Swine Flu Updates and Issues - page 5
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May 27, '09Two More Deaths in NYC
More cases in one place will most likely result in more flu deaths. Of course, they are said to have prior existing conditions. Hopefully, those conditions will be revealed so that we can agree or disagree that those conditions could have contributed to their deaths.
Quote from www.nydailynews.com
Two more New Yorkers infected with swine flu have died, but both had other health problems and it's not clear if the virus killed them, officials said Tuesday.
The announcement, which came as students returned to two dozen public and private schools and five more closed over flu fears, brings the potential death toll in the city to four.
Both victims - a 42-year-old woman from Queens and a 34-year-old man from Brooklyn - died May 22. Autopsies will determine whether the H1N1 virus was the cause, Health Commissioner Thomas Frieden said.
"Until the medical examiner's report comes out, we won't know what else was going on," Frieden said. "It is possible or likely that it [H1N1] may have contributed."
The latest two victims, whose names were not released, also had health problems that made them more vulnerable, Frieden said.
The commissioner said neither victim worked in the school system, as far as he knew. He said neither was "medically attended" before death, meaning they either died at home or couldn't be resuscitated when help arrived.
Preliminary school attendance records showed that 83.26% of the school's 1,550 students showed up at IS 238 Tuesday, compared with about 92% typically.
Nine more city schools will reopen today, and nine others will remain closed, including the newly shuttered Public School 811 in Queens, a school for disabled children.
City Councilman Tony Avella (D-Queens) and parents at PS 31 in Bayside called for their school to be closed for cleaning, citing a high absentee rate. But it wasn't one of the five schools - one in Queens, one in Manhattan, two in Brooklyn and one in the Bronx - that will be closed today...
The Department of Education is seeking a waiver from the state so the school year doesn't have to be extended past June 26 for closed schools. The city could lose some funding if schools don't hold classes for 180 days.
The city has confirmed 330 cases of H1N1, with 131 requiring hospitalization. Frieden pointed out that the city typically has about 1,000 deaths from flu a year, but added that H1N1 appears to be more contagious.
May 27, '09This was copied from Newsweek's article about swine flu, last week:
"The jackpot events in influenza evolution occur when two different types of flu viruses happen to get into an animal cell at the same time, swapping entire chromosomes to create "reassorted" viruses."
That describes mutations of different species, into combinations of "reassorted viruses' that are more dangerous than the original ones....
May 27, '09This may be more information than you need or want, but for those of us who are fascinated/horrified with the possibilities entailed in the current round of flu, here's the whole picture as Newsweek reported it:
The Path of a Pandemic
How one virus spread from pigs and birds to humans around the globe. And why microbes like the H1N1 flu have become a growing threat.
From the magazine issue dated May 18, 2009
Around Thanksgiving 2005 a teenage boy helped his brother-in-law butcher 31 pigs at a local Wisconsin slaughterhouse, and a week later the 17-year-old pinned down another pig while it was gutted. In the lead-up to the holidays the boy's family bought a chicken and kept the animal in their home, out of the harsh Sheboygan autumn. On Dec. 7, the teenager came down with the flu, suffering an illness that lasted three days. He visited a local clinic, then fully recovered, and nobody else in his family took ill.
This incident would hardly seem worth mentioning except that the influenza virus that infected the Wisconsin lad was unlike any previously seen. It appeared to be a mosaic of a wild-bird form of flu, a human type and a strain found in pigs.
It was an H1N1 swine influenza. Largely ignored at the time, the Wisconsin virus was a step along the evolutionary tree, leading to a virus that four years later would stun the world.
Flash-forward to April 2009, and young Édgar Enrique Hernández in faraway La Gloria, Mexico, suffers a bout of flu, found to be caused by a similar mosaic of swine/bird/human flu, also H1N1. And thousands of miles away in Cairo, the Egyptian government decides pigs are the source of disease, and orders 300,000 animals in the predominantly Muslim (therefore not pork-consuming) society slaughtered.
Each of these three incidents is related to the unfolding influenza crisis. It is the manner of human beings to seek blame during times of fear. Fingers are now pointing, either at the entire pig species Sus domestica, or at the nation of Mexico. Such exercises in blame are not only scientifically ill founded, but are likely to prompt government actions that, at the very least, are useless and, at worst, harmful for efforts to control a pandemic.
We live in a globalized world, filled with shared microbial threats that arise in one place, are amplified somewhere else through human activities that aid and abet the germs, and then traverse vast geographic terrains in days, even hours—again, thanks to human activities and movements. If there is blame to be meted out, it should be directed at the species Homo sapiens and the manifest ways in which we are reshaping the world ecology, offering germs like the influenza virus extraordinary new opportunities to evolve, mutate and spread.
Back in 2005, the Wisconsin Division of Public Health hunted for sick pigs in Sheboygan County, but the animals the teenager had helped slaughter came from multiple farms across the area, and every farmer claimed his herd was healthy. The Wisconsin authorities forwarded blood samples from the infected teenager and his family to the Centers for Disease Control and Prevention in Atlanta. The CDC scientists discovered that the H1N1 virus had pieces of its RNA genetic material that matched a human flu first seen in New Caledonia in 1999, two swine types that had been circulating in Asia and Wisconsin for several years and an unknown avian-flu virus.
In 2006 the American Association of Swine Veterinarians reported that humans were passing their H1N1 viruses to pigs, causing widespread illness in swine herds, especially in the American Midwest. A year later at a county fair in Ohio an outbreak occurred, sickening many of the pigs, but not their human handlers. The cause was a type of H1N1 that was a close match to the Wisconsin strain, and may have been spread from human to pig.
Last year researchers from Iowa State University in Ames warned that pigs located in industrial-scale farms were being subjected to influenza infections from farm poultry, wild birds and their human handlers. Writing in The Journal of Infectious Diseases, Eileen Thacker and Bruce Janke said, "As a result of the constantly changing genetic makeup of individual influenza viruses in pigs, the U.S. swine industry is continually scrambling to respond to the influenza viruses circulating within individual production systems."
Something was changing. Pigs notoriously eat just about anything thrown their way, and rub up against each other frequently, readily passing infections within herds. Their stomachs are remarkably tolerant environs for microbes, which since ancient times have caused illness in humans who dined on raw or undercooked pork. Investigation of the 1918 influenza pandemic, which is now estimated to have killed up to 100 million people worldwide in 18 months, revealed that the viral culprit was a type H1N1 human flu that had infected pigs, and then circulated back to humans.
At the viral level, influenza is an awfully sloppy microbe that is in a constant state of mutation and evolution. Its genetic material is in the form of RNA (not DNA, as in humans), loosely collected into chromosomes. When a virus infects a cell, its chromosomes essentially fall apart into a mess, which is copied to make more viruses that then enter the bloodstream to spread throughout the body. Along the way in this copying process any other genetic material that may be lying about the cell is also stuffed into the thousands of viral copies that are made. If the virus happens to be reproducing this way inside a human cell, it picks up Homo sapiensgenetic material; from a chicken cell it absorbs avian genes; and from a pig cell it garners swine RNA. The jackpot events in influenza evolution occur when two different types of flu viruses happen to get into an animal cell at the same time, swapping entire chromosomes to create "reassorted" viruses.
What was infecting that teenager in Sheboygan was a triple reassortment, resulting in a new virus with bits of genes from three species of animals—one of them Homo sapiens.
But who pays attention to such things? Other than vets, pig farmers and the occasional virologist, not many people in public health, government or medicine usually give much thought to the four-legged viral mixing vessels that oink their way around family farms and vast industrial pork-production centers. Thacker and Janke's 2008 writing seems sadly prescient today: "Pigs would be an ideal mixing vessel for the creation of new avian/mammalian influenza viruses capable of causing novel diseases with the potential for producing pandemics in the human population … It is apparent that, in the U.S. swine industry, transmission of influenza viruses between swine and humans is fairly common and is bidirectional."
Nine months ago the Texas Department of State Health Services reported the case to the CDC of an individual who was exposed to ailing pigs. The Texan came down with flu, spread it to no one and was fine after a few days. In the patient's blood, CDC scientists found "a swine influenza A (H1N1) triple reassortant virus, A/Wisconsin/87/2005 H1N1," the same virus that infected the Sheboygan teenager three years earlier.
And then, this March, the outbreak of 2009 commenced. It might not have been noticed, frankly, if things unfolded in the same bird/human/swine manner as had previously evoked only humdrum attention in Wisconsin, Ohio and Texas. But this time, people died.
In mid-March the number of routinely reported influenza cases in several Mexican states suddenly spiked upward. At roughly the same time, public-health authorities in southern California spotted two separate cases of flu in children: a 10-year-old boy in San Diego County, and a 9-year-old girl in Imperial County. Though both children survived their illnesses, there was evidence that it had spread to family members, and samples of the children's blood were examined at the CDC in early April. Bingo: H1N1 triple-reassorted influenza. Meanwhile, in Mexico, more than 50 serious flu cases emerged over the same time period, and the government forwarded blood samples to Canada's top infectious-diseases lab in Winnipeg. The Canadians confirmed that the Mexican mystery virus was H1N1, and the potential pandemic saga unfolded.
In Mexico, attention has focused on little Édgar Enrique Hernández, who is believed to have come down with the new flu on April 2. The blame for Hernández's infection is aimed at an American-owned industrial pig center located near the child's home in La Gloria. Residents had long complained about the stench and dust from the plant, and have eagerly named it as the source of the child's infection. It may be true that Hernández inhaled H1N1 from a pig, but because other cases emerged in March, the timing of the case is off: Édgar Hernández is not Patient Zero in the outbreak of 2009.
This virus has been evolving for a long time, no doubt aided in its transformation by the ecology of industrial-scale pig farming in North America. Some scientists say there are genetic elements in the virus that date back to an Indiana pig farm in 1987. In that sense, it is similar to the "bird flu," or H5N1, which surfaced in wild migratory water birds in southern China some time in the early 1990s and infected people in Hong Kong in 1997. As that virus has evolved over the past 12 years, it has taken advantage of large poultry farms, and major bird-migration centers, to spread rapidly and absorb new genetic material along the way. In 2005, as H5N1 spread to Siberia and Europe, the United Nations and the Bush administration mobilized cash, scientific expertise and the needed infrastructure to find and contain outbreaks, primarily by slaughtering infected chicken flocks.
In Indonesia, where the virus has spread to pigs and humans, it appears H5N1 can be passed, in rare cases, between people, and human infection is an extraordinarily dangerous event: 82 percent of infected Indonesians have succumbed to the flu virus. The global average mortality rate for H5N1 in people is 63 percent, which makes it one of the most fearsome microbes on earth.
Here, then, is where we stand.
We have a new virus in the world that appears to be very contagious between people, and possibly between swine and humans. It is, fortunately, treatable with the antiviral drugs Tamiflu and Relenza (oseltamivir and zanamivir), but it is resistant to the other major class of anti-flu drugs, amantadines. It is still evolving, and moving, and its ultimate trajectory cannot be seen right now. We do not yet know how deadly this virus is: while Mexico has been able to track down the numbers of dead and hospitalized H1N1 cases, it cannot determine just how many Mexicans have been infected with the virus since it started spreading there in late March. It's one thing to say that 150 people out of, perhaps, 10 million infected have died: that gives you a case fatality rate that is roughly what we see with normal, seasonal flu. (Each year, seasonal flu kills 36,000 people in the United States alone.) It's quite another story if Mexico's denominator is 5,000, for a case fatality rate of 3 percent--a full percentage point worse than the rate seen with the 1918 influenza. It is urgent that we discern the denominator.
We have a second, closely related H1N1 human virus in circulation around the world. Though widespread, it is not unusually lethal. Last year this virus developed full resistance to Tamiflu. It would be most disturbing if the 2008 H1N1 human virus were to reassort with the new swine/human virus, as we could then be facing a more drug-resistant pandemic strain of influenza, treatable only with the drug Relenza, which must be administered with an inhaler device.
We have a third, older pandemic in poultry, occasionally infecting humans, that involves the H5N1 virus. This pandemic has circulated long enough so that the virus has branched into several evolutionary trees, including forms that are drug-resistant. In Egypt, where it is common for urban families to raise chickens in their yards, H5N1 has caused a significant number of human cases, and its spread appears to be uncontrolled. The World Health Organization (WHO) is distressed by evidence that H5N1 is becoming less deadly for people. That could mean that the bird-flu virus is evolving toward a less-lethal form that is more capable of spreading between people.
It is supremely ironic, then, that the Egyptian government in late April started slaughtering the nation's 300,000 pigs as an alleged flu-control measure. The swine form of H1N1 may not be in Egypt as of this writing, but the chicken H5N1 most definitely is, and has to date infected 68 Egyptians, killing 23. Egypt has never carried out wholesale slaughter of poultry, as chicken is a staple of the national diet. Pork, in contrast, is consumed only by the minority Christian population. An Egyptian Islamist group has declared that swine flu is "God's revenge against infidels."
The Muslim Brotherhood in Egypt recently declared that the Cairo-based U.S. Naval Medical Research Unit (NAMRU), which has provided public-health work for the entire Middle East for decades, must be shut down, and Egypt must stop sending samples of H5N1 viruses that emerge in the country to the WHO. The Egyptian group, which holds seats in Parliament, is echoing sentiments first put forward by Indonesia's minister of health, Siti Supari, who has refused to share her country's H5N1 samples with the WHO since 2006. Supari is also trying to evict another NAMRU lab from Jakarta. On April 28, Supari declared that the new swine flu was genetically engineered and released in order to promote American pharmaceutical sales worldwide.
Two days later, Supari denied making such statements, though they were con-sistent with her longstanding claim that rich countries--particularly the United States--prey on poorer nations in the interest of drug-company profits. In heated negotiations with the World Health Organization and the U.S. government, Supari has insisted on the existence of "viral sovereignty," wherein nations own any viruses that they discover within their boundaries, have the right to refuse sharing them with the WHO or any other foreign entity and may demand all profits derived from vaccines and other products made from those viruses. Under this principle, Indonesia refuses to allow the outside world access to at least 50 H5N1 strains thought to have emerged in that country since 2005. Without access to the various viral strains, scientists cannot tell if H5N1 is evolving dangerous attributes in Indonesia, or whether the hideously high death rate in infected people there is due to some unique viral characteristics. Therefore, the principle of viral sovereignty directly imperils the entire global community--as well as Supari's own people. On April 30, the WHO repudiated another Supari claim: that Indonesians have special genetic or environmental traits that would keep them safe from the new swine flu.
Happily, Mexico has shown the world how a responsible nation can respond to a potential pandemic. By moving swiftly to shut down schools, entertainment and places of social congregation, Mexico—an already beleaguered economy—is facing dire financial consequences. But its dramatic actions may be saving Mexican lives, and slowing down the outbreak of 2009. In that sense, the world owes Mexico a big gracias.
Governments the world over would do well to pay attention to Mexico's response, and learn from it. Throughout Asia, governments have been pulling their old SARS-epidemic thermal monitors out of mothballs, and scanning people for evidence of fevers. That worked for SARS control because the SARS virus was almost exclusively contagious when people were running fevers. Not so with influenza: flu can be very contagious before the individual carrier has any symptoms at all, much less a fever.
Worse, some governments are banning pork products from the Americas, as if it were possible to get the flu from eating a cooked sausage. It is not.
A wiser set of pig-related actions would turn to the strange ecology we have created to feed meat to our massive human population. It is a strange world wherein billions of animals are concentrated into tiny spaces, breeding stock is flown to production sites all over the world and poorly paid migrant workers are exposed to infected animals. And it's going to get much worse, as the world's once poor populations of India and China enter the middle class. Back in 1980 the per capita meat consumption in China was about 44 pounds a year: it now tops 110 pounds. In 1983 the world consumed 152 million tons of meat a year. By 1997 consumption was up to 233 million tons. And the United Nations Food and Agriculture Organization estimates that by 2020 world consumption could top 386 million tons of pork, chicken, beef and farmed fish.
This is the ecology that, in the cases of pigs and chickens, is breeding influenza. It is an ecology that promotes viral evolution. And if we don't do something about it, this ecology will one day spawn a severe pandemic that will dwarf that of 1918.
Garrett is the senior fellow for global health at the Council on Foreign Relations, and a Pulitzer Prize-winning writer. She is the author of "The Coming Plague: Newly Emerging Diseases in a World Out of Balance" and "Betrayal of Trust: The Collapse of Global Public Health."
© 2009Last edit by lamazeteacher on May 27, '09 : Reason: need for emphasis, emboldening key phrases
May 27, '09The Swine Flu Crisis:
The Government Is Preparing for the Worst While Hoping for the Best - It Needs to Tell the Public to Do the Same Thing!
I stongly suggest that you think about this bit of advice from a famous risk communicator, who is very familar with pandemic preparations.
Quote from psandman.com
...whatever the situation is like by the time you read this, that won't be the end of the story either. A mutated virus (more virulent or more transmissible or resistant to antivirals) could come roaring back a few months later.
The CDC's biggest failure: not doing nearly enough to help people visualize what a really bad pandemic might be like - while helping them also to hold in mind that it's only one of many possibilities - so they can feel the knot in their stomachs that everyone on the inside is feeling, get past this adjustment reaction, gird up their loins, and start preparing.
It is especially important to get this message to business and community leaders, who have prep work to do ASAP in case things get worse.
But individuals also have prep work to do - logistical as well as emotional prep work. All that preparing will stand us in good stead even if The Big One isn't right around the corner yet ... and it'll be essential if it is!
For the ordinary citizen, the U.S. government has so far recommended only hygiene, not preparedness. It has told people to stay home if they're sick, cover their coughs, and wash their hands a lot. It hasn't told people to stock up on food, water, prescription medicines, and other key supplies. Two years ago HHS Secretary Mike Leavitt was crisscrossing the country with that advice. These past few days Acting CDC Director Richard Besser kept evading questions from journalists about whether it's still good advice.
I don't fault Dr. Besser for looking and sounding reassuring. The gold standard in crisis communication is to say alarming things in a calm tone, and he is doing exactly that.
The problem is that he isn't giving us anything to do except practice good hygiene.
From the start of the swine flu crisis, I believe, there was a decision - probably a very high-level decision - to take the situation extremely seriously but to hold off on asking the public to do the same. The result is almost surreal. The federal government has already released one-quarter of the Strategic National Stockpile of antiviral drugs to the states, so there will be millions of courses of Tamiflu ready to deploy if there are millions of sick Americans requiring medication. But it hasn't yet asked those millions of Americans to stock up on tuna fish and peanut butter.
I have been here before. In 2005, the pandemic influenza threat came from an avian H5N1, instead of the current swine-avian-human hybrid H1N1. (Lest anyone forget, H5N1 is still around too.) The CDC and HHS were similarly convinced then that the risk was serious, similarly committed to aggressive preparatory action - that's why we have that Strategic National Stockpile of antivirals - and similarly disinclined to alarm the American people. The feeling was that people had been alarmed enough by 9/11 and the ensuing wars in Afghanistan and Iraq, and that the government had pretty much exhausted its quota of scary utterances. There is much the same feeling today about the economic meltdown.
I was in the minority then, as I am now, urging officials to involve the public in its pandemic preparedness efforts. In February 2005, I was invited to give a day-long seminar on my recommendations to a high-level conclave of CDC and HHS infectious disease experts and officials. They heard me out, sent me home, and reaffirmed their policy of quiet preparedness.
In order to avoid frightening the public, this past week, the U.S. government has avoided clueing in the public that we should all be preparing for a possible pandemic - not just the feds.
Why are officials so leery of describing the worst case vividly and urging people to prepare for that possibility? Here's why:
There is a virtual terror of frightening people excessively (as if that were easy). Although crisis management experts have known for decades that panic is rare, officials routinely go into "panic panic" - either predicting that the public will panic if told alarming things or misdiagnosing orderly efforts to prepare as panic. A Google News search this morning for "swine flu panic" netted over 8,000 hits. Some of them were urging people not to panic (unnecessary and condescending advice); a few were pointing out that people weren't in fact panicking, not even in Mexico City.
Officials who imagine that the public is panicking or may soon panic often feel impelled to make over-reassuring statements, to suppress alarming information, and to belittle those who are frightened as "irrational" or "hysterical" (or "panicky"). These official preemptive strikes leave frightened people alone with their fears, and persuade them that their government has betrayed them and cannot be trusted. The result is an increase in public anxiety, which officials cannot properly channel into effective action because they have already delegitimized the fear and because they are unwilling to involve the public. During the 2003 SARS outbreaks, for example, the Chinese government denied that Beijing was seeing SARS cases and SARS deaths. These false denials led to actual panic in Beijing. Why did the Chinese government hide the truth? To allay panic.
To its credit, the CDC has not made over-reassuring statements, suppressed alarming information, or belittled people's fears. For several days before the first U.S. swine flu death this morning, Dr. Besser continually predicted that there would soon be U.S. deaths. That's excellent risk communication. He's not understating how bad things are or how bad things could get. His failure (of skill? of nerve? of policy?) is subtler than that: He is creating the sense that the CDC will do whatever needs doing to protect us, and that we need do little or nothing to protect ourselves. I think this is intentional, aimed at avoiding what he or his superiors consider excessive public alarm.
Already the same officials that I am criticizing for under-warning the public are being accused by others of over-warning the public. And of course if the virus recedes and this pandemic never materializes, these critics will consider themselves vindicated ... as if the fact that your house didn't burn down this year proved the foolishness of last year's decision to buy fire insurance. It is dangerous nonsense to imagine that warnings are justified only if they are followed quickly enough by disasters. People who don't take precautions often escape injury. That makes them lucky, not wise.
The risk communication solution to this quandary is to issue warnings that are simultaneously scary and tentative. Public health officials need to learn how to say "This could get very bad, and it's time to prepare in case it does" and "This could fizzle out, and we'll probably feel a bit foolish if it does" - to say them both at the same time, in the same sound bite.
Of course we don't know anything yet about the relative probabilities of different swine flu outcomes. Flu experts say the way things look right now is the way a disastrous pandemic could look at this early stage - and it's also the way a false alarm could look at this early stage.
Warnings about swine flu are particularly difficult in another way as well: bad precedent. The problem is partly grounded in the 1976 swine flu fiasco, when the U.S. prematurely launched a vaccination program that caused more illness than that no-show pandemic did. But the bigger source of official hesitation, I suspect, is the 2005-2006 bird flu scare. Public health authorities then seemed to be implying that the bird flu virus was expected to mutate and launch a human pandemic by next Tuesday. But the virus remained (and so far remains) confined to countless millions of birds and a few hundred profoundly unlucky people.
(There are some key differences between the two pandemic threats, other than the fact that one is still theoretical and the other looks imminent. The H5N1 bird flu still hasn't learned how to spread easily from person to person, a skill the H1N1 swine flu has amply demonstrated already. On the other hand, H5N1 has killed over half the people it has infected, whereas the new H1N1 looks comparatively mild so far ... though not as mild as early U.S. reports implied. Another difference: In the U.S. and most of the developed world, we now have a sizable supply of antivirals that are known to work - so far - against the swine flu virus we're facing.)
It's a calming experience to prepare. As psychiatrists sometimes put it, "action binds anxiety." Having things you can do that seem likely to improve your situation gives people a sense of control; it builds self-efficacy, which leads to determination, calm, and even confidence. It's not that taking action makes people less fearful; rather, it makes people more able to bear their fear.
Those who have been working hard not to worry about the pandemic that might be looming will feel more in control after they have taken some concrete steps to get themselves and their family ready.
The other psychological effect of precaution-taking may matter less to the CDC right now, but it matters just as much to the country's prognosis if a pandemic happens. Some people - a lot of people, in fact - are not yet very worried about a possible swine flu pandemic....
When officials urge people to take precautions, that doesn't necessarily pierce the apathy - but it helps. Each time officials repeat the advice, more people take it. Some of them take it skeptically, but take it nonetheless.
As social psychologists know well, attitudes follow behavior far more reliably than they determine behavior.
In other words, we learn from what we do. If the CDC can get insufficiently concerned people to stockpile supplies against a possible pandemic, the mere act of doing so will make them more attentive to swine flu news and more concerned about pandemic preparedness.
So urging people to prepare is a twofer: it calms those whose concern is excessive and arouses those whose concern is insufficient. Not to mention the benefits of having the right stuff on hand if it becomes dangerous to go out in public, or if supply lines are disrupted and the stuff isn't available anymore.
Our thinking about pandemics has been conditioned by H5N1, the bird flu virus that has killed more than half the people it infected. We have become accustomed to assuming that any pandemic would be a catastrophic pandemic. 1918 genuinely was catastrophic, even though its case fatality rate was only 2-3 percent - lower than the apparent rate for H1N1 in Mexico so far (not to mention the appalling rate for H5N1). The other two twentieth century pandemics, 1957 and 1968, were mild, not catastrophic; for most non-professionals they were non-events. The Pandemic of 2009 could be just as mild.
Or it could be catastrophic. Or somewhere in the middle.
So the key question is what to say to the public when a pandemic may well be imminent, but may still fizzle or stay poised at the brink or turn out anticlimactically mild.
May 27, '09
Stockpiling Food for Small Spaces and Small Budgets
For next fall/winter, just in case. I will repeat this practical advice periodically because you never know. Stuff happens and not just pandemics...
Quote from http://www.latah.id.us
This sample plan is designed to give a family of four (2 adults and 2 children under 7) a cheap, compact
way to store a 2-week supply of food to meet their basic nutritional needs. This plan is designed for my
family, taking into consideration our weight, ages, and food preferences (no artificial ingredients) - but it
can easily be adapted for families of different numbers, sizes and ages.
This plan is:
* Compact: A 2-week supply fits into a 66 gallon clear storage box.
* Expandable: add as many 2-week boxes as you wish to get food for your desired timeframe
* Cheap: a 2-week supply of "bare bones basics" costs about $100 (cheaper if on sale)
* Nutritious: It meets our family's basic survival nutritional needs (calories, protein, fiber) and
gives options for meeting vitamin and mineral needs.
May 27, '09Swine flu: "mild strain" kills two more New Yorkers
Quote from scienceblogs.comThe Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.
...As long as it is described in terms of familiar seasonal influenza the public is all right with it -- until they get a good dose of this really miserable illness. Meanwhile New York City's Mayor Bloomberg is getting a taste of what can happen when you minimize the seriousness of a disease that always deserves great respect:
A day after Mayor Bloomberg told reporters that those with swine flu are "lucky" because it's a mild strain, he struck a more sympathetic tone, urging anyone with medical problems to seek help if they feel ill.
"As the virus spreads through the city and through this country and around the world, these deaths sadden us, but I don't think they take us by surprise," he said. 'That doesn't, however, lessen the loss of loved ones." (Carrie Melago, New York Daily News)
This "mild strain" has now killed four New Yorkers in less than a month and put 131 of the 330 confirmed cases in the hospital -- and those numbers are undoubtedly the tip of the iceberg. If this were a food poisoning or an industrial accident it would make headlines in every newspaper in the country.
I have some minor complaints about CDC's messaging (it is false that 36,000 people die of flu every year; no one is served by repeating a falsehood), but I think for the most part they have done it right. Be straightforward about what plausibly might happen and what we do and don't know. The differences between New York's messaging and CDC's have been relatively small but important. They involve tone and the seriousness with which they take the situation. I want to think that this is mainly Bloomberg and not his health commissioner, Thomas Frieden (who will take over as the next CDC Director in June).
I guess we'll see pretty soon. Fingers crossed.
May 27, '09Managing and Reducing Uncertainty in an Emerging Influenza Pandemic
Quote from content.nejm.org(hat tip crofsblog)
The early phases of an epidemic present decision makers with predictable challenges1 that have been evident as the current novel influenza A (H1N1) virus has spread. The scale of the problem is uncertain when a disease first appears but may increase rapidly. Early action is required, but decisions about action must be made when the threat is only modest-and consequently, they involve a trade-off between the comparatively small, but nearly certain, harm that an intervention may cause (such as rare adverse events from large-scale vaccination or economic and social costs from school dismissals) and the uncertain probability of much greater harm from a widespread outbreak. This combination of urgency, uncertainty, and the costs of interventions makes the effort to control infectious diseases especially difficult.
The proportion of severe cases is overestimated in settings where many mild cases are not reported or tested, a situation that is becoming more common as public health officials become unable to test a large fraction of suspected cases. In contrast, severity estimates are biased downward when they are calculated as simple ratios of numbers of deaths to numbers of cases, because there is a delay between the onset of illness and death. During the 1918 influenza pandemic, the mean time from symptom onset to death was 8 to 9 days,2 whereas the number of cases was doubling about every 3 days. With a similar delay, today's deaths would reflect the state of the epidemic three doublings ago, when there were about one eighth the number of cases there are now. If modern therapies have extended the time between onset and death, the censoring bias will be even more pronounced. Such uncertainty has made it impossible to assess severity confidently.
Moreover, several other factors suggest that it is premature to dismiss concerns about severity. First, this virus tends to infect relatively young, healthy people, and it caused a high hospitalization rate of 2% in the United States even before testing shifted to emphasize severe cases.3 Second, the much higher proportion of people likely to be infected in a pandemic (because of limited immunity to the new strain) will mean substantially higher levels of severe outcomes than usual. A virus that is fatal in "only" 0.15% of cases but infects twice the typical number of people would cause about three times as many deaths as typical influenza, or more than 100,000 deaths in the United States. Moreover, this "mild" illness will almost certainly take a more severe toll in less wealthy countries, as infectious diseases routinely do. The Northern Hemisphere may see a decline in transmission over the summer, but the 1918 pandemic demonstrated that sustained spring and summer transmission is possible for a novel influenza strain, and the Southern Hemisphere is entering its influenza season now. The Southern Hemisphere, at least, and possibly the entire world, is likely to see a substantial epidemic of this virus in the next few months, with attack rates exceeding those in a typical influenza season, before significant quantities of vaccine become available.
May 28, '09http://www.recombinomics.com/News/05...hase_Daze.html
Dr. Niman calls it like he sees it, and he is more often right than wrong. He does have a point about vaccines. Remember that a vaccine is always chasing a moving target, and the swine virus is a fast moving one as well.
Quote from www.recombinomics.com
But even as the virus infected people in Britain, Spain and Japan, the agency did not go to Level 6, which signifies spread to a new continent. Dr. Fukuda argued that there was still no proof of "community spread," meaning beyond travelers, schools and contacts.
The above comment, as well as similar remarks by WHO officials and other government agencies, range from delusional to deliberate distortions with regard to the current phase 6 pandemic. The constant rewriting of the phase system to avoid calling a phase 6 pandemic a phase 6 pandemic does significant harm in the monitoring of the pandemic, as well as raising public awareness of the seriousness of the evolution and spread of swine H1N1.
The WHO position and phase 5 designation continues to focus efforts away from the real problem of community spread, and hopeless programs focused on international travelers.
Since the swine virus is now efficiently transmitted in a human host, it will continue to adapt and will likely cause significantly more fatal cases, as was seen in 1918...the community spread will lead to the emergence of new variants, which will be largely missed because of the misplaced emphasis.
When the new variants are identified, they will have established a strong foothold and will spread rapidly, once again avoiding belated containment efforts. The establishment will speed the spread, which will also impact vaccine efforts, because the identification of the emergent strain will happen well after the spread has accelerated.
Thus, the efforts of WHO to deny phase 6, and misplaced surveillance efforts which target international travel, will accelerate the emergence of variants, which will increase the likelihood that containment and vaccine efforts will fail.
May 28, '09CDC Too Optimistic About Flu Peak?
ILI stands for influenza like illness.
Quote from blogs.sciencemag.org
On 26 May, the U.S. Centers for Disease Control and Prevention suggested that the swine flu outbreak in the country might have crested. But Donald Olson, a New York City-based epidemiologist who runs the influenza monitoring project at the International Society for Disease Surveillance (ISDS), disagrees. "If New York City, Boston, and Seattle are indicators of what's to come for the rest of the country, then we ain't seen nothing yet," says Olson.
Although CDC had also noted increases in Boston and New York City, Olson says his more carefully parsed data show "massive increases" that look "mild" in the CDC regional data. CDC also shows ILI in Seattle dropping down at week 20, which is the opposite of what ISDS finds. Unfortunately, says Olson, no one has systematically collected data about the actual presence of the new H1N1 virus, as it would overtax testing labs. "We're dealing with so much uncertainty, and we have imperfect measures," says Olson. "But we need to know what they're weaknesses are."
Olson says it's possible that the epidemic exploded, quickly infected the susceptible population, and will now fade out, but he doubts that, given that New York City has seen the disease peak, drop, and then peak again. "If what New York City has seen in last 10 days is any indication, we're going to be seeing that everywhere else," says Olson.
May 28, '09Australia Orders Vaccine, Releases Antiviral Stocks
Quote from afludiary.blogspot.comHere is an interesting remark about a threshold needed to contain the spread. I have never heard anyone say anything like this before.
With the weather growing colder in the southern hemisphere, and their regular flu season soon to be upon them, concerns over the recent introduction of the H1N1 swine flu virus to Australia are running high.
The number of new cases in Australia have about tripled, to 147, in the past 24 hours.
As a vaccine producing country, Australia is in the position of being able to create their own H1N1 vaccine, and they have now decided to order up 10 million doses.
Until that vaccine can be made available, probably not before late summer or fall, Australia will have to fight a delaying action against the virus using antivirals and other mitigations.
Quote from www.theaustralian.news.com.au
Dr Bishop said the quantity of vaccine ordered would allow mass vaccination of one-third of the population -- the threshold needed to contain the virus's spread -- with the remainder reserved for "priority groups".
May 29, '09About Those Prior Existing Conditions - Two Swine Flu Fatalities In El Paso
For all that the CDC keeps including people over 65 as a high risk group, I can not remember seeing anyone in that age group as having died yet of swine flu. Have you? Maybe I missed it. But, there have been plenty of younger people even even though they did have something wrong with them that could classify them as being more susceptible. Even the littlest kids under age 5, also considered by CDC as high risk, there have not been many that I have read about with a severe outcome.
Quote from afludiary.blogspot.com
At last report, out of nearly 9,000 confirmed cases around the country, over 500 were hospitalized – most of those being in the 5 to 24 age range.
Unlike seasonal influenza, this novel H1N1 virus seems to hit young adults and adolescents the hardest, with (thus far) very few patients over 60.
Today, we learn of two deaths that actually occurred last week due to the H1N1 virus. One was a woman of 24, who was pregnant, a known risk factor for influenza. The other was a 44 year old man.
May 29, '09About the panic thing, my mother unfortunately is one of those that believes that the US government will issue the warning when its time to prepare, and probably come deliver boxes of food and water to everyone if we're being asked to stay home for 4 or 6 or 8 weeks, whatever. She's a very forward-thinking person, and I'm always inspired by her example, but I'm perplexed by things like this. I don't feel like the world is ending, I just feel like I'm grabbing a few extra things in case I'm stuck at home a little while.
Meanwhile, at my house, I've got two metal shelves I bought just to store food and toiletries in. Man... I will be ecstatic if all this blows over and it means I don't have to go grocery shopping for a month or two, though!!
May 29, '09Quote from Girl ScoutI wonder why she thinks so. Secretary Leavitt warned us 3 years ago that the US Cavalry was not going to rescue us....my mother unfortunately is one of those that believes that the US government will issue the warning when its time to prepare, and probably come deliver boxes of food and water to everyone if we're being asked to stay home for 4 or 6 or 8 weeks,
Personally, I like the idea of having extra stuff on hand.
Quote from www.ama-assn
Leavitt has been delivering a similar message to states -- he's visited about half so far. Self-sufficiency should be the goal for everyone, he said. Because a pandemic likely would break out almost simultaneously in many parts of the country, the federal government could not be relied upon to send help to everyone in need. States and localities as well as physicians' offices and households will have to be prepared to fend for themselves. "It's a good idea for people to have a couple of weeks of food and water available, not just for a pandemic but for any community emergency," he said. "Personal preparedness is a very solid ethic that makes a community safer."