Effect Measure

Swine flu: pictures, big and little

As is usual (routine? no, nothing routine about this) in an evolving epidemic contradictory and confusing numbers are appearing. Some of them are the result of information lags (tallies not being updated), some are the result of using different criteria for counting (suspect versus probable versus lab confirmed, etc.), some are just rumors. WHO is saying that in Mexico there are only 7 confirmed deaths, 19 more lab confirmed cases, 159 probable cases and some 1300 being evaluated, based on official reporting to them by officials of a member state, the Mexico. Everyone knows there are many more cases, however, so the WHO related reporting is more confusing than informative. CDC says there are 91 confirmed cases in the US on their swine flu page but 64 cases on the CDC home page as of 12:30 pm ET, 4/29). That’s an information lag, within the same agency. The fact that there are more confirmed cases in the US than Mexico is not a reflection of how many cases are really in each place but how they are being recognized, confirmed, counted and updated.

It’s not just lay people who are confused. The scientists don’t seem to be on the same page all the time, either. The sequences have been published on the web and a scientist who has taken a hard look at them sees only swine sequences, not swine, bird and human as CDC announced originally:

The preliminary analysis using all the sequences in public databases (NCBI) suggests that all segments are of swine origin. NA and MP seem related to Asian/European swine and the rest to North American swine (H1N2 and H3N2 swine viruses isolated since 1998). There is also interesting substratification between these groups, suggesting a multiple reassortment.

We are puzzled about sources of information that affirm that the virus is a reassortment of avian, human and swine viruses. It is true that the H3N2 swine virus from 1998 and 1999 is a triple reassortant, but all the related isolates are found since then in swine. (Raul Rabadan, Columbia University via ProMed)

With fast moving events it is quite understandable that early ideas would be revised, but when CDC’s Dr. Anne Schuchat was asked point blank by a reporter at the Monday briefing if she could tell us which segments were human she gave a one word answer, “no.” She then moved on to another question, so it wasn’t clear whether she was refusing to answer or just didn’t know. If CDC erred in this, as looks might be the case, the simplest thing would be to clear the record immediately and move on. This information isn’t likely to make much difference in actions on the ground. An agency is much more credible when it acknowledges mistakes matter of factly (Obama is a master at this).

What’s the take home message? We should stop fixating on hourly changes in numbers or differences about the sequences and keep our eye on the Big Picture. Right now that picture is still cloudy, but will be coming into sharper focus as new information accrues and is organized. Generally, though, we have a novel virus (in the sense that the human population is immunologically naive to it) that is spreading person to person and seems to have clinical characteristics not unlike usual seasonal influenza. Because of its novelty the number of people it could make sick is potentially far greater than a seasonal virus, however, since there is no naturally acquired immunity we know of at the moment (it may turn out there is some cross reactivity with some other strain from years past but so far we have no evidence of that).

As a Big Picture, it’s not the most comforting, whatever the day to day numbers.

Comments

  1. #1 phytosleuth
    April 29, 2009

    Ug! This is really complex. I forgot about all the isolates. Da. Not every H1N1 flu isolate from this swine flu strain is the same. Meaning…egads! Explosion of possibilities. Is someone constructing a phylogeny yet? (sort of a family tree, folks) There must be a bunch of jobs open at the CDC right now. This is going to take a lot of work just to keep up with all these samples and isolates.

  2. #2 Lisa the GP
    April 29, 2009

    The only things I’m hanging onto right now are:

    1. new virus. low resistance in the population.
    2. finite health care resources and practitioners.
    3. likelihood of tons of cases swamping resources.
    4. unknown actual severity of illness (but looking less and less remarkable as information accumulates).

    I’m thinking–hoping–that this turns out to be primarily a logistical PITA due to widespread regional work absences and heavy simultaneous healthcare use, without much individual personal tragedy.

    I’m hoping it is more worthy of cranky irritation (oh bother, the concert’s cancelled) than fear (bodies stacking up at the morgue! News at 11.)

  3. #3 Lisa the GP
    April 29, 2009

    By ‘hanging on to’ I mean, ‘taking as reasonably firm baseline assumptions’.

  4. #4 revere
    April 29, 2009

    Lisa: Yes, I think you’ve nailed it.

  5. #5 MS
    April 29, 2009

    Hi Lisa the GP –

    What is a logistical PITA? I don’t know all the lingo…

    Thanks,
    MS

  6. #6 Bioethics Enthusiast Lawyer
    April 29, 2009

    I just want to thank the editor(s) for all the information. I am a 35 year old mexican lawyer living in Mexico City, and from the moment mexican authorities announce the alarm last Thursday I have been following your blog. I really appreciate the quality, time and effort you put into it.

    Thank you very much.

  7. #7 River the writer
    April 29, 2009

    Revere and Lisa the GP, Thanks so much for clarifying the various stats issuue. Very helpful.

  8. #8 Goliath
    April 29, 2009

    PITA = Pain In The Ass

  9. #9 James Bowery
    April 29, 2009

    The rates for the Spanish flu was >2.5%[1], about 0.1% for the Asian and Hong Kong flus[2], and <0.1% for other influenza pandemics.

    So there are basically 3 regimes of CFR separated by about a factor of 10 each.

    All it would take is to focus on a standard sample like Mexico City hospital interns, process their swabs while counting deaths.

    Seriously, folks, where are the adults?

  10. #10 Steve Elbows
    April 29, 2009

    I think PITA means pain in the a**

  11. #11 Joe Six Pack
    April 29, 2009

    MS, I read it as Pain In The Arse.

  12. #12 Pork Flu
    April 29, 2009

    Could someone with knowledge about this answer this question: if someone with swine flu is treated with Tamiflu, does the test result come back negative for H1N1 (swine flu) after they have taken it? I think I read somewhere about avian flu (H5N1) about people using Tamiflu and being tested and the results coming back negative after they have been given Tamiflu, but the results were positive before they were given that medication.

  13. #13 S.o.G.
    April 29, 2009

    logistical PITA: a mythical sandwich which is difficult to find, too large and sloppy to eat easily, and which gives you intestinal cramps.

  14. #14 engstudent
    April 29, 2009

    lol Italians call it Pizza

  15. #15 suzanne bunton
    April 29, 2009

    I just found this article in New Scientist that i think you’ll all appreciate

    http://www.newscientist.com/article/mg20227063.800-swine-flu-the-predictable-pandemic.html?page=1

    It strikes a good balance between technicality and readability, and sheds light on the current flu (epi or) pandemic, what causes virulence, the current threat of other flu pandemics (scary, now that i think about it), and how this “snoutbreak” can be correctly said to be both, an all-swine reassortment, or the triple reassortment (bird, swine, human).

  16. #16 LC
    April 29, 2009

    Seems to me with antibiotics freely available in Mexico, abuse is probably prevalent. If a secondary infection were to strike the lungs after the flu has left them weak, that could account for more deaths in Mexico than the U.S.

  17. #17 Lisa the GP
    April 29, 2009

    Chan just bit Fukuda in the butt on international TV.:titter:

    We’ve just gone from 4 to 5 on WHO’s pandemic scale.

  18. #18 GeorgeT
    April 29, 2009

    revere just got quoted on Slate: http://www.slate.com/id/2217019/

    Last paragraph.

  19. #19 Texas Reader
    April 29, 2009

    Given the very high % of people in Mexico who are too poor to get medical help, it’s impossible for us to determine if the ones hospitalized in Mexico represent a SMALL PERCENTAGE of the total infected in that country or a LARGE PERCENTAGE of the total people infected. Therefore, we can’t know if people in the US are getting a milder version.

    It may be that huge numbers of people in Mexico have been infected and aren’t being counted because they are too poor to seek medical care or have none near their homes.

  20. #20 Reiko Shimizu
    April 29, 2009

    Did Miss Chan say that there are people who recover on their own without medicine?

  21. #21 KPM
    April 29, 2009

    Lisa the GP: Please tell! I didn’t watch.

  22. #22 Ron
    April 29, 2009

    The ‘cloudiness’ is highly frustrating. Mexican health authorities are not doing a great job getting transparent information out to their citizens and the world. Statements from Mexican health workers are coming over the internet and paint a picture of a cover up of large proportions. They report a near panic situation in health service facilities. It is so hard to tell what is really going on but my impression is that large part of the noise is
    1. official misinformation and general distrust of government
    2. more people seeking medical help due to fear and uncertainty
    3. desperation among health workers and saturation of public health facilities.

    In other words the panic factor is a big part of the ‘cloudiness’ in Mexico. I wonder if the same problem isn’t behind the phase 4 to phase 5 upgrade. why? Looking at the criteria I don’t see how they can justify this. H2h transmission doesn’t really seemed to have happened at pre-pandemic levels, at least not yet. What do you think?

    Sequences are suggesting this flu strain may have been around a while. Perhaps it is new to Mexico, thus higher mortality. ??

  23. #23 Marcel
    April 29, 2009

    Hi all

    I’ve been following this thread with interest. I’m a biologist at Stanford and I am really interested in how people feel about this developing situation. If any of you are interested to take a short survey (< 5 mins), your input would be most appreciated.

    https://opinio.stanford.edu:443/opinio/s?s=1403

  24. #24 Lisa the GP
    April 29, 2009

    Yes, Reiko, people recover from H1N1 without any medications if they have a mild case. It is a very different virus from H5N1 ‘bird’ flu in Asia and N. Africa.

    Ron, I agree most of what’s up with Mexico is hysteria.

    The American school clusters demonstrate human-human transmissibility.

    I mentally tuned out of the later portions of the WHO conference because Chan was droning on about the duties of wealthy nations to help poor ones and about corporations to ‘live up to their ethical obligations’ in potentially allowing generic knock-offs of patented drugs to get more manufactured quickly.

  25. #25 Bioethics Enthusiast Lawyer
    April 29, 2009

    I live in Mexico City. The city is huge, densely populated and polluted. On an average day you have teary eyes, runny nose and a sorethroat 5 times a day. You USUALLY dismiss these syptoms as normal. You can even feel febrish after standing under the sun for a while. Maybe this was the case for the mayority of the peoplke who have died.

  26. #26 Lisa the GP
    April 29, 2009

    Marcel, this site is going to give you a very biased sample of people who have a longstanding interest in public health issues. I suggest that you try twittering your link to get a greater cross-section of the online population.

    May we repost your link on other sites we visit?

  27. #27 Pat
    April 29, 2009

    KPM and others: Here is the Reuters’ coverage of WHO’s raising of the pandemic threat level (http://www.reuters.com/article/topNews/idUSTRE53N22820090429):

    WHO confirms pandemic threat raised to 5

    Wed Apr 29, 2009 4:38pm EDT

    GENEVA (Reuters) – World Health Organization Director-General Dr. Margaret Chan raised the pandemic threat awareness level to 5 on Wednesday, meaning the world is at imminent risk of a pandemic from H1N1 swine flu.

    “I have decided to raise the level of influenza pandemic alert from phase 4 to phase 5,” Chan told a news briefing.

    Level 6 is the final stage, a pandemic — a global epidemic of a new and deadly disease.

    Chan said she hoped to reassure governments but urged them to prepare for the worst.

    “The world is better prepared for an influenza pandemic than at any time in history,” Chan said. “For the first time in history we can track the pandemic in real time.”

    The H1N1 swine flu virus has spread around the world, killing an estimated 159 people in Mexico, claiming the life of a Mexican toddler in the United States, and infecting people in at least eight other countries.

    It is a never-before-seen mix of swine, avian and human viruses and it is not clear how deadly it is or how easily it transmits from one person to another.

    “No matter what the situation is, the international community should treat this as a window of opportunity to ramp up … response,” Chan said.

    “It is really all of humanity that is under threat during a pandemic.”

    Pharmaceutical companies should ramp up manufacturing she said. Two antiviral drugs — Relenza, made by GlaxoSmithKline and Tamiflu, made by Roche AG — have been shown to work against the H1N1 swine flu strain.

    (Reporting by Laura MacInnis and Stephanie Nebehay in Geneva, Editing by Sandra Maler)

  28. #28 Mike
    April 29, 2009

    German Television has just reportet that the WHO Pandemic Alert Level has been raised from 4 to 5

  29. #29 Dizzy
    April 29, 2009

    The numbers game is going up and down in Scotland too, and I also wondered if it was because the Tamiflu blanket was being applied. It seems from the BBC news reports that anyone in the UK who is in contact with a flu sufferer is being offered Tamiflu (various examples on the BBC website). Not least, a school in Devon was closed after a 12-year-old girl was confirmed as having swine flu and ‘The pupils will be offered anti-viral drugs’. This could also mean the teachers, and possibly even the families of everyone associated with this school.
    http://news.bbc.co.uk/1/hi/uk/8024690.stm
    The BBC will tell the truth, albeit candidly, but they tend not to report speculation.

    Seems to me as a good way to blow our stash of Tamiflu, treating people who aren’t even symptomatic. At this rate the UK government’s claim of enough Tamiflu to cover 50% of the population will reduce dramatically as we clutch at straws.

    Cynically, the UK, Scotland in particular, benefits a lot from tourism in the summer months. It would suit the purposes of TPTB to play down this PITA (Lisa, I like that, I thought myself savvy but hadn’t heard it before). Given the global economic fiasco the last thing we want is tourists not coming to look for Nessie or endure the Edinburgh Festival.

    None the less it becomes harder to shrug off as the WHO have raised their pandemic level to 5. Dr Niman’s unilateral decision to raise it to 6 made me chuckle too, he is good. The company I work for is also about to issue a statement regarding the flu and homeworking, it is a global, conservative and sensible business, and it seems now the time is right to do so.

    At present we are still trying to put out little fires here and there, soon I expect that strategy to change as the task becomes overwhelming.

    As an individual all I can do is look after my family, the people I love, my neighbours and their children (who I am very fond of), and my work colleagues (who I am also very fond of). I recently qualified as a first aider and it is my intention to volunteer for the British Red Cross, even more so now. Mental? Well, I have no kids and sooner or later we’ll all be exposed to it. I might as well get on with it, and be able to hold my head high and know I did the right thing.

  30. #30 Lisa the GP
    April 29, 2009

    Bioethics Enthusiast Lawyer,

    Young folk who haven’t been seriously sick before often think that they can just ‘shrug off’ any illness and don’t recognize when they are seriously ill. So what you suggest is possible. But how can a person prove that theory? I don’t know.

    Can you tell us about what the government in Mexico City is telling people about the outbreak there?

  31. #31 Marcel
    April 29, 2009

    @Lisa the GP – absolutely, please feel free to post the link anywhere.

    Also, sorry that the post got broken up somehow.

    Marcel

  32. #32 Speechless
    April 29, 2009

    Ok, am I the only one wondering what zoonoses is? Is it smelling your way round the zoo, sniffing out disease? Seems unlikely? Could it be related to the Zoon. Is it cracka lackin’? Or could it be a version of Stenosis — which I think is related to problems of the liver or something that happens to court reporters when they take too many notes…?

    So, trying to put myself in your shoes, which I can in no way imagine ever filling, I could see that writing about big picture, little picture issues, one might be noting Zoom-osis. Perhaps that’s what you mean, zoomosis?

    I’m glad for any levity in this murky which surrounds us.

    Anyone

  33. #33 Margaret
    April 29, 2009

    @Lisa the GP: the government and health officials are telling people, “Stay home as much as possible, wear a face mask if you go out, wash your hands often, and if you have the symptoms, seek medical care and don’t self-medicate.

    Eat healthy, stay calm, the situation is under control, there is enough antiviral medication. Trust us.”

    We haven’t been going out much (mostly PSQ) but when we do, although I see plenty of face masks, more than half the people I see are not wearing them, even on public transport. Granted, the masks are only effective against droplets (maybe) and as a reminder not to touch the face, but if people are not wearing masks when they go out, what other guidelines are they not following?

  34. #34 Bioethics Enthusiast Lawyer
    April 29, 2009

    Yes Lisa.

    The Federal Government is being rather cryptic. Once a day the Secretary of Public health gives a press briefing and updates the numbers, very confusingly. Because there is not a clear distinction between “suspicious deaths”, “suspected cases” and “people with severe atypical pneumonia”. Then to add to the confusion the “confirmed” cases were not so after being tested by a laboratory. So the number came down.

    These reports are coming from the Public Heath Hospitals and clinics, as for the private ones they just answer “we don’t know”.

    The Local Government, Mexico’s City Mare, also gives a press briefing daily. Also updates the numbers of “infected” people, and “suspected” deaths from this virus. These numbers also vary day to day, up, down.

    When asked about mortality, virulence, etc. they just answer “this is a new virus, so we don’t know”

    And Both emphasize the importance of washing your hands, disinfecting surfaces not to greet people with a kiss or a hand shake.

    Then the media try to interpret this and then you can imagine the confusion. That´s why I am here.

  35. #35 Sidheag
    April 29, 2009

    Marcel, did your survey, but wasn’t sure whether to count flu sites (here, FluWiki, PFI, FT etc.) as “online media” or “social networking” – they aren’t really either, but they are where I get most of my flu information, and the same is going to be true of many people you find this way…

  36. #36 peggy
    April 29, 2009

    A pandemic, no matter how mild, will kill many people who have other health issues, including asthma, copd, on chemo for cancer, etc. Many young, healthy people will also succumb. If medical services and supplies of drugs are impacted, people in need of dialysis, insulin, transplant meds, and so on, could be in a world of hurt.

    If raising the level to 5 helps with needed preparations, and saves lives, then it was the wise thing to do. I doubt it had anything to do with hysteria.

  37. #37 phytosleuth
    April 29, 2009

    See what journalists think (was published before the Phase Five announcement)

    http://www.j-source.ca/english_new/detail.php?id=3770

  38. #38 phytosleuth
    April 29, 2009

    Zoonosis
    When in doubt, check the Wiki
    http://en.wikipedia.org/wiki/Zoonosis

  39. #39 Vicoria
    April 29, 2009

    As Pandemic Phase 5 has just been called. How concerned should we be? At a guess Revere, what is the likelihood that Phase 5 will be recalled?

  40. #40 phytosleuth
    April 29, 2009

    Because there is not a clear distinction between “suspicious deaths”, “suspected cases” and “people with severe atypical pneumonia”.

    Bioethics: actually, there is a clear distinction on the CDC site: http://www.cdc.gov/swineflu/recommendations.htm

  41. #41 River
    April 29, 2009

    Question: Now that we are at Level 5, (human to human transmission in two countries), what is the critera for Level 6, or full blown pandemic. How will we know if we get there?

    Thanks

  42. #42 Bioethics Enthusiast Lawyer
    April 29, 2009

    Phytosleuth:

    I Know.

    What I meant to say is that there is no explanation given about this terms in the press conference. I seriously doubt the average mexican citizen know the distiction. Not all the people in mexico have access to a computer, not all have internet acces.

  43. #43 phytosleuth
    April 29, 2009

    Bioethics: Ah. Good point.

  44. #44 Dave C
    April 29, 2009

    My university announced last night that there is a student here with a”suspected” case of the swine flu. I presume they are testing now. I’m very much curious–and somewhat apprehensive–about what’s going to happen next.

  45. #45 GeorgeT
    April 29, 2009

    river: http://www.who.int/csr/disease/avian_influenza/phase/en/index.html

    and here are the WHO Regions used in that definition: http://www.who.int/about/regions/en/index.html

    The WHO Regions are silly (looks based on politics more than geographic sense) although in this case, it is simple enough. Basically when they see enough human-to-human transmission outside of the Americas, we are at level 6.

    I give it a week.

  46. #46 River
    April 29, 2009

    GeorgeT, Thanks for the response. One more question, if I may (I’m a writer, not a scientist — obviously, so all of this is new to me). I just finished reading an AP story that reported that the number of swine flu cases in Mexico have peaked and suggested the crisis may be over there. Does that sound likely to you? Seems there are more cases everywhere rather than fewer and that if this flu is peaking the WHO would not have raised the threat level. What’s going on?

    Thanks again.

  47. #47 Texas Reader
    April 29, 2009

    Fort Worth, Texas ISD is closing all schools until May 8. One confirmed case of a middle schooler. However, I’m guessing it’s more than just that – they probably have serious suspicions about students at other schools or they wouldn’t have closed the entire district.

  48. #48 MS
    April 29, 2009

    Lisa the GP (or anyone else who knows…)-

    Re: hospitalized cases in Texas, one was a pregnant woman suspected (not confirmed) of having swine flu. Her baby was delivered by emergency C-section and is doing fine, but she’s in critical condition. Any advice you can give an 33wk pregnant woman about this potential pandemic who’s trying not to freak out?

  49. #49 GeorgeT
    April 29, 2009

    river: this isn’t my field either though I do have my graduate minor in biology. I do have interest in emergency planning and I’m paying attention to this crisis to learn lessons from it. If you pay careful attention, the experts here are saying that there is no way to know the answer to your question.

    This is for several reasons. One is that the Mexican numbers/data is chaotic and almost useless. Second is the numbers may be down to do all the closures, but what happens when they open everything back up? Third, we don’t know if the virus will mutate.

    No matter what is happening in Mexico, the flu has not peaked anywhere else. The US numbers are going to rise for a while – a week, a month, or a year nobody knows. If it doesn’t take hold somewhere else, I’ll be happy but shocked.

    Texas Reader: I think I read in the Fort Worth case (or some other North Texas case) that the infected students had siblings in other district schools and so they thought it wise to close down the whole district.

    MS: the best thing you (or this 33wk woman if it is not you) can do is the following:

    1. Wash hands a lot and make your family/friends do the same.
    2. If you are that worried, get a quality mask to use when you go out.
    3. Minimize your contact with other people. Practice what was termed here as Preventive Self-Quarantine.

    Right now the odds of you being exposed to Swine Flu is extreme low. In Texas (for example), there are 16 confirmed cases and Texas has a population over 16 million so that is 1 in a million (though it is raising).

    Finally, if you follow Lisa’s reasoning, it is looking more and more like we might have a normal strength flu – hospitals should be capable of handling giving birth under those circumstances. There is no reason to panic right now unless you are giving birth in Mexico City in a stadium full of people coughing.

  50. #50 River
    April 29, 2009

    GeorgeT, I don’t know what field your graduate major is in, but it is darned lucky to have you. For “only” having a graduate minor in biology, you sure give bang-up answers. Thanks so much!

    PS. I checked out the links you shared early (thanks, again). I agree. The WHO’s regions do look politically designed! Be well!

  51. #51 Dylan
    April 29, 2009

    MS: You are roughly three to four weeks out from delivery. I will go out on a limb, here, in the interest of caution. Do not go anywhere where you will necessarily encounter, and mingle with other people. Nowhere.

    Do not bring anything foreign into the space in which you live; no mail, no magazines, no super market products, etc. Nothing. Have your significant other prepare meals, and place them at your door. If he works outside the home, then he has to be ensconced somewhere other than where you reside. If you have pets, keep them indoors. Your environment must be kept utterly inviolable. When it is time for you to go to the hospital, go in a private vehicle (I would not trust any ambulance service, at this time); ride in the backseat, and keep all of the windows open. Call the hospital ahead of time, and tell them that you are en route. Tell them that your delivery is imminent. You are clearly concerned, as you should be. But you…and your child, can get through this. Rest. Be clearheaded. Be resolute. Plan.

  52. #52 GeorgeT
    April 29, 2009

    river: Computer Science. I spent almost a decade working for universities including doing some urban modeling for one state. I work on developing computer security products these days. One reason this potential pandemic is interesting to me professionally is that I was around for the Internet worm (http://en.wikipedia.org/wiki/Internet_Worm) long ago and was the computing version of a local health department. While there are differences, the same issues of isolation, quarantine, vaccines, mutation, etc apply.

    I’m a big believer is cross-discipline learning. I think knowledge I will gain here will make me better at my profession and hopefully I can return the favor. Revere and this blog is a godsend.

  53. #53 Lisa the GP
    April 29, 2009

    There’s no reason for a pregnant person to necessarily get an emergency c-section as a result of flu. There was probably more going on in that case.

    Flu of any kind tends to be more severe on the mother during pregnancy. So you will need to be especially meticulous about ‘social distancing’. In theory, its only 7 more weeks (40 weeks is ‘standard’). You can be a hermit that long, right?

    If you do get flu while pregnant, seek meds early. At this time the flu meds have no known ill effects on the baby (but of course the more they’re used, the more chance something will eventually be recognized as happening at a vanishingly low percentage rate.)

    If you’ve been following pandemic flu discussions before this H1N1 outbreak, remember the virus we’re dealing with is not H5N1, which has dominated those discussions. *This* virus is looking more and more similar to seasonal flu–but threatens to be more widespread.

  54. #54 Lisa the GP
    April 29, 2009

    River, the outbreak in Mexico City may well be waning because, though we only learned of it recently, it really has been going on for at least several weeks there before it was recognized.

    It sounds to me like the Mexican government is giving decent advice as to precautions (I think the masks are more psychological than real in protective effect). Where they are failing the people is in giving accurate status reports.

  55. #55 River
    April 29, 2009

    GeorgeT, Fascinating what you’re doing and how your utilizing both disciplines. Good for you! Yes, indeed, Revere and this blog are godsends… but made all the better by kind folks like you and others who help keep the masses (of which I am most definitely a part) informed and the records straight. Be well!

  56. #56 River
    April 29, 2009

    GeorgeT, Fascinating what you’re doing and how your utilizing both disciplines. Good for you! Yes, indeed, Revere and this blog are godsends… but made all the better by kind folks like you and others who help keep the masses (of which I am most definitely a part) informed and the records straight. Be well!

  57. #57 BostonERDoc
    April 29, 2009

    We should take deep breaths. While we don’t know the transmission characteristics of this strain (lack of having these now with the first case reported over 2 weeks ago is a tragedy in of itself). I think, this thing is losing its virulence–at least in the US–since the serial interval has come and gone for what would have been at least 1- 2 generations in the US and we still have yet to see any big spikes in reported cases. Spring break just ended in several regions in the US so the next couple of days may be interesting. If no huge spike by say Sunday then my theory is right.

    Also I would be interested in what people think of the concept that the CDC pushed hard 2 years ago of TLC (targeted layered containment) of strategically rolling out home isolation and home quarantine, school closure and targeted antiviral prophylaxis–and then stopped promoting it altogether. Do you think they are going to start talking about that if we push this up to a WHO phase 6 and I still havent heard the CDC announce their Pandemic Severity Score yet.

  58. #58 Lisa the GP
    April 29, 2009

    BostonERdoc,

    I think they’re implementing it. The public schools in all of Fort Worth, TX, were just shut down for 2 weeks (affects 80k students) (per CNNTV).

  59. #59 Crow
    April 29, 2009

    MS: While I work in a related field, I am not an MD and I am not qualified to give direct medical advice. Noneteless, my strong feeling is that while some social distancing might make sense (especially if it makes you worry less), Dylan’s suggestions are overkill given what we know at present. Yours would be a very fair question to ask your obstetrician — and I hope you’d take his or her advice over that of an anonymous stranger on the internet.

    -Crow

  60. #60 Lisa the GP
    April 30, 2009

    By ‘meticulous at social distancing’ I don’t mean locking yourself away, but more the issues of using hand sanitizer, shopping at low-crowd daytime hours at the grocery, lots of handwashing, making a wide detour around people you think might be sick, that sort of thing. By ‘being a hermit’ I was trying to be a little humorous, but what I really mean is don’t make the local social scene party circuit. Just live a quiet, home-centered life for awhile, which is probably part of your nesting instinct at this point anyway.

    I think Dylan’s advice might be more appropriate if you lived in a flaming outbreak of a pandemic H5N1 with a humongous death rate. I know he’s thinking of the 1918 pandemic which had really abysmal survival rates for pregnant women. As time goes by this particular incarnation of H1N1 is beginning to look like a wimp–still cause for public health to panic, as they still have to deal with tons of ‘extra’ people seeking health care all at once. But starting to look like the actual illness won’t be that severe for the average flu sufferer.

    We really need to figure out why the Mexican data is so different from the US data…

  61. #61 Dylan
    April 30, 2009

    Not my intention to be the least bit alarmist, here; but five days ago we had no reason to be concerned about this problem, whatsoever. We have no information on how this pathogen might affect late term pregnancies. None at all. Unless someone else, here, has information that I have not yet encountered. If so, please enlighten me. On the 23d of this month, I sent the following news report to my ex-wife (we have an eleven year old daughter in common). The email was titled; “This has not yet made the MSM, but I’ve known of it for several days.” It now reads like ancient history. What a difference a week can make. No? How much difference might several weeks make? Err on the side of caution. That is no more than practical advice.

    Canada on alert after respiratory illnesses reported in Mexico

    Canwest News ServiceApril 22, 2009 2:02 PM
    OTTAWA — The Public Health Agency of Canada has told quarantine services to be on alert for travellers returning from Mexico after a number of severe respiratory illnesses (SRI) were reported in some regions of the country.

    Mexican health authorities contacted PHAC last Friday to inform them of the respiratory conditions, which were reported in the south and central areas of Mexico. The cases elevated from flu-like symptoms to severe respiratory conditions in about five days, with “a high proportion” of cases requiring assisted ventilation.

    PHAC, in an April 20 report, said Mexican officials informed the Canadian health agency that the “case-fatality rate was relatively high” and that most cases involved healthy adults between the ages of 25 and 44. A number of health-care workers were also affected (twenty males between 25 and 44 dead, so far, according to a very recent report; many others being kept alive on mechanical ventilators).

    Although no cause has been confirmed, some samples were positive for influenza A and B.

    PHAC said the concern for Canadians travelling from Mexico serves as a “reminder of the importance of the SRI hospital-based surveillance established after the SARS outbreak in Canada.”

  62. #62 Tom N. , Ph.D.
    April 30, 2009

    Where is the barrage of USEFUL, evidence-based video ads to show the public how to minimize spread of the the flu?

    I’ve resorted to posting BBC’s ad for flu prevention to Digg (below). My wording was dictated by my effort to reach the public. Yes, I realize that the word “idiot” is not too congenial but I’m underwhelmed by Pres. Obama simple instruction in his press conference to cover sneezes and wash hands. Weak, lame, inadequate, though maybe better than nothing… Obama should have reinforced his words with an apt video ad. A lost opportunity to reach a huge audience…

    Where are our own glorious CDC and the equally gloriously & patriotic TV networks? Why are they NOT deluging the public with medically sound TV ads showing simple, effective preventive steps that anyone can take?

    One problem: the BBC ad depicts rather casual hand washing which is (if memory serves) is NOT adequate, right? Anyone know the url of a video version of the dummy’s guide to EFFECTIVE hand washing?

    Two other problems: what the best evidence for the efficacy of masks for protecting the individual and/or the public? What grade of mask, if any, should be used by what groups?

    Also what is the url for a the medically sound ad that communicates this vital info on intelligent use of masks to the public?

    Hope the infectious disease epidemiologists on EFFECT MEASURE check the BBC ad to assure that I’ve done more good than harm :-)! Also, hope they post the urls requested.

    Tom N., Ph.D.

    ===========================================
    Digg submission:

    http://news.bbc.co.uk/1/hi/health/8025994.stm

    news.bbc.co.uk — Here’s BBC’s Dummy’s Video for Preventing the FLU. Where are similar ads from our own idiot government and networks? Where is the Dummy’s Video for EFFECTIVE hand washing? The way most people wash their hands is INADEQUATE, but the right way is easy

    ========================================================

    Thanks in advance to Revere et al. for any comments & advice on this mundane but critical facet of a rational approach to coping with the flu problem, viz., providing the public with sound, effective, simple educational video ads.

  63. #63 Tom N. , Ph.D.
    April 30, 2009

    I am concerned that the challenge of educating even sophisticated, disciplined medical audiences to the need for hand washing, for using the apt technique, and for actually changing their behavior to conform consistently to the findings of evidence-based medicine is grossly underestimated.

    Even a sophisticated shop like the Johns Hopkins Hospital has found it beneficial to invest in a sophisticated program of education and to this very day issues constant reminders. Last month, as a patient at my alma mater, I saw the hand washing message on every JHUH computer computer monitor that I glanced at.

    Imagine the number of airings of TVs ads required to change public beliefs and behaviors re hand washing.

    Does anyone know of any credible studies of the amount/type of effort needed to change public head washing behaviors even during epidemics? Similarly is any branch of the government acting on this evidence? Or will the $1.25 billion allocated for dealing with the outbreak/epidemic/pandemic/whatever be spent exclusively on high tech approaches to the detriment of promoting of basic, low tech but effective public health approaches?

    Tom N., Ph.D.

    p.s. Sorry for the lack of sophistication of my posting, but my work has been oriented towards low tech social epidemiology. If I should be posting on this topic elsewhere, please advise me.

  64. #64 TonstantWeader
    April 30, 2009

    @speechless (32): Ok, am I the only one wondering what zoonoses is?
    ————–
    Google’s very first result tells you. Infectious disease, animal to human (or sometimes the other way ’round).

    I don’t know this subject well either, but Google’s been very, very good to me :)

  65. #65 dayshawnae payne merecedes
    April 30, 2009

    HOW DID THIS FLU CAMEE UP WAT HAPPY WHAT R THE CARE FOR THISE FULE

  66. #66 Lisa the GP
    April 30, 2009

    dayshawnae–

    Take care of this flu the same as any other flu.

    This flu does not look very strong in the US. But it looks like a lot of people will have it at the same time. So doctors are upset so many people will come to their offices at the same time. That is why there is so much discussion on TV.

    At home it should be just like regular flu. If it gets bad, then go to the doctor, same as regular flu.

    In Mexico, some people got very sick. But nobody knows why those people got so sick when everyone else just had regular-strength flu.

  67. #67 Tom N., Ph.D.
    April 30, 2009

    Would someone please comment on the implications of the article below for a rational policy regarding use of surgical masks by various non medical groups:
    =================================================
    The First Randomized, Controlled Clinical Trial of Mask Use in Households to Prevent Respiratory Virus Transmission
    International Journal of Infectious Diseases, Volume 12, Issue null, Pages e328-e328
    C. MacIntyre, D. Dwyer, H. Seale, M. Fasher, R. Booy, P. Cheung, N. Ovdin, G. Browne

    I don’t have ready access to this article which I just located in Scientific American.

    thanks in advance,
    Tom N., Ph.D.

  68. #68 tom N., Ph.D.
    April 30, 2009

    My final post for a while — I promise.

    I recall a journal article (sorry don’t have the cite) which indicated that an infectious disease was transmitted to almost all the passengers on a flight IN THE SPECIAL case that the plane remained on the run way for a long period of time WITH MINIMAL air circulation for the passengers — happily the FAA does mandate some modest comforts like frequent air exchange in the cockpit. Unsurprisingly, the folks up front remained healthy.

    Any pros/cons for recommending use of a surgical mask in case a flight is stuck without minimal air circulation? Air flow is not good in the passenger compartment even on a normal flight (the profit imperative — circulating air burns profit, err fuel), so wonder if it would be prudent to use a surgical mask on any long duration flight. If so probably prudent to check this move out first with the powers that be even if it’s medically indicated, lest donning a surgical mask be misinterpreted.

    Tom — the practical, low technology guy. Again if I am posting to the wrong discussion list, please suggest a more apt listserv.

  69. #69 ipmat
    April 30, 2009

    MS:

    You don’t say if you’re still working or on leave for the pregnancy now.

    If you’re working, stay off public transit. If you can’t do that, wear big sun glasses and a disposable mask, don’t touch your face, DISPOSE of the mask and clean your hands with a handwipe when you get off. Do the same on the way home.

    Pack your lunch and stay out of the lunchroom/cafeteria at work. Wipe down your phone, keyboard, door handles, and anything else you touch at work with clorox wipes or the equivalent. Communicate by phone/e-mail and skip meetings whenever possible. Wash your hands a lot, and keep a bottle of hand lotion at your desk to use each time so you don’t tear your hands up. Anyone in your household should at LEAST wipe down their equipment and wash their hands a lot too.

    Make a shopping list. Cleaning supplies, TP, lotion, handwipes, thermometers for everyone in the house, whatever toiletries your household uses, whatever supplies you buy on a weekly basis. Plus whatever non-perishable food supplies you normally purchase. Add frozen/canned foods that are healthy and easy to prepare. Multiply the list by 9 weeks to get you past your delivery date. Hand it to your SO and tell them it’s your version of pickles & ice cream.

    Make a second list with everything the baby will need for the first 2 months, and get that too.

    Send your SO or a friend to the farmer’s market, outdoors in the sunshine, every couple of weeks for perishable foods you can’t be without.

    Then make everyone in your house take their temperature every morning. Yes, EVERY morning. (I just got a work memo saying everyone who has returned from Mexico or is exposed to anyone returning from Mexico has to take their temperature before coming to work.) If anyone gets a temperature, especially combined with any other flu symptoms, either send them to grandma’s house via their doctor, or go stay with grandma yourself till they’re healthy again.

    With your shopping done and the cupboards stocked, you can relax, listen to music, chat on the cell phone with your friends, bake cookies, garden, whatever as long as it doesn’t involve crowds.

    By the time you deliver, the sun will be high in the sky, lovely UV rays killing those nasty flu viruses, and you’ll be stress free and happy cuz everything you need is all ready and waiting for you!

  70. #70 MS
    May 1, 2009

    Thanks all for the advice! I’m normally a very healthy person, but I happened across some studies on the 1918 pandemic and pregnant women and became VERY frightened knowing that my immune system was depressed and I am later on in pregnancy.

    LISA THE GP: Any updates on how this flu is developing? Will there be a time that we can relax a bit? Are the cases in the U.S. new, or are they just coming to light now that all this testing is being done? As in, is the disease still spreading everyday?

    CROW: I did consult my doc whose office said basically to avoid crowds as much as possible, wash hands frequently and wipe down anything I might have to use (buggies at the market for example) while I am out. Not tons of advice.

    IMPAT: I am actually forunate enough to work from home, while one of my pregnant friends is a doc at an urgent care facility, so I do feel lucky that way.

    All: I’m not sure I understand (as a lay person) why it is such a big deal or surprise that it is spreading from person to person, without some people having been to Mexico. As a lay person (and not to be a simpleton), I just assume that’s how viruses spread: if Betty came back from Aruba with the flu and coughed on John, John would have a good chance of getting the flu. Are there some viruses that you can only get in a certain country?

    Last question: when people talk about incubabtion (being 24-48 hrs) and contagious periods (being the term of time you’re sick for adults, or 7 days usually), what’s the difference? Does incubation period mean that once you’ve been exposed to the virus it takes 24-48 hours for you to get sick if you’re going to?

    Thanks all! I love this site!

  71. #71 megan
    May 3, 2009

    stop the swine flu

  72. #72 sam keethreom
    May 6, 2009

    does anyone no how the swine flu started? my sister told me that it started by a little boy. i am very worried about getting the swine flu. well, if you no any of my questoins anwsers please, please e-mail me.

  73. #73 unknow
    May 7, 2009

    i am a student trying to reasearch swine flu so if any of u knoe for a fact how it is deadly please tell me