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.

    1 comment:

    DocJim said...

    We always need to put together the latest gadgets and technology with solid, ancient principles. If you rely solely on one or the other, gonna have trouble.

    This is an excellent analysis and the group think of the WHO and CDC are based, as you pointed out, on expecting air travel to go on undisturbed.

    So our convenience (take the flight anyway) may come at the cost of our neighbor's death. Not nice, but it is realistic.

    Two months saved from reaping the wild wind of the virus spread may save many lives by giving enough time to get vaccines produced. True.