http://www.nytimes.com/2007/02/01/health/01cnd-flu.html 

By DONALD G. McNEIL Jr.
February 1, 2007

ATLANTA, Feb. 1 -- Cities should close schools for up to three months in 
the event of a severe flu outbreak, ball games and movies should be 
canceled and working hours staggered so subways and buses are less 
crowded, the federal government advised today in issuing new pandemic 
flu guidelines to states and cities.

Health officials acknowledged that such measures would hugely disrupt 
public life, but they argued that these measure would buy the time 
needed to produce vaccines and would save lives because flu viruses 
attack in waves lasting about two months.

We have to be prepared for a Category 5 pandemic, said Dr. Martin 
Cetron, director of global migration and quarantine for the Centers for 
Disease Control and Prevention, in releasing the guidelines. Its not 
easy. The only thing thats harder is facing the consequences. That will 
be intolerable.

In an innovation, the new guidelines are modeled on the five levels of 
hurricanes, but ranked by lethality instead of wind speed. Category 1, 
which assumes 90,000 Americans would die, is equivalent to a bad year 
for seasonal flu, Glen Nowak, a C.D.C. spokesman, said. (About 36,000 
Americans die of flu in an average year.) Category 5, which assumes 1.8 
million dead, is the equivalent of the 1918 Spanish flu pandemic. (That 
flu killed about 2 percent of those infected; the H5N1 flu now 
circulating in Asia has killed more than 50 percent but is not easily 
transmitted.)

The new guidelines also advocate having sick people and all their 
families even apparently healthy members stay home for 7 to 10 days.

They advise against closing state borders or airports because crucial 
deliveries, including food, would stop. They did not offer guidance on 
wearing masks, but Dr. Cetron said the C.D.C. would issue advice on this 
soon.

The guidelines are only advisory, since authority for measures like 
closing schools rests with state and city officials; but many local 
officials had asked for guidance, Dr. Cetron said.

The federal government has taken primary responsibility for developing 
and stockpiling vaccines and antiviral drugs, as well as masks and some 
other supplies.

Todays guidelines are partly based on a recent study of how 44 cities 
fared in the 1918 epidemic conducted jointly by the C.D.C. and the 
University of Michigans medical school. Historians and epidemiologists 
pored over hospital records and newspaper clippings, trying to determine 
what factors partly spared some cities and doomed others.

While a few tiny towns escaped the epidemic entirely by cutting off all 
contact with outside, most cities took less drastic measures. These 
included isolating the sick and quarantining homes and rooming houses, 
closing schools, churches, bars and other gathering places, canceling 
parades, ball games, theaters and other public events, staggering 
factory hours, barring door-to-door sales, discouraging the use of 
public transport and encouraging the use of face masks.

The most effective measure seemed to be moving early and quickly. For 
example, said Dr. Howard Markel, a medical historian and one of the 
studys leaders, Philadelphia, the worst-hit city, had nearly three times 
as many sick and dead per capita as St. Louis, which had was hit weeks 
later by the virus moving inland from the Eastern Seaboard and had time 
to react as soon as flu cases rose above averages.

No matter how you set up the model, Dr. Markel said, the cities that 
acted earlier and with more layered protective measures fared better.

Any pandemic is expected to move faster than a new vaccine can be 
produced; current experimental vaccines against H5N1 avian flu are in 
short supply and based on strains isolated in 2004 or 2005. Although the 
government is creating a $4 billion stockpile of the antiviral drug 
Tamiflu, it is only useful when taken within the first 48 hours, and 
Tamiflu-resistant flu strains have already been found in Vietnam and 
Egypt.

No ones arguing that by closing all the schools, youre going to prevent 
the spread, Dr. Markel added. But if you can cut cases by 10 or 20 or 30 
percent and its your family thats spared, thats a big deal.

School closures can be very controversial, and picking the right moment 
is hard, because it must be done before cases soar.

Jeffrey Levi, executive director of the Trust for Americas Health, a 
health policy organization, noted that in poor city neighborhoods, 30 to 
60 percent of all children get breakfasts or lunches crucial to their 
nutrition at school.

What are you going to do about that? he asked.

Dr. Markel said it might be possible to keep the cafeterias open and 
transport food to points where parents could pick it up, a move that 
would also keep cafeteria workers and bus drivers employed.

Several public health experts praised the C.D.C. guidelines, although 
there were some quibbles with aspects of them.

Dr. Michael T. Osterholm, director of the University of Minnesotas 
Center for Infectious Disease Research and Policy, said he saw no point 
in fretting over exactly when to close schools, because his experience 
in meningitis outbreaks convinced him that terrified parents would keep 
their children at home anyway.

I dont think well have to pull that trigger, he said. The hard part is 
going to be unpulling it. How do the principals know when schools should 
open again?

Other experts pointed out that children out of school often behave in 
ways that are nearly as contagious. Youngsters are sent to day care 
centers, and teenagers gather in malls or at each others houses.

Well be facing the same problem, but without the teaching, said Dr. 
Irwin Redlener, director of the National Center for Disaster 
Preparedness at Columbia Universitys Mailman School of Public Health. 
They might as well be in class.

Also, he noted, many employed people cannot afford to stay at home and 
the financial stress from not working could increase domestic violence. 
And he said most states and cities lacked the money to carry out the 
suggested guidelines or to stage drills of them.

Dr. Cetron argued that caring for children in groups of six or fewer cut 
transmission risks. He also argued that parents would keep many children 
from gathering.

My kids arent going to be going to the mall, he said.

The historian John Barry, author of The Great Influenza, a history of 
the 1918 flu, questioned an idea underpinning the studys conclusions. 
There is evidence, he said, that some cities with low sickness and death 
rates in 1918, including St. Louis and Cincinnati, were hit by a milder 
spring wave of the virus. That would have, in effect, inoculated their 
citizens against the more severe fall wave and might have been more 
important than their public health measures.

The guidelines did not suggest using the military to enforce 
quarantines, as President Bush said he might do when he first mentioned 
avian flu in 2005.

Dr. Levi said that using the National Guard to set up temporary clinics 
or move pharmaceutical supplies might make sense.

But theyre not there, he said. The people who know how to run field 
hospitals are in Iraq.

Copyright 2007 The New York Times Company


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