Pandemic Awareness/Preparation

Nurses COVID

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It has been my own personal project to follow H5N1 for the last 3 years simply because it interests me. Attracted to this type of information like a magnet, I've been watching this relatively new influenza virus to see where it will go, how it will change itself, and possibly change our world. I have followed its country by country outbreaks, and watched for the important viral mutations such drug resistance or changes that allowed it to more specifically target mammals.

Keeping in mind at all times that we will be cleared impacted as HCW, as well as being members of our communities, and having families of our own to care for, I wanted to start the new year by opening a single focused pandemic thread that would also look at what we are doing nationally to prepare for a future pandemic. Is this the virus to spark the next pandemic? No one can answer that question. We can look back at the past to the last few pandemics, and in particular to the most devastating one in 1918, and extrapolate useful information about them, but we can not predict the future. We can only make comparisons with our situation now, and learn what worked to lessen morbidity and mortality in those past events. And, we can look at those other viruses, and compare them with what we are seeing now. For example, H5N1 is a Type A virus. We know that all pandemics are caused by Type A viruses. It is also an avian virus. The deadly 1918 virus, H1N1 was also an avian virus.

For this thread, as in the previous threads, I will be making use of news sources, scientific studies, govt bulletins such as the MMR, as well as flu forums and blogs devoted to this subject for my sources. Because press information, particularly the foreign press, is not always available for later access when I am looking back to check recent historical information, the use of these blogs and forums are important because archived information quoting the media and all other sources is always fully and easily available there with no worries about information disappearing or no longer being available. They also fully document their sources or I would not be using them.

With this link from Avian Flu Diary, a well researched source that I highly recommend, we can read the words of outgoing HHS Secretary Leavitt on our state of preparedness. Leavitt has done an admirable job during his tenure, but admits that there is much left to do.

http://afludiary.blogspot.com/2009/01/hhs-releases-6th-pandemic-planning.html

afludiary.blogspot.com said:

A scant 33 months ago, I sent my first message about a race that HHS had just begun. As I said then, it was a race against a fast-moving virulent virus with the potential to cause an influenza pandemic. Since then, we have mobilized experts and resources across the country and around the world. I now send you this final message, as I look back at the unprecedented progress we have made in energizing a national pandemic influenza preparedness movement in those 33 months.

Today, many people mistakenly think influenza pandemics are a thing of the past, but influenza has struck hard in the era of modern medicine – much harder than most people realize. And it will strike again. Pandemics are hard things to talk about. When one discusses them in advance, it sounds alarmist. After a pandemic starts, no matter how much preparation has been done, it will be inadequate.

Specializes in Too many to list.

Today's CDC Swine Flu Teleconference

http://afludiary.blogspot.com/2009/04/todays-cdc-swine-flu-teleconference.html

The two speakers were:

Anne Schuchat, M.D., Interim Deputy Director for Science and Public Health Program

Daniel Jernigan, M.D., Ph.D., Medical Epidemiology, Influenza Division

If there was a theme to today's conference, it was that there is a lot we still don't know about this new virus.

According to Dr. Schuchat, she stated `we are very worried'. That the situation is `serious', and now is the time to prepare.

The numbers are dynamic, and are changing rapidly.

The CDC urges the media, and the public, to be prepared for changes in this story, and in their interim recommendations.

Specializes in Too many to list.

Swine flu: CDC's Saturday press briefing

http://scienceblogs.com/effectmeasure/2009/04/swine_flu_cdcs_saturday_press.php

If they are saying no new cases in the US than that would seem to indicate that the NYC cases are not Swine Flu. However, there is that school closing article in Texas that identifies a possible new case there.

CDC has just concluded a press briefing and the big news is there is no big news. In fact there was hardly any small news. The major questions have been identified -- how transmissible, what is the epidemic curve, are there more cases in the US, are there subtle genetic differences in the US and Mexican versions to account for the apparent difference in clinical and epidemiological features, etc. -- but answering them will take longer.

Meanwhile, no new cases have been identified in the US, but CDC in collaboration with state and local health departments and the academic and medical sectors are working doing aggressive case finding... The state labs now can do these fairly sophisticated analyses because of training consequent to the concern over H5N1 ("bird flu"). This is a good example of how infrastructure development has served a virtal public health purpose. If the specimen is untypable by the state lab it is sent on to the CDC reference lab in Atlanta for a closer look. CDC says that even these untypable specimens can usually be typed by CDC but sometimes something new appears, and that is the case with this virus. After sequencing it was clear it was genetically different than anything in their libraries. This required construction of new PCR primers.

Determining the epidemic curve in Mexico or anywhere else (the evolution of cases over time) for a viral syndrome that is very non-specific (lots of noise from other viruses that cause the same syndrome) and for which diagnostic tests are time consuming, specialized and often unreliable is inherently difficult. It requires painstaking, tedious and time consuming effort. Use of the scanty and spotty syndromic surveillance systems in the US so far does not indicate an unrecognized outbreak of mild disease but CDC and state health departments are looking hard.

Perhaps the most important message is that this is a good time to move forward on strengthening the public health infrastructure and to get ready for the one thing we can be certain of in the days ahead: there will be more uncertainty.

Specializes in Too many to list.

New York schoolchildren had flu, official says

http://www.alertnet.org/thenews/newsdesk/N25476545.htm

The fact that this sophisticated lab in the NYC Health Department could not subtype this flu is cause for concern. It is an influenza A which they could not subtype, and now they have to send it to CDC. Yes, it probably is Swine Flu in New York City of all places.

The fact that the cases are mild is irrelevant, imo. This is only the first wave.

Tests have confirmed that eight New York city schoolchildren had a type A influenza virus, likely swine flu, New York city health commissioner Dr. Thomas Frieden said on Saturday.

Samples have been sent to the U.S. Centers for Disease Control and Prevention for further testing to see if they are indeed the unusual H1N1 flu strain

Specializes in Too many to list.

New Zealand

http://www.3news.co.nz/News/HealthNews/Auckland-students-being-tested-for-swine-flu/tabid/420/articleID/101256/cat/58/Default.aspx

The group of 22 senior students and three teachers arrived into New Zealand after spending three weeks in Mexico.

After some of the group presented symptoms of an influenza-like illness, the Auckland Regional Public Health Service (ARPHS) is conducting preliminary tests to determine the cause of the illness.

"We are taking this very seriously and doing everything necessary to manage this situation in Auckland," says ARPHS Clinical Director Dr Julia Peters. "The Ministry of Health is managing the response to this issue at a national level."

More than 80 people in Mexico are believed to have died and over 1,300 are sick as a result of catching swine flu which has led to the closure of schools in Mexico City.

There have also been cases of the swine flu reported in New York, California and Kansas and a British Airways pilot has been hospitalised in London with flu symptoms after returning from Mexico.

Specializes in Too many to list.

The WHO's Pandemic Threat Level

http://www.calgarysun.com/news/world/2009/04/25/9246676-cp.html

There is some question as to why the WHO did not raise the pandemic threat level, and much speculation that the real reason is because of the economic consequences. These two links have some commentary about the WHO's decision.

Dr. Osterholm heads the Center for Infectious Diseases Research and Policy at the University of Minnesota. He formerly served as a Minnesota state epidemiologist, and Chief of the Acute Disease Epidemiology Section from 1984 to 1999.

Declaring the outbreak a public health emergency of international concern allows the WHO to ask member states to enhance surveillance for human swine flu cases and report those they find to Geneva. A statement issued by the agency Saturday did not preclude the possibility the pandemic threat level would rise in coming days.

The group advises but the decision rested with Chan, who rushed back to Geneva overnight Friday from Washington. She said Saturday that "in the assessment of WHO, this is a serious situation which must be watched very closely."

The decision not to raise the pandemic alert level puzzled some observers and drew criticism from others.

Infectious diseases expert Dr. Michael Osterholm said the decision to keep the pandemic alert level at Phase 3 -- which in WHO terms means no or very limited human-to-human transmission -- "surely flies in the face of all the science that we have."

Osterholm, who heads the Center for Infectious Diseases Research and Policy at the University of Minnesota, said it’s critical that the WHO remain an unimpeachable source of authoritative information. "If they begin to make decisions about science-based facts because of policy concerns, they will quickly lose that necessary credibility," he said.

http://www.flutrackers.com/forum/showpost.php?p=222173&postcount=4

Here is a differing point of view than that of Dr. Osterholm. SophiaZoe is a well known blogger on pandemic influenza. She's a very intelligent woman in my book. Her thinking on the WHO's decision may be correct. And, the WHO may turn around and reverse that decision based on what happens next.

Triggers are scheduled to be pulled once the threat level is raised. Real, concrete, life and livelihood actions and their resultant consequences.

The WHO is not strictly a dispassionate and disconnected "scientific" body unconcerned with nothing more than the "truth" of the "facts'... even as wonderful as those two things are. The WHO serves the world community. The world community is made up of people... a whole bunch of people... 6+ billion of them... many of whom are already in tough financial circumstances, and some of those grave financial circumstances. Raising the alert level will have real financial consequences... maybe not for epidemiologists... but for many other less "disease centric" professions.

Specializes in Too many to list.

Only two options in swine flu crisis

http://www.scottmcpherson.net/journal/2009/4/25/only-two-options-in-swine-flu-crisis.html

Scott Mcpherson is the Chief Information Officer [CIO] for the Florida House of Representatives.

Either this virus will burn itself out, or it will go pandemic. It is that simple, and those are the only two options available.

If it burns out, it will be due to a combination of factors, including trying to slow it down and getting in front of it. But keep in mind that 75% of all influenza pandemics start outside of regular flu season. Part of that reason is because there is no competition for hosts with other, more established flu strains.

Flu bugs fight each other for supremacy. Eventually, one wins out.

In the Northern Hemisphere, H1N1 swine flu today has dramatically reduced competition for hosts. Flu season is essentially over, and seasonal influenza is retreating to wherever it is that it retreats to. This leaves a clear path for swine flu to find susceptible hosts and infect them en masse.

It is now fish-or-cut-bait time for American flu planners. And as many risk communication experts will tell you, now is not the time for mixed messages. We cannot tell people to prepare for a pandemic with an Asian origin and then not tell them to get prepared for one with a Latin origin. The waiting game won't work, especially when the virus has penetrated our defenses. It's time to tell people how to get ready and what to do, if we are to have any hope of burning this out before it jumps the oceans -- unless we're too late already.

But it's worth a try.

Specializes in Too many to list.

How much of this is true, I do not know, but at least some of it has to be. Remember that Mexico had no time to prepare but we do.

Mexico flu: Your experiences

Readers in Mexico have been emailing the BBC describing the sense of fear gripping the country as a result of a flu virus outbreak, which has so far claimed more than 80 lives.

Read a selection of BBC readers' comments below.

http://news.bbc.co.uk/2/hi/talking_point/8018428.stm

I have a website from the "WHO" with daily updates on the swine flu. They don't seem to have a real handle on whats going on in Mexico.

Maria

http://www.who.int/csr/disease/en/

Specializes in Too many to list.

Lethality is all relative if swine flu goes pandemic

http://www.scottmcpherson.net/journal/2009/4/26/lethality-is-all-relative-if-swine-flu-goes-pandemic.html

Scott McPherson is the Chief Information Officer [CIO] for the Florida House of Representatives. Looks like he has been very busy keeping up with Swine Flu today. I am going to post some of what he had to say today.

...in 1918, the spring wave of H1N1 was very mild. It was the second wave -- cooked in the summer and fall of 1918, in the trenches of WWI -- where the virus gained its ability to kill by the millions. And it was the third wave that incapacitated President Wilson (NOT a stroke, but Spanish Flu in April 1919) that allowed the punitive actions of Britain and France against aggressor Germany to move forward, and sowed the seeds for the Third Reich. That is your history lesson for today.

A swine pandemic was feared by experts long before the 1976 swine flu debacle. This is what caused the major calamity that we now call the Swine Flu Debacle. This new strain, with its curious mixture of swine, avian and human genes, is headed for an uncertain future. But we cannot simply assume that a lack of mortality or lethality is necessarily good news in the long run.

http://www.scottmcpherson.net/journal/2009/4/26/sitrep-washington-dc-public-health-emergency-declared-tamifl.html

Besides declaring a nationwide public health emergency, the White House has ordered a release of 25% of the Strategic National Stockpile of antivirals Tamiflu and Relenza to the states, with prioritization to those states with outbreaks and confirmed cases. Additionally, the Department of Defense -- and don't be alarmed, because the SNS is a joint project of HHS and DoD -- anyway, DoD has already pre-positioned some 7 million courses of antivirals. Who do you think guards all those warehouses? Guards from 24?

http://www.scottmcpherson.net/journal/2009/4/26/the-huge-elephant-in-the-white-house-briefing-room-regarding.html

We do not know if we are watching the first infant signs of an epidemic, or if by some strange stroke of Fate we are already experiencing the "first wave" of an epidemic or pandemic. We have not tested enough people prior to April 1 to get a handle on that answer. No one has.

Why not? Simply, the symptoms were not severe enough for anyone to suspect that another strain of influenza was at work -- at least, not until Mexicans started dropping dead in significant numbers. Then, and only then, did the next, more sophisticated level of testing take place.

It is this lack of serious illness that worries us in Egypt, and in Indonesia, and in other regions where H5N1 has become endemic. There is absolutely no way to determine the level of penetration of a virus without testing blood for antibodies. This is precisely the exercise the Egyptian government and the WHO are collaboratively taking with human samples -- to look for antibodies to avian H5N1 and to see if the disease has asymptomatic carriers.

I am wondering if the comment from DHS about the number of swine flu cases abating, and then picking up again after a few weeks, is actually code for the US anticipating a wave of a pandemic. This would make sense if you view the big picture of the US response. The increased surveillance is obviously meant to see how widespread and how rapidly the virus is moving. The pre-positioning of antivirals is not just to be ready to treat mildly sick Americans -- it is also meant to quickly treat deathly ill Americans in case the virus evolves quickly and begins to attack with as much lethality as it appears is currently taking place in Mexico.

Let's look at the current rate of deaths in Mexico. A quick bit of calculus can tell us how many cases may be underreported in Mexico. If we look at 80 deaths and 1400 cases, we see the Case Fatality Rate (CFR) somewhere between 5 and 6 percent. If the CFR were something much more reasonable -- say, 1% -- then we are looking at some 8,000 cases.

Influenza's goal is not to kill its hosts. It is to coexist with its hosts. Even the 1918 pandemic's CFR was somewhere between 2 and 2.5% of those infected. Still, if the CFR in Mexico is at 1%, then the virus is far more widespread and the chances for an epidemic are magnified exponentially.

Also, the fact that young adults are dying is the worst news within this current onslought of reports. These people just are not traditionally ill. Only testing and autopsies will tell us if the dreaded "cytokine storm" of immune overload is at work here.

Regarding the release of antivirals from the SNS: I was fascinated to see the military preposition Tamiflu so quickly (some 7 million courses, or 700,000 boxes of ten capsules). This action tells me that the federal government is itself unsure if this is an early outbreak, or if surveillance broke down and we are a lot further along in this episode than anyone realizes. The absence of data is so glaring, and there is not a doggone thing anyone can do about it until we have more data, better data and good sequencing of the genes of this new virus.

Specializes in Clinical Research, Outpt Women's Health.

So, I go to mexico on May 9th. If I get an RX from my doctor for Tamiflu to take with me is it even available at the pharmacies? Or is it all stockpiled and so not avialable?

So much uncertainty. If everyone gets it are they then immune?

Specializes in School Nursing.

Does a virus that seems to only have a mortality rate of about 6% (my calculations from various media reports) really have the potential to become a pandemic? I am not being argumentative here, I am really curious. Does anyone know what the mortality rate was of other major pandemics? I also wonder if that percentage is not actually even lower because of the possibility that many mild cases were not reported and recovered at home without medical intervention. Any thoughts?

Specializes in Too many to list.

U.S. Airlines Tumble After Swine Flu Raises Travel Concerns

http://www.bloomberg.com/apps/news?pid=20601087&sid=a50yYufORxdg&refer=home

Bloomberg is a VERY credible source. If they are saying that the WHO is going to raise its pandemic threat level, count on it, and there will be serious economic consequences to tourism and other industries. The WHO was supposed to meet tomorrow, but has decided on an emergency meeting today.

The slide extended industry declines as the death toll from the new virus surpassed 100. The World Health Organization will raise its pandemic alert to an unprecedented level today, saying the disease is spreading across North America, two people familiar with the agency said.

Delta Air Lines Inc., the world's largest carrier, fell $1.12, or 14 percent, to $6.76, at 10 a.m. in New York Stock Exchange composite trading. The Bloomberg U.S. Airlines Index tumbled as much as 15 percent, the most since Sept. 17, 2001.

"People are panicked, and you can see that," Helane Becker, a New York-based analyst with Jesup & Lamont Securities, said in an interview. "I don't think people will cancel. A lot of this is short lived and a knee-jerk reaction."

U.S. airlines are staying on "heightened awareness" for travelers with possible swine flu symptoms while maintaining flight schedules to Mexico, where the outbreak is worst.

Passengers are being given the option to rebook Mexico trips without penalties or fees, and airlines are awaiting further direction from authorities including the WHO, spokesmen for U.S. carriers said.

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