Monday, May 4

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.
    This entry is crossposted at RBO and Uppity Woman.


    CGardner said...

    One thing I have noticed is that the New York State totals have barely inched up in confirmed cases over the past few days, even though NYC and NYS DOHs have the kits to confirm swine flu without the CDC Labs.

    As it turns out, they are only testing cases requiring hospitalization or if a case turns up in an area previously thought to be free of the flu.

    I bet Joe Biden knows LOTS more than we do.

    Pundita said...

    Yes, that's exactly what's happening -- and not only in New York. It seems that all states are now following the recommendation to only test for patients who are obviously seriously ill with flu-like symptoms. Some of that I guess is budget considerations but that's one area where they should have asked for federal funds because the recommendation is going to badly skew data collection on swine flu.

    CGardner said...

    Actually, what I believe is happening is that the CDC has begun to treat this like an annual flu outbreak.

    They have a surveillance system from a sample of clinics/hospitals that will do swabs of patients reporting symptoms. From these stats, they make estimates of the number of infected patients across regions in the US.

    This is a very confusing thing to do for people who are worried about swine flu and don't follow the daily updates from CDC. It also leads to a false sense of complacency that the virus has been licked.

    But, that's just my opinion. . .

    Pundita said...

    I think your opinion is on target.

    DocJim said...

    We are indeed reaping the harvest of jet airplanes. The old quarantine methods will be brought back at some point. I gave this some thought as we embarked across the Atlantic ten days ago. Five family members going for a sight-seeing trip across Scotland. I figured the UK might stop us in our tracks upon landing in Glasgow and the next step would be to put us back on flights to the USA as quickly as possible. Yes, we took face masks and Tamiflu with us.
    Good for me and my wife that we were born before 1957 (I recall having "Asian flu" the fall of 1957. It was my only experience with known influenza and I don't really want to repeat it.)
    One of the biggest problems remains with the scientists and definitions. We may have enough partial immunity to get by--from previous flu, from previous flu vaccines, and from anti-virals. But those who are sick from something else or a baby or elderly frail will be the most likely to die.
    It all sounds pretty grim.

    It is time for MANY large companies doing global businesses to start getting into teleconferencing. There is no other reasonable way to run global business. (It is NOT my kind of work, so I am not touting it for personal gain.)

    Between teleconferencing, avoidance of illegal immigration, and quarantine usage we should make this globe a safer place to live. But all these items require giving up what some people feel is their right for total freedom.

    To paraphrase the old sailor's lament (the ocean is so large and my boat is so small), the world is so complicated and our means are so simplistic.

    Pundita said...

    Yes. We need to confront the realities of this era; if we don't then, just as with 9/11, disaster will force us to update our thinking.

    I will be putting up another post on the swine flu situation, hopefully tomorrow, which might make a reference to an earlier comment you left on this blog.

    It's been surfacing in the press that reportedly, more than half of the Mexico swine flu victims showed hyper-immune symptoms -- and I assume they actually died of that rather than the virus.

    No reports yet of hemorrhaging or bruising that would indicate internal hemorrhage. But the cytokine storm reaction does seem to be in play.

    That's not surprising given that swine flu is a new virus, but still very troubling because the healthier the immune system, the more fiercly it fights a new invader -- a reaction which can be more lethal to the sufferer than the actual virus.

    We're not out of the woods yet, not by a long shot.

    DocJim said...

    Is this swine flu new?
    Definitions are tough. Influenza viruses are sort of promiscuous nucleic acids. They play mix and match. That is the rub--the great alarm.
    On the other hand, we will pray that the mix and match doesn't get the bad stuff in it at the same time it is immunologically too distinct and no one has very good antibodies that give partial protection.

    I agree that the statistics look really strange. This virus was moving quickly and all of a sudden there is a drop in the case rates. Sounds like the theory of only type-testing those hospitalized because they are seriously ill may account for that.

    DocJim said...

    Aha, the wonder of mathematical models. Were those not a major part of the real estate bubble and then the collapse??

    I know the importance of having mathematical models, but they hint at things to come rather than define the future.

    I recall the biology professor many years ago touting the notion of the knowledgeable and intelligent making plans for everyone on the basis of that great knowledge. I had the instincts to doubt that predictability.

    I believe the influenza models will join the business models in putting mathematic models into their real and proper place. Nice hints to have, but one must be ready to adapt to reality which just might be different.

    The meteorologists were among the first to announce the results of mathematical models on a daily basis. They have made better forecasts with them, but reality is not always the same temp or rain as the model suggested. Further, local is determined by microclimate matters and completely defined by the big fronts and systems. A local Wash DC meteorologist often stated the forecast of the local weather bureau and then would state his own ideas about some deviation on it. He was often correct in his own notions.

    Isn't that the real value of knowledge/experience? The ability to adjust and shift as the future unfolds.

    Pundita said...

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

    The hope is that while it starts with a bang it quickly fizzles as it moves through more and more hosts -- evidentially a common phenomenon.

    But the stats are a mess. They really fell down there. The CDC lulled physicians into not swabbing all but the most serious suspected cases by telling them that the virus produced common flu symptoms.

    Now they're up the creek without a paddle since Mexico's health minstry announced that 57% of the deaths involved a hyper-immune system response.

    The CDC is trying to brazen it out by saying that they have all the data they need to determine how the virus will spread and that their mathematical models will do the rest. Less math more common sense.