cc  >> Kevin Niemi: Okay, welcome to  the June 24 Wednesday Nite at  the Lab.  I'm Kevin Niemi with the Center  for Science Outreach, and  tonight's discussion will be by  Dr Professor Vicki Bier from the  Department of Industrial and  Systems Engineering, the  Department of Engineering  Physics, as well as the Center  for Human Performance and Risk  Analysis.  And her talk today will be about  an issue that struck me about  three weeks ago when I was going  to Bangkok and had to spend  about 90 minutes in the airplane  in Tokyo just sitting.  Waiting to get inspected for  H1N1 by these Japanese health  officials.  I've heard it's happened to many  people that it's causing some  challenges to travel  internationally, so I'm very  excited to have her talk about  pandemic preparedness.  >> Vicki Bier: Okay, thank you.  Is the microphone on?  Okay.  I should say first of all to  start off with, that as you  heard, I'm basically an  engineer.  I'm not a public health  professional or a physician or  an epidemiologist.  So I'm gonna be talking  primarily about more of the  broad societal impacts that we  could see from pandemic flu and  less about the medical side. 

 And much of this information is  based on a study that I did two  or three years ago for the  Department of Health and Family  Services in the state of  Wisconsin, in preparation for  what, at that time, we thought  might be an avian flu pandemic,  but that is turning out to be  very timely for swine flu, as  well.  So there are three basic topics  that I'm gonna talk about.  What might be the impact of a  pandemic as far as school  closures, as far as business  closures, and that red color  doesn't really work out too good  in this, so maybe we can dim the  lighting a little or something  so you can see it.  The third issue is impacts of  the pandemic on the working  poor.  And then at the end I'll close  with just one slide of what you  as individuals can do to help  protect yourself and your  communities, and where you can  go to get more information.  So starting with school  closures.  Some school districts, before  this most recent pandemic had a  policy that said something along  the lines of, we will close  schools at a time when there is  a high absentee rate in the  school.  If you wait until there is a  high rate of illness and  absenteeism in the school, it's  kind of late to close the school  by then.  If you have 20% of the kids out  sick, that means 100% of the  kids have already been exposed,  and closing schools does little  or no good at that point.  In order to be useful, you  really need to close schools  early, which is actually  something we've seen in this  recent swine flu outbreak, that  schools were closed early when  they had even a single  identified case in the school. 

 They would close the school for  a period of a few days, long  enough to see if anybody else in  the school was gonna come down  with swine flu, and then reopen  if it looked like everything was  okay.  Of course, if you had a more  serious pandemic, one that was  more widespread, and more highly  lethal, you may find some  parents keeping their children  home from school even  voluntarily at times when the  schools had not closed, just  that that parent or that family  decides they want to be a little  more cautious.  One of the big reasons for  closing schools is to reduce  spread of the virus.  If you really want to reduce  spread of the virus, closing  workplaces and schools is even  more effective, but of course,  that has much greater social  cost.  There are a lot of workplaces  that either cannot be closed or  would be very costly to the  employer in order to close.  In studying this for the  Wisconsin Department of Health,  we looked at some of the  historical literature from the  1918 pandemic, which was the  last serious influenza pandemic,  serious in the sense of high  mortality rate, large numbers of  deaths.  And from the historical  literature, first of all,  influenza has a short incubation  period, only one to four days,  but you can be infectious even  before you know that you're  sick.  So it's easy to spread because  if one child infects another  child, that child may not be  showing any symptoms yet, may  not be coughing or running a  fever, but may still be  infectious and spreading the  virus to other people.  Preschool and school-age  children historically seem to be  one of the big conduits for  spreading infections more  broadly in the community.  That's due to several factors. 

 Some of them are biological.  First of all, they may become  contagious sooner than adults,  before they show symptoms.  They may transmit the virus  longer than adults.  So they may still be shedding  virus even after it looks like  they're healthy and recovered  and back to normal.  The third factor which is not up  on the slide but which all of us  know, young children probably do  not have the same hygiene habits  as some of the rest of us.  And you put a bunch of preschool  children or kindergartners in a  room, and there's a certain  amount of sharing of anything  and everything that's gonna go  on in that environment.  So the current thinking is that  even for the regular seasonal  flu, children are some of the  big transmitters, especially in  the early stages.  After a while, almost everybody  has been exposed one way or  another, but in the early  stages, children seem to be the  big spreaders of infection.  If you look back to the 1918  pandemic, there is really  surprisingly, maybe, not very  much data available.  Public health in 1918 existed,  but it didn't have the same  computer resources and data  collection and everything else  that we have now. 

 So a lot of the historical  review is done by looking at old  newspaper articles and figuring  out how much you could deduce  from that.  So there's a lot that we don't  know about the 1918 pandemic  that we would like to know.  But the evidence that we do have  suggests that there is a big  need for early and coordinated  action by public agencies and  officials.  The cities that responded  earlier to the outbreak tended  to have less severe epidemics in  1918 than the cities that took  more of a laissez-faire  attitude.  One of the biggest and best  studies that looked at  historical data for 43 cities in  the US found that an early  response, layered, meaning not  just school closure but maybe  also cancellation of parades or  big entertainment events or  things like that, maybe you  ought to cancel Rhythm and Booms  or whatever.  Those kinds of things were key.  And also sustained.  Some cities removed or lifted  their prohibitions very early,  and then had a second outbreak  flare up because they eased up  on their prohibitions too soon.  According to Markel, those kinds  of precautions, school closure  and those types of things can  reduce both the number of people  sick at any one point in time,  but also the total number of  people who get sick, which is  obviously nice.  Again, my color scheme seems to  leave a little to be desired in  this room, that yellow is kind  of blinding in this color, but  the CDC, the Center for Disease  Control, have identified five  different severity levels of  pandemics, which is really based  on how severely lethal the  disease is, how many people who  get sick will die. 

 And this current swine flu is  down in that yellow category, I  believe, with a very low  mortality rate.  And you can go up to much  higher, 2% or higher fatality  rates, 2% is typical of what was  in 1918.  If you look at the school  closure recommendations, and  again I really had some problems  with the colors, I can tell you  what it says.  In a mild pandemic like what we  saw here, they say most likely  there's no reason to dismiss  students from school.  In a Category 2 or a Category 3,  which is kind of that middle  range, they recommend  "short-term closure," by  short-term they mean up to four  weeks.  That doesn't necessarily sound  short-term if you've got a first  grader running around the house  in the middle of the school year  for four weeks.  (laughter)  Then, for the most  severe pandemic, similar to 1918  they have argued that it may  need to be up to 12 weeks of  school closure.  And again, that's a big deal.  My first reaction when I read  that guidance was, that's easy  for them to say.  There are a lot of families that  are not well-prepared to take  care of their kids outside of  school. 

 Families with two breadwinners  and maybe a critical job, like a  nurse or a police officer that  can't stay home from work.  Families who have children with  sever disabilities, if you have  an autistic child or something,  you can't necessarily just send  that kid over to the neighbor's  house every day to be cared for,  there needs to be special  training for the caregivers.  And even just neighborhoods  where it's dangerous to let your  kids run around unsupervised for  hours on end.  So this recommendation might be  good from a public health point  of view, but it's gonna be very  difficult to implement.  Other recommendations that came  out of, this is from my study,  not just from the CDC.  First of all, the CDC  recommendations are based almost  completely just on fatality rate  of the disease.  But you may want to consider  other factors, such as how  contagious is it, how easily  does it spread, and things like  the age profile of the people  who are most severely affected.  A disease that seems to be  particularly lethal to school  children, you might be more  likely to close schools than one  that's extremely lethal to  infants or the older people, or  whatever.  You may want a different policy  for school closure for teenagers  than for young kids.  Kindergartners are likely to  spread more virus if they are in  school in crowds of 20 or 30  kids in a classroom than if  they're in a small group of two  or three other kids. 

 Teenagers may share less virus  if they are kept busy in class  than if they're left home and  making out with their boyfriend  or girlfriend or sharing a Coke  with their best friend from the  next block or whatever.  It's not clear you want to have  a lot of teenagers unsupervised  in the middle of a pandemic.  And there may be differences  from one region to another.  There may be beneficial health  impacts of school closure but  there are adverse economic  impacts, the impact of school  closure may be different in  urban areas that maybe have a  lot of two income households,  than in rural areas.  There are communities where a  very large faction of the  children are dependent on things  like school breakfast and school  lunch, so if you're gonna close  the schools for a long period of  time, you may need to make other  provisions for those children,  etc.  So the CDC is the best guidance  we have so far, but I don't  think it has necessarily all of  the answers.  If you do close schools, there  are also a lot of other  functions that schools can  perform.  First of all, schools might be  kept open to provide only a  daycare function and not an  educational function.  And in that kind of a situation,  you might encourage that parents  who don't have to send their  kids to school would keep them  home, but parents who really  don't have a safe place to send  them could send them to the  schools.  Schools could be used as  distribution sites for food  supplies, whether that's school  breakfast and lunch for  low-income children, or whether  it's serving as an emergency  food pantry for food from other  sources. 

 Schools could be used as sites  for flu clinics, for  distribution of antiviral drugs  like Tamiflu, for vaccination,  and just for emergency space for  healthcare or other emergency  workers since they have desks  and phones and all the rest of  it.  So if they are gonna close  schools, we may want to think  about what else we would want to  do with those facilities at that  time.  I'm gonna move on to talk about  business closure, but before I  do I thought maybe I should take  a quick question or two about  school closure.  Okay.  Yeah?  >> You talked about, as a place  for flu clinics and distribution  of antivirals, are most people  aware that those antivirals are  only effective if they're  started within the first so many  hours?  >> Vicki Bier: That is  absolutely correct.  Right now the antivirals are  effective within about the first  48 hours, and actually that may  be one reason for having flu  clinics in the schools, because  if you have to wait to get into  your regular doctor's office,  that may be days on end, and  might be too late by then.  Plus, in the meantime, you may  be infecting all the other  people in the doctor's waiting  room for reasons totally  unrelated to the flu, they broke  their arm or whatever.  So there might be some very  quick in, quick out kind of flu  clinics.  I've even seen, I believe  actually in Dane County,  experiments with, could you do  vaccination on a drive-through  basis?  People come in their cars, and  they don't have to get out of  their car, in the middle of  winter they might need to, but  at most times of year, the  health worker could just come up  to them, vaccinate them in their  car, and they would drive home  and not be sitting in a big  doctor's waiting room.  Other questions or comments,  yeah?  >> You mentioned some  commonalities to look for  including age. 

 Did you find any other  commonalities with this past  outbreak, were there anything  else along the way outside of  age, gender, the basics that  came up?  >> Vicki Bier: Not that I've  seen, but I probably haven't  looked as closely as you maybe,  or a lot of other people.  But actually, that is a good  point, that this particular  version of flu that we have  right now does seem to be more  dangerous for young, healthy  people, that's been most of the  people who have gotten sick and  had problems with it.  Okay.  Looking at business closure, we  looked at three different  categories of business.  Entertainment and hospitality  businesses, critical  infrastructure that society  needs, and kind of everything  else, stores, manufacturing,  just your ordinary type of  businesses.  Entertainment businesses, what  counts as entertainment?  There's a wide variety.  Wisconsin has a big gambling  industry, we have spectator  sports, we have performing arts,  we have all kinds of specialized  museums and zoos and amusement  parks.  And recreation industry actually  includes places like gyms and  exercise studios in that.  If you're looking at  entertainment, you also need to  think about community events,  parades, festivals, carnivals,  big conventions.  At one point during SARS there  was supposed to be a big medical  convention happening in Toronto  and they thought, this would be  a really bad idea to bring a lot  of doctors into Toronto in the  middle of SARS, and send them  home to treat patients  afterwards, so I think that got  cancelled or postponed. 

 Entertainment businesses and  hospitality, which is basically  hotels and restaurants, are some  of the businesses that would be  the most likely to be closed in  the middle of a pandemic.  That might be either because  they have to close on order of  public health, they're not  legally allowed to remain open,  or they may just choose to close  if their clientele is greatly  diminished.  For instance, I believe with  SARS in Toronto, the restaurants  in Chinatown saw a dramatic drop  in business so many of them  probably closed for a period of  a few weeks till the worst of  the outbreak was over.  One of the things that  Department of Health wanted us  to do was to make sure we had a  reasonably complete list of all  the kinds of businesses you  might need to worry about in  this category, all the types of  events, because the governor  wouldn't want to be in the  position of, say, having issued  an order to cancel a Packers'  game, only to find out that  there was a huge international  bowling convention happening  that week in Milwaukee and so he  cancelled the Packers' game for  nothing and the disease spread  anyway.  So if you're gonna do this, you  want to be able to do it on a  consistent basis.  What kinds of things might you  look at?  Indoors or outdoors, outdoor  gatherings might be less risky  than indoor gatherings where  people are sitting side by side.  How many people are there, maybe  small facilities could stay open  and not large ones.  How close the people are  together, are they all handling  the same bowling ball or the  same skating shoes, or whatever.  And is it children or adults?  All of those are things you  might want to consider in  deciding which types of  entertainment facilities could  remain open or not.  Critical infrastructure, those  are not just ones you don't want  to close, those are ones you  absolutely want to make sure  remain open and functional. 

 The basic categories of critical  infrastructure that people worry  about are things like energy,  post office, transportation,  basic government offices, a  telecommunications system  including the internet, public  health, emergency services,  that's like fire and ambulance  and so forth, drinking water,  also waste water, food and  agriculture, and there's some  other key resources that might  not be included in there, but  those are kind of the basics  that you really kind of want to  make sure that we have gasoline  in the gas stations, electricity  in our house, etc.  Even in the middle of a  pandemic.  What might need to happen to  make that happen?  First of all, many of the    critical industries that I  listed, like electricity, have  already been engaged in a very  concerted effort of pandemic  planning for a number of years  by now, so they're probably in  better shape on average than  most businesses in being  prepared, but there still may be  some industries that need some  temporary government help in  order to remain open.  So for example, if Woodman's is  able to remain open and sell  groceries but truckers are  refusing to cross state lines to  deliver groceries, or the  truckers are a lot of them out  sick or whatever, you may need  to call on the National Guard to  do things like deliver groceries  for a short period of time.  Other types of things, many  businesses, for example, utility  companies, even if they're able  to keep operating, some of their  customers might not be paying  their bills on a regular basis  if they're unemployed or  whatever.  And so they may need temporary  loan guarantees to be able to  continue operating at a time  when they're not getting their  own bills paid as timely as they  usually would, etc.  What about the normal businesses  that all the rest of us, many of  us work in, or know people who  own or work in?  Many businesses are claiming  that, "Oh, no problem, we'll  just have everybody telecommute  or work from home."  That's not necessarily  guaranteed to work, especially  if you've never tested it  before.  Even if you have tested it, at a  normal time, it may not work  during a pandemic when everybody  else is trying to do the same  thing on the same day.  So there are two separate  issues.  First of all, if your employees  are all trying to dial into your  own corporate database or  whatever, your own internal  computer system in your company  may not be able to handle all  your employees working from home  on the same day. 

 That's something a business can  easily check, either by calling  a snow day, or whatever, to try  it out, or by talking to their  IT provider to say, is our  computer system gonna be able to  handle this?  But at the same time as your  business or your kids' business  or your neighbor's business is  trying to work from home, so is  gonna be every other business.  So are gonna be all those  university professors.  Universities and schools are at  least talking about trying to  provide content electronically  to children in their home.  And never mind when the students  are not using their electronic  school lessons over the  internet, they might be  downloading movies or music or  whatever.  So it's not clear that the  internet is really gonna be able  to handle all the traffic that  everybody is assuming it can  handle.  The other thing to think about  in planning for a pandemic if  you're responsible for managing  a company is that the critical  or emergency functions in your  organization may not be the ones  that you naturally think of as,  this is what my business does.  So for example, here at the  university, our major business  is educating students.  We can stop educating students  with a day's notice.  Right?  Classes tomorrow are cancelled,  or classes Friday are cancelled,  please go home.  Not everybody can go home that  easily, but we can cancel class  at a moment's notice. 

 We can't stop giving lab hours.  That would be a problem.  If your company is expecting  people to be able to work from  home, you may not think of  yourself as an IT company or a  computer company, but suddenly  if you're planning on all your  employees working from home, you  may suddenly become an  information technology company.  Your few computer guys may be  the most critical people in your  whole company during that  pandemic.  Likewise, if you're planning to  close, if you own a hotel or a  water park, your most critical  employees during that pandemic  may be your physical site  security to keep your building  from being vandalized or your  equipment from being stolen.  So you need to think a little  bit creatively about what  functions would be the most  important in your business in a  pandemic.  Again, questions on business  closure, or which businesses are  gonna stay open an closed, yeah?  >> You mentioned hospitals and  grocery stores, you did mention  Woodman's, but isn't that a  place where the risk would be  high?  >> Vicki Bier: Well, yes, there  is risk going to the grocery  store, and I'll actually come  back to that at the very end of  the talk, although not as much  as many other places.  If you look in here, people are  sitting side by side, at the  grocery store you kind of pass  in the aisles, and don't have  quite such close contact, but  people can also choose to go to  Woodman's at least at three in  the morning if they don't want  to see a lot of people.  Hospitals, again, are one of  those, like utility companies,  that have prepared more so than  your average business.  They still may find problems,  because Woodman's, they may see  their staffing go down, but at  least their demand for groceries  is not gonna go up all that  much. 

 Whereas hospitals are gonna be  dealing with a shortage of staff  at the same time as they have a  larger number of patients.  So they do have a very difficult  challenge, but kind of all know  about that by now, and whether  they're doing a good job or a  bad job on planning, I don't  really have the expertise to  evaluate it, and if I had an  opinion, they wouldn't listen to  me anyway.  Yeah?  >> Rather than closure, I'm  wondering about halfway measures  such as requiring people to wear  face masks.  Have those measures been  proposed and how well do they  work?  >> Vicki Bier: Certainly many  people are thinking about it.  My sense is right now there's  not a lot of reliable scientific  evidence about how valuable face  masks are.  The kind they use in the  hospitals are quite reliable,  but they are uncomfortable, you  have to learn how to use them,  they're not something you can  just order off the internet and  slap on your face and be okay  with it.  And for instance, they don't fit  over beards and things like  that.  So those face masks we know are  effective, but I don't think  they're ones that everybody in  this audience are gonna use.  The ones that you see people  wear if they're mowing their  lawn and they're allergic to  grass, or whatever, my guess is  that they're probably better  than nothing, and yeah, is it  worth buying a box and sticking   them in your basement?  Probably.  But we don't really know  scientifically, and so right  now, I don't think the public  health agencies are mostly  recommending that. 

 But yes, you may well find,  especially, for instance, if  people are unwilling to come to  work, the checkout clerk at  Woodman's or the bank teller,  who deals with really large  numbers of people, those folks  might say, "Hey, I'm not coming  in to work unless you get me a  face mask."  So yeah, I think there will be  a place for them if there is a  severe pandemic, more so than  the swine flu we had this  spring, but scientifically, I  don't think we really know for  sure yet.  People have even looked at  things like, if you made a face  mask out of an old t-shirt,  would it be effective, would it  be better than not having one?  And again, probably.  How good, nobody really knows.  Yeah?  >> I was gonna say, you seem to  assume that any business can  have its employees telecommute,  and I'm sure there are many  businesses where that just  wouldn't be possible.  >> Vicki Bier: Absolutely.  If you're making powdered eggs,  or whatever, you can't do that  from home, you've got to be at  the egg factory.  Yeah?  >> Who has the power to order  businesses closed?  Can it be done locally, state,  federally?  >> Vicki Bier: I think it  differs state by state, and I  believe in Wisconsin, it's  local.  Jay, is that correct?  >> State director of health  services, he has the authority  to order things statewide.  (inaudible)  >> Vicki Bier: I  think there are some interesting  things that have not been fully  explored yet.  First of all, in the beginning  of a pandemic, when things are  kind of evolving quickly, you  may have some school districts  closing and another school  district right next door that  does not. 

 And if you're an employer in  that area, that may be hard.  Half your employees are dealing  with the school closure and not  others.  There may also be, we live in a  much more litigious society now  than we did in 1918, and certain  kinds of facilities like  restaurants, we already know  public health has the authority  to order a restaurant to close,  even just if their kitchen is  unclean, let alone in an  emergency.  But could they close a shopping  mall?  I would think it would make  sense that they might be, have  the authority to close a  shopping mall, but the shopping  mall owner might now agree with  me and might take it court,  rather than agree to close down.  So there can be all kinds of  complications that show up.  That we haven't tested out any  time recently.  Some interesting points.  The national strategy for  pandemic influenza lists several  responsibilities of the private  sector.    One is making sure they have an  ethic of infection control at  the workplace, that means not  just things like providing hand  sanitizer and encouraging your  employees to use it, it also  means things like encouraging  your employees to stay home when  they're sick or they think they  might be sick or exposed to  something.  Establishing contingency systems  to make sure they can keep doing  what they need to do. 

 The third one, the national plan  says "establish partners with  members of your sector. "  I actually think partnerships  with members of other sectors  are gonna be much more useful.  After all, if you're a  pharmaceutical company, every  other pharmaceutical company is  probably gonna have the same  problems you have, and won't be  in a position to help you.  But you might, for example, be  able to partner with a cosmetics  company that may have not a high  demand for cosmetics during the  middle of a pandemic, but a lot  of highly trained chemical  engineers and sanitation  workers, etc.  that can come work for your  pharmaceutical company.  Hotels and restaurants.  While they may not have a lot of  clientele, they may be able to  partner with hospitals to  provide overflow bed space or  excess catering that the  kitchens of the hospital cannot  handle, etc.  So there's various cross-sector  partnerships that might turn out  to be useful.  Okay.  One of the things we highlighted  in our study a few years ago  that we were maybe not the first  in the country to highlight, but  certainly almost the first, and  since then it has been noticed  now with this most recent swine  flu, is what are gonna be the  impacts of a pandemic on the  working poor?  So three kind of sub-topics  within that.  First just, what would the  impacts of a pandemic be in  general, second of all, what is  the current status of the  working poor, and third of all,  what policy options do we have  if we think we need to do  something. 

 This is probably too small for  people to see very easily, but I  can give you the high points.  This was published a couple of  years ago by a non-profit called  Trust for America's Health that  showed the economic impacts of a  pandemic state by state.  So the sectors that would be the  most heavily affected in terms  of loss of demand,  transportation, not very many  people are gonna be taking a lot  of traveling vacations or a lot  of discretionary work trips in  the middle of a pandemic.  The two that we already talked  about, entertainment and  hospitality, down at the bottom.  Manufacturing, people don't  think there is gonna be a huge  loss of demand in manufacturing,  but manufacturing is such a big  part of the state's economy,  that even if we had only, say, a  2. 5% loss  of demand for  manufactured goods, that would  still be a big number of people  in the state as a whole.  Finally, that one that you can't  read because of my color scheme,  is healthcare, which would see  an increase in demand rather  than a decrease in demand, but  of course, that's not  necessarily a good thing either.  >> (inaudible)  >> Vicki Bier: Yeah, exactly.  There's various things like that  that we might not want to be  ---.  In general, the analysis that we  did starting from the data from  Trust for America's Health,  suggested that Wisconsin in the  year of a severe pandemic could  have about a 2. 25% loss  of payroll, which is  about $2. 3 billion,  so it's not small.  Note also that it's a little bit  misleading, because it's not  2.25% for the year, it's really  more like 10% for the three  months that the pandemic is  really raging in full swing. 

 So that's a pretty deep  recession, if you want to think  about it that way.  And the numbers of people who  would be affected is actually  bigger than the percentage  because hospitality and  recreation tend to be low-wage  jobs, so a small number of  dollars can translate into a  larger number of people.  We estimate, again, something  like 3. 5%  of jobs that might be lost  temporarily, but that's really  more like 12% to 14% in a short  period of time.  We have some maps that try and  paint different pictures of  this.  The Trust for America's Health  data was at the state level, but  we tried to sort of extrapolate  it down to the county level to  make it real for people.  If you look statewide, the  biggest statewide impacts are,  as you would expect, Dane  County, the Milwaukee area, the  Green Bay area, just because  those are the biggest, most  populated areas with the most  industry and economic activity.  So most of the state job losses  would be in those areas.  But those are also areas with  pretty strong, diverse  economies, so even if a large  number of people are out of  work, it's not necessarily a big  percentage of the economy in  that region.  If you look at which counties  would be hardest hit on a county  level basis, it's basically the  ones that are heavily dependent  on recreation and tourism.  The Great Lakes, Door County, a  few others. 

 But those are the big ones.  And if you look at some of the  white counties in there, like, I  can't even read it from here,  what is that?  Kewaunee County, right south of  Door County?  That looks almost white, but  that doesn't mean Kewaunee  County would necessarily escape  unscathed, because a lot of the  residents of Kewaunee County  probably depend on Door County  for their jobs and commute to  Door County to work.  And so some of those, like  Ashland up north of Kewaunee,  near Door County, could still be  adversely affected, not that  they would have a lot of jobs  lost within the county, but  people who live in those  counties could have a lot of  jobs lost.  Finally, the last thing we did  is to look at the average wages  of the people who became  unemployed.  And in the vast majority of  counties, the average wage of  the unemployed, sorry, of the  jobs lost, was less than $25,000  a year.  And in some places, less than  $13,000 a year.  It's a little bit confusing,  because the data we had and the  level of analysis we were able  to go to, we really could not  track workers, we tracked jobs.  So for instance, that $13,000 a  year average could be somebody  who earned $14,000 a year as a  waitress on one job, and another  $10,000 as a waitress on a  different job, or it could be  somebody who earned $14,000 as a  waitress whose husband was a  truck driver or whatever.  So it doesn't mean people were  necessarily living only on the  amount of money that's in this  chart, but it still says, I  think in general, that the job  losses are going to affect  people who can least afford to  handle job losses.  If you think about this, many of  these are people who right now  are handling their own affairs  without public assistance,  right?  They may not be handling them  well, they may not be getting  ahead economically, but they're  putting food on the table,  sending their kids to school in  winter coats and all the rest of  it. 

 They're not gonna be able to do  that at those income levels if  they're going weeks or months  without salary because of the  job closures in the  entertainment industry.  So this is what the economic  impact of a pandemic might look  like for this state.  What would the impact be on  working poor?  Well, it depends.  Does the family have health  insurance, or not?  Do they have enough resources to  stay home if they're sick?  Would they risk losing a job if  they stayed home sick?  Can they cover their basic  expenses, rent, electricity,  food, etc. ?  Do they have the resources, the  language skills, the social  skills, to understand the  information they're given about  the pandemic and be able to  respond accordingly?  Know what to do and have the  economic ability to do it.  There was a Harvard survey that  tried to address this a few  years ago and asked people, how  many days could you afford to go  without pay?  And a quarter of the population  said if they were away from work  for seven to ten days that would  be a huge financial hardship for  them.  More than half said they would  have a hard time going a month  without pay and three quarters  said, no way could they go three  months without pay.  You saw that school closures  might last up to three months in  a severe pandemic.  Probably not all businesses  would be closed that long, but  some businesses, like in the  entertainment and hospitality  industries might be.  We did one sample calculation  for Bayfield County, one of the  hard hit, tourism-dependent  counties.  We looked at the average wage of  the jobs lost. 

 What unemployment benefit that  individual would be entitled to,  based on their previous wages,  and what the poverty level would  be.  And so poverty level for a  family of two is about $13,700.  And in most of these sectors,  agriculture, trade, even  manufacturing, certainly  entertainment and hospitality,  the unemployment benefits people  would get if they were even  eligible for unemployment, if  they had worked long enough, and  so forth, would be below poverty  level.  Finance and insurance industry,  those folks, if eligible for  unemployment, would be above  poverty level for a family of  two, but still below poverty  level for a family of four.  So there's some pretty  significant hardship that would  be imposed from these job  losses.  Another important issue which I  talked about is level of assets,  it's one thing to have a loss of  assets if you have assets to  fall back on, that might not be  so terrible.  There is a very high rate of  asset poverty in the US.  1/4 of households in the US have  insufficient total net worth to  get by for three months at a  poverty level standard of  living.  Nearly 1/2 have less than $5,000  in liquid assets.  They may own cars or even homes  or whatever, but they have very  little money in the bank or in  investments, savings accounts,  whatever. 

 Rates of asset poverty are  particularly high among certain  subgroups, black and Hispanics,  young head of household, but  young goes up to 34 years old,  that's a lot of the parents of  small kids are in that category.  With 60% to 75% levels of asset  poverty.  Head of household with less than  a high school degree, renters as  opposed to homeowners, and  female heads of household with  children.  So there's large groups of  people that don't have the  economic wherewithal to go  without work for a period of  time.  Some folks may be able to say,  okay, I don't think it's safe to  go to work right now, I'm gonna  quit my job, or I'm gonna stay  home and let them fire me.  A lot of these folks don't have  that luxury.  How can people cope financially?  Well, one issue is what their  legal status is as far as job  security.  Are they entitled to stay home  sick, or can they get fired for  calling in sick?  Sick leave, it's actually pretty  surprising, I don't remember the  numbers, I probably should've  looked them up, but a big  fraction of employees in this  country do not have sick leave.  A surprisingly large fraction.  For instance, under the Family  Medical Leave Act and the  Wisconsin Medical Leave Act,  those apply only to companies  with 50 employees or more. 

 And I really well understand the  hardship of smaller companies,  if you have six employees and  two of them are out sick, I  understand why that's a hardship  for a small firm, but at the  same time, it's also a hardship  for the employee of that small  firm, get their --- to stay at  home when they're sick, without  worrying about losing their job.  What kind of income sources  might apply to people who need  to stay home, either because  they're sick or because their  workplace is closed or whatever.  Well, if you're laid off from  your job, you might be eligible  for unemployment, but not if  you've earned too little money  or worked too short a period of  time at your latest job, etc.  So some of the transient kind of  folks in the entertainment  industry or agricultural  industry may not be eligible.  Many people are not eligible for  paid sick leave, if your company  wants to be nice they may tell  you that you can use your  accrued vacation to stay home  during a pandemic, but they're  not obligated to do that, that  depends on how accommodating  they can be.  There can be disability and  family leave, etc.  But many people are not gonna be  eligible for these for one  reason or another.  And this has already been noted  as a problem, even in the swine  flu outbreak, where, fortunately  it wasn't very lethal.  A neighbor of mine who works as  a nursing assistant in one of  the public schools in Madison,  she said she had two  observations about swine flu.  One is, she knows they had a lot  more cases than ever got  confirmed. 

 Why is that?  If you are a confirmed diagnosis  of swine flu, that child has to  stay home for seven days.  If you never get confirmed, then  the standard rules apply, which  is one day after the fever is  gone.  Families who can't afford to  stay home for their kids, or  don't have the flexibility to  stay home from work for their  kids aren't gonna bother getting  a diagnosis of pandemic flu if  it just means they have more  days that they have to be home  from work.  The other thing, even during the  reason flu season before swine  flu, she said some of the  low-income families, if their  kid got sick, they would dose  them up with Tylenol in the  morning, send them to school,  hope the Tylenol carried them  through the day without their  fever spiking again, and refuse  to answer their phone or refuse  to return phone calls if they  got a call from the school at  11:30 in the morning because  their kid had a fever.  And it's not that they want to  send their child to school sick,  right?  Obviously, most of the folks  would probably much rather be  able to keep their sick kids at  home to get better faster, but  if they know, their employer has  told them, "You can't take  another day off, I'm gonna fire  you," what are they gonna do  when the school calls at 11:30  in the morning to say, "Sorry,  your kid is too sick to be in  school."  They're gonna pretend they  never got that cell phone call.  So that lack of sick leave and  family and medical leave is  already a problem and will be a  much bigger problem if we get a  more severe pandemic.  Actually, in Toronto, they had  the same kinds of problems with  SARS, and actually, in enacted  some new workplace protections  at that time, job security, not  everybody was entitled to be  paid when they stayed home sick,  but if your business didn't  close and your job still existed  after you got better, you were  entitled to have that job back.  And I think for healthcare  workers, they actually also  guaranteed their pay while they  were home sick.  So businesses are responsible  for maintaining an ethic of  infection control in the  workplace, but if your employees  know that they're not gonna get  paid, or that they may be at  risk of losing their job if they  don't come in, they're gonna  come in, sick or not.  So this kind of repeats that. 

 Job security is a major worry  with many jobs, where people  have neither a civil service  protection or a union contract  or whatever else.  Many low wage or part-time jobs,  people may not qualify for  unemployment.  Even workers who have sick  leave, that sick leave may be  unpaid rather than paid, they  may not have the ability to use  their vacation time as part of  their sick leave, they may not  have disability insurance for an  illness that lasts longer than  after their sick leave runs out.  This is the point I already  mentioned.  In Toronto, they had two new  protections enacted in the  middle of their SARS outbreak.  One was job security, you could  come back to your job, assuming  your job was still there, and  two was income continuation for  healthcare workers who had to  stay home because they were sick  or exposed.  What can we do about this?  Well, as I noted, the average  payroll of the jobs that would  be lost is quite low, so I don't  think we can necessarily assume  that all these folks would just  look after their own affairs  they way they're doing right  now.  Many of them are gonna very  quickly become wards of the  state, even if right now they're  self-sufficient.  One of the likely policy options  is disaster unemployment  insurance.  Right now disaster unemployment  assistance is usually, has  historically been interpreted to  mean natural disasters, like  hurricanes, floods, tornadoes. 

 Your workplace was wiped out by  a tornado, you're eligible for  disaster unemployment.  It hasn't historically been  extended to public health, but  almost everybody thinks it would  be if there was a severe  pandemic.  What other kinds of things can  we do that are maybe less  costly, or less burdensome, but  make a difference?  Here in Wisconsin we have a  tradition that we don't shut  people's utilities off in the  middle of winter.  They still owe their utility  bill eventually, and they may  still get their utilities shut  off eventually, but we're not  gonna do it in January.  We may have a similar rule that  says we might have a moratorium  on utility shut-offs during a  pandemic, because we don't want  that poor family to have their  utilities go out and suddenly be  moving in with three other  families in a very high-density  situation.  We may think of the kinds of  options that Toronto looked at,  for instance, short-term  disability or family leave, the  ability to continue people's  income for a short period of  time just to get through the  worst of a pandemic or whatever.  So I think we're gonna need to  be creative and hopefully plan  ahead on what some of these  policy options might be.  Okay.  So now is probably a good time  for questions on this issue of  the working poor, yeah?  >> I find it simply outrageous  that in a talk like this dealing  with a disease, one half of it  or more has to involve financial  or economic issues, and I think  all this, essentially, is why  there needs to be national  health insurance and also many  of these other benefits that  just aren't available in this  country, but would be available  in Canada or western Europe.  >> Vicki Bier: It's certainly  true, a lot of even the news  coverage on swine flu has  commented that, I believe we may  be the only major industrial  country that does not have  guaranteed sick leave, for  instance. 

 And yes, that poses a problem  for us right now during regular   flu season, or whatever, and  would certainly pose a bigger  problem in the middle of a  pandemic.  Yeah?  >> Is it too soon or do we know  anything about Mexico's  experience with their pandemic  precautions?  >> Vicki Bier: That's an  excellent question, and I  actually haven't gone back to  update this and looked to see  how much we know, but that is an  excellent question, because  Mexico certainly has larger  numbers of poor people, and it's  a very good point, somebody  should look to see how all those  folks fared during their crisis.  Other questions or comments?  Okay, in that case I'll move on  to the part that people may be  the most interested in, which  is, what is it you can do?  First of all, there is an  enormous amount of information  available on the web through the  government.  Again my color scheme is not  great, but it's an easy website  to remember.  pandemicflu.gov/plan.  Actually if you go to  pandemicflu.gov  you'll probably find it.  There are checklists there to  help planning for businesses,  for individuals and families,  for churches and religious  organizations, for schools and  daycares, for any kind of  organization you can think of,  practically, there are  checklists there about what you  should do.  I went through that quickly to  pull some of the most immediate  practical recommendations for  individuals, and I tried to  stick pretty closely with the  official CDC recommendations  from that website, but you'll  see in a few places I have some  editorial comments.  CDC is recommending storing a  two-week supply of food and  water.  Water I kind of doubt we're  gonna have a long-term crisis  with our water supply, it  doesn't take that many people to  keep a water utility running. 

 But food, I've seen  recommendations anywhere from  three days to three months of  food.  I personally think two weeks is  a little on the short side.  Three months, that's kind of  impractical, how much are you  really gonna store and where are  you gonna keep it all, and  whatever.  But at home, we've kind of  targeted six weeks.  And you're not gonna live well  on that, I don't have six weeks  of steaks in the freezer, or  whatever, but if there's canned  soup, peanut butter, rice,  beans, pasta, crackers, basic  staples, it's gonna protect you  against two things.  One is, if there are periods of  time when there just isn't food  getting to the grocery stores,  any American city I think only  has two, three days of food  within its city limits at any  point in time.  So if something breaks down,  either in the food manufacturer,  or food distribution system, or  trucking, or whatever, it  protects you against that.  It also protects you against  having to go to the grocery  store twice a week in the middle  of the pandemic and see a lot of  sick people there.  If you have stuff at home, fine,  you may choose to run out and  stock up on something that you  ran out of, or that you really  want, other kinds of things, I  started thinking differently  about what to keep.  More flour and sugar. 

 Powdered milk and eggs, that I  would never cook with at a  normal time, but if you don't  have any fresh eggs at home, it  might go a long way.  So you can get creative about  thinking about things that will  help to tide things over.  Check and make sure that you  have enough supplies of your  prescription drugs at home and  maybe non-prescription drugs  that you take regularly.  You may need to talk to your  physician or your pharmacy about  this to make sure they will let  you have a couple extra months  of medication at home, often  they don't, but at least refill  regularly, don't wait till  you've been out for three days  to go refill it.  Wash your hands frequently, the  CDC says frequently, I would  add, and thoroughly.  I believe, Jay, the  recommendations are to really  wash your hands thoroughly you  should do it long enough to sing  "Happy Birthday" twice.  Twice is pretty long.  Yeah?  >> Can I add one thing?  Wet your hands first, then put  the soap on, and not while the  water's running over them.  Simple things, but that's part  of being thorough.  >> Vicki Bier: Yeah. 

 And twice through "Happy  Birthday" actually seems really  long to me, but once through is  already probably five to ten  times longer than many of you  wash your hands for.  So, and people have been  creative, I've seen posts on the  internet about "Happy Birthday"  may work for kids, but you may  have some other song you want to  sing instead of "Happy Birthday"  as grown-ups.  Other kinds of things.  Stockpile cleaning supplies,  trash bags, tissues, toilet  paper, diapers if you have  babies.  The CDC has not been  recommending that people  stockpile face masks and gloves,  but I think it's not a bad idea  for a couple of reasons.  Face masks are useful if you do  need to go out in public, or  when you go out in public.  Face masks and gloves are both  helpful if you're caring for a  sick family member.  If somebody is upstairs with the  flu and you're trying to keep  the kids downstairs away from  them and you have to go up every  time to bring them their soup or  whatever, it's kind of nice to  be able to deal with some of  those things with a mask and  gloves and be less concerned  about, are you bringing the flu  back downstairs to your other  family members.  Finally, there's local groups  that people can volunteer with,  and Jay, do you want to say  something about what some of  those might be?  >> No.  >> Vicki Bier: Okay. 

 There's various volunteer  organizations, churches and  community groups that have  started dealing with pandemic  flu, and if we get to a sever  point, there's gonna be other  options that are looking for  volunteers.  I think one of the take-home  messages from all of this is,  it's not gonna be business as  usual, and it's not gonna be  something that we can just  figure, government will take  care of us.  So if your religious group  chooses to set up a phone tree  to make sure everybody's okay  and children are not left home  with sick parents, or deliver  emergency food to people who  can't get out to shop or have  lost their job, there's a lot of  things you can do that don't  even necessarily put yourself at  risk medically, but still can  help somebody else who's having  trouble.  That's the extent of my remarks,  and I'm happy to have more  questions or conversation.  Yeah, thank you, I'm gonna start  with Jay in the back, because he  might have some things to chime  in here.  >> The one thing now that I've  thought about.  I would strongly encourage you  to go explore things with your  neighbors.  These are the people who are  gonna be there before the  ambulance, police officer, fire  truck, your elected official  will be there, they're gonna be  there after they leave, too.  So if you go out and say, "Hey,  we'll do some communal shopping  during a pandemic," that's an  idea but after you discover  you're in a pandemic, and after  you know you need to do  something, is a little late to  be exploring options.  Get out and talk with your  neighbors, get to know people,  go to your religious  organization, whatever, so  everybody participates some way  socially. 

 Start looking at those networks  and just be creative.  >> Vicki Bier: And that's an  excellent point.  There was a book written about  the Chicago heat wave.  That looked at two different  low-income communities in  Chicago.  And found, these were not  communities that had a lot of  economic difference between  them, one was not wealthier than  the other, but the community  that had lower mortality rate  had what people call a "higher  level of social capital."  Which basically means, if you  know that your neighbor is shut  in and can't easily go out to  sit in the library in the air  conditioning for an hour, go  check on them, see if they're  okay, do they need their  medication refilled, do they  need a cold drink, or whatever.  And even that kind of thing in  the Chicago heat wave, it was  demonstrated that this made a  difference.  That just having the community  of people who already knew each  other and trusted each other,  yeah, the police or fire  department or ambulance, the  ambulance may or may not come  when you call them after you've  already suffered heat stroke,  but your neighbors can be there  before you have heat stroke to  make sure you have cold drinks  in the refrigerator or whatever  else.  Other comments, yeah?  >> One thing that you didn't  bring up and somewhat concerns  me is the question of  quarantine, and what are the  legal basis for being able to  enforce a quarantine, and then  also, another concern, I think  people would not be used to that  because it's been many years  since they've had that, they  might not be so willing to  follow that order or, in a state  like Wisconsin, you have up  north where people are mostly an  anti-government mentality, and  they'll just refuse to follow  that.  So what do you do in those  situations?  >> Vicki Bier: Well, we haven't  had one for a long time, so I  don't think we really know.  There have certainly been  quarantines on a very isolated  basis, if somebody has been  exposed to monkey pox or some  obscure disease, and  occasionally they will post a  guard in front of somebody's  house if they are not complying  with the quarantine, or  whatever. 

 You obviously can't do that for  very many people, but yes, there  is a legal authority behind it.  But never mind the northern  Wisconsin anti-government types,  you're gonna have lawyers who  decide that they absolutely have  to get to that meeting in DC  tomorrow, even though all travel  has been cancelled.  Or families who decide that  their children are gonna be  safer at Grandma's house in the  country than they are in Madison  and I don't know how it's gonna  work where we try and enforce  those kinds of things.  Yeah?  >> I remember reading that in  the case of the 1918 epidemic,  when people studied their  anti-bodies, virtually 98% of  the people were exposed to it.  So in other words, it suggests  that it's inevitable, that's a  similar virus to the one we're  having now.  In other words, you will be  exposed to it, and all efforts  to avoid it will slow it down  but won't totally stop it.  >> Vicki Bier: Okay, yes, I will  repeat the question.  The gentleman said, and this is  something I didn't know, but  that apparently from the 1918  pandemic, something like 98% of  people who were alive at that  time had antibodies to that  virus.  So everybody will be exposed to  these new viruses sooner or  later.  So the question was then, is it  pointless trying to slow down  the spread?  And I think not for two reasons. 

 One is because some of the big  sort of economic and practical  problems have to do with how  many people are sick at one  time.  And if you can get the absentee  rate down from 30% or 40% down  to 15% or 20%, businesses are  gonna have a lot easier time  doing their normal jobs.  The other things is that as  people have probably seen from  the newspaper, the thinking is  that there will not be a vaccine  available necessarily at the  start of the pandemic, it may  take a few weeks or months after  the pandemic to have a vaccine  that we know is gonna be  effective.  So part of that delaying tactic  is to buy time until there are  large enough amounts of vaccine  available so at that point you  could actually put a stop to it  and protect people from it.  But if they get exposed too  early, you're not gonna be able  to vaccinate them or protect  them.  Yeah?  >> Say that one of the city of  Madison wells became  contaminated.  How long would it take then to  flush that?  >> Vicki Bier: I have no idea.  I guess I would have to say, I'm  not that kind of engineer.  >> I have another question.  Do these viruses, are they  controlled at all by seasonal  temperatures?  Because didn't I read that the  1918 pandemic was very, very  small the year before. 

 And then all of a sudden leading  up to 1918, it totally exploded.  Now if that runs similarly with  the swine flu, would we possibly  be looking at an explosion, and  again my question is, does that  thing travel on warm  temperatures or cold  temperatures?  >> Vicki Bier: Most flu viruses  like cold weather and that's why  flu season is in the winter and  not in the summer.  It's not entirely clear whether  that will be true of this virus,  or of some other new flu virus  that might emerge.  I don't know that that's a  scientific law, but I think many  people are expecting that yes,  even if it dies down somewhat in  the summer, which it hasn't  really gone away yet, but it's  starting to die down, even if it  dies down some in the summer,  it's likely to come back in the  fall.  On the other hand, they  predicted that SARS might come  back the next winter and it  didn't.  Yeah?  >> How much does the mode of  transmission affect the things  you ---.  In other words, if it's  respiratory or intestinal, or  contact.  >> Vicki Bier: Well, swine flu,  the current swine flu, is  primarily a respiratory disease,  but again, I don't think  scientifically people know very  accurately how much is flu  spread hand to hand and how much  is it spread in the air by  coughing and sneezing.  And you know, that's gonna make  a difference in how effective it  is to have hand washing versus  face masks or that kind of  thing.  But I don't think we have really  good answers to that yet, people  probably have some guesses. 

 Yeah?  >> Several things.  I know that they're keeping a  close watch on South America,  Chile and Argentina right now  where it's cold, and see what  happens.  But also, in the 1918 flu, it  seemed like young people with  robust, young adults with robust  immune systems, but also  pregnant women and young  mothers, were especially  affected, where the older people  might have had some immunity.  And it seems to me that mothers  are often the organizers of the  family and the community, and  this is something that I think  we have to prepare for.  I think the CDC has done a great  job right now in disseminating  information on their website for  all different kinds of groups,  but this is where people panic  if it's not good information and  communication.  So what do you think about the  news media, the government  agencies, how they communicate  day by day with people to get  people to do the right thing and  not so panic.  >> Vicki Bier: Overall, I was  actually fairly pleased with the  response to swine flu this  spring.  One of the things that I really  liked was the targeted closing  of schools.  I think some places, like some  communities in Texas, closed all  their schools for a long period  of time.  But here in Wisconsin, they were  looking at individual schools,  is there a confirmed case, or a  known exposure in the school,  and let's close this school for  a few days. 

 So it's a lot less costly, it's  not like crying wolf where after  a while people can't handle it  anymore.  And then they back off it when  they discovered that it's really  not that severe, maybe we don't  need to close the schools.  So I thought this time around,  they actually did a pretty good  job.  >> Versus Egypt where they  decided to kill all the pigs...  (laughter)  >> Vicki Bier: And  Egyptian pigs didn't have swine  flu, right, it was other pigs.  >> (inaudible)  >> Vicki Bier: Yeah, in  the back.  >> I wondered about the  hand-washing gels that were  available, the sanitizers.  Was that just a fad or can they  actually do something, they're  available at almost any counter  now when one checks out at the  grocery store, etc.  >> Vicki Bier: Yeah, I think  they work.  They're considered a valid  alternative to hand washing. 

 They may be subject to the same  conditions about, if you put a  tiny squirt on there and just  rub it around for a few seconds,  it's not gonna do as much, but  yeah, I think they're considered  legitimate.  Yeah?  >> Is it true that they still  actually have samples of the  1918 virus that have been  preserved and that they're  working with them as far as  research?  >> Vicki Bier: I think so, but  I'm not positive, so don't trust  me on that, yeah?  >> The --- did sequence it, so  yes, there are still samples,  and I can't remember his name,  but he's here.  >> Vicki Bier: A Japanese  scientist, I think, yeah.  >> And he was very influential  in sequencing H1N1, too.  And I just heard today some  early reports that it's starting  to mutate.  >> Vicki Bier: I had heard that  also, and I haven't actually had  the chance to get on the news to  see what they say about the  mutations.  Yeah?  >> Let me finally make one more  suggestion, the fact that with  the hand gels, when it was all  of a sudden, "Oh, wait, swine  flu, what do we do "  I know the Walgreens downtown  by where I work had no hand gel.  No nothing.  It was gone within a day.  I asked the manager, like, how  long normally would that stock  have lasted that he had. 

 And it would've lasted over a  month.  Gone in less than a day.  Warning takes place, and with it  though, it's similar to ---,  it's not, you get it, you're  good, you've got change your  behavior.  It's not waiting to change your  behavior when it happens,  washing your hands is something  right now to change your  behavior, get in the mode.  Get your behavior ready for it,  rather than trying to react  when it's gonna be too late.  >> Vicki Bier: That actually  also protects you from a lot of  other germs in addition to swine  flu if it comes back.  >> The regular flu, too.  >> Vicki Bier: Yeah, exactly.  >> We have hundreds of thousands  of deaths every year from it.  >> Vicki Bier: Yeah. 

 Any other questions or comments?  >> Do you think smallpox is  every likely to recur?  Supposedly it's been totally  eradicated, but there are a few  rogue countries?  >> Vicki Bier: Well, I don't  think we're gonna get an  accidental outbreak of smallpox  ever.  I'm probably not the expert on,  could we ever have  intentionally-introduced  smallpox?  But, we're not totally.  I don't know.  Yeah?  >> I heard that the reason why  in the summer we don't have the  epidemics is because we have  more vitamin D because we go  outside in the sun.  And so in the winter, when we  stay indoors a lot.  So if that's the case, then it  wouldn't be that the virus likes  the cold but that we're more  resistant to the virus when we  have more vitamin D in the  summer.  >> Vicki Bier: I think it may  actually be both.  These days people seem to think  vitamin D is good for almost  everything, but I also think  there have been studies looking  at sort of indoor humidity  levels as a factor affecting flu  transmission and things like  that, so there may be some of  both.  Yeah?  >> I been in Phoenix for 12  years, and I tend to get sick in  the summertime, when you get  stressed, it's hot outside.  There's plenty of sunlight, I  get plenty of vitamin D, but I  never got sick in the  wintertime, just every summer. 

 That's when I get sick.  The heat'll get to you after a  while.  >> Vicki Bier: Well, human  beings are complicated, so I  don't think some of these  questions have simple answers.  Yeah?  >> One of the factors in the  1918 flu was World War I and  recruitment centers and soldiers  in close proximity and training,  and the troop ships, where  everyone was very confined in  close spaces without good  ventilation.  And I think even people in these  big tents, army training  centers, they just had one stove  in the middle and everyone was  close around the stove, so it  really spread a lot more than if  they hadn't had that.  >> One last comment about our  own campus here.  We realized we didn't have a  good measure of students going  out to schools for their  activities, for undergrads going  into schools.  There was no way we could  monitor that, so University  Health Services was made aware  of that.  Because I have a number of  volunteers who are undergrads  here, who go into the schools,  not officially for student  teaching or anything, but to  volunteer in the classroom.  And we had no way of tracking  that until we had that  discussion this spring. 

 >> Vicki Bier: Yeah, I think  there's a lot of issues like  that that are gonna turn up.  Including in the early planning  for avian flu, people thought,  well, it's gonna start someplace  overseas, we'll kind of watch it  for a few months, it'll  gradually get here.  If you think about how many UW  students come from all over the  world, how many of our  researchers travel all over the  world.  You never know, UW could turn  out to be one of the only hot  spots of whatever the next  pandemic is, if a bunch of  returning students or  researchers bring something home  with them, you never know.  It can get to be very  complicated.  We should probably close the  formal part of the presentation  now, but I'm happy to stick  around for a while.  (applause)