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Targeted Layered Containment (TLC)

by: SusanC

Mon Nov 27, 2006 at 17:16:47 PM EST


28 October 2006
The purpose of this thread is to get everyone familiar with Targeted Layered Containment or TLC, which is the main concept behind the US government’s containment strategies.
SusanC :: Targeted Layered Containment (TLC)
Note that the final decision has not been made about this, hence even more reason for you to get familiar with it. Because when you go to any of these meetings where the question of policy might come up, you need to be able to back up what you are saying with what the scientists are advising the government with. Which is this.

The basis for TLC is this:

  1. at least 1/3 of all flu transmissions will be due to children (first slide)
  2. closing schools early will reduce the attack rate (AR) for children and decrease overall number of cases, but will increase transmission in community and in households
  3. keeping kids at home will reduce community transmission but increase the relative importance of workplace transmission
  4. household quarantine ie keeping sick people and their family at home, especially with antivirals, will reduce overall transmission further but increase the relative importance of workplace and community transmission
  5. promoting social distancing will result in further reductions

The idea is that understanding the relative effect of each intervention will allow local officials to decide which policy to use and how to evaluate them.

anon_22 – at 01:43

The effect of TLC is a flattening of the curve and a delay of the peak.

The areas under the curves but above the ‘surge capacity’ line represent the load on the healthcare system. Flattening the curve makes it the shortfall at any moment a lot less than the original curve.

Edna Mode – at 10:15

Anon_22, Thanks for starting this thread. In our family, TLC stands for tender loving care, so I wasn’t sure what to expect when I opened the thread!

Anyway…three questions…

First, in the blue Layered Interventions slide, it shows the corresponding decrease in cases with implementation of each layer of containment. If I’m interpreting correctly, each layer builds on the preceding one. Is that right? I ask because I assume that the benefits of any one layer implemented out of the context of the others would not yield the same effective decrease. Is that correct?

Second question: Let’s say my community practices TLC but surrounding communities do not. Would the benefit of TLC be mitigated, and, if so, partially or totally?

Final question: I am still waiting to receive DVD copies of the Education Dept. show that aired on Oct. 17. Once I have it in hand, I am going to preprare information packets for our school board, superintendent, and principals. The information you are including in this thread is the most well articulated, concise summary I’ve seen. Is it OK to use the graphics and text (with proper credit) in my handouts?

anon_22 – at 10:41

Edna Mode – at 10:15

First, in the blue Layered Interventions slide, it shows the corresponding decrease in cases with implementation of each layer of containment. If I’m interpreting correctly, each layer builds on the preceding one. Is that right?

Yes

I ask because I assume that the benefits of any one layer implemented out of the context of the others would not yield the same effective decrease. Is that correct?

Interventions should be utilized in the order on the chart, to provide the appropriate benefit. The single most effective intervention is early school closure. If you do other things without that, you may not get as much benefit.

Second question: Let’s say my community practices TLC but surrounding communities do not. Would the benefit of TLC be mitigated, and, if so, partially or totally?

It’s hard to say. It depends on whether you can exercise movement restrictions effectively. Certainly in 1918, some communities told people you can leave, but when you come back you have to go into 3 days of quarantine. Don’t know how well that would work in the 21st century

Final question: I am still waiting to receive DVD copies of the Education Dept. show that aired on Oct. 17. Once I have it in hand, I am going to preprare information packets for our school board, superintendent, and principals. The information you are including in this thread is the most well articulated, concise summary I’ve seen. Is it OK to use the graphics and text (with proper credit) in my handouts?

Yes.

Pixie – at 10:49

annon_22:

Can you further explain - closing schools early will reduce the attack rate (AR) for children and decrease overall number of cases, but will increase transmission in community and in households

In layman’s terms, are you saying that if we keep the children out of harms way by closing the schools, then the virus (as if it had a mind of its own) will then simply pick other victims until it gets to its goal of 35% community infection before burning itself out/moving on?

anon_22 – at 10:55

Pixie – at 10:49

In layman’s terms, are you saying that if we keep the children out of harms way by closing the schools, then the virus (as if it had a mind of its own) will then simply pick other victims until it gets to its goal of 35% community infection before burning itself out/moving on?

Yes, the virus will continue to transmit until there is herd immunity. So there will be proportionately more transmission that are not dependent on school opening, but the overall rate will be slower ie flattens the curve.

anon_22 – at 10:56

Also, the assumption after the first layer, ie only closing schools, is that the kids will then spread the virus within the community. Unless you keep them at home, which is the next layer.

anon_22 – at 10:58

In case some of you have not noticed it, the green numbers 2.1, 1.9 etc are the R0 at the various layers. Notice in principle you can get it down to <1, and the epidemic will stop. But it will depend on the success of multiple interventions implemented very early on.

Pixie – at 10:59

anon_22:

Ok, so then the early school closing not only helps protect the children themselves, but it prevents the schools from acting like tinder in a California drought?

That is something really useful for town and school administrators to know, as there is a win/win outcome for both side here if they do implement early school closure.

anon_22 – at 11:00

Pixie – at 10:59

anon_22:

Ok, so then the early school closing not only helps protect the children themselves, but it prevents the schools from acting like tinder in a California drought?

Yes

That is something really useful for town and school administrators to know, as there is a win/win outcome for both side here if they do implement early school closure.

Yes, absolutely!

anon_22 – at 11:02

Early school closure being the most effective NPI (Non-pharmaceutical intervention) for flattening the curve overall for the community, was the single most consistent finding from all the different expert presentations in the IOM meeting. Both from modeling studies and from examination of historical data from 1918. So if you can only push one policy, this would be it, IMO>.

anon_22 – at 11:06

How early is early enough? The only ‘recommendation’ we have is from Longini, who says it has to be implemented at <3% cumulative infection in the community. In practice, that is not a good trigger for action, as you may not have enough information available in time for you to catch that moment. This needs to be pointed out to local officials so they can set their own trigger eg first case within community, or first case within a certain distance.

Data from modeling from Ferguson said that closing schools after the first case is reported in the school and closing after the first case is reported within 10km makes no difference to the outcome. So presumably a distance trigger would need to be >10km.

Pixie – at 11:19

For communities like mine the only creatures home in town during the day are the pretty cows and the kids. There is almost nobuisiness done locally here. Everyone travels extensive distances by car and rail daily to Manhattan, by car to surrounding states on nearly a daily basis, by air to many other states in the U.S., and by air to a plethora of foreign countries. A 10km distance threshold will make absolutely no difference. Neither will a 50km or 100km marker.

To be effective in an area like mine which is so incredibly mobile, school closure would have to begin the moment we see the first case get off an airplane, anywhere in the world. I would think that would be true for any major Metro area that experiences a great deal of incoming and outgoing travel also.

Pixie – at 11:34

To further illustrate my point, here’s a recent travel schedule for my family. In the last week, my dh traveled to Toronto, Canada, Buffalo, NY, and Long Island, NY. My kids and I traveled to Massachusetts. and Manhattan. Tonight we will all be traveling 50km to a large dinner gathering of parents and kids.

If we are going to have policies that advise early school closure, then we can’t make the mistake of basing our planning assumptions on 1950′s era communities that mostly stayed close to home. That single flaw, in spite of all the other hard work, would undo the entire logic of the plan. We are a very mobile society and that has to be taken into serious consideration.

crfullmoon – at 13:19

(yes -last winter’s break, various people in my town had flown as far afield as China or Turkey and all come right back to work and school.) Business travellers had been stranded all over, back on 9/11; people travel alot. Many people probably remember where they were 9/11; at this point, pandemic could catch people off guard and all over the place. Who did they come in contact with, who had those people been in contact with? We may have very little (or no) warning.

Dude – at 13:52

Does it not make sense to close entire sections of the country for about two week periods to isolate all cases and stop all transmission? Then, once cases are in quarantine in their units, we clean up, establish home care and resume? Repeat this exercise often during the pandemic. I know the math says this is the best way to mitigate the effects.

Pixie – at 14:00

Dude - at 13:52

Do they even have the guts to try it?

I do know that it’s the military right now that is in the forefront with the “community shielding” concept. Either you shield your community, or they do it for you. But is is at all practical?

lugon – at 16:16

LauraB on the other thread wrote While the 3% case rate is difficult to capture and act upon, it at least is a better indicator of community health.

What’s 3% case rate for where you live. Is it just “clinical infection”? Does incubation period count? Does subclinical infection count?

If it’s in a 1 million people place (to make numbers easy) and only clinical infection, that means … 30 thousand cases. That should be noticeable with a not-so-bad surveillance system. Maybe even a community-based surveillance system. Cell-phone based? Trust?

Dude – at 16:37

Pixie – at 14:00 Well, it would give us time to collect our breath, ck for our infected, stop the spread, and plan our next response. Will people comply? It does not matter. If not they die. If you won’t listen, you won’t live. The next time Darwin holds a lab session, well, they will listen. Will it stop it completely - no. It is a math construct to limit the number of infected/dead for as long as we can. Officials could call for shorter or longer periods as needed. They could make up packages of food/household for those short durations. We are trying to buy by our actions time for a vaccine. If I had my way, everyone would shout down for 18 months and SIP. This way we keep it going in spurts. We still need legislation to curtail payments of debts during the state of emergency.

uk bird – at 16:50

Dude – at 16:37 We still need legislation to curtail payments of debts during the state of emergency.

This is a very rocky option. One person’s debt is another person’s income. Will people get paid? Will shares give dividends? Will accounts give any interest? Will you pay for your groceries? Your utilities? I know where you’re coming from but it’s not that simple.

crfullmoon – at 17:00

Targeted Layered Containment

Total Local Continuity…

Temporarily Limited Currency…

Dude – at 17:11

uk bird – at 16:50 I don’t want to hijack the thread from it’s purpose. I am suggesting that the layered approach does not do enough. I think that a total, short duration, stoppage will do much more to protect us. Why? It has to start with another index case and build again. That takes time. We use that time. Then we go to ground again.

To answer UK bird…it is not rocky, it is solid. Yes, no debt. Yes, no income. No dividens, no interest, no payments due of any kind. Pay if you can, or wait till after the emergency. Buy on credit. Keep all records. We all pay later. That is what I mean when I say, “Bill Me.” I am everyman. You submit a bill for a new porsche and guess what, your problem. Look, we don’t need to worry about accounting or the economy, we need to worry about life. Just keep a record and we can all submit the information at tax time….better than loosing your population and infrastructure. I won’t resond to any other economic questions about SIP in order not to hijack the thread.

Walrus – at 17:51

Without wishing to hijack this thread, its not enough just to close the schools because kids and teenagers get bored easily and will want to socialise with other kids. If this happens, then the effect of school closures will be blunted. I believe it may be necessary to place bans on the movement of children and teenagers, for example allowing travel only in the company of an adult.

To put it another way, whats the point of closing schools if the teenagers then decide to hang out together in a shopping mall? (Not that anyone in their right mind would go near a mall during a pandemic).

To me its close schools, theatres, sporting clubs, churches, no public events or gatherings and work from home to the maximum if at all possible.

janetn – at 19:59

Correct me if Im wrong here, but the goal seems to be to slow the rate of transmission. This would put less stress initially on the healthcare system, essential services ect.. By slowing the rate of transmission absenteism rates would hopefully not peak as high or as quick. This may also allow some of the initial victims time to recover and hopefully “volenteer” in areas such as HC. Does this sound right?

Somebody better explain this TLC plan to TPTB who are planning on keeping schools open.

Bump - Bronco Bill – at 20:19

29 October 2006

lugon – at 03:57

We can and should assess this as fully as we can. “This” being specifically “close schools really early”. The “pros and cons” aproach is not enough - we need “other consideration” too. “Cons” can be worked on separately. “Other considerations” can change the initial plan. “Pros” can show what to strengthen.

So, close schools really early:

  * +
  o Slow down transmission globally.
  o Diminish pressure on health-care system.
  o Diminish pressure on home-care; each home has an all-or-nothing situation, but others can help through phone, etc.
  o Gives more time to organise volunteers etc.
  o Gives time for people to recover and volunteer at later stages (slow mo).
  o Possibly less disruption? I’m not yet sure about this one.
  o What else is good?
  * -
  o People who SIP must SIP for longer.
  o Disruption may last longer.
  o What else is bad?
  * ?
  o What to do about food markets, slums, transport?
  o Has the effect of simple masks been analysed together with these measures? What would such an effect be?
  o What else belongs under “other considerations”?

anon_22 – at 03:57

Walrus,

Keeping kids home is in the 2nd layer of the TLC. Every layer achieves a certain result, and if you do more, you get more. Its not mutually exclusive.

lugon – at 04:00

I’ll add to this: “Others can help through phone”, delivering stuff to your door, etc.

What others ideas are not yet included in such an exploration/assessment?

lugon – at 04:00

hi, anon_22! :)

anon_22 – at 04:03

Closing school early is ranked from all the studies as the most effective intervention. If we cannot even win the debate over school closure, we will not win any debate over any other interventions.

For the purpose of policymaking, we need to make a decision to close schools early, then figure out what to do about the consequences. If we base our decision on consequences, we won’t have any interventions.


I made this point at the IOM meeting, that if you are treating a patient for a life threatening condition, eg cancer, and the treatment eg chemotherapy, has substantial side effects, you don’t just give up the treatment cos of the side effects. Rather you give the treatment and do other things to mitigate the side effects.

That’s how we need to think about any intervention, particularly school closure.

anon_22 – at 04:07

Hi lugon,

I don’t want to mix discussions of other interventions with school closure, cos at the moment that is the single most important thing to push. If we are going to have any interventions, we need to get expert evidence on our side. Currently that’s where expert evidence is.

Starting (and winning) the debate over school closure will do more to promote pandemic awareness than anything else we might be doing, IMHO. Parents and teachers will sit up and take notice, and ask why, and that’s when we can tell them about what a pandemic is like.

lugon – at 04:30

Ok. But some of us are ahead the curve, aren’t we?

And maybe the debate includes consequences - I don’t know.

In any case, let’s focus on the advantages of doing it and the disadvantages of not doing it.

Reader – at 05:24

I agree that closing the schools will help slow things down. However, there are some teenagers in my neighborhood who I would not trust being in the neighborhood all day with no supervision. We have a very bad vandalism problem in the summer. I think we need to account for the fact that at least one parent needs to stay home, especially for teenagers! Plus, it shouldn’t be a holiday. Schools will need to have home schooling materials ready to go home with the kids the minute the bell rings.

crfullmoon – at 05:57

Schools are big on “contracts”; something the student and an adult have to read and sign off on, so the classroom rules/behavior/homework/standards, ect, is clear and parents can’t complain they didn’t know what was expected if rules get enforced.

Maybe something so even teens understand the danger of getting pandemic, and see the triage plans, current cfr, lack of vents and vaxes, ect, needs to get sent home and signed, now, while families still have time to stock up for sheltering-in-place, power outtages, and, make homeschooling plans.

Schools have had a year’s notice about pandemic alert; should have been making distance-learning plans, not waiting “until they are necessary” (and then saying there is no budget money, because they couldn’t ask for it without alerting the public, no time to plan curriculum standards, ect).

US states all had their pandemic influenza “summits”. Do we have to consider the expense of those summits wasted? The point wasn’t “mass vaccine dispensing capability”, which seems to be some place’s only focus.

US Dept of Ed should request primetime tv to run their pandemic webcast as a public service, so parents will see it.

Local school districts are dragging their feet, no matter what the federal or state level has said they should be doing. March 2006 …”Our schools are centers of community life, and educators must be integrally involved in State and local efforts to plan and prepare for a potential pandemic. In preparation for a pandemic, our schools are uniquely equipped to disseminate preventative health information to teachers, students, parents, and the local community. ‘’‘Our schools also must be ready to deal with possible school closings, staff and student absences, medical care for children, and the need to maintain and restore the student-learning environment.

…State and local preparedness is critical. Secretary Leavitt and I have announced the availability of planning checklists prepared by the Department of Health and Human Services through the U.S. Centers for Disease Control and Prevention. These checklists are intended to be a first step in helping the education community prepare for a possible pandemic. The enclosed School District (K - 12) Pandemic Influenza Planning Checklist may serve as a helpful tool to begin those vital conversations in your community, if they have not happened already’‘’.”…

Vital conversations with the community have still have not happened. Not here, anyway.

“Get everyone familiar with Targeted Layered Containment”

(Too bad authorities picked planning spreadsheet attack rates and cfr that would fit nearer to line #3 in the graph at 01:43, rather than more scientifically realistic numbers.)

Reader – at 06:07

Just a thought, but a friend who went through chemotherapy was told by her doctor that chemo kills a lot of patients. Without exact numbers she quoted me for her particular cancer, if you are diagnosed with that kind of cancer and you do not go through chemo, you will die in 2 years. If you go through chemo, you have a 50/50 chance of being cured and a 50/50 chance that you will die from the chemo either during treatment or soon thereafter, a period of about 4–6 months.

I like the odds for chemo better, but I’m just saying the side effects absolutely need to be mitigated. I think it will sound like a pretty drastic measure to most of the public to close the schools and there needs to be a well thought out and actionable plan in place for the parents.

uk bird – at 06:12

Ok so you want arguments for closing schools?

The statistics you came up with for child deaths were a powerful argument.

The potential for H5N1 to disproportinately kill children.

All the arguments about slowing a pandemic down to ease pressures on the health services apply.

Given the media we have, a knee jerk reaction to a pandemic from parents will be to remove their kids from schools anyway. The test will be to convince them to maintain it.

Kids will be at home but hopefully they won’t be at home sick.

Parents will be less likely to catch the flu from their kids.

Other childhood diseases should also diminish (meningitis, chicken pox etc).

Parents will be able to better monitor and correct the personal hygiene habits of their kids.

Parents might get to spend that time with their kids they’ve always promised themselves.

They won’t need the extra money they earn for holidays because there won’t be anywhere to go.

There won’t be the normal consumer pressures so families won’t need so much money anyway.

No school activities (from cheerleader outfits to skiing holidays) to drain time and money.

Kids will have the opportunity to learn practical skills – gardening, cooking, cleaning (maybe not), first aid, etc.

Kids might get some of the household chores done (ok, also unlikely).

Kids might get more active and stop spending so much time sitting down.

I’m rambling now, I’ll stop.

I also don’t think you can win the argument for shutting schools unless you’ve got answers for the sorts of problems people will come up with.

anon_22 – at 06:16

Reader – at 06:07

On chemo odds, it depends on what kind of cancer and what kind of chemo. A lot of conditions have better odds than what you quoted.

In the case of school closure, I find it hard to find anything worse than having 20 years of child death in one year for a 2% CFR. That just about outbalances any side effect we can think of. IMO.

anon_22 – at 06:30

uk bird – at 06:12,

Given the media we have, a knee jerk reaction to a pandemic from parents will be to remove their kids from schools anyway. The test will be to convince them to maintain it.

That is reactive school closure, which is not very effective. Plus by then parents will have gotten so angry at the government for not taking proactive action that the trust that is essential for going through a long and difficult pandemic will have been lost.

I also don’t think you can win the argument for shutting schools unless you’ve got answers for the sorts of problems people will come up with.

I think we can, in the US at least. That’s because public health officials at the local and national levels are just waking up to what they will be responsible for if and when a pandemic happens. They are just beginning to look at the numbers and scream bloody murder, and clamouring for government to give guidance. School closure is the top item on the books as far as effective community intervention is concerned, and public health officials are unlikely to accept not having those tools available.

The talk right now is, given the severity of even a moderate pandemic, not to take any intervention off the table unless they have been proven to not work. ie the balance of evidence is to err on the safe side in the absence of sufficient data.

anon_22 – at 06:32

For example, its likely that enforced quarantine will be off the table. I would like to see that happen, particularly with the quarantine stations at US airports. They will not stop anything, are hugely resource intensive, and are likely to result in more infections not less, if you forcibly put exposed subjects together, ie expose them some more!!!

uk bird – at 06:45

anon_22 – at 06:30 That is reactive school closure, which is not very effective. Plus by then parents will have gotten so angry at the government for not taking proactive action that the trust that is essential for going through a long and difficult pandemic will have been lost.

That’s why it’s an argument for the planned closing of schools. If it’s going to happen anyway the system has to be ready for it. Blue has it right when he asks ‘who won’t pull their kids from school’, very few parents won’t react to the hysteria in the media. The Harvard survey pointed out that most would withstand hardship for a while but eventually other worries might over ride the fear of the pandemic.

crfullmoon – at 06:48

(It might not be media “hysteria” parents react to but facts on the ground about virulence, no surge capacity, and not wanting to risk their childrens’ lives…)

uk bird – at 06:56

If everyone beleived that there was going to be a major pandemic there wouldn’t be a need to convince the ‘system’ to close schools. However even a mild pandemic (if there is such a thing) will overexcite the media. Look at the uproar over one headless swan in a Scottish harbour. My parents can’t even remember the 1968 pandemic but if it happened now you’d know about it. We can’t expect people to react in the same way people have dealt with events in the past.

anon_22 – at 07:01

uk bird – at 06:56

I take your point. but I do disagree. There is no ‘overhype. What has happened is ‘overhyping’ of the ‘overhyping problem’ if you know what I mean. :-) especially in the UK. The headless swan precisely illustrated the problem, that they completely missed what the story should be about, and then sensationalize some trivia so that they can then run other headlines about scaremongering! ARGH!!!!

The media is currently drastically under-excited about such a potentially catastrophic event, so it will be a long while before they can be over-excited.

Reader – at 07:04

anon_22,

I totally agree with you, but first you need to convince everyone that there is a pandemic coming where people will be dying left and right and most of them will be children and young adults. In lou of being able to do that, in order to convince the public that schools need to close and for them to implement plans to do that, there needs to be something there they can get ahold of and say, “yes, that will work”. Otherwise, in spite of scientists and doctors recommendations, the public still believes that flu kills the very old and sometimes the very young and they will not see the need to close the schools. We are a very small percentage of people here that “get it” for what’s going to happen. The majority of parents don’t and there will be a very large outcry from them to not close the schools. They can’t afford it mostly, but there are a lot of reasons they would not want it to happen. And then just think of the reaction when you tell them, well, not only will the schools be shut down, but the day care centers will be too. What will single moms do, and there are a lot of them, are there plans in place to get them food and medicine? We’ll be taking in one mom and her little boy, but dangit, we just can’t take them all in. And, well I guess I’m just playing devil’s advocate here for a minute, but how long will it be for and what will determine when they can go back to school? Before you just tell them we should shut the schools and batton down the hatches, parents are going to ask a lot of questions. If those questions can’t be answered, you are going to have a lot of resistance. And you can’t just tell them that we will mitigate the side effects as we go along. A lot of conditions have a lot worse odds that what I quoted.

anon_22 – at 07:08

On the subject of public health officials in the US and what they want now, here is a link to some really good slides

crfullmoon – at 07:12

(Now, show the public the current cfr, or at least the best guesses what the 1918–1919′s was?)

uk bird – at 07:12

But you’ve go to work with the media you’ve got. You’ve got to predict how they’ll react and I’d bet a lot of money it’s not with common sense. It will go from 0–100% and panic people. Decisions can be made on how you know the public will react.

This thread isn’t about persuading the media to take an interest, it to pesuade the decision makers to close schools. Part of that argument is to include undesireable, but predciatble reactions from the public.

anon_22 – at 07:12

Reader – at 07:17

Ok, I’m talking about the proactive plan calling for school closure, not the reactive one. Reactive is sort of panic driven. In the proactive plan, everyone has a chance to think about it. So there will be questions.

anon_22 – at 07:18

These are slides from the ASTHO annual meeting, (Association of State and Territories Health Organisations).

For the first slide, pay attention to the severe scenario, CFR >0.5%, notice how the proposed policies are different from the mild and moderate scenarios.

The second slide is even more important. We may talk here all we want, but the real process is going on. The IOM workshop is already done, I’m glad I went! The rest is waiting for input from various groups, but the government will find it very hard to refute scientifically based evidence. That’s what I meant at 06:30, that public health officials are now beginning to assert their influence. Or trying to at least.

anon_22 – at 07:19

And if you look at the list of contributors at the end, there are lots of big names. Many of these are engaged in advising the White House and drawing up the pandemic plans.

Average Concerned Mom – at 07:19

interesting statistic from anon_22′s lides — only 4.5% of households in the US are headed by single parents with kids under age 12. Useful information to the quetin — what will single parents with young kids do if schools close? Don’t know what they’d do, but it seems there aren’t that many of them.

anon_22 – at 07:21

Reader – at 07:04

Before you just tell them we should shut the schools and batton down the hatches, parents are going to ask a lot of questions.

We want them to ask the questions. It will be the perfect opportunity to discuss pandemic prep. IMHO.

We’ve been saying here for a long time that people need to be told. This will be the test. Can we manage to communicate effectively?

anon_22 – at 07:26

Back to the contributors list: I believe I am correct in thinking HSC = Homeland Security Council, and NSPI = National Strategy for Pandemic Influenza. ie these guys wrote the panflu plans!

crfullmoon – at 07:31

Those slides on the link at 07:08 should be circulated as widely as we can to parents, community organizations, school PTOs, media, politicians; everybody.

anon_22 – at 07:33

crfullmoon – at 07:31 Those slides on the link at 07:08 should be circulated as widely as we can to parents, community organizations, school PTOs, media, politicians; everybody.

Yes, absolutely.

lugon – at 07:36

anon_22 – at 06:16 … That just about outbalances any side effect we can think of.

I emphasised the “we”. We want to bring many people on the same page, right? (A very “schoolish” metaphor, btw.)

Parents will have to go through their own adjustment reactions on this. I think we want to bring the full-impact picture (to be able to go past “there’s no problem” denial), then dismantle objections based on consequences (to be able to go past “can’t act anyway” denial) and so on.

I feel we should be systematic about this.

Reader – at 07:43

Average Concerned Mom – at 07:19,

Where do you see that statistic? That is wrong. I think you are looking at the Transmission Matrix slide, that’s not the same thing. It’s a very high percentage.

Another question by the devil’s advocate. What will happen to the children who regularly get beat by their parents? Who will see their bruises when there are no school officials watching? Yes, that would take a back seat to children dying, but there will be social workers asking that one.

Average Concerned Mom – at 07:52

Reader — it is ths slide labeled “Labor status” and it refers to how many households have a single working parent and children under the age of 12. It says 4.5% Yes — I was wrong — it isn’t refering to how many households have a sinlge parent (i.e. working or no). It is refering to single working parents. If parents already aren’t working, then closing schools wouldn’t have an effect on their jobs if they had to stay home and care for their kids.

lugon – at 07:53

(I always come in late - you’re all updating pages faster than I am! LOL)

uk bird – at 07:57

Am I the only person here who’s confused? Are we being told about TLC? Are we debating the likelyhood of school closures, the effects, the arguments for or against? Are we being encouraged to help spread the word?

Pixie – at 08:09

Can someone clarify the criteria for the CFR on the Epidemiology Drives Approach slide? Are they saying that in a “Moderate” pandemic the CFR would be 0.1–0.5% and in a “Severe” pandemic the CFR would be greater than or equal to 0.5%? Am I reading this right or have I just not had my caffeine yet. Do they really mean a CFR of 1–5% and a CFR of greater than or equal to 5%? There is a big difference between 0.5% and 5%.

How did these public health planners get from a 79% CFR to a 0.5% CFR for a “Severe” pandemic? Even a 5% CFR would be an order of magnitude several times greater but still a lowball estimate. Are we seeing them use stats for just a “normal” flu pandemic here while attempting to apply them to H5N1?

soccer mom – at 08:29

Don’t overlook youth sports as a means of transmision both in a community and between different communities.

My kids and millions of others play one or two games a week, travelling to towns near and far and coming into direct physical contact with players from many cities and towns. They then go to school the next day could potentially infect their classmates


uk bird – at 08:38

Pixie – at 08:09 How did these public health planners get from a 79% CFR to a 0.5% CFR for a “Severe” pandemic? Even a 5% CFR would be an order of magnitude several times greater but still a lowball estimate. Are we seeing them use stats for just a “normal” flu pandemic here while attempting to apply them to H5N1?

TPTB are having a hard time considering anything worse than CFR of 2.5%. If they were sure it was going to be much worse then some of the decisions they are agonising over would be academic.

Reader – at 09:24

Average Concerned Mom – at 07:52,

Sorry, I tried to open those slides earlier and it was very slow so I skipped it. I went back and waited nearly 5 minutes for it (reminded me of my old 26k modem). You are right about the percentage overall, but you can’t figure in the households without children and the households with children over 12. Out of the other 3 - 2 parents working, a parent at home and single parents, single parents are a big chunk. Now think about the 2 parents who work. One of them will have to stay home. I doubt that (but I don’t know of any statistics, there probably are some) they both work for fun or for their career status. They are working to make ends meet.

uk bird – at 07:12 you said

“This thread isn’t about persuading the media to take an interest, it to pesuade the decision makers to close schools. Part of that argument is to include undesireable, but predciatble reactions from the public.” 

anon_22 – at 01:35 said

“you need to be able to back up what you are saying with what the scientists are advising the government with”.

All I’m trying to do is present questions that will need to be answered. You can’t back up your arguments with “because the government and the scientists said so, that’s why”. We don’t need to convince the children that school should close, we need to convince the PTB and the parents. Now I’m pretending I’m a parent who doesn’t know that this pandemic will attack our children, I still think that flu kills the elderly and people with bad immune systems. I don’t know anything about CFR’s, WHO, TLC’s or anything else about a pandemic, I haven’t prepped at all and wouldn’t know where to begin, and I work hard at a job that I work hard to keep but I’m still just one paycheck away from homelessness. Convince me that closing the schools, destroying my livelihood, disrupting my bliss is a good thing and that I should support it. I’ve been through Y2K and terrorist threats that never happen. Sorry, I find it hard to believe TEOTWAWKI anymore. You can show me your scientific facts and figures all day, but I have questions about real life. Okay, I’m scared when you talk about my children dying, but if all you have are scare tactics and no practical answers for what I should do, then you can take your scare tactics and …

See what I mean? It’s me back. We should be prepared for questions. You can’t effectively present a case for something unless you know the case against it.

Pixie – at 09:26

uk bird - at 8:38

Ok, well even a CFR of 2.5% I could understand. There’s at least the precedent of 1918 for that estimate, flawed as it may be.

But a CFR of 0.1%−0.5% for a “moderate” pandemic?

And a CFR anywhere near 0.5% for a “severe” pandemic?

How will we ever get them to 2.5%, let alone 79%, if they are starting there?

Out of what hat did they pick 0.5% CFR??

Reader – at 09:41

They are basing their numbers on the milder “pandemics” we had last century. Sometimes, to get people to listen, you need to speak softly.

anon_22 – at 10:25

Reader – at 09:24

anon_22 – at 01:35 said

“you need to be able to back up what you are saying with what the scientists are advising the government with”.

All I’m trying to do is present questions that will need to be answered. You can’t back up your arguments with “because the government and the scientists said so, that’s why”. We don’t need to convince the children that school should close, we need to convince the PTB and the parents. Now I’m pretending I’m a parent who doesn’t know that this pandemic will attack our children, I still think that flu kills the elderly and people with bad immune systems. I don’t know anything about CFR’s, WHO, TLC’s or anything else about a pandemic, I haven’t prepped at all and wouldn’t know where to begin, and I work hard at a job that I work hard to keep but I’m still just one paycheck away from homelessness. Convince me that closing the schools, destroying my livelihood, disrupting my bliss is a good thing and that I should support it. I’ve been through Y2K and terrorist threats that never happen. Sorry, I find it hard to believe TEOTWAWKI anymore. You can show me your scientific facts and figures all day, but I have questions about real life. Okay, I’m scared when you talk about my children dying, but if all you have are scare tactics and no practical answers for what I should do, then you can take your scare tactics and …

I didn’t mean it the way you quoted it, :-)

Let’s start again. I got back from 2 days of so much data and so many references (and so much jetlag) that I may be in danger of speaking without enough explanation (although I did do some, apparently not enough!). What I’m saying is there’s very compelling data suggesting certain actions are likely to be effective, in fact, more than I anticipated. If you are convinced of the benefit vs risk, which I absolutely am, then getting authorities to act is the next hurdle. The hurdle after that is getting the public to understand and accept it. These are multiple sequential steps (at least mentally) and there’s still a lot to do.

What I am NOT convinced about is doing it backwards, ie the public will not/ cannot understand or accept this, therefore we must not do it or we must modify it. That is patronizing and probably likely to backfire when a pandemic does happen.

To remedy the issue of ‘so much data’ let me go back and review all that data again, and then I’ll re-write the whole piece with even fuller references. Such vigorous debate is a healthy sign and worthy of more work! :-)

anon_22 – at 10:33

Reader,

but if all you have are scare tactics and no practical answers for what I should do

The biggest challenge of pandemic risk communication is telling the truth, that for many things nobody has good answers. It’s not going to be easy, but it has to start. We should try and find practical answers as much as possible. I’m all for multiple ways to deal with problems and not dismiss any of them even if they are not likely to work all of the time. But if you go out there and do enough of this risk communication, there will come a point when the most honest thing is to say “I’m sorry, I don’t have an answer to that.”

Our destiny is not entirely in our hands. There is that little matter of the virus to think of….

Pixie – at 11:54

Reader - at 9:41:

I fear they were speaking so softly in that presentation to the public health officials that they lulled them to sleep.

We really can handle a flu with a 0.1% CFR and, say, an attack rate of 50%, with the interventions public health officers are accustomed to advising: more frequent hand washing, hand gel, better cough hygiene, etc. I can’t imagine how showing these public health guys estimates of CFR’s this low would impress them with the need to do anything more than what they usally do. If were to tell me that this pandemic will have a CFR that low, I wouldn’t be particularly worried either.

That audience was listening, that is true. But were they listening to the truth - that this particular H5N1 virus that most authorities have said we need to worry about has a current CFR of 79%? We can’t tell them fairy tales just to get them to sit down and listen (geeez, I am sounding like Niman now). And if even the professional public health community can’t be told the harshh facts about what we may be dealing with, how will we ever be able to begin to communicate to the general public the potential risk ahead, and urge them to action?

Pixie – at 12:18

Revere:

If you are reading this, I have come to the conclusion that the public health officials are the weakest link in the pandemic preparedness paradigm. They do great work on a lot of public health issues, but they have not run with the ball here.

Without them onboard, and actively advising their municipalities to action, there is little point in discussing community interventions.

Those interventions need to be discussed and decided upon before a pandemic is raging. Before.

But, in this pre-pandemic period, the public health officers are, nearly to a man (it seems to me), the ones who are recommending only reticence to the town leaders that they advise. These public health officials will often say that they just do not “believe in” a pandemic (as if it were a religion, rather than a scientific event they should evaluate on the basis of more than “belief”).

A great deal of state and local influence lies in the hands of these public health officials.

If they say “prepare,” their municipalities are far more likely to prepare.

If they say instead “no, there is really nothing to worry about” until the point that it becomes to late for anyone to effectively act, there will be no action.

Or should I say, there will continue to be no action because at this juncture I believe it is the public health officials that are populating rooms all over the country saying “don’t worry” when mayors, school boards, and local media, want to begin to move towards active and early interventions and prudent preparedness.

Revere, you have a platform. I would love to see a piece on this, and hear someone of your stature urge your peers to begin to take seriously the fact that it may, in fact, be them who stands between their communities and their communities’ survival if they do not begin to urge action and actively support the movement of others towards the early interventions we are speaking of here. All of this talk of action stays frozen until the public health community is on board in a meaningful way (IMHO). (And sorry to rant, but it seems to me we have to address that elephant in the corner if anything we are discussing here has a hope of being accomplished).

anon_22 – at 12:45

Pixie,

I guess it’s a matter of the glass being half full or half empty, and its a matter of either defending people or urging/helping them to action. This whole discussion is hinged around the process of deciding what are the best courses to take, the timeline being December 2006 for decision.

I personally think it’s a bit premature to judge what officials are going to do, since the major decisions have not been made yet.

And if you think this is very late, I do agree. However, what I understand is that when those tasked with studying interventions got down to work, they discovered (as we expect) that there are not too many tools in the toolbox. And some of the tools did not have enough evidence to help decision making. So the latest round of modeling by Ferguson, Lipsitch, Markel, and Longini were started only a few months ago. Researchers have been looking at data from 40+ cities from 1918, eg newspaper reports etc, and it seems they have uncovered some consistency in the effects of certain measures. The work is ongoing, the analyses are very complex, and these are just interim conclusions. This work is already amazingly fast by the normal standard of public health research, and what I’ve been writing about are still mostly unpublished.

What I’m trying to say is that its a work in progress. We all want that information yesterday. Unfortunately, there was previously no particular reason to do studies of this kind. None of whatever policies being talked about is set in stone. Public health officials are also learning while they are running, so we need to both give them some leeway as well as assist them by vigorous debate, IMHO.

Pixie – at 15:17

annon_22:

I agree that in order to move forward on the finely-drawn specifics, the kind of data modeling and investigative work that is now underway (and it does seem like it is really quality work), is necessary and needed.

However, I don’t believe that our state and local public health officials should, more than a year into the progress of this virus, and after more than a year of very stern warnings from top leaders in the scientific and public health sphere, need detailed graphs and charts to get to work on the basics. And it’s the lack of work on the basics that alarms me, the lack of “belief” in the existance of a serious and actionable problem in the first place.

If our state and local public health officials were simply anxiously grasping at straws about which particular measures to implement in their already ongoing efforts to plan for and mitigate a pandemic, I’d have no argument, and my heart would go out to them. I’d have all the patience in the world while they worked hard to knock out these details.

But for the most part, state and local public health officials - these key people - are not even willing to seriously acknowledge that we have a problem here that is worth considering at even the most basic level, let alone the most serious level.

The pandemic plan produced by my state this week does not in any way acknowledge that a pandemic is something that our municipalities (or individuals and businesses) should be in the midst of preparing for. My local public health officials take their cues from that kind of public health leadership at the state level. They are now officially excused from action.

I agree that Dec. is late, but I also agree that it is better late than never. I am not sure, however, that we can make these elephants dance on the head of a pin in a heartbeat. I’d rather that those entrusted with the public health were already hard at work planning and preparing, actively, in their communities, and were simply awaiting word from your working group as to the end-game particulars, having already done all the heavy lifting locally they could in the meantime. Somebody needs to drop the checkered flag and tell these guys to begin the race.

anon_22 – at 16:03

Pixie,

I agree there’s a lot of work to be done. That’s why we need to get people educated, informed, here, and then go and talk to these local officials. That’s what I’m doing. :-)

I don’t expect people to live up to my standards (knowledge, sincerity, competence, whatever you call it), not because they can’t, but because it will become a source of frustration for me. I’ve stopped thinking like that a long time ago, and chosen to concentrate on working on whatever happens to be the path of least resistance at any moment.

The pandemic plan produced by my state this week does not in any way acknowledge that a pandemic is something that our municipalities (or individuals and businesses) should be in the midst of preparing for. My local public health officials take their cues from that kind of public health leadership at the state level.

We have the same problems, only worse, here in the UK. I can let my frustrations boil over and ruin my day, and I’ve done that, but I won’t.

Don’t let it get to you, is my advice. For what it’s worth. :-)

Goju – at 17:24

anon_22 “I agree there’s a lot of work to be done. That’s why we need to get people educated, informed, here, and then go and talk to these local officials.”

This I have done. And was told that he doesnt believe in the JIT problem.

The Health Officer in my town needs to be hit over the head with a frying pan to see what is going on. I have sent many emails from FW concerning both the advance of H5N1 and what others are doing in different towns as well as key discussions he should be aware of… do i receive any indication that the message is getting through? NOPE.

The health officer admitted to me that he has been reading the FW… Steve, If you are reading and see this post - I am very dissapointed in the non action of our town on this issue. When the pandemic comes , and it is WHO, CDC and all key players in the medical field who say When not IF, the deaths of our children will be on your hands. You have a choice now to be the hero and save their lives.

Yea tough words… cause I am done speaking softly. There is too much at stake - namely my kids lives.

lugon – at 18:46

Learning as we go along.

I bet a number of (written) plans don’t include specifics on what to do about schools, simply because they’re waiting for “permission from above”. Which in turn keeps people blind to secondary effects of “disease itself” and “disease mitigation”. Which is why this conversation, as part of our multipronged aproach if you like, is so very important.

This conversation needs to grow beyond the protective skin of Flu Wiki.

So I just added a link to this thread from the wikipage Explaining Pandemics. The link reads “Targeted Layered Containment: a look at second-order effects, specifically on Education, and why some important things must be planned for”.

Feel free to improve on that link. In time I hope we will have links to presentations (anon_22 or any others who were at the Conference?), interviews (hey, journalists, please do use your muscle on this one!), and local figures (as in “how many single parents are there in Our Town”).

Many other things are needed, but it looks like there are some points that are more central than others in this messy picture. Around “schools” we could see the coalescence of “homeschooling and the role of local and national radio stations”, “teaching kids to grow food locally and how to use local currencies, both as an urgent path to local self-reliance”, and a few other things. Schools do strike a chord, so let’s echo that. Maybe we need an “effects on school” awareness flyer of some sort?

crfullmoon – at 19:12

Goju – at 17:24, I was going to use the shovel ours is going to need to dig graves, not a cooking implement, but, other than the states and names aren’t a match, we’ve got the same “health” honcho problem.

Lugon, “the coalescence of “homeschooling and the role of local and national radio stations”, “teaching kids to grow food locally and how to use local currencies, both as an urgent path to local self-reliance”, and a few other things.” sounds great- means the rusty (Iron Law) bureaucrats will never go for it.

Homeschooling may permanently gain a lot of adherents when parents see how local school officials have been gambling with the public’s lives. Teachers won’t be broke; they can do private tutoring post-pandemic. (Manageable class sizes at last!)

Targeted Layered Containment (helps with Total Local Continuity ;-))

Pixie – at 22:11

anon_22: “I agree there’s a lot of work to be done. That’s why we need to get people educated, informed, here, and then go and talk to these local officials. That’s what I’m doing. :-) “

I think the problem here is that there is a huge chasm between the people you just met with at the meeting which discussed Targeted Layered Containment and the people tasked with managing pandemic preparation (including containment) at our local and state levels. They don’t think it is needed.

There is a chasm.

Goju, crullfullmoon, and I have been doing the rounds of the local officials in the NY to Boston corridor. The level of interest and motivation generated in the meeting you just attended is, I assure you (as Goju and crullfullmooon already have), completely absent at the practical level.

What we are saying is that we are, in fact, already doing what is proposed. We are taking the information we have learned here and all along this long road, and are attempting to implement action at the local level. At this point, we don’t, I think, care which action it is (apart from assurances of mystical visions of a non-existent vax and miraculous Tamiflu), as long as there is some action. Those of us willing to step out and engage at this level are meeting a brick wall. We are not alone. You do not hear of Fluwikians reporting back about successes with their local governments - anywhere. Ever. Reports of local governments being prepared, or at least on their way towards preparation, are nearly non-existent.

Some of us, like you, have spent time in high level meetings that are well focused, engaged in problem solving, and full of people facing the reality of what needs to be done. Those meetings are not only informative, but uplifting and energizing.

But we have chosen a dual role. We have one foot planted over there, but we also have one foot planted firmly in front of those charged with the public health and welfare of our citizens at our state and local levels. When we plant the other foot in that arena, we have entered another world entirely. This disconnect is severe.

The chasm between those meetings, where everyone understands the level of problem we are potentially facing, and the meetings those of us who have actually ventured out on the local level have had, is gigantic. We are talking Mars and Venus here. Without some very real attempt to bring those two sides and outlooks together, one side will continue to talk and intellectualize, and one side will continue to stubbornly do, in reality, nothing or less than nothing.

I expect the tension between what we see happening in the most serious way now at the highest level, and the continuing stubborn inaction at the local level, will continue to grow. My state, and many local public health officials, apparently believe that they can wait until the 11th hour and then make a heroic end-run at this issue. We know that effort will tragically fail. The words “too little, too late” will have meaning as they never have before. The TLC planning assumptions have a weakness - they assume engagement, and preferably early engagement. We don’t have that engagement. Not yet we don’t, and we need to think of some ways to get it, again preferably now rather than later.

Crullfullmooon and Goju speak of wanting to pursue the problem by utilizing various gardening tools and kitchen implements. I won’t add my suggestions. We are frustrated, yes, but it does not ruin our day. We are right back here seeking further strategies that will produce actual and measurable practical progress. Those at the top can talk all day. We here can talk all day (and we do). But it is all for naught if we cannot turn the talk into action.

We could take the path of least resistance, I mean hypothetically at least. We could just hang out here, and talk to each other and the many like minded people who share our views. And, it’s always affriming to attend the meetings where everyone is on the same page and we’re preaching to the choir (they usually provide a nice lunch to boot).

Instead, we have perhaps chosen the path of most resistance. We are your canaries in the coal mines, and the inaction we are finding out there is gut wrenching. But our hypothetical choice to continue is really not a choice. In short, as Goju said, we see dead people. We know too much. There is no choice.

We all work out our ideas here. Goju started the thread the other day about just this subject, although at that time I think the subject was more amorphous, and not so well defined. He noted the increase in high level meetings and other seemingly tense and anticipatory actions at one level, and the nearly complete and utter dismissal of the entire issue at the more local level. The disconnect was nearly complete, and I saw it too. I’ve seen others comment on it recently as well, such as Bird Guano and our nurses. Fourty-eight hours of ruminating about it and listening to input from the Fluwikian hive mind has led me to the conclusion that we have a problem. We have a chasm. Now the question is what to do about it. IMHO, the people who hold the key to reaching our community leaders are our public health officers. They need to be reached. That chasm has to be bridged. If not, we really will be faced with a situation full of dichotomy: the few key leaders who have been consistently urging preparation themselves will be well prepared, and the public health officials who somehow did not get the message will be standing around asking “why didn’t anyone tell me this was serious?”

How do we bridge this? How do we bring about enough engagement to even begin to proceed with TLC or any other meaningful actions? TLC is a pro-active, rather than a reactive, strategy. Without engagement and engaged advance planning, TLC is unworkable, no matter how effective it may be in theory. TLC is not 11th hour stuff.

Goju – at 23:03

Maybe some pressure on these folks?

http://www.apha.org/

Goju – at 23:09

Maybe some pressure on these folks?

http://www.apha.org/

OK folks - Here is the place to go to work

http://www.getreadyf...

post to the comments to get the ball rolloing

Goju – at 23:36

OK Fluwikians - we need your help.

As Pixie pointed out on the TLC thread, there is a major disconnect between the higher Government warnings and the local Public Health Officers who often control our town’s reponses to health concerns - in this case Panflu preparedness.

I found the American Public Health Associations website at http://www.apha.org

They have a Panflu section. It is woefully in need of our expertise.

I also found their Panflu blog… it is here:

http://www.getreadyf...

I have sent a comment already a

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cont'd
30 October 2006
Reader – at 00:39

anon_22 – at 10:33, have I told you lately how wonderful you are?

I do tend to trust someone who tells me they honestly don’t have an answer. I’m just the kind of person, though, who will then go and look for it. I’m a researcher by nature.

lugon – at 03:20

crfullmoon – at 19:12

Lugon, “the coalescence of “homeschooling and the role of local and national radio stations”, “teaching kids to grow food locally and how to use local currencies, both as an urgent path to local self-reliance”, and a few other things.” sounds great- means the rusty (Iron Law) bureaucrats will never go for it.

crfullmoon - who mentioned bureaucrats? ;)

Actually, when I mentioned “coalescence” I was thinking about our wikipages and also, in parallel, about my own mental model. If we have a wikipage with “effect of pandemic on schools”, then we could have other pages “branching out” from it.

Just like when we direct people from the main page to Confirmed Cases Updated then in that page we also have links to “ages more affected”, “clusters” etc.

It’s a now that I have your attention strategy.

Which btw is loosely related to Dave Pollard’s recent entry on A Four-Pronged Approach to Getting to ‘Yes’.

Average Concerned Mom – at 07:40

Pixie at 22:11

Are you able to articulate what is the root of this “disconnect” on behalf of local public health officials?

Is it a lack of the sense of imminence or urgency? Or lack of a sense of how fast thing will move once they get started? I.E. you say that they seem to have a feeling that there will be time later to get ready, once things look more sure?

Or is it simply being overwhelmed by having had this additional huge, complicated health issue thrown on their plate with no reduction of other duties?

Or — all of the above?

crfullmoon – at 07:41

(lugon, I not only “see dead people” now, I find people in authority in town in jobs supposedly dedicated to the good of the public or its children are just bureaucrats, in the wrong places. We need informed, ethical, leadership.)

The 2% crf would currently mean H5N1 would take as many children in one wave as die in 20 normal years sounds like an attention-grabber. (goes off to wander around in circles due to lack of sleep Will come back when I can mentally “coalesce”)

Pixie – at 07:47

Average Concderned Mom - at 7:40

Those are really good questions, and figuring out what the “root” of the disconnect is is a really, really, good issue to focus on.

Like crfullmoon, I need to pour a large pot of tea before I tackle those questions since they really are that good. And, they are the crux of the matter.

lugon – at 08:53

This is off-topic but related to immediately previous posts in this thread: please look at a current threat assessment and look for “lugon – at 08:17″. This is part of what would convince them that “this virus is moving”. But maybe we do need to start another thread: the role of local public health officials (done!).

Goju – at 09:58

Average Concderned Mom

I think the PHO are stuck between a rock and a hard place…

Lets say for instance that PHO Mr. S of SmallTown reads our indo thread and the lightening bolt of understanding hits him square between the eyes. He then starts reading as much as he can to educate himself about Panflu and its effects on the community… takes some time and realizes that he it’s his job to save the lives of the children in his community.

What does he do next? If I were him, I’d go to the WHO, CDC, Fed Government and State Gov Panflu websites.

And what is the message he comes away with? Confusion I’d say. Prep spreads from 3 days to 3 months and longer. CFR’s from .5% to 79%. When/not if but dont know when…

His number one job, which takes all of his time, is not Panflu. So he slowly puts a plan of action together and has to squeeze it into his already hectic schedule… and has to present it to his “bosses” in a way that is believable and doable.

He has to also be “right” or he risks losing his job…. which may be his number one concern.

So our PHO disconnect is not really a disconnect, but confusion as to how to move to what next step.

If he acts boldly, he will either be the hero (if pandemic happens) or a fool (if pandemic doesn’t happen). If he acts not at all, he will either be blamed for many deaths or left alone to do his job as he has always done it. - no risk.

What would you do if you were in his shoes?

anon for now – at 10:06

Maybe (s)he prefers to keep the job in order to be of help when it happens?

Pixie – at 10:12

Goju – at 09:58 “What would you do if you were in his shoes?”

I’d look around at my fine New England town, realize that I was charged with the ultimate responsibility for the protection of the health and safety of these citizens, and realize too that I’d just run into the kind of “100-year event” that is legendary but not common in my profession.

If I didn’t make the decision right then and there to change jobs and go work for Bob Sharp or Pamby, I’d have no other option then than to forthrightly address the potential problem ahead and make sure my town was able as I can make it to withstand even this “100-year event” if it happens on my watch.

anon_22 – at 10:13

Goju,

I think you’ve hit the nail on the head. That the small town PH official is really caught between the rock and a hard place. Hopefully the latest research findings will help him some. But Pixie is also right in that there is a big disconnect, and I see that as the crucial task ahead of us in the next couple of months.

I think for the US, this is the time to take the most credible messages that we are getting from the scientists, and bring them to the attention of local PH officials. To say to them, its not just me saying it, but this is the advice that the highest level of government is getting. It hasn’t filtered down to you yet, but if we have a pandemic soon, you won’t have time to wait for that.

If you don’t want to have to change your plans every 2 months cos of what will filter down later on, you better pay attention to this and start altering your plans in that direction. Start getting people on board, cos you will have your job cut out doing that, and you won’t have enough time.

If and when TSHTF, the public will not forgive you for saying you didn’t have enough time to implement things, cos all they will see is that the information was available by November 2006, so why haven’t you done anything with it.

anon for now – at 10:14

I’ve copied Goju’s and anon-for-now’s posts above over to Forum.TheRoleOfLocalPublicHealthOfficials. I think they belong there - correct me if what I’ve done is not apropriate, please.

Pixie – at 10:17

anon for now – at 10:06 “Maybe (s)he prefers to keep the job in order to be of help when it happens?”

Honestly, anon for now, that’s why we need the highest levels of public health officials to give the clear and direct message that it is “ok” for the local public health guys to move on this issue of pandemic preparedness. If they receive a clear and consistent message from their leadership, there is less of a chance that any individual public health officers on the local level will get thrown under the bus. If they take a “we are all in it together” stance, it is win/win for them all. But then there’s got to be unity there, and clear leadership.

anon_22 – at 10:31

On the subject of keeping their jobs, the small town PH official needs to know that what’s at stake is more than that. As I said to the IOM Committee, losing a child is the biggest trauma that can happen to people. Bereaved parents will want to find fault, and when they know that there were recommendations by credible scientists for early school closure, and the local PH official didn’t do that, the anger is likely to be directed towards these officials personally.

You wouldn’t want to be living in a town where a group of such angry parents think you responsible for their children being dead.

(caveat: this message needs be to every ph official but for legal reasons delivered in way so its not a threat or intimidation)

Jane – at 11:39

anon_22, I’ve been trying to copy the beginning of this thread to take to City Hall, but the graphs don’t copy with the text. I’ve tried apple/c into my email and apple/c into Word, no luck. It copied onto my desktop, though, but still wouldn’t go into email. Do you have any suggestions? (This is great stuff, btw—thanks!)

Mari – at 11:45

Jane – at 11:39 - Try right clicking on a graphic, and chose the “save picture as” option. Worked for me.

Jane – at 12:01

Mari, thanks, it copied the addresses for the 3 graphics and once, after a lot of noise, copied a graph. It takes 5 fingers to do it! So one is on my desktop now. (The noises were alarming, like a warning. :( )

anon_22 – at 13:14

Jane, the slides are from the link on my 07:08 post.

Edna Mode – at 19:28

anon_22 – at 10:13 I think you’ve hit the nail on the head. That the small town PH official is really caught between the rock and a hard place. Hopefully the latest research findings will help him some. But Pixie is also right in that there is a big disconnect, and I see that as the crucial task ahead of us in the next couple of months. I think for the US, this is the time to take the most credible messages that we are getting from the scientists, and bring them to the attention of local PH officials.

I’m not sure if the people posting on this topic understand what I am about to say but haven’t articulated it. I suspect they do. In the event that they don’t, it may help some here strategize their attack plan.

In my lovely New England town, the “public health official” is a retired 90+ year old physician who retains the position out of courtesy. Basically, the good ol’ townfolk are waiting for him to kick the can. So, for all practical purposes, we have no public health official in our town. Nor do we have an emergency response planner. We have a town planner responsible for all municipal planning. Municipal. not school. And there is a distinction.

In NH (which is unique in the way it handles this), the school districts are independent of the town/city planning processes. Town Meeting and School District Meeting are held on separate days for voters to authorize separate budgets and elect officers. The town does not dictate anything to the schools.

In some communities, no doubt, the town/city public health planners may (hopefully!) be coordinating with school officials. However, in all likelihood, if school closure isn’t being discussed in town, it’s because the school board and superintendent are not discussing it.

I plan to focus my energies on our school board. I don’t have high hopes, but I’m going to give it a shot. I think the combination of the DVD from the Ed Department and the info that anon_22 has posted in this thread make a compelling argument.

Speaking of which, anon_22, my school board meeting is Thur. p.m. If there is anything you feel needs to be further clarified (you’d mentioned you would rethink and post later), let me know.

anon_22 – at 20:36

Edna Mode,

I’m waiting to get the slides from the IOM meeting. I’ve emailed them but that might take a while. In the meantime, the only thing that I would add is that the fear of increasing crime rates due to kids roaming the streets are not substantiated by statistics.

This slide shows that there are more violent crimes by juveniles on school days than non-school days, while this one shows that shoplifting remains more-or-less the same.


Source

blockquote>

anon_22 – at 20:44

Also, read this Kick Out The Kids, Bring In The Sales. A lot of malls already have this policy of banning kids and teens without adult supervision during certain hours. During a pandemic, they could very easily just expand that policy to cover all hours, so that only those kids with adult supervision and therefore consent can go to the mall.

anon_22 – at 20:51

Edna Mode, I would suggest that you go through the slides from the link at my 07:08 post in sequence, cos the logic of the argument is all there.

For the purpose of explaining to school boards, just talk about different approaches for mild, moderate, and severe pandemics without going into what those CFR percentages mean. This would help to reassure those who are worried that you want to use the strictest interventions in case of a mild pandemic. J

ust tell them we need to prepare for all scenarios so we know we can cover all possibilities, and exactly which interventions to use will depend on how the pandemic unfolds. The key is this: pandemics happen so quickly there won’t be time to come up with new policies, so they need to be prepared for all the different scenarios, with flow-charts etc, so that they have sets of interventions that are ready-to-go at a moment’s notice.

LauraB – at 21:14

Edna - I live in exactly the same kind of town in CT. Our PHO is a part-timer who doesn’t return phone calls. He’s not a bad person, but he’s just one person who juggles lots of balls. The town has no real government, no leader like a mayor, etc. to take charge (well, there’s a 1st Slectman but he’s useless too). Soooooooo furstrating trying to get anyone to do anything.

Edna Mode – at 21:17

Thanks, anon_22. Keep me posted on the slides. My contact at the ed department said the DVDs should have arrived today. They did not. If they don’t arrive tomorrow or Thursday, I may defer until the December school board meeting. I would prefer to get the ball rolling now, but I don’t want to go in half-cocked.

I know you hear this ad nauseum from grateful wikians, but I deeply appreciate the enormous amount of time you put into sharing this and other information here on the wiki.

anon_22 – at 21:58

Edna Mode – at 21:17 Thanks, anon_22. Keep me posted on the slides. My contact at the ed department said the DVDs should have arrived today. They did not. If they don’t arrive tomorrow or Thursday, I may defer until the December school board meeting. I would prefer to get the ball rolling now, but I don’t want to go in half-cocked.

You might consider going in now, and say that this is preliminary information and you will keep them posted. It is difficult for people to get everything in one go, they will need repeated reinforcements and explanations. Plus saying this right from the beginning gives you the opportunity for follow-up, whether or not they bought your ‘pitch’ the first time.

Edna Mode – at 22:49

anon_22 – at 21:58

Good point, and one that I had considered. I also think the reception may be better if I don’t go in with all guns blazing.

01 November 2006

crfullmoon – at 08:16

anon_22 – at 20:51

“The key is this: pandemics happen so quickly there won’t be time to come up with new policies, so they need to be prepared for all the different scenarios, with flow-charts etc, so that they have sets of interventions that are ready-to-go at a moment’s notice.”

Edna Mode – at 08:20

LauraB – at 21:14

I hear your frustration!

Are you going to try to do anything in your area in re: talking to the school officials about TLC?

Our state is broken into 19 all hazards regions, each of which is responsible for developing a pandemic plan for the region. When I e-mailed our region’s contact to ask her about school closures, she invited me in to meet. I, frankly, think she was throwing up a barrier hoping I would be too shy to meet. Ha-ha. We are meeting on Tuesday. She did tell me by e-mail that school closure will be up to each individual superintendent based on advice from the state that, as yet, hasn’t been decided. I’m also going to a school board meeting to discuss TLC this week. I’m nervous, but I feel like I have to do it.

I hope more people here follow up on the TLC information and try to present it to their local school boards. It’s an uphill battle, but at least we can try.

janetn – at 10:25

One of the biggest problems is going to be the patchwork of local districts with totally different plans. One district might be on the ball and close schools early. But the nieghboring district may choose to stay open. As we know viruses dont respect boundries, therefore the nieghboring district that chooses to stay open is going to effect the transmission rate of the population in the district that closed early.

From what Ive seen the decision to close the schools is going to be left up to the local officials. This is an error IMO. The states need to show some leadership. Im afraid the reason they are passing the buck is they dont want the fallout for whatever decision is made to be on their heads. The sad thing is that this lack of leadership is going to cost many of this nations children their lives and John Q public is going to demand heads roll. So the lackof leadership in passing the buckthem anyway. Just kill more people and drag the infrastructure into meltdown.

Kathy in FL – at 10:52

anon_22

I’m going to go back and read this thread more closely, but a couple of questions spring to mind.

1. As homeschoolers, my family will not be as directly affected by school transmission as some families; however, they attend other activities such as sporting events, academic clubs, and faith-based groups where they do come in contact with students from a traditional classroom setting … sometimes in large numbers. Does those types of contact negate any “security” that homeschooling affords us?

2. Do your transmission figures account for non-school and non-workplace exposure … e.g. church, clubs, etc.?

Sniffles – at 11:07

What I have found is that the schools in my area are not doing much planning because the local health officers would be the ones making the closure decisions. The local health officers are waiting for some guidance regarding how to handle this situation (should it arise) from the state health dept. The state health dept. is waiting for guidance on school closures from CDC who is currently reviewing when and how to close schools, but who knows when (or if) this will be written up and given to state health depts.

In other words, everyone is waiting for someone else to make the decisions for them (because they are either too afraid of making the wrong decision or do not want to have to fight with local businesses/politicians about the decisions they have made) and nothing is getting done.

lugon – at 11:14

Kathy in FL, I think the key word here is “layered”, and I guess by homeschooling you’re already done with step one. You may want to get ready for steps two etc. Contact other homeschoolers if you can - at the highest level you can get to!

lugon – at 11:17

Sniffles, I think we need to look for effective leverage points here. Opinions will be used if they are brought to the apropriate forums. Those of us who can’t be there ourselves should contact our networks. What are those networks? How can we contact them? Those are the key questions at this stage, IMO.

lugon – at 11:21

lugon – at 11:17: Sniffles, I think we need to look for effective leverage points here. Opinions will be used if they are brought to the apropriate forums. Those of us who can’t be there ourselves should contact our networks. What are those networks? How can we contact them? Those are the key questions at this stage, IMO.

Please go to Forum.ThePublicEngagementProjectOnCommunityControlMeasuresRegisterNow and look for 01 November 2006. It’s right there (copied for your convenience!):

Is anyone going to the Seattle one? The above posts about Atlanta tells us that they are quite keen on getting input from the public but especially knowledgeable folks who read FluWiki. So if you are at all able to go, here’s the info:

WHEN:: Saturday, November 4, 2006 | 9 am to 3 pm

WHERE:: Northgate Community Center, 10510 5th Avenue NE, Seattle (across from Macy’s at Northgate Mall) FEE: free of charge, with breakfast, lunch & refreshments provided.


PARKING: Parking is free at the Northgate Community Center, or across the street at Northgate Mall. The Northgate Park & Ride is 3 blocks away.

REGIISTER:: To register for this important citizen group, please call Public Health-Seattle & King County at 206–296–4313, or 1–800–219–6670.

To register on-line: please go to www.metrokc.gov/health/panfluforum

To register by fax: complete form on back and fax to 303–468–8866.

To register by e-mail: send information requested on back of form to strujillo@keystone.org

Make us all heard!

lugon – at 11:23

Please go to Forum.ThePublicEngagementProjectOnCommunityControlMeasuresRegisterNow and leave your comments there. Some people are already planning to go! So go help ‘em!

Snowhound1 – at 11:28

I put this on the “How many kids will die in a 1918 scenario” thread, which was also started by Anon_22, but I also think it is pertinent to this discussion about school closures..

The School Lunch Program subsidizes lunches (4.7 billion in fiscal year 2002) to children in about 6,000 RCCIs and almost all schools (93,000). During fiscal year 2002, average daily participation was 28 million students (57 percent of the children enrolled in participating schools and RCCIs); of these, 48 percent received free lunches, and 9 percent ate reduced-price lunches (Table 15-LUNCHANDBREAKFAST-1). The remainder were served full-price (but still subsidized) meals.

http://tinyurl.com/y...

How are we supposed to feed 28 million kids?

Communities need to be thinking about food reserves, distribution, etc. Particularly if they close schools. Vaccines and anti virals aren’t going to mean a thing if there is nothing for people to eat or drink. I can’t think of a single scenario that is likely to “work” as it is a little like “cutting off the nose to spite the face.” These kids’ families don’t have even have a days worth of food much less 2–3 days worth of food and water, and the rest of society isn’t much better off..


Closing schools may help flatten the curve, but will cause its own set of depressing consequences as well.

anon_22 – at 11:55

Kathy in FL – at 10:52

1. As homeschoolers, my family will not be as directly affected by school transmission as some families; however, they attend other activities such as sporting events, academic clubs, and faith-based groups where they do come in contact with students from a traditional classroom setting … sometimes in large numbers. Does those types of contact negate any “security” that homeschooling affords us?

2. Do your transmission figures account for non-school and non-workplace exposure … e.g. church, clubs, etc.?

To some degree. The population density in a school is far higher than any other situation that you can put your kids in, so homeschoolers will have an advantage. However, if it was my kids, I would keep them home regardless.

If you look at the TLC model, every extra step adds extra benefit. Those events you are talking about would probably fall under general ‘social distancing’. But this diagram is for public health use, ie looking at it from the collective viewpoint. It is very hard to translate that into actual risk for specific individuals in specific environments. Just remember that kids mingling with other kids in enclosed spaces is generally a bad idea.

anon_22 – at 11:56

I am regretting spreading all this info over several threads. I’m going to hold answering questions for now and re-write a consolidated ‘model’ of what we are talking about.


anon_22 – at 11:57

But please do still post questions while i’m doing that, though. :-)

Sniffles – at 12:00

Snowhound1 – at 11:28 How are we supposed to feed 28 million kids?

I know this is going to sound harsh, but there is no realistic way we can feed these children should the schools close. You would have to congregate them in one location for mass feedings, which negates the reason why the school closed in the first place. I am also sorry to say that providing food vouchers (or other form of food purchase - like a pandemic food stamp) may also not work for these families in order to have minimal food at home. Vouchers will not guarantee that any food would be left to be eaten during the time of a pandemic. For example, if a certain number of day’s food were provided and it was eaten prior to a pandemic, would those children still go hungry?

Even now, some school nurses are packing food into backpacks for children to take home with them so that they and their siblings do not go hungry over long weekends. They are sent home with bread, peanut butter, and other easy to serve foods that the children can make themselves. At the local, state and even federal levels, we do not have the food resources to give all of them food like this.

Another issue that will arise should a pandemic occur is that you cannot only give food to the poor. Many middle and upper class people who have not prepared and will not have access to food anymore should the grocery stores close will want access to that food too for their families. You will have a big fight on your hands once this gets started.

These problems might be some of the very reasons why this decision has been avoided so much.

Kathy in FL – at 12:26


The reason I asked is that if I am going to effectively communicate risk to the home educators in my area … as well as nationally as I have some contacts in that area … I have to address specific concerns.

Unfortunately, too often when a group pulls out of one “risk area” they often begin to feel “risk free.” By showing that home educators haven’t really dodged the bullet … though they may have addressed one “layer” of the threat … I’ll communicate the risk more effectively.

For a while there was a tendancy in the homeschooling community to think that since they homeschooled, they no longer had a need to have any interest in the public education system. This has proven to be far from the truth and now a lot of home educators maintain ties to and are active in the public educational arena.

I believe that this will be one area where - perhaps - we can help. School closures make sense on a variety of levels, but there are a lot of practical issues that need to be addressed as well.

Some areas that we might be able to help to brainstorm plans for:

  • Childcare during educational activities for those siblings too young to participate
  • Teaching and reaching multi-age groups in the same room or on the same lesson<
  • Free and low-cost educational resources
  • Sibling interaction and household discipline
  • Decompression issues of moving from a classroom setting to a home setting for educational purposes
  • Addressing learning styles (i.e., auditory, visual, kinetic, etc.)
  • How to maintain a portfolio for proof of what has transpired during the home education program
  • How to get into college without a highschool diploma

Etc.

Snowhound1 – at 12:43

These problems might be some of the very reasons why this decision has been avoided so much. Exactly Sniffles @ 12:00!!

But at the same time, I think that when and if they try to close schools that there will be such a loud outcrying from the unprepared public, that it will cause a “dragging of the feet” by TPTB, realizing that they will be cutting a major lifeline if they close schools. Since “food and water” isn’t the number one priority I hear when reading state and local plans, it seems to me all plans will fail, since they are ignorning the number one necessity of life.

Look at the mindset here on the wiki, prep food and water, prep food and water, prep food and water…

The pandemic mindset and preparedness being put forth at international, national and state levels, (with the exception of a few) calls for social distancing, getting hospitals prepared, vaccines and stockpiling antivirals. They should be stockpiling food and water!

Basic needs should be the first priority because in the end, this WILL BE the MOST IMPORTANT aspect of communities being able to survive a pandemic… No one wants to be faced with this simple fact of life. No plan will be a good plan until this is the number one consideration. IMVHO

blockquote>

Edna Mode – at 12:47

lugon – at 11:21 Is anyone going to the Seattle one?


Yes. I believe JV said s/he was going to attend. Someone else said they were going to attend the Syracuse forum. However, no one is guaranteed of attendance at these forums. You have to fill out a demographic registration form and the sponsors are picking a demographically representative group from all registrants.

lugon – at 14:15

the sponsors are picking a demographically representative group from all registrants.

Sounds like a “let’s flood them, then”, situation, no? :-)

anonymous – at 16:05

I throught this might be about the cable channel? SMILE.

crfullmoon – at 17:05

The Learning Channel for Total Local Continuity during a pandemic year:

Targeted Layered Containment

(where’s your nickname for next time, anonymous?) :-)

10 November 2006
hpw – at 20:33

bump.

11 November 2006

crfullmoon – at 10:31

I hope tptb don’t “plandemic” this idea to death and not show it to the public in time for any buy-in and preparation to occur before pandemic breaks out.

I heard Dr.Nabarro - more than two years ago: he’s always made more common sense than what my locals are still omitting, or, falsely reassurring the public about…

anon_22 – at 11:17

I believe the consultation will wrap up in December.

17 November 2006
anon_22 – at 19:28

bump

21 November 2006

anon_22 – at 09:23

I haven’t had time to write this up till now. The following is a discussion on the effects of combining various mitigation strategies.

See this slide (opens in new window) for Description of interventions

/

anon_22 – at 09:42

Basically, the modelers at Los Alamos started with a 71% infected attack rate scenario (=2x illness attack rate), and add various interventions singly or in combination.

Reading across the chart, you can see that just closing schools (S) only brings it down to 62%, but combining that with keeping kids and teenagers at home (CTsd), or what they call protective sequestration in some slides, brings a dramatic drop to 17%.

If you add adult and seniors social distancing (ASsd), defined as ‘all non-household, non-work contacts between adults and seniors reduced by 90%, work contacts reduced by 50%, household contacts doubled’, brings the attack rate down to 5%.

Adding antiviral treatment of cases (T) alone brings it down to 3%, while quarantine (Q) alone gives you 4%.

However, combining Q and T brings it further down to 2%.

Then you can have the various combinations of antiviral prophylaxis, which reduces the attack rate some more if not combined with all the social distancing and school closure measures. But if you have all of them (S+CTsd+ASsd), there is no further benefit, at least assuming actual conditions reflect these models.

Notice that none of these scenarios or combination of scenarios require full SIP for the whole family. This is important because we know that 99.9% of people will not be properly provisioned for a sustained (eg 12 week) SIP right now, and I personally am not optimistic about getting a significant percentage of people to prep to that extent.

anon_22 – at 10:27

For those who are more graphically inclined, these results can also be seen as a 3D chart.

lugon – at 10:32

SIP is overvalued.

lugon hides from flames

anon_22 – at 10:46

LOL

22 November 2006

anon_22 – at 12:39

Just wanted to add one more important point to this discussion:

Notice that the effect of these interventions do not depend on CFR. ie they work regardly of how lethal the virus is. In fact, it is likely that the higher the CFR, the higher the success rate cos of increased compliance.

Flumonitor – at 14:17

Interesting point on UK discussions higher up in the thread. There is some debate in the UK over school closures, becuase of the potential added affects on staff and workplace absenteeisim. The UK appears to be adopting strategies (or there are arguments at least) that attempt to assume ‘business as normal’ during a pandemic and an assumption that all will continue to run. Ot at least if that is the assumption, more effort will be made to ensure a status quo is maintained, and keep the country running.

I suspect this stems from a base assumption that the pandemic would be relatively mild, and I think it is from here that the present policies, as per the UK press announcement today see FW thread http://tinyurl.com/s... are arising. In this news report it suggests that a pandemic would have to break out BEFORE UK citizens are told to prepare. (i.e at very short notice). ‘If everything is running as normal, then there is no need for preps’ is where the logic might stem from. It doesn’t however legislate for what other countries may do in these circumstances, and trusts that import lines will remain both efficient and open.

However, getting back to the point of this thread, in the UK school closure is still only being ‘considered’ in most planning documents. I hope that this policy attitude is soon revised - and on the bright side, at least SMEs are getting some direction for the first time, which at least some progress!

anon_22 – at 19:23

Flumonitor – at 14:17

Ferguson has a lot of influence in the UK. I think he may still be making up his mind.

Argyll – at 19:42

Anon_22,

Do we have any idea what single factor will likely demand across-the-board school closures? What is the point of trigger?

Many Thanks,

Argyll.

Dr Dave – at 19:52

Argyll,

According to my sources, the trigger for the closure of a college or university in the U.S.A. is 1 confirmed case on campus. To my knowledge, how an east coast school will react to a west coast closing, for example, has not been addressed.

anon_22 – at 19:56

Argyll – at 19:42

Anon_22,

Do we have any idea what single factor will likely demand across-the-board school closures? What is the point of trigger?

I believe the current suggestion is confirmation of the first case in a community. How one defines ‘community’ and ‘confirmation’ is probably still up for debate. And whether that will be adopted is not a sure thing.

anon_22 – at 19:59

Dr Dave – at 19:52

Argyll,

According to my sources, the trigger for the closure of a college or university in the U.S.A. is 1 confirmed case on campus. To my knowledge, how an east coast school will react to a west coast closing, for example, has not been addressed.

I hope they change that. College students fall into one of the highest risk age groups. And with dorm living and so on, it will be a nightmare.

When the first case is confirmed, there will be at least 2–3 generations of cases. How many people on a crowded campus will already be infected? Then we send them home, all over the country…..

anon_22 – at 20:03

In fact, this raises an issue we didn’t talk about before, migration of people from neighboring communities. That is one big factor in failure of any mitigation measures.

To the extent that most college students do not live locally, I would suggest that we consider closing all colleges with confirmation of the first case in the state, and not just a town or county.

ie Colleges should close even earlier than schools.

ANON-YYZ – at 20:05

Dr Dave – at 19:52

If it’s not pandemic yet i.e phase 6, 5, or 4, then it is not totally unreasonable.

If it’s already a declared pandemic, one confirmed case may mean many already infected. Students will be travelling to many different communities. Will they even be allowed to travel?

Dr Dave – at 20:20

To reiterate, my sources have told me that just 1 confirmed case will be the trigger for most colleges and universites. Any campus with a confirmed case will shut down immediately and the students will be sent home. Period. I have had some discussions about the rationale and I understand it to be as follows: 1) the schools do not have the legal right to quarantine thousands of people; and, 2) they are unwilling to incur the medical burden/liability of caring for sick students. They do realize, however, that they may be sending asymptomatic but infected people back to their home communities.

anon_22 – at 20:24

Dr Dave – at 20:20

I understand. In that case, it may be a decision that needs to be taken at a different level than the colleges.

ANON-YYZ – at 20:25

Dr Dave – at 20:20

They do realize, however, that they may be sending asymptomatic but infected people back to their home communities.

Then they should also realize that the plan will fail from the get go. There will be restrictions of movements, especially from an area with a confirmed case. This is worse than failing to plan. This is planning to fail.

anon_22 – at 20:46

ANON-YYZ – at 20:25

Well, plans are still evolving. Let’s help them, not condemn them. :-)

Dr Dave – at 20:57

ANON-YYZ,

My son is at one of these universities, but he has his own PPE, his own car, and multiple routes for making his way back home. After he arrives, we’ll put him in quarantine for about a week. Those without cars may be stranded.

ANON-YYZ – at 21:53

Dr Dave – at 20:57

I just read a news article in the new forum about how difficult it is to detect H5N1 infected patients. I wish your son safe. I have similar situation.

The concern is some routes will be blocked, gas stations may close, and most students and their parents are not prepped. College students will be playing the same role in the next pandemic as soldiers did in 1918. I hope public health authorities address this issue soon.

Argyll – at 22:27

Thanks to all of you for your excellent posts. I have a child that is a freshman in college. This perhaps is the single most important reason I have followed the avian flu developments so closely. The school my child goes to is very proactive and has been pandemic planning since the fall of 2005.

Last fall, I googled univesities and colleges from around the country and sent them a college-oriented brochure that was aimed at college students. I sent it (along with pandemic planners) to 100 or so universities/colleges.

I do feel strongly about early college closure. College students living in such close proximity to one other is tricky. I have stayed in close contact with the university my daughter attends and their pandemic plans are pretty detailed. However, I do worry about travel restrictions —even 3 hours away. I feel strongly that preventative measures —beforehand — will play a key role in helping to combat a potential influenza pandemic.

Argyll.

Argyll – at 22:32

A question about travel restrictions — how detailed are they? Will they close down roads or highways early on? We do have 2 routes mapped out for my daughter, along with the PPE’s for SIP.

Any idea about how they might maintain travel restrictions if needed? Are gates needed?

Argyll.

23 November 2006

Dr Dave – at 07:19

Argyll,

My freshman son is 2 1/2 hour away, assuming that he can still use the interstate highways. As ANON-YYZ has pointed out, detection could make or break a school closing plan, and that will impact the overall TLC plan.

anon_22 – at 10:24

Argyll – at 22:32

A question about travel restrictions — how detailed are they? Will they close down roads or highways early on? We do have 2 routes mapped out for my daughter, along with the PPE’s for SIP.

Any idea about how they might maintain travel restrictions if needed? Are gates needed?

I haven’t seen any plans for closing roads or highways, although whether local government might do that is another story. I personally don’t think that is feasible, and is a bad use of manpower for a project that is doomed to fail and will polarize people unnecessarily.

Argyll – at 12:17

Thanks to all of you for your wonderful posts. This is an important topic and I am very grateful for your responses.

Argyll.


 
 



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


wikipage in need of further edit
This wikipage is in need of further edit power!

I've scribbled a printout with many ideas, and I think the page could be reworked.  I hope I'll have time to do it later.  I think I'll work at a sandbox2 and then port it over to the final place.

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


actually, wikipage being worked on in a different temporary place
http://www.fluwikie....

I don't know if or how to finish it. :(

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


[ Parent ]
biosurevillance to support TLC
I was especially interested in the doubling time assumptions and the IOM meeting information (which didn't show when I pressed the link.  Looking forward to that).
If the onset is as rapid as you say, and the response needs to be done before the population affected hits one percent, that sets a demanding requirement for biosurveilalnce systems.  One week's delay in detection of a community outbreak could lead to countermeasures proving ineffective, if I read your briefing correctly. 
I wanted to note that there are anomaly detection algorithms out there that have been evaluated that may pick up outbreaks on the first day using syndromic data from hospitals that routinely report electronically.  These detection algortihms used ICD-9 codes for the evaluation.  However, practical systems employed today often use natural language processors to bin chief complaints, recorded by triage nurses in EDs, into relevant syndromes, such as respiratory illness, rather than waiting for coding (such as most data in BioSense uses, for instance).  There are a number of metro areas in the US with the requisite detection systems and adequate hospital coverage, but that is certainly not the norm.  An article summarizing the detection algorithm evaluation may be found in MMWR 53 Bio-ALIRT Biosurveillance Detection Algorithm Evaluation...
www.cdc.gov/MMWR/preview/mmwrhtml/su5301a29.htm 

thanks c3rberus
Surveillance is a key piece of the equation to track the extent of the outbreak once it has started. 

However, for the purpose of TLC, the onset of an outbreak of flu is so quick that IMO, once a pandemic is under way, trying to detect the first case anywhere is like trying to catch a falling knife.  There is likely to be so much background noise that a lot of resources may be wasted just trying to chase this. 

I'm not saying we shouldn't do it.  But be aware that while this looks good in principle, chances are once we know that there is efficient h2h overseas (assuming that's where it starts), AND detection of the first case in the country, the window for effective action is so small that local communities will have a hard time figuring out when to 'pull the trigger', so to speak. 

That's why there is an argument for starting the NPI's including especially school closure on detection of the first case in the country.  However, we need to be aware also that any single trigger that is pulled will result in a cascade of events which may spiral out of control. 

So any pandemic plan that details staged responses are, well, just plans.  We still need to make them for the purpose of teasing out where the bugs are, and for everyone to know what they are supposed to do.  But come the real thing, after the first 5 min, all plans will become waste paper, IMHO.



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


[ Parent ]
metro surveillance in an outbreak
Hi, Susan
There certainly is a case to be made for closing schools and implementing other strict containment measures as soon as the first H2H case is diagnosed in the US.  However, how sustainable are those containment measures?  (And why not when the first case is diagnosed anywhere?) Apartments can seem pretty small after even a day or two.  Los Alamos models (EPICAST) for one have indicated that panflu will burn its way through US in about 2 months once it starts here.  However, peak in a community may last for several weeks.  My point was that properly implemented syndromic systems could provide a flu "weather report" on a given day as to just how bad the current situation was (whether an outbreak had started in the metro area or not), so people could decide for themselves (or health authorities could) what measures to adopt in the circumstances.  Of course, those who have thought far enough ahead, and have the resources, could SIP for the duration.  But many people may not have that option, or not choose to make that decision.

[ Parent ]
theory vs practice
I agree with you on the need for syndromic surveillance and so on. I'm just warning that often times the existence of a so-called 'warning system' lulls people into a sense of complacency cos they think they can depend on it. 

There is a chance that at the beginning of a pandemic, you will get over-reporting because of fear in areas where there are no cases, and/or under-reporting in places where they are so overwhelmed that all efforts are diverted towards saving lives and triaging cases than the less immediately urgent business of reporting. 

This is something that might be good in principle, and I'm all for doing it, but it will have a high chance of failure in a rapidly evolving, mass casualty situation with possible infrastructure breakdown.  As a warning to individuals for SIP, the system would fail when those relying on the information may not know that those supplying the information are overwhelmed.

The whole thing needs to be tested and tested again and tested again....



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


[ Parent ]
...
too..  the trend data would reflect symptomatic patients, not infected people..  someone coming out of SIP based on a "weather report" will be coming into contact with the infected people that the surveillance won't show until they become symptomatic and seek care.  there would be a lag on the accuracy of the data - looking back it would be good, looking at now would be uncertain.

[ Parent ]
the biosurveillance money pit
also check this out http://www.govhealth...



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


[ Parent ]
...
using the analogy of a weather report, most people look at the weather forecast, not what the weather was 48 hrs ago; with infected people showing no symptoms for 48 hrs, the surveillance (assuming accurate reporting) shows the people infected in the past, not the people infected now.  for a process that is in control, trending may be predictive; i personally believe this will be an out of control process - wrapping metrics around it will be problematic, and for a number of people, those problems may be fatal.

[ Parent ]
more on surveillance
Hi, Susan and c3jmp

I absolutely agree that biosurveillance is new and needs additional testing and development.  However, I made sure in my first post to include a pointer to a journal article that seems to demonstrate that the concept could work and detection technology exists to implement it.  In that quantitative evaluation, the best algorithms were able to detect flu outbreaks on the first day.  Current generation systems used automated reporting by monitoring a limited number of fields in hospital HL-7 format messages, and then using natural language processing to bin chief complaints into syndromes of interest, like respiratory, and perform statistical analysis on them in search of anomalies.  Older systems, that required human intervention, were found to be impractical.

In your TLC concept description, you would aappear to require a trigger point for activation of your plan, including shutting the schools.  Medical surveillance systems can provide an objective measure that that time is upon us.  Prior to that, they can, in theory, provide some amount of "negative reassurance" that the outbreak had not hit the locality yet.  That may be very important in that the most focused preparation by the general population will be going on during that time:  when the threat is quite real, but before it strikes precisely.  My use of the term "flu weather report" was intended to provide some sort of general information on whether an outbreak had yet hit a particular locality, certainly not the kind of fine tuning one finds in actual weather reports today.  Perhaps syndromic surrveillance would have high enough resolution  to inform several different levels of precautionary steps one might wish to take, but it wouldn't support fine differences.

Prior to a pandemic, some sophisticated syndromic systems can help distinguish between a seasonal outbreak and something more alarming by comparing different data sources to baselines established previously during "normal outbreaks."

In an actual pandemic, once it strikes an area, most syndromic syestems there will overload fairly quickly.  One approach, BioSense-RealTime, that monitors more in-depth data, will probably stand up longer.  However, there are relatively quite few of those installed currently.  Nevertheless, they can also be expected to be overcome as hospitals saturate in the first week or two.

In your TLC description, there also appeared to be a requirement to determine when the outbreak is actually over.  If systems such as BioSense-RT start to "come up" again as the outbreak lessens and they are no longer overwhelmed with "signal", they could presumably help to make a somewhat objective indication about just where the community stands, so that any important restrictions are not lifted prematurely.

I think the particular artcle Susan listed is generally a very good one.  (I take issue with the headline writer claiming that "$Billions" have been spent on biosurveillance; but certainly millions have, although the environmental sampling component of biosurveillance seems to cost a lot more than computer analysis of existing data streams. 

That being said, one of my points is that to meet the performance requirements that you all seem to be coming up with to make TLC work, syndromic surveillance needs to be the subject of some focused attention to assure that it is meeting those requirements.  I see it as an important enabler of the kind of public health approach you all are describing.  c3jmp is correct that syndromic picks up symptoms, so that it may be delayed by 48 hours from the initial exposure.  However, that time period is a great deal less than what we otherwise have "out there" today, and the approach may prove useful.


[ Parent ]
...
i have no argument that it may prove useful technology, nor that it may be an advance over current capabilities.

my concern is the potential misinterpretation of what is being reported; even if the system is reporting in near real time,  it remains limited to the accuracy and timeliness of its input data. if people interpret the reported risk as being current risk, they may place themselves and others in greater danger based on what they believe to have been a current assessment. 

there is another thread here that looks at how the numbers may change over time.  quite a bit can change fairly fast - 48 hrs can make a dramatic difference.

http://www.newfluwik...

i would certainly advocate gathering as much data as we can through this; it will happen again.


[ Parent ]
thanks to both of you, c3rberus & c3jmp
The information is very valuable.  We definitely need to develop this much further.  I personally think we need to do everything, but at the same time be very aware of the limitations, especially at the beginning of an outbreak, where there will be far too many false positives as well as false negatives.  However, it is only when we use it that we can collect enough data for evaluation for future use. 

For monitoring progress and to ascertain when the outbreak finishes, this will definitely be very useful. 



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


[ Parent ]
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