Effect Measure

A concise summary of some additional developments, courtesy Bloomberg:

Three teachers and 22 students from Auckland?s Rangitoto high school are being tested for swine flu after returning to New Zealand?s most populous city from Los Angeles following a three week trip to Mexico, Stuff.co.nz reported on its Web site. Some of the travelers had symptoms of flu-like illness and were being isolated as a precaution pending test results, it said, citing the Auckland?s public health service.

In the U.K., a British Airways Plc crewmember with flu-like symptoms was taken to Northwick Park Hospital, in north London, for tests after arriving yesterday on a flight from Mexico City, British Broadcasting Corp. reported on its Web site. [NB: Bloomberg now reporting the crew member does not have swine flu.] (John Lauerman, Jason Gale, Bloomberg)

Add to this two additional cases in California, bringing the US total of lab confirmed cases to 11.

Now for the zombie idea (promoted to some extent by WHO) that we could ever bottle up an incipient flu pandemic by containing it at the source. As we have pointed out here too many times to count, that never was in the cards for a disease that hides itself in the background noise of prevalent respiratory disease, is difficult to diagnose, and for which there is little good surveillance in most countries. But because it was held out as a possibility, there is a faint whiff of recrimination in current news accounts. First, the premise as seen in a piece from Bloomberg:

The virus has already evaded the first line of defense that health officials had hoped to use against a pandemic. International flu experts preparing for a pandemic had planned to contain the initial outbreak of a new, lethal strain of flu. The swine flu virus has already spread so far in Mexico and the U.S. that the containment strategy is out of the question, said Anne Schuchat, interim deputy director for science and public health programs at the Centers for Disease Control and Prevention, the Atlanta-based U.S. agency.

?We don?t think we can contain the spread of this virus,? she said yesterday in a conference call with reporters. (John Lauerman, Jason Gale, Bloomberg)

Now, the consequence, as seen in today’s Washington Post under the headline, “U.S. Slow to Learn of Mexico Flu”:

In the wake of the 2001 terrorist attacks, the outbreak of severe acute respiratory syndrome (SARS) in 2003 and the more recent emergence of H5N1 bird flu in Asia, national and local health authorities have done extensive planning for disease outbreaks that could lead to global epidemics, or pandemics. Open and frequent communication between countries and agencies has been a hallmark of that work.

Whether delayed communication among the countries has had a practical consequence is unknown. However, it seems that U.S. public health officials are still largely in the dark about what’s happening in Mexico two weeks after the outbreak was recognized.

Asked at a news conference yesterday whether the number of swine flu cases found daily in Mexico is increasing — a key determinant in understanding whether an epidemic is spreading — Anne Schuchat, an interim deputy director of the Centers for Disease Control and Prevention, said, “I do not know the answer to those questions.”

[snip]

In recent years, Mexico has done extensive pandemic planning with Canada and developed a close relationship with the National Microbiology Laboratory in Winnipeg. Tests on virus samples from the Mexican patients suggested the strain was different from this year’s flu. So on Monday, Mexican officials sent lung and throat swabs to Canada to be characterized.

The CDC, in Atlanta, is one of WHO’s four “reference laboratories” for flu. It routinely gets samples from Mexico and many other countries, and processes them with great urgency, Nancy J. Cox, the head of the flu lab, said last night. It, too, eventually received the Mexican samples.

“The only reason the samples went first to Winnipeg is because the paperwork is easier. We were in a rush,” Hernández said.(David Brown, WaPo)

Canada got the clinical specimens on Wednesday and within 6 hours told the Mexican authorities it was the same swine flu virus that CDC had isolated in California. The next day (Thursday), Mexico alerted CDC and the Department of Health and Human Services (DHHS) that they were having an outbreak with the same virus as in the US. The Mexicans then sent specimens to CDC in Atlanta.

The idea that flu could be contained at the source was always a WHO pipe dream. Their flu people knew it couldn’t be done but WHO suggested it might just be possible anyway. Now they see the bitter fruit of this. There is another relevant fact that should be mentioned here. CDC is an agency on organizational hold, with an Acting Director. As public health professionals they are doing a heroic job, but they depend on DHHS, of which they are a part, for building government-to-government relationships. Those relationships suffered badly during the Bush years, with the result that Mexico had a better and more comfortable connection with Canada than the US. So why hasn’t the Obama administration righted the problem? Because, among other things, there is still no Secretary of DHHS. Obama’s nominee, the highly capable administrator Kansas Governor Kathleen Sebelius, has had her confirmation held up by Republican ideologues playing abortion politics.

If ever there was a time when we needed strong leadership at DHHS, this is it. Playing politics has consequences.

Comments

#1 Lisa the GP
April 26, 2009

:winces at the political angle:

New Zealand might just possibly have a shot at containment, but I doubt any other country could accomplish it. Maybe some other islands–Hawaii or Guam, maybe, or Japan (or just Hokkaido).

I know! Easter! Ascension!

Kwajalein!
#2 Bossman
April 26, 2009

Is anyone testing the rest of the passengers on the plane?
#3 Mike Dunford
April 26, 2009

Maybe Guam, but definitely not Hawaii. There’s way, way too much tourism for that.
#4 Ecosse
April 26, 2009

The 11:00 am news on BBC News 24 reported that the BA crew member has tested negative, but they showed the NZ Health Minister’s press conference, where they seem to think they can contain it. I would imagine it’s far too late for that.
#5 revere
April 26, 2009

Ecosse: As Lisa notes, NZ has an outside chance because it is an island with good border control. But I agree with you: this cat’s out of the bag everywhere. We should be trying to think how to manage the consequences.
#6 Andrew Jeremijenko
April 26, 2009

I have written how difficult containment is and that has come from practical experience while in Indonesia. The lack of containment does not surprise me, but I am still surprised at WHOs reluctance to increase the pandemic phase level. I would like to remind everyone of the definition

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic.

(There were a number of clusters with probable human to human transmission in Indonesia. The largest cluster of 8 people in Karo, Sumatra, Indonesia in 2006 had verified human to human to human transmission but the level was not raised at that time. Perhaps they were right, but in my view the world became more complacent regarding pandemic planning after that. Potentially an opportunity was lost.)

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region.

The WHO is no doubt awaiting further information before increasing the pandemic phase. How long will they wait? It should be pointed out that many governments and companies have pandemic plans but they are loathe to act before the level is raised by WHO, which means those countries and companies may be currently underprepared.

I understand that there are politics that influence these decisions and there is a need to ensure they are scientifically justified. There is also a need for WHO to be seen as decisive and ahead of the game, not behind it.

I think the WHO have missed an opportunity to ensure the world becomes prepared quickly by not raising the phase in the meeting on the 25th April. 2009. Let us see what the future holds, but my view is the level will need to be raised to level five relatively promptly once they have the scientific confirmation they are waiting for. I just hope that does not take to long.

Andrew

AS RISK OF PANDEMIC INCREASES
􀁺 (eg moving from phase 3 upwards), move stockpiles closer to end user:
􀁺 Stocks for 10 to 15% of the population at least at a central level in the country
􀁺 Initial stocks moved peripherally with mechanisms for ongoing procurement
PANDEMIC WITHOUT PREPAREDNESS – focus efforts on
􀁺 Social mobilization to promote respiratory etiquette/hand hygiene and keeping
physical distance from others (social distancing)
􀁺 Infection control in HCFs
􀁺 Supportive case management at home and in HCFs
As the risk of a pandemic increases (e.g. moving from phase 3 upwards), move
stockpiles closer to end user:
• Stocks for 10–15% of the population at least at a central level in the country (e.g.
phase 4)
• Initial stocks moved peripherally with mechanisms for ongoing procurement (e.g.
phase 5)
NOTE: concrete actions for phases cannot be given as phases may be skipped altogether
– but rather the principle of moving stocks closer to end user as risk increases (as indicated by WHO).
Pandemic without preparedness – focus efforts on
• Social mobilization to promote respiratory etiquette/hand hygiene and social
distancing
• Infection control in HCFs
• Supportive case management at home and in HCFs
#7 Andrew Jeremijenko
April 26, 2009

Addendum

This is the revised definition of Phase 6. WHO 2009

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

If for instance cases in New Zealand are confirmed as Swine Flu it may very will be that we may need to go straight to phase 6.

A jump from phase 3 to 6 is perhaps less optimal then a more stepwise increase. It leave many countries in the position of dealing with a pandemic with suboptimal preparedness. However if these international clusters are confirmed what option will they have.

Regards
Andrew
#8 Stu
April 26, 2009

So I guess no additional news from Mexico about the situation, I’d be interested to see if they are seeing additional cases and how seriously affected those were/are. A few years ago we would probably not have heard about something like this, but since everyone is primed by H5N1 there’s a hyperfocus and it’s hard to assess the real significance. At least for me.

I’m very curious about the apparent difference in severity between Mexico and the US, maybe it’s just the number of cases seen. Just have to wait and see, I really hope it burns out.
#9 Andrew Jeremijenko
April 26, 2009

I have spoken to an influenza friend and he has asked me to be cautious in what I write and not to induce panic. Of note there is a difference in the mortality rate seen in Mexico and the United States cases. It is important to study the viruses from confirmed cases and determine what differences may exist between them. There is still much unknown about the epidemiology that needs further examination. Furthermore the New Zealand outbreak has not been confirmed and thus it is premature to speculate whether it is or is not swine flu, though he agrees it appears epidemiologically linked. The epidemiology of that outbreak too, will need to be understood first, before the phase implications of that outbreak will be considered if it is swine flu. In his view it is premature to talk about raising phases, as there are a number of things that need to occur first. The consequences and ramifications in rasing a phase are well understood by WHO and he suggested we just follow the recommendations of WHO and CDC and not try to predict what will happen. I believe this is relatively sound advice, but do have a tendency to worry.
#10 revere
April 26, 2009

Andrew: My feeling is that it is not very good advice and typical of many public health professionals. At the same time he/she thinks we shouldn’t speculate, health officials are freely speculating amongst themselves and a high index of suspicion for flu A in recent travelers to Mexico is a publicly announced form of speculation. The attitude that WHO and CDC know best is also wrongheaded. First of all, CDC has all but said they don’t care what WHO’s threat level is. They are proceeding independently. Second, WHO has language about their threat levels that they have now made totally meaningless. By their description we are already at phase 5. If they decline to change the threat level they need to redefine the levels so that we all know what they are talking about. They should also tell us why they are changing the threat level language, if they do. They are behaving very stupidly, IMO.

If you want to induce panic, act as if you know things but aren’t telling the public. Then rumor and speculation will fill the information vacuum. Your flu friend is setting us up for that. The people who are panicking are the flu community. They don’t know what to say and they don’t trust the public with the knowledge they have. Big, big mistake.
#11 Andrew Jeremijenko
April 26, 2009

Revere,
Thanks, I think you are right that there are many conflicting opinions and speculations out there, and that communication of the information is not at a level that either of us are comfortable with. I was just putting another opinion of a friend that differs to mine and was trying to explain that there may be finer nuances that the WHO may read into their definitions that combines information such as sequencing data.

As stated when I read the definitions, I think epidemiologically we should not be at level 3 but I thought that during the Karo outbreak. Then it is Swine flu not Bird flu that rears its head.

I hope this Swine flu burns out like the Karo cluster. I am concerned that it may not burn out. However my information is now from the media and I am outside the inner circle. I am not privy to information such as sequencing data and some of the epidemiologica findings. While as my friend who told me to be cautious has more access to this.

If it does burn out, the WHO will be able to say they were right in not raising the level. Obviously if it goes worldwide and becomes a pandemic then they should have raised the phase earlier. It is always easier in retrospect. From my current position we have reason to be concerned about this virus and the phase levels, but there are others out there with more information than myself who differ.
#12 revere
April 26, 2009

Thanks, Andrew. I have a lot of respect for your opinion. You’ve been there. I am concerned that the opnion of your flu friend is too typical and too prevalent and representative of an attitude that gets us in worse trouble than the problems of divulging what we know. I can virtually guarantee that your friend is not privy to any information that would make a difference in the threat level. By not changing it WHO is in essence saying, don’t pay any attention to how we describe it. We don’t follow that. Just listen to what we say and take our word for it. We won’t tell you why we are saying it. Bad idea.
#13 Habebe
April 26, 2009

Take a look at these comments from Mexican health professionals:

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

Their accounts do not match the official story.
#14 K
April 26, 2009

I hope this will help those who want to close borders to realize that it is futile. Flu at least is going to get over borders no matter what we do. Should we strand all US visitors to other countries, empty our strawberry fields etc of workers, to stop something that can’t be stopped?
#15 CyberLizard
April 26, 2009

I’m just digesting all this information this morning. I hadn’t heard about it before now. My question is, what level of internal panic should I be experiencing? Keep in mind that I’m not part of the tin-foil hat crowd and conspiracy theories hold little interest for me. Oh, one more factor: my wife is currently in NYC, coming home tonight.
#16 revere
April 26, 2009

CyberLizard: You should never panic. That said, different people have different levels of personal concern about this. If you want to be scared shitless, look at what’s happening in Mexico. If you want to be reassured, consider that outside of Mexico, especially in the US, it has been a mild self-limiting disease. I wouldn’t be especially worried about NYC more than anywhere else (except Mexico and San Diego), since the chances are not that good she has had contact with someone from the Prep School or someone ambulatory but sick just returned from Mexico. But your mileage may differ. There’s room for every reaction and good reasons for each of them. Personally, I am too professionally engaged in this to be scared (although I am concerned). But then I’m a cancer epidemiologist and have a detached view of that disease, too. Consider the source.
#17 Shashank
April 26, 2009

Thanks a lot for this great information. I am a bit worried about this virus spreading to Asia. Mainly to the Indian subcontinent, Indo-China, China etc where it would be highly impossible to contain such a virus. Or maybe it has already spread but we haven’t heard anything from these places.. that’s even more dangerous. IMHO.
#18 ij
April 26, 2009

A question for the epidemiologists and clinicians.

In my experience, most people infected with respiratory or gastrointestinal disease seek minimal or no formal medical attention. When someone does make a trip to the doctor with “flu-like” symptoms, it’s exceedingly rare for lab tests to be run (again, my experience… maybe my doctors are just lazy). So how do the important dots get collected and connected? Presumably, only when symptoms become sufficiently serious to prompt hospitalization and/or the treating physicians have some reason to go beyond ‘typical’ sample collection and screening protocol.

Now to get to my question… where does an individual go if he thinks his case warrants formal attention — not, perhaps, because the symptoms are exceptional or severe, but because of the context? Let’s say, for instance, I have traveled recently to Mexico City, I’ve subsequently traveled to other countries, and I’m now back in my home country and sick with “flu-like” symptoms. Under normal circumstances, I wouldn’t give the symptoms any special thought and I’d just wait it out. But under the circumstances, I think my case might be of interest to epidemiologists and public health experts. So where do I go? Do I call my local doctor, probably resulting in advice to drink a lot of fluids, and get some rest? Do I call the CDC, probably resulting in… well… I guess the point is I don’t know… but I can imagine a lot of waiting on hold.

This is a hypothetical scenario, but I’m curious to know the public health/epidemiological perspective. Is the idea that we should “leave it to the experts” to eventually sort out when and where enhanced surveillance should be employed, and wait for them to translate top-down “strategic priorities” into changed behaviors at the ground level where patients and doctors actually interact? Or should there be a greater push to get critical advice out to individuals in certain risk groups so that more of the ‘critical’ dots can be connected a bit more quickly?
#19 phytosleuth
April 26, 2009

Revere, Nigel in posting above seems to be selling his product on your site.
#20 revere
April 26, 2009

phyto: Thanks. Thought it was a free online manual. He’ll be gone shortly.

ij: With that hypothetical scenario there is nothing to do. The person isn’t sick. If they knew they were exposed, a course of Tamiflu or Relenza might be appropriate, but it’s hard to know if you were exposed usually. With that scenario and flu like symptoms, the health care provider is supposed to do a nasopharyngeal swab, do a quick test and if it indicates flu/A send a specimen to the state lab for subtyping. They’ll take it from there. Of course not every provider knows this. Send them to the CDC website: cdc.gov/swineflu for direcdtions.
#21 Phillip Huggan
April 26, 2009

In severe cases do the gastro- symptoms onset at the same time as pneumonia? If diarrhea precedes pneumonia and if the two symptoms always appear together, diarrhea could be used as a marker to treat the deadly pneumonia before pneumonia symptons appear. Assuming treating pneumonia has survival efficacy.
#22 Steve H
April 26, 2009

As I work in a university hospital, it will be interesting to see what the administrators and infection control response will be this week. Even though we would be on the front lines of any swine flu outbreak arising from CAFOs, I’m not confident that any active surveillance measures were in place, and I’m doubtful that they’ll put anything in place. That said, I’ll be taking appropriate measures and educating my staff on the additional protective measures that they can take. Unfortunately its difficult for a hospital to take decisive action (such as 100% screening of all inpatients) because we likely won’t know good procedures for detecting it. Do quick kits react positively to this strain, and then the positives typed? We may not have this information for a few days, and we also need to understand why the Mexican outbreak has resulted in deaths and not the US cases. However, the death rate is at level at the we conclude anything from the few US cases. We will hopefully know much more by the end of the week.
#23 revere
April 26, 2009

Steve: CDC wants clinicians to do a quick test for flu/A and if positive send a nasopharyngeal swab to the state lab. The idea is that the virus is type A, the state lab subtypes for seasonal strains of H1N1, and if untypable it goes to CDC. I think they want to target people with febrile and respiratory sx with travel to Mexico, Calif. or Texas, but with it spreading it may be more general.

More details at http://www.cdc.gov/swineflu
#24 stu
April 26, 2009

Anyone have friends or family in Mexico? I’m wondering if they would be able to corroborate the BBC news postings about the hospitals. Until then I’m somewhat skeptical of that sort of news.
#25 Jon Schultz
April 26, 2009

Does anyone know how many people were infected in the first wave of the 1918 pandemic, how many died, and whether the virus spread worldwide or remained confined to one or a few geographical areas? What needs to be assessed – if this virus “burns out” within a few days or weeks, or spreads worldwide but causes mostly mild symptoms – is whether it will return sometime afterwards with greater transmissibility and/or virulence.

Also, I am continually puzzled by references to the 1918 pandemic as having a 2.5% case fatality rate. I have seen estimations that the worldwide population was about 1.6 billion people, and that about 30% of the population was infected. Thats 480 million infected and if 40 million died (and I believe Dr. Osterholm estimates 50-100 million) that’s one out of twelve or 8.3%. Revere or anyone knowledgeable care to comment?
#26 revere
April 26, 2009

stu: You should be skeptical. Wouldn’t it be better if the authorities provided information one way or another? Until that happens no one knows what to believe and some will believe what they want to or what their fears dictate or be in easy denial.

Jon: This discrepancy has been noticed before. There are lots of conflicting estimates of mortality, and worldwide it’s not an easy number to come up with given the state of record keeping (or not). So I can’t answer your (good) question.
#27 chezjake
April 26, 2009

Revere, according to the AP, several nations are now either banning North American pork imports or increasing their inspections of such imports. Is this in any way relevant to transmission of a swine flu virus?
#28 revere
April 26, 2009

chezjake: The rationale I could see is that we don’t know the reservoir. If pigs have it, then banning raw pork from affected areas might be like banning poultry from H5N1 infected areas. But these ideas have a life of their own. Border controls won’t do any good and may do harm, but we’ll probably see them. Same with airport “fever meters.” A trade war won’t help the global economy much, but a swine flu pandemic, even if mild, will also be a real brake.
#29 Pierce R. Butler
April 26, 2009

Now that the consensus among intelligent, informed people is that containment is a lost cause, isn’t it time for cable news talking heads to demand all-out emergency rush efforts to complete the US-Mexico border wall?

And thanks for highlighting to latest threat to health and lives from “pro-life” crusaders!
#30 Jon Schultz
April 26, 2009

Thanks, Revere. If that much is unknown, then, about the 1918 pandemic, then the CDC should certainly make that clear to the media, so people are not unnecessarily frightened by comparisons which may be invalid.
#31 stu
April 26, 2009

Revere, yeah it would be great if at least the Mexican government would be more responsive. I feel far better about the US, given the recent articles and updates by the various news agencies here. The states have been good about that too, from what I can tell. I guess it’s a fine line between responsive and panic inducing…

I’ve prepared for this, but need to make a call as to the severity of the situation. I’m not doing anything different except to monitor the news and get a few items that would be handy, while things are quiet.
#32 HealthDame
April 26, 2009

Revere:
You’ve put some of the most useful facts and discussion up on this topic that I have seen anywhere. With people getting panicked and conspiracy theories flying, it’s great to see that this kind of forum can keep its head about it, even if there is a bit of railing in the comments now and then.
#33 Jonathon Singleton
April 26, 2009

chezjake and revere, you might be interested in reading ProMED-mail’s veterinary and viral disease moderators “name-game” position on “human H1N1″.

This excerpt appears to be indicative of a scientific and political repositioning by ProMED via nomenclature — human to human exposure and transmission rather than animal/bird to human!?! What ya reckon, is the case, or do I need some sleep!?!

ProMED-mail — “Influenza A (H1N1) virus, human – N America (04)” (Sunday, April 26, 2009)

Excerpt, “[It] appears as if no exposure to swine has occurred among people who have come down with the current novel H1N1 virus. The virus has elements of human, swine, and avian viruses normally found in Europe or Asia. It is this genetic analysis of the virus which has really developed the level of concern for this outbreak. If there wasn’t a match with the US virus the fact that it is being transmitted out of season and in young, healthy adults might have even been overlooked.

So, in summary, the reason that we are calling this virus swine flu is the history and evolution of the virus. It also rests on the fact that some of the genetic analysis indicates that elements from viruses that have traditionally been found in swine populations are incorporated. However since we know nothing of how this particular virus has gotten into the human population but there apparently is no history of swine exposure, it probably makes more sense epidemiologically to refer to this simply as an H1N1 influenza virus.

To some extent a similar nomenclatural history has occurred over time with the H5N1 virus becoming known by its viral strain, rather than bird flu. At least with the H5N1 it can most often be traced to exposure to avian species. But in the case of this so called swine flu, there really does appear to be no exposure to swine and some evidence (father, daughter pair in the US) of transmission without exposure to animals. Realistically, however, the name seems to have stuck in the popular media already and the terms swine flu does reflect what we know about the history of some very important H1N1 viruses.

Unfortunately, this name will imply a simple, zoonotic transmission between swine and people, when in reality [its transgenic] origin and epidemiology is [likely] to be much more complex. Therefore, good epidemiologic studies in swine in Mexico could be very helpful in understanding this apparently new virus…

None of the US cases have any known exposures to either swine or poultry. To date, though epidemiologic trace backs are far from complete, none of the Mexican cases have swine or poultry exposures either. There are a couple of apparent family clusters in Mexico, so with that evidence and no recognized pig/bird exposures, it appears that we are seeing human to human transmission…

ProMED-mail’s veterinary and viral disease moderators have discussed the nomenclature of this condition, and have agreed that we should refer to it in the titles of postings as “Influenza A (H1N1) virus, human”, omitting the word “swine”. For now, at least, that is what we will do…”
#34 CyberLizard
April 26, 2009

I want to echo my thanks for your calm analysis of the issue. I have a feeling that the hysteria is only going to increase as this goes on.
#35 revere
April 26, 2009

Jon: I agree with ProMed completely on this and had already thought the same thing. Everything they say makes perfect epidemiological sense to me.
#36 phytosleuth
April 26, 2009

All this new testing will really help to explain what all the un-typed influenza strains are. Question: are they able to go back to those old samples and track H1N1 strains? Build a phylogeny?
#37 Russell Maugans
April 26, 2009

Could it just be a rougue or even a friendly gov’ts way of thinning population since we are (worldwide) on schedule to run out of resources in 140 years?
#38 K
April 26, 2009

Russell, since our weapons against flu are already compromised it would be foolhardy for any group to use the flu for population destruction as they might kill themselves. Also foolish to use a virus that resorts and recombines and therefore changes so quickly. They would only have to release small pox to get the job done. The vaccine works, can be limited and most of the population of the world is no longer immune. Flu is not a good candidate for bio-warfare or population reduction
#39 cojemema
April 26, 2009

Revere: “I wouldn’t be especially worried about NYC more than anywhere else (except Mexico and San Diego)…”

I live in San Diego, about 10 minutes from the US-Mexico border. I’d say our community is 40-45% hispanic. Many residents here frequently travel to Mexico to visit family. We even have co-workers who are US citizens but live in Mexico because housing is much cheaper there. They cross the border everyday to come to work.

Should we be worried? If so, what precautions should be taken (other than lots of hand washing!!)?
#40 Edna Mode
April 26, 2009

Revere wrote: [i]Steve: CDC wants clinicians to do a quick test for flu/A and if positive send a nasopharyngeal swab to the state lab. The idea is that the virus is type A, the state lab subtypes for seasonal strains of H1N1, and if untypable it goes to CDC. I think they want to target people with febrile and respiratory sx with travel to Mexico, Calif. or Texas, but with it spreading it may be more general.[/i]

Revere and IJ: This is exactly right. But practice on the ground is not ideal. My nephew spent 10 days in Mexico, returned on Sunday. On Wednesday he became symptomatic with ILI. Yesterday, after learning about the current situation, he went to the ER. He told them right off the bat that he was recently returned from Mexico and had ILI (including fever). Instead of isolating him immediately, they gave him a mask and had him sit in a crowded waiting room for 2 hours. They did swab him for flu. He tested negative. Phew for him and everyone else in that waiting room.
#41 Jonix
April 26, 2009

I think this is seriously not an issue that you can use stupid left right politics on… if you do your still among the extreme ignorant and stupid people in this country….. STOP BELIEVING IN LEFT RIGHT POLITICS … this is not a left right issue… this is a possible engineered pandemic issue… and if we don’t take a second to look at how this is even naturally possible… then take an even farther step back and ask “qui bono” and see that certian people have stock in pharma corp that issues more poison, I mean vaccinations…… Don’t believe everything you hear about this issue… It is not always straight forward…
#42 Russell Maugans
April 26, 2009

Thanks K for the heads up. Good to know there aren’t anymore suicidal extremists out there willing to die for a cause. Seriously though, I hope above all else that those far above my pay-grade will be able to thwart this terrible illness. Reading over the US’s plan to deal with such a tragedy, whether I care to or not, it’s difficult to not see political issues arising.(Note Mexico’s President declaration to search it’s citizen’s and seize when deemed appropriate in the name of health) Notice how so many among us are reticent to use their given names.
#43 izzatxeaux
April 27, 2009

general question –

late spring 05, the always fabulous Declan Butler wrote a piece in Nature about Gerberding et al shutting off – or at least severely limiting influenza researchers access to GenBank -

has the policy changed ???
#44 Dr Aust
April 27, 2009

ProMED-mail’s veterinary and viral disease moderators have discussed the nomenclature of this condition, and have agreed that we should refer to it in the titles of postings as “Influenza A (H1N1) virus, human”, omitting the word “swine”. For now, at least, that is what we will do…”

I’m surprised people haven’t started calling it “The Mexican ‘Flu”. Or they probably have.

Actually wouldn’t it make more sense to start naming it for the year for “populist” articles…? After all, “2009 ‘flu” or “’09-’flu” even rhymes with “Swine ‘Flu”.
#45 martin bell
April 27, 2009

do i wear a mask on a plane..fr defensive measure.
#46 Dr David Hill
April 27, 2009

Swine flu

The present state of preparedness for a pandemic caused by pigs, birds and other animals is wholly inadequate and if a pandemic happened today, hundreds of millions would undoubtedly perish.

Pigs are one of the closest matches to humans. That is why we use their organs for human transplantation operations. Therefore the mutation from pig influenza to human influenza, is probably the most dangerous of all due to the nearness of match.

The link between pig and human influenza has been known for a long time. Two important studies are Evolutionary pathways of N2 neuraminidases of swine and human influenza A Virus: origin of the neuraminidase genes of two reassortants (H1N2) isolate from pigs by Kuniaki Nerome et al, National Institute of Health, Japan – Journal of General Virology (1991), 72, 693-698 and Ito T, Couceiro JN, Kelm S, et al. Molecular basis for the generation in pigs of influenza A viruses with pandemic potential. J Virol 1998; 72:736773.

The problem with the present strategy is that it is predominantly targeted and dependent upon at a drug cure which is a totally false strategy. There are two main reasons for this.
1. Flu viruses are constantly remodelling themselves and where when a new strain occurs, like the present state in Mexico, it will take 6 months to develop a drug to combat it. It has to be noted that the Spanish flu that killed between 20 million and 100 million nearly 100 years ago (there is no definitive statistic in this respect as in 1918 the analysis was rudimentary, but where modern pandemic statisticians estimate that it was somewhere between the two huge figures), did its worst in the first 26 weeks. Therefore an antidote would be a fool’s way of solving the problem.
2. Distribution of any new antidote would be a problem of enormous proportions and all affected would be dead by the time it got to them.

Therefore the present strategy is futile.

But unfortunately now again, Tamiflu is in 99% of flu types, not resistant against the viruses.
I cite several points of information that confirm this fact.
(i) HONG KONG (Reuters) — A strain of the H5N1 avian influenza virus that may unleash the next global flu pandemic is showing resistance to Tamiflu, the antiviral drug that countries around the world are now stockpiling to fend off the looming threat. Experts in Hong Kong said on Friday [30 Sep 2005] that the human H5N1 strain which surfaced in northern Viet Nam this year had proved to be resistant to Tamiflu, a powerful antiviral drug. – Reuters, 30 September 2005
(ii) U.S. health authorities (Center for Disease Control & Prevention) alerted doctors Friday that a prevalent strain of the flu is resistant to Roche Holding AG’s Tamiflu antiviral drug – Wall Street Jourmnal: Health (December 19,2008).
(iii) Virtually all the dominant strain of flu in the United States this season is resistant to the leading antiviral drug Tamiflu…This season, 99 percent do… If a Tamiflu-resistant strain is suspected, the disease control agency suggests using a similar drug, Relenza. But Relenza is harder to take; it is a powder that must be inhaled and can cause lung spasms, and it is not recommended for children under 7…Relenza, made by GlaxoSmithKline, is known generically as zanamivir. Tamiflu, made by Roche, is known generically as oseltamivir… – The New York Times: Health (January 8, 2009).
(iv) Tamiflu found to be 99% ineffective against primary flu strain – USA Today (January 8, 2009).

There are only two modern-day drugs supposed to save human life from any pandemic. These are Relenza and Tamiflu as stated above. But both are ineffective (more-or-less totally ineffective in the case of Tamiflu) in certain areas when dealing with new strains. Unfortunately zanamivir (Relenza) is less active against influenza A/N2 neuraminidases (found in Pigs etc). For zanamivir is inhibitory for only certain influenza A neuraminidase variants but not A/N2 neuraminidases. Therefore Relenza does not perform at all well against Swine flu.

There are also terriible side-effects with Tamiflu –
http://209.85.229.132/search?q=cache:uNFhMaU3GLEJ:www.topix.com/forum/drug/tamiflu/T5T8TK967U6DPFEL8+usa+today+tamilflu+april+2009&cd=8&hl=en&ct=clnk&gl=uk

Both these drugs have to be taken within 48hrs of infection, but where the prerequisite is that the host body has to be strong against infections at the time of the start of the dosage. After 48 hours, both are useless according to medical scientsist working at the coal-face around the world. Therefore the question is, how does anyone identify that they have flu quick enough and get a dose within 48 hours ? For symtoms can take several days to raise their ugly head.

Therefore for all the above reasons an international and national strategy based upon a drugs solution is not the answer and where if we continue to pursue this as our primary strategy, there is no doubt that eventually more people will die than has ever been witnessed before in the history of humankind, and potentially over a billion people.

Considering these true facts we have to look at the ‘source’ and therefore not fight the war on the grounds of trying to find a drug solution that will never happen in time. This is common sense and governments should not be pursuing such a basically useless strategy to nowhere.

For this alternative strategy (the only one that will work) we have to look at how animal flu jumps into humans.
In this respect there are predominantly two main reasons how killer flu spreads like this.
(a) In Asia, Mexico and the major rural areas of the world we are talking about cultures where a lot of roosters are used for cock fighting. It is very possible for those handling the roosters to get scratched and pecked with a little break in the skin which leads to bleeding. That’s one way they get infected.
(b) Another way is that it is very common for villagers in these developing countries to have roosters, chickens and pigs (their livestock) tied up or running around freely. A lot of houses are on stilts and the pigs and poultry are tied up under the house. During cold tropical evenings it is also common to see people sleeping in hammocks, or whatever they use as beds, outside amongst the pigs and the poultry. This is very common.

Therefore the world’s resources should definitely be addressing good husbandry around the world and not a drug solution, but where it has to be said that the extremely powerful pharmaceutical company lobby group, do not want this. The reason, both Tamiflu and Relenza have realised for the multinational drug firms, billions upon billions of revenues. It is therefore about time that human life was placed above corporate profits and where in this case, it is fundamental to the survival of a large proportion of the human population.

Dr David Hill
World Innovation Foundation Charity
Bern, Switzerland

Ps. For anyone interested in one of the best websites is
http://209.85.229.132/search?q=cache:5r085nr4Hm0J:birdflubook.com/+bird+flu+by+dr+michael&cd=1&hl=en&ct=clnk&gl=uk
#47 alabama
April 30, 2009

Why not close borders and sit for a few days to protect all countries and peoples – this will not stop itself – only mutate – and Terrorists around the world ARE WATCHING.
#48 Russ
March 8, 2011

Seems we currently are testing negative in the “theory” venue.