Saturday, May 2

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
This entry is cross-posted at RBO.


Anonymous said...

Excellent article, Pundita!

CDC and WHO need to be investigated for their actions in permitting the spread of the virus through the US and around the world.

The earliest date I've seen published is 4/16 for the CDC to recognize they had a new (and potentially deadly) strain of flu virus at the US border:

So why didn't the CDC alert medical personnel at hospitals and clinics, particularly in the border states, to isolate suspicious cases and to take extra precautions in dealing with patients with influenza?

If the strain was deadly, medical staff would have been taken out in a flash.

Pundita said...

Anonymous, I didn't think of that angle but sure, medical personnel would have been sitting ducks.

Anonymous said...

One other question I have is about the timing between CDC's confirmation of the second swine flu case (4/17) and the online publication of their report on 4/21. Note where they say that the illnesses appear to be human-to-human transmission:

With such an important finding, why wait 4 days to post this online? Four days can be an eternity with a rapidly spreading virus.

Pundita said...

Anonymous -- That's astounding. They suspected H2H transmission that early.

I have read the report you sent earlier about the NHRC's key role. That, too, is astounding. Thank you for the tips you've been sending.

What blew my mind was the revelation at the Biosurveillance site that on April 21 Canada's gov hit the ground running: "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."

BTW I just learned that Wikipedia has put up a timeline in addition to their frequently updated "2009 swine flu outbreak" page

Both pages are rich with links to reports on the outbreak. Also, I assume you're following the Veratect-Ozmosis Twitter. The Veratect site has a record of recent tweets.

Over the last few days it's been dawning on me that the USG operational response to the outbreak rests on a fallacy. I'm working up a post on that now and will put up a note here as soon as it publishes.