Effect Measure

The White House held a briefing this afternoon with the Secretary of Homeland Security, Acting Director of CDC and Nat’l Security adviser to the President in attendance. If you have been following this you wouldn’t have learned much, but the overall tone was one of serious concern but steady confidence. It was good security theater, and I say that in a good way. Information was divulged (judging from some of the press questions there was no danger over estimating the knowledge of the audience) and a sensible plan described.

There are now officially 20 confirmed cases in the US in five states (California, Texas, Ohio, New York, Kansas). The Department of Homeland Security will be the lead agency (the incident command) for this, but the health end will be taken by the Department of Health and Human Services (DHHS). Whether it would have made a difference if DHHS had a confirmed cabinet secretary isn’t clear. Obama’s nominee is being held up by Republican abortion ideologues, so there it is a headless Department at just the wrong time. The US version of the disease continues to be relatively mild, although most people expect severe and fatal cases to turn up as case finding intensifies.

DHHS has declared a “public health emergency,” a legal designation that permits certain public health resources like a portion of the 50 million courses of antivirals in the Strategic National Stockpile (SNS) to be prepositioned in the states should the need arise. A number of topics were discussed but not much new information. Daily briefings were promised.

I may be making this sound less valuable than it was. For those following it closely not much new came out, but it was a pretty credible performance overall.

If you want to know what happens when the government lacks credibility and compounds it by not keeping people informed, just take a look at the responses from Mexicans, including physicians, who were invited to comment by the BBC. I’m guessing a lot of the things said here will turn out to be false, exaggerated or distorted in some way. That’s what happens in outbreaks. But which things?

Here are 4 of 17 comments, more or less random (hat tip commenter habebe):

I’m a specialist doctor in respiratory diseases and intensive care at the Mexican National Institute of Health. There is a severe emergency over the swine flu here. More and more patients are being admitted to the intensive care unit. Despite the heroic efforts of all staff (doctors, nurses, specialists, etc) patients continue to inevitably die. The truth is that anti-viral treatments and vaccines are not expected to have any effect, even at high doses. It is a great fear among the staff. The infection risk is very high among the doctors and health staff.

There is a sense of chaos in the other hospitals and we do not know what to do. Staff are starting to leave and many are opting to retire or apply for holidays. The truth is that mortality is even higher than what is being reported by the authorities, at least in the hospital where I work it. It is killing three to four patients daily, and it has been going on for more than three weeks. It is a shame and there is great fear here. Increasingly younger patients aged 20 to 30 years are dying before our helpless eyes and there is great sadness among health professionals here.
Antonio Chavez, Mexico City

I think there is a real lack of information and sadly, preventative action. In the capital of my state, Oaxaca, there is a hospital closed because of a death related to the porcine influenza. In the papers they recognise only two people dead for that cause. Many friends working in hospitals or related fields say that the situation is really bad, they are talking about 19 people dead in Oaxaca, including a doctor and a nurse. They say they got shots but they were told not to talk about the real situation. Our authorities say nothing. Life goes on as usual here.

Young people are going to schools and universities. Buses and planes go and come from Mexico City as frequently as before. Even with two people dead locally, last night the local baseball stadium was full, mainly with young people. What’s really happening? I know vaccines are good for nothing, and if you take care, maybe you won’t die, so, why not acknowledge the real situation? I know that the economic situation is not the best, and it will worsen with panic. But panic comes from a lack of information. Many people travel for pleasure or without any real need. Stopping those unjustified trips can help a lot to ease the situation. We must do something!
Alvaro Ricardez, Oaxaca City, Oaxaca, Mexico

The truth is that it is very strange, what we are living through here. The streets are empty, we are all staying in our houses. People are only going out to the hospitals, drugstores and to buy food. The great majority have their mouths covered. Concerts, festivals, masses have all been cancelled, the football matches have all been played behind closed doors. On the television and radio, every commercial break contains information on the symptoms, saying that if you have them to go to the doctor at once. Although we have been told to go to work as normal on Monday, I am worried because I am employed at a company where there are many people and believe that it could be highly contagious. They say on the news that the cases that are most critical involve people aged 20 to 50.
Nallely T, State of Mexico

I have a sister-in-law from San Luis Potosi state in Mexico and we were told that in San Luis Potosi there have been at least 78 deaths, just in that city alone, not 68 in all of Mexico, as is being reported. Schools have been closed until 6 May in this state and in other areas in Mexico. Also, many public venues are being closed, so this makes it more deadly and dangerous than has been stated.
Migdalia Cruz, Phoenix, Arizona, USA

The Mexican authorities have provided a textbook case on how not to do it.

Comments

#1 Steinn Sigurdsson
April 26, 2009

Is there an A. Chavez at Mx NIH?
Anyone know him or can he be contacted to verify this and provide hard numbers?
#2 David B.
April 26, 2009

You can see the CDC briefing here.

The speakers are Dr. Richard Besser, the acting director of the CDC, and Janet Napolitano, Secretary of Homeland Security.

It struck me as a pitch-perfect instance of risk communication early in a crisis. Dr. Besser described what information would be available, and how often. He mentioned that information would be changing rapidly, and that it might be inconsistent from time to time. He was prepping the information channel! Smart.

The big news for me was that they’ve released 25% of the National Strategic Stockpile of Tamiflu and Relenza.
#3 dmv
April 26, 2009

For what it’s worth, I think there is value in this sort of theater, and to be sure, that is exactly what it was. The CDC guy was quick and competent. The press secretary, who was given multiple opportunities to take potshots at Republicans for blocking the DHHS nominee, showed restraint, conveyed that regardless, they’re on top of things. While perhaps not informative, it was certainly performative.

Now, the press, on the other hand… two questions about bioterrorism? The question about 1918 right after the CDC guy got done saying that they still have a lot to learn about the exact nature and character of this virus, etc. Ugh.
#4 WMDiva
April 26, 2009

There is a great document – “CRS Report for Congress, The Public Health and Medical Response to Disasters: Federal Authority and Funding” at http://www.fas.org/sgp/crs/misc/RL33579.pdf.

The document details the difference between a Stafford Act Declaration and a Public Health Emergency Declaration in a pandemic. It is worth the read.
#5 Tsu Dho Nimh
April 26, 2009

Mexico runs on rumors … and except for the unverifiable Dr. Chavez, these are all friend of my sister’s hairdresser quality rumor.

I read Spanish, and I am finding nothing about any hospitals closed in Oaxaca … one diabetic woman died of an atypical pneumonia last week. The hospital did the usual isolation precautions, etc.

http://www.diariodespertar.com.mx/Agenda/8879-Tensa-calma-zozobra-privan-Hospital-Civil.html

“El área de Urgencias Adultos continúa cerrada y permanecerá así al menos durante 15 días más, debido a un “proceso de limpieza y desinfección preventiva”, ” …. The Adult Urgent Care area is closed for 15 days for disinfecting.

“a mujer ingresó al hospital con un cuadro de neumonía avanzada, debido a que los síntomas se presentaron seis días antes de su ingreso: tenía diarrea y se le detectó diabetes, enfermedad que nunca fue tratada.” she had been ill for 6 days before coming to the hospital, and had undiagnosed diabetes (which never helps anything).

“no se han detectado contagios entre el personal médico o contactos cercanos como familiares y compañeros de trabajo de la difunta.” They have not detected contagion to medical personnel or close contacts like family or co-workers.

“Y negaron que la infección respiratoria leve que presentan 16 trabajadores del hospital no tiene relación alguna que pudiera indicar un contagio.” They deny that a mild respiratory infection in 16 staff are related to the woman who died.

NOTE: if you looked at any hospital of similar size, you would find a certain % of the workers had respiratory infections … they are just tkaing a close look at anyone who sneezes.
#6 Tsu Dho Nimh
April 26, 2009

Recent press conference:

http://www.eluniversal.com.mx/notas/593705.html
“ayer se otorgaron cinco mil 902 consultas en centros de salud capitalinos: cinco mil 289 era infecciones agudas respiratorias y 298 clínicamente sospechosos; 25 de éstos fueron referidos “con carácter importante hacia los hospitales”

Yesterday (the 25th), there were 5902 consultations in clinics [for supposed flu]. 5,289 were mild respiratory problems and 298 clinically suspicious. 25 of these were referred to hospitals.
#7 James Bowery
April 26, 2009

“I’m guessing a lot of the things said here will turn out to be false, exaggerated or distorted in some way.”

I REPEAT: Much more investigative attention needs to be paid to this particular BBC report:

“two of my partners who worked in this hospital (interns) were killed by this new virus in less than six days”

Imputing a case fatality rate CFR = 2/(#interns*prevalence) where #interns is the total number of “partners” this guy has, and prevalence is the fraction (0.0 to 1.0) of the population with the flu, puts us in a dilemma: Any reasonable choice for #interns and prevalence results in a CFR much higher than the 2.5 to 5% 1918 Spanish Flu CFR.

Understand two things here:

1) This CFR imputation is based on a “population”, not of the “hospitalized” but hospital “interns”.

2) This report can be followed up very quickly and inexpensively by any motivated journalist.
#8 James Bowery
April 26, 2009

The CFR imputation is based on the report to the BBC by Yeny Gregorio Dávila, Mexico City. Someone with press credentials please verify the parameters of the CFR imputation: #interns and prevalence (of symptoms among the interns).
#9 qetzal
April 26, 2009

Some questions for revere and/or anyone knowledgable:

1. Will the rapid in-office tests for seasonal influenza infection successfully detect infection with this swine flu variant?

2. How have they determined that the strains in the US and Mexico are the same? Some sort of antigenicity test? Full sequencing? Other?
#10 Dan
April 26, 2009

“Obama’s nominee is being held up by Republican abortion ideologues”

Never mind that she thinks the 9-11 perpetrators entered via Canada (which angered the Canadians, BTW), that entering the US illegally is not a crime (which she told John King on CNN), and that she allowed a DHS report to call veterans right wing extremists. Opposition to her confirmation might center more around her competency than her stand on abortion.
#11 ellie
April 26, 2009

Thank you for your post revere. I have two theories on why the Mexican government has provided the world with little useful information since Thursday. Either its much worse than we think, and they are afraid to tell us.

I find the wildly inconsistent storylines about this flu very troubling. On one hand, we have the American storyline: widespread, mild cases of flu, treatable with Tamiflu; a calm, seemingly transparent government that is “on top of it”; and and regularly confirmed new information from a credible source (the CDC).

On the other hand, we have the Mexican storyline: 1,000 cases with 80 deaths mostly in the pandemic-associated 20-50 age range–information that hasn’t been updated in days; widespread anecdotal stories (like those incredibly irresponsible and unsubstantiated BBC comments) of mass hysteria and death, and little to to no hard numbers from credible sources.

I don’t know much about Mexican government, but what’s the deal with this? Are they incapable of getting the information about number of infections and fatality rates? Are they afraid of telling us (i.e., because of economic/tourism fears, or fear of a loss of power by the ruling government)? Or is there some other spin? Information from Mexico, ground zero of this crisis, is arguably the most important information that any of us could receive, yet there’s been absolutely nothing.
#12 Cheetos
April 26, 2009

Opposition to her confirmation might center more around her competency than her stand on abortion.

Posted by: Dan
————
Dan – I think you’re confusing the DHHS nominee, Sebelius, with DHS Napolitano – who is already confirmed.
#13 revere
April 26, 2009

Dan: What you say might be true but isn’t. The opposition is specifically in regard to her stand on abortion. She had nothing to do with the DHS report, which was a Bush product and did not call vets right wing extremists (but thanks for the Fox news tlking point; much appreciated). She is governor of Kansas and is nominated for DHHS, not DHS. You are confusing her with Janet Napolitano. Among other confusions.

qetzal: The rapid tests is only for influenza type, which can be either A or B. The H1N1, H3N2, etc. are subtypes. So the rapid tests tells if it is flu A, if so and it is in one of the high index of suspicion cases (ILI and traveled to Mexico, for example) a swab is to be sent to the state public health lab. Those labs can subtype, i.e., tell if is one of the current seasonal H1N1s or H3N2s. They use PCR primers specific to the seasonal viruses. If it is a swine flu it will not be typable by the state lab. If they get untypable flu A, the state labs are being asked to send them to CDC, which has the primers for swine flu. Does that help?

James: I am not sure what you are asking. The CFR (case fatality ratio) is the number of fatal cases divided by the number of cases. To get it you need the numerator (# deceased cases from swine flu) and the denominator (total # cases of swine flu). Since we don’t have a good handle on the denominator we don’t really know what the CFR is. Current estimates are surely overestimated because the denominator is too small.

elie: The Mexican gov’t is acting like most governments. The US government and many state and local ones have done the same thing during outbreaks in the past. We hope we have learned something. If you want to see why we shouldn’t do it that way, just look at what’s happening wit public reaction there and the problems it causes.
#14 Kevin R
April 26, 2009

I think there is a difference between security theater and public officals providing a balanced response to some of the press hysteria that inevitably follows these types of stories.

It is refreshing to see a government emergency response that shows a leadership team that is organized, aware, and ahead of the curve
#15 James Bowery
April 26, 2009

James: “Current estimates are surely overestimated because the denominator is too small.”

The numerator, 2, is given in the report from Yeny Gregorio Dávila, Mexico City.

As for the denominator:

That is precisely why my imputation is interesting: It won’t underestimate the denominator due to the nature of the population from which it is drawn.
#16 M. Randolph Kruger
April 26, 2009

Revere, you got anything on official attack rates in Mexico yet?
#17 revere
April 26, 2009

Kevin: I think it’s refreshing, too. Your characterization of it is just what was intended and I think that’s fine. Not all theater is bad. The main point was that was less about substance than form, because there wasn’t much substance beyond “we’ve got a great team and we’ve got it under control.” Which, I repeat, is fine. But recognize it for what it is.
#18 revere
April 26, 2009

James: Don’t mean to brush you off. This has been very hectic and there are multiple threads with different conversations and I also have a day job not related to flu or blogging. I don’t remember how you estimated the denominator. You’ll have to tell me again.
#19 Jane
April 26, 2009

Given that we’re unlikely to see the first case of any kind of flu, are there any estimates for how long the swine flu has actually been in the US? I suspect it’s been here for weeks, but is the CDC or anybody else looking at this question?
#20 revere
April 26, 2009

Randy: Haven’t seen anything and I think any estimate would be shaky at this point because we don’t know how many cases there are.

Jane: I know a number of people who think it’s been in the US population for some time, maybe months, hiding in the background noise of seasonal flu. We might be able to figure that out with seroprevalence surveys. With time.
#21 James Bowery
April 26, 2009

revere writes: “I don’t remember how you estimated the denominator. You’ll have to tell me again.”

The denominator is #interns*prevalence

WHERE

“#interns” is the total number of fellow healthcare workers Yeny Gregorio Dávila, Mexico City claims as “partners” (the “population”, most of which was presumably not symptomatic at the time of his observation)

“prevalence” is the the fraction of fellow healthcare workers (“interns” or “partners”) Yeny Gregorio Dávila, Mexico City claims were symptomatic (but not necessarily dead)
#22 phytosleuth
April 26, 2009

Now I’m finding out from family and friends that people have been sick or are sick with a respiratory illness these past few weeks. I had a rapid onset of chest tightness back at the end of March during a vacation in…yep, San Diego. It scared me good b/c I was afraid to go to sleep for not being able to breathe. No other sx. Go figure. I hit it hard with large doses of herbs every few hours and by morning I felt better and I kept taking the herbs that day. I think swine flu has been here in the U.S. for months now.
#23 bern
April 26, 2009

And the WHO still hasn’t raised the pandemic level from 3? Ugh.
#24 Eric J. Johnson
April 26, 2009

James, if all your data are correct, you are still faced with a small sample size, yielding wide confidence intervals. You also have a publicization bias. Many other observers might also know X number of stricken associates none of whom died, and if so they would be unlikely to report this in public because it seems less remarkable or less interesting. Thus we could be looking through a non-representative window.
#25 James Bowery
April 26, 2009

Eric, in that case we would have ample justification for validating (or invalidating) your publicization bias hypothesis by surveying another hospital or two drawn at random — which would incidentally serve also to narrow the confidence intervals.

The point is that hospital staff is an excellent source of data in the otherwise chaotic environment.
#26 Eric J. Johnson
April 26, 2009

I can basically agree with that.

There’s still the uncertainty, though, about the case fatality in the spanish flu, if I recall correctly what I read above. Also there are the questions Paul Ewald has raised about the spanish epidemic possibly resulting from a virulence-promoting social situation (the war): namely that the sickest soldiers were selectively brought back from the lines to high-transmission environments like hospitals. Ewald used this to argue against the likelihood of a new epidemic of 1918-level ferocity. But anyway, we’ll see what happens.
#27 Miguel
April 26, 2009

Steinn Sigurdsson: about Dr Chavez, at a local newspaper Antonio Chavez posted his email for contact purposes: airantogri@hotmail.com. I really hope you can get in touch with him.
#28 Don Milton
April 26, 2009

The rapid test is only useful to let you know that you have flu in the community. The sensitivity of the quick tests used in recent community based studies of surgical masks as interventions to mitigate influenza transmission, undertaken by seven CDC funded universities, was between 30% and 60%. So, the tests cannot be used to diagnose individual cases.

A major problem remains that we don’t know whether influenza is transmitted just by large droplets or also (or primarily) by fine respiratory droplets that remain suspended in air and cannot be effectively filtered by surgical masks. Surgical masks, however, may have some utility as source control — infected persons wearing them may be less infectious. But, since up to 50% of people with seasonal flu are asymptomatic, this means that everyone must wear them to get optimal impact from them. So, if people wear them because they think that they are effective PPE, they might help even if that is not how they actually work.

All patients with influenza in the hospital should be in respiratory isolation and the patients should wear surgical masks. Ventilated patients should have the exhaust lines HEPA filtered. People taking care of flu patients at home should keep the windows open and fans on. Of course droplet precautions and handwashing is also important.
#29 James Bowery
April 26, 2009

Eric, I read “Plague Time” and am familiar with Ewald’s cogent argument against the evolution of virulence via horizontal transmission from the sickest, outside of very exceptional circumstances. However, it is hard to argue that current circumstances are anything but exceptional, albeit not necessarily the precise exceptions demanded by Ewald’s theory.

Here are a couple of potential contributors:

1) The introduction of enclosed feedlot technology for swine production.

2) The general depression of labor conditions which may result in sick people being ambulatory despite being symptomatic.

I know these are speculative but the our situation demands much of us.
#30 revere
April 26, 2009

Don: So you are saying we are missing half of the flu A with quick tests? The NPV would depend on the prevalence of flu A at the time, I guess. I’m too tired to run the numbers for various reasonable prevalence figures to see if this is a big problem. Have you?
#31 Miguel
April 26, 2009

Ellie: I live in Mexico City. I am a biologist and I used to work for the mexican government as a statistician for the Federal Environment Agency until last December. It is common place to exert censorship of bad environmental news, to avoid any chance that an individual or an NGO sue a Company that might be liable for the pollution of a river or drinking water source. I know water pollution data goes through this censorship to avoid this risk. This is one of the reasons I had to resign to my job. In the case of swine flu, I heard from the epidemic, two days before the official announcement (obviously at the time I didn´t know it was flu, nor swinish) from 1) a pathology student working at a Mexico City hospital who was alarmed by the number of corpses arriving with atypical pneumonia, 2) an MD with too many cases of pneumonia in young adults, and 3)a friend’s sister working at the National Institute for Epidemiology Diagnosis and Reference. By April 21st the problem was already too bad to hide it. In my opinion the real situation is not acknowleged by the government for one main reason. In July 5th we have representatives elections. Acknowledging the inefficiency of our health system could mean losing the majority at the Congress for the ruling conservative party. This is what I dare to hypothesize: Many mild flu cases have gone undiagnosed and unreported, with a broad dispersion among young adults. But during the first weeks, those which developed bronchitis or pneumonia arrived too late to be treated at the hospitals. If in the state hospitals, the order was not to declare influenza as the cause of death, we have a significant underscore of the actual number of deaths. As a 40 years old mexican citizen following the news, I really hope this strain is not as virulent as the first cases detected in Mexico. I agree, it hurts us all every minute the mexican government withholds data from us, but I expect the CDC and the WHO will exert enough international pressure to make the mexican health autorities come to their senses.
#32 Margaret Back
April 26, 2009

How can you prevent the spread of swine flu in children? Teach them how to not get and give germs with the new Germy Wormy Germ Smart for kids teaching program. With this seriousness of this new flu, it may save their lives.

http://www.germywormy.com
#33 Charlie N.
April 26, 2009

I’m going on a high school band trip to Virginia next month, which of course isn’t a concern, but we are departing from LAX. Should I have any cause for concern and/or take any special precautions, or is this just me being paranoid?
#34 Spiny Norman
April 26, 2009

“Germy Wormy Germ Smart for kids teaching program.”

With a title that poorly written, I shudder to imagine the content.
#35 Paul
April 26, 2009

Was once told the only stupid question is the one never asked…so here goes. We now have this new actor which surely has spread everywhere, with its proven high transmissibility rate, combined with what seems to be shaping up as a loss of some virulence – just nasty enough to inconvenience its hosts long enough to successfully move along to the next.

Then we have this mean old highly virulent H5N1, which just doesn’t seem to be able to get its act together with that H2H maneuver without having to rely on those dumb chickens. Well, sooner of later, but inevitably (now that the cat is definitely out of the bag), this mercurial H1N1 variant makes it over to Egypt, or Indonesia, where H5N1 is now endemic, and not too infrequently infecting humans.

And it is during one of these sporadic human infections by H5N1, that H1N1 pops in, and the two long-lost cousins happily reunite, or shall we say reassort.

Increasing the odds of this being a recurrent and less unlikely event, if I remember correctly, due to the chicken vaccination programs in China and Viet Nam, H5N1 has mutated to a non-lethal variant for infected chickens, while maintaining undiminished virulence for the more unsuspecting humans who will be infected by their handling and slaughtering of these now asymptomatic H5N1 reservoirs. (The chickens being apparently not as dumb as the canaries in the mines).

Here’s the stupid question: Is such a reassortment possible, and have the chances for it increased with the introduction of this new strain of H1N1. And if so, wouldn’t this result in an H5N1 with facilitated H2H transmissibility, creating our feared pandemic from Hell?
Posted by: Paul | April 26, 2009 9:57 PM
#36 Don Milton
April 26, 2009

Revere: the problem is that during the seasonal flu prevalence period of a few weeks, once you get a couple of quick tests positive so you know flu is active, the PPV of fever and cough is not improved by doing more tests.
#37 Dylan
April 26, 2009

“Also there are the questions Paul Ewald has raised about the Spanish epidemic possibly resulting from a virulence-promoting social situation (the war): namely that the sickest soldiers were selectively brought back from the lines to high-transmission environments like hospitals. Ewald used this to argue against the likelihood of a new epidemic of 1918-level ferocity.”

Eric: James: The following line of reasoning is not in the least bit speculative:

This country has one of the largest prison populations on the entire planet; two million people incarcerated in many hundreds of institutions. This figure does not include the many thousands of municipal and county jails, across this country, that house vast numbers of highly confined, nearly inert bodies. These populations are equal to anything that the squalid conditions of WWI were capable of presenting ( I worked in a prison, in California). What do you think might happen, if a highly primed pathogen was let loose in all of these institutions? Not a pleasant thought. Ewald’s argument is entirely invalid. What do you think that the prisons and jails look like in Mexico; or any area of Central America, for that matter? At this point, it seems to me that this pathogen is not entirely benign…but it is no “planet-leveler,” either, in its current iteration.

Could it become one? Maybe. Maybe not. Who knows? I certainly don’t. And neither does anybody else.
#38 ellie
April 26, 2009

Thank you for your insightful post Miguel.

I’m not convinced that the US swine flu is less virulent than the Mexican one. If you look at the characteristics of the US cases, the majority of those infected are/were children or teens who were in Mexico on vacation. The sample size of 20+ year old adults who’ve had this flu in the US is very small.

On the bright side, all of these kids have parents or adults who are around them and/or traveled with them. And so far only a few of these people have gotten sick. Does this mean that Mom and Dad aren’t getting the virus? Does this mean that Mom and Dad are incubating the virus, and they’ll get sick in a few days? Or what?

As usual, more questions than answers.
#39 Siun
April 26, 2009

Goodness, the ads just come out of the woodwork, eh?
#40 aces
April 26, 2009

Siun: When civilization ends, all that remains will be cockroaches and spam….like there’s a difference!
#41 Trevor Snapp
April 26, 2009

Hello,
I am a reporter and photojournalist based in Mexico City. Today I met with a family whose child died of the Swine Flu. Tomorrow I plan to investigate further why the government here waited so long to alert the public. The mother only found out her child had the Flu on Friday after 8 days in the hospital and quite a few different drugs and operations.

The government here has locked down on letting information out. This might be smart in one way, but it is causing the public to lose a lot of confidence in the authorities.

Anyway I am writing on this forum as I know very little about medicine, and I was wondering if anyone could recommend a good contact to help with some ideas and questions as I research this more.
#42 Phillip Huggan
April 26, 2009

“…with its proven high transmissibility rate…”

Paul, this is not (yet) proven. Surely if there were independant nodes confirmed spreading from those who’ve travelled to Mexico, to their communities at large (not just immediate family and school), the WHO threat level would be raised to 4 and then 5 quickly. That and the lack of deaths outside of Mexico (excepting immuno-compromised Californian), gives reason not to panic (yet). I’m in full agreement with WHO at the moment and the only screwup I see to date is the inability of various monitoring bodies to miss the spike in 20-40 demographic flu victims in Mexico in March or earlier. Maybe Mexico shared some blame but I wouldn’t expect a developing nation to have developed nation flu surveillence; be a bonus if Mexicans caught this early.
#43 Patch
April 26, 2009

Trevor,

You’ve stumbled upon one of the best sources of information and best places to ask questions. Many of the people here are well informed lay people on influenza and there are some high level posters (as well as lurkers, I believe).
#44 James Bowery
April 26, 2009

Trevor, please contact Yeny Gregorio Dávila of Mexico City and ask him these questions:

1) At the time your two interns died of the swine flu, how many interns were there in your hospital?

2) How many interns were symptomatic at that time?

It is very important that you ask those questions exactly as worded. Mr. Dávila understands English well.

Report here with the figures if you would be so kind.

Then, please ask similar questions of 2 other randomly selected hospitals in the Mexico City area. Again report the numbers here.

It would be most helpful
#45 Amy
April 26, 2009

From PhytoSleuth: “Now I’m finding out from family and friends that people have been sick or are sick with a respiratory illness these past few weeks. I had a rapid onset of chest tightness back at the end of March during a vacation in…yep, San Diego. It scared me good b/c I was afraid to go to sleep for not being able to breathe. No other sx. Go figure. I hit it hard with large doses of herbs every few hours and by morning I felt better and I kept taking the herbs that day. I think swine flu has been here in the U.S. for months now.”

I’m wondering the same thing. In late March, 3 out of 5 of the family came down with Type A flu (based on rapid tests). We all had the flu vax which was supposedly a good match for seasonal Type A. Surprised we got it. The kids got over it fairly easily but my husband had a really hard time with it, and coughed/sneezed and felt like crap for 3 weeks afterwards. I didn’t get it really, just a mild cold, but had the exact thing Phytosleuth described above – a respiratory/chest tightness, and then a week later had I thought was an asthma attack while running (don’t have asthma and I’m an experienced runner). I was also afraid to go to sleep thinking I might not be able to breathe. My kids’ school had tons of kids out with this Type A flu at the end of March. Word was lots of kids sick on spring break from April 3-10.

No one was looking for swine flu a few weeks ago – and it looks like from what I can gather here that the rapid in-office tests for flu only give the Type, not the subtype. Shouldn’t doctors be going back and sending samples to state labs? Wouldn’t that give us a better picture as to what’s going on here? I guess I’m dreaming if I think we already had swine flu and are lucky enough to now have antibodies…
#46 Miles Teg
April 26, 2009

The AP is reporting 1614 suspected cases of swine flu in Mexico with 103 deaths (22 confirmed as swine flu and 81 suspected).
#47 Jane
April 26, 2009

Phytosleuth: FWIW, I had a flu-like illness in early April and passed it on to my parents — and I got the flu shot last fall. No chest tightness, but plenty of coughing and my mom got swollen lymph nodes. Some friends got sick around that time as well. That’s why I’m interested in seroprevalence studies.
#48 Patch
April 27, 2009

Mexico City is how big…22 million was it? The big question for me is how they arrive at 1614 suspected cases? Do you suppose those are just the cases seeking medical treatment (hospitalization)? Or are they going door to door and if so, how could they reach that many households?

It’s almost certain that if 1614 cases have been identified, that they actual number of infections is likely much, much higher. And presumably, there are more deaths not identified as well.

In determining CFR, they would likely catch more the deaths, than suspected cases and therefore, the CFR is hopefully much lower than we appears to be 6% – 7%.

Do you think that’s a fair assumption? Although admittedly, it really doesn’t matter until we know more.
#49 RobNZ
April 27, 2009

Yes agree with the others, the authorities are playing this issue down. Students from two seperate NZ schools visiting different parts mexico have all come down with flu like symptoms. If Mexico are only reporting 1600 or so infections and that the situation is under control I would think this is far from the truth. Lets blow this out and assume that 10,000 are infected, its still only 0.0001% of their total population (109 million)- can we honestly belive that the NZ Kids were infected from the 1600 confirmed infections or even the hyperthetical 10,000 infections. I think this thing is spreading a lot faster than we think. Im not usually a scaremonger but I feel this one is bad news.

Also was just a collegue at work and he was talking to his friend who arrived into Norway from mexico on Sunday night – she said she had flu-like symptoms! Neither of them watch the news regulary so were not aware of what was happening. I have stongly reccomended that he calls her and tells her to visit a GP (as a precaution) – if she has swine flu we may well see it emerging in Norway shortly as she will have been in contact with others on the plane! I will follow this blog and will personally be monitoing ‘actual’ accounts versus ‘new media’ represenations.
#50 Lisa the GP
April 27, 2009

I’m feeling an undercurrent of urgency here that makes me think people even here are a little panicky.

Suppose for the sake of argument you take the Mexican reported numbers at face value.

Then we have a situation slightly milder than 1918. That’s not good. But…

It ain’t bird flu.

As a result of the local and national pestering of officials by many of us here, our national pandemic plans were designed for bird flu–the plans are designed for worse than 1918. Sure, they may not have assumed a 70% death rate (H5N1 in Indonesia’s rate), but at least they considered up to 15%–well above what we’re facing now under the *worst* of assumptions.

The main issue will be to keep the communications honest and open and not cover anything up even if alarming things crop up.

I’m actually *relieved* to see this scenario because I was *expecting* our next pandemic to be so much worse than this.

Not to detract from the amount of work that will be required to deal with H1N1 Mexico, but I think people need to lighten up a bit.
#51 RobNZ
April 27, 2009

UPDATE – I live at the bottom of NZ’s South Island and have just read (posted by local news 5 mins ago) that 7 people here have been quarantined and are being monitored – no further news is currently available. This is all starting to sounds like something off a bad movie.
#52 James Bowery
April 27, 2009

Lisa, what is 103/1614 ?
#53 WW
April 27, 2009

The DHS / DHHS relationship mentioned in your post is how it’s outlined in the government flu plans. Not that it’s correct necessarily, but it’s how the plans are written. Should have nothing to do with an acting HHS Secretary.
#54 jimbo
April 27, 2009

Hey, found this site that has info on symptoms and treatments…

http://www.symptoms-of-swine-flu.info/

looks quite informative…
#55 sff
April 27, 2009

I’m in a large university in Texas. Should I be taking some kind of precautions against this?
#56 BrianC
April 27, 2009

I completely agree with Lisa. There seems little reason to panic. I bet the same people were predicting doom and gloom during the avian influenza outbreaks in asia. Lets try and restrain our imaginations and avoid speculation
#57 revere
April 27, 2009

Don: Your comments hold for the usual use of quick tests. But in this case they are being used to decide on further subtyping and is not the PPV but the NPV we are concerned with. So all hinges on the prevalence of swine flu infection among ILI who have just visited Mexico, California or other outbreak area. If it is around 10% or so the NPV is probably acceptable butt if it is much higher we’d be missing a fair numnber.
#58 Paul
April 27, 2009

“The only stupid question is the one not asked?” Just remembered the rest of that old saw: “Confirmation that it truly was a stupid question, is the one not answered, and probably shouldn’t have been asked.”
#59 C. R. B
April 27, 2009

A quick comment from Oaxaca, Mexico. I live on the Pacific coast of Oaxaca. Two weeks ago I awoke with the following symptoms (they lasted about one week). Headache, chills, fever spiking to 103, muscle aches bad enough to make me moan when I moved in bed. Of course, I’m not sure what I had, but I believe there may be a lot of these symptoms going unreported. Trying to keep people from kissing upon greeting in Mexico is going to be almost impossible. It is part of the culture and is almost reflexive.
#60 Lisa the GP
April 27, 2009

James Bowery– 103/1614 about 6.3%. That is less than some estimates for the CFR for Spanish flu, but more than others.

But, you know, GIGO. The Mexican data is assuredly unreliable–so much so that we can’t even tell which way it is off–over- or under-estimating the severity? The US data suggests that the Mexican data is overstating the case.

Remember everyone has been ‘looking’ for H5N1 to show up, generally by testing *severe* cases of suspected flu for untype-able Influenza A. If they find such a virus, it goes to their health department for further testing and if it remains untyped goes to a CDC lab. This process would catch H5N1 because (so far) it generally produces severe illness, triggering the additional testing. But if severe illness is rare with H1N1 MEX, then the virus might become fairly widely distributed before anyone got sick enough to trip a sample of the bug into the ‘new virus’ detection scheme.

Then once you started looking for it, you’d suddenly find cases that were widely dispersed geographically, since we’re all so mobile these days.

Based on the (admittedly poor) publicly available information, this is my current theory of what’s going on–the reason suddenly cases of ‘new H1N1′ have cropped up in many states nearly simultaneously.

I think there are a lot of ‘potential’ cases (those that might be diagnosed ‘clinically’ instead of by a lab case) that are exactly as C. R. B reports, that are not making it into that 1614 denominator of the Mexico data.
#61 James Bowery
April 27, 2009

Lisa writes: “103/1614 about 6.3%. That is less than some estimates for the CFR for Spanish flu”

Do you have a cite?
#62 Patch
April 27, 2009

Lisa,

I agree, we need to slow down. My point earlier was the same as yours.

1. Mexico would LIKELY notice higher death rates and therefore, count them.
2. But it is highly unlikely they could diagnose everyone who has had, or is currently suffering from this novel virus, as it’s just too large of a sample to gather from in such a short time.

The CFR is conceivably much lower than 6-7%. And thankfully, much lower than the 60-70% of H5N1. Let’s hope that genetic shift has already tamed this somewhat. And then pray it stays mellow.

Years ago, we were screaming for the press to notice. They are certainly taking notice now.
#63 Tsu Dho Nimh
April 27, 2009

The big question for me is how they arrive at 1614 suspected cases? Do you suppose those are just the cases seeking medical treatment (hospitalization)?

As far as my reading of the official Mexican government sites (I read Spanish), press releases and newspapers can tell, they are NOT reporting mild cases because they don’t test for them. The USA is reporting anything that is positive. In Mexico, the prep school cases would not be counted. In the USA, they were counted.

The CDC, WHO, and Mexican health staffers are working out the epidemiology of this mess to figure out the pattern of spread, the prevalence, and the rest of the figures we need.
#64 Lisa the GP
April 28, 2009

james, I don’t have a citation for the high end spanish flu estimates because I’ve read so much stuff I can’t always remember where I read something. I do know that the highest CFR I’ve read regarding Spanish Flu was 15%.

It also depends on what population you’re looking at. I have been led to think that some small (fewer than 100 people) native american settlements in AK were completely killed off. But there’s ancillary issues there–for example were people too sick to keep the heating systems going and froze to death rather than actual virally-induced death? There’s also the issue of genetic uniformity in a highly interrelated, isolated population. So even if that anecdote is true we can’t really extrapolate from it other than to worry that similar modern populations might be at higher risk than average.