Ready (How To Start Prepping)
  Citizen's Guide v 2.0
  Effect Measure
  Dude's FTP

Home
Powered by: SoapBlox