Effect Measure

The third of the recently diagnosed H5N1 cases in Egypt has now died, bringing that country’s total to 18 cases with 10 deaths, the largest outside asia, southeast asia or Indonesia. The case count for 2006 now shows more cases (114) and more deaths (79) than any previous year. And the virus was more deadly, at last measured by a case fatality ratio (deaths divided by total confirmed cases). Indeed the number of deaths in 2006 exceeded the total of deaths for 2003, 2004 and 2005 combined (79 versus 78), although the number of cases exceeded last year’s by only 18%, compared to an 88% increase in deaths over 2005.

The difference is the frightful case fatality ratio registered by Indonesia (82%) compared with the other eight countries with confirmed cases (combined CFR of 58%) and the fact that Indonesia had almost half the cases (55 of 114). Thus the apparent increase in case fatality is being driven entirely by the Indonesian experience. Whether this represents a difference in the virus (a difference in virulence in the Indonesian virus) or a difference in case ascertainment (which affects the denominator, the confirmed cases) or a difference in medical management (which affects the numerator, the proportion of cases that die) or all three combined in various ways, we don’t know.

As in previous years, the second half of the calendar year has seen far fewer cases than the first half. This is the usual pattern. From July, there have been 21 human cases in five countries; from January to June there were 93, an apparent steep drop-off. In 2005 the first 6 months toll of 59 was also followed by a drop-off to 38 cases and in 2004 the numbers were 32 and 14 (data from here with additions of the three Egyptian cases in December). Thus the first half of 2006 was worse than the first half of 2005, but the autumn of 2005 was worse than this year. The general pattern is clear, however. Human cases increase markedly in the first half of the year, and the increase starts now, in January, which has been the peak month in each of the past three years (23, 20 and 25 cases, respectively). We don’t know if this January will be a repeat, but we should be prepared and expecting it.

Any epidemiologist will tell you that trying to read the tea leaves with this much data is fruitless, although it doesn’t prevent just about everyone else from trying. There are more cases, true, but there is also a lot more virus around. H5N1 has spread to poultry and bird populations in a wide geographic area. We don’t know whether it has changed in lethality or not. The same can (and should) be said of transmissibility.

But we are in a bird flu earthquake zone. People in California who know they are living over a fault zone, we don’t know and can’t predict whether The Big One will happen today or tomorrow or in ten years, or conceivably never. In California they still build their buildings and bridges to withstand earthquakes that have happened in the distant past and may or may not happen again and who knows when. They don’t write news stories about “fear of earthquakes overblown” or “what ever happened to The Big One?” for good reason. The conditions for an earthquake haven’t gone away in California and people still feel tremors regularly.

Just consider the bird flu case counts and poultry outbreaks another form of tremor.

And rebuild your public health and social service infrastructures “to code.”

Comments

#1 Tom DVM
December 29, 2006

Revere. clear and concise per usual…thanks for 2006.

Let me know when all of the experts are unanimously convinced that the danger has passed…

… that will be when we are in the greatest danger of a break-out.

After all, nature does have a sense of humour and irony.
#2 Lenn
December 29, 2006

To me, the scariest part (among many, many scary parts) is that even if H5N1 is not the pandemic strain, there will still be a pandemic strain at some point.

For hundreds of years now, influenza has had periodic outbreaks into the human population. Why does anyone think it is going to stop now?
#3 The-Best-Bird-Flu-Blogs-team.
December 29, 2006

I was amazed to see the following blog on our site.

It was the headline actually, from an article by Mr Michael Fumento, writing in the Right Wing News.

Apparently, it was “..My avian flu challenge to the leftist bird-brained squawkers”

Now there has been a lot of online arguments and even some hot words banded around about the possibility, or not, of a flu pandemic.

My question is this.

Why the “leftist bird-brained squawkers” reference?

Obviously Mr Fumento is suggesting that the people who think that there could well be a flu pandemic in the near future, tend to lean to the left of the political spectrum.

That is not the case.

Mr Fumento, I assure you that many of our bloggers, who can be termed as, well, very right wing indeed, happen to hold the view, that the H5N1 could mutate in to a human pandemic virus.

And vice verse!

JM Tom

The-Best-Bird-Flu-Blogs-team.
#4 mary in hawaii
December 29, 2006

In california they build their buildings to code to withstand earthquakes because they know earthquakes happen. Science tells us that, in the current conditions of global climate change, we are likely to be hit with any number of pandemics in the future. So what are we doing as a world to prepare for a pandemic, other than play catch up?

What “codes” are we writing? What codes should we be? If we are lucky enough not to bite the bullet this time, and H5N1 threat goes away, will our governments put all their toys away and go back to business as usual?

We need to do something to improve the overall general health conditions in third world countries. We need to do something to improve rapid testing and reporting of outbreaks. We need, most of all, to put the WHO in authority over the politics and policies of the independent nations of the world in cases of potential pandemics, so that their rights do not supercede the rights of the rest of the world in prevention and containment. Take for example the hajj: in the current situation – teetering on the brink of phase 4 or 5 – should this have been allowed to take place this year? We are one world now, connected by air and economics. The global health community must be guided by principles of logic and science rather than politics, economics and emotion, if we are to truly prepare against future pandemics.
#5 Ron
December 29, 2006

The Indonesia situation should be of deep concern. If I understand what Henry Nimian and others are saying, the strain of virus that is killing so many people is *not* the strain that is infecting, and sometimes killing, so many birds. This means that the transmission that is occurring is no longer bird-to-human, as almost everybody, WHO etc., is assuming. I would say that human H5N1 is already possibly ‘out of control’ in Indonesia, in the sense that we haven’t a remote idea of what is going on and are probably monitoring the wrong animals (poultry). Cats might be the link, but that is really just a wild guess. As the inimitable Nimian likes to say, this is ’cause for concern’. It could mean that the pandemic has already started. With a strain that registers 82% case mortality. I think that is scary. If I was head of WHO or some such I would be making lots of vaccine based on the the human H5N1 strain in Indonesia. Just in case.
#6 revere
December 29, 2006

MiH: The “code” is the general strengthening of public health and social services to make a more resilient and robust community to handle all the potential emerging diseases you suggest we might be in store for. WHO is not a world government, so it can’t decide to do anything its member states don’t want. The Security Council so far is the captive of the five major powers who control it and don’t want to give any power up (includes the US, of course, and the others).

Ron: Indonesia is of deep concern to everyone. Henry looks at sequences and has his own ideas about it but no one knows the relationship of virulence to the sequences at this point so he is speculating along with everyone else. The same with the “Replikins” crowd. What do you have in mind to do with Indon? WHO doesn’t make vaccine, BTW.
#7 mary in hawaii
December 29, 2006

Revere: that is exactly my point. WHO doesn’t, and should. the UN security council doesn’t, and should. We need to set up a body that DOES have ultimately authority over individual nations and concerns when it comes to a global health crisis of this nature….and perhaps only of this nature. If WHO can be revised to have that kind of power in that kind of situation, then it should be. That’s the simplist solution. But it will probably take a pandemic to make people see the light.

We are a global community: A pandemic will affect every nation, every population. How can we allow the short sighted and selfish interests of one nation or group of people endanger the rest of the world? That was the whole premise on which the UN was established, but it has failed. One might argue that the wars and conflicts it is supposed to prevent are potentially just as devastating as a flu pandemic (should they go into a global thermonuclear war). But so far the conflicts the UN Sec council has failed to prevent are regional, and so are the casualities they inflict. A global pandemic is the equivalent of that global thermonuclear war – at least as far as its effects on the human population of earth – in all ways except for the destruction of the environment and long term radioactive poisoning.
#8 revere
December 29, 2006

MiH: I couldn’t agree more. But we “one worlder” types haven’t had in easy time of it in the US. Randy will be all over us like white on rice. Someday, though.
#9 M. Randolph Kruger
December 29, 2006

But building it to code Revere would ensure that you would never get to use it. One worlders as they put it means that China will rule the roost. We now understand in the military we need a 100% kill weapon that is fast, easy to deploy and non-nuclear. Enter Trident II. Non-nuke, dropped from a F-117, B2, and or a Trident class sub. Kills everything in a 3000 meter area. If we deploy it, it will make quite a few people start looking to the skies if they become bad actors.

As for the WHO, their charter is to stop this stuff. So what do they do? They allow China and Indon to become pettng zoos for it… Not one squawk out of the Security Council. Why? Because its bad business for Sanofi, Sino-Vac, and everyone else. Hell, cant make vaccines you want to buy at inflated prices unless people are croaking. Oh by the way, you get to pay for the R&D for us to get rich….Nice!

MIH has some very good points but you know, maybe we should just prepare and not say another thing about this stuff and just let nature do the dirty work. This planet cant support what it has and its straining. If we continue wars will break out if nature doesnt do us. Ascribe to the global warming theory that this stuff we are seeing resurgences of is from that? I dont know and no one does, but its not a bad theory. Problem with it is that if true either by war or pestilence somone is going to have to go and soon. Too few resources. Perfect weapon-Boomers die off in say 25 years, bird bug smacks the living crap out of Indon, China and Asia,, Africa, and a good part of the Western world in the younger ages. Whats left? Only the strongest.. We are going to have a population of about 175 million unless someone gets busy pretty soon and in the next 25, else its swing the doors open for immigration. Lots to consider. One thing is sure though boys and girls, someone is about to get left standing during the musical chairs.
#10 Victoria
December 29, 2006

There are over 6.6 Billion people on earth; hundreds of countries, thousands of languages/dialects/cultures, economic strata, religions etc. Human beings, are ruled not by a single set of objectives, but by individual traits; greed, avarice, love, hate, family, family ties, revenge, stupidity, personal position, promotion, compassion, acceptance, lust, etc. etc. Often these traits become the foundation of their respective communities/states/countries.

Since the beginning of recorded history, dominant nations/dictators/kings and the like have all ultimately failed because of this individualism: the Romans, the British, the Greeks, the Aztecs, the Mayans, etc. There is not one country, not one power, nor one group of people that will accept the dicta of a �controlling� power or country. (For example, any group wishing to impose a set of international regulations over African peoples are likely to be branded by the Africans as neo-colonialist and racist. Not true, but unavoidable� ).

Yes, the world is getting smaller, we can now travel faster, and we can communicate faster (sometimes), but that is all. Technology cannot change the human condition.

In theory, the United Nations is the only body that could maintain world orderliness and by extension, hold individual nations to account. But it too is subject to the same human conditions laid out before. It is testament to this individuality that the UN also has become the toothless tiger.

So instead of worrying about how to achieve complete world obedience, perhaps the august readers of this blog could commence thinking outside the box and come up with truly global solutions. My intuition tells me that a matrix of loosely bound yet all encompassing/intermingling solutions will be far more effective that a single dictate.

Our human individuality may well be the reason why we will have another pandemic.
#11 M. Randolph Kruger
December 30, 2006

Vic-Hey dont get me to lying…I agree. But it is our individualism that makes us what and who we are. I am not just going to lie down for this stuff. NO WAY! Been thru a lot worse and I can tell you it was a lot worse with body counts and I mean that in the plural sense. They dont want the UN to have any power. Toothless tiger? Sheyit, it didnt have any teeth and you are right all civilzations have fallen, giving rise to other civilizatons. Bird flu would be a slate wiper if its high path and has the adaptive mutation in it. Swack us for years with that little bump on its genetic pattern. Each year or so some new kick assed version would merge up and come to visit.

As far as I am concerned the best way to play the game is not to play it at all. The UN is not able to unite or govern. It should be dissolved and reinstituted with no shit teeth. I would lay down my swords as long as I knew that we would respond against ANY agressor that did incursions, attacked school buses, bombed villages and generally laid down the law that like Gort, we will fuck you up pal if you lift your hand to your neighbor.

With than in mind then I would turn to Revere and say okay, you got your healthcare package you wanted. Its quid pro quo. Something for something. I dont know of anyone who has been in a war that liked it if it were up close and personal. We need a society thats not THX 1138 but Gort, plain and simple. But it wot happen. No one makes any money off of living, only dying.

Quick note-73% of all of the birds in Central Vietnam tested are positive for H5N1 and THIS IS AFTER our little rice propelled friends have been assuring us for the last year that all was cool and that their vaccne was nice and working. Just like the Chinese. They will of course blame it on the Chinese rightly or wrongly but the effect is the same. We are in deep shit now. Thahn Nien Daily also is reporting six suspected human cases from eating sick birds.

Revere, doesnt that mean that the receptors are functional now in the mouth, throat, nose (maybe stomach) to acquire H5N1 if they ate a sick bird. Its an assumption of course without all the details but likely a good one.
#12 Victoria
December 30, 2006

Hey Randolph – you get no arguments from me. I don’t hold out any hope that we will avoid the pandemic. We are well over-due for a doozie. Life will change dramatically after the pandemic, let’s just hope it is for the better.
#13 marquer
December 30, 2006

In california they build their buildings to code to withstand earthquakes because they know earthquakes happen.

We do.

Although every single time there is a large quake (most recently the Northridge event in the 1990s), what seismic and structural engineers learn empirically is that the code is not yet sufficiently sophisticated.

Before Northridge, it had been thought that welded steel moment frames in tall buildings were the gold standard for stoutness. It was learned post facto that these have the habit of cracking at the welds. Which greatly reduces their strength and safety in future quakes. And the bloody things are incorporated into buildings in ways such that they are very difficult to retrofit and upgrade.

I suspect that, similarly, a bird flu pandemic will blow up even careful preps in various unanticipated ways.
#14 caia
December 30, 2006

MiH:

Take for example the hajj: in the current situation – teetering on the brink of phase 4 or 5 – should this have been allowed to take place this year?

Why single out the hajj? Why allow the World Cup to take place last summer, or the Olympics in 2008? Why allow international conferences, or tourism in Southeast Asia? Why allow the rotation of troops in and out of Iraq to take place? Any or all of those could or could have facilitated the spread of a disease around the world.

It is easy, here in the U.S. to question the wisdom of holding a religious observance not observed by the vast majority of people in the U.S., because we’re not asking us to give up something important to us. But any world body applying pressure to stop the hajj would be met with a thousand times Bill O’Reilly’s fury over his imaginary War on Christmas, and with better reason.

It would also potentially alienate a fifth or sixth of the world’s population, whose cooperation WHO et al. very much need to control all manner of public health problems, including avian flu.

If there were evidence of H2H in Saudi Arabia right now, then discouraging people from attending, limiting the international permits to attend, and setting up screening processes, would be appropriate. With the cooperation of the Saudi government and respected mullahs, cancellation could be an option, too, (although in a normal year, hundreds of thousands of people with out permits attend anyway).

As it is, suggestions like cancelling the hajj could sound more like reflexive fear of Muslims than like necessary public health policy. I don’t that’s true in your case, but it could be read that way.
#15 M. Randolph Kruger
December 30, 2006

Caia-but its a reasonable view. As far as cooperation, they would or they wont. Indon is cooperating kind of but money goes in and nothing productive happens. They are also heading to the Hajj and one airplane could kill the world. Cancellation? How about the planet getting cancelled. No its not a personal or religious thing. If this comes and a country refuses to participate in keeping themselves as clean as possible and else for that matter, then well there are methods to take care of that. Talk about alienation of a religious group.

IMO they could go to the Hajj but once the outbreak happened, they wouldnt be coming back or I would show them the way to the nearest ocean via an interceptor as long as it wasnt already out and breaking. And I wouldnt hesitate to do it. Everyone can harp and complain but if this comes, the militaries around the world are going to be in charge and their tolerance for things non military are uniformly zero. We try always to apply sanity to something that would go insane almost overnight. It aint going to happen. I have a lot of friends that are Muslims, served with one or two. VERY fierce fighters and I wouldnt want to piss them off on a good day. On the other hand those same Muslims that would be complaining would be the first ones to go down in a pandemic. Not my Muslims though. They are smart, reasonable people and they hate the fact that there are Imams who issue the fatah’s that we are the enemies and should be converted or killed. I want them at my side if this breaks out. They will be a good representation for the future of Islam afterwards.

As for the code. This is and will be the new code during a pandemic and then for some time to come after. You have the right to do as you are told, failure to do as you are told will result in starvation or your death. You have a right to an attorney and one will be appointed for you if you cant afford one, but only when the courts open back up. You were caught stealing food and since its a state of emergency and/or martial law we dont have the people to incarcerate you. You will just be shot. Do you understand these rights as I have explained them to you?

How to prevent that would be as Revere said…Beef up the health care capabilites along with more importantly the food supplies. Thats the true vaccine right now-food. It of course wont work to beef up the health system and at the very least thousands would be sick but it will save many. I havent seen a thing that indicates that going to the Hajj would change the outcomes if they were sitting in Mecca, or Teheran or in the First Baptist Church. It will span the globe in about two months regardless of what we do. The demon is out there and he is hungry, he will feed until he gets his fill and moves on, Hajj or not.
#16 caia
December 30, 2006

Randy, my point was, why single out the hajj? There are vast Hindu pilgrimages in India too. Granted, those mostly involve people within India, but then, there’s been b2b in India.

Yes, the hajj has hundreds of thousands of people going to a central location and then going home with whatever they may have caught there. But the central location isn’t in a country that has any confirmed b2b, so far as I know, let alone h2h. Mecca isn’t in Indonesia.

If the concern is Indonesians bringing H5N1 to Mecca, then the reasonable restrictions would be directed at Indonesians, not at the entire event. Even that would be a bit of stretch at present, since while h2h has occurred in Indonesia, if it were efficient and widespread, we’d have a lot more dead people.

I appreciate that different rules would take effect during a pandemic, but since that’s not yet now, it seemed to me that it would be precipituous and unnecessarily alienating to cancel the hajj. Especially as a sole example.

And especially when it might actually be necessary next year or the year after. I’m all for caution, but if WHO had recommended cancellation of the hajj now, they might not be able to do it next year, even if the danger were greater. They may get to fire that gun exactly once. I’d rather they wait to fire the “this big event cannot go forward” gun, even if it means it’s my World Cup that gets cancelled.
#17 revere
December 30, 2006

caia, Randy: And there is Ford’s funeral (people coming from other parts of the world), world tourism, the Rose Bowl, not to mention the adventure in Iraq. Doesn’t history teach us that disease follows armies?
#18 mary in hawaii
December 31, 2006

Why single out the hajj, you ask. And why now. Ok, first of all it has absolutely nothing whatsoever to do with the religious aspects. That’s all I can say. It is in no way anti muslim, anti arab. Believe that or not, your choice.

However, all those other comparable events you cited (“why not ban the…”) are nowhere near comparable by at least one order of magnitude in sheer numbers alone. The estimates at this point are that three million (3,000,000) are in attendance at hajj, not the “hundreds of thousands” (e.g., 300,000) you cite. And it is not just a matter of volume.

Pilgrims are sheltering together in enormous tents along the way, tents that according to news reports – though huge – are so overcrowded that some attendees choose to sleep outside, even though weather has been poor. May I remind you of the Karo cluster, where several family members contracted the flu from the original case as a result of simply sleeping in the same room with her? So that’s another difference between hajj and say the world cup or Gerald Ford’s funeral. Literally millions of people sleeping, eating, and congregating in prayer and other activities, for 6 full days. They don’t congregrate to anywhere near that degree at these other events you mention.
I also read that these thousands and thousands of pilgrims are loaded into packed buses every day to make the journey from one site to the next…again closed quarters, contained air, close proximity.

In addition are the generally poor conditions for health: reports say that the weather this year is very bad, and people are getting sick from exposure. Also the rigors of the pilgrimage itself every year cause deaths and illness from physical stress related disorders. (heart attacks, etc.)Immune systems weakened by physical stress increase the likelihood of catching the flu, and that in turn increases the likelihood that any H5N1 viruses lurking in a few of the participants might mix with other flu viruses in the ill, allowing for the reassortment or recombination events that could give H5N1 its pandemic capabilities.

Now, why worry about it this year? Why not wait until next to complain? I don’t know…maybe because there are a number of outbreaks of Human cases in Indonesia, Vietnam and Egypt under investigation at this very moment. Maybe because someone from Indonesia’s “Expert staff” is intimating that the reported cases this year in Indonesia were just the tip of the iceberg, and that there were many illnesses and deaths from bird flu that went untested and unreported. Maybe because the virus in some areas has already acquired many of the genetic changes it needed to become more easily transmissable in humans.

Maybe because next year may well be too damn late!!

Now, I am all for religious freedom, freedom of speech, freedom of the press and all the other individual rights and freedoms we have been granted or taken or assumed. However in every case, the granting of individual freedom was never supposed to supercede the general good. That is to say, you can worship whoever and however you choose, as long as in so doing you do not bring harm to me and my loved ones. That is my bottom line. I do not think that people have the right to put the entire world in danger of the kind of horrific death and destruction that this pandemic may cause, for the sake of their desire to fulfill a religious ritual. Why can’t THEY do hajj once the danger is past, for that matter? They have a whole lifetime and only need to do it once.
Final word, Caia….would you still say this while sitting helplessly at the bedside, watching your child or lover or parent die from a pandemic brought to your city or country from a hajj pilgrim? Would you still say they had that right?
#19 M. Randolph Kruger
December 31, 2006

Well I am going middle on this Mary. As I have said before, if it breaks at the Hajj or anywhere else for that matter it wont make a whit of difference. It will still get in somehow eventually. Its a pandemic not an epidemic. and I dont think they have ever stopped one including SARS. So Hajj or not, let them go and if someone breaks with it, you do all things necessary. That includes diversion to prepared airports and they are out there. And if necessary and they dont want to turn to them or away from our airspace, we shoot them down and that would include my family if they were on it. Do they have the right if they know they have it? Not in your eyes or mind. What if it were to get some of that healthcare that we all want so bad?

I do have an answer if it breaks out this weekend. We can blame the Republicans, Gerry Ford and Richard Nixon for the carnage. It will make all Democrats feel better. A Republican Hajj is underway to the Beltway Mecca. Gerry Ford was not elected but he was up to the job. So they cant hammer him too terribly bad. I am sure Hillary will make an appearance to show her “human” side. Lets hope they do bring bird flu if thats the case.

Okay everyone lighten up now…. Its New Years Eve and time to drink and act a fool and get away with it. Now everyone remember these words, “No officer, I am not refusing to take the test. But the Supreme Court has ruled that I may have my attorney present at all times to advise me of my rights.” You’ll go to jail, be fingerprinted and get your call. They cant force you to take a test. The burden of proof is on them.

Happy New Year and dont call for bail money.
#20 v
December 31, 2006

Randolph, I’m with you on that one. Happy New Year
#21 crfullmoon
December 31, 2006

No need to; don’t drink

Musical chairs? “about to get left standing”? -more like left horizontal at ambient temperature…
Hope for the best, if you can, but,
prepare for the worst, ’cause we must.

Happy New Year.

“Indeed the number of deaths in 2006 exceeded the total of deaths for 2003, 2004 and 2005 combined”

Handy point, in case anyone tells us time without a disaster means no disaster possible, earthquake or otherwise, when they review this past year.