Monday, June 29

H1N1/swine flu: China Beats the Devil or Why CDC Scientists Shouldn't Do War Planning

While the governments of Australia and the United States continue to dither about whether to administer a swine flu vaccine to their populations, while they continue to rationalize their failure to deal effectively with the initial stage of swine flu infections in their countries, China's battle plan against the bug continues to unfold with precision:

Phase One: delay secondary or 'community transmission' of the virus as long as possible through non-pharmaceutical interventions (NPIs); e.g., close monitoring and quarantine of international airline passengers, who are the chief carriers of the infection into a country.

This accompanied by aggressive public hygiene awareness and flu education campaigns, which continue during Phase Two.

Phase Two: vaccination of the population at the point where community transmission of the virus finally overwhelms NPIs.

The two phases are not overlapping although the Chinese have come close to the mark. By June 13 Mainland China's health officials announced they could no longer keep track of all the community transmissions in their country, which meant that the airport defenses had finally been breached. But Phase One is to buy time by slowing the transmission of the disease, which it's accomplished.

(Phase One is still in effect on China's Mainland. On Saturday Hong Kong officials announced that June 29, today, they're officially abandoning quarantine of airline passengers because the disease is now circulating widely in the Hong Kong territory. However, their 'management' phase of dealing the disease is still stringent and continues to include monitoring of airline passengers' temperatures. See this report for details.)

Phase One has been accompanied by manufacture of large amounts of anti-viral medications for distribution during the community-transmission phase of the disease and the development of a swine flu vaccine. China is not waiting for the Western manufacturers to toss them a few million doses of vaccine whenever it's ready for distribution:
SHANGHAI, June 26 (Xinhua) -- China's first batch of antiviral drug for influenza A/H1N1, including 256,000 pills, rolled off the production line in Shanghai Friday.

The Oseltamivir Phosphate Capsules, manufactured by the Shanghai Pharmaceutical (Group) Co. Ltd., have passed all quality tests required, Wu Jianwen, president of the company, said Friday.


"Currently, we'll be able to turn out 2 million pills per month, and we can expand the output capacity in the future if the flu epidemic shows new changes," he said.


In addition to antiviral drug production, China has [since Monday June 22] begun laboratory tests on the country's first developed A/H1N1 flu vaccine ... with the seed virus received from a World Health Organization (WHO) lab on June 3.

The vaccines are expected to hit the market in September after 14 days of safety tests in labs and two-month clinical tests from July, Fan Bei, deputy general manager of Hualan Biological Engineering Inc. based in central Henan Province, has said.

The company had produced a first batch of 90,000 doses, but it would be able to make 600,000 doses a day once it was approved, Fan said.

China has 11 drug firms that are qualified to produce flu vaccines. Another drug company, Sinovac Biotech Co. Ltd., announced that it had started development of A/H1N1 flu vaccines on June 15.
Note that China's plan is the essence of simplicity; it approximates the age-old military strategies of disrupting the enemy's supply lines while keeping yours intact and creating a delaying action until reinforcements arrive.

(The enemy's supply lines in this case are large numbers of people that the swine flu virus can quickly infect unless strict quarantine measures are directed against its points of entry.)

When you contrast China's plan with the American approach (which is pretty much the same for the majority of countries) what jumps out is that a plan for fighting the virus never existed; planning, to the extent it was done, was greatly directed at pharmacological interventions. Yet this Washington Post editorial doesn't even notice that the U.S. plan skipped the containment phase and went straight into 'management' of the epidemic:
The Obama administration has taken the proper approach from the outset. It has urged Americans to take precautions (stay home if you're sick, cover your sneezes, wash your hands) while preparing for the possibility that this new form of swine flu could mutate into something more virulent. Antiviral medication has been moved from federal stockpiles to the states. Vaccine development has begun. There are discussions with state and local authorities to plan for an immunization campaign should the need arise.
Just what preparations would those be, in the event the flu mutates into something more dangerous? Flipping through the martial law manual?

As for the Obama administration's public hygiene campaign -- phooey! Take a look at this description of Hong Kong's public hygiene campaign, courtesy of a Concerned Singaporean:
Too Concerned to Remain Silent anymore!
29 Jun 09, 16:54 PM

[...] Hong Kong has learnt her lesson after hundreds died during SARS, and it appears that Singapore has NOT! Hong Kong has taken its education programs very seriously, even announcements throughout the day, everyday, all year round in MTR trains, train stations, public places to "Please wear a mask if you are unwell, sick, have fever, or flu or cold symptoms....". This message is repeated over and over again.
Now that's a public hygiene campaign, not the wimpy effort mounted by the U.S. Department of Health and Human Services in the wake of the swine flu outbreak. Kathleen Sebelius and Elmo showing kids proper sneezing procedure is a beginning, but a far cry from a serious effort. Concerned Singaporean continues:
Private Condos and Public buildings in HK have cleaners regularly cleaning and sterilizing handrails, elevators handrails, and buttons in and outside the lifts are sterilized everyday and little notes like "The buttons in this lift have been Sterilized". You can even smell the dettol or clorox. [...]
Concerned Singaporean is just getting warmed up; you can read the rest of the comments here.

If all that sounds a bit overdone to the American ear -- it would depend on how lethal and infectious the 2009 swine flu actually is, wouldn't it? The CDC and others are still doing tests and collecting data about such matters. But the point is that the Obama administration's idea of a public hygiene campaign is nothing for The Washington Post to crow about.

So how did it come to this? How did it happen that the world's most powerful nation was outwitted and outplayed by a microbe? While a nation still in the 'developing' category of countries mounted an effective campaign to throw sand in the gears of a microbe's blitzkrieg?

There are many causes and conditions that brought about this state of affairs. Yet if you drill down to bedrock, you're looking at the difference between a strategic approach on the China side and a lab-bench science approach on the U.S. one.

China's approach clearly flows from the concept of defensive warfare. The lab-bench approach is driven by data collection and analysis of the virus. So, in place of disaster management, Americans have been treated to a parade of scientists who publicly ruminate on their evolving understanding of the 2009 swine flu:
'This virus will be leaving the Northern Hemisphere any day, then we'll have time to regroup for its return in the autumn.'

A few weeks later: 'Oops! This virus should have been gone by now but it's hanging around the Northern Hemisphere. Well, well, it's not acting like a normal influenza.'

'This virus is no more infectious than a normal flu virus.'

A few weeks later: 'Huh. Lookit the number of medical personnel getting infected with this virus and that's only a small sampling! Well, either that means they're not wearing enough protective gear or this virus is more infectious than we first thought.

'This virus isn't any more lethal than a normal flu virus.'

A few weeks later: 'Hmmm. Maybe those Mexican health officials weren't talking through their hat when they said that some deaths from this virus were due to cytokine storms. And that Escondido woman's death could be showing the same pattern as many deaths from the 1918 swine flu. Interesting.'
All right; I've had my fun. But if I exaggerated -- a little -- it was to pound home the point that biomedical scientists have no business being in charge of planning a nation's defense against an epidemic.

Of course data collection and analysis are crucially important to fighting infectious disease, but that's not saying a forward observer is qualified to prepare a battle plan -- or that a virologist qualifies as a strategic thinker.

In the case of planning for defense against an infectious disease outbreak, decision analysis must favor preparation for the worst-case scenario when:

A) A large number of variables pertaining to the situation are poorly understood or still unknown.

B) The worst-case scenario is so catastrophic that disaster planning can't be based on calculations about mitigating variables.

Both A and B apply in this situation because the 2009 swine flu is new virus and scientists are still on a steep learning curve about how it acts and how the human immune system reacts to it.

Yet so greatly has the virologist's viewpoint come to dominate disaster planning for an infectious disease outbreak that the American public health system is in effect treating the country's citizens as a test subject.

The viewpoint has also forced the rest of the world into the position of a test subject; this, on the highly misleading argument put forward by the CDC (and backed up by the World Health Organization) that once a highly infectious disease has entered a country there's nothing that can be done to stop its march.

On the basis of the argument the United States of America refused to monitor the temperature of inbound and outbound airline passengers. And so the United States, with its huge volume of international air traffic, exported large numbers of swine flu infections all around the world within a matter of days.

To those who'd say I'm being unfair because other countries did the same thing -- my answer is that I'm an American; I'm chiefly concerned with my government's actions in this matter. Readers from around the world are welcome to use the points I've put forward in this post, and earlier ones, to make the same case in their countries that I'm making in mine.

This post builds on a series of arguments I've made during the past two months but if you're looking for one essay that tackles the CDC's argument, the one I posted on May 11 titled Your life riding on the CDC's slow boat from China fills the bill.

At the time I was unaware of China's swine flu-fighting plan, which was just getting off the ground, but it also disputes the CDC's position. And China's approach to slowing the progress of swine flu demonstrates that the temporary border blockades I initially suggested would be unnecessary -- provided other countries deployed China's aggressive NPIs during the first phase of the virus' attack.

I still have a few more counter-arguments to make, which I'll aim to wrap up in the next post.

Wednesday, June 24

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

June 23, 2009
[...] Vaccines for most diseases approach 100 percent effectiveness, but a good flu vaccine is 70 percent effective; a great one is 90 percent effective. The vaccine in the 2007-08 flu season was only 44 percent effective. Hitting the "good" mark for a new virus that may be changing even more rapidly than seasonal flu will be difficult.

Supply is another problem. In a best case, enough [swine flu] vaccine for the entire U.S. population could be available by October as long as an adjuvant is used to simultaneously stimulate the immune system, which lessens the need for antigen from the virus itself.

However, if the virus used to make vaccine grows slowly, or if a dose requires more antigen than seasonal flu, or if two doses are required to provide protection, producing that much vaccine could easily stretch deep into 2010.

In addition, only about 30 percent of the supply will be made in the United States. The more virulent the virus, the more likely it is that foreign governments will refuse to allow export of the vaccine until their own populations are fully protected.


The bottom line? Little can be done in the short term beyond exerting diplomatic pressure to guarantee that foreign governments allow manufacturers to honor contracts to export vaccine. [...]

-- The Washington Post; What Can Be Done -- and What Can't -- To Protect Against H1N1; John M. Barry, distinguished scholar at the Center for Bioenvironmental Research at Tulane and Xavier Universities and the author of The Great Influenza: The Story of the Deadliest Pandemic in History.
Guarantee? Let me see if I get this straight: If apocalypse breaks out, the U.S. will sue if governments don't honor their vaccine contracts. Has Barry lost his mind?

June 17, 2009
Many foreigners chafed at China's quarantine restrictions on travellers, which in some cases seemed illogical. The World Health Organization warned that China's current policy [for fighting swine flu] is too resource intensive to be sustainable should the disease become widespread.

Roughly one-quarter of the confirmed cases in China as of early June were United States citizens, the U.S. embassy in Beijing said earlier this month, suggesting that Chinese caution in quarantining hundreds of American travellers was justified.
So. WHO has gone from warning that quarantines of airline passengers don't work, to warning that China's quarantines are too resource intensive. This is how we measure progress in the wild and wacky world of public health management.

By gum it is resource intensive; the Chinese are hurling God Knows how many renminbi and medical workers into the quarantine program, which they threw together on no notice and are having to refine on the fly. The program is a logistical triumph although complaints from huffy quarantinees are still rolling in.

'Just like being in jail' fumed some quarantined Australians. Another Aussie, who was quarantined in Shanghai for a week just because he was sitting six rows from a sick airline passenger, showed more sense: "It's a week out of your life. Suck it up."

But a week out of some people's lives without enough English-language TV channels in their quarantine room ("We got tired of watching Larry King re-runs"), or with no hot dogs and hamburgers, or with too much cooking oil in the meat dishes, or having to survive 24 hours without a phone in the room -- all this is too much for human flesh and blood to bear.

Most quarantined passengers have been philosophical, however, with the potluck aspect of the experience. (Some draw a five-star hotel, some get a hospital room in the boonies.) And there have been precious few complaints with any merit; those few the U.S. Department of State seized upon to deliver a travel alert that makes Gitmo incarceration seem a luxury vacation in comparison to quarantine in China.

Through it all the Chinese -- who can be as charming as the Irish when they want -- have been solicitous; they've also been extensive survey takers: "Please answer yes or no: Sometimes I feel lonely in my room." All this in an effort to make the quarantine experience as bearable as possible for even the fussiest Westerner and Japanese housewife.

The fact that the quarantines have greatly slowed the spread of swine flu in
China has been studiously ignored by all but unnamed public health officials outside China. And it was studiously ignored in John M. Barry's op-ed for The Washington Post. This would be the same John Barry who once dismissed quarantine as "worthless."

He edged close to backtracking a bit in his piece for WaPo:
[T]he virus is the most important factor, and we have no control over it. But we do have non-pharmaceutical interventions and the possibility of a vaccine. Such interventions would come into play primarily in a moderate or severe pandemic. For a mild one, we may not need to take steps beyond washing hands, exercising "cough etiquette" and keeping the sick at home. But if the virus increases its virulence, other measures, such as closing schools, urging people to telecommute and even banning public meetings, could mitigate the impact.

However, the usefulness of non-pharmaceutical interventions is limited, and even if they work, their chief impact will be to flatten the pandemic's peak and stretch out the duration of a wave of illness to make it easier to handle.
By gum making the outbreak easier to handle would be a consideration, wouldn't it?

Now watch carefully, don't blink:
Scholars Bradley Condon and Tapen Sinha found that in Mexico City this spring, when the government advised wearing masks on public transportation, compliance peaked at 65 percent three days later -- but declined to 26 percent only five days after that. This decline came even as the government was taking the extreme measure of closing all nonessential services and businesses. Such behavior does not portend well for sustained compliance with any measure.
Not that I would want to burden John Barry with rational discussion but if sustained voluntary compliance is hard to achieve, why then does he assume that voluntary measures such as "washing hands" and exercising "cough etiquette" would meet with enough compliance to be useful during a "mild" pandemic?
PUNDITA: What's so funny? I warn I'm not in the best of moods. I'm being slowly driven mad by the U.S. public health establishment.

MICHAEL WRIGHT: I never thought I'd see the day you'd be defending China's government.

PUNDITA: I'm not defending them; I'm defending correct judgment. They happen to be right about quarantining airline passengers.

MICHAEL WRIGHT: Do you know India asked the U.S. to screen outbound plane passengers for flu symptoms?

PUNDITA: When was this?

MICHAEL WRIGHT: Around the middle of this month.

PUNDITA: Was this request made public?

MICHAEL WRIGHT: Yep. So now there's two countries on your side.

PUNDITA: Wouldn't matter if there were a hundred. The CDC has decided that reality is negotiable and that's that.

MICHAEL WRIGHT: Did you see State's alert on China's quarantines?

PUNDITA: I saw it Friday, when they released it. Since when have you gotten interested in swine flu?

MICHAEL WRIGHT: You made me a believer. You were right; this an important foreign policy issue.

PUNDITA: It would be, if there was a policy on foreign relations during a pandemic outbreak or threat but there's no such thing.

MICHAEL WRIGHT: The alert is pretty toughly worded. What's going on with that, do you know?

PUNDITA: State fell down; they didn't issue an alert about quarantines and related procedures that travelers are facing in the swine flu era. They left that sticky task to the CDC, which didn't get around to issuing an alert until May 13.

Then all hell broke loose earlier this month when just about every member of Congress representing Florida descended on State; I guess they practically accused Beijing of being a baby killer.


PUNDITA: Nine Palm Beach teenagers, who'd never been to China before, got caught in a quarantine net during their first day touring China. They were separated from the rest of their tour qroup and put in a quarantine hotel. The kids freaked out. They hadn't been warned about the quarantines.

One mother got a call in Florida from her daughter at two in the morning sobbing that she had to do something because they were being spirited away against their will. The mother didn't know about the quarantines either, so she freaked out. She probably woke up every political representative in the state during the next hour.

MICHAEL WRIGHT: What about the other parents?

PUNDITA: At home. There were 31 teenagers in the group -- ages from 13 to 18, I think. They were accompanied by three teachers, if I recall, who weren't part of the quarantine.

Even after the kids calmed down there were problems with the quarantine. At least a few of the kids complained they weren't getting enough food, that the food they were getting was crummy and not nutritious, and that they wanted Western food.

Yet there was a couple from Dallas quarantined in the same hotel; from the report on their experience they received boxed buffet-style meals three times a day, and they had no complaints about the food.

However, these are teenage American boys we're talking about; they can wolf down three double bacon cheeseburgers for lunch. So they felt as if they were being starved, but the big complaint was that they wanted Western 'comfort food.' Like hamburgers and pizza.

They also complained they were hot because the hotel's air conditioning was shut off in the rooms to prevent germs from traveling through the hotel.

MICHAEL WRIGHT: The Chinese seem to consider the virus more infectious than American doctors do.

PUNDITA: They have a reason for that, Michael. A Japanese study turned up what they claim is a significant mutation of the virus in that it's more infectious than the first isolated strain. China's top epidemiologist has taken the study seriously.

But people shouldn't be in sweltering conditions if there's any way to avoid that. The air conditioning stays on in the hotel lobby so the quarantinees can hang out there, provided they wear their surgical face masks. But they also have to stay in their room for an hour twice a day waiting for their temperature to be taken.

To make matters worse the hotel wouldn't open the windows; the kids seemed to think this was to keep in germs. I don't know what that was about.

The kids also said they were getting dehydrated in the heat because they weren't getting enough bottled water; some of them threatened to drink the water from the shower if they didn't get more of the bottled stuff.

And they were upset that they were missing the tour. They'd looked forward to the trip for many months. Most of all, they were going stir-crazy cooped up in the hotel, particularly because they weren't showing symptoms of influenza.

MICHAEL WRIGHT: How long were they in quarantine?

PUNDITA: A week and a few hours. They'd been told a week, so for every minute beyond that it was, 'Are we free yet, are we free yet?'

The problems got sorted out, as much as possible. And the hotel manager gave them Tai Chi classes to help keep them occupied. Contacts in Beijing got them a computer so they could chat with their parents on the internet. They also gave them giant water guns to help them cool off, and games, DVDS, and food treats. And the kids socialized with other quarantined people in the hotel.

It all had a reasonably happy ending, the children got a clean bill of health, and they were able to make up at least part of the tour -- the ones who could spare the additional time to stay on in China.

MICHAEL WRIGHT: What I'm hearing is they had an adventure.

PUNDITA: That's what one of the boys told a reporter after he got home. He said their parents made too much of what happened.

However, the U.S. ambassador, the parents, and Florida Members of Congress were leaning hard through all this to make sure the kids were well treated. And there were a couple other serious issues. Two boys in the quarantined group showed a slightly elevated temperature so they were whisked off to a hospital. That might be why the group quarantine lasted for an entire week -- the authorities wanted to be on the safe side in case the two boys had been infected.

MICHAEL WRIGHT: How long do the quarantines last, generally, from the reports you've seen? Is it always a week?

PUNDITA: Three to seven days, although I've seen a couple reports that some quarantines last only a few hours or two days. I've seen no reports of a quarantine going beyond a week.

Accounts vary about how long the two boys were in the hospital. One account says two days before they were returned to the quarantine hotel, another says a week.

But the big issue for the parents was that the Chinese authorities didn't get parental permission before putting the boys in the hospital. And all the quarantined children were given blood tests at the beginning; again, without parental permission.

That explains some of the dire language in State's alert.

MICHAEL WRIGHT: Those aren't valid complaints in that situation.

PUNDITA: Well, the parents weren't properly prepared for that eventuality. They didn't know that in a quarantine situation a medical authority doesn't need to wait to get permission to perform medical interventions meant to keep the person healthy. And the parents didn't understand how things are in China.

MICHAEL WRIGHT: Must have been a big stink for the tour operator.

PUNDITA: That was another part of the mess. Technically it's not a tour operator; it's a nonprofit organization called People-to-People. It was established under Eisenhower as a government program to promote cultural understanding, and then it moved to the private sector.

The kids were in China under one of the organization's programs --- as so-called student ambassadors. So you can imagine the organization was behind the eight-ball. They must have leaned very hard on Congress members and the state department.

That wasn't the only incident to be brought to State's attention, I don't think. As luck would have it someone else from Palm Beach, West Palm Beach, was quarantined in a separate situation. He ended up in a hospital in the boonies. He took one look at his room and called for a nurse and a mop. He said the room looked as if hadn't been cleaned in a year. He ended up mopping the halls himself after the nurse finished with the room.

I suspect that this one incident explains the alert's mention of unsanitary conditions.

The man was good-natured about the quarantine, though. However, there was a language barrier; no one taking care of him spoke English and he didn't speak Mandarin. So there was a lot of sign language that didn't always work out. The Chinese at the hospital had never seen anyone so tall; he's six foot two. So they didn't know how much food someone that big needed. He told of one time when the caretakers brought him 15 tomatoes to eat.

MICHAEL WRIGHT: What I'm hearing is an intervention program that isn't standardized yet.

PUNDITA: The Chinese are pulling out all the stops to make it work but there are still things to be ironed out. One of them is the language barrier that can be found depending on where the quarantine takes place.

A big problem is that the quarantines don't always get called at the airport. There was one American school group that saw a few get sick with swine flu symptoms while they were touring Three Gorges Dam.

And if I recall the other student group I mentioned was getting ready to tour the Forbidden City when they were whisked away to quarantine. The Chinese had learned that one person on the children's plane had come down with swine flu, and that these particular nine children had been sitting near him. The kids asked why they were singled out, given that they'd been mingling with other members of their tour group. It made no sense to them.

MICHAEL WRIGHT: They didn't understand about the incubation period. What the Chinese should be doing then is putting hotels and hospitals on alert near the major tourist attractions.

PUNDITA: Yes; I suspect they're getting up to speed on that.

MICHAEL WRIGHT: If State's alert doesn't drive all the tourist business away.

PUNDITA: I imagine China's ambassador to the U.S. is not tickled pink over the wording in that alert. What State should have done was balance the warning. Instead they over-compensated for their initial negligence.

Thursday, June 18

H1N1/Swine Flu Pandemic: China plays Galileo to CDC-WHO's Inquisition.

April 28, 2009: WHO's Dr. Keiji Fukuda said that it was too late to contain the swine flu. "Containment is not a feasible operation. Countries should now focus on mitigating the effect of the virus," he said. He therefore did not recommend closing borders or restricting travel, stating that "with the virus being widespread... closing borders or restricting travel really has very little effects in stopping the movement of this virus."

June 11, 2009: "[New York City's] Pandemic Influenza Preparedness and Response Plan ... is grounded in the reality that we will not be able to prevent pandemic flu from entering New York City once it emerges anywhere in the world ... " -- Dr Thomas A. Farley, Commissioner New York City Department of Health and Mental Hygiene testifying on New York City's response to swine flu

June 11, 2009: "So far, China has not had a case where the source [of swine flu infection] could not be traced." -- Mao Qun'an, China's Ministry of Health

June 13, 2009: "Thomas Lyons, a general practitioner from Eagleby, southeast of Brisbane [Australia], said logistics were "falling over" in the fight to contain the virus, and likened the bureaucrats responsible for organizing the national swine flu response to the generals in charge at Gallipoli."

I wrote this post in reply to a well-informed reader's thoughtful letter, in which she pointed out several factors, in addition to failings at the CDC and WHO, that are responsible for the USA's poor response to the swine flu outbreak:

I don't doubt your observation that the military has input with regard to aggressive interventions such as quarantine and border closings. And I agree that issues such as the need for better leadership, a clear chain of authority, and adequate resources need to be addressed.

I also agree that CYA maneuvers -- from the White House to the Congress and throughout the different agencies involved with public health and crisis management -- are a significant factor. When there are too many cooks, this gives the perfect opportunity for everyone to point a finger at everyone else at the slightest hint of a screw-up.

However, I've focused on WHO and CDC because their view of how governments should deal with infectious disease has the greatest impact on public health measures in the USA and around the world. In the case of a new, highly infectious viral disease outbreak, their viewpoint and recommended approach are based on eras that no longer exist. They're based on mathematical models that are obsolete. They're based on a an Article of Faith in the public health/biomedical establishment that's false.

So at the bottom of all the CYA, poor leadership, and badly allocated funds there exists a situation that's been repeated countless times in history: A powerful establishment rejects evidence that overturns a set of beliefs that were never true, or which have become obsolete. That is the nature of establishments, which of necessity are very conservative and slow to accept countervailing evidence.

In the 1940s an American biochemist named Adelle Davis presented evidence that there could be a cause-and-effect link between bad nutrition and major illnesses such as heart disease. She was branded insane by the American medical establishment. By the 1980s, and after countless scientific experiments, the establishment had accepted her claim as a self-evident fact.

Galileo's run-in with the Catholic Church is the classic example of this kind of situation. Because the Pope knew that the cat was already out of bag about earth's revolutions around the sun, he told Galileo he could go ahead and publish his arguments -- provided he gave equal space to the Church's side of the story. When Galileo said no he learned the hard way just how powerful an establishment can be.

Not to put too fine a point on it, but that situation finds parallels with WHO-CDC's reaction to China's revolutionary approach to fighting a 'pandemic virus.' They have not outright condemned China's approach, nor have they demanded that China's Ministry of Health recant. But they've studiously ignored the implications of China's success. And they've downplayed or frowned at China's aggressive measures to stop swine flu at domestic international ports of entry, particularly airports.

CDC and WHO have done this, not because they enjoy the thought of a pandemic virus running wild, but because they've made mathematics their totem. They've failed to acknowledge that the computer programmer's dictum, "Garbage in, garbage out," also holds true in applied mathematics. If the data's not good; if it's obsolete, it's going to produce a false picture.

China's public health regime, as with every other one around the world, had accepted the false picture, which is based on the Article of Faith professed by New York City's commissioner of health: the Received Wisdom, which is encoded in pandemic preparation manuals the world over, is that once a new and highly infectious virus appears anywhere in the world, it is impossible to stop it from spreading to virtually every country.

Now how did the public health establishment come to this belief? From mathematical modeling of the 20th Century's three official pandemics. And yet the last pandemic of that century -- from 1968 to 1970 -- might as well have been back in the Dark Ages when it comes to the leaps in technology and the vast changes in airline travel patterns since then!

When the Chinese got a look at the earliest data on the 2009 swine flu outbreak in the USA, which was mostly 'probable' cases at that time, they could see that the pattern of the outbreak was not a spread upward and outward from the southern U.S. border.

The pattern was appearing as points or clusters of infections in different geographic regions all over the USA. And this pattern had manifested within hours -- maybe 72 hours after health departments and hospitals were alerted to the outbreak.

So Chinese health officials said, 'Oh. It's being mostly flown into the United States and disembarking at different international airports there.'

The officials then deployed a three-pronged defensive strategy, which was chiefly aimed at stopping swine flu that came from infected airline passengers -- and stopping it before the infected passengers touched off "community spread" of the disease.

(For readers unfamiliar with the term: Community spread means infections that are no longer directly tied to the original infection source. Once CS gets seriously underway in a country, that creates an epidemic. Another term I've seen used to describe the same phenomenon is "secondary transmission.")

I've spoken about the strategy before but to summarize it includes:

  • Use of non-medical technologies to identify international airline passengers who show signs of flu-like illness; e.g., thermal imaging machines and temperature-taking 'guns' to monitor the temperature of passengers; and state-of-the-art air filters on domestically-owned planes making international flights. The last makes it possible to isolate a few passengers instead of having to quarantine an entire planeload if one passenger shows signs of flu.

  • Immediate quarantine of inbound passengers who show signs of flu-like illness.

  • Stringent follow-up monitoring of people (e.g., family members) in China who might reasonably have been exposed to an infected airline passenger.

  • All three strategies are non-pharmacological interventions (NPIs) but of course the Chinese also made use of anti-viral medications to limit the spread of the disease and a variety of other tactics to implement and reinforce the strategies.

    There was briefly a fourth strategy -- suspension of airline flights to and from a country with a large number of swine flu infections. But China's officials quickly learned that globally the disease was following the initial pattern it had in the USA and Canada: it was being flown into international airports all around the world.

    And when China's health officials saw that only a handful of national governments were making even a desultory attempt to limit the spread of the disease in their countries, they knew that short of suspending all China's international airline traffic, the strategy couldn't work.(1)

    Yet even without the fourth strategy China's success at slowing the spread of swine flu in their country (both on the Mainland and in Hong Kong territory) is astounding, as I reported in an earlier post.(2)

    And the success overturned the CDC-WHO argument that once a highly infectious viral disease had entered a country it was useless to attempt measures to stop it from further crossing the border.

    The most amazing sign of success came on June 11, when Mao Qun'an, the Chinese Health Ministry's spokesman, announced that up to that point, China hadn't had a swine flu case where the source couldn't be traced.

    On June 13 China's defenses were finally breached. The onslaught of infected airline passengers from Australia, where swine flu had quickly become rampant, was the tipping point. The ministry announced that they could no longer keep track of all the people in China with swine flu.

    That signaled the onset of community spread of the disease in China.

    There was never any question that China's strategy would ultimately fail to prevent community spread because China got no cooperation from any other country, unless we count Mexico's attempt, toward the end of the worst of their outbreak, to monitor the temperature of outbound passengers.

    Yet despite China's lone stand, their success at holding off community spread for about 30 days (their first reported case was May 10) shreds the argument that a global pandemic is inevitable once a highly infectious viral disease breaks out in a country.

    No it's not inevitable because cutting-edge vaccine manufacturing techniques, which use cell technology rather than eggs for culturing the virus, can produce a flu vaccine in a matter of days.

    There was a delay in the CDC obtaining enough stock of 'vaccine-candidate virus' to distribute to the vaccine manufacturers because the swine flu virus grew slowly in the lab. That meant a delay in getting virus vaccine samples to the vaccine makers. (3)

    But using cell technology, Novartis pulled off the feat of having a swine flu vaccine ready for testing in what I think was less than two weeks -- or maybe even a week. (When I have time to nail down exactly how long they took, I'll publish the information.)

    The point is that in this era of adjuvants, which boost the power of a flu vaccine; cell-culturing technology, rapid-response virus testing; sophisticated anti-viral medications, temperature guns, thermal imaging monitors, instantaneous global communication; and scores of other medical and technological advances -- none of which were available in 1968 -- there is a realistic chance to overturn the Received Wisdom.

    China has demonstrated that it's within humanity's grasp to stop a superkiller virus by slowing its spread long enough so that a vaccine can be developed and distributed.

    China's approach has further demonstrated that viral transmission can be greatly slowed without resorting to draconian blockades and country-wide quarantines, and thus, without crashing national and global economic systems.

    China's revolutionary approach could not have come at a more fortunate time for the human race. We know that ahead is the advent of a super-vaccine: a vaccine that targets not specific viruses but the virus itself, thus relegating viral pandemics to history's dustbin. We don't know when the scientific breakthrough will come -- tomorrow or ten years from now, but it's on it's way. Meantime, we are left to deal with the worst downside of fully globalized, cheap air travel:

    It took the 1918 swine flu virus four months to make its first trip around the world. It took the 2009 swine flu virus about two weeks to do the same.

    In between the last pandemic in 1968-70 and this year is a vastly changed world of travel. In 1968, large parts of the world saw very little to none international air traffic. The Iron Curtain, the Bamboo Curtain, and the fact that many Third World
    countries were lucky to see more than one commercial international flight a week, meant that a pandemic virus had to depend greatly on ships and overland modes of travel to hit every country in the world.

    But in 2009, which sees huge volumes of air traffic between most of world's countries, a virus can tour the world in a few days. Here is the terror of this situation:

    SARS did not touch off a global pandemic, even though it hit several countries. That's because the virus was so lethal that you had no trouble tracking it: you just followed the trail of dead bodies. It's a different story with the 2009 swine flu, which WHO's Margaret Chan calls a "sneaky, subtle virus."

    It was the same with the 1918 swine flu virus. It pussyfooted around the globe the first time in the guise of a mild influenza, then returned as a mass murderer. We hope that's not going to happen with the 2009 swine flu, yet it made such inroads at the outset because it was able to pass as an ordinary flu virus.

    And until the super-vaccine arrives, a "sneaky, subtle virus" is the sword hanging over humanity's head in this era of globalized trade and travel.

    China's health officials -- both in Beijing and Hong Kong -- found a way to beat the devil. (Just goes to show that desperation is the mother of invention.)

    The catch is that if their strategy is to work well enough to greatly slow the march of a superkiller virus around the world, all federal governments will have to adopt some version of China's strategy. And the nations with the largest volume of international air traffic will have to closely hew to the strategy.

    Here we come to a snag. From the United Nations to domestic airline and tourism lobbies around the world, from countless factions in between, and in almost all the world's governments, no one wants to adopt China's strategy.

    Instead, everyone wants the impossible. They don't want a superkiller pandemic but they also don't want to recommend the societal and business adjustments that China's approach requires.

    Useless to explain to these factions that China's approach is only necessary for a few months, until a vaccine can be developed and distributed. They want the impossible and they want it now.

    Failing to obtain this, they've settled for playing Russian Roulette on a global scale. To rationalize their crazy game, they've continued to provide the public with hugely inflated statistics about annual deaths from regular influenzas.

    You might say that the way to deal with this craziness is through the political route and perhaps you're right. But I don't see how governments in the majority of democratic countries can get up the gumption to adopt China's approach until the public health regime's thinking about pandemics is modernized.

    Unless and until "Science Sez" that China's model of pandemic fighting has merit, governments can take refuge in obsolete recommendations to justify Russian Roulette.

    So from where I sit, it is up to WHO and the CDC -- as the world's most visible public health agencies -- to modernize their thinking, and to realize they don't have the luxury of taking half a century to do this.

    1) A report in today's Los Angeles Times states that China's flu-fighting measures include "denying visas to travelers from countries where the virus is prevalent."

    I'm unaware that China has refused visas to citizens in such countries although the government might have done so at the outset with regard to Mexico. I've written the reporter to ask for his source for the statement or barring that to provide me with the names of the countries in question.

    (2) See the post for links to news sources:
    "May 09
    Australia reports their first confirmed case of swine flu; an infected American airline passenger traveling from the USA. Queensland, Australia's chief health officer Dr Jeannette Young said more cases were likely in the future "because we have a lot of planes coming into the country every day".

    June 01
    Australia's confirmed swine flu cases: 401.

    The cases are doubling about every two days.

    May 10
    Mainland China reports their first confirmed case of swine flu, an infected Chinese citizen traveling on a flight from the USA via Tokyo.

    June 01
    Mainland China's confirmed swine flu cases: 38.

    It should go without saying that Mainland China also has a lot of flights coming into the country each day. Yet even with adding Hong Kong's 23 June 1 confirmed cases (which are also stupendously low) to bring the grand total in China to 61, and even accounting for unreported/unprocessed cases in all of China, the difference between the Australia and Mainland China tallies is staggering."
    3) See CNN Senior Medical Producer Caleb Hellerman's May 22 report Candidate virus for H1N1 vaccine arrives at CDC to learn how the swine flu vaccine was prepared for distribution to vaccine manufacturers.

    Wednesday, June 17

    Swine flu mutates in Brazil (LAST UPDATED JUNE 26)

    I suggest you listen to Dr Henry Miller's discussion on Sunday's John Batchelor Show, if you're trying to make sense of seemingly contradictory accounts about the Brazilian strain.

    Here is the link for the podcast; the discussion is in the second segment.

    Here's my recollection of the discussion: The Brazilian researchers indeed discovered a mutation of the swine flu virus but it's not a 'significant' mutation.

    Significance in this context relates to (1) transmissibility (or 'infectiousness') and (2) lethality.

    Henry said that the Brazilian strain was not significantly more (or less) infectious than the one that was first isolated. And it was not more (or less) lethal.

    Would the mutation then qualify for its own designation ("A/Sao/Paolo/1454/H1N1")? I don't see why not; I'd assume that every mutation of the swine flu virus that can be isolated adds to the body of knowledge about the virus, but that's a layperson talking. I don't recall for certain whether Henry addressed this part of the issue; I don't think he did because the discussion was quite brief; he was covering a lot of ground in a few minutes in the effort to update John's audience on the swine flu situation.

    The Centers for Disease Control and Prevention (CDC) and other experts have rejected a report that a new strain of the novel H1N1 influenza virus has been identified in a Brazilian patient.

    Scientists at Adolfo Lutz Bacteriological Institute in Sao Paolo said they found the new strain in a local patient who has recovered, according to a Medical News Today (MNT) report, which was based on information from the institute and Agence France-Presse.

    The story said the scientists found "a number of discrete alterations in nucleotide and amino acid sequences" in the isolate´s hemagglutinin (HA) gene. They also analyzed the matrix-protein (MP) gene and found no changes.

    But CDC spokesman Joe Quimby in Atlanta discounted the report that the isolate is a new strain. "Our scientists have no knowledge of a new strain of novel A H1N1 influenza," he said.

    "It´s the same strain, it´s not a new strain," Quimby added.

    The Brazilian researchers labeled the isolate A/Sao/Paolo/1454/H1N1. They deposited the nucleotide sequences for the HA and MP genes in GenBank under accession numbers GQ247724 and GQ250156, the MNT report said.

    Vincent Racaniello, PhD, a Columbia University virologist who writes Virology Blog, also dismissed the claim of a new strain.

    "Comparison of the amino acid sequence of the HA protein of A/Sao Paulo/1454/H1N1 with those of other isolates of the current pandemic strain reveals no alterations in the HA protein which would allow the virus to infect new hosts," Racaniello wrote in his blog. "The HA protein of this virus and many other 2009 H1N1 isolates are identical. The few amino acid differences with other 2009 H1N1 isolates are in areas that would not be expected to influence antigenicity or host range."

    The MNT report said the virus came from a 26-year-old Sao Paolo man who fell ill shortly after returning from a trip to Mexico. He was hospitalized on Apr 24 and later recovered.

    See Also: CIDRAP
    Swine flu mutates in Brazil
    By Richard Reynolds
    Australian Broadcast Company
    Posted 6 hours 56 minutes ago
    A Brazilian laboratory says it has identified the first genetic variant of the swine flu virus.

    Swine flu has infected more than 30,000 people around the world but so far the new variant has only been identified in one patient. [The number is based on reported confirmed cases, of course; the actual number of infections is much higher.]

    It is not known if it is a more virulent strain than the one that emerged in Mexico.

    The Adolfo Lutz Institute in Sao Paulo sounded the warning, considering the information vital.

    As winter arrives in the southern hemisphere, so does flu season, and as often happens with the influenza virus, it could mutate as it encounters other flu strains and they assimilate their genetic material.

    This could potentially cause an even more deadly strain of the flu than the one that killed more than 100 people in Mexico.
    UPDATE 1:55 PM ET
    Here's more complete information about the new strain from a June 17 report in Medical News Today. Emphasis mine:
    Scientists in Brazil say they have isolated and identified a new strain of the A(H1N1) swine flu virus from a patient who was hospitalized in São Paulo in April and who has since made a complete recovery. The scientists don't know if the new strain causes more severe infections.

    The new strain came from a sample isolated from a 26-year old São Paulo man who started to have symptoms of flu shortly after returning from Mexico. He was hospitalized on 24 April and has since made a full recovery. While in hospital the patient gave a sample for analysis.

    A team at the Instituto Adolfo Lutz in São Paulo, led by virologist Dr Terezinha Maria de Paiva, isolated the new strain, A/São Paulo/1454/H1N1, from this sample at the end of April.

    Using electron microscopes, another team at Instituto Adolfo Lutz, led by Cecília Luiza Simões, looked at nucleotide sequences in the new strain.

    They looked in particular at segments number 4 and 7. Segment 4 codes for the protein Hemagglutinin (HA) which is responsible for virus infectivity and triggers the production of antibodies in the human immune system. Segment 7 codes for the matrix proteins (MP) M1 and M2, which help the virus to develop and maintain its structure.

    When they compared segment 4 and segment 7 of the new A/São Paulo/1454/H1N1 strain against the novel swine flu reference strain A/Califórnia/04/H1N1 they found that segment 7 appeared to be "completely conserved" while segment 4 showed a number of discrete alterations in nucleotide and amino acid sequences.

    The complete nucleotide sequences for these HA and MP segments have been published in GenBank, the American open access gene sequence database, under access numbers GQ247724 (for the HA gene) and GQ250156 (for the MP).

    News of the new strain, together with the newly reported deaths of two people in Argentina to the swine flu virus, have added to fears that South America is heading for a tough winter dominated by the flu pandemic.

    Together with the two new deaths in Argentina, there are two in Chile, and another in Colombia, bringing the total number of officially recorded deaths to swine flu in South America to 5.

    On Tuesday, Chile's reported total of lab confirmed cases leapt from 2,355 to 3,125.

    Argentina has reported 733 cases, Peru 113, Brazil 69, Ecuador 84 and four other South American countries have reported nearly 120 between them, according to AFP news agency.

    The Southern Hemisphere is entering the flu season now, whereas production for the swine flu virus vaccine is still months away from completion, so southern countries will have to face the pandemic without them.

    While the current strain appears to cause mostly mild infections with few deaths compared to the number of cases, there are fears that it will mutate to a more severe form. And the worry is, that the more "hosts" that are present in a population without immunity, the bigger the chance that it will mutate.

    The last time this happened with a pandemic strain was the 1918 Spanish flu which killed millions of people worldwide. It started as a mild version, mutated to a much deadlier form and then returned in a second wave. And like this new strain of H1N1 swine flu, the group most severely affected was healthy young adults, unlike the seasonal flu which mostly strikes the sick and the elderly.

    -- GenBank

    Sources: AFP, Instituto Adolfo Lutz.

    Saturday, June 13

    Ahmadinejad returned to office by wide margin: Pasdaran's referendum on Obama's daffy Cairo speech and Middle East advisors

    It's official: Pasdaran rule Iran. Now we look for purges: prison and disappearances for clerics who tried to unseat Maddy; Qods Forces going after ringleaders among supporters for the opposition.

    The Pasdaran have sprung this kind of trap so many times before you'd think that Teheran's intelligentsia would have wised up by now. But they keep being lulled into the fantasy that there's a democratic process in Iran; that's because they listen to the BBC.

    Then like a fool Obama listened to the Tehran intelligentsia. So then it was off to Cairo so he could take credit for the great triumph of the opposition's presidential win in Iran.

    The only suspense in all this is whether Bibi will be able to deliver his speech without doubling up in laughter.

    This entry is crossposted at RBO along with a cartoon of Obama that's worth a million words.

    Wednesday, June 10

    H1N1/swine flu: Lost in WHO's wonderland

    For readers who saw yesterday's post in the early afternoon: around 3:30 PM ET I added two photographs supplied by RBO. And I added text to accompany the photos although that was hardly necessary. Taken together the photos speak volumes about the vast difference between the U.S. and China's approach to fighting swine flu. China got an efficient flu fighting corps. America got Elmo.

    Before I turn to WHO, a few notes:

    From reader CGardner: "As promised, I researched where the additional monies for H1N1 that Obama promised was sitting. It's in the Supplemental Budget Bill (primarily for funding the Iraq and Afghani wars) and appears to have grown at least to $3.5 billion. As you see in this article, what these dollars will fund remains very, very vague."

    Pandemic Information News blog has been carrying news reports about swine flu that the mainstream media in the USA have missed. Two June 9 reports from PIN:

  • In Canada the outbreak is hitting hard at the aboriginal population; there are reports of a disproportionate number of serious cases occurring among Inuit communities. This pattern has been noted in earlier pandemics and it's raising concerns that swine flu will hit hardest at 'vulnerable' populations in Africa and South America.

  • Yesterday ScienceInsider reported that six sub-Saharan countries have suspected swine flu cases.

  • In Egypt the emergence of swine flu has prompted at least one doctor there to demand the "abolition" of the Hajj, which this year will take place in late November. The pilgrimage to Mecca, attended by Muslims from all over the world, is also the world's largest annual pilgrimage.

  • The report posted by PIN is a bad machine translation from the Arabic but I think the gist is that there's concern that by bringing together large numbers of people from so many nations, and in such crowded conditions, this will increase dispersal of swine flu around the world.

    For those wondering why it's taking WHO so long to raise the pandemic threat level to its highest, this May 3 Associated Press report titled Politics play big role in World Health Organization's decisions will answer the question and many others.

    To boil it down the organization has no teeth and that's the way governments want it. But WHO has a voice and they're expected to use it in times of crisis. My worry is that Margaret Chan, the current director-general, is a little too consensual in her approach and too focused on the negative economic and diplomatic effects of officially declaring a swine flu pandemic.

    Granted, governments do tend to get hopping mad when WHO issues advisories that if followed cause loss of trade and tourist income, which helps explain why WHO has been walking on eggshells since the swine flu outbreak.

    Early on Mexico's government hurled the "discrimination" charge at governments that suspended flights to Mexico. And until Mexico's government realized that China was quarantining every inbound airline passenger who had a suspected case of swine flu, they huffed that China was being discriminatory toward Mexicans for quarantining a group of them.

    However, the AP report dredges up some history that should be applied to the present situation:
    "WHO is in an incredibly difficult position," said Richard Horton, editor of the Lancet medical journal. "On the one hand, its entire modus operandi is that it responds to government requests. But in this situation, what governments might want may not align with what WHO thinks is best."

    Horton cited the 2003 SARS outbreak as a prime example. When the illness began spreading in Toronto, WHO issued a recommendation advising against non-essential travel to Canada's largest city. Similar recommendations were made for cities including Hong Kong, Beijing and Taipei.

    The recommendations sharply cut travel to affected economies, dealing them a big economic blow - but the aggressive WHO action was credited with being key to containing the illness.

    The advisory incensed Canada, and Toronto's then-mayor publicly lambasted the agency, declaring it had no right to issue such guidelines. A delegation of Canadian diplomats and journalists flew to Geneva and camped out at WHO's Geneva headquarters, forcing the agency to reconsider - and eventually lift - the advisory.

    "I suspect the reason WHO has been very reluctant to make any comments about travel (during the swine flu outbreak) is because of that experience with Canada during SARS," said Horton.
    I think Horton's suspicion is correct. But if WHO officials see their position as "incredibly difficult" they need to keep in mind that WHO is not a trade or tourism association -- or government.

    The best WHO can do is carry out their mission statement and if governments howl, that's not WHO's problem. They just need to do their job and stop wiffling and waffling about matters that shouldn't concern them.

    Why is that concept hard for so many moderns to grasp, I wonder? I've noticed that many people in modern societies have a tendency to split their mental focus between making a declaration and trying to predict and control responses to the declaration.

    That's an easy way to drive oneself and others to distraction and create needless problems.

    Look at this statement by Dr Keiji Fukuda, an assistant director general at WHO:

    "One of the critical issues is that we do not want people to over-panic if they hear that we are in a pandemic situation."

    Fukuda is an epidemiologist. How did he get elected Panic Minder to the world?

    And yet he and Margaret Chan have wrung their hands for weeks over imagined outcomes of their decision to raise the pandemic threat level.

    Indeed, all I've heard during the past month from Fukuda and Chan are explanations regarding why they want to be cautious about raising the pandemic alert level to 6. What, then, are the reasons for having a pandemic index?

    Tuesday, June 9

    Thomas Frieden takes up his duties as director at the CDC. I hope Ray Nagin gives him an earful about China's method of fighting swine flu.

    New Orleans Mayor Ray Nagin went through the wars during Hurricane Katrina, which included putting his own life on the line. Perhaps more than other official, Nagin knows the penalties a city pays for being unready for a natural disaster.

    Thus, the strangest twist yet in the strange swine flu story is that Nagin found himself quarantined for swine flu in Shanghai on June 7. That was after Chinese health officials tracked down another passenger on his flight who had a suspected case of swine flu. Bloomberg reported:
    Nagin doesn’t have any symptoms, is being treated with “utmost courtesy,” and remains in contact with his staff, the mayor’s office said in an e-mailed statement. He arrived in Shanghai on June 5 for an economic-development trip.
    The experience has given Nagin a bird's eye view of China's swine flu-fighting measures. I hope he's impressed and that this translates into his reading the riot act to the CDC when he returns to the USA.

    China's decision to battle a modern pandemic by digging their trenches at airports is having astounding success, which mocks the dangerously antiquated approach recommended by the CDC and WHO. Look at these numbers:

    June 8 Confirmed Cases

    Mainland China: 89
    Hong Kong: 41
    Australia: 1,211

    I used Australia for the comparison because that country and China both saw their first confirmed outbreak of swine flu around the same time. (May 9, Australia; May 10, Mainland China.)

    However, the comparison is misleading because on June 4, when they realized they were losing the battle, Victoria's health department pulled the same stunt that the U.S. states did on the CDC's recommendation: they abandoned widespread testing for all but the most severe cases of swine flu. (1)

    Victoria state has seen the largest outbreak of swine flu in Australia. How large? Well, that's for the mathematicians to estimate because you sure won't get anything approaching an accurate count from the state's health department.

    But it's a safe guess that Australia's case count is in the tens of thousands by now. What about China's actual number of cases; isn't it also higher than the confirmed case count?

    I'd say it's a safe guess that they haven't caught every case of swine flu but the official number is much closer to the actual count because they've been chasing down every suspected case.

    Ray Nagin is a good example. They caught up with him two days after he'd disembarked because they learned at that time that someone he'd been sitting near on the plane had come down with swine flu.

    They're going by passenger rows; if they're following Hong Kong's method then if I recall correctly it's six rows to the front and back of the infected passenger, in addition to the row in which the passenger is seated. Once they have a confirmed case they look at the flight manifest and locate everyone who was sitting in those rows, then they track them down.

    If that sounds like a lot of work -- yes but it's do-able because they keep bottling up the small viral outbreak clusters that emerge from the plane flights, thus preventing big clusters which literally go 'viral;' i.e., infections that spread without reference to the original disease carriers.

    And again, China's health officials are intelligently making their stand against swine flu at the airports, where virtually all initial swine flu infections enter a country. Singapore, which has been keeping the case count low (17 at this time), has also realized where the real war is:
    Asian carriers have stepped up cabin cleaning, installed state-of-the-art air filters and allowed in-flight staff to wear face masks, with some replacing used pillows, blankets, headset covers and headrest covers, while others have begun disinfecting the cabins of all aircraft. In China, some airline flight attendants are required to wear disposable facial masks, gloves and hats and even disposable overcoats during flights to select destinations.

    Singapore has been thermal-screening everyone coming into the country, with Singapore Airlines giving passengers traveling to the United States health kits that include a thermometer, masks and antiseptic towels. Its cabin and flight crews are getting mandatory temperature checks before flights. The government recently quarantined a passenger who was later found to have the flu along with about 60 other people on the same flight who were sitting within three rows. (2)
    As to what the U.S. airlines are doing -- they've batted the question right back to the CDC's court:
    U.S. airlines have made no major changes as of the beginning of June, but continued standing practices that include looking for passengers with symptoms of flu, measles or other infections, and rely on in-flight air filters to ensure that aircraft are sanitized. "We take our guidance from the professionals (such as the CDC)", stated an Air Transport Association spokesman.

    The CDC has not recommended that airline crews wear face masks or disposable overcoats. (2)
    Aside to American readers: Starting to feel as if you're living in a banana republic, huh? I've got news: some hardscrabble countries are doing a sight better at fighting swine flu than the world's lone hyperpower nation.

    Laos, one of the poorest countries, is shelling out their precious hard currency to buy 10 thermal imaging monitors to install at their international airport. They're paying $25,000 for each machine, which is $5,000 more than the ones the CDC has been looking at, and looking at, and looking at, and looking at. Yet still the CDC continues to wiffe and waffle. When last I heard they were still complaining about the price and the large number of gates in U.S. international airports; when they get bored with those complaints they complain the machines aren't infallible.

    There is only one drawback to the machine that doesn't have a workaround: the machine isn't clairvoyant; i.e. it can't look at someone who isn't running a fever and predict that a few hours later the person will have one.

    But all the other drawbacks are childishly easy to deal with. For example the machine reads a stationary subject best. So, have the passenger come to a full stop for two or five seconds or however many seconds.

    Here is another problem that seems to have vexed the CDC:

    The machine takes a tear duct as a reference point, which means it doesn't work so well on passengers who wear glasses. So, passengers who wear glasses can remove their glasses when they come to a full stop for a few seconds in front of the machine.

    And if the airlines are too strapped to pay for the machines, take revenue from the congressional pork barrel and spend it on the machines instead.

    I've noted before that rather than haul themselves into this century, the CDC prefers to rely on vaccines. We should all hope and pray that a safe, effective swine flu vaccine will be available; however, there won't be enough of the vaccine to inoculate everyone on the first round.

    Even more ominously, by letting the swine flu virus run riot around the world, that's giving the critter a clear shot at mutating into something far more dangerous. That's the biggest reason for moving heaven and earth to limit the outbreaks.

    Amazingly China has worked a minor miracle without resorting to a blockade. Doubly amazing is that the low case count has held so far, even though the Mainland is being hit with a wave of Chinese university students returning for summer vacation from countries with a high number of swine flu infections; notably, the USA, Canada, and the United Kingdom.

    The way this came about is that in the early part of this decade China's government decided they needed an English-speaking workforce in the 'high-end' professions. That touched off genteel battles among universities in the major English-speaking countries all over the world, as they competed to attract Chinese students and the endowments that were attached. The upshot is that yearly about a quarter million of Chinese are studying abroad -- although not all of them are studying in English-speaking countries.

    That situation is now greatly testing China's airport defense strategy. We'll know in a matter of days whether the strategy held up against the onslaught of university students.

    And yet even without that additional test, China has already demonstrated that their approach works to greatly slow the rate of infection in a country -- and that the strategy is geared to the realities of travel in the present century.

    Is it possible they're fudging the true number of cases? I'd say they learned the hard way during the past decade -- with AIDS, SARS, H5N1, and the 2005 Mystery Pig Illness -- that under-reporting numbers is folly. And after all their bad decisions earlier in the decade with regard to infectious disease China's government now has something to prove; a new virus gave them the perfect opportunity.

    They surely know they're making history. And if they're making the U.S. government look like dummies in the process -- that would be bonus points. Also, the low Mainland numbers comport with the low numbers in Singapore and Hong Kong, which are fussy about accurate reporting. All in all I'd say the count is accurate.

    Meanwhile, over in Australia: Victoria's Department of Human Services spokesman said on June 4 that in the majority of cases patients with flu-like symptoms, and people who shared their homes, would be given Tamiflu without being diagnosed with H1N1. (1)

    Indiscriminately passing out Tamiflu to large numbers of people is as much begging swine flu to build up resistance to the anti-viral drug.

    The irony is that Australia has made a haphazard attempt to emulate China's aggressive NPI approach. Near the start of the outbreak they quarantined a cruise ship that swine flu on board.

    (Technically it wasn't a quarantine, at least not at the beginning; they marooned the ship by not letting it dock. When the ship's captain declared he was happy to cooperate, as if he had a choice, then it become a quarantine.)

    And most Australian states declared they would keep children returning from visits to Victoria from attending school for a week. Tasmania state went a step further by declaring that anyone returning from Victoria with cold or flu symptoms would be isolated in homes and hotels. (1)

    All that was too much for Victoria's Premier John Brumby, who bristled, "I think that is the most bizarre thing I have ever seen, or heard, or read in my life. It is completely contrary to all of the advice of the Australian Health Protection Committee." (1)

    Yes, well. That did threaten to force into quarantine thousands of children attending a rugby match. "And with two interstate AFL teams (Sydney and Adelaide) in Melbourne this weekend as the ski season officially opens, the crackdown could throw the travel plans of thousands of Australian families into chaos." (1)

    Australia wouldn't have been facing such prospects if they'd gone all the way and deployed China's strategy at their international airports. But in that it seems they followed the CDC-WHO guidelines, which discount the idea that aggressive NPIs at airports are any use.

    Meanwhile, back in the USA, things haven't gone exactly as planned. We were led to believe by the CDC that with the onset of hot weather the swine flu virus would pack its bags and head for cooler climes. This hasn't happened in Arizona:
    (June 9) The onset of June and the Valley's typically high summer temperatures usually spell the end of Arizona's flu season.

    Not this year.

    State health officials are still reporting widespread flu activity, a very atypical occurrence they attribute directly to the novel H1N1 flu virus, also known as swine flu, that first appeared in April.
    And it hasn't happened in Utah:
    (June 8) Swine-flu cases in Utah have nearly doubled since last week and health department officials expect the numbers will continue to increase.

    On June 1, Utah health officials reported 369 confirmed cases — and 489 total by the end of last week. On Monday, that number was 713.

    Summer camp officials and other community leaders are taking precautions to avoid creating distribution grounds for infectious diseases such as H1N1, but Salt Lake Valley Health Department director Gary Edwards said the virus is already widespread in the community.

    "I imagine the numbers are smaller than what we really have," Edwards said. "We've scaled back to only testing hospitalized cases. We know that of individuals testing positive for type A influenza, 95 percent of them have the H1N1 virus, and we're not surprised."

    The flu has already jumped from public schools to summer camps and other outdoor recreation activities.


    When initial cases were confirmed in Utah, multiple schools closed out of concern that children mingling and sharing germs would spread the disease, which is defying the tendency of the common flu virus to be seasonal.

    "Usually the flu runs its course by late spring, but we're not seeing that. Every week we're seeing more confirmed cases," said Tom Hudachko, spokesman for the Utah Department of Health. "We would not expect to see this much active transmission of flu. It's one of the questions we're asking, and as a new virus, its behavior is something we're still trying to wrap our arms around."
    In fact, there's been a dramatic increase in swine flu in several states across the USA in the last few days with Florida, Connecticut, New Jersey, North Carolina, California and Washington, DC showing the largest increase. See the chart at News Emergency. The site mentions that the increase is happening because Americans are letting down their guard, but if swine flu was following the seasonal pattern of normal influenzas it should be pretty much gone by this time of year. (Thanks to Bullmoose Gal for sending the chart.

    Meanwhile, back in China, China's Flu Fighting Airport Corps is on the job. Kinda reassuring, isn't it, to see health officials showing they're taking the protection of your health very seriously?

    So. China gets a Flu Fighting Corps. America gets Kathleen Sebelius saying, “We are doing everything we can to protect public health and teach children how they can stay healthy and safe ... Elmo, Gordon, Sesame Workshop, and the Ad Council are delivering an important message to our kids.”

    Meanwhile, over in Egypt, the number of U.S. citizens infected with swine flu at the American University in Cairo rose to seven, after five more cases were diagnosed as positive Tuesday. The new cases —four students and a faculty member — tested positive after a dormitory for foreign students and staff was put under quarantine ...

    1) The Age: Widespread testing of swine flu dropped as cases soar; Mex Cooper; June 4, 2009

    2) Wikipedia: 2009 Swine Flu Outbreak: Airline hygiene precautions
    This post is crossposted at RBO. Thanks, Procrustes, for finding the Flu Fighters picture!

    Previous Pundita posts on swine flu
    June 5
    Swine Flu Pandemic: How worried should you be about birdbrains at CDC?
    June 2
    China's handling of swine flu bursts CDC's bubble
    May 26
    H1N1/swine flu: USA continues to play Typhoid Mary to the world, CDC continues to dither, but York Chow's John McClane moment is a beacon
    May 21
    H1N1/swine flu. Have CDC and Dr Thomas Frieden clouded NYC Mayor Michael Bloomberg's mind?
    May 20
    Stop misleading the public about the true lethality of H1N1/swine flu virus. Memo to CDC, WHO, New York City Department of Health
    May 19
    Mr President, fire NYC health commissioner Thomas Frieden from his post as CDC director before he even starts to work there
    May 15
    Say, whatever happened to that 2007 Senate subcommittee report on CDC fraud, waste, galloping mission creep, and failure to control disease?
    May 15
    Enraged U.S. lawmakers, union leaders, attack Homeland Security's negligent swine flu policy
    May 14
    H1N1/Swine Flu: Was Cuba's airport blockade an over-reaction to the outbreak?
    May 13
    H1N1/swine flu: CDC and WHO help unleash a pandemic
    May 11
    Swine flu/H1N1: Your life, riding on the CDC's slow boat from China
    May 4
    What Joe Biden knows about the jet-setter swine flu that you don't
    May 2
    H1N1 swine flu: WHO circles the wagons in response to criticism they were slow to warn
    April 30
    H1N1 swine flu pandemic threat: While WHO and the U.S. government dithered, Veratect Corporation raced to warn the world
    April 27
    Mexico-U.S. swine flu outbreak and the U.S. Department of Slime
    April 26
    Mexican-U.S. swine flu outbreak. Caution: blind curves and fog ahead

    Thursday, June 4

    On the 20th anniversary of the Tiananmen Square massacre, a candlelight vigil in Hong Kong lights the way for humankind

    I had meant to remember Tiananmen this year by featuring an essay from democracy activist and labor lawyer Stephen Diamond, who has warned for years about the dangers of U.S. labor leaders working with the farce that is Mainland China's government-controlled labor 'union.' My plan was changed by a photograph.

    It has been a tradition for those who write every year to commemorate the events of June 4, 1989 in Tiananmen Square to feature a photograph that depicts the massacre of the protestors. But on the night of June 4, 2009, China time, a gathering in Hong Kong to commemorate the 20th anniversary of the event gave the world, and the cause of freedom, a new image.

    The historic image was captured by Reuters photographer Bobby Yip and is featured in a New York Times report written by Keith Bradsher.

    The day dawned with heavy rainstorms but by evening the streets had dried and a nearly full moon rose in a cloudless sky to reveal 150,000 Chinese gathered in Victoria Park. The assemblage was so large it spilled into nearby streets and shut down traffic.

    Many arrived at Victoria Park because they'd attended every annual Tiananmen commemoration that had been held in Hong Kong. They were joined by Hong Kongers who were angered by their administration's attempt to appease Beijing by barring democracy activists from entering Hong Kong territory for this year's commemoration and for trying to downplay the massacre, which has been called by one Chinese "the darkest day in China's history." Commemoration of the Tiananmen Square massacre is banned on the Mainland.

    By the time the speeches and songs got underway the crowd represented the largest ever gathered in Hong Kong to remember what is often referred to simply as "Tiananmen."

    Suddenly the electric lamps lighting Victoria Park were extinguished. Then thousands in the gathering lit white candles set in inverted conical paper shields.

    White is the color of mourning in China, but I find nothing mournful about the sight of darkness pierced by many thousands of individual lights.

    Steve Diamond closed his essay by quoting American labor activist Mother Jones: “Mourn for the dead, but fight like hell for the living.”

    Of course photographs are not enough; symbols and mass demonstrations are never enough to win or preserve freedom. Yet if we consider that it was not without risk that thousands of Hong Kong residents gathered in public to light a candle, the symbolism of the event takes on profound meaning.

    If the young ask why the process of democratization is so agonizingly slow and tyranny so often wins -- because democracy is not based in the voting booth, laws, street protests, armed revolution, or the size of crowds.

    Democracy's defense, it's only reliable defense, is an arduous process of reasoning about the fundamentals of human freedom coupled with a thorough knowledge of history. If those exercises are absent it's easy for large numbers of people to accept a mirage in place of freedom and human parrots in place of democratic leaders.

    It takes a lot of teaching and studying for many millions of people, let alone billions, to arrive at the maturity of thought that supplants the atavistic herd mentality. That grueling process takes time.

    Yet no sincere retort to tyranny is ever futile. The protestors who were cut down on June 4, 1989 did not die in vain. If you need reminding of that, take a good look at the Victoria Park photograph.

    1 pundita hong

    This entry is crossposted at RBO, which added two YouTube videos of the Victoria Park gathering to the post, and which are very important records. RBO's blogger Procrustes told me in an email, "The videos show the magnitude and attitude of the crowd." The links to the videos are found here and here.

    Tuesday, June 2

    China's handling of swine flu bursts CDC's bubble

    Watch carefully, don't blink:

    May 09
    Australia reports their first confirmed case of swine flu; an infected American airline passenger traveling from the USA. Queensland, Australia's chief health officer Dr Jeannette Young said more cases were likely in the future "because we have a lot of planes coming into the country every day''.

    June 01
    Australia's confirmed swine flu cases: 401.

    The cases are doubling about every two days.

    May 10
    Mainland China reports their first confirmed case of swine flu, an infected Chinese citizen traveling on a flight from the USA via Tokyo.

    June 01
    Mainland China's confirmed swine flu cases: 38.

    It should go without saying that Mainland China also has a lot of flights coming into the country each day. Yet even with adding Hong Kong's 23 June 1 confirmed cases (which are also stupendously low) to bring the grand total in China to 61, and even accounting for unreported/unprocessed cases in all of China, the difference between the Australia and Mainland China tallies is staggering.

    What explains the difference? In one sentence: Mainland China's decision to quarantine every passenger with a fever arriving at their ports of entry.

    The draconian approach to battling swine flu has been controversial -- particularly with Mexico's government. But even before the June 1 numbers came out public health officials were acknowledging that the approach was greatly slowing the rate of swine flu infections. March 28, The Washington Post:
    [...] While the spread of swine flu seems to have slowed for the time being, and other countries have relaxed previous restrictions on public gatherings and travel, China has become increasingly vigilant -- throwing several thousand foreigners and Chinese nationals into quarantine facilities for having little more than a cough, runny nose or slight temperature and having been in contact with someone with a suspected case of swine flu.

    Some public health experts say its aggressive measures to deal with a possible pandemic -- devised after China's slow and secretive response to the deadly SARS virus in 2003 was blamed for spreading the respiratory disease -- should serve as a model for other countries.

    Statistically speaking, China's efforts have been an amazing success this time around. Of a total of 13,400 confirmed infections worldwide, only 14 have been in China, though nearly a fifth of the world's population lives within its borders.

    From a public relations standpoint, however, China's medical checks and quarantine procedures have been a disaster. [...]
    That last sentence is not strictly accurate. How you see China's actions depends on whether you're living in a rich country, whether you have easy access to Tamiflu and Relenza and great medical facilities, and whether you know your government is so rich and powerful it can snap up a big share of swine flu vaccine if/when it becomes available. The more you move away from that profile, the less of a PR disaster China's actions seem.

    The numbers quoted in the Washington Post report are of course behind the June 1 data curve but the low number of confirmed cases has continued to hold. That means the contrast between the Australia and China tally is the worst indictment to date of the CDC's recommended approach to dealing with an infectious disease outbreak.

    The CDC approach, which was aped by WHO, was to refuse to recommend quarantine and other aggressive NPI (non-pharmacological intervention) measures such as suspending airline flights; this on the misleading argument that once a highly infectious virus has arrived in a country such measures cannot stop the virus.

    As I have pointed out many times on this blog, once such a virus is loose "stopping" it is not the issue; what's critical at that point is to slow the rate of infection -- a point that has been made even by the biomedical mathematicians who advise the CDC.

    China's Ministry of Health, and Hong Kong's redoubtable Dr Chow, grasped that simple point, and the procedures they implemented have by now amply demonstrated that they've managed to greatly slow the rate of swine flu infections in their regions of China.

    Yet that simple point continues to elude the CDC, and all the U.S. officials they're advising at the White House and across an alphabet soup of federal agencies: Health and Human Services, Homeland Security, State, Transportation. Not to mention the U.S. state and city health officials the CDC is advising.

    Why are all these people having such a hard time confronting a simple point?

    If you reply that the CDC probably thinks it's not necessary to take the most aggressive NPI measures because the disease isn't all that lethal -- that's mixing up two completely different subjects, and dangerously so. Here's why:

    First I'll review quotes I posted on May 11. (See the post for links to the sources.)

    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."

    As I stressed in the May 11 post, Obama and Napolitano were simply summarizing the thinking at the CDC, which does not address the lethality of a highly infectious disease. The thinking addresses their idea, based on their reading of mathematical models, of how such a disease spreads once it arrives in a country.

    From their reading, there is no way to stop any highly infectious disease from spreading to virtually all vulnerable people in the country -- if there is not an effective vaccine administered to virtually the entire population (a virtual impossibility).

    Ergo, there's no use taking the kind of NPI measures that China is deploying; e.g., blocking flights from a country with a high rate of infection, quarantines, taking the temperature of passengers on international flights even before they leave the plane, using thermal imaging machines at airports and ports to monitor disembarked passengers' temperatures, making constant public service announcements to warn of the disease, urging people who don't feel well to wear surgical masks, etc.

    But then China had the bad form to burst the CDC's bubble by demonstrating that aggressive NPI measures greatly slow the infection rate for a highly infectious disease.

    If you say, 'Back up; are you telling me that the CDC would keep relying on the same mathematical models even if the disease was a superkiller?'

    Well, they're relying on their reading of the models. But by their own reasoning -- the answer is yes.

    If you reply, 'That doesn't sound right' -- Welcome! Welcome to the party! Take off your hat and coat and stay awhile. Why do you think I've been yelling myself hoarse on this blog for the past month?

    I hate to break this news to you all at once but there are lunatics in charge of America's federal infectious disease control agency. Dangerous lunatics.

    How dangerous? That would depend on which country you're in, now wouldn't it?

    The first confirmed case of swine flu in Hong Kong was also the first confirmed case in all of Asia. That was on May 2 -- five days after Homeland Secretary Napolitano passed along the CDC's pearls of wisdom.

    The first confirmed case of swine flu in the United States came on April 14 -- 16 days I repeat 16 before President Obama explained that from the CDC's perspective, aggressive measures to limit the entrance of infected Mexicans to the USA "...would be akin to closing the barn door after the horses are out, because we already have cases here in the United States." (1)

    But the barn door wasn't open at that time in Asia, was it? It wasn't open in many countries, including Australia.

    The first clear sign, the first "tell" that something really strange was going on in Mexico, came on March 18 -- I repeat March -- when biosurveillance picked up an unusual "influenza-like" disease outbreak in Mexico City. The outbreak was initially assumed by Mexican health officials to be "late-season flu" outbreak and not a new virus strain. (1)

    On what grounds did the Mexican officials make that daffy assumption? On the same grounds that U.S. health officials failed to send out alerts to every country on April 14: on the grounds that their protocols were perfectly in synch with their calendar year: 1952.

    So the CDC influenza officials are not the only lunatics in public health. Only a handful of national governments took anything approaching rational action in the face of the swine flu outbreak.

    Why only a handful? Because just as the world was completely unready for the kind of asymmetrical warfare al Qaeda demonstrated in 2001, so the world was unready for the blitzkrieg of the 2009 swine flu virus -- and for the same reason: their defense systems were a quarter century out of date. And so were their mathematical models.

    The CDC is thinking only in inbound terms, not outbound terms, when they say that once a disease is in a country there's nothing that can be done to stop its spread -- at least not without vaccinating the entire population. For the sake of argument we'll accept that thinking. But once a disease is in say, the USA, that doesn't mean it has to proceed from the USA to every country that doesn't have the disease.

    That seems to be one limitation of the models that the CDC references; the models pertain to the spread of an infectious disease in the USA, not globally.

    That was Dr York Chow's point when he said, "I think that everyone has the responsibility to ensure that they do not allow any infection to go outside their country or territory."

    If you say he's asking for the impossible in today's highly interconnected, globalized world of commerce -- no, he's asking for public health officials and citizens to bring their thinking into the modern globalized era, before a catastrophe happens.

    Realize that China's approach to managing swine flu is directed as much at outbound plane passengers as inbound ones. The public health officials on the Mainland and in Hong Kong are knocking themselves to stop the disease from leaving their airports. Are they completely successful? No. Are their actions helping to slow the rate of infection in other countries? Yes.

    And note their strategy does not include blockade. China hasn't pulled up the drawbridge; they're trying to work out a balance between the demands of a highly globalized era and protecting populations from the devastation of a highly lethal infectious disease.

    And this is one of those situations where we don't dare say, 'We'll cross that bridge when we come to it.' That's because the road to the bridge will be impassable with dead bodies, if we wait until after a superkiller pandemic gets underway before we start retooling public health measures for the modern era.

    Retooling will involve wrestling with questions about civil liberties. A reader asked how I'd feel if I found myself led away in handcuffs from an airport to a quarantine area.

    Three days in quarantine, huh? Three days all to myself, no ringing phones, no CNN and Fox news, no poring over the ramblings of CDC and WHO officials; three days being waited on hand and foot. Well, dispense with the handcuffs because I think I could take one for Team Humanity.

    But the reader has a serious point that must be addressed. There are many other points that need addressing. We need to hunker down to those issues fast. This is because the CDC's skill at verbally palming an ace from the bottom of the deck is on full display with their discussion of the swine flu's lethality.

    They've said that the virus doesn't have the "virulence markers" of the 1918 flu virus. I can't read a genome sequence so I'll take their word for it. But notice they didn't say that the swine flu virus has no markers that would indicate a proclivity for extreme virulence.

    Not that I like ending on a cliffhanger note but I see it's almost 3 PM and I'd announced I'd get this post out this morning. I'll pick up the discussion tomorrow.

    1) Wikipedia 2009 Swine Flu Outobreak