Swine flu/H1N1: Your life, riding on the CDC's slow boat from China

Introduction

I wanted to plunge straight into my argument with the Centers for Disease Control and Prevention (CDC) but I decided to first outline my basic position.

There have been several developments on the swine flu front since I last posted, which produced reactions in many Americans that range from, "Whew! We dodged the bullet!" to "I knew from the start the government was making a mountain out a molehill because, after all, 36,000 Americans die every year from regular flu."

From where I sit both reactions miss the point, which is that the CDC's approach to crisis management is on par with the state of Louisiana's before Hurricane Katrina struck. And the CDC's approach to intelligence-gathering about emerging disease threats makes the pre-9/11 CIA's intelligence-gathering efforts look cutting edge.

From top to bottom, the CDC's management of the swine flu outbreak has been an unmitigated disaster. They are so far behind the times, and their crisis management is so completely disorganized, that you don't want to think about how many Americans would be dead today if the Piggy Flu, as one British wit dubbed it, had been an evil genius.

As for the 36,000 influenza deaths per year, which has been quoted ad nauseam by commentators since the swine flu outbreak in the effort to put the outbreak in context: it turns out that the number is a great illustration of the dictum, "Lies, damned lies, and statistics."

The CDC has no idea how many deaths there are each year from the flu because the number is a computer-generated guess based on mathematical modeling -- a model that's been used for more than 40 years, and which needs serious updating.

As the CDC's spokesman, Curtis Allen admitted a few years ago to medical journalist Kelly O'Meara, it's not a "real" number. He 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 the CDC's own data, O'Meara managed to turn up that, "The greatest number of actual influenza deaths recorded since 1979 were 3,006 in 1981." (1, 2)

(A big hat tip to Deirdre Imus, writing for The Huffington Post, for digging up O'Meara's reports.)

Yet the same pesky computer modeling that's greatly overestimated the number of regular flu deaths in the USA is now greatly underestimating the number of swine flu cases and for the same basic reason -- hospitals and physicians are not swabbing every patient who presents with the symptoms of swine flu -- even when the patient is in a region that has shown swine flu infection.

The CDC is making a guess based on the number of swabs that have been tested and found positive. Yet even with all the will in the world to obtain a fairly accurate count, the CDC and public health officials at the state and local levels would be unable to do so because they were caught flat-footed by the outbreak.

They simply didn't have the protocols in place for dealing with that kind of emergency. It wasn't until the weekend of May 2-3 that the CDC finally got a testing kit to several localities, including New York City -- which had been a region hard-hit by the new swine flu virus. (3)

What did New York health officials do before that weekend? They did what health officials in every other U.S. state did: twiddled their thumbs waiting for the CDC laboratory to plow through the mountain of swabs for swine flu cases. That lab was the only place in the country that was equipped to test for the new virus. And it wasn't until May 5 that the CDC got test kits to all 50 states.

To put this all another way: While the CDC does the noblesse oblige thing for other nations and tests for diseases all over the world, such as hoof-and-mouth disease in Pakistan, citizens of the United States of America and their tax dollars have to make do with a horse-and-buggy version of infectious disease management.

But all that outrage pales next to the antiquated reasoning that informs the CDC's view of how best to handle a deadly epidemic that's jumped the US border from another country.

Following the swine flu story has not been easy for me -- and most others, for that matter. Often, news reports seemingly contradict each other, sometimes on an hourly basis or supersede each other at the same rate; there are significant gaps in the timeline of events; and parts of the story are incomprehensible to someone without a degree in a biomedical field.

Because I was out of my depth in the scientific/medical areas I chose to study the situation from the viewpoint of national defense, which I'd gotten familiar with during my years of closely following the Iraq theater of war and the war on terror in general.

I focused on news reports about how the Centers for Disease Control and Prevention and other U.S. government agencies were handling an emergency response to the swine flu outbreak.

I wasn't long into the task before I noticed a glaring contradiction in how officials at the CDC thought about emergency measures for dealing with a highly infectious disease outbreak. It doesn't take a degree in a scientific field, or even extensive knowledge of facts on the ground, to notice a sloppy premise and to argue against it. That's what I began to do in the last post, and that's where I pick up from in this one.
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"One reason for the delay in stronger guidelines is that swine flu caught [CDC] planners off guard; they had anticipated being able to recognize a pandemic overseas, weeks or at least days before it hit the United States." (4)

In the old days -- the really old days -- a virus that started a pandemic far from home had tremendous character. Clinging to the wings of migrating fowl for days and weeks on end, getting buffeted by high winds and pelted by driving rain and snow, the virus that wanted to see the world had true grit.

Then, in the eras of globalized ship travel, an adventurous virus had to endure life in the bowels of a floating shack while cooped up for months with a bunch of smelly ill-tempered rats.

Travel conditions greatly improved for the intrepid viral world traveler with the advent of commercial air travel. These days the pampered virus takes an air-conditioned taxi to the international airport, flounces to a first-class seat, then disembarks a few hours later on the other side of the world, fresh as a daisy.

Yet planners at the CDC are laboring under the somewhat romantic notion that they have as long as it takes a clipper ship to sail from Old Shanghai before they must leap to defend the USA against a deadly viral outbreak on the far side of the world.

How did the planners arrive at such an antiquated notion? From the same report I quoted above:

[T]he official Pandemic Influenza Operation Plan, or O-Plan, of the U.S. Centers for Disease Control and Prevention, is based in large part on a history lesson -- research organized by pediatrician and medical historian Dr. Howard Markel of the University of Michigan. Markel was tapped by the CDC to study what worked and what didn't during the 1918 flu disaster>

In other words, the CDC's O-Plan is based in large measure on lessons learned from the 1918 outbreak.

If you say, "B-b-but this isn't 1918" -- Exactement!

While it is true that those who do not know history are doomed to repeat it, it's also true that those who don't factor present circumstances into their historical analyses can get us all killed.

Markel's research on the 1918 pandemic actually turned up some excellent advice. He stressed the importance of non-pharmacological interventions or "NPIs," as they're called, such as isolation of infected patients. However, from the viewpoint of dealing with a highly infectious disease, here is the critical difference between 1918 and 2009:

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.

The key concept here is "appearing at several points at roughly the same time."

This is a very different concept from "spreading from one point."

Several days ago CNN showed a computer model of how ten isolated disease cases in California can, through exponential growth of infections, infect the entire country. This happens because each one of those ten people is assumed to infect an average of say, three people, and those infect three more, and pretty soon you need higher math to keep count.

That's not what happened in the USA with the swine flu virus. Infected people got off airline flights from Mexico at different points around the USA within a short period of each other.

New York City caught a break because for reasons known only to itself, the swine flu virus that arrived from Mexico with a bunch of private school students seemed to fizzle after clobbering 1,000 New Yorker within a few days. Medical detectives are all over the case. (5)

But the flu's behavior in New York, and the fact that it seemed relatively benign, tended to mask the critical need to update emergency planning for an era in which a serious disease outbreak can suddenly appear at several different points -- near large population hubs -- within a matter of hours.

Instead of updating the CDC stodgily clung to a fallacy, which they foisted on every U.S. official who had to comment publicly on the outbreak. On April 27 Janet Napolitano told a reporter:

"You would close the border if you thought you could contain the spread of disease, but the disease already is in a number of states within the United States."

Mr Obama echoed her statement. When asked at his April 29 press conference whether he was considering shutting the border with Mexico, he replied:

"I've consulted with our public health officials extensively on a day-to-day basis, in some cases, an hour-to-hour basis. At this point they have not recommended a border closing. From their perspective it would be akin to closing the barn door after the horses are out, because we already have cases here in the United States."

Ms Napolitano and Mr Obama were accurately outlining the reasoning that dominates at the CDC.

The problem is that the reasoning is based on the fallacy that stopping a viral outbreak is the primary goal once a highly infectious disease has arrived in a country. That thinking is dangerously wrong because at that point it's critical that the primary goal be shifted from containment to slowing the rate of infection. Why? I'll let a top CDC consultant, Dr Ira Longini, explain:

"The name of the game is to slow transmission until a well-matched vaccine can be made and distributed." (6)

A more precise statement of the goal is simply to buy time:

Yes, time until a vaccine can be developed, tested and distributed. But also time until health facilities can gear up to deal with an epidemic. And time so that the health facilities, and the society in general, won't be overwhelmed by the lightning-fast spread of an infectious disease.

This time-buying strategy is particularly vital today in the USA, given that the average of "3" (the "R" number or number of people that one infected person can in turn infect) is based on analysis of the 1918 pandemic in the USA not on the way things are today. (4)

Not only was the US population much smaller in 1918 and much less densely packed, but the volume of interstate travel and even travel within a city was much smaller. In 1918, many city people in America rarely if ever left their immediate neighborhood.

And there was no real suburbia, as we have today, from which millions of Americans in the workforce commute round-trip to a major population hub during the work week.

Also, you didn't have 4,000 flights a day between Mexico and airports all around the USA, and God Knows how many flights between many points in the USA and other areas of the world that are incubators for lethal exotic virus combinations.

So it's a safe assumption that the average number of people who can be infected by one disease carrier is higher today than it was during 1918.

More importantly, statistical averages go out the window when the disease enters the USA at several points within a short period. The R number might initially be 3 in Atlanta but in the densely packed mega-city of New York, R could be initially higher -- or vice versa, depending on the number of infected people who alight daily from the nearest airport hub near both cities.

The planners seem to have discounted the fact that the United States of America takes up much of a big continent. So the thinking about how to slow the speed of disease transmission should have been directed to seeing where the rate of infection could be slowed from region to region of the country.

In short, the United States isn't a barn and a virus is not a horse.

So of course it slows the rate of infection to suspend air flights and order a border and ports blockade when the country next door is in the middle of a deadly epidemic. Critically, in the early stage of the epidemic, the rate could vary wildly from region to region of the USA for several days or even weeks or months. The variables would translate into many lives saved if time-buying measures were immediately deployed.

If it still doesn't make sense to you to deploy draconian measures when a government knows that the measures have no hope of actually stopping the virus, think it through:

If 5 infected people slip through a border blockade or get past a temperature monitor every day during the outbreak -- if the measures halt 20 infected people every day, that's 20 people a day who've been stopped from infecting an average of 3 additional people each, per day. That's stopping those people who in turn would infect 3 more, and those who would infect 3 more -- and pretty soon you need higher math to keep count.

In short you're racing to brake the speed of the infection transmission in many regions around a vast tract of land, and for this you do everything you can think of:

Temporary border blockade

Quarantine of a suspected cluster of infected people

Temporary suspension of airline flights to and from a country that has a widespread outbreak of the highly infectious disease

Installment of "temperature-taking" thermal imaging machines at all ports -- I repeat "ports" -- in conjunction with tactics to offset the limitations of the machine's camera

Temporarily stopping all but essential off-loading at ports from a country with a highly infectious disease outbreak

"Social distancing;" e.g., urging the population to stay away from situations that have crowds of people, urging them to avoid close quarters with non-family members, etc.

PSAs hurled within hours onto every major media outlet to warn people to pay scrupulous attention to personal hygiene, such as hand-washing.

Again, no one of these tactics or a combination will stop a highly infectious disease from spreading once it arrives in a country. But if they can just slow the rate of infection by a fraction, while that won't stop deaths from a killer disease epidemic it would translate into thousands or even millions of human lives saved -- and a nation's social fabric hanging together during a deadly pandemic.

Realize that the most drastic measures; e.g. blockade, would not need to be lengthy. How long? Until officials got a handle on the estimated length of the virus' incubation time.

Yet what's most striking about the pattern of swine flu infection is that it didn't spread upward and outward from the U.S.-Mexico border region. The early pattern of the swine flu outbreak in the USA points to airline travel as the fast disseminator of the virus, not the Mexico-U.S. cross-border vehicular and foot traffic.

It could turn out that some infected truckers who were heading from Mexico to various points in the USA or Canada helped spread the disease at pit stops across the country. But from what the numbers were saying up to May 5 (the date of the report I'm referencing) there's not much infection in the U.S. border states in relation to other states that have seen outbreaks. (7) And it's the early data on this phenomenon that count most.

With three possible exceptions, which I'll discuss in my next post, virtually all the swine flu cases in the USA represent infected people who recently arrived from Mexico by plane, who were infected by contact with disembarked infected passengers from Mexico, and who in turn passed the infection to others. (6)

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May 12, 12:40 PM ET Update
I'm going to interrupt myself here. I've just realized there's a glaring contradiction in my reasoning. I note in this post that swine flu test kits didn't arrive in all the states until May 5. And even if the border states were among those that received kits as early as the May 2-3 weekend, that doesn't necessarily mean that the test results show up in the numbers quoted in the report I reference.

And the numbers in the report don't necessarily mean that the CDC had been able to test their own backlog of swabs from the border states by May 5.

Yet despite these considerations I assert "it's the early data on this phenomenon that count most."

Yeah, well, that's true in principle. But in this case the "early data" aren't necessarily a good picture, or even a good estimate, of the early number of swine flu infections in the border states. Duh, Pundita.

So, with regard to my assertion in the third paragraph above, I think I should hedge by substituting "a great many" for "virtually all."

This chart, dated May 11, 11:00 AM, shows the number of confirmed swine flu infections by state. Here are the numbers for the four border states:

AZ 182, CA 191, NM 30, TX 179

The question is whether those numbers reflect recent cases or clearing of a backlog.

That's why I've inserted this correction rather than simply editing the paragraphs; the original writing illustrates the difficulty in this situation of arriving at valid conclusions when reasoning from very incomplete and imprecise data.

Now to continue:
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Although it was known early in the U.S. outbreak that initially the biggest known cluster of infections came from a school trip to Mexico by New York students, there was nothing more than a passive effort at U.S. airports to screen incoming passengers from Mexico. (E.g., airline personnel eyeballing arrivals and asking them how they were feeling if they didn't look well.)

And there was no action to suspend incoming or outbound flights to Mexico. This, despite the fact that officials knew that a highly infectious disease had reached epidemic stage in Mexico's capital city.

When did they know? The answer is still speculative; I've touched on the issue in earlier posts and in the next post I'll grapple with it again. However, from all I've read, it can be argued that CDC officials were tardy by several days about alerting the U.S. public, and that their refusal to recommend suspending flights to and from Mexico explains how swine flu appeared in the majority of U.S. states within less than two weeks.

Yet again and again the negligence was rationalized with the argument that because the disease had already entered the USA, there was no use taking measures to attempt to prevent its fast encroachment from Mexico.

What if the disease had been a superkiller and stayed as highly infectious as it did when it first struck in Queens, New York? How many American dead would we be looking at by this time if we multiply the number of inbound infected airline passengers by the number of people they infected and keep multiplying from there?

If Ms Napolitano would tell me that of course the U.S. government would have suspended flights from Mexico if the virus was highly lethal -- according to CDC's guidelines that would be a useless gesture. Ms Napolitano and the CDC can't have it both ways: talk gibberish when it suits them then fall back on reason when it doesn't.

It's not the lethality of the virus that's at issue here. Yes or no: is it good practice to attempt to slow the rate of infection from a highly infectious disease?

If yes, then: Does suspending air flights from an infected country help slow the rate of infection?

If yes, I believe this is where I get to say "Checkmate."

Given that my argument is hard to answer why do officials at the CDC refuse to consider it? Because they've continued to listen to Dr Longini and other members of his biostatistician tribe who advise the CDC.

Longini and his colleagues have recently made public declarations that back them so far away from their assertion that an infection rate should be slowed at the start that they're making as much sense as Wonderland's Red Queen.

Why would several mathematicians start talking gibberish about such a serious issue? I don't know. But TIME magazine's April 30 report, Why Border Controls Can't Keep Out the Flu Virus could be subtitled, "Lies, damned lies, and economics."

"Once the virus has spread beyond its initial focus, travel restrictions just aren't effective," says Ira Longini ... With 4,000 flights a day between the U.S. and Mexico, "it's not worth the social disruption it would cause."

That's not to say that very strict restrictions wouldn't have some effect on slowing the virus. In a 2006 study, Harvard epidemiologists John Brownstein and Kenneth Mandl examined the effect of the sharp reduction in air travel after the Sept. 11 attacks on that year's flu season. They found that the initial flight ban and general decline in air travel in the weeks after delayed the onset of the flu season but did little to reduce the overall number of infections and deaths that year.

The data matches computer models run by biostatisticians like Longini, who found that even the strictest limits on air travel would only slow the start of a flu pandemic, not stop its spread. But, again, while that strategy may benefit countries that have not yet been infected with swine flu, there's still no way to know when it would be safe to lift those restrictions.

"There's no question that air travel spreads the flu," says Mandl, a physician and researcher at the informatics program at Children's Hospital Boston and an associate professor at Harvard Medical School. "But the impact of limiting flights at this point is difficult compared to the downside of the economic impact."

The observations overlook that no special measures were needed or taken in the USA against the 2001-2002 flu, which was seen as common. Yet a "delay in onset" would give health professionals a huge edge in preparing to deal with a superkiller virus.

What I find particularly outrageous about the economic and "social disruption" arguments is their almost inhuman cruelty. I am haunted by a news photograph of an exhausted Mexican mother and her two daughters, slumped in exhaustion against her shoulders as they waited to be examined at a health clinic in Mexico. They were all wearing face masks.

Here's a news flash: all decent people everywhere want to live. Parents don't want to see their children die before their eyes of an infectious disease.

What the CDC and their scientific and medical advisors refuse to consider is that a failure to suspend cross-border and air travel traffic means that the infections are not one-way. Americans infected with swine flu who travel to that country can infect Mexicans -- in a country that is more poorly equipped than the USA to face a killer virus.

So I don't want to hear about social and economic disruption. Memo to all concerned U.S. and Mexican agencies: Coordinate and do something called contingency planning. This, so that disruptions from a temporary border blockade and suspension of flights between Mexico and the USA are not catastrophic for people on either side of the border.

If you don't know how to do contingency planning, if the concept is foreign to you, talk to major corporations and defense departments to find people who are experts in business and military logistics.

Face it; you were lucky. If the death count from swine flu would have been high, all of you would have been straight on your way to Hell, where I sincerely hope you would have spent the rest of eternity sharing a slow boat from China with a particularly mean virus.

1) INSIGHT MAGAZINE via Sci-Tech Archive: Flu Secrets You Should Know; Kelly Patricia O Meara; June, 2004

2) Moms Against Mercury: A Shot in the Dark - Part 1; Kelly O'Meara; 2004?

3) The New York Times: New York’s Lab (Don’t Ask Where It Is) Readies Its Own Tests for the New Strain; Anemona Hartocollis; May 3, 2009

4) CNN: Scientists dig for lessons from past pandemics; Caleb Hellerman; April 30, 2009

5) The Associated Press: Medical detectives probe flu virus spread in NYC; David B. Caruso; May 4, 2009

6) CNN: Expert on flu's spread says new strain here to stay; Patrick Oppmann; April 28, 2009

7) Phoenix [Arizona] Business Journal: Border states show no swine flu spike; Mike Sunnucks; May 5, 2009)
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This entry is crossposted at RBO. Thanks much to Procrustes for proofreading.

What Joe Biden knows about the jet-setter swine flu that you don't

I want to start by noting that when I warn on the matter of infectious disease, I do so only with good cause. That's because Pundita is the anti-scaremonger blog. It's a long story but in one sentence: In 2005, with the help of several readers and a Chinese translator, I ran a panic to ground that'd broken out in East Asia over a mysterious illness. The panic was threatening to waft to Europe and the USA.

I meant to put a file on the sidebar with all the posts about the mystery illness; I suppose I kept forgetting because after a month of thinking about China's pigs I never wanted to see the word "pig" again -- or the word "China," for that matter.

I exerted myself to locate the source of the most sensational rumors about the mystery illness because I knew that few things are more dangerous than to sound a false alarm about a superkiller pandemic. "Fool me, fool me twice." It's the same problem that hurricane forecasters face every year; if the big threat is a dud, many people won't react to the next warning a killer storm is headed their way.

However, after Hurricane Katrina, governors in U.S. states that were at highest risk during hurricane season finally confronted the reality that this was no longer 1902; large numbers of Americans were now living in coastal regions and key industries were perched on the shores.

The governors realized they should worry less about angering constituents and the local Chamber of Commerce, and focus on getting across that from now on, obeying evacuation orders during hurricane season should be considered a way of life. If that caused great inconvenience and unnecessary loss of income when the storm wasn't as severe as predicted -- deal with it by learning to do contingency planning.

This updated approach to the threat that hurricanes pose in this era has not yet been applied by the nation's public health regime to managing government responses to the viral version of hurricane season.

To give you a small idea of how antiquated the regime's thinking is, it would come as a surprise to Americans to learn that the United States has seen several pandemics during the past decade. This isn't generally known because the pandemics are referred to by U.S. public health officials in somewhat Orwellian terms as "flu season."

If it's hard to feature that the annual influenza outbreak in the USA is often a pandemic, that's due to confusion about term. A pandemic doesn't refer to the severity of an infectious disease or the number of people stricken; it simply refers to the amount of territory affected by the outbreak. So there are country-wide pandemics and continent-wide pandemics, and global ones.

Because it's hard for a microbe to create a pandemic unless it's aerosolized
(transmitted by airborne means), pandemics are associated with such means of transmitting viral infections even though AIDS, which is not aerosolized, is considered a pandemic infection.

But again it's the amount of ground covered that defines a pandemic.

As to why the U.S. public health regime doesn't call a spade a spade every year -- if I wanted to be mean I could say it's because they've taken what could be considered an actuarial view of the number of deaths associated with annual influenza outbreaks. Yet it's not that cut-and-dried. A modern society can't function if schools, government, and industry have to shut down every time an influenza season shapes up to be a pandemic.

So, the bottom line is that roughly 30,000 Americans die every year from influenza, many of them elderly, and private and public work sectors are affected by large numbers of absences during an influenza pandemic. But the thinking for many decades has been that the measures needed to drive down the death rate from an influenza pandemic, which includes quarantine, are unacceptable and encroaching on people's freedoms.

However, the federal public health regime, which advises government administrations at all levels in the USA, has their head stuck in the mid-1950s when it comes to dealing with influenza outbreaks. The outmoded view is very dangerous given the realities in this era. And it's prevented the regime from making a distinction between how to treat the present swine flu outbreak and a routine influenza.

Plan A -- for the routine outbreaks -- has been to urge Americans to get a yearly flu shot. Because there is no vaccine available for swine flu, Plan B has boiled down to telling Americans to cover their mouth when they cough and sneeze into their sleeve.

Joe Biden took one look at Plan B and blurted: And stay out of crowded closed environments.

He could have put it more diplomatically but his advice is good. I can only imagine what he advised behind closed doors at the White House. Money says that if he'd still been a U.S. Senator he would have been leading calls to suspend airline flights between the U.S. and Mexico, temporarily suspend cross-border vehicular traffic, and quarantine crews arriving at U.S. ports from Mexico.

What does Joe Biden know that the general public doesn't about the swine flu outbreak? He knows what everyone in government knows by now:

There's not enough time before the onset of flu season in the U.S. to develop and distribute a safe vaccine for swine flu. The emphasis is on safe. If the vaccine is rushed into production without adequate testing, the vaccine can be dangerous. Dr Henry Miller stressed that angle during his conversation on last night's John Batchelor Show.

The swine flu is not exactly 'tapering off' in Mexico, as the Mexican authorities are announcing. It's hopping a plane or hitchhiking to the Southern Hemisphere because the weather is getting hot and humid in Mexico and cool, drier temperatures are coming to the Southern Hemisphere. Flu bugs of all kinds hate hot and humid weather.(1)

The swine flu is not only a new bug, it's also very unusual -- unusual since science has been keeping a record of virus types. So far it doesn't appear to be particularly deadly but it's already shown a tendency to mutate more quickly and broadly across species than the average flu bug. That's what is worrisome.

The estimates, which are based on early studies of the genes it picked up from other viruses, are that the new bug is less than six months old -- maybe three or four months. Yet at its tender age it's already picked up genes from human, bird and swine influenzas. So it's a toss of the coin as to how many times it'll mutate during its jaunt around the Southern Hemisphere, and whether a particular mutation will be highly lethal or even less lethal than its present form. Yet because it's already aerosolized, a very lethal form could touch off a superkiller global pandemic.

The particular problem with the Southern Hemisphere in this case is that it has a lot of open-air farms that keep both chicken and pigs, often very poor sanitation and health care facilities, and so on. All that ups the chance that the swine flu bug will be in hog heaven down south.

By the time the swine flu bug returns this fall to the Northern Hemisphere in its mutated form -- even if a safe vaccine is ready, it'll only give limited protection against the mutation. If the mutation is particularly deadly to humans -- then, how to put this.....unless the public health regime improves on Plan B, we could be facing a high human death toll within a very short period, and with all the dislocations in society that would go with it.

A glimmer of hope is that people in the Northern Hemisphere who were born before 1957 were repeatedly exposed to swine influenzas. That might -- I repeat might-- explain why the swine flu outbreak in Mexico didn't seem to be as hard on older people.

The CDC is dealing with such a big backlog of samples to process that the extent of the infection in the U.S. and its demographics are still not known. But if the pattern of skipping over the elderly holds in the USA, then it could be that our society has caught a break. The bad news is that if the mutation is highly lethal when it returns this fall, it will strike down many Americans in the prime of their life -- those too young to have been exposed to the earlier swine influenzas.

That's what Joe Biden knows.

So this is not the time to ask whether to panic or shrug; those questions went out the window a week ago.

This is the time to realize that there's a storm out at sea and that our nation has five months to prepare, if it hits our shores. Adequate preparation can't go forward until our public health regime updates their thinking about the way that influenzas act in today's era.

To gauge how far behind the times the thinking is, consider the language used by officials last week to describe the progress of the swine flu virus. They repeatedly spoke of the virus as "spreading" around the world.

This virus has not "spread" around the world. This virus has alighted around the world. It's alighted from jet planes. That's how it managed to create a global pandemic in little more than a week, and with a very low number of infected people.

The last time I checked Wikipedia's chart, the bug's presence is suspected in more than 70 countries on all continents except Antarctica. The number of confirmed countries is much smaller; WHO's latest confirmation is 21 countries. But every laboratory processing the samples is dealing with a backlog of cases. So we definitely have a global pandemic on our hands, and WHO will get around to confirming that in another day or two.

Yet there are huge differences between the jet-setter viruses of today and the ones who used air travel in the early decades of transnational commercial air travel:

The earliest transnational commercial jet passengers were mostly from developed countries and the majority traveled to other developed countries, which have modern public health facilities and sanitation, and which have fewer of the rural conditions that are laboratories for influenzas. And the volume of transnational air travel was small.

Today there is a huge volume of air travel between the developed and less-developed countries, and which goes both ways. And the country that has a very high volume of international flights from around the globe -- the USA -- shares a southern border and a large daily volume of cross-border vehicular traffic with a country -- Mexico -- that is a chaotic mix of first-, second-, and third-world living conditions.

The globalized aspect of the swine flu bug -- it has genes from both a 'Eurasian' and North American virus -- means that the index case (the first case of a person infected with the virus) may never be found. The person could have flown into Mexico from somewhere in Eurasia, or driven across the border to Mexico from the southwestern USA, or arisen in Mexico or even further south.

What is known is that humanity's famous luck has been running on fumes since the H5N1 type of bird flu made its appearance; mercifully, it's not in aerosolized form but that could change at any second if it hooks up with the right human, pig, or bird flu genes.

If you say, 'First 9/11, then Katrina, then the financial meltdown; I can't take any more this decade,' all those events are just different statements of the same problem.

The new century arrived right on time with globalized asymmetric warfare and globalized banking but monitoring and crisis-management systems weren't in place to deal with them. That's because the systems were geared to a different set of conditions in an earlier era. The same has happened with the emerging threat from highly infectious lethal diseases that daily travel in high volume around the globe as quickly as a jumbo jet.

And just as with the outbreak of global terrorism starting in 2001, and the 2008 global financial meltdown, there have been warning signs that the public health regimes in countries around the world were living in the past.

That means it's time to update our thinking about how to deal with today's jet-setting viruses.

In the next post I'll talk about what I think is the number one dangerous fallacy U.S. public officials are clinging to, and which they've passed along to President Barack Obama and his Cabinet. If the fallacy can be dislodged from the public health regime, then we can mount an intelligent, humane defense against the worst that a superkiller virus could throw at us.

1) A big thanks to John Batchelor for pointing all that out during his show last night.
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This entry is crossposted at RBO and Uppity Woman.

H1N1 swine flu: WHO circles the wagons in response to criticism they were slow to warn

MEXICO CITY, Associated Press - May 1, 2009

In Mexico, the outbreak's epicenter, new cases and the death rate were leveling off, the country's top medical officer said. Health authorities said they have confirmed 300 swine flu cases and 12 deaths due to the virus.

"The fact that we have a stabilization in the daily numbers, even a drop, makes us optimistic," Mexican Health Secretary Jose Angel Cordova said. "Because what we'd expect is geometric or exponential growth. And that hasn't been the situation."

But as Mexico shut down nonessential government and private business Friday to begin a five-day break aimed at further slowing the spread of the virus, the country's epidemiology chief faulted WHO and its regional branch, PAHO, for not stepping in earlier.[...]

WASHINGTON, McClatchy - April 30, 2009

A Washington state biosurveillance firm raised the first warning about a possible outbreak of swine flu in Mexico more than two weeks before the World Health Organization offered its initial alert about a public health emergency of international concern.

Both federal and international health officials had access to the warning from Veratect Corp. Later e-mails calling attention to the company's subsequent report that the disease was possibly spreading in Mexico were sent to 10 officials of the Centers for Disease Control and Prevention, said Robert Hart, the company's chief executive.

Hart said he wasn't sure why health officials didn't act sooner.

On Monday the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health published on the internet genetic sequence data of A/H1N1 ("new swine flu"). Thousands of scientists immediately began studying the data. By yesterday a few scientists had gone public with their initial analysis. The consensus among the scientists who commented for the Los Angeles Times was that the data indicated that the new strain was not in the superkiller category of influenzas.(3)

A grim caveat came from Peter Palese, a microbiologist and influenza expert at Mt. Sinai Medical Center in New York. After noting that the swine flu lacks an amino acid that makes the disease more deadly, he said that the longer the virus survives the more chances it has to mutate into a deadlier form.

"If this virus keeps going through our summer, I would be very concerned."

Palese's stark appraisal is the backdrop to the growing controversy about WHO and CDC responses to the earliest warnings about the flu outbreak. Events have moved swiftly since Washington Post reports on April 26 and April 30 reports detailed the slowness of U.S. public health officials to respond to important information about the new virus.(4)(5)

And already the Mexican government's chief epidemiologist is calling for an investigation of the World Health Organization's slowness to inform public health agencies and the general public about the threat from the influenza outbreaks in North America.(1)

This aspect of the H1N1 story is about the interface between bureaucratic protocols, politics, medical science, and public health, and has many moving parts. I began sorting through the parts in the last two Pundita posts, but there are still blanks in the story and much fog emanating from as far away as Geneva, the site of WHO headquarters.(6)(7)

We await unfolding events but for now the quotes that introduce this post underscore that Veratect's claims about when they notified the CDC and WHO are not the only issue in play.

The emerging picture is that whatever the extent of their hestitation or confusion at the very earliest stage of the unusual influenza outbreak in their country, health officials in Mexico acted swiftly to comprehensively warn WHO and the CDC. The warnings went unheeded until late in the day.

What we seem to be looking at is a window of anywhere from 18 to 8 days in which WHO (and the CDC) might have taken action in response to warnings from Mexico's government and Veratect, and didn't.

WHO has their side of the story and they're sticking to it.(1) And they have some support from the sheer weight and complexity of the protocols involved in public health bureaucracies and the scientific establishment.

The support tends to crumble, however, when you consider that the Mexican public health officials who sounded the alarm are also bureaucrats -- and scientists:

Mexico's chief epidemiologist accused the World Health Organization of being slow to respond to the country's warning about a health crisis that turned into a global swine flu scare and called for an investigation.

Dr. Miguel Angel Lezana told The Associated Press late Thursday his center alerted the Pan American Health Organization on April 16 about alarming occurrences of flu and atypical pneumonia in Mexico. But no action was taken until eight days later when the World Health Organization said it was "very, very concerned" the outbreak could grow into a pandemic.

"It seems it should have been more immediate," Lezana, director of the National Epidemiology Center, told AP in a telephone interview.

A WHO spokesman said Friday the health body was not informed until April 24 that there was a new flu strain when it learned of the new virus from U.S. authorities. He said the organization then responded rapidly.

[...]

Lezana said that after a rash of flu and pneumonia cases emerged in Mexico in April, his department was so alarmed that it notified by e-mail the local office of PAHO, as called for by international protocols.

"The procedure is very clearly established," Lezana said. "You have to notify the local office, then it sends the notification to the regional office. They analyze the data and decide whether to send it to the WHO in Geneva."

Lezana said the illnesses raised a red flag because the flu was occurring at least a month after flu season normally ends in Mexico.

But four days later, PAHO still had not responded, so the National Epidemiology Center again contacted the local PAHO office and asked for an explanation and whether more information was needed, Lezana said.

PAHO responded that the alert was being handled, he said. But Lezana said that as far as he knew, the PAHO regional office in Washington and WHO took no action until April 24, when WHO announced an epidemic was under way.

Lezana had learned just the day before, from a testing of a sample that Mexico sent to a lab in Canada, that people were coming down with a new, mutated and lethal swine flu virus. By then, more than 1,000 people had been sickened in Mexico.[...](1)

The Veratect part of the story is more complicated because it involves the hestitation of some in the U.S. public health establishment to utilize a research technique called data mining, which Veratect uses to try to identify disease outbreaks at the earliest stage.(2)

However, the criticism that the technique hasn't been properly "vetted" by the science establishment has to be measured against the letter of thanks posted on Veratect's website:

Ihsan Azzam, the State Epidemiologist of Nevada, noted that Veratect's tracking services provided, "The very first alerts I received regarding this Swine Flu Epidemic, as well as the most detailed, accurate, timely and comprehensive."

"Without the continual feeds provided by Veratect, the state of Colorado would have been behind in our understanding of the full scale and magnitude of the current threat posed by swine influenza," said Chris Lindley, Director of Emergency Preparedness and Response, Colorado Department of Public Health and Environment.

So. Thanks to the intelligence of public health officials in their state, Colorado caught a break. The rest of the United States and the world should have been so lucky.

I'll give the last word to "Tucson Willy," who commented at the McClatchy online newspaper site about Veratect's proactive use of data mining to detect early signs of an infectious disease outbreak:

The majority of infection control reports used in our healthcare system are so retroactive they only document what happened, not what can or will happen. Systems/data have three stages - collect some data, collect data and allow reporting of the past data, and finally proactive use of data to predict what will/may happen. Let's give the 3rd stage a chance.(2)

Note: Thanks to RBO's Procrustes for finding and sending the first three news reports I quote in this post.

1) Associated Press: Mexico's epidemiology boss faults WHO; Andrew O. Selsky, May 1, 2009

2) McClatchy: Company warned officials of flu 18 days before alert was issued; Les Blumenthal, April 30, 2009

3) Los Angeles Times: Scientists see this flu strain as relatively mild; Karen Kaplan and Alan Zarembo, April 30

4) The Washington Post: U.S. Slow to Learn of Mexico Flu; David Brown, April 26

5) The Washington Post: System Set Up After SARS Epidemic Was Slow to Alert Global Authorities; David Brown, April 30

6) Pundita: Mexico-U.S. swine flu outbreak and the U.S. Department of Slime; April 2, 2009

7) Pundita: H1N1 swine flu pandemic threat: While WHO and the U.S. government dithered, Veratect Corporation raced to warn the world; April 30, 2009
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This entry is cross-posted at RBO.

John Batchelor Show A/H1N1 Pandemic Alert Special

Note that the KFI portion of the show is now simulcast at WABC. That means the entire six-hour show can now be heard at one radio station/online streaming link. That's great news for Batchelor listeners, and for the show.
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John's show this Sunday will feature five segments with excellent guests to discuss H1N1 and related issues. Below is an outline of the segments and the time of their airing, taken from the show schedule.

See the website for links to live streaming links to both parts of the show, the complete schedule for this Sunday, links to reports quoted in the excerpts below, and John's posts on the H1N1 outbreak.

WABC/WMAL Simulcast (Eastern Time)

705P Eastern Time: Adriel Bettlheim, Congressional Quarterly, re the Obama administration responds to the A/H1N1 outbreak, re the press conference on the outbreak, re the sudden revelation of an advance White House op testing positive for the mid-April visit to Mexico City

805P: Betsy McKay, Wall Street Journal, Atlanta chief, re the search for the origins of A/H1N1, the search for Patient Zero, not Edgar Hernandez of La Gloria, Veracruz, but is it the children in San Diego and Imperial counties? Oaxaca Hunts for Its Flu Victims. The Age of Pandemics

KFI-AM 640/WABC-AM 770 Simulcast (Pacific Time)

705P Pacific Time: Henry Miller, Hoover Institution, re the A/H1N1 outbreak Rapid Spread Makes Pandemic Likely Hong Kong to Quarantine 300 The Age of Pandemics Henry I. Miller: Understanding Swine Flu

720P: Elizabeth Lopatto, Bloomberg, re Killer Pandemic of 1918 Gives Lessons on Limiting Flu, re the WHO declares the new A/H1N1 virus does not closely resemble the 1918 flu.

920P: Jason Gale, Bloomberg, at Singapore, re the A/H1N1 defenses in Asia, re fresh reports of outbreak in Asia.

H1N1 swine flu pandemic threat: While WHO and the U.S. government dithered, Veratect Corporation raced to warn the world

"Requests made over the last five days to WHO spokesmen for a rough chronology of events and interviews with experts have not been answered. Similar requests to the CDC have been turned down."
-- The Washington Post, April 30, 2009 (1)

The chronology mentioned above relates to the progress of swine flu; it's early days to nail that down. But there is another timeline, a sort of chronology of bureaucratic dithering, which is already available.

The Obama White House and the U.S. Departments of Homeland Security and State fell down badly by dragging their feet in reaction to the earliest concrete warnings of an unusual flu outbreak in Mexico. In my last post, on Monday, I voiced my suspicions about the matter. I was not the only person to harbor such suspicions. In an effort to blunt reporters' pointed questions, the White House issued a Q&A on Monday. From the Boston Globe's report on the Q&A:

QUESTION: When did the US learn about the swine flu situation in Mexico?

ANSWER: As John Brennan of the Homeland Security Council indicated in this afternoon’s briefing, we [the White House] did not learn about the swine flu cases in Mexico until late last week.

From this afternoon’s briefing at DHS:

QUESTION: Can you tell us, Madam Secretary -- and perhaps Mr. Brennan, as well -- a little bit about when the United States government first became sort of fully aware of, you know, these events in Mexico [...]

[JANET] NAPOLITANO: Sure. John, do you want to -- OK.

BRENNAN: The first instances of the influenza down in -- in Mexico were the end of last week. In terms of confirmation, it was like Thursday or Friday of last week. [April 23 and 24]. So the Mexican health authorities knew they had a health issue. And, therefore, they sent the samples to both the Canadian labs, as well as to the CDC. And so the confirmation that it was swine flu was last week. [...]

Those replies are precious. They avoid the key issue of when the U.S. government was apprised of an unusual flu outbreak Mexico and the Canadian government's intelligent actions in response.

Yet evidentially Napolitano and Brennan were unaware during the briefing that Veratect Corporation's lead scientist, Dr James Wilson, had gone public with Veratect's timeline, which is published on Wilson's website, Biosurveillance; it details Veratect's strenuous efforts to impress on U.S. public health officials and the World Health Organization the urgency of the flu epidemic unfolding in Mexico.

If Rahm Emanuel didn't know earlier about Veratect I'm sure he found out this morning when he read The Washington Post:

[...] News of an outbreak of severe respiratory illness in Mexico burst into public consciousness last Friday, April 24.

That was 18 days after public health authorities there started looking into unusual cases of pneumonia in their country, eight days after Mexican authorities notified the World Health Organization of the growing outbreak and four days after the events came to the full attention of the Centers for Disease Control and Prevention in Atlanta.

Officials involved in pandemic preparedness at the U.S. Department of Health and Human Services, which oversees the CDC, did not learn of the Mexican outbreak until the day the rest of the world did, April 24. They did know, however, that the CDC was investigating six rare cases of swine influenza in California and Texas.

As Mexican health authorities were finding cases of unusual illness, they at least once officially notified the WHO's regional office in Washington, the Pan American Health Organization (PAHO), of a possibly brewing epidemic.

People in the WHO's Geneva headquarters also received several urgent warnings from a biosurveillance firm, Veratect, based in Kirkland, Wash.

The delay in making the global health community aware happened despite the adoption in 2005 of international health regulations requiring nations to report to the WHO within 24 hours any disease outbreak that is serious, unusual, at risk of spreading internationally or potentially disruptive of trade.

By the time international authorities became fully aware of the outbreak, there were about 800 cases and at least 50 deaths, and the virus was unknowingly being carried into other countries.

What seems apparent is that the world health community's newly rebuilt, well-oiled -- but never used -- mechanism for warning the world about pandemics may have given nations far less lead time than intended.

"After all this work on flu surveillance and setting up a reporting system and then this -- perhaps this isn't the best example of how it's supposed to work," said a highly placed health official in the Obama administration who was not authorized to speak on the record.

After the balky start, however, the WHO's pandemic response system is running well.[...](1)

That's a very nice way of putting it all, but there are passages in the Veratect timeline that are damning.

Before I provide examples: you can abandon the forlorn hope that Veratect's emails and phone calls simply got misplaced or relegated to the low-priority inbox.

Veratect is to pandemic what NORAD is to missiles. It's an early warning system that, working from open-source reports and utilizing an extensive global network of contacts, locates and tracks disease outbreaks around the world -- then warns governments of any disease pattern that might indicate the start of a pandemic. So it's a fair guess that Veratect alerts are immediately opened by everyone on the email list. From the (updated) timeline (emphasis mine):

April 20

Veratect was urgently asked to provide access to the VeraSight Global platform on 20 April by a client in the US public health community, and indicated they had received word from their counterparts in Canada that Mexican authorities had requested support. This client speculated whether notification of all southern U.S. border states’ public health authorities should be done and were confused as to why the CDC had not issued an advisory. Veratect contacted the CDC Emergency Operations Center to sensitize them about the situation in Mexico. CDC indicated they were already dealing with the crisis of recently detected H1N1 swine influenza in California and possibly Texas.

April 21

[...]

Veratect sensitized the International Federation of Red Cross who in turn requested broader access be provided to the Pan-American Disaster Response Unit (PADRU). Veratect moved to notify several US state and local public health authorities, providing the caveat the situation in Mexico remained unclear due to pending laboratory results. Veratect reached out to World Health Organization (WHO) operations, informing them the Veratect team was on an alert posture and available for situational awareness support. They indicated they and their subordinate, the Pan American Health Organization (PAHO) were now aware of the situation but had no further information. Veratect also extended contact to the British Columbia Center for Disease Control and offered assistance in tracking the events in Mexico. All contacts indicated laboratory results were pending.

[...]

Veratect also reported the National Ministry of Health issued a health alert due to a significant increase in influenza cases during the spring season in Mexico.

Officials indicated that there have been 14 influenza outbreaks throughout the country. The most heavily affected states are Baja California, Chihuahua, Distrito Federal (Mexico City), Hidalgo, Tlaxcala, and Veracruz. Local case counts were not provided.

April 22

Veratect also reported the Mexican Ministry of Health indicated that an "unusual" outbreak of laboratory-confirmed influenza caused five deaths from 17-19 April 2009 in Mexico City, Mexico. The deaths occurred at the following three hospitals: el Hospital de la Secretaría de Salud (2), el Institute Nacional de Enfermedades Respiratorias (2), and el Hospital Ángeles del Pedregal (1). According to unofficial sources, the fatal case count was higher than that provided by officials. There were currently 120 influenza cases hospitalized throughout Mexico City. National health officials indicated that influenza vaccines were sold out in Mexico City and that they were attempting to acquire additional supplies of the vaccine.

At this point, the Mexican Health Secretary reportedly stated there was an influenza epidemic in Mexico City and throughout the rest of the county. In response to the cases, the official stated health authorities would launch a public awareness and vaccination campaigns.

Sources reported a total of 20 fatal cases of influenza throughout Mexico over the disputed timeframe. The other cases were located in San Luis Potosí (4), Baja California (2), and Oaxaca (1). The Director of Epidemiology at the National Center for Epidemiological Surveillance and Disease Control characterized the outbreak as "quite unusual."

No information was provided indicating that the strain of influenza itself was unusual. Rather, several sources indicated that it was "unusual" to record this many fatal influenza cases during this time of year. Influenza cases normally peak from October to February, while these cases had occurred during Mexico’s spring season.

Canada announced a national alert for travelers returning from Mexico with respiratory disease, beginning a campaign of public media announcements. Potentially ill contacts were identified returning from Mexico and isolated in Canada. [...]

Why didn't the U.S. government issue a similar alert at the same time? Why didn't State post a travel advisory or at least an alert at the time?

If they answer that such actions are not the U.S. government's traditional way of handling things, particularly regarding a neighboring country -- traditions should have gone out the window after the SARS outbreak.

If they answer that they were waiting for WHO to raise the pandemic alert level to 4 -- here we come to the most interesting part of the story:

If it was left up to WHO we might be still be waiting for them to raise the alert level. But in this crisis WHO has been the caboose and Veratect has been the engine. The general public is the last to know, but Veratect had already raised the pandemic threat level by treating the outbreak from the viewpoint of 'operational reality.' On April 26 James Wilson discussed that reality in a post at Biosurveillance:

Are the WHO Pandemic Phases and the CDC Pandemic Severity Index Relevant in the Operational Environment?

WHO has recently announced they do not have enough information to change current WHO phase of pandemic alert [...]

At this point, it is safe to say the world has moved on with heightened surveillance, response actions, and additional preparations regardless.

DHHS and CDC also have the so-called Pandemic Severity Index, which of course is not in use at the moment because no one wants to utter the dreaded word, “pandemic”.

The PSI has not been publicly used since the beginning of the current swine flu crisis. The reason is semantics - the word “pandemic” has not been embraced yet by the public health community.

And yet, the world clearly has embraced the fact we have an emergency to deal with. [...]

The next day WHO in effect rubber-stamped the Veratect warnings by raising the pandemic threat level to 4. They did the same when they raised the threat level to 5.

WHO really had no choice but to raise the threat level -- and the U.S. government had no choice but to bring up the rear. The global network of physicians and scientists who were plugged into BIWAC -- the Biosurveillance Indication and Warning Analysis Community, which Wilson co-founded -- raced ahead of the lumbering gait of bureaucracy and drove the response to the threat of an emerging disease.

In his post last night at Biosurveillance Wilson found kind words for WHO and the CDC. But he made clear that locating the earliest signs of public health threats requires a particular kind of institutional 'culture' that's quite different from the one generated by a large complex bureaucracy. He also stressed that while the two cultures can be complimentary, they represent -- or should represent -- a division of labor:

[...] The best (albeit imperfect) analogy I use for what our team does versus what public health does is the US National Weather Service versus FEMA.

The National Weather Service focuses its efforts solely on the detection and warning function, whereas FEMA is more concerned with what happens when and after the hurricane hits. The culture of early warning, and the people drawn to that kind of work, are very different from the response culture of FEMA.[...]

I hope you find time to read the entire essay (which is short), because Wilson's observations are at the heart of debates about many areas of endeavor. Fans of Zenpundit will recognize in Wilson's argument the tension between the most creative military minds of today and the military bureaucracy. Yet Wilson misses the mark when he tries to rationalize the ways of bureaucracy:

CDC, PAHO, and WHO must maintain credibility at all times with the public. This is non-negotiable or situational control may be lost. During a pandemic, it would be a disaster for public health to lose credibility. Therefore, they must be sure, confident, and push diagnostic resolution to the maximum degree possible. The downside is that process takes time.

The biggest downside is that bureaucracy is always under the thumb of a political class, which is taffy in the hands of competing special interests and government agendas. The upshot, too often, is screw-ups on a horrific scale. This makes it hard for bureaucracies to maintain credibility at any time with the public, much less all the time.

This brings me to the question: What was Argus doing while Veratect was moving heaven and earth to warn agencies, including the CDC, about the emerging disease threat in Mexico?

What is Argus?

Situated on the tree-lined campus of Georgetown University’s Medical Center in Washington, D.C., is Project Argus, one of the nation’s premier biosurveillance systems for detecting and tracking early indicators of, and warnings about, international biological events. Argus exemplifies real-time global health engagement taking place between academia and federal government agencies tasked with the critical mission of protecting domestic and global public health, and national security.

Argus’ primary function is to alert CDC, and other users, to biological events that may require a public health response. The system monitors media and other electronic sources at the local level around the globe for three types of indicators: reports of disease outbreaks, potential environmental triggers, and social disruption.

Since it began operations in July 2007, Argus has logged more than 30,000 biological events involving pathogens such as avian influenza, Ebola virus, cholera, and other unusual pathogens that have caused varying states of social disruption throughout the world. Argus currently accesses more than 1 million pieces of information daily, and produces, on average, 200 reports per day. Argus covers all the countries officially recognized by the United States. Analysts are collectively fluent in 36 languages.[...]

Would the fluency include Spanish, I wonder?

Taking a shot in the dark, it might be that Argus hasn't been quite the same place since Dr. Wilson left. From his biography at Biosurveillance:

James M. Wilson V, MD [...] is currently the Chief Technical Officer and Chief Scientist of the Veratect Corporation in Seattle, Washington. He was the Principal Investigator of Project Argus, Chief of the Argus Research Operations Center, and Division Head of Integrated Biodefense at the Imaging Science and Information Systems Center, Georgetown University. [...]

I can understand that Dr Wilson would want to maintain a collegial tone with the CDC and DHS (which he also worked for), but let's dispense with the crumpets and croquet, shall we? The U.S. government screwed up by ignoring Veratect's early warnings and the example set by Canada in dealing with the virus.

As for the CDC's fancy biosurveillance agency and its fluency in 36 languages --

Reading through the CDC description of Argus and the US interagency cooperation to deal with health threats around the world -- (E.g., "The strong USG agency ties developed through Argus and the BIWAC helped to identify laboratory collection difficulties in response to a recent outbreak in Tbilisi, Georgia, of African swine fever (ASF), a highly contagious disease affecting pigs that, unchecked, can spread rapidly and cause crippling economic consequences.") -- I was struck by the huge amount of attention that CDC lavishes on far-flung parts of the globe. Yet somehow they were slow to react to a health crisis on America's doorstep.

1) The Washington Post: System Set Up After SARS Epidemic Was Slow to Alert Global Authorities; David Brown, April 30

2) The Washington Post: U.S. Slow to Learn of Mexico Flu; David Brown, April 26

Mexico-U.S. swine flu outbreak and the U.S. Department of Slime (UPDATED 4:10 PM ET)

UPDATE 4:10 PM ET

U.S. set to issue travel warning to Mexico
Mon Apr 27, 2009 3:26pm BST

WASHINGTON (Reuters) - The U.S. government plans to issue a travel warning later on Monday urging Americans to avoid all "nonessential" trips to Mexico because of an outbreak of swine flu, a U.S. official said. [...]

"There will be a travel warning urging Americans to avoid all nonessential travel to Mexico because of the swine flu," said a U.S. official, who spoke on condition he not be named as the warning has not yet been officially announced.

It is likely to be announced by the U.S. Centers for Disease Control and Prevention, although the State Department will also carry details on its Web site, the official said. [...]

And breaking news 4:25 PM ET: WHO has just raised the pandemic threat level to 4, which acknowledges what they knew several days ago, which is that the virus is transmitted primarily human-to-human.

Gee, maybe I should call State "slime" more often. That's about as much humor as I can wring out of this grim situation.
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Yesterday The Washington Post published a report titled U.S. slow to learn of Mexico flu, which begins:

U.S. public health officials did not know about a growing outbreak of swine flu in Mexico until nearly a week after that country started invoking protective measures, and didn't learn that the deaths were caused by a rare strain of the influenza until after Canadian officials did.(1)

But why didn't the U.S. Department of State inform the CDC of the situation in Mexico?

Or are we to assume that both the Mexican and Canadian foreign offices refrained from informing State that a killer epidemic in Mexico was caused by a new -- new, not rare -- virus, as soon as they had such evidence?

The Post also reports, from the same article:

[I]t seems that U.S. public health officials are still largely in the dark about what's happening in Mexico two weeks after the outbreak was recognized.

Asked at a news conference yesterday whether the number of swine flu cases found daily in Mexico is increasing -- a key determinant in understanding whether an epidemic is spreading -- Anne Schuchat, an interim deputy director of the Centers for Disease Control and Prevention, said, "I do not know the answer to those questions."

The rest of the Post article explains how Canada came to be contacted before the United States. But if the CDC is still having trouble coordinating with their Mexican counterparts on this most urgent matter, the ball is in State's court.

Memo to those Members of Congress who're trying to do an end run around Bob Gates by restoring State to the power it had over the U.S. military during the Clinton presidency. You need to reorder your priorities in tbe face of a global pandemic. If Mrs Clinton is unclear about her job duties that problem should trump everything else.

But I want to return to the odd statement, "U.S. public health officials did not know about a growing outbreak of swine flu in Mexico until nearly a week after that country started invoking protective measures ..."

I understand that the Central Intelligence Agency has been very busy talking with lawyers since the CIA memos were released. But this is not the remotest region of the Hindu Kush we're talking about. Aren't there any Spanish speakers at Langley?

In other words why should the CDC have to wait to learn from Mexican officials that there was a killer flu outbreak in Mexico?

Then there's the NSA. And State's own spy agency. Oh -- and there's the DEA, which has a large presence in Mexico.

Didn't any DEA agents phone stateside in early April and say, 'Ship us more Tamiflu yesterday! There's a strange flu epidemic going on here?'

And say, doesn't the U.S. have an embassy in Mexico City -- which is the locus of one of the biggest outbreaks of the epidemic?

No embassy workers rang up State and shrieked, 'Send us more Tamiflu, were trapped in an epidemic?'

Nobody did that, huh?

And nobody at the embassy sent a routine report to HQ in Washington and added, 'By the way, flu season is over here, but there's been an outbreak of something that seems like a really bad flu.'

Oh but then I forgot! You can't contact Foggy Bottom from there because Mexico City is situated on the dark side of the moon.

I don't want to hear that State -- and the White House and the congressional leadership -- didn't know.

As to why they didn't tell the CDC what they knew -- who can plumb the mind of human slime? But you'd think that even slime would have a sense of self-preservation.

There is still no travel advisory from State regarding the outbreak of a lethal epidemic in Mexico, not even a travel alert.

1) H/T No Quarter

This entry is crossposted at RBO.

Dan Riehl links to this post and add his pithy comments.

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.
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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.

Web-Scrubbin Varmits

ACORN does it again, and again they get caught red-handed. This time it's web-scrubbing. RBO nails down the latest twists and turns of those sneaks.