As flu season ramps up in the southern hemisphere, the US, Europe and Asia are keeping an eye on it to see what will happen as swine flu finds new pieces of meat to sate its appetite for human flesh. Sorry about the overheated image. I've been reading what's going on in Australia. Because another lesson the southern hemisphere can teach us is how not to react to a pandemic virus.
Consider the Carnival Cruise Line ship, Pacific Dawn. It docked three days ago in Sydney onroute to the Great Barrier Reef to take on new passengers and let off others. But then, according to news reports (but see this version from the ship's onboard blog; h/t crof), 2 children came down with swine flu, followed shortly thereafter by additional passengers:
Carnival Corp.’s luxury cruise ship Pacific Dawn was asked not to stop at ports in north Queensland after 38 people caught swine flu while on a South Pacific voyage, Australian health officials said.Passengers and crew tested positive for the H1N1 virus after nine days at sea on the 11-deck vessel. Most patients had a “mild illness” and were diagnosed after the ship docked in Sydney on May 25. Pacific Dawn will now reach Brisbane, Quensland’s capital, tomorrow after three new cases were reported, the state’s health department said yesterday.
“All passengers will be screened before disembarking and any passengers with symptoms will be swabbed and provided with masks and a course of Tamiflu,” Jeanette Young, Queensland’s chief health officer, said in a statement, referring to Roche Holding AG’s anti-flu medicine.
Australia’s health ministry said cases among people on board the ship have been found in Adelaide, Brisbane, Canberra, the Gold Coast, Melbourne and Sydney, contributing to a more than twofold increase in the nation’s swine flu case tally to 147 in 12 hours. Southeastern Victoria state said 43 additional cases were confirmed late yesterday, bringing its total to 96. (Jason Gale, Bloomberg)
OK, fine. Doesn't sound too unreasonable, although the cat's out of the bag for sure. But the rhetoric and actions around a futile government attempt to contain the virus are not so fine and they led to predictable results:
Swine flu victims are being kicked out of their Sydney hotels by nervous proprietors who fear bad publicity might drive other customers away.
The Daily Telegraph understands that two hotels are evicting 14 people who were on the swine flu-contaminated cruise ship Pacific Dawn.
It is understood 12 people will be evicted from Meriton Serviced Apartments in Parramatta and two from a Holiday Inn, either in Darling Harbour or Kings Cross, The Daily Telegraph reports.
One of the first confirmed swine flu victims, Nicholas D'Arcy, is staying with his family at the World Tower residential apartments in the CBD [Central Business District]. It is understood the D'Arcy family will be given a reprieve and will not be evicted this morning. (Joe Hildebrand and Holly Byrnes, The Daily Telegraph [Sydney])
Ouch. If you make flu cases sound like lepers they'll be treated like lepers. And the result will be further spread of the disease rather than containment. It's not as if Australia is blazing a trail, here. When this virus was first recognized in California at the end of April there was substantial uncertainty about what to do. But that phase is over. There is now a month's worth of experience in Mexico, the US, Canada and Europe (of course the UK is also behaving irrationally, so it's not just Australia). Australia is geographically isolated and may have thought it could escape this. That was a pipe dream. The world is now too tightly connected to think a major developed country could be epidemiologically unlinked from the rest of the world.
The doubling of swine flu cases in 12 hours makes it obvious that the virus is starting to circulate in the community. There is no hope of bottling this up any more (if there ever was). Australia should be bending all its efforts (and its public education) to managing the consequences of a new flu virus. This means being straightforward with the public about three things. The first is that so far the virus is clinically like seasonal flu. It is reasonable to tell people this, not to allay fear but because it is true. It may change, but that's what we see at the moment. But the second thing to be straightforward about is that seasonal flu is something to respect. It's a "seasonal flu" teachable moment. Flu of any kind can make you very sick and even kill you. The third thing is that even though the impact on the individual is not so very different than the flu people are used to, the effect on the community could be very different because of the potential speed of spread and the age groups and number of those affected. So people need to get ready for that.
We'll be watching what happens there for clues about the epidemiology. In our view, CDC did a fairly creditable job in its messaging. Perhaps Australia should have watched what happened here first.
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Hear Hear, Revere.
Australia's robust focus on containment leads to an obvious dilemma: Fear of the disease can increase stigma, which can increase efforts to hide disease, which can lead to increased spread of the disease. (This is old news of course.)
Another problem is focusing on one strategy, while not simultaneously warning people -- dramatically -- that it is likely to fail.
Australia's "containment" effort has been Quixotically admirable, and may well have slowed the rate of spread -- a benefit in a country which can make its own vaccine, and a benefit in all countries in reducing peak impact on health care facilities.
But a major message is missing in most countries which are emphasizing containment: Preparing the public for the failure of containment, and helping them visualize a widepread epidemic.
One of many admirable aspects of the U.S. CDC's messaging has been the matter-of-fact but regretful emphasis on the likelihood of additional cases, additional severe cases, and more deaths. It doesn't reduce the agony of those deaths for loved ones, but it does help the population brace itself, and feel less shocked and blindsided.
I am currently working in one of many countries that are trying to imagine informing the public, in the future, when the country has its first H1N1 death. These countries know it will not help to just say, "But of course lots of people die of flu every year..." They know people are justifiably more upset about a death from a new flu virus that is even more unpredictable than the "usual" flu.
"Telling people what to expect" is a way of drawing on their resilience, and showing you trust that they can handle bad news -- treating them like adults.
Michael Osterholm did this during the early phases of a meningitis outbreak in 1995: warning people early on that one in seven people with meningitis might die. http://tinyurl.com/nnfkv4
The CDC has provided many good examples of this strategy in recent weeks. Australian officials need to go back and read former Health Minister Tony Abbott's spectacular "pandemic dilemmas" speech from 2005:
www.psandman.com/col/abbott.htm
I pay taxes. Part of my taxes pay people in my state health department to worry about flu. Another part of my taxes pays people in the Commonwealth health department to worry about flu. Another part of my taxes contributes to the WHO who have people who worry about flu.
So I don't worry about flu. If I did I would be wasting my taxes. Why worry about something I have paid others to worry about?
I'm inclined to accept the view that the "kicked out of hotels" story is a media beat up.
Not that there is not a problem, nor that people with flu are not being asked to leave.
But how much money do you have to go on holiday, and how do you budget it? How would your funds hold out if you were suddenly told to extend your hotel stay by 1 week? And if you couldn't pay the extra week, what would you expect the hotel to do?
And have you ever been on holiday and suddenly asked your hotel to extend your booking for 1 week? Would you be surprised if they said they had other bookings and could not accommodate you in that situation?
I think the problem is that because the pandemic has not been officially declared by the WHO, the local governments have not given the local health authorities sufficient powers.
These people "evicted" from the hotels are on "voluntary" quarantine. The only thing keeping them in quarantine is their own conscience and the media opinion if they go out and infect anyone else. Because the quarantine is "voluntary" they get no assistance from the health authorities -- do you really expect them or the hotel to pay the accommodation costs?
Presumably if they were on compulsory quarantine funds would be available to pay for it.
What was the correct response to the Pacific Dawn?
NSW Health authorities initially stopped people disembarking in Sydney while they assessed the situation. And they got criticised for overreacting and leading to a 7 hour delay for the next cruise departing. Last time I went on Pacific Dawn, we had an 8 hour delay because of high seas.
Then they (Health authorities) allowed everyone off, and now they're in trouble for not keeping everyone on the ship.
Now the ship is quarantined in Queensland, and everyone blames NSW Health for allowing it to leave Sydney.
What would everyone be saying if the ship had been forced to stay in Sydney and nobody got any flu?
It seems to me that all the media commentary is based on what has actually happened or what might happen with no consideration of alternatives. And unfortunately this post seems to be taken straight from the Australian media without looking at the real situation.
Well, Tim? You must trust your govt WAY more than I trust mine! In the U.S. the govt has laid in some 40 million doses of Tamiflu, and ordered 12 million more -- for a population of 320 million potential sick folks! I'm SURE the mathematics are not substantially different down there (although I understand Australia is actually the best-prepared-for-pandemic nation on earth -- congrats on that!) -- I know for sure that "my" govt, which takes a huge amount of money from my checks, is NOT worrying specifically about me and my health. And I don't have medical insurance, so I'm not worried about paying for a hotel; I hope to be able to pay for a respirator and nursing care, if god-forbid, I were to catch the flu and get truly sick!
"Big-parent" govt is NOT going to take care of you -- no matter how many taxes you've given them. Children riding in the backseats of cars get to pay no attention to how things go for the family. Adults realize the govt cannot (and will not) provide for them and their families and take suitable precautions, including getting educated and prepared!
Governments exist to provide services to their people. When they no longer provide them their reason to exist vanishes. This increasing inability to provide services to the populace is what proceeds collapse. Everyone should read "The Collapse of Complex Societies" by Joseph Tainter http://www.amazon.com/Collapse-Complex-Societies-Studies-Archaeology/dp… By and large complex societies teeter for a while and then collapse when some event happens that they formerly could respond to but no longer are able to. A pandemic can be such a collapsing event. We should be less worried about the flu itself and more worried about whether a pandemic could collapse the complex world society we live in. (for more on Tainter and his credentials see http://en.wikipedia.org/wiki/Joseph_Tainter )
Here is one shock from France
Hat Tip to Frenchie Girl of flutrackers.com
The original article is at
http://www.ouest-france.fr/...
A lady of 54 yrs old who belongs to the US delegation for the upcoming of President Obama on June 6th at Normandy is diagnosed and treated with themild swine H1N1 virus.
12 other members of the delegation are quarantine in their room for 24 hours.
Snowy
After the first blush of sin comes its indifference. Henry David Thoreau
CDC said, it peaked, the worst is over. While you say
There is no hope of bottling this up any more (if there ever was).
So, how "did CDC a fairly creditable job " ?
"Australia's robust focus on containment leads to an obvious dilemma: Fear of the disease can increase stigma, which can increase efforts to hide disease, which can lead to increased spread of the disease. "
Effort of containment and isolation of infected is heavily emphasized in some Asian countries like Hong Kong. I am not sure how much the above statement will hold true there.
But does it worth the effort of containment to slow down the spread of virus?
BTW, is the American press too quiet about the flu, as it has moved away from the front page of major media in most of the May?
From the perspective of a flu scientist/public health professional, what value would you place on the routine, randomized, confidential, and large-scale sampling of average, healthy Americans?
For example, my husband has been called for jury duty next month. With the goal of keeping our eyes on the viruses that lurk about our population at any given time--would it be beneficial to have a system in place, similar to that of jury duty, that is dedicated to on-going virus surveillance and detection in our "non-ill"? What if, like jury duty, it were considered a civic responsibility to show up at the public health department when asked--probably two or three times over the course of one's lifetime--to voluntarily and confidentially submit to a good ole fashioned nasal swabbing? (Or better yet--put a health department cubicle in each courthouse and give everyone the choice when they show up--nasal swabbing or jury duty!)
Perhaps such a system would even have the side-benefit of engaging typical Americans in world health issues on an on-going, tangible, and more concerted basis. (As opposed to waiting until there is a big scary 900 pound gorilla on the scene that freaks everyone out so much that we scatter like ants.)
Or, in your opinion, would the tracking of the "non-ill" not be worth the expense?
@anon: I'm not sure where you get that "CDC said, it peaked, the worst is over. " My reading of the most recent information indicates that they continue to see an increasing number of cases, especially in certain areas. "there are areas of country, New York City and several other communities, where we believe active transmission and increased illness, including hospitalizations and deaths, are ongoing." and "We do continue to see more cases in more places. Though we're not seeing dramatic large increases, the numbers I'll share with you today will look like a big bump from the last media briefing we've done. And that's really because of no reporting over the long weekend." They also say "This virus is circulating much later than the annual flu viruses. We're really not seeing much of any other seasonal flu viruses any more. But we are continuing to see this strain circulate, even though of course we're almost at June." [Anne Schuchat media release 5-28-09 http://cdc.gov/media/transcripts/2009/t090528.htm ] I guess I draw a different picture from CDC's informational releases than you do. I also agree with Revere that, overall, their information has been pretty good.JMHOMoM
@Elenor: Truth is, I don't trust my govt at all. Even the Commonwealth govt (same party) say the State govt are fools.
But I do personally know the people involved in the state's flu response. And because I know them and have seen their normal work, I trust them in this situation.
And they are the people I was thinking of when I said my taxes pay other people to worry about flu so I don't have to. (This does not absolve me from following the advice of these people -- in fact, as I've paid them for advice I should follow it.)
@Elenor: "In the U.S. the govt has laid in some 40 million doses of Tamiflu, and ordered 12 million more -- for a population of 320 million potential sick folks"
So they are expecting about 13% of the population to need Tamiflu. I guess that's worst case scenario, but maybe it's only average scenario.
So why are you panicking? People with access to a lot more data than you have chosen to buy Tamiflu for 13% of the population. Odds are you will not be in that 13%; if you are, the govt has already purchased the treatment for you.
(Ok, I know US healthcare is different/bad. I have been reading denialism blog. But still, can you not trust your health providers in an emergency?)
My reading of Australian media gave me the impression that the authorities wanted to slow the spread of H1N1 for three reasons. (1) To gain time to develop a vaccine. (2) To keep the pool of infected people small, so that the opportunity for it to mix (assort?) with other flu strains was reduced and (3) to keep the population of infected people small so that the likelihood of mutations into more virulent and/or tamiflu resistant strains would be reduced.
Rupert Murdoch produces newspapers to sell, not to push a political or moral philosophy (well maybe excepting election years). That "hotel" report was in one of the sensational papers.
I've been particularly moved by the posted comments by Elenor Snow re: Tim's statement, "my taxes pay other people to worry about flu so I don't have to" (#4) and Bar's reading of the Oz authorities "management rationale" re: slowing the spread H1N1/2009 (#13).
First off, I agree with Bar's take on the situation -- vaccine antigen is still in production and won't be available to be blended with efficient Australian adjuvants for several months (see CSL press release and my letter to Professor Brown, below). Bar is absolutely correct to assume that the most sensible and scientific course of action by "authorites" is keep the population of infected as low as possible to avoid "evolutionary incidents" and to buy time for vaccine development, production and community uptake.
The Australian authorities are definitely on track here... Indeed, politicians are not to be trusted and would feed their grandmothers to a pack of hungry wolves to ensure they get their taxpayer paid pensions upon retirement:*) But, and this 'but' is terribly important, at least Australian politicians are and have been listening to scientists. I'm utterly saddend by the news US Department of Health and Human Services (HHS) Kathleen Sebelius has directed $1 billion toward clinical studies and commercial production of bulk H1N1/2009 vaccine antigen utilizing conventional (inefficient) aluminum phosphate adjuvants (see my comments below). So...
So Elenor is right to feel disgruntled. She has the power and individual responsibilty to go out and purchase antiviral drugs for herself and family, hoping they will work when the time comes to use them. "Big Parent" government has the power and collective responsibility to listen to the experts and act efficiently. Spending a significant percentage of one billion taxpayer dollars on inefficient vaccine technology (adjuvants) when antigen supplies are in short global supply is (((CRIMINAL))) behavior akin to throwing babies to a hungry pack of wolves...
To be blunt, screw patent protection:*) Global biopharmaceutical companies are playing a really stupid game here and US politicians have a responsibility to override the entire mess and act in the best interests of the public...
CSL Press Release (Friday, May 29, 2009 ) -- "CSL reaffirms its commitment to supply Australia with Novel Influenza A (H1N1) âSwine Fluâ Vaccine"
http://www.csl.com.au/s1/cs/auhq/1187378853299/news/1242703934562/prdet…
Excerpt: "CSL Biotherapies, a subsidiary of CSL Limited, Australiaâs leading biopharmaceutical company, welcomes the Rudd Governmentâs recent announcement of its intention to place an order to supply 10 million Australians [49 percent of the total population] with a vaccine against Novel Influenza A (H1N1) or âswine fluâ..."
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To: "Professor Lorena Brown"
Thursday, May 28, 2009
Dear Professor Brown, I'm a freelance transgenic pathogen research analyst working from the Westcoast of Australia. I hope you don't mind me publicly writing and asking a couple of questions. Your name was referenced for further queries in the May 20. J. Virol abstract (see below)...
Reading the news about US Department of Health and Human Services (HHS) Kathleen Sebelius directing about $1 billion toward clinical studies and commercial production of bulk H1N1/2009 vaccine antigen utilizing conventional aluminum phosphate adjuvant via Sanofi Pasteur and GlaxoSmithKline left me feeling... Well, that old saw is relevant here, "you can lead a horse to water but politicians will intervene and convince it not to drink":*)
Note: Adjuvants are compounds that enhance a vaccine's immune response, offering the possibility of stretching antigen supplies. Conventional aluminum phosphate (eg. AlPO4) adjuvants are much, much, less efficient compared to the recently developed Aussie CSL adjuvant, ISCOMATRIXTM
Professor Brown, you don't have to convince me of the value of CSL Limited's adjuvant technology -- I've done the research. I've been attempting to read up on Glaxo's proprietary adjuvant system, AS03, but there's not a great deal of info around. I believe it's a tweaked version of one of the inefficient aluminum phosphate types. I find it very odd the American government are utilizing taxpayer dollars to purchase a less efficient adjuvant -- both of us know H1N1/2009 antigen supplies will be limited over the next few months and require the most efficient adjuvant available to increase the number of vaccinations available to the US public at risk from this hyper-evolving cross species virus (an unpredictable virus at risk of swapping genes with H5N1 and/or developing antiviral drug resistance)!?!
Just a few thoughts. Anyway, if you have any further info on AS03, efficiency comparison with CSL's ISCOMATRIX, etc...
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JVI -- "Evaluation of vaccines for H5N1 influenza virus in ferrets reveals the potential for protective single-shot immunisation"
By Deborah Middleton, Steven Rockman, Martin Pearse, Ian Barr, Sue Lowther, Jessica Klippel, David Ryan and Lorena Brown. Published online May 20. J. Virol. doi:10.1128/JVI.00241-09 Copyright (c) 2009, American Society for Microbiology and/or the Listed Authors/Institutions.
Excerpt: "Examined here are the [antigen] dose of viral hemagglutinin (HA) and the number of inoculations required for two different H5N1 vaccines to achieve protection in ferrets following lethal H5N1 challenge. Ferrets inoculated twice with 30µg A/Vietnam/1194/2004 HA vaccine with AlPO4,or doses as low as 3.8µg of HA with ISCOMATRIXTM adjuvant, were completely protected against death and disease following H5N1 challenge and protection lasted at least 15 mths. Cross-clade protection was also observed with both vaccines. Significantly, complete protection against death could be achieved with only a single inoculation of H5N1 vaccine containing as little as 15µg HA with AlPO4 or 3.8µg HA with ISCOMATRIXTM adjuvant. Ferrets vaccinated with the single-injection ISCOMATRIXTM vaccines showed fewer clinical manifestations of infection than those given AlPO4 vaccines and remained highly active. Our data provide the first indication that in the event of a future influenza pandemic, effective mass vaccination may be achievable with a low dose "single-shot" vaccine and provide not only increased survival but also significant reduction in disease severity..."
bar: You have the rationale for the interventions correct. It makes sense. It is the messaging that seems to have gone wrong. It tried to get compliance and provided a rationale that instilled fear of the sick, with predictable results. It also was probably carried on beyond the time when it was likely to have provided any benefit.
Jon: Please try to keep the length of comments shorter. Links rather than the whole piece, please.
Dear melbren, I think your idea to truly sample the population is quite excellent. Above you suggested;
"What if, like jury duty, it were considered a civic responsibility to show up at the public health department when asked--probably two or three times over the course of one's lifetime--to voluntarily and confidentially submit to a good ole fashioned nasal swabbing?"
IMO it would be important to know what infectious diseases were present but asymptomatic within the population. To determine this accurately would require that a truly random sample of people that were not sick be obtained on a routine basis.
Organized medicine is principally focused of the diagnosis and treatment of acute life-threatening disorders and the management of serious chronic diseases. In the US, if you have good insurance, the current medical system has a good track record for saving these victims.
In the US almost all the research dollars investing by the pharmaceutical industry and the US government is aimed at treatment of chronic diseases. Almost none is used for prevention of disease.
Your suggestion for taking a random sample from a statistically valid segment of the healthy population and test these for the presence of known pathogens is splendid. What's more there will likely be other organisms found within these specimens that are not currently recognized as being pathogenic that turn out to be later on.
IMO, basic research like this could be very informative. It would only take a few years obtaining statistically random samples from around 3000 people on a quarterly basis to determine whether or not this type of study was of benefit or not. Again, in my opinion and of course in prospect it is not possible to know the outcome, there is the possibility that a study of this nature could revolutionize epidemiology. How? By turning it into a predictive science rather than a reactive one that only comes up with the answer well after the patients with the disease have died or recovered.
Grattan Woodson, MD
I was travelling when the swine flu first started hitting the press, and I got to hear both the CDC response and the UK authorities/"WHO representative" response. IMO, yes, the CDC did the best job, and was about as realistic as possible with information (I was impressed by one interview with a CDC representative, where she pointed out that closing schools was absolutely pointless if the kids just went out to hang out together in the local mall instead, and asking teens to voluntarily forego getting together at the local mall when schools were closed would probably result in poor cooperation -- and they had to plan for that. It's really nice to see people thinking through what real life behaviour is likely to be!). On the other hand, the man they were interviewing for advice in the UK was a complete wibbling idiot. One reporter asked him the (what I thought was a sensible question) of how badly the flu might hit HIV-positive or other immuno-compromised groups, and he wibbled incoherently for a few minutes before saying "I couldn't possibly say, you would have to consult an HIV expert for that." When asked for advice for people who weren't sure what to do when they started feeling flu symptoms (the point of the question being, should they go to the Dr.'s office and risk transmitting it to other patients, or was there a line they could call) he wibbled on about how rotten flu would make you feel, and never answered the question asked. He was useless.
My husband, who has been working with HR in the one of the local universities, was advised that if there were local cases of this flu they would cancel all the graduate seminars and training courses so as not to risk transmission through these groups gathering together. He asked what their employee attendance policy was likely to be, and whether they would cancel undergraduate lecutres as well. He was advised that the rest of the university would probably run as normal and they didn't want to cancel undergrad lectures because that was "too disruptive" -- even after he pointed out that the average graduate training course might have 20 people in a room, whereas some of the undergrad lectures involved hundreds! In terms of actual planning, many places here in the UK seem to be going for the appearance of doing something useful, rather than any substance. There is sometimes too great a tradition of "wishful thinking will see us through this."
Frankly, the UK is lucky it hasn't been hit harder, and hopefully the people behind the scenes working on pandemic preparedness at the government level are more competent than the ones in the public eye. I'm not confident enough of this to bet money on it, but I can hope.
...However, if you REALLY want to see how not to handle swine flu, you can't beatEgypt.
Is anyone cataloging all the bad reactions to swine flu? There certainly is a "teachable moment" here about overly-restrictive and discriminatory quarantine policies and given that we'll see more outbreaks, it would be nice to see someone pushing back on approaches that have no public health relevance.
In South Korea employers of foreign English teachers are confiscating passports, and teachers who have been quarantined are blogging about the experience - an interesting advance in global health communication. As you can see, there are some real issues here about arbitrary detention, lack of oversight, negligent care leading to increased risk of infection, and xenophobia.
http://underquarantine.tumblr.com/
http://web.me.com/superacidjax/Sparkling_Chaos/Welcome/Welcome.html
Also, a recent article here:
http://www.koreaherald.co.kr/NEWKHSITE/data/html_dir/2009/05/29/2009052…
Heyah Tim, the 1918 flu affected 25% of the U.S. population. If "my" govt prepared for 13%, and then with their usual 'politically correct' planning decided to give what Tamiflu they have to grannies and babies instead of the workers maintaining vital services, we'll all be in a bad way. (The grannies and babies are not going to be fightin' any fires! Or pumping any potable water to my house or keeping the electricity flowing...)
This always baffles me -- what about my messages sounded anything like panic? I'm disgusted, annoyed, dismayed-- but panicking? Not even slightly. (Preparing? You betcha!)
Except I know better, so I have purchased my own Tamiflu and Relenza -- even though it took some gentle blackmailing of my physician!
No. My personal provider was pretty generally unaware of bird flu or anything particular about swine flu (except what's in the mainstream media {eye roll}). The (majority of the) "health system" here is less than adequate about preparing and planning.
If they dosed everyone in the country with tamiflu, it would virtually guarantee tamiflu resistance in a wide spectrum of flu strains.
So far I've been pretty happy with the Oz governmental response to H1N1.
The media have been the ones flaming up the leper-stories. The best(?) I saw was Channel Ten's "There are fears that swine influenza virus will mutate into a suberbug and kill us all" (I kid you not, it was those exact words)
Since Friday last week health officials have been stressing that it's no worse than seasonal influenza. But it was a little worrying that from Monday - Friday we saw a doubling of cases each day.
im doing my assianment on the fucking flu