Effect Measure

Yesterday New York reported two more swine flu deaths (a 41-year-old woman from Queens and a 34-year-old man from Brooklyn). CDC and just about everyone else who knows anything about influenza have been telling people to expect this. The influenza virus kills people all the time. We don’t know exactly how many but we know that many people die of various immediate and underlying causes that wouldn’t have died at that time if they hadn’t become infected with the influenza virus in the period prior to their demise. Influenza is like heart disease or diabetes or cigarette smoking: a major cause of mortality that we have become used to. As long as it is described in terms of familiar seasonal influenza the public is all right with it — until they get a good dose of this really miserable illness. Meanwhile New York City’s Mayor Bloomberg is getting a taste of what can happen when you minimize the seriousness of a disease that always deserves great respect:

A day after Mayor Bloomberg told reporters that those with swine flu are “lucky” because it’s a mild strain, he struck a more sympathetic tone, urging anyone with medical problems to seek help if they feel ill.

“As the virus spreads through the city and through this country and around the world, these deaths sadden us, but I don’t think they take us by surprise,” he said. ‘That doesn’t, however, lessen the loss of loved ones.” (Carrie Melago, New York Daily News)

This “mild strain” has now killed four New Yorkers in less than a month and put 131 of the 330 confirmed cases in the hospital — and those numbers are undoubtedly the tip of the iceberg. If this were a food poisoning or an industrial accident it would make headlines in every newspaper in the country.

I have some minor complaints about CDC’s messaging (it is false that 36,000 people die of flu every year; no one is served by repeating a falsehood), but I think for the most part they have done it right. Be straightforward about what plausibly might happen and what we do and don’t know. The differences between New York’s messaging and CDC’s have been relatively small but important. They involve tone and the seriousness with which they take the situation. I want to think that this is mainly Bloomberg and not his health commissioner, Thomas Frieden (who will take over as the next CDC Director in June).

I guess we’ll see pretty soon. Fingers crossed.

Comments

  1. #1 Tom DVM
    May 27, 2009

    “The influenza virus kills people all the time. We don’t know exactly how many but we know that many people die of various immediate and underlying causes that wouldn’t have died at that time if they hadn’t become infected with the influenza virus in the period prior to their demise.”

    Revere: With respect, you have provided not one iota of proof that this is the case other than horseshit modelling studies.

    If you have anything like irrefutable evidence that seasonal influenza is other than a sporadic disease…

    …of the kind that were state of the art twenty or thirty or fifty years ago…for instance like paired sera showing an increase in titre, please present it.

    Thanks.

  2. #2 kristin
    May 27, 2009

    What gets my attention (and what I keep looking for more information on) is what underlying conditions existed in these NYC patients – especially because the ages of fatalities is (so far) fairly well outside the typical risk pattern for seasonal influenza. Like many of us, I’m trying to piece together a picture of patients who might be most at risk of serious, potentially fatal complications.

    For instance, I read that the first NYC victim had an ‘underlying condition’ – but all I could gather is the family reported he suffered from gout. Can that be the only comorbidity the patient presented with – does anyone know?

  3. #3 Zachary
    May 27, 2009

    It’s also been mentioned that Mitchell Wiener (the first NYC death) was obese, but there’s no evidence that this would have put him at more risk. (Some people claimed that the study of hospitalized cases in California showed that obesity is a risk factor — but it didn’t.) It bothers me that we’re still hearing about how Wiener had “underlying conditions,” and it makes me skeptical when I hear the same claims about new victims.

    I also think the pattern of deaths that we’re seeing is worth investigating, but the news reports so far provide little to go on. I’m hoping that we’ll see some actual studies published before long.

  4. #4 revere
    May 27, 2009

    Tom: Tom: Let me try to understand what you are saying. When you ask if there is any evidence that seasonal influenza is anything but sporadic, I assume you don’t really mean sporadic in the technical sense, since if it is seasonal it isn’t sporadic. So I’ll assume you agree that flu is seasonal but think that between its seasonal outbreaks it is completely absent. Since we haven’t been doing surveillance in the summer months, there has been the question about “where does it go” in the summer. I hadn’t meant to imply that I know flu kills the year round (although I in fact suspect that is the case) but that flu kills many people but its role isn’t documented or even identified. Most clinicians believe this to be true and in my post about how we estimate flu deaths lays out some of the reasons. I did a quick search and within a few minutes found a couple of cites that document flu in the summer season (Suzuki et al. J Clin Microbiol. 2009 Mar;47(3):623-9. Epub 2009 Jan 21 and Yang et al. PLoS ONE. 2008 Jan 2;3(1):e1399) and flu outbreaks in camps and nursing homes in the summer are well known. But I’ll grant you we know little about flu during the summer or in tropical climates.

    If it is completely absent then it seems the only other alternatives are it is hiding in some animal reservoir (but none have been identified) or it is in the southern hemisphere and comes back during the winter or is imported into camp or nursing homes from the southern hemisphere, which seems unlikely. Possible, but not at all germane to the post, which was about the fact that seasonal flu (whenever it occurs) is a disease worthy of respect and it can kill you. So your comment missed the point.

  5. #5 The Doctor
    May 27, 2009

    More speculation on influenza

    As I recall people carry asymptomatically a whole host of bacteria and viruses within and on their bodies. These carriers do not seem to be affected by the microbes but when they are spread to a susceptible host, then an infection occurs.

    MRSA comes to mind here since medical professionals caring for patients are one of the more prominent reservoirs for this deadly bacteria.

    Maybe influenza also takes up residence within a portion of the population in some sort of benign state or even a symbiosis (protects them from infection with other flu strains). When environmental conditions favor flu spread, then the virus is spread by the usual means; airborne and fomites.

    More speculation: Cold viruses or even bacteria that cause coughing might augment the spread of flu when the carrier becomes acutely infected with one of these other common diseases. While the flu is not causing a symptomatic infection, it is present in some numbers within the droplets coughed by the patient and when they come into contact with a susceptible person, that person gets the flu.

    Grattan Woodson, MD

  6. #6 Tom DVM
    May 27, 2009

    Thanks Revere.

    Let me be a little more explanatory.

    As you know, the 1918 pandemic was H1N1 and its offspring have dominated the field of play for almost a century…although there are now several avian flu’s present around the world that could emerge pandemically as well.

    However for now, once again, a novel H1N1 has arrived.

    Therefore, the most critical factor in this pandemic will be inherent immunity from previous exposure to the virus.

    The general opinion, backed up by flawed but convenient modeling is that seasonal influenza occurs in epidemic porportions every single year in America…in fact, this epidemic kills 36,000 persons a year (as widely quoted by the WHO and all their subordinates).

    In Ontario, with a population of 12.5 million people, it was also ‘estimated’ that in 2002, there were 58,000 food-meat borne illinesses, with a cost to the healthcare system of 200 million dollars per year (which doesn’t make it right because once again it is a model).

    In 2008, a very smart doctor in Ontario, managed to uncover a listeria outbreak that had been killing persons in senior citizen homes in Ontario (more than twenty identified in the end)…
    \
    …His/her finding forced the regulators to act at Maple Leaf Foods and big surprise, the infection was in their cutting machines…

    …my point being that since it is obvious that persons were dying in senior citizen homes probably for years or decades, how many death certificates had listeriosis as the cause of death or instead, simply stated they died of influenza…a convenient catch all phrase-diagnosis that no one would question and therefore, no further effort or paperwork.

    So the question remains, is influenza a sporadic disease or a disease that killes 36,000 Americans every year of every decade like clockwork.

    It is my opinion, that influenza is sporadic and causes localized outbreaks only…and that most illnesses that are diagnosed as influenza are a myriad of similar respiratory infections (RSV etc) or food poisoining like Listeriosis.

    If I am right, there is little inherent immunity ln world populations which makes this pandemic potential far worse…and we will probably only have to wait six months to find out.

    Now, you might not be the Revere that has repeatedly defended that 36,000 model but it is now being used as a tool to prevent preparation.

    As you now, a model is not proof although it is often sold as such…

    …So if there is irrefutable proof that this disease occurs epidemically each year in the USA, then it is time to produce it.

    The standard of proof in the past were not models but things like full postmortems if the person is dead or paired sera showing a rising titre if the person survives.

    Is there such proof.

    IF there isn’t then the hypothesis is flawed until proven otherwise and we should go forward as if our families, communities and countries have no potential immunity and this pandemic might very well be similar to the 1918 one.

    Thanks as always for the opportunity to voice my concerns!

    /:0)

  7. #7 SusanC
    May 27, 2009

    The NYC saga is a good demonstration of what can go wrong when communication got off at a bad start. If you give less-than-scientifically-supported statements, they will come back to haunt you. Again and again.

    Those who are supremely mindful of their public image and/or career prospects may unfortunately be tempted to stick with the badly mangled message than to admit mistakes and start all over again.

    We don’t know how that will affect future communications out of CDC, once Frieden is in place…

  8. #8 revere
    May 27, 2009

    Tom: Please give me the reference to any model that says influenza produces 36,000 cases a year, like clockwork. On the contrary, the models say there is great variation with many years with no excess mortality and some with a great deal (I wrote an extensive post on this which is linked in this post as is my complaint about the 36,000 deaths number). These are methods that go back to the work of William Farr in the mid 19th century and aren’t some new fangled invention. (these are data models, by the way, so if you don’t like the idea then you are rejecting all of modern statistical methods). So this is a straw man. In its place you have your opinion, which you are welcome to. It’s your opinion.

    As for whether flu is seasonal, there is plenty of virological surveillance data to show it. No models. Just data from specimens. I prefer that to relying on your opinion. But maybe that’s just me.

  9. #9 Tom DVM
    May 27, 2009

    Thanks Revere.

    Of course seasonal influenza is seasonal…that is not my problem.

    My problem is mortality estimates with flawed conclusions that have been misrepresented by people who should know better…

    …but some habits are hard to break…remember the 2005 WHO H5N1 model that stated 8-12 million potential mortality only.

    Is there any proof anywhere, based on anything other than a model, that proves irrefutably that influenza is anything other than a sporadic disease…

    …and by the way, this quality of modeling did not show up until the middle 1980′s…if there was modelling before this, and into the 19th century, then I must assume it was of better quality with reasonable analysis.

    We uniquely seem to have developed the model where if you have enough money, you can easily buy any conclusion you want.

  10. #10 Snowy Owl
    May 27, 2009

    Thomas Frieden (who will take over as the next CDC Director in June).

    Considering the actual situation and Thomas Frieden Swift Precise Motions of the Past Decretary should request that he take Office NOW to the President.

    Snowy

  11. #11 Snowy Owl
    May 27, 2009

    Revere, you say in Summer
    [quote]
    If it is completely absent then it seems the only other alternatives are it is hiding in some animal reservoir (but none have been identified) or it is in the southern hemisphere and comes back during the winter or is imported into camp or nursing homes from the southern hemisphere, which seems unlikely. Possible, but not at all germane to the post, which was about the fact that seasonal flu (whenever it occurs) is a disease worthy of respect and it can kill you. So your comment missed the point. [end quote]

    From the American Hemisphere via First Nstions, Autochtones, from Up-North where Snowy Owl’s feeds on Lemmings to the Deep South where giant Lemmings feeds on Snowy Owl

    Snowy Owl

  12. #12 Snowy Owl
    May 27, 2009

    Sorry the rest did not post;

    …From the American Hemisphere via First Nations, Autochtones, from Up-North where Snowy Owl’s feeds on Lemmings to the Deep South where giant Lemmings feeds on Snowy Owl’s the Shamans Consensus is yes, the viruses are even more sensitive than Migratory Avians and therefore drives via climate… it just want to survive, like all of us.

    Snowy

  13. #13 Snowy Owl
    May 27, 2009

    Tom, Remember the Canadian Cordycepts, people get killed around the Himalayas when they pick it up, it is priceless, the Orientals that buy’s it are Political Leaders, Rich Business leaders, and Wise Dicerners.

    We got to get forward in Preparedness,

    Thats where we are

    Snowy

  14. #14 Tom dVM
    May 27, 2009

    Let me try and come at this from a different angle.

    I am a local coroner and family physician who had a difficult day and previous night delivering a baby. At the end of the day, I get a call to the nursing home for a person who has died. I did not examine the patient but have been called to fill out the death certificate.

    I ask those around what the person had and they say that they had the flu.

    So I do both the common sense and expedient…I put influenza as the cause of death.

    In the real world, that causes no harm, the person leaves for the funeral home, the familly does not have to put up with an autopsy and since this type of death is not unusual, it doesn’t change things for anyone else in the community.

    However, then comes a sorcerer’s apprentice, who decides that they should model the cause of death. They might even be funded by…say a pharmaceutical company in the business of selling products to treat or prevent seasonal influenza…or not.

    So the person decides to scan a representative sample of death certificates for an area…

    …and low and behold…a large number have the diagnosis-cause of death as influenza…

    …so the modeler comes up with a model that estimates a high death rate from influenza.

    Now, in the short term, that also doesn’t cause a problem…and in fact leads to increased profits for pharmaceutical companies and modelers…not a bad thing.

    However, then a pandemic strain shows up…and politicians are panicking which makes regulators panic…so they strategize how to make the politicians feel better…and pull out this flawed death estimate…

    …so they say to the politicians…’don’t worry…seasonal influenza kills 36,000 each year anyway…so a few thousand here or there…no problem (as exactly they appear to have done with Mayor Bloomberg in New York).

    This also has shortterm benefits…everybody calms down and get along with things…just like in 1918…until the shit hits the fan…as it inevitably does.

    There a couple of points to this diatribe:

    1) This virus and H5N1 and H7 and H9 and H3 don’t care…all they care is that there is a lot of ‘low hanging fruit’ in the human population and harvest is about to begin…the more humans blindly downplay the situation the better.

    2) Maybe the influenza vaccine works better than I think…it just doesn’t work to well for E.coli, Listeriosis, Salmonella, RSV and bacterial pneumonias.

    Thanks

  15. #15 Snowy Owl
    May 27, 2009

    Managing and Reducing Uncertainty in an Emerging Influenza Pandemic

    at

    http://content.nejm.org/cgi/content/full/NEJMp0904380

    All thanks to Crofsblog at

    http://crofsblogs.typepad.com/h5n1/2009/05/uncertainty-about-pandemic-flu.html

  16. #16 revere
    May 27, 2009

    Tom: I have no idea what you are talking about. The reason statistical methods are used (these are the models you descry) is because we don’t have the death certificate information we need, so it is necessary to make inferences from more certain data. You need to read the models you criticize so bitterly before passing judgment. They are written by NIH scientists with no connection to drug companies. By the way, how do you know how many people died of 1918 flu? You have no irrefutable proof it was millions or even hundreds of thousands, do you? In fact we don’t know how many people died. We are just making inferences with models. So maybe 1918 flu is also a fantasy. Maybe it was many different viruses or diseases or even fiction. I’m afraid that is the level you are arguing at. You aren’t using models. You are just waving your hands and the breeze is enough to knock someone over.

  17. #17 Tom DVM
    May 27, 2009

    Revere.

    Steady yourself from the breeze.

    So that leaves me with one question.

    We have seen one study that indicates that 36,000 persons die of seasonal influenza in the United States each and evry year…

    …Whether this is how the study describes it…this is obviously being sold to Mayor Bloomberg and other politicians and citizens unchallenged by the scientific community…

    …just like when Dick Thompson attacked Dr. Nabarro over his contention in contrast to the WHO study that between 8-12 million would die from an H5N1 pandemic…and no more.

    Sorry I have two questions:

    1) Has there ever been a complimentary study to fulfill the requirement under the scientific method for independent comfirmation of their conclusions.

    2) Is there any evidence wfdhatsoever other than this study…using irrefutable data-like for instance acute and convalescent sera…that confirms this one conclusion made by one rearcher or one group of researchers?

    …this request seems pretty straightforward.

  18. #18 revere
    May 27, 2009

    Tom: Please give me the cite for the alleged study. There is no such study. No where. Period. The number comes from a paper by Lone Simonsen and it doesn’t say 36,000 people die of flu each year. If you know of such a study, tell me where I can read it.

  19. #19 The Doctor
    May 27, 2009

    Tom is right about how carelessly death certificates are filled out. In fact it is a joke.

    As a physician who has signed many of the documents I can say with certainty that for the most part I had no idea what the cause of death was for the majority of patients.

    While physicians are required to sign these documents and testify to the cause of death so help me God most of the time I didn’t know.

    For instance, last week I signed one. The patient was in her 90s and died in a nursing home. While I was thoroughly cognizant of her medical history and current medical condition, I have no idea what the true cause of death was, besides a broken heart due to the unexpected and premature death of her daughter but that is not a choice the coroner would accept.

    So I placed in the section for cause of death the usual cop out “cardiopulmonary arrest” due to “coronary artery disease” etc. Both were probably true but they were educated guesses only, not the truth.

    I suspect most doctors in my position due the same.

    The lack of autopsies being made as routine part of the deceased patients medical care is the reason for this despicable state of affairs. If we really wanted to know what the cause of death is for those that pass away what we need to do is perform a complete autopsy on at least a statistically significant sample of all those who die.

    This would be a very informative undertaking and a good use of public funds since the information could be used to educate the physicians caring for the deceased in the form of a clinico-pathalogic-conference CPC as well as for statistical purposes.

    Of course for this to gain support from the medical community we would need to institute a form of national no-fault malpractice reform that would view medical mistakes as regrettable but as also an opportunity to learn and do better next time.

    Today, most of those who die in the US do so with no more than a presumption of the cause of death. Experience has taught me that pre-mortum presumptions are often incorrect.

    Grattan Woodson, MD

  20. #20 Snowy Owl
    May 27, 2009

    Grattan,

    I have for years convey your messages, your Wisdom and Pertinence.

    But please read the following.

    Sciences cia autopsies or else can get to the facts, but we are talking of people here, of their dignity and the survivors Doleances.

    I really wish that Science Zealotism get’s out of Humanitarian Affairs.

    Respect Cultures, I am sure that Science will find out The dynamic, please do not bring us nack to inquisition time.

    Humanitarians nor Culturals people are Heretics.

    Do not wish what you suspect or fear to show that you are right in your premice, this is not democracy and respect.

    Wtih deep Respect Snowy

  21. #21 Jon Schultz
    May 28, 2009

    SusanC said: “Those who are supremely mindful of their public image and/or career prospects may unfortunately be tempted to stick with the badly mangled message than to admit mistakes and start all over again.”

    Yes, I think that’s a bad weakness we have, which pandemic influenza can exploit.

  22. #22 raven
    May 28, 2009

    I too am a bit skeptical of the “underlying causes” excuse. Some of these underlying causes, the few where known, don’t seem to have a lot to do with why someone dies of swine flu.

    The school official had gout but according to his family, was otherwise healthy. So what does uric acid crystals in his joints have to do with flu viruses?

    The other problem I’m having with underlying causes is their ubiquity. Pregnancy, RA, obesity, and so on. We are an aging, fat, and sedentary society and many people are being kept alive these days by modern medicine who wouldn’t make it in simpler cultures. There are close to 30 million type 1 and 2 diabetics. In my age group, boomers, a good share of the people I’m acquainted with would fit a loose definition of “underlying causes”. In fact, my guess is many tens of millions have “underlying causes”.

    If we do have a classic pandemic with high attack rates, the ERs are going to be swamped with sick patients with “underlying causes”.

  23. #23 Path Forward
    May 28, 2009

    Tom DVM:

    You have twice cited “…the 2005 WHO H5N1 model that stated 8-12 million potential mortality only.”

    What WHO kept citing (and mis-using) was Martin Meltzer’s calculation of how many people a 1957 or 1968 (I forget which) might kill these days.

    The number was “2 to 7.4 million.”
    http://www.who.int/csr/disease/influenza/pandemic/en

    You may also recall that WHO/Geneva officials chided former WHO / WPRO leader Shigeru Omi for saying that “millions” might die in the next pandemic, and later smacked down the U.N. pandemic coordinator David Nabarro for saying, in October 2005, that up to 150 million people could die in the next pandemic.

    The assertion of this low number also contradicts recent statements by Keiji Fukuda, at WHO press briefings, that WHO had a far more lethal H5N1-related pandemic in mind when they wrote and revised their pandemic phase definitions in 1999 and 2005.

    Now WHO is claiming that all the time it was telling the public it wanted countries to plan for a pandemic in which two to 7.4 million people might die (a relatively “mild” pandemic), and chiding officials who talked about higher death rates, they were actually developing pandemic phase definitions with a much more lethal H5N1-spawned pandemic virus in mind.

  24. #24 Tom DVM
    May 28, 2009

    Path Forward

    Thanks for the explanation

  25. #25 Tom DVM
    May 28, 2009

    So the World Health Organization was looking the public in the eye and saying one thing…and then behind their backs doing the opposite.

    So the bottom line is that if you want to work for Dr. Do Nothing at the World Health Organization, the first prerequisite is intellectual and scientific dishonesty:

    behavior that would get you fired at almost every other institution in the world.

  26. #26 rpsms
    May 28, 2009

    @#24 but apparently not where you work.

    Where’s that cite?

  27. #27 Path Forward
    May 28, 2009

    Tom, while I think it is honorable to refuse to work for certain organizations, I also think it is honorable to try to change the organizations with which one works, from the inside or from the outside.

    You can’t always do it without losing your job, but you can do it without losing your soul.

    (But you have to keep a really good accounting with yourself — and develop a thick skin, against attacks from within and from without at the same time!)

  28. #28 Tom DVM
    May 28, 2009

    Path Forward

    Point well taken.

    rpsms.

    I fired myself.

    If you mean a cite for the 36,000 in the USA that die every year from influenza…it has been stated ad nauseum by the WHO and seemingly all regulators and politicians around the world… quoted day in and day out for more than a month: in every form of media…and since ‘the media is the message’…the “cite” is irrelevant.

    …and since we are now to be measured against the lowest common denominator, the World Halth Organization, it doesn’t really matter whether you have heard the obvious or not, the public got the message.

  29. #29 Kim
    May 30, 2009

    I’d heard that most death certificates were signed off with cause of death as cardiac arrest, as that is usually the end result of any disease process, and autopsies are rare.

    I assume a lot of folks here have Google alerts for “H1N1″ or “swine flu.” I wished I’d saved the links of two alerts in which family members protested the description of those who died from the new flu as having underlying health conditions. They were articles from local news media that portrayed generally healthy young “not old” people who regularly participated in athletic activities. Anyone have those links?

    I suppose that most of us in the lay public want to know if the new flu has an unusually high mortality rate in those segments of the population for whom it would traditionally be shocking to hear of their death from flu. 36,000 yearly flu deaths among elderly, bedridden nursing home patients or the seriously immuno-compromised is sad, but as has been posted, death is expected among the elderly and the seriously ill, whatever the cause. What we want to know is whether the ratio of deaths to infection among younger, comparatively healthy patients is following a pattern not seen since 1918. Many people where I work aged 30 to 60 have type II diabetes or asthma, but function as well as anyone else, and I’d be flabbergasted to hear that they’d died from influenza.

    Is is impossible to get the stats on this because we don’t know how many are infected? But aren’t we seeing an unusual trend of active, relatively young “not old” people dying now of influenza?

  30. Good job! Im glad to read that

  31. #31 M. Randolph Kruger
    July 31, 2009

    It really screwed things up Tom and Kim when it started killing healthy people. Oh crap now what? Got to come up with a new soapbox to stand on. Me, I think this stuff comes rolling in on us like a cat in the fog and blammo. We catch it in the shorts. San Diego, arguably the location of the first case somehow with all of their reporting has failed to raise the case numbers but now the deaths are increasing. When it first broke it was so many zeros to the right of the decimal in March it wasnt worth looking at. BUT, its has steadily marched to the left for six months and its crossing over into the full percentage points.

    Also noted and put out in todays briefing was that if you just took San Diego county they have gone from those many zero’s to the right to a full 1.87 CFR all company included there until tonight when they reported the cause on a woman who died in late JUNE? Uh, thats a month ago. Cant have any reality in the numbers …Easier to put Gratton on it.. Not a slam old son just reality as I said. You going to do samples on the dead whether they got “underlying conditions” or are you going to send them to the morgue with a pnuemonia tag on them when you got 1000 cases standing out on the lawn in the pandemic?

    So, as I have said for a long time we will have only a few thousand cases of confirmed H1N1 and everyone else will be dead from something else.

    Seems to me that WHO came up with a general criteria for calling H5N1 instead of testing didnt they? Shouldnt they do the same for H1N1 or is it because we have 3 strains of ugly floating around.

    Sorry Tom, another one in Ottawa – RIP