Effect Measure

Swine flu: we’re all in this together

This has been a supremely frustrating day for me since I am traveling and must attend to professional business having nothing to do with the current outbreak. I is incredibly maddening to be away from fast moving events. I’ll return home Friday night. In the meantime I will do what I can late in the day and early in the morning, and if I can’t sleep, in the middle of the night. Since there are plenty of other places paying attention you’ll still be getting the latest news and I am hoping the enforced distancing may allow me to give a more detached view. That aside, I have a favor to ask of all of you.

Over the years we have accrued a loyal and knowledgeable readership and in the last week have acquired many more. I am always impressed by the amount of raw brain power out there (as well as the amount of raw nuttiness, of course), and since there is no way I can even read all the comments now, much less answer all the questions, I am hoping you will all help each other. When you are pretty sure you know the answer to a question, jump in and give it. Preface it with the name of the questioner so they can find it easily. Be responsible. Don’t guess, don’t grind your favorite axe, try not to flame. Be genuinely helpful and constructive.

We’re all in this together.

Comments

  1. #1 PalMD
    April 29, 2009

    Anyone who doesn’t love the reveres is insane! I can’t wait to see what q’s come in.

  2. #2 GeorgeT
    April 29, 2009

    revere: I’d love to hear your take on the Egypt Pig Slaughter: http://news.yahoo.com/s/ap/20090429/ap_on_he_me/ml_egypt_swine_flu

  3. #3 MoM
    April 29, 2009

    Communication is why God invented computers. ;^). It is absolutely what they do best. Times are gonna be a little nutz here in my little corner of paradise, but I’ll help if I can.

    MoM

  4. #4 historian
    April 29, 2009

    I’m new to this website. Thanks to the revere team for their calm, thoughtful posts. As a historian, I’m aware that the spread of the 1918 flu was facilitated by WWI bond drives and parades. It’s graduation season here at the U. As of yet, we have no official flu in this state, but I can’t believe it’s not lurking around. So my question is: should I go to graduation this Saturday, or skip it? Should we be having graduation at all?

  5. #5 Cheetos
    April 29, 2009

    Aw, you sound like a sweetheart Revere. Since I know nothing about any of this stuff, I promise not to butt in with any dumb answers or advice.

    But a question did dawn on me today, so I might as well blurt it out here. Since this time of year is normally the end of Flu Season, could this odd timing for the start of this Flu have anything to do with Climate Change/Global Warming? Could climate change affect (or should that be effect?) ‘normal’ flu season patterns?

  6. #6 Lisa the GP
    April 29, 2009

    CNNTV–

    All schools in Fort Worth, TX, will be closed until May 9th (2 weeks) to slow flu spread.

    This affects roughly 80,000 people.

    Story will probably turn up on the CNN site in text form shortly.

  7. #7 TigerHunter
    April 29, 2009

    Since we’ve been invited to ask questions–is this more similar to regular influenza that kills primarily the very young and very old, or Spanish Flu which mostly killed healthy 20-somethings?

  8. #8 Lisa the GP
    April 29, 2009

    Cheetos, a similar situation was seen in the 1918 pandemic. The virus first emerged at the end of the flu season and was comparatively mild, only to come back harshly the following fall.

    As Revere says, ‘you’ve seen one flu pandemic, you’ve seen one flu pandemic’, so we can’t say that this flu will even be a player in next years’ flu season or not (though it seems likely). All we can say is that this pattern is *possible* for flu.

    Since 1918 is prior to our current climate crisis, it suggests that climate change is not required for this pattern from a new virus.

    Climate change may impact seasonal flu. But in what way? :shrug: dunno.

  9. #9 Lisa the GP
    April 29, 2009

    Historian, there’s no certain answer about whether to go to your graduation.

    Listen to the news in your region. If there are no warnings or alerts locally, and if you don’t feel sick and if you think your classmates will be reasonable and skip it if they are sick, then the odds of a problem are still pretty low. Even lower if the event is held outdoors.

    It’s a personal decision.

    We might have a better handle on how severe the average individual’s illness is by that time, too. If it is a mild illness for most, that factors into your willingness to take the risk.

    With available information today, if it were me and nothing changed in the news, I would go. But we can learn a lot in the next two days that will need to be factored into your decision.

  10. #10 Carolyn
    April 29, 2009

    I work in Northern California for a large global company (US, UK, EU, Asia Pacific) and our site’s EHS department stated they were implementing our company’s Pandemic Plan. I’m curious about how many large/med/small companies have these plans? As of today we are advised that anyone returning from any international travel within the last 7 days and going forward must report to EHS when they return(presumably for a screen, but they did not specify). Then, if you came back from Mexico, you must stay home and call them. They said we should reconsider any travel plans. I am going to find the Plan tomorrow when (if) I am back in the office. I am scheduled to fly to the UK on Monday evening and I have been praying they will cancel the trip. I am pretty sure the Plan includes advising people to work from home when we reach a certain point, but not sure yet what that is. What are other companies doing?

  11. #11 Lisa the GP
    April 29, 2009

    Tiger, the answer to that question remains unclear.

    In the US it seems to be striking primarily children and teens, and so far has been mild. The one toddler who died apparently had other health problems prior to catching the flu.

    In Mexico there are reports of cytokine storm in individuals in their 20’s and 30’s. Spanish flu did this, H5N1 ‘bird’ flu does this, and in rare cases even regular seasonal flu does this. But since the data from Mexico is so garbled, the only one of these flus we can say it is NOT like, is H5N1.

    We just don’t have the data to say, right now.

  12. #12 GeorgeT
    April 29, 2009

    carolyn: I’ve worked for all sizes of companies and state government. I’ve never heard of a company having a Pandemic Plan. I suspect it is quite rare.

    I currently work for a small company and my employer keeps offering (often unnecessary) onsites to customers. *sigh* The guy should know better – he’s the one who travels all the time and is sick more than 25% of the time. At least, I telecommute full-time.

    I would like to see employers and government to use this opportunity to increase telecommuting. It’s not for every job/everyone but it is way under-utilized. One point I never seen mentioned is the health one. I’ve been telecommuting for years now. I find that most of the time that I would have been too sick to go to the office, I can still get at least a half-day of productive work done. To me, it’s better than laying around watching daytime TV.

  13. #13 Bob Eckert
    April 29, 2009

    Carolyn
    Many of the larger transnational’s have pandemic contingency planning as part of their Business Continuity Plan. The triggers for various levels of response vary based upon the culture of the company and the time that their plan was built. Since 9/11 in the US especially, we’ve seen more robust, “all threats” kinds of planning done. It sounds like you have a plan, but it doesn’t always cascade through the organization as rapidly as it might. If you have concerns, reach out to your Environmental Health & Safety folks and check in with your concerns.

    For those of you new to the idea of Business Continuity Assurance Planning, I wrote a primer here:
    http://www.newandimproved.com/newsletter/2000.php

  14. #14 WMDiva
    April 29, 2009

    Carolyn, I work for state government and have been working with businesses for the past 4 years. Back in 2006, when pandemic planning reared its head, businesses thought the government wasn’t doing anything so the business contiuity planners got together, had symposiums and actually compared plans.

    Since most of the employees of the larger corporations live in the suburbs, the Box Company execs didn’t want Box Store A cashiers wearing masks and Box Store B cashiers not wearing masks. Since the employees live next to each other, there is likelihood of “My Box Store likes me more than yours likes you – I’m wearing a N95″. Is it true that A loves their employees more? Nope, but the perception is there.

    The business group, emergency management and public health took a tour of our state, promoting business pandemic planning. Large companies helped the mom and pop stores as well. It worked very well… Plus we developed a common set of definitions for businesses to prioritze services.

    On the flip side – when state government started looking at our govermental COOP and vendor agreements – we asked our vendors if they had a pandemic plan and if we could see it.

  15. #15 sylviah
    April 29, 2009

    thank you, revere(s?) for this blog. this is exactly what i was looking for, a few days ago, when i first read the headline: “swine influenza transmittable human-to-human in mexico city”. aaack, i thought.

    fwiw, my business (the UN headquarters in NYC) has a pandemic plan. the only thing they’ve done so far is alert us that there is a threat of pandemic. and they told us to wash our hands a lot. :) wise advice in general, i’m sure.

    the concept of “you’ve seen one flu pandemic… you’ve seen one flu pandemic” is incredibly useful, actually, for organizing my worries about this whole thing. i’ve been comparing this, mentally, against the 1918 flu “model” thus far. it’s good intellectual discipline to know i shouldn’t be drawing facile comparisons.

    keep up the good work, guys.

  16. #16 mia
    April 30, 2009

    Thanks so much, revere (and much thanks to Lisa the GP too)!
    I’m an EngLit PhD, so much of this is quite unfamiliar to me.
    Here’s my question:
    I’m interested in the whole factory farm connection. From what I’ve gathered (on Grist, mainly) the two most likely hypotheses for where this virus came from is either the Smithfield hog concentration camp in Veracruz, or from a migrant worker returning to La Gloria from the US. Of course, it’s too early to point fingers at factory farming practices, but, from a public health perspective, how much in general should we be worried about new (“recombinant” is the word?) swine/flu/human viruses coming from factory farms? I’ve heard that factory farms might be less likely to produce these new viruses since the hogs are all vaccinated. But I’m assuming, that as in human flu vaccines, pig vaccines aren’t going to eliminate the possibility that pigs host influenza viruses? So, even if it turns out that the Smithfield CAFO had nothing to do with this current strain, should large CAFOs still be considered ticking time bombs in terms of future pandemic influenza strains?

  17. #17 Lisa the GP
    April 30, 2009

    Mia,

    It’s going to take some investigative work on the part of health officials to determine what actually happened in the genesis of this virus. Right now there’s even some debate about the initial assessment of the virus as being a reassortment between human, bird, and swine viruses. Now, with more time to look at sequences, some think it’s all-pig in origin.

    It’s probably a good idea for you to read the ‘basic science’ posts on the flu-wiki, as Revere has suggested. This will help you understand words like ‘recombination’ and ‘reassortment’. To many non-science reporters covering these stories, words like that sound similar and they tend to use them as synonyms, when in fact they refer to very specific, very different, biological processes. ‘Reassortment’ is well-established as a process in flu viruses. ‘Recombination’ is common for organisms with a DNA genome, but controversial when applied to RNA genomes such as flu (Henry Niman is a big proponent of recombination in flu, so you may see it mentioned in his writings.)

    I’m using that example because you used the word ‘recombination’, but it is not to imply that there’s any particular importance of that issue over others. The point is, the fluwiki basic science section can get you up to speed on the science fairly quickly. That way, you’ll be able to write about flu accurately, ask better questions of your sources, and detect when someone is trying to bullshit you.

    Now, armed with that knowledge, yes it is possible that factory farming contributes to the rapid evolution of new viruses. In factory farming, animals live only a few months, and are generally in close proximity to each other. Even if they are vaccinated, the vaccines can only cover known viruses. If an animal picks up a new virus (perhaps from a wild animal that wanders into the farm grounds), there are a lot of opportunities for that virus to spread to other livestock even if at first it is fairly poorly adapted to its domestic-animal host-species. It can spread even if it is poorly adapted because of the close proximity of the other animals.

    So in this environment, you have all these livestock crammed together with a new virus. Each new time the virus transmits to a new host, a virus that transmits more easily has the advantage over its fellow. So the transmissible one is more likely to get into a new host first and have more progeny. There’s natural selection for viruses that are better adapted to the livestock.

    Now, these infections leave behind them recovered animals that are immune to the virus. In a natural population, even crammed together, eventually the virus would run out of new animals to infect, except for the new babies.

    In a factory farm, though, where animals live only a few months before being slaughtered and replaced with a new crop of young’uns–that winds up as an ‘all you can eat buffet’. So the virus that was new to that species of livestock has a good opportunity to become well adapted to it.

    Now, if the virus kills the livestock, it may be quickly noticed and addressed. However if it starts off mild, it may be noticed only as a mysterious failure to gain weight at the expected rate. It may take a long time for a farmer to recognize that a virus not covered by the veterinary vaccine is present.

    Meanwhile, you have farm-workers interacting with this pool of livestock, many carrying virus. With an overwhelming dose of livestock virus, there’s a chance some farm-worker will contract a virus poorly adapted to humans. If conditions are right, the same basic process by which the virus adapted to the livestock can happen in humans.

    The ultimate reservoir of flu viruses is birds. It’s not hard to imagine a pig eating an ill or recently dead bird that wandered into the farm yard.

    Plus with all the shipping of livestock around the world, it’s also not hard to imagine that livestock in one region, vaccinated against the expected viruses in that area, might get exposed to something from far away and pick up a virus for which they’ve not been immunized.

    For example, it is thought that bird flu in some parts of North Africa arose from chicks shipped from China.

    I dunno if any of this goes beyond what you were already thinking. Just trying to do a ‘core dump’ of all I can think of on the topic.

  18. #18 suzanne bunton
    April 30, 2009

    Mia, and others concerned about factory farm impact on public health, including viral reservoirs, (as well as other things): you might find this report from PEW commission informative.

    http://www.ncifap.org/

    or here

    http://www.pewtrusts.org/our_work_report_detail.aspx?id=38442

  19. #19 Lisa the GP
    April 30, 2009

    Suzanne, you’re good at finding stuff! :D

  20. #20 historian
    April 30, 2009

    Thanks, Lisa. I’ll watch the news carefully. Another factor to consider, in my case: I’m not graduating, I’m one of the profs. It’s no special occasion for me, and if I don’t go, no one will miss me. I think that tilts the decision-making process a bit further toward caution.

  21. #21 ConnectRN
    April 30, 2009

    I’m finding varied info on how long the flu virus remains viable on surfaces (desktops, door handles, keyboards, etc.). Does anyone have a professional source that I can use?

  22. #22 Lisa the GP
    April 30, 2009

    ConnectRN–this isn’t definitively what you need, but its references list might provide a jumping off point to find what you need. It’s an NIH article about the persistence of Influenza viruses on bank notes (paper money):

    http://aem.asm.org/cgi/content/abstract/74/10/3002

  23. #23 mistah charley, ph.d.
    April 30, 2009

    As Simple as Possible, but Not Simpler

    Those of us reading here may be asked to give advice to people we know, who know that we know more about this situation than they do.

    Last night’s televised presidential press conference, and various other communications aimed at the public, are, in my opinion, keeping it TOO simple. Here’s my version of the “as simple as possible” advice:

    I read quite a bit about influenza during the bird flu “boom” a few years ago. We didn’t get a bird flu pandemic, but I’m sure we will get a flu pandemic eventually. Is this it? We’ll see.

    But we do know some things now. As Obama said in his press conference, if you cough, cough into your elbow, not into the open air or your hand. Wash or sanitize (with Purell or equivalent) your hands frequently. Stay home from work or school or crowds or traveling in mass transit if you’re sick.

    Other things you could do now:

    Accumulate food and water at home in case supplies are interrupted.

    Download and print out the CDC’s home care advice (just as the stores might be empty if this hits hard, the hospitals will definitely be full). It’s at the CDC site, or search for the terms “swine influenza” “taking care of a sick person in your home”:

    http://www.cdc.gov/swineflu/guidance_homecare.htm

    While antivirals and antibiotics require prescriptions, CDC says over-the-counter cold and flu medications will give symptomatic relief (but don’t give them to children under the age of two; don’t give aspirin-containing drugs to teenagers or younger). You might check that you have some of these on hand, just in case. Aches and fever can be helped with acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®, Nuprin®), and naproxen (Aleve).

  24. #24 Tsu Dho Nimh
    April 30, 2009

    It’s EASY to count dead people.
    It’s EASY to count people sick enough to be in the hospital.

    Approximately 7% of the the persons hospitalized for “atypical pneumonia” have died. That’s typical for influenza cases that are severe enough to be hospitalized.

    What we still don’t have from Mexico is any idea of the number of infected people who didn’t go to the hospital and didn’t die. They are only tracking hospitalizations.

    Without a measure of the background infection rate we can’t know if this is a classic “flu”: widespread, mild infection with a few hospitalized and fewer dying, or a nasty but not very infective one that hospitalizes almost everyone who gets it.

  25. #25 ellie
    April 30, 2009

    Quick question to the healthcare professionals: Is the flu virus transmissible orally? I know it can infect through mucous membranes, like your nose and eyes. But can you become infected by ingesting it?

  26. #26 revere
    April 30, 2009

    ellie: the official line is “no.” However the data are pretty scant. For seasonal flu, “no” is probably the right answer. For H5N1 it is a little less clear. We have posted about it a couple of times over the years. See here for an example:

    http://scienceblogs.com/effectmeasure/2007/03/should_you_be_scared_about_bir.php

  27. #27 Lisa the GP
    April 30, 2009

    Tsu Dho Nimh–

    ‘atypical pneumonia’ is most commonly used to describe an ‘interstitial pneumonia’, in which fluid doesn’t collect in the alveoli of the lungs but in the tissue between the alveoli, sort of forming an extra water layer between the air and the capillaries that are supposed to absorb it. This gives a different look to an x-ray than typical pneumonia where the excess fluid is in the alveoli themselves.

    The most common cause for this kind of pneumonia is an infection with an organism called ‘mycoplasma’, commonly called ‘walking pneumonia’ because as pneumonia goes, it is comparatively mild.

    ‘Atypical pneumonia’ is not just a random ‘catch all’ for ‘pneumonia of unknown cause’. It is a more specific than that.

  28. #28 Snowy Owl
    May 7, 2009

    AUDIO

    FDA Moves to Eliminate ‘Informed Consent’ by Patients in Pandemic Context of a ‘Public Health Emergency’…

    What Are the Implications of This in A Medical Privacy Context And In the Context of Patients’ Rights?
    Will a ‘Pandemic Emergency’ Essentially Nullify Medical Privacy and Patients’ Rights ?

    In a public health emergency some very difficult issues confront both the government and the public when it comes to questions such as:

    Should ‘informed consent’ in regards to medical testing be waived in the interest of the general public health?

    Should testing be mandatory?

    Can treatment, including vaccines, be foreced on people even against their wishes in a declared emergency?

    These are questions that go to the balance of individual rights versus the ‘public interest’ in a public health crisis, particularly in the context of an officially declared emergency when the government’s police and other powers become virtually limitless (see the interview below with the attorney David Massa.)

    On June 7, 2006 the Federal Drug Administration issued a new rule eliminating ‘informed consent’ in a public health emergency and putting other measures into effect. (Go Here for the full text of the rule.)
    The Chairperson of the Patient Privacy Rights Foundation, Dr. Deborah Peel, discusses both the apparent lack of due process in respect to the FDA’s move and other concerns about the new rule itself.

    Listen To This Interview (running time=8:45 minutes)
    http://easylink.playstream.com/JJUnland/drpeel.wma

    Snowy

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