Tuesday, May 19

Mr President, fire NYC health commissioner Thomas Frieden from his post as CDC director before he even starts to work there

I had high hopes for Dr Thomas Frieden's tenure as director at the CDC, which is supposed to start in June pending confirmation, after reading about his work in New York City and India to battle tuberculosis epidemics. I'd hoped that he'd modernize the CDC's approach to dealing with highly-infectious disease outbreaks.

Yet after studying Frieden's muddled approach over the past two weeks to dealing with swine flu in New York I'm almost speechless about the level of incompetence. And he's supposed to be an infectious disease expert.

Margaret Chan, the present director-general of WHO, was almost run out of Hong Kong on a rail for the same muddled approach she took toward dealing with SARS.

The argument was that she wasn't really muddled; she was just being a good soldier for Beijing. I find that hard to believe given the extreme lethality of SARS. My guess is that she screwed up because SARS was imported to Hong Kong from the Mainland and so she accepted the same fallacy that's guided CDC actions in the face of the present swine flu epidemic.

I gave much discussion to the fallacy in my CDC's slow boat from China post. The fallacy translates into the silly idea that once a highly-infectious virus arrives in a country it's no use to deploy measures to prevent more infected people from entering the country. The same reasoning takes quarantine off the table.

It's looking as if Frieden accepted the same fallacy, unless you want to argue that he was under pressure from Mayor Bloomberg not to institute quarantines. If that's the case, all the more reason not to allow Frieden to run the CDC if he caves into pressure that easily.

By the way I don't want to hear about John Barry's thesis regarding quarantines in New York City in 1918. We desperately need a biomedical specialist who can think outside the 1918 box and who knows what century this is.

If we can't find that person, I fear America's response to a modern version of the lethal 1918 virus will parallel our lack of readiness to deal with the 9/11 attack, which was a brilliant application of asymmetrical warfare reflecting an understanding of the modern era in air travel. Oddly enough the swine flu virus has the same understanding, in a manner of speaking.

As to the situation in New York I won't even bother to direct my advice to Frieden. If there's someone who can chew and walk in New York City's health department: Can you find a quarantine operations manual? If so, OPEN THE MANUAL and FOLLOW INSTRUCTIONS.

If you can't find a manual, speed dial Hong Kong and ask them to email their copy. They have a manual, because they sure as hell learned their lesson after Margaret Chan.

And if I hear from New York City, 'Oh it's too late; that's shutting the barn door after the horse is out' -- the screaming and yelling reaching your ears will be coming all the way from Washington, DC.

Get it straight: a virus is not a horse.

As you can see I'm not quite speechless; I'll have a lot more to say about this matter later in the week. For now:
No Guidance on How to Rein in the Flu
The New York Times
May 18, 2009

As schools shut down because of the flu — with a dozen closed in New York and hundreds in Texas and Japan — health officials are asking a question for which there is little guidance, even in pandemic plans: what is the best way to stop an epidemic that spreads mostly in schools rather than in nursing homes?

Many school officials have shut the doors and had the custodians disinfect the empty buildings.

But that leaves parents confused and frustrated. Those whose schools remain open may fear that their children are in danger, and those with healthy children whose schools close may feel that officials have overreacted, burdening them with day-care costs and denying their young ones an education.

Even guidance from the top is ambivalent.

On May 4, the acting director of the Centers for Disease Control and Prevention, Dr. Richard E. Besser, said “closing schools is not effective” at halting the spread. Previously, the centers had advised schools to shut for up to two weeks if a confirmed case was found.

On Monday, New York City closed four more Queens schools after outbreaks of flu symptoms, bringing the total to 16 ordered shut since last week. In Texas, hundreds have been closed at various times.

“There’s no right answer,” Mayor Michael R. Bloomberg said at a news conference. “I’ve asked the question, ‘What would you do, Dr. Frieden, if you wanted to prevent the spread of flu around the entire student population?’ And the answer is, ‘Closing the schools for a month, prohibit all interaction among kids outside of school, and even then there’s no guarantee that you can do that.’ The bottom line is, case-by-case basis is probably the right thing.”

(Mr. Bloomberg was referring to Dr. Thomas R. Frieden, the city’s health commissioner, who has just been nominated to be chief of the C.D.C.)

Many parents and teachers have been calling local lawmakers wondering if their schools would be closed, said Eric Gioia, a City Council member from Queens who wants parents to be given the results of flu tests at their local schools and daily attendance figures.

“The lack of definitive information is causing great stress on families,” Mr. Gioia said. “If a school is safe, then the city needs to not only say it is but give parents all the information they need.”

Before closing one, Dr. Frieden said, officials look at documented fevers in students and how fast they are increasing. They also call families to see if children are really sick, not just staying home out of fear.

One thing is clear, infection control experts say: disinfecting closed schools is pointless. Flu viruses are believed to live on objects for perhaps two to eight hours, so a week’s closing will kill them. But when students return, if a few are sick, every cafeteria table, desk, lab beaker, doorknob, bathroom tap and basketball will soon be recontaminated.

Washing schools “is done for looks,” said Michael Olesen, a Minnesota infection control specialist. “It’s not a rational approach.”

The C.D.C.’s swine flu Web sitehas infection-control guidelines for many settings: hospitals, nursing homes, day-care centers and even dialysis clinics. But it has nothing specific to the core of this outbreak: schools full of teenagers.

Teenagers, experts say, are different from the victims of seasonal influenza. The bed-ridden, the very ill and infants can be forced to practice good hygiene, or isolated or sent home if they won’t.

But teenagers resist tedious advice to wash their hands for 20 seconds, cover every cough with a tissue or sleeve and stay away from other teenagers. If school is closed, they are likely to get together at the park or the mall.

Keeping sick students out of school is the most crucial step, said Dr. Yoko Furuya, an infection control specialist at NewYork-Presbyterian/Columbia hospital.

But that can be impractical. And students can shed virus for a day before they are sick.

“I’d lean toward getting surgical masks on them and trying to get to the end of the school year,” said Mr. Olesen, who is reluctant to see schools shut. “The masks capture all those droplets at the point of release.”

And how, he was asked, could students be made to do that?

“I don’t know how, but they make them do other things,” he said.

Amy D. Nichols, chief of infection control for the University of California at San Francisco Medical Center, said she would like to see “schools just as awash in alcohol hand rubs as hospitals are, so it’s easy and quick to clean one’s hands.”

Ms. Nichols favors making students disinfect their hands before entering each class, the gym or the cafeteria.

“In junior high, you want to be like everyone else,” she said. “So schools should have wall-mounted push dispensers. That way it becomes part of the culture of the schools. The more people push the handle, the more everybody else does.”

She also favors cleaning surfaces as often as is practical, because other risks like antibiotic-resistant bacteria persist longer than flu.

What to do with sick students whose working parents cannot afford babysitters is another problem.

Asked if schools could set up cots in a gym for ill students, Mr. Olesen demurred.

“I don’t know,” he said. “Cots for kids in puberty with their hormones raging? That’s a whole other public health problem.”

Even if schools make it to summer break, hot weather may slow, but not solve the problem, the C.D.C. said Monday.

“We’d love to see a decrease in cases, but in the past there have been outbreaks of seasonal influenza even in summer camps,” said Dr. Anne Schuchat, the agency’s interim deputy director for public health.

Confirming anecdotal observations that this flu concentrates in young people, Dr. Schuchat said preliminary studies of family transmission showed that when one member gets infected, the most likely to follow are those under 18, not parents or grandparents.



CGardner said...


Your call for a realistic national policy to guide future pandemics and bio-terror attacks was right on the mark!

Just doing sometime timelining in my head on the second outbreak in NYC made me realize that the culprit was probably Cinco de Mayo.

Some articles I read prior to the holiday noted that Cinco de Mayo is celebrated as a "mini-vacation," with as many travelling from Mexico as going to. One article also said that flights to the US from Mexico were booked and there were few cancellations because of the flu. A local celebration or two may have been cancelled, but apparently people kept on with their vacation visits.

The kids in PS-238 began getting sick right after, with the Principal requesting that the school be closed.

Of course, the government issued no travel warnings, and by then, Dr. Frieden decided that "swine flu was no longer a problem."

Pundita said...

CGardner, Thank you -- and again, thank you for all the data you've been sending and for your observations. (And thanks also for alerting me to Daly's columns on swine flu in New York for NY Daily News!)

Re your remarks about the relationship between a new outbreak of swine flu in some NYC schools and the Cinco de Mayo 'mini-vacation' -- that's an interesting speculation.

The question is whether the outbreak was actually new, or whether it was simply caught around that time. But the consideration you bring up should be carefully investigated.

The NYC health dept. sent a questionnare to the first school students (at St. Francis) who were affected by the flu (both types that have been circulating), which included a question about travel. So I hope the dept. will continue this approach with students in other schools that saw outbreaks.

Re your remark about a travel advisory: The CDC/State Dept. travel advisory was in effect from the evening or late afternoon on April 27 until May 15.

So while the NYC health dept. might not have exerted themselves to stress the advisory to New York schools, it was available to members of the public. Local media outlets could and should have been a help in this matter.

As to the reasoning behind the CDC's decision to rescind the travel advisory, here we're getting into the Cuttlebone school of logic. Maybe a parakeet can make sense of the CDC's train of thought.

Here's the link to State's May 15 annoncement

Re our email exchange about an earlier comment and data link you sent but which you hadn't wanted published -- thank you for your politeness, but I am one person running this blog and already feeling a bit overwhelmed trying to keep up with the many moving parts to the swine flu story.

So if you find a swine flu report or commentary that you think interesting, by all means don't hestitate to send it to the comment section. After all, you've shown excellent judgment so far about the type of information you've sent.

So here I'm going to add the data link and comment you sent earlier because I don't know when I'll be able to snatch time to comment on it in a post. If there's proof of intelligent life at the state level in New York wrt swine flu I'm sure Pundita readers would appreciate knowing this right away. :-)

Again, thank you for your sharp eyes and mind:

"Pundita, Note how NY State Education and DOH agree with your philosophy to slow the spread of the disease!"