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Forum: The Public Engagement Project ASTHO-Syracuse Meeting

26 November 2006

anon_22

I’m going to be in the Washington meeting on Wed, it would be great if people continue to post their comments even if I may not be able write back. That way, I can still read them when I get access. Dem can you make a note of that and ask people to post their opinions? Thanks.

20 November 2006

Pixie – at 10:45

The Public Engagement Project on Community Control Measures for Pandemic Influenza

An initiative is being sponsored by The Keystone Center and Association of State and Territorial Health Officials (ASTHO). Meetings had also been held previously in Seattle and Atlanta and another meeting was held concurrently in Lincoln, NB on 11/18/06. http://tinyurl.com/ygydzf

Summary of Syracuse meeting, 11/18/2006

Main presenters:

Audience:

My own estimate (entirely my own guess) is that about 50% of this audience was very well versed and up to date in the specifics of pandemics and H5N1. The other 50% was of the audience was made up of citizens who were interested, but not fully informed. A number of the latter appeared to be stakeholders in health or education agencies that would be severely impacted by a pandemic.

Questionnaire

The meeting began with the distribution of a booklet containing a questionnaire that tested our existing knowledge of both seasonal influenza and pandemic influenza.

One question asked us how many pandemics have there been in the last 100 years. The quiz was multiple choice, and there were several choices, the closest one to the correct answer, which would have been “3,” (1918, 1957, 1968) was “4.” There was no choice of “3,” although that is the number that they pointed out on their follow-up slides was the correct answer. I got a wry chuckle that their choice of the number “4” rather than “3” may have been quite a Freudian slip, something that I noted later in my written comments.

Other questions asked us to choose “greater goods” from a list of options. For example, one question asked us which we would prefer to see during a pandemic:

In the event of pandemic influenza, who should decide what control measures are adopted or required?

Other questions asked about the degree to which we believed community control measures should be completely voluntary or mandatory (with choices up and down that scale), and when to implement them (choices ranging from when a cluster is discovered overseas to when there are cases found in your own community).

Sense of Urgency

I believe that the findings from these four ASTHO/Keystone meetings will most definitely impact public policy. There was no sense of alarm or urgency in the demeanor of anyone there, but it was noted, and this is a direct quote, that:

This information needs to get back to Washington immediately, like Monday.”

From what was said, it was apparent that the findings from these meetings would be distilled and summarized and would land on the desks of those very high up early this week.

Introduction to Seasonal Influenza & Pandemic Influenza

Quite a lot of time was spent educating the audience about regular influenza. Ten slides were shown on seasonal influenza, and that was followed by ten slides on pandemic influenza.

I cannot stress enough that the presenters, several of them, went to great lengths to urge the audience to please get vaccinated against the regular flu. These appeals really were quite strident and a bit emotional. No mention was made to the larger audience that the seasonal vaccine might provide a bit of protection against a pandemic strain, but that admonition was specifically voiced by one of the meeting organizers in my small group.

One glaring mistake in the presentation, the only one I found overall all day, had to do with the slide (#13) entitled “Are the Same People At Risk of Severe Illness with Pandemic Flu?” as compared to regular seasonal flu.

The slide stated: “The same persons at risk of severe seasonal influenza will likely be at risk for severe pandemic disease, e.g. elderly.”

They go on to add: “BUT, additional groups may also be at high risk of severe disease (E.g. 20 – 40 year old adults, children < 2 years, and elderly at high risk in 1918 Spanish Flu

One codicil added: “May not be able to predict high risk groups in advance.”

So let me pause from my reporting here to comment that I think that moving ahead with these assumptions, namely that the usual groups will be most likely to be affected, or to move ahead with the assumption that the same groups affected in 1918 will be affected now, is unacceptable based on our wide knowledge of the very specific group – children – that H5N1 is affecting now. If 70% of H5N1 fatalities are NOW occurring in those < 20 years old, public health officers and the public really MUST know that in order to make appropriate and informed decisions.

more in a moment…

lugon – at 11:42

Selecting “greater goods”. OMG.

As if there’s no “third way”! Specifically: compliance with recommendations would be better if you treat us as adults, etc. Ah, well, let’s wait and see.

Pixie – at 12:13

Summary of Syracuse ASTHO/Keystone Public Engagement Meeting Continued..

Assumptions for Scenario

Several assumptions were built in to the meeting format and these were explicitly noted:

Question & Answer Session

? What measures were used during 1918 to affect the spread of the virus?

Some cities did very well, but it was noted that some “were just comical.” They explained that some municipalities closed theatres, or put up posters about sneeze etiquette, or distributed cloth masks, but that there were few coordinated and well thought out efforts. This, it is evident even if one was not familiar with the findings from the IOM meetings, is what they hope to do better on today with a more coordinated, and thus effective, plan.

I would like to note that I would have loved to, at that point, seen Goju’s slides comparing Philadelphia vs. St. Louis in 1918 and a brief explanation of their respective approaches to pandemic containment. I think that, in terms of quickly educating this audience, that information would have been very helpful and illustrative of the kinds of impacts their shortly upcoming decisions, or any citizens’ decisions, might potentially have. Again, allowing the public to be fully informed is the key.

? Will the response be local or Federal?

They really wish to leave the legal authority with the local public health office. They also do not want to be in conflict with the state.

An interesting part of this answer was that “prioritization will be based on supply & demand locally.” I assume that they were referring to the prioritization of vital resources such as antivirals, vaccines, etc.

? Someone asked what they should do if they are allergic to flu shots (eggs).

Most likely antivirals will be used for that population.

? What are you doing about the public education system during a pandemic flu?

“We are working with media about that.” (I’m not quite sure what to make of that answer, and I think they answered as if they were referring to how they will educate the public about pandemic flu, rather than the questioner’s intent which, I believe, was to find out about how we will continue with our children’s basic educations during a pandemic).

? The woman sitting next to me asked a question about whether cats can be infected with this potential pandemic flu (she was obviously well informed).

Dr. Nicole Smith, PhD (Berkely Goldman School of Public Policy), currently with the National Influenza office at CDC, answered. (She did not mention her background, I just like to know from whence someone is speaking).

Dr. Smith stated that there has been “no transmission of H5N1 from Bird – Mammal – Humans. She repeated that this does “not translate to a risk to humans.” She then stated that from a pandemic influenza perspective they would work with agencies that deal with such entities as turkey farms, chicken farms, markets where poultry is sold, and wildlife management of birds. She said then that “at a systems level, different agencies will address different concerns.”

In short, she did not answer the question about cats.

? Someone asked a question about whether the virus is now adapting since 2X the usual dosages of Tamiflu are now required for treatment.

The answer given was that for planning purposes, we would have to assume that there will be limited Tamiflu availability.

? Then it was Science Teacher that stood up and asked the very important question as to why, if Hong Kong is being urged to collect food and water sufficient to shelter-in-place for 12 weeks, U.S. citizens here are only being urged to do the same for up to 2 weeks.

The microphone was passed around quite a bit on this question. The first answer came from Cynthia Morrow, the Commissioner of the Onondaga County Health Department. I believe her answer is very important, and illuminative. She said:

“Not everyone has the luxury” of being able to prepare for 12 weeks of SIP.

Then Dr. Gellin (DHHS) moved towards the microphone. He stated that the current SIP recommendations are “mostly to ensure that you can stay home with sick family members.”

I believe that this exchange was perhaps the most important new revelation that I got from the meeting. I think it is important for us all to understand that our government may not feel, from a social equity standpoint, that it cannot risk the frustration of masses of people by recommending measures that they cannot comply with for practical reasons. I believe that they are telling us that the 2 week SIP recommendation will stand (and I do not expect that to change).

This being the case, I think it is critically important that we who know that to SIP for a prolonged period of time may be prudent, and that supply lines may be seriously affected, redouble our efforts here at FW and privately to encourage all who are able to do so to prepare for 12 weeks. We must do it, as I believe that the federal and state governments feel that they simply cannot offer that recommendation if it will be impossible for many people to do so.

We must also, in the time available, urge them to try to do so and give them as many suggestions as possible as to how they can suggest to someone like an average American teacher on an average American salary be able to purchase and store 3 months of provisions. We know it can be done, but they do not, and we need to share that knowledge.

An idea floated at this juncture, which I think was an excellent one, had to do with providing “boxes” of provisions to those in need during a pandemic.

? The question regarding the use of maks during a pandemic and their efficacy was asked.

Dr. Nicole Smith took this question. A direct quote: “The evidence is nonexistent” pertaining to the use of masks during a pandemic. She pointed out that:

I thought those were very interesting comments, and they tell us a lot. No masks.

? What will a pandemic physically look like - 1918 or significantly worse?

“Pandemics occur gradually.”

And “We are using it (1918) as a model of pandemic influenza.”

The question, in short, was not answered.

I do wonder, though, where the “pandemics occur gradually” comment came from, and it made me wonder what is happening currently out there (?).

? My question: Why are we using a 2% CFR when the current rate of H5N1 fatalities is over 50%? As a parent, that number makes a great deal of difference to me – why are we using 2% in our scenarios today?

Dr. Nicole Smith answered this question first:

She said “as the properties of the virus change, that will cause it to make it more transmissible, it will also pick up other changes..”

Then from one of the male presenters up front: “If it were a thinking being it would not be in its interest to kill everyone, it needs to pass it on.”

Dr. Smith again, looking straight at me: “We consider it to be an AVIAN virus. It is NOT a pandemic virus.” (Her emphasis).

She continued on and said that a most severe virus is a virus with a 2% CFR, that that is considered “severe.”

Again, to the front of the room: “Think of it as a dead end street. From an evolutionary point of view, if you kill them (the hosts) they can’t pass it on.”

Then Dr. Gellin got to the microphone before this could become a spitting match between those who knew more and the presenters. His answer, which was the appropriate one, was that they chose the CFR for this planning exercise because it was the rate experienced in 1918. Period.

Ok, I want to add my concern here. I was ready for a spokesperson to tell me, in response to my CFR question, something very like what I heard. I’d also like to mention that Dr. Nicole Smith is a really excellent spokesperson. I’d hire her in a minute to work for me. She did her job extremely well, and from my googling it looks like she’s been doing this same risk communication since Nov. of 2005. She is very well spoken, very good at her job. What alarmed me as I listened carefully to her answer, and watched her demeanor, is that I feel that Dr. Smith, an epidemiologist, may really believe what she is saying. This was the most alarming revelation, to me, of the conference. It suddently occurred to me that the world of those who understand what is happening in the sequences, may be quite a bit smaller than anyh of us in that world care to examine or to admit. The full understanding of the recent H5N1 changes, may not be understood at some quite high policy making levels. That has serious implications. I do, however, think that Gellin and a few key others do, in fact, understand this situation, but the emphasis I would put on “few.” Can they effectively communicate this knowledge up and down the chain of command?

? Someone asked if there is a “Plan B” – what if these measures are not voluntary?

“Right now the proposal is for voluntary” measures. They noted that 3 of the 5 measures we were to later consider and evaluate were completely voluntary.

I did note that in the DOD documents that Clawdia posted yesterday levels 3–5 were clearly described as being expected to require no more than voluntary levels of community control. Level 6 was broken out into another category in those documents. (And I suspect a CFR of over 2% will push things into another level of concern as well).

? What is the CDC’s goal?

“To get the message out now, to not try to ramp up pandemic awareness during a pandemic.” Later it was mentioned several times that they needed to figure out how to do this without causing panic.

More later on our small group discussions…

DemFromCTat 12:24

excellent and thanks!

Several points…

Science Teacher – at 13:39

Dem, Flu Wiki came up when I made reference to it in the last Q&A session with the large group. I gave out this sites address and others. I also gave examples of the kind of prep information that could be found here. People seemed interested.

Pixie, Excellent report! I wish I knew you were there, it would have been nice to meet you! You asked a terrific question! I posted my report on Monotreme’s PFI site but will copy it here as well.

My summary of Saturday’s meeting:

The Public Engagement Project on Community Control Measures (ASTHO) November 18, 2006 Syracuse, NY

Main Speakers:

Roger H. Bernier, PhD, MPH, Senior Advisor for Scientific Strategy and Innovation, National Immunization Program, CDC

Bruce Gellin, MD, Director, National Vaccine Program Program, HHS

Part one: Basic intro and information on H5N1 and a pandemic. This was a very good summary of major points. (We were given a questionnaire to access our basic knowledge when we arrived.)

Open Q&A. with entire focus group:

My question: Recent information provided by the State Department has appeared on Embassy websites in Hong Kong and Tunisia warning Americans that are living/working there to stock up on enough food and water to last 3 months. The Warden system was used to disseminate this information to American citizens in these and possibly other countries. In this country our governments’ websites are recommending enough food and water for only 2 weeks. Could you please explain this disparity?

This was answered very circuitously by a CDC member sitting at one of the tables (a young woman, didn’t get her name). Basics of her reply were something to the effect that different countries require different recommendations. I wanted to reply to this but my microphone had already been given to the next person.

Break time:

I spent my break talking with Roger Bernier and Bruce Gellin. Both had taken note of my question and wanted to ask me questions. Bruce began with ‘What else do you know and where do you get your information? I replied, “Mostly from the flu forums and from international news sources,” and “ ..Well let’s see.. I know about TLC, IOM, and that the paper published in NATURE this week regarding the changes in the Egyptian sequences was deep cause for concern and meant that H5N1 now has the potential for moving up the respiratory tract to make it more likely go H2H.” Startled looks followed. I then said, “There have been rumors on different websites lately that a government report is about to be released recommending the implementation of control measures very similar to what we have been discussing here (and at the IOM). I have read that the report will also contain information about the pandemic lasting as long as 3 years…” I then asked, “Is this true, do you think the pandemic could last for up to 3 years and have you been discussing this?” Dr. Gellin answered that one (paraphrase).He said that they are discussing lots of things and that nothing was set in stone, that they were constantly reviewing information and making changes as needed. The conversation was shifted by one of them to “do you just read or do you write on the blogs? If I go online tonight can I read about today’s conference?” I laughed and answered, “you may have to wait until tomorrow”. We all laughed and loosened up. I told them that if they needed to get information out they should learn how to participate in the blogs. Gellin looked at Bernier and said “I was just discussing that yesterday”. I said, “you need to hire me as your blog liaison”, more laughter but also a request to provide my contact information to both of them. I then turned and focused on Gellin and asked, “so, do you think the pandemic will last 3 years?” He smiled. I asked, “can you tell me that it will NOT last for 3 years? “ Again a quiet smile….

Part two: We sat in groups with a Keystone moderator to discuss 5 specific Control Measures that might work to slow down the spread of a pandemic. We were asked to discuss, evaluate “which community control measures would be most challenging for you and your family to carry out and follow? Why? We were asked to vote in our groups about which measure would have the most adverse effects on the voters (the measure that they would be least likely to support). The measures involved included keeping sick persons at home, keeping people exposed to sick people home for a week, closing schools and daycares, preventing children from congregating, changing work schedules, locations, working from home and cancelling large gatherings. Many of these measures inspired discussions on how to economically survive if folks aren’t getting paid and who will take care of our children if we do work?

I won’t go into too much description of this as many summaries of this have been posted elsewhere. (If you would like me to elaborate on this more, please ask).

My group members all became fixated early on the closing of schools and daycare centers measure. “We wouldn’t be able to work” they said. “Our kids are entitled to an education.” “It would screw up their SAT scores and they won’t be able to attend a good college”. I tried my best to ‘persuade’ but was unsuccessful: my group voted 7 to 1 (me) that this measure was the most unacceptable to them. Many groups had similar results. I felt strongly that a lot of folks at this point were so far from getting the message of how serious a pandemic would be and could just not wrap their minds around the fact that their kids would be in great danger if the schools stayed open.

A lengthy conversation ensued because many folks there had difficulty with some the semantic parameters of the discussion. More information and discussion about this was initiated by the speakers. Apparently this was a new subject of discussion that did not occur in earlier meetings and they did a nice job working through the issue. I think many people understood better after this. By the end of the seminar, I noticed much less opposition to the control measures and more serious expressions on the faces of participants once they began to ‘get it”.

. We were asked to stand up (once) to answer the question as to when these control measures should be implemented in this country. The first 2 scenarios were ‘when an H5N1 pandemic begins and Asia and when it begins in the USA. The speakers were very pleased that quite a few stood up for these 2 categories as compared to earlier seminars. I felt well; maybe the message is getting out. Other choices were, state or regional and community. I got the gut feeling from this that they are seriously considering putting control measure in effect here if it occurs in Asia. They stressed many times before how quickly the pandemic will pass from another country to here and spread quickly within this country. They expressed that early intervention would be necessary. They did an excellent job of expressing this and one could almost see the light bulb turn on for many people.

I did get the mike one more time and recommended some flu sites (CE plus others) for people to visit for more information. Many expressed interest in writing down the addresses and I had to repeat the information several times.. I gave examples of the types of information that could be found on these sites. Hope I didn’t step on too many toes on this one as someone took the mike and stated that people should use reliable sources of information and gave out govt. website.

I did meet one more time before I left with Roger Berliner and Bruce Gellin. They were interested in my opinions as a teacher on the use of blogging vs. in person information. I had commented in the focus discussion when asked the question of why I was at this workshop. I answered that I had tried to participate in State, county and local discussions on Pandemic Planning but had not been allowed to register because I was not an HCW. I said I came here today to share my 2 cents. Roger referred to this comment. I told him that I supported the control measures before I came to the conference and that I did know what the measures would be before I came here and that I still supported them. Also told him that ‘in person’ was a better way to get information but that there were not many opportunities for this. I explained that this is why I read the flu sites.

Also had one last chat with the young woman from CDC who stopped me to discuss her reply to my original Hong Kong and Tunisia question..(She was referred to as an ‘expert’ later in the meeting.) She seemed to me to be apologetic about her reply. I asked when the alert level will be changed from 3 to 4. She said it would stay at 3 as far as she knew. I also asked her, so why are you recommending that people only prep for 2 weeks. She went into the response about poor people not having the money to. I replied with the rice and beans are cheap if spread out over time, if people are alarmed enough to do this and that 2 weeks won’t save many people. Final comment of mine was, “a lot of people will die if you stick to this” before we drifted apart.

Summary: The format and speakers were excellent. I think this was a valuable seminar to get the word out to people on general Pandemic information. The discussion of the predetermined community measures and supportive information provided by the speakers on this specific topic of Community Measures was excellent. I think it did make many folks there to become ‘stakeholders’ and more likely to adhere to community measures once they are implemented. I think many that attended will look for more information on their own. Finally, we each completed a follow-up questionnaire. Based on my own observations, I think quite a few attitudes were changed during this exercise. Everyone there seemed to learn a lot of new information and will hopefully begin the process of individual preparation and share this information with others. IMO we need as many folks as possible to buy into the efficacy of these measures in order to reduce the likelihood of civil unrest once they are implemented.

Please feel free to ask questions.

anon_22 – at 15:57

Science Teacher – at 13:39

Thank you for everything, attending, speaking up, writing here, etc. It’s very interesting to read about the attitude of the organizers and how they seem to be genuinely interested in engaging in dialogue. I’m sure the fact that you were so well informed about the measures added tremendously to your credibility both in their eyes and more importantly those of the other participants.

IMO we need as many folks as possible to buy into the efficacy of these measures in order to reduce the likelihood of civil unrest once they are implemented.

I have a question. Knowing how much you knew already even before you started reading about these measures, what do you think would be the minimum extent of understanding needed for people to even evaluate these measures properly? ie not go into kneejerk reactions when they learn about it.

Bump – at 15:58
BeWellat 16:21

Thanks to Pixie and Science Teacher for your participation and informing the rest of us.

Science Teacher – at 17:26

You are welcome, Be Well and thanks for reading our lengthy reports. : )

anon_22, I watched the knee-jerk reaction work its way through phases in my group. Initial fear from some, changing to some anger. As they were given more and more information from the speakers and also learned from the Q&A responses their perceptions were able to change. In my group, I seemed to be the only one advocating the early closing of schools. At the end when my group voted, all but 1 supported the early closing of schools.

My inference from this is that all people, even those with very little knowledge of an H5N1 pandemic are able to benefit from this type of approach. The information was presented to them in manageable steps and in as non- threatening way as possible. It helped the process in having more aware participants sprinkled throughout the groups to share information as well.

I hope that speakers at this meeting will be assured that this type of learning experience works and that they will be ready to take what they have learned and bring their message to the public in a media campaign so that more will benifit. As a teacher I have been able to analyze many different types of learning styles and teaching methods that work over many years. I think their approach works well, but we also need more of it.

At the same time I think it would be helpful if many of these experts would begin to not just read our flu sites but begin to interact with us as well. We are at a different level here in our understanding and their interactions need to be tempered with that knowledge as well.

DemFromCTat 17:28

How did they react to your discussions about flu sites and communication? I have a keen interest in that. Were they aware of the non-interactivity of the current government sites?

lugon – at 18:51

I think/thought the conference was not meant to teach things to participants, but now you’re suggesting it will also be used for that purpose: so that TPTB (or those humans who represent them, grin) will “learn how to teach”. I hope they use it as such, because that’s a really valuable thing.

I wonder if we could learn from that too. Could we, directed by Teachers, try a few aproaches a bit more systematically? We have the (wo)manpower to do it, the interest and the means. We’ve tried several aproaches already. Collective learning is what this is all about, it seems.

Thanks for your reports and comments. They are valued on this side too!

I hope the conductors of the seminars will find their way here. Did you give them some specifics? Could you, by email or whatever?

abeamreach – at 20:10

I was fortunate enough to attend this forum as well, AND fortunate enough to be seated at the same table with Science Teacher. The only thing that I would add is that there seemed to be surprise on the part of the CDC folks that there was as much support as there was for earlier rather than later implementation of control measures. One other item of interest, it was said, that school superintendents would rather be told to close their schools rather than make this decision themselves.

Science Teacher – at 20:23

Dem, the people I talked were aware of the flu sites. They were startled that I was so current in my knowledge of the latest developments. I didin’t feel that they have visited any in awhile or I don’t think they would have seemed so surprised about what I knew. I asked them if they read the sites or had thought about using them as a way to get information out. I asked if they had ever read youtube or my space. They said they had heard of them but had not read them. I told them that they were the best places to reach young people with their message. Also told them that several of the young ones had even made their own pandemic info. videos and that they should watch them. I suggested they do their own video and post it there. I think they were very interested in learning about the flu sites. I have a feeling that their curiousity will lead them here just to see what I blogged about them. (LOL) When I suggested a blog liason would be a good idea they did respond that they had been discussing the blogs the day before. The wiki web address that I gave out during the Q&A was posted on a chart in the front of the room so they know how to get here. Maybe you could post some info. here from the site meter so that they can see how many hits you get on this site.

I also think if they did some “Town Hall style” meetings on TV and included some bloggers this would be an extension of this project to a wide audience. We need to build trust on both sides, collaborations are good.

Lugon, thank you. These experts have my contact info and said they would be in touch.

Into The Woods – at 20:30

“Pixie: My question: Why are we using a 2% CFR when the current rate of H5N1 fatalities is over 50%? As a parent, that number makes a great deal of difference to me – why are we using 2% in our scenarios today?

Dr. Nicole Smith answered this question first:

She said “as the properties of the virus change, that will cause it to make it more transmissible, it will also pick up other changes..”

Then from one of the male presenters up front: “If it were a thinking being it would not be in its interest to kill everyone, it needs to pass it on.” “

For those like Dr Smith that work from an unbending assumption that increases in effeciency will automatically trade away lethality, they may want to re-read the Sept 2006 WHO Working Group Report excerpted below:

“Influenza research at the human and animal interface Report of a WHO working group Geneva, Switzerland 21–22 September 2006

…One especially important question that was discussed is whether the H5N1 virus is likely to retain its present high lethality should it acquire an ability to spread easily from person to person, and thus start a pandemic. Should the virus improve its transmissibility by acquiring, through a reassortment event, internal human genes, then the lethality of the virus would most likely be reduced. However, should the virus improve its transmissibility through adaptation as a wholly avian virus, then the present high lethality could be maintained during a pandemic.”

While many of us on the flu boards have hypothisized about this possiblity, to see its potential confirmed by a group of some of the best scientists working on this problem (a number of whom are on the WHO pandemic advisory board) gave me chills.

It should be giving the govt officials chills as well.

anon_22 – at 20:45

Science Teacher – at 17:26

My inference from this is that all people, even those with very little knowledge of an H5N1 pandemic are able to benefit from this type of approach. The information was presented to them in manageable steps and in as non- threatening way as possible. It helped the process in having more aware participants sprinkled throughout the groups to share information as well.

That sounds really good.

I hope that speakers at this meeting will be assured that this type of learning experience works and that they will be ready to take what they have learned and bring their message to the public in a media campaign so that more will benifit. As a teacher I have been able to analyze many different types of learning styles and teaching methods that work over many years. I think their approach works well, but we also need more of it.

Now, we have to start thinking of ways of reproducing such learning formats for the many millions who will need to understand this.

At the same time I think it would be helpful if many of these experts would begin to not just read our flu sites but begin to interact with us as well. We are at a different level here in our understanding and their interactions need to be tempered with that knowledge as well.

Absolutely. We have a lot of people on this forum who are ready and willing to help bridge the knowledge gap between officials and the general public, but we need to have far more ongoing interactions to build the trust and understanding needed.

Into The Woods – at 20:46

Science Teacher - Re Flu Sites: Who was it that followed up on your flu site suggestions by suggesting the audience only go to reputable sites (ie offical govt sites)? Was it an audience member or presenter?

I think that the institutional bias against the blogosphere (arising mainly from lack of exposure and limited understanding of the medium) lead many govt officials to discount these types of sites as the gossip and rants of off-kilter keyboard commandos (not that there’s anything wrong with that).

It’s just that they are not used to having to spend time becoming part of an on-line community to discern who is credible on what topics, who is entertaining and who is just plain nuts. It is like any other neighborhood (at least one made up of an incredibly diverse group of people scattered all over the globe) and the give and take of discussion - the roughly enforced rules of citing sources and the occasional emotional outburst would have to seem very foreign to those used to the finely tuned and highly qualified writings of govt and academia.

DemFromCTat 20:58

Science Teacher – at 20:23

We need to build trust on both sides, collaborations are good.

That’s exactly right.

Into The Woods – at 20:30

the refusal to consider the possibility of a worse pandemic than 1918 is startling, isn’t it?

I can contact some of these folks and invite them here.

DemFromCTat 21:06

Please, all, read CDC’s Discussion of Flu Wiki and “new media” if you haven’t.

anon_22 – at 21:07

Into The Woods – at 20:46

It’s just that they are not used to having to spend time becoming part of an on-line community to discern who is credible on what topics, who is entertaining and who is just plain nuts. It is like any other neighborhood (at least one made up of an incredibly diverse group of people scattered all over the globe) and the give and take of discussion - the roughly enforced rules of citing sources and the occasional emotional outburst would have to seem very foreign to those used to the finely tuned and highly qualified writings of govt and academia.

Well said!

anon_22 – at 21:11

On the subject of CFR, as an aside, one thing to note is that the non-pharmaceutical interventions work irrespective of the CFR. If anything, the measures would work better at high CFR’s ie there would be a higher level of compliance.

That’s what makes them so useful, cos we won’t know the CFR till it starts, but plans can still be made and disseminated without being dependent on that.

Science Teacher – at 21:27

Into the woods, I didn’t turn to see the person in the back of the room who made the comment, maybe Pixie did?

DemFromCTat 21:39

anon_22 – at 21:11

Good point! The masks issue still bothers me, though. I don’t know there’s a consensus, and the science of transmission is still being reviewed. Why declare they have no role so early in the process? even though i agree with Dr. Nicole Smith’s comments re respirators, simple masks may still play a role.

anon_22 – at 22:03

Dem, the issue with simple masks is that they are useless in preventing you getting infected, because of the gaps on the side. However, they are useful when worn by patients, cos they definitely reduce the amount of secretions. Now, if influenza is transmissible before symptoms, then I would expect a widespread use of masks in the general population to have some effect, just like any other NPI.

The problem is there aren’t good studies to prove it one way or the other. The experience from Hong Kong during SARS of a reduction in influenza and other respiratory viruses is somewhat convincing, even though we can’t separate the effect of the various actions that people took.

anon_22 – at 22:26

Pixie – at 10:45

I believe that the findings from these four ASTHO/Keystone meetings will most definitely impact public policy. There was no sense of alarm or urgency in the demeanor of anyone there, but it was noted, and this is a direct quote, that:

This information needs to get back to Washington immediately, like Monday.

From what was said, it was apparent that the findings from these meetings would be distilled and summarized and would land on the desks of those very high up early this week.


I missed this earlier. Yes, there is a meeting in DC scheduled for Nov 29–30, see last box on this page National Stakeholder Meeting November 29 & 30, 2006.

I have just been invited and have been told that this is the culmination of the four consultations. It will be a working meeting to “deliberate on and weigh the tradeoffs associated with proposed community control measures and to create an action plan that will mitigate against the negative social consequences that are expected to flow from these measures.”

The inputs from these consultations will be reviewed, and the results will be used in further deliberations in December before HHS releases their formal policy in early 2007.

Into The Woods – at 22:43

They tell us not to use masks because there are not enough N95 or N100 masks to go around for even the HCWs. Simple as that.

As the recent OHSA guideance and the clinicians’ discussions with the CDC folk show, N95 respirators are recommended (even for support personnel) and an ill-fitting mask is better than no mask at all.

If these things are true for HCWs providing care to infected patients, they are true (even if to a lesser extent) for private citizens trying to protect themselves from exposure to potentially infected persons in the community and for private citizens providing home care to their infected family members.

“Clinicians raise questions about respirator use in pandemic

http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/nov1606respirators.html Nov 16, 2006 (CIDRAP News) – Last month the US Department of Health and Human (HHS) called for a greater role for N95 respirators in protecting healthcare workers in the event of an influenza pandemic, and now clinicians are raising questions about potential problems such as inadequate supplies and poor fit.

The Centers for Disease Control and Prevention (CDC) fielded questions from clinicians today during a teleconference with Michael Bell, MD, associate director for infection control in the CDC’s Division of Healthcare Quality Promotion.

In October, HHS issued new interim guidance saying that the use of N95 respirators, designed to stop 95% of small airborne particles, is “prudent” for medical workers providing direct care for patients with confirmed or suspected pandemic fu and is recommended when caring for patients with pneumonia. HHS also said that respirator use is prudent for support workers who have direct contact with patients. …

Other clinicians had questions about how well the N95 respirators have to fit to provide adequate protection. They said respirator products range from models that don’t require any fitting to ones that require time-consuming fitting procedures. Bell said that from a regulatory perspective, OSHA recommends strict attention to the fit of the respirator. “But in a pinch, you’d expect some benefit, even if the respirator isn’t a perfect fit,” he said.

Some clinicians said they were already fielding questions about community use of N95 respirators. Bell responded that HHS has just drafted guidance on such use. He anticipated that the recommendations would be posted on the government’s pandemic flu Web site within the next 3 or 4 weeks. Bell said HHS probably won’t recommend N95 respirators to the general public unless people are caring for family members or neighbors who have pandemic influenza.”

21 November 2006

Pixie – at 00:00

Thanks to GS for posting this article at CE.

Of relevance to this discussion is a new piece in the journal Emerging Infectious Diseases entitled “Nonpharmaceutical Influenza Mitigation Strategies, US Communities, 1918–1920 Pandemic,” December, 2006. http://www.cdc.gov/ncidod/EID/vol12no12/06-0506.htm

Their findings:

First, protective sequestration, if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved, and continued for the lengthy time period in which the area is at risk, stands the best chance of guarding against infection.

Second, available data from the second wave of the 1918–1920 influenza pandemic fail to show that any other NPI (apart from protective sequestration) was, or was not, effective in preventing the spread of the virus

Into The Woods – at 04:18

“First, protective sequestration, if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved, and continued for the lengthy time period in which the area is at risk, stands the best chance of guarding against infection.”

Pixie: It is here that I become most frustrated, as “the lengthy time period in which the area is at risk” sounds an awful lot like “for the time it takes for that wave to have substantially passed out of the area” which under the standard estimate is from 6–8 weeks and under estimates taking into account the enlongating effect of such protective sequestration (or SIP) the period increases by 50–100% according to the Los Alamos models.

So if we are going to ‘craft our plans to encourage compliance’ how can we do so when the vast majority of people will have supplies to only maintain the sequestration for less than one week or two at the absolute most.

The frustration that will come when the population is told that their only recourse is something they could have been, but are not now prepared to do will have significant consequences for all trust, belief, compliance and support elements of governance at all levels. Nothing I have heard as an excuse for lying to these people is worth the results that come from such intentional witholding of the truth.

DemFromCTat 06:21

I’d like to import this important thread at the new place later today.

Pixie – at 07:32

Dr. Gellin - This is the heart of our concern, the heart of the matter from a public policy standpoint. Please fear that people may one day look back in sadness over what could have been done, more than you fear their panic: IntoTheWoods has said it extremely well, I don’t think any of us could say it better:

Into The Woods – at 04:18 “First, protective sequestration, if enacted early enough in the pandemic, crafted so as to encourage the compliance of the population involved, and continued for the lengthy time period in which the area is at risk, stands the best chance of guarding against infection.”

Pixie: It is here that I become most frustrated, as “the lengthy time period in which the area is at risk” sounds an awful lot like “for the time it takes for that wave to have substantially passed out of the area” which under the standard estimate is from 6–8 weeks and under estimates taking into account the enlongating effect of such protective sequestration (or SIP) the period increases by 50–100% according to the Los Alamos models.

So if we are going to ‘craft our plans to encourage compliance’ how can we do so when the vast majority of people will have supplies to only maintain the sequestration for less than one week or two at the absolute most.

The frustration that will come when the population is told that their only recourse is something they could have been, but are not now prepared to do will have significant consequences for all trust, belief, compliance and support elements of governance at all levels. Nothing I have heard as an excuse for lying to these people is worth the results that come from such intentional witholding of the truth.

Average Concerned Mom – at 07:38

Pixie and Into the Woods:

I noticed while reading these summaries that no one actually posted what the five recommendations were under discussion. (I apologize if they did and I missed it.) For anyone new to this discussion, here’s a link to JV’s summary of the same meeting she went to earlier in November, as well as a list of what the actual measures being discussed were.

http://www.fluwikie2.com/pmwiki.php?n=Forum.ThePublicEngagementProjectASTHOSeattle

“The five-part community control measures being proposed for implementation are:

1. Encouraging people sick with influenza to voluntarily atsy at home until well, at least for a week (self-isolation)

2. Encouraging the non-ill household contacts of people with influenza to also voluntarily stay at home (self-quarantine) for at least 7 days

3. Canceling large public gatherings

4. Closing schools and day care facilities for up to 12 weeks or for the duration of the local epidemic, and keeping young children and teenagers from gathering in large groups elsewhere

5. Encouraging people to voluntarily work from home or take leave.”

Now, (Average Concerned Mom here) NOWHERE in these measures is there any indication that people will be asked or encouraged to take a 12-week stay at home. The most these measures are suggesting is sick people will stay at home a week and family members of sick people will stay at home a week -= seems like that’s where the 2 weeks of supplies comes from — they don’t want sick people or household contacts of sick people going out to the stores.

So given that these are the measures being discussed, why is it lying to the public to only tell them to lay in 2 weeks of supplies? (Don’t attack me, being Devil’s Advocate here only.) (-:

Average Concerned Mom – at 07:40

Note — yes, the measures do call for closing schools for 12 weeks to keep kids from spreading infection — but that is not the same as telling people “stay at home and don’t go to the store” — if that is the measure being discussed, then the measure should say “Close all grocery stores for 12 weeks”.

Pixie – at 07:52

ACM - Yes, sorry, I’ve been traveling continuously since the Syracuse meeting and will post the remainder of my notes shortly.

Average Concerned Mom – at 08:04

Sorry Pixie! I thought you were done, and that we were already onto the discussion portion of the thread. (-:

Argyll – at 08:50

Science Teacher,

Great thread! I almost fell out of my chair when you mentioned the last name of one the individuals at the meeting - one of the last names is a family surname - quite unusual. Great information here. I just reread The Great Influenza and John Barry mentioned how preparedness played a pivotal role in the disease response.

Argyll

Pixie – at 09:23

The Public Engagement Project on Community Control Measures for Pandemic Influenza

Small Group Discussion of Community Control Measures

Seating for the small group discussion was entirely random. My group consisted of a facilitator, a person from affiliated with those organizing the session who acted as a recording secretary (everything was written down), a single-parent Head Start teacher, an RN who currently runs a large program for people with psychiatric disorders (she interacts with them on a daily basis, assisting with critical needs and medications), a woman who is taking time from her advanced studies in medical geography to raise small children, a woman whose background I am not sure of who was quiet but who made excellent points, and a woman who was the official representative of an organization that represents local and state public health officials in D.C.

We were asked to review the proposed voluntary community control measures:

We were asked to deliberate:

We were asked then to decide:

A recording secretary took copious notes of our deliberations, and our decision on the main challenge was recorded on easel paper for the report-out to the group later.

My group felt canceling large public group gatherings was a common sense provision, although they realized that it would have economic impact. that most would comply with (although it was mentioned that people do sometimes feel the pressure to go to work when they feel ill, and do sometimes send their children to school when they are sick due to work pressures and lack of child care).

The group felt that encouraging the non-ill household contacts of people with influenza to stay home seemed like a proposition that could, with education, appear to be a reasonable request to most people. It was key that our meeting was told that people are infectious for 2–3 days before they become symptomatic, and this understanding was felt to be necessary for compliance with this measure. The concern over whether one’s employer would accept this excuse for absence was voiced, and it was agreed that it would be better if there was some kind of official policy to ensure no repercussions to those complying, rather than letting them rely on the benevolence of any particular employer. [ I voiced a concern that, while this containment measure is logical, it would only help with identifying the tip of the iceberg as far as the numbers of people any infectious person might have unknowingly infected. If I were to have become ill with flu the next day, for example, my own family members could remain home to prevent spread, but I would have already spread the virus, unknowingly, to the grocery store, three highway rest stops, a hotel, etc., to people I could not even begin to identify. ] Overall, it was felt that most people would comply with this measure, although it was mentioned that people do, in reality, sometimes go to work when they feel ill, and do sometimes send their children to school when they are sick due to work pressures and lack of child care.

My group decided surprisingly quickly that closing the schools for up to 12 weeks was a very necessary measure. There really was not much discussion about it. It seemed obvious to those at my table that to protect the children and to arrest spread of the virus, school closure would be an important and expected step. There was not too much concern over what the children would do while at home either, and the feeling was generally that their safety was more important than short-term considerations. One of the group members is a single parent and a Head Start teacher that would be impacted in several ways if schools were closed (loss of care for her child, potentially losses financially). But she seemed to feel that school closure was prudent, and I think understood that she, as a teacher (and thus her own child), would be safer if closure was undertaken. I do not think she was comfortable at all with the idea of being compelled to work as a teacher during a pandemic.

Both of our group members who work in social services brought up the problem that many children now receive several of their meals at school. However, it was quickly decided that since the budget is already in place for these meals, that their form could be quickly shifted from lunchroom to perhaps boxed lunches or something similar to ensure that that important part of their school day continues.

The subject of people needing child care/school so that they can work did come up, and that led to our next talking point.

Our group felt that encouraging people to work from home or take leave was a very important control measure, but one which many would have problems with. It was felt that school closure would, in fact, happen and that dealing with employers would be the most difficult problem during a pandemic. There was some doubt, again, over whether all employers would act with equal benevolence about letting their staff call in sick, or exposed, or lacking child care, or just scared. We discussed the fact that, ideally, the government would put some kind of protection in place for employees so that they would not be able to be dismissed during a pandemic. Financial risk for employees was also discussed. We discussed how some people might be able to more easily work from home than others. There was great concern for service workers who do not have that luxury. However, our group did brainstorm and come up with ideas as to how two of our groups members, the teacher and the head of a health agency, could convert their employment to an at-home base if certain regulations were relaxed for the period (phone counseling of clients rather than in-person visits, changes in rules on pharmaceuticals which this RN dispenses, and in the way they are dispensed, potentially at-home care of children for the Head Start teacher).

As we deliberated, it became increasingly clear that there was a big division between two types of jobs under discussion. On the one hand, we spoke about how health care workers, first responders, and critical workers (power, water, & communication, etc.) were really the workers we wanted to remain on the job and that perhaps every attempt should be made to keep us non-critical workers out of their way so that they might better be able to do their jobs at the appropriate time.

Interestingly, the idea of closing grocery stores, retail outlets, and malls was just not on the table for discussion. It has already been decided, apparently, that these outlets need to be kept open and operational.

My group, then, chose “Encouraging people to voluntarily work from home or take leave” to be the control measure that was likely to be the most complicated to comply with. It was felt that overt government assistance would be needed to help most people either comply with the request that they take leave from work (via protection from employers) and that practical and financial assistance might also be needed to enable them to do so.

I missed a large portion of the group report-out, but other groups had selected school closure as the most difficult measure, some other groups had also chosen the work-from-home or take leave option as most difficult, and one group chose the self-quarantine while exposed but not sick as being the most difficult option. I thought the most interesting point raised in that final session was that it might be very difficult to get people who don’t feel sick to quarantine. One gentleman pointed out that also, statistically, an attack rate of 30% means that 70% of people will never contract the virus, and it thus seemed unreasonable for the community to ask that unaffected 70% to severely curtail their usual work and personal activities.

More later….

crfullmoon – at 09:54

“Think of it as a dead end street. From an evolutionary point of view, if you kill them (the hosts) they can’t pass it on.”

I don’t think it is H5N1 that is on the dead end street…

For pity’s sake; the public they (you -if you ptb are reading this) don’t want to be honest with is considered to be a group of legally competent adults;

they are allowed to drive, and vote, and join the military, drink alcohol, reproduce, buy and sell and everything; they’re the ones that are why we have an economy, and, a society for these “experts”/ptb, to be a notch up on!

Influenza is contagious before symptoms : there is no earthly reason something cannot make you drop dead as long as it seeds itself in new hosts first; before you feel unwell.

There has been plenty of time to make preparations; even the poorest can give up their little luxuries for a while, if you tell them history is planning a pop survival quiz, and federal and state govt have already recused themselves from this case… Builds character; Americans used to be called on to be more self-reliant.

Do it again; use propaganda and marketing for “Good”: education in safety and health and frugality and community-building, reconsider whether Homeland Security means we need to have our own regional, sustainable food and energy and manufacturing sources, (including medical infrastructure drugs and supplies), and, a national health care system that tries to keep the coming generations healthy, sober, and able to be educated and innovative.

Learn from history; it’s tiring to see Nature pointing out the folly of man again and again…

By not telling the public “because they’ll panic, and, they can’t afford to get ready anyway” THIS ITSELF is creating the conditions to cause what is supposedly feared and to be avoided.

They are not aware, not educated, going to be blindsided, and, going to find out Nature did give us lots of time, thanks to “modern” scientists’ warnings, that “experts”, politicians, bureaucrats, and Jobsworths, would not act on, despite this not being a business-as-normal situation.

Panic sure, and then Outrage that will be much worse long-term, especially if this should happen to be a depopulating event, that could have been mitigated, and wasn’t.

We need to be trying to get through a Pandemic Year; it would certainly make the smaller emergencies/disasters less of a problem than they are now, because households would actually be ready for those. Fear of a real danger is not a thing to be avoided at all costs.

The public is being kept so calm, and so in the dark and fed stable-sweepings, that the actions of those trusted to warn the public verge on criminal negligence.

Pandemic could break out at any time with little or no further warning.

H5N1 is not a state secret here; the current age demographics and case fatality rate with hospital care is known. The surviving public will know what you knew, and when you knew it, eventually.

Tell the public they’ve been in a Pandemic Alert Period, and you hadn’t wanted to alarm them unnecessarily early, but, the threat continues unabated, and you’re sorry you didn’t tell them earlier, but let’s get those community contingency discussions and difficult issues you want the public to buy-into because they helped shape the plans, and have time to prep, started this Mon.

Coping without normal outside aid, changing normal habits to do with less during disruptions, planning how people can help each other without spreading infection, discussing the unavoidable tragic necessity for triage and palliative care for the dying, and how to bury the bodies, get started talking publically, now.

“4. Closing schools and day care facilities” and stores “for up to 12 weeks or for the duration of the local epidemic, and keeping young children and teenagers” and pregnant women, AND, their household contacts “from gathering in large groups elsewhere “

anon_22 – at 10:14

I wrote up the following on the What is TLC thread, but thought it would be useful to include here for this discussion. This is mainly the work of Robert Glass from Los Alamos.

The following is a discussion on the effects of combining various mitigation strategies.

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

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

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

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

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

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

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

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

anon_22 – at 10:23

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

crfullmoon – at 10:29

“not optimistic about getting a significant percentage of people to prep to that extent.” -Would help if, the government tells them to do it and why it is a matter of life or death they do so.

lugon – at 10:31

SIP is overvalued.

lugon hides against flames

DemFromCTat 10:32

the feds can’t get people in hurricane territory to prep, even after Katrina. That’s not a cynical guess… surveys clearly show the prep level went up only minimally.

crfullmoon – at 10:35

Everyone has different situations and priorities, lugon. It’s ok that they do.

passes lugon a bag of marshmallows and a nice stick, in case any flames do present opportunities

crfullmoon – at 10:47

To DemFromCt at 10:32; I’d settle for full disclosure and fair warning; if the public really was told the potential impacts, that would be fair.

Communities should be discussing what will happen to keep functioning and being able to make Recovery with the band of survivors. Children whose parents don’t survive become society’s responsibilty, if society wants good citizens and a good society- even more important if the student age group is targeted by pandemic and that sector of the population drops. Skills are important, and, the whole JIT/unsustainable thing is getting to be a catastrophe waiting to happen. Think globally, produce locally…

DemFromCTat 11:17

I couldn’t agree more… full disclosure, but with realistic expectations.

anonymous – at 13:22

DemFromCT - I agree. Let’s look at the equation:

Pixie – at 13:23

Sorry, that was me above with the equation. Still on the road.

lugon – at 16:55

My above comment above SIP really means this:

I think most people will not SIP. Insisting on SIP as “the” strategy will only lead to frustration and, worse than that, non-examination of the other alternatives. I may be wrong.

Alternatives can and will co-exist with SIP-strategies taken by a number of people. Those alternatives are some variation of Targeted Layered Containment (TLC), plus masks of all types (including surgical masks for what they are worth, simple masks, respirators, all the way up to space suits), asynchronous transfer of part of all the goods and services, UV aerosol killing, and whatever else we may think of.

I think the main point is full disclosure of the whole lot, science included, uncertainties included, alternatives included. The whole lot. And using “accelerated learning” strategies: visuals, auditory, tactile, whatever works. People, many people, huge numbers of people, should be able to “visit the next pandemic” before it comes. Then we’ll see the best preparation activity. We can’t control the wave, but we can control our swimming (at least to a point).

LMontyat 21:59

CRFullmoon, that was the best, most useful on-point and insighful rant Ive seen in a good long while!

I only wish you were saying it at a Congresional Hearing tomorrow.

And the rest of us Flubies were in the gallery behind you, with Pom-poms!

I’d sign up for that trip! :)

Lugon, what you say makes sense. I think that most of us are taking asimilar approach in our own oersonal planning- investigating options and those believed to “do no harm” are considered even if they currently are not evidence based. After all, we may not get the evidence of effectiveness until after the dust settles.

Argyll – at 22:55

Dear Science Teacher,

I just attended a screening of the movie, Happy Feet. Great film. ( unfortunatly I did not see the Happy Feet “Flu Facts” beforehand).

Anyhow, my point is this: there were so many people coughing within the theater that it was really alarming (at least a dozen in a half full theater). I do believe that masks could maximize our protection to any type of influenza, and the sooner people begin wearing them, the sooner we cut down on the passing on germs and potential influenza.

How open are TPTB to having the general public wear them? Would they provide us role models in public wearing them? I know many would be afraid, but if they saw others wearing them, they would probably take the plunge and mask up — especially if they were coughing. And, I would venture to say that many would appreciate citizens wearing masks while sick. I sat 2 chairs over from a lady that was coughing a lot and it really made me tremendouly uncomfortable. I finally got up and moved 2 seats over for my protection. I felt a tiny bit silly, but that wore off very soon!

MASKS —This is something that can be implemented right now that could make a phenomenal difference. We just need someone to kick start it for us. That way we can follow their lead.

“Healthy Habits to Avoid Influenza — One Family’s 24 hour Journey — Lessons Learned along the way …or, how about a lead story in a major newspaper with a picture say on the subway? with an indivual wearing a mask would be most helpful. The old adage, “A picture is worth a thousand words” comes to mind.

Hope you find this information helpful! And, thanks for all of your sharing! These meetings sound as though they are packing quite a punch toward finding solutions that work for citizens on how to prepare and combat influenza.

Argyll.

22 November 2006

DemFromCTat 08:41

MASKS —This is something that can be implemented right now that could make a phenomenal difference.

The trouble is that we really don’t know if that’s true.

Argyll – at 08:55

DemFromCT

You do have a good point. I guess it can’t hurt to try.What about N100′s? My sister lives in Japan and they wear masks quite a bit for protection. They also have a lot of sinks for hand washing from what she told me. Some good things it seems coming from Japan.

Argyll.

DemFromCTat 08:56

people do things and assume they work all the time. ;-)

Pixie – at 09:05

Reading the tea leaves at the Syracuse meeting, I would say that guidelines are clearly in the works that will state that masks may not be or will not be particularly helpful to ordinary citizens during a pandemic.

I believe that they are concerned that there will not be eough masks available for the HCW’s and first resopnders, and I would not be surprised if sales of N95′s to the general public were curtailed or strictly controlled.

If you are not sure that masks are efficacious for the general public (and they are not sure) and you know you will be facing a shortage for those who you know will need them (the new guidance suggests that HCW’s and others like them must wear them almost constantly) the policy decisions become more obvious. We may not agree, but we are looking at it from a present day perspective, a time when N95′s are plentiful. That will very likely not be the case during a pandemic, and decisions as to how to best ration those scarce resources will have to be made.

Science Teacher – at 15:43

Argyll, thank you for your comment and for bringing up the subject of masks. I agree with Pixie that there will not be enough N95′s or N100 masks to go around, whether they work or not. Unfortunately, the folks who are taking care of a loved one ill with bird flu will also need the best mask protection avaiable as well as HCW in a hospital.

I found it interesting that in the bag of free goodies everyone was given at the meeting, the mask inside the bag was a surgical one, not an N95. I have read from different sources that a surgical mask should be used for the person that is ill, but not the caretaker, where an N95 or N100 would be better protection. But again, the jury is still out on this in terms of efficacy.

DemFromCTat 17:13

Pixie – at 09:05

Science Teacher – at 15:43

The issue for me is differentiating between simple surgical masks, N95 masks, HCW and the general population.

There many be some benefit for N95, they are already scarce, they are destined for HCW, they must be properly worn and properly fitted and therefore N95 for HCW makes some sense. If they are in short supply, they will not be available for the population. I can accept that. I have never thought they made much sense to acquire.

What about simple surgical masks and home made masks if surgical masks are not available? They can’t be reused, they have to stay dry, and they do not fit tightly, yet is there really zero benefit (and how do we know)? in fact, these are the exact guidelines:

If supplies of N-95 (or higher) respirators are not available, surgical masks can provide benefits against large droplet exposure, and should be worn for all health care activities for patients with confirmed or suspected pandemic-influenza.

Based on current HHS guidelines, I find the dismissive attitude about simple masks very frustrating.

DemFromCTat 17:17

Of course, large droplet vs aerosol vs contact spread is still being debated, too.

Airborne pathogens may be divided into three functional types: a) obligate airborne pathogens, like M. tuberculosis, b) preferential airborne pathogens that are sometimes transmitted via other routes (like measles virus and variola [smallpox] virus), and c) opportunistic airborne pathogens that can be transmitted through the air under special circumstances that produce a concentrated source of contaminated small particles (1). Influenza virus is thought to fall into the third category, as a pathogen transmitted via large droplets that may also be inhaled (6, 7) if infectious respirable aerosols are present (e.g., due to an aerosol-generating medical procedure and possibly also due to short-range aerosol transmission during other direct care activities, as discussed in Section II)
DemFromCTat 18:15

however, this recent EID paper stresses aerosols, and those are (unllike large droplets) poorly stopped by simple masks:

Abstract In theory, influenza viruses can be transmitted through aerosols, large droplets, or direct contact with secretions (or fomites). These 3 modes are not mutually exclusive. Published findings that support the occurrence of aerosol transmission were reviewed to assess the importance of this mode of transmission. Published evidence indicates that aerosol transmission of influenza can be an important mode of transmission, which has obvious implications for pandemic influenza planning and in particular for recommendations about the use of N95 respirators as part of personal protective equipment.

DemFromCTat 18:20

So, in summary, because aerosol spread of flu happens more widely than previously appreciated, N95s more than simple masks are emphasised. When N95s are not available, simple masks WILL be used in hopes of stopping that which is large droplet spread (the traditional route). It won’t stop aerosol spread, but you do what you can with what you have.

Based on the above, I can see explaining that simple masks aren’t flu-proof, but they might help a little to place on patients and those home ill. So, it’ll be interesting to see what the consensus is when CDC actually obtains one.

Pixie – at 18:53

DemFromCT – at 18:20

Dem, I should have been more specific in my comments on masks - I was referring only to N95′s, N100′s, etc. It is those masks I think they indicated would not be recommended for the use of private individuals, and I theorized that sale to private individuals might be controlled because they’d be needed for HCW’s.

I agree with you that in the absence of N95′s, surgical masks are something they must be looking at, for patients and the public. I believe that they will come down on the “they can do no harm” side, and recommend them (unless they perceive severe shortages there too) for the uses you describe.

I think there is also the aspect to consider, psychologically, of allowing people to “do” something proactive against an invisible foe. The making and wearing of surgical masks would not do harm, and might help for the variety of reasons you enumerate.

lugon – at 20:28

Masks can do harm IF they are useless AND people forget about the other precautions. Think pierced profilactics. Notice the “if” and the “and”.

I still think we need lots of science, made clear to all. Not just recommendations, but the facts or lack of facts they are based on, and then a number of possibilities. We don’t have time for short ads. Give us the lengthy explanation, and some summary. With that, WE shall see. It’s going to be our choice, anyway.

Just as a (powerful) example: the 5 minute “sleeve” video may bring the R-naught down a bit. And every bit counts: try R-naughts of 1.9 and 1.8 with a seed of 10 cases and a generation time of 3.5 days (2 generations a week); see what peak (and what cummulative number of cases) you get after 10 generations (5 weeks, where the peak is supposed to be).

Answer: 6131 vs 3570 (at the peak).

Now go ask your HCW what they prefer.

lugon – at 20:31

Just to insist: education should not be based on 30 second segments. Elaborate. Show the grey points too.

DemFromCTat 20:36

It’s going to be our choice, anyway

That’s really the point. If people want masks, they’ll make their own. if not, they won’t wear what’s available. So, educate and let the people decide.

DemFromCTat 20:40

The 5 minute sleeve video is here.

crsrs31 – at 15:08

pixey, thank you so much for your report….hugely appreciated!!!!!!!!!

argyll – at 15:35

anon_22,

can we ask at the meeting if we might use the public educational system to help educate on pandemic preparedness?

also,if we can have mentors as role models for public ppe’s?

thanks,

argyll.

28 November 2006

Argyll – at 12:57

Anon_22,

I read something on this discussion board that an inspired an idea. With those receiving meal assistance via schools or some other type of governmental program — is it possible that might we be able to plan meetings where provisions ( food, water,medications and essentials, flu shots) could be distributed now (to those qualified recipients) — beforehand? i.e. before a pandemic or SIP begins.

For those that do not attend the meeting, could we follow up with a home visit to provide these items for however many weeks are needed for SIP?

Also, perhaps a phone call could determine what is exactly needed before the home visit takes place.

p.s. call on local restaurants/grociers to provide these essential items. Perhaps a food bank?

Or, a food drive done within schools to provide provisions to those in need. These items could be distributed discreetly. We could mark those items for families directly related to each school.

Just a a couple of ideas …

Argyll.

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