Thursday, October 26, 2006

Pandemic Flu, Nylon Hosiery And The New York Times

Sometimes you get up in the morning, read the paper -- then check to make sure one of your kids didn't just slip you a copy of The Onion instead of the New York Times.

That was the feeling when reading a Times Op-Ed yesterdat by Stanford Professor Lawrence M. Wein concerning preparations for the coming (sooner or later) pandemic flu. Wein's first point, which is probably true, is that we need to be focusing on the airborne mode of transmission -- through aerosol droplets created by sneezing, coughing, breathing, as opposed to "contact transmission," in which virus is transferred via hands or something the hands touch before touching the face.

But there has been some controversy over whether plain old surgical masks are adequate to protect people (particularly health care workers) from flu transmission, or whether N-95 respirators are needed, and if they are, whether they can be re-used.

Surgical masks are basically a barrier or sneeze guard developed primarily for surgeons and others with the intention of protecting the patient from sneezes or coughs from the health care provider. They are not intended to protect the wearer. Respirators, like the N-95 (designed to stop 95% of small airborne particles), on the other hand, fit tightly around the mouth and nose with the intention of filtering out or blocking particles (like viruses) from being inhaled by the wearer. OSHA and NIOSH have always recommended respirators, but Department of Health and Human Services' (HHS) pandemic influenza plan issued last November had said that sugical masks were appropriate. (Revere at Effect Measure has an interesting discussion about differing theories on modes of transmission and the pros and cons of N-95 respirators.)

We thought the mask vs. respirator debate was finally settled when HHS recently issued a new interim guidance document that calls the use of N-95 respiratorsis "prudent" for medical workers providing any direct care for patients ill with confirmed or suspected pandemic flu and recommended in caring for those with pneumonia. It also says respirator use is prudent for support workers in direct contact with patients.

But, according to Wein, the debate is anything but settled. Despite what HHS has decided, Wein has declared that
To our surprise, we found that the filters in surgical masks, although not as good as the filters in N95 respirators, are still quite effective.
And shouldn't we believe him? After all, he's a professor at Stanford. Pretty impressive -- until you realize that he's a professor at Stanford’s graduate school of business. Never mind that the National Institute of Medicine recently concluded that "There is no evidence that mask use by either infectious patients or health care personnel will prevent influenza transmission."

And in what may come to be the classic business school economist impersonation of bad industrial hygeine, Wein goes on to explain why we should be promoting the "not as good" masks over the more effective N95 respirators:

And although a surgical mask fits much more loosely and allows more leakage, it’s also more comfortable — and therefore likely to be effective because it’s used more....The less comfortable N95 respirators would probably result in lower compliance.

You know what you get when you promote an ineffective protective device because it might be more comfortable? A false sense confidence and lots of sick people.

(This reminds me of the debate in the mid 1980's about whether doctors and other health care workers should be forced to wear gloves, and whether dentists should wear masks. "Of course not, many professionals said. "They're much too uncomfortable, it will never happen.")

But wait, it get's better. We now move from Wein's bad industrial hygiene to a scenario that can only thrill the nylon stocking fetishists lurking among us (and who must disproportunately populate America's business schools)
Wearing nylon hosiery over a surgical mask essentially eliminates the face leakage, making this combination a practical, albeit macabre, alternative.
"Macabre" doesn't even come close to describing millions of people going about their business in the streets of New York wearing nylon hosiery over a surgical masks. Anyone who suggested that as a scene from the next "Dawn of the Living Dead" sequel would be laughed right out of Hollywood, if not locked up. Assuming, of course, that there was any real evidence that nylon hosiery worn over surgical masks would actually work in real life, which there isn't.

Wein then goes from the ridiculous to the dangerous. Right now, the federal government has quite correctly been focusing on making sure we have enough respirators stockpiled for health care providers -- a fairly massive and as-yet far off goal. But Wein thinks it would be far more effective for the government to stop focusing on health care workers and ensure instead that everyone in the country is supplied with respirators and masks (and presumably nylon hosiery.)
The government and the public health community must switch mindsets, from the current perspective of protecting workers paid to do a dangerous job everyday, to that of providing citizens with the tools to best protect themselves during a pandemic.

So, instead of focusing on protecting the health care workers who are hopefully going to take care of all the sick people, we're going to pull out all the stops in a probably futile effort to protect everyone in the country using inferior respiratory protection? Does this make sense? Not according to SEIU's Industrial Hygienist Mark Catlin who wrote an (as yet unanswered) e-mail to Wein:

Planning to protect healthcare worker will also help protect the public for the following reasons:

  1. The key limit to providing care in a pandemic will be the number of health care workers who show up to work.
  2. Health care workers can’t work if they are sick.
  3. Health care workers will be less likely to show up if they don’t feel that their Personal Protective Equipment and infection control procedures are effective or if they are sick.
  4. It is critical to keep hospitals from being the spreaders of the flu, as occurred in Toronto with SARS.
Which brings us to a final, very simple question: What the hell is the New York Times thinking allowing a professor of business to take up valuable space on the most respected op ed page in Western Civilization with a bunch of crap that any half-way respectable professor of public health specialist would flunk a student for spewing?

Does this now mean we can expect to see a professor of public health opining on in the New York Times Op-Ed page about the pitfalls of tax cuts or the most effective way to approach North Korea? Are there no other real experts available to write about pandemic flu preparations (or lack thereof?)

UPDATE: More on this here.