Reduction of pandemic deaths with school closures – empirical evidence from Japan

There is substantial evidence that school closures decrease the number of people infected with influenza. So, it is not surprising that a new study from Japan demonstrates the striking effect of this variable on the number of deaths from pandemic H1N1 in Japan and the United States. In my recent blog on the Incidence of death for 2009, I reported an incidence of death per 100,000 people of 0.9 for the United States and 0.1 for Japan. The authors sought to explain the strikingly low number of deaths found in Japan with respect to other countries, including the United States.

In Japan, Tamiflu is prescribed quite readily, even for seasonal flu. So, this may be one possible factor in the lower mortality there than in other countries. However, the authors of the Japanese study also found that many fewer young people became ill with influenza in Japan as compared to other countries. There is one obvious possible explanation – more extensive use of school closures in Japan. From the study:

In the previous section, we showed that the epidemiological characteristics of pandemic H1N1 are unique in Japan, which may have kept the CFR low. The main question arises: why are there unique epidemiological characteristics in Japan? The majority of cases have occurred in age groups of 5–9 years and 10–14 years (Figure 1). In general, children in primary school are aged between 6 and 12 years, and those in junior high school are aged between 13 and 15 years. Therefore, the current age distribution of cases indicates that the majority of pandemic H1N1 cases in Japan have occurred among children in primary and junior high schools. Both pandemic and seasonal influenza outbreaks often start as school outbreaks, which often become a trigger for community outbreaks. This is why early school closures or suspension of classes can be effective in reducing transmission into the community. In Japan, suspension of classes is commonly implemented even for seasonal influenza. For example, during the 2006–7 influenza season, 14,103 institutions (including day care centers, kindergartens and primary, junior high, and high schools) suspended classes. An even more aggressive suspension of class policy has been implemented for pandemic H1N1 in 2009. Between October 25 and December 5, 2009, 94,781 institutions had implemented suspension of classes. On the other hand, the CDC of the United States is not recommending such aggressive measures in the school setting.

Recent reports in the media quote American public health authorities congratulating themselves for their excellent handling of the pandemic. I find this puzzling considering that the United States has one of the highest numbers of deaths, adjusted for population, in the world. We are in the top 10% of deaths per 100,000. Hence, by objective measures, the CDC has done a terrible job.

Policies have consequences. The consequence of Thomas Frieden’s decision to keep the schools open was 9 times more deaths in the United States, including hundreds of children, than in Japan.

Thomas Frieden and the US public health establishment have nothing to be proud of.

Kamigaki and Oshitani (2009) Epidemiological characteristics and low case fatality rate of pandemic (H1N1) 2009 in Japan. PLoS Currents: Influenza.


Facing reality

The CDC, May 3, 2009 ( Reuters):

There are “encouraging signs” that the new H1N1 virus that has raised concerns of a pandemic is no more dangerous than routine seasonal flu viruses that circulate annually, a top U.S. health official said on Sunday. Dr. Richard Besser, acting director of the U.S. Centers for Disease Control and Prevention, also defended actions taken by U.S. authorities in trying to limit the impact of the new swine flu virus, saying there has not been an over-reaction. “With seasonal flu, something that hits us every year, we see 36,000 (U.S.) deaths. Here, we’re seeing encouraging signs that this virus so far is not looking more severe than a strain that we would see during seasonal flu,” Besser told “Fox News Sunday.”

The CDC, November 12, 2009 (abc)

“I do believe that the pediatric death toll from this pandemic will be extensive and much greater than what we had with seasonal flu,” says Anne Schuchat, M.D. from the Centers for Disease Control.

Although Dr. Schuchat’s acknowledgment of the terrible toll this virus is taking on children is welcome, one wonders why she does not take any action to stop it. It is no mystery why the “pediatric death toll” will be so extensive. It is because the CDC strongly encouraged schools to remain open. Even schools with high risk children.

The CDC, August 7, 2009 (AJC)

“Closure of schools is rarely indicated,” said Dr. Thomas Frieden, director of the Atlanta-based U.S. Centers for Disease Control and Prevention.

Except for a few sell-outs (you know who you are), everyone with a brain acknowledges the obvious, the vast majority of kids who died of the new H1N1 got infected in schools. If the schools had not been opened, the death toll among children would be much lower.

The slaughter of the innocents will continue until the schools close. How many more dead children do you want on your conscience, Dr. Schuchat? I know the CDC likes to use arcane models to describe what is happening. At PFI_Forum, we just count the dead and try to honor them as best we can.

Perhaps some of you at the CDC might try this, for just a little while. I invite you to look a the list prepared by Homebody: US Child H1N1 Deaths.

I am hoping that someday soon, someone at the CDC will say to the man in the white coat: “No more.”

Proactive School Closure – The Right Choice

I spend a lot of time criticising people in power for making wrong choices with regard to this pandemic. I don’t enjoy this. But if no-one points out the mistakes being made, they aren’t going to stop. But when public officials make the right choice, it is important to give them credit. And Dr. Bruce E. Storm, Superintendent of Schools for Regional School District 12 in Washington Connecticut deserves praise for a tough decision he recently made.

Here is a memo, which he sent today:

To:        James Hirschfield, Chairman, Region 12 Board of Education
Members, Region 12, Board of Education

From:    Bruce Storm

Re:       Decision to Close School

I want to let you know that after considerable discussion with the Administrative Cabinet and consultation with our nursing professionals, I made a determination to close our schools on Thursday and Friday. As you will note in the letter I have sent home (attached), our absences are not extremely high, but we are seeing a steady increase in those numbers and we would like to try and slow the cycle of infection prior to Thanksgiving in a few weeks. This was a tough decision and can be misunderstood; it is preemptive and precautionary and intended to stabilize the health of our kids. I realize that it may create inconvenience for some families, but on balance we thought it best to err on the side of our students’ health and welfare.

A lot of schools have closed after absences reach untenable levels. These are reactionary school closures. However, if the goal is to save lives, schools must be closed before the damage is done. Superintendent Storm didn’t wait until his school system collapsed in a mass outbreak of ill students and teachers. He was proactive, not reactive. Other school systems are making different decisions, some of them in nearby areas of Connecticut. It is not hard to predict the consequences of these different choices.

Kudos to Superintendent Storm for thinking ahead and put the interests of his students first.

Has the CDC breached standard of care for pandemic flu?

From Wikipedia:

In tort law, the standard of care is the degree of prudence and caution required of an individual who is under a duty of care. A breach of the standard is necessary for a successful action in negligence.


In certain industries and professions, the standard of care is determined by the standard that would be exercised by the reasonably prudent manufacturer of a product, or the reasonably prudent professional in that line of work.

I am not a lawyer. So, my interpretation of applicable law is a layman’s guess and is definitely not authoritative. However, it may be worth considering what we know about pandemic flu from a scientific standpoint, what the CDC is doing, and whether a reasonable person would think that the CDC has taken appropriate steps to limit suffering and death.

It is well-established that closing schools is expected to limit the spread of pandemic flu, both to children and to the general population. There are peer-reviewed scientific papers which conclude this based on general models (Heymann et al. 2004; Glass et al. 2006). In addition, there is specific information from the current pandemic indicating that closing schools slows the spread of the virus while resuming school rapidly increases the spread of the virus. None-the-less, Dr. Thomas Frieden has made it clear that he believes that schools should remain open during the pandemic. He has said this in his official capacity as Director of the CDC. Further, the CDC has issued guidelines to the States specifically recommending that schools remain open.

A CDC Director’s Brief was leaked via Cryptome indicating that the case fatality rate for school age children with the pandemic flu virus was 0.22%. Given an estimated attack rate of at least 30%, it would be anticipated that there will be thousands of deaths among children if the schools are open. Since this information was available to Director Frieden in July, the fact that the CDC itself acknowledges that school children are already dying at much higher levels from pandemic flu is not a surprise. Indeed, this was the inevitable consequence of their stated policy of open schools and their internal data indicating a much higher than normal case fatality rate with pandemic flu as compared to seasonal flu. However, it is important to point out that parents were never warned of the greatly increased risk that their children would be taking when schools opened this fall despite the fact that Director Frieden had internal information indicating that this was likely.

Given these facts, it would interesting to determine whether a lawyer would consider that Director Frieden and the CDC have breached the standard of care with respect to recommending that schools be kept open. It is possible to sue the Federal Government under the Federal Tort Claims Act. The first step is to file a Notice of Claim (form SF95). This must be filed within 2 years of becoming aware of negligence on the part of the Federal Government. The government can choose to settle the claim within 6 months. If it does not, a suit can be brought against the United States in the United States District Court.

If anyone feels that they have not received standard of care from Director Frieden or the CDC, they may wish to contact a lawyer to determine whether filing a Notice of Claim is appropriate.


Heymann et al. (2004) Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization. Pediatric Infectious Diseases Journal, 23:675-677.

Glass et al. (2006) Targeted social distancing design for pandemic influenza. Emerging Infectious Disease.12:1671-1681.

Schools closed in most of Argentina over A(H1N1) influenza.
m & c, July 1, 2009

Director’s Update Brief. novel 2009-H1N1. Friday. 17 JUL 2009 0815 EDT. Day 90

School Closures May Help Limit Swine Flu Damage, Study Finds.
Bloomberg, July 20, 2009

Strategy On Flu Under Revision
Washington Post, August 4, 2009

CDC: Leave school closings to local officials
Atlanta Journal-Constitution, August 7, 2009

CDC: Seventy-Six U.S. Children Have Died From H1N1 Flu.
Wall Street Journal, October 7, 2009.

The Economics of Death

Goldman Sachs got $37 billion dollars in the government bailout (Bloomberg, September 28, 2008).

What’s that got to do with the pandemic? As it turns out, plenty.

Next to movement restrictions, the most effective way to stop the spread of pandemic flu while we wait for an effective vaccine is school closures. Yet, the US seems determined to keep them open. Why is this? The answer is money, in my opinion. If people stay home because the schools are closed, the amount of money that businesses make will be less. How much less? The Brookings Institute tells us:

We find that closing schools in the United States for four weeks would reduce U.S. GDP by between $10 and $47 billion dollars, a cost equivalent to 0.1% to 0.3% of 2008 U.S. GDP.

Well gosh, looks like the bailout that Goldman Sachs got, courtesy of the US taxpayer, would have covered school closures nicely. So, we had a choice, we could have let Goldman Sachs go bankrupt and spent the $37 billion dollars compensating companies for the effects of school closures. But that’s not what we did is it?

And how is Goldman Sachs spending the money it got from the taxpayer? Why on bonuses of course! They are doing so well, after all (Slate, September 25, 2009).

You’ll recall the howls of outrage earlier this year when onetime ward-of-the-state Goldman Sachs (GS) announced that it was setting aside $11.6 billion in compensation for the first half of the year. Surely, given that public outcry and given the bureaucratic gnashing of teeth going on now at the Pittsburgh G20, Goldman has learned its lesson, right?

Apparently not. A Bloomberg story today, citing a research report from Citigroup, says that Goldman may find a way this year to pay its employees more.

Lost in the economic forecasts of the Brookings Institution and the “good news” for Goldman Sachs employees is something I think is more important.

Children died because the schools weren’t closed.

The Brookings Institution did not mention one of them.

We don’t know what Goldman Sachs says to the politicians it has bought and paid for, but probably it is not “We want to give back the money we got from you so you can close the schools”. Not their style you see.

If you can stand it to look at it, Homebody has a list, with pictures of some of the children who died because the schools were kept open. It’s a long list, and getting longer every day.

But let me tell you about just one child: Chloe Lindsey.

Chloe lived in Fort Worth, Texas. She was 14 years old.

From NBC Dallas-Fort Worth, September 30, 2009

A 14-year-old Fort Worth girl who was “perfectly healthy” her entire life died suddenly Sunday after getting the swine flu, her mother said.

Chloe Lindsey died hours after she was rushed to Cook Children’s Medical Center.

Tests confirmed she had the H1N1, or swine, flu, the Tarrant County Health Department announced on Tuesday.


“She was perfectly healthy,” said her mother, Tammy Osborne. “I think she had been sick twice since she was 2 years old.”

She first felt ill on Wednesday and went to the doctor Friday, Osborne said.

“They did the swab test, and it was positive for the flu,” she said.

On Saturday night, her breathing became labored, and by Sunday morning, she could barely breathe.

“She was just gasping for air,” Osborne said. “I asked her, ‘Baby, why are you breathing like that?’ And she said, ‘Momma, it hurts.”

Her mother rushed her to the emergency room.

Doctors tried to put her on a ventilator and another machine to help her breathe. The fluid in her lungs was so thick, it was pressing on her heart, doctors told her mother.

“Before they could get her hooked up to the machine, she arrested,” Osborne said between tears.

She counted 24 doctors and nurses working frantically to give her CPR for more than 40 minutes, but they could not save her.

“It was just like she had the flu, and she was gone,” her mother said.

The Fort Worth Independent School District released a statement that did not name Chloe’s school for privacy reasons, but said custodians had thoroughly cleaned the school with sanitizers.

Chloe was in the eighth grade at Leonard Middle School, her mother said.

Osborne said school administrators should be more open about flu outbreaks so parents will be informed.

“It’s just like when a kid gets lice,” she said. “They send home a letter saying, ‘There’s a kid in the class that had lice. Please check your kids.’ Lice won’t kill you, but the flu killed my baby.”

This is the human cost of keeping schools open. They probably don’t know Chloe Lindsey’s name at Goldman Sachs.  Or at the Brookings Institution. Or at the CDC.

But they should.

The List – Children who died of H1N1 infection after going to school

A recent CDC report discussed the number of children who died after being infected with the new H1N1 virus. However, this report did not include any children who died since August 8, 2009. That’s unfortunate because some schools started to open at about that time.

The result?

Children died.

The following list is based on informati0n compiled by Homebody at PFI_Forum

Date school started – date of death – age of child – location

  • July 30, 2009 – September 4, 2009 – 5 year old – Honolulu, Hawaii
  • August 3, 2009 – August 27, 2009 – age of child unknown – Hamilton, County, Tennessee
  • August 6th, 2009 – August 20, 2009 – 7 year old – Ellijay, Georgia
  • August 6, 2009 – August 27, 2009 – 13 years old – Hancock Co., Mississippi
  • August 11, 2009 – September 9, 2009 – 13 years old – Memphis, Tennessee
  • August 11, 2009 – September 9, 2009 – 12 year olds – New Orleans, Louisiana
  • August 12, 2009 – September 18, 2009 – 18 years old – Valley, Alabama
  • August 14, 2009 – August 31, 2009 – 11 years old – Scottsboro, Alabama
  • August 14, 2009 – September 2, 2009 – 5 years old – Davidson County, Tennessee
  • August 14, 2009 – September 5, 2009 – 19 years old – Baton Rouge, Louisiana
  • August 17, 2009 – September 5, 2009 – 10 years old – Fairbanks, Alaska
  • August 18, 2009 – August 31, 2009 – 12 years old – Midlands, South Carolina
  • August 19, 2009 – September 7, 2009 – 6 years old – Hot Springs, Arkansas

The longer schools are left open, the more children will die.

It is obvious.

Explosive spread of pandemic flu on college campuses

Although there were a few, isolated cases of infection with the new H1N1 virus on college campuses last Spring, the pandemic is now raging on campuses across the country.


Almost three-quarters (73%) of American colleges and universities are reporting cases of influenza-like illnesses among students, with the highest rates in the Southeast and Midwest, the American College Health Association says.

There were 4,045 new flu-like illness cases between Aug. 29 and Sept. 4 among 204 schools taking part in voluntary reporting, the new data show.

One college student, Andrew Salter, has already died. He was a Freshman living in Alumni Hall at Troy University in Alabama. Classes started at Troy University on August 10, 2009. He died on September 4, 2009.

From WFSA 12 News:

The family confirms Andrew had no underlying medical issues. He was diagnosed with Swine flu last week and actually got better one day, but took a turn for the worse on Friday when he passed away from pneumonia at the Southeast Alabama Medical Center in Dothan.

Mr. Salter’s death illustrates that young, healthy adults can die as a result of infection with the new H1N1.

College students are typically between the ages of 18 and 22. According to a leaked CDC Director’s brief, the case fatality rate for 5 – 24 year olds is 0.22%. Approximately 17,500,000 people are enrolled in College this year.  Assuming a clinical attack rate of 30%, 5,250,000 College students will become ill with the new H1N1. Of these, 11,550 are expected to die, using the leaked CDC numbers.

Is there something you would like to say to College students and their parents, Director Frieden?