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
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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