A Severe Pandemic is Likely
This thread is a re-statement of what is obvious to people who have been following the H5N1 story. However, in reviewing the US State Plans, I have come to the conclusion that there are many, including public health officials, who are apparently unaware of the facts. Since planning is heavily dependent on the assumptions made, it’s important that decision-makers, which includes the general public, understand why a severe pandemic is likely.
Although we don’t know what the kill rate of a pandemic strain of H5N1 will be, there is no reason to think that it will be less than the 1918 pandemic strain and many reasons to think that it will be worse, much worse.
Given the available facts, failing to prepare for a severe pandemic is irresponsible and likely to result in the deaths of hundreds of millions of people.
Additional References
Evolution and adaptation of H5N1 influenza virus in avian and human hosts in Indonesia and Vietnam
The viral polymerase mediates adaptation of an avian influenza virus to a mammalian host
Structure and receptor specificity of the hemagglutinin from an H5N1 influenza virus
Monotreme-Do you have the full study on that last recent reference (April 2006)? I tried to access it through the link, but could not find “the key”. I missed that study, if you have previously presented it. It seemed like very bad news, a likely avenue for panflu, even one that we can see with our “blurred vision”. This just keeps getting…..I can’t say it again.
Thank you Monotreme;
I can think of many officials, politicians, (and news outlets!) that need to get sent the Print version of this summary. Assumptions based on on “best-case pandemic” just are wasting time and effort.
Time for the public to know their preparation is needed; no top-down solution possible.
Medical Maven,
Here is a better link:
Structure and Receptor Specificity of the Hemagglutinin from an H5N1 Influenza Virus
This was discussed previously in this thread:
H5N1 Evolving Towards Pandemic Strain.
It was bad news. The polymerase adaptation is also bad news. There is no good news. H5N1 is under positive selection in mammals. This is published. This means an H5N1 pandemic is inevitable, IMO. It is highly likely to be severe and quite possibly catastrophic.
I disagree with some of the above conclusions, as I usually do. Monotreme has made a compelling case that the H5N1 virus is established and has become endemic.
That is not the same thing as establishing that
A severe pandemic is certainly possible. More than that we don’t know. Stating otherwise is dogma, not fact.
crfullmoon – at 18:49
You’re welcome. I started this thread to because I think there are many public health officials who have no idea how bad the situation is. We also need to get this information to decision-makers so that they can urgently ramp their preparations to meet the likely threat. Too many are either not preparing at all or preaparing for a mild to moderate pandemic.
Monotreme,
I have borrowed this and the link to post to my community blog. Thank you.
I am trying a new approach - if my town leaders won’t come to me, i will have to go to the townspeople!
Now, that’s a conclusion I don’t disagree with. Because a severe pandemic is possible, it must be included in all decision-making processes by the states. The lack of significant emphasis in the state plans is a failure of imagination, but also a failure to listen.
DemFromCT – at 18:55
The reason I use the term likely is because H5N1 is under positive selection to adapt to mammals. This is published. It has already partially adapted to mammals. This is published. What would the mechanism be that would stop it mid-adaptation? Serial passage of viruses in a novel host is well-known to result adaptation to that host. Some unknown and bizarre mechanism would have to be invoked to conclude that H5N1 will stop mid-adaptation. The only way to stop the adaptation is to stop human exposure. Want to take odds on that?
Birdie Kate – at 18:58. You’re welcome
DemFromCT – at 18:59. My goal is to get every state to plan for at least a 1918 style pandemic. They won’t do this if they think a severe pandemic is unlikely. The term “possible” includes everything from a 1% to a 99% probability. Based on my understanding of viral adaptation and the widespread distribution of H5N1, I think the probability that H5N1 will become a pandemic strain is well above 50%, hence my use of the term “likely”.
DemFromCt -
Can you update us on your personal feelings on where we are right now and if we are indeed in a countdown? I am assuming that you are not at the same level of concern that Mono, Tom, MM and others are presently at, but since we are your guests and we go way back, could you give us your current take on the situation?
Monotreme at 18:53-I even participated in the thread discussion!! So much water under the bridge it is hard to retain it all. Anyway, in seeing the study and its summary again, I know a “bell tolling” when I hear one. And for the second time.
Medical Maven – at 19:12
I have the same problem remembering all the various bits of information. The summary in my first post was for myself as well. Sometimes the pattern is not clear until all the pieces are put together in one place. There was reason to be concerned in April. There is much more reason to be concerned today.
seacoast – at 19:10
Mildly alarmed. Not willing to sit back and do nothing. Concerned about apathy. Not assuming it’s this year. Worried about indonesia and this fall-winter in southern China. Worried that overhyping will reduce the ability to get states to move. Anyone who ignores H5N1 is nuts, in my opinion, but so is anyone who insists they know what happens next (too many unknown unknowns). Concerned that governments will never get thir act together.
In short, about where i always am. ;-)
What would the mechanism be that would stop it mid-adaptation? Serial passage of viruses in a novel host is well-known to result adaptation to that host. Some unknown and bizarre mechanism would have to be invoked to conclude that H5N1 will stop mid-adaptation.
nonetheless, I’m glad Monotreme put this together… I should have included that.
Monotreme wrote:
‘’‘A Severe Pandemic is Likely
This thread is a re-statement of what is obvious to people who have been following the H5N1 story.’‘’
no. It is not obvious to most people who have been following this.
You will always hear : “no one knows how bad the next pandemic will be”.
A mild next pandemic is still considered more likely by most experts.
Your list of points does apply to other diseases as well and yet they don’t go pandemic. Where in your list appears that we have influenza A here ? We would not be concerned about all this, it it weren’t influenza A, which has a history of pandemics. This is the main point.
Oops, that was me. I hit post before I was done. Sorry.
anonymous – at 19:17 Montotreme: “What would the mechanism be that would stop it mid-adaptation? Serial passage of viruses in a novel host is well-known to result adaptation to that host. Some unknown and bizarre mechanism would have to be invoked to conclude that H5N1 will stop mid-adaptation.”
I think this is key. Statistically, I think you are, sadly, correct. I hope you are wrong.
Dem- Thank you for your comments, I am sure that there are many of us out there in wiki land who do not have a full scientific backgrounds and need help with this complicated “stuff” and the thoughts on both sides helps us fill in the gaps so that we can decide what we think and how we are going to proceed.
I really appreciate all of you, I have grown as a person because I was taught here to think beyond my family, friends and students, but to think that I can help save lives if I get off my arse and become involved in my town and county.
seacoast – at 19:31
we know more together than we know alone. Really, I appreciate Monotreme’s exploring in depth the State plans and updating the wiki on them. He actually read some of them… that’s what, I think, got him going on this. ;-)
When you read what the states say in some of those plans, it’s like “But, have you learned nothing? Have you heard nothing?” he’s absolutely tright about that.
But you must appreciate also that many of the state folks in charge are old enough to remember swine flu in 1976 - the severe pandemic that never happened. It affects their attitude 30 years later; don’t underestimate that.
Monotreme,
As my own understanding of the situation evolves, I keep re-evaluating my own risk perception. The 2 biggest changes in my thinking (and they are still changing) are that:
Which lead us (me) to precisely nowhere.
The only thing that I do know is that our very limited state of knowledge tells us that to assume that a 1918 scenario is the worst case AND an unlikely scenario, and make plans based on that, is highly irresponsible coming from those who should know. Since most officials still don’t really know what they are talking about in terms of pandemic risk, I charge leaders at the highest level, particularly the scientists who advise them, with carrying the responsibility to communicate this accurately and honestly.
See outline summary has “Pandemic risk”: “possibilities”, “probabilities” and “impact”. The outline is not intended to settle the issue, but merely to bring all the positions together. Or maybe we’ll be able to settle on some things.
It’s a tool to talk around. A conversation igniter, maybe.
Dem at 19:43: Dem, are there any studies that demonstrate what effects the mass vaccination program in the U.S. had on the spread of the swine flu in ‘76? In other words, do we know one way or the other whether this strain would have gone pandemic without the mass vaccinations, notwithstanding their side effects?
anon_22 – at 20:10 I charge leaders at the highest level, particularly the scientists who advise them, with carrying the responsibility to communicate this accurately and honestly.
Well Said!!!!
In my Very Humble Opinion, I believe that the world should prep for a 1918 level event AT THE BARE MINIMUM. This will set them up for a very effective All Hazards Preperation.
And I fully agree with anon_22: my perception included 1918 as an extreme. Not so now.
And my updated perception tints a 1968-like pandemic as a highly disruptive one, maybe.
Not getting ready for disruption is silly. More so, when part of that “getting ready” doesn’t mean spending money - it’s about talking openly, planning/organising, cross-training. Things that make sense in any case.
I’m very much concerned about the “talking openly” part.
De jure, there was no ‘spread of swine flu in ‘76′, cos there was no swine flu outbreak (in humans) after the first cluster of cases in a military base.
De jure, there was no ‘spread of swine flu in ‘76′, cos there was no swine flu outbreak (in humans) after the first cluster of cases in a military base.
anon_22 is correct; there was no swine flu outbreak, and not because of vaccination. The authorities did what they did based on what they knew at the time. But based on the flak they got, they’ll not easily pull the trigger again.
See wiki links.
Not preparing for at least a 1918 event, would be like the U. S. Armed Forces not preparing for two simultaneous wars. It would be the height of irresponsibility not to do so. This is national security (for all nations) that we are talking about. The first task of every responsible government is to provide for the common defense of its people. All that is different is that the foe here is Panflu, a faceless enemy that says nothing, threatens nothing, and then is on top of you.
I agree that the swine flu debacle is one reason for the hesitation on the part of some public health authorities in asking for resources. However, from a scientific perspective I don’t think swine flu and H5N1 are in any way comparable. A single individual died from swine flu. There was no world-wide animal reservoir of the virus that killed that individual. Hence, the risk level is much, much higher with H5N1 than it ever was with swine flu. And the risk of swine flu was considered enough to launch a massive pandemic flu vaccination program. The current lethargy on the part of many public health officials is, I am convinced, based on a combination of concern for their careers and ignorance.
As I sit and read about the problem with China, I am worrying about the 2008 Olympics. Families, fans and athletes from all over the world, confined to a relatively small area for a few weeks and then going back to every corner of the world. Could the perfect storm be brewing?
anonymous – at 19:20
You will always hear : “no one knows how bad the next pandemic will be”. A mild next pandemic is still considered more likely by most experts.
It depends on who you consider experts. Drs. Webster, Osterholm and Nabarro? I don’t think they are expecting a mild pandemic.
Your list of points does apply to other diseases as well and yet they don’t go pandemic. Where in your list appears that we have influenza A here ? We would not be concerned about all this, it it weren’t influenza A, which has a history of pandemics. This is the main point.
If I understand your point, you’re correct. Influenza A is different because of it’s rapid mutation rate. This guarantees that will be a huge substrate of variations for evolution to act on. Evolution is important in understanding the risk. This is why I went to great pains to explain the conventional scientific view on random mutation and why I also explained positive selection in other threads.
I still don’t think I have succeeded in communicating how powerful selection can be. In my own laboratory, we set up conditions for positive selection to occur. I can guarantee that it will occur given the knowledge of certain values, the most important being mutation rate and number of individual organisms. If you set up conditions to select for a certain mutation and you have an appropriate number of individuals given the mutation rate, you will get exactly the phenotype you are selecting for. Virologists use this technique to adapt a virus to a particular host. Once the virus is partially adapted, you can be pretty sure that you will get a strain that is fully adapted.
H5N1 already is partially adapted to humans. This is a matter of record. It replicates very well in our cells, today. Its high mutation rate is a matter of record. Its widespread geographic distribution is a matter of record. Its ability to spread human-to-human-to-human is a matter of record. These facts are relevant to the probability that H5N1 will become a pandemic strain.
As I have said before, I am not a virologist. It would be interesting to get a virologist to comment on the likelihood that H5N1 will become a pandemic strain based on the currently available information.
For the statistically inclined, I recommend the following link:
Selection Operating on Quasispecies
Some prefer numbers to words.
worried in NJ – at 21:28 As I sit and read about the problem with China, I am worrying about the 2008 Olympics. Families, fans and athletes from all over the world, confined to a relatively small area for a few weeks and then going back to every corner of the world. Could the perfect storm be brewing?
Worried in NJ, I was thinking that myself after seeing a news story about the US athletes possibly not participating (a political group is pushing for this; can’t remember why as my mind immediately was distracted by implications of Olympics on pandemic). It would be the perfect storm. Since it would be something straight out of B-rated movie, my skeptical side says, “Nah.” Only time will tell.
Hi all — last night I was listening to the American Asian program on NPR and they had a section about China, the incredible availability of transplant organs (you can have exactly the organ you want “installed,” so to speak, , with matching blood types and other factors, within hours of your inquiry.)
To be brief, they believe that prisoners are typed, and held until there is a need, and then sent to a hospital for execution and removal of organs.
They believe that unethical means are used, many non-criminal innocent people who have run up against TPTB have disappeared in this way, and they want to have this exposed before the Olympics.
I was shocked, could not believe my ears, and hope this wouldn’t be true, but gee, it was NPR ----
Hello again — if you are interested, here is a reference url for “Pacific Time” and there is a synopsis half way down the page about Canadian politician David Kilgoren’s assertions. If this is true, maybe the Olympics will find another venue?
heddiecalifornia – at 23:03
We’re getting a wee bit off topic, but it’s true that people who are executed in China are used as transplant donors. They are typed before execution and an ambulance is on stand-by ready to take the organs to their new recipients. The type of tissue desired influences the means of execution. The Chinese government would say: “Waste not, want not.”
Whether all of the people executed are what we would consider criminals is another matter.
Monotreme at 19:07,
My goal is to get every state to plan for at least a 1918 style pandemic. They won’t do this if they think a severe pandemic is unlikely.
why not ? They will do it when the risk is high enough.
Nuclear war was also unlikely but possible in the 60s and they did prepare.
Same with earthquakes,hurricanes, etc.
Is it ethical to lie to them ,or use tricky wordings, and paint the picture darker than you think it is ?
Monotreme, please change the title of the thread, when you think we should only say this to the state-planners , while you are thinking something else.
DemFromCT at 18:55
As usual, thank you for being a voice of reason here.
anonymous – at 23:18
Is it ethical to lie to them ,or use tricky wordings, and paint the picture darker than you think it is ?
I believe everything I write here and have acted accordingly in my private life. I say the same things in public forums. I think my words are pretty straight-forward. I think a severe pandemic is likely. Not sure why you think I don’t really believe that.
My comment regarding the state planners was in regard to the fact that they seem to be ignorant of the available data. I assume that most people at FluWiki are familiar the data I presented in the first post. I was apologizing for presenting information that I though was obvious to people here. Clearly I was mistaken in that belief.
Drs. Webster, Osterholm and Nabarro? I don’t think they are expecting a mild pandemic.
I think, they still consider this more likely than a severe one.
Osterholm is arguing that even a mild pandemic would be bad,
he talks about a severe pandemic (let’s say severe = 1918-type or worse)
and a very severe pandemic , but said that he didn’t expect very severe.
He doesn’t say about severe. He’s a bit like you, exaggerating
so to get people preparing. He often points out this “not if, but when”,
however that refers to an average pandemic and average pandemics
were 10 times less severe than 1918.
Webster says : “no one knows”, so what ?
Influenza A is dangerous not because of its high mutation rates, but because
of the pandemic history. No other virus could cause these pandemics
with infecting 20% or more of people worldwide.
It is unclear what it is that makes it so contagious, the mutation rate might
contribute but’s not the whole story.
Even when H5N1 is fully adapted, it might still be incapable of going pandemic. Rarely a virus is that much contagious. It could be, we have the similarities with other flu-A but who knows whether any pandemic virus is in genetical neighborhood of actual viruses ? If it is, then it will probably be “found” earlier or later.
I am not a virologist. It would be interesting to get a virologist to comment on the likelihood that H5N1 will become a pandemic strain based on the currently available information.
me too. me too. me too.
My bet is that in the backrooms of agencies and Governments and universities around the world, there are alot of dire predictions being made at the moment…
…don’t forget they read the same information we do…they observe what we observe…they have the same fears that we do…and I know they are coming to similar conclusions because you don’t have to be one of the top ten influenza scientists in the world to see things clearly.
I might have misinterpreted your statement at 19:07 then. It sounded as if the (only) motivation to say this were that the state planners had to be convinced, no matter how.
My own personal take on it (having been in the emergency service, also working with various governmental agencies), that the bottom line, not alot will get done, maybe some on paper, but when the rubber meets the road,,,,will be a total diaster in the making,,,and again like fed gov told the states, you are on your own. Which means to me,,,we as individuals are on our own,,,and we are the ones that will be helping out. I do not expect much from any government level.
anonymous – at 23:18
Monotreme at 19:07, My goal is to get every state to plan for at least a 1918 style pandemic. They won’t do this if they think a severe pandemic is unlikely.
why not ? They will do it when the risk is high enough. Nuclear war was also unlikely but possible in the 60s and they did prepare. Same with earthquakes,hurricanes, etc. Is it ethical to lie to them ,or use tricky wordings, and paint the picture darker than you think it is ?
They prepared for a Nuclear war because they were able to see what the A and H Bombs could do with their own eyes. They could “SEE” the threat. No one in power today has “SEEN” the threat so they can not get their minds around it. Hence the threat is not real because they can not “see” it.
I have been on my college debate team, received advanced placement in public speaking, was a toastmaster at 16, I am a trained discussion leader who specialized in small group dynamics and the recognition of blockers and those with agendas that do not fit with the group purpose. I say all this so my words to anonymous at 23:18 will ring loud and clear. You sir, have established no credible evidence to backup your assertions and your assertions have nothing to do with the facts of the discussion. You behave in this case as a blocker. You project lies when none are presented. You use the techniques that you accuse others of using. It is you who are lying when you say others are lying. You can behave better than that, I have seen it.
I have come to the conclusion that 1918 was the ‘rule’…
…and 1968 was the ‘exception to the rule’.
Anon_451 – at 00:06 Your are correct, and that is why the disaster in New Orleans was so great,,,,,it never happened before, not in any of their lifetimes, and this situation is just like that. Has not happened in our lifetime, so wont prepare like they should, UNTIL it happens, they the gov agencies will plan like crazy for the next one. That is if many are left from this one.
Yo, Dude! Stick around — we NEED that kind of analysis here. (and I do get grumped at all the “anonymous - i” — it does get confusing when two or more start posting).
One challenge we all have is that the facts don’t all support strong action. There have been, what, 135 deaths from H5N1 ?(documented). There are probably that many deaths in the US in one weekend from drunk driving. I know, I know, the challenge is that the virus will bust out of the box in a violent and widespread way, but getting local heart rates up over 135 deaths that occurred over months in lands far away is, unfortunately, a challenge.
Gary Near Death Valley – at 00:10 Please know that I have some very good friends in Gov who are trying their level best to get the politicians off their hands. A lot of the career civil servants “See” what is coming but have their collective hands tied by elected morons from both parties.
I can tell you that the Red Cross is (slowly) thanks to the efforts of the NHQ medical director’s office, attempting to come to grips with this with respect to both general relief and blood banking. I can also tell you that their “worst case” is considerably worse than 1918. I posted that the CFR posited was 20% with 50% CAR; I got another look at the document in question and the CFR was 10%, not 20%. My error. Regrettably, these documents are not public, but I can assure you that Red Cross is looking hard at this issue, and lots of resources are being mobilized. The question is whether H5N1 will make this attempt moot or not.
My personal estimate of the situation is that we are more likely than not to see a pandemic this winter in the US. While nobody *knows* what will happen, my assessment is that this will be at least as bad as 1918 and could be a good deal worse. I am planning for 50% CAR and 25% CFR, which is likely to be catastrophic. I am planning as best I can for that, too.
As far as the USG preparing for a nuclear war, they prepared to preserve essential portions of the government from the effects of a nuclear war, but the average Joe was, and is, on his own. I do agree with the essence of the comment above, however, in that it’s difficult for decision makers to realize on a gut level how bad this could be.
Yes I know how gov works, having been in it and worked with it. It is usually the lower level ones that better understand the real world
Monteme: I counted 34 clusters in the reference you gave above. I remember reading that the total clusters were closer to 50. I wish I could pin down the source of my information. I am curious to know what the definition of a cluster hinges on. Is it disease onset date? Does it also require the absence of an animal vector beyond the first case? What is the major element of this definition or is it all factors taken together? It seems that the adaptation to humans is one central tenant of this discussion and I think a very tight definition is in order to prove the point. I recognize the trend in the number of cases has increased, but that may be more bird to human transmission due to the increase in the number of infected birds. The study in ProMed is a source of great concern for me and makes your case much stronger in my opinion.
Anon_451 – at 00:25 I agree that politicians seem to be sitting on their hands - nobody has publically spoken on BF in a year. I have a good friend who is a staffer for a U.S. Senator and I’ve been trying to thing of a way to push this issue without seeming like a kook. I know my message will be conveyed, but am waiting for the opportune time. In my view, our politicians have a responsibility to speak out.
If I understand the adaptation argument correctly, the polymerase issue revolves around the study of unrelated strains of HPH5N1 and each of these separate strains showed that when there are repeated infections in mammals they tend to have convergent evolution toward more virulence and an easier ability to infect mammals (humans). This study does not state how large the N was. Nor do I find a reference to the specific areas of concern in the sequences. I gather that the argument hinges on the ability of this virus to do point mutations that tend to cluster it in a general direction. Is this correct?
tjclaw1 – at 00:44 you are correct that politicians have a responsibility to speak out,,,,,and I wish and hope they would, but seems the message is lost amid the clutter of everything that is going on in the world, even though this should be at the TOP of every politic agenda everywhere. As it is not, shows me, that 1) They have no clue 2) They know and do not want to frighten the herd before the storm as the storm they know is coming and cannot be stopped.
I really hope they get going on this as I am thinking that Dr. Osterholm and others are getting more tired and frustrated with each passing week. To have the avian flu not on the front burner shows me,,,,,,,,well,,,,the country is screwed ,,,,,,,,,,again.
Dude, This may help explain…
Two clusters of human infection with influenza A/H5N1 virus in the Republic of Azerbaijan, February–March 2006
Following the appearance of influenza A/H5 virus infection in several wild and domestic bird species in the Republic of Azerbaijan in February 2006, two clusters of potential human avian influenza due to A/H5N1 (HAI) cases were detected and reported by the Ministry of Health (MoH) to the World Health Organization (WHO) Regional Office for Europe during the first two weeks of March 2006. On 15 March 2006, WHO led an international team, including infection control, clinical management, epidemiology, laboratory, and communications experts, to support the MoH in investigation and response activities.
As a result of active surveillance, 22 individuals, including six deaths, were evaluated for HAI and associated risk infections in six districts. The investigations revealed eight cases with influenza A/H5N1 virus infection confirmed by a WHO Collaborating Centre for Influenza and one probable case for which samples were not available. The cases were in two unrelated clusters in Salyan (seven laboratory confirmed cases, including four deaths) and Tarter districts (one confirmed case and one probable case, both fatal).
Close contact with and de-feathering of infected wild swans was considered to be the most plausible source of exposure to influenza A/H5N1 virus in the Salyan cluster, although difficulties in eliciting information were encountered during the investigation, because of the illegality of some of the activities that might have led to the exposures (hunting and trading in wild birds and their products). These cases constitute the first outbreak worldwide where wild birds were the most likely source of influenza A/H5N1 virus infection in humans.
The rapid mobilisation of resources to contain the spread of influenza A/H5 in the two districts was achieved through collaboration between the MoH, WHO and its international partners. Control activities were supported by the establishment of a field laboratory with real-time polymerase chain reaction (RT-PCR) capacity to detect influenza A/H5 virus. Daily door-to-door surveillance undertaken in the two affected districts made it unlikely that human cases of influenza A/H5N1 virus infection remained undetected.
<snip>
Possible case • any individual with unexplained axillary temperature ?38 °C; • AND one or more of the following symptoms: cough, sore throat, shortness of breath; • AND resident in an area where influenza A/H5 virus infection has been suspected (i.e. undiagnosed mass poultry die-offs, dead wild birds seen or probable/confirmed human cases from the area).
Probable case a possible case AND that had, within 7 days prior to the onset of symptoms, one or more of the following: • close contact (within 1 metre) with a probable or confirmed case; • close contact with sick or dead poultry or with areas heavily contaminated by their droppings; • close contact with wild birds or with areas heavily contaminated by their droppings; • consumption of undercooked bird meat or eggs; • worked in laboratory processing samples (human or animal) suspected of containing influenza A/H5 influenza virus.
Confirmed case • a probable case for whom a specimen tested positive for influenza A/H5 virus infection by PCR.
tjclaw1 – at 00:44 I’ve been trying to thing of a way to push this issue without seeming like a kook.
Print out a copy of the Indo Maps from the great Indo Group. Include a copy of the box score. Add in a couple of the reference’s from Monotreme all hard copy.
In your cover note, just say that you have found some information that the Senator may find useful. Something he/she can use to question DHS HHS and DOD on to insure that they are “protecting” the American people. You may also want to insure that the State Government is meeting this head on and ask them “at the local level” what can the Federal Government do to help now before we are no longer able to help due to the volume of needs once this starts.
Hope that helps. I know that the maps and box scores made a big difference with some folks I spoke with.
Shoot,
Dude, I meant to add the parts about disease onset date…
Epidemiology
Cluster 1 Daikyand is a rural, relatively poor village in Salyan district, with around 4800 inhabitants in 800 households. The village is divided in three settlements: Seydler, Daikyand and Salvan [FIGURE].
Influenza A/H5 infection was laboratory confirmed in samples from seven residents of Daikyand settlement. Six were from the same family and one from a neighbouring family, and became ill over a two week period, with dates of onset from 15 February to 4 March 2006. Four of the seven cases died, and this figure is compatible with the case fatality rate observed elsewhere [5]. The median interval between onset of symptoms and death was 9 days (mean: 11.2 days; range: 8–19 days).
Patients’ ages ranged from 10 to 20 years (mean: 16 years; median: 17 years); five of the seven cases were females aged 15– 20 years.
<snip>
Dude,
That is why the Powerpoint I sent you, the Genogram of Clusters (in Indonesia) is important to see (make) in order to see at a glance the disease onset dates, hospitalization dates, dates of death, possible exposure / (or relationship) to confirmed cases / chickens….
It gives you a good grasp on what is going on even when some tests are returned as negative. (such as the person who tested positive twice, but the third time the test was negative.
Trying to establish attack rates and CFRs and use those in discussions I have found ‘fruitless’. What I have found effective is to give actual numbers in your community (city) that WILL BE SICK AT THE SAME TIME. If you take a city of 5 million people, with little or no immunity to any virus, assume that only 40% will become ill in the first 3–5 weeks, that is 2 Million people sick at the same time - now keep your city operating …
Grin, FloridaGirl, I accept the reasoning that disease onset dates are a critical factor in the determination of a cluster that involves H-H transfer. I can see that the data in you example supports that. The epidemiological factors presented establish a correlation, but unless the sequences are also analyzed and can show the relationship it is not proof of the point. Too often we must infer in the absence of data. I think those inferences are correct, but when I make the case to the people I know, I want to be sure. It seems we have most of the argument correct. I am just looking for the details that will convince people who can understand the argument. Do we have data or a graph that shows the size of the clusters increasing in frequency and size over time? I am slowly getting caught up with all of you, due to other pressures…forgive my inability to review the Power Point presentation. I will, I respect your work. Thank you.
anon_22 – at 20:10
But IF our current extrapolations are valid, which is a very big IF, then a pandemic happening in the near future looks so hellish I have a hard time finding the right words to describe it.
Yes.
In between the chatty posts about chocolate and useful tips for just about everything, there is that.
“to insure that they are “protecting” the American people.”
How many pandemic plans have we see where protecting people is the goal ? How many where the goal is “continuity of government” is the goal ?
Since we don’t know how virulent this will turn out to be, we can only look at the CFR to date. In the 1997 Hong Kong episode it was 6 out of 18 or 33%. Now nine years later based on the latest WHO data, with 247 confirmed cases and 144 deaths the CFR is about 58%. Based on this data it seems unreasonable to expect the only outcome must be a match for the averaged 1918 figure of 2.5% or less.
TPTB are calling a CFR of 2.5% a worst case scenario. It could easily be ten times that severe with a CFR of 25%. Even at that rate the current CFR would have to be cut by over half. What evidence exists to make that a reasonable probability?
Monotreme, great summary. Thank you for being a voice that tends to balance the large number of public reports that represent a worst case scenario as being like the 1918 pandemic. Considering other possibilities is essntial for full spectrum planning.
“Severe” may mean “big disruption”. People have a hard time imagining that.
I’ll have a look at “selection”. It’s not in the “outline”. Where would it go?
Tom DVM – at 00:10 :
I have come to the conclusion that 1918 was the ‘rule’
…and 1968 was the ‘exception to the rule’.
is there anyone else, who came to the same conclusion ?
I can give you lots of referrences, who say 1918 was the exception.
The links to the historical data had been given to you here
several times. You seem to dismiss it. Why ?
Not as a scientist, but working in the “social” fields, I am adding my 2 cents worth of observation. First of all, the government knows that the government is in control of whatever vacine (remember, Bush told the pharmaceutical companies to start working on it a year ago, even if it’s generic, they surely do have something) and anti-virals we have. That is the first problem. They do not worry about access to medicine for themselves, they have control of it. Why would they want to panic our pretty little heads and possibly take that control away from them? Of course they are going to say that it’s not likely to be severe or that we don’t want another 1976 false scare or whatever reason they give out. Now they want you to believe that it’s coming and be prepared, people are the number one resource in America. But they, just the same, want you to think that they have perfect control over it so you will not question their actual control over it. The second part about this is - why do they? The medical professionals should have that control to say who gets what, but they do not. The government will be giving them enough to protect themselves and after that doctors will be told who they can and cannot give anti-virals to. It’s not going to be done by democratic means either, this will be dictatorship control. Now the doctors may protest, but after all is said and done, who will they be facing? The government. Our government has made extreme strategic plans to survive and they will. Have you noticed Bush’s attitude change from last fall to this fall? Last fall he was very concerned about it, but now he rarely mentions it. Why isn’t our president, our leader, standing up in front of America telling us to stockpile a little food and water in our homes? Come on now…when the threat was Iraq, he was out there everyday telling us about WMDs. It’s because he is not worried about his own butt anymore. As many here have said, we are on our own. Monotreme, I adore your scientific approach and logical attitude. I have always laughed at the contradiction of “political science”. Political psychosis would be a better description. You can say that the general public is part of the decision makers but that is severe contradition to what actually is. Your facts are awesome and I believe you are right. It’s just that facts don’t pile up to a hill of beans against politics.
I’m not saying give up, please don’t. I’ll vote for you if you run for president, Monotreme. Every ray of hope is light in the right direction.
See Jerry Pournelles Iron Law of bureacracy-
“Pournelle’s Iron Law of Bureaucracy states that in any bureaucratic organization there will be two kinds of people: those who work to further the actual goals of the organization, and those who work for the organization itself. Examples in education would be teachers who work and sacrifice to teach children, vs. union representative who work to protect any teacher including the most incompetent. The Iron Law states that in all cases, the second type of person will always gain control of the organization, and will always write the rules under which the organization functions.”
It does not matter which political party supposedly controls the administration: the Iron Law states that the unelected bureaucrats will control and make decisions designed to protect the bureaucracy.
Whatever strategy you adopt to effect change must take this law into account or you are doomed to failure.
I also strongly suggest that those reading this also read Rudyard Kipling’s “The Gods of the copybook headings”. I have found this to be an effective poem to get people to set their prejudices aside and look at the facts, both present day and historical.
Sorry, I have no poetry to offer.
In cruising the net yesterday, I discovered that the Workplace Hazardous Materiels Data Sheet for handling influenza virus has been removed from the Public Health Agency of Canada website. I think this reflects confusion. If they post that airborne precautions should be in place, then this will have a trickle-down effect, and all the masks stocked by the hospitals will not meet specs….and people will refuse to work until they have better equipment.
Everytime I try to post the link, this site becomes “non-responsive”.
One indicator that an H5N1 pandemic would not be mild is the study done with the ferrets… Inthat study they showed that it is unlikely for H5N1 to reasort with a current human virus… 1957 & 1968 were reasortant viruses & they were mild… 1918 did not reasort & was severe.
anonymous 6:28. I LIKE YOU…PICK A NAME!!!!!!!!!!!
I don’t remember seeing your references…if they are at hand could you give them to me again…if you have to search for them don’t worry about it.
I can explain how I came to this conclusion. There is very little known about the disease influenza or about historical outbreaks. We have reasonably good information on 1957 and 1968 and as far as 1918 goes their mortality estimates have been out more or less by a factor of 5 times. The information from the nineteenth century is spotty and information before that is like a black hole. Clarke has been repeatedly telling us that some of the plagues in the Middle Ages have to have been influenza’s and I tend to agree with his conclusion.
Okay, if we look at the last two centuries We have an exceptionally mild one…1968, a mild one 1957 and one that was reported as a ‘freak’ in 1918 that was a one-off never to happen again…
…well, it turns out that this couldn’t be further from the truth. I believe there were either three pandemics in the nineteenth century. The pandemic in 1830 was the equivalent to 1918 (Osterholm May 2005 New England Journal of Medicine) and 1890 which was classified as the worst pandemic in 300 years at the time (400yrs. then if you count the twentieth century) (The Great Influenza - John M. Barry).
Therefore, if we take our last two centuries as sample size, we had six pandemics…three were equivalent to 1918 or worse, two were milder than 1918 and one was exceptionally mild (1968)…
…Therefore my statement…
“I have come to the conclusion that 1918 was the ‘rule’…and 1968 was the ‘exception to the rule’.”
so you think, that study was bad news ?
Well, maybe it was. Maybe a mild, reassorted pandemic would be good now.
It could make us somehow immune against a more severe one, although
not very likely considering the large diversity.
And then, we could as well take that prepandemic vaccine.
Maybe we should….
Don’t overestimate this study. They just tested a few of the existing strains
and a few of the combinations and only in ferrets. They also stated
that we shouldn’t too much rely on that study.
My guess is, that it reduced my likelyhood of reassortment by 20%
so it’s still 80% of what it was before. OTOH there seems to be
little reassortment lately in the strains which infect humans.
Although, we don’t really know what’s going on in China
WildBill – at 09:50
“In that study they showed that it is unlikely for H5N1 to reasort with a current human virus”
I think they only tested something like 3 out of 50 possibilities. And because it didn’t reasort in the 3 tests, they concluded that it would be unlikely, even though 47 more tests needed to be done. I remember thinking that they had some nerve to use the word unlikely without the testing being complete. Maybe someone has a better memory of this?
anonymous. Unfortunately, here is how I see it…We have a lot of unstable genetic diversity floating around at the moment…including other diseases and we must not forget about our old friend SARS…it also could mutate to increase transmissibility…the only thing that saved us from a full-blown pandemic last time around in 2003.
In respect to influenza alone, we have H3N8, H7N7…1…3…4, H5N1, and a couple of other high pathogenic ones H9 I think and one other.
For want of a better word, I would call this a ‘mutant tsunami’…I don’t think we can count on a one-off pandemic, there are too many possibilities…I think we are in for several pandemics in the next twenty to thirty years…and these pandemics have the potential to overlap because during a pandemic we should be more susceptible to other viruses and as food supplies drop we too may be eating diseased animals.
If we dodge one bullet…we should not on one hand be self-congratulatory and on the other hand be complacent…we are facing a machine gun!!
Monotreme. Thank you for your opening post. I’ll add it to my awareness arsenal.
It’s a numbers game. I’ll lead as many horses to water as I can. The ones that don’t drink I can no longer be concerned about. We are rapidily running out of time.
TonDVM, again you ignore the best source which is available online:
http://www.blackwell-synergy.com/doi/full/10.1046/j.1365-2672.2001.01492.x
Osterholm is not very credible here. He gives no source. He is an alarmist.
Clarke’s theory is not commonly accepted and he didn’t mention 1830,1890
AFAIR. Numbers for 1890 are partially available, it was much
less severe than 1918. So the Barry reference just shows that 1830 was
less severe than 1890. Barry most certainly didn’t say that either
1830 or 1890 was more severe than 1918.
TomDVM, sorry I misinterpreted “references”. Just looked up the Barry quote, he says 1890 was worst in the last 3 centuries (from now?) _except_ 1918.
What would the past pandemics look like with todays air travel? Should we use past pandemics as argueing points? The world has changed so much.
anon at 10:38-“1830 or 1890 or 1918″---Any one of these pandemics would throw our CURRENT civilzation into a tailspin. And do you really really believe in your heart of hearts based on all of the current data (and I know you like statistics and can tally them in your sleep) THAT we will get by with a “1968 or 1957″ next time out of the chute? So what are we arguing here? Is it whether the rubble is going to be bounced once or twice or thrice?
anonymous. Thanks…I am currently re-reading Barrry at ‘warp speed’…could you give me the page number of that quote.
TomDVM, the other flus, why should they be more dangerous now than
decades before ?
Well, they might provide a source of reassortment for H5N1,
but that’s not new either. They also were that source for H1N1,H2N2.
But, when H5N1 goes pandemic, then the risk of reassortment with
other flus, shouldn’t it increase dramatically compared with now ?
I never read about this, but maybe one pandemic induces another
one, not just a 2nd wave. ?!?
page 261
Thanks.
now ,im anonymous
NOW, I AM anonymous…..drumroll please.
Maybe we all should be anonymous. /:0)
Now Tom, somebody might get an alternate view of the world from the other side of the table, if that were to happen. And we wouldn’t want that to happen. Would we? huh, huh?
I could well imagine that H5N1 might cause an epidemic without going globally. We have antivirals,vaccine, desinfectants,masks,better communication now. And the more severe it is, the more effort will be done to reduce its spread. The pan-virus needn’t be as contagious as 1918. Although - no historic example for a contained new fla-A virus so far. Air travel ? We can always close it or quarantine, if we want.
11:06, what you mean ?
anonymous 11:12
What who mean? Which of us at what time?
That there anonymous a couple (or more) posts above me talking about containing H5N1. In your dreams, baby, in your dreams.
here they say
that 1889–1895 was much milder than 1918 in Switzerland.
Überall in der Welt lag 1918/19 die Zahl der Erkrankungen und der Todesfälle höher als bei früheren Epidemien, doch schwankte sie von Gegend zu Gegend. Das war nichts Neues. Schon für die letzte vorangegangene – weit mildere – Grippewelle von 1889 bis 1895
another source said that 40%(!) were infected in 1889ff (forgot the referrence)
I have given up re-reading Barry’s book…anonymous thanks for 261…here are the statements.
An influenza pandemic has always been a great global infectious-disease threat. There have been 10 pandemics of influenza A in the past 300 years. A recent analysis showed that the pandemic of 1918 and 1919 killed 50 million to 100 million people,1 and although its severity is often considered anomalous, the pandemic of 1830 through 1832 was similarly severe — it simply occurred when the world’s population was smaller. Today, with a world population of 6.5 billion — more than three times that in 1918 — even a relatively “mild” pandemic could kill many millions of people.
Preparing for the Next Pandemic Osterholm Volume 352: 1839–42 May 2003 ……………………………………………………………..
“During and after the 1889–90 influenza pandemic - with the exception of 1918–19, the most severe influenza pandemic in the last three centuries - he (Dr. Richard Pfeiffer) had searched for the cause.
The Great Influenza, John M. Barry page 261.
anonymous. You are indeed right…I stand corrected…their were other statements that I put together to extrapolate my conclusion but I did not save the evidence…so to speak.
If you compare the two above statements…you will see that Dr. Osterholm states 1830 was as bad as 1918…John Barry states 1890 was the worst pandemic in 300 years…and the statement pertaining to Dr. Pfeiffer was made in the context of the initial stages of 1918 when he (Pfeiffer) could not conclude that 1918 was more severe than 1890…
…but I do acknowlege that different literatures have listed vastly different assessments of these pandemics which indicates to me again…poor record keeping during the panic of a pandemic.
Anyway, on the basis of the page 261 quote alone…I stand corrected.
Thanks.
I want to be anonymous too.
minime anon (without the German accent) does not take on faith data offered in a foreign language by an anonymous poster. Just my bias. Now if he/she had a handle..
here they say, that 1890f was dramatic and 40% worldwide “seized”.
But 1918 was the most devastating of all epidemics (probably in the context of influenza ?)
Als dramatischer erwies sich bereits 1890/91 eine Grippeepidemie, die etwa 40 Prozent der Weltbevölkerung erfasst haben dürfte. Der verheerendste aller Seuchenzüge verlief 1918/19 in mehreren Wellen und forderte seine Opfer
I have a handle.
It’s the other anonymous that doesn’t.
Oops, deleted my cookie, the above was me.
Awards go to my alteregos at 11:32 and 11;34
Is than you gs?
Likely - 40%
Okay, let me try that again…is that you gs?
I think if he can be anonymous ,i can too.You see,anonymous,we have handles out of respect and to keep posters in order so we know who the hell we are talking to.Get a handle…
Sorry, Is that you gs?
anonymous – at 11:37
I agree with you.
Or was that me.
anonymous gs, I just tried to read your reference at 6:28 but I am uni-lingual…I can only read Canadian…so it would be really nice if you could give a more expanded description of your references…I admire your command of probably several languages. /:0) Whoops…slipped!!:)
Can the Chinese Government come and get you if you are anonymous?
gs has been resurrected. He is there in the ether. TPTB won’t let him go. One lonely anonymous only has to reach out, and he/she will BE again.
anonymous – at 11:41
Oops, the above was me, as I tire of this.
But anonymous is right. My mind envisions a poster when I see a handle. With anonymous I don’t know which anonymous to envision, the one on the news thread, the one on the Flu Prep thread, the one on the………
I *was* ROTFLMAO… but this is really aggravating. We need the new format requiring registration. Now!
anonymous – at 11:46
was me.
There, I’ve restored my cookie.
God, how does he stand it! Game’s over for me.
Hey this is fun I can talk to my self this way and answer my own questions and argue with my self. I could be a troll and no one will ever know.
here you can read:
In 1918, the cause of human influenza and its links to avian and swine influenza were unknown. Despite clinical and epidemiologic similarities to influenza pandemics of 1889, 1847, and even earlier, many questioned whether such an explosively fatal disease could be influenza at all
so, apparantly it was much more severe than earlier.
see alone the headline:
1918 Influenza: the Mother of All Pandemics
reicht das jetzt ?
(try google for “influenza deaths” +1890)
Anon_22 said: I am less and less certain of whether we can compare H5N1 to anything, and so less able to extrapolate and predict.
I agree. I think we should just be looking at the current data, the current behavior of H5N1, and that tells us all we need to know.
When the idea of a pandemic was brand new to all of us Baby Boom and later kids, there was a need to educate the public about the basics of what a pandemic looks like since none of us had ever spent a minute thinking about the subject, nor had any of us experienced one. At best, the pandemic of 1918 was a footnote in a few history texts. Barry’s book, the bad tv movies, the state pandemic conferences, Osterholm on Oprah, all that has raised awareness of what a pandemic is about in the public’s mind.
But now, the most basic education accomplished, I think that we should not be extrapolating and predicting any future pandemic on the basis of 1918, 1968, etc. They really are not useful and relevant to what is happening today beyond being illustrations of pandemics in general.
Like Anon_22, I have grown uncomfortable with trying to hammer a square peg into a round hole. We need to be focused on what is happening in front of us, what the data from the current situation tells us, and screen out the tales of past histories (which are really distractions now) to formulate policy on how to handle this one. I think we do a great disservice if we use figures like 1918′s 2.5% CFR when the H5N1’s CFR has grown from 50% to 70% this year. (And I don’t think we saw any parallels to that in 1918 anyway). We don’t know if the 1918 virus was seeded around the world by birds, but we know that this current situation has become dangerous because of the speed (in evolutionary time, a flash) that the virus has been seeded around the planet. We know enough about viruses to understand that it is changing, better adapting to humans and other mammals, and I doubt any policy leaders can answer Anonymous’ (yes, please get a name)excellently posed question as to “What would the mechanism be that would stop it mid-adaptation?”
When dealing with policy makers, I would give up all attempts to compare and contrast this possible upcoming pandemic with anything in the past. I would just put the current data in front of them, and return them to the present data whenever their attention wanders. The data in front of us tells us quite a lot if we look at it, in fact it speaks volumes. The only thing it cannot tell us is “when.” Beyond that, policy makers have to be encouraged to take a good hard look at what is happening, real-time, no fudging the data - just look at what is there. We are looking at high fatality rates. And both in terms of the virus’ habits and our own lifestyles we are looking at speed. (And does anybody else think that this current e-coli outbreak in spinach is an object lesson in speed? From 9 CA farms to 25 states in mere days. We are one zippy society). The policy makers need to be focused specifically on what is happening, today’s data, no distractions. Thanks Monotreme for a very sucinct summary up there.
Barry writes: “The great influenza” (title)
The Epic Story of the deadliest plague in history.
So we would hardly expect 1890 or 1830 were
even remotely as severe as 1918
pixie, H5N1 is influenza A. That’s the only known virus which went pandemic in the past. And there were many such examples. And that makes it so worrysome. Else we could just compare it with Ebola or such. And the other pandemics _were_ 1918,1957,1968…etc. And the virus _did_ reassort with other flu-viruses. And so did H5N1. So it’s not so far fetched to compare it with earlier (flu-)pandemics.
Not me at: 06:28 10:23 10:38 10:48 10:55 10:56 10:58 11:01 11:06 11:09 11:12 11:16 11:22 11:23 11:29 11:37 11:41 11:44 11:45 11:47 11:50
Great post, Pixie. But as others have said, if there isn’t a recent (or fairly recent) history of such an event the bureaucrats harbor that disabling doubt in their minds about the need for preemptive action. The old pols just can’t get themselves out of that “box”, and they worry that they will get themselves out on a limb and somebody will saw it off.
but I also see, that H5N1 is quite different from H1N1,H2N2,H3N2. It’s very prevalent in birds and evolves much faster than earlier flus. Also much more virulent, survives in blood. But could still reassort with other flusA and thus become more contagious.
anon0628. I would appreciate your intuition based on your study of the subject pertaining to:
Is a pandemic going to happen…when will it happen…where will it start…will it be a mild one and which previous pandemic would you expect it will be similar to…what will be the attack rate and the CFR.
I would be very interested in your opinion. Thanks.
Closed and continued here.
Medical Maven, point well taken about the pols not wanting to crawl out on a branch. But we also face the risk that if they do take action of some kind, they will utilize old and worn out models that just do not apply (i.e. those state pandemic plans). In the military they call that “fighting the last war.” We’ve done that lately too. Rolling into Baghdad was not met with the same response that rolling into Tokyo and Berlin was met with in ‘45, but that’s because some really key points of present reality were probably left out of the strategic assessment. If we talk about 1918 and 2.5% and having months to prepare a community, we are likely to find out quickly that this new war against H5N1 bears little resemblence to the past influenza wars too. So beyond the broader educational possibilities of describing past influenza pandemics, I’d still stick to the evidence of what is happening now in front of us as the action model for any pols who do want to move towards the end of that branch. It’s a harsh enough reality on its own, and it leads to the conclusion (even apart from any historical models) that they should taking action, even if no pandemic had ever happened in 1918.
Sometimes I think that the comparison to 1918 makes it all look too mild, makes the pols even more complacent. If we were talking about a 2.5% death rate in Indonesia, maybe that complacency would be warranted.