The Children’s Crusade – Special Guest Blog by Pixie

Introducing the new government-approved meme going forward into this pandemic of novel influenza, courtesy of Matt Cartter and your CDC:

Quote:

“The best place for sick children is at home.

The best place for well children is at school”

Yes, really.

Yesterday I attended a meeting hosted by our public health folks here in CT on H1N1 entitled “Illness and Outbreaks in the School Setting.” The title of the meeting is a big clue as to the strategy which public health will apparently be following going forward. The meeting was not focused on closing schools, a strategy that many of us have become familiar with from prior CDC NPI guidance documents. Rather the focus has now moved to managing outbreaks “in” schools, and at this meeting our state public health folks were going to attempt to explain this to our local public health people. school nurses, and district superintendants.

This was no sparsley attended meeting – the ballroom secured for the meeting at SCSU was completely full. The audience was about evenly split between those from the public health community and school administrators. More than 300 people attended from CT’s 169 towns, which speaks to a great level of interest in this subject. It’s clear that people are looking for guidance on the H1N1 pandemic issue.

Matt Cartter, the CT state epidemiologist and frequent collaborator with CDC on such things as the Pandemic Severity Index spoke for an hour.

The first slide in Cartter’s powerpoint presentation reveealed the new meme, as noted above.

On the topic of school closure, Cartter stated that there is “lots of room for debate” on the issue. Now, I could be wrong, but I was under the impression that any number of studies left little doubt that school closure was a very effective NPI. Cartter did not further defend his statement, but just let it lie.

Cartter argued that one must weigh the benefits gained in decreasing “morbidity and mortality against the benefits of keeping our children in school.” As a Board of Education member, my first thought in response to that statement is: which kid? Which child’s “morbidity and mortality” are we weighing, exactly?

Cartter then listed several types of school closures. Schools can be closed fully, the children remaining at home. Or, the children can be dismissed while the administrative staff remains at work. Japan tried this recently, he noted. In this case the teachers would remain at work and would reach out to the students during the closure, checking in on them, assisting with homework, and maintaining contact. In a third model, a reactive closure, too many kids and staff are out sick to make ongoing education unproductive or impossible and the decision is made to close. Alternatively, in a proactive closure schools would close in advance of a projected severe outbreak, and would remain closed from between 4 to 6 to 8 weeks. Cartter noted that this is “what is recommended” for a severe “Category 4 pandemic.” It should be noted that the Pandemic Severity Index itself has been handily revised quite recently, as have the recommendation for school closure of this nature which were in the past recommended for a Category 2 pandemic.

Also brought up by Cartter were partial measures such as moving to half-days, keeping the children at school but reducing their trips to the cafeteria. Cartter again noted that there is much debate on these issues and I’d maintain that there might indeed be a lot of conversation about them, but the studies and the science have already been done and if one is interested in outcomes, rather than conversation, it’s quite clear that proactive school closure is the only measure that objective data indicates is effective, and those studies indicate that it is quite effective in both mitigating community spread as well as morbidity and mortality in the students.

Cartter then turned to the “consequences” of school closure and maintained that there was a real worry about: “What do kids do when they are not in school?” I think this is a terribly transparent red herring. We close schools for the summer because the weather is nice. Which reason, given a moment to pause and apply logic, would you choose to close your neighborhood schools? Because a virus is circulating that has some not negligible risk of severely affecting the health of your student population and maybe taking one or two of their lives? Or because it’s sunny outside (or it’s time for Santa or the Easter Bunny or George Washington’s birthday?). We close the schools. We close them for reasons far, far, less critical than because a serious illness is widely circulating. The kids are fine. We get most of them back after winter break or summer vacation with nary a hair out of place. If that’s not the case, I’d like to see some studies on that which are at least as convincing as the ones that resoundingly state that school closure is a critical and highly effective mitigation strategy for pandemic.

As if anticipating my remarks regarding the necessity of keeping our children safe, first and foremost, Cartter then went on to compare our current pandemic of H1N1 to previous pandemics in 1918, 1957, and 1968. “This one,” he asserted, “is like 1957” when they “did not close schools.” Cartter then stated that what is needed now is an “appropriate response” to risk.

Next, Cartter moved on to the vaccine issue. He stated that they were “moving ahead” with vaccines and that they would be available in “mid-October.” Specifically, he stated that between 80 million to 160 million doses would be available in mid-October. Throughout the day, it was stressed that two doses would be needed. He then reviewed the 1976 swine flu incident. My reaction to Cartter’s statements to this audience of local public health people and school administrators was that it was disingenuous, at best, intentionally deceptive, at worst. Since we’ve seen no federal official stake their reputation on anything like this assertion – in fact, last time I checked Sebelius was still using the qualifier “if” in every other sentence when discussing the subject of a national vaccine program – I have some serious doubts as to whether Cartter’s assertions are based in fact, and wonder if they are not, what his purpose of “sharing” them with this audience was.

Questions were then taken from the audience. One person asked whether anyone will be requiring vax for our school children. Cartter answered in a roundabout way, chatting about the history of flu vaccines (they were once reserved for the elderly, but with new thinking are recommended for children too), and of NJ’s move to require a yearly influenza vaccine as one of the panel of vaccines which are mandated as a condition of enrollment in its public schools. In the end, I am not sure whether this question was really answered or not.

A question was asked about whether FDA approval was going to be given for this vax, and I’m not sure that question was really answered either. Cartter stated that the “goal is” to get the “vax out in October.”

The question I was about to ask was then asked by someone else. They wondered what was being done for our at-risk children, and whether any guidance was in the works on that important subject. Cartter answered that “we’ve struggled with this issue..” I’ll bet they have, since NCLB legislation requires that educational opportunities be extended in an even-handed way, and that presents not a few problems for treating this population differently.

Cartter then explained, quite forthrightly actually, that they are “trying to change the debate.” He stated that the issue they were working on now was: “Not how are we going to close schools, but how are we going to keep them open?”

Yes, the new government initiative in the midst of a pandemic is, quite officially, to attempt to find ways to keep schools open. This is the new thinking from CDC, Cartter reported.

How will they do this? Well, school nurses will be put on the front lines under this strategy. If a child gets sick, they will be encouraged to see their doctor and get treatment with antivirals (which, nevertheless, from what I am hearing nearly everyone is finding difficult to get prescribed) at the first sign of illness. The nurses, Cartter explained, getting back to the question about our high-risk students, know who the high-risk students are within their school populations. The implication is, apparently, that somehow this knowledge and fast thinking on the part of school nurses will save our medically at-risk children from suffering the worst effects of a circulating pandemic strain that has demonstrated that it presents significant risks of morbidity and mortality for this student population. I found Cartter’s answer, and his proposed strategy, to be wanting in the extreme. I say that as a Board of Education member responsible for the safety of the children in our district, as someone all too familiar with the toll that this novel pandemic strain has taken on medically fragile children already, and as a mother who cannot imagine that any other mother who might have a child at risk would find this answer adequate in any way either.

A question was then asked about fomites and how much cleaning had to be done to schools after outbreaks. Cartter maintained that the “virus survives only a few hours” on surfaces. He assured this audience that once a school is closed at 5:00 p.m., by 8:00 a.m. the “virus is cleared” from the environment without any special cleaning advised, and the implication is that school can continue in session, uninterrupted, even if cases arise. No citation was given for this assertion, and I am not at all clear where Cartter got his idea that the influenza virus was not viable on inanimate surfaces within 15 hours after contamination.

A similar question was asked about whether flu is, indeed, contagious before symptoms and Cartter again demurred to his ‘there’s a lot of debate about that,’ deferral and then stressed that most transmission comes from droplets while people are symptomatic. Again, the science gets short shrift in the interest of “risk communications” and clean sound bites. Fortunately, the audience at hand was aware, and aware enough to ask the question and likely wonder about Cartter’s answer.

The next speaker was our outgoing DHS official, Skip Thomas, who will be retiring shortly after 40 years in emergency management and DHS.

Governor Rell made some brief comments. After some general comments about the pandemic, she asked: “Do we close schools?” To her credit, the Governor’s answer was: “Sometimes you just have to use your own common sense.”

I felt like jumping up and cheering, and yelling that somebody should put that lady in charge, but I guess she is in charge. My hope, going forward, is that she thinks for herself and makes use of that common sense.

Rell noted that one consideration was whether we would loose funding from Washington if we make the decision to close. During the July 9 summit in D.C. on pandemic H1N1, that was the question that Rell posed to the feds. She reiterated yesterday that the feds stated that they would give a “blanket exemption” to those who choose to close. However, the Governor also noted that the state legislature did not adopt any exemptions for schools that chose to close this past spring and since we have legislated requirements for hours and days of instruction, that may be an unresolved issue going forward, particularly if decisions on school closures are made independently at the local level. What I’m hearing is that there is some “debate” at the state level over whether the districts that are made up of our 169 very independent-thinking towns should, in fact, be allowed to make the decisions they feel are best, using as Governor Rell put it, “their common sense,” without penalty. Rell is in favor of this kind of local autonomy, but it’s not clear that our state department of public health nor our legislature are firmly behind the idea. This may, then, lead to punitive measures — to the schools, that would mean the withholding of funding and a great deal of red tape involved with remediation of lost instructional time – should a school district wish to break from the pack and, for example, close in an effort to protect its students while most other districts remain open.

A panel discussion followed, with public health officials and school administrators offering a narrative of their experiences of their first H1N1 cases back in April. While offering interesting anecdotes, I couldn’t help but feel that these experiences would bear little similarity to that which our public health and school administrators in the audience will experience in the fall. Focusing on the occasional and rare student with a then-rare illness does not, it seems to me, do much to prepare the listeners for the onslaught of cases they are likely to experience in just a few short weeks. It would have been far more educational to have invited someone from the Coast Guard Academy in New London, CT, to educate us about how that outbreak in which dozens of students have become ill is unfolding in real time this week.

One recurring theme throughout the day was that of HPPA privacy laws. Both administrators and public health officials said that they were sometimes the last to know exactly which student had become infected, even as it seemed the rest of the town knew. Both physcians and patients’ families have at times been speaking to the press before they inform the public health department or the school district, something which caused the officials on the dais no small amount of consternation. The subject of potential fatalities was never mentioned – really rather surprisingly – nor any mention of how to handle that. In fact, the word “fatality” was not used at any time throughout the day, nor was any word like it. I don’t think these local officials have been assisted in preparing for how to handle that inevitable sad eventuality. The time spent focusing on the anecdotally interesting “first” cases might have better been spent reviewing the classes of at-risk children, of the kinds of complications they are encountering, and of the not-insignificant public communications challenges surrounding the deaths of these children from H1N1 which have already occurred.

One side conversation I had was with some school nurses who were concerned that patient confidentiality be maintained, and that the confidentiality of what was happening at their school be maintained. I had to interject, at that point, and ask to what end, and whether it wasn’t true that while individual student information was private, any report about the facility as a whole was something available to the pubic under FOI legislation. The nurses disagreed, and thought that these statistics on illness were supposed to be hidden in order to “protect the institution.” Well, said I, I think that’s a fair use if the institution is a private one, a private company. But in the case of public institutions like schools, where the public is the owner, who, exactly, would you be protecting the institution from if you fail to release this key information? It seems to me that you’d be protecting the “institution” from it’s “owners.” The nurses didn’t want to talk to me any more after that, but I’ll be ringing up our state FOI guy to get a little more clarification on these issues. If there is not clarification forthcoming, these local public health and school administrators will be tripping all over themselves, and each other, when they have to deal with serious outbreaks, students in ICU’s, fatalities, and burgeoning parental concerns. They need to get ahead of these issues now, and handle them well, or as local officials have already learned, the community will handle them for them in a very ad hoc manner. My suggestion is that transparency and honesty be the prevailing rubrics, but what do I know as someone who thinks that’s simply the best model for any “risk communicator.”

One Spring outbreak that was mentioned is being studied further. A group of Greenwich middle schoolers took a trip to a nature camp in northern CT. On May 20, 55 of them reported to the camp infirmary with illness. 19 of the students were very sick. A very broad spectrum of disease was shown. In spite of the fact that Greenwich is intimately tied to NYC where the novel pandemic was clearly circulating, the public health official stated that everyone “had no idea what was going on, at least I didn’t.” She did not think it was H1N1. It was. In the end out of 133 kids, 73 students in the class (not all of whom had made the trip) became ill, 39 had no illness, and they do not have stats for 22 students. I thought this might have been a good time to raise the subject of just how rapid and widespread the spread of this novel virus can be, and of the implications of that should we see greater severity, but that angle was not stressed (at all) and in fact the issue of potentially increasing severity hadn’t been raised at all so far that day.

Next up was a little seminar on “risk communications.” The “Three C’s” were stressed: “Communication, Cooperation, & Community.” They noted that “communication can add to a crisis.” The emphasis was to be put on communicating what you do know, and on stressing that if you don’t know something describing what you are doing to rectify that. I think all the suggestions given were good ones, but still fail to see the critical topic of just *not* sharing information with the public not because an official does not know it, and not because the official is not quite done pursuing that knowledge and wants to explain that, but because the official has determined that somehow the information is ‘harmful’ for the public to know, and so won’t be sharing it for that reason. These reasons are myriad, and can range from excuses like ‘the pubic will misunderstand,’ to ‘the pubic will panic,’ but there are many of these excuses, they are the reality behind many public communications fiascoes, and they are not much discussed in the open, as they were not here.

Some attention was given to what the speakers termed the public’s reaction of “frenzy” when the pandemic began to circulate in the Spring. One speaker noted that it was “almost frightful how things can turn” noting that what they termed “powerful forces” arose. Again, speaking about the public, it was stated that “logic and emotions” that were not appropriate surfaced.

In terms of decision making about school closure, it was stressed again that the state Board of Education would make an exception to the rules about required days and hours of instruction “only in extreme emergency.” Communication is critical in the effort to keep the schools open, they stressed, and they noted that teachers are “key communicators” with parents and a “powerful” source of information for parents as to “what is going on.” So, it looks like our school nurses and our teachers have been drafted into the front lines of defending the decision to keep schools open, and to be key managers of the process the higher-ups have put in place, as well as being tasked with primary communication of the defense of this decision.

For managing the news media, it was suggested that communicators “go over any questions ahead of time.”

I was thinking ’round about this time that a great deal of time and talk had been thus far expended on discussing strategies as to how to ease the path for our decision makers but not much time at all had actually been given over to strategies as to how to keep our students SAFE. Little attention, nearly none at all, was given over to talking about the actual health of our students, of the kinds of experiences they might have with this illness, about who was foremost at risk and why, and about the real potential for fatalities that this novel strain poses to our student population. Nothing at all. Nothing. No education, and not a lot of concern was evinced on that point on the part of our public health leadership, frankly.

The final question and answer session then ensued.

Some had questions as to how the new pandemic strain (always just referred to as H1N1) would be able to be differentiated from the seasonal flu. It was noted that no testing is done now in CT on patients presenting with flu symptoms outside of those hospitalized. If someone is really curious about whether or not they have H1N1, it was noted that the option of ordering a private test for about $300 is open to them. Nothing was mentioned about the respective antiviral resistance demonstrated by this H1N1 (to amantadine) and the usual H1N1 (to Tamiflu). Questions were asked about whether it would be wise to vax children with the seasonal vax and the pandemic vax at the same time. The question was kicked under the table for reasons you might intuit (the availability of seasonal vax and the unavailability of pandemic vax being the primary unspoken reason). The notion that we may see this H1N1 beat out all our other circulating strains was only floated as a possiblity after several questions of this nature. I think the idea is to offer up to local public health officials and school nurses the idea that they will be busy “doing something” and that something may be vaxing for seasonal flu, whether or not it is apparent that it is needed, as an alternative to answering the public with “we’re waiting for a vax, there’s nothing we can do right now.”

The next audience question prompted Cartter to further flesh out the new meme: “The best place for sick children is at home. The best place for well children is at school.”

There are, it seems, at the present time public service announcements in the works both at my state level and, Cartter disclosed, at CDC which will repeat this message to the public.

Yes. The big campaign going into the Fall, into the first Fall/Winter with a novel pandemic virus circulating, will be to keep your kids in school unless they are sick.

This will be a national campaign.

That’s right.

Cartter reported that they may want to use schools as distributions points for vax, but noted that the new idea may be to make use of them after hours — in the evenings and on weekends — for distrubition of vax to the wider community.

That’s right, so members of the community not yet infected by the virus will be entering the greatest viral amplifiers within their community to receive a vaccine that is, admittedly, not effective on the first round. They will be vulnerable to infection until the second dose takes effect. You do the math.

Cartter then reported that at CDC’s low estimates, we’ll get 480K doses of vax initially. That’s a probelm, he admitted, since we have 600-700K school age children in school here in CT. Given that 160 million doses of vax are produced nationally initially the amount allocated for CT will be 1.8 million doses (we have a population of 3.5 million).

A question was raised about severity, and the differences in severity between seasonal flu and this pandemic influenza.

In response, Cartter listed several of the differences between seasonal flu and this pandemic flu that had nothing to do with severity. He noted that pandemic flu comes in waves, it can circulate outside of normal flu season, and that it can affect different age groups than are normally seen for seasonal flu. In addressing the issue of severity that was raised, Cartter said that it was “very unpredictible.” While he had plenty of charts and graphs incorporated into his presntation, he had nothing on this and offered no data to this audience that would effectively answer the severity question (of course, he could have, we well know that). He did not mention the percent of people being treated that need hospitalization, nor the percent of those hospitalized requiring ICU care, nor the percent of those in ICU requireing full mechanical ventilation, nor the number of pregnant women who fall into those categories, etc. The data is there, but Cartter failed to share that critical data with this audience of decision makers.

Cartter then stated that they would have to “adjust the response” according to severity, but again, little guidance as to how to do this, or objective data on what those standards might be, or how close or far away we are from them, was offered.

While Cartter was away from the podium for a moment I asked what was being done to prepare PSAs for the fall and winter in the event that we see an uptick in virulence. Since the state and CDC are working on the “send your child to school” PSAs, given that we don’t know whether or not virulence might increase, but experts seem to agree that it can, what are the state and the CDC preparing in terms of PSAs for that eventuality? I asked whether any such efforts are being undertaken now or whether they would instead be “reactive”? The responder had a very difficult time answering, wandered off to say things like ‘we have done a lot of work for disaster response’ and didn’t really answer the question (likely because nothing at all in this vein is being done on this at this time). Real answer: they are planning for only one model going forward so it’ll be a reactive hodge podge of response by the seat of our pants when things change.

A question was asked about whether the vax would be effective should the virus change. Cartter replied that “we hope so.” He explained that each year the flu strains change, but that CDC has reported that this particular virus seems “remarkably stable.”

An audience member remarked that there was a lot of anger among parents that they could not get their children tested. Carter responded that “that tells us a lot about ourselves as a society.”

My first question to Cartter related to a remark that Superintendant Viccaro, one of the panelists, made. She had mentioned earlier that she’s trying to create some protocols for her district with regard to medically at-risk children. Since I was planning on urging my district to move rapidly in the same direction, I noted that it’s really rather redundant to have 169 individual towns draw up recommendations like these on their own, and suggested that it might be better that the state do that. I then asked what the state was doing about this, where they were on such protocols, and the response I got was a lot of hemming and hawing and a suggestion that they were looking into looking into that. No promises of actual protocols were made, nothing firm. I think that’s because if they spell out the risks to our at-risk population in such a guidance document, it will become abundantly clear that we are not dealing with anything “just like seasonal flu.” They are loathe to do that.

A question was asked as to why the guidance was changed from urging that sick kids be kept out of school from 7 days (now I think it is “24 hours symptom-free”). I’m not sure a clear answer was given to that.

For my last question, I thought it was prudent to bring some clarity to a subject on which I felt they had spent a great deal of time but on which they had been terribly misleading – vax. I noted that as far as my understanding went, “if” the decision was made to move ahead on a national vaccine campaign, the “first” doses of vaccine would be available in mid-October, but that they were reserved for Tier One under the priority distribution guidelines, not our school children. I asked when, exactly, they expected to begin to vax our general population of school kids, and when they expected that effort to be complete. I also added just how that vax would be distributed by the state, since my understanding was that vax would not be available all at once but would instead be rolled out gradually as it was produced. Are they planning to vax children as the vax becomes available? If so, how will they determine which districts get their vaccines first? If not, are they then planning on waiting for all the vax to be produced or perhaps stored up in Hartford so that it can be distributed all at the same time, “equitably,” and if so when do they project that that would be?

What I was trying to do is point out to those attending that vax for their school kids will *not* be available on October 15 as was broadly intimated. I simply wanted to ask the listeners to think more clearly about this issue, to apply their own logic. Vaccine will not be a panacea, and for many of the public health folks in attendance that issue of fairness in distribution may in fact cause more complicated problems for them than their leadership is willing to mention, let alone step up and assist them in solving. For school administrators, it was necessary to dispel their impression that if they can make it to the vax distribution date of Oct. 15, their problems will be solved. No, they won’t, and they shouldn’t be expecting to receive vax on Oct. 15. The answer I got to my question, by the way, was that yeah, the vax will in truth be rolled out and not available all at once, they don’t know how they’ll handle that, if they will hold it or distribute it as it becomes available or under what criteria for which children in which towns they will release it, but they have two (not one, but two) task forces “working on it.” Meanwhile, I suggest they cease offering up vaccines as the ultimate solution. The promise of vax is, in reality at the moment, only useful for their “risk communication” purposes. If they are going to go ahead and talk about it, they might as well be honest about dates, particularly when discussing the issue with key decision makers.

Again, the subject of severity arose and someone asked a question regarding possible school closures in the event of increased severity and whether any work was being done to ensure that education of our kids could continue in some way outside of school while the school are closed. Cartter responded that this is a “difficult line,” that there are “issues around equity” to be concerned with. He then said that we should look to the CDC as the “Holy Grail” for guidance on all these issues.

Yes, he really said that. I’m going to go get out my worship robes any day now.

Now, what CDC has to do with continuing education for our students I don’t know. Isn’t this an “education” issue, and don’t we have federal, state, and local departments of education who are tasked with this issue? When, exactly, did CDC start running the entire country, if I may ask?

Another moderator jumped in at that point, possibly sensing that Cartter was one step away from ufurling Third Reich-like banners and cueing the band to start playing marching music. The Alternative Voice of Reason then said that “no one can know our community” better than you, and that this is “not a one-size fits all” situation.

Thank you, Alternative Voice of Reason.

We ended on that note, somewhere between the forces of facism and common sense. Where exactly on that continuum we are at present, and where we’re headed in the future, I’ll leave for you to decide.

After the event, when I went to the student center’s Dunkin Doughnuts and lined up for a cup of ice tea, the nice young man behind the counter remarked that I was holding my face and my head in my hands like it might explode. I told him that he might not be wrong, and that maybe he should stand back. I think I may have looked a bit like the character in that Edvard Munch painting, “The Scream.”

We’re going into this Fall/Winter pandemic by the seat of our pants, strategy-wise, with no advisory planned for what to do if and when things turn more dire than they already are. Why should we think that Cartter et. al will close the schools at “Category 4” when, when faced with that reality this time around, they just changed the scale itself and its definitions? How much confidence does that engender?

Our at-risk students will remain unprotected and may possibly be disenfranchised as, four months into this pandemic and with that population clearly at risk, no one has prioritized their safety and survival (so much for that “Holy Grail” CDC caring much, in reality, about “equity”). We face a situation where 30% of the fatalities from the CURRENT circulating strain have had no underlying medical conditions, making it impossible to determine which child in any given school population is likely to be lost from this disease.

We are apparently marching forward, firmly adhering to our new meme, one that sounds so great and one that is in opposition to all the clear-thinking pandemic mitigation guidance that came before. Our kids (along with our school nurses and our teachers) are being placed on the front lines while the generals plan the next moves at elegant soirees far from the battlefield. Just what really is this battle about, I have to wonder, and for just which interests do they labor? What kind of leadership is this, really, when the costs of whatever gain they posit will be borne by the most vulnerable members within our society?

I leave it to you to decide if what was discussed, what they failed to discuss, and the direction our decision makers have apparently decided to take our children in is the prudent one. Sorry to have made this post so long but I think it is important to let you consider what was said and as a result you’ll figure out for yourselves what was not said, and be better able to draw your own conclusions yourself.

By the way, when the questions began to get dicey the moderator glanced at the time and suggested that then might be a good time for any who needed to leave to do so. No one left. No one made a move. There is great interest out there in this subject. Now, the question is to how to bring those who are interested accurate and complete information. They want to make good decisions, they really do. I heard a lot of care and concern in that audience, a lot of really smart, good, questions and that is the most positive takeaway from the day.

All the powerpoints made during the presentations yesterday are available at:

http://www.ct.gov/ctfluwatch/h1n1/july22

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