DISCUSSION: Changes in Prioritization Depending on Influenza Pandemic Severity

COMMENT THREAD

• How to give your comments the MOST IMPACT
  

  Submitted by Nicholas Dewar   on 12/5/07 06:19 AM

  I know you want your contribution to this dialogue to have as much impact as possible. Here are some important guidelines:
  
  ACCURATE SUBJECT TITLE: describe exactly what you are going to discuss
  
  KEEP THE TEXT SHARPLY FOCUSED ON ONE TOPIC: if you want to describe something very complex, consider breaking it down into a series of sharply focused messages.
  
  KEEP THE TEXT BRIEF: More people will read your message if it is short.
  
  INTRODUCE YOURSELF: The first time that you make a contribution to the dialogue, start with a short sentence describing why you are so interested in Vaccination Prioritization for Pandemic Influenza (remember to keep it very short).
  

• We are missing a BIG piece
  

  Submitted by Ellen Rice on 12/5/07 06:31 AM

  As I look through the draft guidelines I feel that we are missing a BIG piece. So the sargeant with the keys to the nuclear warhead bin is given Tier 1 Level A vaccination status. I understand that. But what about his (non pregnant) wife, age 33? Or his twin toddlers? Or his step-son from his wife's first marriage? Will our sargeant go off to work while he is desperately worried about his family?
  
  I cannot, for the life of me, visualize a U.S, Senator having a shot and not immediately howling for all of his/her family (including grandchildren and the nannies) also being included.
  
  This expanding circle of demand should be addressed up front. If you are NOT going to vaccinate family members of the "critical" people, then that needs to be in bold font, on the top of every page. This will help families prepare. If you are going to quietly include family members of the "critically needed" people, then your numbers are WAY off. Pick one path or the other.
  

  • Where do family/household members of key personnel fall?
    

    Submitted by Brant Goode   on 12/5/07 06:40 AM

    You've identified a point worthy of discussion. So if the line for vaccines includes everyone, where would you put such family members?
    
    Reviewing the draft guidelines--the hypothetical person's twin toddlers are already in Tier 1, while his non-pregnant wife would be Tier 2. Would you move her up to Tier 1 and, if so, who would you move back in the line?
    
    See the "quick reference" item in the Library tab to see the current draft summarized.
    
    Brant

    • Family members dont fit in
      

      Submitted by Nick Kelley on 12/5/07 06:51 AM

      Brant,
      I dont think this model is capable of fitting family members in. I would assume it was purposefully not included, so the vaccine could do the most theoretical good. The public comment period is allowing the public to say what they think. Theoretically the draft guidance is ok, but it is not practical.
      
      [Nick, I changed your subject line so that more people will understand it, Nicholas/Facilitator]

  • Telling oversight
    

    Submitted by Joel Palmer on 12/5/07 06:41 AM

    That's a good point. Other mass treatment program like CRI (Cities Readiness Initiative - anti-anthrax bioterror) do include the families/dependents of first responders in the priority treatment group. A big difference there is that CRI in designed to provide the entire population with medication and the prioritization is only for the order of delivery.
    
    I have already encountered concerns from responders (police reps) about officers being exposed and then not wanting to return home for fear of exposing their families. Adding a vaccine to the mix will make it even messier.

    • Its a common model to protect familes too
      

      Submitted by Nick Kelley on 12/5/07 06:47 AM

      I would be called to work a mass dispensing site if something bad happened. I would actually work at a mass dispensing site that would provide medication to those working the site the following day, so they are protected. All of their dependents would receive the same medication so the essential staff that are supposed to work the mass dispensing site show up.
      
      I can't imagine health care workers showing up for a mass dispensing site without protection for their families.
      

      • But the supply...
        

        Submitted by Joel Palmer on 12/5/07 06:50 AM

        I completely agree. That is the problem that Ellen cited in the beginning, if we don't plan on setting aside for families we may lose responders.

        • Protecting family members
          

          Submitted by Terry Adirim   on 12/5/07 06:56 AM

          Joel,
          Do you think that if we offered anti-viral prophylaxis for protection of those families of critical persons (in tier 1) that this may help with this issue? Vaccines will be a scarce resource. Adding families in the mix will make it impossible to appropriately vaccinate critical workers. Tough decisions need to be made. I would like to believe that those in tier one would still respond to a pandemic crisis.

          • Probably help, but thats another can of worms
            

            Submitted by Nick Kelley on 12/5/07 07:07 AM

            Given that this would be an informed population...they would probably want a higher dose than what is normally given and for a much longer period of time, which would wipe out our antiviral stockpile pretty quick.
            

            • informed population
              

              Submitted by Terry Adirim   on 12/5/07 07:16 AM

              I would hope that a more "informed" group of people would not want a higher than indicated dose. There is some planning going on for anti-viral prophylaxis and the anti-viral supplies may be more robust than you think. I believe that a solution to this family protection issue may be offering anti-viral prophylaxis.
              
              By the way great discussion. Keep the ideas coming!

              • WHO recomends a higher dose for clinical case...why not prophylactically
                

                Submitted by Nick Kelley on 12/5/07 07:45 AM

                I assume those that are providing health care in a pandemic would be aware of the latest clinical guidance from the WHO (http://www.who.int/csr/disease/a...)
                Given that it is recommended in some cases and the current treatment protocols are based on seasonal data (which does not work for H5N1, but might for another strain), I would want a higher and longer prophylactic dose...I have talked to many other first responders that feel the same way.
                
                Page 2:
                Modified regimens of oseltamivir treatment, including two-fold higher dosage1, longer duration and possibly combination therapy with amantadine or rimantadine (in countries where A(H5N1) viruses are likely to be susceptible to adamantanes) may be considered on a case by case basis, especially in patients with pneumonia or progressive disease. Ideally this
                should be done in the context of prospective data collection.
                
                Page 5:
                A(H5N1) disease is associated with higher levels and more sustained viral replication than seasonal influenza (12,15), and the optimal treatment regimen of oseltamivir is not currently known in A(H5N1) virus infections. The standard dose and duration of oseltamivir treatment are derived from treatment studies of outpatients with uncomplicated seasonal influenza. In adults with uncomplicated seasonal influenza, higher doses (150 mg twice daily in adults) were tolerated as well as the approved regimen but provided no greater clinical or virological benefit (16, 17). Animal models of A(H5N1) virus infection indicate that higher doses and more
                prolonged administration of oseltamivir (8–10 versus 5 days) are associated with improved control of viral replication and better outcomes (18, 19).
                

                • higher doses of anti-virals
                  

                  Submitted by Terry Adirim   on 12/5/07 07:51 AM

                  Well this is an area that needs more research.
                  
                  You need to consider that treatment is different from prophylaxis. In all cases that I know of where post-exposure or pre exposure prophylaxis is employed, a smaller and less frequent dosing works. Also, we don't know how long someone can tolerate antiviral medication. They do have side-effects. I would think that the lowest necessary dosing would be best--both from a resource standpoint and tolerance standpoint.

                  • Totally agree...more research is needed
                    

                    Submitted by Nick Kelley on 12/5/07 08:02 AM

                    That is what I was alluding to when I mentioned antivirals is a whole nothing can of worms. So many unknowns and a limited supply.

                    • prophylactically or not
                      

                      Submitted by Roy Kamen on 12/5/07 09:00 AM

                      I wouldnt use Tamiflu prophylactically. That may cause resistance developing quicker.
                      
                      If someone gets sick, they should take the tami immediately, double dose for ten days as they have done successfully in indonesia.
                      
                      That means everyone should have their seasonal vax and have that stockpile of Tamiflu very handy.

                      • Interesting discussion but is this on-topic?
                        

                        Submitted by Nicholas Dewar   on 12/5/07 09:10 AM

                        Roy,
                        You're making some very interesting points, but you're taking the conversation away from today's topics:
                        How do we prioritize the available vaccine within each specified group?
                        You've got lots of knowledge and familiartiy with this subject so it would be great for us all to have your energy directed at the day's main purpose.
                        I hope that you can help us with this.
                        

                        • You're right Nicholas....
                          

                          Submitted by Roy Kamen on 12/5/07 09:19 AM

                          I do have a great deal of information on this and i am having a problem as i participate today and that seems to be coming out in my posts as thread drift.
                          
                          We are talking about a vax that we may not be able to make in the time the plan specifies.
                          We are talking about an issue (vax) that needs to come after the discussion of the first 6 months addresses (no vax... deadly virus).
                          
                          I believe the conversation with the American people has not happened yet to address what they can do to get through a severe pandemic to that magic 6 month point.
                          
                          I dont know where to talk about that. But THAT needs to be addressed before THIS is addressed.

                      • Actually, that's not true
                        

                        Submitted by Terry Adirim   on 12/5/07 09:12 AM

                        Unlike bacterial infections, use of antivirals when one is not infected probably does not promote resistence. There may be utility in post-exposure prophylaxis for certain populations (families/household members of a patient) and this is being investigated.
                        
                        And I agree wholeheartedly that everyone should get their seasonal vaccine,

                        • How long Terry
                          

                          Submitted by Roy Kamen on 12/5/07 09:21 AM

                          So how long can we keep the tami supply flowing to make it effective?
                          
                          I dont see that as a viable solution.

              • Anti Viral Supplies may be more robust that you think?
                

                Submitted by Caroline Bridgers on 12/5/07 08:17 AM

                That would be awesome news, please share more on this if you can!
                
                Always looking for hopeful and good news!

            • AV supply likely gone before vaccine hits
              

              Submitted by John Talarico on 12/5/07 08:01 AM

              The problem with offering anti-virals to family members in lieu of vaccine is that we are talking about doing this 6 months into the pandemic. Anti-virals - IF EFFECTIVE - will be depleted and even if there were effective intially, there is no guarantee that the will be effective 6- 12 months into the pandemic. Yes, I know that tamiflu is not as prone to induce resistance as the amantadines, however, resistance has shown up.
              
              I think a question that I have not seen yet is the implementation problem with the entire prioritization scheme. I work with 61 local health departments, most of whom believe that the draft guidance would be impossible to implement especially given the insistence by the feds that they be able to document group membership prior to giving the vaccine. During a pandemic - with a projected 25-40% workforce deficit, how do you document that a women is pregnant or that a person is a contact of 6 month old?

              • Interesting discussion but is this On-Topic?
                

                Submitted by Nicholas Dewar   on 12/5/07 09:18 AM

                John (and others on this Anti virals subject)
                This is very interesting stuff and it's good to see how much knowledge and interest you have for this. However, it would be most helpful to us if you would focus your energy on today's topics:
                How should we prioritize the availability of Vaccine between and within each identified Group?
                Please help us by keeping our focus on this important topic.
                Many thanks for your help.

          • The trade off
            

            Submitted by Joel Palmer on 12/5/07 07:11 AM

            That is the problem. I haven't seen the newer studies on willingness to report to work, but I know a study done at Hopkins dealing with hospital employees indicated that: clinical personnel were more likely to report than non-clinical and that fear of infecting family was one of the major reasons for NOT reporting. That study was looking at bioterror rather than pandemic but at least the general results probably transfer.
            
            So is the solution to vaccinate entire families? As you say, that would mean that others have to go without. This is where having a better handle on the production rate would be key. If we could say to people (and mean it) that their families would be vaccinated within a few weeks it might be less of an issue than if the delay is months. Unfortunately, the current vaccine production method is just not 100% predictable.

            • if people won't report to work unless their families are vaccinated
              

              Submitted by Caroline Bridgers on 12/5/07 07:17 AM

              I don't get it.
              
              If you are worried people won't come to work unless you vaccinate them AND their families,
              
              then which critical Tier One Employees are going to show up for work during the first 6 months where there is no vaccine for anyone?
              
              What am I missing here?

              • Not missing anything
                

                Submitted by Ellen Rice on 12/5/07 04:09 PM

                There have been discussions and I believe surveys of Health care workers and attitudes. I don't have a reference (read it on fluwiki.com, I believe) but a standard refrain is that people will offer their services until they feel their own families are threatened. I believe we saw some of this in the SARS outbreak in Toronto. Health care workers were reluctant to report if they felt their own families were at risk.

            • Consider taking this to the "General Population" Focus Point
              

              Submitted by Nicholas Dewar   on 12/5/07 07:18 AM

              Please consider moving this really useful conversation to the place where it will probably get most attention: the "General Population" Focus Point, or, if you think that this is mostly about Health Care (i.e. the dependents of health care workeers), take it to the "Health Care" focus Point.

          • Protecting responders family members
            

            Submitted by Chris Hale on 12/5/07 07:28 AM

            I have been assured by our first responders that they would respond, but given the nature and severity of PI, the reality of them being concerned with being exposed and their families not being treated tier 1 just like them may change their minds. Families of first responders needs to be addressed, but where does that line get drawn...define family?

          • it isn't just meds and vaccines-
            

            Submitted by larry wright on 12/5/07 08:18 AM

            you will need to provide physical security, food, water, heat, etc. or NOBODY will show up leaving family unguarded. I would not, and I doubt most people would either.

          • Medical personnel fleeing a pandemic
            

            Submitted by Martha London on 12/5/07 08:53 AM

            In response to your hopes that tier one people would still respond to a crisis: I did read recently about a similar severe contagious disease outbreak in a province in India. Apparently medical personnel, understanding the severity and likelihood of infection, fled the province in great numbers, leaving the general populace behind. Though some brave doctors and nurses, etc, did stay to help ordinary people, most did not. I apologize for the lack of details here; the book I saw this in is at home and I'll follow up tomorrow with the correct details.
            
            But I think this sort of flight--of all sorts of "strategic" personnel-- is a possibility that we should all consider.

            • Med Persons running in Africa NOW.
              

              Submitted by Roy Kamen on 12/5/07 09:00 AM

              Same thing happening right now in Africa - the Ebola outbreak.

              • Interesting conversation that would be more significant in "Health Care.." Focus Point
                

                Submitted by Nicholas Dewar   on 12/5/07 09:33 AM

                This is an intersting thread that would get more attention from people interested in the Health Care group if you could conduct this conversation there. Roy, would you (or one of the others in this thread) be able to take this topic to "Health Care..." by posting a clearly labeled comment that will start the conversation?

          • A winning combo!
            

            Submitted by Ellen Rice on 12/5/07 04:04 PM

            Now there's an idea that has great promise. Vaccinate the Tier one and hand out antivirals to the families so they have a real chance of beating the bug because they have the antivirals on hand.
            That could work. It's not a 100% but it might be good enough to keep things going.
            

          • My state will not have enough antivirals
            

            Submitted by Katharine Fisher on 12/5/07 04:38 PM

            I attended a big panflu meeting for my state's public health officials several months ago. It was clearly stated there that CT will not have enough antivirals on had to use them as prophylaxis for the families of nurses, doctors, or other critical workers.
            
            CT will also not have enough antivirals on hand to use them as prophylaxis for nurses, doctors, and other critical workers themselves.
            
            Those doing the work on vaccine prioritization need to be completely clear where each of the states is regarding fulfilling their antiviral purchase "goals." My state is flat out refusing to purchase the quantities recommended. They believe it is the federal government's obligation to do so since panflu is a "national problem." There are no future orders of Tamiflu planned.
            
            Offering the families of critical workers, and offering critical workers, here in CT antivirals is just not going to happen because we just won't have any. The pressure to produce and distribute that vaccine, then, will be tremendous once people learn that there really is no alternative.
            
            What do you expect will happen once stories begin to circulate that unvaccinated nurses, doctors, and other critical workers have brought the virus home to their children and families? If this virus is H5N1-related and it retains its preference for attacking children with high virulence, do you think those critical workers will continue to work?
            
            Vaccine is one solution, but it will be a lagging solution. Work needs to be done on interim solutions beyond hand washing and avoidance of crowds. Critical workers may have to be provided with safe quarters away from their families. Perhaps orders for antivirals need to be increased forthwith by some mechanism you'll need to work out because the current one isn't working as planned (Great Britain is increasing its purchases of antivirals substantially as we speak). Thinking caps are needed to fully flesh out this area of concern. Solutions can be found, but not at the last minute and not if the question is not asked and addressed.
            

      • Workers returning home
        

        Submitted by Catherine Jackie Mitchell on 12/5/07 07:43 AM

        There are non-pharmaceutical ways for workers returning to their homes to protect their families from exposure.

        • I disagree
          

          Submitted by Ellen Rice on 12/5/07 04:13 PM

          Influenza can be carried and transmitted before a person shows symptoms. One of the characteristics of flu is that it can emerge suddenly. So a person (health care worker, first responder, electric lineman) can be fine on Tuesday, go home to the family, wash hands, have dinner, go to bed -- and wake up sick as a dog and be dead by Wednesday p.m.
          
          There were some deaths in Australia this last flu season that rapidly resulted in death. I believe one of them was a lady who worked as a receptionist at a medical clinic.
          

      • Distribution
        

        Submitted by Ivan Ferrer on 12/5/07 07:47 AM

        You are right, but I think that the same apply for every other worker.
        

      • Family at risk equals I'm not showing up
        

        Submitted by Ellen Rice on 12/5/07 04:01 PM

        This comment has been heard again and again. There are many health care workers and first responders who are willing to put thier own life on the line but not their families' lives.
        
        If families are vaccinated along with the Tier 1 people, then the numbers explode. If families are not vaccinated along with Tier 1 people, then those Tier 1 people will start to fade away rapidly.
        
        What is most likely to happen is that the official policy will be "Tier one people only" but in practice there will be a lot of "Hey, Captain, your appointment is at 3 and bring your kids and we'll see what we can do. . ." That is human nature and that nature should be thought through as this planning unfolds.
        

  • Protecting family members
    

    Submitted by Terry Adirim   on 12/5/07 06:47 AM

    There is no plan at this time to include family members in the vaccine prioritization scheme (unless they fit one of the prioritized groups). There are other interventions that will be implemented until enough vaccine can be made for everyone (antivirals, community mitigation measures).
    
    There have been others who have brought this issue up and certainly this concern should be addressed. Aside from explictly stating that family members are not in the scheme, what else can be done to get that message across to persons on the list? I can tell you that as someone who would be on tier one (I'm an emergency physician), I would not expect that my family members would be there with me as well. I understand that I have a role to play in a pandemic and that I am in a group that is most at risk for contracting the infection. I would hope that others in tier one would understand that as well. Perhaps we need to focus our educational attention on that group and get the message across that with scarce resources, tough decisions need to be made.

    • Agree...for the prioritization to become practial more education is needed
      

      Submitted by Nick Kelley on 12/5/07 06:56 AM

      Terry,
      I think your perception is valid for a segment of the Tier 1 population but it is the minority perception. More education is needed.
      

    • Deployed forces would not be an issue
      

      Submitted by Nick Kelley on 12/5/07 06:58 AM

      The military commonly provides protection to its troops that the family does not get...they would not be a problem. They would want protection of course but the disciple and role the military places will help with this quite a bit, I hope.

      • Sometimes
        

        Submitted by Joel Palmer on 12/5/07 07:17 AM

        I do know that some of the military plans (bioterror) do include family and there are certain drugs stockpiled at bases for members and families. (A good friend of mine recently looked at some of the prophy programs within USAF.)
        
        Also, the military model is not completely applicable to civilians. The example that comes to mind was the recent (2002-2004) smallpox vaccination program. The rate of vaccination of target personnel in the military was around 85-90% if I remember correctly, while the civilian population was around 20%.
        
        This is not to say that we should discount the military. In fact, there may be valuable lessons the civilian community can learn about educating providers and families regarding the risks they might face and how to deal with them.

        • Consider moving this conversation to the HNS Focus Point
          

          Submitted by Nicholas Dewar   on 12/5/07 07:34 AM

          This is an important topic and will be of interest to those in the Homeland and National Security (HNS) Focus Point. Please consider taking it there so that people interested in this issue are more likely to join your conversation.

    • Healthcare, EMS, Fire, Police and Gov. Leaders...got some work to do
      

      Submitted by Nick Kelley on 12/5/07 07:00 AM

      I think these groups are used to WMD preparedness....in most cases their families would be protected if something happened. I think you're correct to assume that many would show up...but many surveys have shown that many of these workers will not show up without knowledge that their families are protected.
      

      • Immediate Household Family Inclusion in Vaccine Distribution
        

        Submitted by Benjamin Krakauer on 12/5/07 07:12 AM

        I wholeheartedly agree with those who have commented about the need to include the family members of Tier 1 personnel in the federal guidance document/rules for vaccine distribution during a Pandemic Influenza event. Several studies have shown that people will be altrusitic during an emergency as long as their families are taken care of and protected.
        
        We already expect 30-50% of the workforce to remain out of work because they are ill or are taking care of ill family members, evermore reason to ensure that the remaining 50-70% of the workforce report to work as normal, calm, and focused.
        
        As I understand it, many major private businesses go at great lengths (e.g. installing generators at their homes, delivering emergency supplies, etc.) to ensure that critical employee's (usually senior-level leaders) are taken care of during emergencies so that their employees can remain focused on their job.
        
        During a Pandemic we will need every healthy body to assist with response, mitigation, and recovery -- families must be protected.
        
        BJK

        • Absentee rates
          

          Submitted by Terry Adirim   on 12/5/07 07:21 AM

          Hi,
          Where do you get the 30-50% absentee rate from? I'm just curious. The Federal government is using 40% but that is 40% at the peak of a wave. We are basing our planning on the 40% rate. As an aside, in 1918 (I know a different era), the absentee rate was significantly less.
          

      • Immediate Household Family Inclusion in Vaccine Distribution
        

        Submitted by Benjamin Krakauer on 12/5/07 07:12 AM

        I wholeheartedly agree with those who have commented about the need to include the family members of Tier 1 personnel in the federal guidance document/rules for vaccine distribution during a Pandemic Influenza event. Several studies have shown that people will be altrusitic during an emergency as long as their families are taken care of and protected.
        
        We already expect 30-50% of the workforce to remain out of work because they are ill or are taking care of ill family members, evermore reason to ensure that the remaining 50-70% of the workforce report to work as normal, calm, and focused.
        
        As I understand it, many major private businesses go at great lengths (e.g. installing generators at their homes, delivering emergency supplies, etc.) to ensure that critical employee's (usually senior-level leaders) are taken care of during emergencies so that their employees can remain focused on their job.
        
        During a Pandemic we will need every healthy body to assist with response, mitigation, and recovery -- families must be protected.
        
        BJK

        • Families
          

          Submitted by Eleanor Peters   on 12/5/07 08:17 AM

          Obviously a tough question that surfaces again and again. I have not seen this aspect of the response on the question posted yet but perhaps I have not read over every post:
          
          Part of the theory on vaccinating the critical folks and not necessarily their families is that the critical people will be put directly in harms' way or are completely necessary for the rest of us, and with the family members this is not necessarily the case. Some family members might be fortunate enough to stay home throughout the majority of the pandemic. If so, then the major risk to them is the one member who goes out of the house every day. Vaccinate that person and the whole family gets a better chance.
          
          Further Example: You have 2 doses (courses) of vaccine.
          
          An ER nurse is married to a bank teller. The ER nurse comes in contact with flu patients all day. Without him, some patients would go unseen and perhaps die, thereby raising the CFR. The bank teller, she has closed her branch to walk ins and is only using the drive through for business transactions, effectively cutting her risk of exposure to 0 but still staying on the job.
          
          Do we give the bank teller the other dose of vaccine or do we give it to the ER Nurse's colleague?

      • showing up to work
        

        Submitted by Terry Adirim   on 12/5/07 07:19 AM

        I agree that there are some segments of the emergency sector groups that have concerns about protection of their families. I have heard these concerns and we need to address them. Education will be one part of this. There are other means of protection other than vaccination and we need to get that message out.

        • Consider moving this conversation to the "Health Care" Focus Point
          

          Submitted by Nicholas Dewar   on 12/5/07 07:32 AM

          This is an important conversation. Please would you consider moving it to the "Health Care" Focus Point where people looking for discussion about Emergency Responders etc. are most likely to find it and join your conversation?

        • Educating First Responders
          

          Submitted by Chris Hale on 12/5/07 07:32 AM

          First responders are already some of the best educated; that may be why it is so important for them to include their families in the first prophy. They know the likelyhood of low supplies, long lines, mass hysteria and if they know their familis are already covered then they can go about their business. But it is an interesting quandry as to how far we dig down to protect 'family'. It is an endless chain...

        • need to get the message out
          

          Submitted by Roy Kamen on 12/5/07 07:47 AM

          Yes Terry we need to get the message out about preparing every home in America for what is coming.

        • How do we get the message out
          

          Submitted by Roy Kamen on 12/5/07 08:57 AM

          I agree.. the message needs to get out that they are on their own as Sec. Leavitt said.

    • Pregnant women, infants and todlers...good luck just vaccinating them
      

      Submitted by Nick Kelley on 12/5/07 07:05 AM

      Who is going to take care of the kids when the adults get sick?
      
      Just because you vaccinate them does not mean they wont get sick and if the adults in their lives or their significant other get sick, their provider of care is probably not going to provide care to them.
      

      • Consider taking this discussion to the "General Population" Focus Point
        

        Submitted by Nicholas Dewar   on 12/5/07 07:12 AM

        This is a valuable conversation: please consider taking it to the "General Population" Focus Point, where more people are likely to find it.
        

      • Does a high CFR change prioritization?
        

        Submitted by MoMos Mom on 12/5/07 07:17 AM

        Hi, guys, I know that you discussed CFR yesterday for a while. I believe that someone mentioned that a high CFR virus would not exist because it would 'burn' itself out before it infected a high number of people. Am I mistaken in that new scientific research is pointing out the fallacy of that assumption? Weren't the pandemics of 57 and 68 reassortment events of the H1N1 virus from 1918 which decreased their lethality?
        
        http://www.sciencedaily.com/rele...
        
        New Model Predicts More Virulent Microbes
        
        ScienceDaily (Oct. 20, 2007)
        
        The model helps explain the rules that govern the transmission of microbes and how they have operated in human history, says Martin J. Blaser, M.D., the Frederick King Professor and Chair of the Department of Medicine, and Professor of Microbiology at New York University School of Medicine. He and Denise Kirschner of the University of Michigan Medical School, Ann Arbor, are authors of the study.
        
        snip
        
        The model can be used to better understand microbial responses to a changing human world, says Dr. Blaser. Based on their formulations, our biological future will probably be filled with some "pretty bad epidemics," says Dr. Blaser. "Our model predicts that as effective population size increases and as immunodeficiency increases due to the spread of HIV infection, and an aging population, there will be more virulent organisms. This is bad news for us."
        
        Through the course of human evolution, Drs. Blaser and Kirschner propose that three classes of persistent microbes have evolved, each employing a different biological strategy to avoid being eliminated quickly by their human hosts. TB, H. pylori, and Salmonella are an example of each class. Any microbe that was "cheating" the system, in other words, tried to expand its territory in the body, wouldn't survive because it would likely kill its host.
        
        According to their theory, small populations select for certain kinds of microbial agents. More than 50,000 years ago, when humans lived as hunter-gatherers in small, isolated groups, the majority of microbes were transmitted within families or were those that would emerge late in life. Microbes that were not lethal were favored because there wasn't a large reservoir of people to infect. Any microbe that killed off its hosts, wouldn't have survived itself. H. pylori evolved during this time.
        
        As population size increased and humans became less isolated, organisms that had perfected ways to hide in the body for decades, such as TB and Salmonella typhi, and then suddenly reactivate or get transmitted, evolved. These organisms could afford to induce more disease early in life because they had mechanisms to sustain themselves in human populations.
        
        As even larger societies developed, more virulent organisms, such as measles, emerged because the population could permit the virus to spread. Our most recent epidemics, including influenza in the early 20th century and AIDS today, involve organisms that can kill millions because these highly virulent organisms have a huge pool of people to infect, and still be transmitted.
        
        "We did not make the laws of nature," says Dr. Blaser. "Even though we may not like them, we need to understand them to better control infectious diseases."
        

        • CFR and prioritization differences
          

          Submitted by Brant Goode   on 12/5/07 07:33 AM

          The descriptions of virulence levels and adaptation are interesting from a viral evolutionary perspective, but what will we do when actually faced with a non-worst case scenario, i.e. Category 1 or 2 pandemic vs a 5? How might prioritization shift? It's a bit harder to answer because of the unknowns, but it's worth pondering.
          
          Brant

          • Non worst case?
            

            Submitted by Roy Kamen on 12/5/07 08:43 AM

            The plan as is is good for non worst case... like up to 5%
            
            We need a plan for the worst case - say over 50% CFR.
            
            Vax the young first in the most critical infrastructure and security areas.

        • High CFR and the prioritization scheme
          

          Submitted by Terry Adirim   on 12/5/07 07:35 AM

          In response to your title, I do not think that a higher CFR would change the scheme. There are prioritization schemes for "severe", "moderate" and "mild" pandemics. The prioritization scheme for a severe pandemic focuses heavily on balancing protection of security personnel and critical infrastructure/key resources personnel with pandemic responders and the the most vulnerable in the general population which is important no matter how high the CFR. The schemes assume a very high absentee rate (40%) during the peak of a pandemic and so would work for pandemics with a higher than 2% CFR. Also, the draft guidance is meant to be reassessed at the start of a pandemic to assure that the appropriate groups are included based on the characteristics of the pandemic and the vaccine manufacturing capability. As we increase manufacturing capacity, the scheme can be adjusted accordingly to include other groups.
          
          With regard to virulance of organisms, I don't believe that my original argument was wrong. A virus with a 60% fatality rate would not last very long. HIV does not kill its hosts with immediacy and therefore the host has time to spread it to others. The same with the bacterial organisms you cite. If you look at those organisms that kill their hosts within days such as SARS and Ebola, there was not a widespread epidemic.
          

          • High CFR and the prioritization scheme
            

            Submitted by Eleanor Peters   on 12/5/07 08:04 AM

            I agree with Terry. If you look at it from a virus' point of view what is the ultimate goal?
            kill the host
            or
            live forever by replication and transmission
            
            I think it is 'live forever'. 'Kill the host' is a dead end for a virus. So in terms of viral evolution I think it is much more likely that we will see an attenuated version of the current CFR, otherwise transmission will be compromised.
            

            • Thinking on a geological time frame
              

              Submitted by Ellen Rice on 12/5/07 07:51 PM

              Even if you are right and a pandemic flu virus attenuates over time, there are different ways to view "time". Speaking in a geological sense, a year or a decade is an insignificant amount of time -- but it'd be a hecka long time for a human being to deal with the flu. We need to consider a virulent strain that may last at least months and possibly years before it may or may not attenuate.

              • Long Haul
                

                Submitted by Catherine Jackie Mitchell on 12/6/07 05:25 AM

                Somewhere someone reminded me that this is a marathon not a sprint. It was a great reminder because it is so true. We do not know what tomorrow may bring. We do know that we need to prepare for "it" whatever "it" may turn out to be.
                
                Perhaps we are witnessing a time of a complete restructuring of our society. Sounds drastic. A virulent strain that does not attenuate would be a drastic situation. In that case I am sure that we will all find out the "stuff that we are made of" individually AND collectively.
                

          • High CFR look at historical pandemics
            

            Submitted by MoMos Mom on 12/5/07 08:11 AM

            'With regard to virulance of organisms, I don't believe that my original argument was wrong. A virus with a 60% fatality rate would not last very long. HIV does not kill its hosts with immediacy and therefore the host has time to spread it to others. The same with the bacterial organisms you cite. If you look at those organisms that kill their hosts within days such as SARS and Ebola, there was not a widespread epidemic.'
            
            I'm still trying to wrap my mind around the 2% CFR assumption, which in my mind ignores collateral damage of any kind. If we look at historical pandemics, than we see organisms like the bubonic plague that have killed a very high percentage of the population (60% -70% in parts of Europe), that did kill their hosts within days, and that still exist on this planet to this very day. Ebola has been infecting people in Uganda, Africa since August. The CDC has just announced that the strain infecting the current 90 people is a brand new strain. I think that this situation bears close scrutiny to see how effective the containment measures are for this new strain that is currently circulating. It does seem to have a lower CFR than Ebola historically does, but only time will show if the attack rate is insufficient to spark an African epidemic.
            
            MRSA and the adenovirus 14 are both examples of diseases that have naturally selected themselves to be more virulent, some argue based on the indiscriminate use of antibiotics in our food and by prescription. Is there any possibility that the use of Tamiflu in Indonesia is selecting for a more virulent strain of the virus? The CFR has gone from 60% to 80% in Indonesia which is currently the country with the highest mortality rate and highest rate of infection. There has also been evidence that the use of Tamiflu might naturally select for a virus that is resistant to the use of Tamiflu.
            
            Wouldn't the prioritization for vaccines have to reflect the CFR? For instance, if we immunize babies, what happens if their care givers are in the 19 - 45 age range and die in a high CFR pandemic? Who would be left to pick up the pieces and help society resume in that event?
            
            In 1918, 41% of the US population were farmers. In 2005, 2% of the US population are farmers. We import a whole lot of food these days. Do you think that that fact should change the 2 weeks worth of food recommendation? Shouldn't people try to prepare for the whole wave that would last between 6 - 8 weeks?
            

            • Children and Elderly First? Absolutely NOT.
              

              Submitted by Cairelle Perilloux on 12/5/07 07:30 PM

              I understand society's "warmth and fuzzies" towards our youngest and oldest and most vulnerable citizens (I have them myself), but the fact of the matter is that, during a high CFR pandemic, they will be able to do nothing to keep some modicum of an economic and civil infrastructure in place.
              
              Some additional points to ponder about prioritization (info from http://www.cdc.gov/ncidod/EID/vo... ):
              
              "The curve of influenza deaths by age at death has historically, for at least 150 years, been U-shaped, exhibiting mortality peaks in the very young and the very old, with a comparatively low frequency of deaths at all ages in between. In contrast, age-specific death rates in the 1918 pandemic exhibited a distinct pattern that has not been documented before or since: a "W-shaped" curve, similar to the familiar U-shaped curve but with the addition of a third (middle) distinct peak of deaths in young adults &#8776;20–40 years of age. Influenza and pneumonia death rates for those 15–34 years of age in 1918–1919, for example, were >20 times higher than in previous years. Overall, nearly half of the influenza-related deaths in the 1918 pandemic were in young adults 20–40 years of age, a phenomenon unique to that pandemic year. The 1918 pandemic is also unique among influenza pandemics in that absolute risk of influenza death was higher in those <65 years of age than in those >65; persons <65 years of age accounted for >99% of all excess influenza-related deaths in 1918–1919. In comparison, the <65-year age group accounted for 36% of all excess influenza-related deaths in the 1957 H2N2 pandemic and 48% in the 1968 H3N2 pandemic."
              
              SO, if I'm reading correctly, basically this tells us that it's a possibility for a pandemic to heavily strike the 20-40 age range - the very ones who are most represented in the work force - so, IMO, the prioritization needs to be modified to protect the ones who have the most potential to contribute to maintaining our society.
              
              I hate to sound cold and unfeeling, but this is the reality.
              

          • high CFR does not equal quick burnout
            

            Submitted by larry wright on 12/5/07 08:33 AM

            The problem with influenza is that infectiousness precedes clinical symptoms by several days. Whether or not the infection kills you is essentially irrelevant, as you have already transmitted the disease to those with whom you have had contact before you die (or don't) Ultimately, I agree that evolution would tend to favor a virus that kept the host alive and infectious for a longer period, but over the next few years that slight tendency does not guarantee a less lethal strain during the commencement of the pandemic. Of much more interest is the mechanism by which our candidate virus, (H5N1, or H7N3 or H7N8, or whatever) acquires the needed traits to become a sustained efficient human to human strain. If by reassortment, then, yes, it is more likely that the infection will become less lethal, but that is NOT the only mechanism by which such traits are conserved in the viral genome; direct mutation and recombination are also possible. Certainly, H5N1 clades 2.2 et seq. have demonstrated an impressive ability to acquire traits which promote human/mammalian infection without losing much if any lethality along the way.
            
            But really, the thing that will determine the fate of most of us in North America is not how many die after being infected, it is how many get seriously ill in the first place. Absenteeism is going to determine what the immediate impacts of a pandemic are on our society; if the lights go out because 2/3 of the electrical power workers are out sick, we are in big trouble EVEN IF THE CFR FROM FLU IS ONLY 0.1%.
            
            If we can use NPI to prevent our most critical people from getting sick, we are going to be very much better off.

          • I think we were just lucky to be able to contain SARS
            

            Submitted by Caroline Bridgers on 12/5/07 08:35 AM

            My understand of the way SARS spread is, it was very virulent BUT it wasn't contagious until people started showing symptoms. Therefore with a high amount of vigilance, we were able to track people down and use isolation and quarantine to stop the spread.
            
            I was under the impression that we physically STOPPED SARS, that it didn't just die out because its victims died.
            
            Is this incorrect?
            
            Boy oh boy, I would love to know for sure that a pandemic such as H5N1 simply couldn't, ever, at all, become a pandemic at say over 2.5% fatality rate. But I have been looking into this for quite some time and I cannot find any studies that say this can't happen.
            

            • Serial Interval
              

              Submitted by Catherine Jackie Mitchell on 12/5/07 09:04 AM

              Perhaps then we should be addressing serial intervals by comparison. Severe acute respiratory syndrome has a serial interval of 8 to 10 days. Peak infectivity occurs at week 2 of illness. This gave us an advantage with SARS that we may not have with pandemic influenza which does not allow as much time to implement isolation and quarantine measures to a great degree of success.

            • how did SARS stop
              

              Submitted by Brant Goode   on 12/5/07 12:16 PM

              Hi Caroline,
              
              Isolation and quarantine of ill and exposed persons worked to stop SARS as well as strengthening respiratory protection controls among medical care personnel who found themselves more likely to be exposed. This included use of personal protective equipment esp. during procedures that were more likely to produce airborne particles such as intubation. The precautions are very similar to what are recommended for pan flu.
              
              Regarding how this might affect prioritization: a virus with lower virulence may not require the depth of control measures we needed for SARS. It might be a new virus like the one that emerged inthe '70s: novel but no real increase in mortality over prior seasonal flu events.
              
              Brant

              • so high virulence in SARS didn't preclude it from becoming a pandemic?
                

                Submitted by Caroline Bridgers on 12/5/07 01:08 PM

                Thank you so much, Bryan. that's what I thought.
                
                My comment that we were lucky to stop SARS were related to an earlier comment someone made, that a virus like SARS couldn't become a pandemic because it would kill all its hosts before it spread. Clearly we had to work hard to contain the spread of SARS and stop a pandemic of SARS from starting -- it didn't just die out on its own.
                
                My further understanding is that most professionals and scientists agree that we can TRY to stop pandemic influenza but sooner or later it will happen, no matter what we do, because it can be spread at least 1 day and in the case of children maybe a few more days before symptoms start, so the measures used to stop SARS just won't be as effective with pandemic flu.
                
                also, to your comment:
                
                "Regarding how this might affect prioritization: a virus with lower virulence may not require the depth of control measures we needed for SARS. It might be a new virus like the one that emerged inthe '70s: novel but no real increase in mortality over prior seasonal flu events."
                
                Thank you again! I think I understand that a pandemic MAY be quite mild. Fortunately if it is, the long wait for a pandemic flu vaccine (6 months and more) probably wouldn't be a very hard one, and the need to prioritize vaccine only for certain groups, well, that decision would be much less difficult. With a mild virus, fewer people would take avoidance measures, more would just get ill and then recover; and the fear and subsequent demand for a vaccine would simply be much much less.
                
                A virus with a higher virulance -- say one as fatal as SARS was -- only say we didn't manage to stop SARS -- and the prioritization of vaccines 6 months later is just a completely different picture. So much of what will be needed 6 months into this scenario would really depend upon what had happened to our society and economy in the intervening time period.
                

                • between pandemic start and vax availability
                  

                  Submitted by Roy Kamen on 12/5/07 01:33 PM

                  Caroline says "A virus with a higher virulance -- say one as fatal as SARS was -- only say we didn't manage to stop SARS -- and the prioritization of vaccines 6 months later is just a completely different picture. So much of what will be needed 6 months into this scenario would really depend upon what had happened to our society and economy in the intervening time period."
                  
                  Words of wisdom Caroline. It is worth a dialog in itself... how the Government can recommend people have just 2 weeks of supplies at home when clearly they state the event will have a 6-8 week duration with widespread shortages and outages.
                  
                  AND what is the plan for the first 6 months of a severe pandemic (60-80%CFR)?
                  What is the plan to keep the most vulnerable and critical workers protected till then (age and occupation dependent)?
                  AND when are they going to tell the American people this?

              • so high virulence in SARS didn't preclude it from becoming a pandemic?
                

                Submitted by Caroline Bridgers on 12/5/07 01:09 PM

                Thank you so much, Bryan. that's what I thought.
                
                My comment that we were lucky to stop SARS were related to an earlier comment someone made, that a virus like SARS couldn't become a pandemic because it would kill all its hosts before it spread. Clearly we had to work hard to contain the spread of SARS and stop a pandemic of SARS from starting -- it didn't just die out on its own.
                
                My further understanding is that most professionals and scientists agree that we can TRY to stop pandemic influenza but sooner or later it will happen, no matter what we do, because it can be spread at least 1 day and in the case of children maybe a few more days before symptoms start, so the measures used to stop SARS just won't be as effective with pandemic flu.
                
                also, to your comment:
                
                "Regarding how this might affect prioritization: a virus with lower virulence may not require the depth of control measures we needed for SARS. It might be a new virus like the one that emerged inthe '70s: novel but no real increase in mortality over prior seasonal flu events."
                
                Thank you again! I think I understand that a pandemic MAY be quite mild. Fortunately if it is, the long wait for a pandemic flu vaccine (6 months and more) probably wouldn't be a very hard one, and the need to prioritize vaccine only for certain groups, well, that decision would be much less difficult. With a mild virus, fewer people would take avoidance measures, more would just get ill and then recover; and the fear and subsequent demand for a vaccine would simply be much much less.
                
                A virus with a higher virulance -- say one as fatal as SARS was -- only say we didn't manage to stop SARS -- and the prioritization of vaccines 6 months later is just a completely different picture. So much of what will be needed 6 months into this scenario would really depend upon what had happened to our society and economy in the intervening time period.
                

          • Not as clear as one thinks
            

            Submitted by Nick Kelley on 12/5/07 09:38 AM

            There are many assumptions that factor into a high CFR dropping during an influenza pandemic. These assumptions have been derived from historical events and some theoretical modeling. Many of these assumptions dont take into account influenza...which has different transmission dynamics and infection prevent guidelines.
            
            I think given these assumptions and the way H5N1 has changed our understanding of influenza A, we should not be so quick to assume a high CFR for an influenza pandemic would burn itself out.
            
            I would agree that a CFR of 60% is probably unlikely but I cant find any theoretical reason why its not possible given what we know about influenza.
            

            • Interesting issue but is it On-Topic?
              

              Submitted by Nicholas Dewar   on 12/5/07 09:45 AM

              Nick
              You (and others on this thread) have such familiarity with this topic. It would be really helpful if you would try to keep the discussion focused on today's topic:
              What are the vaccine allocation prioritizations for the specific Groups?
              It's very important for us to get your opinions and questions about this(and the questions and opinions of others with your level of interest) .
              Please would you help keep the discussion on-track.
              Many thanks for your help.
              

      • what would you community need and do during a pandemic?
        

        Submitted by Don Greenstein   on 12/5/07 07:22 AM

        Nick: What would happen to children is likely a local community issue. In the public engagements in other cities, which I have been facilitating, some people said that day care centers would need to remain open and day care providers should be in a higher tier of prioritization. No one plan will work in every community. I believe your community, your employers and your day care centers need to start thinking about this issue. This is called “guidance” because that’s what it is. What happens in your locality needs to be discussed and planned for before the next pandemic occurs.

    • protecting families
      

      Submitted by Barbara Volz on 12/5/07 07:31 AM

      I come from a small public health department. While all 20 of us would respond, we have already recognized in our plans that we would need many more 'volunteers' to actually be able to do our jobs in an emergency situation. If the volunteers do not think that their families would be protected then they are unlikely to show up. This would mean that our response would be very limited.

      • Volunteers
        

        Submitted by Catherine Jackie Mitchell on 12/5/07 08:00 AM

        Fully educated volunteers who know the risk may still avail themselves. I would show up in an emergency and I would return home to my non-vaccinated family with a side trip to a hot shower first. Some viruses may be entirely lethal and yet be somewhat unstable and easily killed. We cannot lose sight of other methods of protecting our families at home when we return to them.

        • Volunteers
          

          Submitted by Eleanor Peters   on 12/5/07 08:21 AM

          Catherine - I admire your dedication. We need more people like you. However, I want to make clear that if you come in contact with the flu virus like this, a hot shower is not going to be the solution. You can still take one, but what would be most effective in protecting one's family would be seperating oneself from them for a period of a few days after volunteering to make sure that you have cleared the incubation period.

          • I agree
            

            Submitted by Catherine Jackie Mitchell on 12/5/07 09:06 AM

            I was thinking more in terms of short term separation. I do not oppose that idea. Of course, my family is older and more self-sufficient. All the more reason for someone like me to be "out there" allowing another whose family needs them to stay home....its a matter of practicality.
            
            But thanks for the pat on the back ;)

          • Volunteer self-isolation and family
            

            Submitted by Bill Pritchard on 12/5/07 10:14 AM

            Good point about Medical Reserve Corps or other volunteers self-isolating instead of returning to their families after shifts in points of dispensing or other sites where they could possibly come in contact with ill persons. Has anyone out there thought through a policy or procedure?
            

            • I have
              

              Submitted by Catherine Jackie Mitchell on 12/5/07 10:30 AM

              But I have removed myself from the response loop in my town so that I can focus on family and individual preparedness.
              
              My suggestion would have been to dedicate our community school for the use of volunteers in the community who are exposed and need evaluation. I would move them through the facility according to date from exposure.

            • Volunteer self-isolation and family
              

              Submitted by Jeffrey Duchin   on 12/5/07 02:27 PM

              It is true that ideally, exposed persons should avoid close contact with others until they are no longer likely to become ill and pose a risk of transmitting infection to others. However, most front line health responders in a pandemic will be exposed frequently, necessitating almost constant separation from their househld members. Understanding how flu is transmitted, employing infection control measures in the home, and promptly recognizing and treating symptoms of flu are probably going to be more realistic to expect.
              

    • Need to Clarify to Emergency Management for MRC & CERT Volunteers
      

      Submitted by Cathy Pinette on 12/5/07 07:44 AM

      This message needs to be clarified to Emergency Management personal. I know that it has been conveyed to volunteers (CERT, MRC, etc) that they will be vaccinated and that their family members will also be vaccinated. Many volunteers have only signed on board to be able to protect their families.
      
      I also know that many non essential government works have been told the same.
      

      • Please clarify all ACRONYMS MCR and CERT =?
        

        Submitted by Nicholas Dewar   on 12/5/07 07:48 AM

        Cathy, I know you're used to using these acronyms, but please remember that many participants, especially the hundreds who are reading this, but not posting messages, won't know what you're talking about!

        • MRC = Medical Reserve Corp
          

          Submitted by Nick Kelley on 12/5/07 08:09 AM

          The mission of the Medical Reserve Corps (MRC) is to improve the health and safety of communities across the country by organizing and utilizing public health, medical and other volunteers.
          
          more info here (http://www.medicalreservecorps.g...)

        • CERT = Community Emeregency Response Team
          

          Submitted by Nick Kelley on 12/5/07 08:12 AM

          CERT teams are trained community members that meet the needs of a community that are not met by the first responders...
          
          "If we can predict that emergency services will not meet immediate needs following a major disaster, especially if there is no warning as in an earthquake, and people will spontaneously volunteer, what can government do to prepare citizens for this eventuality?
          
          First, present citizens the facts about what to expect following a major disaster in terms of immediate services. Second, give the message about their responsibility for mitigation and preparedness. Third, train them in needed life saving skills with emphasis on decision making skills, rescuer safety, and doing the greatest good for the greatest number. Fourth, organize teams so that they are an extension of first responder services offering immediate help to victims until professional services arrive."
          https://www.citizencorps.gov/cert...

      • Volunteers and panic
        

        Submitted by MoMos Mom on 12/5/07 08:39 AM

        It seems like most PH officials are worried about panicking the American public. We must balance our message without causing panic. How many volunteers will show up if they do not think their families will be protected? Some people do not have the resources to isolate themselves from their families when they return home from their duties?
        
        Wouldn't there be more panic when people are seeing their neighbors becoming ill and worse dying? Isn't it better to educate people now rather than trying to do it when mass hysteria might be reigning supreme?

        • panic comes from fear of the unknown.
          

          Submitted by larry wright on 12/5/07 08:54 AM

          If caught unawares by an unexpected disaster, people panic.
          
          When faced with a very serious disaster that they knew about ahead of time, most people react appropriately.

          • Public education about a severe pandemic (60-80% CFR) is key?
            

            Submitted by Roy Kamen on 12/5/07 02:16 PM

            Larry said "If caught unawares by an unexpected disaster, people panic.
            
            When faced with a very serious disaster that they knew about ahead of time, most people react appropriately."
            
            so Larry you are saying Public education about a severe pandemic (60-80% CFR) is an important element of the PLAN?

            • When will Public Education Begin?
              

              Submitted by Cathy Pinette on 12/5/07 06:19 PM

              Most of us here have been following this for a long time and many have stopped trying to talk to others about it. Pandemic preparedness is not on the minds of the American people.
              
              Our friends whom we have tried to educate are turning a deaf ear.
              
              Nothing can be done without the buy in of the American people.
              
              To plan for a community event such as pandemic flu, the community must be involved. Why is there so much secrecy as to what the projected impact could be?
              
              How do you expect people to prepare when no one is telling them?
              
              When the people in charge start to tell the public that they must prepare, the pandemic has started (as most plans say they will tell the public when it happens) there will be mass panic by the citiens of the US and many will be left with nothing.
              
              It is an injustice to not spread the word constantly to the American people starting now about the high CFR numbers and the predicted age group.

      • Sorry about that....
        

        Submitted by Cathy Pinette on 12/5/07 10:00 AM

        MRC = Medical Reserve Corp
        CERT = Community Emergency Response Team
        

    • a family plan for HCPs
      

      Submitted by Charlotte Thompson on 12/5/07 10:49 AM

      As a Family Nurse Practitioner who works in an ambulatory care clinic, belongs to my County MRC, and a parish nurse, I will share my family plan with other HCPs who might find it useful.
      In a pandemic, I will be among the first vaccinated but my grown daughters with pre-school and school-age children probably will not. Their husbands are not in critical positions but are working. My husband is a retired law enforecement officer. When the balloon goes up, my daughters and their children will come to our house where there is enough room for them and my husband will stay to help care for and protect them (six small children). We have several weeks of food and water set aside for them. I will not go back to my home after I am in contact with sick people but will stay in touch by phone. I will figure out where to stay at the time.
      My daughters husbands will stay at their homes and continue to work as long as they are able. If one or both of them becomes ill, I will care for them as well as continue with my community work. As things progress, we may designate a 'sick house', a 'well house' and a 'recovering house'. I am convinced that voluntary isolation is the only real method to enhance survival.
      I am 60 years old and am very willing to die in the effort to use my skills to help others survive this pandemic. I very much want my children and grandchildren to survive. This is my plan and I am at peace with it.
      

      • The Key Word in this Discussion is PRIORITIZATION
        

        Submitted by Christine Kardong on 12/5/07 11:54 AM

        You assume some "best case scenarios" I think, but I admire your advance planning - it's similar to mine. I wouldn't be able to sleep at night if I didn't think I were doing something to be proactive.
        
        However - on the subject at hand- It is within the realm of possibility that the vaccination prioritization will change - and YOU won't be vaccinated. It's possible that an effective vaccination won't be able to catch up with mutations. It's possible that due to some breach or suspected breach in national security - the big nice matrix of who gets vaccinated and when - is thrown away and those able to protect our country and its infrastructure will be made the highest priority, to be followed in some descending order of importance to the government at the time. What we are engaging in is a "nice conversation," but IF a pandemic affects the US, all this input, all the dialogue, all the planning - could be moot.

      • bravo Charlotte
        

        Submitted by Caroline Bridgers on 12/5/07 12:01 PM

        This is the type of creative planning that needs to happen on a family and household basis -- to get us through to the time when there is a vaccine, and allow workers to work but reduce the attack rate overall with other NPIs.

      • Good plan but what happens after a few weeks?
        

        Submitted by Roy Kamen on 12/5/07 02:19 PM

        Charlotte,
        
        Good you have a great plan... but you realize the stores will not be open after a few weeks of a severe pandemic.
        
        Now that you've done a few weeks expand it out to 6-8 weeks then 12.
        Cover your meds, water, heat, security.
        Good luck.

    • Be bold and upfront
      

      Submitted by Ellen Rice on 12/5/07 04:17 PM

      You can prepare yourself and family IF you know what the vaccination strategy will be. If you are certain that you will be vaccinated but your spouse and kiddies will not, then you will put in place a plan (I'll bunk in the basement or You take the kids to Grandma's). But the vaccination strategy has to be made abundantly clear that it DOES NOT include the family.
      
      Otherwise, what will happen is that 500 units will arrive at your hospital and it won't stretch to 500 health care workers. It will cover the administrators (and families) and the docs (and families) and some other folks (LPN's??) will fall off the list.
      

  • Agree
    

    Submitted by Tanya Silva on 12/5/07 07:52 AM

    Need to make the statement before it happens that the only the individual will get vax. That help the person mentally knowing it before hand. I believe that the household of that person should get the vax also. Imaging going to work knowing that your family (includes son wife/husband) will be in danger.
    

    • An upleasant suggestion for keeping families safe
      

      Submitted by Kay Lock on 12/5/07 08:09 AM

      They would be in danger if the worker returned home after being exposed, right? Maybe we will not be able to return home until a vaccine is available for everyone in our family. NOT a pleasant thought, but a safe one.

  • Changes in prioritization
    

    Submitted by Jacob Mbafor on 12/5/07 10:54 AM

    The draft guidelines speaks of equity and fairness, and I agreed that it's better to be certain that the numbers are "WAY OFF" than leave out groups in TIER 1 that would enter without the knowledge of all parties. The message must be very clear and consistent.
    

• Who are the people in the critical infastructure
  

  Submitted by Vicki Duey on 12/5/07 08:10 AM

  Given the situation I believe the prioritization plan is as good as you can devise. The key factor that will change everything is how a deadly strain affects people and who it affects most severely.
  
  We have been holding town hall meetings and joint meetings across the four counties that our public health serves in a rural area. Identifying the critical infastructure in a small community is very difficult. People play many different roles and it is hard to find someone who isn't employed by a critical economic/survival unit such as utilities, government and grocery stores. In some of our rural areas it will not be a choice as was mentioned in one of yesterdays points--if there are no groceries here we will go to the next store. One of our counties has two grocery stores and they are in the same town. There is no place else in the county to go.
  
  Another issue was identified yesterday. If you have vaccine for just the father or just the mother, how can they in their hearts justify taking it and not having vaccine for their children. Logically the fact that they are a critical health care worker makes sense. Ethically and emotionally we will have tremendous problems. Behavioral health needs to be included in drafting not only the priorities, but the ways in which it is all presented in an actual event.
  
  Entertwining the message of social distancing along with the prioritization will be a key to survival. For those who can stay home we will need to make sure that employers have a plan for them to do so. I know that these plans are being encouraged--this needs to be continued.
  As in yest

  • Identifying 'critical infrastructure' is easy.
    

    Submitted by larry wright on 12/5/07 08:52 AM

    There really is only one truly critical infrastructure- generating and distributing electrical power. The grid is the foundation of this society, period. True, you need fuel and food and water and communications, but without electrical power there are none of these things.
    
    If we can protect electrical power distribution, everything else can be dealt with. Volunteers can cook food for the sick. If water flows from the tap, people can disinfect it at home. If the power is on, you will be able to go and get vehicle fuel, and listen to the radio or TV. you will be able to get online and check with your employer, or work form home.
    
    There are workarounds for everything except electrical power. That is the first priority. If we fail to protect that, we're screwed.
    
    And no, I don't work in that industry, I work in a health-care related industry. I would happily give up any chance I might have at access to a vaccine if I could be sure the lights would stay on.

    • Critical Infrastructure
      

      Submitted by MoMos Mom on 12/5/07 09:20 AM

      I agree with Larry on this. If we lose the electrical grid, there will be a lot of deaths that result just from this and the loss of potable water. If potable water is not available, epidemics such as cholera and dyptheria will reemerge as problems.

      • agreed
        

        Submitted by Roy Kamen on 12/5/07 09:22 AM

        100%

  • Consider taking this to "Prioritization in the Critical Infrastructure" Focus Point
    

    Submitted by Laurie Maak   on 12/5/07 09:02 AM

    Please consider moving this really useful conversation to the place where it will probably get most attention: the "Prioritization in the Critical Infrastructure (CI) Group."