Effect Measure

The first death in the US from swine flu in a Texas toddler is being widely reported, but a piece just in from Bloomberg says the infection was acquired in Mexico:

The first confirmed U.S. swine flu death was a 22-month-old child from Mexico, according to a Houston official.

The toddler was brought to Houston for medical care last weekend and died on Monday, Kathy Barton, spokeswoman for the Houston Department of Health and Human Services said today in an interview. (Mary Schlangenstein, Bloomberg)

The national origin of the victim is of some epidemiological import but irrelevant to the human tragedy. The news that a previously healthy 22 month old died from this virus put a human face on the outbreak, even if we don’t know the baby’s name. I have a 23 month old grandson, and while I can at times become hardened to news like this (regrettably), my daughter was very distressed. In place of “22 month old in Texas” she automatically substituted the face of her own little one. There was both fear and profound empathy in her reaction.

Some of the fear will be lessened by the new knowledge that the baby contracted the disease in another country. The empathy remains, as it should. Mexican babies are still babies, loved by their parents and grandparents even while being hostages to fortune like everyone.

As this outbreak moves forward we will be barraged by numbers and statistics. This is a form of spectator sport to which we have become accustomed. We follow baseball, the Dow Jones and public opinion polls.

But these numbers are different. As the late epidemiologist Irving Selikoff once remarked about the horrific toll of asbestos victims, “death statistics are people with the tears wiped away.”

Indeed.

Comments

#1 mistah charley, ph.d.
April 29, 2009

“A single death is a tragedy, a million deaths is a statistic.” — attributed to Joseph Stalin
#2 sandy
April 29, 2009

here is the bloomberg link
http://www.bloomberg.com/apps/news?pid=20601087&sid=aXZ7s4f9bkCM&refer=home
#3 Nancy
April 29, 2009

Thank you. I had very similiar feelings when I heard about this and have been thinking about my 18 month old grandson with a lump in my throat ever since.
#4 g336
April 29, 2009

Referring back to an earlier blog entry: I’m going to propose a term for “choosing to stay home so you don’t catch it.”

“Preventive Self-Quarantine,” and the acronym “PSQ.”

Strictly speaking it’s a mis-use of the term “quarantine,” however it appears to be the best overall construction because:

The word “preventive” makes it clear that the individual is not sick at the time. There is not a shorter word that is as readily understood for this purpose.

The word “self-” makes it clear that it is a voluntary measure. “Self” is preferable to “voluntary” because it’s a shorter word by three syllables.

The word “quarantine” is preferable to “distancing” or “isolation” because for most people it is more of an abstraction and carries the connotation of a health measure. In contrast, “distancing” and “isolation” both have additional highly unpleasant emotional connotations at a time when people want to *feel* connected even if they are physically separated.

Also, the acronym PSQ is preferable to other combinations: PSD is a file extension for PhotoShop Document (34 million Google hits), PSI is widely used in psychology (39 million Google hits), and both of those are fairly common. PSQ is used in investment management but is less common (only 514,000 Google hits).

In common use, people might say “I’m going into preventive self-quarantine for a week” and then as the term becomes more well known, “I’m taking a week of PSQ” and “employees who can work from home should do PSQ for a week.”

OK folks, there’s the proposed term and the rationale for it. What do you think?

Sorry to post this twice in different places, but the previous discussion showed that there is clearly a need for a term for this, and since no one else had anything better, I figured it was worth a try.
#5 Lisa the GP
April 29, 2009

I’m taking a junior college class for fun and last night one big buff bodybuilder type guy came in to class snorkeling the entire time and coughing almost incessantly.

It sounded rather wet for flu and I think if he had flu with that degree of respiratory involvement he’d be prostrated with exhaustion (he probably had a bad cold) but *still* I was furious that he came to class and potentially exposed us when he was so obviously sick. Was also upset that the professor didn’t simply tell him to go home.

But, said nothing…
#6 engstudent
April 29, 2009

I have a 2 yearold and have been following this since saturday. I have to say this scares the living shit out of me.

The CDCs 11 oclock update is up.
http://www.cdc.gov/swineflu/
#7 Lisa the GP
April 29, 2009

almost 100 identified cases, 5 hospitalized, 1 dead.

That gives us a first working assumption for how severe this illness is, assumption at least for today.
#8 James Bowery
April 29, 2009

Only 7 swine-flu-deaths not 152 says WHO.

If 152 deaths are a “statistic”, then what are 7 deaths?
#9 River the writer
April 29, 2009

Questions: As of 11:49 EST, the WHO is stating that there are 79 confirmed cases of swine flu in Mexico with 7 confirmed swine flu deaths. The CDC is saying there are 91 confirmed cases of swine flu in the US and one confirmed swine flu death. Yet, it appears from news stories that the prevelence of the illness is far greater and deadlier in Mexico, with more than 6,000 people sick, than in the US where there are “hundreds.” So, what is the average laywoman to take from these statistics? That 1). there is a very quickly spreading virus running amok. 2) We have greater access to labs and faster results on tests? and/or 3) That the virus is spreading much faster in the US than in Mexico and elsewhere?

Also, if the US now has almost 100 confirmed cases and “hundreds” of suspected cases, hasn’t the spread of the virus reached the WHO’s definition for Level 5? Some help, please.
#10 revere
April 29, 2009

river: You have to have some tolerance for confusing and contradictory data for the moment. CDC’s website says 64 lab confirmed cases, and as for Mexico, that’s all WHO counts. So you need ot know what the criteria are for counting a case. The exact numbers probably are no longer that important. It’s the overall pattern, which is this is now being spread person to person and seems to be like seasonal influenza, clinically.
#11 engstudent
April 29, 2009

All of the above River and I personally thought a phase 5 WHO alert wouldve been appropriate yesterday.

I wish there were reports and information on what the epidemiologist were doing and learning from thier work in Mexico – is there a way you can get access thier notes and reports. I wonder what they suspect, what are they thinking after working the problem for a few days already. It may help us understand how things are going to unfold here in the US and the rest of the world.
#12 River the writer
April 29, 2009

Thanks, Revere. You may need to refresh the CDC page. At 11 o’clock or there abouts they updated the numbers to a total of 91 confirmed cases and 1 confirmed death.

As for the virus spread now meeting the WHO’s criteria for Level 5… are we there yet?

Thanks!
#13 Lisa the GP
April 29, 2009

almost 100 identified cases, 5 hospitalized, 1 dead.

That gives us a first working assumption for how severe this illness is, assumption at least for today.
#14 Dr. Mom
April 29, 2009

As I get ready for work, and our morning breifing on SF where I serv e as chief of staff,tears are streaming down my face. There are tears for the Ill 24 month old with a positive rapid flu test in my office yesterday. There are tears of fear for the children and familes I will see today. This is decidely the point when the face of this becomes much more than a statistic or a news report. May we all proceed with the composure and compassion required.
#15 River the writer
April 29, 2009

Thanks Engstudent and Lisa the GP. Appreciate your responses. And Engstudent, while I do not know the ramifications of the WHO declaring a Level 5 pandemic threat, nor the political implications for the US and other nations, it seems to me also that the virus spread has met the criteria.
#16 Lisa the GP
April 29, 2009

Dr. Mom,

Unless you have information I don’t, H3N2 is still likely to dominate the flu cases you identify. Not every positive flu test is going to be the new flu.

Flying by the seat of my pants, you can take todays US count at face value–but we know the one who died came from Mexico, which puts a little question mark on the data point. But todays ‘death rate’ is about 1%. The hospitalization is about 5%. I have more confidence in the hospitalization number. So lets say 5% require hospitalization.

The death rate reported for Mexico has a denominator of hospitalized cases rather than general cases. So if you guess that maybe their hospitalization rate is also around 5%…suddenly the reported death rate isn’t nearly so scary when compared to that of regular flu.

This isn’t bird flu. As it spreads, every doc’s office can expect to get swamped by the numbers of patients. But I don’t think we’re going to have a huge percentage of bodies stacked up. If the absolute quantity of dead becomes high, it will be because the number of mild infections is staggering.

Cry for the individual who died. But for the ones you’re diagnosing, no tears, because they’ll probably be fine.

You might wind up crying from lack of sleep before this is over, though…
#17 Patch
April 29, 2009

Lisa the GP…you’ve come a long way!

I’ve read your posts for years now. I’ve found each of them interesting in its own way. But your last post is possibly the most grounded I’ve seen. Nicely said.

Dr. Mom, my prayers are with your patients and families AND all the health professionals that are on the front lines.
#18 phytosleuth
April 29, 2009

”It’s the overall pattern, which is this is now being spread person to person and seems to be like seasonal influenza, clinically.” – Revere

So. Mystery box flu. We weren’t sure what it was going to do.

So far, this is looking like a very contagious flu that kills about as often as a regular seasonal flu (which is often enough). We have learned then:

We should not take this flu lightly, because people die from the regular seasonal flu, and this one seems easy to catch, so that means there could be more deaths than normal just because no one has immunity to it.

If it continues at the current level of lethality (similar to deaths from seasonal flu), this buys us time to prepare on state, local and personal levels, in case this flu shifts and becomes more lethal (more virulent) and IF it retains the ability to infect (i.e., it could lose this ability some or not at all).

It could fizzle out.

It could come back in August or October with a vengeance if it mixes with enough bad guys in the interim. Therefore, we should all get organized and prepare over the next few months, just in case. If everyone does this, then the damage is not as great because we’ll know what we have to do (wash hands regularly, isolate ourselves, stay home if sick, teach kids at home, work from home, have enough food and supplies, etc).

Then again, it could fizzle out and return in twenty years.

Let me know if I’m right on this, Revere. If so, our bitty human brains are not going to GET this unless our governments really push it hard. We are, after all, terribly busy people and I’ve got work to do. Argh!
#19 decal
April 29, 2009

Forgive me for an off-topic question, but I’d like to hear what you all think about this. The American Lung Association has very different yearly mortality data for influenza (1812 deaths in 2005) than the numbers bandied about by the media (36,000/year by CNN). You can find them here: http://www.lungusa.org/atf/cf/{7a8d42c2-fcca-4604-8ade-7f5d5e762256}/PNEUMONIA%20&%20INFLUENZA%20SEPT%202008.PDF (page 13). Why is there such a pronounced difference? Does the CDC use a different system than the ICD-10?
#20 Lisa the GP
April 29, 2009

Wow, Patch, way to dress up an insult to make it look like a compliment!
#21 revere
April 29, 2009

declame: ARC uses death certificate info only. CDC numbers are estimates of flu mortality based on plausible modeling of pneumonia and influenza deaths seasonally.
#22 Rogue Epidemiologist
April 29, 2009

“The national origin of the victim is of some epidemiological import but irrelevant to the human tragedy.”

Don’t think me callous. Peds deaths make me feel awful — hence I never considered pediatrics as a profession.

But you’re right, national origin is important to epidemiologists. I don’t like the fact that this particular fatality is bandied about as the first US fatality. It’s NOT. It’s a Mexican fatality. That doesn’t make it any better or worse — it’s a tragedy that a baby died. However for those of you who don’t work in any level of government epidemiology, you probably don’t understand how discretely the lines are drawn. Territory matters. From a reporting perspective, this child is Mexico’s case; he only happened to be treated in the States, and he only happened to die here. Unless he officially took up residence in (Brownsville?) TX, then he is not Texas’ case.

Yes, the hospital still needs to notify CDC of the death and the incident. But from a pure numbers and epidemiological standpoint, he is not part of the US population and should not be included in the data set.

Speaking from experience, I have investigated cases of other things almost to completion, but when I find out that the patient lives outside the lines we have drawn for our jurisdiction, I have to abort operations immediately and fax my work to the appropriate health officer.
#23 Lisa the GP
April 29, 2009

CNN cannot be more specific due to patient confidentiality, but they are now reporting that this toddler had some other serious medical condition from before the kid got the flu.

The death is no less tragic but probably can’t be used as a basis to extrapolate the danger for other toddlers.
#24 Patch
April 29, 2009

Lisa,

You misinterpreted. We’ve been watching this a long time together. I admittedly didn’t always agree with you on HPAI. I understood you to be a glass half empty sorta gal. But absolutely no insult intended. I value(d) your posts and read them in their entirety with great interest. There are few I respect more than you.

I believe as you do, that at THIS POINT IN TIME, we seem to be dealing with a virus that clinically, resembles seasonal flu. Like you, I have been convincing myself that high CFRs were possible after watching HPAI for years. So statistically, there is some relief in the numbers. In other words, the glass may be half full (as much as it can be under these circumstances) and I found your post grounded in that philosophy.

Having said that, I remind myself that 1918 started with a mild first wave as I know you are aware.

So while it’s possible that we don’t have cases to be statistically significant at this point, there is some good news in seeing what appears to be a low CFR. Hopefully, the first wave will remain relatively mild and give us time to find ways to protect ourselves against any more virulent drift.
#25 GeorgeT
April 29, 2009

g336: I like the PSQ term. I’m doing partial-PSQ. I’ve cut back on the number of trips I take out into public – eliminating non-essential ones.

I do wish the government would come out and suggest people do some “Preventive Self-Quarantine” especially in areas with known cases – it may help slow the spread some. My view is that the most important thing right now is to minimize the number of cases going into the summer – the fewer cases then the less chance we have of a more potent strain developing this fall. Plus it may delay the onset of the fall flu season some giving more time for a vaccine.
#26 Pat
April 29, 2009

This from Reuters AlertNet (http://www.alertnet.org/thenews/newsdesk/LT910095.htm)

WHO moves closer to raising flu pandemic alert 29 Apr 2009 18:05:19 GMT
Source: Reuters

* Flu infecting people who have not been to Mexico

* Virus spreading between humans, not from contact with pigs

* New strain causing everything from mild to fatal illness

(Recasts with details of infection patterns, virus risks)

By Laura MacInnis

GENEVA, April 29 (Reuters) – Swine flu is infecting people who have not been to Mexico and the outbreak shows no sign of slowing down, the World Health Organisation said on Wednesday.

The WHO’s emergency committee had not scheduled a meeting to increase its pandemic alert level but was likely to do so soon, acting Assistant Director-General Keiji Fukuda said.

“It appears we are moving closer to that, but we are not there yet,” he told a news conference. “At this point there is very intense analysis of all available information going on.”

WHO experts are scrutinising the transmission patterns of swine flu to see if it is spreading among people who have never been to Mexico — the epicentre of the outbreak — or had close contact with those who had.

Fukuda said people who have not travelled were among those falling ill, although many of those had contact with people who had recently travelled to Mexico.

Once the disease showed signs of spreading in a sustained way within communities in the United States, Europe or elsewhere, Fukuda said the WHO would look to again raise the alert level, as it did on Monday from 3 to 4.

The U.N. agency’s official guidance indicates: “the declaration of Phase 5 is a strong signal that a pandemic is imminent.”

WHO Director-General Margaret Chan could call an emergency committee meeting at short notice, Fukuda said, saying this could happen “whenever the evidence suggests”.

In its own laboratories, the WHO has confirmed only eight deaths from swine flu, including seven in Mexico and one in the United States, a case that U.S. authorities have said was a Mexican toddler. Mexico has reported as many as 159 deaths from the virus.

Fukuda also cited 114 confirmed swine flu infections in Mexico, the United States, Canada, Israel, Spain, Britain and New Zealand, with mild symptoms reported outside Mexico. “It is clear that the virus is spreading and we don’t see any evidence of this slowing down at this point,” he said.

There is no link between contact with pigs or eating pork and infection with the virus, which is spreading from person to person and appears to cause more diarrhoea than seasonal flu.

Infection with swine flu could cause symptoms from very mild to fatal illness, according to Fukuda, who stressed more analysis was needed before the virus risks could be understood.

“It is possibly premature to think of this as a mild pandemic or as a severe pandemic,” he said.
#27 Noadi
April 29, 2009

My sister-in-law is stationed in Texas and she’s currently 3 months pregnant. It scares me that her or my future niece/nephew might be at risk. A baby dying hits awful close to home for me right now.
#28 Lisa the GP
April 29, 2009

Ok. Sorry to misunderstand, Patch. My bad.

For HPAI I am ‘glass half empty’. I’m almost ecstatic that all we have to deal with here (the most dire estimates, which probably grossly overstate the case) are something like 1918.

Which is actually pretty funny, to be ‘relieved’ to have an ‘Andrew’, because I was expecting a ‘Katrina’.

This whole thing is going to be a real long nuisance. Buuut… it doesn’t have anything remotely like H5N1′s 60+% mortality in Indonesia. So I’m happy.
#29 Joy
April 29, 2009

Isn’t a 5% hospitalization rate about 10 times the “normal” flu hospitalization rate?
#30 GeorgeT
April 29, 2009

Noadi: first of all, Texas is a huge state – it takes more than 12 hours to drive from one end to the other. By stationed, it sounds like military. The major bases I know are in San Antonio, Fort Hood and out by El Paso. The information I have is a suburb of San Antonio had 3 cases with no known spread right now – it may have been contained. The other two haven’t had anything at all so far.

By the time the baby comes, I don’t think it will matter where in the US she is. The whole thing will be over or it will be spread all over the country.

I wouldn’t fear for her any more than the rest of us.
#31 suzanne bunton
April 29, 2009

Lisa (the GP): I’m really glad you said it: ecstatic, indeed. Me too! I’ve just been afraid of seeming insensitive to the suffering of the sick to say it, and shy about adding electronic clutter.

I don’t think we “flu believers” could ask for a better trial run for extant pandemic preparedness measures, and convincing evidence that the world is poised for pandemics. (Note the plural).

So far, this one has taught the world: a) that pandemics really can happen, and quickly b) that we have to expect for it to come from unexpected viral, reservoir, and geographic sources anc c) that despite the internet and ubiquitous jet travel we can’t expect to know much of anything useful about the cases while they’re emerging.

If only it can also teach the public to start coughing into its sleeves, wash hands often, stop using antimicrobials willy nilly (soap works just as well and doesn’t create resistant strains), stock a deep pantry, and finally (yes, this is a causality stretch, and obviously reflects my own bias) put an end to Big Meat’s environmental abominations by simply ceasing to buy its products–either go vegetarian, or buy only organically farmed, free-range meats, eggs, & diary.
#32 pft
April 29, 2009

We are truly a nation addicted to fear. All this hype for a variant of H1N1 that seems not very virulent and is actually Tamiflu sensitive, unlike much of the H1N1 in circulation or H5N1. By next flu season, this strain will likely be in the seasonal flu vaccine. Lets hope Baxter does not “accidentally” contaminate the vaccines with live H5N1 which might give us a real pandemic.

Looking at all the hype, I can only conclude this is a media psyops operation. A new bill is probably in the works as I type which will give more control over people to government in an “emergency”. Only instead of muslim terrorists to worry about we have viral terrorists. Just a matter of time before we start hearing the words “manadatory vaccinations” and “mandatory quarantines” in the Global War on Swine.

Wonder if these vaccinations and quarantines for public health will be paid for with public funds? If not, will the manufacturers or service providers be asked to operate non-profit during said emergency. LOL.
#33 Nancy
April 29, 2009

To pft
Yes, and we’ve also become addicted to denial and conspiracy theories. Pandemics have always been a reality, politics not withstanding. I came to this site to avoid the panic mode found elsewhere. The legitimate concern for sick people is warranted. Business will be affected, parents that have no day care outside of schools that may close, will be affected, people without health insurance, will be affected. These are things worth recognizing. This isn’t a ‘sky is falling’ dialog, but rather an informed, reality-based discussion.
That’s my take on it for what it’s worth. No drama, just reality and not really LOL-worthy. I love snark, but this isn’t really the place for it IMHO.
#34 trained entomologist
April 29, 2009

I’m in a state with no reported cases. I haven’t cut back yet on my forays into the public, although I have been consolidating errands for 2 or 3 years in order to save gasoline. I have been buying just a little extra staple food in case the situation gets bad, and I’m paying a couple of bills now so I don’t need to roam around next week paying them.

For the last year and a half or so, mostly connected with an exercise program, I have been regularly taking a multivitamin supplement and some vitamin C. (but no flu shot the last several years). My overall number of colds/flu is way down, and I attribute some of that to being more conscientious about the vitamins. Several years ago, before I “believed in taking vitamins,” I got several colds/flu while doing some foreign travel.

I’m not very emotional about this situation, partly because a couple of years ago during the winter, I saw many more people coughing/sniffling than I did this year or last. The neighbor’s kids have gotten sick at school in the past couple of years, but I haven’t seen too many people sick at the grocery store or gym. Stuff happens in this increasingly overcrowded world. I figure we’re overdue for pandemic flu, since the last one was pretty much back in 1968.

Although there is some debate about their effectiveness, I do think it would behoove people, especially those who are in crowded workplaces or situations like school or college, to consider taking a multivitamin supplement, just in case folks have small nutrient gaps somewhere in their diet. The daughter of some friends recently missed enough days of school from a cold and then a case of strep throat that her grade in a class went down and she may not be able to qualify for an afterschool activity she wants to do.

What I have changed in response to the news is that I have become more vigilant about washing my hands. If it gets more serious, I will buy some more food to keep around the house in case I need to stay home a while. I was also contemplating a vacation to Mexico soon, and I will either put it off or choose another destination.

I plan to get a flu shot this fall as well.
#35 pft
April 29, 2009

Nancy. I agree the potential for pandemics exists. I do not deny that, and have been based in China during the SARS and H5N1 scares.

“Business will be affected, parents that have no day care outside of schools that may close, will be affected, people without health insurance, will be affected”

Hyping what amounts to be nothing more than a mild-moderate virulent strain of H1N1 as a possible pandemic is affecting people already in the manner you have outlined. At some point, when a real pandemic hits, people might tune out.

As for the quality of the discussion, this comment here is mind boggling:

“I don’t think we “flu believers” could ask for a better trial run for extant pandemic preparedness measures, and convincing evidence that the world is poised for pandemics.”

I can imagine Cheney saying the same thing about 9/11, in essence, “what an opportunity to Rebuild Americas defenses”.

As for being addicted to “denial” and “conspiracy theories”, note that ad hominem attacks are always used to attack the truth. An addiction to the truth would serve this world better than acceptance of the Noble Lies which feed fear and ignorance to move the herd to a consensus that serves a larger purpose. And that is an open conspiracy, deny it if you wish.
#36 bill610s
April 30, 2009

You guys have hit an interesting fork in the road. Check MarketBlogic’s statistical questions about this “swine flu” pandemic and my response at:

http://scienceblogs.com/aetiology/2009/04/us_up_to_91_cases_including_1.php

I also fail to see anything warranting the panic mode.
#37 Leticia
April 30, 2009

Any recommendations to a worried mother about how to lessen the risk to our family? I work in a school therefore I’m surrounded by sneezing and coughing high schoolers…. So ready for summer break. We are lucky to live in isolated Wyoming but have plane tickets to Hawaii via LAX…what to do, what to do…appreciate any help!
#38 Medical Microbiologist
May 1, 2009

Has the basic reproductive number or the secondary attack rate been determined for the H1N1 outbreak in Mexico City?
#39 suzanne bunton
May 1, 2009

pft, one of the surest ways to twist someone’s words is to take them out of context, like you did mine, before you effectively compared me to Dick Cheney–a paragon of obfuscation and non-compassion. I feel outraged, frankly.

Or am i in the wrong? Was my overall post was that stupid, and/or lacking in compassion?
#40 suzanne bunton
May 1, 2009

Re–my last message & question to PFT.

Now that i’ve calmed down a little, i can see how my post could be construed as compassionless, if you take the post itself out of the context of spending 4 years worrying about a pandemic that’s virulent, and the comment from another sincere worrier of the same issue, to whom it was responding.

I’m not ecstatic that we’re having a pandemic. I so fully expected this to happen, and i’m so thoroughly prepared that i almost have no emotion about the fact of its happening. I’m ecstatic with *relief* that our first modern pandemic produces such mild disease, and that it’s being handled quite well overall, compared to what i was expecting from H5N1. Just like (I believe) Lisa the GP is.

I thought *why* i was ecstatic would go without saying, so I didn’t say. I wish i had now—apologies to all who took it like pft did.
#41 Michael Fumento
May 3, 2009

Pay no attention to the statistics? In other words, the statistics have made mincemeat of your earlier statistic-based claims. They are showing this disease to be a piker compared to garden variety seasonal flu. They are showing this is not the devastating pandemic you’ve been waiting for. So now you’re emphasizing anecdotes. How pathetic and predictable!