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Sunday, April 26

Mexican-U.S. swine flu outbreak. Caution: blind curves and fog ahead (UPDATED 3X)

UPDATE (See the end of this post for the other two updates.)

When did the White House, high-ranking Members of Congress, U.S. Department of State, U.S. Department of Homeland Security, U.S. Centers for Disease Control and Prevention, World Health Organization, and the government of Mexico's President Felipe Calderon learn about Virus X?

The outbreak of a new and lethal virus in Mexico happened in March. Yet it was not until yesterday that President Calderon declared a State of Emergency in his country, the CDC issued a health advisory, and WHO issued an alert. Saturday also saw seemingly coincidental announcements from health officials in New York and Kansas about an outbreak of the virus in their states.

Speaking of coincidences, I must say that these weekend surprises, which divert much U.S. public attention from a controversy that President Obama created the previous week, are turning out to be a regular -- coincidence.

However, Virus X is not a spin machine. So it is deeply troubling that both the Mexican and U.S. governments were slow to react. Let's hope X turns out to be a dud; this country can't afford to be asleep at the wheel when it comes to the threat of a killer pandemic.
***********************
11:30 PM ET, Saturday

A new strain of swine flu has broken out in Mexico and the United States. There are so many discrepancies in the news reports about the outbreaks that a few minutes ago I threw in the towel and turned to Wikipedia, which already has a richly-sourced entry up titled 2009 H1N1 flu outbreak. Wikipedia also discusses the outbreak at their Swine Flu entry.

Go to both articles to stay current on the news about the outbreak but be warned that Wikipedia's wealth of information doesn't mean they have all the story straight, either. This is a very fast-moving series of events with many parts, and much about the disease and the way it acts is still unknown.

Just to give you an example of the foggy patches: here's this from Wikipedia's article about the outbreak:
The strain was unusually virulent in Mexico, causing more than 60 deaths, mostly in Mexico City and central Mexico ... Some cases in Mexico and the United States have been confirmed by the World Health Organization to be a never-before-seen strain of H1N1.
There seem to be two different viruses in play. The one that's been identified as new has (at this point) been confirmed to have killed 20 or 14 people in Mexico, depending on the news report, not 60. There have been roughly 70 deaths in Mexico from the outbreak; so far there have been no deaths from the U.S. outbreak.

Why so much fuss about a few deaths from flu? Because the pattern of the outbreak and infection in the US and Mexico reveals some remarkable similarities to the 1918 swine flu killer global pandemic. The story is still unfolding but here is what I've picked up so far about the possible similarities:

  • In Mexico (but not the US) the new virus (I'll call it Virus X) has "primarily struck young, healthy adults, much like the deadly Spanish Flu of 1918. This is unlike most influenza strains which produce the worst symptoms in young children, elderly adults, and others with weaker immune systems." (Quote is from the Wikipedia article on the outbreak.)


  • Virus X seems to be breaking out 'spontaneously' in different regions -- in this case, North America. The outbreak among eight children in New York City who came down with Virus X after their private school class visited Mexico was not 'spontaneous,' of course. But cases of the disease have also appeared in Kansas.

    It might be possible to discern a chain reaction in the USA if the "index case" -- the first known patient with an illness -- can be located in the U.S. But right now the outbreaks are suggesting a pattern of spontaneous and near-simultaneous infections. This was the same in the 1918 pandemic.


  • Some people have a mild case of the influenza and don't get pneumonia. For several people in Mexico, there has been the pneumonia complication and severe onset of the virus. Again, this is similar to the 1918 swine flu


  • I don't think much is known yet about the incubation period for Virus X but another troubling feature is that it doesn't seem to progress with dazzling speed, as did SARS. (This was the same for the 1918 swine flu, if I recall.) SARS was so fast-acting that despite its extreme virulence the pattern of its spread could be quickly identified, which is the only way that effective quarantine was set up in places such as Hong Kong. Virus X seems much more subtle in its action.

    Taken all together, what is known at this point about Virus X paints a picture that is disturbingly similar to the 1918 swine flu pandemic. Wikipedia notes:
    In the spring of 1918, swine influenza mutated into a severe human form in just a few months. Some of the victims became severely ill and died, while the rest suffered from mild symptoms.
    Aside from my concern about the obvious health risk of the outbreak, I am alarmed because of the foot-dragging and waffling on the part of the Mexican government and the Centers for Disease Control and Prevention (CDC).

    The Mexican government did the same thing that China's government is famous for: initially they suppressed information concerning the outbreak and dragged their feet about turning to international labs for help in getting the virus tissue samples properly tested. So Mexico and the entire world have lost time if the outbreak should turn into a killer pandemic.

    The CDC has been caught flat-footed because they are without a director; they only have an acting director. That's because Julie Gerberding was told to resign by the incoming Obama administration. It's standard practice for a new President to bring in his own crew for important positions. But it doesn't get more dangerous in this era than to play politics with the CDC.

    Obama should have kept Julie Gerberding at the helm in the way he did with Bob Gates and for the same reasons.

    Worse, because of the present delicate relations between Mexico and US, there is a distinct possibility that the CDC was initially told by the U.S. Department of State or even the White House to downplay the situation to the public.

    Yesterday (unnamed) "CDC officials" were speculating that the virus might not be completely new, and that perhaps better testing and surveillance had simply turned up a previously unidentified virus.(1)

    Meanwhile, up in Canada, which was hit hard by SARS, dateline Saturday:
    “It re-combined to create something totally new,” David Butler-Jones, Canada’s chief public health minister, told reporters yesterday. “How, when, or where it did that I don’t think we know. What it will lead to is impossible to predict.”(1)
    In short, the situation at the CDC leaves WHO Director-General Margaret Chan and her staff at the WHO to do the heavy lifting during the present health alert.

    Earlier on Saturday Mexico's President Felipe Calderon finally grew a brain and declared a national emergency because of the viral outbreak.(2) Yet as soon as he made his announcement on Thursday about the outbreak, other Latin American govenrments have been scrambling to get out alerts to their people and monitor their borders.(2)

    And from the reaction of a furious Mexican I read about in one news report, Calderon's foot-dragging will cost him the next election if the death toll in Mexico from the outbreak continues to rise, no manner how many drug cartel members he kills.

    What's striking about several news reports I read on Friday is that they don't mention that in Mexico the outbreak was noted there as early as March. So we come to questions about when the U.S. Department of State and the CDC knew of the outbreak, and why they did not issue a travel advisory at the time.

    If a global pandemic materializes from the swine flu it could be that the USA lost not just precious hours in dealing the pandemic, but weeks.

    In addition, the WHO announcement on Saturday was so bizarre that it suggested pressure had been brought to bear on the organization:
    The World Health Organization declared the outbreak of the previously unknown virus "a public health emergency of international concern."

    In a statement posted on its Web site, the agency advised health workers in all countries to monitor patients closely for signs of flu-like illness and severe pneumonia.

    The Geneva-based agency's recommendation came after a committee of international experts gathered in an emergency session Saturday to consider raising the alert level for the outbreak to 6 -- a pandemic -- which could have led to travel advisories and additional restrictions to combat the disease.

    The WHO's alert for the virus remains at phase 3, meaning a flu with "no or very limited human-to-human transmission." The committee said it needs more information before changing the threat level. But Dr. Margaret Chan, the agency's director-general, told reporters Saturday that the outbreak has "pandemic potential."(3)
    So are we to assume that two people in Kansas, eight people in California and Texas, people in New York, and people from all over Mexico petted the same sneezing pig?

    Reportedly, the Virus X outbreak has not been localized in one family or region in Mexico; it's broken out across the country.

    So let's not clown around. Virus X has spread chiefly through H2H -- human-to-human transmission. And the CDC announcement on Saturday backs this up.(3) Unless WHO wants to argue that a very busy bird or flock of birds with a severe case of diarrhea pecked at infected pig feces in one location, then flew around North America plopping their droppings onto select people in Mexico, Kansas, Texas, California, and maybe a Manhattan private school.

    Stranger things have happened but the best guess at this time is that X Virus spreads through H2H. And that means it could have walked on two legs off at least one plane flight.

    The CDC response on Saturday to the crisis 'harmonized' with the WHO one while still managing to convey the true seriouosness of the outbreak:
    [...] About the same time the WHO committee issued its statement, two new U.S. cases of the flu were confirmed in Kansas. New York health officials, meanwhile, had evidence of eight probable cases, CNN reported.

    "People are taking this extremely seriously. We have a very severe situation," said Dr. Anne Schuchat, the interim deputy director for science and public health program at the U.S. Centers for Disease Control and Prevention in Atlanta.

    Speaking to reporters by telephone earlier Saturday, Schuchat said the CDC is aiming its efforts at slowing the spread of the disease, which has killed at least 68 people in Mexico in the past month. [Again, there are different versions of how many Mexicans who died from flu actually died from Virus X.] 1,000 others in the Mexico City area have developed flu-like symptoms, according to media reports.

    In addition to the latest cases, eight people in the U.S. -- six in California and two in Texas -- were confirmed to have come down with a similar strain of the flu found in Mexico, according to the CDC. [Another report says that the CA and TX strains are a genetic match to the Virus X found in Mexico.] All eight have recovered, the CDC said, with only one patient needing hospitalization.

    Given that the new virus has appeared in diverse populations and in many communities, containing it is no longer feasible, Schuchat said.

    "We're not at a point where we can keep this virus in just one place," she noted. "We do expect more cases and we do expect them in other communities."(3)
    So, was WHO pressured by the government in Mexico and/ or the United States into keeping the threat level at 3?

    And was the CDC pressured by the U.S. Department of State or even the White House not to announce a travel advisory about Mexico?

    There's a lot at stake here aside from the economic and diplomatic considerations. If WHO and the CDC sound a false alarm they know the consequences could be horrific when the real deal shows up at some point.

    So, for right this minute, WHO gets a pass by keeping the threat level at 3, even though Virus X is clearly transmitted from human to human.

    Correction: they get a pass unless Virus X turns into a killer global pandemic. And unless it recombines with H5N1 and sets off the superkiller global pandemic that virologists have been dreading.

    Virus X, by the way, is a recombination or reassortment of specific bird, human, and pig viruses that produced a new virus. To my knowledge the avian part of the assortment is not H5N1.

    The good news is that many people around the globe have survived H5N1 infection. H5N1 antibodies have been found in poultry factory workers in India. So I have argued since 2005 that H5N1 might be diluting its superkiller potential as it cycles and recycles around the world through humans, fowl, and animals, looking for just the right pig flu virus to combine with.

    But I wouldn't place money on my bet. And I would not expect any humane government to gamble on my argument, particularly because it's a reassorted version of H5N1 with pig flu virus that's the biggest threat. Put sick pigs and birds in too close proximity and you have Nature's bioweapon lab.

    That brings us to another patch of fog. Given the subtle action of Virus X, it could have been introduced to Mexico from the US side then returned to the US.

    If you say it's most likely that it arose in Mexico: it's most likely that it arose in a market that sells live pigs and fowl for slaughter to people who want freshly-killed meat for their cooking.

    These markets exist in Mexico -- and in Texas and probably in other border USA states. The stateside markets are to serve the large Mexican and other 'southern' Americas transplants and immigrants who live stateside. But US 'natives' also shop at the markets.

    There was an outbreak of a bird or swine virus at one of those stateside markets just a few years ago; I am pretty sure the outbreak was at a market in Texas.

    In any event, many of the markets cram live pigs and fowl close to each other while they're awaiting sale. Same can happen during transport to the markets from Mom-and-Pop farms. Both scenarios replicate conditions that have made mainland village China the laboratory for so many killer virus outbreaks.

    So right now it's a coin toss about where Virus X was born.

    UPDATE

    I've just read John Batchelor's Saturday night post titled Pandemic Potential, which has a good summary of the story -- along with the sardonic observation, "The White House wants us to know that POTUS is watching the developments through the reports of CDC, State and Homeland Security."

    Here's the passage from John's report that really caught my eye:
    [Dr] Henry Miller, Hoover Institution, sent me an alert on this development on Tuesday 21: "...adjacent southern California counties ...two cases of febrile respiratory illiness... caused by infection with a swine influenza A (H1N1) virus... contain a unique combination of gene segments..."
    So Calderon must have known from that report out of the USA there was no way he could continue to keep a lid on the situation in Mexico.

    I am glad to learn that DHS is keeping the President updated on the Virus X threat. A quick check at the DHS website, however, leaves me in the dark about how or whether they're keeping the public updated.

    Granted, it's late and I'm tired, so I might be missing it, but as of this hour I could find nothing about Virus X on the site, even when I typed "disease" into Homeland's search engine.

    I did come across Homeland Security Presidential Directive 21: Public Health and Medical Preparedness. The abstract begins:
    It is the policy of the United States to plan and enable provision for the public health and medical needs of the American people in the case of a catastrophic health event through continual and timely flow of information during such an event and rapid public health and medical response that marshals all available national capabilities and capacities in a rapid and coordinated manner.
    Yes, well, I suppose the timely flow might not include things like posting information on the DHS website about a new virus with lethal qualities that has appeared in the USA and Mexico.

    My visit to the U.S. Department of State website also did not turn up any mention about the viral outbreak in Mexico. There is a travel warning, dated February 20, 2009, which relates to the violence in the country. But one would think that with Spring Break, and just for the general safety of U.S. tourists and businesspeople traveling in Mexico, State would have made at least some small mention of the outbreak in a travel warning.

    UPDATE

    I've just read a second Batchelor post from early this morning on the pandemic threat. He observes at the end:
    In Japan, they have already introduced temperature screening to passengers arriving from Mexico. Asia is said to be "on alert." In Mexico City, President Calderone has started emergency powers to order closings and quarantines. In Washington, the White House confirms that President Obama was in Mexico City and meeting ... with possibly flu infected officials on April 13.

    The word "panic" is commonplace in news bulletins from Mexico. The headlines just hint at border closings and blockades. The White House has been quick to say that the POTUS is monitoring the moving story through the CDC, State and Homeland Security. It is a fair guess that many municipal and state authorities along the Mexico-US border are meeting and conferring from Saturday to Sunday to Monday to discuss potential defenses. One school has already been ordered closed in Texas, more likely will follow in California, New Mexico, Arizona and Texas. In precaution.[...]
    Again, evidence of a serve viral outbreak in Mexico occurred as early as March.

    Janet Napolitano, the United States Secretary of Homeland Security met with President Calderon in Mexico on April 3. Secretary of State Hillary Clinton met with Calderon in Mexico the week before.

    Were Napolitano and her staff, Clinton and her staff, and President Obama and his staff provided with the anti-viral drug Tamiflu or Relenza before they left for Mexico? Were they inoculated with the H5N1 vaccine for the trip?

    1) Bloomberg: Swine Flu may be named Event of International Concern - Update 2, April 25, 18:22 EDT.

    2) Bloomberg: Mexico’s Calderon Declares Emergency Amid Swine Flu Outbreak - Last updated April 25, 16:45 EDT

    3) Market Watch: Swine Flu could become global - April 25, no time stamp

    This entry is crossposted at RBO.
    Comments:
    your blog is feel good
     
    Just as clarification - it'll never be listed as 'virus x' on any government site, because virus outbreaks are always listed by the alpha-numerical indicator for that particular virus. They're still typing this one, but for now, CDC carries it as H1N1 (http://www.cdc.gov/swineflu/). The designator may change when serotyping and genetic analysis is complete since this appears to be a new strain. Notices went up on the CDC website as early at March 28 (they may have been there earlier, but that was the first time I looked for them). WHO (http://www.who.int/csr/disease/swineflu/en/index.html) put up notices after the first cross-border cases were confirmed.
     
    Jennifer -- Thanks for the props!

    bullmoosegal -- Thank you for your observations. I went through the roof when I first came across the H1N1 designation in a news report; I think more than anything that decided me to write a post on the topic. However, your comment brings home that with hindsight I should have least mentioned that this is what they were calling it -- "it" being very unclear if there are two different viruses in play.

    As for the timeline -- around 6 this morning Procrustes at RBO sent me what she found at the CDC website, which I published in a 4th update. I yanked the update shortly afterwards with the thought that I'd do a separate post on the topic.

    Again, hindsight. It wouldn't have hurt if I'd simply plopped the data into the second update with a promise to discuss it later.

    The decisions we make on no sleep.
     
    One of the most interesting things about this rapidly spreading virus is the difference in clinical symptoms between Mexico (D.F.?) and parts of the USA. Since the virus seems to be typing out so similarly as H1N1, it suggests a shift in thinking will have to come to the CDC and virologists.

    Immunization with the USA 2009 influenza vaccine may be partially protective. It seems to moderate the severity of illness. That's better than nothing!

    A few years ago I heard a presentation about avian influenza from a NIH clinician. At the end, I asked why we were not immunizing people right away with the parts of the virus that we can do so, since there are some relatively benign bugs with parts of the avian influenza type. He agreed that it sounded like a good idea and he had proposed it, but he said the lab guys said it wouldn't work. I am emboldened to say it may be HELPFUL, but contagiousness will likely remain.

    In other words, influenza is very easily spread and very contagious, but if partially immunized then more people may survive. Even though there is economic loss from time off sick or from events cancelled--I would rather have that chance than just hand-wringing about the failure to prevent infection.
     
    DocJim -- Are we talking about one virus or two? Yesterday's news was that there seemed to be two epidemic-producing viruses on the loose in Mexico. Today -- now that governments have come alive --we're just hearing about one (unique) virus.

    So this is pea soup fog we're dealing with at this point.

    As for your other comments, I am practically shouting, YES YES. This has ALREADY been amply demonstrated just this last flu season! The cocktail for last year's flu vaccine missed the virus that turned out to be the 'epidemic' one. But reportedly those who received the vaccine did better at fighting off the virus than those who didn't get the shot. I don't think there's been a study on this but surely in many cases -- particularly those at high risk -- the vaccine was the difference between life and death.

    So I could not agree with you more.
    I firmly believe that every bit helps, although I would probably get an argument from a viologist.

    You might want to listen to Dr Henry Miller's discussion on the John Batchelor show tonight -- the podcast will be available tomorrow. The segment opens the show at WABC/WMAL

    But I have long had a problem with the concept of a 'unique' virus that involves a bird flu strain. Supposedly antigenic mutation can create a totally 'new' virus. I am sorry but I cannot accept that, not when it comes to influenza -- which is practically another way of saying 'bird flu.'

    We've been living with bird flus ever since our time began. The human immune system has evolved to fight influenza, so I think it can 'recognize' bird flu no matter how deeply the bug burrows into a mutuation.

    Like a cop who'se been working on a bunko sqaud for 20 years. He can just sniff and spot a scam. I think the healthy immune system is like that.

    Thanks for your observations and information.
     
    There certainly is the possibility that two H1N1 viruses are spreading: one uncommonly lethal with a portion of the bad Spanish flu/avian flu and one that has many similarities but not that bad "gene" that often causes death.*

    I do not know whether the flu vaccine used in Mexico City medical personnel in April 2009 is the same as the vaccine widely distributed for USA 2008/2009 flu season. This is an important factoid too look for in future dispatches.

    The CDC web site was very useful on Thursday/Friday, but on the weekend it had no good technical updates.

    * Some say the ultra-lethal portion of the Spanish flu virus has element(s) in common with African hemorrhagic fever and that many of the deaths in the USA in 1918 were due to this phenomenon. The avian influenza strains that were so worrisome a couple of years ago were said to have that segment in them.

    We await reports from Mexico City medical personnel about evidence of large "bruises" on the victims who died. That would unfortunately confirm this hypothesis. Some of what we see looks like two H1N1 viruses, both hitting epidemic stages in Mexico City, one lethal and one without that very lethal aspect. Both viruses spread "effectively" but the bad, bad one tends to burn itself out when rigorous containment measures are used. On the other hand, the less sick people are, the more they move around in the community and go to mass/church or other events-- so that kind of virus keeps going.
     
    DocJim - your mention of reports of bruises is alarming. Prior to receiving your news I was just beginning to exhale, thinking that we might have dodged the bullet, because I'd found nothing in news reports that might indicate hemorrhaging in the stricken. Of course these are anecdotal accounts. So we can only wait. And pray.
     
    DocJim -- I just re-read what you wrote. You're not saying that there have been reports of bruising; just waiting to hear whether such surface. It helps to read lol. But just seeing that word turned my brain to butter for a minute.
     
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