Effect Measure

If I knew for sure what was going on with the reported human bird flu outbreak in Pakistan’s northwest border region I’d tell you. At this point it appears no one knows for sure — not WHO, not CDC, not even the Pakistani authorities. The region where the cases are reported is near the Afghan border and is not under firm government control. The unsettled political situation merely adds to the usual confusion inevitable in the early days of any outbreak. We are all looking for a pandemic signal embedded in a lot of noise, difficult enough, but we don’t even know what the signal sounds or looks like. It is now Sunday evening in Geneva and after midnight in Pakistan, so this is as good a time as any for a summary. I doubt more information will be available before tomorrow (Monday, December 17, 2007).

As best I can tell from scanning the reports, this is the current status. I am synthesizing and using my best judgments among conflicting and confusing news and official reports. Some of this may change. At this point there appears there are two (or three, depending on how you count) groups of cases, one a family cluster involving four brothers and two cousins (with two deaths); the other involving three workers involved in culling infected poultry,including a man, his niece and a third unrelated person who, however, worked at the same farm as the index case.

The index case was one of five brothers, an agricultural official who worked on a culling operation on an infected poultry farm and fell ill in October. He has since recovered. Two younger brothers who visited and nursed him in the hospital, however, fell ill and died. Both were students at an agricultural school, so may also have been exposed there. One was said to have been confirmed to be infected with H5N1 by testing at Pakistan’s National Laboratory. Specimens are being sent to a WHO reference laboratory for definitive confirmation. The other died and was buried before there was suspicion of H5N1 infection. A third brother, a primary school teacher who also visited the index case, developed mild symptoms and has recovered. Testing on him was not complete. A fourth brother, living in the US, traveled to Pakistan for the funerals of his siblings. There are conflicting reports whether he showed any symptoms. Upon his return to the US (Nassau Country, New York) he notified his doctor of a potential exposure and voluntarily quarantined himself in his home. Subsequent testing by CDC and the New York Health Department showed he had not been infected (his son was also negative for infection). Two cousins of the family are also reported to have had mild symptoms and to have tested positive. We have no exposure information on them at this time. They have since recovered. The three cull workers also have recovered. Finally, a doctor involved in the care of the index case was well but a non-standard diagnostic test (not specified) showed she may have been infected.

Meanwhile there is time for fingerpointing in Pakistan, which I take to be a good thing. That usually happens when people aren’t so fully occupied with the crisis they have no time for anything else (see excellent reporting over at Avian Flu Diary [link fixed; ht GMan). The politics of this region are complex and multiple agendas are in play simultaneously. Reports of some additional suspect cases are not only expected but desirable. In this setting there should be high index of suspicion, with a diagnosis of H5N1 in an exposed person with flu-like symptoms a rebuttable presumption of avian influenza. It will take some time to sort all of this out. WHO and CDC are collaborating with Pakistani authorities. Some additional diagnostic confirmations may come tomorrow (Monday) or Tuesday.

To sum up, as best we can tell there are possibly nine cases and two deaths (one buried before testing could be done). We are told three of the cases (brothers) visited or tended the index case in the hospital. Thus this cluster is suspicious for person to person transmission of the disease. While there were two fatalities, most of the cases have recovered, very different from the pattern in Indonesia where most cases have a fatal outcome. The Indonesian case fatality ratio [CFR] is 80% and the overall CFR just over 60% but it is driven by the very bad outcomes in Indonesia. The CFR outside Indonesia is just over 51%. Vietnam’s CFR is less than 50% and Egypt and Turkey lower still (see latest WHO compilation of confirmed cases), so the apparently better outcomes so far in Pakistan may not be so unusual. There is always the possibility that this is a milder but more transmissible variant.

Meanwhile it is reported that Tamiflu has been rushed to the area “for treatment and prophylactic purposes.” We don’t know who is being treated or prophylaxed, if anyone. Pakistani hospitals and clinics have been put on alert. Like everyone else, we’ll await further developments.

(some sources for this summary here, here, here, here, here, here, here)


  1. #1 Joe Six Pack
    December 16, 2007

    Trading lethality for transmission?

  2. #2 Carl
    December 16, 2007

    Hi – I’ve been in Atlanta (non-public health related)over the weekend so catching up. Would not pretend to second guess public health expertise on board but have some familarity with regional politics. Please take this as observation and not political pejorative: Some Islamists in remote regions of NW may encourage belief H5 is U.S. plot / doesn’t exist etc. (seen similar with Polio campaigns in Northern Africa). I would suggest factoring into analysis intentionally “burried” cases dismissed as something else due to lack of belief in H5 (additional “burried” cases in other finger pointing situations already addressed by Revere). With significant areas outside gov’t control, under al-Queada influence, I would suggest considering this in analysis of numbers. Widespread real infections would become evident but it might create some additional delay ability to pick up early signals of such.

  3. #3 revere
    December 16, 2007

    Joe: Possible but not necessary. See a previous post here.

    Carl: Interesting points. Disease is always intimately woven into the fabric of a community in very complicated ways. I assume there have been missed cases. The question is, is there a missed explosive outbreak? Could be, but I doubt it.

  4. #4 Patch
    December 16, 2007

    Thanks for a great job of summarizing Revere. I appreciate you objective view. Thanks.

    As usual, I’m having trouble sorting through the hysteria at some of the other sites.

    I have nothing but my previous news watching experience to go on, but my gut feeling is that this isn’t the explosion we all fear.

    I still think of the Turkey clusters a few years ago that scared me to death. I just recently donated several nearly expired “canned good” items to our local food bank that I procured during that time.

    From that experience, I learned to stay on the alert, but rational. I just want you to know that this is where I come to get an update on the real situation. You and the good folks here are wonderful.


  5. #5 M. Randolph Kruger
    December 16, 2007

    Pandemic panic? Well I for one aint there just yet. If the numbers continue to increase and its so easy for one guy to hit the dusty trail I hope that Osama doesnt find anyone to send to New York to visit for the holidays. Pandemic 4 criteria has been met or exceeded several times in the last year or so, but they never raised it.

    This one is moving right along though. If they get a handle on how many cases then we might be in trouble, or not. I fully agree with the CDC evaluation of 50 people or more that are brought in undiagnosed quickly in a metro area anywhere in the world. If the numbers continue to increase from that point then I would say that the gig is over. Someone will be on a bus, a plane, train, or boat without even knowing they are sick. This guy in New York had to have transited either Rome, Frankfurt, or Paris on his run back to the US. Hello Andrew Speaker.

    To his credit he volunteered that he might have been infected and turned himself in. Fortunately he isnt infected else we might be getting our ropes out by now.

    Key to what happens next? Watch for additional cases. Reaction will be swift and to the point. If its out there then they will BS us for a week to ten to get the right people into place and then the “big announcement” will commence complete with media hype, lack of facts and then general panic.

  6. #6 revere
    December 16, 2007

    Patch: Yes, I thought this was reminiscent of Turkey, too. With luck it will have the same outcome.

  7. #7 wenchacha
    December 16, 2007

    Will they bring out the Tamiflu blanket? How far is the blanket supposed to spread when it is used? How many Degrees of Kevin Bacon, as it were?

    Patch, good plan to stay rational, I think. I have absolutely no way of knowing, of course, but the bubbling could go on for a while before AF started to really take hold. On the other hand, it could go into hiding again, couldn’t it?

    All the more time to plan, prepare, publicize in the meantime.

  8. #8 Dipl.-Ing. Wilfried Soddemann
    December 17, 2007

    H5N1 avian flu: Spread by drinking water into small clusters:
    Human to human and contact transmission of influenza occur – but are overvalued immense. In the course of Influenza epidemics in Germany recognized clusters are rarely (9% of the cases in the season 2005).
    In temperate climates the lethal H5N1 avian flu virus will be transferred to humans strong seasonal in the cold via cold drinking water, as with the birds feb/mar 2006.
    Recent research must worry: So far the virus had to reach the bronchi and the lungs in order to infect humans. Now it infects the upper respiratory system (mucous membranes of the throat e.g. when drinking and mucous membranes of the nose and probably also the conjunctiva of the eyes as well as the eardrum e.g. at showering). In a few cases (Viet Nam, Thailand) stomach and intestine by the H5N1 virus were stricken but not the bronchi and the lungs. The virus might been orally taken up, e.g. when drinking contaminated water.
    The performance to eliminate viruses of the drinking water processing plants in Germany regularly does not meet the requirements of the WHO and the USA/USEPA. Conventional disinfection procedures are poor, because microorganisms in the water are not in suspension, but embedded in particles. Even ground water used for drinking water is not free from viruses.
    In temperate climates the strong seasonal waterborne infections like norovirus, rotavirus, salmonellae, campylobacter and – differing from the usual dogma – influenza are mainly triggered by drinking water dependent on the drinking water temperature (in Germany minimum feb/mar maximum august). There is no evidence that influenza primary is transmitted by saliva droplets. In temperate climates the strong interdependence between influenza infections and environmental temperatures cant be explained with the primary biotic transmission by saliva droplets from human to human with temperatures of 37.5C. There must be an abiotic vehicle like cold drinking water. There is no other appropriate abiotic vehicle. In Germany about 98% of inhabitants have a central public water supply with older and better protected water. Therefore in Germany cold water is decisive to virulence of viruses.
    In hot climates/tropics the flood-related influenza is typical after extreme weather and natural after floods. Virulence of Influenza virus depends on temperature and time. If young and fresh H5N1 contaminated water from low local wells, cisterns, tanks, rain barrels or rice fields is used for water supply water temperature for infection may be higher as in temperate climates.

    Dipl.-Ing. Wilfried Soddemann
    eMail soddemann-aachen@t-online.de
    Epidemiological Analysis: http://www.dugi-ev.de/TW_INFEKTIONEN_H5N1_20071019.pdf

  9. #9 bar
    December 17, 2007

    If you had lots of investments, and you heard that H5N1 had gone H2H, what would you do?

    I notice there seems to be a lot of selling on the world bourses. Pharmaceutical companies seem to be rising strongly. (Rigel, 5.7%, Marin 22%)

    I smell a rat.

  10. #10 PFT
    December 17, 2007

    In China there are a number of people who believe the US created SARS due to it’s propensity to affect Asians and not Caucasians. In Canada most of the victims were Asian.

    Some feel the same way about H5N1, and this could explain the reluctance for some of these countries to share samples with the West, thinking this will assist us in perfecting the H5N1 to wipe out a big hunk of Asians.

    In Pakistan, it’s interesting that the people are being told it does not exist. Probably to keep the fear level down as those same fears that the Chinese had could come up. Fear as we have learned can lead to the people asking for more security, and can cause instability in a government, local or national, that does not have the tools to deal with the terror, natural or man-made.

    Other Arab nations have also been affected with human spread of H5N1 but nothing in Europe or the Americas.

    As much as I like conspiracy theories, I have a hard time with that. But if H5N1 takes off from NW Pakistan, I might rethink it. Comes down to a choice between Coincidence Theory and Conspiracy or Accident Theory. Too many darn coincidences and accidents the past 7 years.

  11. #11 M. Randolph Kruger
    December 17, 2007

    PFT-WADR do you honestly think that we in the US could engineer a virus that would only eat Asians? Do you know how many Americans of Asian descent there are here? It would be like Falwells suggestion that AIDS/HIV was Gods vengeance upon homosexuals. Only problem with that is the plain fact that it affects more hetero’s than homo’s. Reality check.

    As for SARS it came from Civet Cats. A Chinese raccoon by any other name. Hell, I had to look it up to get a picture of the thing. It was also a corona virus. A virus not previously thought to be able to eat humans much less Asians. In addition, those were Canucks that were affected here in the US and not Asians. I think the last word on it was that 43 people were infected badly and they were Caucasians. The Chinese also could have immediately come clean about SARS with the world but didnt. So really whose fault is that?

    I too trust no government on this planet but I also have to work within the system. Shit, I am part of it if BF breaks in the US. I am committed with a large insurance policy on my country butt to work during this thing. If I get infected, then because of my age and possibly my ethnic background I MIGHT survive. On the other hand I would not make the supposition that it was “engineered” any more than I would the Belgian connection to polio. Shit happens. Mistakes are made.

    My guess? There are too damned many people on this planet and we have gone politically correct on so many things from relations with our fellow man, to wars, waterboarding, and diseases. Everyone has bought into the idea that having people alive is a good thing. Even though they become almost non productive by age 65. Sorry but someone has to go.The resource list is dropping and even UHC ends up with what? More people alive in a system that is already unable to properly support about 3.5 billion. So lets keep more alive by dumping resources into them? I dont agree or disagree. I just throw it out there for conjecture.

    IMO its survival of the fittest and save the seed corn from every race and country if BF comes. They are our future. Revere in his wisdom recognized that by taking his life in his own hands the other night in a blizzard to grab the grandson. With the resources he had in hand he was able to effect a rescue. There isnt anything he wouldnt have done to get to his grandson. His son knew that Pop would take care of it or go down trying. If this had been a BF event and the power was out, son was sick along with young mom I guarantee you that he would have done just that to protect him. He always says he is too old to prepare. Think again. If BF comes he might have too to protect the youngest Revere. God forbid, he might end up having to raise him.

    This is where we are with BF. There are the grasshoppers, there are the ants. The cool breeze of September was two years ago with BF. Still time for the grasshoppers to prepare, but they havent. The ants though have prepared for winter, then seeing a lull doubled their efforts and tried to get some of the grasshoppers to become ants. Some have. Most havent.

    I can only think of the sounds we are going to hear that are going to tear at our souls if and when it comes and how people will do things they would have never have done if it comes high path. There really isnt any way to engineer the flu virus to a point that it wouldnt go after us all. Vektor tried and failed as each time it went runaway and mutated beyond their capability to make a vaccine to stay ahead of it. They gave up some 20 years ago and decided on some really nice Ebola, Anthrax, Tularemia etc. to use as weapons. Now those we can control to a certain extent… but not flu.

    Vaccine? Shit, that vaccine would be boutique at best. Might provide some protection for some very few, but alas our friend the flu virus would mutate beyond that particular freshly made, untested Kool-Aid within a month or two. The vaccine could kill you as indicated by Dr. Webster and his known cure for BF in his freezer. The cure though might leave you crippled and organ damaged permanently with lungs so scarred you would be an invalid in a post flu world. Not a pretty thought.

    Be advised I asked the same question about coincidences and accidents of my parents in 1979 when it seemed that the world was about to go under the holocaust with Carter as President. Nope they said, its been a lot worse. So I went with it and this particular stuff BF is our scourge of our time. We might get to see a really bad deal run out of Pakistan, maybe not.

    I suggest you go to something called EM-DAT in a web search. The randomization of what is happening is not random. In fact what you are seeing is cyclical. Each time something has come along and culled the people when we have gotten a population to the level it is now to the food supply. Its a natural occurrence and likely God has little or nothing to do with it. Vengeance is mine sayeth the Lord, but it doesnt say he will come back every century or so to visit plagues upon the earth. Shit, why send plagues? Its messy. Send an asteroid instead and it swacks so many.

    Thats my read on it and I have to stick with it unless you have something more than the conspiracy or random accident theory. You could be right and I respect your suggestion, but I doubt it.