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Unpacking the Interim Pre-pandemic Planning Guidance

by: SusanC

Mon Feb 05, 2007 at 03:13:36 AM EST


Community Strategy for Pandemic Influenza Mitigation in the US - Early, Targeted, Layered Use of Nonpharmaceutical Interventions
SusanC :: Unpacking the Interim Pre-pandemic Planning Guidance
This diary attempts to summarize in bullet-point form the major components of the recent interim NPI guidance.  The intention is to make it easier for everyone to figure out what is contained in the document, and to have a coherent debate.  It is, however, not complete.  In addition, I have highlighted certain points that do not fall under specific categories and may otherwise be missed.
Download document here http://www.pandemicf...
Definition of worst case scenario from IOM report: A severe pandemic in a fully susceptible population, such as the 1918 pandemic or one of even greater severity, with limited quantities of antiviral medications and pre-pandemic vaccine.

What it is:
  • Interim planning guidance
    • Interim - provisional or temporary
    • Guidance - advice or information aimed at resolving a problem or difficulty
    • To be used by state and local PH for pandemic planning for communities
  • With mechanisms set up for further consultation and feedback based on community engagement and exercises, which are intended to explore any adverse consequences and strategies to mitigate them.
  • Such feedback will be incorporated into later updates, which will also include latest information from ongoing research.  The guidance and recommendations will be refined and improved over time.
What it is not:
  • Federally mandated policy
  • An assessment of possibility or imminence of a pandemic
  • An assessment of the severity of the next pandemic
  • Prediction of future
  • Set in stone

What it also is:

  • Based on current limited understanding of past influenza pandemics and their consequences
  • Based on current best guess by modelers
  • Based on limited but increasing historical data
  • Fully documented with 108 references
  • The result of collaboration between the following agencies/organizations and the CDC
    • Department of Health and Human Services
    • Department of Commerce
    • Department of Defense
    • Department of Education
    • Department of Homeland Security
    • Department of the Interior
    • Department of Justice
    • Department of Labor
    • Department of State
    • Department of Transportation
    • Department of the Treasury
    • United States Department of Agriculture
    • United States Environmental Protection Agency
    • United States Office of Personnel Management
    • Department of Veterans Affairs
    • White House Homeland Security Council
    • Association of State and Territorial Health Officials
    • Council of State and Territorial Epidemiologists
    • Harvard School of Public Health
    • Infectious Diseases Society of America
    • Institute of Medicine
    • National Association of County and City Health Officials
    • National Association of Local Health Boards
    • MIDAS Modelers
    • University of Michigan
What it also is not:
  • A panacea for all pandemic-derived problems
  • A solution to inadequacies in the public health infrastructure
  • A solution to poverty and social inequity
  • An instrument of social and/or political reform
  • Without cost
  • Without consequences
  • Guaranteed to succeed automatically or easily
The goal:
The community strategy for pandemic influenza mitigation supports the goals of the Federal Government's response to pandemic influenza to
  • limit the spread of a pandemic;
  • mitigate disease, suffering, and death; and
  • sustain infrastructure and
  • lessen the impact to the economy and the functioning of society.
In a pandemic, the overarching public health imperative must be to reduce morbidity and mortality. From a public health perspective, if we fail to protect human health we are likely to fail in our goals of preserving societal function and mitigating the social and economic consequences of a severe pandemic.
The Interventions:
  1. Isolation and treatment (as appropriate) with influenza antiviral medications of all persons with confirmed or probable pandemic influenza.  Isolation may occur in the home or healthcare setting, depending on the severity of an individual's illness and/or the current capacity of the healthcare infrastructure.
  2. Voluntary home quarantine of members of households with confirmed or probable influenza case(s) and consideration of combining this intervention with the prophylactic use of antiviral medications, providing sufficient quantities of effective medications exist and that a feasible means of distributing them is in place.
  3. Dismissal of students from school (including public and private schools as well as colleges and universities) and school-based activities and closure of childcare programs, coupled with protecting children and teenagers through social distancing in the community to achieve reductions of out-of-school social contacts and community mixing.
  4. Use of social distancing measures to reduce contact among adults in the community and workplace, including, for example, cancellation of large public gatherings and alteration of workplace environments and schedules to decrease social density and preserve a healthy workplace to the greatest extent possible without disrupting essential services.  Enable institution of workplace leave policies that align incentives and facilitate adherence with the nonpharmaceutical interventions (NPIs) outlined above.
Pandemic Severity Index:
  • 5 discrete categories of increasing severity
  • using case fatality ratio CFR as critical driver
  • designed to enable estimation of the severity of a pandemic on a population level
  • use of mitigation interventions are matched to severity of pandemic
  • tool for local scenario-based contingency planning for pandemic preparedness
Interventions by Severity Click for bigger pic


Local Planning Considerations

  1. Not less than 12 weeks school closure for severe (Cat 4 & 5) pandemic ie threshold 1% CFR
  2. Trigger - laboratory confirmed cluster + community spread (ie > 1 household) at state or proximate epidemiological region
  3. Planning for 12 weeks of school closure in severe scenarios provides baseline level of readiness
  4. Milder scenarios become subset of these measures
  5. Cat 2-3 duration of NPI 4 weeks or less
  6. Cat 1-3 how much of NPI to use will depend on local epi parameters, risk assessment, availability of countermeasures, and local healthcare surge capacity
  7. Preparing for Cat 1 - 3 will include assessment of surge capacity, ability to deliver countermeasures, implementation readiness
  8. Escalation  of responses based on WHO and US govt pandemic staging
    • Alert - notification of personnel
    • Standby - initiate decision making process for imminent activation, including mobilization of personnel and resources
    • Activate - implementation
  9. For Cat 4,5
    • Alert = WHO stage 5/US govt stage 2 - confirmed human outbreak overseas
    • Standby = WHO stage 6/ US govt stage 3 - widespread human outbreaks in multiple locations overseas
    • US stage 4 - cases in US - standby except for location with cluster + community transmission
    • Activate = cluster + community transmission
  10. For Cat 1 - 3
    • Alert = US stage 3
    • Standby = US stage 4
    • Activate = cluster + community transmission
  11. Duration of implementation
    • 1918 - significantly associated with overall mortality rate
    • stopping or limiting implementation while virus was still circulating temporally associated with increased P& I deaths in many communities
    • For planning purposes - assume 12 weeks
  12. Planning to reduce consequences
    • Stay home cos family ill
    • Stay home to care for children
    • Education
    • School meals
    recommendation for 12 weeks preps page 53 "During a severe pandemic, it will be important for individuals and families to plan to have extra supplies on hand, as people may not be able to get to a store, stores may be out of supplies, and other services (e.g., community soup kitchens and food pantries) may be disrupted. Communities and families with school-age children who rely on school meal programs should anticipate and plan as best they can for a disruption of these services and school meal programs for up to 12 weeks."
  13. Pre-identify those who will find implementation most difficult, eg
    • people who live alone
    • poor/working poor
    • elderly [particularly those who are homebound]
    • homeless
    • recent immigrants
    • disabled
    • institutionalized, or incarcerated
  14. Planning guides available for
    • businesses and other employers
    • childcare programs
    • elementary and secondary schools
    • colleges and universities
    • faith-based and community organizations
    • individuals and families.
  15. Costs and  consequences of NPI
  16. Costs and consequences of not having pre-planned NPI -
    "The potential exists for such interventions to be implemented in an uncoordinated, untimely, and inconsistent manner that would impose economic and social costs similar to those imposed by strategically implemented interventions but with dramatically reduced effectiveness."
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jump-starting community preparedness
To my mind, the most important thing about this guidance is that it is going to put the ball squarely in the court of the local and state PH to take concerte action.  Now that the next steps are pretty much spelt out (prepare your community for 12 weeks school closure and everything related to that), it will be much harder for the shirkers and deniers to muddle through the next phase of pandemic prep.  Nor will it be easy to just do paper plans, since underlying the guidance is a set of very specific questions that local PH needs to find answers to eg identifying the vulnerable, exploring the consequences for these groups, and finding actual mitigation strategies for them.

A couple of comments in CIDRAP reflect this view.
http://www.cidrap.um...

"The community measures will pose "extraordinary challenges because they will totally alter people's lives, and no one in the United States has lived with those kinds of changes for nearly a century now," added Namkung, who is health officer for Santa Cruz County in California."

Jeffrey Duchin, MD, chief of communicable disease control for Seattle King County Public Health in Washington, praised the new guidance, while stressing that it means a lot of work not only for local public health but also for businesses, local organizations, families, and individuals.

"A huge amount of work needs to be done to survive the guidance, basically," he said. "I think this is necessary advice. But this is not a cakewalk. It's going to cause hardship, so people need to look at this guidance now and start planning for how they can do this."

Yes, Wake-Up Time has arrived...



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


Implementing guidance
"A huge amount of work needs to be done to survive the guidance, basically," he said. "I think this is necessary advice. But this is not a cakewalk. It's going to cause hardship, so people need to look at this guidance now and start planning for how they can do this."

////

And yet I haven't seen much risk communication out of the government, federal, state or local that would indicate this was a priority.

Frustrating.

-- "You're going to be staying home for one year. There will be no school, there will be no work... all we'll be doing is trying to keep ourselves alive." Richard Canas, NJ Homeland Security Director


[ Parent ]
same thing as Oct 2005; they were supposed to start then. n/t


[ Parent ]
thanks, SusanC
not surprisingly. this is a complex document that will take time to digest.

The focus now shifts to local/state review and implementation.

This is going to be a long march, not a sprint.But at least now there's fed guidance to refer back to. My local people are going to groan and ask lots of questions about "how are we...". But it's here and the process continues.


Complex - where are the simple steps?
Hi,

  Like DemFromCT, it is taking me a while to read through and digest the document.
  I was hoping for "Buy two or three canned products that have their exporation date - not a MFG code" There are several products that do not have either!
  Wash and save empty milk bottles to be used later for storing water.
  Try making bread with your kids. Try powdered or condensed milk.
  Rotate what is in the pantry according to expiraton date.

Kobie


[ Parent ]
clarification on 2% CFR
Many people have questioned or objected to the Pandemic Severity Index using 2% as Cat 5.  Their rationale is that 2% is nowhere near the worst case scenario, and we have to give people a real picture of what might happen to get them involved.

While I agree with the underlying paradigm, that 2% is not the worst case scenario, people need to be told the truth, and people need to get somewhat scared before they will pay attention, the pandemic severity index is designed to be used primarily as a planning tool.  Now you might say that, well, we need people to prepare for 20 30% CFR, and again I agree.  However, in this context, what most people miss is that

1) the CFR quoted is a threshold, not a ceiling.  What this scale means is that if there is a pandemic with a CFR of 1% or above (Cat 4), the recommendation would be that 12 week school closure would be activated.  ie 1%, close schools, 5% close schools, 20% close schools.

Now, since the intervention would be activated when the first confirmed cluster with community spread occur, and that's not a large no of cases, not enough to give you a valid CFR, you're going to have to depend on data from other places or countries that have already been affected, eg Indonesia.  What this will mean is that if there is a pandemic breaking out, with efficient h2h, and 100 people got infected in Indonesia and 2 died, and then a confirmed cluster involving more than 1 household occurs in your state, that would be the trigger to close schools! 

Notice that this maybe a very small cluster, of say 10-20 people in a whole state, and there doesn't have to be any deaths for you to activate the intervention.

2) In the context of NPI with voluntary compliance, 12 weeks school closure + protective sequestration of kids is just about the upper end of what is available to use.  ie if I had a couple more tools that I can use for even more severe scenarios that I wouldn't use in 2%, then it would make sense to create higher Categories.  Otherwise, if you are going to use the same intervention whether the CFR is 2% or 50%, then you don't need the higher Categories differentiation.  The recommendations here are already very complicated as they stand, we need to not add more complexities that are not relevant here.

Having said that, if the intention is to use the Severity index for other types of countermeasures as well, then in principle, the scale needs to reflect both the actual/likely CFR and operate at the same order of magnitude as the interventions considered.



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


what higher CFRs do and do not imply
I agree: with our current tool-box, an even higher CFR (say 5%, 10%, 20%) doesn't imply we'd be using other tools, simply because we have no more tools!

A higher CFR will mean more people will do as told, IN THE FUTURE.

But we'd like more people to do as suggested NOW (i.e. a higher degree of compliance in prepping).

So we also need to hammer the open-endedness of Cat5.

And maybe we need to put the full picture together: our civilisation is fragile, be it panflu or peakoil or global warming.  And we humans need to have fun while doing the right thing.  So we'd better get going! :-)

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


[ Parent ]
Bravo!

So we also need to hammer the open-endedness of Cat5.

But not to waste time and energy speculating how high it is and to be sucked into a fruitless debate, and delaying prepping action.

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.


[ Parent ]
One tool of deniers
is to suck the flu forums to push something extreme, in order to destroy credibility of proponents of preparation.

I vividly recall a moment when we were having a good discussion about forming a group to appeal to the government, and suddenly some one was talking about mushroom clouds.

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.


[ Parent ]
here's the slide from which
the concept of pandemic severity index can be seen more clearly.  So Cat 5 is actually the whole of the red area, and 1918 is on the lower end of that scale.





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


[ Parent ]
It's a good graph, but it will be better if CFR is the vertical axis n/t


You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
ooh! Good point! Someone, make it so, please! n/t


[ Parent ]
there are several separate issues addressed in this document
One concerns the levels needed for the triggers of NPI.  It's a real victory that these triggers have been set at a very low threshold, and those that worked so hard for them deserve our genuine thanks.

Another outstanding aspect stressed by the plan is that the more layered the NPI, the better.  There will not be a perfect result, but it's good to state the goal that a little is good, more is better, and that there is an exponential relationship there, not simply linear.

So far, the 2.5% CFR has been quoted widely.  Some involved with the creation of this document have stated that the deaths in the worst case scenario can be expected to be "up to" the 2.5% level.  My own state's planning scenarios end at the 2.5% CFR point as well.  I am willing to suspend judgment that the 2.5% will not be used as shorthand for what is possible, or as a cap.  But to do so, I'd like to see some state and federal plans that explicitly plan for a higher CFR event.  From a professional point of view, these guys should not be, and should not need to be, "scared" in order to do this - it's just their job.  They need to look at the data, and the data just is what it is.  If there is reasonable scientific reason to believe that a possible pandemic may unfold at any number of specific given levels of CFR, then I expect them to look at all those levels and plan for them. 

I do disagree with those who believe that there is nothing more that can be done, policy and planning wise, with a CFR that is higher than 2.5%. In New Orleans, failure to fully plan for the "outside" but possible was due to capping the thinking about solutions too early.  There are answers for these complex problems, even the really serious ones. The thing is, I am an optimist.  I think it can be done.  But to do so, we need to look at the valid possibilities.  That includes whatever levels of CFR may be (scientifically) possible, and the length and number of waves (Barry has criticized the document for not giving enough attention to the concept of multiple waves), or perhaps that there won't even be very discrete waves but a more drawn-out event (since our world differs greatly from 1918), or the possibility of a prolonged period between pandemic virus emergence and vax.  These are complex problems, yes, but they need to be considered, just because the data says we should consider them.  And, like I said, I am an optimist, so I think if we do, we can handle them.  :-)


[ Parent ]
more lowdown on CFR's
Some involved with the creation of this document have stated that the deaths in the worst case scenario can be expected to be "up to" the 2.5% level.

If you really heard it, it is incorrect.  Read the top of my diary, the definition of worst case scenario from IOM, is also what is behind the whole document.  Also the various charts.  That's why I suggested printing the document out if you are going to meet any officials. 

But to do so, I'd like to see some state and federal plans that explicitly plan for a higher CFR event. 

Yes, we would all like to see stuff like that.  However, let me challenge your model by suggesting that you think of the whole thing in a different way.

A pandemic is not a linear, static event.  As and when it starts, the AR and total mortality will be affected by what we do with NPI's.  At the same time, the virus which has just switched host, is not fully adapted to humans yet.  It is still evolving, so the characteristics of the infection as well as the CFR is likely to shift.  As a result of all these, added to the systemic overload and the inability to confirm cases (think Indo now then multiply by 10,000 times), I expect we will have no idea what the CFR is for the first few weeks of the pandemic at a minimum, before we hit the peak. 

But the secondary and tertiary consequences are already there.  What to do?  Policy should be driven by CFR, correct.  But do we want to be spending a lot of time in those critical weeks trying to chase data and debating CFR with each other?  What kind of policy in an unfolding pandemic is so not-urgent that you can afford to debate that, perhaps for weeks?  None.  Everything will have to be decided based on sketchy information.

Therefore, let me put it to you that policy rigidly attached to CFR's will fail, cos we won't have that info.  But policy categorized by intervention type, is a different story.  Whatever happens in an unfolding pandemic, social distancing is social distancing.  The form may vary somewhat, but the essence is the same and everyone is familiar with it.

Hence we come to an important oxymoron: policy should be driven by CFR, but we won't have CFR to drive it.  The design of this whole set of NPI is based on what is needed to combat a pandemic of a particular CFR, (except for Cat 5, which has no ceiling) ie CFR is used as a construct during the thinking and design of policy.  It will be used in implementation too, but only as a threshold beyond which you can just drop the matter and focus all resources on mitigation.

Put it in another way, once you hit 1%, you are pulling out the big guns.  Once it hits 2%, you can assume you are going to take out everything, whatever else you've got, including innovations we haven't thought about before, as intervention.  Now in a pandemic with CFR > 2%, at the peak, most societies will not be able to cope however well they are prepared.  ie you have already mobilized all your tools, there are no additional tools in your toolbox, and you are still short.  At which point, however high the CFR goes, all you are doing is triage.  It's like you're in a leaky boat, all you are doing is plug the holes with whatever you've got, and hope you can stay afloat long enough to hit shore, ie get past the peak.

I would suggest therefore that you use the model in this document to direct NPI, but also do everything else to boost critical infrastructure and community resilience.  These are always going to help in whatever CFR.  Unless we are lucky and don't have a pandemic for many many years AND countries are still conscientiously boosting critical infrastructure despite no pandemic (which I find unlikely) or unless for some unforeseen reason there is a massive reversal of globalization, we will always be susceptible to systemic failures.  ie the inability to boost critical infrastructure sufficiently will NOT be because of a flaw in the planning (ie using too low CFR) but because of the intrinsic nature of a globalized world.



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


[ Parent ]
btw when I said we will have no idea
what the CFR is for the first few weeks.  Well, a modification: we will have no idea what the CFR is beyond the fact that it is above a certain level.  It will be easy to know we are at > 2% (see how clever this is?) but it will be much harder to be more accurate, cos the sum total of problems (see above post) piling up at the same time will make determination of CFR moot, and triage the top priority!



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


[ Parent ]
I think we will have an idea of what the CFR is, fairly early
We have that after a few weeks of watching H5N1 in Egypt during these few new weeks of 2007, and we have a pretty good handle on the CFR in Indonesia for the same period too.  By the time the pandemic strain of a virus has circulated for three weeks, a month, it will be easier to quantify the difference between 1% and 8% (or 12%) than it will be to quantify whether we are in one of their categories 2 or 4.  This planning document does, indeed, make the assumption that they are going to quantify CFR, and they are going to try to do so at very precise levels below 2.5%.  Category 2 denotes a CFR of 0.1%-<0.5%, while Category 4 denotes a CFR of 1.0%-<2.0%.  So, they are going to try to quantify.  Given that fact, levels need to be built for the range above 2.5% too. 

Also, there needs to be emphasis on planning beyond the initial days and stages of a potential pandemic. The converstion here keeps being brought back to the initial few weeks, and that is fine, again, when discussing triggers.  But we need a more robust plan that moves well beyond the initial days and sets its own additional set of triggers as a pandemic potentially develops beyond the 2.5% CFR level as well.  We simply can't fail to plan for that. 

As to whether the 2.5% will be used as a "cap," as I said I'll withhold judgement until I see whether state and local agencies are using it that way.  Here, however, is one early example of its use in that sense, widely quoted by ABC News:  http://abcnews.go.co...

"There are very significant repercussions of these guidelines, and there need to be systems in place to deal with these repercussions," said Dr. Jeffrey Duchin, chief of communicable disease control at the University of Washington's Division of Allergy and Infectious Disease. Durbin is also part of the working group that devised the recommendations.  "A lot of the burden of these measures falls on individuals and communities," he said. "They would need to figure out how they can survive the cure. The disease is bad, but the cure in this case is no cakewalk."...[snip]..."When we're talking about Category 4 and 5, we're talking about a pandemic that would have 10 to 20 times the impact as a regular flu season," Duchin said. "It would result in up to 1 million deaths."

That, to me, sounds like a cap.  Right now my state's pandemic plan is ready for an incident up to that which includes a CFR of 2.5%.  Will the planners now move beyond that threshhold, or will they take this new CDC guidance as evidence that they do not really need to do that?  Whether we call it mitigation or triage, those plans for a higher level event need to be in place too, and our policy makers need to make them. This is probably not the place to begin listing them, but these varied elements of mitigation and triage do need discussion, and routinely bringing the subject back to a 2.5% CFR, or a 3-month event parameter (implying that about covers it, as I think this document does), may squash this necessary discussion. 

I don't know how it works in the UK, or in Canada, or in other places, but here in the U.S. we need to use discussion and advocacy now or we'll find ourselves in the familiar stew pot that we often find ourselves in.  Every Saturday night, there are Americans in every corner bar whining and complaining about whatever latest misadventure we've managed to get ourself into.  Americans are very good at whining and complaining post fact.  We don't like that our leaders didn't consider the worst case scenario, we don't like that those that advise them didn't maybe play the full hand out in front of the boss.  We don't like hearing whispers of secret meetings with big business that unduely influences decision makers.  We sit and chew the fat over our beers about how in the world we have found ourselves in some internationally embarassing position again (and this scenario works in all administrations of any party over any period of time).  Why does this happen?  Because the same guys crying in their beer don't take the time, pre-event, to pick up the phone and call their congressman, or email their senator, or get on the case of whichever agency is involved in advising the leadership and the citizens and make sure they've got the whole situation in view, worst case scenario included.  Often, the guy with the beer had no idea as to the complications that could have arisen from seemingly simple and straightforward policy decisions because the discussion of the finer points, the more complicated points, had been cut off too early and never turned up in his New York Post.  So, the populace remains uninformed and uninvolved.  They can't and don't advocate, which is their responsiblity, really, under the peculiar government we have chosen.  Then they complain later. 

If it seems like some of us are pushing our government, we are.  It's our job as citizens to do so.  Or, rightly later, they'll be able to tell us that we didn't care, that we implied by our lack of reponse and action that we were satisfied with the bits we saw early on.  If we're not, and we think they could be doing a better job, we have to say so.  Otherwise, we'll just be sitting around crying in our beer about this situation too one day, with many only then realizing it could have maybe been avoided with robust discussion of all the pertinent information, and some citizen involvement too.

For our system of government, full and complete discussion remains the best form of NPI and mitigation, and the earlier and fuller the discussion is, the better.


[ Parent ]
we can use categories here at fluwikie, and then
what would we do?  Can we come up with further recomendations for categories 6 (CFR=5% to 10%) to X (CFR=70% or more)?

We might say that for Cat7 (whichever way it's defined) we need, say, N95 for each and every citizen, for 6 months.  That's non-pharmaceutical, right?  Those things are just not posible right now, we can agree.  So what?  It's not posible to have 4 weeks stockup for every citizen, either.

We'd be accepting that we're ready for Cat1, but not for any of the other levels.  That's one way to frame it.

Pixie, now I'm sitting on the fence.  There might be other NPIs along the way.  What are they?  I'm thinking about Dr Woodson's "close airports" one.  Are there two categories of NPI: those we believe we can do, and those we don't think we could really implement?  Is it a matter of belief?  Can we reach for the moon on this?

Still thinking about it.

But, to be practical, I think we want to walk both pathways: use the document as is to push our neighbourhoods little by little, AND engage in a dialog with TPTB and within us, to push the current state-of-the-art (we're all learning!) much further than it stands now.

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


[ Parent ]
when we put our minds to it
we did put a man on the moon.  ;-)

[ Parent ]
In the future
there will be someone at the National Weather Service that will propose going to a 10 level hurricane system because everyone is familiar with a level 10 pandemic.

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

[ Parent ]
I want people to consider a CFR of 10%
and I pick 10% because the reason given by "experts" when asked why H5N1 won't likely go pandemic at its current CFR of over 50% is -- the virus can't spread when it kills off its hosts.

But SARS had a CFR of about 10% (I believe)and it spread just fine.  It didn't just die out -- we needed to actively control it -- and we eventually did, but only because it wasn't very infectious until sypmtoms were present.

But there's my rationale for at least 10% CFR.  I can't see any expert saying an influenza virus wouldn't be able to spread at that high a lethality.

And at 10% CFR -- really anything over 1% but especially at 10% we are talking loss of electricity, water and communications, and agriculture, and I really deperately want to believe that the people in the CDC care about these things.  I realize that's not their usual provence, but someone is or should be advising our critical infrastructure about the medical possibilies of this virus -- H5N1 in particular -- and the CDC is where people in the US turn for medical advice. 

I get that this document is about NPIs and not about telling critical infrastructure and businesses what CFR to prepare for.  But if everyone is supposed to be on the same page it would be really nice if at some point the CDC could say "Go ahead and make some kind of plans for a 10% CFR too.  It could happen."

GetPandemicReady.org - non commerical website with practical ways for families to prepare.


[ Parent ]
cfr
It does not have to have a low CFR to spread.  It all depends on the length of incubation and length of illness. As long as it can multiple and infect others before the person dies, it spread.

I have no idea on the biology of the required mutations to go H2H.  But the math in me says the "best guess" (with the current lack of information) is the mean between the current 60% or so and zero.  So my guess is a 30% CFR. 

Be Prepared


[ Parent ]
AverageConcernedMom, I alway smile
when I read that "the experts" say.... the virus doesn't want to kill off its host...

High PAth is so defined because it kills (I think) > 50%

So we have a virus....  HPAI H5N1 (in chickens) that is killing about 90% or greater of all the chickens it infects... which is most of them.  And it has been doing this for several years now.

Why would the "experts" think humans would be any different? Do they think that the virus likes us better?

(smile)... I'm with you.......

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


[ Parent ]
I think it is a mistake to imagine that >2% is the end of the world
Nobody wants to think about their own death, but we still go out and make wills. A >10% CFR will be a tough one- but nothing that our species has not encountered and survived a thousand times before. I think the biggest impediment to proper planning, and dissemination of information is this sickening perceptions that we (the citizens) are pathetic, insipid babies.

In this document, there is no respect for potential of the adversary, H5N1. There is no respect for the human inhabitants of this planet. The message is pap. Why can't they summon the same intensity and passion as an infomercial for a sit up machine?? It all rings hollow.

Reality is just that- the cold hard facts. Every single one of us comes up against it at least once in our lives.


[ Parent ]
Because it isn't?
Why can't they summon the same intensity and passion as an infomercial for a sit up machine??



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


[ Parent ]
I switch channel when I see infomercial n/t


You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
you are right
there ARE things that can be planned for CFR higher than 2,5%, but they are not NPI's.  eg plans for mass burial.  Protecting society against breakdowns in law and order.  These are not NPI's, they fall under critical infrastructure and services.



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


[ Parent ]
new better version(s)





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


how about ;-) another bright pink one
and, the cfr bar needs to at least go to 10% cfr.


[ Parent ]
these are from the document itself
see my post above about use of CFR for this purpose. 

Same old, same old...lol



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


[ Parent ]
How come the CFR goes down as the infection rate goes up?
The virus runs out of hosts?

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

[ Parent ]
no, not like that ;-)
for a higher CFR, you get the same no of deaths with a lower infection rate. 



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


[ Parent ]
so you mean...
that they have the dependent and independent axes reversed.

Whoever prepared the slide must have a background in economics rather than science, I think the convention for economists is 'backwards' when compared to chemists, physicists, biologists, etc.

A 70% CFR is notably absent from the curves.  (I need a 'stir the pot' emoticon here. :P )

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.


[ Parent ]
What's the current infection rate in Indonesia? n/t


You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
infection rate or R0
is applicable only when we are talking about h2h.  Even if you try it on right now, if you have 100 cases of H5N1, of which you determine say 15 of them probably got infected as a result of h2h, then R0 would be 15/100=0.15. 



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


[ Parent ]
oops sorry
that was a mistake, not R0.  This is the attack rate, ie % of people infected in a population.  Currently?  Very low.



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


[ Parent ]
Does the plan advocate any particular mehods
of enforcing social distancing?  I know they say the locals now need to pick the ball up and run with it but do they encourage any particular kind of reactions ... i.e., curfews, quarantines, parents being criminally responsible for minors congregating vs. social distancing, organizations that don't cancel public events, temporarily banning ... with financial/criminal consequences ... congregating in any numbers?

I know that it isn't "federally mandated policy" but do that take that extra step and specify some actions that the locals might be able to inact to address the social distancing issues?  Or, any of the other issues at the different severity levels?

Also, I guess I'm wondering if they suggest how we get voluntary isolation of the home to work? 

I'm not being snotty though I'm sure it could be read that way.  I'm just trying to follow along here.  Since this strategy doesn't really have any teeth to it, to they suggest "teeth" for the local PTB?

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


no, you're not snotty
all these measures are voluntary.  They are not recommending any ocmpulsory anything at this point and for this document.

I know it's frustrating, we all wish that we could cover everything all at once.  But the whole pandemic prep is such a complex subject and creates such huge logistical problems that we know that won't be possible.



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


[ Parent ]
Thanks SusanC
Appreciate the reply and the understanding.

I guess what I was looking for wasn't really that they were telling people they HAD to do things one way or the other ... I personally don't believe that would work anyway just because of so many dissimilarities in the US population.

I was just seeing whether they had made some specific suggestions rather than general recommendations so that the local PTB had a starting place.  My fear is that the locals will try and recreate the horse with their own non-binding declarations before they actually start doing something concrete.

If they had more concrete suggestions, maybe there would be less tap dancing around the subject and less time wasted in trying to "understand what they really meant" by social distancing, etc. and did they really mean we should enforce it ... and what does "enforce" mean anyway. [groan]  I've seen a lot of time wasted in city council and county commissioner meetings where they are defining what something means, or trying to do everything be give a finite definition to some action or other. 

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
Balancing robustness against flexibility
There is a glossary section on page 69.  Did you download the document?  It's here.  http://www.pandemicf...

When trying to define these terms, one needs to be careful and retain enough specificity so people understand what you are talking about but not be so prescriptive as to reduce the options available to the local PH.

My fear is that the locals will try and recreate the horse with their own non-binding declarations before they actually start doing something concrete.

The next phase: State and local PH are tasked to start preparing the community based on these guidelines, and explore adverse consequences and solutions.  There will be continuing process of feedback between local and the Feds. 

In addition (from Rajeev Venkayya's speech Feb 2).  4 working groups will be set up, led by Federal agencies but including public and private stakeholders.  Each group will work on their area, to refine the guidance, explore the consequences and solutions to negative consequences.  The 4 working groups are:

  1. business/private sector
  2. education including schools, colleges, and childcare
  3. faith-based, community-based organizations, and NGO's
  4. healthcare, public health

The interim guidance will be updated based on the result and feedbacks from these working groups and other stakeholders.

In addition, the Feds are also starting to engage stakeholders in exploring the most effective ways of communication.  And that's only one that I know, I'm sure there are other processes that are now starting cos this document is in place. 

btw It's worth looking through Appendix 2, the Interim Guidance Development Process.  The huge number of agencies and stakeholders from many sectors as well as the range of activities is unprecedented.  If we consider that this process was started only May/June 06, it's a staggering achievement in such a short space of time. 

Always the dilemma was creating something that is robust enough to work across all communities in a fairly equitable manner, while providing enough flexibility to take into account the needs of specific localities or groups, in a timeframe that is probably 1/3 to 1/4 of what it would normally take.



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


[ Parent ]
got it ... just taking me longer to read
for content.  I had glanced over it for points of interest.  Should have gleaned a little more finely.  Thanks.  And thanks for the specifc page numbers.  That helped immensely.

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead

[ Parent ]
page numbers
they are very useful.  Cos I spent a long time wandering around the document trying to find stuff.  ;-)

Another suggestion: download the file, print it out and put it in a binder.  This is as close as you're going to get of a reference for community prep.  When you have any community engagement event, bring it with you, so you can share the info or in case any discrepancies come up.



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


[ Parent ]
enforcing, criminalized; didn't in 1918
they have trouble; can't haul sick people into court and then lose the criminal justice system to illness?

Can communities think up some teeth, that don't tromp people around more locations (contaminate the police cars?, the local jails?) - are we going to have trouble coming up with ideas?

If staying home gets rewarded in some additional way to not getting sick?

Or, if getting caught breaking quarantine has some sort of offical - ooh this sounds bad; marking/identification?
Or, some put to work on some supervised outdoor task near where they are found?

If community conversations started now, can the troublemaking issues get addressed now? Defy out of denial? Defy out of need to socialze, need for food/water/meds, what about any emergency medical care? (they need to know; if not available, at least they might not go looking for any) if local neighborhood ambulance and a tent = doc in a box for minor non-flu problems, would that help? Get faith leaders to tell religious communities alternate modes of worship are acceptable? Plans for homeschooling, and plans for picking up the dead, providing support without infection....


[ Parent ]
enforcing
This is something no one will particularly like; however, if a person is found violating social distancing - even if, or maybe especially if - it is a child, then they must be suspected of contamination.

Those individuals could be transferred to a congregate living facility - without due process? - until they are "cleared" to return home.

Juvenile detention centers could be used for the youthful population as they already have lock down cababilities. 

But again, will it be an issue of "due process"?  Will depend on the situation perhaps.  Enough teenagers being hauled away with no questions asked and placed into what is essentially total isolation, and most of them will get the message.  There will always be those who don't expect to get caught or who just don't give a crap.

If they are found to be in violation of any social distancing scheme due directly to lack of parental supervision ... which does not include a teenager disobeying their parents rules and sneaking out of a window at night ... then the parent could be held accountable at some point.  In the world that I currently work in that could mean loss of financial aid or federal assistance.  It could also be something like being "black listed" for student loans.

Other violators can be put in "forced labor" units which is actually what enforced community service is.  You do your assigned job, stay in a congregate living facility until you are cleared of infection, then allowed to return to your home.  That could equate with a 30 day jail term with time served.  [shrug] Again, it will depend on the severity of the CFR.

Frankly, at a certain point, breaking social distancing rules will have its own, much harsher, consequences.

The rules put in place, and how they are enforced, is going to depend on just how serious our state/local public officials are about addressing violations of social distancing.

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
enforcement, compliance
Personally, I think the nature of the influenza pandemic virus makes this both unnecessary and ineffective.  All we are doing is to reduce the attack rate.  Remember ultimately, unless you vaccinate everyone, the virus will continue to spread until it has infected all available hosts. 

Instead of focusing on individual non-compliance, what we really need to look at is overall compliance.  The following 2 slides show 2 things: how the results do not require 100% compliance, and how combination of partially effective measures produce significant reductions in AR.






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


[ Parent ]
No enforcement
I work for a public health department and while we would like to be serious about violations of social distancing, there is absolutely nothing we can do about it.  We do not have the staff to monitor violators of social distancing, and the last thing we would want to do is put people into any kind of a congregate setting during a pandemic.  Our primary role during a pandemic without vaccines/antivirals is going to be to educate the public on personal hygeine, hand washing, respiratory etiquette, and to avoid anyone with ILI.  Public health is not going to be the flu police during a pandemic.  We are going to be as hard hit as anyone else staffing wise and education and influenza tracking (is the pandemic still on an upswing?, is it in decline?) are going to be our major roles 

[ Parent ]
it will work in some places and won't work in others
I have a feeling that without enforce-ability, unless the CFR is high-enough to self-enforce the necessity for social distancing a lot of people are just going to blow TPTB's efforts off.

They are going to get mad, scared, hungry, etc. and are going to take it out on someone.

It would even take large numbers of people with this frame of mind to cripple an already struggling system. 

I understand the limitations, I really do.  I worked in mental health for 10 years and KNOW that you can't fix everything. 

I just also work with populations that will flat out laugh in your face if there is essentially no "real" reason for them to not do precisely whatever it is they are inclined to do when they feel like doing it.

I don't think enforcing will be an issue with Cat. 4 & 5 as there will be a natural enforcement - you break social distancing, you get sick.  And I don't thin there will be many problems with a 1 or 2 cat ... its that middle ground that will get you every time.

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
I agree
I think there will be more compliance the more severe the pandemic.  However, don't underestimate the power of social sanctions.  During SARS in Asia, if you coughed or sneezed in public and you were not wearing a mask, people would stare at you very angrily, or quickly move as far away as possible.  True, there are always irresponsible types, like the doc from Taiwan who went on a package tour of Japan despite having a fever. 

The important thing, though, is to remember not to chase the last few percentage points.  What do I mean by that?  This goes back to the 80/20 principle.  ie 80% of your success will be achieved by the first 20% of your effort.  The remaining 20% will take all of the remaining 80%.  If we don't try to aim for the difficult last percentage points, but instead stack the deck by using multiple interventions, the results are extremely powerful, because you are using the 'first 20% achieving 80%' portion of each goal, so you get more bang for the buck.

Re: limitations - yes, there are a lot of them.  That's why IMO a lot of tough work still lie ahead, to gain community consensus, find resources etc for implementation.



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


[ Parent ]
social sanctions
again, that is a concept that will apply to some populations and will not work in others.

Many of the "at risk" populations have pretty much blown passed the point where social sanctions alone can control their actions.  And those that do are usually reverse of what work with the rest of the populations.

A lot of "direct experience" people are going to have to come in on this.  In our area that would be the Salvation Army, Metropolitan Ministries, St. Vincent's, the Homeless Coalition, and the drug and alcohol programs for the various age groups.  FMHI (Florida Mental Health Institute) out at USF were probably be another place to enlist some professional experience.  The state hospital in Chatahoochee would probably be another place.

I might just forward your synopsis to as many people as I can think of.  If nothing else, maybe it'll start some people thinking.

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
you're right
I might just forward your synopsis to as many people as I can think of.  If nothing else, maybe it'll start some people thinking.

Whatever our individual opinions, the most important thing is to get as many people involved as possible.  Giving out clear unambiguous information is the first step.  This is early days yet, we are all still exploring the many ramifications of the process.



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


[ Parent ]
Enlist gerontological specialists as well
I think we might want to enlist the aide of gerontological specialists and departments/programs as well.

Since the current "worst-case" hypothetical pandemic planning is based on a 1918-like scenario that means that it would affect the older populations least ... at least directly though it may have an affect on their quality of life in many different fashions.

AARP and other groups dedicated to the welfare of the older adult population, and its many subgroups, should certainly have signficant input if they will have to "pick up the slack."

Veteran Administration may be able to assist in getting experienced workgroups together from their clients that could assist such things as engineering, medicine, crowd control, etc.  Most Vets have specialized training ... and that doesn't just go away.  They would be an especially useful group if we had to go back to doing it "old school."

There are an amazing number of groups that would be good resources for any number of tasks ... I better start making a list and buying some postage.  [grin]

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
Social pressure
I hope so. Jails are not only over crowded now but would be a huge breeding ground for flu. The guards do go home after their shift.

  The reccomendation of only shopping once a week and staying home is its own reward. When the weather man says "Blizzard comming, stock up" - people listen.

  There will still be people driving around taking care of essential services(fixing sewer pumps, trash pickup, repairs, etc), delivering gas, doing raido/TV broad casting, babies will be delivered, pharmasists still have to work and such. I suspect there will be sight seer's as well. The roads may not be empty even during a quaranteen.

  I guess this means no "Fast Food" but to bring lunch from home.

kobie


[ Parent ]
and if an infected person is
..."transferred to a congregate living facility - without due process"... it becomes a death sentence for those people, and a charnel house, right?

:-/

I do think a lot of gravedigging by hand will be called for, when mechanized equipment goes "offline" from various problems.


[ Parent ]
Not only is it not a priority,
in most places I'm guessing it's not even on the list. I hope we're still alive when that long march is over.

redundancy
Why can we be exposed hourly to the most graphic violence on TV and on video games, and nobody is worried about our sensitivity- but we can not scare people about the possibility of a H5N1 pandemic.

Virus were here billions of years before humanity, and I suspect will be here billions of years after us as well. Nuclear war and global warming would just be a bump in the road for them.

I think it is fine to overestimate the threat of pandemic flu. Engineers ALWAYS overestimate critical systems- they build 3 or 4 back ups- they overestimate loads by hundreds of percent. That is how Nuclear reactors are built- Way overbuilt, with lots of redundancy.

The consequenc3s of underestimating a pandemic however, are horrendous.

It is like a dyke- If you build it 10 meters high, but the storm surge is 13 meters high, you could have saved yourself the effort and money- because the results will be as if you had done nothing.

If we prepare for a 2% CFR pandemic, and a 15% pandemic arrives, the result will be as if we hadn't done a thing to prepare. A big waste of time and attention.

If we prepare for a 50% CFR and a 15% CFR arrives, then we will lick our wounds, consider ourselves lucky, and carry on a wiser species.


[ Parent ]
not everyone agrees with your view
Re-posted from another response, cos it also applies here:

As to whether one should plan for more severe scenarios, I want to add this to what I have already said.  This document is the work of many agencies, many stakeholders.  The long list of references show the breadth of opinion and science gathered to create this, including the IOM letter report.  We have to remember that this is the consensus opinion and recommendation of a very large number of people and institutions, with very divergent views and interests.  While each of us have our individual personal views, we live in a free democratic society, which means that those who hold opposing views to us on this forum have as much right to have their view taken into account as we have.



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


[ Parent ]
A rocket ship designed by consensus will not fly
This is an engineering problem, not a philosophy discussion. Your heat pump was designed and built  by engineers and electricians, not by psychology or marketing majors.

It is a simple risk/reward situation. Those who prep for a >10% CFR, and the pandemic doesn't happen, or is < 2% CFR, still get to live.  And they get to keep the houses and apartments stuffed full of discount food.

Those who don't prep or prep for a 2% CFR, and a >5% CFR pandemic happens, lose the houses and their lives. The houses have no food or preps in them so are fairly worthless anyway.

Do the maths. I spend a few thousand dollars on supplies I get to keep, and possibly save my families life- or I buy a wide screen TV, which I possibly lose in post pandemic chaos.

 


[ Parent ]
A review of the CDC's new NPI plan
The latest iteration of NPIs proposed by the CDC is an improvement over the impractical quarantine heavy recommendations contained in the US DHHS PIP published in November 2005.  The new plan is better focused, relies mainly on simple voluntary approaches to NPI, and provides a more realistic view of the personal and financial sacrifices the public will be required to make complying with these strategies.

The introduction of the Pandemic Severity Index and the plan's use of triggers to implement the Alert/Standby/Activate NPIs is an important advance for dealing with the pandemic.  This method improves the US Governments ability to clearly communicate pandemic risk, the appropriate level of NPI required, and the timing of their implementation.

A major weakness of this and past US Government plans is avoiding direct discussion of more severe scenarios where clinical attack rates and case fatality ratios are significantly greater than those given for a category 5 event as defined by the plan. The new CDC plan only addresses this possibility indirectly.

A more robust and realistic approach to pandemic planning would assume clinical attack rate possibilities of 30% to 50% and define mild, moderate, and severe pandemics as having case fatality ratios of <2%, 2% to 4%, and >4% respectively.  This would provide for a better appreciation of the potential risk we face today and lead to more appropriate plans for mitigation of them.  The current sanguine estimates of potential pandemic severity replaces the sound strategy of preparing for the worst and hoping for the best with the risky one of planning and hoping for the best. 

While many pandemic-aware people are concerned about the economic effect of the pandemic, this must not be the first concern.  In may portions of the CDC plan, economic concerns seem to be crowding out public safety.  The life and health of the people must be placed above all other concerns.  To a certain extent, legislation and deficit government spending can relive even severe economic dislocations due to the direct and indirect effects of pandemic.  While mandatory debt restructuring, tax changes, and federal subsidies can be legislated to prevent the wholesale bankruptcy of people, companies, municipalities, and states, no law can bring back the dead.

Taking these more severe pandemic models into consideration, the NPIs suggested or implied in the CDC plan could well save millions of lives but would need to be implemented much more aggressively and with consistency nationwide to be effective.

Aggressive measures for coping with a truly severe pandemic as envisioned above include:
· Centralizing the decision making process under the US DHHS for when and how to implement the NPIs rather than leaving it up to local authorities
· Set the appropriate trigger for full implementation of NPIs as no longer than one month after WHO Phase 6 has been declared (assuming the case fatality ratio reveals a severe pandemic event (CAR >40% with a CFR of >4%)

Appropriate NPIs for responding to a truly severe pandemic include:
· Closure of all airport, train, and bus transportation hubs
· Discontinuation of intercity bus and subway transportation
· Strickly limit personal automobile use
· Closure of all daycare, pre-school, public and private schools, colleges and universities
· Cancellation of public attendance at sports events, concerts, conventions, parades, or any other gatherings
· Closure of shopping malls, theaters, and restaurants

While it is important to plan for mild, moderate, and severe pandemics, it is only a truly severe pandemic that profoundly threatens human health and our social and economic infrastructure.  While mild and moderate pandemics are a concern as defined by the plan, there is little doubt about the ability of the US and most nations to cope with them effectively. 

The time required for a pandemic virus to reach the US from its point of origin is unknown but we can assume that US DHHS Secretary Leavitt's statement that this will occur within 1 month of its outbreak a reasonable estimate.  The US will need every day and hour of pandemic free time remaining to allow our citizens to prepare for self-sufficiency for the duration of the pandemic or make their way home if living abroad or elsewhere temporarily. 

Grattan Woodson, MD, FACP


the goals are clearly stated
In may portions of the CDC plan, economic concerns seem to be crowding out public safety. 

Actually, the document was very clear on the goal, right from the beginning.

Executive summary, second sentence p 7:

Communities, individuals and families, employers, schools, and other organizations will be asked to plan for the use of these interventions to help limit the spread of a pandemic, prevent disease and death, lessen the impact on the economy, and keep society functioning.

On the same page:

The goals of the Federal Government's response to pandemic influenza are to limit the spread of a pandemic; mitigate disease, suffering, and death; and sustain infrastructure and lessen the impact on the economy and the functioning of society. Without mitigating interventions, even a less severe pandemic would likely result in dramatic increases in the number of hospitalizations and deaths. In addition, an unmitigated severe pandemic would likely overwhelm our nation's critical healthcare services and impose significant stress on our nation's critical infrastructure.

This is re-stated in the Intro of the main document, page 17,

The community strategy for pandemic influenza mitigation supports the goals of the Federal Government's response to pandemic influenza to limit the spread of a pandemic; mitigate disease, suffering, and death; and sustain infrastructure and lessen the impact to the economy and the functioning of society.2 In a pandemic, the overarching public health imperative must be to reduce morbidity and mortality.  From a public health perspective, if we fail to protect human health we are likely to fail in our goals of preserving societal function and mitigating the social and economic consequences of a severe pandemic.3-8

As to whether one should plan for more severe scenarios, I want to add this to what I have already said.  This document is the work of many agencies, many stakeholders.  The long list of references show the breadth of opinion and science gathered to create this, including the IOM letter report.  We have to remember that this is the consensus opinion and recommendation of a very large number of people and institutions, with very divergent views and interests.  While each of us have our individual personal views, we live in a free democratic society, which means that those who hold opposing views to us on this forum have as much right to have their view taken into account as we have.



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


[ Parent ]
Grattan,
I believe you still haven't gotten the main point of this document.  This is NOT a pandemic risk assessment document.

This is a document concerning the use of NPI in a pandemic (not just the next one, or one caused by H5N1, but any influenza pandemic) for the specific purpose of reducing and delaying the peak, and reducing the overall attack rate and mortality. ie It is answering questions like these:

  1. If we have an influenza pandemic, what possible interventions do we have? 
  2. What interventions should we use? 
  3. What evidence do we have to suggest they will have the result that we anticipate?
  4. Under what circumstances should we use them?
  5. What triggers would be most appropriate? 
  6. What are the consequences, and how do we mitigate them?

A pandemic risk assessment document would be answering a different set of questions, such as:

  1. What is the likelihood of a pandemic in the next 6 months /1 year/ 2 years, etc?
  2. What is the most likely virus causing the next pandemic?
  3. How likely is it going to be due to the current H5n1?
  4. What would be the epidemiological characteristics of a pandemic caused by H5N1?
  5. Would would the CFR be like? 
  6. What would be the attack rate? 
  7. What would be the transmissibility or R0?

If we attempt to draw the 2 ends together, and try to answer the question, what NPI should we be using for a severe pandemic caused by H5N1 with CFR of 40% in the near future?  The answer would still be prolonged and early school closure, protective sequestration of kids, social distancing, isolation of cases etc etc.  ie the KIND of NPI used and how and when you would use them in a 40% CFR is the same as in a 2% CFR pandemic. 

What would be different would be the impact, which we will have to mitigate by other measures such as mass fatality management, or distribution by emergency services of critical items such as food and water, which fall under disaster management or recovery, but would have no effect on the attack rate or total deaths directly attributed to flu.



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


[ Parent ]
How can you protectively sequester kids if there is no food??
"The answer would still be prolonged and early school closure, protective sequestration of kids, social distancing, isolation of cases etc etc."

It sounds great except none of it will work unless everybody has at least 12 weeks (or much more) of food, tobacco, alcohol, toiletries, contraceptives, DVDs, water, music etcetcetc at home. What ever it takes to keep them quietly at home. Otherwise, we are just wasting our breath.


[ Parent ]
12 weeks preps
is at the top diary.  There is food if we start getting our act together now,

None of it will work unless everybody is willing to have a go making it work!

Who was it who said, "I never promised you a rose garden"?



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


[ Parent ]
I guess the next question is who's going to pay for it.
Some citizens will be willing, others will not.  Some will say let the 'government' pay for it, but then who's going to pay increased taxes. At the end of the day, different communities may have different level of 'willingness' to pay, either individually or collectively. There needs to be debate in each community with varying degree of wealth or disposal income to prepare.

If we knew we have exactly one more year to prepare, we could  take the time to debate the details. Since we don't know when time is up, we may be better off to make use of what's announced, while continuing this discussion to improve the plan, which should include what it takes to have a workable solution, not just a list of why it won't work.  The truth usually is some where between 0 to 100%.

I get the sense that the government is now struggling with duct tape solutions, some what like Apollo 13 - a race against the clock.  I would much rather they do this than waiting to get a perfect solution.

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.


[ Parent ]
Analysis paralysis n/t


You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
everybody will have to do their best, I guess
It reads to me like a recommendation for families to increase their stockpile.  Which does not imply government picking up the bill.

Since we don't know when time is up, we may be better off to make use of what's announced, while continuing this discussion to improve the plan, which should include what it takes to have a workable solution, not just a list of why it won't work.  The truth usually is some where between 0 to 100%.

Well said.  Absolutely agree.

I get the sense that the government is now struggling with duct tape solutions, some what like Apollo 13 - a race against the clock.  I would much rather they do this than waiting to get a perfect solution.

Yes and no.  My sense is they are under great pressure because of the deadlines that they set for themselves (in a way).  Which if you think about it is quite admirable.  To give you a counter-example, the Canadian government is undertaking public consultations about whether to use antivirals for prophylaxis.  The draft recommendation, we are told...Drum rolls please...will come out at the end of 2007.

I can't speak for some of the other initiatives that I have observed or taken part in, but this particular team, Marty Cetron, Carter Mecher, Matt Cartter, Lisa Koonin, to name a few, has some of the brightest thinkers (not just scientists) I have met together in one place.  In that sense, since you mention Apollo 13, it does remind me of it, a race against time to find a solution by a group of dedicated bright young minds. 

Gives me goosebumps...but they succeeded in the end, so that's ok.



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


[ Parent ]
OK. Americans are luckier than Canadians.
the Canadian government is undertaking public consultations about whether to use antivirals for prophylaxis.  The draft recommendation, we are told...Drum rolls please...will come out at the end of 2007.

Oh, s**t. Are you sure?

We have a minority government. All parties are jockeying for a election this year. So no 'pandemic talk' before then.



You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.


[ Parent ]
yes, I am sure
this was in the seasonal and pandemic flu conference in arlington last week.  The speaker was Theresa Tam, you can look up her job title, and I was the one who asked the question.



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


[ Parent ]
also, the NPI's that you listed
such as closure of airport, stopping trains and other transport, etc are all examples of social distancing, which IS included in this document, except that they have left out the specifics for state and local PH or for later decision.  For example, this paragraph comments on the effectiveness of closing airports with the highest connectedness, but this will also result in correspondingly significant disruption.

Our social connectedness provides a disease transmission network for a pandemic to spread.50, 53-58 Variation exists with respect to individual social connectedness and contribution to disease transmission. Such a distribution is characteristic of a "scale-free" network. A scale-free network is one in which connectivity between nodes follows a distribution in which there are a few highly connected nodes among a larger number of less connected nodes. Air travel provides an example of this concept. In this example, a relatively small number of large hub airports are highly connected with large numbers of originating and connecting flights from a much larger number of small regional airports with a limited number of flights and far lesser degree of connectedness to other airports. Because of the differences in connectivity, the closure of a major hub airport, compared with closure of a small regional airport, would have a disproportionately greater effect on air travel. Given the variation of social connectedness and its contribution to the formation of disease transmission networks, it is useful to identify the nodes of high connectivity since eliminating transmission at these nodes could most effectively reduce disease transmission.

The document then goes on to discuss the notion of social density and other modes of transport.  Then it moves to the topic of targeting school children, and give a number of reasons why children are responsible for a disproportionate degree of transmission eg shedding longer, etc.  Some value judgment is made here, based on available evidence, so that the option of targeting school children and teenagers seems to be the better option than closing airports, although the document does not exclude that option either.

Therefore, given the disproportionate contribution of children to disease transmission and epidemic amplification, targeting their social networks both within and outside of schools would be expected to disproportionately disrupt influenza spread. Given that children and teens are together at school for a significant portion of the day, dismissal of students from school could effectively disrupt a significant portion of influenza transmission within these age groups. There is evidence to suggest that school closure can in fact interrupt influenza spread.

Certainly preliminary data from 1918 suggests that stopping transport didn't make any difference to outcome, whereas school closure did.



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


[ Parent ]
Thanks Susan
I appreciate your comments and references to the CDC plan. 

The plan most certainly does make a risk assessment for the next pandemic and from that assessment comes the NPIs recommended.  You can not have one without the other.  The point is the NPIs recommended are appropriate for a mild or moderate pandemic event as I define them but would be completely ineffective for a severe event (CAR 40% + CFR >4%). 

The aggressive measures I proposed for a severe event were, as you pointed out, all drawn from the CDC plan but with significant modification.  They mention airports and intercity transport as important means for viral spread but do not propose closing them as I do because their risk assessment is too low to justify such a dramatic step. 

The aggressive measures I suggest for coping with a severe event will shut down the economy and throw the country and world into an economic depression if prolonged which of course they will be.  Since I think a severe pandemic will do this anyway, we only have lives to save by imposing these measures early in the course of the emergency.  To me, this makes the most sense as healthy people are every country's greatest economic asset. 

Of course I am aware of what the CDC plan claims to be its guiding principals.  The case can be made that these are met for a mild to moderate event but IMO it appears that economic interests play a role in preventing the CDC from addressing the truly severe event.  The robust measures required to really slow transmission during a severe event are simply not provided by the present plan.  Why?

You have not commented on my recommendation to centralize activation of NPIs.  What is your opinion about this?  Do you think that local officials will be able to act efficiently during the pandemic and take the steps recommended by the CDC or will they be confused, pressured by local or regional interests that cause them to delay their decision resulting in an ineffective implementation?

Also, I have provided a specific trigger time.  Please comment on the advisability of this suggestion.  Is it too short or too long? 

Thanks for starting this diary.  It is quite stimulating.

Grattan


lots of interesting points
I'm not going to answer all of them tonight ;-)

Centralized activation of NPIs - I can immediately think of many problems:

The pandemic could and is likely to start and peak at different times in different parts of the country.  Activating all at the same time will result in closing schools etc in places that might not get the virus for weeks.  But eventually (since it is the nature of flu) the virus will arrive in the area, and it will still take the same no of weeks to 'work through' a location.  What you've got then is an unnecessarily prolonged activation of NPI, with more consequences,

Even if we agree that that sacrifice is worthwhile, there is also the issue of NPI-fatigue and complacency starting, and possibly peaking right at the point when the virus actually arrives.

The US (hey it's your country!) Constitution gives jurisdiction on such matters to States, not the federal government.

At a time where systemic including communication breakdowns are likely, I believe as much of the decision making power should be at the local level as possible

A simultaneous shutdown or slowdown of essential services is an unnecessary and extremely harmful thing to happen.  In our modern system of complex networks, rolling, sporadic, localized pockets of failures can often be compensated/adjusted for/absorbed by adjacent capacity.  Such failures are easier to recover from due to the small size of each failure and the lower chance of combined failures causing second and third level consequences.  In addition, massive combined failures have a high chance of cascading to a point of irrecoverable total system failure.

Efficiency - let me ask you this question: which of the following would be easier and faster to turn around in a harbor, a sailboat or an aircraft-carrier?  Look at the list of agencies involved in this document, and ask yourself this question, how much co-ordination was needed to get this done, vs if you and I, just the 2 of us, were to decide the whole thing between us?  Now the multi-agency/CDC method might be more effective cos of access to expertise (or it might not), but you and I are going to be way more efficient than them!

(btw Let me tell you a secret.  Ready?  Dictatorship is always more efficient than democracy!  lol)

On the subject of local pressure, I would suggest it is the other way round.  Suppose you are the one who will have final say about activation for the whole country.  You live in DC, cases are sprouting in say Arkansas, you are under pressure to delay activation.  You would be far more likely to give in to such pressure because you and your family are not under imminent threat, and the same would apply to whoever is pressuring you! 

Now, there is a situation where you are more likely to be influenced by local pressure, and that is BEFORE the pandemic, while plans are being made.  Why?  Again cos the threat is not imminent, to either of you.  That's why it is so important for everyone to scrutinize the decisions that will be made at the local level in the next few months, cos that's the most likely time when these interventions are diluted and/or set up to fail.

Finally, on trigger time of not more than 1 month after WHO stage 6.  I don't really understand the need for that at all.  I am guessing, and some of the other comments also point the same way, that you are basing your whole strategy on shutting down contact with abroad, and shutting down movements within the country. 

While that might stop the virus dead in its tracks, the secondary consequences are so extreme I absolutely believe more people will die as a result of that.  Why?  Yes, you might buy time, but time to do what?  If the whole system is shut down, what kind of prep can the country do that will significantly reduce the death rate if and when you open up to the world again?  Antivirals?  Vaccines?  But you can't make any of that cos you have no supplies for anything!  Remember that your country is dependent on the outside world for much of what it needs.  Yes, in theory, it could learn to be self-sufficient, but the road to self-sufficiency is long and difficult, and certainly not one that can be endured in crisis mode with shortages of everything!  In the meantime, you will have all the secondary and tertiary deaths due to lack of medication, no food, no fuel etc.  Eventually, this massive self-quarantine will be breached, say by illegals crossing from Mexico.  At this point, your country has already been weakened by repeated and chronic shortages (think of the former Soviet Union) and breakages that can't be fixed.  NOT a good space to deal with the virus that has now arrived!!!



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


[ Parent ]
find this part hard to imagine; people travel too promiscuously
..."could and is likely to start and peak at different times in different parts of the country.  Activating all at the same time will result in closing schools etc in places that might not get the virus for weeks"... (Overlapping waves are also possible.)

And why can't goods be shipped without infectious contact between people? It is the millions of human travellers who are more the problem, not containers. But, do we have anything anyone needs; why bother sending essentials out of country to the US?

..." all the secondary and tertiary deaths due to lack of medication, no food, no fuel"... are going to happen anyway, in the first weeks, or later in the pandemic year(s)...

Why not start the hard road for self-sufficiency before we have to? (Because short-sighted human greed and  human nature ain't going there, yeah, but, people are going to wake up too late and wish they had done it differently. Tragic.)

Privilege is never give up without a struggle.

..."there is also the issue of NPI-fatigue and complacency starting, and possibly peaking right at the point when the virus actually arrives."..

I find that difficult to imagine, except the govt that thinks so may be imagining having to tell people to prep without telling them the current cfr and prospect for survival in an overwhelmed medical system; without telling them it is life and death.

Look at what the US public has put up with in terms of money spent and lives lost or damaged (and civil liberties lost) because of our attacking Iraq?

Can't that sort of psy-ops be put to telling the public their family's lives and security (and their nations' continuity) relies on they and their communities being better prepared for avoiding a deadly virus during the most trying time our country has ever had to face? Conserve energy, make pushes in sectors we need the most strengthening?

Not cut funding for Law Enforcement, prevention programs, hospitals and nurses, right when we need them ??



[ Parent ]
Reply to Susan's POV
In my US state of Georgia, I have had an opportunity to interact with our local officials and in my judgement, they will delay the decision to implement NPIs and those they do choose to implement will be too little too late.  For this reason, I have very little faith in the ability of the state and local public health and political leaders to make the decisions needed in a timely manner.  My discussions with others from around the US has lead to the unfortunate discovery that their leaders are likely to drag their feet in the same way as my leaders.  I don't know about the UK but would be interested in your opinion. Cornwall, Yorkshire, Ipwitch, London, Bath, Edinburgh, Birmingham; how do you think the political and public health leaders in these diverse ares of the UK will react? 

I think you may be underestimating the importance of the connectiveness factor.  This has resulted in an incredibly mobile world population in all the developed nations and most of the underdeveloped.  Population density plus this type of connectivity are new epidemiological factors not present during past pandemics.  IMO, these features of the modern world will mean that the pandemic will speed incredibly fast worldwide such that it will be everywhere virtually at the same time.  If this occurs, the wave behavior seen in the past may not occur being replaced with a high transmission rate (R=3) and a prolonged duration of 6 to 9 months.  This tsunamic pandemic view is what drives my thinking regarding the necessity for a complete and total shutdown of the transportation system and aggressive implementation of social distancing NPIs. 

What I am saying is that if we are destined to experience a truly severe pandemic (CAR 40% + CFR >4%) this will destroy the economy anyway and fast.  Why not take steps, like the NPIs suggested above, that might slow the transmission rate to R = 2?  Why, because IMO summer is one of the factors that interrupts pandemics.  Weather change and the inefficient means of human transportation are the probably dual causes of past pandemic wave phenomenon.  So, if the R can be slowed for enough time to pass for summer to occur and this suppresses the virus, it will give the survivors a chance to catch their breath, resupply, and get ready for the return of the pandemic during the following fall or winter. 

Grattan Woodson, MD


[ Parent ]
Hey doc ;-)
Take a look at the 2 new updates that I just posted.  Notice that at CAR 40+% and CFR 5% (Scenario 2) you can bring the death rate to 1% of what it would have been without intervention (from 6,360,000 to 67,000) with implementation of the NPI's proposed in the Guidance document (prolonged school closure + sequestration of kids + social distancing + case isolation + quarantine of contacts), at 60% compliance + antiviral treatment for 60% of cases + family contacts.

Which, IMHO, trumps your 'shut the whole country down' strategy.

Grattan,  I've been following and studying this whole problem closely for a few months, I still had to go through these figures in great detail to become convinced.  What I mean is what looks logical on the surface may not be, what looks unachievable may turn out to be amazingly achievable.

they will delay the decision to implement NPIs and those they do choose to implement will be too little too late. 

Well, FWIW, here's your next step.  Go out and work with your local PH officials.  Inform them, help them convince others, mobilize your community, help those in need.  Run drills and exercises, explore this

If you look at the numbers, it's worth it.  And it's a lot healthier than shutting down the whole country to the rest of the world.  In the process of planning for this, if American community exercises show anything within this range of results, then we need to sell it to the rest of the world.  You are only as safe as you can make others safe; Don't shut them out. 

Cos bottomline?  When it's all over, how many friends do you want to have left?



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


[ Parent ]
Use loaves and fishes!!
I think that we need to write Loaves and Fishes into the guidelines, just to help facilitate the closed schools, sequestered children and the social distancing.

I think if every town had a loaf and a fish- and probably two or three in all the big cities, around the World, we should just about cover it. By my calculations (tip of the hat to GS) we will need about 453 loaves and 453 fishes to save the entire World.

Put that in your pipe and smoke it fear mongers!


[ Parent ]
anti-virals
"...antiviral treatment for 60% of cases + family contacts."

But what if there aren't enough anti-virals for all these people?  And what if the virus becomes largely or even partially resistant to them?  (As in Garbhiya.)


[ Parent ]
good question!
60% of 40%, assuming no mitigation is 24% of all population, which is the goal for the US procurement, as far as I know.  Same as many countries.  But with NPI, the big reduction in attack rate will also save a lot of antivirals as well,

Resistance: we won't ever have solutions to all problems on this planet today.  Resistance is right now not an obvious problem, we don't know what it will be tomorrow.  In the absence of perfect solutions?  We play it by ear, IMO.

;-)



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


[ Parent ]
But but!
a) this ignores the treatment of family contacts completely

b) isn't the 25%-ish aim based on current dosing recommendations, which, consensus now seems to say, are too low by a factor of 2 at least?

Not to mention the little matter of whether the virus stays tamiflu-sensitive of course.

Seems to me that this figures based on the assumption that practically everyone gets tamiflu when it would help are not very realistic.


[ Parent ]
;-) like I said
not enough tamiflu?

So is the rest of 99% of the world!

We'll just have to make the best of what we've got, I guess.  Nobody wants a pandemic, and we know the world is woefully short of everything.  I wish we have more low-cost and abundant solutions, but we don't.  And that means the whole world, as I said.

Unless we can convince leaders to be more visionary and to get on with statins research..

Plus if the pandemic does not happen for a couple of years, we'll have a lot more in the stockpile.



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


[ Parent ]
Stability and Environmental Sources of Influenza Viruses
Doc says "Why, because IMO summer is one of the factors that interrupts pandemics.  Weather change and the inefficient means of human transportation are the probably dual causes of past pandemic wave phenomenon."

Webster says "Stability and Environmental Sources of Influenza Viruses

  Another important property of avian influenza viruses is their remarkable stability in aqueous suspension. Many subtypes retain their infectivity for more than 100 days at 28°C when the initial concentration is 106 TCID50. Although the infectivity of the 1997 Hong Kong H5N1 virus lasted only 2 days at 37°C, aqueous suspensions of post- 2001 H5N1 viruses remain infective for 4 to 6 days at 37°C. Other H5N1 variants circulating in Eurasia are also environmentally stable, providing additional opportunities for these viruses to transmit to people and poultry through untreated water.

snip

  These viruses kill more than 50% of humans that they infect. One such virus infected a family cluster of eight persons in Indonesia, and included three sequential human-to-human transmissions. Fortunately, however, that particular cluster did not expand. Moreover, in humans, the H5N1 viruses remain poorly transmissible between individuals. In over 40 years of experience with influenza, the Asian H5N1 is the most virulent virus I have encountered (R.G.W.); if it does acquire consistent human-to-human transmissibility- it will likely be catastrophic.

http://www.asm.org/m...

Tell the truth


[ Parent ]
I Will Share It
Although you folks have done a splendid job of pointing out the deficiencies of the new pandemic mitigation plan, I am going to share this document with my friends, relatives, and colleagues.  I believe that the increased prep recommendation (from 2 weeks to 12 weeks) will help me convince a lot of skeptical people that they need to get busy and start prepping.

You are running out of time.


http://tinyurl.com/37bl45


great attitude, Dr Dave! n/t




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


[ Parent ]
other things to do for higher CFR
Let me summarise a few ideas from this thread, and then add my own:

My summary:


A CFR > 2% will mean:
- more compliance for the available NPI toolbox
- more local details of said tools
- things that are outside NPI

What would those "things outside NPI" be?  Harvesting this thread, and in no particular order:
- plans for mass burial
- protecting society against breakdowns in law and order
- other critical infrastructure and services
- community resilience
- a massive reversal of globalization
- distribution by emergency services of critical items such as food and water
- (add your own)

And this is what I believe:


I believe we can wrap up a package for our local folks, consisting of:
- the NPI document we're discussing in this thread http://pandemicflu.g...
- this video where someone important (?) says peak oil is really near http://youtube.com/w...
- this information about global warming (scientists are 100% sure) and the role of humans (scientists are >90% sure) http://www.greencarc...
- this information about urban agriculture http://www.fao.org/f...
- some information about community currencies such as http://www.transacti... (by Bernard Lietaer, no less) and http://www.birdshot....
- we can also use wireless communication among us, in order to help each other  http://wndw.net/

So, you see, there are many reasons for local resilience, community currencies, edible gardens, and making friends with your neighbours (well, some of them at least).  Global warming, peak oil, panflu, personal stress and dissatisfaction, violence, you name it!

And many reasons to believe we can help all kinds of efforts (not just grassroots, not just top-down) to make that happen.

The way I see it, all of this, put together, may be psychologically very disruptive to many.  I mean, how on Earth are we going to do all of that in a short period of time?

Truth is, we can't, if we're alone.

But we may be surprised: some of our neighbours will be glad to see the dots connected, some of them will feel ready for at least part of the whole lot, and we can work together with them to move things in that "sector" of preparedness.  A gardener who doesn't want to stock up but who is ready to grow community gardens is helping, isn't she?

Talk about having more tools in our toolbox! ;-)

ok, or maybe i'm an idiot, but i had to try

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


urban agriculture correct link (sorry, this is the one)
http://www.fao.org/n...

This one is dated 1st Feb 2007.

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


[ Parent ]
Exploring some high CFR scenarios
UPDATE #1
I thought this might be a good time to explore some high CFR scenarios, and see how well these NPI's might reduce mortality. 

This is a theoretical model and is based on R0 of 1.9.  From the work of Irene Eckstrand at MIDAS, this model gives a baseline CAR (clinial attack rate) of 42.4% assuming nothing is done - no NPI, no treatment.  (This is an artificial construct, cos in reality there will always be some interventions.) 

First look at the first 2 columns:

  • At NPIs (30%/60%) = various NPI's at 30% compliance + treat 60% cases & contacts, the CAR becomes 3.9%.

  • At NPIs (60%/60%) = various NPI's at 60% compliance + treat 60% cases & contacts, the CAR drops further to 0.5%

Using these attack rates, at various CFR's 2%, 5%, 10%, 20%, 40% 60%, the total deaths with these scenarios are shown in column 4.

Notice the dramatic reduction in deaths, and also how the benefits continue proportionately even at high CFRs. ie NPI's work just as well in high as in low CFR scenarios

These results assume that all NPI's are instituted when 0.1% of the population is infected. They are even better if NPI's are started earlier eg 0.01% or even 0.001% of population.  The following gives some examples of the number of infected cases in different cities or states before NPI's are instituted. 


State/citypopulation0.1% 0.01%0.001%
California36M36,0003,600360
Massachusetts6.5M6,50065065
Connecticut3.5M3,50035035
New York City8M8,00080080
Houston2M2,00020020
Detroit900,000900909


The question to ask is how many people do you think need to be infected in your local area before the presence of a cluster + community transmission is detected? 



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


Could you construct
the same table, but leaving out all the effects of treatment? i.e. assume the NPIs as you did, but don't assume any treatment of anyone? Then we'd have figures in between which the truth lies. I think mixing up NPIs and tamiflu is clouding the issue.

[ Parent ]
same table without tamiflu ... and with statins? :-)


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

[ Parent ]
I didn't construct it ;-)
I asked someone else to work it out for me, I don't have the modeling tools! 

But, the key to TLC, it's more powerful with combinations of inadequately carried out partial mitigation, than fewer options of perfectly executed solutions for fewer people. 

So if you have 3 interventions x, y, z.  It is more effective with 30% success of x, 40% of y, and 20% of z, than 100% of any of the interventions alone.

This is similar to the 80/20 principle in management, that you can get 80% of your result by 20% of your efforts, but the last 20% will need all of the rest of that 80% effort left.  But if you do several things each to 20%, ie get 80% result with each, you will end up with far better results.  Caveat though: this is a management paradigm, not a mathematical one.  ;-)



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


[ Parent ]
mixing tamiflu and NPI
No, the lesson from MIDAS is that instead of trying to find one perfect solution, the imperfect implementation of multiple imperfect solutions in combination can produce dramatic results. 

Look at the charts in this comment,  http://www.newfluwik...



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


[ Parent ]
NPI Compliance Graphs: Project death against CFR scenarios
It would be useful to have a graph with Projected Death being y-axis and CFR being x-axis, and with each NPI/Treatment compliance plotted as a line.

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
60% CFR is actually in the table.
A graph like this would educate more than MSM's lazy reporting that the maximum CFR is 2%. Since not every one has to comply to make this work (partially), there will be less stigma for preppers as in "those selfish b*st**d hoarders".

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
selfishness
so if preppers don't stigmatise themselves that's good too? :)

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

[ Parent ]
Non-preppers or deniers may try to stigmatize preppers.
Counter that attempt, and there will be less resistance to prep.

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
hey, what about making prepping kewl?


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

[ Parent ]
Always time to prep - NOT!
Each hurricane season is meet with the the same list of things to buy/have. Instead of buying them early, people buy them a week before hand. The TV shows long lines, empty shelves and many without the faintest idea of how to hook up a generator or board up windows.
  JFK's speach of "The time to fix the roof is when the sun is shining" seems lost.
  Lugon, if you have any ideas on makine prepping kewl please let us know.

  BTW, the only thing I can not stock up on is medical supplies. ADHD meds, contraceptives (could be a post pandemic baby boom) and such.
  Any one have any thoughts??

kobie
"Fear is believing that what you can not see, nor touch nor change will happen."
Faith is believing that what you can not see, nor touch nor change will happen."


[ Parent ]
NPI compliance level and societal impact.
Has there been a study of how 30% and 60% NPI compliance correlate with availability of infrastructure i.e. electricity,  water and food supplies? At what point, if any, would NPI be counter productive? Is that most feared by TPTB?

You want perspective. I want perspective. Let's talk. We don't have to agree on every thing. If we do, one of us is redundant.

[ Parent ]
great questions, and then we need to think of ways to overcome that


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

[ Parent ]
Evaluating Pandemic Severity Index
UPDATE #2  I've had another look at the Pandemic Severity Index.  To the extent that this is an interim document, I expect there will be items that need to be modified/refined.  The problem raised by Pixie and others is that Cat 5 being defined as 2% CFR or higher may result in local PH ignoring the 'higher', and to assume that 2% IS the worst case scenario.  The question then arises: does it matter?  Would it make any difference if local PH use 2% and no higher as the top end for planning?

In that context, let me explore how well this index works for different purposes and what might need to be changed. There are various situations where this might come up for consideration:

  1. NPI with mild/moderate consequences and voluntary compliance:  Let's say I need to get some NPI specifically for the purpose of reducing attack rate and and mortality, etc and I'm only going to use voluntary measures.  The tool in my toolbox that is going to be toughest in terms of secondary consequences will be prolonged dismissal of school and protective sequestration of kids.  I'm going to activate that at 1% max 2% CFR, and I have nothing to add if the CFR turns out to be even higher.  In this instance the current scale woud be perfect.

  2. NPI with severe consequences and/or compulsory enforcement: examples include full border closure, stopping all flights, compulsory quarantine, etc.  The question here is are we ever going to use these countermeasures?  Have we completely excluded them?  Are there situations where these might be brought out?  If yes, are we going to use CFR as a driver for that decision?  If yes, are there interventions that we would not use at 2% CFR but would use at higher If yes, then we need differentiation at the higher levels.

  3. I can also approach the whole problem, including the use of NPI, as a capacity building process. The question behind the process becomes what do we need to do to be able to handle increasing levels of CFR.  In a way, capacity building is more easily calibrated by moving from where we are to where we want to be, which on the index would be from the lower levels upwards. (Julie Gerberding sort of touched on it today with her speech at the CIDRAP meeting, but didn't elaborate on it.)  There may then be a case for saying, well, since we are currently so unprepared it's going to take a while for us to be up to 2% and beyond, so right now we don't really have to worry about it.  Now that is a very unsatisfactory response, because we need to know what we are aiming for during the process.  Are we aiming for 2%, 10%, 30% as an eventual goal?  What is `adequate', `feasible', or necessary'?  What we aim for does affect the choices that we make with limited resources and maybe limited time.

  4. other countermeasures not NPI ie not primarily designed to reduce AR or death rate related directly to infection, but geared towards maintaining infrastructure or social order, mass fatality management, etc.  For these, responses at 30% CFR could conceivably be very different from 2%.

  5. It has also been suggested that this index might be used for vaccine prioritization.  How well that would apply would depend on whether there will be any major changes in considerations if the CFR is much higher than 2%.  I suspect the situation is probably the same as with the NPI's, ie beyond 2% you are looking at major triage of whatever is the most expedient, depending on what's happening on the ground. 

Therefore, the Pandemic Severity Index as currently set up in this document is appropriate and easy to use for the purpose of planning NPI's such as school closures.  Where there may be difficulty is when the same index is being used for planning other measures by local PH.  It would be good to have some clarification as to whether the intention is to use this Index across all types of measures, or only with the NPI's proposed. 

Having said that, the previous post on high CFR scenarios shows that with good prepandemic planning and implementation the dramatic reduction in total deaths may make it possible to sustain civil society through a pandemic with very high CFR's, making the necessity for other more draconian measures far less likely.



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


I think the biggest overall danger
is believing that the government will have adequate backup plans to keep things from being 'too bad.'  I was talking to my roommate about my worries that a global pandemic, h2h flu will break out with a high fatality rate with transmission possible before showing symptoms.  I think most people on FWiki get it (but my roommate couldn't seem to grasp) that it's highly likely government plans will fall way short of protecting even the individual, much less larger chunks of social machinery. 

I feel that there's a point at which an NPI simply won't work, given a finite amount of resources, and given uncertainty of how bad a CFR could be.  Someone( or more than one) said this earlier in the thread.  For instance, CFR of 10% versus 50%.  I think that survival of an individual who has done their homework and taken an enormous amount of personal responsibility and resources (most people even in the U.S. simply won't be able to) to prep has as good of a chance to survive either CFR scenario.  Naturally, it assumes that all the prepping is meant to keep you from not catching the virus at all so the 10% versus 50% doesn't really matter to an individual.

I think it's inevitable that the government can only protect people to a small-ish degree.  So I just don't know that an NPI can be any better than what we see they have done. 

The big difference between a 10% and 50% (given same % of people catching it) is how much of a toll the after effects have on the survivors.  With either CFR, it's something nobody can really prepare for.

The responsibility is on the individual, if he's brave enough to take it on.

Meteorologist in Florida!?!  Now we're talkin'!!!


I'm glad you said that
I agree, the responsibility is in the individual.  However,

The big difference between a 10% and 50% (given same % of people catching it) is how much of a toll the after effects have on the survivors.

Actually, if you look carefully at the figures, the biggest difference is not between the CFR, but in the attack rate (CAR column 2) notice the dramatic reduction of attack rate.  That is what results in the big drop in death, AS WELL AS sickness.  Which means the whole system has a higher chance of holding up.

Plus, as I said, you don't need a 100% compliance.  Those numbers are from 30% and 60% compliance only, plus the tamiflu treatment for 60% of those sick, of course.

In a way I (sort of) don't agree with you, in your underlying assumption that results will base on resources and/or what the government does.  The biggest difference in results will be compliance, which depends on how much you can help your neighbours support themselves through the period, and early implimentation (see second table on same post).

This is a project that needs everyone, or at least as many of possible of those who are able, no matter how well equipped the government is.  That's why the next stage of community education and mobilization is crucial.



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


[ Parent ]
compliance means a couple of things
Compliance will depend on:
1.- people understanding the issues (the basic science, the implications, their personal small-but-addable responsibility)
2.- people stocking up (a bit or a lot)
3.- people growing more and more of their own food and energy closer to home
4.- people learning to do things for themselves and for their neighbours
5.- people organising with other people just in case
6.- people reinforcing their systems from systemic failure
7.- people planning for mass burials and the whole lot
8.- people doing many other things

Did I mention "people"? :-)

It's not pan-preparedness, it's preparedness-demic!

Of course, you get to select which number you work on first.  But this is not a poll: just pass the whole thread to others and have the hive work on it, no?

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


[ Parent ]
"basic" science as in "simplified", not as in "molecular" ;)


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

[ Parent ]
You avoid the virus LIKE THE PLAGUE.
"the biggest difference is not between the CFR, but in the attack rate (CAR column 2) notice the dramatic reduction of attack rate.  That is what results in the big drop in death, AS WELL AS sickness."

It is exactly like AIDS, you don't want to get it in the first place.  And, exactly like AIDS, the way you do not get Pandemic Flu is a combination of "good practice" and luck. You avoid the virus LIKE THE PLAGUE.

The foundation of "good practice" for Pan Flu is being able to SIP with food, water and supplies. The luck part is hoping the virus doesn't sneak its way or force its way into your safe house. You avoid the virus LIKE THE PLAGUE.

IN the USA, you can't drive a car without insurance. Require (force) people to have food, water and supplies for three months of SIP. IT is so simple. Why do we struggle with the idea?

We can do it now- once a pandemic begins, we won't be able to do anything.

Big hearted volunteers are going to go out and help people after a pandemic begins. But they will risking their lives and the lives of their families in order to do it. I can see asking people to do this, if there were no warning. But we have had our warnings. Not to require people to start stocking up with food and water is just stupid negligence.


[ Parent ]
Require (force) people to have food .. etc for 3 mo?
Sorry, it is a non-starter from the get-go.

How is car insurance enforced? Either you are stopped by a cop for some other reason and are asked to show proof of ins. or some states require POI when applying/re-applying for a driver's license.

How do you expect to require (force) people to have 3 months of supplies ?  Ain't gonna happen. 

It cost $$, time and effort to prep for what is still a possibility/probability ..  yes, the gov, and people in general will be closing the barn door after the horse has bolted (trying to prep after a pandemic has begun ..).

You also pre-suppose that having 3 months of supplies equals 3 months of SIP.  Human nature being what it is ... a large majority of people will be out & about even during a high CFR situation for a variety of reasons.

Everything from work, buying supplies, entertainment, dinner, socializing, travel, boredom from SIP, "I'm not going to get it ..", on and on and on ...

Why do think HIV/AIDs continues to spread in the US?
People know that particular activities are high risk, and some people go ahead regardless.

Said to say ... but ... oh well ... a few will be prepared,
many / most won't. 

life (and death) goes on ...


Do not anticipate outcomes. Await the unfolding of events. Remain in the moment.- William Gibson, _All_Tommorow's_Parties_


[ Parent ]
there are no absolutes
Sure, HIV/AIDS still spreads because people engage in dangerous behavior.  But it IS preventable, and wherever public education programs and needle-exchange etc are instituted successfully, you see results.

As anon.yyz said earlier, the truth lies somewhere between 0% and 100%.

Whatever is being recommended to the public, you will see the full range of behaviors, from total die-hard SIP to do-nothing.  But as awareness grows, the percentage of people who do prep, for 2 weeks, 4 weeks, 12 weeks, 12 months, will grow.  Look at if from a societal point of view,

it will be the cumulative relative preparedness of a community that will decide how well it will work.

It's a process, not an end-point.



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


[ Parent ]
reducing the death rate
The fastest way to have society collapse in a moderate to severe pandemic is for everyone to close their doors and stay home. Very few people could afford it-even if paying bills seems to become a moot point. That would start a cascade of events that would ultimately affect everyoone- no water, no light no heat, no vital supplies. Food not moving even if there was some to move.

Cops, EMT's, firepeople, nurses, pharmacists, doctors, truckers, nursing home aides, Walmart shelf restockers, janitors, people who wash dishes, hospital beds,laundry workers, grocery clerks-who is expendable? Most businesses have cut back their employees to the ultra-bare minimum to improve the bottom line.

Who would I suggest to SIP-pregnant women, young nursing children, the immunosuppressed, the elderly and their caregivers. everyone else will be needed. And we will need to be brave.

It is better to look ahead and prepare than to look back and regret.


[ Parent ]
Sorry Grace. It's not that I'm not brave. It's that I'm not stupid.
I'm barely at the start of my career.  My life is just now on its way.  I am not going to risk all that just to show that I am some brave soul who risked her life just to hopefully keep the economy rolling.  I honestly think that the economy could use a living Kelly as opposed to a dead Kelly, and no one can convince me otherwise.

I have been spending all my extra disposable income on preps instead of things my friends are spending their money on--vacations, shoes, cosmetics, clothes, jewelry, etc.  If I knew that I would have to work outside the home during a pandemic, what's the point in prepping?  I might as well blow all my money on cool junk and live it up for as long as I live--which will not be very long once the panflu hits.


[ Parent ]
Comfert and life
Kelly,

  The world is better off with you, than without you.

  Prepping for this helps make you more prepared for other disasters. At worst you live better than those who are not prepared. At best you kept youself well and worked when others could not. Its not fair but which group do you want to be in. Those with food or those without. This is no guaruntee that it will get that bad or that all your plans will work out. 

  I also hope you try what you bought. The worse thing to hear during a disaster is "how do you work/use this thing?"

  Do you feel better having the supplies on hand??

Kobie


[ Parent ]
SIP
I don't know what your age is or your occupation, but I can tell you this-even if you went out during a pandemic, odds are you wouldn't get sick. A 30% CAR means 30% of the susceptible population would get the disease-that leaves 7 to 10 odds that you wouldn't.

A pandemic will be scary and difficult- no 2 ways about it. It will not be-IMHO- a "TEOTWAWKI' event. Things will be different, but we will go on.

You have to do what is comfortable and acceptable to you.

It is better to look ahead and prepare than to look back and regret.


[ Parent ]
Individual situations will determine SIP
For my family we will likely SIP unless the pandemic is very mild.  The reason?  Well, I'll give you five actually ... my kids who are all in the current kill range.  Five kids between the ages of 16 and 3 years of age.  Even at 7 to 10 odds, I could still wind up with the sick child or a dead child ... once it is in the home maybe more, maybe all. 

I know that the pandemic is unlikely to be a world-ending event.  I'm not even sure how much things will change, even if it is a worst-case scenario ... things will eventually return to "normal."  Human nature being what it is I really don't have great faith that all that many lessons will get learned by the greater majority.  Look at the hurricanes that we've experienced time and again over the last couple of decades ... heck, the last couple of years ... and I can tell you there are still tons of people who live in trailers and do not prep for hurricane season and who choose not to carry home or flood insurance.

But, I've still have the responsibility for taking care of my little piece of this world ... and that includes my kids.  We'll SIP until I have a good enough reason not to.  I'll chose losing my current economic status over losing any of my children.

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
they made up that 30% CAR, and the cfr is currently fatal
certainly will not be enough modern medical care in the quantities and duration needed.

Everyone is suseptible to every new panflu strain, however many those end up being. Whatever the real attack rate is, it would not be a once-and-done thing.

People need to decide what they will and won't do, but, I want volunteers, and, govts to give them the right PPE, volunteers whose families are prepped, not people forced, and, in every essential sector, people held in reserve the first six months at least. They'll be needed.


[ Parent ]
not everyone needs to SIP
to bring the attack rate down.

This whole set of ideas is so new, and so unusual. it's going to take a little while and a fair amount of public education to understand.  The beauty of the targeted layered approach is you don't need full compliance. 

In the example that I gave, you only need 30% compliance of the NPI to bring the attack rate down from 40% to 3.9%.  This fall in attack rate does not just protect those who SIP, but also those who don't.  Essential workers who have to go to work will have a higher chance of being infected than those who stay home, but it will still be lower than if those people do NOT stay home.

Say it in a different way,

selective SIP is good for the whole community, including those who don't.




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


[ Parent ]
Susan, I'm utterly baffled.
So...how will people's chances of being infected be lower than if they do NOT stay home?  Isn't home the safest place to be in a pandemic? 

[ Parent ]
look at the chart
on UPDATE #2 here http://www.newfluwik...

And read the explanation there.  The most important column to look at is the CAR, or clinical attack rate.  Notice how it can drop from 40+% to 3.9% at 30% compliance, and to a dramatic 0.5% at 60% compliance. 

30% compliance means 30% of people following the official recommendation, which is keeping their kids home, staying home if sick, don't go to public gatherings etc etc.  Since the official recommendation is NOT total SIP, you don't even need 30% of the people being in total SIP to achieve a reduction from 40+% to 3.9% CAR.  More for 60%, of course.

NPI works by reducing the overall amount of mixing, and thus the overall percentage of population infected. 

Imagine you have to go out during a pandemic.  If a significant proportion of people are complying with the above, you will a) meet fewer people, and b) because of the overall drop in infection rate, your chance of catching the virus from those whom you do meet is also correspondingly reduced.



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


[ Parent ]
no, because my chance is determined by your chance!
This is the point: if children are not together, then they and their families have a smaller chance of infection.  A smaller chance in a large number of people means that, yes, some people are 100% infected themselves (a yes/no for the individual) but a larger number of people are 0% infected.

Shifting from "me" to "we" is difficult, I know.  But "we" is a lot of "me"'s.  Less people infected is less people infected.

Now, there's nothing as zero chance of infection unless:
- we stop each new pandemic in it's start (may have been done in Hong Kong 1997, but it doesn't look doable in Indonesia 2007)
OR
- we all grow our own food and energy so close to home that we can effectively shut down countries if we want to and as soon as we want to

All in all, I believe we have to work in several fronts:
- insist that Indo does what's needed, and help them think of ways forward (yes, a new thread/diary/conversation)
- prepare locally for NPI
- work within to refine our inborn ability to be efficient (a small secret: I've just lost mine in public, locally, so I know!)

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


[ Parent ]
How quickly do the 30% need to comply
to get the effectiveness you have planned on?  If you get 30% compliance but it is too late in the game, there goes your home field advantage.

There appears to be a lag time in knowing what category the pandemic winds up being.  Since the suggestions currently have no teeth, there is no certainty that every community will follow them, nor at what point school closures will occur.  We don't know how quickly the hypothetical pandemic will travel either.

If communities hesitate even a bit over the school closures, or any public event closures for that matter, then that would topple your statistics wouldn't it?

Again, its back to the enforcement issue ... people, or at least many people, will not follow the rules unless there is a clear and present reason for them to do so and a hypothetical situation just isn't one of them.  I've experienced too many hurricanes and near misses to know for a fact that unless there are dead people in the street many people will still be living on the "it can't happen to me" syndrome. 

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
good question
the earlier the implementation, the better the result.  Look at the following slide from Marty Cetron,

Initiating early is going to be the key.  As a ballpark figure, I think aiming at compliance before the 0.1% of the population gets infected is a good cut-off point to use.  Problem is, you won't know when you get to 0.1% of infection, because this kind of information takes time to gather and can be very unreliable.  So what to do?

In a known pandemic, ie there is clearly established and widespread efficient h2h in the world, you would expect the local community to become infected sooner or later.  In that sense, once you know that the virus has arrived locally, there is no reason to wait for the number of cases to reach 0.1%.  In a pandemic with a generation time of 2-3 days and R0 of around 2, you are expecting a doubling of cases every 2-3 days and a 10 fold increase in about 1 week to 10 days.  There is not much room for authorities to wait and think about when is a good time to close schools.

That's why the current trigger being set at 'lab-confirmed cluster' at the state level is a good idea, cos it takes away the guesswork by local authorities who may not have the resources or will to start implementation, IMO.  Assuming moderate vigilance in surveillance, chances are when such a cluster is identified, the vast majority of local communities eg towns may not have the first case yet, or even if they have, they are still way below the 0.1% that you are aiming at. (50 cases for a town of 50,000)

There appears to be a lag time in knowing what category the pandemic winds up being.

That actually is very simple.  Anything over 1%, you close schools for 12 weeks.  Remember also that in the absence of local data, you just use whatever is known, eg overseas data.  So if you know that in Indonesia, there had been 300 cases, out of which 5 died, you already know you are going to close schools soon as it arrives in your state.

The guidance is a bit more flexible in Cat 2 or 3, and says only 'consider' closing schools for 4 weeks'.  This is something that should be worked out with your local authorities ahead of time, whether they are going to close or not.  Suppose they agree that schools will close at Cat 2.  If you look at the charts, Cat 2 starts at 0.1% CFR.  Which means 1 in 1000.  Now imagine a pandemic breaking out, and people are getting sick all over the world, and you hear that only 1 in 1000 are dying, would you be very worried if your town missed closing schools while they are trying to figure out whether the CFR was 0.09% or 0.12%?

Again, its back to the enforcement issue ... people, or at least many people, will not follow the rules unless there is a clear and present reason for them to do so and a hypothetical situation just isn't one of them.

Again, I agree.  However, since school closure is such an integral part of the intervention, it is mighty difficult for individuals to not comply (what are they going to do, drop off their kids at school anyway?).  Compliance with one component serves to raise awareness and sets them up for further compliance.  Just imagine if school closure is not part of the package, only social distancing and staying home when you are sick, the level of awareness and compliance will be a lot less.

Another thing is, don't underestimate what people will do to protect their kids.  If a pandemic happens with the kind of age distribution we are seeing with H5N1, people will go to extraordinary lengths to comply, even with a low-ish CFR.



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


[ Parent ]
It depends on who decides to close schools ... the level of authority
The school closures in each state are determined by different levels of authority.  In FL I think the state can suggest school closures, but I think they have to be agreed upon by local district on an area by area basis.  Districts here in FL cover more than a single county, so under each district there are county administrators as well.  At each level there must be an agreement to close schools and each level receives their own pressures ... political, social, and parental ... that will ultimately determine whether the school closes.  That relationship may be more streamlined in other states, and I'm sure some are even more complicated.

I tell you who could make the schools close here in FL ... the insurance industry.  Schools have to carry insurance.  If the insurance industry set some pandemic standards for schools and businesses you would have some teeth without having to have legal mandates.  I'm not sure if that would be applicable in other states, but here the insurance industry plays hardball and does major amounts of CYA.

For a fact, I know there are parents who will do whatever they have to do to protect their kids.  The problem is that is not an across the board concept, parents send their kids to school sick every day all the time, triggering many "epidemics." 

Unless I'm missing something here, and I admit that I might, what you are actually saying is you need on 30% compliance for the general population, but nearly 100% compliance for kids for your stats to work.

Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead


[ Parent ]
compliance
the 30% means 100% school closure, which doesn't really require compliance per se, and 30% compliance in everything else, eg keeping kids away from malls.



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


[ Parent ]
good point about insurance
Do you think insurance might use the federal guidance as CYA?  If that is the case, then making sure the insurance industry is informed will be a crucial activity IMO!



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


[ Parent ]
I'm not sure ... but it has to be on their radar
Insurance is all about risk management so if panflu and the official documents concerning it isn't on their radar then someone isn't doing their job .... especially considering all the trouble they've had the last couple of years with hurricanes and other natural disasters.


Never doubt that a small group of thoughtful, committed citizens can change the world, indeed it is the only thing that ever has. -- Margaret Mead

[ Parent ]
forcing people to prep
What are you going to do if people don't?  Fine them?  Send them to jail?

# 1 rule of lawmaking if you are the government:

Don't make anything compulsory that you cannot enforce.

Cos, let's face it, that's what you are talking about, writing it into a law somehow that says people have to prep for 3 months.

The first thing about any law enforcement is how would you know if someone has broken the law?  Cos they don't have enough food in the house?  How much is enough?  I could be anorexic and one carrot a day is all I need! 

And if the reason why I'm not prepping is because I can't afford it, do I qualify for extra help, or am I a criminal to be prosecuted?  Cos that's what it will be about, punishing the poor.



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


[ Parent ]
Asked to plan...
Re: "Communities, individuals and families, employers, schools, and other organizations will be asked to plan for the use of these interventions to help limit the spread of a pandemic, prevent disease and death, lessen the impact on the economy, and keep society functioning."

When, when, when will they be asked-how will they be asked and who is going to do the asking? I have been begging our county's DOH to please tell-not ask, not suggest, not reinforce, to our local board of health the need to start working on a pandemic plan for our community-something with guts in it. And don't drag your feet starting it, because there is alot of work to do.

The silence is deafening. A really big fish will have to tell-in no uncertain terms-each mayor/governing body that they need to start doing this asap. They may ask how to do it, who will pay for it, just do it for us, give us a template, it's not our job....but someone has to start it and very soon.......

It is better to look ahead and prepare than to look back and regret.


they ARE being asked
right now.  This document is now official.  Your local board of health should have been required to have a pandemic plan by now.  Under that obligation, the next step is to refine those plans incorporating advice and guidance from the federal government.  I didn't put every point on the top diary, obviously, but the guidance also includes sections on risk communication and public engagement.  Which means talking to you.

This is something that needs to start right now.  However, there is a huge variation in awareness and willingness to do anything, so if you are concerned about inaction, I would suggest that you get proactive (again).  Download and print the document, put it in a binder.  Get familiar with the different sections.  Go talk to your board of health, your board of education, you county PH official, your elected representatives, etc.

Before now, local and state PH often used 'lack of guidance' as an excuse for doing nothing.  Well, now we have guidance, and the basic theme is very clear: get your community ready for early school closure of not less than 12 weeks, and everything related to that.

Tell them you are worried about the secondary consequences, that they need to run drills and exercises to figure out where extra work is needed to cushion the consequences.  It may go down better IMO to tell officials you want to help them figure out how to implement this, rather than to tell them they have to implement it.



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


[ Parent ]
Starting
I can tell you from first hand knowledge that on the local level (ie township) in New Jersey USA we are not required to prepare a pandemic plan, no one-other than me-has asked us to get a pandemic plan started. To the contrary-it's been pure resistance the whole way. I am not allowed to bring in speakers at will, to get approvals for ideas without laborious time consuming ie months of delays.

I know the county department of health may be working on a pandemic plan for the county per se, but nothing specific for each township. Out of 37 townships in our county, we're the only ones even trying to do anything. I haven't heard of any concrete plans from the county, so who knows how far any pandemic plan has come.

And at the rate we're going, we'll be done in say, 2018.

It is better to look ahead and prepare than to look back and regret.


[ Parent ]
let's hope we get exponential faster than the virus :)


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

[ Parent ]
the discussions have moved
over to this diary, for the last couple days http://www.newfluwik... Just in case you were only diligently following this thread, you should go check out the other!

These things seem to have a life of their own ;-)



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


and prior to that
a good deal of discussion here http://www.newfluwik...



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


[ Parent ]
Volunteers
We'd better put our hopes on volunteers who turn out, prepped or not. To anticipate any type of assistance on the local level from any government is to wait in vain. There are alot of top-heavy meetings etc going on but IMHO it is worthless unless something effective filters down to the locals.

And nothing has yet, at least in my neck of the woods..And I doubt we're the only ones...

It is better to look ahead and prepare than to look back and regret.


Jody Lanard commented on Volunteers
http://www.psandman....
And specifically here: http://effectmeasure...

Also covered, from a different angle, at http://www.worldchan...

And of course, the BIG picture!  http://www.fluwikie....

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


[ Parent ]
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