[NB: I have been traveling and offline all day. No way I can even read much less respond to the many excellent comments, tips, questions. Thanks to all. Help each other. Back at home base now.]
Closing US borders with Mexico for swine flu is fruitless since the virus is already planted in a dozen or more countries. And while right wing xenophobes are trying to blame Mexican immigrants, most of the international spread has come from commercial travelers, either tourists or business people. If we had sealed the borders, would it have included all American nationals in Mexico? Somehow I don't think so. Maybe I'm too cynical.
Shutting down commercial air travel? Again, the virus has already reached its destinations (and is making connections), so shutting down flights wouldn't do much to prevent it. It might even make things worse by putting obstacles in the way of essential people, goods and services and the economic costs would be great. In any event, the US can't shut down Mexican or other non-US air carriers and as long as planes are flying into an out of countries where the virus exists -- including the US -- it won't help. Shut down all commercial air service into and out of the US and within the country? To make that effective you'd also have to shut down interstate highways, trains and buses.
Currently several countries (including the US) are checking passengers for signs of illness when they arrive at an international port of entry. It's reported that fever sensors have been installed in international airports in Saudi, Ankara, Tokyo, Sydney, Melbourne, Brisbane, the Gold Coast, Cairns, Adelaide, Perth and Darwin. There is little evidence they do any good, however:
Using temperature scanners in airports to try to identify and block entry of sick travellers during a disease outbreak is unlikely to achieve the desired goal, a report by French public health officials suggests.
Their analysis, based on a review of studies on temperature screening efforts like those instituted during the 2003 SARS outbreak, says the programs may be of limited use in the early days of a flu pandemic, when governments might be tempted to order screening of incoming travellers to try to delay introduction of the illness within their borders.
[snip;]
One of the key figures in Toronto’s SARS containment effort agreed with the conclusion, saying temperature screening was more about optics than about actually preventing the spread of disease.
“I think actually that probably is a large part of it. Sort of a sign that you’re aware and you’re trying to do something, whether or not it actually works,” said Dr. Donald Low, head of microbiology at Toronto’s Mount Sinai Hospital.
[snip]
During the SARS outbreak a number of countries, including Canada, introduced airport temperature screening. In some cases it was an attempt to keep out the sick. In Canada’s case, it was also an effort — adopted under pressure from the WHO — to ensure sick Canadians didn’t ignite new outbreaks abroad.
A 2004 study on Canada’s airport screening efforts showed that 4.6 million travellers were screened between May and November of 2003. Only 1,435 had an elevated temperature and none of those people had SARS.
Even a federal government report at the time acknowledged the machines were better at assuaging public jitters than detecting disease.
“While the scanners are not necessary from a (SARS) detection perspective, their value lies in their ability to build public confidence in the screening program,” the report said. (Helen Branswell, Canadian Press [prescient: dateline February 16, 2009]
O-Kay . . .
That's on the receiving end. There is some evidence that foreign soil screening might have some effect. That's checking people for illness before they get on a plane at the point of embarkation. In theory it could keep some symptomatic people away. But people can, and do, shed virus up to 24 hours before onset of symptoms, so those people wouldn't be caught. The amount of virus they shed is less than after they start to feel sick, but the important thing is they would get their travel in first and they wouldn't be picked up at their starting point. For seasonal flu it's thought that almost half of all infected remain asymptomatic. They also shed less virus, so we don't know for sure how infectious they are. But if H1N1/2009 (aka swine flu) is like that, and there is no reason it couldn't be, then that is a consideration.
The simple, if unwelcome, fact is that reducing transmission is now a local, not long distance, affair. It probably never was a long distance affair. Flu is not the kind of disease that can be bottled up. Local application isn't less painful. Canceling events, losing work and school time, interfering with leisure activities are all harmful in their separate ways. They have the advantage that they are the kind of social distancing that seems to have an effect, unlike border closings and air travel shutdowns.
It is time to turn our attention to the task at hand: preparing to manage the consequences of spreading illness in our communities. It may never happen -- and if it doesn't, the aggressive social distancing policies now being used may be a reason -- but with what seems to be an easily transmissible flu virus to which the bulk of the human population seems to have little natural immunity loose in our communities, prudence and common sense dictate we prepare.
Of course if we had been acting prudently we would never have let our public health and medical care systems deteriorate. As for common sense. It's just not that common.
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"Help each other."
Hasn't that been the lesson for the entire time we've been studying H5N1 and the history of pandemics here and at fluwiki?
We don't need you, Reveres, but it sure is nice having you around.
Meanwhile, per local radio, San Francisco is trying not to gloat over its economic bonus of getting all those cruise passengers originally scheduled for the 'Mexican Riviera'.
Im curious about how if so many people getting sick outside of peak flu season if not very probable the new h1n1 flu, so that we shouldnt have to wait for confirmation from the cdc( who arent inclind to do thousands of diagnosis anyway)
What changed in mexico that they stopped reporting dead and hospitalized "suspect" cases and just started reporting confirmed cases.
The only way to confirm a case is to send a sample off to an overtaxed CDC office no? Is it like NY where they just stopped counting. Im a little thrown off by the numbers - whats the point of tallying the confirmed cases if the number of actual infections is probably well into the hundreds of thousands already in the US.
engstudent, the CDC-only testing seems to be no longer true; at least, this morning's Boston Globe said that the Mass state lab can test for the strain as of today. That should help with both taking load off the Atlanta lab, and reducing the time to get results, since samples don't have to travel as far. I'm guessing the same is probably happening in other states.
News now says the turnout for the Mexican election is expected to be extremely low because of the flu scare. Wonder how that will skew the result?
Splitting Vaccine Production
============================
A very significant decision will have to be made very soon: whether to produce a vaccine for H1N1 or continue with seasonal vaccine production.
However, the right choice might be to split production: to use a slight majority of vaccine production capacity for H1N1 and use the balance for the seasonal flu vaccine.
There might be multiple reasons for splitting production: people who are really vulnerable could get both vaccines (i.e. elderly). Or, those who would mainly benefit from one could just get that single vaccine--i.e. young people most at risk for H1N1 could get just the H1N1 vaccine.
By splitting the vaccine production, you would reduce the total number of infections and reduce the potential for death by reducing infection density. So, even if you cannot vaccinate everyone against both threats--seasonal flue and H1N1, you gain the advantage of reduced infection rates (fewer people to transmit disease).
Also, by producing both, you reduce the possibility of an all-or-nothing situation developing. If you put 100% on the H1N1 production, and there are problems in production or it is clinically ineffective, then you have totally missed the seasonal virus. In this case, the seasonal flu might kill many more than its usual awful toll of 30+ thousand.
If you put 100% on seasonal production, and the H1N1 flu returns, then you have made a serious mistake.
Moreover, it may be proven that the H1N1 vaccine can be stretched to cover far more people.
It seems like the best way to reduce risk and harm is to make an attempt to produce both.
For the past several years, the flu vaccine has included both H3N2 and H1N1, I thought, as well as flu B. So why not substitute new flu for the prior seasonal H1N1 moeity?
Great.... I appreciate your posts and you being objective... and in particular
"Closing US borders with Mexico for swine flu is fruitless since the virus is already planted in a dozen or more countries. And while right wing xenophobes are trying to blame Mexican immigrants, most of the international spread has come from commercial travelers, either tourists or business people"
You are right but there is a lot of people who do not understand it
That is thje reason why I recommended your bloy on my blog
Oooh! The horses got out! Let's close the barn doors!
Lisa GP: they were considering that for a few days, but it looks like doing so would significantly delay the production of seasonal flu vaccine, and also raises all the problems of trying to figure out proper dosing, etc. for a novel virus. It seems that the consensus they've come to is to go ahead with seasonal vaccine production, and ramp up to be ready to produce a pandemic vaccine as well if warranted. The latter vaccine would then be given as appropriate (with adjuvants and/or booster doses), while the season vaccine would be given normally.
O.jeff makes a reasonable argument for producing both, and I suspect that is a fairly likely outcome. There is also the possibility of using newer technology for producing pandemic vaccine more quickly: while such vaccine is not yet FDA-approved for seasonal use, several such technologies are in advanced clinical trials, so the FDA would likely approve one of them for use in essential situations if it's the only thing available.
Well, the level of acceptable risk for a new vaccine is going to be directly proportional to the severity of the fall virus.
If it started acting like H5N1 in terms of mortality (sic. not gonna happen unless the two swap strands without disintegrating each other), I think you'd see a lot lower threshold for some reckless 'clinical trials' via public innoculation.
Since this seems so far to be a mild virus, I suspect we'll wait to use long-tested technologies, even if they're slow to meet quantity demands.
I reaaly appreciate your coments here... I think you try to keep an objetcive and more grounded opinion about theis problems... This is the reason why I stronlgy recommend your blog in my blog....This is a good commnet
"Closing US borders with Mexico for swine flu is fruitless since the virus is already planted in a dozen or more countries. And while right wing xenophobes are trying to blame Mexican immigrants, most of the international spread has come from commercial travelers, either tourists or business people. If we had sealed the borders, would it have included all American nationals in Mexico? Somehow I don't think so. Maybe I'm too cynical."
I am living in mexico City and we are hearing a lot of news from everywhere with this "right wing xenophobes" tone... this is sad... and we still do not know were this all come from... I sure you know better than I...
There appear to still be no H1N1 sequences from Mexico in the NCBI database.
Any idea what is going on there?
Alejandro, remember that what gets on the news is often what is unusual or shocking.
The vast majority of Americans don't think that Mexicans are at fault for this virus any more than a person whose house is robbed is to blame for the robbery. It's just that the xenophobic idiots, being out of the ordinary, are interesting, so they get on TV.
Now, that said, I'm a hard-nose against illegal immigration. But legal immigrants from Mexico, and Mexicans in Mexico, have my goodwill.
If we had sealed the borders, would it have included all American nationals in Mexico?
In a sensibly run America, of course it would have. In addition to including American nationals abroad in any other country.
Americans abroad would, under such a scenario, have been able to come home. Straight into a cordon sanitaire on U.S. soil, where they would be isolated and medically monitored for a few weeks. Evaluate them at the end of that time.
If they do not become sick? Release them.
If they become sick during the evaluation period? Give them medical care inside the isolation zone. But for goodness' sake don't let them out.
It doesn't look as though these sorts of measures are going to be required for this particular bug. But one day they will be required. And we'll be kicking ourselves for not having implemented and rehearsed them well in advance.
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Hong Kong is trying to quarantine a hotel right now with 200 guests and 100 staff. Earlier, revere said that quarantines do not work because people evade them. Maybe in this case, they can avoid that since it is a confined area that can be controlled.
They said they would release people in 7 days but in reality shouldn't they wait until everybody is well for a couple of days.
Never underestimate the power of stupid people in large groups.
Natural selection speaks softly but......
Some people choose to find the "best" information, some people behave like lemmings,science is so cool.
If the 2009 H1N1 flu is relatively weak, is it good to let it spread a bit so that people can get some antibodies, and it would be better in case its strength get stronger later on?
And, how much genetical change will make the vaccine or anti-bodies created after inflection ineffective?
No you don't want to spread it around more. The more people who have it the more chances it has mutate into something worse.
Re: the first post, "We don't need you, Reveres, but it sure is nice having you around."
I disagree. Every good blog needs a good moderator. Without one, it quickly turns into a meaningless void of mishmashed words and nonsensical ideas.
With Revere, we not only have an excellent moderator, but one who is obviously well-informed and deeply engaged in the subject matter. Thus the blog is meaningful.
That it is meaningful is what attracts all the other excellent contributors...
IMHO.
River, I meant that in the context of a 'catastrophic' pandemic (of the kind we worried about regarding H5N1), we here who survived would carry on with that mind-set in our communities even if the bug ate the Reveres.
My misunderstanding, Lisa.
Heaven forbid a bug eat the Reveres, you, or any of us!
Be well!
There is something suspicious about the mexican numbers... currently showing as 300 confirmed cases.
http://news.bbc.co.uk/1/hi/world/americas/8021547.stm
The UK jumped from 1 to 15 in the space of about a week... which is quite an astonishing rate of growth.
Given the headstart that Mexico had then I would expect their numbers to be in the many thousands by now (judging by the UK experience - and we do have pretty good labs/surveillence).
Sealing the borders will not contain the disease but it could slow the spread to allow time to better understand how virulent this bug is.
Chris
So does it mean the only safe way to spread is through vaccine?
It seems there is another theory that we cannot always live in a harmless, virus-free greenhouse.
As it is basically ineffective to stop the virus to spread, what is our optimal strategy to deal with it?
chris:
If based on the UK's record of jumping 1 to 15 in a week, then in Mexico for 4 weeks, the infected cases would be 50,625. The mortality 16/50,625=0.04%, perhaps is seasonal flu's mortality.
It implies that 1 out of 2,500 cases globally will have the death case.
I could not speculate what is the number of infected patients in Mexico so far. I trust the labs in the UK anyway. Maybe the infected patients in Mexico is down below 50,000, or more? Who knows?
passerby: An effective vaccine would be an important public health tool for a specific viral strain. But the ultimate way to prepare is to have communities that are resilient and robust to shocks of all kinds. In our view, that means generic investment in public health and social service infrastructure. Infrastructure investment in public health laboratories has already paid off handsomely in this instance. It was prompted by the threat of a different virus (H5N1) but worked just as well for this one. But machines don't run or interpret analyses. Human resources do that. And we are laying off public health workers just when we need them.
paiwan:
We must bear in mind that a good number of the 15 UK cases were contracted in Mexico... anecdotely including some whilst on a particular flight back from the UK from Mexico. So accurate extrapolation of the rate of transmission within the UK is not yet possible.
That said, I am highly suspicious of the Mexican numbers - there does not seem to be good reason to close down a country on the basis of the (400) number currently identified. I fear that there is a (somewhat understandable) incentive to downplay the numbers.
The reason that this is important is that closing a border would be unwarranted... if there were only a small chance of somebody who is infected crossing. However, if the numbers are higher then some form of restriction would be a more realistic proposition. We just don't know.
In summer 2006, my husband & I took the Certified Emergency Response Team training (CERT) offered by the local fire dept. After figuring out the the training was concentrated on responding to earthquakes and fires (considered the likliest to occur in San Diego), I meekly asked if any training would be developed for pandemic flu.
I was told that the CERT training was funded w/Homeland Security $, and that those HS funds did not include any for prepping for pandemic flu.
I don't know if the current CERT program includes training volunteers to respond to pandemic flu, but if not, woe be us.
chris:
I may dramatize the number of extrapolating 50,000 cases. But your suspicion makes sense to me.
If based on the local newspapers, this swine flu has been circulated for a while in Mexico until very lately it seems that Mexico administration has been shocked and relinquished the control totally perhaps has over-reacted due to the unknown fear.
As the forming of global village, we do need the responsible administrations to provide the swift and transparent public health situation. We have long way to go; it is good to be alert now.
CERT training in my area included a mock mass-vaccination program for flu as one exercise, and response to a terrorist bio-agent attack at a sports facility, as another exercise.
Quarantines and border closings over what is now a mild flu?. Madness or is something else involved here.
Lisa the GP "News now says the turnout for the Mexican election is expected to be extremely low because of the flu scare"
Thanks, now I have another motive to add to my theory.
I, for one, would be just fine with thermal scans integrated w/ TSA security at all airports. If you are sick, then you don't fly - the end. Unfortunately, you could just game the system by taking a fever reducer. But, I am just so tired of our American culture that encourages dragging ourselves everywhere when sick. I moved to Japan just as SARS was winding down, and if you set foot in public w/ any signs of illness, you sure as heck had better have on your mask and you were still socially shunned. Sometimes in America, I think we are TOO much about the rights of the individual -- whether it is the smokers right to smoke or the sick persons right to go and do whatever the heck they want to, because the rest of us are just being whiners.
SoCal-Likely no training about pandemics was included in that CERT training. I am an 800 level and I am telling some of the people in public health here that they might want to revisit some of their decisions. We have three active cases in TN, with 32 suspected right next door in the adjacent county. School closed for an evaluation.. WTF is an evaluation after they turn a positive A? Close it and then do the checks afterwards.
The gomers that I work with at the airport level are trained however for obvious reasons. One of those who is in charge of airport operations on the shift side told me that the suggestion of closing the borders was discussed, but due to the time elapsed it was as Revere said, already too late. Two or three days max in an airport city. Gone and got.
But IMO it could have been slowed for the rest of the world. It WASNT too late to close the airspace into Canada maybe, but for the UK and beyond? You betcha. Protocols were NOT followed and that is to lock it up, tie it down and slow and if able... Kill it in place. That means letting it burn out or burn slowly if thats all you can do. Another case got off the plane from Cancun and a vacation today. 9 year old.
The training for a quake, pandemic or hurricane is pretty much the same though SoCal. The needs of the people are the same and you take you meek little self up to them when you see them screwing up and tell them what they are doing wrong and explain it. They are volunteers mostly and are going to go down swinging if it goes high path its their nature like mine. If everyone gets scared into doing something wth this bug starting to slow on its own on preparedness then this little exercise has been well worth it. More than one has asserted that it will be back in the fall, something for sure the annual bug will have in it or a new more powerful ugly will come at us. Either way, your hubby is on the line and should be admired for it. Make sure he has the proper equipment even if its not provided by government. Its going to be in short supply if it does and four more months or so until the bug likely starts to manifest itself again. Backlogged cases are gong to be positive or negatives and the numbers will go up... And then there is the S. Hemisphere which is going into their cold season. Case study in what may yet be coming.
Chris.. Mexico is on a self imposed isolation. Sealing the borders would have done something back when. Instead of picking up the phone, the Mexican government took samples and sent them to CDC and Toronto. That only took four days to get it in and clear Customs. They insist that they informed PAHO but well they apparently didnt understand emails, telephones or fax.New concept that telephone... only been around for about 130 years. Ah, but thats just me.
Certainly some cases could have been prevented, but the outcomes so far in the US have been okay except for Mexican nationals. Average age has been 16 years and they STILL dont know for sure what the vector is. E.g. airlines without a doubt delivered it to New York, maybe Boston. But it doesnt say how it got into the humans that got it in Mexico. Feathers for H5N1, contact, infected air? Pick one. Likely going to be right on that too. So now its a slow it down mode. Slow it, and close your internal borders of your town or state. Keep it out during the summer. Dont screw around waiting for your school to shut it down if there is a case. They will generally close them too late and reopen them too early. Dont let one infection happen that can be helped.
Since we are in the Here and Now and have to Cope accordingly with the situation, your SteppingStone was Honorable, RespectFully.
Quebecois coming back from some Francophones Countries state the following, succintly..., they felt stygmatised because of their Origines, as a North American I know it is the same for Canadians and United States Citizens.
Xenophobics Cultural Behaviors are counter-productive in the Coping in the unfolding of a pandemic.
Thank you to all of you
Snowy Owl
maybe there could be a vaccine that could totally cure a person who has H1N1, thus this pandemic disease can rapidly scatter through physical contact., here in asia: In hongkong, where the 1st asian country to ba affected by the syndrome, does not have enough vaccines of the said disease...