DISCUSSION: Prioritization in the Homeland and National Security (HNS) Group

COMMENT THREAD

• How to give your comments the MOST IMPACT
  

  Submitted by Nicholas Dewar   on 12/5/07 06:16 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).
  

• Clarification on the Military
  

  Submitted by Ellen Rice on 12/5/07 06:41 AM

  Deployed Military is given Tier 1 Level A status but only 700,000 folks are listed. Further down (Appendix C, page 31) there are another 1.5 million doses listed for other military. That's a lot of folks combined.
  
  I would rather see Critical Infrastructure people have a higher rating. Our military is spread across 770 bases around the world (Wikipedia). Are the airmen in Thule, Greenland appropriately a higher priority than my local ER docs? It seems to me that the guys and gals in Thule would be strong candidates for Sheltering in Place and avoiding influenza through isolation rather than vaccination.
  
  Again, as on other threads, I ask the question: What is the priority for the family members of all those labeled Critical to our society?

  • Quarantine vs Vaccine
    

    Submitted by Mona Wenger on 12/5/07 07:25 AM

    I agree with Ellen. Who will be affected by the Pandemic first? Isolation worked in stopping pan flu transmission with certain populations that chose this course of action in 1918. Theoretically, this should work for those in remote areas.

  • priority for the family members of all those labeled Critical to our society?
    

    Submitted by Roy Kamen on 12/5/07 07:32 AM

    You cannot expect someone to go into an environment where they could catch and/or bring home a deadly disease, infect and possibly kill their own family. I suspect many would be willing to go to work or help where needed if they knew their families would be taken care of either by having essential supplies delivered to them, pre-positioning adequate supplies in their homes for them (or letting them do it themselves by giving them truthful information about the effects of a severe pandemic), or moving them into the same facility that their family member is working at (like a power plant).

    • Need to Clarify This to Local Emergency Management Organizations
      

      Submitted by Cathy Pinette on 12/5/07 07:43 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.
      

      • volunteering with benefits
        

        Submitted by Catherine Jackie Mitchell on 12/5/07 08:10 AM

        If someone volunteers with the idea that they will receive vaccination, anti-virals or other benefits for themselves or their families should be made aware that their actions have a far-reaching impact when they fail to honor their part of an (unspoken) contract.
        
        Someone who has benefited from receiving protection and then does not show up to work is taking away from those who could receive protection and would show up. A double negative impact.
        

        • Volunteering JUST for Benefits
          

          Submitted by Harold Burchards on 12/5/07 07:05 PM

          As a 20+ year volunteer with WA state Emergency Services I've never met anyone who joined for this reason. There are just too many other hazards involved and people who don't pull their weight are "asked to leave".
          This isn't something I see as a big problem.

          • Harold I applaud you
            

            Submitted by Catherine Jackie Mitchell on 12/6/07 12:34 AM

            I applaud you. We need more people like you. I am being totally sincere when I say this.
            
            BUT
            
            Some of the general public who may step forward, who normally would not, may not have the same motives as you do during a time of national crisis.
            
            Hopefully, there will be more people like you who step forward.

        • Honesty is the best policy
          

          Submitted by David A. Sherman on 12/5/07 07:26 PM

          I agree with both Cathy Pinette’s and Catherine Jackie Mitchell’s comments about clarifying messages to volunteers. This entire process, as has been stated before in this and previous discussions, must be as clear, honest, and public as possible.

    • education
      

      Submitted by Tanya Silva on 12/5/07 07:48 AM

      Good point. Your information raised a question. If this people felt safe going to work. What would happen to the children would they stay home? would they be taking clases at home? Education plan needs action for the long run.
      

      • Pandemic, students, and learning
        

        Submitted by Mona Wenger on 12/5/07 08:56 AM

        Indiana has had quite a few tabletop excercises concerning school closures and one of the questions that keeps popping up is how to continue teaching students. Suggestions have been made such as using the public television channel or some high schools have their own tv station in partnering with the local stations, or good old fashion books. So, thinking on these lines this is another group that would need to be vaccinated first (i.e., media and teachers). That is if another first priority is educating students during a pandemic. If they are provided an education during a shutdown then the teachers will get paid!! This would be an incentive for schools to work on while preparing.
        

        • Students Prep America
          

          Submitted by Roy Kamen on 12/5/07 09:24 AM

          A group of Columbia University College students created Students Prep America at
          www.studentsprepamerica.org
          to help educate college students and administrations.

        • Preventative
          

          Submitted by Alison Lee on 12/5/07 11:52 AM

          I agree that if we are prepared with ensuring that our educators have knowledge and receive the vaccine during the first tier it would then show to parents that we are prepared and here for them. Teachers would then continue to be paid through other check ins with parents such as phone conf. calls.etc.
          
          Why is this not rolled into our Emergancy training programs and part of what we need to sign off on before receiving our certificate?

          • Preventative
            

            Submitted by Sherry Williams on 12/5/07 12:02 PM

            In Texas, some schools are funded based on attendance so how would that play out in this instance sicne the children would not be actually attending a class? What if families don't have a phone to participate in conference calls? Continuing to educate students is a good idea but just not sure how it would work for all students.

        • Preventative
          

          Submitted by Alison Lee on 12/5/07 11:52 AM

          I agree that if we are prepared with ensuring that our educators have knowledge and receive the vaccine during the first tier it would then show to parents that we are prepared and here for them. Teachers would then continue to be paid through other check ins with parents such as phone conf. calls.etc.
          
          Why is this not rolled into our Emergancy training programs and part of what we need to sign off on before receiving our certificate?

        • Preventative
          

          Submitted by Alison Lee on 12/5/07 11:53 AM

          I agree that if we are prepared with ensuring that our educators have knowledge and receive the vaccine during the first tier it would then show to parents that we are prepared and here for them. Teachers would then continue to be paid through other check ins with parents such as phone conf. calls.etc.
          
          Why is this not rolled into our Emergancy training programs and part of what we need to sign off on before receiving our certificate?

        • Preventative
          

          Submitted by Alison Lee on 12/5/07 11:53 AM

          I agree that if we are prepared with ensuring that our educators have knowledge and receive the vaccine during the first tier it would then show to parents that we are prepared and here for them. Teachers would then continue to be paid through other check ins with parents such as phone conf. calls.etc.
          
          Why is this not rolled into our Emergancy training programs and part of what we need to sign off on before receiving our certificate?

          • Educators and the Vaccine
            

            Submitted by John Carney on 12/5/07 02:53 PM

            I'm not certain why Educators would need to move the first tier. If those who are single and choose to go to work (or stay home and webcast on their webcams) they are no more at risk than anyone else. If the virus mutates to such an extent that it becomes a severe pandemic (with an AR of 30%) that means 70% of people don't get sick. Many educators would be in that group - otherwise healthy midlifers (not eligible for the vaccine). If they are at home caring for their kids who are out of school or ill, they can either teach from there (via webcam or conference calls) or just be at home to tend to their families. I'm not understanding the need for higher status for them.

            • Are we really prioritizing no one?
              

              Submitted by David A. Sherman on 12/5/07 07:57 PM

              This entire discussion regarding 1st-tier status for teachers only emphasizes the dilemma of vaccine allocation, and the need for a process like this to develop a clear policy. It really does take a village to raise a child, and only the people in that village who are healthy enough can help do so. But at a certain tipping point (as with the question of early vaccination for families of high-risk workers), we start to talk about prioritizing everybody. We could take this even further: parents are also necessary in childrearing, and thus a part of maintenance of social order (Note that Secretary Leavitt has said that priority for treatment in a pandemic should go to those who keep society going; this would have to include parents). Unfortunately, with limited vaccine supplies, prioritizing so many means prioritizing practically no one. (Full disclosure: I'm a direct caregiver, and parent of a teen and a 10-year-old)

      • Education During Pandemic
        

        Submitted by Christine Kardong on 12/5/07 10:14 AM

        I work in the field of basic education. We have a pandemic preparedness plan... and when it comes to educating children during a pandemic, the plan simply says, "Plan to keep moving children forward with 'no child left behind.'" In other words - it's up to each school district to work it out. In my district we have a lot of technology that would help us - to post assignments on our web site, to email back and forth between home and school, etc. We know we can do it if we have to.
        
        But, if a pandemic were to reach the "science fiction" level of severity that appears to be possible, we have a hell of a lot more important things to do than email assignments home. We'll have to worry about whether or not we have little ones at home sitting with dead parents.
        

      • If infrastructure is down
        

        Submitted by Cindy Deutsch on 12/5/07 02:09 PM

        School districts should also think about what they would do if the grid goes down and they are unable to communicate with their students via email & television.
        
        They could send packets home with kids at the begining of a pandemic. Maybe they could have worksheets for math - books to read for language arts, etc. It wouldn't be perfect but it would keep their minds working.

        • THE GRID MUST STAY UP
          

          Submitted by Roy Kamen on 12/5/07 04:53 PM

          THE GRID MUST STAY UP

          • Does anyone here know how much of the grid is automated?
            

            Submitted by David A. Sherman on 12/5/07 08:00 PM

            Or how long batteries can last in a laptop?

            • Laptop Batteries
              

              Submitted by Tammy Brown on 12/6/07 08:46 AM

              Laptop batteries usually last (depending on the age of the battery) 1 1/12 to 2 hours before dying. There are some other alternative methods I've used during week long power outages. Use a converter to connect to your vehicle, this will charge you laptop battery and allow you to use the laptop at the same time. Be careful.....you may have issues with gasoline usage. You can also keep a spare car battery for such a use, but it can be tricky if you don't know how to hook up the converter directly to the car battery.
              

    • Family should be first priority
      

      Submitted by Timaly Shepherd-Miller on 12/5/07 07:58 AM

      I agree. Most individuals regardless of who their employers are will not leave their families and homes unattended in the event of any major disaster or pandemic. Service begins at home and escalates abroad, so unless their is an actual plan where families will be housed in the event a pandemic occurs we may all be confined to our homes.
      

      • Right Timaly - we may all be confined to our home
        

        Submitted by Roy Kamen on 12/5/07 11:30 AM

        Timaly said "Service begins at home and escalates abroad, so unless their is an actual plan where families will be housed in the event a pandemic occurs we may all be confined to our homes"
        
        And we'd better have the supplies we need there ... 6 month sis a long time to wait for a vax.

    • Prioritization and Hard Choices
      

      Submitted by Tammy Brown on 12/5/07 09:42 AM

      As I have looked at the prioritization and thought about the number of individuals that will die and those that will live. I have to set all emotions aside. What I am about to say some of you probably will not agree with and you may believe that I am being cruel. With this you have to consider who will die. Those who have lived a long life, those who have not experienced life yet, or those who are the majority of this nation and will be here to raise the children who's parents don't survive.
      
      Tier 1 (IMHO) should remove high risk population. Add other healthcare from critical occupations tier 3.
      Tier 2 (IMHO) should remove high risk population. Add critical occupation from tire 3 including other CI sectors and active duty.
      Tier 3 (IMHO) should be Healthy children, adults ages 19-60 years (including pregnant wormen), and other govt.
      Tier 4 (IMHO) should be infants, toddlers, infant contacts, high risk children
      Tier 5 (IMHO) should be high risk adults and elderly (ages 61 and up)

      • I empathize
        

        Submitted by Catherine Jackie Mitchell on 12/5/07 09:51 AM

        Tammy, this is tough isn't it?
        
        I understand where you are coming from with this. I have wrestled with this issue from an ethical stand point.
        
        I also see merit in what you are saying and can almost agree with your suggestions. I am a tier 5'er by definition and by choice..whether I remain there depends on what I am called to do. Many people would gladly give up their higher tier status for others.
        
        Another consideration is the impact on our social psyche. That remains a consideration, at least for me.

        • Empathy
          

          Submitted by Tammy Brown on 12/6/07 09:02 AM

          Catherine,
          Honestly, I don't believe that whatever tier I fall into (right now tier 5) myself, my husband or my children (tier 3 ages 8, 9, 10 and 15) will be vaccinated in the first or second waves of a pandemic.
          
          In consideration of our social psyche, I know many will lose their parents and loved ones. If I have to choose losing my parents or having a child lose a parent, I will choose my parent. Our nation is already struggling with foster care and orphanges, and the saddest part of that is the children are the ones struggling and paying that price. Worst of all our Nations systems are struggling with this and losing.
          
          My heart and my head fall to Darwin's survival of the fittest. If we ensure those children and partents survive then that would hold this countries largest population. It's not fair and it's not right, but we don't live in a perfect world. That is why the public doesn't make the decisions for who is vaccinated first.
          

      • Prioritizing groups
        

        Submitted by John Carney on 12/5/07 03:10 PM

        Tammy - You seem to be arguing for what I think may be called a "complete lives" approach a very sophisticated and defensible position, but I think based on a more pessimistic projection of vaccine availability, and higher CFR and AR attacks rate than 3/30%. While that may happen, the experts in yesterday's discussion allayed my fears about that more negative scenario and I'm becoming more comfortable with the HHS recommendations.
        
        If 70% of the population never gets infected and less than 3% of those infected die, we need to pay more attention to those who are vulnerable.
        

    • Germ carrier
      

      Submitted by John Carney on 12/5/07 02:56 PM

      Are you suggesting that someone who is vaccinated will carry the virus back home and infect their family members because they have been exposed but do not themselves come down with it. Maybe I don't understand the meaning of human to human contact.
      

    • We can't prioritize too many people
      

      Submitted by David A. Sherman on 12/5/07 07:18 PM

      Family members of high-risk employees are certainly a concern, and one that may limit the work of those responsible for maintaining society and healthcare itself. But the problem is that if we vaccinate those relatives and close contacts too, at the early stage when supplies are limited, we'll almost surely outstrip the supply we have at that stage. At that point discussions like this one become essentially moot.

      • Prioritization
        

        Submitted by Donavan Merck on 12/6/07 02:24 PM

        I haven't seen the plan for prioritization within prioritizations. Will the Emergency Room Doctor and nurse receive vaccination before the doctor/nurse who deals with patients after admittance? Yes, this may involve a too-detailed plan, but if these kinds of decisions aren't made up front, I see a lot of in-fighting among staff on the topic of "Who Gets It First." Yes, we love our fellow-man, but when it comes to survival, will we be so docile as to say, "You go first within our tier; I'll be last"?
        

  • Categorization within Tiers: Which subsets come earlier?
    

    Submitted by Brant Goode   on 12/5/07 08:16 AM

    Hi Ellen,
    
    See the draft guidance description of 'sub-prioritization' of Tier 1 on page 11: ED docs and others come even before the first 700,000 of the military listed. It strikes me that you'd concur with this recommendation, right?
    
    Brant

  • Clarification on the Military
    

    Submitted by Jeffrey Duchin   on 12/5/07 02:13 PM

    The 700,000 figure is an estimate for deployed and mission critical personnel. Other groups, including national Guard and border protection personnel, make up the balance of the 1,500,000. This corresponds toe the "essential personnel" of the military and national security sector.
    
    Critical infrastructure has very high ratings in all scenarios where shortages of critical infrastructure personnel are anticipated. Because of the limited supply of vaccine, the current plan does not allocate vaccine to family members of priority personnel. If that were done, some of the people currently prioritized would not be able to be vaccinated.
    

  • Military must stay mobile
    

    Submitted by David A. Sherman on 12/5/07 03:01 PM

    I take your point about local ER docs outranking isolated soldiers, but I'm not sure we can mandate the latter's Sheltering in Place. In a pandemic they may have to redeploy, to the 50 states or abroad to provide relief--it wouldn't be the first time the US military would provide foreign relief--or to defend against an opportunistic attack by a foreign adversary (which may not have been hit so hard by the pandemic at that point). For that reason they have to maintain their mobility to flu-stricken areas.
    
    At the same time, young soldiers are likely to have been screened for significant medical history, and serve based in part on their lack of comorbidities. This may make them lower-risk than the comorbid civilian population, and thus unfortunately put them lower on the priority list.