Effect Measure

Swine flu this fall: turbulence ahead

Making predictions about something as unpredictable as flu is foolhardy. I rarely (if ever) do it, but I’m going to do it now. I am predicting a bad and early H1N1 swine flu season in the northern hemisphere next fall and winter. The reasons for this departure from our usual custom is a paper in Nature from 2007 I just re-read. It’s entitled “Seasonal dynamics of recurrent epidemics” by Stone, Olinkyl and Huppert from Tel Aviv University and it appeared in vol. 446, pp 533-536, 2007 (doi:10.1038/nature05638; html version here, if you have a subscription). The paper isn’t specifically about flu and it is a mathematical modeling paper that presents an analytical condition for whether there will be a full epidemic or a minor “skip” in a seasonally forced SIR model. It’s mainly concerned with childhood diseases like measles, not flu. But it seemed to us it was of immediate relevance to swine flu. We’re going to try to explain why we were so struck by this paper (and if you want to know more about mathematical modeling for flu, you might try our 17 part series that takes a single paper and explains it, paragraph by paragraph and equation by equation at a level suitable for most educated readers; you won’t need it for this post, though).

It is an adage in the field of mathematical modeling that “all models are wrong, but some models are useful” (attributed to George Box). We think this is a model that is useful because it provides insights into what could be happening with flu. Not the whole story, but an important part of the story. Even relatively simple models for disease dynamics — for example, ones incorporating crude assumptions like the probability of transmission is proportional to the rate of contact between infected and susceptible people — can behave in very strange and counter-intuitive ways, especially when you include seasonal forcing in the equations. In simple terms, seasonal forcing says that some periodic environmental factor that varies throughout the year — opening of schools or absolute humidity or temperature — is altering the transmissibility of the virus. Many systems have their own inherent periodic behavior that don’t require outside forces. A weight on a spring bouncing up and down or a child on a swing (i.e., a pendulum) are two examples familiar to any college student taking physics or differential equations. The rate at which the child swings back and forth after an initial push is characteristic of the swing apparatus and only depends on the length of the chains attaching it to the top bar (yes, I am neglecting damping and non-linearities from larger angles; so sue me). The reason a pendulum clock can keep time is because the period of swing is regular and fixed. Now, after the child is swinging back and forth in a regular, periodic way characteristic of the swing set-up, do some periodic forcing. What this means is that you start to give the swing an additional push but not at intervals corresponding to its inherent periodicity but some other period completely independent of the swing’s inherent period. There are a huge number of behaviors of the swing that you can produce (including chaotic behavior) by different kinds of external forcing (pushing at odd intervals, say at the bottom of the path or as it is on the way up to you as you stand behind), and the mathematical analysis of inherently simple periodic systems with external forcing can quickly become intractable. But the authors of the Nature paper sidestep some of this analysis to see if there are some broad underlying regularities that might be useful:

Theoretical studies have shown that seasonal forcing can be responsible for inducing similar complex population dynamics such as higher-order cycles, resonances and deterministic chaos. These complex responses can easily mask any simple underlying mechanistic processes that might otherwise help in forecasting future epidemics. The modelling framework used here helps uncover, and gives new insights into, these processes. (Stone et al., Nature [cites omitted])

One of the innovations in this paper is that instead of trying to predict a specific outbreak, the authors concentrate on post-epidemic dynamics. In other words, they are looking at pairs or triples of outbreaks, not single outbreaks. It has been known for a long time that seasonal childhood diseases have really bad years, sometimes several in a row, and then suddenly a “skip” or year with a minor peak (the peak is there but its a mini-peak). Sometimes there will be several skips, then another bad year. Flu does the same thing. Last year was bad but the three previous seasons were “mild” but the one before that was also bad. Stone et al. tried to find a simple explanation for this behavior with the help of a mathematical model for seasonally forced infectious disease dynamics where there are just three kinds of people: those who are Susceptible, those who are Infected and those who are Recovered (or dead). It’s called an SIR model for the three categories. Our series on modeling antivirals looks at a model very similar to this in concept.

One of the main results in this paper is a mathematical formula for a threshold of the proportion of susceptibles in a population required at the outset of a season for it to be “bad” (have a high peak). If the number of people susceptible when the outbreak starts is above that threshold, then there is an epidemic that year. If it is below the threshold, there is a “skip.” The exact formula isn’t important for us, or even so much what goes into it (things like the size of the forcing function, the rate of entry into the population of new susceptibles, etc.). What is interesting is the insights it gives into what’s going on.

On one level the analysis just seems to confirm conventional epidemiologic wisdom: if there is a really bad year, most of the susceptibles are “used up” and the following year there aren’t enough people left who aren’t immune for the virus to get going. The virus confronts “herd immunity” produced by the previous bad year. But that doesn’t always happen and the analysis shows why. It’s not just how big the previous year’s outbreak is, but its timing within the flu season (which they refer to as early phase or late phase). Instead of paraphrasing it, I’m going to quote directly from their paper. The two symbols used are S0 and Sc. The first is the minimum number of susceptibles left in the wake of the last year’s outbreak, while the second is their threshold criterion. If S0 exceeds Sc then there will be a bad year:

First, consider the case in which there are only two main seasons each year, a ‘high’ season (high disease transmission) and a ‘low’ season (low disease transmission). Suppose an infected individual is introduced into a population of susceptibles during the high season. It makes a crucial difference whether the individual enters the population relatively early or late.

First, consider the scenario in which the infected individual is introduced early in the high season and proceeds to initiate an epidemic. This gives plentiful time for the development of a full-scale epidemic. These large protracted epidemics eventually die out, exhausting the susceptible pool (S0) in the process. If S0 < Sc, there are too few susceptibles to fuel an epidemic in the following year. Second, in contrast, should an infected individual enter the susceptible population very late in the high season, there may be little time available for the build up of a large-scale outbreak. Being late, the epidemic is more likely to be affected as the season changes from high to low. The smaller contact rate associated with the low season can act to curtail the epidemic, and cut it short. As a result, a large susceptible pool S0 remains. Should S0 > Sc, the number of susceptibles will be enough to trigger an outbreak in the following year.

Stone et al. present very credible evidence that when the peak of the previous year occurs late in the season and is cut short by the “off season” factors (whatever they might be), then the following year is bad, because the aborted late appearance (aborted by the lack of seasonal forcing) leaves enough susceptibles to exceed the threshold for a bad year. While the insights here came from looking at the behavior of a mathematical model, the reasoning is fairly robust to its assumptions. I think you can see where I am going with this. I am not predicting a bad year because number crunching in a mathematical model said it must be so. On the contrary, through the use of the model, we are able to see some implicit logic about what goes on in systems like this.

Here’s how I see it applying to swine flu. This started late in the flu season. We’re not sure when, exactly, but probably in March sometime. Because there was no natural immunity in the population and in other respects the virus transmitted with the facility of seasonal flu, it could spread pretty fast and widely before whatever factors involved in flu’s seasonal forcing lowered transmission to the point it started to subside. It’s true it is not subsiding everywhere but it is subsiding in many places in the north. However it is not the fact it is subsiding but the reasons why it is subsiding that are important. If it is starting to wane because it had burned itself out by using up the susceptibles, that would suggest next year wouldn’t be so bad. But in fact, while there was a lot of flu around, most people didn’t get it. If it is subsiding it is probably because whatever is involved in the seasonal forcing of flu (and we don’t really know what that is) has started to cut it short before the “tinder” of susceptibles was used up. Everyone expected this to happen when the summer came and the fact it didn’t happen right away was a surprise. It suggests this virus is quite transmissible and combined with the lack of immunity could overcome the extra push to transmissibility the seasonal forcing gives it. But it looks to be subsiding now. When the forcing starts again in the fall all the makings will be there for an early and big flu season if the threshold for it is exceeded. I feel pretty confident there are plenty of susceptibles around for the virus. True, I don’t know how many are needed because I don’t know what the threshold is. But I’m betting it’s not too high. Meanwhile the vaccine won’t be available to decrease the susceptibles before the virus can pick up a head of steam.

I would dearly like to be wrong about this and making any prediction about flu is undoubtedly stupid. Doing so on the basis of a mathematical model may be even more foolhardy. But sometimes you just go on scientific hunches, and my hunch is that Stone et al. have this pegged right, even if they didn’t intend it for this flu. We’ll just have to see. But meanwhile, I’d keep your seat belts fastened because I see evidence of turbulence ahead.

Comments

  1. #1 andy
    August 6, 2009

    Very interesting analysis. According to the model mentioned above, given that the flu season in the southern hemisphere was just starting in march/april when the virus emerged, the flu season in the southern hemisphere should be a bad one. Is it a bad one ? Then we will probably see a bad one in the north in fall/winter, assuming the virus stays the same.

  2. #2 Grahame Grieve
    August 6, 2009

    Yes, it’s a bad one. By any criteria and/or evidence (both personal information, news and official statistics), this is a bad winter here in Victoria Australia (swine flu central right now). Interestingly, not only flu – I don’t know what that means.

  3. #3 raven
    August 6, 2009

    That the swine flu will come back early and bad was my prediction as well.

    We are still seeing H1N1 cases here on the west coast and this is August. The flu won’t even have to migrate north from the southern hemisphere to flare up again. All you need is cooler weather and the opening of the schools.

    The swine flu hit hard in Chile, Argentina, and New Zealand according to the news reports. Some of the ICUs in New Zealand and Argentina were reported to be full. What do you do with serious cases after “full”?

    It’s going to be a close race between getting the vaccine out and the cold season uprising.

  4. #4 karen
    August 6, 2009

    We are still in H1N1 season here,but everyone now treats it quite lightly and doesn’t bother the docs.I know five people who have contracted this in the last week alone and I haven’t left my tiny village in that time,so I expect things to get nothing but worse here in the UK.We won’t have to wait for flu to return it will still be here.The government have absolutely no clue as to numbers,none of the five family and friends have contacted any sort of health service,luckily they all have had minor symptoms,one day feeling off colour, one and a half days feeling sh**ty and then just feeling unwell for a few days after.Sadly to no avail I spend all my time trying to convince people to take more than the day and a half off work,I keep explaining that it is alright for them but what if they pass it to someone who is more at risk……..

  5. #5 phytosleuth
    August 6, 2009

    It “looks” like cases are dwindling in the U.S., but is that really true? Surveillance has changed. Are doctors still testing? Are less people reporting it to a doctor when they get it?

  6. #6 jbh
    August 6, 2009

    The process you describe here is what happened in 1918 as well, correct? In 1918 there was a more mild outbreak of the new flu in one flu season that roared back the next season. I have always read that the reason the 1918 flu roared back the following flu season was because it “evolved” and became more dangerous, but really, the explanation may be as simple as the fact that there was plenty of susceptibles around in the environment to pounce on once the seasonal pressures that quelled the previous “mild” outbreak subsided. So no evolution was necessary.

  7. #7 revere
    August 6, 2009

    phyto: It probably is subsiding (although we don’t know for use and is likely uneven, yes in some places, no in others), but the more infection there is out there undetected the more herd immunity there will be. The worst case is if it really is subsiding or slowing because of the absence of the forcing and then, with sufficient susceptibles left, it gets a huge push from whatever is involved in seasonal forcing.

    jbh: All quite possible. We don’t really understand the dynamics of flu. This is another possible mechanism. The model by Stone et al. does require recruitment of new susceptibles, which could be from new babies born (that’s probably the childhood disease mechanism) or antigenic drift in the case of flu. The model wasn’t designed for flu but it is applicable to it (noted by the authors, not just me).

  8. #8 BostonERDoc
    August 6, 2009

    Interesting indeed. Guess I better rest up cause the ED is gonna get busy earlier than I thought. Hopefully we wont have any HC reform since all that will do is cause a ER super nova with the flu a coming.

  9. #9 caia
    August 6, 2009

    Lucid and illuminating, thank you Revere.

  10. #10 Sarah
    August 6, 2009

    I know one of the Reveres wrote in June that it would be a very good idea to get the pneumonia vaccine to protect against influenza related pneumonia. Recently the LA Times weighed in with that same advice.

    Yet I cannot get it for my son or husband. My son is 8 and his pedatrician says the CDC doesn’t recommend it and the MD doesn’t carry it, so while he doesn’t recommend it, if I really want to — try the health dept.

    My husband’s doc doesn’t have it in his office either.

    My MD has it, I’ve had since I have asthma, but she won’t give it to my husband or son because, 1. they are not patients with her practice, and 2. the CDC doesn’t recommend it and “there can be side effects from vaccines you know.” When I brought up the fact that the flu vaccine might be delayed this year, and the upcoming flu season is looking rough, she claimed that the regular flu vaccine would be on time and that only the swine flu vaccne “might” be delayed. “Besides.” she said “We don’t know how bad the upcoming flu season is going to be — no one knows that.”

    She knows I have immune issues and thinks that I am just being hypervigilant and overcautious.

    I offered to send the CDC recommendations that said that the pneumnovaccine is fine for children over 2, it’s just not currently recommended for them.

    She went back to “we don’t immunize just to immunize for nothing. There has to be a reason,” and she didn’t think trying to protect against swine-flu related pneumonia complications was a sound reason. She also wouldn’t do it “just to make you feel better.” Get the vaccine for the swine flu when it comes out…well, we will, but who knows when it will come out or how much will be available.

    At this point our health dept. doesn’t appear to have any pneumonia vaccine, not according to their web site.

    I still think it is a good idea, and I will pursue it, but wow, should it be so hard to get the pneumonia shot? What’s the downside?

    FWIW, I have passed on your recommendations and the link to your blog that recommended the shot to friends and am hearing similar stories back: their doctors are saying no, especically for their kids. And these are kids who did not get the child’s Prevnar 7.

    Anybody else having similar problems? Is it just the DC area?

  11. #11 slongo
    August 6, 2009

    I obtained a pnuemococcal polysaccharide vaccine (pneumonia shot)at the local health department for my daughter during a flu and pnuemonia shot clinic. I said she was becoming insulin resistant and was borderline diabetic. Not entirely true but since she struggles with her weight it IS something I worry about (since diabetes is such an epidemic in children). This was several years ago, pre-Prevnar.

  12. #12 Kate
    August 6, 2009

    Sarah,

    Not knowing where you are located, you might try CVS drugstore for a pneumonia vaccine for your husband. They have MinuteClinics at some locations, and offer a variety of treatments and vaccines, including Pneumovax. For more info, visit http://www.minuteclinic.com/en/USA/. [I am not affiliated with CVS in any way – just passing on some information that may be helpful.]

    I don’t believe they will provide the vaccine for your son without a doctor’s order, but it may take care of your husband.

    Regards,
    Kate

  13. #13 Monotreme
    August 6, 2009

    revere, please don’t take this the wrong way, but my initial reaction upon reading the first paragraph of your blog was “No shit, Sherlock”.

    I understand that models are important to you and I’m sure you have done a good job explaining one. However, it should be obvious to anyone paying attention to what is happening in South America, right now, that this virus is going to cause us some “turbulence”. Hospitals are on the verge of collapse, patients are being left in ambulances and health care workers are dying in droves. Unless one believes that people in the Southern Hemisphere are some sort of genetic freaks, it is obvious that the same thing will happen here in the fall.

    I will, without using any models or statistics whatsoever, make some additional predictions that I guarantee will be 100% accurate:

    There won’t be a vaccine in time for most of the world’s population.

    There won’t be enough PPE for health care workers.

    And if Director Frieden, aka “the bonehead”, gets his way and the schools remain open, “the tinder”, aka, our precious children and grandchildren, will provide the tinder that triggers a massive pandemic bonfire.

  14. #14 revere
    August 6, 2009

    mono: You are entitled to your usual obsessions, but just for my edification and since it is obvious to anyone like you who is paying attention, exactly how many dying health care workers constitute “a drove”?

  15. #15 Magpie
    August 6, 2009

    Hospitals are on the verge of collapse, patients are being left in ambulances and health care workers are dying in droves.

    I’m not sure that massive exaggeration is very helpful. I don’t know if there’s a precise definition of a “drove”, but the present numbers don’t suggest anything like that to me. What’s your source?

    Of course the southern experience is important to look at, but we’ve got a weird issue in the north of having had a “mini-season”, a much larger population, and time lag since the initial outbreak that might effect resistance and so on. You can’t just wave your hands in the air and say “this will be catastrophic, man the bunkers”, because the public will only listen to (what they see as) cries of wolf so many times.

    It will be bad, but most places in the south are holding comfortably (Australia for example). It’s going to be worse in places with big populations and worse healthcare, but that’s not news – it’s worse there for everything, medically. but modelling is useful to show to people who can make decisions now, to give them real estimates that, however tenuous, is more reliable than the hand-wavings of random bloggers.

  16. #16 Magpie
    August 6, 2009

    Dammit, I knew I shouldn’t have interrupted my post by talking to co-workers – I’ve been gazumped by Revere. Curse human interaction!

  17. #17 Paul
    August 6, 2009

    I live in the Atlanta area. My daughter-in-law is due in October. I’ve tried impressing her and my son that the best prevention for her would be “house arrest,” September thru October; be the first two withdraw their other two children from scholl at first sign of H1N1 arrival. They are non-bleievers in this whole thing; think I’m way overboard. Asked her to consult with her obstetrician about the Pneumovax. He told her absolutely not indicated.

    Some things are just out of a parent’s control at some point.

  18. #18 Monotreme
    August 6, 2009

    revere and Magpie ,a drove is not precisely defined. However, I would say it means “a lot”. 10% of the dead in Argentina are health care workers. At least 300 are dead there now and another 400 deaths under investigation are likely to be confirmed. 10% of 700 is 70. I would argue that that constitutes “a lot”. Further, we are not told how what percent of the dead in other countries are health care workers. I see no reason why Argentina should be the exception in this regard, especially in Latin America. Although the US has only been lightly touched by the pandemic, thus far, a nurse in California has already died. HCWs who read here might want to contact their colleagues in the Bay Area for information about the protest that occurred yesterday.

    As regards exaggeration, I assure you my comments are simple statements of fact.

    Here is a story you might want to read:

    Perth emergency departments ‘close to meltdown’

    Just because you don’t see it on American TV doesn’t mean it isn’t happening.

  19. #19 Monotreme
    August 6, 2009

    It occurs to me that I did not provide a link to my assertion that the 10% of the dead in Argentina are doctors and nurses.

    Here it is:
    El 10% de los fallecidos son médicos y enfermeros

    For those wishing a less filtered view of what is going on in Latin America, I recommend using the Spanish language version of Google. Search “páginas en español” and click on the news (noticias) using the word “influenza”. If you don’t read Spanish, try Bablefish to translate the stories. Latin American press provides the gory details of who is dying and how they are dying. The American MSM tends to leave most of these unpleasant facts out when they translate the stories to English.

  20. #20 Jimmy
    August 6, 2009

    Revere- “But in fact, while there was a lot of flu around, most people didn’t get it.”

    Do we know this for sure? There were confirmed Swine Flu infections all over BC, Canada this spring and anecdotally many folks I know had a late spring, mild ILI but since there isn’t comprehensive monitoring in our jurisdiction can we say for sure that wasn’t this flu?

  21. #21 revere
    August 6, 2009

    Mono: The facts will sort themselves out and we’ll see. I’d add, just because you read it on the internet, doesn’t make it true, even if it is in Spanish. But we’ll see.

  22. #22 downeast
    August 6, 2009

    Really wish a few samples from last flu season (Feb. 2009, northeast US) would be retested for this particular swine virus. Did we already see this virus come through certain parts of the U.S. late last winter? Seems who will ever know, with all eyes paid set on this coming fall, with short glances back over the shoulder. I know you say it’s easier said than done, Revere, to retest, but surely a lab somewhere….

  23. #23 Monotreme
    August 6, 2009

    revere, the story about 10% of the HCWs appeared in a mainstream new source. The names of who said what are given. If you have some reason for distrusting this source or the people quoted, could you state what they are?

    You don’t question that an American nurse died in Sacramento, do you?

    Here is the California Nurses Association site .

    You can find a description of the nurse who died, including her picture, as well as a movie showing the rally asking for stronger protection against pandemic flu.

  24. #24 another
    August 7, 2009

    revere asks: “…exactly how many dying health care workers constitute “a drove”?”

    Monotreme and Magpie point out that the term is not precisely defined.

    Let’s define it then, shall we?

    If we can believe Wikipedia, on the Chisholm Trail “[t]he typical drive comprised 1,500-2,500 head of cattle.”

    Let’s call it 2,000 head of cattle. Assuming that the head of the average HCW is worth two of cattle, we end up with the nice, round figure of 1,000 per drove.

    Thus, 1 drove = 1 kHCW.

  25. #25 magpie
    August 7, 2009

    From the article you linked to, Mono, “close to meltdown” is apparently defined as kids with the sniffles needing to wait a whole 90 minutes to see a doctor. Christ, at the best of times I expect 6+ hours at my local emergency department for anything less than immediately life threatening. Well done Perth.

    Slow triage is a cost saving procedure, and even “ramping” happens on occasion. The local hospitals (I’m in Canberra) struggle every friday night, and blow their target any time the city’s football team is playing a home game. Using this stuff as a measure of imminent doom is reaching just a tad.

    In Australia we have pretty high expectations of our health system, and it’s a heavily politicised issue as we have UHC. Of course there are scary headlines, since telling taxpyers that politicians are mis-spending their money will always sell papers. But look at the facts. We’ve not lost anyone due to lack of space in the hospitals. I was at hospital a couple of weeks ago with chest pains and I was in a bed and strapped to the machines that goes PING in about 5 minutes.

    Sure we’re cancelling / rebooking *some* (note – not all, even in the most overstretched areas) elective surgery, but that’s always been the plan for a pandemic, and a lot was from earlier on in the pandemic to free up space in advance of more incoming sickies. We still have room to move even now (the most serious of what we define as “elective” surgery is hip replacements and heria ops – both serious, but not immediately life threatening).

    This is worse than normal flu, but we really can’t say how much worse yet, and it’s certainly not at the level you seem to think it is.

    Look, no-one disputes this is serious, or that more resources are needed for public health (which are pathetic at present, even here), but your “pandemic bonfire” and “dying in droves” quotes make you look like someone getting off on disaster porn, fondly imagining rows of dead. This is not the disaster you think it is.

    …it might change, sure, and it’s good to keep a close eye on it, and especially good to staple this close-call (so far) to the foreheads of every penny-pinching politician out there. This will be worse in the north, I’m sure, with big populations treated by worse healthcare than the southern average. There will, in any case, be much bigger pandemics to come – and it might even be next year when this bug has another go. But don’t make the real issue into something it isn’t.

    We’re doing ok so far. We are. Honest.

  26. #26 M. Randolph Kruger
    August 7, 2009

    Magpie… Which end of the country are you in?

  27. #27 melbren
    August 7, 2009

    Revere- I trust your hunches more than anyone’s on this subject; you have a lengthy and consistent track record of approaching such matters responsibly, rationally, intelligently, and honestly. Because nothing about this issue seems to be black or white, I truly appreciate that you are willing to share a hunch with your readers–particularly at a moment such as this. “Hunches” of those who are uniquely qualified, informed, and experienced on a particular topic often provide the most important tool for assessing a situation during a crisis.

    When I first met him, my husband was driving a crummy old Volvo. Really crummy. Gradually, one of the headlights began to collect water whenever it rained. It rains a lot in Atlanta, and before we knew it–our headlight looked like it was in a fishbowl. The light itself worked fine; it was just embarrassing more than anything. No one else seemed to be driving a car that sloshed when it came to a stop.

    My husband’s mechanic wanted about $400 to fix the problem–had to order a part from Sweden, remove the engine, blah blah blah. My mechanic wanted a bit more, but was going to replace the other headlight cover proactively. We didn’t have $400 to replace something that we basically viewed as cosmetic–and we didn’t want to put any money into the crummy old Volvo.

    One day, I was driving past a no-frills looking auto repair shop that had dozens of Volvos crammed into its humble parking lot. I pulled our sloshing car into the lot, double parked, traipsed in, and found the owner, David. He was a very quiet man. And as I do in most situations with quiet people–I tend to fill in the quiet space with meaningless rambling. As I rambled on, he got up from his desk, fetched a tool from his garage, walked out to our car, stooped down and, in about two seconds’ time, had drilled a small hole into the bottom of the headlamp. As the water began to dribble out, he stepped back, said, “no charge,“ and walked back into his shop. (Since then, no other person has laid a hand on one of our cars.)

    But the point of my story is that sometimes we have to accept that–for whatever reason–a perfect solution to a problem may be out of reach. And that “good enough” is best.

    As much as we know about swine flu–it’s apparent that there is even more that we do not know. And at some point, the heroes of this crisis are going to be the mechanics in the room who just grab their drills and do the best they can with the information and tools they have. This close to the beginning of traditional flu season, with a novel pandemic flu virus gearing up for a second swipe at the globe, limited vaccine several months away, shrinking quantities of (and confidence in) antiviral medication–I think we (the lay public) need to applaud otherwise cautious flu and public health experts for using one of few tools we truly have to combat this crisis–the hunches, gut feelings, and sixth senses of the relatively small fraternity of recognized experts in the fields relating to epidemiology and public health.

    In my estimation, an epidemiologist’s version of grabbing the drill would be the publication of a hunch–a commitment to the unknowable; indeed, a very difficult thing for a scientist to do. I feel quite sure that scientists prefer to leave the hail mary passes to athletes–and, I too, generally prefer my science to be really “scientificky.“ But the best science we may have over the next few months may be the hunches of our very best scientists.

    And, just as sports fans don’t hold quarterbacks responsible for hail mary passes that fall short, we, the lay public, should cut flu scientists and other public health officials the slack they deserve if they happen to miss a few marks at this point in the game. Particularly over the next few months, there is going to have to be some hunch-following to fill in scientific gaps that currently exist; my gut tells me to listen to what the flu scientists’ guts are telling them.

  28. #28 Grahame Grieve
    August 7, 2009

    Magpie was in Canberra, the federal capital of Australia. And he’s right – our system is under pressure, but is holding (just, in places). We haven’t, as yet, had to actually change gears yet.

  29. #29 kenzie
    August 7, 2009

    My niece, an ICU nurse who cared for H1N1 patients, got what most likely was this flu. She became very sick, with diarhhea, severe headache with light sensitivity (encephalitis?), fever, and so on. She works at one of this country’s most highly regarded hospitals, but they don’t use adequate protection when caring for these patients.

    Another niece got this flu and was unable to get out of bed for a week. She was taken to ER when she started having difficulty breathing. Luckily, she has recovered, but I believe it could have gone the other way.

    My son, who lives in Orange County, got this flu and it really was quite mild for him. He lives at the beach and gets lots of sun exposure. Maybe that helped him.

    My sister got this flu in Miami, had to go to ER where they kept her overnight on a cardiac monitor because she was having irregular heart rate. She said the place was packed, with hundreds of patients, but she didn’t know how many were there with flu or fear of having the flu.

    Bottom line: I think if this flu comes back any worse than the above, we will be in a world of hurt.

  30. #30 Monotreme
    August 7, 2009

    magpie and Grahame Grieve, I appreciate your first hand accounts on the situation in Australia. However, I’m trying to reconcile your assurances with the stories coming out of Cairns. For example, this one:

    A CAIRNS woman now critically ill with swine flu and pneumonia was initially sent home from hospital with a few pain pills, says her shocked husband.

    Rod Morrow fears his de facto wife of 17 years – mother of eight, Rosie Anna Gesa – did not receive the care she needed because of language barriers and the flood of flu patients at Cairns Base Hospital.

    Ms Gesa is now in a coma and her partner is “bracing for the worst”.

    The shock story comes as Prime Minister Kevin Rudd prepares to meet today with Cairns medicos to discuss a possible federal takeover of state hospitals.

    Mr Morrow told The Cairns Post Ms Gesa was sent home by doctors when she first went to the Emergency Department on Sunday night with aches pains and a bad cough.

    Last night, she was one of six people with swine flu fighting for their life in intensive care in Cairns.

    Perhaps things are worse in Cairns than Canberra?

  31. #31 M. Randolph Kruger
    August 7, 2009

    Mono is pretty much on about this I think. The info I am getting is more in line with what he is saying than what Magpie is touting. Pretty much anything south of the 30 degree line is having a large problem with flu… Collapse is a relative word. That is to say if one of YOUR relatives is in the hospital and has to wait for a bed, a machine, or anything then its damned sure not fast enough.

    It would seem that here in the US that there are a lot of severe cases, I know of four personally now and that included one of my people. Three are in NC and they have all of the equipment, they are in ICU’s and they are and have been there for weeks now.

    Dont borrow trouble? This Administration is already moving to a federal FEMA response with the military in charge for “testing” centers with the 3rd ID in charge of six camps. You turn a positive, you will be boxed up and shipped to one of these facilities. A dirty little secret and knucklehead states like Mass. are facilitating what could be the greatest limitation of your rights in the history of this country. Or, it could be very shortly a complete takeover and thats going to get more people dead than the flu would ever kill.

    Best way not to lose your country is to ensure your state is prepared, you are prepared and with no declaration it falls to this Administration to comply with the law. We have under the last three administrations worked to ensure “help” comes with all of the trimmings and those trimmings are going to one day ensure that there IS a takeover. .

    Magpie-I will ask an obvious question and you can answer or not. Since there is no counting being done, not even sampling now… How would you know if it was going down the tubes. N. Zealand is and I have friends in Perth, Melbourne and Wellington and the story they are painting in their towns is that there are one helluva lot of cases, people are on a waiting list and that there are no beds, equipment or people to operate them. Crafty little Ozmanians though were the first I think to do bypass and that seems to be helping more than anything. But there are only 25 of those machines in the entire country.

    Not a slam old man, but it is what I said before… Too much for private, too much for public healthcare to handle. The UK is straining under the weight. Its been a bit more slow there and they are coming up to the task I think.

    If its adapting to the situation, then we will see it continue for the next couple of years and H5N1 lurks to the north of you. BTW you wouldnt know it, but do stay out of Bali for the vacation this year.

  32. #32 tardigrade
    August 7, 2009

    It’s been a long time since my last visit… Been thinking about this H1N1 and how it folds into the health care debate. I always felt that ‘opportunities’ would raise their ugly heads. Sometimes, need stripes away politics.

    For all of the worry that H5N1 caused, we didn’t get our collective fecal excrement together… The flu (or any robust communicable disease), the economy, personal finances, will all work together…. I just wish we could do things before ‘opportunities’….

  33. #33 Tsu Dho Nimh, BS, MT(ASCP)
    August 7, 2009

    Mono –
    I read Spanish, and you are overlooking two things. The person being cited is a politician – una diputada – not the health department, and you have missed this part of her complaint: miles de estos trabajadores presentaron síntomas y medio centenar se encuentra en estado crítico con cuadros de neumonía y Gripe A Translation: Thousands of these workers have had symptoms and about 50 are in a “critical state” with a case of pneumonia.

    Given that thousands have had symptoms and fewer than 100 have died … it’s not a good news kind of thing, but it’s not exactly “hordes” of them.

  34. #34 Monotreme
    August 7, 2009

    Tsu Dho Nimh, I don’t think it is useful to discuss what constitutes “a lot”. People have different thresholds for this term. So, let’s stick to numbers. The article claims that 10% of the dead in Argentina are health care workers. Do you have any reason to doubt this number? There are at least 300 dead in Argentina and likely 700. If the 10% number is accurate, that would be 70 dead health care workers.

    In Mexico, there were anecdotal reports from health care workers that many of their colleagues were severely ill or dead. It got so bad that some of them were abandoning their hospitals. We don’t have hard numbers on this, AFAIK, but HCWs there seemed to think it was “a lot.”

    In California, one nurse has already died. Do you dispute this? There are about 80 deaths in California so far. Thus, HCWs make up over 1% of the deaths in California. It would be nice to have good numbers on how many HCWs have died in the US. Has the CDC bothered to collect or publicise this information?

    So, here is my interpretation: early in an outbreak, Tamiflu and PPE are available and the workload is low. Under these conditions, few HCWs will be infected and die. However, as the cases mount, exposure to the virus will increase just as PPE, Tamiflu and ventilators run out. When this occurs, the percent of HCWs who die will go up.

    What is “a lot”? We all have different numbers in mind for this, apparently. But I can tell you with some assurance that nurses in California consider 1 death “a lot”.

    It is easy to dismiss other people’s concerns about their safety. And I’m afraid that many in public health are doing precisely that. They will very soon find themselves in direct opposition to the AFL-CIO (see below). At that point, they will have to make a decsion: are they with the workers or with management?

    It will be interesting to see which side people here choose.

    Nurses Rally for Strong Swine Flu Protection

  35. #35 daedalus2u
    August 7, 2009

    Maryn points out that the nurse in CA who died had MRSA pneumonia.

    http://drugresistantstaph.blogspot.com/2009/08/catching-up-on-some-reading-health-care.html

  36. #36 kenzie
    August 7, 2009

    Revere: You have always been a great advocate of workplace safety. What is your opinion about healthcare workers being exposed to pandemic flu because of lax infection control, and the opinion of the above poster that “fewer than 100 have died” and “50 are in a critical state” seems to be acceptable to him/her?

  37. #37 caia
    August 7, 2009

    melbren — Well said.

    Randy — What has Massachusetts done? I’m not familiar with what you’re referring to.

  38. #38 Anonymous
    August 7, 2009

    We learned today that our clinics would be receiving seasonal influenza vaccine in the next week or so and we are planning to follow CDC recs to start vaccinating those over 65 ASAP.

    My understanding is that clinical trials to determine safety of administering both seasonal and H1N1 vaccine are just starting. I am surprised that they are pushing the seasonal vaccine so soon. Is there any possibility that administering seasonal vaccine might affect the immune response to H1N1 vaccine?

  39. #39 SusanC
    August 7, 2009

    anon

    Is there any possibility that administering seasonal vaccine might affect the immune response to H1N1 vaccine?

    The NIH is doing clinical trials on that very question. See the slides by Gorman, at this link http://www.cdc.gov/vaccines/recs/ACIP/slides-july09-flu.htm

  40. #40 Grace RN
    August 7, 2009

    Monotreme-re:…”A CAIRNS woman now critically ill with swine flu and pneumonia was initially sent home from hospital with a few pain pills, says her shocked husband….”

    Same thing occurs here all the time in the US-just look at what happened in 1990 with Jim Henson (Muppet master).

    http://en.wikipedia.org/wiki/Jim_Henson

  41. #41 Anon
    August 7, 2009

    SusanC,
    Yes, and that’s why I’m wondering why they are recommending the seasonal vaccine be administered as soon as available, before the question has been answered.

    Seems like it would be reasonable to wait a month or so, after we have some data. I can’t think of any good reason to start vaccinating for flu in August.

  42. #42 Magpie
    August 7, 2009

    Mono re: Cairns (and to follow from Grace), yes, this sort of thing happens at every hospital on earth. Diagnosis is never perfect – people get sent home incorrectly a great deal, as “return” stats will show – but in any case sending people home with pills (probably Tamiflu) in the Hospital At Home programs we run is a perfectly reasonable response to patients with flu.

    The worst of it would seem to be: “My doctor today told me he couldn’t understand why they didn’t send her in straight away and give her an X-ray. She was critically ill,” Mr Morrow said.

    …which is the guy’s doctor discussing the event which he probably wasn’t even present at, commenting on what a distraught patient told him had happened, as reported second hand by that same distraught fellow to the newspaper. Is that the quality of information you want to use here? If she really was “critically ill” when she presented, then I don’t see how translation problems, cited in the piece, lead to misdiagnosis – but even if it was, the fact that the hospital does not employ a 24-hour translation service is not exactly a flu-related stress on the system, is it?

    Note that she’s in intensive care right now. When she presented the second time she was taken straight to X-ray. It wasn’t necessarily a lack of resources (though as I’ve mentioned earlier, poor resorcing at triage is a problem we’ve had for years), she just got misdiagnosed or simply got sicker than others – which happens.

    Note also that Cairns is a fairly small place (population around 150,000) with a large indigenous population (including the patient in question), who are extremely susceptible to the flu (that “genetic freak” thing you so tactfully mentioned earlier). In other words, yes, things in Cairns are about as bad as it gets in this country. Yet there’s still room in the ICU.

    MRK: your question was “how do you know it’s not going down the tubes because they stopped testing”? Is that right? I know because 1. the hospitals are doing ok, 2. if ANYONE died because there was no room in the ICU it would be in the family’s interest, the medical associations’s interest, the media’s interest, and the opposition politician’s parties’ interests to tell everyone in the country about it – it would be front page news (note this Cairns story where it seems to be a pretty routine triage problem), and 3. we stopped testing because we are now assuming that all flu cases in the country are swine flu. If anything, we are now overstating our swine flu problem.

    I’m annoyed that we stopped *counting* properly, but I don’t think it’s unreasonable – the mechanisms just aren’t in place for anything like an accurate count. We have UHC, but it’s administered by a US-based federal system, with the states all running their own systems. There’s a lot of talk, including in the Cairns article, about putting it all in the hands of the federal government to help with just that sort of coordination.

  43. #43 raven
    August 7, 2009

    Not sure if the seasonal flu vaccine is worth bothering about.

    The swine flu might crowd out the seasonal strains.

    In ecology, only one species can occupy a niche at the same time/place.
    Besides which, IIRC, this has been observed to happen before.

  44. #44 Anon
    August 7, 2009

    Raven,
    I agree, but if the CDC makes a recommendation to vaccinate those over 65 as soon as it’s available ( and they just did that), clinicians are sort of going to have to go along with it.

  45. #45 Lea
    August 7, 2009

    Paul with the family in Atlanta. You’re not alone with the “they are non-believers in this whole thing; think I’m way overboard”.
    Two years ago my mantra was Detachment and just this last month I’ve started anew with the Detachment. It’ll hurt when we see our loved ones die from something we had knowledge about and tried to help them see. When this happens, don’t beat yourself up with the usual, “I should have done more, I should have been more forceful” stuff. A great many hearts are going to be hurting and grieving, not a pretty picture and not easy to imagine right now because the Big One has yet to arrive.

  46. #46 Magpie
    August 7, 2009

    Gah, the melodrama is strong with this one.

    It’ll hurt when we see our loved ones die from something we had knowledge about and tried to help them see. When this happens, don’t beat yourself up…

    Again with the disaster fantasies.

    IF this happens, not WHEN. It’ll be no bloody wonder they don’t listen to you if you’re telling them with anything like the certainty in your language here that they’re all about to die. What happens when, as is the most likely case, this pandemic does nothing more than give a few people in your family a week in bed? A minority of people catch the flu, and a minority of those are hospitalised. A very small minority of those die. And you’re talking about getting ready to deal with the deaths of your loved ones! The chances that any of them will die is vanishingly small.

    You ARE way overboard.

    We need more resources in public health. We need better preparation and education. There will inevitably be very damaging pandemics, and we should be much more ready for that than we are. But crying wolf does no-one any good. It is enough, I would have thought, to point out how stretched we are in the south, so look at the trouble you’re going to have in the north, and to demand better preparations. But we don’t have to keep on conjuring visions of widespread death as so many have been. It just makes people think that the medical community and media are not to be trusted.

    It makes your family think you are not to be trusted. You’re telling people to cower in their homes when, in the south, business is going on pretty much as usual – and it’s likely this will be so in the north. So at the end of all this they’re going to look back on your advice and think you’re insane. Especially if they actually followed it.

    Just… tone it down. A really big one will happen some day, so it’s good to have some preparation ready. But you just damage your own credibility if you advise people to treat every pandemic like the end of the world. And if they don’t listen to you at all, then you can’t do any good at all.

  47. #47 The Doctor
    August 7, 2009

    Congratulations Revere for getting such an enthusiastic response to this thread.

    Simply put, the novel N1N1 is an influenza strain that most humans have no immunity to. This means the vast majority of the Earth’s population are susceptible.

    What we do not know is whether the novel strain will be severe in the northern hemisphere during our coming flu season.

    The fact that the novel H1N1 virus does not yet posses the HA 627 polymorphism required for ideal reproduction within the temperature of human upper respiratory tract is something that has impaired its reproduction rate. That it will acquire this PM soon is likely. When it does, then it will be much more fit; meaning its spread among humans will be enhanced.

    It appears that this pandemic strain like past ones for reasons we do not understand spares those over age 50 years. This is a fact but not something we understand. It infects children and kills them but not to the extent that it kills those between age 15 and 45.

    So, here we go. A new pandemic strain to which we as a species are naive meaning that we are all susceptable but the virus as in past pandemics prefers to prey on healthy young adults rather than the usual victims of seasonal flu.

    We all know this.

    What is important to consider is that it arrived in the NH in February and has remained here. There has been no let up in the north. Sure, there seem to have been a drop off in cases in Mexico, New York, and the UK. Yet the virus continues to circulate in all regions it has appeared in and does not seem to be going away, even temporarily.

    As Revere has pointed out so often, the more we observe about the flu the less we realize we know about it.

  48. #48 downeast
    August 7, 2009

    Whoa. Don’t tell me that, Doctor. We rely on you scientists to get to the bottom of this, to make sense of the novelty. Kill the brain, kill the ghoul.

  49. #49 Victoria
    August 8, 2009

    Magpie (an annoying Australian bird that swoops and attacks humans),

    You are way overboard!

    Hey! Live and let live. Lea has every right to express her opinion. You are carrying on like a two bob watch. Who made you judge and jury?

  50. #50 SusanC
    August 8, 2009

    Anon,

    My understanding is that the final logistics of how exactly to administer the H1N1 vaccine will need to be worked out locally. The biggest group that receives the seasonal vaccine is still the elderly, and they are NOT on the target group for H1N1 vaccine. In fact, they are last in line, in the ACIP recommendations.

    I suspect the reason why they recommend the seasonal flu shot to be given ASAP, is precisely to get it out of the way, for those who need both, so that they can receive the second shot in a few weeks and still, hopefully, be ahead of the pandemic curve. But I imagine there won’t be perfect solutions and some confusion will be unavoidable, and that overall, people getting 2 shots too early before they know whether there is interference, may be the lesser of 2 evils, compared to them not getting the H1N1 shot and then getting adverse outcomes because of that. Just my speculation, I don’t have any insider knowledge!

  51. #51 caia
    August 8, 2009

    Victoria (a queen whose grandchildren comprised most of the heads of state during WWI),

    S/he may have assumed more than was necessarily indicated, but Magpie made a good point. Over-the-top warnings damage one’s credibility in the long run… and it may be sorely needed later.

    Look at Revere(s). They’ve resisted making broad predictions about H1N1 (and previously H5N1) for years, other than to predict that the viruses will surprise us because of how little we really know about flu viruses. That means that when they DO make a prediction, even one as moderately phrased as this, I sit up and pay attention. A whole lot more attention than I would to the people (scientists, commenters, etc.) who’ve been saying the End Times were nigh since 2005.

    If you really want to motivate people to take precautions, you have to start from where they are. Giving dire warnings may make us feel like we’ve “done what we could to warn them,” but it has the drawback of being unlikely to actually work.

  52. #52 victoria
    August 8, 2009

    Caia,

    All that is certain, is that there will be a “right” position as to the pandemic flu virulence. Unfortunately, this position will only be known in retrospect. You may have your position (based on your life experience), Lea will have her position and I will have mine. Arguing over correctitude in advance of an event is meaningless. Let your mind be open to all possibilities both benign and catastrophic.

  53. #53 Monotreme
    August 8, 2009

    I agree with victoria whether we can tell how “dire” the situation is or will be. I would argue that we really don’t know what is going on in many important respects. For example, NYC has apparently stopped reporting their deaths, at least to the general public. Why? Do we really know what kind of decisions are being made in ICUs in Australia?

    I am struck by the resemblance between the 1918 pandemic and the 2009 pandemic with respect to media control. The same bland reassurances that come from public health officials, and in some comments on this blog, were common in 1918. Many people at the time did not really know just how bad it was in the world. They only knew their personal experiences. A full accounting of just how “dire” things were did not come until decades later. I would not have thought that similar information control could occur today. But I was wrong about this.

  54. #54 Lea
    August 8, 2009

    Interesting … since the comment made was directed towards Paul in Atlanta. It was not written to insight or create gloom and doom or over-the-top warnings.
    mag took it the wrong way, as did you caia, both of you read too much into the comment. Do either of you deserve further explanation from me? No……

  55. #55 Magpie
    August 8, 2009

    Well Lea, Paul was telling people to hide in their houses for two months and take their kids out of school. You seemed to be agreeing with him, and also preparing for the imminent death of your loved ones.

    Was that a wrong impression? You don’t think such advice / preparation is a touch extreme in this situation?

    Mono: if health officials are being bland, that’s because the science is bland. Sure, misrepresenting the facts and taking hearsay out of context (as I’ve shown you have, and you’ve not bothered to defend) is all very well for random bloggers, but if the medical establishment does that for this pandemic – well, we’ll get a great response this time round, in the event it does turn out to be as apocalyptic as you seem to hope. But if it’s the pandemic it’s likely to be, all the dire warnings are going to make people stop listening.

    In Australia right now, the TV, radio and newspaper commentary is all along those lines: well, that was a whole lot of nothing, wasn’t it? (Actually, that’s what it was like a month or two ago – now it’s rarely mentioned, except to report the latest death or to give a comical name tyo your trivia-night team). This makes it that much harder when something worse come along, or just to argue for better preparation in general.

    And that was with the “bland” warnings you deride. The media is going to play up even the slightest medical threat – how many in the public completely misunderstand the threat from H5N1 from all the “bird flu is coming to kill us!” stories? The only sensible approach from public health officials is to be bland and stick to what they know, or think is likely.

    Victoria: yep, my name was chosen with that in mind. Magpies are also easily distracted by shiny things. I enjoy self-deprecation.

    Lea is allowed to express her opinion, this is correct. I am also allowed to express mine, which is something you seem to have missed – just as you expressed your opinion about my opinion. See how that works?

    We – anyone who knows much about this sort of thing – genuinely have an opportunity to save some lives in the event of a serious pandemic. For most of us, we might only be able to communicate to a few – our neighbors and family, maybe co-workers – but that’s still important. So I think it is important to advise “our” people not to go around like chicken little every time an acorn drops. Yes, this is a serious situation, but giving people the advice Paul and Lea seem to be promoting is almost certainly going to destroy their credibility, and is almost certainly wrong.

    So you can say: this MIGHT be a huge event and their advice might be good – but this is their one chance. If this pandemic is not as earth shattering as they seem to think, well that’s it. No-one is going to listen to them next time (as they don’t seem to be listening this time). And all the data points to this NOT being the carnage generator they seem to think it will be…

    The other issue, and this is where I might be reading too much into people’s posts, is “disaster porn”. It just seems to me that some people (not you) are so blinkered, so keen to read dire events into out-of-context fragments, that on some level they find the possibility of widespread disaster exciting. Their posts read to me like gleeful rubbing of hands over the imminent horrors to unfold, and their rejection of information that falls outside of their fantasy reinforces my view. They’ll take the most unreliable third hand information as true, if it means that we’re all doomed, but when far more reliable sources contradict that, they ignore them.

    Historic events are exciting. People want to be “part” of them somehow, in a way that the masses aren’t. Fondly imagining that everyone will some day say “Oh Mono, if only we’d listened to you!” makes people feel important. Believing you’ll be the the one to grimly carry on when all around you are panicking and dieing gives you a sense of drama and purpose.

    I think it’s not just distasteful, it’s counter productive.

    I realise this is possibly a pretty insulting position for me to take, but I believe it’s true, and deserves a mention. I think people need to have a good long look at themselves. They probably won’t, and maybe I’m wrong, but I think it’s worth a try.

  56. #56 caia
    August 8, 2009

    Victoria,

    I made no argument as to the actual future severity of H1N1. I have no particular opinion on it. I am not a scientist. I was arguing that trying to convince people that they needed to shelter in place (SIP) for two specific months this fall both is and looks alarmist. It is not yet knowable whether that’s an appropriate reaction or not. And giving this advice before it can be known is both unpersuasive and potentially self-defeating if it turns out to be unwarranted.

    You yourself say there is a wide range of possibilities. Therefore, how is saying “don’t leave the house in September or October” justifiable? With all the associated costs (social, academic, financial)? It’s self-defeating to make those kinds of arguments. They only ensure that people won’t listen at all.

  57. #57 Lea
    August 8, 2009

    Let’s have a “Beer Summit” to settle our differences, I’ll buy the first round. LOL

  58. #58 Magpie
    August 8, 2009

    And thus Magpie should learn how to let it go and not rant like a loon. Thanks, Lea, for the good response.

    In my defense, I’m as over critical of myself – which is why I do pretty much nothing for fear of my future self’s inevitable opprobrium (who will still mock my inactivity, but at least it’s a failing we’ll both share).
    :P

  59. #59 Grace RN
    August 9, 2009

    daedalus2u, the article also points out she had H1N1, then developed MRSA pneumonia. That counts as a flu death with a superimposed MDRO ( multi-drug resisant organism) pneumonia.

    I’ve been in healthcare almost 40 years and have no doubt a surveillance swab of my naso-pharyneal area would show I am colonized with MRSA. I had a total knee 5 years ago, and scrubbed the operative area twice a day for a month preop with Betadine-thank God I didn’t get infected. (That doesn’t prevent a MDRO infection starting somewhere else later on and ‘seeding’ itself out in hardware.)

    I don’t agree with hype or exaggeration of numbers, but you have to count them where it’s documented.

  60. #60 Grace RN
    August 9, 2009

    Re:”… “My doctor today told me he couldn’t understand why they didn’t send her in straight away and give her an X-ray. She was critically ill,” Mr Morrow said…”

    His idea of critical doesn’t MAKE it critical-my idea of critical is based on a physical assessment, vitals, labs etc. A person with a cough and fever but normal o2 saturations measured over a period of time in an ER is not my idea of critical, but it could be to a layperson.

  61. #61 jake_gittes
    August 9, 2009

    I hope I’m not too late in this thread to still have some readers. My wife and I are German and American expats (respectively) living in Luanda, Angola, Africa the past two years. We have read about the swine flu in the northern hemisphere (Europe, North America and Asia) last spring and the southern hemisphere (Australia and South America) the past few months, but I have not yet read much about Africa. I am certainly not an alarmist, but I just recovered from the worst bout of flu I’ve experienced is several decades (I’m 55 years old) and several things came to mind as a result. When I went to our company expat doctor to check for malaria (the biggest potential health problem here) and that turned out negative, I asked him about checking for swine flu. He said that they don’t even have facilities to check for that here.

    I realize that this is my personal case of flu and does not mean anything in a larger context, but it started us thinking about the conditions here that would be fairly “ideal” for influenza incubation. Looking out my front window I can see, less than a block away and within 2km of downtown Luanda, streets covered with in raw sewage and with people, pigs, goats, chickens, ducks, dogs and cats going about their daily business. In the construction industries that are fueled significantly by Chinese interests, there are many 10s of thousands of expat workers from China. In the petroleum industry there are probably 4 to 5,000 permanent expat residents, primarily from Europe and North and South America, but the velocity of people traveling in and out is very high (we all go on vacation at least twice a year, and many are on rotation where they work 8 weeks and have 4 to 6 weeks off). Suffice it to say that public health as discussed in this blog does not exist.

    After all this I have a copule of questions.

    First, how does Africa (or should I say “does Africa even”) figure into the world health monitoring of influenza? I remember when I lived in the US we would rarely hear of hemoragic (sp) fever outbreaks in Africa, but nothing more. Right now with Hillary Clinton on the ground in Luanda I can find next to nothing about her African tour in the American press. So I would not be surprised to discover that Africa is not much considered.

    Second, how long after being infected by the virus can samples be taken and the critter identified? I will be going to Europe for vacation in a week and I’ve wondered if I could get tested to find out if this is indeed the newH1N1 or just some garden variety virus. This is just a personal curiosity. There is no possibility of testing or tracking here in Angola so the results would not be of any other use. But I do not know if there is a time limit from exposure or if once you have gotten the thing, some of stays around for awhile so that it could be looked at.

    Thanks for your help.

  62. #62 revere
    August 9, 2009

    jake: We don’t know much about what is happening with swine flu in Africa. Is this because of a reporting/diagnosis problem? Likely, but much of Africa is also tropical or semi-tropical so the disease dynamics might be very different. In addition, there are competing risks that might mask diagnosis. The only way to test if it is swine flu is via some sophisticated PCR that is unlikely available in most places in Africa. But there are so-called rapid tests that can be done with someone acutely ill to see if they might have flu A or flu B, of which swine flu in one kind of flu A. If you are recovered there is no practical way to see if you had it. Looking for cross-reactive antibodies is a research level test, not fool proof and not available to you.

    BTW, the Clinton trip is being covered daily in national news broadcasts and papers here. It’s not attracting a lot of public interest, but it is being covered (esp. her Kenya trip and the concern over Somalia).

  63. #63 wenchacha
    August 9, 2009

    I haven’t checked in much since my daughter and her boyfriend were sick back in mid-June. They both had aches, fever, along with vomiting. I wasn’t there to monitor all the symptoms, but this was at the same time that H1N1 was showing up in the pediatrician’s office as well as the rest of the county.

    Both made somewhat of a recovery, then rebounded with very painful strep throat, which was treated with penicillin.

    Though they were not tested for H1N1, it seems a fairly good bet that they had it. They were wiped out for a couple of weeks, then finally returned to health.

    I had managed to get my daughter a Pneumovax before she entered college, though it was not a suggested vaccination for her. I reminded her ped. that she often gets dehydrated quickly when she is ill and that it takes her a long time to recover. She didn’t think it was necessary, but she gave her the shot, and insurance covered it.

  64. #64 Paul
    August 9, 2009

    It’s interesting what a ruckus I caused. But I think those accusing me of over-reacting missed an important detail. I wasn’t advising “everyone” to stay in their homes for two months. I was specifically (and strongly) advising my pregnant daughter-in-law, due in October, to do so. As you are aware, pregnant women are at a higher risk of severe disease should they contract the virus.

    The fact this H1N1 is still circulating up here, worries me that the seasonal surge may occur earlier, somehow facilitated by this factor.

    Although on a more personal note, their first child has CP from premature rupture of membranes, (I assume.) The family doesn’t need anymore disasters, or another disabled child.

    Their normal life-style, as it is for most young folks in Atlanta, is highly social, restaurants, public events, gathering of friends, etc. I think her going on like this in the last two months of her pregnancy, sending her children to school (which will never be closed in a timely manner – risk vs. benefit for administrators – same dilemma for epidemiologists), is a significant crap shoot as to whether she catches the virus.

    So all you, who are worried about crying wolf – you’re speaking from a theoretical concern. For me, it’s quite personal, and if I’m wrong about a pandemic, I won’t sweat that call.

  65. #65 RM - ProActive News Room
    August 13, 2009

    I read another article similar to yours giving the same predictions and my questions is if the elderly are being made to take the shot as a precaution why not the children as well?! They are as vulnareble as the elder population. Knowing these facts are the school systems making preparations to handle sick students and the sanitation process required to keep the rest of the children healthy??

    I pray that this paper is incorrect and that it’s not as bad as we are hearing for the sake of our children who are heading back to school!

    Thanks for this post!

  66. #66 PanFluPlanner
    August 14, 2009

    First off, thanks very much for the many informative posts about H1N1 and influenza in general. It is certainly helpful to us lay people.

    I’m not sure if the link will work, but it leads to a situation report from the Australia Dept of Health about the current flu season down under. Does the data there give any more indications about what the upcoming flu season will be like in the Northern Hemisphere? Is there any historical correlation between severity of flu seasons in the two hemispheres?

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