Here are four interesting items I learned yesterday from King County’s chief epidemiologist, Jeff Duchin, MD.
- Lesson learned: Closing individual schools is not effective for limiting flu transmission in a community. Next time — if the virus appears to be more deadly — the health department will close all schools in the county, perhaps for 8 weeks or longer.
- Lesson learned #2: This virus spread far more rapidly than planning scenarios had predicted. Basically, flu virus can be widespread before we know what’s hit us.
- Who’s first in line for a vaccine, if there’s a limited supply? Heavy-duty planning is underway for how to distribute an A-H1N1 (swine flu) vaccine next winter, assuming it’ll be available. This will be in addition to the normal, annual flu shots. First-responders, and most medical workers, are clearly at the top of the list. Pregnant women, and people with compromised immune systems. After that, it might be all children under 18, given signs that they’re being hardest hit so far. (Normally, the elderly are considered most at risk, but not in this case.)
- If the virus remains less severe? Expect simply a lot of people to be out sick, especially in schools, as everyone who didn’t get sick this spring, gets it on the second pass. But, it wouldn’t be much different from what we’ve seen this past month.
And one note to the King County Board of Health: Anyone watching (the meeting was recorded by King County TV) might be disappointed at the level of questioning by board members, as Dr. Duchin and other staff testified. They asked thoughtful questions to clarify the facts. But, nobody on the Board asked the simple questions, What parts of the “pandemic plan” did not work? What surprises did the staff face? What needs to be improved before we face a severe pandemic? (The lessons learned above came from a private interview, after the meeting.)
Science and Wonder 
I agree that closing schools did not work. This did not stop kids from socializing or going into public places, and additionally we cannot assume that adults over 18 are immune either (there were adult cases of swine flu). I think that what public health officials need to learn is that during a pandemic is that diseases will spread to people outside their households or to people who are not related by household, employer, or school. This means identifing who was exposed may not always be possible and that going out in public will be done “at your own risk”.
I also think that vaccines should be optional and that we should not impose martial law or forced vaccinations. Vaccines have risk and that if one decides not to vaccinate and ends up with the disease that should be treated as an individuals choice. Some studies have shown that peoples immune systems are stronger with less vaccination, not more and some have died from vaccines including H1N1 vaccines. As such, this should be an individuals choice and they should be informed of the risks of any vaccine they choose to take before taking it.
One more thing. I also beleive that there were other factors why school closures did not stop the spread, too, such as:
1) Years ago, many households were single income households. Today in many households, both parents have to work to pay the mortgage, and some barely can make ends meet (just look at the number of foreclosures these days, and see this URL: http://www.youtube.com/watch?v=akVL7QY0S8A . This means that there is often not a stay at home parent at each household to watch the children, so the children have to go elsewhere during the day while the school is closed.
2) Many children don’t like being lonely and will simply invite friends over to their house anyway during the closure or will willingly fill their time with non-school sponsored activities during this time. This is why many children and teens choose to go to malls, bowling alleys, movie theaters, libraries, arcades, recreation centers, daycare centers, friends houses, and the like.
3) Some children and parents are undeterred by the risks of the flu and think the CDC’s actions are overblown and decide to continue with their normal lives during a school closure due to the flu. There are even some people who had “swine flu parties” in which they want to expose themselves to the flu and feel that their immune system will be stronger having to fight the flu.
4) Some parents have no sick leave or insufficent vacation time to take that time off of work to care for the kids during the CDC’s closure.
5) In the college environments with shared classrooms, dining halls, sports stadiums, libraries, and other facilities shared and in tight quarters, determining which student gave the flu to another while in college is nearly impossible due to the nature of the campus environment.
I would like to add one more thing. I don’t think a eight week school closure will stop the spread for the reasons above. One study in Australia and another in North Carolina showed that the children were out of their home an average of once a day during the closure, many of which to social events like sports, parties, and to public places.
I bet that even if Martial Law or police enforcement were called in, I bet there would not be enough police to insure that every child stays home for eight weeks.
I also wanted to say that the outbreak continued during the summer. This lead to children mixed with people outside their school at camps, public places, pools, daycares, and friends houses.
I think that in an eight week closure, out of home experiences for children will probably intensify if the adults do not get two months off of work and don’t have the savings to pay the bills for that time.
I also don’t think that a friend is going to call the police because someone from a closed school came into their house.
The real lesson is that “closing schools” should not be assumed to be “all children under house arrest” and the actual benefit is usually lower than the percieved benefit.
Stephen –
You’ve got a pretty thorough argument! I’m not going to go through it line by line. I think you’re off the mark on vaccines; there’s paltry evidence to support the critique of vaccines. But to your main point — that closing schools is ineffective at containing a flu outbreak — you’ll find a lot of people agreeing with that. But, I don’t think you should overlook the exceptions to your argument. If officials are looking to buy a little bit of time (measured in weeks), slowing the spread of the outbreak until other steps are taken, then closures might make sense. If they are able to respond rapidly enough that only a few clusters of disease exist in the community, then closures will be more effective. And, most importantly, if the disease is much more severe than the pandemic we had last year, then more drastic steps might make sense.
But in reality, at least based on our experience last spring, there was no way to react with such precision. It takes time to figure out what’s happening in the community, and by the time you have enough information, it may be too late to contain a flu epidemic. I’ve written before about the hardship that school closures create for working parents, and how the apparent indifference of local leaders actually undermines any possibility that containment would work. Maybe, being aware of these limitations would lead to more skepticism (by officials) about closures strategy.
As for the mingling of kids outside school, I think the mathematical models of disease spread take into account that it was not a true quarantine. But, the mixing outside of school is far less intense than in schools.
I think public health researchers and policy-makers will begin to integrate these lessons into future action plans. As far as I know, there still isn’t any good data evaluating school closures. Until there is, we can have lively debates.
(I’m not sure if King County is still thinking of 8 weeks; I haven’t heard any updates on this sort of planning.)