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Monday, June 29

H1N1/swine flu: China Beats the Devil or Why CDC Scientists Shouldn't Do War Planning

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.
Comments:
And add one person with H1N1 who was taking TAMIFLU and still came down with a moderately severe clinical case of H1N1.

Scientific reports just released online by the New England Journal of Medicine showed an attack rate of up to 20% among hospital workers within 2 meters of ill patients with H1N1 (Mexiflu).

And the New England Journal of Medicine online articles show how terribly severe the pneumonia of Mexiflu can be in otherwise healthy people.

I think we can conclude that the CDC is not ready and cannot even take the lead in this. It is bigger than their imaginations.
 
Doc Jim -- Thanks for the news from NEJM. The hazmat gear worn by China's medical personnel while treating suspected/known swine flu patients are making more sense with every additional news cycle on swine flu.
 
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