Forum: CFR Estimates Any Good

an excerpt from an article entitled “Disease Mitigation Measures in the control of Pandemic Influenza” published in Biosecurity and Bioterrorism, volume 4 No. 4 2006 reads (pp2)

“….The HHS and HSC documents assume that, in the worst case, the case-fatality ratio would be equal to that of 1918 (about 2.5%). {footnote 10 and 11} Such data as are available from the past 300 years show the 1918 influenza pandemic was, by far, the most lethal.

To date, the current case-fatality ratios have been 50% or more. H%N! infection has been clinically more severe, and many patients have symptoms that differ from those caused by other influenza strains. {footnote 12 and 13} So far, the virus has exhibited little ability to spread from human to human. it has been widely assumed that if the current strain of virus did transform into one that is more readily transmissable, the virus would assume characteristics and case-fatality ratios more closely resembling previous pandemic strains…..”

Footnotes 10 and 11 refers to the HHS and US national panflu plans respectively.

So where is the science to back up these “wide assumptions” that are being made? I don’t see any. It may be worthwhile to email Jennifer B. Nuzzo, one of the authors, and ask her this question- her email is Jnuzzo at upmc dash biosecurity dot org

This paper goes on to make a number of recommendations based on this unsupported assumption (that the pandemic will be no worse than 1918). A response that is appropriate for a 1918 event would be disastrous for something more serious. This “assumption” needs to be challenged, IMO, since it drives a lot of the complacency we encounter.

assume; put an = after the second “s”, put a + after the “u” if we risk lives believing some old spreadsheet where the job may have been, Make a do-able scenario for COOP plans that doesn’t panic anyone.

See also Must A Pan Flu Decrease in Lethality? , Fatality Rate Question , and Are Hospitals Prepping? - our current capacity isn’t even up to months of extra sick people surges, even if it wasn’t fatal, which H5N1 sure still is; with hospital care and meds now.

(and where was that thread; making the case H5N1 was harder to get from contact with sick birds compared to how easy it seems be to get from contact with a sick person?)

Dr. Nabarro had said, scientists had told him it was possible to go pandemic without losing virulence. Gartner Fellows interview, Dec 2005…” The biology colleagues that I speak with tell me that if the pathogenic characteristics of H5N1 were to be taken forward as it mutates into having a human-to-human transmission capacity, then we would have a virus with high pathogenicity. “…

I have yet to see a scientific paper that supports the assertion that the CFR of H5N1 will drop to 2% while explainng the mechanism by which this will be accomplished. Is there such a paper out there somewhere? There may be, I just have not seen one yet. What is the basis for the HHS and HHCs assumption of a 2% CFR?

As you say, OnandAnon, the assumptions are shared wildely, but the evidence is not so readily produced. In conversations with physcians, scientists, and officials I often hear the assumption of a 2% CFR, and have repeatedly challenged them to bring me supporting evidence for that claim. So far, there have been no takers. The good thing is that at that point, that is when the serious conversations about how to mitigate the impact of a pandemic begin.

I meant to say “widely” up there, not “wildely,” but that may have been a Freudian slip.

Pixie – at 11:43 “What is the basis for the HHS and HHCs assumption of a 2% CFR?”

IMO, they stay with such a low figure because intuitively they know we are screwed if the CFR is even double their ridiculously low estimate.

I have given this some thought.

Q- What group of federal employees is going to be most affected by a pandemic?

A- The TSA. The TSA screeners are in constant contact with people who are travelling from all over the world. If there is a flu pandemic they are going to get hit first and hit worst.

I deal with the TSA all the time. None of them know anything at all about a flu pandemic. Their supervisors tell me when I ask that there is no stockpile of PPE, no drugs, no way to protect their staff. If the word got out to the TSA employees about what would really happen to them and to their families, they’d all quit and go back to flipping burgers or mopping floors, and there would be no security screening. I think this is a major reason why there is strong resistance to speaking the truth.

Do we have this on the Wiki yet?

Oct 15 …”Hundreds of medical experts are discussing the scenario of an Avian influenza pandemic at the Hobart conference.

They say bird flu has already been detected in 53 countries, and if the virus spreads to Australia the predicted mortality rate is 35 per cent.

Professor Marcus Skinner, from Tasmania’s North West Regional Hospital, says existing preparedness plans do not anticipate the rapid erosion of front-line hospital staff in the event of an avian flu outbreak.”…

Oh, but they’re clever! By saying 1918 was “the worst in 300 years” they get to exclude the plagues of the middle ages that wiped out 1/3 or more of the European population. The faulty thinking that the CFR “must/will” decrease is doing so much harm. By stating 2% “worst case” people think it won’t be nearly that bad and decide to take their chances and not prep. Given where it is right now, I’d be happy with 10%. Two percent is a dream scenario.

Something has really bugged me for a long time and I want someone to correct me if I’m wrong. I have read on various BF forums for two years now that the CFR for the 1918 pandemic was somewhere between 2 and 2.5%. Everyone seems to agree on this.

Also, there seems to be agreement that about 40% of the people in the world became infected with somewhere between 20 and 100 million deaths with the most recent studies leaning to the higher number. I will split the difference and use 60 million deaths.

In 1918 there where approx. 1.8 billion people.

So, 1.8 billion x 40%= 720 million people became sick.

60 million deaths divided by 720 million infected people equals a CFR of 8.3%

Big difference.

econ101,

That too was extensively debated at one point. I believe the answer is that a) we don’t really know, as so little data is available, and b) the numbers given are extrapolations of estimates of a non-randomly chosen small sample of ‘’whatever city (see the bias?) was most convenient to research or kept the best records, all done by (mostly) Western or Western-biased researchers.

If you are only 1 or maybe 2 people who has researched a particular subject, and if one could give an accuracy score of 0–100, and you got 23 while the other guy got 18 (neither being very accurate), then your ‘research’ will still be preferentially cited.

The more often you are cited, the more likely people will take that as ‘proven’ or ‘God given truth’.

TY anon 22 but it’s still a hugh diffrence when assumtions are being made on 2.0% CFR.

Pixie – at 11:43

I have yet to see a scientific paper that supports the assertion that the CFR of H5N1 will drop to 2% while explainng the mechanism by which this will be accomplished.

We do have the opposite, opinions by several famous scientists who say that may not necessarily happen. H5N1 Outbreaks and Enzootic Influenza, Robert G. Webster, Malik Peiris, Honglin Chen, and Yi Guan, Emerging Infectious Diseases, Jan 06.

The paper concludes:

We cannot afford simply to hope that human-to-human spread of H5N1 will not happen and that, if it does, the pathogenicity of the virus will attenuate. Notably, the precursor of the severe acute respiratory syndrome (SARS)–associated coronavirus (31) repeatedly crossed species barriers, probably for many years, before it finally acquired the capacity for human-to-human transmission, and its pathogenicity to humans was not attenuated. We cannot wait and allow nature to take its course. SARS was interrupted by early case detection and isolation, but influenza is transmissible early in the course of the disease and cannot be controlled by similar means. Just 1 year before the catastrophic tsunami of December 2004, Asian leaders rejected a proposed tsunami warning system for the Indian Ocean because it was too expensive and the risk was too remote. This mistake must not be repeated in relation to an H5N1 avian influenza pandemic. We must use this window of opportunity to prepare and to begin prepandemic implementation of prevention and control measures.1

Keep this source in your portfolio of quotes.

econ101,

I gave that by way of explanation, not justification.

OnandAnon – at 10:36

So where is the science to back up these “wide assumptions” that are being made? I don’t see any. It may be worthwhile to email Jennifer B. Nuzzo, one of the authors, and ask her this question-

If you read the document very closely you will notice how carefully the authors avoided personally endorsing this assumption while not challenging it directly either. What they are doing IMHO is assessing the plans based on the assumptions given. That is, they are essentially saying to the government, “if you think this is what’s going to happen, and I’m not challenging you on that point right now, lets see if your mitigation strategies for these assumptions will work.”

This is the pragmatic approach, and offer some moderately useful advice for the government to use. IF, and I’m only speculating, that assessing the government’s plans in relation to their assumptions is the job description they were given for this paper, then this is understandable.

How far individual experts are willing to deviate from the task at hand depends on many things, among them consensus if there’s more than one author.

I think they can and should go a lot further, because we may be running out of time. Their next assessment really should be on the assumptions themselves, as those are the deeper level issues that drive policy.

If a problem is worse than expected by say 30% or 50%, it may still be feasible although difficult to take your mitigation strategies and just upgrade them, ie do more of the same.

If, however, the problem is actually worse by 20 or 30 or even ‘just’ 10 times, then the secondary and tertiary effects are not just exponentially greater, but very likely to be qualitatively different as well. ie the nature and not just magnitude of the problem is now entirely different, then it is unlikely that policies suggested for the original scenario will work, however much you expand them. They will need an entirely different, probably novel, kindof response.

“More of the same” just ain’t gonna do it.

econ101 – at 23:28 of Oct 19

“Something has really bugged me for a long time and I want someone to correct me if I’m wrong. I have read on various BF forums for two years now that the CFR for the 1918 pandemic was somewhere between 2 and 2.5%. Everyone seems to agree on this.”

When one speaks of CIR and CFR, they should probably be country specific to be clear, or state that they are using world averages. The numbers can range all over the map from high to low. I believe the numbers of which you speak above relate to the United States, and are likely based on the following:

Population: 100 million-----------Flu cases: 28 million, therefore the CIR would be 28%

Deaths: 675,000, therefore the CFR would be 2.4%

Hope that helps. Some countries, such as India, had CFR that far exceeded the numbers above.

The other problem in using 1918 as a guide (okay, besides the fact that it was a totally different strain) is we really don’t know what the infection/cfr rates were. They are purely estimates based on imcomplete data. Accurate records were not kept, and many patients were cared for and/or died at home. Too many cases where they have been used as “fact.”

Besides, I totally don’t buy that it will fall from >60% to 2%, but that’s just me lol!

Mamabird – what happens to the fatality numbers if you take the low-cfr spreadshhets and wonder what would happen if all the people supposed to need hospital care can’t get it? Or, that all the people who fall sick may need hospital care that isn’t available, even on the community-overflow level?

(It keeps sounding like New Orleans planning only only getting hit by a Cat1 hurricane or something…because it is too hard to make a prepare for a Cat5.)

Found a White Paper pdf that used 5% to 7% cfr (and only 25% of population infected)

If this is defined as a pandemic, specifically because our (virgin) immune systems have never encountered the pathogen before…

…then what is physiological etc. process by which 75% of the population is going to escape infection?

I have yet to hear an explanation that is even remotely believable.

It is one thing to say that we won’t have a pandemic at all…that is defendable. It is quite another to say that ‘fairy dust’ is going to protect us from a unique virus.

crfullmoon – at 12:50

Excellent point, and I like your analogy of the Cat 1 and 5 hurricane. Very appropriate.

What I have seen and heard about CIR and CFR (and none of this may ultimately hold water) is that if you have a 1957 variety pandemic, you may have relatively high clinical infection rates (because it is a novel virus and the populace has little natural immunity), but the illness is mild. That is, not much need for hospitalizations (except for those persons that have other complicating physical issues), and higher than normal death rates, but nothing socially serious like in 1918.

So, for example if H9N2 or H7N3 were to break loose as a pandemic virus, you theoritically could have 40% clinical infection rates, but only a .2% case fatality ratio. Lots of folks would be home sick and away from the workplace, which will be problematic, but hopefully there wont be fear and panic that causes a lot of SIP, which could seriously hamper society and the economy.

On the other hand, if you have a 1918 variety pandemic, you not only have a relatively high CIR, say 30%, but the virus causes severe illness in those that it attacks as well. This of course results in high hospitalizations and high death rates, and evidence of that occurring may cause fear and panic as well, excerbating the social problems. What I’m told is that in 1918 a substantial number of deaths could be attributed to the virus itself, and not the clinical infection rates. A CFR of 2.5% would generally be experienced if 30% of the population was infected or only 3%. Now some say that with today’s medical care, a lot of the secondary bacterial infections of the 1918 pandemic would be better controlled, thus saving lives, but an H5N1 virus appears to result in death for other reasons, in spite of quality care.

So, I guess an in between scenario is possible which might assume high infection rates, and a virus that causes fairly severe, but treatable disease. In other words, if one gets proper medical care, you recover, but if that care is delayed or limited, you have a higher chance of death. In that case, I agree with where you are going - a low CFR can not be assumed because the high CIR with such a virus would quickly overwhelm a medical response system that is already limited.

Unlike the citizens of New Orleans that will likely run from the next major hurricane, unfortunately it is difficult to dodge a pandemic. So, prepare for something ugly, and then pray for Low Path.

So, we’re back to Dr.Osterholm’s original two-word prognostication…

Good luck, people! Keep being Worst-case Preparation gadflies. (since it doesn’t look like anywhere really has a few months of surge capacity up its sleeve)

Tom DVM – at 13:58

“…then what is physiological etc. process by which 75% of the population is going to escape infection?”

I can only relate to you what others in the field have stated, and which is that there may be a couple of reasons for some hope: 1)the pandemic is caused by a virus that is not completely novel, and/or 2)some people may have a genetic disposition for avoiding infection.

The first can be explained by comparison of the 1957 and 1968 pandemic events. Although five of the eight gene segments of the 1957 H2N2 had been circulating in the human population for decades, the HA, NA and PB1 segments were novel. Therefore, the CIR of ‘57 was similar to the CIR of 1918.

On the other hand, in the 1968 pandemic, the H3 was novel, but N2 was not completely new. It was the former N2 of the 1957 virus, but with mutations that had been seen by the population to some extent. Therefore, its CIR was only a bit higher than CIRs seen in robust seasonal flu outbreaks, less than 15%.

Now H5N1, is clearly novel as to the HA component, but at the time of the pandemic outbreak of this virus, the N1 component may not be too disimilar to the N1 in the H1N1 seasonal flu strain that continues to circulate widely today. Since the body builds antibodies toward both the HA and NA of the influenza virus, there may exist partial immunity to H5N1 in today’s population. And to this point, the seasonal flu vaccines may provide partial cross immunity for H5N1.

As to the second point, I will admit to speculation on the part of the folks making predictions. It goes to the point that in the H5N1 clusters we have seen to date, they seem to stick fairly near to blood relatives and closely related family members. The H2H2H transmissions have not been confirmed and documentated outside these families. We also may have seen some evidence of this factor in 1918. The Brevig Mission isolate from Alaska was from a member of the Inuit tribe in which 85% of the population succumbed. Are these infections due to host genetics or perhaps simply because all of these family members live in close quarters. Who knows?

I’ve been reading John Barry’s book, “The Great Influenza”. He interviewed survivors who were children at the time of the pandemic. In Philidelphia, they hung crepe on the doors of houses where someone had died. White for child, black for adult, gray for elderly. Practically every other house had crepe on it. Virtually every household had at least one person sick.

The vast majority of people died without ever being seen by a doctor or nurse, because there were just too many sick and dying people. The city came to a virtual standstill. People were just to terrified to leave their houses. The Red Cross had tens of thousands of volunteers across the country who delivered food door to door to people so they wouldn’t starve. The food was left outside on the stoop.

Entire households were wiped out. Bodies were left inside houses for days because no one would go into them to take them away, not even for $100 an hour. Family members abandoned other family members to die. Orphaned children starved to death amidst their dead parents’ bodies because no one would bring them food.

If all of this is true, I don’t believe that the case fatality rate was only 2 or 3 percent.

Hi Mamabird and TJD!s. Thanks for the comments.

Mamabird. We can speculate as to what will happen down the road and hopefully for all of us either H5N1 will go away never to bother us again or the pandemic will be mild when it comes.

However we can come to some conclusions from the data we do have.

Three of the last six pandemics (1830.1890 and 1918) were of approx. virulence. In otherwords we have a fifty percent chance of having a pandemic like the one in 1918.

Dr. JFT has stated that morphoglogically, H5N1 is a ‘kissin cousin’ of H1N1 (1918)

While the 1957 and 1968 pandemic viruses were formed by reassortment between H1N1 (1918) and other viruses, 1918 was a pure avian virus that attained pandemic potential by mutation. The similarity and behavior of H5N1 indicates that it too, carries the potential to mutate to pandemic potential.

Given the fact that the H1 has not altered in the past nine years to decrease virulence as predicted, it must be assumed that the eventual mutation to pandemic potential will leave the N1 gene also unrelated to any N1 in the environment or in the past.

The changing in estimates for mortality in the 1918 pandemic over the decades and recently, indicates that there was no accurate record keeping or way to now determine the actual CFR. As That’s Just Ducky! says…the likelyhood that it was only 2.5% is unlikely. An actual CFR of 8–10% now appears more likely and reasonable given the data.

Novel viruses (ex. smallpox) result in an infection rate of somewhere between 80–95% of the population. I will accept the argument that 25% in 1918 were infected in the second (virulent) wave that lasted six weeks…but I cannot except that the end result for H1N1 was a total infection rate of only 25% of the population…

…In John Barry’s book, it stated that 1919 was either the second or third worst time period for influenza deaths in the twentieth century and at that point the pandemic was supposed to be over…in another section of the book he describes epidemics of H1N1 that continued throughout the nineteen-twenties.

In my opinion, the historical and scientific facts indicate that 95% of the population over possibly ten years will be infected with a novel virus equivalent to H1N1 which was not formed by reassortment, leaving no opportunity for the human immune system to have ever seen it before.

As the old saw goes “There are liars, damn liars, and statisticians”. How true and appropriate for this thread.

The answer to OnandAnon’s thread starting question is; no one really knows. But we can guess and cloak these guesses in high-sounding terms like the one I used to describe my own guesses in an earlier thread “mathematical model”. The truth is that models start with a few basic facts like population size and then makes assumptions (another big word for guess) about how the flu will act and what effect its actions will have on human health.

Models can be adjusted for conditions that increase or decrease the effect pandemic influenza might have on a population. The problem is the adjustment of a model increases uncertainty in the outcome. At the same time, failure to adjust a model can result in a result that is way off the mark.

Models are truly “pie in the sky”. They are totally unreal, existing only in the mind or computer of their maker. Always keep this in mind when evaluating a model’s prediction. They are usually wrong and at best only in the ballpark.

That said I have been busy modeling the 1918 and coming pandemic since becoming interested in the problem 2 years ago. The predictions made by my simple models have helped me to get a grasp on the magnitude of the problem pandemic influenza represents. Being a model maker, I know it would be foolish to rely on a specific prediction made by one of my models or anyone’s models of anything. The value of a good model is not the actual prediction it returns but the range possibilities surrounding it.

Real statisticians, unlike duffers like me, can provide you with this range called “the standard deviation of the mean”. Here is the good part. The true answer is pretty likely to lie within the range provided around the models mean AKA result. So, lets say to pandemic model returns a case fatality rate of 8% ± 2%. In this case, the proper interpretation of the model is that the CFR for the flu is likely to be between 6% and 10%.

If you know how many standard deviations were used to calculate the ± 2% range, then you can know how probable it is that the real result is within the range. For instance, if they used 1 standard deviation, the predicted result will fall within the given range 2 out of 3 times. If they used 2 standard deviations, the certainty increases to 19 out of 20 times.

So, models can be very useful. They can also be manipulated as in “garbage in garbage out”. In my study of other’s writings on the pandemic and its impact on society and health, I have encountered some of the most egregious manipulation of assumptions so that the results of the model will not contradict a hoped for outcome by a governmental agency. In fact, this practice appears to be widespread.

My best estimate of the CFR for a severe pandemic in the US and EU is 8%. I don’t give a range because my work is so unsophisticated that it would be ridiculous to do so. I suggest that you just assign one, like the ± 2% like we used in the above exercise. (Its all just guess work anyway so don’t get your panties in a twist about it.)

I wrote my results down and published them on the www.BirdFluManual.com website where it can be downloaded. It is called Estimates of Illness and Death During the Pandemic. The article discusses the model, the adjustments made in it and why. I hope this post and the article helps provide those of you who have questions about this issue some insight into how this guesswork is done and also just how fragile these predictions are. When you read the article, keep this post in mind. Models are just fancy guesswork.

http://www.birdflumanual.com/articles/illnessAndDeath.asp

Grattan Woodson, MD, FACP

Sorry, one thing I forgot to mention in respect to CFR:

They did catch one break in 1918. Whether we will in the future…only time will tell.

The virulent wave in 1918 was the second of three waves. That meant that those who were infected in the first wave were protected in the second…if not completely, enough to prevent death…some of these infections would probably have been asymptomatic…

…this would significantly lower CFR.

To extrapolate from this to the present day…even if H5N1 is the equivalent to 1918, if the virulent wave is the third wave then the CFR would be lower than 1918 automatically.

However, if the virulent wave is the first wave…well then God Help Us All!!

This time there may not be (probably won’t be, actually) individual shorter waves, there may (probably) be only one, because of the way that transportation has changed since 1918. It no longer takes weeks for disease to be transmitted across countries and continents. Many more people travel now, and they travel and a much faster speed. Let us hope that if this turns out to be the case, that it has a low case fatality rate.

I agree with TJD’s comment that this coming pandemic’s epidemiology and worldwide spread is very likely to be different from past pandemics due to the affect of modern human travel methods. Waves may still occur though if it is temperature change (spring and summer heating) that interrupts the progress of the virus through the susceptible.

Grattan Woodson, MD, FACP

Think of all the ramifications of an estimated 50% of the world’s population becoming infected, 3 billion people, within a very short period of time, say 6 months, all at once with the peak of the bell curve lasting approximately 3 or 4 months with a case fatality rate of 8 percent, 240 million people.

Actually not the peak of the bell curve, probably the top third third.

Dr. Woodson, you make a good point.

I am sure experts have already done this modelling. I would love to see what such modelling looks like on a global scale.

I am also sure that they have already modelled the estimated ramifications to such an event.

All good points from above - stimulating conversation that reminds me why I chose a career other than that of an actuary.

And of course, case fatality rates (for any given number of actual deaths) are inversely proportional to the the clinical infection rates. So, for example, if you believe that approximately 675,000 persons died in the US as a result of the pandemic of 1918, the CFR would only be about 2.4% if CIR was about 28% for a population of just over 100 million. If the number of actual infections were twice as high, making the CIR closer to 50%, then the CFR would be about half or only 1.2%.

There are actually two approaches that have been used to guess at the number of pandemic deaths. One is the actual counts from all the local records, which as stated above can easily miss the mark. The other way is based on population figures, which of course are not always perfectly accuate as well, but would give a quick check to mehtod one.

Prior to the pandemic the population of the US was just over 100 million and had been steadily growing by 1 million for each of the prior ten years. The population after the pandemic was just under 100 million. Therefore, assuming that the birth rates were only minimally affected by the pandemic, then it would seem that the outside number of deaths would be around the 1 million mark. Disturbing yes, but of course nothing approaching the CFR of current H5N1.

Another aspect to consider; it is estimated that we will have collateral damage at 100% of the actual deaths due to infection, due in large part to our modern JITD system.

If this be the case, then it is no wonder to me that TPTB are somewhat reserved on the subject.

Tom DVM – at 15:17

“An actual CFR of 8–10% now appears more likely and reasonable given the data.”

Just looking at these numbers, there can be a range of results. For example, if the CIR was 28% during the 1918 pandemic, and the CFR was in the range of 8–10%, then the death count would range from 2.2 to 2.8 million persons out of a population of 100 million. That’s pretty far removed from the official population figure changes during this time period.

On the other hand, if the death count was about 1 million and CFR was 8–10%, then the infection rates could only have been in the range of 10–13%, which seems awfully low given all the accounts of the event.

So, while I certainly share your concern with H5N1 going pandemic with exceptionally high mortality rates, I think 1918 stats are not too far removed from those that have been documented except for the number of people that became infected. No one has much comfort with those figures for a variety of reasons.

Mamabird – at 16:30

Why would we think that the CIR in 1918 pandemic might have been only 28%?

By all accounts in John Barry’s book, by the way, the second wave was not only much more virulent, but also had a much higher CIR, or CAR. This doesn’t seem to hold with the postulated reduction of CFR to increased CIR/CAR. In 1918–1919, the virus didn’t trade virulence for transmissibility, as some are postulating that H5N1 will do. I really don’t know how they came up with that postulate. There must be some reason.

“No one has much comfort with those figures for a variety of reasons.”

Mamabird. I agree completely with your statement.

If I was faced with the catastrophe they were faced with, I don’t think I would care much for recording data either.

The overall CFR for the pandemic would include differential CFR’s from around the world and I believe that North America, at the time, got off relatively better than the rest of the world, possibly due to population density that by now has equalized somewhat.

Secondly, it depends over what time period, the CIR and CFR may have been measured over. I was wrong in my post above, I believe 1920 produced the third highest influenza deaths in the twentieth century behind 1918 and 1919.

As you said above, it all comes down to how novel the virus is when the pandemic takes hold…if it is as novel as 1918 (50% probability) then the CIR and CFR may go on for most of a decade with 85–95% of the population infected, under natural circumstances with no effective vaccine avaliable…

…and as TJD! says, that does not include collateral damage.

The last time North America made out better than the rest of the world…I wouldn’t take bets on that one this time…it seems to me that North America is less self-reliant and more prone to infrastructure collapse now than most other parts of the worlds.

Tom DVM – at 17:13 “The last time North America made out better than the rest of the world…I wouldn’t take bets on that one this time…it seems to me that North America is less self-reliant and more prone to infrastructure collapse now than most other parts of the worlds. “

Yes I agree. Actually, I think that instead of saying North America, I would instead say western civilization.

This likely collapse of the infrastruture collapse of western civilization are the ramifications I was alluding to in:

That’s Just Ducky! – at 15:59 Think of all the ramifications of an estimated 50% of the world’s population becoming infected, 3 billion people, within a very short period of time, say 6 months, all at once with the peak of the bell curve lasting approximately 3 or 4 months with a case fatality rate of 8 percent, 240 million people.

I was also thinking of the collateral damage when I wrote that, I just forgot to write it.

I wonder about how accurate that figure of 675,000 fatalities from the Spanish Flu is, and whether it might have been a lot higher.

If you recall, TPTB of San Francisco covered up the extent of the damage and the loss of life in the 1906 earthquake, so it wouldn’t have such a negative impact on the city, economically. They wanted people and business to come to SF, so they painted a much rosier picture than what was really the situation.

In 1918–1918, TPTB, for political and economic reasons, first ignored and denied the risk of the pandemic time after time, even when presented with evidence of the risk and the unfolding epidemic. Then, they lied to the public about what was happening, telling them that the risk was over when it wasn’t, telling them every day that the peak of the pandemic had come, and would begin it’s descent the next day, when it continued to rise steadily for quite a long time. They were able to get away with this because of the comparatively primitive means of mass communiations at the time. I am sure they then saw to it that the CIR and CFT were significantly minimized to cover up their incompetence and negligence.

If you read John Barry’s book, released in 2004, you can see amazing corrollaries between the actions of TPTB of SF in 1906, the actions of TPTB in 1918–1919 and TPTB today.

TJD!!. I completely agree. I had the same thing written down about western civilization but removed the tail end of the post because I didn’t want to appear to pessimistic.

We are not what we were in 1918. They were tough, used to epidemics and pandemics (an equivalent pandemic twenty years earlier), they had just come through a war, most new how to grow food, store food, heat their own houses and didn’t require hydro or cars to survive.

The third world today has the self reliance and resilience that we exhibited in 1918.

I have great faith in our resourcefullness in the face of adversity. It’s just that we don’t have a lot of experience with it and I am afraid the tsunami wave of infrastructure collapse that hits all of us at once…may be a little bit of a challenge…

…but I know that once we get over the initial shock, genetics will kick in and our frontier spirit will save us. /:0)

We will probably never be able to estimate the exact CFR and CIR for 1918…but we know for sure worldwide it had to be far higher than the statistics given in the past…and we should not assume that H5N1 will be similar…nature never repeats itself.

One thing I forgot to mention was that in 1918, they were used to seeing those around them die and they often prepared the dead and had wakes in their houses…in a sense they were acclimatized to death…and we aren’t.

In all fairness, I should acknowledge that TPTB really didn’t have control over the establishment of this JITD system, and, at least to some degree, did not *intend* to overlook or fail to plan for the extent the risk, anymore than TPTB in any other period of time did. That being said, I still believe that what I said at 17:44 is still true.

Tom DVM – at 17:50

True. Hadn’t even thought of that. They were somewhat fortunate and more easily able to cope psychologically with all the death than we would be now.

In case I seemed to be straying a little off topic with the talk of TPTB, I should explain my thinking. This may have something to do with the idea that the CFR should go down so drastically. There may be pressure being brought to bear on scientists to say this, and this could have something to do with all the controversy and lack of agreement between the scientists over whether that may or may not be true.

Speculation to some degree on my part, no doubt.

Thats Just Ducky!. The virus is not the only thing that has evolved in the past eight months…the level of debate on flu wiki has evolved as well. I couldn’t find very much on this thread that I don’t agree with…all of the comments have been thoughtful and at a very high scientific level of debate…it’s an honour to be included in it with the rest of you.

“This may have something to do with the idea that the CFR should go down so drastically.”

Okay. What is drastically. From 50% to 25%…that’s pretty drastic…or from 70% to 20%…that’s even more drastic…

…and that is the real issue…H5N1 has a long way to fall to reach H1N1…hard to believe but true.

About now, I would go for the miracle disappearence except that leaves H7N1, and H9 and H11 and H3N8 and SARS and Nipah…I’m sure you get my drift.

It is a known fact that suspots (radiation) effects mutation rates. As Medical Maven has said…we are in an unprecedented period of sunspot activity that doesn’t reach a maximum until 2012…one way or another the next five years are going to be an adventure…

…I think I liked the last century better.

That’s Just Ducky! I guess what I meant to say was that they were acclimatized…we’re not. They were self-reliant…we’re not. They were tough as whalebone…we’re not.

This is an interesting thread with more than reasonable comments. I wonder if we didn’t have Barry’s book, what else would we be looking at for comparison? I know from reading the old Army reports written 1920 after they looked back on their own records that they were blindsided by H1N1 because they battled viral epidemic after epidemic. It snuck in basically and slapped them awake. The nation at war made the issue foggy because the illusion of keeping fresh troops in Atlantic transit was more important than asking what slapped me? Bottom line, even when a few doctors knew they had something bizarre going on they couldn’t stop the momentum of the disease. That might be our lesson as well. We can’t stop it. We don’t know if or when it comes or how it will present, so the sane thing is to utilize public health or bolster it so we come out of the disease in a stonger position. I just don’t know how to make that happen.

Yes, and let us head into the wind in the face of the storm.

Leo7 and TJD!. I am not afraid of H5N1…okay I am afraid but at least give me the tools to give children a fighting chance.

I worked out the cost of collecting the antibiotics etc. for the county I live in today…it came to 2 million dollars…for that small price to pay, we could have a treatment to hand out to every family and every member of a family.

For another two million, we cold probably have enough food arranged so that we wouldn’t be short of food either.

I don’t think the cost is so outrageous.

You know what the real problem is…Dick Thompson and his friends at the WHO. They told the world that only 2–7 million would die from a pandemic and then in Canada, Health Canada threw in the statement that we lose more to smoking each year anyway…that message seeped from the WHO to federal authorities to provincial authorities to municipal authorities…

…and we at flu wiki will never change that.

Now the thing is that if I have all the food I need and all the medications I need and my five neighbours don’t…then if I was them and my family was at risk, I would help myself to the supplies I had stockpiled as well…

…bottom line…it has to be community based and the above have made that impossible.

Leo7 – at 18:44 “That might be our lesson as well. We can’t stop it.”

Hindsight is always 20/20. We can try to corrolate similar situations in the past to contemporary situations, in an effort to try to predict, to try to make sense of, but the problem is that the variables are never the same. We can’t see the situation clearly enough in present time. We can’t even identify the variables until it’s over. We think we should be able to control events, our destiny, if we plan well enough.

We know we will have another pandemic, we always do. We will muddle through as best we can, like we always do, then in the end we’ll go on from there with whatever is left. I think it’s probably about as simple as that.

TomDVM: You have a laser beam on H5N1. You understand it much better than I do. Tom at 15:17 above. I agree with you about H and N. Mamabird has her fingers on the pulse of some information—and it’s not MSM. Both of you make my head ache from the potentials…Keep debating.

Tom DVM – at 18:59 said “For another two million, we cold probably have enough food arranged so that we wouldn’t be short of food either.”

You’re talking 6.1 cents for each of Canada’s 32.6 million people. What are you going to buy with that nickle and dime that’s gonna prevent a food shortage ?

anonymous LOL! I told you to come and live in Canada.

Actually, the first thing I said was “ I worked out the cost of collecting the antibiotics etc. for the county I live in today…it came to 2 million dollars…”…

…followed by…“For another two million, we cold probably have enough food arranged so that we wouldn’t be short of food either.”

There are approx. 75,000 people in my country according to a meeting held recently by the Chief Medical Officer of Health. Two million divided by 75,000 would equal approx. 27 dollars to stockpile dry goods that could be used in a pandemic. Then when the pandemic hit, we could grind oats, wheat and corn that would go for cattle feed into foodstuffs and slaughter animals locally to provide food as well.

The big problem in my mine is where in North America are we going to get enough antibiotics to treat 30–50 % of the population within a very short time-frame.

In my opinion, if you want a recipe for instant anarchy, provide young parents with no medical support of any kind coupled with no antibiotics etc. and by extension no hope.

Geez…county not country @ 22.11

That’s Just Ducky! – at 17:44: “I wonder about how accurate that figure of 675,000 fatalities from the Spanish Flu is, and whether it might have been a lot higher.”

Although it’s impossible to know the real number, the U.S. death estimates for the Spanish flu pandemic have been generally accepted by researchers.

Note that the 675,000 figure is the sum of 550,000 for 1918–1919 plus an additional 125,000 attributed to a 4th wave in 1920.¹

Notes

1. Glezen, W.P., “Emerging Infections: Pandemic Influenza,” Epidemiologic Reviews (1996) 18(1):64–76.

Give other than a trivial CIR (any more than annual flu), you can just assume NO modern (even at the level of 1918 knowledge) health care for the victims in calculating CFR once the pandemic is under way.

People’s ability to deal with serious illness and death is very low. I speak from being willing to present with a number of families for deaths of people in their family, and supporting them in dealing with the experience and the choices. I estimate a majority will go to pieces as a family member(s)become seriously ill or dies in the very prolonged and messy process without the support and buffer of the healthcare system. My parents brought my grandfather into my home when I was young for him to die among family. I will always be grateful for learning about this process at a young age.

Most of the children of sick and dead parents will simply receive no care if ill (or simply starve and die even if well). The high rate of single parent homes are now far from family, not to mention single person households. Contrast this with the much higher rate of extended families in the early 20th century.

Therefore, CFR (and ancillary deaths)will be much higher with a SIMILAR virulence to the 1918 strain due to the lack of even basic care (food,water) to a much higher percentage of sick people.

Fiddlerdave – at 16:39 I totally agree with your comments. For many people, death is a sterile process. As a society, we are not comfortable with death. Many years ago, I used to work in an oncology unit and saw that even with patients that had known about their conditions and that they were dying, they and their families would have difficulty coping and many did not want to be there with their dying family member because they were not comfortable with death and dying.

The comment you made about single parents was also a good one. In 1918, most people lived in a “community” and helped each other out if they were ill, injured, or had a family member die. That really does not happen anymore. We are on our own. IMHO, the concept of community, or lack of it, will adversely affect how these families will survive through a pandemic.

“I estimate a majority will go to pieces as a family member(s)become seriously ill or dies in the very prolonged and messy process without the support and buffer of the healthcare system”

Fiddlerdave I agree, and it’s not a reason for the local health dept/”all-hazards emergency planners” to not tell the public we’re in a pandemic alert period. We need to start trying to become more resiliant households and communities.

10 Things you need to know about Pandemic Influenza

The WHO thought, back in Oct 2005, that we “need to know” a lot more than our state and local authorities think we “need” to know now!

1. Pandemic influenza is different from avian influenza.

2. Influenza pandemics are recurring events.

3. The world may be on the brink of another pandemic.

4. All countries will be affected.

5. Widespread illness will occur.

6. Medical supplies will be inadequate

7. Large numbers of deaths will occur.

8. Economic and social disruption will be great.

9. Every country must be prepared.

(10. well, hey; 9 out of 10, nobody’s perfect)

I made these 2 slides for a recent presentation. They are self-explanatory.

Bumping for good measure.