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Wednesday, June 24

H1N1/swine flu: State Department tells of China quarantine horrors; Pundita tells State to suck it up.

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?
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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.
Comments:
Thanks for this summary, Pundita. Seems like China is using a lot of common sense in NPI (non-pharmacologic interventions), while the USA is playing bureaucratic games among the government drones.

Time for the grownups to take charge in the USA. Are there really any grownups at these agencies?

I'm not sure this is an Obama administration problem in origin, but it is certainly a problem that needs attention NOW. We may face a worsening virus in October 2009 or the deadliest Avian flu then or soon after. This needs policy attention and simultaneous science.

(And I would imagine the Chinese will get adept at handling their USA tourists in finer fashion soon. They tend to learn pretty quickly.)
 
DocJim -- Yes. They are fast learners when they decide they need to be. It took them many years and a lot of tragedy for themselves and others to acknowledge that they needed to share information with outside health agencies about infectious disease outbreaks on the Mainland. So it's a profound irony that now China is leading the way in fighting the 21st century's first pandemic.
 
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