decision trees and swine flu

I have a masters in public policy degree, and people sometimes ask me what exactly do you learn in a public policy program.  The answer is a little bit of lots of things — some economics, some statistics, some political science, how to write a 2 page memo, a fair amount on whatever topic you specialize in.  But probably the core skill they try to teach is about decision making with imperfect information.  And when I was in grad school, the main example they used to illustrate this issue is the 1976 swine flu vaccination decision.

The short version of it is that in February 1976 two soldiers at Fort Dix died from a swine flu, with a significant number of soldiers infected, and no exposure to pigs involved.  This was known to be related to the flu that had caused the 1918 pandemic, most people didn't have immunity to it, there was a theory of cyclical pandemics that suggested that we were overdue for one, and this strain had proven itself to have the ability to kill otherwise healthy young men.  The government asked the vaccine manufacturers to produce a vaccine, and in the fall, they swung into action with a full-fledged immunization drive.
As it turns out, swine flu did not reemerge in the fall, and the vaccination campaign was suspended (after about 40 million people had been vaccinated) when some of the vaccinated individuals came down with Guillain-Barré syndrome.

With hindsight, it's clear that the vaccination drive was unnecessary.   But with the information available, was it the wrong thing to do?   The people who made the decision still think it was the right call, writing: "When lives are at stake, it is better to err on the side of overreaction
than underreaction. Because of the unpredictability of influenza, responsible
public health leaders must be willing to take risks on behalf of the public."  My public policy classmates were less convinced, generally concluding that it made sense to produce the vaccine, but that they should have held off on immunizing people until there was some evidence that the swine flu had returned in the fall.  We felt the president had been pushed by politics to overreact to a low-probability but high risk event, fearing the headlines if tens of thousands died and the government had done nothing. 

Which brings us to today, and the headlines that half of Americans could be infected by the swine flu this year.  So, I'm glad that they're making vaccines.  But I'm not sure whether I want to line up — or line my kids up — to be immunized.  If you've got some time to spend thinking about what the vaccine strategy should be, the CDC is holding two web-based public forums to collect input and is looking for participants.

For us, a complicating factor is that D has a history of mild asthma.  And viral infections are his primary trigger.  He's been doing so well that we've had him off of the inhaled steroid, but I emailed his pediatrician to ask if she thought we should start him again with the start of the school year.  She responded that the risks of the inhaled steroid were very low, while the flu was an unknown, so she'd advise going ahead with the steroid.  So we're going to do that, and otherwise we're waiting and seeing.

What are you doing?  Will you get vaccinated if offered it?  Do you think your local school system is overreacting, underreacting, or getting it right?  Do you have a plan for what you'll do if schools are closed?

25 Responses to “decision trees and swine flu”

  1. K Says:

    My dad just got back from spending a week down at the CDC. He is recommending that we get vaccinated, if a vaccine is available to us. In my 10 years of parenting, he has never recommended anything before. So, whatever it was they told him, it scared him.
    My kids have never had a single complication from a vaccination or a medicine, so I have less worries there. If we had dealt with a complication, I would be much more hesitant.
    My hope is that those poor people who were vaccinated in 1976 are magically immune this time? Probably not, but it would be nice….

  2. urbanartiste Says:

    So far, my school district is not planning on closing, which is the protocol they followed when swine flu was in school this past year. Our pediatrician says not to vaccinate, the regular flu is more life-threatening than swine flu. I do plan on vaccinating our family with the regular flu vaccine. I just had a bout of a virus that took 2-3 weeks to get rid of and I definately think if there is an large outbreak of swine flu schools will be forced to close out of low attendance. Many of the parents kept their kids out of school when there were a few cases.
    K, I would love to know what your dad found out. I know it is not the same, but there was a lot of panic around 9/11 with people freaking out. My mind keeps comparing it to that, that we should not get that overreactive.

  3. Jody Says:

    Our pediatricians are running a trial on the H1N1 vaccine, and soliciting volunteers among their patients. I told the kids about it (the three blood draws, in particular) and they said NO WAY. Then I said they could keep the money, and they said they’d reconsider. But 5 study visits strikes me as too much time, and that’s what would be involved.
    I’m not inclined away from the vaccine on safety grounds, though. I sincerely hope they offer it through the schools here, because otherwise, we’ll be looking at 3 flu-vaccination visits to the pediatrician’s office, and they’ll be overwhelmed.
    I’m still at home, so if schools close, we’ll manage just fine in that regard. Calder’s university employer is test-running lecture taping right now, as the semester starts, so that they can shift all the large lecture classes to internet broadcasts if the flu sweeps through campus. His university actually had outbreaks of H1N1 in summer camps this year, and so they’re reasonably concerned. I don’t think anyone expects H1N1 to kill a lot of people, but having an entire campus come down with any flu is a pretty big problem.
    BTW, Wilder’s not going back on steroids this fall, but he’s still on Singulair, Zyrtec, and Nasonex, and the steroid prescription has been refilled, just in case. Our pediatrician is reasonably concerned that this could be a tough year for kids with respiratory problems.

  4. bj Says:

    I like the characterization of “public policy” or public policy decisions as being decision making with imperfect information (and, I guess, even more significantly, decision making for other people with less than imperfect information).
    We also got an offer to be in the study Jody describes (H1N1, dosage trial, 5 office visits) and have decided not to do it because it’s too many visits.
    I’m usually gun-ho pro-vaccination. But, I find the decision making with the flu vaccine difficult because of the vaccine itself. When making vaccination decisions I’m including 1) personal risk of exposure 2) effectiveness of vaccination (including how long it lasts) 3) risk of infection 4) risks of the vaccine 5) public health benefits to others of improving rates of vaccination. For something like chicken pox for the kids I come out vehemently in favor. But for the flu, I inevitably end up having questions about each of the variables: 1) I don’t interact with many people, so my risk is often low — though this is changing with the kids. 2) the vaccine is only effective for a particular flu, and the exigencies of flu vaccines make them less effective than those for child hood illnesses, if only for the term of protection they confer. 3) flu doesn’t usually seem like it will be all that bad. 4) since the vaccines are new, and being changed constantly, it’s difficult to perceive them as more risky — though I have no idea if that’s a valid perception. 5) I don’t know enough about the public health benefits. This could be the issue that would tip it for me, because I’m borderline on the other values, but if they could convince me that at risk populations, the young, the elderly, those with asthma, cystic fibrosis, aids, were at significant risk, and that by vaccinating I could improve public health, that might tip me over the edge, even when I don’t see the personal benefits as clearly.
    It’s interesting to hear about the web seminar, and I hope that those incipient efforts I see at education become a larger part of vaccination programs (I think they are). Because, even when scientists think hat the people are being irrational, if we’re not talking and educating, the irrationality will result in bad outcomes.

  5. amy Says:

    The only thing I’m concerned about is whether the rush to production is going to lead to some dangerous screwups. Beyond that, on a personal level, I’m all for insuring against low-probability, high-risk events. It’s why I wear seat belts, carry an umbrella policy and a catastrophic health policy, background-check my tenants scrupulously, and follow the man’s instructions about going into the tornado shelter when funnel clouds have been spotted within 15 miles or so. I’ve also got asthma, and will probably get the H1N1 shots along with the regular one.
    That said, I understand the considerations on a public-policy level are different, and that the same level of belt-and-suspenders can sink a national budget and erode authority. On the other hand, this is a touchy, one-off event, and the politics aren’t to be discounted. The only way Obama loses with pushing vaccines is if the vaccines themselves make people sick or kill them. Even if the vaccine’s a dud and lots of people still get sick, the admin can say that even more would’ve gotten sick without it, and cloud the issue sufficiently to make it go away.
    Yeah. I think your question conflates policy-level and individual-level concerns.

  6. amy Says:

    Oh. And if schools are closed, Miss A. will go to daycare until/unless she gets sick too. (And yes, she’ll get the shots.) Those lovely sane people view illness as a normal part of life. Unless a kid needs hospitalization, they’ll just put a sick kid on a cot and be nice to her. They tell the parents if there’s a kid who’s had strep, lice, chicken pox, or other infections that might make parents decide to keep their kids home.

  7. kosier Says:

    I really liked your post and I’ve commented on your blog in the past about sicknesses aned asthma.
    It’s such a tough call but with two children with pretty severe asthma who always have problems after colds, etc., I would be more inclined to let them have the vaccinations. on the other hand, the flu shot never helps my oldest, she gets a tough case of the flu every single year no matter what. we all got the seasonal flu in February and it was horrible.
    by the way, my youngest has been in school a mere 4 days and is out sick already — low fever, severe cold, lots and lots of coughing, sore throat. i’m taking her to the pediatrician today and am thinking, does she already have swine flu — my pediatrician a month ago said they had a child in there with just the sniffles and it turned out to be a case of the swine flu.
    i hope this isn’t the start of a bad year . . .

  8. urbanartiste Says:

    Just wanted to add, my pediatrician said the final swine flu vaccine or kids will have to be administered in 2 doses and then the annual general flu vaccine. So it looks like three vaccine visits for flu.

  9. Virago Says:

    The executive director of the National Association of School Nurses had an online chat w/Washington Post readers today, and lots of people asked good questions and/or raised good points. One post was from a parent who has a child in third grade and a spouse in college and who works at a place that doesn’t allow paid sick days.
    “If I miss work, I risk losing my job, and also, just missing a few days jeopardizes everything: my mortgage, my car payment, etc. People come to work sick here all the time because we have no paid sick days and they can’t afford to miss work.”
    What a thankless situation. That’s just not right.
    Here’s the transcript of the whole discussion: http://www.washingtonpost.com/wp-dyn/content/discussion/2009/08/20/DI2009082002698.html
    The post that I quoted is about 3/4 of the way down, but all of it is pretty good.

  10. jen Says:

    What you’re saying about having a child with mild respiratory problems really resonates. We also have a kid on the Singular/Nasonex train, who has had pneumonia once and bronchitis twice in her tender six years.
    So yeah, shots it is. Given how long her coughs have lasted in the past (sometimes months) it’s totally worth the three visits to the doctor.

  11. amy Says:

    virago, too true. Which points up one unexpected benefit of working crazily to stay in a middle/upper-middle-class neighborhood. Suppose our schools closed and my daycare guy was so sick he closed up shop too. Most of the women I know are stay-home moms or work itinerant or part-time, many of them for the school district. Even the divorced moms are divorced from guys with fat incomes, so child support and alimony pay for big houses and lots of free time. So I could always turn to one or several of them, asking if they’d take Miss A. for a day or two while I worked. And they would, for free. Some would welcome it because having another child over is fun for their kids and/or breaks up sib fights. They expect nothing in return, because they know I’m single, working, etc.
    Funny world….

  12. Sarah Says:

    I had the regular flu 2 or 3 years ago and hated it. So I have become a good flu shot getter. I am a little on the fence about the H1N1, but will probably vaccinate. None of us tend to get sick in the lungs – even my mild asthma is more exercise induced than tied to any of my other allergic reactions. But the double shot combined with the iffy-ness of whether it will work, whether we’ll need it, etc. I am left feeling like it is a gamble. I have to admit I’d rather run to the clinic we know and love 3x than have it done at the kids’ school. That creeps me out.
    I am planning to go back to work outside of the house this fall, but my mom, who lives with us, will be the child care for my youngest. And will be able to handle the overflow if the bigger kids get it. Or schools close.

  13. Jennifer Says:

    Here in Australia, we’re just finishing winter, so we’ve had swine flu during winter. I’ve been surprised that it hasn’t been that much worse than a regular flu season. In my company’s absence stats, it hasn’t shown up as much worse than a normal winter. And I personally always notice it when it is a bad winter, because June and July are our busiest periods when we don’t let people have holidays. I work with a few people who’ve had it, but it hasn’t been that bad. They’ve all just had a normal flu experience.
    I would be really scared, though, if I was pregnant. At the height of the scare (which was probably back in July), there were a lot of news stories about the number of pregnant women who were in intensive care, with babies having to be born seriously premature to help save the woman’s life.
    None of our schools have been closed – they were right at the beginning when it was just coming to Australia, but now nobody bothers. People are a bit more scrupulous about staying at home when they are sick, but even that is declining as people stop worrying about it.
    I always get a flu shot, ever since I had pneumonia a few years ago and the doctor told me to, so I would probably have the swine flu shot if available. I probably should do the same for the kids, particularly as my older boy has a bad history with respiratory disease (although not asthma), but haven’t got the regular flu shot for either of them yet.

  14. Ana Says:

    What concerns me is that we’ve got all this talk about flu shots but no talk at all about supporting our immune systems. What vitamins/ diet/ lifestyle changes will help you avoid getting the flu? (and as a side benefit, avoid getting other illnesses like colds?)
    Personally we don’t take the flu shot, since there’s no guarantee it will keep the flu away. And the fact that the flu shot changes seasonally also scares me, there’s never a chance to ‘test’ the flu shot fully because its always rushed into production. Right now it feels like our kids are going to be the guinea pigs for this H1N1 flu shot. Other shots are proven (or not), but at least there’s history that parents can review and make choices.
    I’m still very unclear regarding what’s so deadly about this flu strain versus other strains, at least for the USA. Seems most people who died from it already had other complications that contributed to their deaths.

  15. lisa Says:

    When I was in college 20 years ago, a friend got Guillain Barre from a regular flu shot at age 19. Thus, I have never had a flu shot. Now I have a 3yo and 2yo and am struggling with rethinking that avoidance. My daughter is never sick. My son got pneumonia last month after a virus, and we are currently waiting for an allergy appointment. My MD friend is freaked out about potential H1N1 epidemic and disagrees strongly with my response. I really don’t know what I will do but probably need to make a decision soon.

  16. amy Says:

    Lisa, your friend may have had the flu shot and then gotten Guillain-Barre, but the cause of Guillain-Barre is unknown. It’s known to strike sometimes after mild infection, but the flu virus is a killed-virus vaccine. The flu shot does not cause infection.
    Pneumonia, on the other hand, is known to be very slow to heal — adults who have pneumonia are often prone to bronchitis after any mild upper-resp infection for years afterwards — and is dangerous. I understand your concern but think you have your immunology mixed up.

  17. amy Says:

    Sorry, I meant “the flu vaccine is a killed-virus vaccine.”

  18. lisa Says:

    I think you’re questioning my semantics rather than immunology. There was an unusually high rate of GBS following flu shots in northern IL in the 92-93 season. There was a lot of media at the time and questions about batch contamination. Since I am rarely sick, I made the decision to skip the shots and never researched further on the risk. Now that I have a child who is highly susceptible to respiratory infection, I need to revisit it. And we are having clinical trials here too.
    I guess my point is that I find myself looking at policy decisions from a different perspective as a parent than I did as an independent single adult. And I am also living in a subculture that is somewhat anti vaccine/flu shot altogether, which increases my children’s risk.

  19. amy Says:

    Lisa, your semantics are fine.
    My point is that since the vaccine didn’t infect, and since the cause of GBS is unknown (all we know is that it sometimes follows other infections; it appears to be an autoimmune disease, and autoimmune diseases are still largely mysterious), it does not make good immunological sense to say “people got GBS from the flu shot.” We don’t know why those people got GBS, just as we don’t know why the rate of autism appears to be higher now than it was 50 years ago. Did the vaccine’s carrier contain something that kicked some susceptibility in those with unlucky genes, maybe, but we don’t know; and in any case then you’d have to wonder about all vaccines, not specifically the swine flu vaccine.
    The take-home: The risks of the shot are unknown, but it’s unlikely anyone will release a vaccine that puts half the people who get it in the hospital. The risks of the lung-loving flu in people with jumpy lungs, esp. given the existence of antibiotic-resistant pneumonia strains, are pretty predictable. It looks open & shut to me.
    And yes, your friends are putting all of you at risk. Viruses mutate with great ease, and all they need is a ready incubator. Let them live in the non-vaccinated, and the vaccinated may find their immunity is no longer so helpful against the dominant strain.

  20. KMP Says:

    WOW! Lots of insight to consider here. I agree with Elizabeth….not sure I want to get the H1N1 for myself or my kids. AND I work in healthcare so I know the benefits of a good vaccine. I remember being vaccinated in 76-77. We were herded onto buses and shipped to the high school where they lined us up, 3-4 at a time, and vaccinated us in groups.
    BUT! I also have 2 kids….a 9yo which is hyper sensitive to his body (ie I have a tummyache so therefore I have a virus which will make me throw-up. And then does. Usually he just needs a good poop.) and a 5yo who has respiratory distress syndrome in the past. When he gets a cold, it sems to linger for weeks.
    Hubby and I have pushed washing hands when coming in from being out and NOT touching the face, nose, eyes etc. But kids are kids and these things will happen unconsciously. I have been to the school on several different occasions and am amazed at the number of students coughing and sneezing. I am guessing unless they are heaving or falling over, their parents will send them to school regardless of the warnings from the school This area of Ohio (soutwest) has been hit hard by the recession.
    My husband stays at home. But is (how can I say this delicately) easily suggestable of disease. When the kids are sick….he winds up with it eventually. Which means lost time at work for me. And I only work with 4 other people.
    Hmmm…

  21. Kari Osier Says:

    I already commented on this site but have to comment again. my oldest got very sick on 9/16. the pediatrician tested her for flu and strep, negative for both but said she seemed to have flu symptoms, gave a prescription for tamiflu and told us to only take it if the fever is over 100 degrees. she never got a fever (except it seemed the night she first got sick). well it is now 9/30 and she is still ill. she has asthma. this illness was strange in that it morphed from one thing to another — first a very bad sore throat, then a very bad cough, then cold symptoms, lingering and lingering. my little one got it (has asthma as well) and it did the same thing in her but in a milder form, she missed only 2 days of school whereas my oldest missed a week and is going to miss the rest of the week now. now she has a full fledged cold. so she has had something for around 2 weeks, my youngest for 10 days (she has swollen lymph glands and chest congestion at the moment).
    to get to the point, the other day my oldest told me her friend who sits behind her in math class confirmed positive for H1N1. all the doctors believe my girls have both had H1N1. would I have my kids take the vaccination? unequivocably absolutely YES. did hand sanitizers work in my oldest who used them constantly? absolutely NOT. maybe it is mild in other people but we are dealing with something very different because of the respiratory problems.
    keep in mind fever is not always a classic sign. that’s what makes this so difficult to identify. 38% of hospitalizations for H1N1 have been for asthma-related problems. it may be mild in form but knowing my child has been suffering like this for almost 2 weeks is very scary.
    some people may think I’m dramatic but I would guess they’ve not encountered what I have. Please please be vigilant, especially if your children have underlying illnesses. do not hesitate to demand a specific H1N1 test to determine whether your child has it or not. Rapid flu tests can miss many cases.
    Thank you for listening

  22. lisa Says:

    Thought you might find this interesting: http://www.denverpost.com/ci_13494407
    My decisions may have been deferred. From a policy perspective, I find it fascinating that they didn’t adequately account for the demand increase in response to all the media.

  23. lisa Says:

    Hah-after reading Kari’s comment, I called our ped and concluded that my son and I most likely had swine flu, sans fever, 2 weeks ago. And yes, we were really sick, but with the vomiting and no fever, I assumed it wasn’t flu. But it was lots of respiratory stuff.

  24. Kari O. Says:

    Oh my gosh thank you for listening. I think it’s best to be a careful and well informed parent. I think what scared me most was when I listened to my daughter’s back and was scared by all of the different sounds I heard. I’ve done that before but I just had such an odd feeling with this because somehow it just seemed different.
    My house is clean. Sadly, at our sister high school in Naperville, a 14 year old girl has supposedly died from H1N1. They will not announce this until toxicology tests come back but she had been out sick all week and had had flu-like symptoms. Please pray for her soul and family — I don’t think she will be the only one.

  25. dave.s. Says:

    We got seasonal flu vaccines for all 3 kids and self last week, and will get H1N1 vaccine whenever we can. Anyone reading this comment who is pregnant or might fall pregnant soon should read: http://www.newscientist.com/article/dn17920-flu-in-pregnancy-leaves-a-mean-legacy.html
    and note the bad outcomes for people who were in utero during previous flu outbreaks.
    Elizabeth, I did the same swine flu case you did, and came away with the idea that Gerald Ford was a hero who did the best thing he could thing with the information he had. One interesting thing to think about there is, in 1976 there were people in public life who were 70 and remembered 1918. Now there are none. How did that change people in their receptiveness to do something about flu risk, even something risky?

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