Effect Measure

As I write this the US has 279 confirmed cases and one death from H1N1/2009 in 36 states. WHO has tallied 1085 1124 cases in 21 countries with 25 deaths. There is a backlog of samples waiting for confirmation, so by the time you read this the counters will probably have rolled upward, especially as state laboratories become facile with the new primers and are able to do their own confirmation. And predicting an increasing case count is about all anyone can say with certainty at this point. What we said once about flu pandemics can be said just as appropriately for the flu virus: “If you’ve seen one flu virus, you’ve seen one flu virus.” While a likely scenario would be that sustained person to person transmission will take root in some countries outside North America, nothing is for sure with a flu virus.

One major question is whether it will move to the southern hemisphere as that half of the globe edges into their usual flu season. As WHO’s Keiji Fukuda noted at the daily press briefing, the virus appeared in the northern hemisphere at the end of the flu season and was not competing with any other circulating subtype or strain. So watching what happens in the southern hemisphere may tell us something about the relative fitnesses of H1N1/2009, seasonal H1N1, seasonal H3N2 and seasonal influenza B.

As we continue to try to sketch out the descriptive epidemiology — the spectrum of severity, who is getting sick, what is the incubation period, where is disease happening — the recommendations and judgments of CDC, WHO and local agencis will change in response. That may be confusing or unsettling but it is the only rational way to proceed. We are all learning as they go along, and in some cases, making it up as we go along.

I make the same kind of allowances for the public. We hear talk (some of it hysterical) that the public is suffering swine flu hysteria. Sometimes that talk comes from people who are clearly in denial. It is quite understandable that people become alarmed when they hear the word pandemic, not realizing it refers to the extent of disease spread, not the severity of the disease. Outside my profession, there is little acquaintance with pandemics or disease outbreaks except as fiction or popular history. With the help of some decent reporting and non-MSM sources like this one, people will learn. The public has a right to make it up as they go along, too. It’s not such a bad thing. Even if it were, it is what it is. There is no sense wringing our hands over it.

As we move forward from here, the fact that so far the virus is relatively benign — for a flu virus — we need to remember the operative word is “relatively.” 35 of the 279 cases in the US have been hospitalized, and two patients in Canada are reported severely ill. The fever, headache and joint and muscle pains characteristic of this and all influenza can be miserable and keep you out of work or school for a week or more and feeling lousy for weeks after that.

Relatively benign isn’t benign, unless your comparison is a stay in the intensive care unit or a fatal outcome.


  1. #1 paiwan
    May 5, 2009

    I wish that Effect Measure keeps the title-Swine Flu, and the side title (aka H1N1/2009).

    Why? to keep the pressure on FAO and WHO. I speak this on the stance of a stakeholder of food producer.

    Bird flu at least has reflected the connection with poultry. Therefore, the eye and pressure on poultry are prominent.

    We are not sure the cycle of infection. The Canadian case has confirmed that the H2H virus can jump to swine.

    Let us keep the eye and the pressure on pig farms, until they are innocent by scientific proof. We can not afford to take the risk of public health by the mistake of the pig farms as the medium of lethal flu virus. Especially now, FAO and WHO have not developed effective management system on the prevention of diseases transmitted via cultured animals.

  2. #2 TJC
    May 5, 2009

    If I am making the calculations right, that is about a 12% hospitalization rate in the US (35 divided by 279). If this thing gets bigger (more widespread), it seems to me that this rate alone will cause significant problems in terms of our capacity to provide necessary care for those with more severe presentations of this flu.

  3. #3 LibraryLady
    May 5, 2009

    Dear Revere,
    I have been checking your site for a while now and the information is excellent and much appreciated. I cannot find the answer to a question I have. Would you mind if I asked it here?

    If the WHO pandemic level is raised to 6, what does that mean for the average citizen? Do the countries start shutting down, as Mexico did, asking citizens to voluntarily isolate themselves? Does air travel stop?
    What happens, exactly, especially in the U.S.?

    Library Lady

  4. #4 lTom DVM
    May 5, 2009

    It’s a little cooler in Canada and the virus seems to be acting a little different here.

    Also,I would think South America would be a good area to watch in the next few months.

  5. #5 Lisa the GP
    May 5, 2009

    TJC, the possibility of that happening (small fraction of a large number swamping hospitals) is the reason we need to be aware of ‘pandemic’ status even when a virus is mild for most folk.

    I’m guessing that some of the current hospitalizations are out of an abundance of caution, so 12% will probably prove to be higher than what we observe when people are less panicky about this virus. But that probably doesn’t matter much because the overall number of folk affected is likely to climb high enough to swamp hospitals even if the percentage needing them is pretty low.

    It’s still appropriate to call ‘bird flu’ ‘bird flu’ because it is circulating bird-to-bird and occasionally bird-to-human, not human-to-human. (this is why it makes sense to cull chickens in affected districts)

    H1N1 2009 is now circulating human-to-human and occasionally human-to-pig. So ‘swine flu’ really doesn’t apply to it anymore. (this is why it makes no sense to cull pigs in affected districts)

    WHO level 6 means more to officials having to allocate resources than it does to folk on the street.

    Regardless of what level the WHO labels the pandemic, if enough people in a region become sick at the same time, it could shut down the local economy, and that effect could ripple out of that locality due to our global economic interdependence.

    So if it gets *really* widespread it is possible we could see some items go temporarily short in stores. It’s important to be aware of this–have a buffer of common essentials such as prescription medications and toilet paper to get you through a short outage in supply. And then if you see a shortage, remember it is temporary and will probably be fine again in a week or two as folk in the affected region go back to work.

    The thing we don’t need is to see a flu-related supply-chain-slowdown and have people panic and start hoarding–exacerbating a minor problem and making it a major one. If people have a little buffer and know to expect the possibility of supply-chain glitches, then it just becomes time to roll your eyes and say ‘damn that pesky flu’.

  6. #6 revere
    May 5, 2009

    LL: Mostly the WHO threat level is not relevant to the US. It is relevant for many of WHO’s member countries. It is a signal to them to start getting ready and it enables WHO to get some aid and support to countries that don’t have the resources of the US or European countries, e.g., for antivirals and advice. Each country decides to act on its own. WHO cannot compel them to do anything and WHO is advising against border closure, but any country can decide to do that if it wants to.

  7. #7 Lisa the GP
    May 5, 2009

    I just keep imagining that 20% of LA dockworkers get flu the same week, none of the ships want to land and risk catching it, so they all divert to Oakland, swamping Oakland’s capacity and essentially losing 100% of LA’s capacity (because no one willingly docks there).

    That would be an epic supply chain mess.

  8. #8 stillarebel
    May 5, 2009

    Thanks for your coverage of this flu and also for all the comments. The other areas of the blog are interesting too.

    I like your use of the phrase “relatively benign”. Over-use of “mild” by spokes-people is winding me up. Even hangovers can be worse than mild!

    Thank goodness it has been this “relatively benign” flu we are dealing with, so far. We might be in awful mess if it had been something worse.

    I’m concerned about the capacity of all countries for surveillance. Kind of worrying that lab capacity was overwhelmed so quickly. (I’m not saying every case needs lab confirmation). Also, honesty seems to have dreadful economic consequences. Does it have to be that way?

    Tales of mandatory isolation are also concerning.

    In our policies, we may be unwise to put too much faith in a vaccine that hasn’t been produced yet (timing) and drugs that bugs can potentially beat. I am disgusted, but not surprised that in some places anti-virals can be bought OTC.

    We also need adequate capacity in health care systems. And there must be equality of access. The capacity has to be worldwide, or none of us are safe.

    Sick, vulnerable workers can’t follow public health advice, because they don’t get paid if they don’t work. Other fearful workers are constrained by draconian absence policies. The poorest can’t afford to stock up on groceries – they are already on food aid.

    Health care workers need to know they and their families will be taken care of afterwards, if a pandemic with a lot of fatalities kicks off. Otherwise some may not show up for work. Who could blame them when you look at precedents like 9/11 and Sars, in that regard?

    Nursing Times (UK) had an article about student nurses being expected to work during a pandemic. Fair enough, but will they get wages, sick pay, or a pension for themselves or their dependants if it goes wrong for them?

    It’s all public health.

    So glad to have found this blog. MSM is so all or nothing. If we’re not all dead within a week, there’s no story.

  9. #9 FT
    May 5, 2009

    “With the help of some decent reporting and non-MSM sources like this one, people will learn.”

    One has to wonder why the MSM does not contract with someone like you to vet news before broadcast.

  10. #10 ConnectRN
    May 5, 2009

    FT – a calm, rational, scientific based approach to medical news? Boring!!

  11. #11 GeorgeT
    May 5, 2009

    From CNN “Federal officials now recommend that schools stop closing when a case of swine flu is confirmed at a school, Health and Human Services Secretary Kathleen Sebelius said Tuesday.”

    I haven’t heard why this reversal in policy.

  12. #12 GeorgeT
    May 5, 2009

    More info from MSNBC:

    The change in the school closure guidelines reflects the observation that the virus is widespread but mild, said Dr. Richard Besser, acting director of the Centers for Disease Control.

    “We know that in communities that are seeing cases in the school, they’re already seeing cases in the community, so the strategy of trying to stop the transmission by approaching it as a school problem is not very effective,” Besser said.

  13. #13 revere
    May 5, 2009

    I think this has more to do with pressure from those affected than any change in the science. Essentially what Besser is saying is that we can no longer expect to slow this thing down. I’m no sure that’s true, but everything is a trade off.

  14. #14 GeorgeT
    May 5, 2009

    By “those affected”, I guess you mean the parents at the schools that are closed and the school administrators who are listening to their bitching.

    Since a school within 2 miles of me is closed, I was ready to do my parts if the schools my children are in were affected.

  15. #16 Danny
    May 5, 2009

    Leading Advisory Team Leaks Valuable H1N1Swine Flu Triage


  16. #17 LC
    May 5, 2009

    Received a call from a co-worker who took an American Airlines flight out of Miami last night at 9pm. They landed in Chicago at 12:00am.

    An Hispanic passenger fainted on his way into the bathroom mid-flight, did not regain consciousness, and during landing was lifted and seated next to my co-worker who was then vomited on several times.

    Co-worker says passenger was running a high fever, eyes rolled back in the head, and would not respond to an interpreter. Airline attendent handed him several “wipes” to clean off the vomit and when the plane landed all passengers were escorted off the plane at which time the paramedics responded.

    Co-worker had to catch another flight and called me mid-air to see if I could find out what happened to the other passenger. My co-worker believes the man died. American Airlines won’t give out any information nor will Logan Airport.

    If this is the way things are being handled, I have a problem. If any journalists are reading this, it might be a good story to follow up on. Three passengers were hit with the flying vomit.

  17. #18 Lisa the GP
    May 5, 2009

    LC–try CNN’s ‘news tip’ email address under ‘contact us’ at the bottom of the page. You’ll need to give names.

  18. #19 GeorgeT
    May 5, 2009

    LC: Although they are alternate media, the Dallas Observer (http://www.dallasobserver.com) have the best reporters in town. And the key thing is that they know Tim Wagner, who is American’s head PR guy, well enough get him to post on their blog on airlines issues on a fairly regular basis. They might be able to get more out of him than someone just calling up American plus they might be able to use it for a blog entry at a minimum.

  19. #20 LC
    May 5, 2009

    Thank you for your response. I will contact both immediately.

  20. #21 Lisa the GP
    May 5, 2009

    LC, keep in mind you can’t see a fever–the guy might have just been really drunk or moderately overdosed on a drug. There are a lot of potential reasons for something like that to happen on a plane, that are not infectious diseases.

  21. #22 Lisa the GP
    May 5, 2009

    LC, keep in mind you can’t see a fever–the guy might have just been really drunk or moderately overdosed on a drug. There are a lot of potential reasons for something like that to happen on a plane, that are not infectious diseases.

  22. #23 LC
    May 5, 2009

    Thanks, Lisa. I’m aware of that. The vomit did not smell of alcohol nor did the man. The gentleman was sweating, the eyes were rolled back in his head, his eyes were open but he wasn’t there, and he was unable to walk. He was allowed to lay on the floor until landing when he was lifted and seated in the passenger seat directly behind Ryan. He was in his early to mid-twenties. No comments were made by passengers or attendents that it was alcohol related. Many statements were made as to how ill the man was. How frightening it seemed. Most passengers remained exceptionally quiet, with each of them looking from one to the other, all thinking the same thing.

    I think more than anything, an answer ought to be available to passengers that were on the flight considering the times. However, I do understand privacy concerns too.

  23. #24 LC
    May 5, 2009

    I might also add, that after landing, Ryan looked back and the man didn’t appear to be breathing. His eyes were half way open and they had a glazed over look.

    Certainly it could be drug overdose. Anything is possible. I’m just not sure how I stand on this “privacy” issue when it comes to public heath.

  24. #25 crockett
    May 5, 2009

    Its impossible to say for sure – but the situation you are describing re: man collapsing on flight sure sounds like a drug “packer” overdosing, especially given the departure location of the flight. This is a common fate for “mules” who ingest balloons or condoms packed with narcotics.

  25. #26 Lisa the GP
    May 5, 2009

    Crocket that’s one possibility I was also thinking. Cops might not want to let details out yet if they’re looking for associated criminals involved in something like that.

  26. #27 paiwan
    May 5, 2009

    Lisa: “It’s still appropriate to call ‘bird flu’ ‘bird flu’ because it is circulating bird-to-bird and occasionally bird-to-human, not human-to-human. (this is why it makes sense to cull chickens in affected districts)

    H1N1 2009 is now circulating human-to-human and occasionally human-to-pig. So ‘swine flu’ really doesn’t apply to it anymore. (this is why it makes no sense to cull pigs in affected districts)”

    Call it swine flu doesn’t mean has to cull pigs.

    The bird flies. The transmission via birds is more likely. Pigs’ transmissions are via human basically. And this disease makes human more suffered than pigs themselves. The rodents in North America carry Hantavirus, they will not die. But if Hantavirus infects human, we die. Luckily we don’t have rodents farms. 😉

    Both pig and rodent animals are mammalians. Rodent perhaps is more close to human in evolution sense.

    Evolution theory fights with creationism which wrongly depicts the history of 6,000 years. Our FAO or WHO health experts maybe only use 300 years as the time frame for solution. I will not follow that logic.

    Our public health should work towards to be free from animal viruses’ fear. Poultry and pig farms are the area of man-made medium. Using millions years as the time frame is the first step. Watch out carefully.

  27. #28 Julie Stahlhut
    May 5, 2009

    Sick, vulnerable workers can’t follow public health advice, because they don’t get paid if they don’t work.

    Undoubtedly this is the way a lot of nasty little bugs get around — flu, bad colds, norovirus, etc. It’s easy to blame on the person who came to work or school while sick, but it’s going to happen when people don’t have any paid time off if they get sick or have to take care of a sick child. And some very small businesses — like many restaurants — don’t have the wherewithal to cover this, so it becomes nobody’s job to protect either the worker or the public.

    Then again, some people who have a choice and should know better just don’t use their heads. Some years back, my husband and I attended a small party at a friend’s house. One woman at the party brought homemade snacks, and waited until after many people had eaten them to announce, blithely, that she was glad she felt okay to come to the party because she’d awakened that morning with a GI bug (“Throwin’ and goin’ all day!”) Four or five people at the party, including my husband, came down with unpleasant cases of “funny tummy” within a day or two. Fortunately, none got any sicker than the original idiot did.

  28. #29 pft
    May 5, 2009

    Seasonal flu by definition is a pandemic, no? If the flu is not any more severe than seasonal flu, us denialists are just saying draconian measures like quarantines and school closings should not be implemented. The CDC now agrees, at least on the latter.

    Unfortunately, some countries like China have resorted to quarantines, making life that much more difficult for those who must deal with the threat of being detained because of our nationality or travel history and the fact we may have a cough or some sniffles. Thanks.

  29. #30 raven
    May 6, 2009

    It is way too early to call this swine flu “mild”..

    We don’t have the data, yet. Need the case fatality rate (ratio). Also need the characteristics of the patiients with serious disease or death.

    All we can say so far is that it isn’t as deadly as the 1918 H1N1 outbreak. No flu since has been. There is some evidence that it is more serious than seasonal flu.

    1. In Mexico, quite a few people were hospitalized or died. They were atypical for flu victims in that many were young and healthy.

    2. We haven’t had that many cases in the USA and already two youngish people have died in Texas. The hospitalization rate also seems to be higher than endemic flus.

    My guess from fragmentary data is that it will have higher morbidity and mortality than seasonal flu. Can’t tell whether this is due to its novel appearance with no residual or herd immunity or whether it is a more pathogenic than seasonal flus. We really need the data, not guesses.

    Regarding health care workers, they are a problem and at high risk in a major pandemic. They had problems in Mexico with panicking health sysem workers not wanting to deal with flu victims. This is where a vaccine would be ideal. It would be prudent to prepare a few million doses of swine vaccine now while we have a lead time. Then, in a widespread pandemic, vaccinate the health care workers first. That way they don’t have to worry and your whole medical system isn’t going to be out sick just when you need them.

  30. #31 revere
    May 6, 2009

    raven: Judgments have to be made as we go along. The characterization of this virus as “mild” may be misleading because even mild flu is nasty, but I don’t think it is implausible to say that what clinicians are seeing so far doesn’t indicate a flu virus as bad as H3N2 but more like seasonal H1N1. You are correct that no definitive judgments are possible but we need to make intermediate judgments as data become available. I think those “on the spot” are reporting what they see, which is what they should do, not modify it by how they think it will be received. I want to know what they think. While you or I may not think the same thing, we aren’t the ones on the ground.

    pft: No, seasonal flu is not a pandemic. While it may be widespread, it is an endemic disease, not a worldwide epidemic (an incidence greater than expected).

  31. #32 River the Writer
    May 6, 2009


    Reuter’s AlertNet (http://www.alertnet.org/thenews/newsdesk/N06391128.htm) is reporting that Canada’s late-season flu, H3N1, may have mutated and the mutated version traveled to Mexico where it, too, wrecked havoc along with A/H1N1-2009. Have these two combined? Does this increase the danger of A/H1N1-2009 increasing in verulence?


  32. #33 revere
    May 6, 2009

    River: Thanks for the heads up. The virus is H3N2, BTW, but that’s not so important. I’ll need more info than in this article. I’ll head over to ProMed to see what I can find out.

  33. #34 River the Writer
    May 6, 2009

    Revere: You’re welcome. Sorry about the typo. It should have read H3N2. I’m curious about what you discover and will check back in the morning. Thank you!

New comments have been disabled.