Pundita

BERLIN -(Reuters)

A badger in Germany got so drunk on over-ripe cherries it staggered into the middle of a road and refused to budge, police said on Wednesday.

A motorist called police near the central town of Goslar to report a dead badger on a road -- only for officers to turn up and discover the animal alive and well, but drunk.

Police discovered the nocturnal beast had eaten cherries from a nearby tree which had turned to alcohol and given the badger diarrhea.

Having failed to scare the animal away, officers eventually chased it from the road with a broom.

(Reporting by Dave Graham; editing by Myra MacDonald)

And now for the press analysis:

The Sun (U.K.): DRUNK UNDER SOBER EXTERIOR! SECRET LIFE OF MR BADGER IN 'THE WIND IN THE WILLOWS' UNCOVERED BY GOOD POLICE WORK!

The Nation: Police Brutality? Wildlife Attacked By Broom-Wielding Officer

World Net Daily: Germany's Police State: Innocent Animal Not Allowed To Sleep Off A Bender! Is America Next?

The New York Times: CDC orders Study of Connection Between Fermented Cherries and Alcoholism in Children, Wildlife

My excuses:

1. It's Friday.
2. We're, er, drunk with exhaustion from poring over reports on Piggy Flu.



*********************
Procrustes at RBO is to blame for finding the pix of what just might be a tipsy badger.

(Emphasis throughout news reports mine)

May 6, 2009, The Washington Post

U.S. May Add Shots for Swine Flu to Fall Regimen

Vaccine and pandemic experts are working with the administration to determine how to produce, test, track and educate the public about two different influenza vaccines in the same flu season.

"They have never tried this before, and there is going to be a great deal of confusion," said William Schaffner, chairman of the Department of Preventive Medicine at Vanderbilt University School of Medicine.

Memories of the nation's earlier experience with a swine flu vaccine present another challenge. In 1976, hundreds of Americans developed neurological disorders after they were vaccinated for a swine flu strain. The public was asked to receive one of two vaccines developed to combat the strain.

Health officials have asked manufacturers to ramp up production of the seasonal vaccine scheduled for rollout this fall to make way for the possible mass production of a swine flu vaccine.

A decision on whether to produce such a vaccine will have to be made soon, because it typically takes five months to produce a new vaccine and authorities would want it available for the next flu season.

Some medical experts said rolling out two vaccines would present additional challenges in terms of testing and tracking adverse reactions. Health officials and manufacturers will need to know what the negative reactions might be for each vaccine on its own and in combination with the other. Initial tests would be done on animals, and then clinical trials would be conducted with people to determine side effects before either vaccine is rolled out.

Harvey Fineberg, president of the Institute of Medicine, part of the National Academy of Sciences, said officials will have to weigh the risks of the time spent on testing.

"All this takes time, money and organization," said Fineberg, who led an investigation into the government's handling of the 1976 swine flu vaccinations.

The greater challenge will be tracking any adverse reactions as millions of Americans get multiple vaccinations in a matter of months this fall and winter.

"There will be adverse effects to any vaccine. That's just science," said Michael Hattwick, who ran the CDC's vaccine-tracking system during the last swine flu scare.

No sir, that's not science. That's poor quality-control, awful planning, and crummy logistics. But to continue:

Hattwick said a "real-time" tracking system would need to be established to provide constant updates to the CDC about adverse reactions. That information, he said, should include lot numbers for the vaccines so health officials can trace each side effect to the manufacturer and the date of production. Routine flu vaccinations are not traced with such precision because reporting is voluntary and often delayed, Hattwick said.

Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said he does not expect additional adverse reactions with two vaccinations. The traditional flu vaccine is designed to attack the three flu strains health officials believe to be the greatest threats in a regular season, he said.

"In a regular seasonal flu, you get three vaccines. Adding an additional one should not present a problem," Fauci said.

A record-keeping system would also need to be devised to track which doses patients have received, health experts said.

Without such a system, patients could lose track of which of the three shots they have received or could fail to get the second swine flu inoculation at the proper time.

"We will have to keep them straight and separate," Vanderbilt's Schaffner said. "This will be an enormous challenge, and we haven't figured out how to do it yet. That's one of the things we are trying to sort out."

May 23, 2009, The Washington Post

The federal government has asked three drug companies to make enough swine flu vaccine to immunize at least 20 million people in key positions in health care, national security and emergency services, officials said yesterday. [...]

The government's pandemic preparedness plan divides the U.S. population into five tiers of priority for getting the vaccine. The first tier, of about 24 million people, includes deployed armed forces members; critical health-care workers; fire, police and ambulance workers; pregnant women and small children. [...]

June 30, 2009, AP

Obama consults experts on 1976 swine flu outbreak

WASHINGTON — President Barack Obama is hoping that lessons learned from a 1976 flu outbreak can help the country act wisely to combat the current spread of swine flu.

The president and other top administration officials met Tuesday with six experts on the 1976 flu so that — in his words — "we can further prepare the nation for the possibility of a more severe outbreak of H1N1 flu."

In 1976, a mass vaccination against a different swine flu was marred by reports of a paralyzing side effect — and that time the flu didn't spread beyond an outbreak at Fort Dix, N.J.

Among those meeting Tuesday with Obama was the president of the Institute of Medicine, Dr. Harvey Fineberg.

June 30, 2009, CQ

Health Experts Say U.S. Is Prepared for Swine Flu Pandemic

Two public health experts painted a relatively rosy picture Tuesday of the United States’ ability to respond to the swine flu pandemic, saying the country had learned from earlier mistakes and from plans developed during the avian flu scare several years ago.

“The public health measures that were put in place were quite sensible,” said Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, at a briefing on the H1N1 virus held by the Center for Strategic and International Studies, the Congressional Global Health Caucus and the Kaiser Family Foundation.

Fauci and Harvey Fineberg, president of the Institute of Medicine, said the United States had learned from the 1976 swine flu scare. Fineberg, who wrote a book about the scare called The Epidemic that Never Was [1], said a decision to go ahead with nationwide immunizations was made in January 1976, when only a few soldiers at Fort Dix, N.J., had contracted the virus. Even though the disease didn’t spread, 40 million people were still immunized.

Then, Fineberg said, decision makers were “entirely driven by the worst-case” scenario and overreacted to the problem.

“Today, we need to not make the complementary error of only preparing for the most likely case,” he said.

Plans developed for the avian flu, or H5N1, in the middle of this decade should help combat any mass swine flu outbreak, Fauci said. Fortunately, swine flu has proven to be less deadly than its avian cousin, which has killed about half of all those it infects.

Fauci and Fineberg said health officials will need to watch how swine flu spreads and behaves in the southern hemisphere’s winter in order to prepare an appropriate response.

One worry is that the United States won’t be prepared for a mass immunization campaign, if one is necessary. “The real concern is getting organized throughout the country to administer what we need to administer,” Fineberg said.

But there likely won’t be a need for widespread immunizations.

“H1N1 now is acting like a seasonal flu that is out of season,” Fauci said.

But both experts warned predictions about the flu are notoriously difficult to make.

“The thing you can say about influenza that’s predictable is that it’s unpredictable,” Fauci said.

By gum, sir, you're right: the behavior of flu viruses is notoriously hard to predict -- especially new flu viruses of the very rare kind that show a quadruple reassortment, such as the 2009 swine flu, and which is to the 1976 swine flu virus what mashed potatoes are to kiwi fruit.

Moving along:

July 10, 2009, The Washington Post:

Students 1st in Line For Flu Vaccine: Mass Campaign Against Pandemic May Begin in Fall

School-age children will be a key target population for a pandemic flu vaccine in the fall, and they may be vaccinated at school in a mass campaign not seen since the polio epidemics of the 1950s.

The federal government should get about 100 million doses of vaccine by mid-October, if the current production by five companies goes as planned. But enough vaccine for wide use by the 120 million people especially vulnerable to the newly emerged strain of H1N1 influenza virus will not be available until later in the fall.

Those were among the messages administration officials delivered to about 500 state, territorial, city and tribal health officials yesterday at a "flu summit" at the National Institutes of Health's Bethesda campus.

President Obama, speaking by audio link from the Group of Eight summit in L'Aquila, Italy, urged "complete ownership" of preparations for what he termed a "significant outbreak" of H1N1 flu in the next few months.

"We want to make sure that we are not promoting panic, but we are promoting vigilance and preparation," he said. He added that "the most important thing for us to do is to make sure that state and local officials prepare now to implement a vaccination program in the fall."

Children, pregnant women, adults with chronic illnesses, and health-care workers would probably be first in line for the vaccine, Health and Human Services Secretary Kathleen Sebelius told the gathering. [...]

What happened to "deployed armed forces members ... fire, police and ambulance workers?" Are they still on the list of priority candidates for the vaccine?

And who are the other "vulnerable" members of the population besides "children, pregnant women, adults with chronic illnesses, and health-care workers?" The ones who won't receive swine flu vaccine until "later" in the fall?

In other words -- what happened to change the U.S. government's view between May 6 and July 9?

Here's what happened: Three days after Anthony Fauci suggested it was unlikely that a mass immunization program was needed, the bottom fell out:

Public health authorities in Hong Kong announced Friday [July 3] they have found a case of Tamiflu resistance in a woman who hadn't taken the drug. That means she was infected with swine flu viruses that were already resistant to Tamiflu, the main weapon in most countries' and companies' pandemic drug arsenals.

The two earlier cases, reported from Denmark and Japan, involved people who had been taking the medication. While always unwelcome, that type of resistance is known to occur with seasonal strains and may be less of a threat to the long-term viability of this key flu drug.

"It was not at all surprising to see resistance in patients on treatment but seeing it in someone who was not treated, it certainly is more concerning," says Dr. Malik Peiris, a flu expert at the University of Hong Kong.

There is a risk inherent in using the drug to prevent illness. If people who are already infected but aren't yet experiencing symptoms are put on prophylaxis, there won't be enough drug in their systems to kill all the viruses they house. Those that survive develop resistance to the drug.

And that, it appears, may be what happened in the resistance cases in Denmark and Japan. In both instances the women involved had been given Tamiflu prophylaxis after a contact developed swine flu.

But the Hong Kong case was different. A 16-year old girl travelling from San Francisco was stopped in Hong Kong's airport in mid-June after setting off a fever detection device.

She was taken to hospital where she tested positive for swine flu. She had not been taking antivirals and declined to be treated with the drug. She was kept in isolation until she recovered.

Dr. Jennifer McKimm-Breschkin, an influenza expert from Australia and a member of the team that developed Relenza, says this case shows resistant swine flu viruses can spread.

It was previously thought flu viruses that developed resistance to the drug would be crippled in the process and would not transmit to others. But that belief was shattered in 2008 when it was discovered Tamiflu-resistant versions of the seasonal H1N1 viruses were spreading rapidly around the globe. They have since all but wiped out Tamiflu-susceptible seasonal H1N1 viruses.

"This is a patient that hasn't been treated, who has gone from San Francisco to Hong Kong. What that means is that she has caught a resistant virus in San Francisco," says McKimm-Breschkin, virology project leader at the Commonwealth Science and Research Organization - known as CSIRO - in Melbourne. (McKimm-Breschkin does not receive royalties for sales of Relenza.)

"So that means this virus has been transmitted from somebody who's presumably been treated. Which means it's been fit enough to transmit. And that is of a lot more concern than just resistance in a treated patient."

Experts have worried the seasonal H1N1 viruses might reassort or swap genes with the swine H1N1. If swine flu picked up with neuraminidase gene - the N in a flu virus' name - from the seasonal H1N1, it would acquire the resistance its seasonal cousin has developed.

Authorities in Hong Kong have not yet told the WHO whether that is what has happened in this case.

But whether the Hong Kong resistance case is due to reassortment, or from the fact that some swine flu viruses have developed resistance on their own, the situation demands careful monitoring, Fukuda and others say.(2)

Just to make sure you're clear on the danger of the mutation found by the Hong Kong lab:

The case in Hong Kong indicates that the mutant virus is capable of being transmitted among people, said Jennifer McKimm - Breschkin [...]

“It’s very disturbing that, fresh into the human population, this one appears now to be able to retain fitness despite having the mutation and to be able to spread” [...] (3)

The hope was that as the virus continued to mutate it would lose punch. So far that hasn't happened.

As I first warned on May 20, "[I]t is very likely that Tamiflu, and not a wimpy version of a swine flu virus, explains the low death rate so far from H1N1 infections."

And I castigated public health officials for not acknowledging that widespread Tamiflu use to treat swine flu was masking the true lethality of the disease.

However, WHO officials continued to say that the swine flu virus was "very stable" -- not mutating in any significant fashion -- and so the public health establishment continued to play ostrich.

From sticking their heads in the sand to running around like chickens with their head cut off in a few weeks: now that a Tamiflu-resistant strain of the virus is out there, of course everybody on the planet has to get vaccinated yesterday.

But there's simply not enough vaccine yet, and not enough time to adequately test the first batches -- and a hastily devised triple-vaccination program for tens of millions of people is a blueprint for pandemonium.

This says nothing about the chaos that could be unleashed with any possible thrown-together plan for widespread school closures as a means to attempt to slow the virus' spread. Read the rest of the July 10 Washington Post report for information on that angle.

Not to keep pounding the lectern but note how the Hong Kong case was caught: First it walked in front of a thermal scanner at the international airport. Yet WHO deems thermal scanners useless. (4)

Then the mutation was nailed during a routine surveillance of flu specimens by Hong Kong's Public Health Laboratory Services Branch.(3)

Yet many state-run labs, the world over, are overwhelmed by swine flu cases. And WHO is preparing to recommend that the labs abandon testing for 'routine' swine flu cases.

How is that Hong Kong's lab wasn't overwhelmed? And how do those other state labs expect to catch the Tamiflu-resistant mutation if they abandon routine testing?

For a detailed answer to the first question new readers can work backward through all my posts on swine flu. The short answer, which readers who've followed my posts well know, is that Hong Kong followed China's model of fighting swine flu, which greatly slowed the spread of swine flu cases in the country. Among other things this meant their laboratories weren't overwhelmed by swine flu specimens.

Regarding the second question: I don't know the answer and I doubt any public health official does, either.

As to the emphasis I gave to the National Institutes of Health and the names Anthony Fauci and Harvey Fineberg, that's in the nature of a question mark in my mind.

In one my earlier posts on swine flu I suggested that if there was proof of intelligent life at NIH that they shove the CDC out of the way, given the CDC's flat-footed response to the H1N1 outbreak.

Of course it's easier for administration officials to get to Bethesda than Atlanta, and I don't know whether Fauci and Fineberg have a particular connection to NIH. But if a reader notes mention of NIH or those two names in a news report on swine flu, I'd appreciate it if you could send me the report. Thank you.

1) Dr Fineberg was the co-author; Richard E Neustadt was the lead author on the book, the full title of which is The epidemic that never was: Policy-making and the swine flu scare.

The three used paperback copies available at Amazon are selling for $175 each, which gives an idea how much public interest there was in the topic at the time of publication. I haven't looked up the publication date but clearly the book was written and published before the 2009 swine flu outbreak, else the authors would have added "1976" to the title's mention of swine flu.

2) Canadian Press: Tamiflu resistant H1N1 from Hong Kong more worrying than earlier findings; Helen Branswell, Canadian Press Medical Writer; July 6, 2009.

This is the best analysis of the three Tamiflu-resistant cases and their import that I've found in the general media. I note that the writer provides flu updates on Twitter at CP-Branswell.

3) Bloomberg: Tamiflu-Resistant Swine Flu Virus Found in Hong Kong (Update2); Nipa Piboontanasawat (in Hong Kong) and Jason Gale (in Singapore); July 3, 2009.

I read every Bloomberg report filed or co-filed by Jason Gale I can find; he is among the handful of 'lay' journalists who began specializing in swine flu reporting from the start and who've educated themselves about the disease. I recommend that you read the entire report; taken together with Helen Branswell's analysis it's a good briefing for the layperson on the three swine flu mutations under discussion.

4) Slate: Heat Check: Swine flu, body heat, and airport scanners; William Saletan; April 28, 2009.

Since the start of the swine flu outbreak I've plowed through many articles that point to gross incompetence and institutional bias in the biomedical and public health establishments' approach to pandemic planning. But this one takes the prize. Don't miss the reports the article links to; if you're a high-strung type I suggest you steel yourself before reading the government-funded study of the scanners.

I see WHO has moved the goal posts again:

July 8, 2009:

The World Health Organization will recommend that nations curtail efforts to confirm swine flu cases and assume the H1N1 virus is the culprit.

[...]

Meanwhile, the virus is continuing to spread through the Northern Hemisphere this summer -- even though flu normally doesn't spread well in hot weather -- and its effect is growing in the southern half of the globe, which has begun its traditional winter flu season.

[...]


Within the next few days, the WHO will suggest that countries with major outbreaks of swine flu move away from laboratory confirmation of cases and toward larger, national indicators of disease, such as the number of people with flu-like symptoms and cases of pneumonia, Dr. Keiji Fukuda, WHO assistant director-general, said Tuesday in a telephone news conference.

The large number of cases in such countries is overwhelming labs and making it "very hard to keep up" with testing, he said. The new guidelines will "ease the burden on laboratories," he said. In most countries with major outbreaks of the virus, 95% or more of total flu cases are being caused by H1N1.

"In countries with no cases, we will continue to recommend that people be tested so the presence of the new virus can be confirmed," Fukuda said. "In all countries, we will continue to stress testing for unusual cases, clusters, unusually severe cases and new symptoms."

But the number of swine-flu-free countries is likely to be small soon. The most recent figures reported to the WHO indicate that more than 98,000 cases have been confirmed in 120 countries, with 440 deaths, though officials estimate the number of actual infections at 10 to 100 times that. [...]

A big thanks to Photoshop artiste "Freedom Fairy" for sending me the above report.

Now why is WHO making such a recommendation? Why are they trying to influence how each individual country collects data on swine flu cases? The rationale WHO provided in their 'pre-announcement announcement' goes nowhere near answering that question.

WHO has no political teeth, and in the swine flu outbreak it has played the caboose to the CDC (U.S. Centers for Disease Control and Prevention) and governments that contribute the most to WHO's upkeep, such as the USA.

The CDC has, from the earliest weeks of the swine flu outbreak, encouraged U.S. health departments to abandon swine flu testing for all but the hospitalized cases. This approach was copied by Australia and several other countries, which have substituted mathematical modeling (based on very uncertain data) to project the number of swine flu cases, in lieu of extensive laboratory testing.

It's been hard enough up to this point to get even a rough estimate of the number of swine flu cases in a country; if the majority of countries follow WHO's planned recommendation, that will make it virtually impossible to pursue an empirical approach to studying the swine flu outbreak on a global basis.

Researchers will have to rely on whatever mathematical models a country's federal health department favors. As to how much faith can be placed in the models:

On July 3 Freedom Fairy alerted me that the Drudge Report had posted a group of scary headlines about swine flu including this one: "40 a day could die by end of summer in London," which linked to a report in the United Kingdom's Mail Online newspaper.

The prediction was based on math quoted by Britain's Health Minister, Andy Burnham. He announced to the House of Commons on July 2 that swine flu "Cases are doubling every week, and on this trend we could see more than 100,000 cases per day by the end of August -- although I stress that that is only a projection."

This elicited a remark from John Oxford, the professor of virology at St. Bart's and Royal London Hospital who's been a favorite quotable source for reporters since the swine flu story broke:

"It seems like a lot of mathematical modeling and not too much common sense."

But just to make sure Mr Burnham understood how math-challenged he was, an editor at Effect Measure blog got instructive:

The statement that the UK might have 100,000 cases a day made headlines, as well it might. But it's based on the idea that if the current exponential growth rate continues for months on end, then it could reach 100,000 a day by the end of August.

Anyone familiar with exponential growth and/or epidemiology (is it too much to hope a Health Minister might be familiar with both?) knows that exponential growth cannot and does not continue for very long.

If cases double every week, then by the end of September, one month after Burnham's estimate, they will have increased by a factor of 16 or 1.6 million cases per day. A month later, at the height of flu season we'd be seeing 25 million cases a day. [U.K. population: 60,943,912 ]

Of course if you put E. coli in a petri dish and watch it double every 20 minutes, before long all the mass in the known universe would be incorporated into the E. coli culture you started.

Did I mention this doesn't happen? Ever? What a bloody moron.

I believe the more precise operative term is "useful idiot." Mr Burnham is young (39), new on the job, and (as with his American counterpart, Kathleen Sebelius) spectacularly unqualified by education and experience to hold a post relating to public health, medicine, science, or math of any kind. His previous posting was Secretary of State for Culture, Media and Sport; he was appointed Secretary of State for Health in Gordon Brown's June 5 Cabinet reshuffle.

However, the troubled expression on Mr Burnham's face (see the video of his announcement at the Mail link) suggests he's old and smart enough to have figured out that he is Labor's designated sacrificial goat, if Britain's death toll from swine flu skyrockets.

So if Mr Burnham was guilty of bad math, at least he mustered enough survival instinct to strongly warn the British public that swine flu is not to be taken lightly. And he surely knew by last week what has only come to public light today: "Swine flu: Scots will be forced to wait 1½ years for full vaccination."

All right; I've had enough fun for one day with Britain's health ministry. What's really going on with WHO? Well, Ouija is out for repairs again but taking a blindfolded shot in the dark:

"From April 25 to July 5, a total of 8,272 people entering China with flu-like symptoms were transferred to medical institutions for quarantine. Some 228 of them were confirmed as H1N1 flu patients."

The report doesn't say whether the statistic refers only to the Mainland or to the combination of the Mainland, Hong Kong territory, and Macau. But because the announcement came from the central government's Ministry of Health, I'm going to tentatively assume it covers all three regions, which is not ideal for my purpose. However, the statistic gives a rough idea of how many people have been quarantined on the Mainland. Now watch carefully don't blink:

MAINLAND CHINA

Population: 1,338,612,968

May 10
Mainland China reports their first confirmed case of swine flu, an infected Chinese citizen traveling on a flight originating from the USA..
June 01
Confirmed swine flu cases: 38
July 7
Confirmed swine flu cases: 1,151

Confirmed death toll from swine flu as of July 7: 0
(One death by accidental electrocution of a Chinese patient in quarantine).

AUSTRALIA

Population: 21,007,310

May 09
First confirmed case of swine flu; an infected American airline passenger traveling on a flight originating from the USA.
June 01
Confirmed swine flu cases: 401
July 07
Confirmed swine flu cases: 6,353

Confirmed death toll from swine flu as of July 7: 18

I'm not picking on Australia; I'd prefer to pick on my own country. But I used Australia as the comparator because it's a modernized, economically advanced democratic country and the date of their first confirmed outbreak is close, by one day, to the Mainland's.

I note that Australia's health system was quickly overwhelmed by swine flu cases. From a June 13 report:

Angry GPs have slammed a "conspicuous lack of leadership" in Australia's response to the swine flu crisis, with some patients waiting eight days for test results or receiving anti-viral drugs too late to limit the infection.

The number of Australians infected with the new H1N1 strain is ... believed to be far higher than last night's official national tally of 1391 because Victoria [state] has abandoned its daily caseload updates.

The state last Wednesday cut back its laboratory testing for the virus from about 500 to 1000 samples a day to 50 to 70 a day, after acknowledging it could no longer contain the disease.

Even then, patients were falling through the cracks in the testing system, Melbourne GP Kirstin Charlesworth told The Australian. [...]

All this means the comparison is unfair to China, which up to this point has scrupulously tracked down and recorded every swine flu case they could find in the country. But when you compare the data, there's the answer to WHO's observation that China's strategy for fighting swine-flu is "resource intensive."

Yes, if only one country does it, the strategy is very resource intensive, both in terms of money and labor. But China's strategy worked to greatly slow the spread of swine flu infections in their country; Australia's strategy didn't do the same for their country.

With few exceptions Australia's experience has been echoed by every country that's been hit by an outbreak.

Governments can stack and rack their excuses any way they want -- and I interject there have been some very creative excuses. But they are up against the reality of China's accurate record-keeping -- a feat China pulled off because their way of fighting the pandemic was to greatly limit its spread at the start. That doesn't mean they caught every case. It means they caught every case that came to the attention of a physician or hospital.

Australia's strategy for coping with a pandemic virus is a copy of the CDC one, which WHO has also followed.

The CDC pandemic-fighting model is based largely on analysis of the 1918 swine flu pandemic. China's model is based on empirical observations of the way 'airborne' or aerosolized infectious disease first spreads from country to country in the 21st Century; namely, via globalized, heavy-volume commercial airline travel.

There is no way to erase the data on China's success at doing the Number One thing a national pandemic fighting plan is supposed to do: greatly slow the spread of the disease in a country. But there is a way to downplay the data, to bury it in plain sight:

If every other county abandons laboratory testing for all but clusters of infections and "special" cases, this will skew the country-by-country data on swine flu infections to such an extent that China's data on swine flu becomes meaningless as a comparator.

"For the first time, we can quickly integrate information about worldwide air traffic patterns with information about global infectious disease threats. What this means is that cities and countries around the world can now respond to news of a threat earlier and more intelligently than ever before."

-- Kamran Khan, BIO.DIASPORA project

Kamran Khan, M.D., M.P.H. will be on John's radio show tonight at 9:20 PM Eastern Time on 77-WABC AM in New York (and on 630-WMAL AM in Washington D.C.).

See the schedule for more details on tonight's show and other cities in which the show airs.

The links I provided are to WABC and WMAL online streaming. For listeners outside the USA, WABC can be heard online in many countries around the world. And a podcast of the show will be available on Monday at John's website.

Dr Khan will be discussing the BIO.DIASPORA project with John. It's not possible to overstate the importance of the project; in one sentence it is the best chance humanity has for getting free of the Dark Ages in the public health regime's approach to infectious disease control.

BIO.DIASPORA is not new; it was started in response to the SARS outbreak. Yet governments are still not making effective use of the project's approach.

For readers who missed my last post, here is the BIO.DIASPORA mission statement:

[To] understand global patterns of human travel via commercial airlines as a way to predict how emerging infectious diseases are most likely to spread around the world -- and consequently apply this knowledge to help the world's cities and countries better prepare for and respond to global infectious disease threats of tomorrow.

The project, which is based at St. Michael’s Hospital, a teaching hospital affiliated with the University of Toronto, reflects a convergence of public health management and various scientific, mathematical, and computer disciplines.

BIO.DIASPORA used data obtained from the International Air Transport Association to map how the 2009 swine flu virus spread via air travel. This June 30 Reuters report summarizes the study, which is described in greater detail in a June 29 letter published in The New England Journal of Medicine.

The research outlined in NEJM plotted the relationship between international air traffic flows to different countries and H1N1 importation to reveal that "countries receiving more than 1400 passengers from Mexico were at a significantly elevated risk for importation" in the early months of the outbreak.

If you ask why it should take statistical analysis to demonstrate that the sun shines and rain falls downward: Yes it's self-evident that near-simultaneous outbreaks of swine flu around the world were due to arriving international air passengers infected with the disease. But BIO.DIASPORA puts the observation on a scientific footing.

And without Science prodding them, the public health establishment, and the governments they answer to, will continue to play ostrich about the obvious need to make international airports the staging area for the first line of defense against a pandemic.

This is the strategy that China's government mounted against swine flu, which allowed them to greatly slow the spread of infections in both the country's Mainland and Hong Kong territory. This bought the country's vaccine developers and health departments precious time to gear up for wider outbreaks of the disease.

And because China monitored outbound air international passengers, they prevented the wholesale export of swine flu infections from their country. (Mexico did the same once they realized what they were dealing with.)

Countries that made little or no attempt to monitor inbound air passengers for fever and other signs of illness were quickly overwhelmed by the spread of the disease. And countries with a high incidence of swine flu cases, and which made no effort to monitor outbound air passengers for fever, played 'Typhoid Mary' to the rest of the world.

This negligence is no less barbaric just because 'everybody does it.' Everybody did a lot of dumb and inhumane things in humanity's past. It is time for us to leave the Dark Ages in infectious disease control. If you can help get the word about BIO.DIASPORA to your government and local media outlets, that would be a step toward the light.

"Today, a superkiller virus from the other side of the world can alight in large numbers on the same day at several U.S. international airports scattered all around the USA -- even before the lethality of the virus has been discovered by a government."
-- Pundita, May 11, 2009

It was obvious more than a month ago, even to a casual observer, that the swine flu pandemic is a phenomenon of the almost blanket globalization of air travel. With the exception of a very few countries, such as North Korea, even many of the poorest countries see significant international airline flight arrivals.

The phenomenon has meant that West European and Canadian air passengers have brought swine flu to several countries, and that in the last few weeks infected passengers from Australia have been depositing swine flu around Asia.

But the largest number, if not an overwhelming majority, of the first swine flu carriers to many countries have been airline passengers who've flown from or via a U.S. international airport.

Despite this, the U.S. government has clung to CDC-WHO dogma to rationalize their ongoing refusal to install temperature monitors at international airports in the USA.

Over a series of posts I think I've done a pretty good job of challenging the arguments supporting the dogma, which is that once an airborne infectious disease enters a country there's no way to stop its spread and therefore it's no use to set up draconian surveillance measures at international airports.

And China's success at deploying such measures to slow the initial spread of secondary swine flu infections has pulverized the CDC-WHO arguments.

Yet Washington has continued to play ostrich about installing computerized temperature monitors at U.S. international airplane arrival gates -- when even tiny, dirt-poor Yemen has scared up the wherewithal to install one of the gizmos at their international airport.

It's uninformed to blame this on airlines. As I noted in an earlier post, the U.S. airline industry takes its guidance from the CDC on infectious disease control measures at U.S. airports.

And given that protecting Americans from lethal infectious diseases is a key part of homeland security, this is one of those expenditures that justifies federal funding.

So what the heck is the problem?

The answer was inadvertently supplied n the closing paragraph of a June 30 Reuters report that RBO's Procrustes forwarded me on the same day:

The researchers said the United States receives more than 76 million international visitors from around the world every year and the United States and Canada together generate and receive about one-sixth of the global volume of international air traffic.

To be more specific, the answer is found by applying the statistics in the paragraph to the issue of temperature monitoring machines for the U.S. international airports.

In earlier posts I've detailed China's airport-based swine flu battle plan, which relies heavily on computerized temperature monitors and the use of manual thermometers to take the temperature of inbound international air passengers.

The measures are accompanied by quarantines of infected passengers and ongoing surveillance of suspected swine flu cases among the airline passengers, even after the passengers leave the airport.

WHO's Margaret Chan called the plan "resource intensive." It would be incredibly resource intensive if applied in the United States. The bottom line is that given the huge volume of international air traffic in the United States, the expense of buying and installing thousands of thermal imaging machines is the least of the problem:

The machines have to be monitored by trained personnel. And if a machine catches an elevated temperature, what then? Simply allowing the passenger to continue on would defeat the purpose of the surveillance, particularly during a pandemic-threat situation.

At the least, medical attention would be required. And quarantine would be required, if you really wanted to slow the rate of secondary infections in the United States and help countries that see inbound air traffic from the USA do the same. But the US government, not the passengers, would have to foot the bill for the quarantines.

So even setting aside the deterrent to air travel that quarantine creates, it's expensive to put someone in a hospital or hotel for anywhere from three to seven days of the quarantine. The isolation must include meals and round-the-clock medical attention -- which, for passengers who test positive for the disease, would include prescription medications.

And readers who followed my discussion about China's quarantines know that there are some finicky air travelers out there, and that all kinds of complications arise during even a brief quarantine.

So it's not just a matter of throwing sick airline passengers into a room and handing them three meals a day. They want phones in their room, they want a TV and internet access. They have dietary requirements.

Oh and by the way those hotels and hospitals have to be guarded so quarantinees understand it's useless to attempt escape. That means money spent on guards.

But after American tax dollars have been lavished on thermal imaging machines and quarantines, it'd be pretty stupid, wouldn't it, to do the job halfway?

The machines can miss passengers with a temperature. So if you wanted to do it up right, you'd need to send medical personnel up and down the plane aisles with thermometer guns, checking the temperature of each passenger. That means more labor, and I'll bet those fancy thermometers don't come cheap.

Then what about the passengers who're sick, but not yet manifesting a temperature? That'll require follow-up surveillance and notification.

All that isn't even addressing the expense of having to track down and quarantine an entire row of passengers just because one person in the row tested positive.

By now American readers might be developing a little sympathy for the CDC's stubborn adherence to dogma. Yes indeed, it's easy to cheer on China's Flu-Fighting Brigades -- as long as it's not your tax dollars footing the bill.

I can just see Glenn Beck hunching over his desk and saying to the camera, 'That would take another layer of bureaucracy, and -- ' (pausing for effect)'a Flu Czar.'

So. When the numbers are crunched it turns out that only on paper is it a good idea to install thermal imaging monitors in U.S. airports -- provided you remove a superkiller pandemic from the picture. When you add the superkiller to the accounting ledger, suddenly the picture completely changes.

Even if you remove the direst threat -- the so-called "Armageddon Virus" -- and look only at the billions USD being diverted to the present swine flu pandemic emergencies worldwide, and at the billions lost because of lost tourism and airline profits, etc., China's approach to fighting swine flu plan is the essence of cost-effectiveness. That is, provided all the major trading countries -- the ones with the heaviest commercial international air traffic -- implemented the plan.

With that proviso in mind, imagine the future as the past: Return to early March 2009. The global biosurveillance network is working as it was designed. That means Mexico's health officials quickly spot an atypical pneumonia and flu outbreak. So a Mexican health technician sits down at a computer and types.

Seconds later warning lights in every international airport in North America signal that the biosurveillance alert level has been raised to its highest level.

Airport personnel run to their stations, thermal imaging monitors are switched on, medical personnel climb into hazmat suits, and loudspeakers announce to airline passengers from North America that there will be a delay while their temperatures are monitored.

At the same time all airport personnel and airplane crews don face masks, protective glasses, and gloves when they're in contact with passengers. Restaurants in the airports also put their workers on alert, hand out hand sanitizer to customers, and institute special sterilization procedures in the table areas.

None of this activity creates panic or uncertainty among airline passengers because they've been well-briefed on the necessity for biosurveillance alerts at international airports.

Meanwhile, rapid test results from hospitalized pneumonia patients in Mexico are being analyzed to determine whether the pneumonia is connected with a known virus.

Personnel in all major cities are alerted to be on standby for the analysis results; temperature monitors are switched on as governments inform their international airports to begin close surveillance of passengers from North America.

As soon as analyses indicate that the pneumonia is connected with an unknown virus, the Mexican technician returns to the computer. Seconds later major biolabs all around the world are notified to be on standby, so they can start working on genome mapping for the new virus. All vaccine manufacturers are alerted about the new virus.

And within an hour of the first analysis every federal health department in the world has been notified of the situation, and is busy notifying hospitals and health departments nearest to their country's international airports.

Now let's return that future to the present. Go to Google News and look for the thousands of reports posted there on the 2009 swine flu pandemic sweeping the world; there are none because there is no pandemic. There are only a few reports on the progress of vaccine development for the 2009 swine flu, and a smattering of reports on small outbreaks, mostly limited to North America.

Eventually, the few outbreaks will create secondary infections that over a period of several weeks could lead to the pandemic of today. That's because you can't spot every sick person who alights from a plane.

But in the future scenario, that sequence of events will be blocked. That's because humanity has bought itself enough time to allow for the development, manufacture and distribution of a vaccine before the outbreaks create wide-scale secondary infections; i.e., infections in a community that are no longer directly tied to an infected airline passenger.

The future scenario also means something else: a large number of quarantines, of the kind China is using to fight swine flu, won't be necessary. With every major trading country doing their share to monitor airline passengers with fever, and with all countries monitoring passengers during the high alert periods, there just won't be that many passengers with a fever. It will be thinning the forest, greatly.

And that means the cost of good biosurveillance at airports would be manageable for the United States and Canada, despite those countries' high volume of commercial air traffic.

If you ask, 'Would that approach also work for regular influenzas?' -- I think the next generation is going to look back on our methods of infectious disease control with the same patronizing pity that we look back on the medical practice of applying leeches to patients.

The super-vaccine is on its way -- maybe a year from now, maybe a quarter century from today -- but it's going to happen. And when it does we won't have to worry anymore about doomsday pandemics. And just in time, I hope; mathematicians didn't factor in a few things, decades ago, when they calculated that human overpopulation would be a big problem down the line. The problem for humans turned out to be the opposite.

Yet between the advent of the super-vaccine and today is a cliff-hanger era for humanity.

Anyone who tells you, 'Oh don't worry; the Armageddon Virus is a very remote possibility' -- file that along with "This ship is unsinkable" and other Famous Last Words.

As to how far away we are from the future scenario I outlined -- we could be closer than seems evident to you at this moment, unless you've already heard of the BIO.DIASPORA project. The project has been around for a few years but the 2009 swine flu outbreak is giving it a big boost.

What is BIO.DIASPORA? Here is the mission statement:

[To] understand global patterns of human travel via commercial airlines as a way to predict how emerging infectious diseases are most likely to spread around the world -- and consequently apply this knowledge to help the world's cities and countries better prepare for and respond to global infectious disease threats of tomorrow.

The project, which is based at St. Michael’s Hospital, a teaching hospital affiliated with the University of Toronto, reflects a convergence of public health management and various scientific, mathematical, and computer disciplines.

BIO.DIASPORA used air travel data obtained from the International Air Transport Association to map how the 2009 swine flu virus spread via air travel. The June 30 Reuters report I quoted from summarizes the study, which is described in greater detail in a June 29 letter published in The New England Journal of Medicine.

If you'd like something to smile about today I suggest you read the June 29 letter, then visit the BIO.DIASPORA website and look at all their cool graphics, which show just how interconnected this world is through airline routes.

I'll give the last word to BIO.DIASPORA team leader for the H1N1 study, Dr Kamran Khan:

"For the first time, we can quickly integrate information about worldwide air traffic patterns with information about global infectious disease threats. What this means is that cities and countries around the world can now respond to news of a threat earlier and more intelligently than ever before."

"One contributing factor for death in our patients may have been delayed admission and delayed initiation of oseltamivir [Tamiflu]."

-- From Pneumonia and Respiratory Failure from Swine-Origin Influenza A (H1N1) in Mexico: an original article published June 29, 2009 in The New England Journal of Medicine.

The article is written by a team of physicians at Mexico City's National Institute of Respiratory Diseases (INER); it reports on the clinical and epidemiological characteristics of the first 18 persons with pneumonia and laboratory-confirmed S-OIV infection ("swine flu") hospitalized at INER.

The authors use "may" to qualify their observation about Tamiflu partly because their study only involves 18 patients. And because their methodology was simply to retroactively review medical charts and radiological and laboratory findings on the 18 patients.

However, Tamiflu's life-saving role in fighting swine flu is by now established through anecdotal accounts from physicians and public health officials in the USA and around the world.

The use of antibiotics has also played a life-saving role in curing secondary infections arising from swine flu infection, as the Mexican study also highlights. And yet the CDC continues to avoid publicly acknowledging the implications of the low death count. So at the risk of being tedious I'm going to repeat myself:

From the May 20, 2009 Pundita post titled Stop misleading the public about the true lethality of H1N1/swine flu virus. Memo to CDC, WHO, New York City Department of Health:

Officials at the above-named organizations have deployed a verbal sleight-of-hand in their communications with the public that is as dangerous as the swine flu virus itself:

The officials have announced that the death rate from swine flu infections is low. They have leapfrogged from this fact to the inference that the virus is not particularly lethal. Would that be with or without the administration of Tamiflu to affected patients?

Now let's stop clowning around. Officials do not know for certain how lethal swine flu is. But it doesn't take a lot of data collection to figure out that if a teenaged healthy patient presents with symptoms of a 103 degree and rising fever, and who is unable to move, and who "looks as if she was run over by a truck," as the father of one swine flu sufferer described his daughter's condition, she might not be long for this world without rapid medical intervention. The student in question started a quick recovery after two doses of Tamiflu.

From this, and from many aspects of the data so far, it is very likely that Tamiflu, and not a wimpy version of a swine flu virus, explains the low death rate so far from H1N1 infections.

That also explains the higher death count in Mexico. Money says that many of the Mexico deaths occurred before doctors in Mexico realized they were dealing with more than an ordinary flu virus and thought to administer Tamiflu or Relenza.[...]

Another verbal trick is the claim that the number of deaths in the United States from swine flu is very low in comparison to the 36,000 deaths in the USA from the annual influenzas.

One would think that after hearing health officials invoke the same number, year in and year out, some quick-minded reporter would ask, 'Why is it always 36,000 Americans who die each year from flu? Is there ever a year when far more than that number die from flu, or far less?'

As I've mentioned in earlier posts such a reporter exists. Her name is Kelly O'Meara. At the time of her investigation she was (and I assume still is) anti-vaccine -- or at least anti-flu vaccine. But because she suspected that the CDC was inflating the number of annual deaths from influenza, she was like a terrier with the magic number.

A CDC spokesman, Curtis Allen, admitted to O'Meara that the 36,000 statistic was not a "real" number; it was a computer-generated guess. A wild guess.

Allen told her, "There are a couple problems with determining the number of deaths related to the flu because most people don't die from the influenza...We don't know exactly how many people get the flu each year because it's not a reportable disease and most physicians don't do the test [nasal swab] to indicate whether it's influenza."

However, using data she got from the CDC, O'Meara discovered that "The greatest number of actual influenza deaths recorded since 1979 were 3,006 in 1981." (See this post for citations.)

That doesn't necessarily mean the number of deaths from influenza for those years was that low; it means that the U.S. health system is not set up to accurately record the number of annual deaths from influenza.

It also means the CDC is unable to distinguish between deaths from influenza and deaths from underlying medical conditions in people who've died while suffering from the flu.

What all that means is it's useless to attempt to determine the true lethality of the 2009 swine flu by comparing the number of deaths from the disease to the CDC's magic number of 36,000.

The same holds true for trying to determine the lethality of swine flu by comparing deaths from the disease to annual worldwide deaths from seasonal flu because that annual number is also a computer-generated wild guess.

It is the same for using the number of deaths from the 1918-20 pandemic or any other pandemic in the attempt to determine the lethality of the 2009 swine flu. The number -- the range of numbers -- is a wild guess.

In short, mathematical models that assess the lethality of the 2009 swine flu by using death rates for previous pandemics and seasonal flu deaths are hoodoo.

Yet it's been extremely useful hoodoo, hasn't it? Useful, that is, for governments and the public health systems they fund. One is hard pressed to find a news report or official statement about swine flu deaths that does not conjure the magic numbers; this, to put the number of swine flu deaths in 'context.'

So it's also been a dangerous hoodoo; it's led the public to believe that swine flu is no more lethal than a garden-variety influenza.

And with that belief has come a casual attitude about protections against swine flu and a very negative attitude about epidemic-fighting measures that are inconvenient or a hardship, such as quarantine and self-quarantine.

The hoodoo is losing some of its power now that the death count from swine flu is starting to rise, which brings me to a passage in a June 19 Wall Street Journal report:

[...] Those who dismiss the H1N1 bug, also known as swine flu, as a hoax like to point out the death rate, so far, has been extremely low. Seasonal influenza generally kills about 36,000 Americans a year, while the H1N1 virus has only resulted in 44 confirmed deaths, as of June 12.

But those numbers are misleading, say health experts. They point out that the official death count includes only victims whose diagnoses were confirmed by a special laboratory test. The actual number of infections is believed to be far higher, and should continue to climb as the virus gains traction.[...]

I'm happy to learn that at least some "health experts" are pointing out that the magic 36,000 number is misleading, even though they don't seem to be anxious to reveal the magic trick. Yet I had to read the passage twice before its implications sank in:

I'd fumed because U.S. health departments had quickly ceased testing for all but the most serious swine flu cases, which meant they couldn't provide a good estimate of the number of swine flu cases. But like an idiot I'd assumed that the death count was accurate.

Duh, Pundita, they wouldn't automatically test for swine flu in every person who'd died in the United States since March.

So. We don't even have an accurate statistic for the number swine flu deaths, do we? In that event it would be a help if the CDC, WHO, and all others who publish a swine flu death tally would add "Estimated" alongside the numbers. It'd be a help to the public, that is.

While the governments of Australia and the United States continue to dither about whether to administer a swine flu vaccine to their populations, while they continue to rationalize their failure to deal effectively with the initial stage of swine flu infections in their countries, China's battle plan against the bug continues to unfold with precision:

Phase One: delay secondary or 'community transmission' of the virus as long as possible through non-pharmaceutical interventions (NPIs); e.g., close monitoring and quarantine of international airline passengers, who are the chief carriers of the infection into a country.

This accompanied by aggressive public hygiene awareness and flu education campaigns, which continue during Phase Two.

Phase Two: vaccination of the population at the point where community transmission of the virus finally overwhelms NPIs.

The two phases are not overlapping although the Chinese have come close to the mark. By June 13 Mainland China's health officials announced they could no longer keep track of all the community transmissions in their country, which meant that the airport defenses had finally been breached. But Phase One is to buy time by slowing the transmission of the disease, which it's accomplished.

(Phase One is still in effect on China's Mainland. On Saturday Hong Kong officials announced that June 29, today, they're officially abandoning quarantine of airline passengers because the disease is now circulating widely in the Hong Kong territory. However, their 'management' phase of dealing the disease is still stringent and continues to include monitoring of airline passengers' temperatures. See this report for details.)

Phase One has been accompanied by manufacture of large amounts of anti-viral medications for distribution during the community-transmission phase of the disease and the development of a swine flu vaccine. China is not waiting for the Western manufacturers to toss them a few million doses of vaccine whenever it's ready for distribution:

SHANGHAI, June 26 (Xinhua) -- China's first batch of antiviral drug for influenza A/H1N1, including 256,000 pills, rolled off the production line in Shanghai Friday.

The Oseltamivir Phosphate Capsules, manufactured by the Shanghai Pharmaceutical (Group) Co. Ltd., have passed all quality tests required, Wu Jianwen, president of the company, said Friday.

[...]

"Currently, we'll be able to turn out 2 million pills per month, and we can expand the output capacity in the future if the flu epidemic shows new changes," he said.

[...]

In addition to antiviral drug production, China has [since Monday June 22] begun laboratory tests on the country's first developed A/H1N1 flu vaccine ... with the seed virus received from a World Health Organization (WHO) lab on June 3.

The vaccines are expected to hit the market in September after 14 days of safety tests in labs and two-month clinical tests from July, Fan Bei, deputy general manager of Hualan Biological Engineering Inc. based in central Henan Province, has said.

The company had produced a first batch of 90,000 doses, but it would be able to make 600,000 doses a day once it was approved, Fan said.

China has 11 drug firms that are qualified to produce flu vaccines. Another drug company, Sinovac Biotech Co. Ltd., announced that it had started development of A/H1N1 flu vaccines on June 15.

Note that China's plan is the essence of simplicity; it approximates the age-old military strategies of disrupting the enemy's supply lines while keeping yours intact and creating a delaying action until reinforcements arrive.

(The enemy's supply lines in this case are large numbers of people that the swine flu virus can quickly infect unless strict quarantine measures are directed against its points of entry.)

When you contrast China's plan with the American approach (which is pretty much the same for the majority of countries) what jumps out is that a plan for fighting the virus never existed; planning, to the extent it was done, was greatly directed at pharmacological interventions. Yet this Washington Post editorial doesn't even notice that the U.S. plan skipped the containment phase and went straight into 'management' of the epidemic:

The Obama administration has taken the proper approach from the outset. It has urged Americans to take precautions (stay home if you're sick, cover your sneezes, wash your hands) while preparing for the possibility that this new form of swine flu could mutate into something more virulent. Antiviral medication has been moved from federal stockpiles to the states. Vaccine development has begun. There are discussions with state and local authorities to plan for an immunization campaign should the need arise.

Just what preparations would those be, in the event the flu mutates into something more dangerous? Flipping through the martial law manual?

As for the Obama administration's public hygiene campaign -- phooey! Take a look at this description of Hong Kong's public hygiene campaign, courtesy of a Concerned Singaporean:

Too Concerned to Remain Silent anymore!
29 Jun 09, 16:54 PM

[...] Hong Kong has learnt her lesson after hundreds died during SARS, and it appears that Singapore has NOT! Hong Kong has taken its education programs very seriously, even announcements throughout the day, everyday, all year round in MTR trains, train stations, public places to "Please wear a mask if you are unwell, sick, have fever, or flu or cold symptoms....". This message is repeated over and over again.

Now that's a public hygiene campaign, not the wimpy effort mounted by the U.S. Department of Health and Human Services in the wake of the swine flu outbreak. Kathleen Sebelius and Elmo showing kids proper sneezing procedure is a beginning, but a far cry from a serious effort. Concerned Singaporean continues:

Private Condos and Public buildings in HK have cleaners regularly cleaning and sterilizing handrails, elevators handrails, and buttons in and outside the lifts are sterilized everyday and little notes like "The buttons in this lift have been Sterilized". You can even smell the dettol or clorox. [...]

Concerned Singaporean is just getting warmed up; you can read the rest of the comments here.

If all that sounds a bit overdone to the American ear -- it would depend on how lethal and infectious the 2009 swine flu actually is, wouldn't it? The CDC and others are still doing tests and collecting data about such matters. But the point is that the Obama administration's idea of a public hygiene campaign is nothing for The Washington Post to crow about.

So how did it come to this? How did it happen that the world's most powerful nation was outwitted and outplayed by a microbe? While a nation still in the 'developing' category of countries mounted an effective campaign to throw sand in the gears of a microbe's blitzkrieg?

There are many causes and conditions that brought about this state of affairs. Yet if you drill down to bedrock, you're looking at the difference between a strategic approach on the China side and a lab-bench science approach on the U.S. one.

China's approach clearly flows from the concept of defensive warfare. The lab-bench approach is driven by data collection and analysis of the virus. So, in place of disaster management, Americans have been treated to a parade of scientists who publicly ruminate on their evolving understanding of the 2009 swine flu:

'This virus will be leaving the Northern Hemisphere any day, then we'll have time to regroup for its return in the autumn.'

A few weeks later: 'Oops! This virus should have been gone by now but it's hanging around the Northern Hemisphere. Well, well, it's not acting like a normal influenza.'

'This virus is no more infectious than a normal flu virus.'

A few weeks later: 'Huh. Lookit the number of medical personnel getting infected with this virus and that's only a small sampling! Well, either that means they're not wearing enough protective gear or this virus is more infectious than we first thought.

'This virus isn't any more lethal than a normal flu virus.'

A few weeks later: 'Hmmm. Maybe those Mexican health officials weren't talking through their hat when they said that some deaths from this virus were due to cytokine storms. And that Escondido woman's death could be showing the same pattern as many deaths from the 1918 swine flu. Interesting.'

All right; I've had my fun. But if I exaggerated -- a little -- it was to pound home the point that biomedical scientists have no business being in charge of planning a nation's defense against an epidemic.

Of course data collection and analysis are crucially important to fighting infectious disease, but that's not saying a forward observer is qualified to prepare a battle plan -- or that a virologist qualifies as a strategic thinker.

In the case of planning for defense against an infectious disease outbreak, decision analysis must favor preparation for the worst-case scenario when:

A) A large number of variables pertaining to the situation are poorly understood or still unknown.

B) The worst-case scenario is so catastrophic that disaster planning can't be based on calculations about mitigating variables.

Both A and B apply in this situation because the 2009 swine flu is new virus and scientists are still on a steep learning curve about how it acts and how the human immune system reacts to it.

Yet so greatly has the virologist's viewpoint come to dominate disaster planning for an infectious disease outbreak that the American public health system is in effect treating the country's citizens as a test subject.

The viewpoint has also forced the rest of the world into the position of a test subject; this, on the highly misleading argument put forward by the CDC (and backed up by the World Health Organization) that once a highly infectious disease has entered a country there's nothing that can be done to stop its march.

On the basis of the argument the United States of America refused to monitor the temperature of inbound and outbound airline passengers. And so the United States, with its huge volume of international air traffic, exported large numbers of swine flu infections all around the world within a matter of days.

To those who'd say I'm being unfair because other countries did the same thing -- my answer is that I'm an American; I'm chiefly concerned with my government's actions in this matter. Readers from around the world are welcome to use the points I've put forward in this post, and earlier ones, to make the same case in their countries that I'm making in mine.

This post builds on a series of arguments I've made during the past two months but if you're looking for one essay that tackles the CDC's argument, the one I posted on May 11 titled Your life riding on the CDC's slow boat from China fills the bill.

At the time I was unaware of China's swine flu-fighting plan, which was just getting off the ground, but it also disputes the CDC's position. And China's approach to slowing the progress of swine flu demonstrates that the temporary border blockades I initially suggested would be unnecessary -- provided other countries deployed China's aggressive NPIs during the first phase of the virus' attack.

I still have a few more counter-arguments to make, which I'll aim to wrap up in the next post.

June 23, 2009

[...] Vaccines for most diseases approach 100 percent effectiveness, but a good flu vaccine is 70 percent effective; a great one is 90 percent effective. The vaccine in the 2007-08 flu season was only 44 percent effective. Hitting the "good" mark for a new virus that may be changing even more rapidly than seasonal flu will be difficult.

Supply is another problem. In a best case, enough [swine flu] vaccine for the entire U.S. population could be available by October as long as an adjuvant is used to simultaneously stimulate the immune system, which lessens the need for antigen from the virus itself.

However, if the virus used to make vaccine grows slowly, or if a dose requires more antigen than seasonal flu, or if two doses are required to provide protection, producing that much vaccine could easily stretch deep into 2010.

In addition, only about 30 percent of the supply will be made in the United States. The more virulent the virus, the more likely it is that foreign governments will refuse to allow export of the vaccine until their own populations are fully protected.

[...]

The bottom line? Little can be done in the short term beyond exerting diplomatic pressure to guarantee that foreign governments allow manufacturers to honor contracts to export vaccine. [...]

-- The Washington Post; What Can Be Done -- and What Can't -- To Protect Against H1N1; John M. Barry, distinguished scholar at the Center for Bioenvironmental Research at Tulane and Xavier Universities and the author of The Great Influenza: The Story of the Deadliest Pandemic in History.

Guarantee? Let me see if I get this straight: If apocalypse breaks out, the U.S. will sue if governments don't honor their vaccine contracts. Has Barry lost his mind?

June 17, 2009

Many foreigners chafed at China's quarantine restrictions on travellers, which in some cases seemed illogical. The World Health Organization warned that China's current policy [for fighting swine flu] is too resource intensive to be sustainable should the disease become widespread.

Roughly one-quarter of the confirmed cases in China as of early June were United States citizens, the U.S. embassy in Beijing said earlier this month, suggesting that Chinese caution in quarantining hundreds of American travellers was justified.

So. WHO has gone from warning that quarantines of airline passengers don't work, to warning that China's quarantines are too resource intensive. This is how we measure progress in the wild and wacky world of public health management.

By gum it is resource intensive; the Chinese are hurling God Knows how many renminbi and medical workers into the quarantine program, which they threw together on no notice and are having to refine on the fly. The program is a logistical triumph although complaints from huffy quarantinees are still rolling in.

'Just like being in jail' fumed some quarantined Australians. Another Aussie, who was quarantined in Shanghai for a week just because he was sitting six rows from a sick airline passenger, showed more sense: "It's a week out of your life. Suck it up."

But a week out of some people's lives without enough English-language TV channels in their quarantine room ("We got tired of watching Larry King re-runs"), or with no hot dogs and hamburgers, or with too much cooking oil in the meat dishes, or having to survive 24 hours without a phone in the room -- all this is too much for human flesh and blood to bear.

Most quarantined passengers have been philosophical, however, with the potluck aspect of the experience. (Some draw a five-star hotel, some get a hospital room in the boonies.) And there have been precious few complaints with any merit; those few the U.S. Department of State seized upon to deliver a travel alert that makes Gitmo incarceration seem a luxury vacation in comparison to quarantine in China.

Through it all the Chinese -- who can be as charming as the Irish when they want -- have been solicitous; they've also been extensive survey takers: "Please answer yes or no: Sometimes I feel lonely in my room." All this in an effort to make the quarantine experience as bearable as possible for even the fussiest Westerner and Japanese housewife.

The fact that the quarantines have greatly slowed the spread of swine flu in
China has been studiously ignored by all but unnamed public health officials outside China. And it was studiously ignored in John M. Barry's op-ed for The Washington Post. This would be the same John Barry who once dismissed quarantine as "worthless."

He edged close to backtracking a bit in his piece for WaPo:

[T]he virus is the most important factor, and we have no control over it. But we do have non-pharmaceutical interventions and the possibility of a vaccine. Such interventions would come into play primarily in a moderate or severe pandemic. For a mild one, we may not need to take steps beyond washing hands, exercising "cough etiquette" and keeping the sick at home. But if the virus increases its virulence, other measures, such as closing schools, urging people to telecommute and even banning public meetings, could mitigate the impact.

However, the usefulness of non-pharmaceutical interventions is limited, and even if they work, their chief impact will be to flatten the pandemic's peak and stretch out the duration of a wave of illness to make it easier to handle.

By gum making the outbreak easier to handle would be a consideration, wouldn't it?

Now watch carefully, don't blink:

Scholars Bradley Condon and Tapen Sinha found that in Mexico City this spring, when the government advised wearing masks on public transportation, compliance peaked at 65 percent three days later -- but declined to 26 percent only five days after that. This decline came even as the government was taking the extreme measure of closing all nonessential services and businesses. Such behavior does not portend well for sustained compliance with any measure.

Not that I would want to burden John Barry with rational discussion but if sustained voluntary compliance is hard to achieve, why then does he assume that voluntary measures such as "washing hands" and exercising "cough etiquette" would meet with enough compliance to be useful during a "mild" pandemic?
***************************************
PUNDITA: What's so funny? I warn I'm not in the best of moods. I'm being slowly driven mad by the U.S. public health establishment.

MICHAEL WRIGHT: I never thought I'd see the day you'd be defending China's government.

PUNDITA: I'm not defending them; I'm defending correct judgment. They happen to be right about quarantining airline passengers.

MICHAEL WRIGHT: Do you know India asked the U.S. to screen outbound plane passengers for flu symptoms?

PUNDITA: When was this?

MICHAEL WRIGHT: Around the middle of this month.

PUNDITA: Was this request made public?

MICHAEL WRIGHT: Yep. So now there's two countries on your side.

PUNDITA: Wouldn't matter if there were a hundred. The CDC has decided that reality is negotiable and that's that.

MICHAEL WRIGHT: Did you see State's alert on China's quarantines?

PUNDITA: I saw it Friday, when they released it. Since when have you gotten interested in swine flu?

MICHAEL WRIGHT: You made me a believer. You were right; this an important foreign policy issue.

PUNDITA: It would be, if there was a policy on foreign relations during a pandemic outbreak or threat but there's no such thing.

MICHAEL WRIGHT: The alert is pretty toughly worded. What's going on with that, do you know?

PUNDITA: State fell down; they didn't issue an alert about quarantines and related procedures that travelers are facing in the swine flu era. They left that sticky task to the CDC, which didn't get around to issuing an alert until May 13.

Then all hell broke loose earlier this month when just about every member of Congress representing Florida descended on State; I guess they practically accused Beijing of being a baby killer.

MICHAEL WRIGHT: What?

PUNDITA: Nine Palm Beach teenagers, who'd never been to China before, got caught in a quarantine net during their first day touring China. They were separated from the rest of their tour qroup and put in a quarantine hotel. The kids freaked out. They hadn't been warned about the quarantines.

One mother got a call in Florida from her daughter at two in the morning sobbing that she had to do something because they were being spirited away against their will. The mother didn't know about the quarantines either, so she freaked out. She probably woke up every political representative in the state during the next hour.

MICHAEL WRIGHT: What about the other parents?

PUNDITA: At home. There were 31 teenagers in the group -- ages from 13 to 18, I think. They were accompanied by three teachers, if I recall, who weren't part of the quarantine.

Even after the kids calmed down there were problems with the quarantine. At least a few of the kids complained they weren't getting enough food, that the food they were getting was crummy and not nutritious, and that they wanted Western food.

Yet there was a couple from Dallas quarantined in the same hotel; from the report on their experience they received boxed buffet-style meals three times a day, and they had no complaints about the food.

However, these are teenage American boys we're talking about; they can wolf down three double bacon cheeseburgers for lunch. So they felt as if they were being starved, but the big complaint was that they wanted Western 'comfort food.' Like hamburgers and pizza.

They also complained they were hot because the hotel's air conditioning was shut off in the rooms to prevent germs from traveling through the hotel.

MICHAEL WRIGHT: The Chinese seem to consider the virus more infectious than American doctors do.

PUNDITA: They have a reason for that, Michael. A Japanese study turned up what they claim is a significant mutation of the virus in that it's more infectious than the first isolated strain. China's top epidemiologist has taken the study seriously.

But people shouldn't be in sweltering conditions if there's any way to avoid that. The air conditioning stays on in the hotel lobby so the quarantinees can hang out there, provided they wear their surgical face masks. But they also have to stay in their room for an hour twice a day waiting for their temperature to be taken.

To make matters worse the hotel wouldn't open the windows; the kids seemed to think this was to keep in germs. I don't know what that was about.

The kids also said they were getting dehydrated in the heat because they weren't getting enough bottled water; some of them threatened to drink the water from the shower if they didn't get more of the bottled stuff.

And they were upset that they were missing the tour. They'd looked forward to the trip for many months. Most of all, they were going stir-crazy cooped up in the hotel, particularly because they weren't showing symptoms of influenza.

MICHAEL WRIGHT: How long were they in quarantine?

PUNDITA: A week and a few hours. They'd been told a week, so for every minute beyond that it was, 'Are we free yet, are we free yet?'

The problems got sorted out, as much as possible. And the hotel manager gave them Tai Chi classes to help keep them occupied. Contacts in Beijing got them a computer so they could chat with their parents on the internet. They also gave them giant water guns to help them cool off, and games, DVDS, and food treats. And the kids socialized with other quarantined people in the hotel.

It all had a reasonably happy ending, the children got a clean bill of health, and they were able to make up at least part of the tour -- the ones who could spare the additional time to stay on in China.

MICHAEL WRIGHT: What I'm hearing is they had an adventure.

PUNDITA: That's what one of the boys told a reporter after he got home. He said their parents made too much of what happened.

However, the U.S. ambassador, the parents, and Florida Members of Congress were leaning hard through all this to make sure the kids were well treated. And there were a couple other serious issues. Two boys in the quarantined group showed a slightly elevated temperature so they were whisked off to a hospital. That might be why the group quarantine lasted for an entire week -- the authorities wanted to be on the safe side in case the two boys had been infected.

MICHAEL WRIGHT: How long do the quarantines last, generally, from the reports you've seen? Is it always a week?

PUNDITA: Three to seven days, although I've seen a couple reports that some quarantines last only a few hours or two days. I've seen no reports of a quarantine going beyond a week.

Accounts vary about how long the two boys were in the hospital. One account says two days before they were returned to the quarantine hotel, another says a week.

But the big issue for the parents was that the Chinese authorities didn't get parental permission before putting the boys in the hospital. And all the quarantined children were given blood tests at the beginning; again, without parental permission.

That explains some of the dire language in State's alert.

MICHAEL WRIGHT: Those aren't valid complaints in that situation.

PUNDITA: Well, the parents weren't properly prepared for that eventuality. They didn't know that in a quarantine situation a medical authority doesn't need to wait to get permission to perform medical interventions meant to keep the person healthy. And the parents didn't understand how things are in China.

MICHAEL WRIGHT: Must have been a big stink for the tour operator.

PUNDITA: That was another part of the mess. Technically it's not a tour operator; it's a nonprofit organization called People-to-People. It was established under Eisenhower as a government program to promote cultural understanding, and then it moved to the private sector.

The kids were in China under one of the organization's programs --- as so-called student ambassadors. So you can imagine the organization was behind the eight-ball. They must have leaned very hard on Congress members and the state department.

That wasn't the only incident to be brought to State's attention, I don't think. As luck would have it someone else from Palm Beach, West Palm Beach, was quarantined in a separate situation. He ended up in a hospital in the boonies. He took one look at his room and called for a nurse and a mop. He said the room looked as if hadn't been cleaned in a year. He ended up mopping the halls himself after the nurse finished with the room.

I suspect that this one incident explains the alert's mention of unsanitary conditions.

The man was good-natured about the quarantine, though. However, there was a language barrier; no one taking care of him spoke English and he didn't speak Mandarin. So there was a lot of sign language that didn't always work out. The Chinese at the hospital had never seen anyone so tall; he's six foot two. So they didn't know how much food someone that big needed. He told of one time when the caretakers brought him 15 tomatoes to eat.

MICHAEL WRIGHT: What I'm hearing is an intervention program that isn't standardized yet.

PUNDITA: The Chinese are pulling out all the stops to make it work but there are still things to be ironed out. One of them is the language barrier that can be found depending on where the quarantine takes place.

A big problem is that the quarantines don't always get called at the airport. There was one American school group that saw a few get sick with swine flu symptoms while they were touring Three Gorges Dam.

And if I recall the other student group I mentioned was getting ready to tour the Forbidden City when they were whisked away to quarantine. The Chinese had learned that one person on the children's plane had come down with swine flu, and that these particular nine children had been sitting near him. The kids asked why they were singled out, given that they'd been mingling with other members of their tour group. It made no sense to them.

MICHAEL WRIGHT: They didn't understand about the incubation period. What the Chinese should be doing then is putting hotels and hospitals on alert near the major tourist attractions.

PUNDITA: Yes; I suspect they're getting up to speed on that.

MICHAEL WRIGHT: If State's alert doesn't drive all the tourist business away.

PUNDITA: I imagine China's ambassador to the U.S. is not tickled pink over the wording in that alert. What State should have done was balance the warning. Instead they over-compensated for their initial negligence.