When is a pandemic not a pandemic?

By revere on May 19, 2009.

Is it a pandemic or is it not a pandemic? Since the world has never had a chance to make a call like this at the outset of a pandemic, nobody is quite sure how to handle it. The usual definition -- an epidemic (an increase in cases beyond what is expected) of global dimension -- has a lot of wiggle room and WHO and everyone else is busy wiggling. One reason is not whether this meets the definition or not but what the consequences might be of calling this "a pandemic":

Britain, Japan, China and other nations urged the World Health Organization on Monday to change the way it decides to declare a pandemic -- saying the agency must consider how deadly the virus is, not just how fast it is spreading.
The debate arose as WHO began its annual meeting, a five-day event attended by hundreds of health experts from the agency's 193 member nations. Swine flu is expected to dominate this year's conference _ and WHO must consider whether it should raise its alert level or tell manufacturers to begin making a specific swine flu vaccine.

WHO's current system focuses on how widespread the disease has become without regard to its severity. Some member nations are anxious to avoid having the agency declare a swine flu pandemic, because the ramifications of that scientific decision could be very costly and politically charged. (Frank Jordans, Washington Post)

The reticence is not mainly at the WHO level but at the level of its member states. There is also suspicion this reluctance is affecting how thoroughly or honestly some countries are reporting cases of infection with the novel swine flu virus within their borders. The idea that severity should be an additional criterion is (sensibly) being resisted by WHO:

"Severity and the broader impact on society is something that we really can't set globally, because of the unique conditions in every community," WHO spokesman Dick Thompson told the AP. "Severity is going to be different in different countries. And within a country, it will be different in different populations." (WaPo)

The argument boils down to this. We shouldn't call a pandemic a pandemic, because people might misunderstand that this means it's a pandemic. And then they would do things like panic, like UK officials are doing now when the prospect is broached we are having a pandemic. And since even the considerable wiggle room of the current definition of a pandemic is insufficient to avoid calling this one a pandemic, please provide us with some more wiggle room by adding severity to the mix, so we can then argue about whether the pandemic is severe enough to be a pandemic.

Two of the US's premier risk communicators have wryly taken note (via a commenter at The Flu Wiki):

In response, here is another modest proposal from Jody Lanard and Peter Sandman:

If WHO decides not to call a widespread "mild" swine-origin Influenza A/H1N1 pandemic a pandemic, then we believe they are obliged to announce that the H2N2 event of 1957 and the H3N2 event of 1968 were also not pandemics.

They should then announce that the last influenza pandemic occurred in 1918, and there have been no flu pandemics since that time.

WHO should also review the list of pre-1918 "pandemics" and decide which of those events were also not really pandemics, so we can re-calculate how many times per century, on average, a pandemic can be expected.

That way, we can be doubly relieved: Not only that swine flu H1N1 isn't a pandemic, but also that pandemics are very much rarer than previously thought.

Now if someone will please tell the virus, we're all set.

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Revere, thank you for this posting -- it is rather amusing to me reading about government officials in China, Europe and Japan (folk who own lush family homes, SUVs and city and innercity rental investment properties) bitching about "viral CFR severity":*)

Yes indeed, we all know "viral severity" depends on the evolutionary mechanisms at work within these apparently new cross-species viruses. Some of us indeed worry about low CFR H1N1(2009) doing a squishy homologous recombination dance with high CFR H5N1 in animals and/or humans co-infected with both types...

There are several positions taken with regard to evolutionary mechanisms. For example, I believe in artificially generated HGT recombo caused by unstable viral promoters used in genetically modified food. Irrespective of position taken, educated folk like us are sure of one thing, "Pandemic pathogen severity" is just around the corner. So we better invest in this eventuality and prepare.

Excerpt from an e-list email sent out today:

To: "Angela Huang, ProMED-mail Rapporteur"

To: "Adrian J. Gibbs" ,

Tuesday 19 May 2009

Angela, I've read and for the most part agree with your ProMED-mail post commentary Re: PRO/AH/EDR> Avian influenza (36): China (QH), wild birds (Mon 18 May 2009). I've made a number of public health blog comments regarding transgenic H1N1(2009)/H5N1 host co-infection evolution (see below).

Given the speed of this evolution, mentioned recently by a prominent member of the International Committee on Taxonomy of Viruses (ICTV), Adrian J. Gibbs, I feel your belief in conventional reassortment evolution vis a vis H1N1(2009) and H5N1 to be inconsistent.

The speed increase can be explained by the recent evolutionary paradigm of "horizontal gene transfer and recombination".

Adrian, I discussed your "accelerated viral evolution" observations re: H1N1/2009 samples here: Crof's H5N1 Blog -- "Branswell: Did the swine flu evolve in a lab?" (May 12, 2009)
http://crofsblogs.typepad.com/h5n1/2009/05/branswell-did-the-swine-flu-…

Angela, I discussed H5N1 and H1N1/2009 viral mutation and host co-infection here on 8 May, 2009: Crof's H5N1 Blog -- "Egypt: Pigs slaughtered as farms closed in Jordan" (April 29, 2009)

"Since the world has never had a chance to make a call like this at the outset of a pandemic, nobody is quite sure how to handle it."

We are presently watching base-human nature undo a century of progress.

All this does is continue to harm the reputation of WHO. What is the point of the defined influenza pandemic phases? We base our response plans around them as well as the historical experiences of the recorded pandemics of the past century. Just because we have a scenario that meets the technical criteria of a pandemic but isn't (yet) comparable to a 'worst-case scenario,' there is so much reluctance to embrace it for what it is and not let politics interfere with public health--but I guess that will never change.

Additionally, I have yet to read any reports regarding community transimission in areas that have documented several SOIV/H1N1 cases (Spain, for example). I find it hard to believe community transmission is not occurring in countries that happen to be in different WHO regions that have confirmed several cases like it has in the North and Central America.

To clarify the second paragraph of my above post, I am aware of the documentation of community-level transmission in North and Central America; however, what I am not seeing discussed are reports of the same in countries in separate WHO regions that have reported several cases.

I have a question regarding the difference between a level 5 and a level 6 WHO pandemic alert. I have read the general guidelines, but, as a practical matter--how would our daily lives be impacted if the alert were raised to a level 6? Would each state have the authority to interpret its own perceived threat?

I happen to live in a state that has consistently been reporting an unrealistically low count of "confirmed" swine flu cases. Because we have such low numbers, would our state have the authority to--in a practical sense--circumvent compliance rules as it sees fit? In a sense, I guess I am asking the following: can the system be gamed--and if it can be gamed--shouldn't we assume that it will be?

What should be a teachable moment is instead turning into a sad circus of dithering, warning, hand-wringing and pooh-poohing.

The great lesson of the 1918 pandemic is that people who get (and trust) the information they need generally don't panic. Panic sets in when reality looks a lot more harsh than the Official Story would have it.

The WHO, bowing to pressure from member nations whose leaders haven't learned this lesson, continues to be slow to publicly admit that we've got a pandemic on our hands... and it's damaging the institution's credibility.

Instead of prevaricating, they should declare that we've reached Phase 6 and use the resulting publicity as an opportunity to get the message across that:

A) A pandemic is defined by how broadly it's spread, not by its severity
B) A pandemic can start relatively mild and become more virulent (e.g. 1918)
C) A pandemic can start relatively mild and stay relatively mild, but that doesn't mean it isn't dangerous enough to warrant your attention; a number of people have died already, and being sick with this virus is no picnic even if you recover fully
D) There are a number of effective ways of preventing the transmission of the virus, including frequent handwashing, good cough/sneeze etiquette, staying home when you're sick, and staying away from sick people when you're well
E) You should get vaccinated, when a protective vaccine becomes available

Melbren:

The practical impact is that some countries use the phases of the Pandemic Alert Level as trigger points for particular actions. It's been awhile since I last glanced at the state-level plans here in the U.S., but for the most part, I don't think the Pandemic Alert Levels play a major role in triggering responses at the state level here. (They don't really have much of anything to do with the national-level response in the U.S., either; the CDC has its own measures, including a severity scale.)

Also, it's important to understand that the number of confirmed cases in the U.S. should not be expected to be anything like the true number of cases. Not everyone with the virus is getting tested, and -as much as I'd love the data- that is as it should be.

In many (probably most) places, testing is now focusing on those with severe disease, those at high risk due to underlying conditions, and those whose cases might be indicative of the virus moving into new environments (the first n cases in a given state, cases from a particular school), and which therefore represent an opportunity for slowing the spread of the virus (or, at the very least, better understanding its epidemiology).

Testing every single person with a suspected, or even probable, case would be cost-prohibitive and would lead to a backlog that would slow the receipt of test results for those targeted groups I mentioned above.

But it does seem reasonable for governments to request more information than just the extent of human spread in order to know what the appropriate level of alert should be. They can be forgiven for not wanting to mount a full-on public health response to a tribble pandemic.

Traumatized:

Well, certainly, it makes sense to take the severity of the disease into account. For instance, there's no need to start standing up field mortuary sites at this point.

But that's not an argument for ignoring reality. A pandemic is a pandemic, regardless of its severity level. The dichotomous question of a pandemic's existence (yes/no) and the more continuous variable of its severity (mild, medium, well-done) are two complimentary, but entirely different, pieces of information.

If you had a fire in your house, you'd want to know, even if it was just a small kitchen fire. You wouldn't want to wait until the whole house was ablaze to declare "this is a fire." First, you'd want to recognize that there is a fire (dichotomous existence question), and then -while taking steps to control it- you'd want to assess the continuous variable of severity.

The problem with all this politicing about pandemic level is that WHO refuses to advise the production of a vaccine.

"Manufacturing capacity for antiviral drugs and influenza vaccines is finite and insufficient for a world with 6.8 billion inhabitants," Chan said. "It is absolutely essential that countries do not squander these precious resources through poorly targeted measures." Dr. Chan

http://www.cbc.ca/health/story/2009/05/19/swine-flu-vaccine465.html

I read this to say, people in developed countries can die along with people in undeveloped countries because we won't advise production of a vaccine that will likely only save those in the developed ones. Isn't this bias diverting rational pandemic planning to a fatal degree?

Am I hearing appropriate level of response in the same sentences and context as good sense? The numbers of deaths are starting to pick up a bit. Larry King had the husband of the pregnant woman on the tube the other night and said she was in perfect pregnant health when she got the bug. This counters completely what the Administration and in particular Napolitano said. The woman the government said had underlying conditions. News to daddy and thats where the government had better watch its step. Minimize a pandemic and the scenes from the French Revolution come to mind. They are grown people and they had better start treating them as such.

Great thing about lying on the TV.... It shows all of those crinkly little lines and the worry on the face when the acting CDC Director is taking the company line at the behest of Napolitano. The problem? The US did NOT follow the prevention protocols or even attempt to and now we got dead people, going to see some more. Slow it down, stamp it out, throw the antiviral blankets.... Anyone seen any of that going on. If I was a Canuck I wouldnt go to Mexico out of spite, more than good sense. The Mex's didnt contact the WHO, or PAHO. Nope, they didnt even send an email. No, they sent samples to CDC and to Toronto (or Montreal) for analysis and waited for a week. Pure unmitigated bullshit.

So then we got H1N1 09 variant. But, now we are complicit in the "crime" and then because of politics dont do anything about it because Obama was in town.

SHIT !

Politics, politics. I can tell you that seed samples are rocketing out to every lab that can make a vax and then some. Vaccinia seems to be the interim fix for the severe cases and that aint the best of stuff or so I am told. But it keeps you alive. One of the readers here has a case of it and she is immune compromised. She has had it for three days and she is on fever break number 4. 102.5 at the highest. She got honked on at a conference by someone from New York and from the sounds of things she may be in the hospital by tomorrow if it continues. No pneumonia... more like the system shutdown stuff from the initial Mexico cases.

So what faith are we to have in the Administration? The "mild" pandemic is killing people and quite a few down this way in the South.. Sunday a 28 year old oil rig worker died in Little Rock H2H. 82 cases confirmed in Tennessee. So many they cant count in Texas. They are dropping in New York and Rikers Island has four now in the prison population. Flu vax by their own admission will be a minimum of two doses, maybe three and will take 12 months to make...interrupting the seasonal flu vax production. There is the problems with tracking reactions as well as they freely admit that this stuff is going to be field tested in humans with not a lot of the normal safeguards in it.

Add in the fact that its in close proximity to H5N1 in China, Indonesia, Egypt and making a vax for this, might not work for that and its a fine pickle we are in. Me, I would call Pan 6. People might start doing something a bit differently and we save yet a few more. I have been looking at modeling information and models of course are spurious at best, but they serve a graphical purpose. We can see it moving and the spread. 100,000 this week and about 4-5 million if it holds by this time next month. There will be a percentage that dont make it. Low right now, down from about 10% to less than 1%. But that too can change.

But it aint a pandemic remember? What number is it going to take to get them to call it? Remember as you are taken down by this stuff for weeks if not permanently that its a "mild" flu. If this is mild, I shudder when I think of severe.

Revere-please put up something about TB/H1N1 and that one is a virus, the other a bacillus and that the two shall not meet in genetic heaven. There are a few nutz out there saying that this flu has TB in it.

Jesus

Good post Tom DVM.

Have there been any reports of prevalence of asymptomatic or mild cases? I would have thought field epidemiologists would have done some random sampling to look for this, but have seen no reports of incidence.
Too soon?

Randy: She did have an underlying medical condition, a known risk factor for serious flu complications -- pregnancy. The fact that this wasn't mentioned specifically doesn't alter the fact. I would say to you what I have said to others: the decisions being made now by public health authorities are very difficult on every score because the virus is unpredictable and we are in uncharted territory. There are too many uncertainties and consequences for every choice. People will make different judgments about this and if I were in their place I might do some things differently, but I have seen nothing from CDC, WHO or New York that I think is beyond what could be persuasively argued for.

I am grateful I am not on the spot for making these decisions because there is no way to make the "right" one. Whatever you do you will be criticized, as we prove here daily.

Steinn: My understanding is that viral shedding and household/care giver contact studies are being done now. It will take a little time.

"We shouldn't call a pandemic a pandemic, because people might misunderstand that this means it's a pandemic."
OMG, what an intricate intrigue...

I would like to know more about the pathology of the hospitalized cases.

Swine flu without typical flu symptoms: no fever, but "system collapse". I presume that means things like renal shut down and pulmonary collapse after a day or two of mild symptoms such as cough and body aches. Is it that sudden?

A study came out yesterday of 30 California hospitalized cases. All but one presented with fever (97%), 77% presented with cough, 46% with vomiting, 43% with shortness of breath.

Yes Revere you are right. But 40 years of agreements and protocols went out the window and this went off like a bomb in our back yard and we didnt even get up to look. Obama was too busy trying to protect the economics of Mexico and not ours when it came down to it. They knew it was there when he arrived because the damned samples had been at CDC for almost 10 days... No, no passes given out on this one, he knew it.

Then he puts Napolitano in charge.. What Blanco was too busy for an appointment?

Those protocols were agreed upon in this country and nearly the entire world and we didnt even bother to tell people until they started dropping like rocks in Mexico City. The cases in California and Texas were known and they did absolutely NOTHING ! They held the information on those kids in New York for a week before we found out about it... failed to mention they had been to Mexico. I would say that was a notoriously omitted fact if you were trying to stop the spread.

Fact is, they didnt seem to want to stop it. Yeah, I get to second guess a lot of bad decisions. BTW how many pregnant women slip into a coma when they get seasonal flu... You know, that mild strain we have?

I am not beating on you Revere. I trust you and you know it, but damn man if this had been H5N1 we would have been carting them off by the train car load by now for burials. When in the Hell is/was/will the national pandemic flu plan be used? Seems they forgot what aisle it was on at the library.

What a dithering mess we are witnessing!

If one thing is clear from the past history of influenza pandemics it is that at the beginning of a pandemic it is impossible to predict how severe it will be as it evolves.

The reason for this is not known but that this is a fact is incontrovertible.

The purpose of the WHO Pandemic Alert levels was to provide the world with an early warning system for when a pandemic has begun. If the WHO had stayed with their original plan, then it would have functioned as desired. They changed the rules a couple of years ago so they could ignore the fact that limited H2H had occurred with H5N1 in 2005 and thereby keep the level at 3. Now they are under pressure to change the rules again to use severity as a criteria rather than efficient H2H occurring in two WHO regions.

It is not cricket to change the rules so much within the same game!

The purpose of being able to "see" a pandemic early in its course is to give the public and governments as much time as possible to prepare for it when in deed it is possible to do so. It appears however, that our governments do not want to be warned or more precisely don't wish for their public to be warned since of course they are much better informed than we and we obviously see that pandemic outbreak occurred in Mexico on or about February 12, 2009.

So, the question is why don't they want the general public to know a pandemic is underway?

Grattan Woodson, MD

Thanks to the Reveres, Dr. Woodson and all the MDs & RN's for the informative posts.

M. R. Kruger- Respectfully, there was at most a 24 hour reporting lag in NYC. I live here, in Queens. This is the St Francis Prep timeline:
4/13/09 SFP students leave for Cancun spring break trip
4/19/09 (approx) SFP students return from Cancun
4/20/09 Classes resume at SFP
4/23/09 SFP nurse Mary Pappas reports flu outbreak to NYC DOHMH as soon as she notices symptomatic students
4/24/09 NY media reports SFP outbreak, including the fact of the SFP students' trip to Mexico.

I disagree with Mayor Bloomberg on MANY issues, but I don't think he has pulled any punches here. Revere was correct about the damned if you do/don't aspect- particularly with school closings in NYC.

That said, I am grateful you experts are questioning the government at every turn. Keep 'em honest.

Thank you Revere,

I do my best, (in a Cultural Region of North America within wich we have Narrow Relations, Natural Solidarity, an Historical Layout that is still active)to avoid the replication of past epidemics and pandemics Impacts in our Communities.

Sincerely, I believe that these Days we are indeed in a Trail that is allowing us to avoid the worst of Impacts of Our Past in our Todays Communities.

There are Viral Impacts and Communal Impacts.

Our youngs have lost a lot of Memory toward the Weaks, Elderlies, Woman, Childrens and Warriors Brothers and Sisters.

Unlike in the 16' hundreds or like in Russian Grippe of 1889-1892 or in the Great Inluxenza of 1918 up to ...., Communal Impacts Today is very different of the ones of our Past.

Finally, .. Public Health now consider this factor in the equations in determining morbidity and mortalities.

So we are facing Viral Impacts and Social Impacts. Who says What? .. and for wich Field?

Federals, (Politics and Scientists) and Regionalists (Politics and Regional Leaders) are right into the Trail.

As Regionals consider Federal Executive Powers more apt in Social Order in crisis, Federal Deliberative Powers consider Regional Leaders more apt in Public Health Efficiency.

Therefore, the most apt to reduce morbidity and mortality in epidemics and pandemics are the Feds in maintaining Humanitarian Governance and Regional Leaders in maintaining adequate Public Health.

Best of both Worlds.

Snowy Owl

I think the way the AP story worded it, nailed down the issue a little more clearly:

"Fearing a swine flu pandemic declaration could spark mass panic and economic devastation, Britain, Japan, China and others asked the global body on Monday to tread carefully before raising its alert." (emph. added)

http://www.google.com/hostednews/ap/article/ALeqM5gzz357patY4-QaJFvo9O9…

Salutations HornBlower,

Economic Impacts are a Survival Experience for many who are already at the end of the rope.

Survival is enshrine in our most antiques genes, Maximum economical shrinking Impacts triggers Survival Regency, it cannot be ignored coz its triggers can generate some primitive non logical, mathematical behaviors.

Anybody has memory of this or equation for that ?

Just considerating it Granths the answer.

Snowy

There are a handful of unconfirmed, but likely deaths being now reported. I suspect they are waiting to identify an "underlying medical conditon" on autopsy on some of these victims before they announce, so we don't all get alarmed that healthy people in the prime of life are being cut down. Some of these "underlying medical conditions" are just that, but some are being described by their families as healthy. Just to be clear, obesity, undiagnosed left ventricular hypertrophy, undiagnosed COPD, diabetes and a subclinical ding on the kidneys might be some of those underlying medical conditions, i.e., stuff you have but don't realize and doesn't really effect you now. People think we are much healthier than in 1918, but keep in mind unlike then, there are 12 million diagnosed COPD cases + another 12 million undiagnosed (so they say) COPD cases running around. The case fatality rate has been pegged at no greater than 0.6% with 95% confidence, but I wonder whether the sample size (which consisted of La Gloria the town with the little boy who almost certainly was not "patient zero") included the array of pulmonary diseases we face in this country.