From Flu Wiki 2

Forum: CDC Hospitalization and Mortality Estimates

05 August 2006

Medical Maven – at 10:47

Are hospital administrators up to this sort of triage even if the plans were put into place? It is one thing to have a plan, and it is another thing to implement it.

I have always thought it was a stupid waste of resources and valuable lives for hospitals to become the first casualty of panflu just to prove a point. The Grace RNs of this world deserve better and will serve better in other capacities elsewhere and later.

Medical Maven – at 10:49

Where did anon_22′s initial posting go????

anon_22 – at 11:21

This was posted on the Aug 4 news thread. A set of slides for a CDC conferencing:

http://www.bt.cdc.gov/coca/pdf/PanFlu­­_nsmith_v2.pdf

I had a look at them and thought this was significant:

Notice that for the 1918 scenario, their expected mortality is much higher than ICU admissions. Given that not all ICU patients will die (one hopes), this means the vast majority of patients who die will do so with no access to high end care.

The gap for ventilator care is even higher. I wonder if those numbers are based on estimates of clinical need for ventilators, in which case, an estimate of 745,000/90 million sick = 0.8% of infected people needing ventilator care bears no resemblance to what we know about H5N1. It is likely this figure is severely ‘massaged’ to more closely reflect the actual number of ventilators available.

anon_22 – at 11:25

MM, I made a mistake in one of the figures and had to do a re-write to avoid confusion. sorry!

anon_22 – at 11:29

Now, the US currently has a stockpile of 7 million ‘course’ of tamiflu. Orders were placed in March 2006 for another 16 million, making a total of 23 million. The regular ‘course’ of tamiflu is 75mg twice daily for 5 days = 10 tablets, which is what you get in 1 packet.

I will use the word ‘packet’ to indicate 10 tablets as the definition of what is a ‘course’ of tamiflu depends on what you are treating.

I don’t know when they expect delivery, but let’s say sometime in the not too distant future, the US government will have 23M packets of tamiflu.

If you only use the standard dose, that is not even enough for the people who are expected to seek medical care, for the 1918 scenario.

Anybody who is skeptical about our chances for orderly distribution of healthcare should reflect on this number alone.

anon_22 – at 11:33

Current almost-official thinking about the dosage for treatment of H5N1 infections is that it requires at least twice the dose for at least twice the duration. That is 150mg twice daily for 10 days. Which means each patient needs 4 packets.

23 million packets will be enough for 5.75M patients, assuming that 100% of the stockpile will be used for treatment, and assuming perfect match between local need and local availability.

This means there will not be enough for all hospitalized patients.

Hospitals will be saturated with virus contamination in short order.

If that is the case, how many HCW will decide to go to work?

anon_22 – at 11:38

Given that tamiflu gives the best chance of survival if given early, ie before patients become very ill, what should the policy for hospitalization and/or use of tamiflu be?

They may need to do some pretty ruthless triage so that only those with a fair chance of survival will get tamiflu and/or will get hospital treatment.

Which means turning away the more severely ill at the hospital door and admitting only the ‘walking’ infected, and all those admitted will get tamiflu.

This may be the only way to prevent hospitals becoming deathtraps for HCW.

anon_22 – at 11:41

Who has the stomach for such kinds of triage?

If most of the severely ill are children and young adults, what will desperate families/parents do at the triage station?

Who can blame the Canadian HCW in a recent poll the majority of whom state that they will refuse to work at triage if we have a pandemic?

But such kinds of triage, horrible as it is, is probably the only way to save some patients because HCW are willing to work heroically to save them.

Average Concerned Mom – at 11:42

anon-22

if that becomes the case at hospitals, and that fact becomes known, then all potentially infected people with even a smidge of fever and the sniffles will come walking up to the hospital at the first sign of illness…. right? Overwhleming hospitals in short order with… the worried mostly well, possibly sick? Using up scarce resources even faster?

(Sorry for lack of clinical terms here. A smidge of fever….)

FL Watcher – at 11:45

Given that tamilfu will work with a new strain. Speculation is still in the running.

anon_22 – at 11:46

Average Concerned Mom – at 11:42

if that becomes the case at hospitals, and that fact becomes known, then all potentially infected people with even a smidge of fever and the sniffles will come walking up to the hospital at the first sign of illness…. right? Overwhleming hospitals in short order with… the worried mostly well, possibly sick? Using up scarce resources even faster?

Exactly!

I was just going to write something like that! Now I can skip that post, thank you!

Average Concerned Mom – at 11:48

Frankly, I hate this conclusion, but everything I am learning here on fluwikie is pointing to the conclusion to me that giving the public informatino is a bad idea.

Am I being paranoid or thinking like a politician? Or some one in public health?

Ugh.

anon_22 – at 11:52

FL Watcher – at 11:45

Given that tamilfu will work with a new strain. Speculation is still in the running.

Current indications are still that tamiflu and other NA inhibitors will work with influenza A viruses in general. Exceptions are still rare. So expecting tamiflu to work is NOT speculation. How well will it work? Will it improve survival rates by 10%, 30%, 50%, 80%? (It won’t be 100% for sure, but neither will it be 0%.). We don’t know, but we still have to do the best we can.

So planning based on use of tamiflu is not speculation, it would be irresponsible to NOT do it now, IMHO.

anon_22 – at 11:54

Average Concerned Mom – at 11:48

Frankly, I hate this conclusion, but everything I am learning here on fluwikie is pointing to the conclusion to me that giving the public informatino is a bad idea.

Well, that would be one way of thinking about it.

Am I being paranoid or thinking like a politician? Or some one in public health?

Ugh.”

No, yes, and yes.

It is always a good exercise to try on the other person’s shoes. Ugh indeed!

LauraBat 11:56

Just the rate of 9.9 million hospitilizations demonstrates the futility of it all. There are not that many beds in U.S. hospitals, and god forbid some people have babies, heart attacks or car accidents that would also require a hospital stay.

Average: the gov’t has released the estimates of “worse case” scenarios, which is the 1918 scenario. However, I don’t think most have then taken the time to translate that to hard core reality numbers. And many on the wiki think that the 1918 CFR is optimistic given the current CFR of over 50%. TPTB are walking a fine line between trying to get people to prep and not freaking everyone into a complete panic.

anon_22 – at 11:57

FYI, I used to think of 1918 as the worst-case scenario.

Now with H5N1 I think of 1918 as the best-case scenario.

<sigh>

Only way to deal with this is to keep doing our best.

Plan for the worst, hope for the best.

anon_22 – at 11:59

LauraB,

Second time on this thread when someone has the same thoughts as me and at the same time.

FL Watcher – at 12:06

The reason I even have mentioned it is that my husband is a family practice doctor and many of his associates, internal medicine, infectious disease, and some very repected researchers say this. Do they have tamiflu on hand? NO! I have asked! I agree in that it may help and given the circumstances they most likely will take itif they are encountering sick patients, I would hope! I personally think its the one avenue the government will use to calm fears. Your right about it would be irresponsible to not try every every avenue available. It will be the hope of many people before a vaccine can be made.

anon_22 – at 12:07

If you stare at those figures long enough, and still don’t want to give up, then you will probably come to the same conclusion as me, that:

1) there are no good options, only mitigation and triage

2) we can only do our best

3) our best, in most instances, will only affect the ultimate results marginally, if at all

4) ie there will only be ‘long shots’ and ‘not-so-bad’ options’

5) but multiple ‘long shots’ together might make a small but critical difference, especially to the sustainability of the infrastructure and healthcare system

MAV in Colorado – at 12:11

in the WHO/CDC “plan”/ reports I have seen, many millions of those vitamin “T” doses are designated to chemically cordon areas where clusters may occur. Ie.prophylactic treatment of those in the area surrounding H2H transmissions.

FL Watcher – at 12:16

anon_22 You hit the nail on the head, exactly what the attitutde was. You can imagine my attitude as a lay person who follows the flu-wiki and wants to have all the preps ready and in place. Many times the wind has been taken out of my sails as to can I really help my family? With all this prepping and reading I do it if becomes pandemic its only a crap shoot if I have made a difference.

anon_22 – at 12:20

MAV in Colorado – at 12:11

in the WHO/CDC “plan”/ reports I have seen, many millions of those vitamin “T” doses are designated to chemically cordon areas where clusters may occur. Ie.prophylactic treatment of those in the area surrounding H2H transmissions.

Yep, I’ve seen those too.

Most experts that I have spoken to, excluding those with personal career stakes on the ‘containment’ idea, think that it will mean a big waste of life-saving drugs in a futile exercise.

Just to prove a point…

There will be severe social repercussions as a result of this policy, IMHO. Those living in areas of initial outbreak already risk being shunned by those in other neighbourhoods, should they try to re-locate, which many will be tempted to do, and the government will be in no position to stop them. Now they risk being attacked for possibly having tamiflu on them as well.

Maybe that is one way to enforce a quarantine?

Just kidding…

anon_22 – at 12:31

Back to hospitals and HCW.

Some people have been advocating buying more ventilators.

Personally, I think the single most important equipment to spend limited resources on will be PAPR Powered Air Purifying Respirators

The only way HCW will come to work is when they believe they will be adequately protected.

anon_22 – at 12:39

Here’s a better photo of what a PAPR looks like.

Average Concerned Mom – at 12:43

How expensive to buy and maintain?

anon_22 – at 12:50

Average Concerned Mom – at 12:43 “How expensive to buy and maintain?

I knew this would come up soon as I post that. :-)

Answer is, I don’t know, but way less than a ventilator, I should think.

anon_22 – at 12:58

probably in the order of USD500−800 per unit.

Average Concerned Mom – at 13:01

Not that I’m thinking of buying one! (-: But I was wondering if it would be something reasonable for a HCW to buy on his/her own, if the hospitals weren’t going to do so on their behalf. Sounds too expensive under ordinary circumstances for a hospital to be willing to purchase for every HCW.

anon_22 – at 14:23

Not every HCW. But 20–50 for the most critical posts. I’m sure with volume discounts they can bring the price down. Let’s say at $300, 20 units cost $6000, 50 units $15,000.

MAV in Colorado – at 14:57

the PAPR’s I have looked into are in the $700 to 1100 range with filters which are changed in pairs each day around $40 each. The hoods with face shields as shown above are around $50 for the set up and disposable hood/shiels around $15 each, Tyvek suits around $10 each etc etc

Leo7 – at 15:06

Anon 22: Good thread and good points.

PAPR is a home run! Perfect for HCW to be in comfort zone. The number of vents is pointless if there aren’t HCW’s available to manage them. Also, to triage. The Naval lab on the carrier can test for H5N1 and have results in one hour. I hope that technology gets out to the hospitals for triage and that will hold back the tide of worried well as mentioned earler.

anon_22 – at 15:12

The reason why I raised the issue of PAPR is that they just about carry the only hope for significant numbers of HCW to continue to turn up for work, especially after the tamiflu is all gone and hospitals will only be offering supportive care.

anon_22 – at 15:18

Let’s say $40,000 will get you 50 PAPR with all the accessories and enough disposable supplies to last 3 months.

THAT alone will keep a medium sized hospital running through the worst of a pandemic.

Monotreme – at 19:24

If a severe pandemic were to start this fall, this is no doubt that there will be insufficient resources. If you were a central (federal) government planner, how would you allocate those resources? If you allocate them across cities based on population, they will do little good, IMO. They will simply be used up by the worried well in every city and few of the early genuine cases. Then the health care system in every city collapses and possibly essential services as well.

We are always talking about triage in terms of individuals. But I am convinced from this thread, and many others, that that will do little good. But what about triaging cities? Is it possible that there is a list of essential and/or savable cities which will receive federal stockpiles of medical and other resources? And coversely, a list of hopeless cities, where the effort will go into contatinment?

Is this why almost nothing is being done in New York City and so much is being done to prepare in other cities?

I have said before I think New York City has been written off as unsaveable. I remain convinced of this.

Melanie – at 19:28

‘Treme,

I suspect you already have the answers to these questions. Care to share them?

Monotreme – at 19:43

Melanie,

All I have are guesses based on fragmentary information. And my guess is that certain cities, most notably NYC, will be contained but not helped in any substantial way. Other cities will receive very substantial aid.

I think the US and much of the developed world will not return to the dark ages, even if H5N1 goes pandemic with its current mortality rate. Targeted application of available resources can prevent this. However, I think there are cities within the developed world where the contained populace will envy their medieval ancestors.

Melanie – at 19:50

A bow to you, sensei.

janetn – at 20:40

Anon 22 I wish you were in charge. If you were more HCWs would show up, and fewer would die. Which translates into more lives in the general public saved. TPTB just dont get it, HCWs are not sucidial.

anon_22 – at 21:37

janetn.

Thank you.

I understand HCW concerns cos some of my best friends are HCWs. And some of them work in the highest risk areas.

06 August 2006

anon_22 – at 06:29
rrteacher – at 08:51

Hmmmm. Anon_22, you mentioned WHO/CDC and the making of policy decisions regarding resources. The current plan, I believe, according to Emergency Support Function 8, is that HHS, through the Office of Public Health, Emergency Preparedness will be in charge of all materials/personnel logistics. Through a complicated process, the Assistant Secretary, now Rear Admiral William Vanderwagen, will run the Secretary’s Operation Center and distribute materials based on advanced Emergency Response Team assessments which generates a Mission Assignment. I have some slides of the process but don’t know how to post them. It appears very complicated, but the task would seem require it. The planning seems sober but it has been the execution that gives us fits.

MAV in Colorado – at 13:25

Without the ability to respond quickly with an effective treatment, an outbreak of any virulent novel bug in a major city is a bad outcome. As we have seen, nothing requireing this level of response happens fast enough and effective treatment seems to be very questionable at this point. As Monotreme mentions above, “writting off” major cities may be part of the plan. Historically quarantines have worked, in the sense that the bug eventually dies out inside the zone protecting the multitudes on the outside. I anticipate that cordoning off these areas will be the only federal option. I don’t think you need to have a plan to contain a fire.

07 August 2006

anon_22 – at 01:24

rrteacher

“I have some slides of the process but don’t know how to post them.”

you can email them to me anon_22 AT hotmail DOT co DOT uk.

Average Concerned Mom – at 08:48

Leo7 at 15:06

“ Also, to triage. The Naval lab on the carrier can test for H5N1 and have results in one hour. I hope that technology gets out to the hospitals for triage and that will hold back the tide of worried well as mentioned earler.”

I don’t know much about this one-hour flu test, or any flu test for that matter. But it stands to reason that a 1 hour test would be a lot more expensive than the test that takes about 2 weeks to carry out. Does anyone know how expensive the tests are that are capable of being done in the Naval lab? It would be great to think that these tests could be performed for triage in a pandemic setting, but I just am pessimistic — that would be al ot of people needing to be tested.

LauraBat 13:48

I also worry that a quickie test may have a high rate of false negatives and/or false positives, either of which could be dangerous. Isn’t there a 3-day test curretnly being done in Thailand? A lot can happen in three days, but if it’s accuracy rate is high it’s a lot better than two weeks.

Leo7 – at 14:19

I for one wouldn’t give the one hour test without a fever being present. Anyone else sent away! False positives is more likely if the HCW doesn’t have protection like the PAPR because I’m guessing it will require and up close with someones mouth and sputum. The idea is to keep the hospital functioning, not worry about false post testing. The worried well will get irritated if they have to wait 3 days before getting into the hospital, wouldn’t you? Still have my fingers crossed for 1 hour testing.

nsthesia – at 14:40

anon_22 @ 1518:

“Let’s say $40,000 will get you 50 PAPR with all the accessories and enough disposable supplies to last 3 months. THAT alone will keep a medium sized hospital running through the worst of a pandemic.”

Uhhh…you and I agree on MANY things, but IMHO, 50 PAPRs wouldn’t keep a medium hospital functioning for 3 months. Let’s say one caregiver (per suit) to each patient, maybe 2. These will ALL be critically ill patients, otherwise, they wouldn’t even be ALLOWED into the hospital.

This equipment would be utilized 24/7 for the duration. That is asking a lot of a piece of life-saving equipment. I haven’t read the specifics, but hopefully, one filter will last 24 hours. I might be thinking I’d change it once per shift. Plus, you better have some back-up suits for malfunctions and accidents.

So, each suit (with a HCW inside) can care for 1 - 2 (3 is stretching it) patients. It will be tough working inside a suit. And your actions will be encumbered. I assume the suit requires electricity or batteries to work? No electricity, no workee?? And electricity will be required just to endure the heat inside a suit.

I’d double your numbers to 100 to perhaps care for 200 - 300 patients. And that is just bedside workers. What about the lab techs, x-ray, etc., etc.??? I’d bet that a 200–300 bed hospital would easily see tens of thousands of patients in three months time.

BTW…IMO, this is one of the most realistic threads on this subject yet.

Leo7 – at 14:54

I don’t think a suit is implied—that’s a barrier gown isn’t it? It looks like respiratory equipment attached to belt at waist. I agree this is the most realistic thread concerning hospitals and health care. I watch the absolute waste in money ie Katrina and Iraq and state for the record it’s time to fund something for HCW’s that will benefit patients and communities and not just corporations. The PAPR’s are a realistic option and I for one would feel valued if it were purchased by my health care facility. (Note to other sniggering HCW’s-I know I stretched the “feel valued” section).

Leo7 – at 14:55

Ooops that should be snickering HCw’s. Too much on call duty!

Grace RN – at 15:08

anon_22 – at 11:57 FYI, I used to think of 1918 as the worst-case scenario. Now with H5N1 I think of 1918 as the best-case scenario. <sigh> Only way to deal with this is to keep doing our best. Plan for the worst, hope for the best.

EXACTLY my thoughts.

rrteacher – at 15:20

Anyone here worked for any length of time in a Level C set up? Its noisy and hot. HAZMAT teams using A-B-C gear limit time in the Hot Zone to minutes, not hours. Nsthesia, Grace, Leo-Try intubating or doing a blood gas or starting an IV in one. You can PAPR till the cows come home and all you have to do to die is touch your nose after fomite contact when you get out of it. Masks or any variety for patients (to curtail DROPLET spread and washy the hands for everyone. This virus behaves like All Influenza A, (except killing you when you get it) and good preventative measures will work. PAPRs should be reserved for risky procedures or screeners in a busy triage area.

nsthesia – at 15:23

Leo, my dear…

I wouldn’t hold my breath…(no pun intended, cuz apnea just might be the best equipment we get). I’m sure many of us would purchase a PAPR, but I sure wouldn’t want to be the only one with one on in the hospital. You’d become a focus and I’m sure it would ensure your getting the worst cases. With the disposable ones, you’d have to change it with each break. I wouldn’t dare let it out of my sight either, cuz it wouldn’t be around for long.

Also, I’m not sure how the public in general, would react to them outside in the community. There are reports of healthcare officials having their protective gear ripped off their bodies by neighborhood crowds in Indonesia. I can easily see the same happening here.

Tom DVM – at 15:28

Grace and annon 22…’ditto’.

Medical Maven – at 15:40

Monotreme at 19:24: I assume your idea on containment/triage for cities means containment by means of National Guard troops via the main roadways. And that this containment would be for the purpose of preventing an outspread of civil disorder into areas that could be saved? The virus, of course, would be on its way to everywhere at this point. If it gets very bad, you are probably correct about this scenario.

heddiecalifornia – at 15:53

Anon 22 at 11:38

shortage of Tamiflu etc. might be solved the same way that the Morphine shortages of WWII were solved — placibo. Just give them something to take — a package of any kind of pills “ go home, take one of the 2 times each day and stay in bed with plenty of fluids “ and it gets the person out of the hospital and back home where they are “more safe” but still sick. Sad. I am getting so cynical —

Grace RN – at 16:01

rrteacher – at 15:20 DH used to do HAZMAT, and was certified to wear multiple types of suits; he told me about how tough that was, especially the heat/sweating problems.

Fomite contamination will always be a problem-washing hands will be the only solution, now and forever.

nsthesia – at 16:25

rrt,

All true. I agree it would be most difficult to work in such gear. I also think HCWs would be exceeding the usual time working in whatever gear is allocated to them. I’ve worked during hurricanes and there were no designated hours. With the shortages a pandemic would cause, I can see long hours at the bedside, even in PPEs.

Your point is well-taken regarding the use of such equipment. But, IMO, what is more dangerous than direct care of an intubated/extubated, infectious patient with probable fulminant secretions (bloody?) and diarrhea? I can see a LOT of suctioning and spewing of secretions, let alone the GI situation. RTs would also have significant exposure. A large number of these patients may develop DIC. So…the HCWs with the patients with fulminant pulmonary secretions/edema/hemorrhage + generalized hemorrhage from every orifice and puncture site + massive diarrhea…THEY get the SUITS!!! (in my fantasy). These will be messy patients.

One of the most dangerous aspects of patient care with SARS patients was during the actual intubation. I agree, not an easy task, but IMHO, I would want a respirator just for that procedure alone.

As for a screener in a triage area, slap a mask on every patient that presents with upper respiratory symptoms and give the screener an N-100 with face shield, gloves, gown, etc.

Leo7 – at 16:26

Nsthesia:

I often have been known to hold my breath and go apneic while working in full barrier gear on burn patients. This occurs when I’m pulled to other area, not my norm. Yes, I know how hot these setups are—but I meant for the PAPR to be available for triage purposes and the ED. The rest of us as Grace Rn notes will fall back on the more simple. ICU’s have the vents and I would not suction if I didn’t have resp gear. I am also the HCW who said, “I don’t think I have to die to prove my dedication.”

Go on—keep workin’ on me. There’s still time to change my mind. I’ve been re-reading Dante just in case I find myself in the bowels of hell on earth. I’ll have a lot to ponder while I wash my unprotected hands.

I predict that nail bitters will be an all new risk category.

nsthesia – at 16:41

Leo,

What a mental picture…just a tinge of cyanosis to go with your yellow isolation gown…

I’m not worrying my pretty little head about it all. I’d be surprised to see some decent N-95 masks available in any quantity.

The one thing your post brought to mind is that IMO, ALL beds will likely be ICU beds, with only the very sickest patients. I hope and pray that hospitals/facilities will be designated as flu-free or not in an attempt to keep the well from getting sick. And if we are NOT in a “flu-free” hospital, then all bets are off. You’re gonna become an ICU nurse on the spot. I’ll even teach you to intubate - for about 2 weeks.

Leo7 – at 16:57

nsthesia:

So true, except the nurse I was with started saying, “You’re not gonna puke are you?” So I suspect I looked green in my yellow isolation gown. So kind of you to teach me how to intubate (although I have taught ACLS), but I plan on beeping you sleepers so you can join me in the bowels. BTW-How long before adhesive runs out?

anon_22 – at 18:09

rrteacher – at 15:20

Anyone here worked for any length of time in a Level C set up? Its noisy and hot. HAZMAT teams using A-B-C gear limit time in the Hot Zone to minutes, not hours. Nsthesia, Grace, Leo-Try intubating or doing a blood gas or starting an IV in one. You can PAPR till the cows come home and all you have to do to die is touch your nose after fomite contact when you get out of it. Masks or any variety for patients (to curtail DROPLET spread and washy the hands for everyone. This virus behaves like All Influenza A, (except killing you when you get it) and good preventative measures will work. PAPRs should be reserved for risky procedures or screeners in a busy triage area

I have no doubt that scientifically you are absolutely right.

However, I am talking about what will get HCW to work.

I am reminded of a slide that was shown by a Health Minister from a country affected by SARS, showing a HCW wearing a N95 mask answering the phone. He said he shows this all the time, and the criticism was always “why does she need a N95 to answer the phone?”

The point was, they went through SARS, and one of the most valuable lessons that they learnt was that sometimes trust was more important than science or even logic.

His answer to the criticism was that it became apparent that they would have massive staff defections if they didn’t bend over backwards to reassure the HCWs. So his response, and his message, was “If a HCW thinks she needs a N95 mask to answer the phone, she GETS a N95 mask to answer the phone.” That was the ONLY way, they found, that they could buy the trust and dedication of the staff.

Leo7 – at 18:15

Anon 22:

You hooked me on it! It’s far better than the pathetic versions we’re currently using. I also think triage workers wearing them will scare the worried well into turning around and going home. When they see that get-up they know the hospital is not where you want to be, especially if you know you’re a hypchondriac.

anon_22 – at 18:19

nsthesia,

It won’t be one PAPR per patient, it will be one PAPR per staff, who will have to take care of as many patients as possible. Preventing cross infections will unfortunately be a line that will have to be abandoned very early on, and the frontline will be withdrawn with the final line being protecting enough HCW for them to keep functioning.

One filter is good for an 8 hour shift.

Also, during SARS, often the HCWs could not endure spending long hours in the full PPE with N95 or N100 masks, because of sweating and the increased breathing efforts. PAPR helps this somewhat, as you get a constant supply of air at least through your face and head, if not the rest of the body, and it keeps you alert and fresh.

The other problem was that changing in and out of PPE was found to be the most hazardous time for staff to get infected. So a lot of the staff decided to go for as many hours as possible without food, drink, or bladder relieve. Many opted to use incontinence pads so they could stay in the ward, their aim being able to finish the whole shift without coming out and changing even once. Some of them were eventually able to do that.

These unnamed heroes and others like them deserve all that we can do to reassure them that their safety is paramount. SARS showed that once they are reassured, most HCWs worked tirelessly and many were willing to drive themselves to the brink of exhaustion to save lives.

anon_22 – at 18:26

“If a HCW thinks she needs a N95 mask to answer the phone, she GETS a N95 mask to answer the phone.”

It’s also a bit like banking, the only way to stop a bank run is to pour in as much much money as anybody could want, often visibly, into a bank, so that people will stop lining up to withdraw their savings.

anon_22 – at 18:41

nsthesia,

I re-read your post, and I think you may have mistakenly thought that PAPR includes the gown. It doesn’t. A PAPR unit include a (usually) belt-mounted air filtration unit connected by a hose to a head gear, usually a Tyvek hood with a clear face-shield. The unit is battery operated, and the battery will need to be re-charged after about 8 hours. This is used instead of N95 or N100 respirators.

The gown is a separate thing. During SARS, before they eventually started using PAPR’s, or if they didn’t have them, barrier protection with full-length water-resistant gowns were standard requirements, together with N95 masks.

ANON-YYZ – at 18:45

Toronto hospitals recently announced that ALL workers in the building will have Tamiflu available, including cafeteria and cleaning staff. The logic was the hospital cannot function if support staff don’t show up for work.

Melanie – at 18:52

ANON-YYZ,

Have you got a link for that?

nsthesia – at 19:01

anon 22,

I understand that a PAPR is one per staff member, but that one respirator will be used for that one patient 24/7. And, due to the cumbersomeness(?) it will make moving around difficult. These patients will require A LOT of care. So, a nurse/doctor/RT doing total patient care will only be able to care for 2 or 3 patients maximum. All the while trying not to contaminate themselves or damage the equipment.

So, one respirator will cover the direct bedside care for, let’s say 3 patients in a 24 hour time frame. If you have 300 beds, that’s 100 respirators - with no replacements.

I don’t envision this to be a scenario in which one nurse could care for 10 patients. These will be the sickest patients these nurses will have ever seen.

A disposable respirator would have to be changed with each exit from the patient area and in between staff member usage. I have no idea about the cleaning of a reusable one.

Now THAT is if the electricity still works. Without electricity…NO ventilators and NO battery recharging for respirators, NO air conditioning for patient comfort and staff comfort in protective gear. Then, I’d reduce the care to either one on one if there are enough staff to hand ventilate for a while. Or let the sickest die (WITH sedation) and focus on those with the best odds.

“These unnamed heroes and others like them deserve all that we can do to reassure them that their safety is paramount. SARS showed that once they are reassured, most HCWs worked tirelessly and many were willing to drive themselves to the brink of exhaustion to save lives.”

I agree that HCW safety is paramount. I AM one of those HCWs! But I want more than reassurance. HCWs have been “reassured” during their careers to the point of exhaustion. We need access to safe, reliable equipment for the duration of a crisis. The problem with this is that many hospitals do not have the supplies/equipment TODAY needed to take care of patients OR staff. And who can anticipate the amount of supplies that MAY be needed in a panflu? And who will pay for that inventory to sit while we wait? Not many facilities will do this.

The SARS situation that you speak of occurred in Canada - a socialized medicine situation. Each sick or dead staff member in Canada was a “governmental responsibility.” Here, in the US, it is each individual for themselves. <of course, our system will not be able to continue as it is, in the midst of a panflu> And SARS was a local epidemic. Methinks there won’t be a lot of reassurance to go around with a global pandemic.

OK…time for a “happy”, non-reality-based thread…

ANON-YYZ – at 19:22

Melanie – at 18:52

T.O. hospitals to stockpile drug

By HELEN BRANSWELL

TORONTO (CP) - Toronto’s largest hospitals have agreed to buy enough of the antiviral drug Tamiflu to try to protect all staff from becoming ill during a flu pandemic, a group working on pandemic preparedness for the hospitals announced Wednesday.

All hospital staff, not merely health-care workers, will be offered the drug on what is called a prophylaxis basis - a drug administered in advance of exposure to protect against infection. That plan will require enormous and costly reserves of Tamiflu.

http://tinyurl.com/jrfs4

Melanie – at 19:25

Helen is the Gold Standard.

kmc RN – at 22:14

Hi all, From another nurse’s perspective: it’s not just the shortages of PPE that I’m concerned about. It’s the workers who actually keep the hospital infrastructure running that worries me - the NA’s, the kitchen staff, housekeeping, laundry, pharmacy, etc. Our floor gets its panties in a twist if housekeeping takes too long to clean a recently evacuated room - right now we are running at capacity even WITHOUT something like BF in the equation. Every ICU bed is full right now - how can we possibly hope to function when BF hits?

I had my annual fitting for a respirator mask last week, which got me thinking. How many small N95′s does my hospital (the only tertiary care facility in my STATE) really have on hand for me to rely on? And how long before that supply is gone? And how long before there’s no food, no clean linens, no more drugs coming from pharmacy?

It gives me a real case of the willies to think about it. Kathy

Monotreme – at 22:43

Medical Maven – at 15:40

I assume your idea on containment/triage for cities means containment by means of National Guard troops via the main roadways. And that this containment would be for the purpose of preventing an outspread of civil disorder into areas that could be saved? The virus, of course, would be on its way to everywhere at this point.

Yes, you’re interpretation of my meaning is correct. Shutting down airports and blocking highways may slow the virus down, but it won’t stop it from spreading everywhere on any continent. However, if instead of triaging people, the real plan, the workable plan, is to triage cities, then travel restrictions could be quite effective. If the high-priority cities are at least 200 miles from any other large cities, blocking interstates and state highways should be very effective in minimizing spread of civil disorder from the low priority cities. A few fit, 22 year olds may be able to make it by foot, but that number will be small. A total blockade would not be necessary to maintain order in the high-priority cities assuming that substantial resources, including security, is provided to these cities.

Note, I am not advocating this policy. It’s ugly, life-boat ethics. I’m just trying to understand why the TPTB are doing what they are doing and this is the only thing that makes any sense.

Medical Maven – at 22:52

Monotreme at 22:43-You are damn good, one hell of a deep-thinker. No need to reply.

Tom DVM – at 23:00

Medical Maven at 22:52. Same goes for you my friend!!

LMWatBullRunat 23:13

‘treme

your scenario is exactly what I am expecting to see happen, with the addition of a lot of effort made to keep the lights on and the water flowing. I think it won’t work, however, since most of the Guard and Reserves have families, too.

Grant did not defeat Robert E Lee, William Tecumseh Sherman did. WHen the home front is not safe, the soldier has his willingness to fight significantly degraded.

The triage effort will fail since TPTB don’t have the stomach for a real quarantine imposed early in the outbreak. That is the only step that has a prayer of working. Once they get to city quarantine, it’s too late.

Leo7 – at 23:16

Monotreme:

I pity the people who try to stop a stampede. You’ve just whispered a hint to everyone expecting to leave big cities for Sip cabins, to toss that idea overboard-they won’t make it out. The govt will know long before the average joe that the quarantine is going down. If you’re right those plans are strategically drawn up, evaluated and waiting for orders. This measure would totally change the country.

ANON-YYZ – at 23:55

Monotreme:

TPTB may be planning this at the outset, but they will soon realize draconian measures don’t work during a pandemic. Even within the inner circle, they will hear objections.

In Ontario, Canada, there was a plan to force any ‘essential worker’ to go to work or face a jail-sentence of 1 year and/or $100,000 per breach (i.e. for each day). By the time it got passed, the emergency legislation changed the tone completely from using ‘sticks’ to using ‘carrots’ i.e. voluntary with incentive for HCW.

This war called the pandemic can only be won if everyone FOLLOWS the leader with clear moral authority. If there is the slightest perception of favoritism e.g. one city over another, there will be work-to-rule, boycott, fear, every-one-for-himself, divide-the-nation and the war will be lost.

If what you whispered is true, then TPTB will soon find out it won’t work, and instead of choosing and abandoning cities, TPTB will abandon the ‘traditional’ planning doctrine i.e. how do we keep and increase OUR votes. Every body rally around a war time President for an external threat. No one rallies around the President that chooses to divide a nation.

08 August 2006

Monotreme – at 08:12

Medical Maven, thanks.

LMWatBullRun, I agree soldiers and national guard would never shoot at their own family or friends. However, if they were ordered to create blockades on key bridges and highways and told this was to protect cities from disease?

Also, many blockades will occur naturally, without any effort from the federal government. See Katrina for an example.

Feds Probe Post-Katrina Bridge Blockade

NEW ORLEANS — Federal authorities will review last year’s blockade of a Mississippi River bridge by armed police officers who turned back Hurricane Katrina evacuees trying to flee New Orleans.

[snip]

Several hundred evacuees claimed that police from suburban Gretna blocked them as they tried to flee New Orleans for safety on Sept. 1.

Many of the evacuees, who had been stranded at the New Orleans convention center without food and water, said they were told to cross the bridge to be evacuated from the city. But Gretna police confronted them on the bridge and forced them to turn around.

Police later said they blocked the evacuees because there were no supplies or services for them on the other side of the river.

Monotreme – at 08:16

Leo7 – at 23:16

This measure would totally change the country.

I agree completely.

ANON-YYZ – at 23:55

Every body rally around a war time President for an external threat. No one rallies around the President that chooses to divide a nation.

This is true. But I can’t comment further without violating Fluwiki’s non-partisan credo.

Medical Maven – at 08:36

Monotreme: Natural, chaotic processes involving transport will block the outflow of inhabitants. You have hit upon maybe the most telling factor. Have you ever seen a four or six-lane interstate after a semi-trailer and several cars tangle? There is no way you could get by that kind of mess except with a motorcycle. And where would the heavy equipment be to clear the mess? How long would it take?

As you said, it could be a de facto rather than a de jure blockade.

And with law enforcement overwhelmed ordinary citizens would block major arteries coming into their community, (your Katrina example).

Then when you add the quick exhaustion of the gasoline supplies, and I doubt that the federal government would need to do anything, even if that was their intention.

If I lived in a big city, I would buy a motorcycle, a big one.

Monotreme – at 08:44

Medical Maven,

Having been stopped in traffic in a couple of major cities for long periods, I can attest the ease of blocking major traffic. Put a few obstructions (big disabled construction equipment would do) on chokepoints like bridges or tunnels and backed up cars will do the rest. Won’t be long until gasoline is exhausted.

Note, I’m not suggesting a cordon sanitaire or complete quarantine of a major city, I agree that would be impossible. And I do think people will leave major cities on foot, if necessary. So, I think bedroom communities will be overwhelmed. But most people will not be able to go more than 200 miles on foot.

Tom DVM – at 08:59

I think humans have an innate, instinctual requirement for freedom at whatever cost.

I think the effectiveness of quarantine has been well exposed recently in Indonesia.

They couldn’t keep patients from escaping hospitals. I think any chance of soldiers with sick colleagues and sick wives and children, keeping everyone in a city in a state of anarchy is remote to nil.

Let’s hope it doesn’t come to that…and it won’t.

Monotreme – at 09:05

Tom DVM,

…keeping everyone in a city in a state of anarchy is remote to nil.

I agree. I think people will leave the cities, but not quickly and not in cars. And they will have a hard time going more than 200 miles on foot.

My overall point was that I think cities will be triaged, not quarantined. What I mean by this is that some cities may get considerably more resources than others. I think this is already happening, in certain ways. Travel restrictions and blockade of major highways will simply prevent people from low priority cities from overruning high priority cities, especially if the high-priority cities are more than 200 miles from the low priority cities.

Tom DVM – at 09:10

Monotreme.

Survival of the fittest…natural selection for aggressiveness.

A little off topic but I have been wondering recently about world order and the strategic advantage of one country that has secretly produced or found effective preventatives for its citizen vs. an adversary that does not.

Lauralou – at 09:13

Seems to me that there might actually be three areas: “high priority”, “low priority” (ie. Monotreme’s NYC example) and “no priority”. “No priority” would be rural areas and low dense population areas which would be left to fend for themselves as there would no way to “concentrate” any efforts.

This leaves me to wonder if I would prefer to be a “high priority” or a “no priority”?

Medical Maven – at 09:44

Lauralou: Give me “nature” as the adversary any day. The “high priority” areas may see a forced redistribution of supplies. All it would take would be a neighbor ratting on you, saying to TPTB that you are a “hoarder”.

Historically, this is a common scenario. And under martial law they will have the authority. For the Common Good will be the rationale. And yes, it may be the best thing to do for the community, but you and all of your planning will be up the creek without a paddle, along with everybodyelse.

ANON-YYZ – at 09:46

I don’t think there will be a mass exodus from any city. There is no where else to go if you haven’t prepared that is safer than where you are. You will also run out of gas, stranded in the middle of nowhere. I don’t think a blockade is necessary. There will be an appeal from the government to ‘stay where you are’ and ‘help your neighbors’.

When the pandemic starts, efforts will be visibly made to support every locale. Soon, the public will realize it cannot be done and some tougher choices need to be made. When every one runs out of gas, a policy shift can be announced with lesser impact, still no blockade.

From then on, the more prepared a locale is, the more likely resources will be provided to save the maximum number of lives. Even then, the moral decisions will be very hard. It will have to meet the common sense test of fairness. Otherwise, there will be huge social chaos.

Grace RN – at 09:58

How depressing is this: as I understand it from speak with one of our county’s OEM people (Office of emergency Management), they are planning…to convert some centralized building(s) to house quarantined people.

Maybe I’m wrong, but this sounds like the dumbest diea I’ve ever heard. I think anything other than voluntary quaranting is a waste; but if anyone has info that this is good,please explain it to me. (I truly do not think quarantining is effective.)

Hillbilly Bill – at 09:59

The really hard part of this scenario for me to grasp, but I’m sure it is true, is that plans have already been drawn up and decisions made as to where governmental resources will be allocated. Thank God that is not my job.

Grace RN – at 10:14

Re:

“Several hundred evacuees claimed that police from suburban Gretna blocked them as they tried to flee New Orleans for safety on Sept. 1.

Many of the evacuees, who had been stranded at the New Orleans convention center without food and water, said they were told to cross the bridge to be evacuated from the city. But Gretna police confronted them on the bridge and forced them to turn around.

Police later said they blocked the evacuees because there were no supplies or services for them on the other side of the river.”

Now imagine this scenario in each large city and rural hamlet….only one of a multitude of nightmares…

Monotreme – at 10:32

Lauralou – at 09:13

I agree, small rural areas will be no priority. They will be completely on their own.

ANON-YYZ – at 09:46

I don’t think there will be a mass exodus from any city.

It depends. If there is chaos and no food in the city, I think people will attempt to leave, at least some of them. See Katrina for an example.

There is no where else to go if you haven’t prepared that is safer than where you are. You will also run out of gas, stranded in the middle of nowhere.

I agree with that. Hence, a backpack with some power bars and water tablets might be a prudent prep. This would be an excellent time to take up hiking as a recreational activity.

I don’t think a blockade is necessary.

Just a few disabled pieces of construction equipment on key bridges, tunnels and toll booth areas, would be sufficient.

There will be an appeal from the government to ‘stay where you are’ and ‘help your neighbors’.

I agree with this. The question is, if there are no plans to supply the millions of people who have not prepared with food, how long will they stay put. Not long, IMO.

ANON-YYZ – at 10:44

Monotreme – at 10:32

Any sign that the government is trying to blockade will multiply the panic exodus many times over. The government will have to try to show every one we are not making it a bigger mess. There will be a few stragglers trying to find a better haven, and as long as individual freedom of movement is not restricted, few will try to move. I can see night time curfew etc, but not blocking the roads. Emergency vehicles need to move, and so do army escorted supply convoys.

Tom DVM – at 10:50

Don’t forget guys that those doing the controlling are going to be at half-strength and further and continual erosion in troop strength each day due to serious illness. This combined with threat to family and family property is going to lead to large scale desertions…

…it seems to me that this is a whole different set of conditions than the hurricanes last summer.

Grace RN – at 11:08

..not to mention how many troops will even be stateside?

ANON-YYZ – at 11:12

Tom DVM – at 10:50

Agreed. There won’t be enough troop strength just to keep minimum order, protecting convoys, defense from external threats.

The only way out of this is volunteerism - that means absolute moral high ground and selflessness. Decades of well honed government playbooks will be out the window. Everything back to basics. Common sense will prevail.

Monotreme – at 11:28

I think we may be working from some different assumptions. I don’t want to stray to far from the central premise of this thread, but the reason I think the main reason people will leave the megacities is lack of food. I can see no reason that a very severe pandemic with a kill rate higher than 5% can not occur. If so, food production will decline. Imports will cease. There will not be enough food for everyone in the US under those conditions.

The rules change when there is not enough food.

Hillbilly Bill – at 11:34

“The rules change when there is not enough food.”

And very few people in this country have ever experienced such a situation.

Tom DVM – at 12:37

Monotreme Agreed. Food is one of many ‘weak link in the chain’ but the most important.

However, there may be a problem before the food runs out. Each of us, first and foremost, feels duty towards our families and the children we brought into this world…and grandchildren for that matter…

…what happens to normally sane people who are calm, cool and collected, have never had a speeding ticket and have always supported church, state and community…

…what happens when they are looking at ‘deathly ill’ family members and take them to their nearest doctor whose office is closed down, go to the hospital to find a sign on the door saying it is closed and then go to the pharmacy to find that the world’s meager supplies of antibiotics etc. are exhausted!!

How are these people going to react…and these are the calm ones!!

anonymous – at 12:38

Anon yyz - “There will be a few stragglers trying to find a better haven, and as long as individual freedom of movement is not restricted, few will try to move. “

I think most city people who have friends or family in the sticks or ‘burbs WILL try to flee. Especially if they’re scared or hungry, both of which seems likely. If no help (food) is on the way, and it won’t be, then what else can they do?

ANON-YYZ – at 12:46

anonymous – at 12:38

People who have friends or family in the sticks or ‘burbs WILL try to flee. But it won’t be a mass exodus. And allowing them to flee will actually help ‘the cities’, nothing wrong with that.

ANON-YYZ – at 12:48

Tom DVM – at 12:37

The job of TPTB is to try to calm, not to provoke, and patiently let them be resigned to fate.

There is no silver bullet.

Monotreme – at 13:05

ANON-YYZ – at 12:48

The job of TPTB is to try to calm, not to provoke, and patiently let them be resigned to fate.

Some may not go into the good night quite so calmly.

There is no silver bullet.

Yes, I agree. It’s all about mitigation. The question, what’s the best mitigation strategy: Distribute all available resources evenly or do you triage cities? If the latter, what is the prepandemic strategy? Perhaps urge people in the high-priority cities to prep like crazy and tell the people in the low-priority cities, don’t worry, everything’s fine.

ANON-YYZ – at 13:27

Monotreme – at 13:05

Federal government already told the states and by extension the cities “you are on your own, we only deal with researching vaccines etc”.

State and cities have to mitigate on their own. Each city or state will decide on its own whether it is ‘high-priority’ (i.e. well prepared) or not. As a percentage of supplies in the chain, there is not much of a federal stockpile, if any, to prioritize distribution. Each state politician will try hard to protect it’s own resources and powers, including who’s running the National Guard (think NOLA). Try take that away from a ‘low-priority’ city/state and see if you will get agreement. The Soviets, Chinese, Vietnamese, North Korean etc have tried centralised planning, allocation and distribution, and it failed miserably. Why would it work here? The role of the federal government is to lead where it can, follow if it cannot, and otherwise get out of the way.

anonymous – at 13:34

“The Soviets, Chinese, Vietnamese, North Korean etc have tried centralised planning, allocation and distribution, and it failed miserably.” Under what conditions? bird flu? when? “tried” for what circumstances? what failed? how do you know?

Medical Maven – at 13:39

If the system survives, one salutary effect will be increased public involvement on the State and Local level again. That involvement has atrophied, and virtually all of us have been at fault. Not only will it be good in a political sense, but it will be good in a pragmatic sense. Many people will get a first-hand look at what is really possible within the machinery of governmental entities. I, like many others, expect a rebirth of self-reliance among the survivors as well as an accompanying acknowledgement of the need to be involved in local affairs.

But that assumes we make it past the “chokepoint”.

ANON-YYZ – at 13:47

anonymous – at 13:34

Communism = Centralised planning, allocation, distribution by government = Failure. This is well known. I don’t believe our regular readers here need proof of that. It does not matter if you don’t agree on this point. We can agree to disagree.

If you want, you may argue: Centralised planning, allocation, distribution by government = Success during a pandemic. I remain to be convinced. I think it equals chaos. Again, we can agree to disagree.

anonymous – at 14:11

what argument? i didn’t disagree with you, yikes! i was THINKING and asking what you meant. sounds like you meant in general terms, those countries political and governing systems, infrastructre, i guess?

nothing to argue with - don’t know what you mean. yeesh.

LMWatBullRunat 16:43

‘treme-

What I was referring to was the lack of morale of soldiers whose families were not protected and were getting sick and dying while they participated in a futile effort to keep people from leaving the cities. Our military is very effective as long as they act in the knowledge that their actions keep their loved ones safe at home. If there is high infection rate and high CFR, with attendant breakdowns in civil order, the military will be of limited effectiveness. Bear in mind that most military families live in or near large cities.

As regards critical resources, most people in this country won’t starve in a month of no food. The real issue is maintaining control of the broadcast media. The internet will be allowed (encouraged?) to die an early death, but broadcast media will soothe the masses as long as the power is on. THAT is the real issue; if TPTB can keep the lights and the TV stations on, they can keep the lid on. “local food shortages” will be mentioned only casually at first. Curfews and no travel orders will be posted early on. The real issue is what happens when the power is out and the water and sewers stop working. That is the point at which the system will come unwrapped. You’ll die in 2 or 3 days with no water, and you’ll die in a week or so from contaminated water (cholera, etc.) The cities will boil at that point and there will be no stopping the exodus. That neglects the effects of the flu in masses of people, which will be considerable.

All in all, not a pleasant thing to consider

Monotreme – at 21:43

LMWatBullRun,

I don’t think soldiers will be needed to do much in the low priority cities. I also think they won’t know much about what’s going on in their hometowns or anywhere else, for that matter. Security in the high-priority areas can be provided by local Guard.

It is possible that the media campaign has already begun, but the valence differs depending on where you live.

I won’t argue about the importance of water. If that goes, the low priority cities become ghost towns very fast. Still, I don’t think many people will make the 200 miles to a high priority city (in my fictional scenario).

amt – at 22:34

While its possible that the Feds might concentrate their resources on certain strategic cities and geographical areas, I believe that (under a worse case scenario) it is highly likely that within metropolitan regions, that some neighborhoods/populations will be prioritized for resource distribution, and others triaged. I would imaging that areas around major medical centers, and other ‘key’ strategic areas will probably see more help than industrial and low-income residential areas.

Also keep in mind that the States control their Guard unless they are Federalized, so while New Jersey might send up their Guard to block the Holland Tunnel, the Ohio Guard might have other priorities. Another thought is that many Cities have substainal police forces, and other staff. There has to be local-state-federal cooperation. Which, in my experience only works out if everybody can agree on a game plan.

LMWatBullRunat 22:48

We’ll see whether this is academic. Hope so, but afraid not. The military will not be effective IMO. I also doubt that classification of low and high priority will make much difference in the event. If this is much worse than 1918 I expect to see wholesale breakdown of order in most metro areas.

Okieman – at 22:52

I want to throw in a quick (and probably silly) observation that might have no meaning whatsoever, but have you noticed that Walmarts has changed their dogfood bags in the past week or two. They were paper, and now they are all of a sudden the plastic type that is similar to what the large bags of rice are sold in at Sams. I know, I know, probably silly, but if the government needs a large supply of heavy duty sacks where is the best place to get them and who has the best distribution system. Hey, Walmart might even be able to convert their dogfood plants over to humanfood plants. Mix it, cook it, bag it, haul it.

Not_Again – at 23:01

If you want to know where the best locations are for food, find out where the Walmart distribution centers are in your area. Just in case things get really really bad, those warehouses may still be full of food, even if the store shelves are empty. Betonville, Ark. is the main distribution site. So if you are starving in a pandemic, don’t forget about all of the warehouses and semi trucks, probably parked off of the road if things go bad.

09 August 2006

Hillbilly Bill – at 08:24

Okieman – at 22:52

I did notice a difference in the bags and wondered about the change. I’m glad, it allows me to store more dog food for a longer time without it going stale.

Medical Maven – at 08:40

Not_Again at 23:01: Everybody should have bought their handy-dandy, extra-large bolt cutters at this point. : )

10 August 2006

anon_22 – at 01:27

14 October 2006

Closed - Bronco Bill – at 21:33

Closed to maintain Forum speed.

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