Swine flu 2009: what went right and tip of the hat

New York Times correspondent Don McNeil is an excellent medical reporter. He always asks intelligent questions at the CDC pressers and he writes good articles. And he's written one for The Times yesterday that I agree with, although his support for it seems to me less than objective. In essence he asked the country's flu establishment how well the US handled swine flu. None of his sources are CDC employees but all of them are deeply involved in flu and flu policy in one way or another. And they gave themselves a big pat on the back. I hope they didn't wrench their shoulders. That might be a bit snarky, because in fact I agree with everything they say. I just find it amusing they are being used as authorities:

The decision to order vaccine made with a 50-year-old egg technology, rather than experimental methods, was controversial.

The outbreak highlighted many national weaknesses: old, slow vaccine technology; too much reliance on foreign vaccine factories; some major hospitals pushed to their limits by a relatively mild epidemic.

But even given those drawbacks, “we did a lot of things right,” concluded Dr. Andrew T. Pavia, chairman of the pandemic flu task force of the Infectious Diseases Society of America.

Federal officials deserve “at least a B-plus,” said Dr. William Schaffner, chairman of preventive medicine at Vanderbilt University’s medical school.

Even Dr. Peter Palese, a leading virologist at Mount Sinai Medical School, who can be a harsh critic of public policies he disagrees with, called the government’s overall response “excellent.” (Don McNeil, New York Times)

The alleged curmudgeon of the group, virologist Peter Palese, is one of the world's authorities on the flu virus, but he is so comfortable with the virus he has spent his life with in the lab he often seems to fear it less than many others. Maybe that's the right attitude. After all, there aren't many people in the world who know that tiny hunk of protein, lipid and genetic material better than Palese. On the other hand, being a virologist doesn't make you a clinician or an epidemiologist or a health services expert or any of a number of other crucial things needed to take the measure of this versatile pathogen. No one knows what this thing will or will not bring. Palese is among the handful of scientists who have "written the book" on the flu virus. But now, in the space of a year, that book is being rewritten. Again.

As for Pavia and Schaffner, they are solid figures in the infectious disease establishment. They have looked out at their creation and pronounced it good. Some of that is good fortune. We object to calling an flu pandemic "mild" but it can certainly be said this one could have been much, much worse, although it was bad enough and no one is sure it's finished with us yet. So far we've had good luck:

The virus and the vaccine cooperated. While the former proved highly transmissible in children, it was only rarely lethal, remained susceptible to drugs and has not thus far mutated into an unpredictable monster. Vaccine supply was a problem, but one small dose was enough. (By contrast, an experimental avian flu vaccine protected people only when it was six times as strong.)

For that reason, the relatively cautious decisions by the nation’s medical leadership contained the pandemic with minimal disruption to the economy.

For example, in the early days, they ignored advice to close the Mexican border and pre-emptively shut school systems. They released part of the national Tamiflu stockpile, but did not give it to millions of healthy people prophylactically, as Britain did. They ordered vaccine made with a 50-year-old egg technology rather than experimental methods. They bought adjuvants — chemical “boosters” — that could have stretched the first 25 million vaccine doses into 100 million, but did not use them for fear of triggering a backlash among Americans made nervous by the messages of the antivaccine movement.

All of the decisions involved were gambles and if the virus had been just a little bit different than it was we would have lost some of them. But so far we haven't. So far. Many of the problems with distributing the vaccine can be laid, as does McNeil, to overly optimistic projections on viral antigen yield. What he doesn't mention, but which I think deserves to be, is that we sent out the vaccine into a broken public health system. It's no surprise this resulted in patchy, misdirected and uneven distribution with failure to get the vaccine to target groups. It's the old story of broken infrastructure. The bridge didn't fall down because so far we haven't had to send too much traffic over it. If the pandemic had been worse, well, you think this was a mess?

There are also some summary judgments in the article I think are premature. Things like, "It is now clear that this is the least lethal modern pandemic." Again, that may turn out to be true. But given the data we have at this point and the difficulty in making these judgments, it wouldn't surprise me if this changed as we are finally able to analyze and interpret the mass of data being generated and still to be generated. That will take years.

Finally, one more omission, not surprising coming from the New York Times:

One real triumph, several experts said, was how little damage misinformation did. In 1976, many people refused shots after three elderly Pittsburgh residents died shortly after getting theirs; it took the C.D.C. five days to explain that it was just a coincidence.

This time, many rumors arose but were quickly debunked: That thousands had died in Mexico. That the virus had circulated in the Midwest for a decade, undetected. That it had escaped from a laboratory. That seasonal flu shots made catching swine flu more likely. That flu shots did not work or caused autism. That the administration would make them mandatory. That Tamiflu resistance was widespread in Northern California. That a flu shot had disabled a Washington Redskins cheerleader, or that she was cured by chelation therapy by a doctor associated with the antivaccine movement. That mutant killer flu strains were circulating in Argentina or Ukraine or North Carolina.

The debunking succeeded, Dr. Osterholm said, “despite the fact that there are many fewer reporters who understand medical issues than there used to be.”

First, credit where credit is due. I think CDC did a terrific job in this crisis. Rich Besser, Anne Schuchat and the rest of the team responsible for providing information at a time when hardly anyone, including CDC, knew what was going on, were superb. Director Frieden is not in Besser's league, but Schuchat and her colleagues are still carrying the ball effectively. But what Mike Osterholm said is also important. There are far fewer knowledgeable reporters covering flu than in times past, part of the collapse of the print media. But the superior work of reporters like Helen Branswell, Declan Butler, Maggie Fox, Jason Gale, Don McNeil and a bunch more (who I hope will forgive me for failing to mention them) has been amplified, reached more people and been supplemented, complemented and explained by the new media. Yes, I'm talking about bloggers like Crof, Mike Coston and online forums like DemFromCT and the crew at Flu Wiki and Flu Trackers and many more who I hope will forgive me for failing to mention them (if you want a great list go to the sidebar at H5N1, the blog of the indefatigable Crawford Kilian, "Crof"; looking at that list I am already chagrined at the many extremely worthy sites I've left off).

If the infectious disease establishment can pat themselves on the back -- appropriately -- so can we in the New Media. I think my colleagues in flublogia deserve a nod and a tip of the hat.