Comments

1. #1 Frank Mirer

   March 26, 2007

   Several comments about protection against infectious aerosols.

   1. Water droplets evaporate, eventually to nothing at all. Droplets with snot in them don’t go to zero because the non-volatiles hold some water in. Even the big droplets don’t fall so fast.

   2. The most important issue with respiratory protection is not filtration efficiency, it’s fit. Poor fit is a catastrophic failure of the respiratory protection system.

   3. This whole discussion ignores exhaust ventilation in the contaminated area and appropriate filtration of the exhaust air.

   4. It’s curious why cdc continues its fierce opposition to the OSHA respirator standard. I’ve come to think it’s because this issue symbolizes the ineffectiveness of infection control measures. If your doctor — that’s who’s running this part of the hospital, and also CDC — the daily danger of failed infection control is obvious. Psychologically the best way to deal with it is to deny it.

2. #2 revere

   March 26, 2007

   Frank: Your points on ventilation are well taken for the usual workplace. They are not so pertinent for the general environment or for many hospital workplaces. The main point about masks in pandemic influenza is their widespead use by the public. Fit is critical, although one still asks whether there is any partial benefit: not elminating the risk but decreasing it. We still don’t know.

3. #3 indigo

   March 26, 2007

   But, they do come in a pediatric size. Won’t fit every kid though.

4. #4 stu

   March 26, 2007

   How does the topic of relative effectiveness of face masks against H5N1 fit with:

   “The real bottom line is that we better get busy and strengthen our public health and social service infrastructures because we’re not going to get by this one by hiding in a bunker or wearing a mask 24/7. We’ll only get through this together”

   How will strenthening the social services infrastructure prevent or reduce the transmission of aerosols? I guess if you subscribe to the theory that every person in the world will be exposed to a pandemic agent and nothing can stop it, then I suppose you’re right. Personally, I will try to isolate me and my family as long as possible. If you plan on venturing out in the middle of it, then I would think you would be very keen on protection. Revere, what’s your plan? N95 mask, full suit, or nothing? Not trying to be an ass I’m just curious.

5. #5 revere

   March 26, 2007

   stu: I’m not prepping like that. I figure we’ll only get through this if we work together. I hope I’ll be able and brave enough to help others. People do that in disasters. Only time will tell if I am one of them.

6. #6 ConnectRN

   March 26, 2007

   Whether the masks (N95 and surgical) are effective or not, people are going to want to do something. They have seen too many medical TV shows where the staff are wearing masks, gloves, and gowns when dealing with infectious patients. Some people insist on antibiotics when they have a virus, because they feel better knowing they are doing something to fight the disease (even if it’s the wrong thing). So start stockpiling those masks, the public is going to demand that they have them.

7. #7 Claire

   March 26, 2007

   This study only repeats what people have already been saying.

   I’m not sure any N95 masks fit well enough. We’ve tried four types, and none seal perfectly. The more air-tight they are the more difficult they are to wear. I tried using one while cleaning and got kind of dizzy–so wearing one to care for a sick family member might be difficult.

   My doctor’s response to my questions about a pandemic was, “You’re right. There won’t be ventilators and meds for everyone, there won’t be hospital beds and doctors and nurses. You’ll either get it or you won’t, you’ll either die or you won’t.”

   Like Stu, I don’t understand ‘we’ll only get through it if we work together.’ That’s usually true and it’s true if the death rate goes way down. But if no one has immunity and there’s no care available and the death rate stays high sticking together seems like a way to make sure more people die. Honourable, but sort of Charge of the Light Brigade. If my neighbour calls, “Help, we’re sick,” and I go help them, won’t I likely get sick and won’t I likely take the bug home to my family? It’s horrifying not to help, horrifying to think of loved ones far away not getting help, horrifying to think of infecting your family. I don’t know. If someone in town falls through the ice and a few people try to save her but the ice is breaking and they all fall in, too, should everyone in town jump in because it would be wrong to stay safe on shore?

   So far, after a year plus of reading about this, all I’m hearing is that nothing will help and that if I’m one of the few with enough food I’ll have to fight off desperate people who want it. I can’t imagine doing that. All in all, I’m starting to concentrate on enjoying now.

8. #8 claire

   March 26, 2007

   Not to worry, Revere. It’s amazing you can sift through all the info and post every day of the year–as well as doing your day job! And some people may not have seen the old story.

9. #9 Greg

   March 26, 2007

   Claire sez, “So far, after a year plus of reading about this, all I’m hearing is that nothing will help and that if I’m one of the few with enough food I’ll have to fight off desperate people who want it. I can’t imagine doing that. All in all, I’m starting to concentrate on enjoying now.”

   The fascination for technofixes, N95 being only one example, should perhaps be the topic of a Freethinker Sermon. N95 will save us. No it won’t. We need something. N95 will save us.

   We are a society who worship technofixes. Big Tobacco, Big Booze, Big Pharma, Big Screen, keep us that way. Crack cocaine also is a technofix.

   We don’t know how to get through together. We don’t know how to help our neighbour without bringing home their bugs. We don’t know how to identify nor to evaluate the risks. We don’t know how to choose nor to reduce the risks. We don’t know how to ask, each oneself, what am I willing to commit, who am I committing with me.

   The Bigs stoke our fears. They offer to sell us a technofix. When there is none. And we will buy it, with all the sold separately accessories, knowing no other course.

   Revere, this is another piece of what I periodically harrass you about.

   You know clinics and hospitals, and schools and public hearings. You can comfortably count on reacting prudently and effectively no matter what comes to you there. Kruger knows guns and ditches; and that is where he intends to meet the enemy. I know politicians who will burn every available caregiver before admitting there is a danger; and I have taught one little person in my corner of the world to be ware and to choose whether she will be used that way.

   Most of us are lost in the wilderness. All of us are blind to some of our horizons.

   You chant “public health and social service infrastructure”. We on this side of the screen don’t know what that is. Less do we know what we can juryrig as substitute.

10. #10 revere

    March 26, 2007

    Greg: You are not the only one who has harrassed me about this. My flu wiki partners also want me to spell it out. I’ve made a couple of attempts but I’m finding it hard to spell out something that seems fairly clear to me. So I need to work on it some more. I’ll do that. I understand it’s needed.

11. #11 Greg

    March 26, 2007

    Thank you. It was obvious, last time you responded to my prodding, that you knew what you meant.

    We should help you.

    HINT -> Maybe the French can help.

12. #12 marquer

    March 26, 2007

    
    In principle, the disposable N95 respirators will stop them, but to be effective these masks have to be carefully fitted to each user and if you have any facial hair, forget it. They also don’t come in pediatric sizes. And if inanimate objects are an effective route of transmission, they have to be handled carefully because the outside of the mask will be contaminated from others sneezing in the environment.
    

    I had been opining in an earlier thread that N95 was better than nothing, and that my own experience would suggest such masks would reduce somewhat (*not* eliminate altogether) new aerosolized infections in a pandemic situation.

    That said, Revere is spot on with a couple of these points of criticism.

    Facial hair? It absolutely has to go. At least with N95/N100 type masks, the seal of which will be rendered thoroughly inutile.

    A fullface will go over many trimmed facial hair arrangements. A drape hood will cover even the guys from ZZ Top. Although do note that the U.S. Navy, who use fullface and hood respirators, nevertheless prohibit beards and mustaches due to fit risks. Note as well the huge cost and logistical complications of distributing such large, complex units compared to the tiny and simple N95s.

    Any instruction kit or PSA on this topic has to tell men in unambiguous terms to shave, immediately. It is worth noting that it is a giant pain to have to shave off a full beard with something like a safety razor. The blade assemblies clog on every swipe. A very slow process. Scissors or clippers are called for.

    As for pediatric sizes, N95 designs could easily be made in sizes (and shapes) to fit children’s faces, but I think that compliance would be awful. Young kids would throw a crying jag — wetting the mask with tears and mucus and reducing its effectiveness. Probably also pulling unfiltered air in around the edges with deep ungentle breaths. Older ones would fidget and pull at the mask with hands, immediately contaminating and compromising it. Any serious pandemic plan has to hustle youngsters into segregated quarantine right quick.

    And yes, an N95 should be considered a single-use burn bag item. (Which is why stepping up production today would be sensible.) Revere is completely right that the outside of such a mask, after exposure, can and will contaminate hands during doffing. Has happened to me with fiberglass. Itch itch itch. Better on fingers than in lungs.

    Put it on and don’t take it off until you can do so under carefully controlled conditions. Little spray bottles of isopropanol would be great, if people could be made to use them sensibly: hold breath, close eyes, mist outside of mask with isoalcohol, let spray settle, remove mask, into biohazard waste with the discard, deep breath, wash hands at once.

    FYI, for those of you who have never gone through a fit test with a serious industrial respirator, the procedure utilizes a bottle of isoamyl acetate. Banana oil to you and me. Your fit assistant tightens all straps and fittings and then uncorks the bottle and waves it about. If you smell bananas, well, you had better not rely on that mask.

    –

13. #13 M. Randolph Kruger

    March 27, 2007

    My friends at DHS were conducting a little exercise back in November down in Mississippi which was to test the effectiveness by military standards of the M-95 paper/cotton masks. They were to work in them for about four hours in what was explained ot me as a dye laden environment (have no idea what that meant), could have been old smoke bombs, or spray or whatever. They worked setting up tents and apparently ministering to sick people as if they were primary care givers. Patients wore the masks too. This dye while not toxic if the mask didnt fit properly or leaked (remember the masks are to designed to keep bugs in, not out) would contaminate the skin at the penetration points. Interesting because all around the nose area and eyebrows/eyelashes there was contamination as well as on the skin in high order. The poor fitting masks actually concentrated the dye around the sides of the nose. That means that they would fail miserably I guess at keeping the simulated bugs out…. Answer? Only one and thats the 98-100% effective full face plates with the removable filters as best I can tell. Those were the only ones that could work apparently without being exposed (didnt say infected). One of the DHS guys told me that it wasnt a rinky dink op either as there were lots of military, police, fire, etc. All were randomly selected for their positions and everyone thinking they were going to get to use their own equipment pulled back the big surprise that they were going to be using what the people were going to be getting…Maybe.

    The response of the DHS guy that I know was to immediately order full face plates types for the family and hood for the younger one.

    FYI.

14. #14 Melanie

    March 27, 2007

    Randy, have you got a news story with a link to that sim? I’d like to read it.

15. #15 crfullmoon

    March 27, 2007

    Too bad the DHS guy didn’t think telling the public- or at least the municipalities- to pay up for their responders and hcw effective PPE… Getting prepared for supply chain disruptions is necessary, too.

    Selfish, secretive, short-sighted bureaucrats are more dangerous than the virus, at this point.

16. #16 M. Randolph Kruger

    March 27, 2007

    Mel, no news story. I will check with John to see if he wants me to give up his email address. Last time I sent something to someone on a personal note I was vilified when they put it on Flu-Wiki without my knowledge. Monotreme be advised, two strikes and you are out.

    CRF-Not so fast to the lets go bash someone line. Since mid point of last year the DHS budget has been changed from like 80% to counter-terrorism to 80% national response capabilities. They are doing it based upon the threat likelyhood for whats in front of us.

    If you are in the US, call up a small town fire chief or police department. They are sending millions to the states for response to this and/or national disaster. Why they arent advertising it I dont know. It is a fact. Anyway call them up and see how much money they got from the federal grant process. All they had to to was to match 20% to qualify.

    My town got 380,000 for a population of 50,000 in the burbs of Memphis. Not bad but it would last about . (yeah thats a dot) in the event of a pandemic but its a start. Reveres are right about one thing, we need money and that means taxes. 1 cent at the pump that is a consumptive tax rather than a progressive one would go a long way towards rectifying a really shitty situaton. No matter what we do the flat rock is coming towards a lot of heads if this comes, M-95′s and/or the 120 buck masks nothwithstanding.

17. #17 stu

    March 27, 2007

    Now we are on to something. Those who want/need to work in a H5N1 contaminated area should not rely on N95 masks, but should instead use (fill in the blank here) respirators and drill for proper use/fit procedures. I assume these same people should wear protective garments and gloves, and follow some virucide douche routine to prevent tracking it into the safe area.

    I do agree that the general public is being misled by anyone claming some cheesy masks will be the magic bullet in a pandemic. A lot of so-called flu preppers are counting on this, when I tell them how easy it is to negate protection they go quiet. It’s all in the DOD field manuals, good reading if you want to operate in an NBC hot area. I got them a long time ago when I was into Civil Defense, lost ‘em but I remember the procedures.

18. #18 stu

    March 27, 2007

    Oh yeah one more thought…anyone who plans on running around business as usual if this ever does hit is fucking nuts, IMO. I might even just get some protective gear so I can help my neighbors instead of being a self-centered bastard

19. #19 M. Randolph Kruger

    March 27, 2007

    Stu, I have the manuals if you want or anyone else for that manner. You would just insert the procedures for your particular mask and suit into the blank instead of the full MOPP 4 chem/bio suits from the military. They are carbonized anyway and you would be a walking vector. You cant decon them other than to wash in bleach, then rinse in water. Takes about a day. Even the military doesnt reuse them now.

    Manuals ? memphisservices@bellsouth.net. No charge.

20. #20 Earl E,

    March 28, 2007

    As regards the mask fitting issue, I do not understand why no one recommends taping the N95 mask on with first aid tape.

    For a single use of a disposable N95 mask—I think this is a good idea.

    There are great first aid tapes on the market now that are easy to remove.

    Please point out why this is not recommended.

21. #21 M. Randolph Kruger

    March 28, 2007

    Earl-Okay so you put the mask on. Great you did it because you were sick or you didnt want to. So on one side of the mask is the devil one way or the other. Taping it down is fine, but you exhale and based upon the temp you will either start to develop water droplets or in cold conditions ice. Its itchy and uncomfortable. So lets say you work all day in an environment that the bug is on the outside. You have been honked on, coughed on, atomized crap in the air has settled on your body and in particular if you dont have a full face plate mask in your hair, the mask, your skin, your hands etc. So now it comes time to take the damned thing off. Its ALIVE with virus. You also dont have any protection for your eyes and skin and you are putting this thing on your face? Now lets take it off, you will flick the stuff in small particles into the air right next to your air inlets, the nose and mouth. The conjunctivae (eyes) also can have it impact into it at the same time. We arent even going to talk about the stuff in your hair, eyebrows, eyelids because you didnt have them protected by a suit.

    If this comes and you are working around the house, you can wash the car, you can roof the house, you can paint the thing. Just make sure that you arent mowing the grass where your dog pooped, dont pet the cats and once they go out they stay out for the duration. Above all the only people you should be in contact with is your family. If one goes to work, make a reservation at a hotel that has its own individual room units. They filter the air in that particular room and clean the place yourself. Change the linens with fresh each day and pick them up in housekeeping when the staff is away from it. Dont let them touch it. Everything will be a possible vector, doorknobs, the car door handle, and that bathroom is going to get sprayed down after every use because Bubba isnt very clean. Bubba what be infected in a public bathroom goes all over the place when someone flushes. It atomizes fecal matter into the air and lands again on you. Chances are that the vector capabilities are limited, but it only takes one in the proper place in your airway to get this shit. I have seen some stuff that indicates its like someone shoves a blowtorch down your airways into your lungs and gives you almost the same effect. Inflammation of the highest order is what gets you along with pinholing of the lungs, sloughing of dead cells, snot and that funky stuff called cytokine. So you drown. That M-95 is like trying to stop a raging bull on speed with a BB gun.

    You dont need a mask if you follow proper protocols and stay at home. Job opportunities will abound 15 minutes after this passes. Besides Earl, the masks are made in….Indonesia.

22. #22 Greg

    March 28, 2007

    Since we can’t all have effective gear, (a) learn to avoid contaminating situations, (b) tape down the edges, especially around the nose.

    I have heard duct-tape recommended. It probably beats dying. Experiment with medically approved adhesive tapes. Don’t be afraid to destroy a few masks. That beats dying too.

23. #23 Greg

    March 28, 2007

    As for children complaining about masks. We are simply insane.

    Watch video and still pictures from “less developed” nations. Kids can know what to do. Kids can do what they are told. Kids can even do the right thing when there is nobody to tell them.

24. #24 Earl E.

    March 28, 2007

    I have read over and over that authorities don’t think a mask will help because of the FIT ISSUE.

    My family and I are planning to stay home when it blows.

    Here is an emergency procedure I would use to leave home if things get horrible—-but I MUST go out:

    If you MUST go out into the sick world, I think a taped on mask, goggles, and gloves will keep virus from reaching mucus membranes.

    Viruses need moisture to survive.

    You come home—you strip outside—leave the gloves, mask, and goggles on—-you wash yourself completely with soap and water left outside—you remove the gloves, wash your hands, and put fresh gloves on—you gently remove the mask and goggles and leave them outside. You take the gloves off there too. You wash up again—first hands, and now face too. Wash the rest of you again.

    Put on clean clothes left outside the door—leave shoes outside and go in.

25. #25 revere

    March 28, 2007

    Earl E.: Note that viruses don’t need anything to “survive” because they aren’t alive. They just replicate. They don’t grow in size. They need a host to do that, that’s all. They can remain replicable on absolutely try, hard surfaces, depending on the virus and other factors.

26. #26 SoCal

    March 28, 2007

    1. Somehow, N95 respirators and surgical masks have been used in health care settings for years and years, and have provided some measure of infection protection for health care workers and patients.

    2. Now, it becomes known that there will not be enough N95 respirators available for all who will need them in the pandemic period.

    Call me cynical, but I believe that the current discussion calling into question the effectiveness of respirators has more to do with #2 than #1. (“I don’t care that I can’t buy any respirators, they’re not any good anyway.”)

    In Econ 101, this translates to: To achieve equilibrium, if you can’t increase supply, decrease demand.

27. #27 M. Randolph Kruger

    March 28, 2007

    Earl-Be advised that many cases were happening during the summers in Indon. 98 degrees no less and testing found it in the dirt and dried feces. It would last up to 4 days I think and in winter it would last in Turkey up to 30 something days in the soil in 34 degrees. Very resilient and its been posted here many times that the vector will be around in birds who happily poop on your car or in your cat that ate the sick bird, or you petted your dog that sat in the crap or ate the cat or the bird, that ate the mouse, that ate the rat, that the hawk smoked, or the rabbit ate the contaminated grass that the cow got from another cow and on an and on.

    Dont depend on the mask as Revere said. If you want a site that sells the full faceplates and suits put in SGE400 into a search. Thats the type that I have for myself and crews, and my kids. Has a drinking tube and you can modify it by drilling a hole thru it for a microphone for your cell phone and headset. I have duals for mine that will allow me to plug into a standard phone, or to the cell. You simply use one that can be sealed with epoxy or rubber based silicone and be dunked in water/bleach.

28. #28 M. Randolph Kruger

    March 28, 2007

    You might also want to put into a browser search something called a SPUR (single patient use resuscitator). Its not a ventilator but oxygen they may have, but the national stockpile for airway tubes and machines to ventilate them is about 16 days…. under normal consumption. Why dont they get more? 100,000 per machine for a country that would need over 200,000 of them and someone to operate them. Simple oxygen masks are time dated along with the airways. Oxygen they will have but oxygen masks, ventilators and folks they are going to come up short on. As for the SPUR they are a little pricey but you will at least be able to force air into someones lungs. Make sure you get the type that holds it onto their faces. You could decontaminate this thing if you needed to and use it again. You would only use it on someone who was sick and then transfer it to someone who was….sick. So who is going to get sick if you do decontaminate it?

29. #29 revere

    March 28, 2007

    SoCal: They have been used for specific purposes and in specific contexts. The question to ask what purpose and context to use them in for this.

30. #30 Into The Woods

    March 28, 2007

    One side of this issue rarely addressed is that while most now agree that N-95 (or above) masks and other appropriate PPE are recommended for persons providing care to pandemic flu patients in health care facilities, if we experience a severe (1918-like) pandemic – somewhere north of 1/2 or 2/3 of the patient care will occur in people’s homes and be provided by untrained family members.

    If the chances of infection for these untrained care givers can be decreased by any measureable degree by their use of PPE, including n-95 or even surgical masks, then that fact should be stated clearly. Studies that neglect that aspect may indeed be open to the suspicion of working towards Equilibrium.

    It seems to me that a family who feels they may be caring for an infected pandemic patient at home would be wise to mimic the infection control practices recommended for their trained brethern (as closely and fully as they can manage) and have the necessary supplies pre-purchased to do so.

    Searching the web for ‘home care for pandemic patients’ and ‘home care infection control pandemic patient’ will provide a good start.

31. #31 revere

    March 28, 2007

    Into The Woods: Unfortunately there are no studies, so it isn’t possible to state anything clearly (except that we can’t state anything clearly). You are right about home care, but that also is a setting where there will likely be multiple pathways for infection. I’d tell you the answer if I knew it.

32. #32 Earl E.

    March 28, 2007

    Revere:

    I know viruses aren’t alive. They do not become alive until they enter a living cell, replicate, and then break out of the cell.

    If you keep them OUTSIDE of your body they cannot harm you.

    They cannot penetrate skin or hair.

    Even people working with nasty viruses in Biosafety 3 labs wear N95 masks—without tape.

    So tell me why taping them on will not solve the “FIT ISSUE”

    that I am constantly hearing about?

    MRK: Good idea on the SPUR devices. Thanks.

    I do not have pets. Many N95′s have exhalation valves

    that help reduce heat buildup and moisture.

33. #33 M. Randolph Kruger

    March 28, 2007

    Into-The only thing we have to go on is biowarfare training. Treat it as such and your survival chances go up. Infected people are between 67%-83% auto-dead right now depending on who you talk to. Hence the reasons for the masks and portable decontamination facility that I have here. Its a necessity for me but you could make one yourself. Treatment of bio-infected patients is covered in the books but the outcomes for those that are sick with this stuff appears to be generated by their own immune systems rather than anything we are doing. E.g. point to Tamiflu and tell me who survived as a result of having it. So its all about NOT getting sick which is the discussion on the masks. One thing is sure, if you get it you have easily a 50/50 chance of visiting Batesville Casket. They are very informative on how to protect yourself and family at the very least, irreplaceable when it comes to isolation and quarantine. I also suggest a copy of “Where There Is No Doctor.”

    Want those manuals? Downloaded and ready to send.

34. #34 Lea

    March 28, 2007

    Silly thought perhaps.
    For those that are going to venture outdoors and to public places during a pandemic, when they return home would not an outdoor decontamination shower work?
    Pricey no doubt but those that have the money could get one. Most likely even Do-it-Yourself plans available.
    Have seen a simple set-up in many workplaces for hazardous waste and so on.

35. #35 revere

    March 28, 2007

    Lea: Since we don’t know the major modes of transmission of the virus it isn’t clear a shower would do a thing. If you’re worried about drinking water, I don’t think you’d want to use whatever you have this way. Of course, I’m not worried about drinking water, so I’ll be OK.

36. #36 Into The Woods

    March 28, 2007

    Ralph: Thanks, but I am have WTIND (as well as some of the related free downloadable docs you find if you search for that title.) I have some decon supplies and have stocked what I can for now. Skill set is an entirely different matter, as is compliance discipline.

    They tell me it takes adults about 6 weeks to make a practice into a habit. That’s a long time to pay strict attention to a new skill set – newly and poorly learned.

37. #37 Into the Woods

    March 28, 2007

    Revere: Yup. No hard answers but I am willing to accept the same uncertain evidence that supported OSHA and CDC recommendations for health care workers’ use of PPE.

    Not sure what you meant in your comment “Since we don’t know the major modes of transmission of the virus it isn’t clear a shower would do a thing.” We may not have certainty, but that’s far from “don’t know” and we are looking for what might help, not absolute guarantees of success.

    Are we applying a higher certainty requirement to this kind of advice than what seems to be generally required for advice to the public on how to avoid infectious diseases like the seasonal flu?

    That higher threshold leads to equivicating comments like yours above, which in turn lead people to reject what otherwise might be sound practices. I don’t mean to jump on your comment in particular, but that also seems to be the general approach of the IOM mask report as well.

    In the absence of definitive guideance, I am willing to operate on ‘can’t hurt, might help’, so if washing hands is good, then showering is probably a good measure under a variety of circumstances.

    What makes me uncomforable is lack of discussion and emphasis on one of the most certain aspects of a pandemic – the significant family home care that will be required.

    The only myth about We The Public greater than “They Will Panic”, seems to be the “They Have Nothing to Offer” myth.

    We lack neither grit nor smarts. What we need is information, encouragement and some small amount of assistance in building new capacity and re-building some old fashioned resilience at the individual and neighborhood level.

    I appreciate your efforts at supporting both but sometimes despair at convincing elected and appointed officials of the need to trust the people that put them there with hard choices on complicated matters. These decisions will be hard and the issues complicated, but frankly no more so than many issues faced by these same people on a daily basis.

    Even if none of the outcomes can be changed, preparing the public to care for their loved ones at home is worth the effort.

    In truth, I do not want to face a post-pandemic society full of families, mothers and fathers, who had to watch helpless and futile as their loved ones died – families that did not know what to do nor have the supplies with which to do it – even if it only would have meant the ability to provide comfort care.

    Knowing there is little you can do and at least providing that small level of care is one thing.

    Thinking there might be something you should do if only you knew what to do or had planned to do it – might be more than some can stand.

    After all is said and done, they will need to know they did what they could.

    We owe them that much.

38. #38 revere

    March 28, 2007

    Into the Woods: OK, I’ll be blunter. Showers as a protection won’t work, are useless and could be counterproductive by making people think they are protected when they aren’t. A waste of water, effort, energy and commitment. I would say the same thing about prayer, although lots of people say it makes them feel better. Masks for high exposure operations like intubating or sunctioning make sense, and that’s what the recommendation is. Masks for the bus, the street or your house I think aren’t useful. My opinion. They will promote a false sense of security, the opposite of panic. I’m not worrying about the public panicking. I’ve posted about that many times here. You need to tell people the truth as you see it, and that’s what I’m doing about masks. Some people don’t want to hear it because they want to think masks willl work as a way for average people to protect themselves. I don’t.

    No one knows, not me, not you. I’m just giving you my opinion, which is an educated opinion but not based on enough information. I don’t have masks for myself or my family. I refuse to advise them on the basis that they can’t hurt. With a huge investment of money and resources and energy and (IMO) a misperception the will hurt because I don’t think they work and people might be tempted to do things they wouldn’t otherwise do. I won’t advise prayer either. If you want to do it it’s not my business or my advice. At least it’s free.

39. #39 marquer

    March 28, 2007

    
    I also suggest a copy of “Where There Is No Doctor.”
    
    Let me echo that, and also, if available, the U.S. Army Special Forces Medical Handbook (which is written for Green Beret types operating in unimproved remote villages with minimal medical supplies to hand).

    There is a core assumption among many N95 critics that the masks will not protect in a highly concentrated aerosolized viral environment. I share that belief.

    HCWs and others who are going to have to enter such environments in a high-infectivity, high-lethality pandemic are going to need far better protection (and decontamination). For that read drape hoods with supplied air. If not full moon suits. Relying on N95s in such conditions would mean that you would run out of healthy HCWs rather promptly. If only because many would refuse to work.

    The critics go on from the inutility of N95 for high-risk areas to conclude that reliance on N95 in any context is thus ipso facto useless. I demur. There will be circumstances where ordinary citizens have to operate in public spaces where the risk of infection is present, but much lower than in hot spots such as a hospital (or morgue, or what have you). For them, N95 will offer some protection, at an inexpensive enough cost to make mass advance deployment plausible. Imperfect protection, but that is preferable to zero.

    Consider the unavoidable case of an ill individual coming into brief proximal contact with well persons in public. Under completely unprotected conditions, we may expect that n of those uninfected people would then fall ill. Modest protective prophylaxis (N95 plus behavior changes) would reduce that to n-m.

    Can m be made large enough by these expedients to defuse the whole pandemic? Not at all. What will happen if you contrive a large enough m is to help slow and blunt the impact. Even if you only delay the rate at which people first become sick, without reducing the total number of infections that occur, that has positive implications for the continued functioning of critical societal systems.

    Randy, the last time I stocked N95s, they were Made In USA. Sourcing varies by manufacturer. As do quality and features. Exhalation valves were mentioned upthread. Those are a key function and comfort feature of a good mask. Should be made a specification standard.

    –

40. #40 revere

    March 28, 2007

    Blogging often means you say things that piss people off or get them exercised. There is a list of hot button issues: atheism, guns and masks for flu. I continue to be amazed at how attached some readers are to the mask idea. For the record (again), I don’t believe in masks but if you want them, get them. As many as you want. As many as you can find. Wear them. All the time. Indoors, Outdoors. In the shower. In bed. It’s fine with me. Really.

41. #41 Into the Woods

    March 28, 2007

    As I mentioned in my previous comment, while general exposure may not merit the type of protective equipment w are talking about, my particular concern is in-home care provided by family members to infected individuals (or suspected).

    I am not sure you intended your comments to apply to both, but your failure to differentiate between the two gives that impression.

    I would be interested in your comments on the comparison of your recommendation and appraisal of whether masks work with the recommendations of HHS, CDC and OSHA relating to the question of whether N-95′s should be included as part of a comprehensive infection control program (in or out of the hosptial) and their inclusion of N-95 respirator recommendations in many circumstances outside of “high exposure operations like intubating or sunctioning”.

    Your comments/recommendation:

    “Showers as a protection won’t work, are useless and could be counterproductive by making people think they are protected when they aren’t.” (While I have not included all of the various recommendations contained in the following referenced documents about using various types of PPE clothing, goggles etc, to protect against exposure to the skin and heavy emphasis on hand hygiene from which I would infer that if proper protective clothing is not available, similar hygiene measures would be advisable for any potentially exposed areas when providing in-home pandemic care.)

    “Masks for high exposure operations like intubating or sunctioning make sense, and that’s what the recommendation is.”

    “Masks for the bus, the street or your house I think aren’t useful.” (As stated above, my specific focus is the ‘house’ – more specifically a house where family care is being provided to an infected individual.)

    HHS Recommendation:
    “Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings during an Influenza Pandemic
    October 2006
    …Development of authoritative responses is hampered by the lack of definitive data about the relative contributions and importance of short-range inhalational exposure, large droplet mucosal exposure, and direct inoculation via hands or inanimate objects contaminated with virus (i.e., fomites) on influenza transmission There is only limited information on optimal interventions to prevent influenza transmission and the effectiveness of interventions on an individual basis. The lack of scientific consensus has led to conflicting recommendations by public health partners. Moreover, a large amount of incorrect, incomplete, and confusing information about surgical mask and respirator use has been disseminated on the Internet and by other popular media.
    …
    The prioritization of respirator use during a pandemic remains unchanged: N-95 (or higher) respirators should be worn during medical activities that have a high likelihood of generating infectious respiratory aerosols, for which respirators (not surgical masks) offer the most appropriate protection for health care personnel. Use of N-95 respirators is also prudent for health care personnel during other direct patient care activities (e.g., examination, bathing, feeding) and for support staff who may have direct contact with pandemic influenza patients. If N-95 or other types of respirators are not available, surgical masks provide benefit against large-droplet exposure and should be worn for all health care activities involving patients with confirmed or suspected pandemic influenza. Measures should be employed to minimize the number of personnel required to come in contact with suspected or confirmed pandemic influenza patients.”

    CDC Recommendation (Avian Flu):

    “Interim Recommendations for Infection Control in Health-Care Facilities Caring for Patients with Known or Suspected Avian Influenza
    …
    Recommendations for Avian Influenza
    All patients who present to a health-care setting with fever and respiratory symptoms should be managed according to recommendations for Respiratory Hygiene and Cough Etiquette and questioned regarding their recent travel history.

    Patients with a history of travel within 10 days to a country with avian influenza activity and are hospitalized with a severe febrile respiratory illness, or are otherwise under evaluation for avian influenza, should be managed using isolation precautions identical to those recommended for patients with known Severe Acute Respiratory Syndrome (SARS). These include:

    Airborne Precautions
    Place the patient in an airborne isolation room (AIR). Such rooms should have monitored negative air pressure in relation to corridor, with 6 to 12 air changes per hour (ACH), and exhaust air directly outside or have recirculated air filtered by a high efficiency particulate air (HEPA) filter. If an AIR is unavailable, contact the health-care facility engineer to assist or use portable HEPA filters (see Environmental Infection Control Guidelines) to augment the number of ACH.
    Use a fit-tested respirator, at least as protective as a National Institute of Occupational Safety and Health (NIOSH)-approved N-95 filtering facepiece (i.e., disposable) respirator, when entering the room.
    …
    Patients managed as outpatients or hospitalized patients discharged before 14 days with suspected avian influenza should be isolated in the home setting on the basis of principles outlined for the home isolation of SARS patients… .” (Link provided in original that leads to the following document.)

    Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS) Version 2
    Supplement I: Infection Control in Healthcare, Home, and Community Settings

    …
    5. Personal protective equipment (PPE)
    Gloves, gown, respiratory protection, and eye protection (as needed) should be donned before entering a SARS patient?s room or designated SARS patient-care area. This level of protection is required for the majority of patient contacts. Additional guidance for performing an aerosol-generating procedure on patients with SARS Co-V disease is provided in Section III.D.11 below. …

    Respiratory protection – Wear a NIOSH-certified N-95 filtering facepiece respirator for entering an AIIR or designated SARS patient-care area.3 If N-95 or higher level of respiratory protection is not available, then wear a snug-fitting surgical mask to prevent nose and mouth contact with large respiratory droplets. Discard respirators upon leaving the patient room or area.
    …
    11. Aerosol-generating procedures
    Because aerosol-generating procedures may pose a greater risk of SARS-CoV transmission, additional precautions are recommended for healthcare workers who perform or assist with these procedures. Procedures that stimulate coughing and promote the generation of aerosols include aerosolized or nebulized medication administration, diagnostic sputum induction, bronchoscopy, airway suctioning, endotracheal intubation, positive pressure ventilation via face mask (e.g., BiPAP, CPAP), and high-frequency oscillatory ventilation….

    IV. Infection Control for Prehospital Emergency Medical Services (EMS)
    …
    Activities
    􀁹 Prehospital care providers who directly handle a patient with SARS-CoV disease or who are in the compartment with the patient should wear PPE as recommended for Standard, Contact, and AII Precautions (www.cdc.gov/ncidod/hip/ISOLAT/isopart2.htm). These include the following:
    o Disposable isolation gown, pair of disposable patient examination gloves, eye protection (i.e., goggles or face shield).
    o Respiratory protection (i.e., N-95 or higher-level respirator)
    􀁹 Personnel in the driver?s compartment who will have no direct patient contact should wear an N-95 or higher-level respirator during transport.
    …
    V. Infection Control for Care of SARS Patients at Home

    Patients with SARS-CoV disease who do not require hospitalization for medical indications may be isolated at home.
    …
    A. Assessment of the Residence
    Objective: Ensure that the residential setting is suitable and appropriate for isolation of a SARS patient.
    Activities
    …
    B. Infection Control Precautions for SARS Patients Isolated at Home
    Objective: Ensure the use of proper infection control precautions in the home setting to minimize the potential for SARS-CoV transmission.
    Infection control principles used in healthcare settings also apply in the home care setting. However, due to practical limitations, there are some differences between what can be done in the home and the healthcare setting. For example, AII Precautions cannot be practiced completely outside of fully controlled settings such as healthcare facilities. Since SARS-CoV is most likely transmitted through contact and droplet spread, the use of modified precautions that focus on preventing droplet and contact spread are recommended for isolation in the household setting.
    …
    Infection control measures in the home …
    Source control — Patients should cover the nose/mouth when coughing and dispose of tissues in a lined waste container. If possible, the patient should wear a surgical mask when others are present. If the patient cannot wear a mask, persons in close contact with the patient should wear a mask. Masks should fit snugly around the face and should not be touched or handled during use. If masks will be reused by persons in the home, procedures for identifying each person?s mask and containing it between uses should be in place. A supply of masks should be available based on the volume needed each day.”

    CDC Recommendations (seasonal flu):

    “GUIDELINES & RECOMMENDATIONS

    Interim Guidance for the Use of Masks to Control Influenza Transmission
    …

    Likewise, when a patient is not wearing a mask, as when in an isolation room, having health-care personnel mask for close contact with the patient may prevent nose and mouth contact with respiratory droplets. However, no studies have definitively shown that mask use by either infectious patients or health-care personnel prevents influenza transmission. In the United States, disposable surgical and procedure masks have been used widely in health-care settings to prevent exposure to respiratory infections, but they have not been used commonly in community settings (e.g., schools, businesses, public gatherings).
    …

    The following recommendations focus on the appropriate use of masks as part of a group of influenza control strategies in health-care settings. Masks are not usually recommended in non-health-care settings; however, this guidance provides other strategies for limiting the spread of influenza in the community.

    …

    Health-care Personnel
    A surgical or procedure mask should be worn by health-care personnel who are in close contact (i.e., within 3 feet) with a patient who has symptoms of a respiratory infection, particularly if fever is present, as recommended for standard and droplet precautions. These precautions should be maintained until the patient has been determined to be noninfectious or for the duration recommended for the specific infectious agent.”

    OSHA Recommendation:

    “Guidance on
    Preparing Workplaces for an Influenza Pandemic
    OSHA 3327-02N 2007

    How Influenza Can Spread Between People

    Influenza is thought to be primarily spread through large droplets (droplet transmission) that directly contact the nose, mouth or eyes. These droplets are produced when infected people cough, sneeze or talk, sending the relatively large infectious droplets and very small sprays (aerosols) into the nearby air and into contact with other people. Large droplets can only travel a limited range; therefore, people should limit close contact (within 6 feet) with others when possible. To a lesser degree, human influenza is spread by touching objects contaminated with influenza viruses and then transferring the infected material from the hands to the nose, mouth or eyes. Influenza may also be spread by very small infectious particles (aerosols) traveling in the air. The contribution of each route of exposure to influenza transmission is uncertain at this time and may vary based upon the characteristics of the influenza strain.
    …
    It should be noted that there is limited information on the use of surgical masks for the control of a pandemic in settings where there is no identified source of infection. There is no information on respirator use in such scenarios since modern respirators did not exist during the last pandemic. However, respirators are now routinely used to protect employees against occupational hazards, including biological hazards such as tuberculosis, anthrax, and hantavirus. The effectiveness of surgical masks and respirators has been inferred on the basis of the mode of influenza transmission, particle size, and professional judgment.
    …

    Personal Protective Equipment (PPE)

    Employees who have high-frequency, close contact with the general population that cannot be eliminated using administrative or engineering controls, and where contact with symptomatic ill persons is not expected should use personal protective equipment to prevent sprays of potentially infected liquid droplets (from talking, coughing, or sneezing) from contacting their nose or mouth. A surgical mask will provide such barrier protection. Use of a respirator may be considered if there is an expectation of close contact with persons who have symptomatic influenza infection or if employers choose to provide protection against a risk of airborne transmission. It should be noted that wearing a respirator may be physically burdensome to employees, particularly when the use of PPE is not common practice for the work task. In the event of a shortage of surgical masks, a reusable face shield that can be decontaminated may be an acceptable method of protecting against droplet transmission of an infectious disease but will not protect against airborne transmission, to the extent that disease may spread in that manner.”

    Your recommendation concerning ‘can’t hurt-might help’:

    “With a huge investment of money and resources and energy and (IMO) a misperception the will hurt because I don’t think they work and people might be tempted to do things they wouldn’t otherwise do.”

    People may be tempted to not provide care for their family members if they feel they have no protection from infection. (Think that’s harsh – look back to 1918.) While amateur protection will always be less effective than trained professionals, we won’t have any of those in our houses so we will need to do what we can to provide care and survive.

    IMO that includes using the kind of infection control, including but not limited to the PPE, recommended by the documents referenced above.

    I would gladly take corrective pointers on anything that is either out of date or incorrect in this, my uneducated opinion of what constitutes the current recommendations.

42. #42 crfullmoon

    March 28, 2007

    “Masks for high exposure operations like intubating or sunctioning make sense, and that’s what the recommendation is. ”
    What intubating? Places are lucky if they need a whole hand to count their ventilators.
    ISCUs do not plan on much in the way of “modern” treatment; those altruistic but (as of yet) uninformed volunteers don’t deserve respirators as they give cotside care to neighbors and schoolkids become panflu cases?

    Being sent/left home; do you say no one should be trying to stay well/not infect a whole residence by using masks?
    How can advanced invasive medical proceedures (or, going into a village to get samples) need moonsuits, but, caring for (dying?) people who are trying to breathe while their lungs are falling apart – that isn’t going to be a high risk; to be avoided?

    What about people who have no choice about who breathes on them if they do their work? Do you want police and firefighters on the job? Going to tell them, don’t worry if no one bothered to buy you PPE for a long-expected, long-term event? (and the plumbers? and whoever cares for the unattended minors? et cetera)
    Don’t bother trying to decontaminate – you can still go home to your loved ones who are SIP and not worry you’ll bring pandemic in and cause your kids or pregnant wife to die? Is it avoidable or unavoidable? If their loved ones are well at home, and they want to serve on the front lines, responders should accept they can’t keep from contaminating their families, even with masks and showers, if that’s what you said; then, they need to know they’ll have to stay apart. Preparations need to be made.
    Govt and politicians obviously aren’t going to fund your “public health and social service infrastructures” (however you envision that – what do you want done that will somehow preclude the need for grassroots household education and preparedness??) in time for this year, nor next.
    Into the Woods’ point about the: …”They Have Nothing to Offer” myth.
    We lack neither grit nor smarts.
    What we need is information, encouragement and some small amount of assistance in building new capacity and re-building some old fashioned resilience at the individual and neighborhood level. “… certainly seems true; all it would cost is some ethical leadership; a little backbone, maybe a clearer conscience, to tell the public what’s up, and tell them they need state and local Pandemic Preparedness Coordinating Committees.(See pandemicflu.gov state/local checklist tab; First Task for definition) Volunteer positions; this is life or death; don’t say, can’t do it because it is not mentioned in the budget. If we want essential services done, we need people to last more than a week on the job, and it might take respirators, full PPE for some, and communities need to be making choices themselves, now; while things are still as good as they’ll get this year.

43. #43 Into the Woods

    March 28, 2007

    “atheism, guns and masks for flu”

    You forgot guns in your previous post.

44. #44 SoCal

    March 29, 2007

    Reveres, I do so much depend on your expertise, objectivity, etc., as I navigate this pre-pandemic period. Thank you so much for sharing your knowledge and experience with us. That said, your point on context dictating respirator use is well taken.

    Maybe it’s the title of the article, “No Use…” that’s got everyone going. It might have been, more accurately, “unknown benefit from…”

    I, like crfullmoon, am keenly interested in home care recommendations. I think it’s been under-discussed on the flu boards, e.g., which is the best room in your house for a sick room? Can you create negative pressure for that room, even without electricity? How will you disinfect surfaces (wood, plastic, metal, carpet)? How will you enter and exit? How will you daily monitor your family’s health (temperature-taking?)? Who will be designated to care for your sick? Who is the alternate, and how well trained are they? Do you have a bathroom that can be segregated from the healthy persons’ bathroom? Can you create a “warm zone” that separates the hot zone from the rest of your home?

    Masks/respirators are a small piece of that puzzle, and IMHO are simply the intro to dealing with the bigger, more difficult questions. I think we need to get to those more difficult question–very soon.

    And after those issues, we’ll need to think about how we’ll clean, wrap and bury our dead. Is it legal to do so in one’s yard? How can a body be best preserved for later formal burial in the post-pandemic period? Are there public health questions, e.g., could a well/water supply be in jeopardy because of where you chose to bury your dead? How deep a burial will keep animals from digging up a corpse?

    …Lastly, IMHO blogers/the online flu community would do well to use the term “pre-pandemic period,” as often and as widely as possible. We need to get this driven into everyday usage, to increase awareness of precisely where we are right now, and how certain we are of where we are headed.

45. #45 revere

    March 29, 2007

    SoCal: I agree home care will be essential and for most the only kind of care there is. I have said little about it here because I am less a clinician than a public health person (although I am a licensed physician, I have not really been a treating and diagnosing physician for most of my longish career; I am a researcher, academic, activist and, I hope, good public citizen, although that’s for others to decide). I don’t focus on those critical areas because I think there are others who know more than I about what to suggest, especially members of the nursing profession. I hope they are active in giving everyone their thoughts.

46. #46 Earl E.

    March 29, 2007

    SoCal: You have the very best post I have seen in a very long time.

    Right now we are definitely in a pre-pandemic period. I personally do not think we have much time left to prepare ourselves for a pandemic. We need answers to your questions and we don’t have them. WHY is that?

    Take the mask issue, for instance.

    Here is a free link to the entire study done by the Institute of Medicine:

    http://www.nap.edu/catalog.php?record_id=11637#toc

    The Associated Press article that Revere quoted above is INCORRECT.

    The bottom line of IOM study was NOT what was quoted. This is WRONG:

    If a worldwide flu epidemic strikes, don’t reuse a face mask – and don’t assume, either, that it will offer a lot of protection, the Institute of Medicine said Thursday.

    That’s the bottom line from an anxiously awaited probe requested by the government as it stockpiles supplies in case a flu pandemic begins. (AP) WRONG

    The IOM study focus was REUSABILITY of facemasks in a pandemic.

    The IOM study conclusion was:
    A surgical cloth mask put over an N95 could possibly prevent having to dispose of an N95 mask after it is used only once.

    See page 60 in above link.

    Revere does not know if masks will work or not.

    He is not going to wear one. That is his right.

    Revere—-it is time to express your responsibility to public health by FINALLY expressing SPECIFIC guidance to the PUBLIC regarding your statement from above:

    REVERE QUOTE:The real bottom line is that we better get busy and strengthen our public health and social service infrastructures because we’re not going to get by this one by hiding in a bunker or wearing a mask 24/7. We’ll only get through this together.

    Better to start planning for that now.

    HOW REVERE???????

47. #47 revere

    March 29, 2007

    Earl: I think it’s a fair request you make that I spell out in more detail what I mean when I say strengthen public health and social service infrastructure. I have hinted at parts of it frequently here, but putting it together in a coherent analysis — because that is what it requires — takes time, time I haven’t had. I have it as an important task but my pesky day job keeps interfering and there are other things I want to do on the blog as well, so it is a matter of juggling things. Right now I am in the middle of the modeling paper series and can’t drop that midstream.

    However when I do get to it, it will not be specific guidance for the public. What I am advocating is a strategy for public health, meaning public officials, non-profits, activists, businesses, etc., to prepare for a pandemic. It is less specific techniques like masks and Tamiflu and more what it sounds like — strengthening infrastrucutre. Investing immediately in surveillance systems, vital records, maternal child health, etc. In other words, beefing up routine public health and social service systems so they won’t crumble at first shock and can function to do needed things — the most needed things — should there be a catastrophic panndemic. Why this is needed and will work is what requires analysis and argument, although history also teaches us the same lesson.

    I don’t assume, BTW, that a pandemic will be catastrophic with high CFR. I actually think it won’t. But I think it would be foolish to prepare for anything but that because it could very easily happen that way. That’s just my opinioin and I have no way of knowing any more than the rest of you, so don’t bother to argue with me about it. It’s a waste of time for both of us. We agree that preparing for it is the way to go and the rest will be answered by events.

48. #48 M. Randolph Kruger

    March 29, 2007

    Hang on Earl, lets not kill the messenger. In fact Revere has many times said that he will not prepare even though the ugly vast Republican conspiracy (me) has asked him to. He might not even have put his mind to it. If it comes I think that due to his age he and missus R will be out there doing their thing and if they go they will go as any good American does when faced with inevitability. That is by helping as many of us as he and she can and could.

    You are kind of like my Pakistani family on my street. It took me almost a year to get them to punch the clock and embrace the horror. Time to get past the inadequacies of government, Tamiflu and all of the other cliche’s of what to do. Its action time my friend.

    I am perfectly happy to converse with you as I do with people in the Netherlands, S. Africa, Canada, Mexico, Australia etc on how to make it thru what promises to be a very dark night for this country if it comes. It still might not come, it still might revert to a less fatal disease. We have been swinging thru the trees for about 50,000 years Earl, we will likely lose a few but the fact of the matter is that we as a species will adapt and overcome. This dark cloud will come over the top, drop rain and hail, maybe a tornado or two and like all dark clouds it will pass.

    Revere is not a Godful man by choice but I find him to be more Godful than those who profess it. Ironic. By choice he decided not to prepare and you have. That too is ironic. So you are fearful and thats good. Fear can be used and channeled. You just dont want someone punching your buttons in the middle of the stuff. You want to be able to sit back and say that you cant go to work today because of BF, go fishing instead. Cant get bird flu fishing from the bank of a river or lake. Nor will you need a mask to do it.

    Okay, so lets get you up on a war footing for it and if it comes you will be the first kid on your block not to have one of your family members die. Thats good. On the other hand if you think life as you know it will be the same after this in the event of even a 5% CFR then you are mistaken. It will no longer be business as usual. All things WILL change. So lets not panic. I have a mile long street and now we as a group are prepared and in that there is strength. We will lose a few, but not the core. But the core will care for the few. We will rebuff attempts by foragers, but we will take their kids and isolate them in various houses to preserve the seed corn until we

    You are seeking answers from someone who I respect in his field of expertise and he is mightily good at it. If it comes and its looking mightily that something wicked this way comes, it steps into mine. If it happens the move will be directly to the system and pretty right of center in response to the do’ers rather than the “what we should have done” which is what I rank the post Katrina types with. E.g. Louisiana vs Miss. Guess which one is in better shape.

    So here’s the email: memphisservices@bellsouth.net

    Hit me with a personal or business email and get a lot of disks and paper because I will innundate you with information. You have to adapt to your situation and if its in a zero lot line house and in a city, time to make other arrangements. Fire alone will probably take care of most of the cities if its an 8% event. Getting the idea? Revere might have been a Boy Scout. I was a Boy Scout and later grew up to be a Boy Scout with an M-1, M16, MRE’s, Claymores, bioshelters, decontamination facilities, buried fuel and water supplies, hydrogen generators, field medical kits and an EMT rating….

    So you can make the decision on which way to go. What you and SoCal need to do and especially SC is to start your plan and right now. Failure to do so and in particular failure to correctly estimate your capabilities and personal situations is going to result in fatalities either from BF or lack of essentials. SoCall needs to because if he/she is in So.Cal that place is going to implode completely. You cant live on oranges, and the veggies in the Imperial would last about a week. Things will get very, very ragged and in particular due to the lack of weapon ownership, the crooks will be in charge. SoCal’s position is one of the most precarious that there is.

    I’ll be waiting

49. #49 Into the Woods

    March 29, 2007

    I have a mile long street and now we as a group are prepared and in that there is strength. We will lose a few, but not the core. But the core will care for the few.

    MRK: I am interested in the process by which this was achieved. Was the street organized (even informally) before this process started? Did the process focus on a potential pandemic or was it more all-risk? Are you doing anything on an on-going basis to sharpen the saw?

    REVERE QUOTE:The real bottom line is that we better get busy and strengthen our public health and social service infrastructures because we’re not going to get by this one by hiding in a bunker or wearing a mask 24/7. We’ll only get through this together.

    Better to start planning for that now.

    Earl: You ask Revere “How?”

    Folks often wait for someone else to step forward and address this kind of societal issue – hoping for some charasmatic leader to show the way.

    My suggestion is stop waiting. We are the ones we have been waiting for. (Hat tip to Jim Wallis.) Frankly even when (if) Revere gets around to laying out the Plan, if there is no wind it does no good to raise the sails.

    Start organizing your own neighborhood around disaster preparedness (with specific emphasis on pandemic preparedness).

    Search the web for “Disease, Disaster and Democracy: The Public’s Stake in Health Emergency Planning”. (A UPMC conference report.)

    Look at Appendix 8 – Pandemic Influenza Community Mitigation Interim Planning Guide for Faith-Based and Community Organizations (see specifically item “7. Help Your Community”) of the recently issued CDC Document: Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States.

    For examples of and guidance on neighborhood organizations’ role in dealing with disasters look for “September 11th and the Role of the Neighborhood Association” and “Neighbor to Neighbor: The Downtown Solution IPNTA’s Guide to Community Healing” and “Neighborhood Emergency Service Team Captain’s Handbook” (a guide intended to assist you in preparing your neighborhood, school, business, building, or floor for a disaster.)

    The National Crime Prevention Council – Neighborhood Watch Program is expanding into emergency preparedness and is also a model for local approaches coordinating with existing governmental programs.

    To help guide you in discussing this issue with your neighbors take a look at both “Framing Interconnectedness Talking About Public Health: Developing America’s “Second Language” Lawrence Wallack, Regina Lawrence” and “What to Say When a Pandemic Looks Imminent: Messaging for WHO Phases Four and Five by Peter M. Sandman and Jody Lanard”

    Masks are no silver bullet. Neither is anything that may eventually be produced by Revere or adopted as government policy. Many things will help.

    Few things will be as important as living in an engaged community dedicated to working for the common good. That does not happen by itself but it can be accomplished by anyone with a will to see it happen.

50. #50 Earl E.

    March 29, 2007

    THANK YOU for answering me—Into the Woods. I am community concerned now—because I am comfortable with my personal state of preparation.

    Step 1: Prepare yourself and family.

    Step 2: WAKE UP the neighbors.

    Step 2 is where I get stuck. No one believes a word I say about “imminent pandemic”.

    Associated Press and their clones are not covering it.

    Thus, I am adding Step 1A: Pressure whoever??? or whatever??? to get this inside the public’s belief radar. The public has no clue–so I get nowhere. We need to know who controls the news media???

    Maybe I will switch tactics with the neighbors—-and say we need to prepare for nuclear war. That is looking more and more likely as well.

    Perhaps the very, very FIRST step should be:

    HATE NEEDS TO END. LOVE NEEDS TO REPLACE IT.

    Then perhaps we could make some progress and stop being barbarians.

51. #51 Into the Woods

    March 29, 2007

    Earl: Most definitely take a look at the Sandman article. I found it very enlightening. Work your local officials – county commissioners, city council, local emergency preparedenss directors, state legislators – all have a stake in this though some don’t seem to recognize it yet. Actually that is an important aspect of community organizing – getting folks from the neighborhood to place one call to a couple of the folks above lifts the issue up much higher on their radar than you might imagine.

    The all-risk approach has lots of advantages when talking to both neighbors and officials, especially because the eternal struggle between probability and severity is biased towards the urgent instead of the important.

    Glad to hear you are out rousing the rabble (of which I am a card-carrying member).

52. #52 v

    March 29, 2007

    MRK, Earl E., into the Woods

    I gave up on my neighbours a long time ago. No one, it seems, thinks that the pandemic is imminent.

    In putting pressure on your neighbours, aren’t you just saying “Look at me, I have food, I have water, I have Tamiflu”? The word will also get out to other areas, you could possibly be over run.

    I for one am keeping mum about my preparedness.

53. #53 Lea

    March 29, 2007

    v: It’s a matter of personal choice in the end. Nothing is wrong with not wanting to prepare everyone. Personal responsibility comes to mind. Far to many people have placed their safety and well-being onto others shoulders instead of their own.
    Even if we could help other’s prepare we would not. We are in a situation where we Could Not start a neighborhood type of movement anyway.
    My mother laughs at me, as do others that I’ve shared the possibility with. So I’ve let go.

54. #54 Earl E.

    March 29, 2007

    Every person has a unique situation.

    It is up to each person to try to define what they think is their personal responsibility.

    We are not responsible if people ignore repeated warnings and suggestions.

    I have even given up trying to convince my two best friends. They won’t even get a seasonal flu shot.

    Every perception of every person on this planet is unique and different.

    Let us just try to love instead of hate and fight.

    I love the Serenity Prayer:

    “Lord grant me the serenity to accept the things I cannot change,
    the courage to change the things I can, and
    the wisdom to know the difference.”

    — Saint Francis of Assisi

55. #55 M. Randolph Kruger

    March 29, 2007

    First I did it by word of mouth. Its a normal propaganda routine in a neighborhood. I went to the biggest loudmouth and told her about it and planted the seed. Of course I put her on my email list for the nearly daily good or bad news for BF. It was under the guise of both pandemic and disaster prep. Then the local DHS director and I tooled up a preparedness list and a how to at least stay at home healthy guide. How to make good water out of bad. We sprinkled in a lot of good pointers for a non-electrical situation. Around here the ground was very fertile because we had two nearly back to back 4.5′s two years ago and Hurricane Elvis which was a windstorm that literally flattened Shelby County in many places. Most places were without power for a month out in the ‘burbs.

    Then you wait just a tad. She has to network you know. You give her the same printout information that you are getting like its on the sly, even though its not. The real intel stuff you have to sign for and return each day. Then you know you have won when you tell her you have the guides and lists for anyone that wants one….Then the first call comes in. I of course by now have thrown in excepts from the 1980′s Day After, the news from the Great NE power outage from what 7 years ago?

    I add a dash on the disk of the interview with Webster from last year. Pictures and videos of dead and dying chickens (some of you have seen this already). I shake gently and it costs me about a whole 40 bucks to produce enough disks for a neighborhood. It includes that and the sites for biowarfare manuals, basic survival techniques, and a few other pointers such as other websites to visit. One disk, two disks, and then out the door go nearly 100. Freeware. Now they are handing them out as they get reproduced in many places.

    Then finally everyone is acknowledging that they are preparing on the street in various methods. Little meetings happen and the lawyers on the street agree to do free wills for everyone, DNR statements, organ donor etc. Everyone but the damned Pakistani family. I had to work HARD on them to get them to as they were traditionalists in their religion and that this would be the will of God. So with a lot of logic, feeding their cats on vacation my Muslim brother finally decided that the Christian Gringo down the street wasnt so bad after all and that GWB while a little inept has kept inflation down and the economy rolling. We just agreed to disagree about Iraq and now he is a hard and fast friend.

    ITW-It really starts with just talking to people about it. Raising the awareness level and giving those numbers and facts out without the hype thats associated with it. They can all read the graphics from the WPRO WHO site and thats enough to get most going. We will survive this on this street or we will survive longer than most. But at least we will go as friends. Now what could be better than that?

    V. That situation was discussed and everyone to a man/woman said that we would take children in and isolate them individually in various barns and outbuildings. If they were not sick at 21 days we would put them into the fold with the rest of us. The lawyers said they would prepare custody papers for them if and when they showed up. Anyone who was foraging as a marauder, well you have seen most of my posts here. It wouldnt be pretty and we likely would be able to find out how deep you would need to bury someone if the situation presented itself.

    Lord grant me the serenity to accept the things that I cannot change,
    the courage to change the things I can, and
    the wisdom to be able to properly dispose of the bodies of those who cross my defensive perimeter without proper password, call sign or armed for a hostile situation.

    Gunnery Sgt. R. Lee Ermey….I think.

56. #56 Earl E.

    March 30, 2007

    MRK: I hope you have stored your manual typewriter and reams of paper. Your writing style is so——brutal, but so funny.
    A paradox writing style, I guess.

    You are >right on< about the neighborhood loudmouth.

    I talked to her in her vegetable patch last summer about bird flu. SHE brought it up!

    It is time to talk with her again about it. A perfect solution for those who can trust their neighbors.

    Every neighborhood has one—-the nosy—in your face—gossip hound. They are now valuable.

    Go figure.

    Thanks MRK.

57. #57 v

    March 30, 2007

    MRK – wonderful suggestions. If I have the time I will try to implement some of your ideas. Thank You. I agree Earl E.

    Unfortunately, just had a look at News Now Bird Flu, a doctor treating an H5N1 patient in Indonesia has just come down with H5N1. Lets hope that this is not the start of a new direction for H5N1.

58. #58 M. Randolph Kruger

    March 30, 2007

    V. Yeah, I sent that info on that HCW to Revere this afternoon. Sounds like he might be a little older. That being the case and if he is over 50, then he has a 2 out 3 chance of making it. Mild case I hope.

    Earl-Man dont feel like the Lone Ranger out there. I get the same thing from Sydney to Hong Kong and down to Kano Reservoir. All sorts of people are asking “What do I do?” I give it to them as a mental modeling but its also based upon Katrina, Andrew, the Northridge quake, the tsunami, 9/11all rolled into one. Assume the absolute WORST will happen. Then if you mitigate and prepare to meet that threat you’ll likely make it along with family and friends. The criteria we have established in the neighborhood is that IF we see a cluster of more than 50 the email goes out and we move immediately to the grocery stores and load up for six months. If we see multiples of more than 50 we go and load up for a years worth. Especially if said 50 and multiple clusters are in a city with an airport. Might as well because money is going to be worthless in a fast hurry. Jobs will dissapear overnight. Think of it as waiting thru a long hurricane like storm. Not much you can do and you wont like what you see outside when you do come out, but you likely will come out if you prepared.

    Masks MIGHT be a good idea but you have to get the right type and frankly I dont put a lot of stock on something thats designed to keep stuff in and not out e.g. paper M-95′s. So a full face place mask, a suit or two would be nice, multiple booties and a portable shower. You will look like a redneck from Mississippi with it on your front porch but you know, you will be washing that crap off and cleaning your masks and boots each day, maybe going to work, maybe walking a defensive perimeter with a rifle.

    Its survivable my friend but masks arent the BIG THING. Its the food, water, secondary medicines, ability to defend your perimeter as some have asserted. Brutal Earl? Yeah, I commanded quite a few people and you give it to them as Patton did, loud, long and dirty. Dont mince words when you are sending someone into combat and that folks is what this is, entry into a combat zone. You dont know where the enemy is, you know its sneaky because you cant see it. The IFF (Identification Friend or Foe) beacons are not working so every animal is a potential death sentence, every person you contact the same. Treat them as such and you will survive.

    We all live in relation to our friends and people we dont like. Both will get treated the same by me and my little block party if it happens. We will take their kids, but if the grasshoppers havent stoked back like the ants have then winter will take its natural course. My block will be a work in progress during this time and we have cows, horses, chickens (them little bastards will be the first to go for dinner and cooked over a smoker!) and everyone is on acreage. This year everyone is planting a garden with legacy seeds. Fruit trees are going in everywhere. I think the message is that if it gets you then its destined if you prepared, if you didnt in the face of the rising wave well thats destined too.

    I know Revere doesnt believe in God but I do. I almost feel that this is being orchestrated in someway. E.g. Why in Hell would the governments of the world seeing an 67-83% mortality rate not do more and MAKE the people do something via tax credits or outright buys of food and necessities? The friggin’ Kiwi’s are and their annual national budget is less than my state. So what gives? Are we being dumbed down for the taking? Global climate change being called global warming? Was it already in the works? We only have 150 years of data on climate, the rest is all in ice, trees and sediments and a few other things. We also know that pandemic of some kind is inevitable. Flu, ebola-flu, XDR-TB… hey you know its bad but you have always heard you have to die of something. Please pick one. Preparations are pretty much the same. The viruses we are seeing might be ones that were trapped in that same ice 50,000 years ago. I dont know, but it just seems we are on a climb to the first hill on a roller coaster into Hell. Anyone else get that?

    All sorts of shit is happening and as I said before the end of days section over at the UN monitors this stuff and it IS getting worse across the last 40 years. Hurricanes, tsunami’s, quakes etc. all are on the upswing and I have sent that to Revere as well. It fits my agenda to put it out there and I could be right, so could Revere. But I do see one thing in the future and you can put the number here _____ and the cause _____ here. Bottom line is that I see dead people in my immediate future and not by my hand.

    Guess what though Earl? We will all be right but you have to make damned sure that since the warnings out there that you take heed. And it is out there. This might be the one that slaps us down as a species. If it comes and its over 8% worldwide or domestically in any nation, then all things in that nation will change permanently. If its more than that in an either or then chaos will ensue, anarchy will take over. It will be put down eventually but it will be there. You have to become everyones best friend and fiercely neutral if it comes and a clique of control starts to form. As long as we have a government post of this if it comes, things will eventually get better.

    Right now this whole thing is in Revere, GraceRN, Tom DVM, Tan06′s court and they represent order, things we would like to see happen, things they make happen and the ability to argue over the finer points of modeling and the like. If it comes, then it moves into my court where I try to keep everyone fed, plop a sickie in front of them when I think they have the bug, provide a facility for them to recover or die in, sanitation as best able and then have enough outcomes that are favorable to say we did good. I dont accept the “best we could” because the US and everyone else is soft pedaling this stuff like its as bad as a bee sting, only a few sicken and die kind of thing.

    I dont plan for me or my family to be in that 8% or anything greater than that. Assume the worst, prepare for it. If it doesnt happen then you’ll be eating pork and beans and freeze dried pemican for the next five years. Will make a Hell of a block party for food if it doesnt. Again, with friends.

59. #59 cougar

    March 31, 2007

    Randy:
    “Are we being dumbed down for the taking?” Sure seems that way. I get it too. To some of us, the signs are painfully apparent, so why are so few paying attention? Why are we being lulled into complacency while the threat looms large in front of us? Like cattle being herded to the slaughterhouse, a thinning of the species is about to take place.
    Beautiful post, thanks for telling it like it is and for all you do to help others walk the path of survival!

60. #60 Earl E.

    March 31, 2007

    You said it all, MRK. I especially agree with your comment of:
    “Its survivable my friend but masks arent the BIG THING. Its the food, water, secondary medicines, ability to defend your perimeter as some have asserted.”

    There is a SEVERE lack of perception of the danger we all are facing.

    I have prepared for worst case scenario. I hope people read your posts here over, and over, and over, until they get it.

    I trust and have faith in God.
    Whatever happens, I will trust and keep my faith in God.

    BUT—–God gave us all a brain to think with.

    AND—-the actions of the media and authorities do not warrant or merit trust. There is not enough of anything to go around. If they tell the truth to the 6 billion people on this planet before the flu turns deadly—-PANIC and CHAOS will rule—and economies will suffer. So the WHO keeps it at Phase 3.

    All the more reason to get moving on preparing.

    Here’s a BRUTAL personal opinion of mine: I think the cluster of 50 has already happened.

    NOT—a cluster of 50 deadly pandemic flu cases—but a cluster of something new—a pandemic flu strain.

    We won’t hear anything about it UNTIL it turns DEADLY—which it eventually will.

    WHEN?????—-I do NOT know.

    BUT—it will be more gruesome in America than a thousand hurricane Katrinas.

    The reason it will be so gruesome is because Americans have lost all their basic survival skills.

    Can the average American grow, harvest, and store food?

    Can you live without your prescriptions?

    Can you obtain water if it does not come out of the tap?

    Are you isolated with no family or friends?

    Do you have items to barter with?

    Are you prepared to care for orphans?

    We have lost so much in America. It is time to honor the past Americans—-by standing up as real Americans who love and care about each other!

61. #61 v

    March 31, 2007

    MRK – I too am an avid reader of your posts. Could you please direct me to the best websites for water decontamination. I have been toying around with the idea of using different density sands, rocks and sponges for filtering. Which method is the cheapest and the easiest to use? I would appreciate the information. Thank you.

62. #62 M. Randolph Kruger

    March 31, 2007

    V-Hit me at memphisservices@bellsouth.net and we will get that particular little issue taken care of. You can make water out of wet sewage with the right stuff. I need to know roughly where you live and the amount of even crappy water you have available.

    Dont want to jack the blog for this kind of chatter.

63. #63 Earl E.

    April 2, 2007

    As MRK said—masks are NOT the issue. But just because I have trouble letting things go:

    Besides tape—another way to avoid worrying about the “FIT
    ISSUE” is to use costume adhesive.

    Spirit gum may crumble when exposed to moisture. There are
    other acrylic or silicone adhesives for the theatrical industry.

    DON’T FORGET TO BUY THE REMOVER for the product as well!!!

64. #64 revere

    April 2, 2007

    Earl: When, where and how long do you intend to wear a full face respirator?

65. #65 Earl E.

    April 2, 2007

    I am talking about getting the N-95 to have a secure seal if you have to go out——to avoid a “FIT ISSUE”. I also want to have adhesive and masks for other people I know who won’t prepare.

    I am not talking about a full face respirator.

    But now that I think about it……..if you are going around with an expensive deluxe full face respirator—-it might be a good idea to glue that sucker on so nobody tries to steal it off your face!

66. #66 revere

    April 2, 2007

    Earl: And your eyes? Goggles, too?

67. #67 Earl E.

    April 2, 2007

    Yep. Barney Google.

68. #68 crfullmoon

    April 2, 2007

    Considering cases look to be “Resolved” in about 3 days,
    (and if it happens next, week, month, year, that looks like “resolved” as in, “BOYD”) and no one will likely have immunity to the strain(s), every day that as many people as possible can remain uninfected and alive, the longer your “infrastructure” can totter along, and we have any hope of a post-panflu year Recovery.

    http://www.thejakartapost.com/detailgeneral.asp?fileid=20070402165939&irec=2 …”In the two-day “Panstop 2007″ training exercise, the H5N1 virus has mutated into a strain easily spread among humans. The simulated situation tests for the first time the WHO’s ability to rapidly avert a pandemic, officials said.

    The drill involved officials at the WHO Western Pacific regional headquarters in Manila talking by phone with counterparts in Cambodian, Singapore, Indonesia and Japan.

    As of mid-morning, four out of five people infected with the virus in the mock scenario were dead,“…

    Sounds like they are working with 80% cfr?
    Why are tptb here planning on letting the first wave burn through an unwarned, unpreppred populace?
    We would have been much better prepared if we had started 18 months ago; they certainly could keep the public’s attention; if tptb didn’t care more about their own power grab, Iraq’s oil and our huge new compound there. Martial Law because the states’ and communities’ citizens didn’t hear enough to know pandemic was looming and form PPCCs, buy supplies, and make contingency plans they can make work themselves, suits tptb fine.

    If you/they expect the public/health care workers/first responders to go out without any protection, we could end up with a 1492-type depopulating event.

69. #69 revere

    April 2, 2007

    cfullmoon: The model doesn’t assume cases are “resolved” in 3.3 days. It uses this as the average period of infectiousness, not the same thing. In any event, I would like to ask you to read over your comments and edit them a bit for ceomprehensibility. I suspect you have something to say but I have a lot of trouble deciphering exactly what it is. It should be possible to boil down your comment to a paragraph or two. I’m asking this for my sake so I can consider your thoughts, not to chastise you.

70. #70 Melanie

    April 2, 2007

    crfullmoon, conflating the reveres with tptb would be really comical if you knew the reveres.

    Please recall that the reveres are one of the founders of Flu Wiki, and that citizens and communities can empower themselves.

71. #71 Miroslav

    April 29, 2009

    By my bad English:

    mask are choice by political persons. you cannot see hand hygiene, you cannot see personal hand wash, etc. But when city mayor give to people masks. it is very visible and “politicians taking care” for people, mostly on TV.