Effect Measure

Pandemic prep teachable moment

For years those concerned about the consequences of an influenza pandemic from an exceptionally virulent flu virus, like A/H5N1 (“bird flu”) have despaired about motivating business, government and neighbors to take it seriously enough to make serious preparations. It’s understandable. There’s are a lot of potential catastrophes competing for our attention and while each can be made plausible if we can get someone to listen long enough, it’s rare we can do this. As I said, too much competition. Now that a real life influenza pandemic has arrived, the concern of some is that the public isn’t being told how bad this could become, possibly even 1918 level. My view is different. In terms of stimulating genuine pandemic preparedness, I think we are extremely lucky to have a pandemic that so far is nowhere near worst case scenario (and let’s be clear: it isn’t anywhere near worst case). The pandemic is no longer theoretical. It is here and tangible. And it is having some tangible effects in unlikely places, like hedge funds. Hedge funds?

Although talk of the swine flu has largely been out of the media for the past few weeks, a rush of new cases of the H1N1 virus is expected to hit financial centers in the fall and winter ” and organizations, and in particular hedge funds, need to be well prepared for a pandemic.

Bob Guilbert, managing director of marketing and products at Eze Castle Integration (booth 1804), which provides outsourced IT technology and services for hedge funds, says his firm has been taking a proactive approach to the pandemic.

“We’ve drafted our own response plan which we’ve issued to all our employees. The plan takes a look at if they’re ill, how to get checked out; if they travel to countries with the virus, what procedures they should follow. And if the company is in a situation of a pandemic, it maps out procedures for working remotely, etc,” he says.

[snip]

Hedge funds in particular must make sure they have a solid plan in place, he adds, since they must conduct business during trading hours. They need to assess how they are going to stay operational if the virus sidelines their employees.

“We told them to think of a disaster recovery plan to make sure they can stay active. We have given them procedures on how to gain remote access to their working environment,” he said.

To avoid the spread of the virus, recommendations include having employees who are sick stay home for at least 7 days. They should then obtain a doctor’s note that they are clear.

In the case of a pandemic, firms should hold meetings by conference call where possible, and ensure that all employees have remote access to their work environment.

The hedge fund industry in general is keeping a wary eye on the pandemic, Guilbert says. (Melanie Rodier, Wall Street and Technolgy)

The fact is it is a lot easier to envision the consequences of a quarter or a third of your employees being out sick than to contemplate and accept as a reason to plan that there will be a total collapse of critical infrastructure. And it is a lot more likely, too. Even in 1918, critical infrastructure didn’t collapse. Piped water still ran, gas and electricity still flowed, there was still food in the markets. My mother was a teenager in 1918. Neither she nor any member of her generation ever mentioned those years to me. I myself have lived through two pandemics (1957 and 1968), each of which killed a great number of people. During one I was a teenager and the other already a doctor. I was aware of both, but only peripherally. They were public health catastrophes compared to most outbreaks, but they made little impact on most people. Having an easily visualizable problem, like absenteeism, is much more motivating than any apocalyptic vision of societal breakdown.

If this pandemic virus is like the moderately severe one of the 1957 pandemic it will have more of an impact, of course. First, we are a more tightly interconnected world. Things happen faster and on a broader scale than in earlier times. Second, we find out about them faster and on a broader scale than before. Earlier pandemics were well underway before they were recognized. Now we can know about one as it’s starting but not know where it’s going. This uncertainty can generate (appropriate) anxiety which can cause its own problems. Third, the US health care system is much more brittle than in 1957 and cannot absorb the shock of even a moderate increase in demand. It will break down and people will fall through the cracks.

We need to take it very seriously but we should welcome the lack of high public anxiety. As WHO’s Director General noted, we are being given a grace period during which many important things can get done with a clear head. Hedge funds aren’t unusually prescient (as the current financial debacle shows too plainly). They are just an example of what I am guessing is going on in many venues.

This is a pandemic preparation teachable moment.

Comments

  1. #1 Sam Dawes
    June 24, 2009

    For a glimpse of what’s happening in a Caribbean country, I’m in Jamaica this week and there has been an outbreak of H1N1 flu at an elementary school in the Manchester (Jamaica) region. About a dozen children at one school are sick, so the principal closed the school and the Minister of Education decided to close the other schools in the district. Their final exams will be taken next semester, since this is the last week of school. There was concern that public events, including an important track meet this weekend, might have to be canceled or held without any fans to watch. As of today, there is no decision to do this. The public health advice has been “stay home, avoid sneezing or coughing on anyone, and get supportive care.” There was one death a little while ago, apparently because the sick individual was quarantined in a hospital room, got pneumonia, and the staff didn’t check on the patient in a consistent way to monitor his course. All this is a learning process very similar to what has happened in North America, only delayed a month or two. Seems like a rehearsal for this country that will prepare it for the next wave, if and when it comes.

  2. #2 River
    June 24, 2009

    Revere,

    I wonder if that grace period is about to end and the moment is about to become really, really teachable. Multiple news agencies are quoting Joerg Hacker, head of the Robert Koch Institute for infectious diseases in Germany that there are signs in Australia and South America that the swine flu is mutating into a more aggressive form. (http://www.reuters.com/article/healthNews/idUSTRE55M5EA20090623).

    A week or so ago, there were reports that a variant of A/H1N1 had been found in a Brazil patient. (http://medheadlines.com/2009/06/18/new-h1n1-swine-flu-viral-strain-discovered-in-brazilian-patient/).

    Is the flu mutating, becoming more aggressive, are these alarmist reports, or does the evidence point to something in the middle?

  3. #3 Snowy Owl
    June 24, 2009

    Teachable Moment indeed.

    On Social desorganisation though there is a huge difference between 1918 and today, particularly on the food accessibility.

    In the town where my Grand Mother lived they had about 2 500 daily sources of food from the Farmers all around.

    90 years later there are only about 100 sources of food available mainly Big centralised Corps.

    There is one more difference too, in 1918 Harvest Time all family canned and stored food for the Winter, when the second wave hit, disruption on food delivery did not impose much stress because od the food reserves family had. This is not the case today.

    One more point, I was at a meeting of Drug Store Chain Medicine Providers, a lot of critical medicine is in our days imported and with the High ROI imperative of JIT (Just in Time delivery, almost no inventory) we are already have some problems concerning vital and chronic medicines importation for the Fall.

    On top of this the Domino effect of the pandemic on Nations incline somes to seized medicinal products for their Fall need, we will have the rest. Same for PPE (Protective Personnal Equipment).

    We should start to investigate alternatives on medicines and medical equipment.

    Beside there are now Govern Mental moves that do not look to good.
    cf: H1N1 2009 Pandemic Domino Effect
    http://snowyowl.wordpress.com/

    Finally I would like to remind us what Margaret Chan said in her speech on “Greater equity in health should be a progress indicator”

    The pressures of a pandemic, on top of the rise in chronic diseases, could alone cripple fragile health services.

    On present evidence, the main risk factors for severe or fatal H1N1 infection are two-fold: pregnancy, and underlying medical conditions, like asthma, cardiovascular disease, diabetes, and obesity.

    To make my point, I need just two figures: 99% of maternal mortality, and 85% of the burden of chronic diseases are concentrated in low- and middle-income countries.

    I firmly believe that this pandemic will reveal, in a highly visible, measurable, and tragic way, exactly what it means, in life-and-death terms, when health needs and health systems have been neglected, for decades, in large parts of the world.

    We will see, in extremely tragic ways, the consequences of our long-standing failure to ensure basic care during pregnancy and childbirth.
    http://www.who.int/dg/speeches/2009/global_health_20090615/en/index.html

    Again thank you Revere to keep Daring to Care and sharing your opinion.

    Snowy Owl

  4. #4 raven
    June 24, 2009

    Is the flu mutating, becoming more aggressive, are these alarmist reports, or does the evidence point to something in the middle?

    Sort of what I’ve been wondering . There are only 4 drugs for flu from 2 classes. This virus is preloaded with amantadine/rimantadine resistance, most likely due to past antiviral usage.

    That leaves Tamiflu/Relenza, both NIs. How long will it take for swine flu to mutate to resistance to one or both drugs?

    If this virus does, that leaves us with exactly zero flu antivirals.

    There is also a potential game changer for the northern hemisphere. We now have the capacity and ability to rapidly manufacture a novel flu vaccine, cell based substrates, live virus reassortments such as Medimmune’s Flumist and so on. We should find out if this will make a difference in a few months.

  5. #5 risk_comms_guy
    June 24, 2009

    Far as I can tell, the public health authorities across most of North America have used this “teachable moment” to assure people that the flu is mild, that the “pandemic” is more a technical than a real problem, and that everything that needs to be done is being done.

    In consequence of our don’t-worry-about-it messaging, we have achieved a high level of disinterest in, and complacency about, the pandemic. Published polls show this to be true. For example, see:

    http://www.gallup.com/poll/120863/Despite-Pandemic-Swine-Flu-Worry-Dwindles.aspx

    If/when we need to actually motivate people to take steps to protect themselves, and if/when we need to start talking up complicated and problematic community level interventions, then we will no doubt be seen by many as, and accused of, once again, being either a) scaremongers, or b) Pollyannas who failed to tell people earlier about the risk.

    Which is to say I think we have failed to communicate in a manner consistent with known principles of effective risk communications. The practical result of this may well be that our eventual management of this outbreak will be less effective than it should be.

    As in: more people will die than would be the case if we were leveling with people now about what may be coming down later.

  6. #6 Just-a-Mom
    June 24, 2009

    I discovered your blog several weeks ago and have very much appreciated the authoritative and practical information provided. Now it’s even more compelling to me since my 10-year-old son was diagnosed this morning with Type A influenza.

    Last week was our final week of school for the year. My son’s fifth grade classmates were disappearing from school in large numbers, sick with fevers, etc. None of the parents I spoke to got their children tested for the flu — my gut feeling is that they didn’t want to know because if they knew, they would have to keep their children home from all the special activities and ceremonies.

    My son got a sore throat last Friday, and developed a runny nose and cough over the weekend. The fever only began yesterday (Tuesday). Since he didn’t react in the same way that he had done several years ago to influenza, and since I hadn’t heard of his classmates actually having the flu, I delayed in getting him tested. The result — too late for Tamiflu.

    I actually think that the flu has been downplayed to the point where it is spreading rampantly in our community because people aren’t getting tested and aren’t taking the appropriate precautions anymore. Our pediatrician said they have had a number of cases in the past couple weeks, including 5 on Monday. They did not send my son’s swab to be further tested or subtyped and I don’t know that they have any reporting requirements.

    Meanwhile, children like my son, who has reactive airway disease, are put at greater risk because there is little coverage of the flu situation at this point.

  7. #7 MM
    June 24, 2009

    Interesting article on MRSA and H1N1

    “Both children were unusually ill with severe lung disease, and both required ECMO, and that was unusual,” said Dr. Howard S. Faden, chairman of infection control and director of virology at Women & Children’s.

    http://www.buffalonews.com/cityregion/buffaloerie/story/711734.html

  8. #8 revere
    June 24, 2009

    Sam: Interesting glimpse of places outside the US or Europe. Sounds like they are taking it with the required seiousness.

    river/Raven: No evidence yet of mutation or reassortment, although it may well happen soon. The Brazilian report has been retracted. But some evidence of drift is inevitable and if there is reassortment with seasonal H1N1 in the Southern Hemis. we could get Tamilu resistance (most seasonal H1N1 is resistant). We still don’t have a handle on virulence and since virulence depends on host as well, it is bound to differ in different places. Lots of eyes on it.

    risk_comm_guy: Getting people’s attention in the face of so much going on isn’t easy. And it’s hard to justify putting flu ahead of Iran or the economy if you are an editor. But I think it has gotten the attention of business and institutional planners. I know it has at my university and I don’t think the hedge fund example is unusual. It is easy to understand the absentee issue and it is happening to some extent, so that will stimulate things at another level.

    Just-A-Mom: Hope you folks weather this as well as my family did (so far). Keep an eye on your son and use your mom’s sense of when something seems to be going wrong. That’s a better criterion than any checklist. Most flu is self-limited and resolves fine. But not all, so be normally prudent.

    MM: The MRSA connection is well known and a danger to adolescents and teens with flu.

  9. #9 tymbuktu
    June 24, 2009

    Revere: With all the discussion of an increase in virulence, you likely saw the editorial in The Boston Globe with the following quote:

    ” Infectious disease experts say that the swine flu H1N1 virus would not have to mutate into a form as lethal as the infamous 1918 flu to take more lives. It could increase its toll simply by becoming resistant to Tamiflu, a much more likely development.”

    I wonder if anyone has any idea how many people haven’t become seriously ill and/or died from H1N1 because of Tamiflu and how, with no increase in the virus’ virulence per se, that development would impact the whole situation.

    Thanks.

  10. #10 revere
    June 24, 2009

    tymbuktu: I have a hard time imagining that Tamiflu is saving many lives. Some, perhaps. But I don’t think it’s making much difference except at the margins. But I don’t know for sure. Some data would be nice.

  11. #11 M. Randolph Kruger
    June 24, 2009

    River-The UK Chief of the Flu said last week that he thought up to 1/2 of the people in the UK would be down with H1N1 all at the same time. Problem with us is that if that happens here we are going to have a real problem in the NE in particular if its maxing out in mid-winter. From basically the Kentucky line North it could become a Day After Tomorrow scenario. The power grid snaps.

    You may have heard me talk about the coal supply. Three weeks max. If someone is sick they cant go into the mines and if they do they will come out for likely one last visit. Nukes make up about 1/3rd and very little hydro so its all coal fired. It takes a full rail car just to get a boiler started and several hundred gallons of diesel or kerosene. Once the boilers go down it takes days to get them back up to production and hey, what do you do when the pipes freeze in the meantime? Yeah… Lots to think about. An on foot exodus with sick people making not more than 100 miles in two weeks. No electricity means no gasoline and no gasoline/diesel means no transportation of food and supplies. The rails would have to be hand clocked on the switch frogs and if they are frozen because the line heaters are without power then it becomes a real cluster.

    It indeed could happen and with our fearless leader Janet in charge I just have the warm fuzzy feeling. Its the same feeling I got when they didnt close the borders to H1N1 or do anything to stop it.

    Not that GWB was any better prepared but at least they were following the NPFP. Revere will talk about robust health care and the like and frankly he know as I do that this would only save incrementally a few more and spend another couple of trillion dollars. Look at Australia…Now running 50 million USD from H1N1 costs and its early yet. Add it to their 8 billion in the hole already. Healthcare in this particular bug or H5N1 isnt going to change much. You get it, you resolve it or you die. Pretty cut and dried. One thing is certain though, UHC you bankrupt a country, the other way you bankrupt a company. I like the latter.

    I am waiting for Obama to cure the common cold, or the flu because if he doesnt and this shit comes rolling in here in a hard way then he wont be President if people are dropping like flies. They will impeach him just to show they are doing something. Its going to take decisiveness as to who gets what resources and I dont think thats going to include ACORN people. If they do then frankly there will be a revolt.

    I think that Navy Cmdr. whats her name Suchat? down at CDC should be in charge of the flu response rather than DHS. But thats just me. DHS is a political organization, CDC is to a lesser degree. But if suddenly vaccine goes to say Chicago and every city down south is hurting for it then Obama is going to be in trouble and fast. I mean think of it this way. Say Tamiflu is available and because of the noise machine they say its effective against H1N1. So Obama gives it to the same guys who were registering voters? How long do you think it would be before it was black marketed?

    Yeah, LOTS to consider because if politics enters into what may be the biggest game in 600 years you might see the end of the US.

  12. #12 River
    June 24, 2009

    M. Randolph Kruger,

    What a fascinating response! While all that you suggested may be possible outcomes of the second wave, it seems like a set of absolutely worst case scenarios. Sure, if the flu returns with an aggressive, virulent vengeance, coal miners could get hit, the North East’s power grid could collapse, Illinois could get a disproportionate amount of the vaccine (assuming A/H1N1 hasn’t reassorted and rendered them useless), we could in a fit of helpless pique impeach President Obama, and the nation as we know it could collapse. But, I certainly hope not though I’m well prepared if it does happen. (I live entirely off the grid, raise my own food, have a well-stocked larder and medicine chest, and have everything necessary to hunt, fish, and protect myself. I’m neither a survivalist nor Unabomber. Just a burned out reporter fulfilling a life-long dream).

    Of your litany of disasters, the one that frightens me the most is the potentially devastating effect a deadlier form of flu will have on our healthcare system. If that fails, and considering how overburdened it already is, it would very quickly fail, it won’t just be flu victims that will suffer. Everyone who has a treatable disease, disorder, or injury but cannot obtain the healthcare s/he needs will suffer, too. Suddenly, even the most minor health issue could become potentially fatal. An infected cut. A broken bone. An asthma attack. Childbirth…

    Mr. Kruger, It’s not just a fear of pandemic flu that scares me. The possible ripple effects from a collapsed healthcare system are downright terrifying.

    Be well,
    River

  13. #13 M. Randolph Kruger
    June 25, 2009

    River-Its already happening in Australia. They were 8 billion in the hole, H1N1 has cost them 50 million and they are out of beds, and its early yet.

    Call me crazy but the healthcare system IS going to collapse around our ears be it UHC or private. Those people (both) are going to start to show up at hospitals and if its killing in high numbers, the lid is going to come off.

    Worst case? Shit, they had one die waiting on an intensive care room in Oz today..Not that it would have mattered in his condition. The media isnt reporting it as it should and that is that this is one big shit problem. Once it starts whacking us but good in the fall, they’ll get the bit in their teeth and they might Gerry Ford Mr. Obama. Only this time… It will be the real deal. You didnt do enough Mr. President. By then he will have been in office about 9 months…Kind of like GWB on 9/11. Obama is going to have to sink or swim with his administration and I dont know if there are enough life preservers. And you are right, suddenly no matter what system you are under, no matter where you are in the world… Healthcare is going to be rationed to those who have something that they want.

    Remember these words, ” I was the sole voice of reason…”

    We will just have to wait and see who says them 5 years later. Add in the fact that the Arabs likely will demand gold and we will be in the biggest no shit problem since 1941 or the Cuban Missile Crisis.

    History repeats itself, but we never learn.

  14. #14 M. Randolph Kruger
    June 25, 2009

    River-I would say that the UK is on the ropes too.

    Time to start keeping our powder dry for the US for the real pandemic thats coming.

    http://www.dailymail.co.uk/health/article-1195283/NHS-axe-services-swine-flu-cost-Treasury-say-theyve-spare-cash.html?ITO=1490

    So what they are saying is that you are now pretty much on your own in the UK for healthcare of any kind. No more money. 30 billion over budget and they aint even really started yet.

    Lose the BC/BS or lose the country, take your pick. Again, it doesnt matter which care you have its going to be no care pretty soon River. It will collapse pretty soon.

    I suggest the Hesperians “Where there is no Doctor”

  15. #15 v.collier
    June 25, 2009

    Go Randy! You are FAB!

    It, I presume, will be a given that H1N1 will have acquired some immunity to Tamiflu/Relenza. Maybe it is time to start looking at combinations of drugs that might work?

  16. #16 River
    June 25, 2009

    Mr. Kruger,

    Yes, the healthcare system is in dire straights and the patients who do and will need it if the flu persists and/or reassorts will suffer greatly. I agree.

    However, I don’t see this crisis as causing the collapse of the world as we know it. Could it happen? Maybe. Will it happen? Unlikely.

    The people with a voice of reason will remain calm, separate the reasonable from the unreasonable/unlikely, and do whatever they can to assist, educate, and instruct without increasing panic and terror. Rare birds! Kind of like the Reveres, don’t you think?

  17. #17 Charlie B.
    June 25, 2009

    It’s really a bit hard to tell what’s really going on in Australia, as they’re simply not testing people in high numbers. As I found out last week when my wife and I both went to see our local GP with flu symptoms. She gave us a high probability that it was indeed swine flu, as our symptoms matched hers (she was better by then!) and she had been tested (and there’s not much else in northern Melbourne…).

    A week later and we’re back at work. Bit fuzzy. Wasn’t as bad as the last time I had ‘flu, but it wasn’t much fun.

    Anyway, given the way they’re not testing much unless one is developing serious symptoms and in one of the high risk groups, I think it’s going to be very hard to say that it’s getting more virulent based on fewer than a handful of deaths in thousands of cases.

  18. #18 M. Randolph Kruger
    June 25, 2009

    Hey River… I hope you are 100% right. But you can bet that if it gets to even 5% of the worlds population that all things as we know them are going to be gone or changed dramatically.

    We wont be beating each other up with sticks and rocks. But be aware and historically speaking if it gets 5% it will take about 3 generations to return to normal. At a 30% event we would take almost 15.

    Just a little history..It might not happen at all.

    My Ozmanians are scared shitless because they can see it unraveling down there already. The statement is for everyone to remain “calm.” Not bad advice but when pressed the officials are not really forthcoming with anything of substance. The out areas are now taking cases from the cities and the news is becoming scarce and the old information two step where they are parsing is starting.

    They will keep it up right until there is no way that the facts can be ignored and then, we will lose more because no one wants to treat you like an adult in the nanny states of the world. Cant really blame them and its mostly because of losing control and order. First it was pandemic might come…Okay, we got the type wrong H1N1 instead of H5N1 but pandemic came. Then they parsed…”Its mild”. I wouldnt say that the people who died from it looking at how they went thought it was mild. Then they said its “moderate” and the Lancet published and said it was going to be “8.8%” which is an acknowledged .8% over what is considered to be the tip over point for disaster. They made the statements without any additional testing as noted, just samplings which is scientific but doesnt tell the story, just a minor part of it. Then they made estimates, without any backup of the information. Then there is more and more of the BS and that is that a shitload of people are dying from “pneumonia” around the world than ever before..Remember you cant have H1N1 or H5N1 or a combi of the two unless you have testing. No testing and the only thing they can put onto the death certificate if they have one is pneumonia. Think of that in very high numbers.

    As for government?

    You will be on your own.

  19. #19 Barnaby Dawson
    June 25, 2009

    With regards to possible mutation there does seem to be an unusually high proportion of deaths in Argentina (21 out of 1,391 confirmed infections). Of course there are many sources of error here and any higher CFR might be due to demographic or poverty factors rather than a mutation. These figures still seem to merit further discussion, though.

  20. #20 Jon Schultz
    June 25, 2009

    A lot of people have been influenced by Dr. Michael Osterholm, who has made statements like:

    “An influenza pandemic of even moderate impact will result in the biggest single human disaster ever – far greater than AIDS, 9/11, all wars in the 20th century and the recent tsunami combined. It has the potential to redirect world history as the Black Death redirected European history in the 14th century.”

    and, referring to a severe pandemic:

    “This is going to be the most catastrophic thing in my lifetime…. When this situation unfolds, we will shut down global markets overnight. There will not be movement of goods; there will not be movement of people. This will last for at least a year, maybe two.”

    And he has talked about how society now has a “just in time” delivery system for goods and services that would be seriously disrupted by the mass work absenteeism a pandemic could bring.

    Maybe Dr. Osterholm was exaggerating to draw attention to a problem but even Secretary Leavitt was on TV a few years ago advising people to buy an extra can of tuna fish, or something, when they go shopping to prepare for possible food shortages. I hear very little of that now, even with the death toll of young people mounting, knowledge that the virus may well develop Tamiflu resistance and the ability to replicate at lower temperatures (if not other changes which would bring about increased transmissibility and/or virulence), and the opinions of some very intelligent people that there are striking parallels between what is happening now and what happened in 1918 – with H5N1′s continued existence and development an additional factor.

    I still think a somewhat higher level of public alarm may be warranted.

  21. #21 revere
    June 25, 2009

    Jon: I know Mike well and have quoted him often here. I believe he was referring to a pandemic with a fairly virulent flu virus like H5N1, which if got loose would be unimaginable. But if we are talking about a 1957 or 1968 pandemic, it is clear that it won’t bring down critical infrastructure, although it could create lots of local problems.

    In general, as many have observed, that in drawing up our pandemic plans we were envisioning H5N1 or something similar as the culprit, not something with the virulence of a seasonal virus. In that sense we were planning for a different pandemic. That’s fine. It wasn’t wasted. But we need to recognize that all pandemics are different. If 1918 is your only idea of what a pandemic is or could be, you will be wrong. It could be worse but much more likely not as severe. As for changes in the virus that will increase transmissibility, not likely, because it is already as transmissible as any flu virus as far as we can see. It’s there already. Virulence is another matter and depends not only on the virus but the host.

    It is easy to speculate endlessly. I am trying not to do that. We need to plan for it to be much worse but that doesn’t mean I think it necessarily will be.

  22. #22 River
    June 25, 2009

    There’s that voice of reason!

    Thanks, Revere!

  23. #23 miso
    June 26, 2009

    “That leaves Tamiflu/Relenza, both NIs. How long will it take for swine flu to mutate to resistance to one or both drugs?”

    How unfortunate Relenza and Tamiflu are linked like Siamese twins, and like Siamese twins, one member is a weak, dependant cripple, and the other one healthy but disadvantaged by the association.

    Tamiflu was a cripple from the day NI’s were born.

    Tamiflu resistance by influenza A was recorded at the first ever Tamiflu clinical trial recorded by Gilead, and every trial and public use since, whereas Relenza resistance by influenza A still hasn’t occurred.

    If GSK wasn’t so busy investing billions in supporting influenza vaccines there might have been some effort to R&D, manufacture and advertise the facts of Relenza, but that would not serve GSK with vaccine demand so Relenza is unique because there is no company trying to profit from the sale of Relenza, therefore misinformation is never corrected and the faults of Tamiflu are assumed to also be the faults of Relenza.

    GSK crushed research into IV zanamivir, and yet Biocryst is pumping IV peramivir support even though peramivir is susceptible to H274Y resistance, and since the seasonal flu dominated by H274Y in influenza A, none of the peramivir trial results nave been positive. Will GSK support IV zanamivir now?…Hell NO.

    GSK has known for years that diskhaler reduces the ease of use of Relenza on the elderly, and children under five, but GSK has ignored the problem, because GSK profits from the diskhaler and increases the demand for a “better solution” GSK’s influenza vaccines.

  24. #24 Charlie B.
    June 26, 2009

    I’d like to say in response to a post above it’s NOT “unravelling” Down Under. The public hospitals might well be screwed if this was a virulent pandemic, but the death of one guy from swine flu that might be attributable to the lack of intensive care beds when he was in a country area (where there are small clinics, not big hospitals) and had pre-existing medical conditions is not a sign of the country, or even the state of Victoria, going to hell in a handbasket. People are still working, clinics are still chugging along – my wife and I easily got an appointment to see our GP a week ago.

    Maybe the 4th H1N1 death announced today will scare more people into clogging up GPs and emergency rooms, but triaging will keep it under control. This isn’t Rage Virus, for goodness’ sake.

  25. #25 Kobie
    June 26, 2009

    Teachable moment or “dry run” seems to be silver lining of H1N1.
    Yes virus do crop up and travel with enourmous speed – like the text books say. Yes people do not panic.

    Sadly the government can shut down information. Mike Leavitt of HHS used to have bi-monthly webcasts. During the first few weeks of H1N1 it was Mrs Secretary Janet Napolitano not Mrs. Secretary K Sebelius, who did many of the webcasts. In Mrs. Sebelius defense she had just taken over the US Dept of HHS.

    What bothers me is the lack of reporting from Austrailia, South America and now UK is seeing a rise in H1N1. “A smart man learns from his mistakes. A wise man learns from others” IMO the average person is not learning the H1N1 lessons from other countries because it is not reported in the mass media. Nor is there more than a news listing on HHS websites.

    Lots of news goes out via Twitter, FluWiki, FluTrackers, Fla_Medic and EffectMeasure. Thanks to all.

    Last bit of news – September is National Preparation Month. There is a new #npm09 hastag on Twitter for this. The DHS website is http://www.ready.gov/america/npm09/ I feel the news will avoid this as well.

    In short – living your life by the news is like driving using only the rear view mirror. Both only show a selective part of the past – not the future. Please post your feelings about the future. A good idea or skill should not be kept to oneself.

    Regards,
    Kobie
    #npm09

  26. #26 M. Randolph Kruger
    June 26, 2009

    I have people in Perth, Melbourne, Sydney who are telling me just about the same story like below. One has a mother who was discharged with active tachycardia and high blood pressure… One GP does not a country make. They are also acknowledging a 8 billion shortfall in bucks for current UHC and 50 million so far in addtional costs. Very soon as the UK has said, no more money for swine flu patients.

    Down south we say the nut cutting has started. Decisions are going to soon be beyond being able to be made. At what point will someone who is critical with Swine Flu be turned away in lieu of the other cases. Just refuse to treat them?

    You know why I believe that this is about to get nasty? The US is preparing 160 million doses for this shit and they arent even sure what the final version is going to be yet. The vax makers also dropped trou just to go and do this instead of seasonal stuff. So it means the old people will go from the lack of vax and the young ones will go because this is targeting them. Me, I’ll be masked up with a full face plate and full decon measures at all times.
    ——-
    AAP
    June 24, 09

    A man diagnosed with swine flu after he died had waited up to three hours for an intensive care hospital bed the day of his death because none were available in Victoria, his parents say.

    Victorian health authorities say the man, 35-year-old Anthony Splatt of the western district town of Colac, tested positive to the influenza A(H1N1) virus but will not say whether it caused his death.

    Anthony Splatt went to Colac Hospital with flu-like symptoms on Friday and was transferred to Maroondah Hospital in Melbourne’s outer east, where he died on Saturday.

    Test results released on Tuesday show he had tested positive for swine flu after swabs were taken following his death.

    His parents, Brian and Judith Splatt, say their critically ill son waited at the Colac Hospital for three hours for an intensive care bed, which was eventually found at Maroondah Hospital.

    “His poor GP was pacing the floor in Colac because he was getting sicker and sicker,” Ms Splatt, a nurse, told the Herald Sun newspaper.

    Mr Splatt said: “There were no beds in Victoria. It seemed like forever (before a bed was found). We hope in a way his death makes more intensive care beds available.”

    Victoria’s acting chief health officer Rosemary Lester said Anthony Splatt had a range of underlying medical conditions.

    She would not confirm whether his death was a direct result of swine flu or one of the other medical conditions.

    “I’m obviously not the clinician – that’s for the clinicians to decide what he’s died from,” Dr Lester said.

    “My information is that it is respiratory failure but other than that I can’t make any comment.”

    Dr Lester said the man received treatment consistent with the symptoms of his severe illness.

    “He wouldn’t have been treated any differently if we’d known that he had swine flu from the outset.

    “He arrived with an influenza-like illness and then, I believe, he rapidly deteriorated.

    “His respiratory function deteriorated and he went into shock quite quickly.”

    The Splatts said Anthony seemed to be suffering from a common cold before he collapsed at home two days before he died.

    By Friday, they were told he had only a 20 per cent chance of surviving as his respiratory system began to fail.

    The death comes amid fears that indigenous Australians in remote communities may be particularly vulnerable to the disease.

    A 26-year-old man from Kiwirrkurra in Western Australia last week became the first person with swine flu to die in Australia.

    Federal Health Minister Nicola Roxon said people in remote indigenous communities may be hit harder by swine flu than those elsewhere.

    She said federal and state governments were taking steps to ensure they received adequate supplies of Tamiflu, the antiviral drug used to treat the illness.

    Meanwhile, Dr Lester has apologised to Splatts.

    The parents of Anthony Splatt have told of their distress that no one from the Department of Human Services contacted them before Dr Lester talked to the media about his death.

    “I am very distressed personally that we have caused this family further distress and I unreservedly apologise for that,” Dr Rosemary Lester told the ABC.

    She said she had tried to call Brian and Judith Splatt at their Colac home but had not been able to get through.

    “I will continue today until I get through and give them my personal apologies,” Dr Lester said.

    “I have been assured by the hospital that the family had been told about this and, of course, we would never have gone public and caused the family further distress.”

    She said she had asked the hospital to tell the Splatts that she would be talking about their son’s death publicly.

    “I don’t honestly believe that it would have been appropriate for me, as a public servant, to initially contact the family but because we have caused them distress I will of course contact them now,” Dr Lester said.

    She said the department preferred that clinicians who look after the patients are the ones who speak to the families.

    Anthony’s sister Samantha told AAP that the family was not making any comment at this stage.

  27. #27 Victoria
    June 26, 2009

    Randy,

    Here in Perth, Western Australia, the hospital system is short 400 beds (population around 2 million). I live in the western suburbs, the average wait for an appointment with the doctor is 2 weeks. We do not have enough doctors or hospitals to service the community now, let alone during in the second wave. My guess is that when the second wave hits (and if it is more virulent), the panic will set in. I would think that hospitals and medical systems around the world are in the same boat. There is nothing that can be done to overt what is to come.

  28. #28 Phillip Huggan
    June 27, 2009

    http://www.google.com/hostednews/ap/article/ALeqM5je2GVM9EkdR6jk8gvAnmDKpADX8gD992ODC82

    Pig physiology is halfway between bird and human receptors. If you can’t socially distance the farm from birds, quarantine from humans at least or better yet, slaughter. Playing with fire otherwise. Pigs experiencing H5N1 are barely symptomatic.

  29. #29 revere
    June 27, 2009

    Phillip: Let me once again direct you to the sidebar, Bird flu: biology. There you will find much more background information about flu receptors, and much else. A little knowledge is a dangerous thing. This is complicated stuff. You can’t just grab bits and pieces from the news media and think you are an expert.

  30. #30 Phillip Huggan
    June 27, 2009

    The specifics are pigs have 50/50 human respiratory and bird enteric receptors. Birds 20/80, and humans I assume 100% human but not sure. And pigs infected with H5N1 are barely symptomatic, which is very dangerous in that it underestimate the level of surveillence required to *safely* aloow an epidemic to sweep through farms.

    AFAIK I’m the only one forwarding the suggestion to socially isolate pig farms from birds here. This is basic. When the world’s epidemiology (or acriculture or DoD or whoever takes the interdisciplinary ball) community smartens up enough to advocate social distancing of pig farms from birds, I’ll briefly stop create Industrial Macroeconomics long enough to crack open my biochem text.

    In any event I appreciate this site’s openness (banned from virology.ws and H5N1), but you(s) are being hypocritical. When I suggest humidifiers as a strategy to limit spread, you bring up an unrelated post about seasonal Nicaragua incident rates. When I suggest cytokine storm is caused by (probably linear) epitopes from a lyzed virus mimicking amino acids (probably chains) produced in or on our lungs as an immune system response, you suggest I complete the multi award winning research of identifying what specific lung or immune system component mimics what specific lyzed amino acids. Revere, you made it clear you have career priorities and probably the wrong specialties to respond specifically to me, I also have other study interests. I suppose the solution is to create a blog, but the marketing seems an unnecessary hassle.
    Again, the book on pig farm biosafety has yet to be written, not in your link. I’m not afraid of lobbies, or harming my career by guessing wrong. It seems the whole of the world’s community excluding me, is. I’m sure they’ll get around to it, very slowly. I’m grateful not to be banned; was the first to cry rabbit, this isn’t mild cytokine storm. I’ll do it again wherever I’m not banned.

  31. #31 revere
    June 27, 2009

    Phillip: What i am suggesting is that you don’t know the science here. The point about Nicaragua was that we don’t know what causes seasonality. Nicaragua has its peak during the season of highest humidity. The point about cytokine storm is that a simple minded “solution” can make matters worse: steroids, for example, seem to make things worse. The point about pig receptors is that pigs and humans and birds all have alpha2,3 receptors and the host specificity depends on more than that. I directed you to some posts about the science because, well, the science is important. And it’s hard and not well understood. You talk as if you have it figured out. That’s because you don’t really understand it. People have been working on this for decades and we and others have been blogging it for years on a daily basis. There’s more to it. Much, much more to it. I was directing you to some of what more there was to it. But you don’t seem to want to bother.

  32. #32 Phillip Huggan
    June 27, 2009

    Flu season runs like a calendar. It starts in China because that is the largest concentration of animal and human hosts (this is very strongly suspected by mainstream community though these reports don’t make your list). That is, the tiny little isthmus of central America is not going to excert any forcing whatsoever on the calendar of global flu spread. To refute the paper about droplets slowing down the spread of flu, someone could do experiments with different sized droplets (I’ve suggested this to a couple hundreds researchers by email in 2007, I doubt ever read) or test different humidity levels in infecting ferrets. Yes I don’t have time to do such volunteer work or spend a decade to get paid to do such research. I was highlighting a need that the mainstream community seems too stupid to realize is a need (which is why I don’t mind spamming blogs, Veratect proved emails as prsently utlized are useless and I’m not going to phone evey research group in the english world). I believe I got the receptor-by-species figures from a google scholar search (why assume I invented it? I didn’t, I assume someone dissected these animals and counted receptors types somehow); I’ve skimmed some of your references but you are missing this known analysis.
    You still haven’t mentioned an opinion on socially distancing pigs from birds (no has, it might be the easiest way to prevent cytokine storm). Does anyone in these very well paid (in 1st world) fields have an opinion on this? Why am I the only one suggesting a strategic stockpile of fusion proteins?
    I’m being an ass about this because I’m highlighting the existing response is slow and a little broken. Prolly fine while threats aren’t designer.

  33. #33 revere
    June 27, 2009

    Phillip: That work has been and is being done. We’ve reported it here. but it’s techically difficult work and there aren’t many hands and labs available to do it. It’s not just a matter of saying, “this or that should be done” or “we should find out this or that.” It’s a matter of resources of all kinds, not just money, but skill and time.

  34. #34 Phillip Huggan
    June 27, 2009

    Yep. I think the interdisciplinary stuff happens at annual conferences (at least it does for chemistry research). I’m just saying that might be too slow given dynamic pandemic evolution, in the case of potential pandemics (say if this one turns or turned into Hong Kong Flu or worse, the slow response would cost lives).
    A very good idea someone forwarded on one of these blogs is to publish a list of ideas for scientific research. It is something I’ll get around to in the new year simply because it is so good an Ivy League or European Univerity will eventually take over the task if it is demonstrated good. I don’t really care about being banned given publicity of Swine Flu introduces new blogs, but for instance, I’ve a comment I’d really like to make on the recent H5N1 blog GMO thread. I can’t give a cursory evaluation to scientific paper ideas for most fields, but probably enough and at a high enough amateur level to get the ball rolling. The droplet size research I suggested was to test whether paper masks and face shields really blocked exhaled flu; suggested literally two dummies that exhaled different sized droplets.

  35. #35 M. Randolph Kruger
    June 28, 2009

    Revere-Medical Emergency declared in Buenos Aires… 1488 cases, 23 dead confirmed 1.5% CFR. True numbers no known as an additional 4500 are now in and even the military hospitals are being brought on line. 200 additional that are in morgues are suspected as having died from it but no one is available to do the autopsies. If its 1488 and 223 in truth, then its a CFR of 14.88%.

    The unions are threatening action and that could bring the government down.

  36. #36 revere
    June 28, 2009

    Randy: According to the Latin American Herald Tribune:

    “The emergency does not mean we’re closing everything down, the emergency is a frame of reference for having medicines ready for direct purchase and mobilizing health personnel,” said Claudio Zin, health minister in Buenos Aires province where the greatest number of deaths and infections have been recorded.

    Zin said that this alert, which doctors’ organizations have requested for days, “is a frame of reference for taking quick decisions” to combat the illness.

    “It doesn’t mean we’re going to close schools and shopping malls and suspend transport on the metro,” because “that’s not the point,” he said.

    As for bringing down the government, they are having an election this week. Yes, it could affect the outcome of the election, so in that sense “bring down the government.” But that’s somewhat different than the same circumstance without an election, as your comment implies.

  37. #37 Jon Schultz
    June 28, 2009

    Randy, what is your source for “200 additional that are in morgues are suspected as having died from it but no one is available to do the autopsies”?

  38. #38 Rufus T Firefly
    June 28, 2009

    l Niman’s saying 26 confirmed and 15 probable deaths in Buenos Aries…

  39. #39 Rufus T firefly
    June 28, 2009

    Niman also says that In Argentina it’s hitting those under 50 especially hard….”The targeted population as well as the description of the rapid deterioration sounds remarkably like the reports on the 1918 pandemic”…The 200 dead figure comes from an Argentine blogger named ferfal…He’s a professor down there who’s blog is a great source of info on the economic & social collapse of Argentina since 2001….On another site someone has listed all the 24 fatalities in N America…Only two were over 40 & one had severe heart problems while the other was obese….

  40. #40 Jon Schultz
    June 28, 2009

    Thanks, Rufus. I see the blog entry at:
    http://ferfal.blogspot.com/2009/06/more-on-flu-in-argentina-and-face-masks.html
    “The director of the Malbran hospital said there’s 10.000 infected and 200 dead, and enough beads for 100 patients…”

    That’s also reported on this page:
    http://www.ar15.com/forums/topic.html?b=10&f=17&t=625118
    “Malbran Hospital director: ‘Over 200 dead, and over 10.000 sick’”

    Revere, let me know if you don’t want these kinds of postings here.

  41. #41 revere
    June 28, 2009

    Jon, Rufus: I’d prefer not to have unverified or speculative postings here (except when we do it, of course). There are plenty of great sites that encourage this in the interests of having as much info as possible and I have no problem with that. But I don’t think that’s why people come here. For what we do here, which tends to be more reflective, it’s not useful, so please refrain. Thanks.

  42. #42 Jon Schultz
    June 28, 2009

    Understood. Thank *you* for the great blog.