October 03, 2005
Influenza Hits Preschoolers First

Influenza cases show up several weeks earlier in preschoolers than in adults.

Current immunization policies recommend universal flu vaccination for children aged 6-23 months, but shots are advised for older children only if they have high-risk medical conditions. New data compiled by researchers at Children's Hospital Boston and Harvard Medical School, reported in October 1 issue of the American Journal of Epidemiology, suggest that otherwise healthy 3- and 4-year-olds drive flu epidemics, a pattern that may warrant consideration when formulating immunization policy.

The researchers leveraged a real-time computerized biosurveillance system linking five diverse health-care settings in Greater Boston, and examined medical visits from 2000 to 2004. Children aged 3 to 4 clearly led influenza epidemics, presenting with flu-like respiratory illness as early as late September. Children aged 0-2 began arriving a week or two later, while older children first arrived in October and adults began arriving only in November.

Moreover, flu-like illness in children under age 5, compared with all other age groups, was the most predictive of pneumonia and influenza deaths in the general population as determined from a Centers for Disease Control and Prevention database. Visits by children aged 0-2 provided the best prediction of mortality, but those of 3- and 4-year-olds followed close behind, suggesting that preschoolers, not just infants and toddlers, are important spreaders of flu to vulnerable groups.

"The data make sense because preschools and daycares, with their close quarters, are hotbeds of infection," says Dr. John Brownstein, the paper's lead author and a faculty member of the Children's Hospital Informatics Program at the Harvard-MIT Health Sciences and Technology program. "The data suggest that when kids are sneezing, the elderly begin to die. Three- and 4-year-olds are sentinels that allow us to focus our surveillance systems."

Influenza kills tens of thousands of Americans each year. Previous studies have shown decreases in household flu transmission and in adult flu mortality when children are immunized. Additional studies have also suggested that preschoolers drive flu epidemics, but they are based on simulations.

"Our study was not a simulation," says senior investigator Dr. Kenneth Mandl, an attending physician in Children's Department of Emergency Medicine and an informatics program faculty member. "This was real life."

With that previous report in mind consider this next report. H5N1 bird flu is currently very lethal to children.

The disease has been particularly deadly for children. In Thailand, 89% of patients under the age of 15 years died an average of nine or 10 days after illness onset.

Protection of children is the biggest problem in a pandemic. During a pandemic of high lethality schools will be closed. But lots of kids are in day care and kids come into contact with each other while playing. Also, with so many working mothers kids end up under the care of others during the day. This sets up transmission belts of influenza from home to children to day care environments to other kids and then to other homes.

Some ideas to protect children from a deadly flu pandemic:

  • Keep all boarding schools open but quarantined. Staff and teachers should live on the premises and agree that if they leave they can't come back. Only occasional delivery trucks should enter the grounds to drop off large crates of supplies which then get collected by staff after the delivery trucks leave.
  • Some summer camps for children should get converted into year-round boarding schools with the same quarantine rules as those put in place for boarding schools.
  • Child labor laws should get temporarily lifted so that adolescents can join the workforce to work and live at quarantined workplaces (which I call "workplace cocoons").
  • Farm houses out in plains states should take on children as boarders to live in isolation. The farmers would have to agree to avoid all contact with outsiders except for rare carefully made large supply deliveries.
  • Where economically feasible mothers could stay home and home school their children. If they have spouses the spouses could stay somewhere else in order to avoid bringing infection into the home.
  • Turn abandoned towns (such places exist in the US plains states) into quarantined camps for children.
  • Take hotels and turn them into quarantined boarding schools.
  • Poorly behaving children should be put in separate facilities to reduce quarantine rule breaking and skin contact when kids beat on other kids.
  • Identify isolated islands (e.g. Catalina) and valleys where entry and exit could be controlled and where children could move to stay in homes and in camps set up over larger areas. This would allow much larger areas in which kids could roam, go to school, and function in more normal fashion.

To move children or adults into longer term quarantine facilities requires intermediate quarantine facilities where people stay even more isolated for a week or two to establish that they do not already have a flu infection. So one problem is how to process large numbers of children through about 10 day cycles to separate out the infected from the infection-free. Then the infection-free could be transported under quarantine to quarantined longer term living facilities of the sorts listed above.

Children do not work in the economy. Therefore their isolation from society should be easier to manage than the isolation of working adults. At the same time, children are the biggest transmission belts of influenza. So their isolation would do more to reduce the spread of flu virus than the isolation of most other members of society. Plus, they would be at great risk of dying from an H5N1 pandemic.

Share |      Randall Parker, 2005 October 03 01:29 PM  Pandemic Prepare Children

Bob Badour said at October 3, 2005 1:45 PM:

I see some flaws in your suggestions. Preschool children are very tactile. They are much much more likely to spread the disease through hugging and kissing than through beating each other. And then there is the whole putting toys in their mouths thing.

I suspect a major reason why old people start dying when preschoolers get sick is grandparenting. Day care costs money so preschoolers likely spend more time with grandma than their school aged siblings. And when playing with grandma they are much more likely to spend a long time on her knee: hugging and kissing her.

Younger grandparents probably have elder-care issues of their own and then transmit the disease to great-grand-dad down at the nursing home.

Mothers will not likely agree to separate themselves from their preschool children. It's one thing to send a 6 or 7 year old off to board, but sending an infant or toddler is tantamount to giving the child up for adoption.

jerryofva said at October 3, 2005 7:44 PM:

Just a comment. The current outbreak in Indonesia has at least count infected 62 people with 6 deaths. The mortality has been reduced from 50% to 10%. Some people believe the strain is weakening but more then likely more people are being tested for Avian flu when they show up sick at the doctor. There are probably hundreds of case still going unreported because people in third world countries don't go to the doctor unless they are really sick. It is beginning to look like H5N1 will be like the Hong Kong flu in the 1960's. WHO is now saying that H5N1 will kill anywhere from 5 million to 150 million worldwide. In other words they don't know and are probably already hedging so they don't look like chicken littles.

Randall Parker said at October 3, 2005 7:58 PM:


6 deaths? What's your source? Henry Niman says 9 dead in Jakarta and 4 in the rest of Indonesia. However, I agree that both cases and deaths are probably being undercounted. Indonesia's a fairly poor nation. Also, when and where they take samples results in missed detection. Viral load is higher deeper in the respiratory system.

DJ said at October 4, 2005 4:31 PM:

So how long is this Influenza obsession going to last?

jerryofva said at October 4, 2005 6:33 PM:


It was on a google or yahoo news story from late last week. Deaths are not being undercounted, the death rate is being over counted. As I repeatedly stated that only the very sick go to see doctors in countries like Indonesia. There we can assume that only the most serious case have been reported. People who die of a flu like disease are going to be tested for the presence of H5N1. People die at home when a disease with the mortality rates that people have assumed for Avian flu. There has been little evidence of home deaths from this virus.

Randall Parker said at October 4, 2005 7:03 PM:


I see from looking elsewhere that an officia death count of 6 is being reported. However, again, some scientists (and Henry Niman has the requisite Ph.D.) are arguing that testing methods are leading to an undercount. Read some of Niman's reasoning for how undercounts are happening.

Also, even Indonesians with severe bird flu cases are getting turned away at hospitals due to lack of respirators.

I do not think we can trust the official numbers from Indonesia as counted by that government or by the WHO.

jerryofva said at October 5, 2005 7:08 AM:


What makes you think that "media reports are only covering the major hospitals and some possible flu cases are not admitted even to the lesser hospitals." is any more accurate then hundreds of rapes and murders in the Superdome?

Randall Parker said at October 5, 2005 9:33 AM:


I think it because Henry Niman searches the Indonesian press and finds reports only about a small number of larger hospitals getting suspected bird flu cases.

Use your own judgement. I have a high opinion of Dr. Niman's judgement having followed his writings for a year or so.

jerryofva said at October 5, 2005 10:59 AM:

Your judgement is only as good as your information source. If the US press exagerates and fabricates, why would you believe the press in a country like Indonesia? Dr. Niman may be an expert but he has no reliable information source to make a realistic assessment. Why do you think the WHO now warns that between 5 and 150 million people will die worldwide? As a warning officer in the US intelligence community, I can tell you that when warnings of such a broad nature are issued it means that the analysts have no idea what the true state of the world is. It is a sign that WHO is beginning to realize that their dire initial predictions were based on limited, third world data where only the very sick even make the treck to the doctor. Most people who die of high mortality diseases die at home even at low rates of infection. We have never seen that with Avian Flu. I have always been skeptical of the 50% death claim for that reason. I think most avian flu cases have gone unreported because most people who get it don't get any sicker then they do with other flu strains. I think we are looking at a Hong Kong 1960's type lethality.

jerryofva said at October 5, 2005 6:55 PM:


Here is story from Fox News. It looks like H5N1 has a way to go before it becomes a human-to-human pandemic virus.


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