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.

The Barry/Markel Drama - part 2. Little evidence for New York City quarantine in 1918 pandemic?

by: SusanC

Fri Nov 30, 2007 at 04:45:41 AM EST


An examination of some source documents, on the 'Barry vs Markel' controversy - and a follow up to this diary Is the CMG Hanging by a Thread?

I said yesterday I don't believe I am qualified to pass judgment on who is right and who is wrong in the claims made by John Barry against the accuracy of the data in the study done by Howard Markel and colleagues, on the efficacy of NPIs in the 1918 pandemic.  That position has not changed.  I have however since then obtained copies of a few of the source documents cited by both sides.  I am indebted to a friend who has much easier access to such materials than I, who was able to help me find some of these documents.  I believe it is in the public interest to explore the issues that come to light with this new information.

SusanC :: The Barry/Markel Drama - part 2. Little evidence for New York City quarantine in 1918 pandemic?
First of all, two caveats.  

1) If you haven't been following this, and haven't read part 1, you are likely to find this discussion mind-bogglingly tedious, and will probably ask, what is the point?  To avoid descending into that state, I would recommend that you read Part 1, to get the big picture of what the controversy is about, and the accompanying implications for public health policy in a pandemic.  

2) This is NOT meant to be an exhaustive examination of the issues raised by John Barry and Osterholm, and the rebuttals by Markel and colleagues, but only a look at a few snippets of information that happened to come my way.  Having said that, I do think it is possible to at least make some sense of most of the important points raised in JAMA and CIDRAP.  Whether you can come to any conclusions, and what these conclusions are, I will leave to your own judgment!

In the article he wrote for CIDRAP, John Barry had this to say, as a preamble:

I support many (though not all) of the proposed interventions, but I do not support analysis based on weak data - especially when those data that are flatly contradicted by better information. Yet that is what could happen in this case.

His position appears to be endorsed by Osterholm, who said

"I believe Markel and colleagues did not address the important challenges that Barry presented.....How will we ever be able to dismiss and even condemn the crazy things that some will try to do during a pandemic if we don't base recommendations on the strength of our science? We must hold ourselves to that standard now and in the future. I believe John Barry makes a clear and compelling case below that Markel has not met that standard. We must."

Barry focuses on 2 cities New York and Chicago, but feels some justification to extrapolate his concerns to the other 41 cities studied as well:

By pure happenstance, I am familiar enough with events in New York and Chicago to make a judgment on the quality of his assessment of those two only, and I do not know how valid his findings are in the other 41 cities. But his interpretation of data in Chicago and New York does not inspire faith in the rest of his analysis.

Essentially, as far as I can determine, Barry made 2 claims, that there is no evidence to support that
1) New York city imposed isolation and quarantine in the 1918 pandemic, and
2) Chicago imposed any NPI early (Day -2, ie 2 days before the excess mortality was double the baseline)  as defined in the JAMA study ie school closures, banning of gatherings, and isolation and quarantine.

CHICAGO

I'm going to take the second question first, cos it has a rather short answer.  For Chicago, Barry complains that one cannot determine what action was taken on what date, because no specifics were given in the paper, and the 1,144-item bibliography's "size obscures rather than elucidates"  He did, however, look up a source, with the following findings:

...according to the Chicago health department's 100-plus-page "Report of an Epidemic of Influenza in Chicago During the Fall of 1918," which is not in Markel's bibliography, only two actions were taken on day minus-2: The state banned public funerals and the city issued orders for teachers to inspect schoolchildren. These actions fall far short of the authors' metrics.

Yesterday, I did have this query, whether 2 of the citations in the bibliography, the 1919 and 1923 editions of the Report of the Department of Health of the city of Chicago, by JD Robertson, might actually be the primary source documents that Markel used.

As it turned out, not only WERE they the primary documents for the various NPIs that Chicago implemented together with the dates of implementation, the reference that Barry cited, "Report of an Epidemic of Influenza in Chicago During the Fall of 1918," was in fact one of the chapters within the report itself!  

The following are clipped from scanned copies of the cover of the report, and page 40 showing where the chapter starts (click to enlarge)

It would appear that Barry has mistakenly taken the title of one chapter of the report, to be the title of the whole report itself...maybe...

NEW YORK

For New York, the issues are a little more complex, because it isn't just a matter of determining whether New York did or did not implement quarantines during the pandemic, but there are additional issues that I believe require scrutiny.  But still, first things first.

Was quarantine implemented in NY?
According to Markel et al, there is abundant data including numerous newspaper accounts of the actions of health authorities in relation to quarantine, but the primary evidence that quarantine was in fact used as a public health measure came from the fact that the NY City Board of Health met on Sep 17, 1918 and changed the Sanitary Code to make influenza and pneumonia reportable diseases, and the minutes of the meeting reflected that.  This is NOT disputed by Barry.  It is the interpretation of this act, making a disease reportable, that is at issue.

Markel and colleagues maintain that in New York at the time, making a disease reportable had a very specific meaning, namely that those diseases that were reportable were also actionable, requiring the isolation of cases.  This is reflected in newspaper accounts appearing the next day.

The following is a clipping from the Sep 18, 1918 copy of the NY World.  It's a little hard to read, but I did want to include the image here.  

Here's part of the text:


The Department of Health is sending to-day the following letter to all resident physicians: "Your attention is herewith called to the fact that influenza, acute lobar pneumonia and bronchial or lobular pneumonia have been included among the infectious diseases which are required to be reported by physicians and superintendents of hospitals and dispensaries.

"These diseases were made reportable by action of the Board of Health in amending section 86 of the Sanitary Code.  You attention is called to section 89 of the Sanitary Code, which requires prompt isolation of persons affected with infectious disease and such other action as is or may be required by the regulations of the Department of Health"

The New York Times also reported on this, with the headline "Must Report all Spanish Influenza".  There are other interesting points about this article which I will return to later.

What about Barry's claim, that New York did NOT impose isolation and quarantine?

John Barry, in his letter to JAMA, claimed that Health Commissioner Royal Copeland never imposed the measures that he told reporters he was going to impose.  Barry cited 3 pieces of evidence, 2 of which involved the absence of isolation and quarantine being mentioned in a) an article in the NY Medical Journal by the health commissioner's assistant, and b) the health department's annual report.  

Suffice it to say that absence of evidence is NOT the same as evidence of absence, and that IMO the reason why you have to look at multiple sources is BECAUSE each source is not necessarily complete.

However, it is the third claim made by Barry that to my mind is most significant and deserves a little more detailed examination.  This is a direct quote from his letter to JAMA:

Although the health department had made some effort early in the summer to monitor individual cases coming off ships, the commissioner argued against isolation and quarantine: "[E]ven if we went through some Utopian method of policing to confine every person to his or her home, it is doubtful whether the epidemic could be measurably diminished."3

The citation is: Copeland RS. General survey of the influenza epidemic. NY Med J.1918;108(17):715-718.

Markel in his rebuttal said Barry had quoted Copeland out of context, that Copeland was NOT talking about isolation of cases and quarantine of contacts, but "rather the futility of potential home confinement of all New Yorkers and universal closure of public places".  Barry countered this in the CIDRAP article:

It's one thing to surveil three or four people coming off a ship. It's another to wait for a case to be reported (and hope cases are in fact being reported) and then try to isolate dozens, then quickly hundreds, then thousands of influenza cases.  No wonder Copeland debunked the idea, as he did in the quotation used in my letter to JAMA. Markel accuses me of taking this quote out of context. Rather than argue with him, I will happily fax the articles to anyone who requests them (print quality of the articles prevents including a link here) so readers can judge for themselves.

Well, the following is a copy of the article.  I didn't get it from Barry, as he appears to be traveling, but still it worked out in the end!  I am putting up the relevant page, so that, as Barry said, "readers can judge for themselves".

 

For those who may have a challenge with viewing images, here's the relevant text:

As to closing the theatres, moving picture shows and the like, a discriminating attitude has been  adopted, those places being shut down which were found upon inspection to violate the sanitary laws and to be favorable to the breeding of disease.  Had we adopted a universal order with respect to the closing of theatres and moving picture shows, we should then logically have closed every department store, every office and factory, every restaurant, and cabaret show, and every club.  The disease is one which is spread to a large degree by contact in the home, and even if we went through some Utopian method of policing to confine every person to his or her home, it is doubtful whether the epidemic could be measurably diminished.

Did the NY Commissioner of Health lie?

One of the central arguments that Barry uses to support his claim that quarantine was not implemented, is that Copeland lied about it, to reporters from the different newspapers, as well as to the JAMA, which in a Sep 28, 1918 article said "Citizens who have contracted the disease are quarantined and the health department is prepared to compel patients, who may be so situated as a menace to the community to go into hospitals."  

What is the argument used to support this idea?  I'm a little unclear on this point, but it appears to center around the issue that Copeland was a homeopath not an MD (which btw was not unusual in those days.  Even today, most public health officials in the US are NOT MDs), and that he was appointed by a corrupt political elite.  

In addition Barry in the CIDRAP article proposes various reasons why Copeland might lie about quarantine, one of which had to do with what was happening in Jersey City:

The same day that New York made influenza reportable (Sep 17), Jersey City imposed an actual quarantine. The Times reported both actions. It is easy to imagine that this put pressure on Copeland. At any rate, the same day the information about Jersey City was published, he told the Times that New York City was using "strict isolation and quarantine," in effect calling Jersey City on quarantine and raising it on "strict isolation."

Now is there any EVIDENCE that was what happened, that the fact that Jersey City had imposed a quarantine placed Copeland under so much pressure that he lied about it?  Well, the said NY Times article on Sep 18th, "Must report all Spanish Influenza" is available here.  Again, judge for yourself.

EPILOGUE

Let there be no doubt, that I wrote this with great sadness, and a heaviness of spirit that goes beyond my usual concerns about pandemic preparedness, planning and policy.  I'm no scholar by any stretch of the imagination, but I was brought up on a diet of books and lessons, of inquisitiveness and even argumentativeness.  I believe in respecting different opinions.  As a dear friend once said, "If we are exactly the same, one of us is redundant."

My efforts are minor on the grand scheme of things, compared to all the great achievements of John Barry, Howard Markel, Mike Osterholm, Marty Cetron, and others.  I have no soapbox to stand on, in this debate, except to wish everyone well, and that our energies can be directed towards the greater common goal, of getting the world prepared for the eventual pandemic, to whatever degree we can, and however imperfect our efforts may be.  


That is the least, and the best, we can do.  

There is no Plan B.

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

thanks for the review
Let's not make it more drama than it is - a dispute among highly qualified academics that in the end does not change policy or major conclusions.

however, I am on the side of getting facts right, and I think the review is terrific. I hope John Barry has the chance to respond, and I hope the same of Howard Markel. I suspect if they do it will not be here.


btw
it was not any easier then than it is now to come up with sane policy and then implement it.

That's what I learned from this. kudos to Markel and Barry for looking into it in the first place. Let me know when you work it out, fellas.


[ Parent ]
the word "drama"
is as non-judgmental a word as I can find.  



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


[ Parent ]
colloquium?
dialogue?

discussion?


[ Parent ]
whatever.. LOL
It is whatever one makes of it.  As I said, I leave it to the readers judgment, and I make no claims to being right, just trying my best to unravel a complicated issue for the benefit of the public.



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


[ Parent ]
i don't know what to make of this,
(meaning I don't really understand what might have happened) but I have a probably very minor caveat: if people around political deciders thought about quarantine, then maybe some quarantine was carried out regardless?

This would be similar to this "intention to treat" term I've come across in some drug studies (long ago, so I don't know).  In this case, it would mean that if enough people thought this new entity was "worthy of contention" then they would have done at least some of that even if the official recomendation was not clear.

What I'm trying to say is that quite likely things were not all or nothing, and maybe just considering those specific NPI strategies had an effect because then the idea was in people's minds?

Yeah, maybe this is just wishful thinking on my part, dunno.  But this is what I indulge in when I daydream that if many people read about SusanC's somewhat crazy "three families" idea (2 parents SIP with 6 children while 4 parents go to work), then some will actually do it so it will have some effect.

Continuous (as opposed to discrete) variables make for more difficult data analysis, I guess.

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


ugh, I meant worthy of "containment" - excuse me English


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

[ Parent ]
I don't either
(meaning I don't really understand what might have happened)

hence the need to look very carefully at the information.  One cannot discern the motivation behind any person's action without first going through some of the information in detail.  I don't have all of the information, but what I came across was very disturbing.  Hence what I said about writing with sadness.

Scholarly disagreements are not uncommon, but this is more than that, IMHO, as I look at the whole thing.  Others may not agree and that's fine.  I just thought it is a matter of public interest, when certain powerful voices make allegations against others, to scratch a little under the surface and find out what I can.  As I said in part 1, this can have major effects on many things, especially if the controversy is allowed to spread, and especially if we only hear one side of the story, unfiltered by more objective judgment such as the editorial board of the JAMA.



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


[ Parent ]
buttin in :blush:
How do we rise above drama? We remove ourselves from it. Does it matter who is right ultimately. Right now we have to sort through all that both have said and come up with the best practice approach for this time, and for this information that we have. What did we learn from SARS?

I really am just looking at this as simply as I can....simply is not necessarily simplistic or naive.

is it about quarantine, isolation, containment or about avoidance altogether----at first anyway.

An initial blanket approach as soon as first cases of sustained h2h anywhere makes sense. Isolation and Quarantine as a firebreak when the cases DO show up in an area.

If the solution lies in avoidance until a vac. can be made and distributed, then it makes sense to me that the first measures must be taken with avoidance in mind. Herd immunity can then be allowed to be established as we are able to. People, ultimately, must be able to have health resilience as well as heart resilience.

To my heart the solution lies somewhere in here. As to how to implement all that...well that is for greater intellects than mine.

I am really sorry if I am butting in and stepping out of line....

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
what i see is two scientists
debating about some elements of the foundations for the accepted set of conclusions.

We'll see where that takes us.

For the time being, what I see is that none of them really challenges the actionable part: "NPI as a whole work better than other available tools, the sooner the better, and we should continue to prepare to make them work" (not that they said so much).  Please correct me if I'm wrong!

I also see some talk-work (as different from muscle-work), which may be a couple of things (just like Rorschach inkblot test, or maybe we should judge the issue by the real-life effects):
- a deterrent for practical work now that we have "god given time"
- a temporary distraction that doesn't do any harm
- a teachable moment that we could use to atract attention from people to (IMO) more profound issues
- a lesson waiting to be learned (as in "hey, folks, we people have a tendency to become tangled in (relatively) minor things when there are important things to do, so watch out when in time of real crisis")
- other things I'm ready to perceive as soon as others point them out

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


[ Parent ]
since
I am still chewing on this myself....I will bow out of this thread.


Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
sorry missed this part before
For the time being, what I see is that none of them really challenges the actionable part: "NPI as a whole work better than other available tools, the sooner the better, and we should continue to prepare to make them work" (not that they said so much).

yes, of course, you are right. The question is even people with major influence in implementation and/or other countries who are seeking to follow this path may not do their own independent assessment of the argument, but accept them on strength of authority.  

Notice that the study itself was peer-reviewed by JAMA, but the allegations (not all of them at least) are not.  But how many will take care to scrutinize the information in that light if and when this is used as an argument?

Once doubt sets in, the strength of the case becomes weakened regardless.  That's my concern.



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


[ Parent ]
Terminology part of the problem here?
It seems to me that you and Barry may be at cross-purposes here (though I haven't read Markel, so excuse me if this is not pertinent: I have read Barry's recent screed).

Barry argues that quarantine was not done, not that isolation of cases was not done. You present evidence that isolation of cases was done. There's no reason you can't both be right. (Maybe? But see below)

Isolation: known-infected people are kept away from others (except in as far as essential for their nursing).

Quarantine: exposed people, e.g. those in the same household as infected people, are kept away from others,

Since it makes no sense to do quarantine without isolation, we get this phrase "isolation and quarantine" meaning the same as just "quarantine".

IIRR, work you reported earlier on Tamiflu showed that giving it to cases and their families was enormously more effective than giving it to cases alone? That would be consistent with the suggestion that quarantine with isolation of cases would be far more effective than isolation of cases alone.

What would make this interpretation wrong would be if "proper [NB not "prompt" as you wrote in your transcript above] isolation of persons affected with infectious disease and such other action as is or may be required by the regulations of the Department of Health" actually included quarantine of their contacts. Did it?


to clarify
Barry argues that quarantine was not done, not that isolation of cases was not done.

Actually, Barry included both, in his letter to JAMA.  Here are 2 examples:

New York City health commissioner Royal Copeland did tell reporters on September 18 that he would isolate and quarantine cases,2 but apparently never actually imposed those measures either.

the commissioner argued against isolation and quarantine

But both Barry and I also used the word quarantine loosely to denote a SET of interventions that include isolation of cases and quarantine of contacts.  At least that is how I read what he wrote, and that's how I have been using the word.



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


[ Parent ]
I think this might be a parse error
I think Barry writes (paraphrasing)

isolation and quarantine were not done

and you interpret this to mean

isolation was not done AND quarantine was not done

but he means

isolation-and-quarantine was not done

which if we're going to be propositional logic about it is the same as

isolation was not done OR quarantine was not done

Nothing you've presented looks to me like evidence that quarantine of contacts was done. Is it?  


[ Parent ]
you may be reading more into this than exists ;-)
I think if you read how Barry writes on CIDRAP, he wasn't writing with the linguistic precision that you are trying to pin down.

Bottomline, I personally do not think this is a 'dispute' about quarantine alone vs quarantine AND isolation.  This is about whether or not NY City implemented the set of measures as announced by the city commissioner.  Barry thinks they were not implemented.  Markel and co say they were.

THAT is the gist of the debate.  At least that is how I read it.



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


[ Parent ]
respectfully
I guess I do not understand the emphasis being placed on something that we may not have a handle on...ever...we may never know exactly what took place then, the motivations, the compliance, the lack of the "tools" that they used and how well they were used then and there. There are too many variables and too many unanswerable questions.

Having said all that I do not have the depth of knowledge in this area so I am probably just overlooking something or not completely understanding what you mean. That is why I cannot understand the emphasis on this particular debate.

If it is a credibility issue...we have said that no one will get it all right. We have to look at the body of the work.

How else can we discover the answer to the greater question of what the best course of action is to go forward?



Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
I think you do understand
a lot more than you realize.  LOL

If it is a credibility issue...we have said that no one will get it all right. We have to look at the body of the work.

Yes, no one will get it right 100% of the time, and very few people will get it all wrong either.  The truth is always somewhere in between.  But I agree that we have to look at THE BODY OF THE WORK.  One can never hope to be entirely sure with such historical enquiry, hence the need to look at large data sets, in this instance 43 cities and a large amount of data.



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


[ Parent ]
somehow
That makes total sense to me. Wow, that was quite a post SusanC.

I sure hope that someone could put some supercomputers on the problem... We could use some solid data right about now for some great minds to chew on!!! (Right SZ!)

Know of any statisticians around with some spare time?

....sounds like these forums. Come out, come out, wherever you are!

You guys seem like a welcoming community ;)
Fluwiki the working forum....our homes everywhere else...our living rooms (where did I hear that before ;)?)

I would suggest that we would have to share the data with everyone!! "Do unto others as you would have them do unto you" :)

{{{{as i dance around my room}}}}



Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
well, they did
I sure hope that someone could put some supercomputers on the problem

both with the modeling work from Los Alamos, and most likely with Markel's paper.



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


[ Parent ]
well there ya go
...sounds like you guys really know what you are doing!
From my perspective that gives me great comfort.

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
not me! lol n/t




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


[ Parent ]
I'm not trying to present a full set of 'evidence'
Nothing you've presented looks to me like evidence that quarantine of contacts was done. Is it?  

I don't have the ability to do that.  I'm only making public the information that I was able to obtain, which is just a handful of documents out of a 1,144 item bibliography, each item often consisting of volumes rather than pages, for the public to get a better idea of what is under dispute.  You should draw your own conclusions.  LOL

Also, I am only commenting on what I can directly observe, when there is actual text for me to quote, eg with the NY Medical Journal quote that Barry suggested was evidence that Copeland was against isolation and quarantine, and that Markel said was quoted out of context.  In this instance, I am highlighting the text so you can determine which of their version you agree with.

Apart from that, I am only putting up as quotes what each side's position is.  Note that I am not saying whether I think quarantine of contacts was done, but only presenting what Markel and colleagues use as evidence to support that quarantine was done.  Just for example.



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


[ Parent ]
Susan
You do an excellent job of presenting all of the data that we need to have to think through the problems for ourselves and then add our voices.

Kudos to you!!!!! ...and a hearty hug as well...

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
thank you n/t




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


[ Parent ]
Computer Modeling - Community Mitigation
Just so the focus on the analysis of 1918 does not confuse anyone, leading them to mistakenly believe that the CDC Commuinity Mitigation Guidelines were based solely on the study being discussed in this diary, I thought I might pull together a couple of things from the FW archive:

In the introductory discussion of their guidance on proposed application of NPI (community mitigation), the CDC has the following statements, taken from the section entitled: Rationale for Proposed Nonpharmaceutical Interventions

No intervention short of mass vaccination of the public will dramatically reduce transmission when used in isolation. Mathematical modeling of pandemic influenza scenarios in the United States, however, suggests that pandemic mitigation strategies utilizing multiple NPIs may decrease transmission substantially and that even greater reductions may be achieved when such measures are combined with the targeted use of antiviral medications for treatment and prophylaxis. Recent preliminary analyses of cities affected by the 1918 pandemic show a highly significant association between the early use of multiple NPIs and reductions in peak and overall death rates. The rational targeting and layering of interventions, especially if these can be implemented before local epidemics have demonstrated exponential growth, provide hope that the effects of a severe pandemic can be mitigated. It will be critical to target those at the nexus of transmission and to layer multiple interventions together to reduce transmission to the greatest extent possible.

http://www.pandemicflu.gov/pla...

(Some interesting notes are found on page 59 :Key areas for further research)

For Newcomers wondering 'what in the blazes are they talking about' - here's a couple of good places to start:

Community Mitigation Demystified - 1. The Big WHY (+)
http://www.newfluwiki2.com/sho...

Community Mitigation Demystified - 2. Five Things You Need to Know
http://www.newfluwiki2.com/sho...

For more information about some of the computer modeling that has been done, here are a couple of places to start:

Connecting the Dots - NPI's Preps and Early Vaccines, Would it work?
http://www.newfluwiki2.com/sho...

Targeted Social Distancing Design for Pandemic Influenza

Emerging Infectious Diseases (IED) Volume 12, Number 11-November 2006
Robert J. Glass,*  Laura M. Glass,† Walter E. Beyeler,* and H. Jason Min*
*Sandia National Laboratories, Albuquerque, New Mexico, USA; and †Albuquerque Public High School, Albuquerque, New Mexico, USA
http://www.cdc.gov/ncidod/EID/...

IOM  Modeling Community Containment: Workshop Agenda  
(See resources and links at bottom of that page for the various presentations)
http://www.iom.edu/CMS/3793/37...

 

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


Here are a couple more studies.....
Interesting discussion....
My thoughts...... Anything above Cat 1.. Do everything and do it early.   :)

Mitigation strategies for pandemic influenza in the United States
Timothy C. Germann, Kai Kadau, Ira M. Longini, Jr., and Catherine A. Macken
doi:10.1073/pnas.0601266103
PNAS 2006;103;5935-5940; originally published online Apr 3, 2006;
This information is current as of January 2007.
& Services
Online Information
www.pnas.org/cgi/content/full/103/15/5935
etc., can be found at:
High-resolution figures, a citation map, links to PubMed and Google Scholar,
Related Articles
www.pnas.org/cgi/content/full/103/15/5633

A related article has been published:
Supplementary Material
www.pnas.org/cgi/content/full/0601266103/DC1

Supplementary material can be found at:
References
www.pnas.org/cgi/content/full/103/15/5935#BIBL

BIOSECURITY AND BIOTERRORISM: BIODEFENSE STRATEGY, PRACTICE, AND SCIENCE
Volume 4, Number 4, 2006
© Mary Ann Liebert, Inc.
Disease Mitigation Measures in the Control
of Pandemic Influenza
THOMAS V. INGLESBY, JENNIFER B. NUZZO, TARA O'TOOLE, and D. A. HENDERSON

Never believe that a few caring people can't change the world. For, indeed, that's all who ever have. ~ Margaret Mead


[ Parent ]
How Severity Trumps Uncertainty
Even if, and I believe that's a big if, this discussion were to eventually cause some level of additional uncertainty about this study it is probably good to put this study into perspective by looking back at how the public policy was put together that relates to community mitigation efforts, as currently recommended by the CDC (and a host of cooperating agencies - whose seals appear at the bottom of the title page of the report.)

But it is also worth noting that in those discussions, severity trumped the acknowledged uncertainty, even when the severity being discussed was most likely capped at 1918 levels.

http://www.pandemicflu.gov/pla...


Appendix 2 - Interim Guidance Development Process

...Pandemic planning with respect to the implementation of these pandemic mitigation interventions must be citizen-centric and support the needs of people across society in as equitable a manner as possible. Accordingly, the process for developing this interim pre-pandemic guidance sought input from key stakeholders, including the public. While all views and perspectives were respected, a hierarchy of values did in fact emerge over the course of the deliberations. In all cases, the questionwas whether the cost of the interventions was commensurate with the benefits they could potentially provide. Thus, there was more agreement on what should be done when facing a severe pandemic with a high case fatality ratio (e.g., a 1918-like pandemic) than on what should be done when facing a pandemic with a lower case fatality ratio (e.g., a 1968-like pandemic); even with the inherent uncertainties involved, the cost-benefit ratio of the interventions clearly becomes more favorable as the severity increases and the number of lives potentially saved increases. Many stakeholders, for example, expressed concern about the effectiveness of the proposed interventions, which cannot be demonstrated a priori and for which the evidence base is limited and of variable quality. However, where high rates of mortality could be anticipated in the absence of intervention, a significant majority of stakeholders expressed their willingness to "risk" undertaking interventions of uncertain effectiveness in mitigating disease and death. Where scenarios that would result in 1918-like mortality rates were concerned, most stakeholders reported that aggressive measures would be warranted and that the value of the lives potentially saved assumed precedence over other considerations. However, the feasibility of these approaches has not been assessed at the community level. Local, State, regional, and Federal exercises will need to be conducted to obtain more information about the feasibility and acceptance of these measures. In addition, ongoing engagement with the public, especially vulnerable populations, is essential. ...

In looking at the cost/benefit analysis of implementing NPI, it is important to reflect that the potential 'benefit' is affected rather strikingly by the severity of the pandemic.  A significant majority of stakeholders supported NPI (in spite of the costs and acknowledged lack of certainty in effectiveness) at a severity level equivalent to 1918.  This is an important point to remember for those of us that believe a 1918-like pandemic is not worst case.

http://www.pandemicflu.gov/pla...

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


3 factors: effectiveness, severity, and mitigation's mitigation
ITW highlights two important things when we consider using NPI/CMG, and I add the third because I think it's very important too:

1) effectiveness: which is what's apparently being debated, and which is not all-or-nothing, but depends on early (!), layered/Swiss-cheese, sustainable, etc.

2) severity: cat 2 and 3 have "consider" in some boxes.

3) mitigation's mitigation: we can make student dismissal work better if older students take care of the young, there's a pervasive need to prepare in many other areas, etc.

I'd rather sort things out now that we have time, and now that doubts might have an effect on moving on with preparedness activities.

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


[ Parent ]
Right on target
The severity will be what it will be.

http://www.youtube.com/watch?v... (Sorry.  It's Friday.  Couldn't resist. :^ O )

But, if we act now, we can potentially increase effectivenes and decrease the 'costs'.  

That's why debating the precise history of the disorganized and poorly implemented NPI in 1918 has diminished appeal for me.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


[ Parent ]
public engagement
The Community Mitigation Measures were the subject of a key piece of public engagement work organized by ASTHO and Keystone Center, but with the participation of a large number of stakeholder groups as well as private citizens.

http://www.keystone.org/Public...

Participating organizations:

Association of State and Territorial Health Officials (ASTHO) | New Jersey Department of Health & Senior Services | Center for Biopreparedness Education-Omaha | Centers for Disease Control & Prevention (CDC) | F.O.C.U.S. (Forging Our Community's United Strength) Greater Syracuse | Georgia Department of Human Resources-Division of Public Health | Infectious Disease Society of America | National Association of County & City Health Officials (NACCHO) | Nebraska Health & Human Services System | New York State Department of Health | Public Health-Seattle & King County | Searcy, Weems-Scott & Cleare | The Keystone Center | United Parcel Service (UPS) | U.S. Department of Education | U.S. Department of Health & Human Services

The following table is from poster that I made for the ReadyMoms.org collection, showing the high level of support from both members of the public and stakeholders and professionals.





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


[ Parent ]
worst case
2,000,000,000 people, 30% CAR and 40,000,000 deaths means CFR=6.6%.  So maybe 1918 was not 1918 ... meaning maybe 1918 was not 2% or 2.5%.

But overall worldwide figures are not too useful in my view ... and if NPI work at 2.5% they would work even better (i.e. more compliance and more of a difference between best and worse cities) at 6% or higher.

43 cities compared + computer models + common sense are useful (again in my view).

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


[ Parent ]
Thoughts
Why I said what I said here:

http://www.newfluwiki2.com/sho...

This diary reminds me of this:

Parturient montes, nascetur ridiculus mus.
"Mountains will heave in childbirth, and a silly little mouse will be born."  Horace

I saw the article from CIDRAP about two hours after it came onto the net.  I read it and decided it was not worth posting because...well it should be obvious by now.

What happened in 1918 happened.  It is worth taking a look at yes, but within certain limits.  After that, well...we need to be looking at the present.


[ Parent ]
yes, and we're at the preparedness stage now


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

[ Parent ]
I agree with Okieman on this n/t


[ Parent ]
it's interesting, and unsurprising
that there is a wide range of reactions to the CIDRAP article.  Personally, as I said, it doesn't change anything for me as far as the credibility of the study by Markel and colleagues is concerned, nor does it change my conviction about the policy implications that arose out of the data.  I have given this so much thought, and written and debated about the CMG so many times and in different venues, in the past year that frankly, there are very few arguments either for or against that are new or surprising to me.  In that sense, I can agree with Okieman and Dem's stance, that the whole business is not worth our attention at all.

At a deeper and perhaps wider level, though, I do think maintaining the standard of scientific/scholastic rigor is important.  As Osterholm said, the public relies on the integrity of scientists and professionals, to ensure that the information with which public policies are made are as accurate as possible.  No one expects perfect policies, nor perfect data - at least I don't.  But I do think the public have a right to expect that professionals will act in good faith, that the extent of uncertainties are portrayed as accurately as possible.  

And when for whatever reason strong allegations are made by credible voices against a substantive piece of research, then we even as private citizens surrender our rights and sell ourselves short if we let the debate go over our heads without curiosity or scrutiny.

In a sense, my curiosity was initially aroused only because I was seeing only one side of the debate, when I first read the CIDRAP article.  That of course led me to seek more information, from JAMA etc, and to give the whole saga more attention than I would have, if both sides of the case were laid out for all to see.    

The rest, as they say, is history.



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


Agreed.
While no overall policy changes may arise from this debate on its own, it behooves us to understand the substance of it.  Since there is no doubt those arguing for policy changes will cite Barry and Osterholm's criticism, I think it's important to know how much weight to give to the arguments, not the people.  Barry is well respected, and I respect his work, too.  It's just that his criticism is based on clear biases.  In the historiographical sense, that makes his response less useful.  In a primary source, bias is a good thing.  From a secondary source, clear bias is a detriment.

For example, Barry claims that national public health officials lied about the severity of the pandemic.  Copeland was saying the same things.  Therefore, Copeland must have been lying.  See, there's a bit of a stretch there because of Barry's bias operating in the criticism.  Probaby, Copeland was in touch with national public health officials, and he quite possibly believed everything they told him.  Also, when compared with other cities, New York was faring pretty well.  Since the basis for Barry's argument is that Copeland was dishonest, I think for his argument to have weight, he has to convict Copeland on more than just guilt by association with Tamany Hall.  If he can't support his claims with more than his own opinion, I don't know why we consider that scholarly.

Bias is welcome in a primary source for giving a snapshot of a person's worldview at a certain point in history.  In secondary sources, personal biases detract from the usefulness of the work.  

Millions for defense, but not one cent for tribute!


[ Parent ]
I agree with what you say
but for one difference.

Since there is no doubt those arguing for policy changes will cite Barry and Osterholm's criticism, I think it's important to know how much weight to give to the arguments, not the people.

The problem arises when people who cite Barry and Osterholm's criticism are not in the habit of scrutinizing the arguments and determining for themselves whether they are valid in order to decide how much weight to give to the arguments.  

Just like when someone reads something from a prestigious journal like the JAMA or Science or Nature, they don't go and verify the methodology or data each time.  People simply don't have the time.  The majority don't have the ability either.  So they read the papers, read the conclusions, and trust that the journal editors have done due diligence.

CIDRAP of course is not JAMA or Science.  It isn't peer-reviewed.  But it is credible enough and Osterholm is respected enough that many will approach it in the same way, assume the arguments to be based on rigorous methods and that due diligence have been observed (I'm not saying they haven't, I'm only commenting on how readers may approach the issue), and accept the arguments made without doing their own investigation as I have done to a small degree.




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


[ Parent ]
I don't have any objection to going over the material
and well done by you. I consider it an interesting academic dispute that should be covered but should not be personalized.  

[ Parent ]
I respect that opinion
but I beg to differ.

There are instances where the behavior of the parties involved are also important considerations too, not because it is anything personal, but simply because they are public figures and persons of influence.

You and I may have the ability to determine for ourselves the nuances of the academic debate.  Most people don't.  And that includes many who have influence in the implementation of policy, including members of the public, local businesses, and many in the public health professions.

How many local PH officials have you met who are in the habit of reading scientific studies in the original to determine for themselves what the science says?  My experience tells me most do not; they rely on the opinion of those whom they trust.

Which is why the HOW these respected public figures arrive at their opinions and how they go about sharing those opinions become a matter of public interest.

There is nothing personal about this.  If Osterholm or Barry were expressing their opinions in private, then there is no need for us to have this discussion at all.  But CIDRAP is widely read, it is an institution whose purpose is to disseminate credible information on pandemic planning.  

This information is also sent out via email to lots of subscribers, including those who have taken part in business continuity events organized by CIDRAP and/or Osterholm.  I know because I receive them.  How they go about fulfilling this important task of informing the public and the professionals and businessmen who receive their information becomes a matter of public interest.



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


[ Parent ]
that, too, can be criticized
without personalizing it. In fact, everything can. Motivations aren't the issue for most readers, it's where the facts take you. After all, sometime people just err.  ;-)

[ Parent ]
I'm confused
I am assuming that we can talk about the actions of individuals as and when those actions have implications for the public interest.

How is that "personalizing it"?



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


[ Parent ]
actions and ideas
Your excellent posts are devoted to the issues and facts, and thank you for posting them.

The issue should be "questions raised" about "what was published, and "how that may (or may not) change our view of what happened in 1918". That, in turn, may (or may not) affect current policy. The consensus so far is that it does not. I do not believe local PH will read this at CIDRAP and change what they think, one way or another, when it comes to larger policy. I'd be delighted if many people did read it, because I'd be delighted if many people read here and there!

You can name names, but the issues raised are name-independent, except that credibility is attached to names. I still don't care for the title (sounds like a WWF smackdown), though I recognize that's just me.  ;-P


[ Parent ]
i swallowed my gum...LOL
(sounds like a WWF smackdown), though I recognize that's just me.  ;-P  

give and take...   small sigh

How about Readyasican....I liked that because what rolls off the tongue is "be" an action word!!! :)

a thought...

You could point to some nations who have responded to disasters and were/are shining examples of wonderful heart qualities.

a request...

But remember, full disclosure, from sources that volunteer their information, not to be compelled :)  

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
with all respect, I disagree
That, in turn, may (or may not) affect current policy. The consensus so far is that it does not.

We have never, on this forum, sought a consensus on any issue.  That is one of the most important features of the work that we do, that we can all agree to disagree.

On that note, I do disagree that this does not affect policy.  It does not affect policy as per recommendations by the Feds, cos that is already done.  But we all know that implementation is at the discretion of state and local officials.  I think it at least has the potential to affect policy as and when implemented at the state and local level.

There is an additional bigger context.  The world does not consist of only the US, and I'm not sitting here writing only for the US audience.  Right now the EU is opening up the issue of these CMG measures for public consultation.  The deadline for public comments is end of January.

For internationally recognized figures like Osterholm and Barry, and a widely reknowned pandemic resource like CIDRAP, their opinions have repercussions that go beyond the US.  Any doubt cast on the veracity of the data on which the CMG was based, undermines the international efforts in developing these policies.




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


[ Parent ]
as an involved citizen at the local level
I would remind all of what I said to my local BOH you can take credit for this information but it needs to be disseminated and since it is coming out in the newspaper on December 5 it will be in the public hands anyway. It would be better for all if they take credit for disseminating the information that needs to reach the public, for the overall good of the public. Without their prompt action or decision I will consider this as permission to continue to disseminate the information on my own since it will have already gone to press. (of course if it doesn't make it to press then I am a bit shut down)

Since "we are on our own" as individuals and families to mount a defense then we simply must have full disclosure of all information related to pandemics, infectious diseases, morbidity and mortality related to pandemics and infectious disease outbreaks, and information regarding any other issue that addresses the health and well being of the citizens. All educational and preparedness information [that the government has] must be placed in the public domain for all to use and share alike as well as transmit on the public airwaves and through the media.

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
I don't presume to know that IS the case
Motivations aren't the issue for most readers,

How do we know that motivations aren't the issue for most readers?

I'm just asking that as a question in principle, not that I'm implying any motivational issues are important at this point.  

Notice I PERSONALLY have not raised any motivational issue at all.  With all respect.



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


[ Parent ]
this speaks to the motivation question
so I will jump in...

I would say that the test is in the usefulness not in the source. Let people determine what they will as long as there is full disclosure.

------- an example -----------

A question...how do you determine when the 'teachable moment' is when you have foreknowledge of a disaster? You may have written about it and I did not see it.

It seems to me that you must take into account the fatigue level of the audience, including me. Am I saying prepare NOW because I am exhausted and unprepared (this has helped me to move forward with passion) or am I feeling this pressure to say prepare NOW because I truly sense that this is the time for that particular message to come forward from my heart?

This is best left up to the intellects to determine, I don't have all the pieces of the puzzle (not that I want them either)...just that my heart tells me to caution that the 'window of opportunity' for the public may be smaller than we may have thought. Many factors supply and demand, Holidays, learning curve have they been considered?

I would suggest a poll of the greater flubie community to determine how long it took them to prepare, how much it cost, etc. These are very important statistics in determining the learning curve to action equation for the public.

At some point you have to stop chewing and decide. The concept is sound. I am not pushing you either. Just saying...those statistics would help to determine where the horizon line is (or whatever you use as a point in time).


Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
and yes
I am that committed if that is the question.

Always apply the standard "above all else, do no harm".  

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
in addition
This debate goes beyond nuance or subjective opinion.  There are FACTUAL issues involved as well.  Let's just take Barry's comments on Chicago:

We do not know what action Chicago took that day, because the Markel article does not identify any action in any city on any date, nor does it provide any documentation for any of these specific actions.  

In actual fact, the documentation IS provided within the JAMA paper, by providing the link to the online bibliography.  Which Barry does go on to acknowledge, only without saying that this IS part of the JAMA article:

Markel does offer a 1,144-item online bibliography,

The statement that the JAMA article did not provide any documentation is therefore simply incorrect.

There is however an even bigger FACTUAL problem, in the next paragraph in the CIDRAP article, when he cites

the Chicago health department's 100-plus-page "Report of an Epidemic of Influenza in Chicago During the Fall of 1918," which is not in Markel's bibliography

As it happens, the "Report of an Epidemic of Influenza in Chicago During the Fall of 1918," is only 1 chapter INSIDE the actual 100+ page report called "Report and handbook of the department of health of the city of Chicago for the years 1911 to 1918 inclusive (Chicago, 1919)."  ie. in no way was the citation AS GIVEN BY BARRY 100+ pages long at all.  

The point is, the WAY that this has been presented in the CIDRAP article, gives the reader the impression that Barry has gone through an important 100+ page official report from the Chicago Department of Health and did not find the specifics of the NPIs nor the dates of implementation as claimed by the Markel study, and that this very important report containing primary data was not used by Markel, since this did not appear on the bibliography, when in actual FACT, the report WAS used, had all the primary data including dates of implementation of specific NPIs, only the data was NOT in the chapter that Barry cited (which was NOT 100+ pages long), and it WAS included in the bibliography, only the name of the report was not the one that Barry was looking for!



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


[ Parent ]
here are some thoughts
on the issue of discussing issues vs discussing personalities.  And I'm not just responding to Dem's comments, but more because I think these are issues we need to get clear whenever we talk about public policy, in general.

I guess for me the essence of the debate is this: does public policy exist in a vacuum outside of personalities?  For example, can we debate pandemic flu policy without sometimes debating whether Leavitt or Vanderwagen or Agwunobi or Venkayya did the right thing?  Or whether Margaret Chan is a better or worse DG of the WHO than her predecessor?

Even outside of government service, scientists also carry similar levels of public accountability.  When Webster or Osterhaus or Fred Hayden make a comment about vaccines or antivirals, the issue that emerges may or may not be pure science.  Some of these major scientists also do consulting or other work for commercial entities as well.  

Where do we draw the line, as to what is acceptable and not personal?

For me, the answer lies in this question.  Are you challenging or questioning the behavior, or the person?  

Sometimes it may be hard to determine what exactly is coming under question, but let me give an example.  It is no secret that on the whole I think Venkayya was a great leader while he was in office at the HSC.  It doesn't mean that he was perfect; there are things that one can disagree with and still respect and work with someone.  But when there was an instance when it appeared that what was being done was in major conflict with what the public had been given to believe, I was the first person to take him to task about it, and in a much harsher tone ;-D than how I am approaching this current issue.

Let the record speak for itself, that until I had clear confirmation and an explanation that settled the question, I made my objections both online and in person to his staff, very vehemently indeed!  

It was not personal, and he was enough of a gentleman and a leader to understand and take it in that spirit.

THAT in essence is what we have to separate here in such discussions, to get clear in our minds what we are talking about.  The question is do we believe as a matter of principle that public figures by reason of their ability to influence public policy do owe the public a certain degree of accountability for their actions?  

As usual, we don't have to have any consensus, but for me the answer to that question is Yes, they do.  It comes with the territory, that if you seek to influence public matters, then you can and should be held accountable for your actions.

This accountability I believe also extends to institutions or organizations, including Flu Wiki and CIDRAP, that if such institutions portray issues in manners that are outside of accepted professional norms (eg academic differences over points of evidence should be resolved via the properly peer-reviewed channels where independent 'adjudication' can happen) and/or give a one-sided view with no built-in mechanism for an alternate view (eg on FW, if I give a one-sided view, anyone else can post a rebuttal), then it is perfectly legitimate to query the appropriateness of such actions.

And that, as usual, is just my personal opinion.



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


so as to...
...remove my personality from the discussion of the citizens desires as far as the autonomy of their health is concerned I posted a topic here: http://planforpandemic.com/vie...

It is not my position, nor desire, to sing a solo. I truly want to hear the chorus. We all have a stake in this---all across the tiers. There should be an opportunity for open, honest discussion.

In order to establish why I bring this to the public forum is so that my own personal motives may be examined.

As I have said before, mistakes are inevitable. What is done in the light of day with eyes wide open is a firm foundation on which to frame policy with the publics interest in mind.



Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
What I understand from these 2 diaries is that Markel wrote an article that demonstrates historical support for NPI implementation,
and Barry has questioned the strength of his argument and details of his research.  Barry's questions and assertions can undermine mitigation at the local level (if locals hear about it), but Barry's case itself has holes in it.  If the flaws in Barry's argument aren't dealt with soon, the logical but [short-term] economically-costly NPI may be bogged down in disputes in localities all over the world, and thus not implemented when needed (especially since there will be plenty of those who don't want to rock the boat anyway).  Is this a fair summary?

Susan C, will you be writing to CIDRAP about this?  

A thousand thanks for your work and your focused intelligence!

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


actually, no ;-)
Susan C, will you be writing to CIDRAP about this?  

I think they already read our forum anyhow, so that's ok.  I'm writing this more for informing the public than for any other reason. But feel free to email them if that's what you want.  ;-)



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


[ Parent ]
my biggest concern
is not that 'locals hear about it', but that this kind of stuff gets quoted and spreads.  Like in meetings and other places where people get their information.



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


[ Parent ]
other than that,
yes, Jane, it is a fair summary.  lol



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


[ Parent ]
Formal Response to Barry's and Osterholm's Critique of the Markel Study
http://www.cdc.gov/ncidod/dq/1...

A Commentary on the JAMA Study's Interpretation of the Influenza Experiences in New York City and Chicago, 1918-19
...

Recently, assertions were made on the internet challenging our interpretation of the historical record of New York City and Chicago during the 1918-19 pandemic. We therefore offer the following additional evidence to support our conclusion, and invite you to review the primary source documents linked to the endnotes of this commentary.

Among the assertions made are claims that our interpretation of data in New York City and Chicago is incorrect, and that such "putative errors" are sufficient to drop the findings below statistical significance.  This assertion, however, ignores our approach in doing robust statistical analysis using a comprehensive dataset.  Our comprehensive analysis of all 43 cities across the United States is far more robust than a disputed data point for a single city.  
...

Conclusion
The historical record is, by definition, incomplete and often fragmentary.  Indeed, scholars frequently disagree about interpretations and meanings of the past and a healthy exchange of ideas makes for a better understanding of the human condition.  While we make no claims to definitive conclusions about important questions raised by our paper, as scholars committed to scientific and historical inquiry, we insist on the rigor of peer-reviewed and evidence-based research to formally support or contradict any scientific study.

We hope that the additional historical insight and facts provided in this commentary clarify some of the misinformation that has recently been directed toward the study.  We stand by the conclusions made in our JAMA paper and are confident that a careful, scholarly reading and review of our work demonstrates the rigor with which the research was performed, especially given the constraints and limitations of investigating a pandemic that occurred nearly a century ago.

The long awaited response.  It looks like it was worth the wait.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


thanks for posting it
yes, the detailed response and the historical documents are really interesting.  




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


[ Parent ]
We are beginning to see data from other countries
Here's one recent paper from Australia

Caley et al, Quantifying social distancing arising from pandemic influenza. J R Soc Interface. 2007 Oct 4

Abstract

Local epidemic curves during the 1918-1919 influenza pandemic were often characterized by multiple epidemic waves. Identifying the underlying cause(s) of such waves may help manage future pandemics. We investigate the hypothesis that these waves were caused by people avoiding potentially infectious contacts-a behaviour termed 'social distancing'. We estimate the effective disease reproduction number and from it infer the maximum degree of social distancing that occurred during the course of the multiple-wave epidemic in Sydney, Australia. We estimate that, on average across the city, people reduced their infectious contact rate by as much as 38%, and that this was sufficient to explain the multiple waves of this epidemic. The basic reproduction number, R0, was estimated to be in the range of 1.6-2.0 with a preferred estimate of 1.8, in line with other recent estimates for the 1918-1919 influenza pandemic. The data are also consistent with a high proportion (more than 90%) of the population being initially susceptible to clinical infection, and the proportion of infections that were asymptomatic (if this occurs) being no higher than approximately 9%. The observed clinical attack rate of 36.6% was substantially lower than the 59% expected based on the estimated value of R0, implying that approximately 22% of the population were spared from clinical infection. This reduction in the clinical attack rate translates to an estimated 260 per 100000 lives having been saved, and suggests that social distancing interventions could play a major role in mitigating the public health impact of future influenza pandemics.





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


260 per 100,000 lives saved
from wikipedia, largest metropolitan areas by population
http://en.wikipedia.org/wiki/L...

http://en.wikipedia.org/wiki/L...

City (Metropolis)PopulationLives saved
Tokyo32.5 million84,500
Mexico City20.5 million53,300
NYC19.8 million51,480
Jakarta18.9 million49,140
Hong Kong-Shenzhen15.8 million41,080
LA15.3 million39,780
Cairo14.5 million37,700
London12.9 million33,540
Beijing12.5 million32,500
US Only
Chicago9.5 million24,700
Dallas/Fort Worth9.5 million24,700
Washington DC (National Capital Area)5.3 million13,780
Atlanta5.1 million13,260
Seattle3.3 million8,580
Minneapolis-St Paul3.2 million8,320
Oklahoma City1.2 million3,120

Note that this is based on the lethality of the 1918 virus, 38% reduction in contact rate, and the population of Sydney in 1919.  



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


[ Parent ]
How much is a child's life worth?
You know when people say what is the cost of social distancing, and that we need to be careful the consequences of the measures are not more severe than the epidemic itself, I'd like to ask them, what ARE the consequences of inaction?

No one can accurately say how many lives can be saved by social distancing measures.  But if, when we look at such numbers, we make ourselves stop thinking of them as numbers, but as being made up of individuals, somebody's father, mother, child, aunt, husband, etc then this kind of data tells a different story.

For me there are 2 bottomlines, in the midst of 'insufficient evidence':

1) What is the cost of inaction?  Remember we cannot compare mitigation measures against the business-as-usual scenarios.  We have to take into account the primary, secondary, and tertiary consequences of a severe unmitigated pandemic as well.

2) How much is a life worth?  Specifically, in the case of school closure, how much is a child's life worth?  

How much is YOUR child's life worth?  What would you pay to save the life of your child?  

What would your community pay to save the lives of 10 children?  20 children?  100 children?  100,000 children?

THAT is the issue that needs to be raised, when it comes for communities to make such choices, in their planning for the next pandemic.



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


[ Parent ]
it's actually very simple

This stuff works!

Social distancing saves lives, by reducing the contact rate between people.  

The greatest contact rates are in schools.  

Therefore we must close them, as early as possible in anything but the mildest of pandemics (CFR<0.1%)

How much simpler can it get?



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


[ Parent ]
social distancing
is there any evidence, that seasonal flu is larger in
areas/times with shool rather than holiday ?

in times/areas of other social-gathering events
like Christmas, Chinese new year, Carneval ?

in societies/areas with non-social jobs, families, farmers
rather than Kindergarten, factories ?

are some professions more prone to flu than others ?

gimme statistics

ask experts for their subjective
panflu death expectation values
and report the replies


[ Parent ]
some papers, off the top of my head.
also from the references for the ECDC consult:

higher AR in kids -
Glezen WP, Emerging Infections: Pandemic Influenza, Epidemiol Rev. 1996;18(1):64-76.

incidence during a school strke -
Heymann A, et al. Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization. Pediatric Infectious Disease Journal 2004; 23: 675-677

vaccination of schoolchildren reduced incidence in all age groups, compared to non-vaccinated neighboring village - Monto et al, Effect of vaccination of a school-age population upon the course of an A2-Hong Kong influenza epidemic. Bull World Health Organ. 1969;41(3):537-42.

pediatric emergency room visits precede adult visits -
Brownstein, et al Identifying Pediatric Age Groups for Influenza Vaccination Using a Real-Time Regional Surveillance System  Am J Epidemiol. 2005 Oct 1;162(7):686-93.

Don't know any in relation to jobs.



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


[ Parent ]
more from the ECDC diary
http://www.newfluwiki2.com/sho...



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


[ Parent ]
A Must Read and A Comment
The CDC published a commentary page, "A Commentary on the JAMA Study's Interpretation of the Influenza Experiences in New York City and Chicago, 1918-19".

http://www.cdc.gov/Ncidod/dq/1...

The commentary (a rebuttal made by the JAMA study authors) makes clear the fact that terminology and common practices of quarantine were hardly codified and standardized in 1918; they also mention that the public apparently dodged some of the public control NPI mandates.  Not everyone will follow rules.  

That is going to be the most difficult hurdle in the upcoming epidemic waves.  For example, where traffic control officials have placed cameras to nab red-light dodgers in accident-prone locations, an astounding number (in the many hundreds to thousands) were caught running red lights. That was in less than one year, in a particular spot in a plains state (not exactly a ghetto location).  It's become a form of low-key common anarchy. And it no longer just occurs in the wee hours of the night.  It's public endangerment action - and it speaks to a marked lack of personal control and risk perception among a hefty percentage of the population. Indeed, the fact that nearly half of all adults who engage in frequent sex with multiple partners STILL will not take standard barrier precautions against communicable disease suggests that implementing non-pharmaceutical interventions against contagion will be at best, an uphill battle.

If I may be blunt: the public seems to have an arrogant disregard for it's safety and will, if provoked, flaunt authority without regard to risk to themselves and others.

I also maintain that there is emerging and quite solid physiological cause behind this risky behavior. But that will be fodder for later discourse.

The authors make a curious statement: "Furthermore, our paper demonstrates no significant statistical association, positive or negative, between the excess mortality rates due to influenza in the 43 cities and the successive wave experiences (i.e., the Spring, 1918 wave, the Fall 1918 wave, the Winter, 1919 wave, and the Winter 1920 wave". (comment made in addendum to prior statement addressing supposition of public acquired immunity to successive waves).

But that runs contrary to nonstatistical evidence.  Many of the successive waves appear to have occurred when public quarantine practices were relaxed prematurely between waves (as was the experience of many cities) - and this anecdotal connection is mentioned in many Spanish Influenza public documents/reports.  The relaxation of public vigilance during interwave periods resulted in successive waves within many cities (including enforced closure of ports of entry and restrictions on movement between towns, in smaller communities).  The intrinsic problem of contagion control lies in maintaining public awareness, support and participation between waves (months apart).  

There is also evidence of an abrupt shift in influenza strain symptoms and lethality between the first (Spring 1918) and the Fall 1918 outbreaks. The reasons for the excess mortality of the 1918 pandemic have not been fully explored, IMHO.  I will address that paucity shortly, in print.


successive wave experiences
"Furthermore, our paper demonstrates no significant statistical association, positive or negative, between the excess mortality rates due to influenza in the 43 cities and the successive wave experiences (i.e., the Spring, 1918 wave, the Fall 1918 wave, the Winter, 1919 wave, and the Winter 1920 wave". (comment made in addendum to prior statement addressing supposition of public acquired immunity to successive waves).

--------------------------------------

so, what are "successive wave experiences" ?
What did they measure ?
Whether public or private measures were better or more successful
in later waves ?

ask experts for their subjective
panflu death expectation values
and report the replies


[ Parent ]
Oracle, "public disregard for safety" - or for rules
I guess there's a triad at play here:
- whatever objective reality is out there
- my own free will and risk assessment
- advice or rules by others (higher-ups I respect or not)

I recall seeing a http://www.worldchanging.com article about cross-road safety, mentioning an experiment in which taking away traffic lights actually diminished accidents, because people were not distracted by rules, and had their brains fully free to pay attention to other drivers.

There may be other factors at play, but it's interesting to say the least.

I can't find the reference: http://www.worldchanging.com/a... with gmoke's comment is as close as I can get to it:

Principles of smart growth sounds like A Pattern Language, or a pattern language.

There's a NYTimes article on 1/22/05 about a Dutch experiment with removing road signs to improve traffic safety that may have tangential relation. No patterns to the language is a pattern language?

Posted by: gmoke on January 22, 2005 10:51 PM

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


[ Parent ]
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