Is Everyone in the Loop on Flu?

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We’re well into the second week of the second wave of swine flu and some parents, politicians and union leaders are complaining that the city isn’t saying enough about the situations in schools. They want to know what goes into closing a school – and they’re either not hearing, or not satisfied, by the answer of Mayor Bloomberg and other city officials. The answers so far have been:

a) There’s no set formula, number, percentage, tipping point or protocol.

b) We (the city) don’t just go on absenteeism, but look at several factors, including the number of confirmed fevers and the rate at which things appear to have gotten worse.

c) Therefore, we’re making school-closing decisions on a case-by-case basis.

d) We’re updating you as quickly as we can.

Bloomberg yesterday used the “S word:” he said these are subjective decisions. You gather data, and then you make an informed judgment about whether the public would be better served by keeping a school open or closing it. Health Commissioner Dr. Thomas Frieden (still in place for a couple weeks until taking over the CDC) is a bit more disciplined and has not called the decision making “subjective” though he’s of course more or less said the same thing, both to the public and, presumably, to Bloomberg.

This is an interesting admission for leaders who believe so earnestly in the power of data: it turns out that there often isn’t a set formula and, as doctors and researchers often say, it’s an art as well as a science. But people want clarity and certainty and they want to know what's going into these decisions.

One of the complaints is that the Health Department isn’t sharing what data it does have and isn’t doing so quickly and transparently enough. Health officials say they are giving daily updates and they are sharing the pertinent information. For instance, yesterday around 7:30pm they shared the following about three newly-closed schools:

P.S. 130 (Fernando De Soto, 1081 students), in Lower Manhattan. A total of 76 students were documented with influenza-like illness during the last six school days.
P.S. 35 (Nathaniel Woodhull, 615 students), in Hollis. A total of 32 students were documented with influenza-like illness during the last seven school days.
Merrick Academy Charter School (495 students), in Jamaica. A total of 19 students were documented with influenza-like illness during the last two school days.

That does tell part of the story, but leaves out, among other things, how many are absent. The Health and Education departments’ line is that absenteeism is misleading because so many kids are staying home either for illness that isn’t flu or simply as a precaution.

These daily updates so far have also left out any details whatsoever about swine flu cases among adults. Are schoolchildren 95 percent of the cases, 50 percent of the cases or 5 percent of the cases? By all indications, they’re the majority but who knows? Getting precise numbers would be impossible – and no one has suggested that every suspect case should be tested, or that every hospital and medical practice should instantly enumerate its true-versus-suspect flu cases and share the figures with health officials who would tally and publicize them. Still, it should be possible to get estimates.

Three weeks ago, during the outbreak at St. Francis Prep School in Queens, I spoke with Dr. Don Weiss, who runs the Health Department’s surveillance system. I asked him about the picture from the daily emergency room data and he told me, “The few days before this started . . . .[there were] about 100, 150 visits total throughout the city a day for adults – those 13 and over – who had fever . . . Yesterday and today, we’re at 600.” “Fever” is a broad category, and it’s a “chief complaint,” not a positive diagnosis. Still, it gives a picture: ER visits had quadrupled!

Also at that time, health officials spoke of daily downloads from Intensive Care Units yielding “one to two cases a day” that could be swine flu and were being monitored closely.

I’ve asked DOH officials to update those two categories and have gotten two answers: Dr. Weiss and others are too busy to break away and share the information, and, in response to the ICU question, that they’re not monitoring them “as aggressively as we were before.”

Really? Seems to me people would like to know these sorts of thing and that sharing them would go far toward providing the transparency Mayor Bloomberg says is a goal.