On Thursday, November 19, and Saturday, November 21, 2009, I spent about five hours each day working as a volunteer at a vaccination clinic run by the Monroe County Public Health Department (DPH). It was one of five each day held to vaccinate at risk groups for pandemic H1N1, the Swine Flu. I worked at the one held at the former Medley Center Mall in Irondequoit.

The DPH did a great job publicizing the clinics, with the cooperation of the local media. Attendance on Thursday was somewhat overwhelming, while that on Saturday was more even in flow.

The DPH contracted with private companies for the actual vaccine administration. DPH personnel and volunteers were used for crowd control.

The observations in this piece apply only to the location I worked at, unless otherwise stated.

The Mall is empty. That meant no heat either day, and somewhat uneven hallway lighting. It also meant sparse sanitary facilities, and the men’s room had been damaged by vandalism prior to the clinic. In fact, it was flooded on Saturday. The Irondequoit Kiwanis had coffee and donuts earlier on Thursday and through about 2 on Saturday. There were no other sources for food and drink in the Mall.

On Thursday, there were four to six people giving the vaccines at any one time. The private contractors made sure that they got all their breaks in. In the late afternoon there were some 400 people in line, and a four hour wait. I was told by DPH staff that the holdup was that the providers were having to answered questions. While that may have been the case, it was clear that there were far too few providers for the demand.

Just before 5 p.m. we were told to refuse entry to any additional patients, even though the clinic had been advertised as open until 8 p.m. Most people took the news with some grace, though several self-important individuals chose to create a problem.

I had begun work at 2:30. Throughout the afternoon it was obvious that the five clinics did not seem to be talking to each other. We were getting news from patients who had been turned away from other clinics and came to the Mall. We were not the first clinic to close its doors, as far as I can determine.

On Saturday, some changes had been made. There were now about eight to ten providers, and a separate line for people with children. We were given handouts to provide patients that would answer many of the common questions.

We closed at six on the dot. During the time I was working, there were no lines beyond the clinic area, and the only real wait was in the children’s line in the clinic, perhaps 15 minutes.

Both days, we took patients with movement or other issues straight to the clinic, about 50 yards from the Mall entrance, rather than ask them to make the much longer trek around to the clinic entrance. Even then, the distance was a little daunting for some.

Signage was poor. There were two manufactured signs, one that said “Clinic here” and another that gave the target groups for the clinic. The remaining signs were made on a computer, did not last well in the rain on Thursday and did not look at all professional.

We had no handouts on Thursday and ran out of the handouts on Saturday.

Far too many adults over 65 came. Whether they thought it was the seasonal flu vaccination or not, I do not know. The clinic was not intended for them and those doses could have gone to more at-risk populations. The only people turned away had valid medical reasons for the denial, such as an allergy to eggs or being ill with a fever.

On Thursday, the clinic closed before the hour advertised. There seemed to be no interest on the part of the DPH staff in continuing to give vaccinations while they had demand.

The Monroe County DPH has about 239 employees. It would seem logical that the department would be able to staff these clinics without volunteers from other county departments and from the public. In fact, other departments did have volunteers there, and those county employees will receive comp time for the hours that they worked past their normal quitting time.

Most of the public probably is not aware that clinics like this have been planned and discussed for years, as the potential for bioterrorism arose. A great deal of time and effort has been devoted to the problem of dispensing vaccinations to a large population in a short period of time. Sites have been selected, and plans made. I cannot determine if the clinic I participated in was the result of this planning. If so, a lot of people wasted their time in the last seven years.

Why was it necessary to use contractors to give the vaccinations? The DPH employs many people with the training and qualifications to give injections. They also have, in their plans for this eventuality, other groups of people they could have called upon, such as paramedics or hospital staffs.

Why were volunteers needed? The DPH had a couple hundred employees at work on Thursday who could have worked at a clinic. Those same employees could have been used on Saturday, as well. If it was all about overtime pay or union contracts, then just how would the clinics have worked if smallpox had been used in a terrorist attack as all of those folks planned for?

Thursday was cold and rainy. Saturday was cold. I kinda resent being cold and wet while DPH secretaries sat in warm offices and surfed the Web. If the department charged with preserving and protecting public health in Monroe County cannot generate an “all hands” response for a project like the Swine Flu vaccine clinics, I have to wonder just what they would do in a more serious situation.

The Irondequoit clinic vaccinated many, many people in the hours that I worked. In that respect, it achieved its goals. More clinics are being discussed for December.

For the future clinics to be successful, there must be:

• More communication among the sites
• Site locations suitable for large crowds, to include heat, lighting, bathrooms and refreshments
• More communication with the media, especially when it comes to closing sites early
• Professional signage – it can be reused
• a perception that the Monroe County Department of Public Health, as an organization, takes the matter seriously

New York State follows the example of the CDC and its reporting is at least a week behind at any given time. In the week ending November 7 2009, flu activity continued to explode in upstate New York.

New York State is reporting the level of this pandemic in several ways. In labs statewide for the week ending November 7, over 4,000 specimens tested positive for the A flu virus, 99% of those testing positive for flu. At the state laboratory, 43 of 45 specimens tested positive for Swine Flu.

The state is also tracking visits to hospital emergency departments for influenza like illnesses (ILI). In the Western Region, including the cities of Buffalo, Rochester, Corning and Elmira, the rate was 19.8% of all emergency department visits. This was a 10% increase from the preceding week and a new peak for the year.

The Central New York Region, including the large military base at Fort Drum and the cities of Syracuse and Binghamton had a 19.1% ILI rate. That is an 8% increase from the preceding week and a new peak for the year.

The Capital Region is the area with the highest reported ILI visit rate in the state, 22.5%. That is a 15% percent increase from the previous week and nearly double the rate from two week prior.

The Hudson Valley Region and Long Island have much lower rates though the Hudson Valley is now just above a 10% rate. During the Spring wave of Swine Flu, this region reached a peak of 14% of visits to emergency departments for ILI.

Click for a larger image

The latest report from the New York State Department of Health on the influenza situation outside of New York City shows a dramatic increase in visits to hospital emergency rooms for flu like illnesses in Upstate New York. The October 24 report shows nearly a 50% increase in such visits from the October 17 report. The Hudson Valley and Long Island regions show a much smaller increase.

Here is the article

Here are some of the colleges and universities in Upstate New York, and the latest information they have on their websites about Swine Flu. It is good to see that several of them have received the H1N1 vaccine and are distributing it.

• University at Buffalo (UB):
  

  So far, UB officials are aware of only a small number of cases of influenza-like illnesses on campuses—probably instances of swine flu, Raab says. Still, some offices are taking such precautions as cross-training employees and receiving briefings from information technology specialists on how staff can work and access files on UB servers from home.

• The College at Brockport:
  

  The number of Brockport students with influenza-like illness (10 today) reflect the general trend of increasing flu activity on campus and in the community. Information on vaccine clinics will be available as soon as we receive the vaccine, which is expected in the near future. Symptom severity is unchanged; mild to moderate illness. There have been no known hospitalizations. There have been no particular patterns regarding students’ residences or academic majors. Students who have symptoms of fever, cough and/or sore throat are requested to call the Student Health Center at 585.395.2414 to talk with a nurse.

• Houghton College:
  

  H1N1 remains the prominent circulating influenza strain, and continues to be a significant issue on many campuses. During the week of Oct 3–9 nearly 6,000 new cases of influenza like illness (ILI)—presumed to be H1N1—with 8 hospitalizations, were reported by 259 colleges across the country (ACHA surveillance data). While we have had a handful (or two) of people who have had symptoms consistent with ILI, so far no one on campus (that we are aware of) has tested positive for influenza.

  The Allegany County Department of Health will be on campus this Wednesday, October 21, between 1:30 and 5 p.m. to administer the H1N1 vaccine to all interested students age 24 and under, and to anyone else who meets CDC priority criteria. I strongly encourage you all to take advantage of this opportunity.

• SUNY College at Geneseo:
  

  It is important that we keep an accurate count of our students with Influenza-Like-Illnesses, so please keep us informed!

  SUNY Geneseo has a dedicated team of professionals who have been working closely together for several years to establish an effective plan for handling a pandemic flu outbreak. This team has been monitoring the recommendations of the CDC, WHO, State, and local government health departments to stay current on updated information regarding the HINI virus.

  Although the H1N1 influenza outbreak has not proven to be as severe as expected, Geneseo will continue to take additional precautions to prevent the spread of the flu as much as possible.

• University of Rochester:
  

  The University recorded its first case of influenza-like illness among students this semester on Sept 8th. Three new cases was identified today. The total number of cases identified is now 62. Five students are confined to their rooms at present.

  There are no changes to University of Rochester operations or activities because of public concern worldwide about novel H1N1 influenza.

• Rochester Institute of Technology:
  

  The RIT Student Health Center reported it treated five students with an influenza-like illness between Oct. 12 and Oct. 19. It is difficult to distinguish between seasonal and H1N1 flu. The center has advised these students to recover in their rooms. Students who are ill must self-isolate until they feel well and have had no fever for 24 hours (with out fever-reducing medicine).

• St. John Fisher College
• Elmira College:
  

  At this time there are no students or employees with confirmed cases of H1N1. However, due to the increase in reported Influenza-Like Illness cases in Chemung County and no further testing being done for confirmation of H1N1Flu unless a person is hospitalized, EPIC is initiating the Flu Protocol at this time. The information in the link below provides specific guidelines concerning how Elmira College will respond to the H1N1 Flu on our Campus. Included is a list of expectations of students, parents and employees.

• Syracuse University
• Cornell University:
  

  The first, limited, shipment of H1N1 influenza vaccine arrived at Gannett Health Services late on Friday, Oct. 16. Following CDC guidelines for situations in which vaccine supplies are limited, these initial doses will be targeted to STUDENTS at greatest risk of complications from the flu, including: those with underlying health conditions, those who are pregnant, and/or those who care for infants under 6 months old.

  There is no doubt that your vigilance and thoughtfulness are making a difference in reducing spread of the virus in our community. The number of students with H1N1 influenza has dropped dramatically since the early weeks of the semester. At Gannett, we have been diagnosing 5 to 10 students per day for the past couple of weeks (as compared to 50 to 100 during in early September). Levels of illness in the communities surrounding Cornell are also reported to be low.

Latest Upstate New York data

Local media nationwide have been reporting the cancellation of seasonal flu vaccine clinics as well as the limited availability of vaccine for the Swine Flu. The limited number of doses of vaccine for both types of influenza is due to several factors.

Dr. Ann Schuchat, the director of the National Center for Immunization and Respiratory Diseases, spoke to reporters on October 13. Several of the questions related to the short supply of seasonal influenza vaccine and the distribution of the Swine Flu vaccine. 77 million doses of seasonal vaccine have been distributed and nearly 10 million doses of Swine Flu vaccine were available for order.

For the rest of this article, please visit the Rochester Infectious Disease Examiner.

New York regions defined by NYS Dept of Health

Swine flu continues to spread in New York State. Data compiled by the NYS Department of Health suggests that this fall’s wave of pandemic flu will be larger and affect more people than the spring wave did.

The graph above illustrates the numbers for Flu-like Illness in NYS hospital emergency departments as percentage of total emergency department visits, by Region (3 month snapshot). FLI is the primary indicator being used in NYS, and all of the testing being done demonstrates that pandemic Swine Flu is the overwhelming influenza virus making people sick.

In New York City, the situation seems to be different at this point. After large numbers of Swine Flu cases this past spring, the indicators for the illness are well within normal expectations for this time of year.

For the rest of this article, please visit the Rochester Infectious Disease Examiner.

The military is always challenged by the medical needs of young men and women going through the stress of recruit training. There have been on-going outbreaks of Swine Flu, pandemic H1N1, in every service. This is the first known death.

A Soldier stationed at Fort Jackson, S.C., who died Sept. 10, possibly is the first H1N1-related death suffered by the U.S. armed forces, Army officials here said.

Army Spc. Christopher Hogg, 23, of Dayton, Fla., died of pneumonia, but autopsy reports released yesterday confirm his death was the result of complications caused by the H1N1 virus, better known as swine flu, said Karen Soule, a Fort Jackson spokeswoman.

Fort Jackson doesn’t yet offer the H1N1 vaccine, but officials there expect the first supply to arrive this month, she added.

Fort Jackson is taking the issue seriously, Soule said. The base is the largest Army training facility with more than 10,000 soldiers stationed there at any given time. An H1N1 epidemic there could compromise the Army’s ability to effectively produce soldiers to support fighting in Iraq and Afghanistan, she explained.

Hoggs was a basic training recruit in his fifth week of training when he was taken to the hospital Sept. 1 for a fever and respiratory issues. He was set to graduate Oct. 15.

DVIDS
Story by Staff Sgt. Michael J Carden

All military personnel will be vaccinated against the H1N1 flu virus, and the vaccine will be available to all military family members who want it, a Defense Department health affairs official said today.

The H1N1 vaccination program will begin in early October, said Army Lt. Col. (Dr.) Wayne Hachey, director of preventive medicine for Defense Department health affairs.

The vaccine, which has been licensed by the Food and Drug Administration, will be mandatory for uniformed personnel, the colonel said. “What we want to do is target those people who are at highest risk for transmission,” he said.

Health-care workers, deploying troops, those serving on ships and submarines, and new accessions are at the top of the list. “Any place where we take a lot of people, squash them all together and get them nice and close and put them under stressful conditions will get the vaccine first,” he said.

The department will use the usual seasonal flu vaccine distribution chain for the H1N1, Hachey said, noting that while the mass H1N1 vaccinations are new to the general population, the process for vaccinating against seasonal flu is old hat for the Defense Department. “We’ve been doing this for decades,” the colonel said. “The system is tried and true.”

The department initially will receive 1 million doses of the H1N1 vaccine, and another 1.7 million doses later in October.

Officials don’t know yet whether people will need one dose or two, Hachey said. “The assumption right now is that people will need two doses, 21 days apart,” he said. “That may change.”

FDA officials still are studying H1N1 and the vaccine, and the results should be known by the end of the month.

Seasonal flu vaccine already is available, and the Defense Department will begin giving those shots shortly, Hachey said. “That has been our message to immunizers: to try and get as many people as they can immunized against the seasonal flu early,” he said.

Guidelines for giving priority to family members will follow those for the general population, Hachey said. The Department of Health and Human Services is buying millions of doses of the vaccine.

“Installations are going to register with each state as an immunizer,” Hachey said. “They will tell how many people they care for. This includes dependents, retirees and so on.”

The Centers for Disease Control will place the order and will ship the vaccine where needed. Family members will have multiple opportunities to get the vaccine, whether at Defense Department medical facilities or off post, Hachey said.

The CDC has established target groups for those at greatest risk for transmitting or being affected by the H1N1. They include pregnant women, health-care workers, those younger than 25 or older than 65, and those with pre-existing health conditions.

Hachey said previous plans are serving the Defense Department well. “We have been preparing for pandemic flu because of its potential impact on the mission,” he said.

The symptoms of the H1N1 flu are almost the same as the seasonal flu: fever, sore throat, runny nose, nausea, muscle aches and feeling rundown. The 2009 H1N1 virus – formerly known as swine flu – is a pandemic virus, according to the World Health Organization. U.S. officials call the virus “troubling” and urge communities across the United States to take actions to mitigate the effects of it. The federal government is urging states and municipalities to begin preparing now for the fall flu season.

President Barack Obama addressed the H1N1 pandemic following a White House meeting today.

“As I said when we saw the first cases of this virus back in the spring, I don’t want anybody to be alarmed, but I do want everybody to be prepared,” he said. “We know that we usually get a second, larger wave of these flu viruses in the fall, and so response plans have been put in place across all levels of government.”

But government cannot do it all, and the American people have a responsibility to stop the spread of the disease, Obama said. “We need families and businesses to ensure that they have plans in place if a family member, a child or a co-worker contracts the flu and needs to stay home,” he said.

“And most importantly, we need everyone to get informed about individual risk factors, and we need everyone to take the common-sense steps that we know can make a difference,” the president said. “Stay home if you’re sick. Wash your hands frequently. Cover your sneezes with your sleeve, not your hands. And take all the necessary precautions to stay healthy. I know it sounds simple, but it’s important and it works.”

The H1N1 is a never-before-seen combination of human, swine and avian flu viruses, officials said. First detected in Mexico in February, it quickly spread around the world. According to July WHO statistics, there have been 94,512 H1N1 cases worldwide, and 429 people have died from it. In the United States, 33,902 contracted H1N1, and 170 have died.

DVIDS
Story by Jim Garamone

University of Alabama

University of Alabama officials say 54 cases of influenza were reported on the first day of school.

John Maxwell of the Student Health Center says most of the cases are likely the swine flu and says health officials believe the outbreak started with sorority rush last week.

Anderson University (S.C.)

Two students at Anderson University have tested positive for the H1N1 flu virus, the school confirmed Tuesday. H1N1 was formerly known as swine flu.

The positive tests came back Friday, according Barry Ray, the school’s director of marketing and communication. “They tested positive for the five-day flu, which is an 80 percent chance the illness is H1N1,” Ray said. Conclusive results won’t be back for a few more days, he said.

Carnegie Mellon University

Eighteen suspected cases of H1N1 influenza have prompted Carnegie Mellon University to take action to reduce exposures and prevent a full-fledged outbreak.

In a university e-mail yesterday, officials said 18 students have contacted Student Health Services about having flu-like illness.

Classes will continue.

Penn State University

Eight new cases of swine flu were confirmed at Carnegie Mellon University yesterday, bringing the total to 26 students with H1N1 influenza, and the number is expected to climb.

Penn State University also confirmed several cases, while other local universities reported no problems to date.

Mississippi State University has a great page on its site devoted to pandemic flu, Swine Flu, novel H1N1. It’s difficult to tell which name ought to be used, but the MSU folks are on top of their situation. As of Friday they report 136 cases on campus.

Mississippi is at the heart of a significant outbreak, with at least 508 cases in public schools. During the spring outbreak, Mississippi lagged the nation until late May and June. It looks like it may lead the nation, at least until the larger states open their schools. Mississippi’s schools were among the first in the nation to open for fall. It follows that Swine Flu will be more active there.

Mississippi – 150 cases reported in 19 districts as of August 11

Boyle county, Kentucky

Numerous absences because of flu-like illness prompted the Boyle County school district to cancel classes for the rest of this week at Junction City Elementary School, Superintendent Mike LaFavers said.

Health authorities are assuming that the cases are H1N1 swine flu.

Junction City Elementary has 353 students.

Grand Bay, Alabama

Sick children are being sent home left and right from one Mobile County Middle School. All of this coming on the heels of a confirmed case of Swine Flu. The school system is encouraging everyone, to safeguard yourself by washing your hands. Parents are also asked to keep sick students home.

Camden county, Georgia

Several students at Camden County Middle School were sent home today, because of flu-like symptoms.

School nurses say students were experiencing fevers (100 degrees or higher), lethargy, lack of appetite and coughing. Other symptoms of influenza including the swine virus can also include runny nose, sore throat, nausea, vomiting and diarrhea.

Marshall county, Kentucky

It did not take long for one Heartland school district to come face to face with H1N1 also known as the Swine Flu. Just days into a new school year, the Marshall County School District has two confirmed cases of the flu.

The school district received word from the Marshall County Health department Friday afternoon. While the Marshall County Superintendent says he expected to see the illness at some point this school year. He says they did not expect to see students getting sick already.

Much more at the link.

The costs of pupil absenteeism nationwide will vary by district. As of 2007, there are over 13,800 school districts in the United States and 275 that have 25,000 or more pupils like the Rochester City School District. Those districts account for 16.5 million students. With an average of 3 days lost, and a Swine Flu infection rate of 25-33%, these schools will lose 12.4 to 16.3 million pupil days. That may mean lost revenues to those districts alone in excess of a half billion dollars or more.

Examiner

The news is beginning to report scattered cases of swine flu, pandemic flu, novel H1N1 in various states where schools have opened for the fall.

Granite Bay High School, Granite Bay, California – 8 cases

As of Tuesday, August 11, it has been confirmed that seven Granite Bay High School students have contracted the H1N1 strain of flu (also known as the Swine flu). In addition we are aware of about a dozen students who have been kept home or have been sent home due to feeling ill with flu-like symptoms. It is important to note that we have students who have the flu that has been confirmed to NOT be the H1N1 strain.

After eight of their classmates came down with confirmed cases of the H1N1 virus, students at Granite Bay High were taking swine-flu fears in stride this week – but with plenty of precaution mixed in for good measure.

“I have like, 12 of those little hand wipes in my backpack,” said Kevin Ranger, a junior.

All of the affected Granite Bay students had mild cases and were expected to make a full recovery, said Steve Williams, the district’s pupil personnel director. One other confirmed case was reported this week at Antelope High School, he said.

“Some of these kids have already begun to make their way back, but we’re keeping more or less a running tally,” Williams said.

It wasn’t clear whether the outbreak of the novel flu form was ramping up or on its way out. Officials say they think the first cases originated at a band camp before school started on Monday. It’s since spread to students who weren’t among the 130 at the event.

About 39 other students at Granite Bay were at home with flu-like symptoms on Thursday, including a fever, cough and sore throat, officials said, but they cautioned those were not confirmed cases of H1N1. The school was communicating with families through phone calls, letters and its Web site, at www.granitebayhigh.org.

Roseville Press Tribune

Hilsman Middle School, Athens, Georgia – 1 case

A Hilsman Middle School student was diagnosed with H1N1 swine flu over the weekend – the first reported case of swine flu among Athens public school students, a Clarke County School District spokeswoman said.

The student’s parents notified a teacher at the Eastside school Sunday, school district spokeswoman Anisa Sullivan Jimenez said Wednesday.

“The parents knew to follow protocol and not bring the child to school on Monday,” Jimenez said.

Athens Banner-Herald

Lee County, Mississippi – unk number of cases

Asheville, NC – 1 to 3 cases, plus cases in local college

Meanwhile, two students at Roberson High School were diagnosed with H1N1 following a soccer camp late last month.

A football player at Erwin High School also was suspected to have swine flu Monday, though the case was not confirmed as of Tuesday, Buncombe County schools spokeswoman Jan Blunt said. Letters were sent home to parents about swine flu showing up in student athletes, including tips for safe hygiene.

Rates and numbers of cases of pandemic influenza in the United States are lower than they were when schools were open in the spring. Public Health officials expect that to change as schools reopen for the fall.

The average incubation period from exposure to symptoms for this swine flu is 2-3 days, though it may be as long as 10 days. If the infection rates remain the same, schools will begin seeing clusters of pandemic flu nine to sixteen days after they open.

Through today, most of the schools in six states have reopened for a new school year. You can locate your state at this link. The various states are assessing the CDC’s recommendations about handling the H1N1 or Swine Flu pandemic in schools and some have begun to take action. The state websites are linked to the state names. News media reports on the subject follow.

1. Arizona: KVOA reports that schools are prepared in the Pima County area. Schools are setting up areas where sick children or adults who come to school can be isolated from the general population. Coughing or sneezing into the crook of your arm is going to be taught in the schools.
2. Hawaii: KHNL 8 reports on a school that suffered a cluster of pandemic flu cases last spring. KHON 2 talks about Hawaii’s Stop Flu in School Program.
3. Alabama: The Gadsden Times reports that school officials will be “fighting flu with common sense”. The Times Daily in northern Alabama says that local health officials and schools will base their initial pandemic fight on educating the public.
4. Georgia: Fox 5 Atlanta reports that health officials and school administrators are concentrating on convincing parents to keep their children home if they are ill. Good hygiene habits, such as handwashing, are going to be stressed in schools.
5. Tennessee: The Tennessean reveals that officials plan on keeping schools open, per the CDC recommendations. Last spring there were some school closings related to the pandemic flu.
6. Louisiana: The Daily Comet quotes health officials in Louisiana as stressing the importance of good hygiene habits.

A microscopic photo of the pandemic H1N1 virus

Of note in the latest Department of Defense report on novel H1N1 or swine flu are these statements:

• Fort Bliss (Texas) and Fort Sam Houston (Texas) and Tripler Army Medical Center (Hawaii) continue to report increases in pH1N1cases
• Isolated cluster of hospital-acquired pH1N1 observed among healthcare workers at Landstuhl Regional Medical Center
• Marines and Navy personnel in Okinawa, Guam and Hawaii are seeing increases in clinically mild influenza activity in active duty service members returning from joint military exercises in the Southern Hemisphere.
• Febrile respiratory illness (FRI) rates in recruits at MCRD-SD and Parris Island are substantially elevated.
• States experiencing noticeably higher ILI visit counts include South Carolina (Fort Jackson, Parris Island), New Jersey (Cape May) and California (NMCSD, MCRD-SD, Camp Pendleton)

The Landstuhl report is significant because of the phrase hospital-acquired. It suggests that universal precautions are not being used effectively. We saw failures of similar nature in the SARS epidemic, and those in the Canadian healthcare system were especially deadly.

Hawaii has just opened its schools for the fall. As our only tropical state, the pandemic never reduced in severity as we saw it do in northern states. The potential for clusters in school settings is high and should be evident by August 14 or so. One concern is the nature of the infections arriving from the Southern Hemisphere. Any genetic variance could alter the expected virulence of the pandemic in the islands.