Wednesday, May 13

H1N1/swine flu: CDC and WHO help unleash a pandemic

I've taken up a new hobby: collecting definitions of "pandemic" that have emerged since swine flu became news. I suspect that as with stopping genocide, the closer officialdom is pushed into battle mode against pandemic, the more the goal posts move ever so slightly as to the meaning of the word. This means, at least as of this minute, that WHO still hasn't raised their pandemic threat level to Pandemic.

How about if we keep it simple? When a lot of people on a continent or all over the world are getting sick from a human-to-human transmitted disease that can't be contained, that's close enough.
"On April 17, 2009, CDC and the California Department of Public Health determined that two cases of febrile respiratory illness occurring in children who reside in adjacent counties in southern California were caused by infection with a novel influenza A (H1N1) virus."
-- CDC influenza surveillance report, week ending May 2

May 1, 2009 - AAAS ScienceInsider:
Exclusive: Interview With Head of Mexico's Top Swine Flu Lab

Microbiologist Celia Alpuche heads the laboratory in Mexico that has become ground zero for the country's outbreak of swine flu. Alpuche spoke to Science yesterday from her office at the Instituto de Diagnóstico y Referencia Epidemiológicos (InDRE) in Mexico City.

Many people have raised questions about whether Mexico could have detected this outbreak earlier and contained it before it spread elsewhere. But as Alpuche explains, InDRE had a confusing situation because the virus surfaced in the middle of flu season--and it may not have originated in Mexico anyway. Alpuche also sets the record straight about why it took several weeks to link the outbreak to the first case with symptoms, a 4-year-old boy from La Gloria in Veracruz state. And she frankly describes the limitations of her own lab.

InDRE has worked closely with the Public Health Agency of Canada and the U.S. Centers for Disease Control and Prevention (CDC) to identify the virus as the cause of the outbreak, and Mexico continues to collaborate to test samples of suspected cases.


Science: When did you learn of the first two California cases of swine flu that were reported in the MMWR on April 21.

Alpuche: CDC sent me a preprint. I'm not sure exactly when.

Science: When were samples sent to Canada and CDC?

Alpuche: April 21. We asked for help from both at same time. The CDC is my collaborating center in the WHO network. They always help us, doing quality assessment for us, giving us reagents, doing training, transferring technology. But to do shipping for both of them, it was kind of hard. It was a little delayed to get all the permission from the U.S.

Science: Was your decision to send it to Canada also because U.S. authorities were holding up your samples?

Alpuche: No, not at all. I sent these samples to the CDC because they are my collaboration center. That's the way to do it. We get all the help we need from the CDC.

Science: But I think it's important for the United States to learn from this. How long were your samples held up and why?

Alpuche: It was just 1 day difference. I cannot tell you if this is because it is more difficult to send things from Mexico to the U.S. instead of Canada. To be honest, I cannot explain that.

Science: I imagine you were frustrated by the delay.

Alpuche: Yeah, but we knew we were going to get the help that we needed, and we got it. It was just a small difference.

Science: When did you first hear back from Frank Plummer [head of the National Microbiology Lab at the Public Health Agency of Canada] about your samples?

Alpuche: We got the preliminary results April 22. Dr. Plummer got the samples at 3:00 in the afternoon, and by midnight he was calling me to say we had influenza A. Some of the samples I sent him, we knew they were influenza A. That week, we started seeing the A's and we started to change our mind about this influenza B prolongation of the seasonal influenza.

Science: When did you learn that they were positive for a new swine flu virus?

Alpuche: I first learned that it was swine from Frank Plummer; that was in the afternoon of April 23. And later that night Dr. Nancy Cox [of CDC] in a teleconference we had with Mexican experts, we were discussing this and she gave us the preliminary results that we have some swine strains, the ones that just arrived that day at CDC.

The entire interview is riveting but here I only quoted from a small part of it. If you ask whether it was really an interview or the Third Degree -- well, I doubt AAAS applied thumbscrews but it's a scientific organization that's concerned with science policy. So there are parts of the exchange that read more like a cross-examination than an interview.

Three days later ScienceInsider published another riveting interview. May 4, 2009:
ScienceInsider Exclusive: SARS Sleuth Tracks Swine Flu, Attacks WHO

HONG KONG: Yi Guan has plenty of experience at ground zero of an epidemic. In spring 2003, the virologist at Hong Kong University (HKU) isolated the SARS virus from masked palm civets in a wild animal market in China’s Guangdong Province. When the virus flared up again in late 2003, his team’s recommendation to slaughter all captive civets in the area may have been the key to stopping SARS in its tracks: The virus has not reemerged since.

Although SARS is his claim to fame, Guan has spent most of his career studying influenza after earning a Ph.D. in swine flu under eminent flu expert Robert Webster of St. Jude Children’s Research Hospital in Memphis, Tennessee. He is currently collaborating with Webster’s group.

Guan has been highly critical of what he sees as WHO’s slow response to the H1N1 emergency. He took a break from marathon hours in the lab and 3 a.m. conference calls with U.S. colleagues to speak with ScienceInsider.

—Richard Stone

Q: Where did WHO go wrong?

Y.G.: Friday night [24 April], I was in Bombay airport, waiting for a flight back to Hong Kong. They [WHO and CDC] already knew the situation in Mexico. Mexico said they had human-to-human transmission, and MMWR [Morbidity and Mortality Weekly Report] reported three cases in America—these cases were community cases. Already it was an outbreak in the U.S., although it wasn’t severe, it didn’t kill people. I was still optimistic we could contain H1N1. Then nothing happened all weekend.

Q: So WHO should have raised the alert level sooner?

Y.G.: Yes! WHO should have gone to level 4 or even level 5 on Friday.

We missed the golden period to contain the virus. Several hours could be another couple hundred cases. Every second was valuable at that time. We made a huge mistake. From then on it was countdown to the pandemic.

Do you get the feeling it's a good thing he wasn't in the room when Alpuche told the interviewer that a one-day delay was just a small difference?

On Monday, April 27 at approximately 3:30 PM ET, Reuters reported that an unnamed U.S. official had said that the CDC and probably the U.S. Department of State would announce, later that afternoon, a travel warning about Mexico.

At approximately 4:25 PM ET on the same day, the news broke that WHO had raised their pandemic alert to 4.

It seems that WHO (headquartered in Geneva) coordinated their announcement with the U.S. one.

Just so we're clear on what we're dealing with, here's a quote from a ScienceInsider report on the key role that U.S. Navy researchers played in spotting the new form of swine flu. The report puts the day back to April 16 when the CDC knew that an unusual new flu had appeared in the USA. That is one day earlier than in the CDC report I quoted above:
Late on the afternoon of 16 April, 5 days before the public first learned about the current outbreak of swine flu, Michele Ginsberg ... chief of community epidemiology for the San Diego County Health & Human Services Agency ... received word from the U.S. Centers for Disease Control and Prevention (CDC) that a 10-year-old boy in San Diego County had tested positive for the rare infection.
To make extra sure we know what we're dealing with, U.S. News and World Report's May 11 article on swine flu quotes Gordon Dickinson, chief of infectious diseases at the University of Miami Miller School of Medicine and the Miami VA:
U.S. public health departments are so overwhelmed [with testing for swine flu] Dickinson said, that they are asking facilities not to send samples for testing unless there is a cluster of outbreaks or a particular clinical need.

"They can't keep up," he said.
If you're wondering whether a congressional inquiry would help, there's already been one. A House of Representatives panel was convened on May 7:
The swine flu outbreak revealed gaps in pandemic preparedness, including inconsistent regulations and response practices, witnesses told a House committee Thursday.

"We discovered that we did not have a system in place to track and report the individual schools that had been ordered to dismiss students due to H1N1," state Superintendent of Public Instruction Jack O'Connell said during an Education and Labor Committee hearing about pandemic readiness in schools and work places.

"Another issue that certainly needs addressing in order to improve our response to such outbreaks is school nurses."


Representatives from the government and business agencies said pandemic plans put in place in 2006 to respond to the avian flu provided guidelines that helped communities deal with the swine flu virus. However, they said they would continue working to better coordinate responses.[...]
The panel didn't take the CDC to task for dragging their feet about warning the public and firing up their emergency operations center, but drag their feet they did. They should have issued a travel advisory about Mexico at least as early as April 22, when Canada's government issued theirs, and warned the public in other ways as well.

I think it's taking time we don't have at this point for Congress to launch a thorough investigation of the CDC's actions because the agency seems to have a lot of problems. Over the years it's taken on a dizzying array of functions, which extend around the globe.

The worst of the problems might be solved by breaking the agency into a few smaller ones and absorbing some functions into other agencies, but any such solutions couldn't be implemented quickly.

The United States seems to be catching a break with the swine flu's first pass through North America. Yet if our luck holds, that should be viewed as buying us a couple months to retrench before the bug returns. Retrenching might include placing CDC's infectious diseases threat assessment and emergency response operations under an agency that's dedicated to handling such challenges.

That could mean moving those national defense-related functions under the authority of a defense agency. Right now all the CDC centers are under the Department of Health and Human Services.

If anyone has a better suggestion I'm all ears. It's not as if the CDC isn't trying. It's just that their best wasn't good enough this year, when Nature sprang a surprise. So instead of heading off a humanitarian disaster they might have helped create one.


Thanks to CGardner for the link to the ScienceInsider report about the Navy's role in spotting swine flu, which introduced me to the very valuable SI website.

This post builds on four earlier Pundita ones:

April 30
H1N1 swine flu pandemic threat: While WHO and the U.S. government dithered, Veratect Corporation raced to warn the world

May 2
H1N1 swine flu: WHO circles the wagons in response to criticism they were slow to warn

May 4
What Joe Biden knows about the jet-setter swine flu that you don't

May 11
Swine flu/H1N1: Your life, riding on the CDC's slow boat from China


DocJim said...

Most importantly, this was a God-given opportunity.

THIS swine flu has NOT been broadly severe clinically--some people have died, but not many.

This was a dress rehearsal for serious influenza, like the worries about the bird flu strain.

The CDC needs to go back to being the "Communicable Disease Center" and to keep its lab and epidemiology focus. Congress needs to get legislation on this ASAP.

DocJim said...

"All but one patient (Patient 7) initially received a diagnosis of infection with an influenza A virus that could not be subtyped, on the basis of reverse-transcriptase (RT-PCR) testing."

NOTE: "could not be sub-typed" in this sentence. I believe this means it was not one of the previously known human sub-types.

From New Engl Journal of Medicine online, article entitled "Triple-Reassortant Swine INfluenza A (H1) in Humans in the United States, 2005-2009" by Shinde, et al, at New Engl J Med website.

First case of type A influenza with partial genes from swine, human and avian strains was found in Dec 2005 and they describe 11 cases over these 4 years, most of whom had contact with pigs. All survived.

No one has said so far that this is the "same" as the Mexican flu, but it may be.

This makes a good case for "containment" or "isolation" or "quarantine" (choice in terms) when odd bumps in cases of influenza appear. An editorial article in the same online NEJM series very gently reiterates the importance of this.

Pundita said...

DocJim, I agree that Congress needs to act fast. I am just not sure exactly what's to be done with CDC.

From reading their website, they've clearly taken the position that because communicable disease is a part of life, they have to be involved everywhere: Hurricanes, tropical storms, large public gatherings, you name it.

So I dunno. I think this is what's called mission drift.

Re the info from NEJM -- that's fascinating, although I'd assume that if the 2005 virus was exactly the same we'd have heard about it by now.

However, the gene sequence for the 2009 H1N1 virus hasn't even been on the internet for two weeks, I don't think, or not much longer than that. So who knows what will turn up once more scientists study the gene map?

If you find time could you send the link to the NEJM editorial you mentioned? Thank you.

CGardner said...

This is a link to Senator Tom Coburn's report on CDC, which briefly discusses bio-terrorism readiness and "mission creep:"

Senator Coburn, of course, is conservative, but makes some excellent points on CDC's prevention programs and the lack of accountability to produce results.

Pundita said...

CGardner -- Thanks for that info! I can't wait to read what Coburn (who's an MD) has to say about the CDC

DocJim said...

The "triple reassortant swine flu" URL is below

Pundita said...

Thanks, DocJm!

Anonymous said...

The author of has written an excellent article. You have made your point and there is not much to argue about. It is like the following universal truth that you can not argue with: There is always someone more intelligent than you (and they will NEVER call when you do tech support). Thanks for the info.