From simple to stupid

Epidemic: from the Greek, epi- (upon) + -demos (the people)

Pandemic: from the Greek, pan- (all) + -demos (the people)

Pandemic (according to the WHO): from external pressure and internal weakness, highly-virulent + "justified" panic + all + the people

The definition of a pandemic used to be simple: a worldwide outbreak of disease in excess of what would normally be expected (a global epidemic).  

The WHO even came out with a definition of worldwide spread (community transmission in 2 or more WHO regions).

But now, apparently, the WHO intends to change the definition of a pandemic from simple to stupid.

Bowing to pressure from member nations, the WHO is (according to the New York Times) going to change the definition to include the severity of disease, and will probably do so in such a way that the current H1N1 outbreak will never count as a pandemic (unless it becomes more virulent, which it very well might).

Now, you may remember that we've had three pandemics in the last century, one in 1918, one in 1957 and one in 1968... or, at least, that used to be true.  If this new definition goes into effect as described, we'll have to erase those last two from the list, because they were no more severe than this new H1N1 strain appears to be right now.

Whether a given outbreak is a pandemic or not is a separate question from how severe that pandemic is.  

If the WHO thinks a severity scale would be useful, then by all means they should create one. There are some good arguments against using a severity scale (flu viruses evolve so quickly, severity varies between and within countries, etc.), but it's possible a severity scale would help countries and communities to better plan for and respond to a pandemic... but the role of a severity scale should be to better describe an existing pandemic, not to determine whether an outbreak is a pandemic.

If the WHO goes through with this, there will be two definitions of a pandemic: One used by epidemiologists and other public health professionals, and one used by the WHO --because the WHO's new idea for a definition doesn't make any rational sense.  By setting up such a situation, the WHO will be undercutting its own credibility in a time when its ability to lead is more important than ever.

Instead of caving to the pressure of politicians from the member nations who feel that declaring a pandemic would cause "unjustified panic," the WHO should be using this as a teachable moment, to educate the public about what a pandemic is, what can be done about it, and why panic is never a justified reaction regardless of severity.

   

Swine flu + Japan = Karaoke boom?

Apparently, a lot of students at Japanese high schools that have been shut down due to the H1N1 outbreak haven't been staying home; instead, they've been going out for karaoke. 

As someone who discovered firsthand that karaoke microphones make good fomites (someone shared a nasty cold with me once, by way of a karaoke mic), I'd like to point out that this is a Very Bad Idea.  --All the more so, since a lot of the karaoke venues in Japan include smallish private rooms, where the ratio of students to square feet (and, therefore, the opportunities for large droplet spread) can be quite high.

Is this an argument for not shutting down schools, then?

Probably not.  

Unless a very high percentage of students from these closed schools are crowding into the karaoke joints or other venues where there is a relatively high risk of transmitting the flu, school closings are still likely to be more effective than not in slowing the spread of the virus.

The experts (and I do mean experts) at Effect Measure have posted an excellent discussion of why "swine flu parties" are a really bad idea.

I'd like to thank them for doing so.  Not only does this post get out an important public health message that will help people make better decisions about how to keep themselves (and their families) safe... but it also saves me some work!

Suspected H1N1 in Indonesia

Apropos of my last post:

The Jakarta Post is reporting the first suspected case of H1N1 in Indonesia.  

The patient was identified by thermal scanning in the airport at Surabaya after arriving from Hong Kong, and is being treated in an isolation unit at a nearby hospital.  H1N1 infection has not yet been confirmed.

Indonesia is epicenter of the H5N1 epidemic in humans.  Not only is it the country with the most H5N1 infections to date, it is also home to the deadliest version of the virus.  The most recent official numbers* from Indonesia are 115 dead out of 141 cases, for a case fatality rate of 81.6%.  

*As you can see here, the WHO hasn't received official reports of any cases at all this year, despite the fact that we know the disease continues to occur in Indonesia, so any recent changes that might be occurring in the spread or virulence of the virus would not be reflected in these numbers.

If you're interested in (necessarily) unofficial reports of suspected cases and the latest news on H5N1 avian influenza in Indonesia, check out Bird Flu Information Center. 

Egypt's ham-fisted, pigheaded ploy leads to riots

In Egypt today, Coptic Christian shantytown residents rioted over government attempts to slaughter all pigs in the country.  The government's action was ostensibly undertaken as an attempt to prevent the introduction of the H1N1 swine flu virus into the country.  However, as the story linked above (from the Telegraph) says: 

"The Egyptian authorities have admitted since ordering the slaughter last week that it was mainly a pretext for carrying out a reorganisation of the country's pig farms, which are used to supply the country's Coptic Christians, ten per cent of the population." 

The goal, apparently, is to ensure that pigs in the country are no longer raised in small, "unhygienic" holdings, for instance by trash collectors who feed their hogs with the trash they collect.

A story by Reuters opines that:

"...culling swine, largely viewed as unclean in Muslim Egypt, could help quell any public panic in the most populous Arab country."

So far, the only known case of this H1N1 Swine Flu strain actually being found in pigs occurred in Alberta Canada when a farmworker who had recently visited Mexico passed the virus on to his porcine charges.  That's right, human-to-swine spread, not swine-to-human.  (The pigs are all expected to recover, by the way.)  

There have been no cases of the disease identified in Egyptian swine (or any other beyond that one farm in Alberta).  There is certainly no epidemiological justification for slaughtering an entire nation of uninfected pigs.  

Both the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) have issued statements condemning the action, but Egypt is clearly not as interested in the science of the situation as they are in the propaganda value of being seen to do something (especially if that something only hurts a powerless minority group).

So far, the only Swine Flu-associated casualties in Egypt aren't cases of the disease, but 13 to 15+ civilians and police who have been injured in the rioting.  Let's hope it gets no worse. 

First Cases Identified of Swine Flu in Pigs

The Canadian Press is reporting that an official announcement will soon be made that the epidemic strain of H1N1 Swine Flu has been found in pigs in Alberta, Canada.  The pigs are thought to have been infected by a farm worker who became ill after traveling to Mexico.

Too soon to say

Suddenly, stories like this one abound, implying that the outbreak of H1N1 Swine Flu may not be such a big deal after all.

Of course, we all hope it turns out not to be a big deal, but as they finally got around to mentioning in paragraph 5 of the new article, it's "...too soon to be certain what the swine flu virus will do."

We are so early in this outbreak that we really don't know much about the epidemiology of this virus at all.  

• How many people have the disease?
• How many people have died?
• How readily is it transmitted from person to person?  
• What risk factors are there for infection (does it spread well among people crammed into the same airplane for several hours, but poorly in more open settings; are smokers or the elderly or some other group more likely to catch it)?  
• How lethal is the virus to those who catch it?  
• Who is most at risk of severe disease?
• When it does kill people, is it the flu infection itself (primary viral pneumonia) that causes death or is it secondary bacterial pneumonia that moves in after the flu virus is gone?
  

And it will be awhile before we have many of the answers.  In the UK, they are waiting for the results of more than 600 tests for the virus.  Mexico has a backlog of over 35,000 samples waiting to be tested, and their total number of confirmed cases shot up by nearly 250 overnight to 397 as a result of additional testing (not necessarily correlated to any new cases).  In the US, it's taking 4 days to get test results, which -with a virus that has only a 24 to 96-hour incubation period- means that our picture of confirmed cases here at home is far behind the times, as well.

And all that only goes to the epidemiological situation now.  The situation is likely to change over time, as the virus mutates.  In the case of the 1918 Pandemic, for instance, the first wave of infections spread around the world in the spring, and it was pretty mild.  It wasn't until the fall, when the next wave of infections struck, that the virus became so frighteningly lethal.

So I'm very pleased that the CDC, the Department of Health and Human Services, and the Department of Homeland Security are all continuing to take the situation very seriously and are doing an excellent job of letting the public know what we do and don't know.  

Dr. Besser, Acting Director of the CDC, has done a particularly good job of communicating the expectation that the government's response, the guidance to the public and the guidance to healthcare professionals will all continue to change as the situation evolves --and that that's a good thing. 

Yesterday's webcast on the swine flu outbreak

Here is yesterday's webcast from the Department of Health and Human Services and the Department of Homeland Security.

 
Dr. Besser, Acting Director of the CDC, Secretary Sebelius of the Department of Health and Human Services, and Secretary Napolitano of the Department of Homeland Security did an excellent job of answering questions from the public.

From the comments: Is the bioengineering theory really rubbish?

Doxocopa writes:

"Complete rubbish???

For a start... still, not yet a SINGLE PIG INFECTION was reported, as far as I'm aware. Could you please answer two things?
1 - If no pigs seem to be affected at all, how on earth a pig flu virus turned suddenly to a human airborne disease? - First human cases from other species Flu virus begun by direct contact with the infected animals
2 - This virus is indeed a genetic chimera; independently of what people think about its origins, so probably can infect humans, pigs and birds, so how can it survive in Nature without an epidemiological reservoir?"

Hi Doxocopa,

Thanks for commenting.  Yes, actually: it's complete rubbish.  But I can certainly understand why the situation would be confusing to someone who hasn't studied the flu... especially because this strain was unfortunately saddled with the misnomer "swine flu."  What we're really all paying attention to right now is a HUMAN flu with swine-, avian- and human-flu progenitors.

This flu has four grandparents, if you will: two from different regions of swinelandia, one from birdlandia, and one from humanistan –and it LIVES in humanistan: really, it’s a human flu, even if it is an immigrant.

So, to answer question 1:

What does it mean that we haven’t seen any cases in pigs yet?  It could mean any one of a number of different things:

1. The virus may cause asymptomatic infection in pigs or cause only very mild symptoms.  That is, they might get infected and be able to spread the disease (both to humans and other pigs) without showing any sign of having the disease.

2. It may be that the cases in pigs have simply been missed, even if the disease was severe.  There are a number of diseases that cause illness in pigs, including “normal” swine flu, and the affected farmers may not have recognized that anything new was happening.  We can’t be sure yet where the virus first emerged, but there may simply not be a very robust veterinary public health surveillance infrastructure in the country of origin.

3. The recombination may have occurred a human, instead of a pig.  We are also capable of being infected by human, swine and avian flu strains.

4. Even if the recombination DID occur in pigs, that doesn’t mean that the new virus was best-suited to reproducing in pigs vs. humans.  Remember, the pig in question would have been infected by 2 or more strains of flu at the same time; its immune system was likely compromised.  A compromised immune system may be the reason it was infected by more than one flu strain in the first place.  Even if not, the infections, themselves, would have worn down its immune response. (Secondary bacterial pneumonia is what usually kills most people who are killed by seasonal influenza.) 

If this is true, even if the virus was better-suited to humans than pigs, the virus may have reproduced sufficiently in this one pig to infect a human handler and enter into circulation in the human population.  It might never have been, and might never be, primarily a disease of pigs.

 

As for question 2:

What is the “epidemiological reservoir?”  Humans appear to be the primary host species for this virus.  That’s why I saw “swine flu” is really a misnomer.  As far as anyone knows right now, this is solely a disease of humans, and WE are how the virus is “surviv[ing] in nature.”

What's more, this virus would be a profoundly stupid bioweapon.  No one would benefit from it.

Bogus: Bioweapon claims for H1N1 Swine Flu

Some segments of the blogosphere are all atwitter (pun intended) with the theory that the H1N1 Swine Flu must be the work of some nefarious group of bioengineers because the virus contains segments from 4 different progenitor viruses --2 different swine flu viruses, an avian flu virus and a human flu virus.  Some even seem to imply that US government researchers working on the 1918 pandemic flu virus (which was also an H1N1 virus, though very different) might have been involved in weaponizing it.

Much of this seems to be driven by a story written by Wayne Madsen of Online Journal:

It turns up all over the place, at PrisonPlanet.com, Know4Life, InTheseNewTimes, and elsewhere.

Jeff Denmark at Drudge Retort quotes the article:

"According to two mainstream media journalists, one in Mexico City and the other in Jakarta, who spoke to WMR on background, they are convinced that the current outbreak of a new strain of swine flu in Mexico and some parts of the United States is the result of the introduction of a human-engineered pathogen that could result in a widespread global pandemic, with potentially catastrophic consequences for domestic and international travel and commerce." 

And goes on to say: "WMR has been informed that the CDC and U.S. Army dug up the body of an Inuit woman who died in 1918... from an outbreak of Spanish flu. . . . . WMR has been told the genetic material recovered by the U.S. government from the corpse of the Inuit woman provided the basis for the development of the H5N1, or bird (avian), flu strain at the U.S. Army Medical Institute of Infectious Diseases (USAMRIID) laboratory at Fort Detrick, Maryland, the point of origin for the Ames strain of anthrax used in the 2001 bio-war attacks against the U.S. Congress and the media."

This is, as they say in Jolly Olde England, complete rubbish.

"How, then" you may ask "did a brand new virus that's made up of four different viruses suddenly spring into being and spread all over the world? Doesn't it have to be the result of bioengineering?"  

...Actually, no.

This is exactly the sort of thing we've been expecting for years.  

If more than one strain of flu virus infects the same cell, the two strains can mix up their genes, leading to what is called a recombinant virus.  That simply means that the genes from the two (or more) viruses have recombined to create a new strain.  In effect, it's a lot like sexual reproduction in humans; parents mix up their genes with the result that a child might have her mother's hair and her father's eyes.

This recombination happens especially easily in pigs, because they can be infected by swine flu viruses, avian flu viruses and --you guessed it-- human flu viruses.  The pig as a "mixing vessel" scenario is something we've long known to be a threat when it comes to pandemic flu.  In fact, this is believed to be what caused the last two pandemics, in 1957 and 1968, as this figure illustrates.

This is perfectly natural and expected.  That doesn't make it good, of course, but there's no hidden conspiracy behind it.  The virus arose naturally and the epidemiological evidence seems to show pretty clearly that it's spread so quickly because of air travel --something else we knew to expect-- not because it's being used as some kind of very inefficient bioweapon.

We humans are all on the same side on this one.

Swine Flu Map

Update: The map has been re-designed to be easier to read and continues to be updated frequently.  The link for the map has changed, and the link listed below is the latest version.

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This site maps confirmed and suspected cases related to the swine flu outbreak and gives information on mortality, along with reports of suspected cases that turned out not to be swine flu:

tinyurl.com/swinemap09

It's a useful tool for visualizing the outbreak and because it links to the news reports that back up the data it's mapping, you can assess the reliability of the information yourself.  So far it's being updated very frequently, despite (or perhaps because of) the fact that we're in the middle of the weekend, so keep an eye on this site for the latest.

Time to update your pandemic flu plan

With the H1N1 “swine flu” outbreak unfolding across the globe, the threat of a flu pandemic is higher than it has been in decades.  We don’t yet know whether this new virus will become the next pandemic or (as we all hope) simply fizzle out, but now is a good time for families everywhere review their plans for coping with a pandemic and make sure they’re up to date.

What is a flu pandemic?

A flu pandemic is caused by an Influenza A virus, the same type of virus that causes the seasonal flu we deal with every year.  The difference is that a pandemic flu strain makes a lot more people sick than the seasonal flu and that it doesn’t just occur during the regular flu season. –A pandemic may last 18 months or more.  One other important difference is that, unlike the seasonal flu, which is normally only dangerous to infants and the elderly, pandemic flu strains often cause severe illness among teenagers and young adults, as well.  This is a pattern we’re seeing in the preliminary data from the swine flu outbreak, which is cause for concern.

Three conditions must be met in order for a flu virus to cause a pandemic:

1. It’s new to humans so that we have little or no pre-existing immunity to it
2. It readily causes significant disease in humans
3. It spreads easily from person to person

  “Swine flu” is a flu virus that normally infects pigs, and most swine flu viruses only meet the first of those three criteria: we’re not immune to them, but they don’t easily causes disease in humans (and such diseases are usually mild when they do occur) and they are rarely ever transmitted from person to person.  While the virus implicated in this outbreak is causing significant disease in humans and, based on early reports, is probably spreading from human to human, it is too early to say whether it is doing so at a level that could cause a pandemic to occur.  But whether this is the start of the next pandemic or not, it’s an important reminder about the importance of having a plan in place for keeping your family safe when a pandemic does strike.

How should you prepare?

The website www.pandemicflu.gov is the federal government’s one-stop source for pandemic flu-related information, and it offers useful advice on how to prepare.  The following checklist comes from that site and will help you to make a good start toward doing what you can to keep your family safe:

 1. To plan for a pandemic:

¨ Store a two week supply of water and food. During a pandemic, if you cannot get to a store, or if stores are out of supplies, it will be important for you to have extra supplies on hand. This can be useful in other types of emergencies, such as power outages and disasters.

¨ Periodically check your regular prescription drugs to ensure a continuous supply in your home.

¨ Have nonprescription drugs and other health supplies on hand, including pain re­lievers, stomach remedies, cough and cold medicines, fluids with electrolytes, and vitamins.

¨ Talk with family members and loved ones about how they would be cared for if they got sick, or what will be needed to care for them in your home.

¨ Volunteer with local groups to prepare and assist with emergency response.

¨ Get involved in your community as it works to prepare for an influenza pandemic.

2. To limit the spread of germs and prevent infection:

¨ Teach your children to wash hands frequently with soap and water, and model the correct behavior.

¨ Teach your children to cover coughs and sneezes with tissues, and be sure to model that behavior.

¨ Teach your children to stay away from others as much as possible if they are sick. Stay home from work and school if sick.

3. Items to have on hand for an extended stay at home:

Examples of food and non-perishables

¨ Ready-to-eat canned meats, fish, fruits, vegetables, beans, and soups

¨ Protein or fruit bars

¨ Dry cereal or granola

¨ Peanut butter or nuts

¨ Dried Fruit

¨ Crackers

¨ Canned juices

¨ Bottled water

¨ Canned or jarred baby food and formula

¨ Pet food

¨ Other nonperishable foods

Examples of medical, health, and emergency supplies

¨ Prescribed medical supplies such as glucose and blood-pressure monitoring equipment

¨ Soap and water, or alcohol-based (60-95%) hand wash

¨ Medicines for fever, such as acetaminophen or ibuprofen

¨ Thermometer

¨ Anti-diarrheal medication

¨ Vitamins

¨ Fluids with electrolytes

¨ Cleansing agent/soap

¨ Flashlight

¨ Batteries

¨ Portable radio

¨ Manual can opener

¨ Garbage bags

¨ Tissues, toilet paper, disposable diapers

How can you help?

If you are interested in helping your community prepare for and respond to a possible flu pandemic, consider volunteering through your local Medical Reserve Corps unit.  You don’t need to be a medical professional to join; you just have to be willing to help. You can find out more about the Medical Reserve Corps and how to contact your local unit at www.medicalreservecorps.gov.

You can also volunteer through the American Red Cross (http://www.redcross.org/en/volunteertime), your local Community Emergency Response Team (CERT) (http://www.citizencorps.gov/cert/) or any of the national, state or local Voluntary Agencies Active in Disaster (VOADs) found here: http://www.nvoad.org/.

Take home message

There’s no need to panic.  Right now, we don’t know whether this new swine flu virus will become a pandemic or just fizzle out.  It’s just too early to tell.  But either way, now is a good time to review your plans for keeping your family safe during a flu pandemic.  Make sure you have two weeks worth of non-perishable food and water at home.  Make sure you have a continuous supply of any medications you rely on.  Keep up to date with the latest information and advice at www.pandemicflu.gov, and consider volunteering to help your community in the event of a public health emergency.  Because even if this isn’t the next flu pandemic, eventually there will be one.  Being prepared before it strikes could make all the difference for you and your family.