NOTE: This Discussion is closed.

DISCUSSION: What is Pandemic Influenza

COMMENT: risk communication


Submitted by Martha Salyers Active Panelist  on 12/4/07 8:33 AM

Interesting take. A great deal of communication, planning, preparation, etc. is taking place among the groups you listed--for example, see the tabs on the www.pandemicflu.gov webpage, which are directed towards those groups.

I am a believer in the importance of sharing knowledge with the public, and that there are ways to share it that people can understand and feel empowered to act on. That is one of our chief challenges in public health.

One of the big problems that you express is how people who don't have enough to live through the week, or the day, can stock up. There are ways to do it gradually and to work through churches and other religious institutions, civic groups, etc. to help each other prepare as a community.



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What does "severe pandemic" mean?

Submitted by Roy Kamen on 12/4/07 05:46 AM

In the materials presented, on this website, a "severe pandemic" is one in which the CFR - Case Fatality Rate is about 2%.

For the purposes of this discussion, this number is very important. The 2% is taken from the historically severe pandemic of 1918. However the virus that is the one experts are worrying about today is H5N1 with a CFR of about 60%... and currently about 80% in Indonesia where cases are being treated in Hospitals experienced in H5N1. i would assume that without hospital care, the CFR would be higher.

Policy makers hope the CFR of H5N1 would decrease if it became the pandemic strain but research has shown otherwise.

How we prioritize vaccine distribution is dependent on how severe the pandemic is.

  • Wednesday's agenda has more on response depending on severity

    Submitted by Nicholas Dewar Facilitator  on 12/4/07 06:09 AM

    Thanks for your question Roy. You've probably noticed that on tomorrow's agenda there will be a discussion on "changes in prioritization depending on pandemic severity". I hope that you'll be able to join that discussion too.

    • Does "severe" mean a CFR of 2% or 60% ?

      Submitted by Roy Kamen on 12/4/07 06:15 AM

      However, the aim of this exercise clearly depends on how severe "severe" is. Many times in the materials presented, the reason that you are concerned is not the mild pandemic, but the severe one. If for purposes of this discussion you will be using 2% as "severe" when clearly the virus we are afraid of is running a 60%+ CFR then say so. It is wrong to use 2% when in reality 60% should be used for "severe".
      (ROY, I changed your subject line to make sure that your comment gets more attention from other readers - Nicholas/Facilitator)

      • Thresholds and variables

        Submitted by Catherine Jackie Mitchell on 12/4/07 06:43 AM

        Sometimes we have to first agree upon a starting point and then move through the variables. We still do not have any clear indication of how severe the pandemic will be. Starting at a baseline helps me to focus on the theory of what we are addressing. A pandemic with a CFR of 60%+/- ... I don't think anyone could come up with how we would be able to respond, prioritize a worldwide disaster of that magnitude. I am not saying that the CFR won't be that, that since we do not know we should focus on the threshold that we CAN respond to.

        • not just a finger in the dike

          Submitted by Ellen Rice on 12/4/07 06:52 AM

          I disagree. We need to know that some times a finger in the dike is NOT enough to cope with the leak -- sometimes heavy equipment is needed for lots of fast heavy lifting! We can't be telling people to have "3 days" of emergency food when they may be experiencing weeks of disruption. It is better and more honest to say "we don't know how severe a pandemic may be. One possibility is 60% rate or worse."

          Not everyone will prepare or can prepare -- but an HONEST reporting of the range of possibilities will help at least some.

          • honest reporting

            Submitted by Catherine Jackie Mitchell on 12/4/07 06:56 AM

            As a concerned citizen who has taken a proactive approach to community preparedness I have always stated the 6 to 12 weeks of food, water and medicines. I agree that honesty is best but there are times when people will see this as completely insurmountable and giving them the worst case scenario may be counter-productive to enabling actionable response.

            • Lets not alarm society unnecessarily

              Submitted by Timaly Shepherd-Miller on 12/4/07 07:02 AM

              I agree. We should not alarm society unneccessarily without validating our facts. However, the reality of it all is that we wont know until a pandemic happens.

              [Timaly, I've changed the Subject Lines of some of your postings to be sure that they attract readers. Nicholas/Facilitator]

              • Credibility

                Submitted by Catherine Jackie Mitchell on 12/4/07 07:07 AM

                This is always an issue. Once we gain the public's attention enough to teach the facts we just have to be cognizant of the fact that at some point they will tune out...especially when we focus on the more severe of scenarios, which may in fact happen. So how do we present accurate information, at the level we are at now in our knowledge, and present it in such a way as to stimulate an actionable response in the public. A 2% CFR is not understood yet by most...telling them 6 to 12 weeks, they will understand.

                • Honesty is the best policy

                  Submitted by Roy Kamen on 12/4/07 07:14 AM

                  The reality is that a worst case would be the current indonesian strain going pandemic and keeping its 80% CFR (with hospitalization).

                  IMHO - This is what needs to be told to the public by credible sources.

                  • most people I talk with don't even know what the word pandemic is

                    Submitted by Holly Reischman on 12/4/07 10:12 AM

                    In my opinion,telling the public the CFR wouldn't matter much...JQPublic barely knows the difference between pan flu and seasonaL flu. I speak with many people on a daily basis --almost all ask me "what does pandemic mean?" And most add "well this is the 21st century not 1918, we have technology and advanced medicine." We are no more qualified or capable now thet we were back then, 2 deal with a severe pandemic. I do agree with info 2 the masses, but alot of them are turning a deaf ear on this subject.

                    • Agree with the lack of information

                      Submitted by Abelardo Martinez on 12/4/07 11:13 AM

                      I totally agree with Holly. Our society and citizens are living obliviously because they do not know the difference between a pandemic and seasonal flu. When people thing bird flu they associate it with chickens in china? There is no connection and the U.S. population can grasp the severity or even associate the two. Information to the public at hand is our key. Everyone is clueless!

                      • Society requires Visuals & Numbers they can Comprehend

                        Submitted by Diana Tolladay on 12/4/07 01:04 PM

                        In order for society to understand the severity of the potential they need to be addressed and shown in a manner that they can comprehend and act on. Society today is predominately visual. That means they need to see graphic animation showing them the scenarios of a pandemic. How quickly it will spread, how the symptoms would progress and so on. An example - Who cannot remember the drowning polar bear from the video "An Inconvenient Truth" To the powers that be - take note- people will respond if you give them the information they need in a way that makes sense to them.

                        • Providing Educational Materials in Picture

                          Submitted by Greg Ewert on 12/4/07 02:16 PM

                          I agree with Diana, insofar that we must provide visuals, and gage them to a learning curve; middle school levels of comprehension. I deal with people everyday that do not understand the materials handed to them. So they just set it down and dismiss it.

                      • American Trust That All is Well

                        Submitted by Christine Kardong on 12/4/07 02:32 PM

                        I am fairly well educated (as a JQ Public) because I work for the government and have seen a lot of information about the subject. But - when I discuss the pandemic flu with others - well, they simply do NOT believe that the United States could be affected like the rest of the world. We do not have a truly global focus, nor do we believe that we can perish in such masses in our own country. We are too young a country and a populace. We are "upstarts," and a pandemic could really, really hurt us because of these rose colored glasses. That is why I worry so much about national security.

                        • "Trusting" Americansq

                          Submitted by Martha London on 12/5/07 05:32 AM

                          It is true that Americans lack a global focus, cannot believe that "it could happen here"--most of the public lives in a state of denial regarding real news. But I believe that this is because they're not given a coherent, workable way to take action: no one really believes in the electoral process anymore, and they don't know how to get involved in any sort of community action or mutual support. I agree with the earlier comments about reporting the truth of the percentage of fatalities, rather than sugar-coating it down to 2% from the more accurate 80%. But if you tell the truth you must also provide a rational, workable plan of action for people.

                      • What does the public know?

                        Submitted by Patty Dineen on 12/4/07 04:14 PM

                        I have to say that my experience is somewhat different. I think a lot of people do know what a pandemic is-- they may not worry much about the terms, but I think many people know that aside from the year to year flu that comes around and that vaccinations are available for, there have been exceptionally serious ones that occur less commonly, and that scientists are watching other parts of the world for emerging "killer flu" strains.

                    • communication about pan flu

                      Submitted by Brant Goode Active Panelist  on 12/4/07 11:54 AM

                      Hi Holly,

                      Many people still don't understand the specifics about disease transmission in general, and then sometimes a little knowledge leads to more questions and sometimes even more conjecture. See the recent MRSA coverage as an example. Fortunately we have some durable guides in public health that help lots.

                      One of these is the Control of Communicable Diseases Manual, published by the American Public Health Association. You may know this reference--it is excellent but not generally for the non-health care public. Its contents need 'translation' for others to appreciate the facts as we know them.

                      Brant

                • acurate timely information - please

                  Submitted by Terry Laura on 12/4/07 01:47 PM

                  It is important to give the most up to date acurate information to the public at all time if they are going to have faith in our message. We can then reenforce the PSA regarding handwashing, isolation, vaccination.

              • we wont know... but we do... sort of

                Submitted by Roy Kamen on 12/4/07 07:10 AM

                we dont know for sure what virus will cause the pandemic nor how bad it will be... but everyone is planning because of what we do know - H5N1 and it is very bad right now.

                I am not suggesting we alarm anyone... but only tell the truth. If you find the truth alarming... then prepare accordingly.

                • Communication is the Key

                  Submitted by Timaly Shepherd-Miller on 12/4/07 07:58 AM

                  It is critical to educate and inform society concerning all potential disasters. Everyone must be a willing participant which includes not only the government but others including ministers, teachers, school nurses, medical providers and the list goes on and on. The battle is not just limited to a small group of individuals but includes an entire nation involvement. However, the dialogue and efforts of so many caring individuals brings us to this point of discussion and for that i am greatful.

                • Educating the public with all the facts is the only responsible thing to do...

                  Submitted by Kay Lock on 12/4/07 08:30 AM

                  We didn't know if an atomic bomb would hit our county in World War II, but we educated people what do in case it did. (The following is a link to a webite http://www.foody.org/atomic/atom...) We don't know if, when, or how bad a pandemic will hit either, but I feel the only responsible thing to do is let the public know what we know, what we recommend and they will do what they can to prepare.

                  • Educating the public

                    Submitted by Tricia Kassab on 12/4/07 10:59 AM

                    I agree that we need to be educating the public and provide transparency and honesty in our communications. How and when we provide the communication is crucial. Many people focus on short term issues and truly do not believe that a pandemic will occur. We need to provide the public ongoing, short communications and education on what the pandemic is, personal preparedness, and the personal impact of whether to stockpile supplies for 1 weeks vs. 12 weeks. The goal is not to create chaos; rather to promote education and personal responsiblity.

                    • Getting the US Public's Attention

                      Submitted by Christine Kardong on 12/4/07 02:39 PM

                      It sure does not help that the possibility of pandemic influenza is not on the news every single day. We're discussing taking this seriously and how our people should be presented the information - all that's great - but we truly should be doing more - our government should be doing more to prepare it's people. This completely "behind the scenes" attitude bothers me a lot. One has to be truly proactive to get any information. I understand not wanting to cause a panic, but the almost complete lack of information is appalling to me. What I've seen on TV are public service messages from pharmaceutical companies. I have to give them credit for at least DOING something.

                  • Reply

                    Submitted by Alison Lee on 12/4/07 03:54 PM

                    Thank you Ms. Lock. As an early childhood community, if we can get parents at each site to prepare their earthquake kits and get them into us by a set date. They can certainly sign off after talking with them about the Pandemic flu and how to then lessen to help it not spread as quickly.

              • Fear of "Alarming" VS Need to "Educate"

                Submitted by Doug Fredericks on 12/4/07 08:39 AM

                We have to be very cautious not to fall into the trap of not wanting to be too strong with our words and warnings, for fear of alienating and scaring people away from "wanting" to hear the news about a pandemic.

                The absolute positive value in public education ahead of an event as well as during an event simply has to take place and it has to be timely and be effective.

                We have to carefully weigh the value of risking a potentially, overly dire prediction that does not come to fruition and angering some by doing so. We also have to not act in an overly cautious manner and leave the public unprepared for the breadth and scope of the horrors of a pandemic.

                I don't have a magic formula for how far on either side of this issue to lean, but I do know it is a very delicate balance and one worthy of discussion and even better - take a stand ahead of time and integrate that into your "Crisis Communications Plans."

                • agree

                  Submitted by Martha Salyers Active Panelist  on 12/4/07 08:52 AM

                  Very well put, Doug! And good advice for preparedness planning.

              • Prepare Society

                Submitted by Diana Tolladay on 12/4/07 12:55 PM

                The Less we prepare society - the more alarmed they will be.

                There are those among us: Menonites, Amish, Mormons, and others not religiously aligned that have made preparation a part of their lives. Yes, it takes time, perhaps more than we have, but the reality is that the more prepared a society is - the less severe the repurcussions of catastrophe (influenza pandemic especially). It does not have to be a fear based process.

                Preparing (stocking up, planing, training . . .) could be the result of an efficient organized endeavour just as the Bond Drives were in WWII.

                Let's not forget the willingness and need for people to feel like they are contributing

                • Prepare Society

                  Submitted by Jane Lenz on 12/4/07 02:07 PM

                  Preparedness is a mindset. Unfortunately, most people (including the government at times) do not think about tomorrow. That is someone else’s concern.
                  Past generations would sacrifice there wants and needs to ensure a better world for future generations. All the work done on the nation’s infrastructure in public work projects provided for future generations.

                  For example, the country wants a short cut to fix the levees in New Orleans and else where. No one sees these decade long projects benefiting them so they don't get done.

                  A culture of preparedness needs to come for everyone! The reality is the culture of live for today for who knows what tomorrow holds rules.

                  • Some have trouble preparing

                    Submitted by Sharon Hutchins on 12/4/07 03:06 PM

                    This is a good and true comment about our society and humankind in general.

                    Let's not forget, however, that for some people trying to put together a three day supply of food is a huge challenge (they may not know from day to day whether their kids will be able to eat). Telling them to prepare 6-12 weeks of food may just make them think there's no point in trying - leave it all in the hands of fate or God and hope/pray for the best.

                    How to inform and motivate people is really a delicate balancing act!

                    • They will also have trouble in a pandemic

                      Submitted by Caroline Bridgers on 12/4/07 03:22 PM

                      There's no gentle way to say this.

                      If a pandemic brings disruption to our economy and social structure "similar to war or a widespread economic crisis" then people who already struggle to put food on the table in regular times will not find their lives any easier in a pandemic.

                      We nevertheless need to prepare. Secure communities are based on secure individuals and families, who can then help others.

                      http://www.pandemicflu.gov/plan/...

                      Pandemic Influenza: Preparedness, Response and Recovery/Guide for Critical Infrastructure and Key Resources (Dept. of Homeland Security.)

                      "Unlike geographically and temporally bounded disasters, a pandemic will spread across the globe over the course of months or over a year, possibly in waves, and will affect communities of all sizes and compositions. In terms of its scope, the impact of a severe pandemic may be more comparable to that of war or a widespread economic crisis than a hurricane, earthquake, or act of terrorism."

                    • Cant prep - vs- can prep - what to do?

                      Submitted by Roy Kamen on 12/4/07 08:08 PM

                      Sharon,

                      It is true that many... too many cannot afford to prep for 3 months. But many can if they knew what the danger was in not prepping. If they did prepare for 3 month SIP (Shelter In Place) they would not need gov assistance, freeing up valuable resources for those who truelu need it.

                      Not telling those who can prep for 3 months because it is not "fair" to those who can't... is just wrong.

                • People want to help

                  Submitted by Patty Dineen on 12/4/07 04:50 PM

                  I absolutely agree that the public wants to help; wants to be asked to get involved. Not everyone, of course, but many, many people will answer a call to help others in whatever way they can. A call for people to step up to the plate will he heeded and responded to. I really believe this about my fellow citizens. The Bush administration could make this happen.

            • The APHA agrees

              Submitted by Roy Kamen on 12/4/07 07:08 AM

              We just interviewed Dr. G. Benjamin from the American Public health Association. He completely agrees with you. He feels that most people can't and wouldnt prepare for 3 days. His suggestion is to aim for 3 and if you can do that go to a week, then 2, then more if you want. He also said a severe pandemic was not likely and it would be like 1918. I clearly do not agree.

              I myself recommend at least 3 months.

              • fence sitting

                Submitted by Catherine Jackie Mitchell on 12/4/07 07:13 AM

                In my little town of 8500 people who for the most part struggle recommending even one week will be tough BUT saying the 3 day recommendation most people said "oh yeah, I always have that" or "we go camping, we are always ready"....saying 6 to 12 weeks made them think a little deeper about what I was saying.

              • Severity of the Pandemic

                Submitted by Charles Thomas on 12/4/07 07:29 AM

                I think that it could possibly be much more widespread than 1918 and therefore more severe because of more people being involved. Just look at how people travel around the world not to mention from location to location in the US. It would be spread at blinding speed compared to 1918. The more we can prepare people the better off they will be.

                • informing people

                  Submitted by Martha Salyers Active Panelist  on 12/4/07 07:32 AM

                  I agree. In Public Health, we're working hard to get this message out from the national to the local level.

                  One problem is that this is a "maybe" or theoretical issue to most people. That is, it's something we feel will happen, but we have no idea when or how severe it will be. That makes it hard to get people interested in the issue. One approach I like is to talk to people about being prepared at home for any disaster, whether earthquake, ice storm, or hurricane. Those incidents are more real to people, and are often more likely to lead people to get ready.

                  • all hazards approach

                    Submitted by Catherine Jackie Mitchell on 12/4/07 07:34 AM

                    There are some things though that are unique to public health hazards that are NOT addressed by the all hazards approach.

                    • public health and/vs. all-hazards

                      Submitted by Martha Salyers Active Panelist  on 12/4/07 07:38 AM

                      You're right that some public health scenarios are different from the "usual" disasters. But the definition of an all-hazards approach is that the basic activities are the same across the board, with additional activities/plans that are specific to a given hazard. If we could all be prepared on a basic level as families/individuals, I think that would be a big step in the right direction.

                      • Not your typical disaster

                        Submitted by Catherine Jackie Mitchell on 12/4/07 07:41 AM

                        I agree with you. "Better to light a single candle than to curse the darkness."

                        BUT

                        When we are faced with something that will overtake the entire world, albeit in waves and areas of epidemic, to my mind the all-hazards approach has hurt in that people see this as a typical disaster, if there is such a thing.

                        • Have seen this often

                          Submitted by Nick Kelley on 12/4/07 07:46 AM

                          Many business, Schools, Organizations have the mentality that it will be like other disasters. A perfect example of this is that a lot of planning around alternative care sites, depend on resupply, which probably wont happen. Which raises lots of ethical issues.

                          • scope of pandemic flu and ethical issues

                            Submitted by Martha Salyers Active Panelist  on 12/4/07 07:49 AM

                            Absolutely. And this web dialogue is here to help us talk about some of these ethical issues.

                            • Should the supply chain be vaccinated then?

                              Submitted by Nick Kelley on 12/4/07 11:49 AM

                              Given that the CI is dependent on long supply chains...would it be more useful to vaccinate critical people in supply chains even if they are offshore? What is the point of vaccinating health care workers if all they can do is provide austere care, as their have no supplies they depend on.

                              • supply chain vax

                                Submitted by Roy Kamen on 12/4/07 12:00 PM

                                Nick - good point. I suppose the only way to do that is involve Big Biz. After all its their workers who pull the oil out of the ground, refine and ship in one instance.

                              • Protect the grid before all else.

                                Submitted by larry wright on 12/4/07 02:01 PM

                                If we have reliable electrical power, much can be dealt with.

                                Without electrical power, we are in big trouble- no pipeline transmission of fossil fuels, no manufacturing of essential goods, no Internet, no communication.

                                Protect the electrical power system.

                                • Bring this to "Prioritization for Critical Infrastructure" tomorrow

                                  Submitted by Nicholas Dewar Facilitator  on 12/4/07 03:02 PM

                                  Larry,
                                  Please bring your interest in this issue to the discussion tommorow (Wednesday) in the Focus Point "Prioritization in Critical Infrastructure"

                                • Protect the oil

                                  Submitted by Roy Kamen on 12/4/07 04:55 PM

                                  without gas and diesel we have no farming, no water treatment chemical delivery, no coal delivery, no medical delivery, no fire trucks... the list goes on and on.

                                  At a meeting with a big oil co, they said they said they were confident THEY could keep the gas going but once it left THEIR storage facilities it was in the hands of regional and local carriers... out of their control.. there was not much optimism that oil will flow to the gas station.

                        • not your typical disaster

                          Submitted by Martha Salyers Active Panelist  on 12/4/07 07:47 AM

                          Ah, yes! interesting point! But from a public health planning perspective, using the all-hazards approach has enabled us to get the attention of emergency managers and government and then get it across that this could be the worst disaster that could ever befall us, us being the entire world.

                        • Be ready

                          Submitted by Ivan Ferrer on 12/4/07 09:28 AM

                          It is better to be well prepared than to regret.

                          • Regrets

                            Submitted by Catherine Jackie Mitchell on 12/4/07 09:33 AM

                            No one will get everything perfectly right. Those that don't prepare adequately enough may not have the opportunity to "move on". There will be regrets though...we have to be prepared for that inevitability and learn to forgive our own mistakes.

                  • Educating people and preparedness

                    Submitted by Jordy Blackey on 12/4/07 02:44 PM

                    Spent today in "observation" capacity. Education discussion is great, personally, team it up with some action, and we're on to something. I see 18 wheelers in grocery parking lots with ONLY Pan flu nesseccities( we the people, need help remembering staples/nutrition) and basic, rational info. Some can goods better than no canned goods. We are such a charitable and giving people after national/international disaster, If we could look at
                    " food drives for us". People could donate " 1 week supplies to their counties" ,

                  • All hazards benefits and shortcomings

                    Submitted by Sharon Hutchins on 12/4/07 03:22 PM

                    Martha's point about pushing preparedness as beneficial no matter what the emergency might be is an excellent one. But the following comment about some situations being qualitatively different from others is also good. This ties in to Roy's commments about some mass vaccination drills that did not incorporate wearing of personal protective equipment (PPE). Our county did such a drill with an anthrax scenario, which was appropriate - anthrax does not spread from person to person, so masks are not needed or helpful. However, for mass vaccination for pandemic influenza, which will be transmissible from human to human, PPE is a much bigger issue.

                • Severity of the Pandemic

                  Submitted by Glenda Ford-Lee on 12/4/07 07:46 AM


                  International travel makes this possibility very high.

              • Preparing for Pandemic

                Submitted by Tammy Brown on 12/4/07 08:26 AM

                While it might be the right thing to do you also have to look at the capacity at which the general populations can do this. Your average American family does not have the storage capacity or expendable income to store 6 to 12 weeks of food, water and medicines. Also keeping in mind that you would need to rotate medicines and possibly food staples for expiration. When you start talking about "the Public" you also need to consider what their reaction is going to be even to a diluted version of the truth. Even our government troops only store 2 to 3 weeks of supplies at a time, on any given opporation.

                Education is key and necessary, but in my opinion, if you begin to educate the general public at this point you will only be creating panic in the American population. That panic could cause more damage than good. Education and planning should begin with the government (Federal, state & local), school boards, churches, health care providers (hospitals, etc.) and businesses. Then when the general public needs to know more details it can be communicated as we actually have answers instead of speculations.

                • risk communication

                  Submitted by Martha Salyers Active Panelist  on 12/4/07 08:33 AM

                  Interesting take. A great deal of communication, planning, preparation, etc. is taking place among the groups you listed--for example, see the tabs on the www.pandemicflu.gov webpage, which are directed towards those groups.

                  I am a believer in the importance of sharing knowledge with the public, and that there are ways to share it that people can understand and feel empowered to act on. That is one of our chief challenges in public health.

                  One of the big problems that you express is how people who don't have enough to live through the week, or the day, can stock up. There are ways to do it gradually and to work through churches and other religious institutions, civic groups, etc. to help each other prepare as a community.

                • Too Late

                  Submitted by Katharine Fisher on 12/4/07 08:34 AM

                  If the general public is not informed until we have all the "answers instead of speculation," we must understand that that point will only be reached when the pandemic begins in earnest. At that point, it will be too late to prepare the public. When the public realizes that it is too late, there will almost assuredly then be panic. Prior and complete information can help to prevent this, even if it is discomfiting information.

                  Education and preparation must be honest and take place ahead of actual pandemic onset. Honest discussion of the virus that brought us all here - H5N1 - and its historical and current (and rising) fataltity rate, as well as the 2% CFR planning scenario based on the 1918 numbers (defined as such), must take place. The American public deserves to be educated, without censorship of the difficult parts of the information.

                • panic...the P word

                  Submitted by Catherine Jackie Mitchell on 12/4/07 08:35 AM

                  I think complacency is the biggest enemy. Panic will happen when people realize that they need goods and there aren't any to be had. Just my opinion, of course.

                  If people prepare in waves we may be able to alter the course. Some will just not prepare or be able to prepare. The more that can, the more they can also help others. The public won't assist those who can't unless they themselves see the need and are prepared themselves. This takes a LOT of time.

                • Preparing for Panic

                  Submitted by Roy Kamen on 12/4/07 08:36 AM

                  Tammy, You raise important issues... but i think given the potential for complete disaster with a severe pandemic we have no choice. Everyone can find more space and money to store critical supplies. And those who cannot need help in doing so.

                  The American people deserve to be told the truth and not be treated like small children who cant handle the truth.

                  Better we have a run on supplies while they can be replenished than wait "until something bad happens" to have that run and leave empty shelves... then you'll first see an unimaginable panic.

                  • reactions to disaster

                    Submitted by Martha Salyers Active Panelist  on 12/4/07 08:56 AM

                    Are you all familiar with studies of people's reactions to disaster? Some studies indicate that people's primary reaction may not be panic and disorganization, but pitching in to help and organize.

                    Do you all think that this will be different in a pandemic, which as we've talked about is a huge disaster that is likely to affect everyone equally (leaving no "reinforcements" to come in and help)?

                    • reactions to disaster

                      Submitted by Glenda Ford-Lee on 12/4/07 09:16 AM


                      I think some people will help and others will stay back in fear mode. Which is normal. Some people feel a deeper need to help other people. This is what we have to prepared for.
                      The training and education of the public. What little things we can do to help. (any and everyone) Again, Education and Training.

                    • peoples' reaction to disaster

                      Submitted by Jordy Blackey on 12/4/07 11:35 AM

                      The Pan scenario is JUST TOO different. Even at best, after hurricane Erin and Opal, It seemed only a matter of a few short weeks before people were behaviorly frustrated and, at times exceptionally unrealistic. We went to local bars, and churches to congregate, this can't happen during panflu.

                    • I would fear to help if it exposed me to danger

                      Submitted by Caroline Bridgers on 12/4/07 11:40 AM

                      I think a lot of the general public would be like me, to be honest.

                      I want to help out however I can, but not if it will compromise the safety of myself or my family.

                      Here's a hypothetical example. Say our next door neighbors are close friends of ours, and our children play together. The neighbors work as police officer and ER nurse.

                      In a hurricane-type disaster, with schools closed but the parents needing to work; I wouldn't hesitate to offer to watch their children so they could help out the community.

                      But -- supposing a severe pandemic, with an infectious disease that could be fatal? Now I am not so sure I would be willing to take on their children each day. What if mom the nurse, or dad the police officer, contracted the illness and passed it on to their children? I would probably prefer to avoid that risk, if medications were not in abundant supply at least.

                      In addition, if there are any problems with supply chains, and people not having enough food or water and electricity, I think people (especially if this comes as a shock to them and they are unprepared) will find it hard to be generous and come together and support one another.

                      Moms I know, who have diapers and formula to spare, will go to great lengths not to see a baby on their street go hungry or uncomfortable.

                      Those same moms, who are counting their last supplies and wondering how far they will stretch, will out of necessity, turn away from having another mouth to feed; another dirty behind to figure out some makeshift measure.

                      • Check out similar conversations going on now at "Pandemic Scenarios ... Ourtown"

                        Submitted by Nicholas Dewar Facilitator  on 12/4/07 11:53 AM

                        It's so interesting to think this through from a personal perspective. There's some of this discussion going on now at "Pandemic Scenario: What would the story be in Ourtown". Another of todays' Focus Points. You may want to join that discussion too.
                        Also, on Thursday there'll be an opportunity to discuss how the Draft Guidance will affect us and our families.

                      • The truth is brutal sometimes

                        Submitted by Roy Kamen on 12/4/07 12:42 PM

                        Caroline - you speak truths only a mother could speak.

                      • willingness to help, adequate information

                        Submitted by Cary Heath on 12/4/07 03:02 PM

                        I think you're right Caroline. Many people would fear to help others. I have heard even a fellow healthcare worker state that he would not be in the hospital taking care of patients if he feels it will jeapordize the health of his children.
                        I believe we must be honest with the public about the risks and the need to prepare. What I see and hear from friends and accquaintances is the attitude that Pandemic Influenza is not here now why do I have to worry about it. Too much information might make some become apathetic and not prepare. Others may panic. It is a hard decision to make as to how much is too much information and what the public has a right to know. I myself feel we the public have the right to know the risks, the posible senarios and the preparation needed to make it through a pandemic. We get information on how to prepare for a hurricaine. While it is not the same by any means the information should be out there.

                    • Help thy neighbor

                      Submitted by Terry Laura on 12/4/07 02:04 PM

                      I believe that once everyone has had a few days to get used to the idea and make a plan for their own families then they will pitch in and help their neighbor.

                    • Reaction to emergencies - panic or altruism?

                      Submitted by Sharon Hutchins on 12/4/07 03:29 PM

                      Martha brings in a very important new thread - the long history of how real people have acted in real disasters, which has often been much more rational and pro-active than the experts would have predicted. However, some anthropological work on societies' reactions to very severe and prolonged disasters (e.g. Colin Turnball's book the Mountain People about the Ik people of Uganda who were moved off their native land and lost their way of life) shows that responses often change over time. Initially, people pitch in and are cooperative. Then as the situation continues over months to years, social institutions begin to unravel, until finally nuclear families may even be torn apart, husbands vs. wives, parents vs. children etc. Luckily, a pandemic shouldn't last this long, especially if we prepare now to help mitigate the consequences.

                  • Maybe raise this issue in the "What would be the story in Ourtown" Focus Point?

                    Submitted by Nicholas Dewar Facilitator  on 12/4/07 08:58 AM

                    This interesting issue is probably more exactly on-point in the Focus Point now underway at "What would be the story of Pandemic flu in "Ourtown"". Perhaps you'd like to check into that discussion?

                  • Preparing for Pandemic

                    Submitted by Tammy Brown on 12/4/07 09:04 AM

                    I agree in part with all comments that have been made to my last comment. I do believe that education needs to continue. I work for a Globe company that has been actively planning for a Pandemic for the past 2 years. Our plans are aligned based on Region. Included with the company wide pandemic planning activities we also have awarness training that we send out quarterly to our employees. While I don't believe they understand the full impact of what could happen, I do believe that while providing the information to the public, how we deliver that information is Key.

                    If the agencies and business are acting responsibly (if) then most of the population have some knowledge of this already. Giving the American public credit for keeping track of international events, and then providing an appropriate level of knowledge on an on-going basis to the public would be wise.

                    Also keep in mind that even with hurricane Katrina, the local government and public knew well in advance that this would be a terrible hurricane. They still did nothing, and panic still happened. The local government had the authority to force an evacuation and they did not. This situation will not be like that. People will be infected prior to showing symptoms and will be contagious.

                    Effective communication and education of proper hygiene followed by consistant levels of knowledge regarding the potential pandemic on an on-going basis would be my suggestion for the American public.

                    • agree

                      Submitted by Martha Salyers Active Panelist  on 12/4/07 09:13 AM

                      great comment!

                      We don't know how long or how infectious people will be before showing symptoms. We do know that with seasonal flu, you can spread the virus about a day before you have symptoms. If you're not coughing or sneezing, and if you use good hygiene, it's less likely that you'll spread it.

                      • transmission

                        Submitted by Catherine Jackie Mitchell on 12/4/07 02:41 PM

                        I read that the incubation period averages 2 days with a range of 1 to 4 and that viral excretion peaks early? Is this not so?

                  • Finding Space

                    Submitted by Jane Lenz on 12/4/07 02:21 PM

                    Roy, I agree everyone can find more space and money for critical supplies. I have a colleague that truly thinks out of the box on space. He stores some provisions in air tight containers under his children's bed and other "non-traditional" storage areas. It just requires a bit of imagination and thought.

                    As far as money, I make choices. Instead of buying X say a DVD, I put the money in the emergency cash. I buy one or two extra of certain items. I use the year-end holiday break to organize my plans for the year including what will be purchased when.

                    I have another friend that has everything organized in Excel pivot tables (a bit much for me).

                    People need to find what system works for them and get moving!

                • Pan Flu Education for General Public

                  Submitted by Mona Wenger on 12/4/07 09:10 AM

                  Your are right, education is key and necessary and we have been educating the government, businesses, and schools for the past 3 years. However, I am not sure of the educational level of churches or health care providers (exception PHNs and hospitals)and I think that it is time to educate the general public as well to allay panic. A good PP on seasonal, Avian, and Pandemic influenza will create a simple educational message. Schools are already sending information home with the students. Now is the time to inform those without children.

              • Power of Persuasion = Preparation

                Submitted by Diana Tolladay on 12/4/07 02:16 PM

                The APHA has far less faith in the public than I do. If the public were persuaded to, they can and would prepare for far more than a few days or a few weeks. It seems to me that the target should extend beyond the second wave. If the community outbreaks last 6 to 12 weeks then the public needs to prepare for a period of time beyond that. We also need to remember that the 1918 Pandemic lasted 18 months.

            • Risk communication

              Submitted by Joel Palmer on 12/4/07 07:13 AM

              You hit on the key aspect of risk communication - getting an accurate, factual version of events out to people without terrifying them. One of the best ways to do it that I have found is to give a compound message: one part information about the risk (fear) and one part education on what steps should be taken (empowerment).

              • Fear Factor and Education

                Submitted by Glenda Ford-Lee on 12/4/07 07:19 AM

                I agree. You have to handle both areas or people shut down. The fear factor is the hard part for public education and professional also. Many do not want to deal with the numbers.

                • Numbers and the public

                  Submitted by Catherine Jackie Mitchell on 12/4/07 07:24 AM

                  Focusing on how to prepare seems to be working a lot more than focusing on something that most people don't even want to try to understand. We have to be cognizant of the fact that many people are already overwhelmed with life's struggles. They just don't want to take another "issue" on. Focusing on the how to rather than the why to is working for me. That being said, I don't hide the truth either. I am just careful about what that truth is. We really don't know an honest AR/CFR yet.

                  • focusing on being prepared

                    Submitted by Martha Salyers Active Panelist  on 12/4/07 07:33 AM

                    I agree! Being prepared as a family or an individual is something everyone can do.

                    • Individuals and Families Only?

                      Submitted by Mona Wenger on 12/4/07 09:14 AM

                      So, you are saying the government, public health, and Emergency Responders can prepare their families, but what about the family that does not have a loved one in these job descriptions.

                      • Clarification

                        Submitted by Catherine Jackie Mitchell on 12/4/07 09:40 AM

                        Mona, I am not sure what you mean.

                        I am just a private citizen preparing a family and town...and further I hope. I am preparing and telling others to do so too. This takes everyone and it isn't a single sector responsibility.

                        Then again maybe I just misunderstood your point :blush:

                • risk communication

                  Submitted by Martha Salyers Active Panelist  on 12/4/07 07:29 AM

                  I agree too. The world is hard enough to live in. Making sure that our messages empower as well as inform, as Joel said, is crucial. Also, making sure that our messages are understandable by those we address is very important. Many Americans do not read at a very high grade level, and become even less likely to understand if they are frightened. There is a whole branch of risk communication/health education that is aimed at making messages that a large variety of people will understand: health literacy.

                  • American Culture of Optimism Works against us

                    Submitted by Caroline Bridgers on 12/4/07 07:40 AM

                    Americans have a culture of believing "things will all work out somehow" but that may work against us in wrapping out minds around a severe pandemic, that could have devastating long term secondary consequences.

                    We believe somehow things will work out and we do not want to live a life of fear and worry.

                    But few people are motivated to make difficult changes in their life without the impetus of fear. Think of an overweight man who finds it too hard to lose weight, until he has a heart attack. Motivated by fear, he finds the energey to make life changes that are not comfortable.

                    Fear is a motivator. We do not need to live our lives in fear. We can fear what could happen, and take proper, prudent and sensible steps to avoid what we fear, and then live with less fear.

                    • Excellent point

                      Submitted by Catherine Jackie Mitchell on 12/4/07 07:43 AM

                      Caroline, this is an excellent point!

                      Fear certainly does motivate ;)

                      how we hit on the right amount of fear seems to be changing with the audience we are addressing.

                      • Fear is not a motivator

                        Submitted by Katie Denter on 12/4/07 08:32 AM

                        I disagree with using fear as a motivator. I don't think people respond well to fear tactics. I feel that after the initial bump of fear they will tune out subsequent messages. I would like to see more messages focusing on little steps people can do to get them started on the path to preparedness, rather than freaking them out.

                        • Fear can be an appropriate motivator

                          Submitted by Caroline Bridgers on 12/4/07 08:38 AM

                          In my opinion, fear can work just fine as a motivator, provided you do not exaggerate the possibilities; that is that the level of fear involved is proportionate to the potential disaster. In addition there must be clear steps people can take to mitigate the problem.

                          Where people go wrong is when they use fear disproportionately; they exaggerate the danger and people eventually tune the message out because they are not idiots.

                          If something is a legitimate danger, people SHOULD be afraid of it. A severe influenza pandemic is a credible threat, and it is in my opinion something people SHOULD fear and desire to avoid.

                          In my opinion of people do not feel fear with regards to a severe influenza pandemic, they do not yet fully understand the possible consequences.

                          The trick is to use natural fear to energize and collaborate NOW, to work better together in the future, and have much less fear because people are prepared.

                          Just my opinion.

                        • Honesty with Evidence

                          Submitted by Catherine Jackie Mitchell on 12/4/07 09:58 AM

                          The combination of honest facts and evidence of something may produce fear but it is not necessarily a "tactic". Fear is the response to a threat. There is an honest to goodness threat approaching. Fear of it is healthy. Action an appropriate response.

                      • Fear can backfire

                        Submitted by Sharon Hutchins on 12/4/07 03:38 PM

                        Actually, research in public health (for example in trying to convince people to stop smoking) shows that fear is not always a good motivator!

                    • Things Definitely May Not Work Out if...

                      Submitted by Mona Wenger on 12/4/07 09:36 AM

                      I know fear would be more of how the population would react if we do not prepare them for a Pandemic. As with anything if one prepares, then when the event arises the fear factor may be 1)alleviated, 2) still exist, or 3) become exponential. An individual given knowledge is given the ability to become empowered. Pandemic Flu education will empower.

                  • Health Literacy

                    Submitted by Katharine Fisher on 12/4/07 08:18 AM

                    I agree with you that many Americans read and comprehend only at a basic grade level. However not all do. Many Americans are very able to understand a detailed message about a complex topic such as pandemic influenza. An appropriate risk communications program must meet the needs of many demographics, and not just focus on some perceived "lowest common denominator" (as if such a beast exists).

                    It is true that attempts at risk communication must seek to include and addresss those with a lower reading level, just as they must be careful to include those who do not speak English as their primary language (and typically, important health information is printed in multiple languages to meet this need). But a detailed and more complete message must also be a part of any risk communications program and must be made available to those who would seek it out. Those who are able to comprehend complexity and choose to seek out detailed information on advanced concepts related to pandemic influenza must be able to access it, if only to answer their inevitable questions and to secure their peace of mind. If that cohort does not receive more than a 6th grade level message, they will distrust that message, and will reject it as insufficient and it's providers as disengenous and possibly not completely competent as well. That will only serve to breed distrust in a very influential cohort.

                    • reach one, teach one

                      Submitted by Catherine Jackie Mitchell on 12/4/07 08:24 AM

                      An important part in getting this particular message to spread is those that do understand, across our society, share that understanding with others. Health professionals cannot do it all. Neighbor to neighbor is crucial. We know best how to speak with our neighbors...at least I hope so.

                      Although I have had limited success on my own ;)

                      • Neighbor to Neighbor

                        Submitted by Glenda Ford-Lee on 12/4/07 08:29 AM


                        This is the only way for small and large communities to maintain preparedness. Food banks will become low with food. Children alone with sick parents. This will bring about a new meaning to Neighbor to Neighbor.
                        Church to church. Think about it.

                        • Neighbor to Neighbor

                          Submitted by Roy Kamen on 12/4/07 08:39 AM

                          Yes, I've thought about it. And I don't like what i think.

                          • neighbor to neighbor

                            Submitted by Martha Salyers Active Panelist  on 12/4/07 08:57 AM

                            Please expand.

                            • Neighbor to Neighbor

                              Submitted by Glenda Ford-Lee on 12/4/07 09:06 AM


                              Those neighborhood watch groups could expand. Helping each other with food, medications and just calling to check in with each other. However, you have to know you neighbor to do this.

                              Social Isolation can hurt as much as a disease. Little food and no one to talk to. Sick and no one to drop off medicine to assit you. Food drops on the steps of your home.
                              Global- The very same thing.

                              • Social isolation can be detrimental

                                Submitted by Sharon Hutchins on 12/4/07 03:42 PM

                                Glenda's point is excellent. People are social animals and tend to gather with loved ones when trouble arises. Telling people they cannot go to church when that provides for important social and spiritual needs will be a problem unless we help offer alternatives. With the new social networks on-line, perhaps we need to expand the idea of community bonding to the internet - connect those who need to talk/vent/grieve through MySpace and such sites in addition to more traditional means.

                                • Outreach

                                  Submitted by Catherine Jackie Mitchell on 12/4/07 06:03 PM

                                  I believe that there have to be some in the community who don their PPEs and go door to door in order to give people that human interaction that provides some stability. Also, we can check on others, see if there are needs. Check on children and the elderly, see if there is enough food and water, etc. Better having it come from a team of neighbors...

                            • what i fear more than the flu

                              Submitted by Roy Kamen on 12/4/07 09:16 AM

                              Martha,

                              I fear my neighbors. They have ignored my information. They are not prepared. after 1 week they will become frightened when the Stop & Shop closes. After week 2 they will have almost run out of their 2 week supply. After week 3 they will be hungry, scared and on the edge of doing the unimaginable to feed their kids.

                      • Peer Education Works

                        Submitted by Mona Wenger on 12/4/07 09:40 AM

                        I agree with Catherine, peer education has been known to be successful (Gyarmathy et al., 2004).

                      • Reaching parents

                        Submitted by Aloha OR on 12/4/07 10:54 AM

                        The best way to reach the community and encourage planning/preparedness is through the parents. Once a parent realizes the threat to her/his family, the parent will speak to other parents.

                    • health literacy

                      Submitted by Martha Salyers Active Panelist  on 12/4/07 08:38 AM

                      I completely agree! People who can understand these topics at a high level, like you, are critical to our ability as communities to prepare for and respond to a pandemic. That's why I think blogs, wikis, etc. are great networks to share information and ideas.

                      Much of the information produced about pandemics, though, is aimed at relatively high grade levels. For example, the instructions to log into this dialogue are written at a college sophomore level. Good for people with a lot of education, but you're right--we need a wide spectrum!

                    • Population Receiving Message

                      Submitted by Mona Wenger on 12/4/07 09:37 AM

                      Need to know your population before you provide the message. Those who want to know more will ask.

                • Public Education & The Media

                  Submitted by Diana Tolladay on 12/4/07 02:29 PM

                  Yes, and all the various forms of media can and should contribute to the disemination of information. However, we can't for get the effectiveness of the public education system in distriburting information and if need be modifying behaviors i.e., the anti-drug anti-smoking campaigns of the past.

            • Notifying the Public

              Submitted by Charles Thomas on 12/4/07 07:22 AM

              I would favor a worst case scenario. I think if people prepare for the worst they would be better off if less occurs. At any rate I don't believe that most people have thought this through after talking with a lot of them.

            • I disagree

              Submitted by Ellen Rice on 12/4/07 06:53 PM

              I disagree with the notion that some people will find "prepping" insurmountable. I find retirement planning overwhelming and have not done all that I should -- but I have taken some baby steps and that is a heck of a lot better than doing nothing at all.

              I think we should treat adults like adults. It is CRIMINAL to gloss over situations and not tell the truth and the whole truth as we know it.

              We live near a volcano (Mount Rainier). That is a choice my family has made. Thank goodness there is information out on lahars (volcanic mudflows). Some people choose to live in potential lahar pathways. That is their choice -- but they have at least been INFORMED as to the possible consequences of that choice. I'm not comfortable with that choice, so our home choice is out of the pathways. Will it ever be a problem? Who knows. But I appreciate being informed by geologists so I can make an informed choice.

          • Not everyone will prepare or can prepare

            Submitted by Jane Lenz on 12/4/07 10:43 AM

            Hurricane Katrina made very visible the complete spectrum of preparedness attitudes in the U.S. People need to own their preparedness.

            * Currently roughly 12% of the US population falls below the federal poverty threshold. This group is especially challenged with the ability to prepare. They typically live pay check to pay with little or no safety net.

            * A significant percentage of the population simply will not prepare for a variety of reasons. Its not going to happen to me, I'm too busy, It won't be that bad, the government will fix it (though Katrina should have adjusted that thinking), planning won't really help, etc...

            Those that want to prepare are the ones that the appropriate messages will reach. I agree with many of you about the need to be honest of what is known and possibly how severe a pandemic could get.

            • Preparedness

              Submitted by Jacob Mbafor on 12/4/07 12:59 PM

              The uptake of or enrollment into entitlement services for the segment of the population cited is low. It maybe by outreaching more and encouraging that population to currently make full use of availaible services would enhance their preparedness.

          • Not everyone will prepare or can prepare

            Submitted by Jane Lenz on 12/4/07 10:46 AM

            Hurricane Katrina made very visible the complete spectrum of preparedness attitudes in the U.S. People need to own their preparedness.

            * Currently roughly 12% of the US population falls below the federal poverty threshold. This group is especially challenged with the ability to prepare. They typically live pay check to pay with little or no safety net.

            * A significant percentage of the population simply will not prepare for a variety of reasons. Its not going to happen to me, I'm too busy, It won't be that bad, the government will fix it (though Katrina should have adjusted that thinking), planning won't really help, etc...

            Those that want to prepare are the ones that the appropriate messages will reach. I agree with many of you about the need to be honest of what is known and possibly how severe a pandemic could get.

        • Increase above 2% or we may fail

          Submitted by Timaly Shepherd-Miller on 12/4/07 06:55 AM

          I agree to some degree. I guess my primary concern is that if we do not increase the margin above a little more than the 2% then we could possibly be setting ourselves up for failure.

      • I Agree

        Submitted by Timaly Shepherd-Miller on 12/4/07 06:50 AM

        I definitely agree with the statement. If there are actual documented cases where individuals who are exposed to the the Avian Flu has a mortality rate of greater than 2% then please lets review it from this perspective.---------- Mrs. Timaly Shepherd-Miller

        • Education on Pandemic Influenza

          Submitted by Glenda Ford-Lee on 12/4/07 07:16 AM


          To understand this difference between Pandemic and Seasonal Flu you must also add the factors of the culture that the virus is spreading in at this time. Does the USA contain the same factors that would spread the virus throughout our country? What about international flights? These are the factors that many people ask me in any educational session from the public.

          • Novel viruses know no culture

            Submitted by Catherine Jackie Mitchell on 12/4/07 07:28 AM

            When this begins in it's sustained human to human form, culture only matters to the culture experiencing the epidemic in their area.

            Understanding how we (collectively) create a scenario in which zoonotic virii have opportunities to impact humanity is a different thought line...to me. Just my 2c.

            • spread of an epidemic

              Submitted by Martha Salyers Active Panelist  on 12/4/07 07:35 AM

              Do you mean the difference between a localized response to an epidemic and the global response to a pandemic?

              • Culture clarity

                Submitted by Catherine Jackie Mitchell on 12/4/07 07:52 AM

                I was responding to the sense that it will not matter very much to me and mine what culture this developed in when I am trying to keep my children breathing.

                As far as localized response...I guess the same applies.

                How we end pandemics in the future altogether? Maybe this one will motivate us to change our cultural behaviors. We are all interconnected. I just do not think that culture is germane to the discussion once a novel strain has taken off.

                • Culture clarity

                  Submitted by Glenda Ford-Lee on 12/4/07 07:58 AM


                  Once we understand the culture we can help with the treatment and the diagnosis. This can help with early diagnosis and even development of treatment. Maybe even preventing the spread of the virus. The information is vast.
                  We are all connected. The world is much smaller and we must try to understand this. It only takes hours to fly from country to country.

                  • Culture and risk of infection/outcome

                    Submitted by Sharon Hutchins on 12/4/07 03:54 PM

                    The discussion about the relevance of cultural differences to pandemic influenza risk is interesting. I think some cultural differences are crucial to understand and will definitely affect people's likelihood of becoming infected, of getting medical treatment, etc. One reason (of many!) that H5N1 case fatality ratios (CFRs) may be so different in different parts of the world is how likely people are to seek Westernized medical help and when (right away vs. delayed to the point where antivirals are of limited if any help). Also, re infection risk, think of cultures where close contact with poultry and other animals is very common, increasing the risk of H5N1 spread from animals to people. I think other cultural differences will make themselves known in a pandemic situation.

                • culture/geography and pandemic

                  Submitted by Martha Salyers Active Panelist  on 12/4/07 08:00 AM

                  Gotcha. Where it matters to me is 1) the earlier we can characterize an outbreak (who gets it, what the strain is, how severe the disease, etc.) the better, so cooperation between cultures/governments is crucial, and 2) as you say, we need to be proactive and respond strongly, quickly, and as one no matter what cultural differences, since it's likely that it will kill us pretty equally.

                  • culture/geography and pandemic

                    Submitted by Glenda Ford-Lee on 12/4/07 08:03 AM


                    Yes. The pandemic is like a bullet. It does not have a name on it. WE all want to miss this one and we will help anyone that gets hit.
                    Once the bullet is out, we must understand it and figure out how we can stop it from happening in the same way.

            • Culture

              Submitted by Glenda Ford-Lee on 12/4/07 07:40 AM


              The culture allows the virus to spread. Population and living environment. The number of hospitals and number of trained medical professionals. Acess to medical care. Diagnosis of the strain. Time of treatment.
              This is the impact of culture on any disease and medical treatment on any population world wide. Education of the population. (level of education) We have to educate and understand the population world wide, to treat and understand the novel virus.
              This could help with the education and the stance we take here in the US and other parts of the world.

              • global planning and response for pandemics

                Submitted by Martha Salyers Active Panelist  on 12/4/07 07:52 AM

                I agree! This is an issue that is GLOBAL. CDC, WHO, and other public health organizations are working hard to create and expand global public health surveillance networks, so we can detect and define spread quickly; coordinating on submission of virus samples worldwide so we know what the H5N1 (or other flu virus) is doing; planning strategies to contain outbreaks; etc.

              • many voices

                Submitted by Catherine Jackie Mitchell on 12/4/07 07:59 AM

                And this is why many people need to be involved in the solution. Kudos to discussion groups and the people who set them up.

                You make a great point. I may not understand how a different culture group may respond to information and planning since my focus is rather narrow.

            • Notification of human-human sustained transmission

              Submitted by Mona Wenger on 12/4/07 09:44 AM

              and hopefully we will be aware of the event within a matter of a few days, not weeks.

      • from what I have researched..

        Submitted by Holly Reischman on 12/4/07 10:15 AM

        The phases of severity are catagorized like hurricanes- with 2% and higher being LABELED a severe pandemic. I believe this is #5.(on a scale of 1-5)

      • How severe is severe

        Submitted by Terry Laura on 12/4/07 01:41 PM

        I would also agree, but in today's crowded urban centers, where there is no historical memory of the 1918 influenza outbreak, a 2% CFR and quickly turn to 60% CFR when people disregard the severity of the situation.

      • Acronyms

        Submitted by Christine Kardong on 12/4/07 02:24 PM

        One direction before this even began was to explain acronyms. I take it hat CFR must mean something about fatality rate, but I'm not exactly sure. Please clarify.

    • Pandemic Flu

      Submitted by Timaly Shepherd-Miller on 12/4/07 06:45 AM

      Yes, I will be participating in the dialogue today and continuing through Thursday.

  • AR or CFR more important?

    Submitted by Joel Palmer on 12/4/07 06:40 AM

    Roy has made some very important points about assumptions around the CFR, especially the one about how the CFR will drop as the virus mutates to be more H-H transmissible. A question I have, which also fits into the case definition issue (in other words, when to we call it 'pandemic'?) is about the Attack Rate (AR).

    An illness with a high CFR is a problem, but one with a high AR may be more damaging to infrastructure and society at large. We have a medical system well-adapted to dealing with deadly illnesses but not one well-adapted to dealing with 35% or higher of the population falling seriously ill at the same time. My question, as a companion to the CFR/severity question poised by Roy is at what AR do we make the formal declaration?

    • The Vulnerable Age Group is Important Too.

      Submitted by Geraldine Cox on 12/4/07 07:13 AM

      My understanding is that the most vunerable population to the Avian Flu virus is the healthy pre-middle age adult. This was the case with the 1918 pandemic that killed my grandfather in his prime leaving his wife with two young sons to raise. If young, healthy adults are the most susceptible, perhaps our planning should focus on protecting that age group more than other age cohorts. Loss of significant numbers in this age group would have a long-term devistating impact on society.

      Is my understanding correct about the concentration of fatalities in this age group?

      • 1918 fatalities

        Submitted by Joel Palmer on 12/4/07 07:18 AM

        The main reason the 1918 pandemic hit the young/healthy so hard was the "cytokine storm" where the immune system went haywire responding to the infection, so people with stronger immune systems were hit harder. This is what I was trying to get at - is that a general attribute of avian influenzas and therefore something we should reasonably expect, or is it an assumption being made based on the 1918 pandemic alone?

        • vulnerable population in H5N1 (avian flu)

          Submitted by Martha Salyers Active Panelist  on 12/4/07 07:25 AM

          Joel & Geraldine--

          You raise good points about vulnerable populations being a critical part of planning. In seasonal flu, the most vulnerable are young children and the elderly. You all pointed out that the 1917-18 pandemic also killed young healthy persons selectively because of the overwhelming immune response (cytokine storm, as you said) to that strain of flu, which was new to humans at that time.

          The current H5N1 outbreak is also killing a larger proportion of young people, especially older children and teens. Part of what we are working to understand is whether that's related more to their exposure (to poultry) or to the disease. We don't really know yet.

          In terms of planning, there is a lot of work going on around "continuity of operations plans" (COOP), which are plans for business, government, health care--every sector of our society--to be able to continue critical operations in a situation where a high percentage of people are sick. There is not a specific attack rate that will trigger certain actions, and each sector has to create a plan that will not only work within it but coordinate with other groups.

          The most basic COOP is what you all are also talking about--a plan that each family or individual should have if ANY disaster strikes. www.ready.gov has excellent resources for this type of plan.

      • the w effect

        Submitted by Catherine Jackie Mitchell on 12/4/07 07:32 AM

        Is this something that we can be sure about before the novel strain is out there and attacking the population?

        WHO-confirmed deaths in Indonesia, by month Plus [notes of deaths which were unconfirmed but suspected H5N1].

        July '05 --- 2 (38M, 8F) confirmed death, [+1 UNCONFIRMED -- 1 death of family member]
        Aug '05 --- 0
        Sept '05 -- 3 (37F, 27F, 23M) confirmed
        Oct '05 --- 1 (19F) confirmed
        Nov '05 --- 4 (16F, 20F, 35M, 16?) confirmed, [+2 UNCONFIRMED -- 2 deaths of family members]
        Dec '05 --- 2 (8M, 39M) confirmed
        Jan '06 --- 4 (29F, 13F, 4M, 22M) confirmed, [+1 UNCONFIRMED -- 39M {Masalis, Jan 2}]

        Feb '06 --- 6 (15M, 22F, 27F, 23M, 27F, 3M) confirmed, [+10 UNCONFIRMED -- 38F {Wati, Feb 6}, 26M {Risma, Feb 9}, 27M {Ubaidillah Ahmad, Feb 12}, 15F {Linawati, Feb 16}, 27M {Dede Wise, Feb 16}, 1Y {Fadli Ahmad, Feb 26}, 35F {NY Ami, Feb 18}, 1Y {Habibah, Feb 20}, 10Y {Nandya Kurnianan, Feb 28}, 11M {Bayu Destianto, Feb 28}]

        Mar '06 --- 3 (12F, 1F, 5M) confirmed, [+7 UNCONFIRMED -- 3M {Wahju Kurniawan, Mar 2}, 10M {Cahyono, Mar 4}, 4M {Harnes, Mar 6}, 42M {M. Yussuf, Mar 14}, <1Y {Yudha Pratama, Mar 16}, 6M {Sasongko Superior Nugroho, Mar 19}, 4? {AG, Mar 28}]

        April '06 --- 2 (24M, 30M) confirmed, [+6 UNCONFIRMED -- 35F {"H", April 2}, 2YO {RNR, April 9}, 23M {April 23, Fahmi Fajar}, 1YO {H, April 22}, {Fakhruddin, April 16 + other family}]

        May '06 --- 12 (17M, 28F, 15M, 10M, 1F, 38F, 12M, 32M, 10F, 18M, 38M, 15M) confirmed, [+5 UNCONFIRMED -- 38F {Praise/Puji Beru Ginting, May 4}, 20M {Aris Ashar, May 20}, 30M {Pulang Young, May 19}, ?M, Papua Province, 10M {Toni Ramdani, May 28}]

        June '06 --- 4 (7F, 13M, 5M, 14F) confirmed, [+9 UNCONFIRMED -- 4 {Yudha, June 9}, 4 {Yudhi, June 10}, 5 {Masyani, June 11}, two sisters of 15yo {June 14 and June 22}, 1M {Adtya, brother of Rizal, June 20?}, 17? {Andri Winarti, sibling of Akira, June 15}, 56F {Hj Sukria, mother of Akira, June 22}, 1F {Ma, from Takaran, June 5}]

        July '06 --- 2 (3F, 44M) confirmed, [+2 UNCONFIRMED – 8? {Tyo Styoningpuji, July 6}, 4M {Sardi, July 31}]

        Aug '06 --- 4 (16M, 17F, 9F, 35F) confirmed, [+5 UNCONFIRMED -- 13F {Rubiyah, Aug 1}, 20M {Misbah, cousin of Umar Aup, August 6}, ?F {wife of Suwardi, Bekasi, Aug 10}, 9F {Dea Amalia, Aug 14}, Dede {villager in Cicadas}]

        Sept ’06 --- 3 (11M, 9M, 20M) confirmed, [+3 UNCONFIRMED -- 2M {Risman Husni, N. Sulawesi, Sept.13}, 23M {Indra Jayakusuma (older brother of Zakaria), Sept. 24}, 11F {Marlina Bt Sitorus (child of family of 5 in RSU Adam), Sept 18}]

        Oct ’06 --- 3 (27F, 11M, 67F) confirmed, [+7 UNCONFIRMED -- 1F {Farida, possible measles, Oct. 6}, 2 months {Fajrin (from Bontopaddingin, Sulawesi) Oct.15}, 5 {M. Pious (RSUD Takaran, from A the Buji Frog), Oct. 15}, 4 {“The Dawn” (from Parangtambung, Sulawesi), Oct. 16}, 7 {Wiji Riyati, Oct. 21}, 4 {Yusuf Maudana, Oct. 21}, ? {from S. Sulawesi, admitted with Ilyas, Oct. 31]

        Nov ’06 --- 2 (2M, 35F) confirmed, [+3 UNCONFIRMED – 17M {Juanto/Juwarto, in Public Hospital Purkwokerto, E. Java, Nov. 6}, 6/2 child {OS/OR/SS, Medan, RSUP Adam, Nov. 15}, “a child” {from Ciledug, Tangerang of Banten – older brother in hospital, child died Nov. 24}]

        Dec ’06 --- 0 confirmed, [+1 UNCONFIRMED – 3F {Febri, from Benai Subdistrict, RSUD Telukkuatan, Riau, died 12/13}]

        Jan ’07 --- 6 (14M, 37F, 22F, 27F, 32F, 6F) confirmed, [+5 UNCONFIRMED – 46F {Sumiah unnamed patient, from RSDK, Semarang, died 1/13}, ?? {Unamed patient, died 1/16}, 20F {Okta/Otafika, died in RSPI Sulianti Saroso, N. Jakarta, died 1/21}, 10F {Joni Iskandar, Pancawara Village, Way Serdang Subdistrict, Tulang Bewang, Sumatra died 1/30}, age? {Lengkong Makarao, in RS Prof. Kandou, Manado, North Sulawesi, died 1/30}]

        Feb ’07 – 1 (20F) confirmed, [+4 UNCONFIRMED – 9M {Supandi, died in Dr. Slamet Garut, died 2/11}, 26M {Tata Mulyana, died in Hasan Sadikin on 2/21, policeman from Ciruluk Village}, 8-month-old {Nasiah, died in Mahammad Jamil on 2/23, West Sumatra}, 12M {Casmudi bin Ali, died on 2/27, from Bangas, Indramayu, W. Java}]

        Mar ’07 – 7 (20F, 32M, 22F, 16M, 39M, 14M, 29F) confirmed, [+3 UNCONFIRMED – 46M {Tambai Hadi, date of death unknown, younger brother of WH (confirmed), died after two weeks of sickness}, 17F {Nesya, died 3/30?, from West Sumatra}, 6/16F {Siti Rohayati, died 3/30 in Abdoel Moeloek Hospital, Banda Lampung, from Tulang Bawang Regency}]

        April ’07 – 3 (23F, 15F, 29M) confirmed, [+5 UNCONFIRMED - 3M {Edward, died 4/3? in RS Prince?, Grogot, from Balikpapan}, 2M {Erpan, died 4/3? in RS Prince?, Grogot, from Balikpapan}, 4F {Raisya/ “RZ”, died 4/7 in Padang City, from Lubuk Begalung Subdistrict}, 48M {Yanto, died 4/16 in RS Handsome Sadikin Bandung , from Karanganyar Village}, 12M {Angga Saputra, died 4/30 in RSUD Moewardi, Solo, from the Grobogan Regency, Central Java}, ]

        May ’07 – 5 (29F, 26F, 5F, 45M, 16F) confirmed, [+1 UNCONFIRMED – 26M {Suyatno/ Syt, died 5/3 in RSUD Wonogiri, from Tiyaran, Sukoharjo Subdistrict of the Bulu Regency (Hair)}]

        June ’07 – 1 confirmed (26M), [+2 UNCONFIRMED – 11M {“YES”, died 6/1 in RSUP Adam Malik Medan, from Asahan Regency}, 1F {Galli, died 6/26 in Daerah Public Hospital (RSUD) Indrasari, Rengat, from Ukui, Pelalawan}]

        July ’07 – 1 confirmed (6M), [+1 UNCONFIRMED – 45F {Watini/ Watinah, died 7/23 in RSU Dr Soetomo Surabaya, from Bukur Village, the Sumbergempol Subdistrict, Tulungagung}]

        Aug ’07 – 3 confirmed (29F, 17F, 28F), [+9 UNCONFIRMED –5 months {Dila/Zila Zazila, died 8/1 in RSUD Arifin Achmad Pekanbaru, from the Simpang Petai Village, Kecamatan Singingi, Riau Province}, 33M {Surya Seorang, died 8/5 in Gedung Bedah Pusat Terpadu (GBPT), employee of RSU Dr Soetomo, from Surabaya}, 5F {Dian, Luh Putu`s five-year old child, died on 8/3 in RSUD Negara, from Dangin Tukad Aya Village, Negara, Kabupaten Jembrana, Bali}, 42F {Ni Ketut Sari Asih, died 8/25 in RS Sanglah, Denpasar Bali, from Jalan Yudhistira}, 4 Residents of Pekon Karang Buah and Sawang Balak, Pulau [Island] Tabuan, {Fauzi (25), Ja'far (50), H Asnah (60) and Marhakim (60) – may have had Typhus and/or Malaria?}]

        Sept ’07 – 2 confirmed (33M, 21M), [+1 UNCONFIRMED -- 30F {Ida Khadijah, died 9/22 in RSHS Hasan Sadikin, Bandung, from Indramayu, West Java}]

        Oct ’07 – 3 confirmed (12M, 44F, 5F), [+2 UNCONFIRMED – 10F {Gozi Sultia Ningsih, died 10/20 in RSUD Arifin Ahmad, Riau Province, from Berempan Hulu, Kabupaten Siak}, 17F { Riri Rianti, aunt of Gozi (10F), died 10/11, in Gawat Darurat, Riau Province, from Berempan Hulu, Kabupaten Siak}]

        Nov ’07 – 1 confirmed (30F), [+2 UNCONFIRMED – 31M {Muhammad Nabi, died 11/6 in RSUD Arifin Achmad, from Babussalam village, Mandau subdistrict, Bengkalis regency}, 20M {Deni S, died 11/8 in RS Sanglah, Bali, from Kedonganan, Badung, reportedly died of severe pneumonia}]

      • Age-related differences in risk from H5N1

        Submitted by Sharon Hutchins on 12/4/07 04:04 PM

        Geraldine, the WHO data on the H5N1 cases to date show that over 50% have occurred in people less than 20 years of age; only 10% are 40 or over. However, we do not now WHY this is true. It may be that younger people are more likely to be exposed to the virus (e.g. be more likely to care for poultry) and thus get sick than that they are more susceptible to illness or get more severe illness. I think seroprevalance studies showing few asymptomatic infections would support this point.

        By the way, it was the 1918 pandemic virus that hit folks in their 20s-40s so hard. The new pandemic virus could be completely different and show a different pattern of impact.

    • They are both important

      Submitted by Nick Kelley on 12/4/07 07:19 AM

      They are both really important in making the decision. A high attack rate will make the situation more complicated, and it will make the wave shorter. The more that get sick sooner, the more become immune to that strain. If a high attack rate is accompanied by a high case-fatality rate,then we got a major problem. This will be noticeable relatively easily due to the disruptions it would cause, where ever it started.

      Would we start vaccinating when WHO goes to phase 4 or 5? or is vaccination only started after the PSI is determined?

      • 6 months for vaccines

        Submitted by Catherine Jackie Mitchell on 12/4/07 07:37 AM

        It is my understanding that there will not be vaccines, initially. It could take 6 months or more before a vaccine is developed.

        • vaccine availability

          Submitted by Martha Salyers Active Panelist  on 12/4/07 07:41 AM

          you are correct; when a pandemic hits, it's by definition a new virus strain for which we won't have a vaccine. With our present technology, it will take 3-6 months to produce and distribute a pandemic vaccine.

          There may be SOME crossover immunity from current seasonal flu vaccine and from exposure to previous influenza viruses, but we won't know that until the pandemic hits.

          • Vax Production People Priority?

            Submitted by Roy Kamen on 12/4/07 07:46 AM

            Martha,

            you wrote
            "it will take 3-6 months to produce and distribute a pandemic vaccine. "

            That is the time for creating the vax... then we'll ned time to manufacture it with all associated components - needles etc. Keep in mind we will be in the midst of the collateral effects of the pandemic during this phase... so perhaps the Vaccine creators, manufacturers and deliverers should be placed high up on the priority list

          • What about our stockpile

            Submitted by Nick Kelley on 12/4/07 07:49 AM

            In the last HHS pandemic update they stated that "Some 12 million doses (enough for 6 million people) have been stockpiled by the U.S. Government."
            http://www.pandemicflu.gov/plan/...

            I wonder when these will be used...at WHO phase 4, 5, 6 or when we assess the PSI for the nation?

            • vaccine or VACCINE

              Submitted by Catherine Jackie Mitchell on 12/4/07 08:05 AM

              the current estimate of US population is 301,139,947

              six million....

              the numbers speak volumes.

              • numbers of doses of vaccine

                Submitted by Martha Salyers Active Panelist  on 12/4/07 08:09 AM

                Right. That directs us to the strategy for vaccinations when there is not enough for everyone--stay tuned--that will come up tomorrow!

                • RE 6 million stockpiled doses

                  Submitted by Jordy Blackey on 12/4/07 08:17 AM

                  Is there not a line of thought pursueing the issue it might take 2 "jabs" for theraputic value? Hence, cutting supply from 6 mill to 3???

                  • 2 "jabs"

                    Submitted by Roy Kamen on 12/4/07 08:24 AM

                    excellent point.

                  • 2 shots

                    Submitted by Martha Salyers Active Panelist  on 12/4/07 08:44 AM

                    Yes, that is part of the planning for the current formulation of the pandemic vaccine and in projecting how many doses of pandemic vaccine will need to be produced.

                    Many vaccines take more than one shot to produce a high level of immunity, so this isn't new. However, a pandemic situation would make this a real challenge, as you say.

                    • 1st jab = infection

                      Submitted by Roy Kamen on 12/4/07 08:55 AM

                      Lets face it, The pandemic vax clinic will be overrun with people who need medical care. Anyone who shows up for their first jab stands a good chance of being infected. How do we deal with that?

                      They wont make it for their 2nd shot.
                      Does anyone have info on Drive Through vax Drills? (assuming there is gas for the cars by then)

                      • goal: keeping the sick away from the well

                        Submitted by Martha Salyers Active Panelist  on 12/4/07 09:02 AM

                        Yes, there is a lot of vaccination clinic planning around screening people who come in--i.e., triage. Best case scenario, people will not be contagious or will be minimally contagious before they have symptoms. And yes, there have been many localities who have had exercises using drive-through clinics. These local public health agencies are sharing their best practices to work toward the goal of getting the vaccine to people as quickly as possible.

                        • screening people?

                          Submitted by Roy Kamen on 12/4/07 09:23 AM

                          Martha says "Yes, there is a lot of vaccination clinic planning around screening people who come in--i.e., triage. Best case scenario, people will not be contagious or will be minimally contagious before they have symptoms. And yes, there have been many localities who have had exercises using drive-through clinics. These local public health agencies are sharing their best practices to work toward the goal of getting the vaccine to people as quickly as possible."

                          Martha,
                          As you are aware... for those who dont know... flu is contagious 1-3 days prior to symptoms (please correct me if i am wrong) How can you screen healthy people who are actually shedding virus like crazy?

                          Also, from what I saw of my town's vax drill, it there was no thought of seperating people from each other. People sat at tables together and in line waiting to go in... no PPE (personal protection equipment - masks, gloves, eye protection, etc) to be found.

                          I am sure mom's with sick kids who cat go to a hospital will show up at the vax centers.

                          • Reduce Spread By Healthcare Workers

                            Submitted by Heather Jensen on 12/4/07 10:25 AM

                            This also means that health care workers would need to have all the supplies they would need in place so that they do not spread germs to those being vaccinated, especially if it takes two jabs for the vaccine to work.

                          • Preventing spread among those that present for vaccine

                            Submitted by Suzette Brotton on 12/4/07 11:42 AM

                            My background is hospital infection control. I am now responsible for PHEP planning at a Local Health Department. We are stockpiling inexpensive "isolation" masks for the purpose of asking everyone who presents at a POD for pan flu vaccine to don one. If you cut off the source of the virus you can reduce spread even among those that don't know they are infected. Placing alcohol based hand sanitizer at the point of POD entry and instructing everyone to use it would also be a helpful strategy.

                            • isolation at vax clinics

                              Submitted by Roy Kamen on 12/4/07 12:02 PM

                              Suzette - you are right on with this. I wish all vax drill did that. I believe they would have a wake up call as to how effective their drills really are.

                      • Drive thru vax

                        Submitted by Mona Wenger on 12/4/07 09:57 AM

                        There have been drive thru flu vaccines PODs at the local firestations in our district. They have been considered successful.

              • Amazing Numbers

                Submitted by Timaly Shepherd-Miller on 12/4/07 08:11 AM

                Interesting! How can we determine from the number of people within our population who, when and why certain individuals would be able to get vaccinated first?

                • who gets vaccinated?

                  Submitted by Martha Salyers Active Panelist  on 12/4/07 08:18 AM

                  I hate to sound like a game show host, but stay tuned! That is the discussion that will happen tomorrow and Thurs.

                  • Pre-Pandemic vs Pandemic Vax

                    Submitted by Deborah Robinson on 12/4/07 04:01 PM

                    Martha, my question is similar to the previous person. (I actually posted it on "How Will the Vaccine Be Used" discussion, but it seems this thread is more lively). I also wanted to know how and when the pre-pandemic vaccine currently stockpiled will be used. For all my reading, I must have overlooked this. When it has been verified that an influenza pandemic has occurred, will the prioritization scheme be used to first administer the PRE-PANDEMIC vaccine to the highest target groups/levels?

                • Prioritizations

                  Submitted by Mona Wenger on 12/4/07 09:59 AM

                  I would go with the CDC recommendations. Get the news paper media along with radio, and TV to publish who will receive, when they will receive, and where they will receive. Of course, the issue of security is high at this point.

            • When will the current stockpiled vaccine be used?

              Submitted by Sharon Hutchins on 12/4/07 04:10 PM

              Nick asked when the vaccine that the US government is currently stockpiling will be used in the pandemic. I think IF it is used will greatly depend on the virus that is causing the pandemic. If it is one of the current H5N1 strains or one not too much mutated, this vaccine may well work well enough to vaccinate people with it. However, if an entirely different strain of influenza is the pandemic strain, the current stockpile may be of little or no use at all.

              Re the timing of use, I am no expert here , but I think some of the materials in the library for this discussion indicated that the US government might give some strategically to fighting the pandemic as it begins to emerge (most likely in another country) to try to stop or at least slow the pandemic. This would argue for an earlier rather than later use for at least SOME of the stockpile.

          • What to do while we wait for the vax?

            Submitted by Katharine Fisher on 12/4/07 09:05 AM

            I see that CDC has mandated and funded mass vax clinics and that many public health departments have undertaken successful clinics within their communities. This will no doubt make us better prepared to distribute a pandemic vaccine when it becomes available to the public.

            However, it appears that public health departments not been mandated or funded to undertake any activities that would help their communities prepare for and better survive the half year (to potentially a full year) period during which panflu circulates and vaccines are not yet an option.

            This seems a critical oversight.

            • Delivering education messages.

              Submitted by Mona Wenger on 12/4/07 10:04 AM

              There is the private educational sector. If the public health departments cant do it then maybe the businesses can help fund a health education group to speak to their employees and families etc. The Indiana State Department of Health has nine field epidemiologists (Public Health and ER Preparedness Federal Funding) around the state that can give Pandemic Flu education anytime day or night requested.

            • Local BOHs

              Submitted by Catherine Jackie Mitchell on 12/4/07 10:08 AM

              There sometimes are issues with shortsighted thinking. Many on local boards do not have medical/scientific backgrounds. There is a learning curve issue here. That and most local boards are composed of volunteers with their own issues and needs locally. The information about h5n1 has been in the public domain since 1997. I cued in on it then and in 2003 began mentioning the problem to a friend in town government. It wasn't until this year that something finally clicked. Not all are engaged still. Funding alone is not the answer.

            • Mandates for preparing for NPI

              Submitted by Sharon Hutchins on 12/4/07 04:13 PM

              From my knowledge, many public health departments are working hard on developing plans and policies concerning the period before we will have vaccine. We are looking at various non-pharmaceutical interventions (NCI) like school closures, cancelling large gatherings, encouraging telecommunting and many other forms of social distancing. California's money to local public health does require such planning and exercises based on it. They are very challenging, as they offer so many agencies and facets of the community. Also, such exervises may be harder to show on TV than mass vaccination clinics!

          • Pan Flu Vaccine

            Submitted by Mona Wenger on 12/4/07 09:54 AM

            We do have the H5N1 vaccine being stock piled, but of course, this may or may not be helpful. However, I assume that the community involved with the first outbreak will get vaccine supply first (whatever vaccine it may be) . Correct?

      • PSI

        Submitted by Martha Salyers Active Panelist  on 12/4/07 07:39 AM

        Nick, could you explain PSI?

      • Would we start vaccinating when WHO goes to phase 4 or 5?

        Submitted by Roy Kamen on 12/4/07 08:10 AM

        Nick says "Would we start vaccinating when WHO goes to phase 4 or 5? or is vaccination only started after the PSI is determined?"

        I dont think they can have a pandemic vax matched by then. They'd have to use a prepandemic vax... that may be something to talk about... if it looks like the CFR will be over 2% (like 60-80%) the plan should include prepandemic vax for critical workers.

        • Perhaps take this discussion to the "How is Vaccine Used ..." Focus Point?

          Submitted by Nicholas Dewar Facilitator  on 12/4/07 08:14 AM

          Roy,
          This interesting discussion might get attention at the "How is Vaccine Used ..." Focus Point that is going on today.

        • when vaccination would start

          Submitted by Martha Salyers Active Panelist  on 12/4/07 08:24 AM

          Thanks, Roy. I am having trouble keeping up with questions.

          You're right; in the first wave, we can assume there will not be a pandemic vaccine. Yes, at this time H5N1 "prepandemic" vaccine is being manufactured, but we don't know if or how well it will work against a pandemic mutation of the H5N1 virus or another virus strain.

          This dialogue is mainly about priorities for pandemic vaccination, but the question you all raise also applies to antiviral medications--if we don't have vaccine, we will depend on community control measures, hygiene, and antivirals--and we have limited supplies of those. There are strategies in each state pandemic flu plan for use of antivirals; in NC, my state, antivirals will be used for treatment first and preventive use (prophylaxis) later.

          Again, a discussion of who will be (or should be) vaccinated when is the main topic for the next 2 days of this discussion. Stay tuned!

          • NPIs

            Submitted by Catherine Jackie Mitchell on 12/4/07 08:28 AM

            NPIs are also important considerations.

            • NPI=non-pharmaceutical interventions

              Submitted by Martha Salyers Active Panelist  on 12/4/07 08:46 AM

              These are the primary spread-limiter we will have to depend on. Any thoughts on how the population will react if/when our government will have to impose limits on public gatherings, school/day care closure, etc.?

              • NPI=non-pharmaceutical interventions- Social Distancing

                Submitted by Glenda Ford-Lee on 12/4/07 08:57 AM


                Social Distancing-
                I had one person state that she could understand the not going to the malls but she will always attend her church services. Which will cause many people to rethink how do we enforce the 3-5 feet separation between people or no large gatherings held in the community.

                Does the government had the resources to enforce this? I don't think.. So people will choose what they think is important for them to observe in Social Distancing.

                • social distancing

                  Submitted by Martha Salyers Active Panelist  on 12/4/07 09:06 AM

                  Great comment. No, there is no way the government can enforce this at every level and in every locality.

                  To me, that makes it all the more important for all of us to discuss this issue in every group to which we belong--church or other religious institution, civic group, school, work, club, etc.--and think about 1) how we would continue what we need to do if we couldn't meet together, and 2) if we absolutely feel we must continue to get together, how we would accomplish social distancing in that environment?

                  • Social Distancing

                    Submitted by Glenda Ford-Lee on 12/4/07 09:11 AM


                    Education on Change and Education of Change. Simple yet complex.

                  • Church Services

                    Submitted by Catherine Jackie Mitchell on 12/4/07 09:25 AM

                    It would take a knowledgeable church leader to explain the necessity of NOT attending services. Perhaps visits to the home would work for those needing outreach. PPE and controls to limit spread in place, of course.

                  • School Closures - NPI

                    Submitted by Jane Lenz on 12/4/07 10:53 AM

                    Closing schools could be problematic. Many poorer school districts are looking at keeping the doors open as they have are concerned about students getting feed and being safe.

                    • School Closures - NPI

                      Submitted by Glenda Ford-Lee on 12/4/07 11:08 AM


                      Some governnment agencies are considering expanding the population for the event of an Pandemic. WIC & Food Stamps program. Which will assist people who can not go to work because of school closures. Also, many people will lose their jobs and can not afford food. (The food that we hope will be there in the stores).- Then you still have to consider- Social Distancing.

                      The children will spread the virus but they still have to eat!! Good One for the Government and the social organizations to provide directions.

                      School Closures brings up what to do with the children that can not stay home alone?

                • Caring for children at home from school

                  Submitted by Sharon Hutchins on 12/4/07 03:03 PM

                  In our county we've been trying to address this issue by talking with faith community nurses and leaders. In so far as possible, if communities can set up systems where members can help each other, that will relieve the enormous pressure on governmental agencies to do so. Of course, this means a lot of education and planning ahead!

                • Churches, etc. and Social Distancing

                  Submitted by Patty Dineen on 12/4/07 05:10 PM

                  Churches especially need to get information about spread of infections such as influenza and need to start rethinking practices such as pot luck dinners where everyone brings a dish to share; cookie exchanges (wouldn't hurt for everyone to stop doing that); and for deli's and grocery stores to stop putting out plates or dishes of foods to sample.

              • No Public Gatherings

                Submitted by Mona Wenger on 12/4/07 10:07 AM

                A lot easier to digest if they are aware that it might happen then if not told anything until it does happen.

      • They are both important

        Submitted by Eleanor Peters Active Panelist  on 12/4/07 08:22 AM

        Hi Nick,

        It is my understanding that yes, we cannot vaccinate people until we know what is affecting them. There is currently a vaccine going through FDA approval for H5N1 (perhaps already approved, I have not checked in on this for a little while). So if that precise strain of flu is what creates the pandemic then we are in pretty good shape for the vaccine. But, if it changes then yes we have to start from scratch by
        1. Identifying the Pandemic Strain
        2. Developing and producing vaccine
        3. Distributing the vaccine

        As for which stage we will start vaccination, that is a difficult question to answer because the pandemic will not necessarily go from 3 to 4 to 5. The progression could be fast enough that we go past 4 very quickly into 5, or past 5 quickly into 6. My guess is that once there is increased human to human transmission (level 4) that production on the vaccine for that strain will amp up (like H5N1 vaccine has done at level 3).

  • case fatality rate & severe pandemic

    Submitted by Martha Salyers Active Panelist  on 12/4/07 07:13 AM

    Hello Roy and others--

    CDC is using the 1917-18 pandemic as our model for a "severe" pandemic with a case fatality rate (CFR) as you said of ~2%. Given that the mortality rate for seasonal flu and its complications is far less than 1%, this is a significant mortality rate.

    For those who aren't clear on the difference between mortality rate and case fatality rate, mortality rate is the number of deaths in a known population over a given period of time. CFR refers to the number of deaths among known cases of a particular disease.

    This is important to remember in pandemic discussions, because with the current H5N1 avian flu, we have to deal with CFR. That is, of the people we KNOW have laboratory-confimed H5N1, 60%+ have died. We do NOT know how many people have had H5N1 and have not been diagnosed--and who perhaps recovered. The rate of death among all people who have had H5N1 may be much smaller--we don't know. In addition, many of the countries where people are getting H5N1 do not have adequate access to health care for many of their citizens, and the CFR may be higher because people are getting diagnosed and treated late.

    All these are variables that have to enter the discussion.

    • seroprevalence studies have been done

      Submitted by Caroline Bridgers on 12/4/07 07:30 AM

      Martha,

      Thanks for your comments.

      My understanding is, seroprevalence studies HAVE been done in areas where there have been human H5N1 fatalities, and that the results have shown that evidence for widespread asymptomatic infections is not there.

      http://www.fluwikie.com/pmwiki.p...

      • seroprevalence studies

        Submitted by Martha Salyers Active Panelist  on 12/4/07 07:45 AM

        FOr those who are not familiar with this term, seroprevalence studies means studies done on a population to see exactly how many were exposed to a particular disease and either didn't get sick from it or who got ill but didn't seek care and recovered.

        You're correct, some seroprevalence studies have been done or are underway, but they are very limited (see Dr. Osterholm's comment on the wiki you sent). Think about the populations of the countries where there is H5N1--billions of people. We don't have to test every one of the population, but there is still not enough of a sample to tell us how high or low the seroprevalence is. We need this data!

  • case fatality rate & severe pandemic

    Submitted by Martha Salyers Active Panelist  on 12/4/07 07:13 AM

    Hello Roy and others--

    CDC is using the 1917-18 pandemic as our model for a "severe" pandemic with a case fatality rate (CFR) as you said of ~2%. Given that the mortality rate for seasonal flu and its complications is far less than 1%, this is a significant mortality rate.

    For those who aren't clear on the difference between mortality rate and case fatality rate, mortality rate is the number of deaths in a known population over a given period of time. CFR refers to the number of deaths among known cases of a particular disease.

    This is important to remember in pandemic discussions, because with the current H5N1 avian flu, we have to deal with CFR. That is, of the people we KNOW have laboratory-confimed H5N1, 60%+ have died. We do NOT know how many people have had H5N1 and have not been diagnosed--and who perhaps recovered. The rate of death among all people who have had H5N1 may be much smaller--we don't know. In addition, many of the countries where people are getting H5N1 do not have adequate access to health care for many of their citizens, and the CFR may be higher because people are getting diagnosed and treated late.

    All these are variables that have to enter the discussion.

    • past testing results show little experience w/ H5n1

      Submitted by Roy Kamen on 12/4/07 07:33 AM

      There have been a few tests done on people in SEA... almost NO antibodies were found from what i recall.

      • you are correct Roy - no evidence of mild H5N1

        Submitted by Caroline Bridgers on 12/4/07 07:42 AM

        See this resource for more information.

        http://www.fluwikie.com/pmwiki.p...

        • seroprevalence

          Submitted by Martha Salyers Active Panelist  on 12/4/07 08:03 AM

          Don't get me wrong. I really like fluwikie and strongly support communication networks around pandemic flu. Just be sure that you read information carefully and understand the basics about population studies, exposure, etc., and read a wide variety of information.

          There is some information about seroprevalence of H5N1, but not enough to generalize from. WE NEED MORE DATA.

          • evidence is mounting that mild cases of H5N1 do not exist

            Submitted by Caroline Bridgers on 12/4/07 12:40 PM

            By the way, I LOVE Fluwiki but also read a great variety of information; like this report that came out last summer:

            http://www.medpagetoday.com/Infe...

            "The evidence, including Dr. Dejchipai's study, is mounting that mild or asymptomatic cases of H5N1 don't exist, said Joseph Bresee, M.D., of the CDC, who moderated the session and was not involved in the research.

            Some investigators had "the suspicion that the high case fatality rate was because we were missing part of the pyramid," he said. "There were asymptomatic or mild cases that weren't presenting to care, for various reasons."

            I understand that there are still few studies to generalize, and of course I am only a layman, but at least there's someone from the CDC that "evidence is mounting" that mild cases of H5N1 do not exist. WHich is even stronger than my statement, that there was no evidence of mild cases!

            NOT meaning to harp on this issue at all, but I think it is a very important one.

        • seroprevalence

          Submitted by Martha Salyers Active Panelist  on 12/4/07 08:05 AM

          So far is the key phrase....We don't know enough about whether people who have been exposed develop immunity without getting very sick, or how many people get mild, moderate, or severe disease without dying.

          But we're working on it!!

          • We don't know for sure how severe the next pandemic will be!

            Submitted by Caroline Bridgers on 12/4/07 08:25 AM

            I have no problems with "We Don't Know" because for sure it is true.

            There's plenty we don't know. Anything could happen.

            Would you say this is a fair statement?

            We currently have no publicly available evidence of mild cases of H5N1 in humans, and have not had any such evidence since studies done in 2004.

            • seroprevalence of H5N1

              Submitted by Martha Salyers Active Panelist  on 12/4/07 08:49 AM

              To my knowledge, you're correct. I keep on harping on this, but we have very limited information and don't know if we can generalize on that.

  • cfr is not as important as CAR

    Submitted by larry wright on 12/4/07 01:57 PM

    It is the number of people absent that will affect the infrastructure, especially the electrical grid, not the percentage of those infected who die.

    • CFR and CFR will both be important

      Submitted by Caroline Bridgers on 12/4/07 02:28 PM

      In my opinion, CAR wil of course be important in how many people are affected; but with a CFR of anything over about 2% I would expect an enormous amount of (understandable and completly reasonable) fear and avoidance behaviors.

      This (understandable and completely reasonable) fear-avoidance would add significiantly to absenteeism, unless the public were adequately prepared ahead of time AND strict Community Mitigation Measures were in place EARLY enough to make a difference, such that, even with a severe CFR, very few people were actually ill at a given time.

      But I agree -- a mild pandemic that affected a lot of people at the same time would have a significant effect on people showing up for work for a week or two at the peak, especially.

      A SEVERE pandemic that affected a lot of people at the same time... yikes!

    • Please clarify acronyms! CAR?

      Submitted by Nicholas Dewar Facilitator  on 12/4/07 04:28 PM

      Hi Larry, please clarify the meaning of acronyms so that even those who don't know them can understand what you're saying!
      Thanks