Swine Flu outbreak

[Skeptic Ginger]

Should we start having swine flu parties (In the style of chicken pox parties) where infected children play with non-infected ones? What fun!

No need. Besides, it is still important to spread these infections out as much as possible. There are local shortages of Tamiflu and respiratory protection masks. If you happened to be one of the more serious cases, you might find limited access to treatment.

I prefer to avoid it until the planned vaccine is out this fall.

 

[Skeptic Ginger]

That may have been true initially, but the Mexican authorities have been trying to trace the source of this virus. The normal method of doing so is to ask those who had contact with known cases if they had the flu, then testing those that did for the specific virus.

I'm not sure of your point. Mexico is not reporting probable cases based on contact tracing and they certainly don't have good number yet to get a denominator for calculating case fatality rates.

The investigation of the origin of the virus is well on it's way with genetic analysis and following the trail of the first cases. There was a significant outbreak of influenza like disease in La Gloria Mexico in February and March. No one was looking for swine flu until it was detected by the US sentinel surveillance system at the end of March but once detected, investigators decided it was worth checking into the La Gloria outbreak. At least 2 of those had specimens left that could be tested and swine flu was confirmed.

The genetic investigation has already determined when the genetic segments were first found to be circulating in pig populations in both N America and Europe. Now they are looking for where these genetic segments were prior to reassorting into the current strain.

 

[Skeptic Ginger]

....
The trouble is, we don't know for sure at the start whether it's a deadly virus or a mild one, and since waiting would make it too late, I think it's incumbent on authorities to do something.

How do you strike a balance?

In hindsight, of course.

 

[Skeptic Ginger]

Originally Posted by Dymanic
The main object of interventions is to reduce mortality.

No, it's containment and maintenance of public health [link]..

Those two goals are not mutually exclusive. Are you suggesting mortality is not a measure of public health? Are you suggesting containment does not result in reduced mortality?

BTW, we passed the ability to contain this virus before it left Mexico, including before the first cases were IDed in the US.

 

[Skeptic Ginger]

...
Can't go along with that. The local peak of a seasonal flu epidemic typically last about six to eight weeks. It is reasonable to regard it as very likely that some of the students (or staff) will be contagious with flu during that time (and keep in mind that children have the potential to become superspreaders; they often remain contagious quite a bit longer than adults). It's not easy to predict when that peak will occur, but it is possible to make an educated guess. ....

The reason for closing schools was two fold. If you have only isolated cases such as we did with SARS outside of China, closing schools can indeed nip an outbreak in the bud. And two, had people begun dropping like flies, then extreme measures to stop the spread would have been warranted.

As CDC and WHO and The Atheist and I have been saying, a week ago there was not enough evidence to know whether school closing was needed and was going to be effective. So you have to act until you know.

Then the virus was seen spreading too fast for school closures to be effective, and, the virus was not severe enough to warrant extreme measures. Thus one adjust course.

Anyone who calls it an over reaction is just ignorant of the influenza organism and the proper response public health officials should be taking given the circumstances.

An excellent blog on this issue can be found at Effect Measure. (The Editors of Effect Measure are senior public health scientists and practitioners.)

Swine flu: the overreaction overreaction

Laurie Garrett of the Council on Foreign Relations and a well-known authority on emerging infectious diseases was on PBS's Newshour last night and she made a very important but little appreciated point. Mexico has made a major national sacrifice for global public health by shutting down its country and interrupting transmission of disease. The cost to Mexico has already been enormous it will continue to pay in other ways. The reputation of the government has suffered because of the way it handled this -- the lack of transparency, the initial slow footedness (which of course it denies), its lack of credibility in the eyes of its citizens. There will continue to be a halo of risk and danger for an indeterminate time. And there will be the inevitable backlash against the government's actions, which went from cold to scalding hot in a week. We are starting to see this in the US as well: the "overreaction" backlash. So it's important to sort all of this out. What is the Big Picture at this point?

[go to the link to read the body of the blog]

It's an urgent task that must be started immediately. If there is an overreaction to perceived overreaction, the job of rationally preparing for a plausible near future event will be made much more difficult.

 

[GreNME]

Had you read that blog post, you might have noticed that Dem (whom I do respect very much) is referencing CDC and WHO data. I don't disagree that this flu appears to be turning out mild, and I'll go one better: I think this wave is going to fizzle in the Northern Hemisphere as the days get longer.

I don't care who wrote it. The CDC has made a public statement re-evaluating the need to close schools. It's leaving the ultimate decisions up to the school systems (natch), but even when they didn't make this change they weren't encouraging systematic school closings when a scare popped up in a district. They simply said it was understandable and it would have basis. They were acting on a level not far from what WC suggested anyway, while some actual school systems were going overboard with closures.

It's not me you're arguing with here. It's yourself. You post the CDC statement:
"CDC’s response goals are to:

Reduce transmission and illness severity, and
Provide information to help health care providers, public health officials and the public address the challenges posed by this emergency."

...and you even bold it. Then you turn right around and say that is says something it doesn't say. I agree that the statement is quite straighforward. Can it be that you don't grasp the difference between "reducing transmission" and "containment"? (Oh and, "maintaining public health" isn't in there either; it says "provide information").

Providing information is the only thing the CDC really does in the general sense. You are correct that I used the wrong word with containment. Mea culpa on that point. Their goal is to keep it from spreading, not to reduce mortality. As skeptigirl points out they are indeed not mutually exclusive, but the focus is different than what you imply. Their goal has a different stated purpose, and the wording for these types of statements are very carefully worded to be as precise as they are terse.

Perhaps you misunderstood. I was saying that the change in policy -- from recommending school closures to not recommending school closures -- makes perfect sense considering that the virus is turning out mild. You appear to agree. How can I have a proper argument with you if you insist on not disagreeing with me?

The only thing we're disagreeing on is whether WC was making a strawman. In light of the evidence, it's obvious he was not. Even before they began releasing information about the infections being mild, they (the CDC) were not insisting on school closures.

So, given that information, could you please go back and answer the question Belz put forth about why you accused WildCat of both a false dichotomy and a strawman? If you had stuck to mild hyperbole or unnecessary sarcasm as your descriptor, I might have even answered for you. However, since it seems par for the course in this thread (and many others) to respond in kind when the hype starts flyin', I'm more interested in seeing if you can just back off the original accusations and be a bit more reasonable in response.

In fact, that would be marvelously refreshing.

 

[Skeptic Ginger]

Has the number of people who died from this strain broken a hundred yet?

In Mexico, yes.

What's the current rate of fatality as we know it right now, at this moment, with the available data?

Still unknown.

As far as I can tell, we're still well below your estimated fatality rate, and you've yet to quantify how you're reaching such a high number outside of guessing.

And we are still only ~2 weeks into an epidemic that took 2 months to kill > 100 people in Mexico. If we could make the predictions you believe are possible at this point, I'd say let's all apply for the MDC while we are at it.

Slaughtering whole pig populations, holding Mexican citizens in quarantine against their will, and government public statements urging citizens to stay away from Mexico aren't worthwhile examples? How many do you need and at what severity of the behavior will reach the bar you've set?

Definitely absurd reactions but keep in mind, reasonable reactions should not be lumped together with these.

Also, those are politically motivated. Apparently Egypt has been trying to clean up urban backyard pig farming for a while. There is a Christian sect in Cairo that keeps backyard pigs for their own consumption. Lots of cities ban certain livestock in highly populated areas for good reason. The Egyptian government may have been just taking advantage of the situation to deal with a long standing problem.

As for China, could either be payback for their being offended we often accuse them of being the source of new diseases, or sensitivity given the experience they had with SARS. That's purely my early opinion on the matter.

 

[Dymanic]

Are you suggesting mortality is not a measure of public health?

You too? Jeez, my communications skills must be off today. Help me put a finger on it. I said:

"The main object of interventions is to reduce mortality."

Could I have phrased it more clearly somehow? Now, GreNME doesn't seem to agree because reduced mortality isn't explicitly stated in the CDC's response goals, but I still maintain that it's there nonetheless, though implied. If the virus didn't have the potential to cause mortality, there would be very little energy being devoted to weighing the relative benefits of various intervention strategies.

Are you suggesting containment does not result in reduced mortality?

I'm saying containment is a myth. You can dedicate all the resources you want to containment, but no, it doesn't result in reduced mortality, mainly because it doesn't work. Might work with some pathogens, but not influenza, because influenza thrives in lurk mode. By the time you see it, your containment is a bust already. Once everybody's done coming to terms with that reality, the resources can be dedicated where they actually do have some chance of doing some good by slowing the rate of transmission -- which is not pass-or-fail, but can (and will) be done with varying degrees of effectiveness in different communities.

The reason for closing schools was two fold. If you have only isolated cases such as we did with SARS outside of China, closing schools can indeed nip an outbreak in the bud. And two, had people begun dropping like flies, then extreme measures to stop the spread would have been warranted.

Yeah, sometimes you gotta try even though you know it probably won't work.

As CDC and WHO and The Atheist and I have been saying, a week ago there was not enough evidence to know whether school closing was needed and was going to be effective. So you have to act until you know.

Then the virus was seen spreading too fast for school closures to be effective, and, the virus was not severe enough to warrant extreme measures. Thus one adjust course.

Anyone who calls it an over reaction is just ignorant of the influenza organism and the proper response public health officials should be taking given the circumstances.

I agree with all of that.

An excellent blog on this issue can be found at Effect Measure. (The Editors of Effect Measure are senior public health scientists and practitioners.)

And co-founders of FluWiki. It would take years to read all the material posted there, (Well, took ME years, anyway). Careful, though; mentioning them is an argument from authority, dontcha know, and some people don't care who is writing what.

 

[GreNME]

Wow, this is getting really bizarre. A whole lot of people are reading my mind today.

I have an idea: how about everyone who is posting just try to make their next post without a shred of hyperbole. I promise to hold myself to this same standard. Just one post is all I ask.

 

[The Atheist]

Has the number of people who died from this strain broken a hundred yet? What's the current rate of fatality as we know it right now, at this moment, with the available data? As far as I can tell, we're still well below your estimated fatality rate, and you've yet to quantify how you're reaching such a high number outside of guessing.

I said I was guessing!

I used a 10% infection rate and a 0.001% mortality rate, which is extremely low.

On current data, we have some 1085 confirmed cases and 25 deaths.

As Skeptigirl and I keep saying, extrapolating anything from current data is not necessarily a guide to what will happen in the future, and since annual 'flu kills 1/2 million a year, I think expecting 60,000 deaths from H1N1-A isn't an overestimate.

Slaughtering whole pig populations, ...

That is clearly a political muslim vs christian problem and doesn't count. It's not a sign of panic, but a sign that muslims will flex their political muscle at every opportunity.

...holding Mexican citizens in quarantine against their will, and government public statements urging citizens to stay away from Mexico aren't worthwhile examples? How many do you need and at what severity of the behavior will reach the bar you've set?

It's hardly panic. As Skeptigirl just posted, it might look like panic in hindsight, but with an unknown disease, a degree of caution isn't wrong. Was it too much? Possibly, but it wouldn't have been anywhere near enough if the death rate was much higher.

Here, let me help you:
CDC: Maybe Schools Shouldn't Close
Outbreak of Flu is Less Severe Than Feared

Yep, hindsight's fantastic.

The CDC wasn't saying that last week.

My suggestion for starting to have some balance here in this thread is to start re-evaluating your position based on the re-evaluations the major health organizations are doing. The reason I suggest this is because the "we don't know for sure" argument falls way too short-- there is never 100% certainty with things like this pandemic, and waiting until near-100%-certainty will definitely cause problems. That's why these health organizations operate from a "what we know right now" group of data. Not for nothing, but you might want to give it a shot.

Nope, I just don't see it like that.

I haven't seen any panic, but I agree the response is out of order with what we now know.

It isn't out of order against what we knew ten days ago.

 

[Kestrel]

I'm not sure of your point. Mexico is not reporting probable cases based on contact tracing and they certainly don't have good number yet to get a denominator for calculating case fatality rates.

My point was that Mexico has been investigating cases that did not show up at a hospital. If you assume that most cases of this virus are mild, and knowing how influenza is spread, the investigators should be finding a fair number of these mild cases. People who had the H1N1 flu, but did not require hospitalization. For Mexico to not include them in the counts reported to WHO would be rather strange.

 

[Kestrel]

On current data, we have some 1085 confirmed cases and 25 deaths.

Actually 26 deaths, you forgot to include the one death in the US.

 

[Dymanic]

However, since it seems par for the course in this thread (and many others) to respond in kind when the hype starts flyin', I'm more interested in seeing if you can just back off the original accusations and be a bit more reasonable in response.

You know what? I'm interested in seeing if I can do that too. This is supposed to be fun and informative, but it's turning into a grind. I'll try.

I have an idea: how about everyone who is posting just try to make their next post without a shred of hyperbole. I promise to hold myself to this same standard. Just one post is all I ask.

I, for one, find your proposal acceptable.

 

[Skeptic Ginger]

You too? Jeez, my communications skills must be off today.

They are because I was posting in support of your comment.

I'm saying containment is a myth. You can dedicate all the resources you want to containment, but no, it doesn't result in reduced mortality, mainly because it doesn't work. Might work with some pathogens, but not influenza, because influenza thrives in lurk mode. By the time you see it, your containment is a bust already. Once everybody's done coming to terms with that reality, the resources can be dedicated where they actually do have some chance of doing some good by slowing the rate of transmission -- which is not pass-or-fail, but can (and will) be done with varying degrees of effectiveness in different communities.

Again you aren't reading well today. Containment worked for SARS so we know it works. Containment of swine flu was announced from the very beginning by both CDC and WHO as being past the window when containment is possible. You really seem to have false memories here about what's been posted on containment.

BTW, the WHO described the conditions needed for pandemic flu to be addressed by containment years ago. They concluded that one needed to detect a new flu strain outbreak within 2 weeks of the first case or it would be too late.

And co-founders of FluWiki. It would take years to read all the material posted there, (Well, took ME years, anyway). Careful, though; mentioning them is an argument from authority, dontcha know, and some people don't care who is writing what.

I'm not sure of your point here. I was referring to the specific article. I wasn't suggesting people read everything on the Effect Measure site unless of course they find it interesting.

 

[Skeptic Ginger]

My point was that Mexico has been investigating cases that did not show up at a hospital. If you assume that most cases of this virus are mild, and knowing how influenza is spread, the investigators should be finding a fair number of these mild cases. People who had the H1N1 flu, but did not require hospitalization. For Mexico to not include them in the counts reported to WHO would be rather strange.

You are confusing "investigating cases" with reporting "confirmed cases" and even with reporting "probable cases". Just because they are investigating cases of suspected flu in no way means they are including those cases in the number of reported cases. In fact, they are not including them.

 

[Kestrel]

You are confusing "investigating cases" with reporting "confirmed cases" and even with reporting "probable cases". Just because they are investigating cases of suspected flu in no way means they are including those cases in the number of reported cases. In fact, they are not including them.

I was not talking about counting probable cases.

Tracing the spread of the virus requires tracking down mild cases and sending samples to the lab for confirmation. Are they counting those samples that came back positive?

 

[I Ratant]

The media hype has infected -everyone-!

 

[GreNME]

I said I was guessing!

I used a 10% infection rate and a 0.001% mortality rate, which is extremely low.

On current data, we have some 1085 confirmed cases and 25 deaths.

As Skeptigirl and I keep saying, extrapolating anything from current data is not necessarily a guide to what will happen in the future, and since annual 'flu kills 1/2 million a year, I think expecting 60,000 deaths from H1N1-A isn't an overestimate.

It's a large overestimate so far. There would have to be a huge rise in the number of infections from this strain at some point this year for that to be a possibility, and by all indications it's currently reaching a plateau.

That is clearly a political muslim vs christian problem and doesn't count. It's not a sign of panic, but a sign that muslims will flex their political muscle at every opportunity.

You cannot choose which reactions do or do not count when asking for examples without first laying out the criteria you're filtering. That can result in your statements looking like shifting goalpost.

It's hardly panic. As Skeptigirl just posted, it might look like panic in hindsight, but with an unknown disease, a degree of caution isn't wrong. Was it too much? Possibly, but it wouldn't have been anywhere near enough if the death rate was much higher.

That only works with "ifs" and "coulda-been" though. Also, it doesn't look like panic in hindsight, because I've already pointed it out as examples of panic currently. How does someone pointing it out as panic as it happens count as hindsight?

Yep, hindsight's fantastic.

The CDC wasn't saying that last week.

They were also not saying that school closings should be mandatory. They left it up to the municipalities (who, in some cases, over-reacted).

Nope, I just don't see it like that.

I haven't seen any panic, but I agree the response is out of order with what we now know.

It isn't out of order against what we knew ten days ago.

And I think this is why we won't reach an agreement. We're not even agreeing on what constitutes the conditions of the things we're trying to claim. I say there's too much over-reaction in the public sector, you say the health officials' responses have been fine. I point out some public responses, you disregard them as media hype, silly politicians, or not too overboard in your opinion (or religious/political actions you call irrelevant). Only on a very few talking points are we ever addressing the same thing at the same time, and that's really reducing the level of discussion and creating a lot of unnecessary cross-talk. So I'll try to break down my main talking points:

1. I'm not saying the health officials' responses have been poor in any fashion. Their responses have been far more level-headed than those of politicians, media, and local/city municipalities all over the place.

2. The over-reactions and panicky behavior I am pointing out are those of politicians, media, and local/city municipalities. This includes not just media hype, but outrageous political and economic decisions like destroying pig populations or holding civilian travelers in quarantine against their will (or discouraging public travel).

3. The CDC and WHO have indeed been cautious in approaching this, I agree, but they have not been focusing as much on the possibility of a deadly strain as seems to have been implied in several posts in this thread. They have, as early as last week, begun to adjust their assessment of the strain from being possibly deadly to being relatively average in risk, to now being relatively mild. On this matter I tend to trust the CDC in their assessments.

4. I do not agree that erring on the side of caution to over-reactive degrees is reasonable for public response, and (I believe) that it will in fact be the likely contributing factor if in the future something worse does come down the line and it is ignored. I consider the assertions to the opposite contradictory.

Are those clear? Should I attempt to clarify?

 

[Bill Thompson]

I heard that someone has gone to Canada and has infected pigs on a pig farm with the swine flu. And people are suspecting that this could make the current swine flu evolve into a more deadly one that will come back to humans and be more deadly and harder to get rid of. We can hope. I don't know about you, but I am rooting for the flu to rid the world of the human infestation so that the next big thing can evolve which I hope will be a better life form.

Human beings have not lived up to my expectations. I don't have any hope we will or can.

 

[Dymanic]

They are because I was posting in support of your comment.

I know! I already knew that you agreed with me on that, so it was obvious that some wires had gotten crossed somewhere when you phrased it: "Are you suggesting mortality is not a measure of public health?"

Again you aren't reading well today.

That's certainly a possibility. I just started a course of Levaquin, and they say it can affect your thinking. My typing was the first thing I questioned, but I suppose my reading could be affected instead.

Containment worked for SARS so we know it works.

Well, maybe it's false memory, but that does sound familiar. I will respectfully dispute that the SARS model may be easily extrapolated to influenza. I recall us discussing the debate over airborne versus fomite transmission with SARS. That debate has not been fully resolved as far as I know, but it's less controversial where influenza is concerned. The basic reproductive number for SARS is estimated at 1.1 for Hong Kong and 1.2 for Singapore. Any pandemic influenza virus worth its salt ought to be able to do, what? twice that? three times? We've just seen an influenza de-lurk from a porcine reservior, apparently achieving a significant spread before we spotted it. Containment might be a viable option if that were seen as unusual behavior for an influenza, but it's really not. SARS, I don't know.

Containment of swine flu was announced from the very beginning by both CDC and WHO as being past the window when containment is possible.

Right. I don't see any reason to place much confidence in it being possible at any point.

I wasn't suggesting people read everything on the Effect Measure site unless of course they find it interesting.

I would. And I have. And I do.