I have been writing articles lately about the reasons for the H1N1 vaccine shortage and what to do about it. You can find these pieces in Forbes.com, Slate, and most recently as an oped in Wednesday’s NY Daily News. I believe that fear has played a major role in governing our public health response to H1N1 swine flu and the pressing need for a plentiful pandemic vaccine. I realize that it is easy to bludgeon our officials with the retrospectoscope, on the other hand, many of these nervous responses are chronic, and require significant adjustment going forward:

• Vaccine fear mongers do significant harm. Fear of thimerosal (a mercury-containing preservative that is used to bundle doses and has been shown not to cause autism) led to too much time spent trying to produce single vaccine doses without it.
• The CDC’s fear of overreacting to a possible pandemic, as they did in 1976 when 40 million people were vaccinated unnecessarily for a pandemic that never came, led to too much caution here, where instead a shift in vaccine production to the H1N1 vaccine could have led to many more million doses available now.
• Fear of seasonal flu, which doesn’t peak until much later, if at all (maybe crowded out by the H1N1 pandemic strain), led to 115 million doses of seasonal flu vaccine produced, when there is no seasonal flu around.
• Fear of new vaccines in the U.S. has led the FDA to fail to approve several new vaccines which use more up to date technologies such as mammalian cell culture instead of hen eggs, or additives known as adjuvants which make vaccines more potent so a smaller supply can be used for more inoculations. One American company, Baxter, makes a mammalian cell vaccine that will be used extensively in Europe, especially for those with egg allergies, but is not approved for use here.
• Fear of vaccines has led to poor compliance, especially for children, the group that currently seems to be most at risk for complications of the disease.
• Fear of admitting error has led our public health officials to delay in acknowledging the shortage or in correcting it, delay in accepting that it is H1N1 that is the predominant flu this year, not the seasonal strains.
• Fear of the spreading flu may be useful to combat fear of the vaccine, but a better approach would be a rational discourse based on statistics and real risk.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

There has been a lot of push back when it comes to the H1N1 flu vaccine. Of course, as with any medication, there could be side effects because not all immune systems are created equal.

But what people have to remember is their reasons for not supporting the vaccine – mainly because of the fear that it was rushed and long-term side effects are not yet known – are some of the same reasons preliminary reports of possible side effects could also be coincidental. For example, if someone has a heart attack after receiving their H1N1 flu shot, are they going to assume it’s directly related to the vaccine or attribute it to unhealthy lifestyle decisions?

The Associated Press recently published an article on this topic that looked at how the government will be intensely tracking the side effects of this vaccine and separating legitimate medical concerns from inevitable coincidences.

This is a proactive plan. The government is going to be putting information together for the public in an effort to stop the spread of false rumors and try to put the public at ease.

One major focus will be miscarriage since they are encouraging pregnant women to get the vaccine and miscarriages are quite common anyway.

Like the seasonal influenza vaccine, medical professionals expect the side effects associated with the H1N1 flu vaccine should be minimal. The most common side effect with all flu vaccines is soreness at the injection site, and sometimes people feel achy.

Many Americans are concerned about the safety and efficacy of the newly developed H1N1 flu shot because of a similar vaccine that was linked to a swine flu-like outbreak at Fort Dix in 1976.

Guillain-Barre occurs naturally following upper respiratory illnesses, digestive illnesses and on rare occasions – is associated with drugs and vaccines. However, the frequency is still 1-2 per 100,000 people.

I’ll be keeping a close eye on this, and if anything is reported, I’ll be the first one to let you know.

Here is the latest about the novel A(H1N1) swine flu pandemic virus, and what we are doing about it. Also check out my new Ebook: “Swine Flu; the New Pandemic.”

The best way to decrease the amount of circulating AH1N1 flu virus is to vaccinate as many people as possible. This is known as herd immunity.

The current H1N1 though mild, has infected millions and hospitalized more than 10,000 here in the U.S., killing close to 1000, so mass vaccination is warranted.

Unfortunately, once the vaccination program starts, it will be TOO easy to blame ANY deaths on the vaccine. This happened in Great Britain with the HPV Vaccine, where Cervarix is expected to cut deaths from cervical cancer by 650 and 1.4 million women have already been vaccinated, the vast majority with no problems. Yet a single death which was later found to be unrelated to the vaccine caused hysteria.

Though the 1976 swine flu vaccine was linked to several hundred cases of Guillain Barre Syndrome (paralysis) for a pandemic that never happened, this time there is a real pandemic, and the vaccine has been well studied in clinical trials and found to be very safe and has not been linked to GBS.

This vaccine is made the same as the yearly flu vaccine, with hen eggs, and will be just as safe, with the major complication in the vast majority of cases being local irritation around the injection site.

In discussions with senior officials at the CDC I have determined that it is acceptable to give both the seasonal flu shot and the H1N1 swine flu shot at the same time.

The CDC also recommends H1N1 vaccines even for those who believe they have had the disease. Serological tests to confirm immunity are considered unreliable and are not readily available.

The flu mist inhaled vaccine is being released this week. Since it is using an attenuated (weakened) live virus, it should not be given to pregnant women, those with chronic conditions, or those who are immunocompromised. It has also not been tested in the elderly.

The injectable inactived H1N1swine flu vaccine will start becoming available in two to three weeks. It uses an inactivated (dead) virus, and can NOT give you the flu. It is safe in all except for those with severe egg allergies. It should be given first to health care workers, pregnant women, children, and those with chronic conditions. 250 million doses should be available by sometime in November, and I will be recommending it for all.

Swine flu parties are a bad idea. They are an example of deliberate infection to provoke immunization. Since flu is so easily transmissable, it can easily get beyond the party and spread to someone who is more likely to have a severe outcome, such as a pregnant woman, a young child, or someone with a chronic condition.

The risk of the flu is far greater at this point than the risk of the vaccine. It is still a very mild virus, but must be taken seriously, as flu is tricky, and can kill. Coming out of the southern hemisphere, whose winter just ended, the prevailing strain of H1N1 swine flu is a good match for the vaccine.

For daily updates on the H1N1 swine flu strain, twitter me at marcsiegelmd.  I will post my latest articles, updates, and answer questions.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

If you are a child:

• Children have not shown any immunity to this new strain of flu.
• Kids are super spreaders of flu, with schools being petri dishes for spread.
• Children should wash hands frequently for at least 30 seconds with soap and water, use hand sanitizers, and sneeze or cough into their sleeve.
• Children who have fatigue, fever, sore throat, nausea, or muscle aches, should STAY HOME and the family pediatrician should be consulted.
• Rapid flu tests are about 60% sensitive for H1N1 swine flu, and a presumptive diagnosis can be made by a child’s doctor, based on symptoms.
• Kids with the flu should stay home for at least two days after symptoms resolve.
• The H1N1 swine flu vaccine will be available beginning in late October. ALL children should take it, especially those with chronic illnesses. It will likely be offered in schools. It is not clear yet whether children will require one or two shots.
• The use of Tamiflu (anti-viral) in children is somewhat controversial; recent studies from the UK appear to show that it isn’t well tolerated or effective, though previous studies have shown that it is safe, shortens the course of illness, and can also prevent spread (80-95%) if given to close contacts. This was the experience of several summer camps in Maine this summer, where Tamiflu was also well tolerated.
• Secondary bacterial infections are common, and should be treated promptly with antibiotics.

If you are an adult:

• Especially at risk are adults with chronic illnesses such as COPD, Crohns Disease, Rheumatoid Arthritis, HIV, cancer, etc. These patients should be especially careful, take Tamiflu early for flu symptoms, be on the lookout for secondary infections including bronchitis, pneumonia, sinus and ear infections.
• The H1N1 vaccine should be given to these groups as soon as available, as well as pregnant women (currently in clinical trials), health care workers, and close contacts of those with chronic conditions.
• New studies just published in the New England Journal of Medicine show that the new vaccine works in 7-10 days, is well tolerated, and provides immunity with a single dose.
• Elderly patients appear to have partial immunity to this H1N1 swine flu strain, if born before 1957, probably because of exposure to a related virus when they were younger, but should still be considered for this vaccine, especially if they have chronic medical conditions.
• Those who had H1N1 swine flu in the Spring or Summer are likely immune. There may be a blood test available to test this.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

I’ve been getting many e-mails over the past couple of days concerning swine flu.  So I’ve decided to answer a few of them here.

Dear Dr. Manny,
If I had the swine flu in 1976 after I received the swine flu vaccine as a college student, do I have any anti-bodies that may help ward off this version of the virus?
                  —Amy Gorman
                  Lutherville, MD

Probably not. This current swine flu’s genetic makeup is different from the swine flu from the ‘70s, and therefore the vaccination won’t be protective for you. But the silver lining is that this current swine flu is less lethal, and there may components in it that more Americans have been exposed to. So you may have a greater chance of being protected already which can minimize the symptoms.    

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Dear Dr. Manny,
We have friends who have returned from a trip to Mexico City two weeks ago. How long would it take for swine flu symptoms to show up if they were infected?
Thank you for your time,
—Alan

The typical incubation time for a virus is 48-72 hours.  So if your friends have been back for two weeks, and don’t have any symptoms, you can feel confident that they are safe. 

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Dr. Manny,
My wife and I are very concerned of the complications swine flu/treatment would pose to her pregnancy. Are the approved drugs for treatment approved for use during pregnancy?
Thanks,
Ben Demaline
Jacksonville, FL

Yes, all of the current flu treatments can be given to pregnant women. As a matter of fact, we tend to be more aggressive in treating the flu in expectant mothers because pregnancy can make flu symptoms worse and put the patient at higher risk. That’s why it’s recommended that all pregnant women get flu shots annually.

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Dr. Manny,
I will be flying to Las Vegas next week with a two-hour layover in Atlanta. I had a liver transplant five years ago and have done really well. Do you think that I should wear a mask at the airport and on the plane? I am very concerned about the large crowds and would like your opinion.
Thank you for any answer!
G. Savage

As a liver transplant recipient you are probably taking immunosuppressant therapy drugs and therefore you do have to take precautions to avoid exposure to the swine flu ― or any kind of flu. Even though I’m not a big advocate of wearing masks, I do feel that you should wear one. But remember: Not all facial masks are created equal, so get one that has been proven to protect against viruses. There are many supply stores that carry this specific mask for viruses. Also, try to wipe down all the surfaces on your airplane seat with antibacterial wipes. Be sure to wash your hands before, during and after the trip. And avoid any contact with anyone who you suspect might be sick. I know that this is a big stretch, but until we know exactly the extent of the spread, in your particular case, I would be extra cautious. I hope that this doesn’t ruin your vacation! 

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Dr. Manny,
I have no choice but to commute using public transportation everyday.  How should I take precautions against the swine flu?
                  Thanks,
                  —Paul

If you can avoid public transportation, especially crowded subway cars, then do it.  But if you can’t here’s what you can do:

• If you are a healthy individual you can just use antibacterial products, including wipes and gels, chronically throughout your trip.
• Avoid contact with people who are coughing or appear sick.  If they are in your car, move to another one. 
• As soon as you get home or to the office wash your hands, wipe down your cell phone, iPod or any device that you used during your trip. 

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Dear Dr. Manny,
I’m a chronic nail biter and I’m really concerned about the swine flu.  What should I do?
Best,
                  —Mel

First and foremost — wash your hands. Your hands are the most common tool for picking up germs and viruses in general. So if you are a nail biter, this would be the perfect incentive for you to quit. Also, biting your nails can make you ingest things other than viruses that you don’t want to have in your body.

I have long been concerned about potential overuse of the anti-flu drug Tamiflu, in fact there are sections on this topic in both my book on fear and my book on flu. But in my opinion, the current situation with H1N1 swine flu calls for the careful use of Tamiflu at large camp outbreaks. Use of the drug is warranted to help decrease shedding time in patients with mild cases and to prevent additional cases in their close contacts.

The CDC does not agree with me.

Here are the plusses:

1 – Since Tamiflu is highly successful at slowing spread, its use to squash outbreaks can help keep camps open which has the added benefit of keeping sick kids from bringing flu home to many different zip codes and thereby expanding the outbreak. People who are more at risk (including pregnant women, infants, and those with chronic conditions) may catch it that way. Even though this is a mild virus so far, with millions of cases around the world and only 700 plus deaths, there is always the chance that it will get worse; in fact a recent study shows that it lingers in the lungs of Ferrets (who react to flu like humans), causing lung infections.

2 – More circulating virus may increase the chance of a lethal mutation. The famous second mutation that may have occurred in 1918, when the virus became much more severe in time for the fall flu season, is extremely unlikely, but possible.

3 – Children seem more at risk for severe cases, perhaps because of a lack of immunity to an older H1N1 virus that was circulating before 1957. Older patients who have that immunity may have milder cases.

4 – Isolation of sick people and their contacts is the first priority, but use of Tamiflu (especially when there is no vaccine available), is a useful adjunct which may help to keep the camp open.
Here are the minuses:

1 – Use of Tamiflu may increase the chance of resistance occurring. There are some excellent articles on recent Tamiflu resistance, which also demonstrate that resistance sometimes occurs spontaneously, without exposure to flu:

H1N1 swine flu – the non-sustained Danish and Japanese resistance cases were in patients taking Tamiflu prophylactically. (see New Scientist article)

The interesting case in early July of a girl from San Francisco who picked up Tamiflu resistance in Hong Kong but NEVER took Tamiflu. (see NY Times article)

And the spontaneously generated resistance to seasonal H1N1 (NOT SWINE FLU) in last year’s flu season which led to massive resistance to that strain. (See NY Times article)

2 – Tamiflu shortages could emerge (although the CDC has stockpiled 50 million dose courses, and it is difficult to envision a scenario where there is a shortage of this magnitude, especially with a vaccine in the offing.

3 – Potential side effects of Tamiflu, including nausea, or an allergic reaction. But side effects are rare, Tamiflu is a very well tolerated drug overall.

4 – By having the flu now, when it is mild, a person should be immune later on, during flu season, when the flu could return in a more severe form.

I must admit, some of what drove me to put my own 12 year old son on Tamiflu prophylaxis at Camp Modin where there were more than 80 cases was because I have a 4 year old son at home with asthma and chronic ear infections. I was worried about my older son bringing the flu home. But my own scenario was far from unique, which is why I recommended that all of Camp Modin take Tamiflu.

My article on the Modin Protocol I created was published in Slate on July 10th. (see Slate article)

This was followed by a front page article by Tamar Lewin this past Thursday July 23d in the NY Times which described the problem – and solution – at the camp. (see NY Times article)

The following day, Dr. Anne Schuchat, director of the National Center on Immunization and Respiratory Diseases at the CDC, reacted to the Times article by disagreeing with camps using Tamiflu to control outbreaks. She said she “strongly recommended” giving the drug only to people already seriously ill, or to their family members who are pregnant, have asthma or have other conditions that could be life-threatening if they caught the flu.

Finally, on Saturday, July 25th, Donald McNeil wrote an excellent balanced article in the Times describing Camp Modin’s use of Tamiflu, the rationale for my advice compared to the reasons for the CDC’s disagreement. (See NY Times article)

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

There’s no doubt that this H1N1 flu, also known as swine flu, has been a real doozy. With more than 1 million people infected in the U.S. alone and approximately 263 deaths, attention must be paid to a potentially worsening condition.

I typically don’t like to scare people into paying attention to health care issues, but I do think that as soon as a vaccine becomes available here in the U.S. for the H1N1 virus, you should get it.

I recently learned of two alarming cases where pregnant women became affected with the H1N1 virus. Any type of flu can be quite devastating for a pregnant patient. The reason for the significant effect in pregnancy is that pregnant women typically have suppressed immune systems and their pulmonary compliance is significantly altered due to the pressure from the pregnant uterus. So when they get the flu, it could very quickly turn into a deadly pneumonia with very high degrees of complication for both the mother and the unborn child.

That was just the case with these two recent reports — one from Australia where a mother fell ill from the swine flu and ultimately the baby died in utero, and in the other case, a woman in Florida had to deliver at 27 weeks of gestation due to the flu, and the infant ultimately died from complications associated with his prematurity.

So the message is loud and clear: This new virus is very contagious. We don’t have natural immunity, and if you have any risk factors — especially if you’re pregnant — get the vaccine as soon as it is available.

Click here to read the full story.

 I don’t want to be picky, but I have to admit that as a fear expert I was more affected by President Obama’s statement a few weeks ago in response to the emerging swine flu threat that we should all wash our hands, then I was to Vice President Biden’s blatant misstatement about not flying on planes. Let me explain: clearly, we carry many bacteria and viruses on our hands, and in fact most of our stomach viruses as well as cold viruses are passed back and forth this way. It is hard to fault anyone for recommending hand washing, but consider that Obama’s statement carried the subliminal message that we might be carrying this virus, despite the fact that the statistical chances of that then and now remain extremely low.

The president followed that up by asking Congress for $1.5 billion to prepare us for this flu, an amount that seems totally reasonable until you consider what other health care needs it might be taken away from. Stockpiles of the anti-flu drug Tamiflu will have to be discarded if they aren’t used in 5 years, and we still have no idea what the extent of spread or severity of this swine flu virus will be. Preparing a vaccine seems wise, taking needed resources away from current pandemics like TB, HIV, or even the yearly flu does not.   It is paramount that at a time when our government is considering expanding the system for health coverage, that issues of allocation and proper use of resources be at the top of the list.

The Centers for Disease Control and Prevention has been front and center during the initial stages of the swine flu outbreak, and they have been very effective at identifying and tracking the virus, somewhat less effective at explaining it in context during press conferences (this may have something to do with the nature of the beast – press conferences themselves immediately become amplified).

I have more of a bone to pick with the World Health Organization in terms of their poor conveyance of contextual information. The WHO all too often seems like “fright night” though they too have been tremendous when it comes to “boots on the ground.”

Check out my article in today’s Slate magazine about how the WHO has dealt with swine flu.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

As we watch swine flu through the rear view mirror, and our concerns begin to fade, it is easier to see it in a more proper context. I tried to do just that in my oped in USA Today.

Even as we turn our attention to the southern hemisphere, and watch via the World Health Organization FluNet tracking system for the extent of the virus over the winter, I can’t help but comment on the WHO handling of the Pandemic Alert System as it applies to the swine flu outbreak.

The problem is that the current alert system was put in place in 2005 in reaction to the Avian Flu scare. Of course a tracking system in response to a scare has a built in tendency for overreaction. I don’t have a problem with the notion that level 5 involves sustained transmission of a new flu strain from person to person in 2 countries in the same region. Nor do I have a problem with the idea that a full pandemic (a scare term which is too vague to be descriptive) involves a sustained outbreak in different regions of the world. What I do have a problem with is the lack of statistics —number of cases and number of deaths don’t factor in. So it is possible to have a pandemic with only a few thousand cases. Where would the Bubonic Plague or the Spanish Flu, diseases which killed many millions of people, fit on a pandemic alert scale where a relatively small outbreak of Swine Flu is already listed near the worst possible ranking?

Not only that, but these pandemic alerts are used by the U.S. and other countries as a justification to divert needed health resources from other essential medical problems to the fear of pandemics. Sometimes that is justified, but often it isn’t. Keep in mind that Tamiflu and vaccines (which are stockpiled and then mobilized in anticipation of a pandemic), are perishable. We have already discarded hundreds of thousands of doses of unused smallpox and anthrax vaccines. How much excess expensive Tamiflu will we also discard when it expires?

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

As cases of swine flu are reported each day, the realization that your community could be affected begins to set in. While government officials make it clear there is no need for panic, it does not hurt to err on the side of caution and consider the possible repercussions of this illness hitting home. The solutions for dealing with school-based clusters of swine flu seem simple: Close the school for proper cleaning, make sure ill students are evaluated and treated, then, re-open the school.

Approximately 400 schools in the United States have closed due to outbreaks in their districts. As every parent and educator knows, any time spent away from the classroom is time lost. In the spirit of being prepared, here are some tips for continuing your child’s education at home should schools in your community close for any length of time.

• Keep a consistent schedule for your child. Have him wake up as if it were a typical school day and structure the day with a variety of activities. Have work sessions before and after lunch. Make sure bedtime remains consistent as well. Keeping a routine will make sliding back into a normal school week much easier.
• Read every day. Your child can read aloud to you or a sibling or she can read silently. Students who are not reading independently can have books read to them by family members. Students in grades K-3 should read for 20 minutes each day, students in grades 4-8 should read for 30 minutes, and high school students should read for 30-45 minutes. Consider other opportunities for reading, such as reading the local newspaper and having a family discussion on local and national events.
• Utilize the same online worksheet generators teacher use! Finding age-appropriate worksheets is only a click away. Type the content area keywords, such as third grade fractions worksheets, into any search engine and choose worksheets from the many options that pop up. Be aware that many websites are free, but some charge a small fee. There are plenty that are available free of charge so there is no need for you to spend your money on a service that could potentially only be needed for a few days.
• For a science activity, make a chart to monitor the weather each day. Your child can watch the news or search on-line to get the local forecast. Record daily temperature, humidity, precipitation, and pollen count. Your child can print out pictures of rain, sun, and clouds and glue them to each day’s report.
• Bring gym class to your backyard. Play a game of basketball, walk around the block or have family relay races. If you’re stuck with a rainy day, pop in a workout DVD. Make exercising a family affair and you could develop a new healthy habit!

Remember to speak to your child about proper hygiene. Health experts suggest covering your nose and mouth with a tissue when you sneeze or cough, washing your hands and using alcohol-based hand sanitizers. These are all good habits to continue regardless of the type of illness spreading around.

Talk to your children about the realities of the flu. Most people, if treated timely and appropriately, recover with no complications. Setting the tone for a calm reaction to a potentially scary situation will help your child understand how the swine flu is affecting people all over the world.

Many school administrators are being proactive in sending letters home and posting information on their Web sites. Since the school nurse and principal are likely inundated with questions and concerns, take an informal poll of the parents in your child’s class and submit a list of questions from the class. Acting as a spokesperson will help continue the flow of information between state officials, schools and parents.

Whether or not swine flu affects your community, consider this an opportunity to be prepared!

Jennifer Cerbasi teaches at a public school for children on the autism spectrum in New Jersey. As a coordinator of Applied Behavioral Analysis programs in the home, she works with parents to create and implement behavioral plans for their children in an environment that fosters both academic and social growth. In addition to her work both in the classroom and at home, she is also a member of the National Association of Special Education Teachers and the Association for Supervision and Curriculum Development.