Forum: IOM Workshop Modeling Community Containment for Pandemic Influenza

Today was Day 1 of the workshop, and it was mainly about the various non-pharmaceutical interventions (NPI) and what evidence we have that they might work. The evidence presented today was from various modeling studies. Tomorrow, there’ll be discussions on the use of historical data.

To re-cap, this is the ‘Statement of Task’

The Institute of Medicine is convening a committee to assess the technical merit and applicability of models of influenza outbreaks as a guide to policies on community containment, whether community-wide interventions have a role in reducing infection transmission, and if so, the community impact of implementing community containment strategies.

The committee will convene a major workshop to review:

• the quality of existing models about a potential influenza pandemic and their utility for predicting the effects of various community containment policies on disease mitigation;
• the available science and previous analyses of the efficacy of community mitigation approaches; and
• the historical record of community interventions utilized during previous influenza pandemics and other relevant outbreaks. Consideration will be given to the feasibility and secondary consequences of policy implementation.

The committee will prepare a report based primarily on information from the workshop that will include conclusions and recommendations, based upon available evidence, regarding:

• Strengths and weaknesses of the models presented, and strategies to improve predictive ability and usefulness
• Conclusions that can be drawn from the historical record and available science, gaps in current knowledge, and approaches that would narrow these gaps
• Whether community-wide interventions have a role in reducing infection transmission and the community impact of implementing community containment strategies

The policies to be considered are those to be used in the United States. The workshop will be open to the public and attendance will be sought broadly. The workshop format will allow for dialogue among workshop presenters, the committee, and the audience.

This was today’s agenda:

8:30 a.m. – 9:00 a.m. Welcome and Introductions Adel Mahmoud, Committee Chair

Charge to the Committee Admiral John Agwunobi, Assistant Secretary for Health, DHHS

9:00 a.m. – 9:30 a.m. Targeted Layered Containment: Policy Perspective Rajeev Venkayya, Homeland Security Council

Targeted Layered Containment: Scientific Underpinnings Martin Cetron, Centers for Disease Control and Prevention

9:30 – 9:45 a.m. Questions

9:45 – 10:30 a.m. Modeling influenza transmission in households and other indoor spaces Lawrence Wein, Stanford University

10:30 – 11:00 p.m. Infectious-disease models as policy tools Ellis McKenzie, Fogarty Center, NIH

Overview of MIDAS role in policymaking Jeremy Berg, National Institute of General Medical Sciences, NIH

11:00 – 11:15 p.m. Break

11:15 – 1:30 p.m. (45 minutes each)

Modeling Targeted Layered Containment: The MIDAS efforts Neil Ferguson, Imperial College, London

Steve Eubank, Virginia Polytechnic Institute and State University

Ira Longini, University of Washington School of Public Health and Community Medicine

1:30 – 2:45 p.m. Lunch

2:45 – 3:30 p.m. Local Mitigation Strategies for Pandemic Influenza Robert Glass, Sandia National Laboratories

3:30 – 4:15 p.m. Robust Models of Non-Pharmaceutical Interventions for Pandemic Influenza Steve Bankes, The RAND Corporation

4:15 – 4:30 p.m. Break

4:30 – 5:45 p.m. Panel Discussion: Strengths and Weaknesses of Models and Their Utility in Community Containment

Discussion led by Dr. Mahmoud

5:45 p.m. Adjourn

The various modellers more-or-less focused on social distancing and whether that is going to have any effect. The strongest case and certainly repeatedly discussed throughout the day was school closure. Both the CDC model (Cetron) and UK (Ferguson) models estimate transmission due to schools at about 30%, (see transmission matrix but that if you close schools, then other means of transmission will increase. The following diagram sort of explains the effects:

targeted layered transmission

Ferguson approaches it from a different way and assumes a lot more about antiviral prophylaxis for contacts etc. Still he agrees that school closure would have some effect, although he thinks reactive (ie after the first case appears in a school) and proactive (first case within 10km) closure will have the same effect.

Anyway, the big fight is going to be about school closure, IMHO. Cos there is a lobby against that based on the objection that closing schools will mean parents have to stay at home to look after kids, and therefore infrastructure breakdown and economic effects will be profound. However, today they’ve been pretty mild, the only objection being that if schools close, then they will hang out with their friends so that might not make much difference.

For me Cetron’s TLC model (see diagram above) elegantly lays out the case for closure. In addition, Ira Longini, who has done a lot of modelling on this, makes the point that the timing of any intervention will determine its effect. He showed a graph with a very steep increase in Attack Rate (AR) in relation to small increases in R0 at the very beginning. As R0 gets bigger, the effect of such increase becomes less. So very small changes early on will cause huge drops in AR. For example, if you look at communities infected. When R0=1, the outbreaks die out quite quickly. When R0=2, only 15% of communities have small epidemics, everyone else has very large outbreaks. At R0=4, only 2% of communities will have no epidemic. So R0 is often a critical threshold determinant.

His conclusion is that closure of school has biggest impact, but must happen at <3% infection in the community. He emphasizes that you can’t wait for 10% cumulative attack rates to close schools.

Robert Glass estimates the attack rate in a different rate, with 50% infected at R0=1.6, and 70% infected at R0=2.1

He also says that children are 1.5x more infective than adults (excluding longer virus shedding) and teenagers are 1.25x more infective than adults.

Last post from previous thread Pixie – at 23:36

anon22 -

I think that the single most effective change that could be made right now by the kinds of people you are seeing at your meeting would be to encourage them to begin to move decisively to involve the public health officers of this country fully in pandemic flu preparation.

The public health officers are the link between state and federal goverment and the individual decision makers running our cities and towns. However, in my experience, the public health community has been slow to become enthused about encouraging their communities, and the decision makers they report to, to prepare for a pandemic. Their reticence is not without merrit - if they are wrong, and the pandemic threat eventually evaporates, they fear that their jobs and professional reputations may evaporate also.

How can public health officers be encouraged to move beyond these valid fears? How can they become engaged and be motivated to take the threat of a pandemic seriously, and to advise the leaders of their communities to do the same?

A typical town mayor cannot wear all hats, and must delegate questions of public health to those with that title. This is working against us, at the moment, because most public health officers do not seem to be leading the pandemic preparedness movement. However, it seems to me that if we can manage to effect change in this one area, that it’s reach would be felt in many, many, mayor’s offices in this country. And that, in the end, is where the ultimate local decisions are made, where the funding is allocated, and where plans to prepare for pandemic influenza will either receive a “go” or “no-go” decision. If as many public health officials as possible could be encouraged to urge the decision makers they advise to move towards a “go” decision), action will happen, organization will happen, and lives may be saved. Without the impetus of their public health officials clear advise, though, most local officials will see no problem in continuing to ignore a threat that they have been advised does not really exist on a level that should worry them, and will instead, on that advise, choose to do nothing.

As Revere pointed out recently in an Effect Measure post, there is quite a difference between individual/family preparation and community preparation. A vigorous and effective effort to reach the public health officials of this nation and to encourage them to lead the effort to prepare their communities for pandemic influenza could be a simple and yet highly effective strategy.

Perhaps the most surprising finding is from Lawrence Wein of Stanford who presented unpublished data on transmission within indoor spaces. However, his work was based on rhinovirus and I didn’t catch how he extrapolated the findings to influenza virus. That said, he claims that the major mode of transmission of influenza is by aerosol, not droplet nor contact.

He said that if the chance of being infected by the airborne route is 1, then infection by contact is 1 in a billion, and droplet is 1 in 10,000.

He said that N95 gave 30% reduction in infection if used during symptomatic period only, and the major cause of the low effectiveness is noncompliance.

The surprising finding, which he wrote about in NY Times was that surgical masks are actually quite effective if you can find a way to make sure that it adheres to the face. His suggestion was to wear a surgical mask and then nylon stockings over it, ie like bank robbers!

Because of aerosol at close range, he suggests that the way to prevent infection from other family members is to make sure that everyone wears a mask whenever they go into a room where there is someone else, and that everyone sleeps in a different room.

I must warn, however, that his data is unpublished, the methodology is unknown, and he admits that this is extrapolation from rhinovirus.

Steve Bankes from RAND Corporation gave an unintelligible presentation trying to make the case that there is a collection of small interventions favored by experts which are more effective than the costlier one of school closure, except that as far as I can tell, he did not give who were the experts, what the data was, etc etc. Suffice it to say that I wasn’t the only one who didn’t get it, there were at least 2 scientists whom I spoke to whose names will be instantly recognizable on this forum who didn’t get any of that either!

He also put up a chart that claims that on reviewing something like 18 different interventions (suggested by other people, of course) none of them work, at which there was quite a bit of skeptism from the audience!

So much for that…

OK. I’m sitting at my desk wearing a surgical mask and panty hose over my head. It is decidedly *not* more comfortable than a N95.

(No. I will not describe what else I’m wearing.)

Nothing like a preview of our own execution to make our minds focus.

There’s a school nearby and through an entrance where two cars wouldn’t fit together there’s a river of more than a thousand children coming out at the same time.

So maybe they could come out in shifts (how long apart?) or wearing masks for half an hour (the time they need to come out)? I would suggest they do that even if there are no pandemic cases here yet.

• Call it “minor interventions” and make it a concept. There would be other ideas stemming from that concept. It’s likely that most everyday actions can be done in a safer and in a not-as-safe way. We’d want to look at maybe 50 activities and have 50 “minor improvements”.
• Call it “pull up mask” (just like scarfs). How good could such a “pull up mask” be?
• Call it “every bit counts” and give people all the available information (no recomendations: just the information!) so they may choose each minor action in the best possible way.

If a pandemic were to start today, I would use and recomend all of this, unless there’s evidence that it makes things worse. And of course, we have time to look for even better things.

Thanks for keeping us informed, Anon_22.

aurora – at 01:46 OK. I’m sitting at my desk wearing a surgical mask and panty hose over my head. It is decidedly *not* more comfortable than a N95.

Try cutting the panty hose so that it doesn’t include your eyes. Then bat your eyelashes in the general direction of fluwikie’s audience. Is it more comfortable now? And more important - does it work?

• Focus: community containment of pandemic influenza.
• Tools:
  • Actions (individual or society-wide): school closure, bow salute, asynchronous transfer …
  • Devices (wearable or in offices etc): masks, poli or glass windows as between clerks and customers …
• Needed:
  • Evidence: history, research, “obviousness”.
  • Ideas: lateral thinking to the rescue.
  • Ways to assess the efficacy of ideas: a description of methods used for such. We may even need a framework to assess efficacy in real time (in town 1 if you live in town 2).

Sounds like a wikipage to me. Is there one already or do we create it? What would be the title of such a page?

Needless to say, such a wikipage would be a nice-to-have resource for local decision takers everywhere. It should be a fluwikie project. And I know saying “it should be a fluwikie project” doesn’t quite work but I have to try. ;)

(don’t touch yer eyes… go get yer goggles)

If school children’s parents were clued in that compliance might be the difference between life and death for their kids -understood No vaccine, no anti-virals, no space in hospitals, maybe sent away for an IV in a mass shelter (until staff and supplies are gone); high chance of “bad outcomes” for their children, (tell the children, too) most parents would think of something.

If the business community - and essential utilites- could pre-identify who needs to be held in reserve until after the pandemic, retired people may volunteer, or, people who see their job not functioning during public quarantines or supply disruptions may volunteer to be cross-trained now (some sort of Civilian Continuity Corps)for essential functions, especially if they already have some skill sets that might be needed.

But officials have to be willing to have the community at the table, and the public brainstorming how their neighborhoods would cope. (Real troublemakers could at least be identified and dealt with now, while law enforcement is not sick, for officials that fear “riots” if they told the public we’re supposed to be getting ready in case of pandemic influenza.)

anon_22 - Do you have any feeling as to whether this conference is focusing mostly on preventing the loss of life of citizens as the primary goal, or is their focus on keeping as much of our usual life (business, schools) functioning as normally as possible during a pandemic? Or, are they splitting the difference at this point?

It seems to me there is quite a difference in focus between those two goals for policy makers and the policies which they implement.

I agree with crfullmoon its ludacris what they are saying. You tell parents that their child has a good chance of dying if you send him to school and they think people will send little Johnny on his merry way, come on! Although maybe I am giving people way too much credit, this will probably happen anyway cause “people” are stupid and lazy. The thinning of the heard will happen wicked fast and with equal brutality.

Pixie—I think it doesn’t matter what way they lean. Either they try and save lives and everything shuts down fast causing additional death or they try and save the infrastructure a little longer and it causes death by disease exposure. No one said life was fair.

Or, they try to save both lives AND infrastructure (and thus significantly more lives) by spending money to prepare to “protectively sequester” workers and families at key workplace sites. And/or spend money to increase staffing to a high enough level that the company could continue minimal operation at 50% staff for a significant period of time.

I can see why neither of these options would be attractive to any for-profit company. Why should THEY bear the financial burder of a possible pandemic, unless they had to? I can see why there would be a lobby to keep schools open rather than spend money to address possible problems with staffing beforehand. money

concerned mom— I want to live in your world.

I think schools will shut themselves down, so to speak. But that will take time. So it’s better to deal with it as a policy so they will be shut down when it’s thought to be most useful. Also, if we think of it before it happens, then we can think of the consequences, the bad consequences of doing a good thing, and get ready for that.

He said that if the chance of being infected by the airborne route is 1, then infection by contact is 1 in a billion, and droplet is 1 in 10,000.

but, that’s not what they’ve told us all the years

remember the recent paper, where they said that keeping the children and teenagers at home would reduce the attck-rate by 90% !

I don’t know oif this belongs here but AI Pandemic Preparedness One In Four Americans Has No Home Caregiver for Flu Pandemic

10/26/06 Bloomberg—More than one in four Americans said there would be no one to care for them at home during a possible flu pandemic, a Harvard study said. Almost half of those surveyed said they would run into financial problems or might run out of important drugs if health officials asked them to stay home for a week or more, said Robert Blendon, a Harvard School of Public Health policy expert who will give the results of a survey today in Washington. Health officials and scientists are debating whether to recommend that people keep children out of school and treat sick relatives at home during an outbreak of lethal influenza. Lack of home care and access to food and medicines might make it difficult or impossible for people to comply with those measures, Blendon said. `These are the kinds of things that I doubt are going to go away,’‘ he said yesterday in a telephone interview. `Many more people than that may discover they’re going to have problems over time.’‘ Health officials and researchers are gathering in Washington today for a second day of discussions about the strength of the science behind possible social measures to slow or halt a pandemic. The spread of a deadly bird flu strain, called H5N1, has raised concern that a possible global outbreak of flu could kill millions. H5N1 has killed 151 people in 10 countries and might set off a pandemic if it becomes contagious in people, experts have said.

Anti-Pandemic Recommendations

The U.S. Centers for Disease Control and Prevention and the Department of Health and Human Services are expected to make detailed recommendations about anti-pandemic measures, many of which involve keeping people at home and apart from others, to state and local health departments in December. Many health officials at the meeting said they expected the stay-put recommendations to be controversial among the public. Blendon’s survey found that 93 percent of Americans would be willing to avoid air travel for at least a month, 92 percent would avoid public events, and 91 percent would avoid malls and department stores. `It would probably be impossible to keep a teenager indoors for two months,’‘ said Isaac Weisfuse, Deputy Commissioner of the New York City Department of Health and Mental Hygiene, at the meeting in Washington yesterday. `If I suggested it in New York I’d be laughed out of town.’‘ Close to nine out of 10 would cancel all their non-essential doctor visits, reduce contact with anyone outside the home, and limit their use of public transportation. About eight out of 10 would avoid going to church and would postpone family events.

Actual Experience

Blendon called the results similar to an election poll in that the responses might change during the actual experience of a pandemic. `This is probably what they’re likely to do in the early part of a pandemic,’‘ he said. `Over time, their experiences and major events change what people actually do. We have a picture of what the first few weeks of a pandemic might be like.’‘ Financial security, medical care and access to needed drugs are all likely to figure large in people’s minds as a pandemic progresses. At least one in four Americans said they would be hurt in some way by staying home for more than a week to 10 days. About 27 percent said they might lose their job or business because of such measures, and 48 percent said they would lose pay or have financial problems. About 43 percent said they would lose access to drugs, and about one-third said they would be unable to get care for seniors or children in the home. `This focuses attention on where some of the next steps need to be in terms of preparedness,’‘ said Carter Mecher, chief medical officer of the Department of Veteran’s Affairs, Southeast division, in Atlanta, in an interview in Washington. `These are areas where we might engage churches and community-based organizations to assist people. I look at it as an area for investment in preparedness and planning.’‘ One-quarter of all U.S. homes are occupied by people living alone, Mecher said.

Here is some related news although not directly related to the conference.

Los Alamos Licenses Avian Flu Modeling and Simulation Software

LOS ALAMOS, N.M.--(BUSINESS WIRE)--Oct 18, 2006 - Santa Fe-based CIVA (The Company for Information Visualization and Analysis) signed an agreement to license Los Alamos National Laboratory’s epidemiological modeling and simulation system, called EpiCast. Developed by Los Alamos scientists Tim Germann, Kai Kadau, and Catherine Macken, EpiCast was designed to help epidemiologists understand the spread and impact of an Avian Influenza (H5N1) pandemic. The system models the pandemic at the individual human level using the most current data on the natural and deliberate spread of pathogens in human populations.

“The EpiCast system is a useful tool for predicting and combating the spread of Avian Flu,” said Duncan McBranch, leader of the Technology Transfer Division at Los Alamos National Laboratory. “We are thrilled to enter into a commercial agreement with CIVA that will allow a private company to take this much-needed technology to market.”

The computer simulation models a synthetic population that matches available census demographics and worker mobility data by randomly assigning the simulated individuals to households, workplaces, schools, and the like. Travel data is used to model long-distance trips during the course of the simulation, realistically capturing the spread of the pandemic virus by airplane and other passenger travel. Additionally, the model of disease transmission involves probabilities that any two people in a population will meet on any given day in any one of a number of settings, such as home or workplace.

Other elements of randomness modify the simulated disease course. A significant fraction of infected people never develop clinical symptoms, although they are themselves infectious. In addition, the durations of the incubation and infectious periods can vary and are randomly chosen from distribution functions for each individual, involving more throws of the virtual dice. With its unprecedented level of detail, EpiCast has been used to evaluate various medical and non-medical mitigation strategies in the event of a pandemic influenza outbreak in the United States.

As a result of its licensing arrangement with the Laboratory, CIVA will be able to run these flu-impact models for government, public, and private organizations as early as this month using a service-centric business model - meaning CIVA will provide customers with modeling results derived from the software, not the software itself. While for-profit enterprises will be charged a fee for this service, the cost to subsidize nonprofit organizations and agencies will come from nonprofit endowments, government grants, and nongovernmental organizations.

“We feel we have a responsibility to humanity to disseminate the modeling as widely and as fast as possible,” said Dr. L. Robert Libutti, CIVA chairman. “We are making every effort to make EpiCast available to any and all organizations that could benefit from the insight the model affords.”

Los Alamos National Laboratory (www.lanl.gov) is a multidisciplinary research institution engaged in strategic science on behalf of U.S. national security. The Laboratory is operated by Los Alamos National Security, LLC (LANS), a team composed of Bechtel National, the University of California, BWX Technologies, and Washington Group International for the Department of Energy’s National Nuclear Security Administration.

Los Alamos enhances national security by ensuring the safety and reliability of the U.S. nuclear stockpile, developing technologies to reduce threats from weapons of mass destruction, and solving problems related to energy, environment, infrastructure, health and global security concerns.

The Company for Information Visualization and Analysis (CIVA), based in Santa Fe, New Mexico, was founded to commercialize the great wealth of information visualization and data mining technologies developed at U.S. national laboratories including Los Alamos National Laboratory, Sandia Laboratories, and Pacific Northwest Laboratories. CIVA is backed by private equity and led by Dr. L. Robert (Bob) Libutti.

Contact

Los Alamos National Laboratory Hildi Kelsey, 505–665–8040 hkelsey@lanl.gov or CIVA Deborah Blackwell, 407–774–1505 deborah@civaglobal.com

mojo – at 11:06 This is another article about the same survey you discussed (is a Canadian newspaper, so the word spelling will be different), but it had some comments from Michael Osterholm that were very interesting. (I apologize - I do not know how to do a small url yet!)

<snip> Blendon said workplace worries were a major problem, too. Many people live paycheque-to-paycheque, and more than one-quarter of respondents said they would lose a job or business if they had to stay home for seven days to 10 days. Only one-third thought they still would get paid if they missed work.

This real-world feedback is important as long as policymakers understand people will act less rationally in a crisis, said Michael Osterholm, a University of Minnesota infectious disease specialist who has advised the government on flu preparations.

His bigger concern is that the stay-at-home plans are far too simplistic.

“If you want to guarantee that society will collapse in terms of the economy, tell everybody to stay home,” Osterholm said. “Somebody’s got to move the food, take away the garbage, provide health care, law enforcement, to assure that communications continues. … We will very much put at risk things like electricity, food.” <snip>

http://www.mytelus.com/news/article.do?pageID=cp_health_home&articleID=2430625

With Osterholm’s comments, he does not believe people should be staying at home and that this would ensure an economic collapse. With everyone continuing to go to work and school, it will ensure the fast spread of the virus should it become pandemic. He states these plans are too simplistic - well, what could be done? Do you force these people to work? How can we, as a society, create a situation to keep society functioning, but still reduce the risk of becoming infected to a minimal level? I have no good answer. Any comments?

lugon - at 06:22 “Try cutting the panty hose so that it doesn’t include your eyes. Then bat your eyelashes in the general direction of fluwikie’s audience. Is it more comfortable now? And more important - does it work?”

Well, now we can see my lovely eyelashes, but several problems remain.

N95 respirators and surgical masks are not designed to perform the same function. An N95 respirator helps to protect the wearer from exposure to airborne contaminants. A surgical mask is not designed to protect the wearer from airborne contaminants, but to prevent contamination of a sterile field or work environment from the wearer.

Also, they have taken the idea of a fight fit and gone astray.

The pantyhose does compress the edges of the surgical mask against the face somewhat, but it also compresses the surgical mask against the nose and mouth – which is not good.

We do not want to have a moist surgical mask - covered with airborne contaminants and likely larger particles as well - plastered to the nose and mouth. It’s a bit like wiping up with a paper towel,plastering it to someone’s face, and telling him to breath deeply.

thanks aurora - for the experiment and for the comments

maybe some kind of frame to force the filter away from the mouth and nose? doesn’t look too practical, wearable or anything

maybe we just need to have specific aims and meassure airflow and usability - not there yet

Today there was quite a lot of useful information. This first segment is on interpreting historical data, from 1918, to find out whether non-pharmaceutical interventions (NPI) worked.

This is from my notes which I know are incomplete, as everyone spoke so fast cos of time constraints and there was just a lot of data. The slides will eventually be posted on the IOM website and I’ll check them then. So look out for corrections.

The bottomline is this, there is strong correlation between early school closure and the peak of the curve. There is weak or no correlation with total epidemic size, ie total no of people infected. This is consistent across the 3 presentations, by Howard Markel, Marc Lipsitch, and Neil Ferguson, analyzing the data from American cities in different ways.

There is also correlation with no of early NPI’s and lowered peak. ie multiple early NPI results in flatter curve. The NPI’s that worked were closures of school, churches, theatre etc. Those that didn’t work included isolation, banning of public funerals, making flu reportable.

The biggest effect of early school closure is reduction of attack rate in children. AR in adults were either not affected, decreased, or increased.

There was an interesting slide from Ferguson, to show the relationship between clinical attack rate and R0, and the theoretical basis of interventions. He plotted two lines, minimum and maximum. The maximum or unmitigated showed that as the R0 increases to 3, the clinical AR rose to above 50%.

The minimum line was the ‘best you can achieve’, and it showed the clinical AR reaching 25–30% at the higher R0. Ferguson explained that this was the ‘minimum’ because this is the percentage of infections needed in any community for the epidemic to stop, which is similar to the percentage of people you need to vaccinate to achieve herd immunity.

On the maximum or unmitigated line, clinical AR was 40% at R0=2.

I guess that answers the question that’s been asked so many times on this forum, that how do they know what the AR is. Well, the answer is the AR is derived from R0, and the estimated AR depends on what your estimated R0 is. And the R0 starts at 1 for a pandemic and grows as the virus spreads. Multiple NPI’s used early enough and sustained over the duration of the outbreak could bring the R0 back down to <1, and abort the epidemic. Which is probably what happened in the first wave in 1918.

Then another RAND guy got up and gave a presentation on how NPI won’t work.

Maybe it was after lunch and I was sleepy, maybe his presentation was, well, not worth recording. Or maybe I was biased.

Bottomline? I’m looking through all my notes and find that I didn’t write any….

Ferguson also gave a brilliant presentation on data from France on school closures. It’s very complicated and my notes are insufficient for reporting accurately, so I’ll skip that for now.

I think I’m gaining a new respect for the guy….

Now I get to what for me was the most significant slide of the day. Carter Mecher, from the US Dept of Veteran Affairs, gave a presentation supposedly on second and third order impacts of NPI, but he put up one slide of deaths in the US from early 1900′s to now, showing the spike in 1918–19.

Then he said, that if we have a 1918 scenario now, with 40% AR and 2% CFR for aged 0–19, the number of children killed would equal those (of that age group) who died of all causes in 2 decades.

Did you get goosebumps just reading that?….

anon_22 – at 21:10 The bottomline is this, there is strong correlation between early school closure and the peak of the curve. There is weak or no correlation with total epidemic size, ie total no of people infected. This is consistent across the 3 presentations, by Howard Markel, Marc Lipsitch, and Neil Ferguson, analyzing the data from American cities in different ways….There is also correlation with no of early NPI’s and lowered peak. ie multiple early NPI results in flatter curve. The NPI’s that worked were closures of school, churches, theatre etc. Those that didn’t work included isolation, banning of public funerals, making flu reportable.

Anon_22, Thank you so much for sharing this info. I have a question. I may have misunderstood you, but I thought in a post earlier in this thread you said that kids are 1.5X more infective and teens 1.25X more so than adults. If that’s the case, then wouldn’t school closure (assuming kids aren’t out and about in other venues) ultimately reduce the total epidemic size. Secondly, by isolation, do they mean protective sequestration, and are they saying that as an NPI it did not work?

Edna Mode – at 23:26

I thought in a post earlier in this thread you said that kids are 1.5X more infective and teens 1.25X more so than adults. If that’s the case, then wouldn’t school closure (assuming kids aren’t out and about in other venues) ultimately reduce the total epidemic size.

No, the epidemic just went on for longer, so in the end the same number of people got infected, but the peak was much reduced so there was less stress on the system. That was the consistent finding.

Now, there may be anecdotal instances where the actual epidemic size was reduced, but there was not enough consistency across many cities in those findings to give more than what one would call a weak correlation. Remember you can’t draw conclusions from 1 or 2 cities like St Louis, because what you observe there could be the result of some other factor.

Secondly, by isolation, do they mean protective sequestration, and are they saying that as an NPI it did not work?

Their finding was there was no evidence that ‘protective sequestration’ worked. Doesn’t mean that that didn’t work, just there there is no evidence to suggest that it worked.

Pixie – at 07:54

anon_22 - Do you have any feeling as to whether this conference is focusing mostly on preventing the loss of life of citizens as the primary goal, or is their focus on keeping as much of our usual life (business, schools) functioning as normally as possible during a pandemic? Or, are they splitting the difference at this point?

It seems to me there is quite a difference in focus between those two goals for policy makers and the policies which they implement.

You are right. My impression was members of the committee are genuinely trying to be neutral and to find the right solution to recommend to policymakers, while there are two camps each wanting to promote their thesis.

So there were various people making presentations saying how much impact there would be and all the consequences of closing schools etc.

anon_22 – at 23:47 Has anyone even talked about the possible failure of the infrastructure (Power Grid, water etc) and the effects that may have on the overall out come???

Here are some of the points that I made over the 2 days, mostly during the last session, but some on the first day.

• this is a difficult task, and one would prefer more definite evidence of effectiveness of any NPI.
• perhaps the committee can consider, on the various NPI, to assign or rate different degrees of certainty, as a guideline to policymakers.
• local officials would also need clear trigger points for action. eg closing schools before 3% cumulative infection is meaninless as policy guideline as officials will have no access to data that will tell them whether they are at 3%, not in the middle of a pandemic. A trigger point based on distance, eg 100km of first case, would be much easier to identify and utilize.
• while one would want to make policies based on best evidence, there are times when one has to adopt certain policies despite insufficient evidence of effectiveness and despite the possibility of adverse consequences. We would need to consider doing that when the consequence of inaction is catastrophic.
• the committee needs to figure out the trigger point, when one would need to apply this ‘precautionary principle’.
• I’ve been looking for that trigger for the past 2 days, and I believe I’ve found it, in the form of Dr Mecher’s slide, that a 1918 scenario with 40% age specific AR (at R0=2) for ages 0–19 and 2% CFR would result in the same no of deaths as the total deaths from all causes of that age group in 2 decades of our ‘normal times’.
• there is widespread agreement in psychology that the loss of a child is the most severe trauma possible for anyone.
• the trauma will be compounded if parents believe that the government could have done something, or believe that government lied to them.
• the widespread loss of trust that will result if significant numbers of bereaved parents feel that way, will make implementation of any other policy impossible, due to this loss of trust.
• we shouldn’t let the negative consequences of closing schools stop us from using that as NPI. The analogy that I used was chemotherapy: you know that there will be side-effects, some dangerous, but it doesn’t mean that you should abandon that kind of treatment. We would still go ahead with using the chemo, and try our best to mitigate the side-effects.

Anon_451 – at 00:03

Yes, but only as a passing reference. There was no big discussion about that. This workshop was focused on collecting information around NPI.

Following my statement, one of the speakers concurred and suggested that in the face of such catastrophic consequences, he would be unwilling to take away any NPI as policy unless there is clear evidence that it doesn’t work. ie the burden of proof needs to err on the side of using NPI rather than not.

anon_22 thanks for all this. a couple questions: - was there any/much talk about the early wave in 1918 (either winter/spring 1918 event in US or summer 1918 in Europe)? Like did regional experiences impact subsequent pandemic wave impact? - was there any talk about how long a region should keep schools closed?

Ants, were all ants running around on the surface of this planet in order to generate wealth. What is wealth? Food, shelter, goods, medical care, entertainment, etc. What activity is necessary for a nation as rich as ours to survive for six months with nobody going to work unless you are part of that minimal, absolutely necessary activity to keep us alive. I personally believe we can muster the resources to feed, house, and keep some of the lights on for long enough during this 6 mo. for most of us to survive, if we jut suspend the stupid economy that is not necessary. Bill me. I will agree to work off the effect on the Gross Domestic Product. So, just figure out who is necessary and shelter them at the place of work and figure out how to keep the water, lights and food coming. Let that be the only essential activity. Now, we can think of lots of creative ways to stop a “few” essential workers from spreading the flu when they do things and move about. We might have enough n95 masks, PPE, and pre-flu vaccines with some protection to get just that job done. And if we pass national legislation that suspends all contractual obligations without interest for the duration of the emergency and pay those who are involved in essential services a bonus for the risk (bill me for that too) then we may just save almost everyone and come out with our infrastructure and workforce in tack and rested from a home “vacation” with family and or friends. So, we are not capable of planning that? Give me a break. Stockpile everything you can think that we would need to do this (oh, bill me for that too). I don’t give a damn about the economy, I care about the people. Let us see the models of that.

anon_22 – at 00:14 Following my statement, one of the speakers concurred and suggested that in the face of such catastrophic consequences, he would be unwilling to take away any NPI as policy unless there is clear evidence that it doesn’t work. ie the burden of proof needs to err on the side of using NPI rather than not.

Concept: we need a “side-effect early-detection and rapid-mitigation” strategy.

As an example, we may need a way to find out why exactly essential workers are not going to work (fear, children, disease?), and ways to find out how to help them (masks, child-care, treatment). Of course this is best planned for. Which is part of what we’re doing in parallel with the conference you’re attending, but you see, we can’t just watch and do nothing - we’re fluwikians in Forum.AlternativesToFullScaleSchoolClosures.

So, in short, we’ll need to harvest what the side effects can be, and look at ways to minimise them. That way we’ll be able to apply full force on NPIs.

the larger the CFR will be, the more social distancing measures will be applied. So, at which CFR would it be reasonable to close schools, keep teenagers at home, allow public working only in protective cloths, require masks in buses ,… We need answers to these questions, so we can prepare accordingly.

Delaying the peak, even when the number of victims isn’t reduced, is important to gain time for vaccine production and for organising other counter-measures.

Dude - I love it when you post. You get right to the heart of the matter. As a matter of fact, some of the things you were suggesting reminded me of the extraordinary measures the country undertook during the Great Depression. A 25% unemployment rate, famine and soup lines, a President declaring a Four Day Bank Holiday, and several employment programs were only a few of the things that this free market society could never have foreseen. Many Americans thought it was the end of Democracy and capitalism. I apologize for straying from the original intent of this thread, but my point is - we will make it through whatever hardships there are if governments and businesses cooperate (e.g., the Great Depression) and recognize the crisis for what it is. That is they shouldn’t expect business as usual and instead cut people some slack so that they can purchase foods and medicines rather than paying the mortgage or rent for a few months. And if that isn’t an option, we can just bill Dude.

Robert Blendon’s presentation on public opinion polling data is available here so I’m not going to report it.

(fredness – at 14:34. What, Sim City gets pandemic influenza?)

Thank you for attending and reporting, anon 22. Just have to repeat this part again, in case officials are lurking:

“I’ve been looking for that trigger for the past 2 days, and I believe I’ve found it, in the form of Dr Mecher’s slide, that a 1918 scenario with 40% age specific AR (at R0=2) for ages 0–19 and 2% CFR would result in the same # of deaths as the total deaths from all causes of that age group in 2 decades of our ‘normal times’.

there is widespread agreement in psychology that the loss of a child is the most severe trauma possible for anyone.

the trauma will be compounded if parents believe that the government could have done something, or believe that government lied to them.

the widespread loss of trust that will result if significant numbers of bereaved parents feel that way, will make implementation of any other policy impossible, due to this loss of trust”

Some remarks that I made on the How Many Kids Will Die In 1918 Scenario thread is related to this discussion.

What can the avg FluWiki member do to educate their local Public Health Representative? What resources here should we bring to their attention?

fredness – at 02:25

What can the avg FluWiki member do to educate their local Public Health Representative? What resources here should we bring to their attention?

In your case, everything that you know, basically.

I suspect the difficulty will be in figuring out what to say when. It may be helpful to download some of the presentations from the ftp, even if you are not doing a presentation, cos they will give you a framework of the kind of information to be covered, and you can plug in the appropriate pieces as you see fit.

Further explanations for Targeted Layered Containment here.

fredness - explaining pandemics could be expanded with “community interventions” and “home care” and so on.

We’re learning while we teach + teaching is a good way of learning. We need to work on the summary or create different summaries.

anon_22 – at 23:44 On layered interventions….

Correct these assumptions anyone:

1. A person will be able to infect another for a period of 3 days before symptoms appear.

2. Droplets that can infect another can stay airborne in dry air for an indefinite period, but in moist air (>40% humidity) they fall to the ground after a few minutes.

3. An H5N1 virus on a hard surface in cold weather can last for 3 months.

Once these assumptions are pinned down, we can map in terms of the range of times needed, the most effective containment strategy for us to use in a community.

Here is what we might do:

At a certain level of nearness of an outbreak or # of cases in a community, we have a large area go to ground order. EVERYONE is forced to return to their homes or a designated SMALL shelter.

We wait long enough for symptoms to appear and monitor the number of cases. We deliver medication, medical help and any needed supplies to each unit or shelter. They are now on our home care and support list. The unit is also in quarantine. The large scale area is in quarantine. This may need to be done nationally and close the borders for the duration of each SIP.

In all public places and places of work we undertake cleaning of surfaces with bleach solutions. We up the humidity. We clean the keypads, doors, counters, etc. Once that is completed by the designated crews, we come out of our SIP units and return to work.

I think this will work the best because the math involved requires that you mitigate at the initial ascension of the infectious curve as many times as necessary for the maximum benefit of saving as many lives as we can. This is the area under the curve.

As can be seen, the flattening of the curve makes it a longer duration event, but this is going to with us until we get a vaccine anyway. So, I go with saving the people. Oh, and bill me for the effect on the GDP and all the lost wages and overdue bills.

Anon - I have difficulty with the “cases within 100km” scenario. Like pixie said, so many people travel great distances to go to work these days and could be exposed to all kinds of sick persons just in an oridnary day. Add air travel on top of that. I know of at least three parents at my kids’ school who ahve been to Asian countries in the two months. My DH travels all the time. While the 3% case rate is difficult to capture and act upon, it at least is a better indicator of community health.

Picture the entire new england states shutting down for say, two weeks. Cleaning, locating cases, essential workers staying at work locations, no commerce, no movement except for medical care givers coming to your home. This virus would be stopped in it’s tracks. Just repeat as often as necessary. This would have the best mathmatical outcome of saving lives. Would our government trade lives for productivity? Watch what they do, not what they say.

Dude, we need to look at that scenario in slow-mo. You ask “what if” - try it with day 1, day 2, etc, and see what happens. I don’t know!

Dude, a short response, cos I just got home. Any plan that calls for full community participation will have an extremely high non-compliance, and high enforcement cost.

That’s why school closure is a good intervention to use, cos it’s not dependent on compliance of individuals. Whether they keep kids home will depend on compliance, but even if a proportion of kids do not stay home, you have already achieved the 1st level of the TLC effect. (see chart)

bump, so more people find this

kids will be home part of the time, and they will be in smaller groups

maybe, even, in “persistent” groups - 1 in contact with the same n-1 every time - urban tribes, maybe even with some badge to show who you should not get near to?

I’m posting this for ‘drd191′ who for some strange reason has been unable to post. We’re getting pogge to look at this:

Since I am on the west coast (US), I am joining this conversation rather late. I want to REALLY thank anon_22 for the original post. I also attended the IOM meeting in DC last week and have been thinking about how best to synthesize all the info presented.

As anon-22 has mentioned proactive school closure was consistently mentioned as the most effective NPI. In fact, someone (I forgot which presenter) had incredible graphic that depicted the spike that will occur in child death with a 2% CFR; more child death in one year than the previous 20 years. Anon-22 do you have that slide?

But I wanted to share some other key slides and info. First, Robert Blendon at Harvard found that 6 out of 10 people surveyed didn’t know what “pandemic flu” meant. 41% said they knew, but that was just self-report, so the actual % is probably even lower. That’s a major problem right there. He said that there has been a huge disconnect in understanding between “bird flu” and “pandemic flu”. See http://www.hsph.harvard.edu/press/releases/press10262006.html for all slides he presented.

Second, I wanted to support Reader’s comments and share my concerns about the “unintended consequences” of a school closure policy. I should note that the entire afternoon of the second day of the conference was dedicated to exploring consequences of mitigation strategies. I’m personally most concern with what will happen to the poor, minority, immigrant, homeless, and other vulnerable populations during a pandemic. While I understand anon_22’s position that it is imperative that we implement the most effective non-pharmaceutical strategy, there will be a Katrina event in every major city across the United States if the “unintended consequences” are not solved. And I have little confidence that the problems facing vulnerable populations will be addressed, especially given the lack of finances at the local level that all the local health departments are screaming about.

Okay, I have run out of time and I must deal with some family issues for the next few hours. But I promise to make a list of the negative consequences similar to the list uk bird at 06:12 put up in relation to the positive aspects. This is not to take away the importance of a school closure policy, it is just to add information (so much that I learned at the conference) of the implications of such a policy.

The graph drd191 refers to is this:

This thread is interesting, informative and important, Kudos to all especially anon_22.

My husband and I are both teachers, many of our friends are teachers and despite what some think, as a whole we are not dopes. We already know that schools are germ factories, we watch colds and virus’ past throught the schools on a regular time table. The main thing that we are pretty much in agreement on is that IF this thing hits, we are not going to be sitting ducks in schools taking care of sick kids that should be home in bed. Parents regularly send sick kids to school because they have to work. the poor kids come to school and they pass their germs around and make sure that 30 - 40% of the other kids get sick too. If there was a pandemic the schools could not be a better place to keep the virus alive and happy. But, TPTB are going to have a bigger problem, because 95% of the teachers I have spoken to said they will not be reporting for duty. This is not the same horrible decision that doctors and nurses have to make, but merely one of good sense. We are not going to risk our lives and those of our loved ones because TPTB want to keep the economic engine running…

This is not a hard decision, and I am glad I am only a teacher and do not have to make the horible choices that health care workers have to make and whatever decisions you make, we honor you.

 ~horrible ~

Since H5N1 kills the age groups it does, and we won’t have pharmaceutical interventions this year or two (or 5?), and teachers won’t want to show up, and parents won’t want their kids to die,

why not do the cruel-to-be-kindest thing and explain pandemic influenza now to parents and communities, so people have a chance to reduce debt and non-essential spending, and stock up on food and meds their families already need, so we can try and migitate a catastrophe? Schools have also had ages to think about (non-electric) home learning plans, but losing an academic year is better than losing a municipality’s children.

crfullmoon – at 18:20

Since H5N1 kills the age groups it does, and we won’t have pharmaceutical interventions this year or two (or 5?), and teachers won’t want to show up, and parents won’t want their kids to die, why not do the cruel-to-be-kindest thing and explain pandemic influenza now to parents and communities, so people have a chance to reduce debt and non-essential spending, and stock up on food and meds their families already need, so we can try and migitate a catastrophe? Schools have also had ages to think about (non-electric) home learning plans, but losing an academic year is better than losing a municipality’s children.

That’s why personally I want lots of debate and publicity about early and proactive school closure.

Many of us have experienced cool or nonexistent responses when we try to talk to others about pandemic prep. I suspect that school closure with all the implications eg childcare arrangements will cause a lot of people to get in on the debate. Parents will sit up and take notice. They will want to know why we need to do such a drastic thing.

THAT is the chance you get to explain how fast a pandemic virus spreads and CFR and all the rest of it.

In trying to understand the need for school closure, they may very well come to other conclusions eg SIP on their own.

Whatever the ultimate decision about school closure, getting people to pay attention through this is well worth the effort, IMO.

Slides for this workshop are available here

Bump.

anon_22 -

I have reposted this question here from another thread. I want to go over what the experts are stating as to the latest a TLC program could be instituted.

In Neil Ferguson’s presentaion at IOM, he stated that to achieve a low (total) local attack rate of <4%, the TLC must be implemented (and complied with) before the local attack rate reaches 1%.

So does that mean for a city of 500,000, for the attack rate to end up <4%, the TLC must start before the attack rate reaches 5,000 (1% of 500,000)? This does seem awfully late to wait for 5,000 people to come down with symptoms (and be diagnosed). But this would then mean that if TLC started (in a city of 500,000) before 5,000 people became ill with H5N1, then the total number to become ill would not exceed 20,000 (4% of 500,000). I completely understand that the TLC would have to be quickly put in place, and adhered to fairly well. Also, I assume this TLC would use antivirals for treatment and contacts, but not vaccines.

I keep reading 1% used as the standard, so that the TLC must start before that attack rate. However, I believe I have also read 3%, which seems way too high.

Also, are there any others who suggest that a lower AR must/should be used to start the TLC. Obvioulsy, this would be better, but do any others actually state that?

Sorry if you have gone over this completely, but I want to nail this concept down for the forum tomorrow. I personally would vote for one person to be diagnosed with H5N1 to start the TLC, but I have to use what the experts have been stating.

JV,

These are good questions, reflecting the conundrum around modelling, because there is always going to be a gap between a model and reality. When we say TLC must start before 1% attack rate, its easy to conceptualize that mathematically as a modeller, but how does one translate that into reality? Ferguson admits there are real issues here. For example, we need to define almost every word of this statement:

TLC must start before local attack rate reaches 1%.

When you start attempting that, you will notice immediately there are lots of assumptions built into every word. For example, which part of TLC are we talking about? In this instance, Ferguson is talking about school closure with 60% of children successfully kept at home, and social distancing >=50%. How does one measure this last parameter?

What about the word ‘start’? Is that an announcement, or are the schools all ready to just close soon as you give the word? Are parents ready to take kids home at a moment’s notice? Is there a timescale from ‘start’ to full implementation, with the % compliance assumed? There is going to be variation between different communities with the speed by which this compliance is achieved, from the ‘start’.

And, as you rightly pointed out, how do we define AR of 1% for this purpose? There is going to be a time-lag, probably a big one, between suspected cases turning up and confirming them. And do we have to wait to confirm ALL of these people? I suspect the mathematical model is not based on the time at which 1% of people are confirmed to be infected, but a theoretical notion that 1% of infection has happened, without specifying how one is to find out when that has happened.

From all this, you can see that every piece, and I haven’t covered all the parameters, will have a built in level of uncertainty, so that someone who tries to strictly adhere to that statement, not understanding that that statement is a reflection of a theoretical concept and not a practical parameter, will fall behind immediately and will be playing catch-up for the whole of the pandemic.

Longini, again speaking theoretically, gives <3% AR as the line beyond which school closures will not make a significant difference.

Maybe the most useful way to think about this is to separate (and discuss separately) recommendations extrapolated from modelling and what the trigger(s) need to be in reality. I don’t think they have come to any useful conclusion yet about how to define a trigger, and, absent of that guidance for the moment, local authorities will have to fully understand and be able to interpret what the models are saying, and then decide their own triggers.

My preference is just to use the first confirmed case in a community as the trigger. Because if it is a confirmed case, and it is a pandemic strain, aka it is already spreading rapidly in other parts of the world, there is no reason to believe that this one case will be contained. If policies are started immediately, and then it turns out there are no more cases, officials might come under fire for jumping the gun too soon. However, if the R0 and especially the CFR is quite high from observing other communities or countries, then this action may still be justified, with properly explanation to the public, of course. Or it could also be viewed as a dress rehearsal, on the assumption that once a pandemic has started, it will arrive locally sooner or later anyway.

Remember a pandemic develops very quickly, with a 10-fold increase in no of cases every 7–14 days.

It is more useful to think of the 1% as the threshold beyond which interventions are likely to be useless, rather than think of it as a trigger.

Consider a house fire. The sooner you use the fire-extinguisher, the more likely you will put it out. Theoretically, there is a point beyond which the fire-extinguisher will not do the job. Do you want to wait for that point? It would make more sense to start trying to put it out right away.

I think the usefulness of the 1% is in this. That if you have an intervention where the modellers tell you the intervention has to start at 0.1% attack rate or even 0.01% attack rate, you know that there is a high chance that you will miss that threshold, so you might decide not to use that particular intervention.

So Longini’s 3% is useful in that it tells us that early school closure as an intervention is feasible and achievable.

Also, the doubling time for each generation of cases is 2–3 days, or at 10-fold every 7–14 days. So the time difference between 1% and 10% is only 1 week, max 2 weeks.

At R0=2, if you act at 0.5%, you are only 2–3 days away from the critical 1% threshold, beyond which the interventions are unlikely to work.

So because of the speed of an influenza pandemic, acting early only involves a few extra days of interventions over the wave of a pandemic. The additional cost of acting early would be relatively small. Plus those extra few days are easily consumed by delays in implementation, compliance, communication, etc.

anon_22 -

I understand. I was hoping there was something more concrete. From what I get from all of this:

1. A community must be informed early, clearly, completely, and honestly that a pandemic might happen so the citizens can:

• prep/stockpile
• network to help solve problems that will arise, and basically help themselves and others when the government can’t
• completely understand what will be asked/required of them if a TLC is called for, so that people will/can comply quickly and willingly at a moment’s notice
• trust in the government that they are working in the best interests of the population (and have thought this all through). Then, in the future, other instructions/directions from the government will/might be complied with. Trust in the government will only come after honesty from the government.

2. There is truly no reason to wait till there is a 1% AR to call for a TLC. At least, in the US, there should be no reason for misdiagnosis of H5N1 in symtomatic patients, especially if there are a few. To wait till 100 or 200 have been diagnosed in a city of 500,000, is not really acceptable.

3. What will destroy this whole extensive planning on paper is if the government does not explain everything as I outlined in #1. It is totally up to them now. If they do not come forward and get people’s attention, and make them understand, they will be to blame (and believe me we will all blame them) for mass fatalities. TLC seems to work on paper (+ or - antivirals) even without 100% (or much less) compliance. The whole glaring part that is missing is the government stepping up to explain what may happen and what we all need to do. If all of a sudden, one day we are told about this possible disaster, and three days later it is in our city, all these plans will not work. People need a lot of time to compute what they are being told, and understand the implications and what they need to do, prep, and network.

I should note that when the government finally explains this situation to the public, there will be a huge outcry about many shortages from food to medicines, etc, that might occur. The government will simply have to give explanations as to how they are working on it (and work on it), and act at least as if they truly care about the welfare of people. That is all that is needed, I believe. I think we can somehow forgive shortcomings, in the end, if at the present time we feel that the government is trying very hard to correct the problems, and has empathy for the people.

anon 22, I added your 14:36 statements to the Case for Early School Closure thread, hope that was ok.

JV, I totally agree (and wish the public, media, and officials could hear that this week…)

crfullmoon -

I just plan to simply state all these points at the meeting tomorrow in Seattle in a very toned down manner so as not to appear fanatical. I will lose credibility if I pound my shoe on the table (although I would really like to)! I need them to listen to me. I will make my statements over the 6 hour period of the forum, so I won’t have to hog the forum. I will be pleasant, but I will know all the facts. They have to have a dialog with the audience so they can figure out what the public in general can manage to do in a disaster. Periodically, they will simply have to document my statements.

JV, looks like we - the grassroots people - need to look at ways to call people’s attention on this. And when I say “people” I think I mean parents, teachers, journalists, people who talk and others listen, etc. And not only in the US - but wherever any of us can apply any level of gentle pressure.

The question, of course, is: How?

JV – at 15:30

2. There is truly no reason to wait till there is a 1% AR to call for a TLC. At least, in the US, there should be no reason for misdiagnosis of H5N1 in symtomatic patients, especially if there are a few. To wait till 100 or 200 have been diagnosed in a city of 500,000, is not really acceptable.

Yes, that’s why it’s important to emphasize it at every turn, the idea that the 1% is the point beyond which things won’t work, using the housefire analogy, and to emphasize the very short timescale we are talking about for starting any policy.

Here’s another problem, how many cases do you think there would be already when you have ocnfirmed the first case? We are likely to have a situation with a large number of sick or worried people being tested, a number of whom will be false negatives, so we can only guess at the answer.

Maybe the first sign is an unusually severe respiratory infection in a young person. The lag between the death curve (or when you realize something serious is happening) and the ill curve is about 8 days, so a rough guestimate would be that you would have at least 3 doublings before you diagnose your first case. Plus some deaths would have been attributed to other causes as we have seen in Indonesia and other countries.

So when you confirm your first case, you are only seeing the tip of the iceberg.

But to backtrack a bit, don’t be too certain about being able to diagnose H5N1 cases. It is far more likely that the first cases will be missed.

The message is: TLC works if started early enough, we are talking about very short timescales here, in a matter of a few days, that will determine the difference between success and failure.

JV - we were typing away at the same time. Of course one answer to my How? is what you’re going to do, which is great. I’s trying to think of other ways. Maybe tell a journalist about your attendance?

JV,

What will destroy this whole extensive planning on paper is if the government does not explain everything as I outlined in #1. It is totally up to them now. If they do not come forward and get people’s attention, and make them understand, they will be to blame (and believe me we will all blame them) for mass fatalities. TLC seems to work on paper (+ or - antivirals) even without 100% (or much less) compliance. The whole glaring part that is missing is the government stepping up to explain what may happen and what we all need to do. If all of a sudden, one day we are told about this possible disaster, and three days later it is in our city, all these plans will not work. People need a lot of time to compute what they are being told, and understand the implications and what they need to do, prep, and network.

I should note that when the government finally explains this situation to the public, there will be a huge outcry about many shortages from food to medicines, etc, that might occur. The government will simply have to give explanations as to how they are working on it (and work on it), and act at least as if they truly care about the welfare of people. That is all that is needed, I believe. I think we can somehow forgive shortcomings, in the end, if at the present time we feel that the government is trying very hard to correct the problems, and has empathy for the people.

I agree. However, I would also suggest that at this point it may not be easy or even useful to emphasize too strongly the problems they will encounter with explaining it to the public.

Consider how challenging it has been for you to get from knowing almost nothing to understanding and accepting what you know today. It may be necessary to pace their responses and at this point put all your energy into educating and convincing them, rather than scaring them away by the fear of no being able to sell it to the public. They need to fully understand this whole thing backwards and forwards and many times over before they can even begin to figure out how to tell the people. My worry is that officials often suffer from ‘premature closure’, thinking they understand when in fact they don’t, or deciding that since selling it to the public is so hard, they should cut corners on their policy. So paradoxically, there may be a case for persuading them that it won’t be too hard to sell to the public.

All this is in the context of communicating to your local officials, ie persuading them. In the context of tomorrow’s meeting, the focus may be different. The people holding the meeting may be very well informed and just looking for your feedback and input on the ‘hard’ policy (ie exactly what interventions to use) rather than the ‘soft’ side (ie how to sell those to the people). So my comments may need to be applied differently depending on what comes up.

lugon -

I am going to e-mail a couple of journalists now to see if they won’t even sign up and cover this. As of yesterday, only 90 people has signed up. They limit it to 100.

anon_22 -

Right. I really meant that I would state all the basic points about needing to get the public’s attention now so that everyone can prep and comply. It will not help for me to hammer at them that no one will trust them if they wait, and all the problems they might have to deal with, etc, etc. Just proactive statements. I tried to also explain that I will make a statement (nicely) once, and then, in general, not repeat it. If everyone is on page one of a physics book, it would not help for someone to keep chiming in about stuff on page 200. An occassional, non-hostile comment, OK, but otherwise people will stop listening to me. I need for people to listen to me.

I agree with you!

I also agree with your points at 16:00.

JV,

You’re a good person. Good Luck!

JV, do you want the attention of the convenors of the public meeting, or the attention of the convened so they may realise what you’re saying and add their own point of view? I guess I’d daydream about being ready for both :-?

lugon -

1. I honestly understand what you mean. I will try to be everything for everyone! I honestly want all their attentions. I will see how well I can do. But believe me, all I really want to do is to pound my shoe on a table!

2. I have sent 6 e-mails to journalists at the P.I. and Times newspapers (the two major newspapers in Seattle), and also to the local radio talk-show hosts here.

I hope this turns out well. At least I will have tried my best. I will try to post everything tomorrow PM.

anon_22 -

What is the origin of the very first slide (on the first post) on this thread? It is labeled “Layered Interventions,” and the R0 goes from 2.1 to 0.9. Whose presentation did it come from?

JV,

It was from Marty Cetron, CDC, from one of his earlier presentations, not at the IOM. But this slide has been used by various people at the CDC and HHS as well.

anon_22 -

OK. Thanks

JV, You can look for Cetron’s slides, and for everyone else’s slides too, here:

http://www.iom.edu/CMS/3793/37624/37630/38059.aspx

They are all PDF files, and the sum of sizes is about 7 megabytes.

Martin Cetron’s is less than 1 megabyte - less than a single floppy disc.

I write this in case someone wants to show the slides to schools etc. All it takes is a CD or a pendrive or a laptop. Let people look at things and tell you what to do, for a change?

lugon -

Yes, I have looked at all of the slides from the IOM conference. Some are quite good, and I copied them off. I couln’t find that slide, and that is why I asked the question. I thought it should have been there, but it wasn’t. Thanks!

Good luck JV. Start a new thread when you have the time to fill us in on how the day went.

Edna Mode -

I certainly will. Hopefully I will get it all posted tonight!

awaiting it … thanks!

You know, a number of fluwikians don’t live in the USA. These things are being discussed in the USA. Maybe, just maybe, other countries will start talking about these recently built pieces of evidence, their implications for policies, and the implication of policies for public involvement in preparedness. It will take time, but we need this to reach as many as possible. The whole world needs to learn. As much as possible of the whole world.

Again: Thanks!

bump

if we find a link to JV’s report we could put it here - please.

This thread has been copied to the new forum and discussion will continue here. Thanks!