a few meta-comments on 1918 CFR
Must a Pandemic Strain of Influenza decrease in lethality?
This is a question that has been addressed several times on this forum, but new data prompts me to consider the question once again. We now know that H5N1 truly is a highly lethal virus in humans. The recent release of seroprevalence data has established this as fact. The arugment that a flu virus must avoid killing its host has been discussed extensively. My conclusion is that this is not true because virus is shed before the host becomes ill, so there is no selective pressure to spare the host. Additional recent evidence, and a rethinking of the genomic structure of influenza viruses provides additional reasons to think that H5N1 may be able to retain a very high level of lethality when/if it becomes a pandemic strain.
Influenza is an unusual virus in that its genes are separated into 8 distinct segments. The hemagluttin gene (HA) is responsible for entry of the virus into the host cell. It is also likely that this gene is important for initiating a pandemic as it must acquire the ability to infect the upper respiratory system in order to be transmitted efficiently between humans in respiratory droplets.
Viruses evolve via 3 mechanisms - random mutation, reassortment and recombination. Reassortment involves exchange of entire viral genomic segments while recombination involves exchange of subsegments. However, regardless of how H5N1 evolves, because of its segmented genome, HAs can change independently of other H5N1 genes. Recent studies demonstrate that this viral gene swapping occurs much more often in influenza viruses than was previously thought. Thus, H5N1 could acquire an HA adapted for efficient spread of virus without affecting the other genes in its genome. Thus, the question of which genes contribute to its virulence become key in understanding its potential lethality as a pandemic strain.
Both the polymerase gene complex and NS1 are thought to be major contributors to the high lethality of H5N1. They are not on the same genomic segment as HA. So, there is no reason to think that a change in the HA gene that permitted efficient human to human spread would affect the lethality of the virus, at least that part of the lethality that is due to genes other than HA.
There is still much we don’t understand about influenza viruses, so there may constraints in its behaviour that put an upper limit on its lethality in pandemic strains. But if so, we have no evidence of them that I am aware of. We have concrete reasons to think that the virus may be much more lethal than the 1918 virus. Yet, all our official planning is based on the assumption that a 2.5% fatality rate is the maximum. I would argue that, based on the available evidence, not only is a much higher fatality rate the true worst case scenario, it’s the most likely scenario if H5N1 becomes a panflu.
References
The NS1 gene of H5N1 influenza viruses circumvents the host anti-viral cytokine responses
Absolutely irrefutable, M. Those are among the cards in the big deck. And these are the cards we’re only too apt to be dealt.
‘Read ‘em and weep’ as they say at the poker table.
Thank you for your time, effort and courage.
Monotreme:
Since your weighty post, the silence has been deafening… The title, plus your credibility, guarantee many have read this post. The final paragraph should be engraved on walls.
May I ask, in due time, your observations on the impact of this, and the spreading strains of H5N1, on Panflu51 VACCINE(-s) development?
Clearly, the more lethal the virus, the more vital effective vaccination protection. High lethality agents are possible civilisation busters…
H5N1 keeping its’ current mortality rate during panflu would make the clips that I have seen from the ABC movie airing on the 9th, a little less dramatic fiction and a little more dramatic reality. Very scary, clearly an all bets are off scenario. Great post, Monotreme, scary but great….in my town, you’re talking over 10,000 dead….
Monotreme: Thanks for another penetrating post.
As a practical matter, probably but not necessarily.
- Monotreme
I have read your post, and right after, Revere’s comment on H7 in UK.
I have just been shell-shocked. Both of you have brought home to me just how bad, really bad, it’s going to be if/when…
My deafening silence is going to be converted into extra energy geared towards even more thorough prepping.
FrenchieGirl. I certainly share your feelings on the subject. Part of the reasoning is on the current thread ‘H5N1 spreads more efficiently H-H than B-H’.
However, something we should keep in the back of our minds, is that there is another group of scientists, with reasonable arguments, that state there is a barrier and it will never happen.
The truth is…no one knows. We have the evidence of past pandemics and of H5N1 and H7 viruses of the past ten years but little else. One of the greatest surprises to me has been just how little we know. This area of research must have been almost completely ignored for a very long time. I know of no equivalence from the field of Veterinary Medicine. I don’t know how the determined researchers managed to continue…thank god they did or we would know even less.
So as we continue to observe, we should all remember anything can happen including a rapid disappearence of H5N1. I personally don’t think so but we must acknowledge the possibility.
Monotreme Speaking to those folks who have shown an interest in attempts to educate them about the Pandemic possibility, have always noted that there was a good chance there was about a 1 out of 3 probability of something similar to 1918. If mentioned at all I would say there was a very slight chance of something worse. Your post is certainly sobering to say the least.
Let’s hope that this worse case scenario does not come about. Reading info on H7 certainly does not offer encouragement.
Thank you for sharing your insight with our community.
I’m just bumping this up as I think everyone should read Monotreme’s analysis.
Thanks everyone for your kind comments. I’m still hoping, however, that someone will find a flaw in my logic. Tom DVM is right that it is possible that H5N1 will just fade away, but that seems unlikely at this point. Recall that with SARs that we had hard time finding an animal reservoir. Same thing with Ebola. Not so with H5N1. We will all be able to find animal reservoirs in our backyards soon. My last reference also increased my personal estimate that H5N1 would become a panflu. The recent release of large numbers of H3N2 virus sequences from the NIH has changed peoples ideas of how often influenza viruses exchange genes. This makes it more likely that H5N1 will acquire an “humanized” HA gene at some point, IMO.
Nikolai---Sydney, “civilisation buster” is an apt phrase. To me, the only comparable threat was all out nuclear war between the US and the Soviet Union during the cold war. That didn’t happen, but it was close. Here in the US, no expense was spared in contingency planning and preparation. Unfortunately, the decision makers in most countries don’t seem to understand that we face a similar scale threat with H5N1. I’m not sure how, but we have to convey to them the seriousness of the threat.
Monotreme: That “last reference” was a hard read for me, but I agree with your conclusion. And if you pair that information with Dr. Niman’s suppositions, it seems we have two equal chances of being “knocked-out” by H5N1--a reassortment “right hook” or a recombinant “left hook”.
Tom DVM,
This thread is H2H vs B2H. I’ll expand on why I was shocked, but I may find it difficult to put into words, bear with me please.
Some days ago, I read an abstract on PubMed
QUOTE “Quail carry sialic acid receptors compatible with binding of avian and human influenza viruses.” UNQUOTE
This abstract essentially says that quail carry both types of receptors, sialic acid alpha2,3-galactose (SAalpha2,3-gal) linked receptors, and abundant sialic acid alpha2,6-galactose (SAalpha2,6-gal). The conclusion being QUOTE “these results are consistent with the notion that quail could provide an environment for the spread of reassortants between avian and human influenza viruses, thus acting as a potential intermediate host. UNQUOTE
I read further litterature on why H5N1 should attach/not attach to human lungs owing to the various locations of these receptors in the human respiratory system. And all sorts of scientific arguments on why H5N1 will/will not reassort/recombine, etc.
Then I read Monotreme’s extreme logic.
Then I read Revere’s blog on the subject of these human receptors being used by H7N7 and H7N3 and ALSO that these two “mild” flu candidates share some common features with HPAI H5N1.
Many farms breed not just chickens or turkeys, but also quails, at least in France where I live now.
I hope I got my scientific reasoning wrong, but what happens if a mild H7N7 or H7N3 meets not just chickens, but quails, and then humans, and by nasty occurrence, there’s a few swans/geese also carrying H5N1 either bred on this farm or wild landing for some food on these farms? Isn’t that just what we are fearing?
In addition to realising that there must be something terribly wrong with the UK system of testing - Remember they tested thousands of birds a few weeks ago and did not find ANY avian flu except the “Scottish Illegal Immigrant Swan” whereas bird flus ARE common in birds and they should have found x% of some (mild) avian flu in the thousands of birds. Not to mention some authorities questioned their way of keeping swabs. Plus Revere’s remark about false negatives.
I am not enough of a scientist to jugdge, but that’s what gave me the shivers.
PubMed ref: http://tinyurl.com/q2w86
Revere ref: http://tinyurl.com/jdnmb
Monotreme - The one question I have about your last post regards the animal reservoir. Is there any reason to assume (or not to, for that matter) that a human adapted avian flu would become endemic in birds or mammalian wildlife such that we would be “surrounded” by vectors, no matter which way we turned?
If this were the case, then we would either need to find a vaccine right soon, or else all become vegetarians eating only from our own hermetic greenhouses. And this assumes no insect vectors.
Monotreme, thank you for all you do. (Wish you lived in my town)
I remeber that the 1918 flue got more and more deadly till it couldn’t spread faster then it killed. Some variations of it were extremely deadly.
The possiblity of 50% is certainly out there. I think those of us who are better educated w/BF and have been tracking it likely agree. It’s another huge unknown that will imapct all of us yet, yet we have no control over it. Most mainstream media coverage uses 1918 as a reference point (for lack of anything better to use). I think people hear “less than one million dead from 1918 in the U.S., that’s not so bad.” Nobody wants to concede the fact that it could horrifically worse. So bad that ignoring it is better than facing the possibility.
Polymerase Chain Reaction - Xeroxing DNA National Center for Human Genome Research, National Institutes of Health. “New Tools for Tomorrow’s Health Research.” Bethesda, MD: Department of Health and Human Services, 1992.
Who would have thought a bacterium hanging out in a hot spring in Yellowstone National Park would spark a revolutionary new laboratory technique? The polymerase chain reaction, now widely used in research laboratories and doctor’s offices, relies on the ability of DNA-copying enzymes to remain stable at high temperatures. No problem for Thermus aquaticus, the sultry bacterium from Yellowstone that now helps scientists produce millions of copies of a single DNA segment in a matter of hours…
more at: http://www.accessexcellence.org/RC/AB/IE/PCR_Xeroxing_DNA.html
I wonder if we could see a reassortment of H5N1 into a quasi-‘58/’68 strain, (through a co-infection with an H7 or other virus) while the global resevoir continues to recombine into a quasi-1918 strain.
I wonder if the reassortment event would provide a primer, or natural vaccine of sorts to the human population? If it preceded the H2H recombination of the ‘other’ virus significantly that is….
A reassortment event would give us a novel potentially pandemic strain, but it would not stamp out the currently evolving ‘thread’, would it?
Comments?
IIRC, the deadliest, percentage-wise, plague to hit Europe was about 35% fatal. While European diseases which came to the New World were closer to 70% fatal. Does that sound right? If so, then the potential for the same percentages in this pandemic could be that high. Someone better have all their ducks in order for vacceine R&D if and when it does go h2h.
3L120 immediately,(and all above):
The worse a prospective pandemic may turn out to be, the more vital it is that societal disruptions be minimised, as they can magnify the final death toll dramatically.
Some have pointed out that fewer survivors means less drain on resources, which may be true. But it also means fewer human resources, especially technically able, to encounter the challenges.
The urban infrastructure must not be allowed to completely collapse or even come very close. Whatever draconian laws and policies, the vital workers, and their families, MUST be protected—but also COMPELLED to keep electricity and water, at least, ongoing.
Think about that—and pray your government is also.
AJ: We have batted around the idea of the possible benefits of a “primer” pandemic from time to time. Some have even suggested to create one, but nobody has taken that seriously. The timing and the nature of the reassortments and/or recombinants and their respective waves (or lack thereof) will probably determine whether we are layed low or totally crushed. Too much luck in life, that’s for sure.
Monotreme,
“I’m still hoping, however, that someone will find a flaw in my logic.”
I’m working on it…
I am in a strange country and lost the use of my laptop. Now I’m borrowing someone else’s much slower machine with no access to my file :-(
I hope I DO find some flaw in your logic, for once.
Vaccine development
Several have raised this issue. I think the expansion of conventional vaccine production plus acceleration of new more rapid methods should be of the highest priority. We are in an arms race with influenza and other viruses and we are losing.
Societal disruption
Oft discussed on flu sites, but it really hasn’t sunk in yet among TPTB. Despite Katrina. Amazing, simply amazing. I suspect the ABC tv movie on the subject won’t even come close to depicting how bad it could really be. And you just know it’s going to have a happy ending. A flu pandemic with 30% CFR isn’t going to have a happy ending for anyone, unless we get our act together.
Monotreme. With a 30% CFR, it isn’t going to have a happy ending even if we get our **** together.
Tom DVM, not for the 3rd or 4th world. That’s for sure. But for the developed countries, I’m not so sure. As Osterholm and Senator Frist have suggested we need a Manhattan project for pandemic prep.
One rosy scenario, panflu holds off for 2 years, DNA vaccines are intensively researched and turn out to work, massive food and medical supplies are stockpiled near every major population center, redundancy is built into every mission critical societal function, detailed contingency plans are developed as well.
See,it could have a happy ending. For gs, the probability of all of the above happening is .000001%.
Just as the human race gets too big for its’ britches, Mother Nature reminds us again who is really in charge. And it ain’t us!
crfullmoon, thanks and good luck to us all.
anon_22, your computer may be slow, but I your brain is still fast.
One possible mechanism for decreased lethality would be if the current high lethality were due to the alpha 2,3 affinity of H5N1. Perhaps a switch to alpha 2,6 would somehow decrease lethality. I’m not very optimistic about this, but perhaps you can make a better case for this than I could.
AJ raises an interesting issue regarding re-assortment. If H5N1 reassorted with H3N2 and became an H3N1 pandemic strain, would those of us who had infection-acquired or vaccine-acquired immunity to H3N2 be protected against the pandemic reassorted virus? Even if this did offer some protection, most children have no immunity to H3N2. This is one reason I made sure my family and friends got vaccinated last year. It’s a small hope, but one worth pursuing I think.
Of course, if H5N1 evolves into a pandemic strain by random mutation or recombination, this small hope is gone.
Monotreme. My probabilities demonstrate that the first world is going to be hit far worse than the third. They have food in their backyards, we have none…They don’t have hydro, we can’t live without it…they know what it is to not have healthcare, we don’t…they know what it is to do without, we don’t…they know what it is like to lose children periodically to disease, we have no idea. We are nieve, idealists and superiorists at the same time…bad combination.
Human nature says that we will not respond until it is too late. There will be no Manhattan project for H5N1.
Questions: Does this lethality present a range of figures for the case fatality rate of 40% to 50%? What would be a best fit estimate of the clinical attack rate? I wish to revise my projections made in another thread of total deaths in the United states. I don’t want data from 1918. I have already calculated those figures and projected their consequences for the current United states population. I am looking for best guess based on a realistic appraisal of current information. It is my contention and has been for many months, that we are underestimating the task we face. The only way to make good decisions is to have an idea of what we face. Thank you Monotreme - you have just become one of my heroes no matter what happens. You have courage and intelligence. Grin, I am not worthy and your head is too big for your body.
Sounds like you and Robert Webster are on the same page.
Tom DVM, your portrait of the third world applies to rural areas with intact social systems. I agree that those areas have the advantages you mention. Isolated villages may do quite well. Although, no guarantee of that. Very isolated villages in Alaska lost almost their entire population to the 1918 flu.
However, there has been a transformation of the third world in the last 20 years that has involved mass migration from rural areas to megacities and an erosion of traditional societal ties. I’m thinking of shanty towns in Mexico City, Lagos, Mumbai, and many other places. Many areas of Africa are totally dependent on foreign aid for food and basic medical care. What happens when all aid and infrastructure collapses in these overcrowded death traps? Sorry, but I think they will suffer much worse losses than the first world.
I agree that we will probably not respond adequately in time. Sigh.
Thanks Dude. Yeah, a lot of people say my head is too big ;-)
Regarding fatality rates, they vary from country to country. The low is about 30% for Turkey to a high of 100% for Cambodia. There are several ways to reconcile these differences, but I think it comes down to supportive care. 30% CFR with prompt administration of Tamiflu to all contacts of the index case, ventilators, round the clock nursing, state of the art ICU, etc. Take these things away and you’re looking at a nearly 100% mortality rate. During a pandemic, we will all live in Cambodia. Hate to say this, but a 30% CFR may turn out to be a best case scenario, and perhaps unrealistic during a pandemic.
anon_22, fix your computer and stop me before I depress myself any further.
Monotreme. There are a couple of arguments that I have had trouble with the more I think about them. 1) We are healthier than 1918…don’t think so. 2) We have effective treatments they didn’t have…don’t think so. 4) We have better healthcare systems…don’t think so 3) Our advanced systems would prevent a societal collapse…don’t think so. etc. etc. etc.
When I look at the first world today, I see a population spoiled by success and infrastructures that will fall like a ‘house of cards’. Their technological quick fixes that were to save us 12 months ago, now appear largely useless.
However, I have great hope in individuals and individuals within communities. They have saved us in the past and I hope they will limit the damage in the future…and I hope we are wrong and this virus goes away but I don’t think so.
So, a person to person clinical attack rate for a novel virus - pandemic? You agree with 50% or higher?
Tom DVM hits the nail on its unfortunate head. And I’m hearing a lot of this happy talk in the “secular” (that word means non-professional) press.
Tom DVM, I think it’s a mixed bag. We do live longer now than in 1918. The elderly, especially, are in better shape now than at any time in the past. Infant mortality is greatly reduced compared to 1918. Hygeine, for most people in the first world, is much better than in 1918. On the other hand, our current health care system is strained to the limit and will collapse under the weight of a pandemic in short order. And everyone who needs health care to live, will die, as the diabetics did at the Convention center in New Orleans.
I think our advanced systems could ameliorate the damage of a pandemic, but I’m not optimistic that they will be used for this purpose.
I agree, community is the key. We will live or die as communities.
As a computer tech, former radar repairman, and general nerd, I think society is in big trouble. There are very few people at any given moment that are “up” on what it takes to keep this together. We better have rush plans for cross training of critical services!
Dude, the recent Seroprevalence data suggests the observed attack rate is the clinical attack rate, few to none subclinical cases were found.
The attack rate will vary depending on the area. It will be very high in shanty towns and very low among Flu Wikians ;-). So it’s hard to come up with a projected world-wide number. I do think that in the first world, we have a chance to keep this number down, with adequate planning. All this being said, I have seen models that project attack rates between 30–50%. So, Webster’s extreme statement may not far off the mark, unfortunately.
Melanie, send those happy talkers to this thread. I’d like to hear their logic.
AF may just be the trigger of the disease cascade. Here in San Diego, I expect to see Cholera in short order and god knows what else as systems break down and the work of surviving gets hard. How long will people boil water for everything, I’d say maybe a week for many, then the work will be just to much. Beyond the AF how many will die from things we have forgotten about?
US Population in 2006 = 296, 500,000 Cases in the United States (based on 50% infection) = 148,250,000 30% and 50% = case fatality rate (infected who die) Fatality Rate X Clinical Cases = Dead on/about 2006–7 30% X 148,250,000 = 44,475,000 dead in USA on/about 2006–7 or 50% X 148,250,000 = 74,125,000 dead in the USA on/about 2006–7 You can estimate that roughly one fourth of the world population will die based on a 50% clinical attack rate. With that figure you get 1.625 billion people.
I was pretty young, admittedly. But I don’t think the hospitals were that great 30 years ago. My sister died about 43 years ago, to a disease that is easily treatable today. I keep hearing that hospitals are in such bad shape, but are they truly any worse than they were 100 years ago? Certainly our health care system was strained back then. Come on!
When my mom gave birth to me some 40 years ago, we stayed in the hospital for several days. OTH, when my youngest was born 9 years ago, they sent us home the next day. Hospitals and the care received there is much better than it was even a half a century ago.
A failure of the health care system is inevitable in a worst case scenerio. I can not argue that. But in comparison, the health care system is much better off than it was in 1918.
When we make these arguments, especially in trying to convince people of the seriousness of the situation, we need to be realistic. Is making comparisons to the 1918 health care system and concluding we are worse off realistic?
Dude – at 00:44
Those are sobering numbers, in a worse case (and that is worse case).
Remember though….here is certainty…6 times that many will die in the next 100 years, including me and you.
No problem.
Dude4-−00:44
“You can estimate that roughly one fourth of the world population will die based on a 50% clinical attack rate. With that figure you get 1.625 billion people.”
I agree these figures are altogether possible, highly so. Please don’t think I’m trying to be ‘cute’ with words though, if I remind us of the ‘glass’ analogy.
We ‘get’ in the sense the figures come up with, but we actually LOSE 1.625 billion people. Our ‘glass’ is then one-quarter empty, compared to today.
At those grim figures, we have left, just approximately, 5.7 billions. Our depleted ‘glass’ is still three-quarters full. Earth’s population a relative few years ago!
Next, at our human reproduction rate in the handicapped regions of this planet, the population will be back to the present, earth-resources-devouring, level in a scant ‘few years’, biologically speaking….
And we think viruses replicate fast! Like we don’t?
Just some off the top thoughts I may instantly regret after posting!
Monotreme : your reasoning is logical, I accept it in full. Whatever mechanism would produce an efficient H2H strain of H5N1 will have to happen though. AFAIK, these gene jumbles happen haphazardly and more than one coincidence has to occur for a pandemic to take off. Estimating that probability is impossible, with some experts saying 10%, others predicting 30%, some say 100%. To conclude that it is going to be bad, very bad, catastrophic, incites panic in some people and laughs in others.
I noticed that the threat is taken a bit more seriously now than a couple of months back. where I live, some Embassies and big private companies have already stashed Tamiflu for their staff and families. One Embassy has advised its staff to prep…. for five days ! I have told them to make that three months at the very least but don’t know yet if the message got through.
Mono-I agree as well. Look at where and when pandemic flu, or any lethal virus perhaps, shows up. If the heard encroaches on new turf, over-crowding/population, weakened species imunity. Just a thought, that besides replicating, these “organisms” seem to be the cullers of heards. Of all the candidates for the job, some are too weak, (rhinovirus, etc) and some are too hasty, (perhaps Marburg, Ebola), but influenza may have the right resume. Not a scientific speculation, but it seems that killing the host (or hosts) in this case is the primary job.
Patch - I agree that in many ways hospitals are not much better than years ago. However, Americans have come to expect that medince will save them. All the press on new technologies, new medicines, etc. that have eliminated incurable diseaes, saved or improved people’s lives. And dont forget the E.R. factor - people assume you go to the hospital there will be heroic measures taken to save everyone and a few charges to the chest will do it. But it’s not that simple. There are fewer hospitals and fewer beds today than many years ago. There aren’t enough nurses. Too many doctors are specialists and ill trained to handle infectious diseases. The doctors and nurses will be sick also. Many have lost the dedication to the profession seen years ago and will simply walk away to protect themselves or their families. There aren’t enough respirators, which are about the only thing that can help someone in severe respiratory distress. And with supply disruptions there may not be enough critical meds like antibiotics to fight secondary infections, one of the leading killers in 1918.
(I remember this monthy-python(ish) movie about the Atlantis inhabitants who sang while their island was sinking.)
Monotreme, I’ll try and find flaws in your logic, too. So far I can’t find any. Sorry.
There’s something I noticed in a hurry, and that is speed and number of case-generations. Maybe if we manage to slow it down (simple masks or whatever) then we will select the less deadly strain? Or is this just wishful thinking as the more deadly strains selected themselves somehow in 1918?
I like your “rosy picture”. We need to work on that. We’re just a few here so we need to:
We need to think strategically, on a high level: Just How Do We Organise Our Abilities?
Fast cross-training of essencial services is a must. We need to tell them to create the apropriate templates to be copied fast and wide in an emergency. Again, emergency learning.
Surge capacity means planed-for priorization: just stop moving furniture around, and move food around. No gadgets for a while, just antibiotics and insuline. This needs planning and an open conversation? Ok.
On-the-fly prioritization will need electricity and water. You (meaning Monotreme) worked on water supply. Electricity has lagged behind. Emergency communications is somewhere in resilience technologies.
We will have no Manhattan project, but we can create a grassroots coalition, of which we (fluwikians) are one important member.
Now we know it can be really bad (or maybe not, depending on Nature, who is really in charge). Let’s not over-predict, and instead get going as fast as we can.
lugon hides behind a rock, scared as a mouse
I hardly speculate any longer. Just prepping as best I can on minimal finances, in a large city, in a small flat…
All my speculation is overshadowed by one major unknown, even bigger than transmissibility, or lethality, or governmental preparedness…
Is the ‘Ultimate Variable’ TIME? Is my situation analogous to a movie script where the crowd is fleeing the irresistable menace, the nuclear bomb about to explode, and TIME is all that will affect the outcome? Will there be time for them to flee far enough to achieve safety?
Concretely, will it start this October-November? Or will I have until October of 2007? 2008?
If it comes in say six months, I feel as Melanie quotes… Osterholm was it? Or Webster? “We’re screwed.”
Putting it in another light: What should we do with 1 month? With 6 months? With a year?
Or, once you have 1 month of food (or whatever): What should you do next?
Anyone cares to create a list or outline or wikipage with the options?
Interesting first comments from the Singapore meeting on AI
http://tinyurl.com/kexy7
QUOTE
By Tan Ee Lyn
SINGAPORE (Reuters) - Leading influenza experts urged nations not to lower their guard against the deadly and hardy H5N1 virus, saying it now survives longer in higher temperatures and in wet and moist conditions.
[…]”When we tested the virus in Hong Kong from 1997, the virus was killed at 37 degrees Celsius (98 Fahrenheit) in two days. The current H5N1 is still viable for six days at 37,” said Webster, from St Jude Children’s Research Hospital in the U.S. city Memphis.
“H5N1 at room temperatures can stay (alive) for at least a week in wet conditions,” Webster told Reuters on the eve of a bird flu conference organized by the Lancet medical journal in Singapore.
[…]Webster said heat-stable strains of H5N1 were already circulating in ducks in Vietnam, Indonesia, China in 2004 and 2005 and experts would have to test if this trait was in the variants now circulating in India, Africa, Europe and parts of the Middle East.
[…]The virus’s growing adaptability to water has ominous implications because it means untreated water might no longer be safe, Webster said, and it was important to drink boiled water.
“This means that water supplies for feeding chickens, or water supplies where people are swimming and water supplies for villages have got to be treated,” he said.
UNQUOTE
Not just Webster being quoted in this article, but also John Oxford, Kennedy Shortridge
So even if the virus was going to become less lethal, we would be liable to catch it during a period three times longer, assuming we do not handle the job of disinfection perfectly…
Now, is there anyone of us who is capable of disinfecting, and repeating all the gestures to disinfect for days on end, every single teeny-weeny speck on: clothing, hard surfaces, moist surfaces, soft surfaces, furnishings, shoes, containers, baths, showers, door handles, stray hair, etc., do a perfect job of this during 6 days after a (supposed or real) contact with the virus?
What if the house next to yours is upwind from you with ill people in it, the sick are burning with fever, it’s summer, weather hot and humid, they open the windows, the wind blows towards your house with your own windows open - how do you disinfect your windows, blinds, curtains, etc. and again and again and again during six days, and then repeat the whole process at every opportunity the virus might have to get deposited in your home? Are you going to live quarantined with all windows and doors locked shut in stiffling heat, possibly with no air conditioning, in darkness??? We don’t just need months of food, we need tons of disinfectants and cleaning agents
Even if the virus becomes less lethal, it won’t matter if it can live longer outside a warm blooded-living creatures, we’ll be no better off.
Hi everyone. Dude…thanks for the spelling advice the other day.
I believe our regulators self-comparisons to 1918 have bred complacency so I thought I would bring up a few points about that.
In 1918, a large majority of North Americans lived on farms. They produced all of their food supplies, heating supplies, were not reliant on hydro, could and did self-isolate. These people were totally self-reliant that would make any survivalist today blush.
They had experience with all manners of tragedies including repeated experiences with localized epidemics (ex. cholera) that left large numbers of children etc. dead. They were also ‘battle-hardened’ from four years of world war. They were tough!!!
The advance in life expectancy in the twentieth century has been the result of markedly decreasing childhood mortality (antibiotics) and loss of women in childbirth. I you walk through a cemetery from that time period, you will notice, other than the deaths I just mentioned, how many persons lived into their late 80′s or 90′s.
Today, we are living in a era of rapidly deteriorating health whether you look at asthma, food allergies, auto-immune disease, cancers, tuberculosis, malaria and other infectious diseases of public health significance.
Our immune systems are not better prepared to withstand a pathogenic insult. The evidence clearly indicates that immune sytems in 1918 were much stronger and better prepared.
There was a functioning healthcare system in 1918. It appears that there will not be one in 2006 if a pandemic occurs. Therefore, the 1918 healthcare system was, in effect, better prepared.
A wonderful job on many fronts was done in the 1918 pandemic…we should be so lucky.
Eccles – at 11:16 Is there any reason to assume (or not to, for that matter) that a human adapted avian flu would become endemic in birds or mammalian wildlife such that we would be “surrounded” by vectors, no matter which way we turned?
Eccles’ point goes right to the issue of the probability of a pandemic occuring. There is little doubt in my mind that H5N1 will become endemic almost everywhere in the world. The geographic spread is inexorable. Further, many more mammalian carnivores will be infected. We don’t know how many more changes are necessary in the HA sequence to become a human adapted strain, but it may be as little as 2. I can think of no biological or physical law that would make these changes impossible. Anyone who can, please let me know what they are. If these changes are not impossible, then it is simply a matter of probability. I acknowledge the probability is likely quite low, yet the opportunities for the virus to acquire these changes are endless. Unless H5N1 fades away for evolutionary reasons, ie, it is displaced by a more fit virus, I think it is inevitable that a human adapted strain will emmerge. When? That’s what we don’t know.
Montoreme. In my opinion, for what its worth, within twelve months from today.
Monotreme. With the latest information from Egypt, 4 of 12 died, does this not mimic the findings in Turkey and Azerbizan. I think the reason you have not seen the Turkey and Iraqi sequences is because your intuition was right.
We have a unique strain demonstrating increased transmissibility and decreased virulence.
Tom DVM, I have been wondering about whether there is a new strain that began in Turkey. There were large clusters there and in Azerbaijan. Not sure about Egypt. The US Navy did deposit a sequence from Iraq, but there were no surprises there. Also, no clusters, and the death rate was high there.
As to the 30% death rate in Turkey, Azerbaijan and Egypt,I don’t know if this is because of a new strain or because of the quality of medical care. Hard to know without animal studies comparing the different strains.
Monotreme. Vietnam, from what I observed in a documentary, had Western equivalent in terms of care. I don’t think better healthcare is the reason because of the pathogenicity of H5N1.In most cases the damage would be done (cytokine storm) before you could realize that you had H5N1.
This has to be an adapted strain. Have we seen any sequences from Turkey etc?
I agree with Monotreme that H5N1 will be growing in the wildlife population year by year, due to it’s strong traits of fast replicating, pervasive species adaptability, and hardiness in the environment. Although bird virus have rarely crossed from Euro-Asia, it has happened in the past, and if any virus can cross with migration, this one can. It may be hard to find the first year, but year by year, the problem will be growing. We have many subsistence lifestyle people in Mexico, Central America, and South America, who depend on their backyard poultry. The bird flu virus will be more than a nuisance eventually for them too.
In birds, the virus has so far shown that it can keep it’s virulency without a continuous close quarters infection process. The deadly outbreaks can be spread apart in time and location. The wildfowl carriers who are not as susceptible to the illness, have not caused H5N1 to wimp down. The idea of moving to a normal level of pathogen-icy, is not occurring as a matter of course. What may often happen is not perhaps to be considered a “rule”.
If the close quarters of the World War I trenches are believed necessary to fuel the 1918 pandemic lethality, the world has many times more soldiers today, including militia in poor countries with low health care standards. But the density of populations in large urban slums give an even greater tinder box condition, that makes invalid the argument that we can’t have a virus as bad or worse than 1918. Far worse than developed nation slums are the third world slums. There are 1 billion slum dwellers, according to UN-Habitat. Comprehend these population densities-
Dharavi (Mumbai) –571,000 per km.sq.
Delhi (India) – 300,000 per km. sq.
Kibera (Nairobi) – 200,000 per km. sq.
Cite-Soleil (Port-au-Prince) – 180,000 per km. sq.
City of the Dead (Cairo) – 116,000 per km. sq.
-and so on, for many third world countries. For a basis of comparison, Manhattan and Tokyo are 13,400 per km. sq. Try to imagine how much denser the populations must be in these other slums, than our skyscraper cities. Tell me this isn’t a much worse fuel potential than what existed in 1918. Consider ourselves very, very lucky if the next new flu strain that crosses to humans, is a mild pandemic.
Monotreme,
Thanks for another one of your stimulating well thought out posts. After wasting a whole day my laptop is finally up and running, and that’s just after one moment of spilt drink! Perhaps illustrative of the consequences of our dependence on technology, as Dude so aptly said at 23:55 “As a computer tech, former radar repairman, and general nerd, I think society is in big trouble. There are very few people at any given moment that are “up” on what it takes to keep this together.”
The upside was I got some unexpected downtime waiting for my number to be called at the repair center; occasionally an enforced time away from the keyboard brings up some interesting thoughts, so I hope this is useful.
I would agree with your broad hypothesis, suitably with a ? at the end. There really is no automatic rule that says a pandemic strain has to correspond to a decrease in lethality. But that’s not what you want to hear. So let me give you some counterarguments and some counter-counter-arguments if you know what I mean.
“So, there is no reason to think that a change in the HA gene that permitted efficient human to human spread would affect the lethality of the virus”
On the other hand, there is no reason to believe a change in HA receptor binding is the necessary and SUFFICIENT condition for efficient h2h. Because receptor binding is not the same as transmission. There may be (in fact, likely to be) additional factors eg the way that the virus is shed, or how long the virus can remain viable in the environment, or how likely is it to be airborne, that determine whether a virus can cause a pandemic. If virulence hinging on PB2 or PB1, for example, or virus-host interactions based on NS1, also affect transmissibility due to an unknown factor x like the above, or multiple factors x1, x2, x3, and so on, then a mutation in PB2 causing an increase in transmissibility contributing to a pandemic could at the same time have an effect on virulence. This effect could be positively correlated to virulence (which would really suck and we can all go home) or it could be negatively correlated, resulting in a reduction in lethality and an increase in transmission.
I am using this hypothetical x factor(s) to show how little we know. Yes, Webster et al’s various papers are brilliant and demonstrate how these different proteins MIGHT work, but these are extremely simplified models and they are by no means close to demonstrating EVERYTHING about these proteins, their mechanisms of action, and their genetic requirements. If we think of cytokine storm for example, this is a clear example of a complex interacting cascade of events individual components of which may have either inhibitory or facilitatory effects on every other component. As with cytokine storm, so can viral protein mechanisms be just as complex. In fact, they are far more likely to be so than not, especially with H5N1.
“There is still much we don’t understand about influenza viruses”
Yes, we only know what we know, or what we think we know; we have some vague notions that there are gaps in our knowledge, but it is possible that we don’t even know in which universe those gaps lie, let alone whether that has to do with HA or polymerase. And therein lies the problem of trying to extrapolate and make predictions from limited laboratory results obtained in circumscribed artificial environments.
“One possible mechanism for decreased lethality would be if the current high lethality were due to the alpha 2,3 affinity of H5N1.”
Yes, one could hypothesize that a change in affinity would reduce the viral dose at the cellular level in the lungs. Since lethality is mostly dose-dependent, one might think reduced binding > reduced cell entry > reduced lethality. However, I could also argue (here’s my counter-counter-argument) that the affinity of the virus for the upper respiratory tract may not be so benign, since there you also have entry into cells and viral replication. If, as appears to be the case, HA does not change viral replication per se, then the virus can just as easily multiply in the cells of the upper respiratory tract to the same degree (not directly causing ARDS but maybe cell necrosis and other kinds of tissue damage), and then shedding the virus in huge quantities some of which will end up in the lungs. (I know this really sucks, I’m sorry.) In which case the ARDS type illness might be slower in developing but may not be milder, still that would buy a little more time for antivirals to work.
Now as to Nikolai---Sydney’s , ‘civilisation buster’.
There may be some comfort in knowing that these happen extremely rarely, in the order of thousands or tens of thousands or more years. And if flu is such a common occurrence, variations in seasonal strains happen yearly, pandemics happen several times per century, the incidences of each of these decreasing by several orders of magnitude, so ‘civilization busters’ (to the extent that they are so rare) must require an extremely high level of complexity or combinations and/or sequentialness of mutations plus environmental and human conditions that the chance of a civilization buster would be several orders of magnitudes lower than a regular pandemic
You can think of this schematically as the observed incidence (past) or probability (future) over time of the following happening (brackets my rough estimates for illustrative purpose only):
People catching influenza (millions per year) > seasonal ‘epidemics’ due to small mutations within circulating strains (1–3 per year) > pandemic (3 per century) > ‘civilisation buster’ (ask the dinosaurs?)
I do not agree with the comparison with nuclear war. During the cold war, there were long periods where everything was in place for that to happen except for the decision in the minds of a handful of people. The mechanism to trigger it was clear-cut and ready to go. Without orders from these leaders, none of the other components necessary for a war could be changed significantly, ie these conditions were static, stable, and present, which is hardly the case with a virus. In that sense, there was always more chance of a nuclear war than a pandemic of a ‘civilisation busting’ degree.
“Take these things away and you’re looking at a nearly 100% mortality rate.” “anon_22, fix your computer and stop me before I depress myself any further.”
The way to stop depressing yourself is to stop thinking of 100% mortality, or 50% or even 20%.
I started off a while back thinking of 2.5% as worst case scenario, then I got really freaked out thinking that might be the best case scenario. Now I still think that it is possible and maybe likely enough to be threatening to have a 50% CFR. But I’ve come to a point where I realized I needed a cut-off point in my thinking. I needed it for several reasons, not just for my sanity, but mainly because preparing for a 2.5% CFR is going to take so much of our energy which as a society or globally we are so far behind that to consider anything beyond that will significantly take away our energy and willpower and material resources and ability to persuade others that it is currently counterproductive to go there.
If you can get yourself prepared to ride out a pandemic with 2.5% CFR, and succeed in helping everyone else in your community achieve that, and able to persuade all governments of every country to prepare for that, it will take everything that you’ve got for the next several years assuming that you do not take breaks, indeed do not sleep, eat or whatever, and you will still be lucky to achieve it.
This is not science, it is personal philosophy and choice.
Plus it is extremely hard to prepare for scenarios again several orders of magnitude removed from the current situation because it is likely that conditions will be so different from what we anticipated sitting in front of our PC today that all those efforts will be wasted.
“There is little doubt in my mind that H5N1 will become endemic almost everywhere in the world.”
Because of the frequency of multiple sublineages, instead of ‘civilisation buster’, it is likely that we may see multiple pandemics of varying lethality over an extended period, eg 5 years instead of 18 months. One strain may cause a pandemic, but instead of producing enough immunity after several waves to subside into background levels of prevalence and severity, another strain that arose from a different sublineage can cause another one because of insufficient immunity, and so on, depending on how much diversity is obtained in the avian pools. That’s why the multiple sublineage paper is worrying, not because it implies higher chance of having one pandemic strain (although it does that too due to increased participation at any one time of candidate strains) but because it implies more chance of causing MANY pandemic strains over the medium term.
THAT is my worst case scenario, for planning purposes.
bump for comments please
Hi Anon-22, Tom, and Monotreme!
Thanks for all you do for us!
Dumb Mom questions…
If the virus mautated and began to infect Alpha 2,6 instead of Alpha 2,3, do you think Relinza would have a better chance of working, since perhaps the medication could directly reach the initial infection receptors?
Is it possible the mortality rates were lower in Turkey and Egypt, because of better communication within the general public? Could people have panicked and run in to be evaluated, giving those with very early infection, a chance to be positively screened and treated earlier? Some countries have much better (or worse) public communication and I’ve read over and over again, that in many impoverished countries, even many of the poultry farmers still don’t know about bird flu.
Tonight I am going to the first ANYTHING our county has had. It is a pandemic summit. It is actually for business and civic leaders and they have had a poor response getting many to commit to come. I was asked by someone at our local health dept. to come. Don’t know what help I’ll be, am really afraid to disclose what lengths I’ve gone to, to prepare for my chicks, but then want others to see what they can do. Mostly I just want to tell people this…”Look inside your circle of life and use everything possible in it to prepare. Be creative! Do you have land to garden, an abandoned well, a little extra change saved up, a dusty, forgotten canner? Use what is in your life now….Then think outside of the circle. I think there are things we can do, that would shock even docs., but we can do them. I have had several chidlren sent home with feeding tubes. This isn’t an especially fun thing to do for your child, insert a tube down the back of their throat, but it also isn’t hard. That is if you are properly trained. My plan is to insert one down any of my young chick’s, as soon as I would suspect they have H5. Maybe they would have a fighting chance, if they don’t become dehydrated. We can also learn to give injections and maybe vaccinate our own or even those incapable of doing this for their own families…. when the time comes, that vaccine is available. We can teach each other food preservation and canning…But the clincher is that we need to be sharing this training NOW! Not when a pandemic breaks out. We need changes in laws and waivers allowing laymen the chance to learn some of these medical techniques. The thing is, when the insurance now says, go home, you are taught all kinds of things, mighty fast! Why can’t we just learn them ahead of time to save our families ?
I’ve also suggested that we start a food bank for a disaster, of any sort. We could keep the site of storage hidden. When we donate something to the regular food pantries, we could bring along an extra can or two and donate to the disaster storage. Extra medical supplies could be donated as well. When my parents died, we had a difficult time finding places to donate any leftover supplies. We could encourage our hospital and doc. offices to keep extra supplies of antibiotics etc.
I suggested that we have volunteers, set up central websites, where community memebers could report signs of illness. We could have volunteer citizens monitor these sites and report where there was severe illness and make sure medical, food, and other supplies could be delivered to the home. This would insure that families with sick members would be taken care of and also limit infection, by carriers, as they left their homes seeking help etc.
Now these are my mom ideas…do those of you with the science background have any suggestions I could pass along? Please make them simple, my brain isn’t as large as yours! Thanks!
You are well come Tom DVM. Anon_22 glad your puter is back up. May I suggest a rugged notebook, that can take a spill of a fine wine served in crystal and a drop. They cost about 150–200 more. All my life I have struggled to be a realist. I know that the mind numbing projections of a pandemic “civilization buster” are going to inhibit discussion because many of our homeostatic tendencies will not be able to deal with those implications. The key is to first figure out as best as we can, where the truth is at a given point in time. We NEED to give honest projections, or I can not figure out the scope of the problem. It may be well and good to offer up some more obtainable and manageable scenarios and work with those. That has efficacy, but the plans themselves MAY be affected by what we project. If we think that all we are capable of is survival in a 2% situation, then it may be a self fulfilling prophecy. It is never my job in life to walk in another person’s shoes, but it is my personal objective to seek the truth in every discussion. The trick is to accept what life gives you and move on to the next moment. I will never be a deer frozen in the headlights as death approaches. I know nobody is suggesting that, but just for illustration….
So, if anon_22 @15:17 is right and I have the highest respect for him based on my constant lurking and thinking and cross checking, we have to develop plans to live in a hostile environment for much too long. How can that be done? Dry homes, wet suits, spray with bleach, ultraviolet light chamber, swimmer goggles, N95 masks stored in black boxes with salt and glass tops kept in the sun for 5 days and reused after a rotation with time in a above/below UV chamber, hepa filters on our air supply. You see we can start a discussion of some plan, but we must know the extent and what is coming.
Tom DVM.
Agree with you that our health care system will be inadequate within a very short period if the Big One comes down on us. Even my Doctor agreed with me there.
Does anyone know what the ratio of population to hospital beds was back in 1918? Because as we all know, many, many hospitals have closed in recent years. I would hazard a guess that there were more back then, although there would be better care overall. Today I spent much of the day in a local regional hospital with an elderly relative, who hopefully will be fine. They have recently expanded and modernized their emergency department, have improved their handling and reduced time spent in the admitting process. They provided wonderful care to her, but I was struck by the fact that I only saw, for example, one negative pressure room in Emergency, and also that although it was a light day for them, almost every room there in the Emergency ward was occupied.. Scares me to think what it would be like if hundreds of Pandemic victims arrived within a few days after an outbreak.
Many thanks to all who contribute. Let’s hope that it will not happen, at least in our lifetime, although that sounds like a hopeless wish.
anon_22 is a she, just soes y’all know.
NauticalMan,
A lot of the discussion on the end of this thread is so theoretical as to be nearly meaningless. Our city EDs are already routinely on diversion on Friday and Saturday nights. The EDs and the hospitals will be overwhelmed within hours of the infection moving into a local area. The hospitals and what is laughingly called our “health care system” are not going to be players in a flu pandemic. We handle this on our own or we don’t handle it at all.
NauticalMan. In 1918, most medicine was done at home by doctors on housecalls. In the country, deaths were also handled in the parlour of the home. These were tough, self-reliant people who did not have the social protections we have today. They were conditions to many types of tragedies including the expected deaths of a percentage of children born as well as deaths of women in childbirth. They had hospitals but were not as quick to use them as we have grown accustomed to today. I know how good a job they did in 1918 and I have an immense amount of respect for their stoicism.
What really bugs me is the re-invention of history when it serves the interest of regulators and governments which in effect are their own interest group.
1) We are healthier now…nope…look at cancer, asthma, food allergies, auto-immune diseases, rates of heart and lung disease etc. etc. etc.
2) Our modern healthcare system, we have technologies that were not avaliable to them:
a) Antibiotics are the single most important invention in our history but they will not stop the majority of flu pandemic deaths from the ‘cytokine storm’. It occurs because of direct viral damage (antibiotics have no effect on viruses) and the bodies immune response to the presence of massive numbers of viruses.
b) Just because you make a vaccine does not mean it will work. Flu viruses mutate away from vaccine strains too quickly for them to have much effect. INFLUENZA VACCINES DO NOT WORK. (sorry).
c) The primitive anti-virals presently avaliable will not work either and they have been found, in their limited use, to have the potential for serious, life-altering side-effects.
d) ventillators, intensive care, hospitals…there will be no one to run them.
3) Our infrastructure is better…This is not worthy of a response.
I could go on but my post is already too long.
anon_22, thanks for your response. I agree with much of what you say, but disagree on philosophical issues.
HA and efficient H2H
It’s possible that changes in other genes are also necessary, but I don’t think so. The polymerase complex of H5N1 works quite well right now, and it is correlated with virulence, regrettably. The virus has no problems replicating in humans or other mammals. Both pathology in humans and animal experiments support this. Once it get’s into us, it also has no problems infecting multiple organs, including the brain. These multi-organ infections cannot be due to an initial loading dose, they must be due to very efficient replication in many cell types. I could be wrong, but I do think the only left on H5N1’s list is alpha 2,6. In any case no concrete arguments against this, we just have to hope that something else is necessary.
Unknown mechanisms
Hard to argue against these. Kinda like proving God doesn’t exist. Of course, there really might be unknown mechanisms that block H5N1 from becoming a pandemic strain, or at least one with a high fatality rate. I hope so, but we can’t plan based on this. (Of course you know this).
Multiple pandemics for 5 years
I have been thinking this too. Let’s hope DNA vaccines can be made to work. The only hope under these circumstances, I think.
Civilisation buster
I don’t buy the argument that such a rare event is unlikely to happen in our lives. Most civilisations have already died, and natural events like weather and plagues have been implicated in their demise. Ask the Babylonians.
The cold war analogy leaves a lot to be desired, but I was searching for some other event of similar probability and destructive capability. In the later stages of the cold war, the greatest danger was a random mistake, miscommunication, a la “Fail-Safe”, or computer error etc, not deliberate armageddon. I do think almost everything is in place for H5N1 to cause a horrific pandemic and only a few random events, which may or may not happen, separate us from disaster.
I understand your decision about using 2.5% as a cutoff, but I’m with Dude in wanting to know the truth, no matter how bad. People work in BSL4 facilities every day with the most dangerous microbes one could imagine. They know if they make a mistake, they will die. But, this is their job. No matter how dangerous H5N1 turns out to be, there will be ways to lessen the risk of infection. If a high CFR turns out to be the most likely possibility, then mission critical workers need to be told this now. And they need to be told how to protect themselves. They know if they don’t do their work civilisation will crumble and their families will suffer along with everyone else’s. Let’s tell them the truth, and help them prepare for the worst. The real worst.
Monotreme and Annon. Hope you don’t mind if I take a little run at the issue you two have raised. I look at things this way.
When Nabarro came out and gave the two mutations comments, Dr. Osterhaus came out to qualify because his opinion was meant to be an ‘off the record’ comment. He did not deny saying it. I believe Dr. Webster also made a similar if not the exact same comment about two mutations. These are the two most renowned and experienced virologists in the world. What I conclude from their unanimity is that the virus is in fact one or two mutations from pandemic potential and our discussions on flu wiki since it came back have also hypothetically proven the same fact…and now we have an area of the world that is consistently demonstrating an increase in transmissibility combined with a mortality rate which has dropped to 33% from over 50 %….the virus continues its linear adaption to humans and I believe it will be pandemic if not this fall before this time next year.
The second issue was the eventual CFR or mortality rate of the pandemic virus. As kids, we all had lots of experience with hills. If we conceptualize a long hill, H1N1 in 1918 started from say half way down…it had lower mortality probably because it was from a low pathogenicity subtype as demonstrated by no bird die-offs in the preliminary stages.
H5N1, on the other hand, starts at the top of the hill…it is the first example of a high pathogenicity subtype affecting humans. Therefore, it can afford to fall a lot farther and still be a killer…if it loses 50% lethality, it still will be 10 times as lethal as the 1918 pandemic…and so on and so on.
They can speculate all they want, we have as close to absolute as possible in the lack of solid knowledge about any influenza’s let alone this ‘freak of nature’. We must do this from circumstancial evidence. The circumstancial evidence is crystal clear…all the other stuff is clouding the issue…forest for the trees…Thanks.
Monotreme and Annon. First, the ‘they’ I used in the last paragraph did not apply to either of you.
Secondly, I estimate that there will be a 10 % mortality rate and a 10% chronic sequelae rate and a loss of 10 % due to collateral damage (infrastructure).
Tom DVM, of course you, and anyone else is welcome to comment on this thread.
I think the idea that we may be only two mutations away from a pandemic has alot of support. It’s possible that more mutations may be required, but 2 is definitely within the realm of possibility.
I can’t say I know what the final CFR will be, but I do think the available data suggests a very high CFR is very possible, if not probable.
If this is the consensus, and it seems to be, it seems to me that we have a moral responsibility to warn workers who will be deemed essential that may be facing a very lethal virus and to help them prepare. If that means buying them all moon suits and teaching them how to use them, then let’s get on with it.
Monotreme. There is very little that the three of us disagree on…in fact our frequency on flu wiki indicates that we have reasonably patient partners and really don’t have a life…just kidding.
Dr. Osterhaus and Dr. Webster clearly said it…they didn’t retract…end of story.
Secondly, Dr. Webster has not retracted his comments of a month ago…he may be frustrated with the way they were presented but he has not publically retracted them…end of story.
I think we are discussing on this thread what we clearly proved with avaliable circumstancial evidence on the other thread. I was convinced 16 months ago, I was convinced before we had that conversation, and I am more convinced now then ever.
My question is why are they downplaying the risk now. Things aren’t looking better, they are looking worse?
You and I and our colleagues on flu wiki are powerless to change this spin…but watch for Dr. Osterhaus and Dr. Webster and their comments in the near future…they don’t tend to beat around the bush.
Tom DVM, part of the problem is just plain stupidity, exhibit A, Dr. Gerberding, and the other part is ignorance, exhibit B, almost all politicians. I do think there are individuals within various agencies who are fighting to get the word out. Dr. Nabarro is the best example of this, IMO. We need to support these people as much as possible.
Monotreme. Exactly, the evidence would be ‘a lot less circumstancial’ if all of the information from Turkey re: strain, seroprevalence and cluster data was freely disclosed as is required under the first precept of scientific principles, we would already have the evidence…and could move on.
Of all the times to start downplaying and spinning the issues, this is not the time. If there was ever a time for openness it is now. If there was ever a time to grab every avaliable mind and turn it to solutions it is now…and what are they doing…spinning everything and even managing to convince a few on flu wiki that the threat is over…
…they will be lucky if they are not lynched in the end.
Sorry, They are standing on the head of a pin and stating more or less categorically that there is a barrier and H5N1 is not going to go to pandemic potential.
Their margin of error is not great…once again they have proven to be poor probability theorists.
I susptect many are under political pressure not to “panic” populations and that is why they are retreating a bit. The White House doesn’t want to come out with it’s “worst case scenario” (which is a joke anyway) then be refuted by people at the CDC.
I just got back from this. Two things come to mind that are related to this topic:
1 M Peiris on Pathogenesis of human H5N1 diseases, asked exactly this question: “Will adaptation of H5N1 virus to efficient h2h attenuate its virulence for humans?” The short answer was that previous models on pandemic causation focussed a lot on reassortment, so if a reassortment occurs and the virus acquires a whole segment from a non-virulent human flu strain, its lethality may decrease due to the removal of some of the avian genome which could be contributing to high virulence. However, if there is no reassortment, and mutations cause a pandemic strain to form which is of purely avian origin, then the lethality may not decrease.
2 Fouchier, in his discussion on H7N7 outbreak in Netherlands 2003 and the difference between the one fatal case and the other non-fatal conjunctivitis cases, compared the sequence and found a lot of changes in PB2, and noted that E627K was found only in the lethal human case but not in other non-lethal cases. He said, “We understand determinants of virulence; we do not understand determinants of h2h transmission.”
Ok, then - strategies time:
Now, imagine we have 2 months and we want to get the most important and effective stuff done in that time. What do we do?
If someone wants to start a Fluwikians Job Strategy thread, or use some other name, then that’s fine.
The main idea is we are a number of determined people. By “we” I mean frequent posters, not so frequent posters, lurkers, and those “touched by us” (think Revere’s blog’s readership).
What to do, what to do, what to do - the outlook was decidedly blue (As sung by Ella Fitzgerald.)
Ok, I’ll start it as Fluwikie Strategy - just a minute …
The apropriate wikipage here
Tom and lauraB, and even Monotreme :-)
I think the theoretical construct that Monotreme proposed at the beginning of this thread needs to be debated as theoretical constructs. We were invited to comment on Monotreme’s thinking, brave soul that he is :-). This is a pure epistemological problem that needs to be worked through, and not to be mixed up with our opinions and what we suspect is happening with the CDC or WHO or Turkey. (These are also important but they are not the primary purpose of this inquiry.)
So Monotreme, when I say your supposition is not necessarily right, it doesn’t mean that it is not. It only means that as a thought process there appears to be some serious problems present. Consider the following:
“It’s possible that changes in other genes are also necessary, but I don’t think so. The polymerase complex of H5N1 works quite well right now, and it is correlated with virulence, regrettably. The virus has no problems replicating in humans or other mammals. Both pathology in humans and animal experiments support this. Once it getfs into us, it also has no problems infecting multiple organs, including the brain. These multi-organ infections cannot be due to an initial loading dose, they must be due to very efficient replication in many cell types. I could be wrong, but I do think the only left on H5N1Œs list is alpha 2,6. In any case no concrete arguments against this, we just have to hope that something else is necessary.
There is a subtext in this paragraph implying some kind of logic that goes like this: gites doing very well, why should it need anything more? Therefore I donft think it needs anything more. Therefore it must only need one more mutation.h I am grossly simplifying, of course, but you get the drift :-) In this instance, you are in danger of falling into a kind of circular logic where you convince yourself by your own logic which is in turn based on your own opinions or assumptions.
“These multi-organ infections cannot be due to an initial loading dose, they must be due to very efficient replication in many cell types.” The multi-organ infections are not of course due to initial loading dose, they are most likely due to increased tissue tropisms plus efficient replication. My reference to initial loading dose was the hypothetical one examining whether there might be a case to support some peoplefs suggestion that a change in receptor affinity might reduce the lethality. In any event, if you follow my logic on that to its completion, you will find that I do not support that notion. (Notice however it doesnft mean that I support the opposite notion either.)
Meanwhile, lugon has gotten a worthwhile effort going. :-)
It may appear that I am engaging in drivel in comparison. But getting our thinking straight is very important precisely because we may be challenged with TEOCASKI. If things are as bad as described on this thread, we will all be thrown into situations that bear no relationship to our normal life, and our ability to rise to the occasion will depend heavily on our ability to (ruthlessly) examine our own thinking and tease out all the blind spots, pseudo-logic, wishful thinking or fixation and obsession disguised as conviction, and so on.
anon_22 I have a question for you. I took a look at the conference you are attending. Will a summary document be provided at the end and will it be available on the web? I want to read about each session. It seems that this is what I do with my spare time now. <g>
Dude, I don’t know if there will be a summary. I intend to post tomorrow the most significant points that I gathered. I don’t want to post today as some of the thoughts will be continued tomorrow. I will certainly post a link if there is one at the end of it.
Monotreme, sorry, I missed an important point with the last post.
Receptor binding is not transmission.
It was one of the first points but I accidentally deleted it, now I can’t be bothered to re-write the whole paragraph, so I will leave you to ponder it.
Blame it on the UK-US-UK-HK-Singapore-in-6-weeks kind of jet-lag..
ZZZZ,,…ZZZ..
No, BBB, it wasn’t drool that ruined my keyboard… Cross my heart, honest… <g>
Regarding a vaccine, I was reading the announcements that the company called Vical had successfully tested an H5N1 vaccine against mice and ferrets. One of the more detailed articles is here: http://tinyurl.com/juz9u
The study tested two vaccines: one was against NP (nucleoprotein) and M2 (transmembrane protein from matrix gene), which are considered to be conserved proteins; and the second vaccine included H5, NP, and M2. The news article indicates the first vaccine provided “significant” protection, the second “complete” protection when the animals were challenged with Vietnam/1203/2004 H5N1 virus. And that the NP/M2 version also provided “significant” protection against other strains of human influenza virus.
Now if the NP/M2 vaccine were eventually proven to show efficacy in humans, that would be a definite step ahead. But there is a question nagging in my mind about this. If the highly-conserved NP/M2 antibodies are proposed to be effective against multiple strains of human infl A, why wouldn’t we all have some degree of resistance against multiple strains once we’ve suffered through a session of influenza A, due to presence of NP and M2 antibodies?
Mice and ferrets have shorter life spans than humans, so raising the production of NP/M2 antibodies via a vaccine would give them a “fresh” supply. The implication here might be than once humans have had influenza A, the presence of these conserved antibodies wane as years pass. Some people seem more prone to getting influenza than others, why these antibodies would not protect them more thoroughly is puzzling. Perhaps it is a balance of antibodies and immune system response.
Perhaps this is heresy to say on this group, but I am reluctant to jump on the vaccine bandwagon, and agree with Tom DVM at 20:46 (yesterday) than influenza vaccines don’t work well. If something were found to be effective against this looming H5N1 cloud, that would be wonderful. But I would want to be thoroughly informed about it, including the adjuvants and how it is prepared. Not to detract from the current discussion, but current influenza vaccines do contain thimerosal as a preservative. Sorry, but there is significant indication there are genetic sensitivities in some animals (and people) to mercury levels in the body. Additionally, influenza vaccines are grown on chicken eggs, and I have significant concern about indigenous retroviruses present in chickens, some of which are strongly related to cancer-causing viruses…not to mention other possible pathogenic contaminants which can be present in vaccines. So, while a reliable and safe H5N1 vaccine would certainly be welcome, I would need to be convinced it is indeed effective, reliable and safe, and would want some science behind such statements.
Tom, thanks for posting about the hardiness of people living in 1918. I do a bit of genealogy work, and yes so many people from that era were farmers. Even my grandmother who lived in the downtown part of a city, told stories of how she had to tend the ducks in her backyard. Having poultry living nearby has been a part of much of human civilization for a long time, and no matter what the danger of H5N1, is not to be easily changed, especially in what we call “third world” countries.
I remember the day looking through some church death records, and being shocked that 7 children in 3 related families living near each other (the children were all first cousins), all died within a period of 3 weeks due to a diphtheria epidemic. Childhood mortality was a reality of life - and this was only a bit more than 100 years ago. My attitudes have been humbled.
Monotreme et al. I have just been re-reading the thread because once again Monotreme has re-focused debate on key issues: is H5N1 going to initiate the next pandemic: if so, is there a potential for the morality rate to exceed the 2.5 % CFR of 1918: and most importantly, how far down the human adaption trail have we gone…when will the pandemic begin?
One interesting aspect has been the genotypic vs phenotypic discussion. I understand that phenotypic expression can not occur without genotypic analysis, it’s just that I get totally lost when Monotreme, Annon 22, gs, NSI and others begin to discuss segments.
I believe you can most often extrapolate answers by examining existing avaliable evidence of the phenotypic expression of H5N1 and after ten years there is quite a bit of this evidence avaliable.
In comments today, Dr. Shortridge who was involved in the 1997 eradication effort in Hong Kong, states that he believes that it was one or two mutations from a pandemic in 1997. Once again we here the same comments as that from Dr. Osterhaus and Dr. Webster.
How has the virus changed since 1997.
1) Dr. Webster states that although the 1997 virus was killed within two days in an environment of 37 C, today it lives more than six days at this temperature and lives more than a week on moist surfaces. To me, this is clear evidence of significant environmental adaption.
2) Several distinct strains with individual phenotypic expressions have been identified. All known strains have maintained mortality rates greater than 50%.
3) Turkey etc. A strain that has not been released to independent scientists clearly indicates increased transmissibility and decreased mortality. This indicates that in an effort to adapt the virus decreased its mortality to 33% from 50% and it is not fully adapted yet.
4) The virus can enter through by respiratory, oral and gastri-intestinal routes. In addition, it can infect tissues considered atypical for other influenza’s excepth the 1918 subtype.
5) The virus is adapted to a wide variety of mammals and birds, both symptomatically and asymptomatically, a feat that would have been thought impossible a few years ago.
All of this since Dr. Shortridge considered the virus one of two mutations away in 1997.
Concerning Monotremes concern about mortality rates, the existing evidence indicates that the mortality rate will decrease before pandemic potential will be reached but probability strongly suggests that since H5N1 mortality rates had so much farther to fall then those of H1N1 in 1918, the final mortality rates will be multiples of the 1918 rate of 2.5%.
When? The evidence indicates to me that it will be within the next twelve months but this estimate would be the weakest to be arrived at from pre-existing phentoypic evidence.
My question to Monotreme et al would be what are the possibilities of more than one pandemic virus at the same time. The possibility of this situation seems to be growing although again the linkage to existing evidence would be considered weak.
Monotreme Annon 22 et al.
Thought you might be interested in this.
“If this virus becomes a pandemic, will it attenuate its virulence in humans? I think that would be a rather optimistic assumption to make.”
Mallik Peiris Univ. Hong Kong.
Tom DVM: Do you have the article from which that statement was reported?
As an aside, even though the evolution of H5N1 seems to have temporarily slowed down (or maybe not) I am no less unsettled. In fact, I am making major life decisions based on the likelihood of this beast rearing its head within the next couple of years. So it is not only time and money that I am putting up front. I am putting the rest of my life on the line, and I don’t feel like I have “fallen down the rabbit hole”. Just logic at work here, and also a somewhat “out of body” overview of how events are playing out.
Hi Medical Maven. As you may know, I am computer disabled…If you go to the current week on crofsblog H5N1, the second story is: ‘Singapore: Nearly 150 types of bird flu pose threat.’ The quote is from that story.
Tom DVM: Thanks, good enough.
Monotreme, you wrote: We now know that H5N1 truly is a highly lethal virus in humans. The recent release of seroprevalence data has established this as fact.
May I ask what “recent release of seroprevalence data” are you referring to. This area is one which I try to follow closely (and haven’t had the time lately).
I would appreciate a hint, link, or description. I assume these seroprevalence studies show what all the rest have shown.
Thanks much….
anon_22, I appreciate your concerns regarding language, but I don’t want to get bogged down in semantics. So, let me review my position.
As you and Tom DVM point out, Dr. Malik Peiris has also answered this question no. As has Robert Webster. As has Michael Osterholm. I see no reason to assume 2.5% is the worst case scenario. Magical thinking is required to believe this. That doesn’t mean that a pandemic with a 30% CFR will happen, but it’s certainly in the realm of possibilities.
FloridaGirl, here is the Seroprevalence information.
As they said in the movie, “I’m with you fellas.” I think we must have an idea of what to do in true “worst case” situations. Look, think of the dynamic…a panflu starts…people get infected…it spreads…lots of people get infected…it spreads…Can we tell the Attack rate or the case fatality rate? No. All we will know is that lots of people are sick and lots of people are dead. What matters is that we keep essential services functional. We can’t do that if we do not plan for the worst. Why? There won’t be time if we have made an assumption that 40% of the workforce will be absent from work for two weeks at a time…(pardon me I don’t swear at all,) but in this case, that is bullshit. We must plan for this before the fact. I see no other alternative. I personally think that Monotreme is right. Yet, I am very comfortable that we could also only end up with a common cold from this.
As always it would be difficult to argue with the common sense of Monotreme, anon 22, Dude, Medical Maven FloridaGirl and everyone else.
Monotreme. How do we warn people given the current downplaying of the risk…’its only a bird disease’. Human nature is such that if the message is not 100% consistent as in …we are all going to die, no one will do anything…we will be ignored.
They didn’t believe us in the past, they don’t believe us now and they’re not going to believe us in the future. That’s the problem with human nature. The only thing they will believe is when the Koffi Annan goes on television to tell the world…’whoops it was out of control before we identified it and by the way…we’re screwed’.
We are a few water beetles swimming against a tidal wave of denial.
Tom DVM… Maybe some good news. After the U.S. Presidentcial Flu Plan was released today, our local television station did pick up on three things the public need to do. The need to prep was one. With all digits crossed, maybe all is nt lost. gina
Tom DVM, see my poorly written attempt at fiction on the Essential Workers to get my take on two possible scenarios. The key, IMO, is opinion leaders. There are some people whose opinions we respect more than most. These are the people we need to persuade. If we can convince these people, they will help us convince everyone else. Now, how to identify them and get our message to them…
Hurricane Alley RN. Thanks. I am impressed by the increasing trend of complete honesty with US regulators. I am from Canada…our message…nothing to worry about, we’re the best and we are going to look after you…and the losses would be 2–7 million worldwide in a pandemic anyway.
We are but a few water beetles swimming against a tidal wave of denial. I do not believe we will get enough attention to be able to change things given the current environment (as I believe we are less than a year from a pandemic).
Monotreme. I read your scenario but there was only one. Is there a second installement coming.
I have total belief in the eventual success in getting the information released because they read this site and we will shame and embarass them into acting.
I fear that this second one has little hope of success because the message would have to be consistent across the board…and we know they are downplaying the risk…its a disease of birds…they have their walking papers and their ‘talking points’ and these are not going to change until the corpses are piling up at their office doors.
Why would the general public believe us when it is only a disease of birds.
I think we should organize a wiki panflu demonstration in washington DC to get the attention of the media. Ask everyone to demonstrate, have good speakers, music, and a spin team for press releases so the press knows what to write about. Have it on CDs in word format so they can cut and paste. Have some video ready to show them. Have some street theatre. Call it a national day of concern. Create some momentum.
MOnotreme,
My posts on this thread were all attempts to suggest counter-arguments. I could have called it nit-picking by invitation. We can get out of that now if you prefer. :-)
As I said, I do broadly agree with you, with the caveat that “we really won’t know the answer till at least 2–3 weeks into a pandemic” (Roy Andersen, at the Lancet Asia Forum today). If that is the case, the next question is how does one prepare for this, how do communities, government, etc cope.
Because this issue is so big, consequences so severe, politicians and people so not prepared, we, (yes you and I and fellow fluwikians who know quite a bit more than them and had gone through the shock and despair somewhat) may need to do our own triage initially as to what and how to communicate risk.
As with all triage, there are some difficult decisions and choices, and we all have to make them for ourselves. I have tentatively chosen the straight forward way of using the worst case scenario that the world has seen so far ie 1918, as a reference point. I know full well that far worse can happen, but at this point, the political climate is not ready for that, and anyone going beyond that is likely to get shot down before you can achieve anything.
Also, as I said earlier, the gap between our current capacity in anything, eg healthcare, infrastructure, and what is needed to cope with a pandemic is so big that to go beyond a 1918 scenario will be counter-productive in terms of return for time/resources spent.
If I think of the near term, then I would say let’s get them to prepare for a 1968 scenario first. To quote another speaker from the Lancet forum, Martin Meltzer, economist, CDC “there is no healthcare system in the world that can cope with the surge in demand even with a 1968 scenario.”
The outcome is to achieve a balance between seeking the truth and coming up with pragmatic strategies.
Tom DVM… When it comes down to the when this flu goes H2H, I think you are 100% correct in you guesstimation. Less than a year or sooner… you bet. This influenza has it’s own time schedule and that doesn’t mean ours. I plan on contacting the t.v. station in the morning. Now is not the time to become complacent. It’s time to grab the bull by the horns. No pun intended. gina
the fatal 2003 H7N7 case in NL had a lot of mutations. More than 20, AFAIR while the other human cases had very few mutations. I don’t understand this. Was there any other similar thing ever observed ? Not with H5N1 or H3N2 or H1N1 as far as I know (AFAIK).
It could be that one mutation S227N in the Qinghai strain is sufficient for a pandemic and it did already occur. (Add/replace to this G228S+Q226L or G228S alone.) When it occurs again under other conditions - in a school or such - it might be enough to start an epidemic or even a pandemic.I don’t consider this very likely, though.
This Qinghai strain is not included in the actual US-vaccine BTW. while the Indonesian strain is. If there were secret Turkey mutations which were considered dangerous, wouldn’t they include it into the vaccine ?
There is no significant evolution of H5N1 in humans yet. The evolution and the changes which lead to different strains took place in birds. The potential of H5N1 in birds has already been tested by nature quite a lot and we don’t expect that H5N1 might wipe out 10% of all birds or such. But we consider the pandemic in humans that is threatening as different from the pandemic in birds that is taking place here in this thread. Is it reasonable ? 1918 H1N1 was quite different with respect to contagiousness, why should H5N1 suddenly become as contagious as 1918 H1N1 ? It seems more likely to me that it would slowly become more contagious, if at all. That would maybe leave us some time to develope vaccines for the dominant strains. We don’t really know, how suddenly H1 in 1918 became more contagious. H2 in 1957 and H3 in 1968 apparantly reassorted. H5N1 isn’t really reassorting actually. But I think, we should test its reassorting+recombining potential in a lab. With mice or ferrets or chicken or maybe even cats or pigs … until some moderator closes the discussion for ethical reasons , as politicians closed/discouraged
pandemic plans with high CFR. Yes, I also think that these “worst case” scenarios or the CFR’s assumed in most of these pandemic plannings are just not very interesting or realistic. I think, they just _do not want_ to plan with any worse scenarios. The consequences would somehow touch their ethics and they just don’t find appropriate words to describe it without people getting uncomfortable, or just refutative for ethical reasons, not logical reasons. Also they want to avoid panicing.
So more severe scenarios are just not to be discussed in public (too much).
Dude, I do not think, speakers,music,street theatre in Washington would be the appropriate envelope to increase pandemic awareness. You can sell anything with enough advertisement, but panflu is a matter of life and logic and scientific analysis rather than just advertisement. What we need to convince the politicians and the public are serious probability estimates by the experts and engaged+controversy discussion about these. The current discussion is just too hypothetical, everyone has too much room to interpret the statements just as he wants.
The fatal case of H7N7 crucially had E637K mutation, which was not found in the other cases nor in the avian isolates available. However, virus samples gathered at the farm from which this vet was supposed to have contracted the virus for some reason have stil not been sequenced (Fouchier, oral commumication, Lancet Asia forum, May 3, 2006) I don’t know why, perhaps somebody thought they didn’t have samples and then discovered them recently? Anyhow, the important question is did this mutation happen in the bird or in the human? We should keep an eye out for this information when it comes out.
We are all making guesses about what mutations are needed. The most detailed data so far is still this study. It would appear that it is not just what mutations, but also the configuration/orientation of both the receptor and the virus antigen that might determine binding affinity.
Re anonymous at 03:57:
I see your points on difficulty of getting through to others. Also agree strongly that “The current discussion is just too hypothetical, everyone has too much room to interpret the statements just as he wants.”
That is true, and will remain exactly that way until history in the fullness of time, instructs us further.
How can a discussion be anything BUT extremely hypothetical when we don’t KNOW 1)if it will mutate, 2)when a pandemic will commence, 3)what pattern of waves 4) what additional strains may occur, 5)how deadly it may be, 6)how well will it communicate, 7)How effective our antivirals would prove,
8)How effective vaccines would be, 9)How effective production and distribution of vaccines, 10)How disruptive
to social order the pandemic may prove to be, adding to the death toll of the pandemic proper… Etc, etc…
This discussion, and any other, is structurally confined to a series of hypotheses. Statistical likelihood of ANY expert or organisation hitting All of them is astronomically beyond any rational expectation.
AND if anyone DID unlock this complex sequence, HOW WOULD WE RECOGNISE IT as the valid, correct scenario?
Like the medieval monks who argued ‘how man angels can dance on the head of a pin?’ we, ourselves, with all intelligence and knowledge and sincerity, are likely to only appear to TPTB and the public as…pinheads?
Tragic. I could weep in frustration.
Fat head/fingers, read ‘How MANY angels… BTW, this is an historical fact. The argument was about whether spiritual beings have dimension, and was pointedly illustrated in that analogy…
“I have tentatively chosen the straight forward way of using the worst case scenario that the world has seen so far ie 1918, as a reference point.”
Annon_22- the thing about 1918 flu is that it depends completely on your point of view 86 years ago. If you were white American, your chance of dying was say 1 in 100. If you were Western Samoan, your chance was 25 in 100. If you were an Inuit, your chance could have been something like 60 in 100.
I suspect that you are going to go on and say- “1918, 2% CFR”- You might as well say “Nobody died in 1918 from the flu, because I am using the CFR from American Samoa which had no flu cases in 1918″.
Using a 2% CFR as a worst case is wrong. I am sick of white Americans extrapolating their personal experience to the entire world. If the CFR in white USA had been 18% in 1918, even if the worldwide CFR had been 2%, then 18% would be touted (by Americans) as the worst case scenario.
It is a very big world out here and the USA is just a little, but noisy, part of it.
And another thing! Everytime I read anything about 1918, there is a different death toll. Everything from 15,000,000 dead to 100,000,000 dead world wide. So if there is a 700% disparity on the total death toll- It is reasonable to deduce that there would be a 700% disparity in the possible world wide CFR from 1918. In other words, the CFR from 1918 could have been as high as 15%−20%, if you include all the millions and millions of nameless people living in tiny little remote places- or giant 2nd and 3rd world cities- In which nobody was counting the numbers of people sick, or the numbers of people who died. They just disappeared.
Does anybody have any idea where this 2.5% CFR from 1918 come from? It is just a random, unsubstantiated number. Probably somebody’s (an American newspaper reporter?) hunch at the time. Then repeated in the papers. It is extremely dangerous to all of us, because if we are basing our worst case scenario planning on a number that has no basis in fact………………………..well ….
Clark:
Steady, lad. Steady, now. Manners, please. Don’t break the keyboard now.
The posters on this wiki are predominately Americans for the simple reason of its origins. And it is statistically likely 80% are European-Americans, based on USA demographics.
You and I have come into this wiki as guests. We were not forced to and are not coerced to stay. Even with my modest intellect, I very early on realised this was an American based site, and could take it or leave it at that.
I have been treated with patience and courtesy, even when I have skirted the edges, and in turn I have tried to not be aggressive about attitudes and emphases that, for me, are a bit parochial.
As if our Australian site isn’t parochial! Or the ‘private’ thread “Australia and New Zealand #X”
To be meaningful and relevant and to communicate, the wikians here need to use an American Dialect spelling, weights and measures, the milieu of US culture—strengths and problems. They should be free to ‘see things through their own eyes’ without criticism.
If you or I don’t like it, I suggest we set up our own site and Modferate it to OUR ‘superior’ standards.
Are you quieter now. I speak to you as an elder brother, a visitor to a largely alien land here, and one who also has been a little irritated once or twice. The perils of the traveller, to India, France or…Australia!
Cheers!
clark
I am not white American,
AND quit the racist talk.
I will respond to the rest later.
Nikolai- the wiki is not in America- it isn’t anywhere. It only exists because people come here and communicate. I am not here to insult.
This wiki is full of rascism- But no one minds as long as it is directed towards the 3rd world or the USA poor.
The rascism I am pointing out is in the numbers- what numbers are reported- what numbers are ignored. In 1918, soldiers of the Indian army had a CFR of 22%, (wikipedia). 17,000,000 Indians are reported to have died.
Why is this not important information in 2006 as we face a flu virus that is very similar to the virus that killed so many Indians? Why didn’t John Barry mention India, or New Zealand or China or Indonesia or Korea or Samoa or Iceland or Norway or Nigeria or hundreds of other countries in his Great Influenza Book? Don’t we exist? Why is the May 9 flu movie set in New York, even though it was filmed in New Zealand?
If we are going to use numbers, lets use real numbers- and accurately define them. Picking a number because you are comfortable with it is a good stategy for lotto or the horse races. It is not a good stategy if you are a scientist of Flu Policy person.
It freaks me. I see it everywhere, everyday. “I am not comfortable with that number, so I’ll just pick this number”. “Oh, and we will plan our World’s, Nation’s, State’s, City’s, neiborhood’s, company’s, family’s flu prep on this random number”….. and hope for the best………
For what its worth, I don’t like the use of the terms ‘racist or racism’. These terms are very much in the eye of the beholder. There are racists in the world but there are no racists on flu wiki.
Each of us brings a particular skill to the table. I see Clark as flu wiki’s resident historian on past infectious disease outbreaks, epidemics and pandemics. He makes facts that I would never have thought, more than relevant to the discussion.
He was a little frustrated earlier…we have all been frustrated at one time or another in the few months I’ve been here. That doesn’t make him a racist.
I would suggest we all re-read his posts because his arguments are sound in logic and sound from all the historical evidence that I have read but could not have put as succinctly.
Clark’s facts are absolutely essential if we are ever to see the full picture of 1918 and use the information to help us going ahead. Thanks.
Clark: A bit ethnocentric perhaps, but not at all racist. We colonials usually see the world from our slightly different, but English-European roots. The ABC film actually starts in Asia, (highly probable) and wings its way to NY, (highly probably). Made by an American network for Americans. J. Barry is from New Orleans, but focused his book in Philly. It was about flu, but more about science and politics and the struggles of a nation. If you want to hawk about racism, find a Border Security thread. This is a species thing.
Monotreme and others,
Thanks for the great discussion. Like many others I think this is an important thread.
My current concern is the possibility of H5N1 and an H7 virus acquiring characteristics from each other to improve human to human transmissibility, particularly by a reassortment/recombination event occurring between the two viruses.
My own personal view is that it may be possible to maintain the current fatality rate of H5N1 with increased human to human transmission, although making any predictions as to what may need to be exchanged between the two viruses is impossible.
However, one of the central questions for me is whether the ability of an influenza virus to induce ARDS in humans [acute respiratory distress syndrome (ARDS)] will always be necessarily associated with lower human to human transmission rates. ARDS is one of the features of H5N1 infection in humans and appears to be one of the major factors responsible for its high fatality rate.
In the case of the 1918 pandemic, this influenza appears to have only caused ARDS in a proportion of cases (when it did, these cases were often fatal). The 1918 influenza had reasonable rates of human to human transmission and a lethality rate significantly lower than H5N1.
Although, this whole question may be seen as a re-phrasing of the debate that bird viruses infect cells of the lower respiratory tract and that human viruses infect cells of the upper respiratory tract, I think that this issue goes further than this.
ARDS is a complex clinical presentation. As discussed previously on the Wiki and lately in this thread, the ability of influenza virus to produce ARDS may also be dependent upon mutations in genes such as PB2 for efficient replication, and mutations in NS1 being able to induce prolonged virema and inhibit interferons in a subject.
The 2003 H7N7 outbreak in the Netherlands is interesting in this regard. It appears that this outbreak had the ability to transmit readily efficiently between humans (see Revere’s comments). The majority of individuals infected in that outbreak had only symptoms of conjunctivitis, indicating that the virus did not replicate well in the respiratory tract.
In the cases of human to human transmission that were sequenced, these cases did not show any changes in the HA gene, indicating that the virus already had acquired the necessary characteristics for relatively efficient human to human transmission.
As discussed above, there was also one fatal infection in a veterinarian, who showed acute respiratory distress syndrome (ARDS). The sequence of the viral isolates from this individual showed amino acid substitutions over that found for the milder cases in a number of genes, including HA, NA, NS1 and PB2 (one of which was the E627K mutation). This data suggests that at least some of the amino acid substitutions outside HA may have been responsible for this ability to induce ARDS.
As far as I can tell, there were no cases of reported human to human transmission from the veterinarian, so the jury is out.
The crux of all the above is that we just don’t know what’s going on. However, and playing devil’s advocate, it may be that the changes in a virus that are responsible for ARDS (and hence high lethality) are generally associated with lower human to human transmission. For example, changes in the NA gene that might be required for ARDS to occur in cells deep in the respiratory tract (say by prolonging viral presence in the cells) are also associated with altered or reduced viral escape from cells of the upper respiratory tract, leading to reduced transmissibilty.
Prepper A- My thinking is that if the virus is predominantly in the lung parenchyma, (terminal bronchioles and alveoli), whether from siliac acid receptor preference or not, it can not easily be expelled out through the conducting airways. It typically takes an invasive procedure to recover material from alveoli. A virus that infects and sheds from bronchial smooth muscle airway, however, can easily be expelled in droplets or as airborne particles. The defences of the lung would prohibit droplets from reaching the alveoli, so infection is probably a two step process, where more typical flu symptoms create a bronchorrhea drainage that usually causes a lobar or focal pneumonia (alveoli filling) setting up the alveolar attack. The insult in any one location of lung tissue can cause ARDS
Clark - John Barry did mention many countries and I found his reporting very helpful in making the same point you are trying to make. He no doubt was limited in research to what can be found or translated. Wikipedia may have used the info from his book. From “The Great Influenza”, not quotes, as that would take pages, but some of the numbers.
Yes, included is Western Somoa - 22% mortality of the entire population. Strict quaranting of American Samoa a few miles away, saved them from having any deaths.
Frankfort- 27% mortality of those hospitalized with the flu.
Paris - 10% of mortality of victims.
Cape Town - 4% of the entire population in the first four weeks of reported cases. (note “entire” is not just the CFR of cases)
Gambia - 8% of Europeans but whole villages wiped out.
Guam- 10% of the entire native population.
Fiji- 14% of entire population.
Chiapas, Mexico- 10% of the entire population.
Russia and Iran - 7% of the entire population.
Labrador- 33% of entire population.
India - troops 21.69% CFR. Further studies keep pushing the total up to 20 million deaths in India alone.
Huge unknown numbers in China, decimated Inuits, Eskimos, Pacific Islanders, Africans.
John Barry also mentions higher world totals from different studies. In 1940 Nobel laureate Macfarlane Burnet estimated 50–100 million. This was reaffirmed by a 2002 study that reviewed the data. Given the world population of 1.8 billion app. in 1918, that would be a mortality rate of 5% of the “entire” population (the CFR of cases would be much than 5%)
It is not accurate to claim 2.5 or whatever, as the CFR of 1918. The expolating that is being used as a worse case scenario is underestimated.
NJ. Preppie. The evidence as provided is crystal clear. The 2.5% CFR is wrong. I think was the point that Clark was trying to make.
Your well-presented information raises several issues and inconsistencies that are going to take some time to fully absorb.
Thanks.
To all. IN the pandemic of 1918 did the moryality rate take into account those who died from starvation or other causes or were all causes of death classified as flu? gina
clark,
AND EVERYONE ELSE PLEASE READ
This thread was about whether the current estimates might be too optimistic, and (as far as my post 01:58 that triggered your diatribe was concerned) how might one approach this problem from the point of view of risk communication.
If you want to discuss whether the numbers for 1918 was wrong and/or ethnocentric, feel free to start a different thread, with supporting sources if possible. Or even just discuss it, as NJ Preppie is doing!
YOU HAVE NO WAY OF KNOWING WHAT I WAS GOING TO SAY, WHO I AM, WHAT I THINK, and why I use certain numbers (which btw I hadn’t even mentioned, the 2.5% was started by yourself) except what I choose to post here.
To suggest that you know what I think and then make inferences based on WHAT YOU THINK I THINK, ie like a white American who ignores the experience of other ethnic groups or races, which btw is an accusation that is extremely racist in and of itself, is the height of arrogance.
As I said, I am neither white nor American. I grew up in the Third World. If you have a gripe against white Americans, you are barking up the wrong tree.
SHOVE IT OR TAKE IT SOMEWHERE ELSE!
For everyone else, I don’t think the wiki is racist, at least not any more than any other community where a majority of the group shares a common background. Opinions can sometimes be limited by the experiences of participants. For my views on American or western-centric worldviews, Read my post on the b2h/h2h thread at April 26 05:17
And Tom, Whether the 2.5% CFR was wrong or not does not give clark the right to make his point in the way that he did.
anon_22, calm down. You’re overreacting. Better concentrate on H5N1.
anonymous,
When someone makes statements like this (clark 07:45) “This wiki is full of rascism- But no one minds as long as it is directed towards the 3rd world or the USA poor.” there is a need to respond and set the record straight.
Let’s not be anonymous. I appreciate letting a fine mind speak their mind. I can’t believe how racism gets used for everything, and the 1918 CFR isn’t American and no journalist made it up. WHO and all the international groups, experts, all err on the extreme low estimate side, as if everyone can’t stand to err on the high side. Fearmongering is a scientific deadly sin. Why do the experts always damp down what the CFR rate could be for H2H - Are we nuts to believe how bad it could be- that’s what this thread subject is debating.
Well said, NJ, the way it should be said.
You all dance around the real question, will the death toll be high enough to break down social cohesion and the working of society? The number of deaths may be quite different in different groups and in different areas, but the real question still remains, will society continue to function and on what level.
anon_22, you are an excellent choice to moderate. Thank you. (BTW I am Canadian and many ethnic derivations, by and large everyone here is about as neutral in attitude as you can get in that regard- let’s not forget what we’re really here for)
We know that the World population was about 1.8 billion people in 1918. The most recent estimates of world wide death from the flu in 1918 are 50,000,000 to 100,000,000. The most recent estimates of the attack rate of the 1918 flu are 20% to 30%. These are the estimated percentages of the World’s population who became sick with the flu.
Therefore, based on these numbers, the Case Fatality Rate (CFR) in 1918 was between 9.3% and 28%.
The average of those two extremes is 18.65%- an estimated CFR for the 1918 flu as experienced by the entire World.
I think Clark brings up some very legitimate points. While no posters to this thread have ever made any overtly racist comments, there certainly have been such comments made - by others - on other threads.
But much racism and/or nationalism is more insidious than that, and I do think the CFR commonly used for 1918 could be an example of that (although Anon_22, even having mentioned 2.5% earlier in the thread, is certainly not to be blamed for its widespread usage). And if 2.5% was the CFR for only the U.S., then gratitude for the wiki should not preclude anyone from bringing it up.
2.5–5% is the consensus world wide average. Locally, conditions were all over the map. For example, the 1957–58 pandemic was considered a “mild” one in the US, but it was devestating for the city of Liverpool.
Although I disagree with how clark expressed himself, I agree with the substance of his remarks regarding a CFR of 2.5% for 1918. The .5% implies a false precision that cannot possibly be supported by the data. Ridiculous really, when you think about it. If the death toll really was 100 million, there is no way you can get that with a 30% attack rate and a 2.5% CFR, not even close. Further, there were cases where more than 50% of the members of a community died, so we know that one number cannot express what happened. I suspect that both the attack rate and the CFR varied depending on a number of variables: hygeine, density of population, general health, access to supportive care, etc. Given that the 2.5% number has no rational basis, I think we should stop using it. Let’s simply tell people the truth, the current death rate from H5N1 is 50%, on average, and this number may or may not decline if H5N1 becomes a pandemic strain. We don’t know how many people will die in a pandemic, but we do have ways to decrease the attack rate and improve the survival rate. Let’s trust people with the facts and concentrate on getting them prepared.
Hear, Hear Monotreme.
Almost exactly what I was going to say.
<crawls back to bed>
Thanks anon_22. Hope you feel better soon.
Well, it’s nice to know that our passion for the subject(s) is still intact after many months of debating and discussing the issue.
“But much racism and/or nationalism is more insidious than that…”
Scaredy Cat (May 2006)
I was going to put it slightly different…one man’s patriot is another man’s racist.
We sit at our keyboards, slapping off posts without the opportunity of sober second thought or editing for that matter.
This was not a racist issue but an ethnocentric one with qualifications. I do not think that the intention was to insult: it was to inform. We have all said things we regret on flu wiki or wish we could take back. I hope the next time I do it, you will understand and visa versa.
anon_22, what I was saying was not directed towards you specifically, but towards experts in general. I have been going on about this “invisability” of other people’s 1918 experience for nearly as long as I have been posting on the wiki. It is one of my memes. Honestly, I did not mean to offend you. If I did, I appologize with no reservations. You are one of the good guys.
Every time you read about how banks (power, phone, water, police, garbage disposal, internet) are planning to stay open because they are relying on 33% of their staff showing up (33% are sick and 33% are looking after them)- you know that their Flu Policy Analysis is betting the farm that 2% CFR is as bad as it can get.
clark, “Every time you read about how banks (power, phone, water, police, garbage disposal, internet) are planning to stay open because they are relying on 33% of their staff showing up (33% are sick and 33% are looking after them)- you know that their Flu Policy Analysis is betting the farm that 2% CFR is as bad as it can get.”
Exactly right. We need to kill this urban myth and get them to prepare for a more challenging possibility.
clark,
Apology accepted. Also point accepted.
Monotreme’s post reflects what I think about how to approach this issue of numbers.
Martin Meltzer of the CDC and I have had several long discussions about the use of numbers. Even though he is an economist(think ‘number cruncher’) and policymakers hound him for numbers, his point of view, and I concur, is that straight numbers are meaningless and misleading without accompanying understanding of how one arrived at them, what are the confidence limits, the context in which these data was collected, sensitivity analysis, and so on. What you get depends as much on what questions you asked and how you asked them as the data that you collect.
In other words, Garbage in, Garbage out.
If I look at 1918 and ask those same questions, immediately what comes up for me is that the degree of accuracy varied widely all over the world. Where does one start? Sure, you can start with China or Gambon, but let’s say I’m kinda lazy (or my research grant is running out soon) and just want to start with what appears to be relatively accurate for a first assessment, I would start with data from US or British cities. It doesn’t mean that I ignore Gambon, but I am hypothesizing that the accuracy for Gambon would be a lot less than US, and that gives me an index or reference point to work from.
Let’s say some of the mortality figures were taken from health department records because doctors were required by law to report flu cases. Since CFR = no of deaths/no of clinical cases, the accuracy or confidence with which you can declare your CFR accurate depends on many things. To name just a few:
Other issues include distortions by: demographics, urban vs rural, people movements in or out of the affected area, loss/damage of records over time, etc.
Whatever number you are getting carries with it a configence limit, or a range best expressed for laymen as x(± y)%.
For 1918, attempting to get an ‘accurate’ average worldwide CFR would leave you with results where y is likely to be >>> x.
(I learnt this using the example of one study to assess effectiveness of vaccinating every child for measles in stopping an epidemic, measured as the % fall of cases over time, which sounds like an uncomplicated study where one would expect high accuracy, but where a 20% (x) fall in number of cases which sounded reasonbly good became meaningless because when you add up all the confounding factors, any one of which on its own sounded trivial, y became > 20. Hat-tip to Meltzer.)
Garbage in, garbage out.
Racism is not the issue of those who frequent this wikie. A horrific potential Pandemic is. I am sorry if I have given offense and I also feel sorry for those who perceive offense when none is in fact there. Racism is not what I am about at this moment. (FYI I have Native American ancestors, I don’t even wish to go where the discussion of racism and the dominant American culture has been with respect to that.) I have come to respect the regulars on this thread. I have not forgotten who I am when I do that. In my not so humble opinion, racism discussions really belong somewhere else. They are a distraction. They have great import to me, but not here, not now. We have a more pressing monster to contend with.
Since there is little accuracy or hard science to fall back on, how you communicate becomes a matter of personal choice. And some people are more pragmatic than others.
For me, I would try to assess whether someone:
→1 have close to zero idea of what a pandemic is and what is H5N1
→2 have little time, patience, tolerance for complexity
→3 have a vested interest or resistance to preparing
→4 demands a quick answer by way of probability or percentage
→5 requires those numbers to convince their boss, spouse, the finance department, their subordinates
→6 needs to be motivated by fear
→7 goes into denial or complete paralysis and unable to take action if there is too much fear
→8 is likely to shoot the messenger
and use whatever method that is going to get them to do ‘the right thing’. But then frequently because of limitation of resources the gap between current status and ‘the right thing’ is so big, and the danger of yourself being discredited is so extremely high currently, that I choose to err on the conservative side in risk communication, knowing that even the ‘conservative’ and ‘expert’ estimate of 2 or 2.5% will require far more than any of these folks are likely or able to commit to doing.
Rather than freak them out and have the door shut in your face.
It’s a personal choice.
A thought occur to me: were doctors licensed in 1918? Does anyone know? It’s in John Barry’s book, I think.
“Since there is little accuracy or hard science to fall back on”. anon_22
The population of 1.8 billion in 1918 is an accurate number. The world wide attack rate of 20%−30% is a conservative estimate. This includes everybody on Earth.
The 50,000,000- 100,000,000 estimated deaths in 1918 from the flu are numbers that I believe have been arrived at by scholorly analysis and recently corroborated. Saying that these numbers are inacurrate (meaningless) because they don’t fit with your world view is not very rigorous.
“his point of view, and I concur, is that straight numbers are meaningless and misleading without accompanying understanding of how one arrived at them, what are the confidence limits, the context in which these data was collected, sensitivity analysis, and so on” anon_22
As Mark Twain said “There are lies, damned lies and statistics”….
If you have to resort to statistics to support your point of view, well, IMO, you are on thin ice.
“The population of 1.8 billion in 1918 is an accurate number.”
Really?
How did you arrive at that?
Do you have peer-reviewed sources that carry that consensus, that 1.8 billion in 1918 is an accurate number?
“If you have to resort to statistics to support your point of view, well, IMO, you are on thin ice.”
What is my point of view? Which part, and in what context? Do you really know enough to make that judgement?
If you are saying is the current CFR very high and is a pandemic with H5N1 likely to be devastating, the answer is Yes. (btw, Monotreme and I were the lone voice for a long time about a very high CFR.)
If you are saying that suggestions that CFR must fall are not supported by hard science and CFR may not fall, or may not fall a lot, therefore let’s not be complacent, then Yes.
If you are saying that the CFR for H5N1 pandemic in 2006 has to be very high, I would disagree.
If you ask me to give an educated guess, gut feeling, place a bet as if I am in a casino, I would say it could be anything between 2–50%, with a median of approximately 30%, based on my limited understanding of virology and epidemiology, as of now. But that could change as information becomes available.
If you are saying do I think the CFR for 1918 was 2.5% or was it higher, I would say, a rough overall guess is that it was higher. But there were local variations due to many factors, just as there will be if we have a pandemic in 2006, so one must be careful how you interprete such numbers.
If you ask me how much higher, I would ask you a question back and say for what purpose are you asking this question? If it was for intellectual curiosity, then good for you, please go and do more research and share the information, but remember to also share all the limitations of the data. Remembering that all data has limitations.
BTW, notice I carefully choose not to condemn people who disagree, whereas you have no qualms in doing so persistently, as in “As Mark Twain said “There are lies, damned lies and statistics”….”
If you want more exact estimates to prove a point, I would say what point? To prove people are liars? Then what?
To prove you are right? Then what?
If your point, which by now I am very sceptical about, is to facilitate pandemic preparedness in communities or governments, then I would say use whatever number works for you. Just don’t tell me that I lie because I use it differently.
And THAT is not even close to the sum total of my point of view.
For everyone else,
This conversation between clark and myself is NOT a vendetta or whatever. There are important issues being thrashed out, including science, communication, ethics, personal prejudeices, to name a few.
If we have a pandemic, ALL of these and more will come up for resolution for a lot of people.
BTW how is 1.8 billion population in 1918 not statistics????????
>Martin Meltzer of the CDC and I have had several long discussions// >about the use of numbers.//
// looks like some philosophy of math,logics,set-theory…// //
>Even though he is an economist(think // >number cruncher) and policymakers hound him for numbers, // >his point of view, and I concur, is that straight numbers are// >meaningless and misleading //
// what are “straight” numbers ?// //
>without accompanying understanding// >of how one arrived at them,//
// that holds maybe for a teacher who has to decide whether the// student does understand the approach.// It doesn’t hold, when it’s clear that the approach is understood// and tested, e.g. an established computer program.// //
>what are the confidence limits, // >the context in which these data was collected, sensitivity // >analysis, and so on.//
// it’s up to the operator to decide this, and the other experts // to check it. But don’t bother the average reader with the details,// how the result was achieved.// //
>What you get depends as much on what questions you asked // >and how you asked them as the data that you collect. //
// sure. Proper interpretation is important.// //
>In other words, Garbage in, Garbage out. //
// Meltzer is one of those who even early in 2004 worked on// models to predict the likelyhood and impact of a pandemic.// But he did _not_ answer a clear formulated question about// his subjective probability estimate.// (what’s your subjective estimate of the probability that// there will be more than 1e8 panflu deaths in the next 10 years)// Now what he is trying here to explain to you looks just// like an excuse, why he does not _want_ to give his estimates.// Clear question in, void out.// You must question the whole sense of the analysis, when the// decisive conclusions are withhold.// //
>If I look at 1918 and ask those same questions, immediately // >what comes up for me is that the degree of accuracy varied // >widely all over the world. Where does one start? Sure, you // >can start with China or Gambon, but let us say I am kinda // >lazy (or my research grant is running out soon) and just want// >to start with what appears to be relatively accurate for a // >first assessment, I would start with data from US or British// >cities. It does not mean that I ignore Gambon, but I am // >hypothesizing that the accuracy for Gambon would be a lot// >less than US, and that gives me an index or reference point// >to work from. //
// so what ? Of course you should use the best data available// and make the estimate as good as you can.// Others will use the same data and give their own estimates,// based on their interpretation and experience.// Some other person might start with Gambon.// Some third person might read both approaches and find an even// better estimate etc.// //
>Let us say some of the mortality figures were taken from health// >department records because doctors were required by law to report// >flu cases. Since CFR = no of deaths/no of clinical cases, the// >accuracy or confidence with which you can declare your CFR // >accurate depends on many things. To name just a few: // >…//
// not necessary. However long that list is, it can be extended.// It’s not necessary for the reader to dig into the details. // The question is clearly formulated.// Let’s just compare the answers. You don’t want every reader to// elaborate on it, that’s what we have the experts for.// The differences in the answers depending on these “things”// is not very big anyway. It gives some uncertainety, but the// estimate is still useful.// //
>Garbage in, garbage out.//
// it’s not important what happens on “Garbage in”.// It’s important what happens when the input obeys to // the rules and can be processed. Some programs even then// produce garbage.// // // //
>anon_22 at 00:36 // >Since there is little accuracy or hard science to fall back on, // >how you communicate becomes a matter of personal choice. //
// but some choice it better than the other// //
>And some people are more pragmatic than others. //
>For me, I would try to assess whether someone://
>1 have close to zero idea of what a pandemic is and what is H5N1//
>2 have little time, patience, tolerance for complexity//
>3 have a vested interest or resistance to preparing//
>4 demands a quick answer by way of probability or percentage//
>5 requires those numbers to convince their boss, spouse, //
> the finance department, their subordinates//
>6 needs to be motivated by fear//
>7 goes into denial or complete paralysis and unable to take//
> action if there is too much fear//
>8 is likely to shoot the messenger //
>9 is likely to be shot by others for being the messenger //
>and so on. //
// so, you assume being asked by someone. And then you select your// answer depending on the personality of the questioner rather than// the scientific truth ? The same question produces different answers// depending on _who_ asks ?// //
>and use whatever method that is going to get them to do // >the right thing. But then frequently because of limitation// >of resources the gap between current status and the right thing// >is so big, and the danger of yourself being discredited is so // >extremely high currently, //
// when there is chance of discredit, there is equal chance// of credit. Avoid speaking/writing altogether when you’re// afraid of discredit.// //
>that I choose to err on the conservative side in risk communication, // >knowing that even the conservative and expert estimate of 2 or 2.5% // >will require far more than any of these folks are likely or able// >to commit to doing. // >Rather than freak them out and have the door shut in your face. // >It is a personal choice. //
// we want scientific fact here, it is important.// Not just fine smalltalk and nice behavious.// //
>anon_22 at 00:47 // >A thought occur to me: were doctors licensed in 1918? // >Does anyone know? It is in John Barrys book, I think. //
// sort of licence. But he complained about the standards.// And in the pandemic they took almost anyone.// // // //
>clark at 01:12 //
// yes there are 2 papers about these estimates.// I found a reference in the CIDRAP-guide// //
>As Mark Twain said There are lies, damned lies and statistics.//
// is Mark Twain a scientist ?// //
>If you have to resort to statistics to support your point of view,// >well, IMO, you are on thin ice.//
// if you have no statistics to support your point of view,// well, IMO, you are on thin ice.// anon_22 at 01:53// //
>> The population of 1.8 billion in 1918 is an accurate number.// > Really? How did you arrive at that? //
// it is pretty exact. No one really doubts it. It could be 1.6 or 2.0,// but that is within the margins of the other uncertaineties.// //
>a pandemic with H5N1 likely to be devastating, the answer is Yes.//
// that is much more debatable// //
>(btw, Monotreme and I were the lone voice for a long time about// > a very high CFR.) // >If you are saying that suggestions that CFR must fall are not // >supported by hard science and CFR may not fall, or may not fall// >a lot, therefore let us not be complacent, then Yes. //
// it may fall. We must try to estimate how likely it is and how much// it might fall. Just saying : it need not fall is not enough.// //
>If you are saying that the CFR for H5N1 pandemic in 2006 has//
>to be very high, I would disagree. //
>If you ask me to give an educated guess, gut feeling, place //
>a bet as if I am in a casino,//
// no need to go to a casino. We bet all the day intuitively on all// sorts of things. Guesses and gut fellings as you call it are// very common in science. Rarely (never) are you 100% certain.// //
>I would say it could be anything between 2 - 50%, with a median // >of approximately 30%, based on my limited understanding of virology // >and epidemiology, as of now. But that could change as information // >becomes available. //
// yes, thanks for the estimate of 30% . Don’t know what you mean with// median here. I think, it’s lower , say 10%. And I assume you agree,// that most expert’s anticipated estimates are closer to my 10% ?!// //
>If you are saying do I think the CFR for 1918 was 2.5% or was// >it higher, I would say, a rough overall guess is that it was higher.//
// yes.// //
>But there were local variations due to many factors, just as there// >will be if we have a pandemic in 2006, so one must be careful how // >you interprete such numbers. //
// of course. It’s the global CFR.// //
>If you ask me how much higher, I would ask you a question back // >and say for what purpose are you asking this question? //
// the true answer of that question cannot depend on the purpose.// It seems that you are trying to give deliberately a wrong answer// if it serves a certain purpose.// //
>If it was for intellectual curiosity, then good for you, please// >go and do more research and share the information, but remember// >to also share all the limitations of the data. Remembering that// >all data has limitations. // >BTW, notice I carefully choose not to condemn people who disagree,// >whereas you have no qualms in doing so persistently, as in // >As Mark Twain said: There are lies, damned lies and statistics// >If you want more exact estimates to prove a point, I would say// >what point? To prove people are liars? Then what? // >To prove you are right? Then what? // >If your point, which by now I am very sceptical about, is to // >facilitate pandemic preparedness in communities or governments,// >then I would say use whatever number works for you. //
// that is not what the government pays the scientists for.// //
>Just do not tell me that I lie because I use it differently. //
// he cannot know whether you lie. It is an estimate.// Just if you are permanently wrong with your estimates,// that reduces your credences of a good estimator and people// might start weighting your estimates lower and concentrate// more on other people’s estimates.// //
>And THAT is not even close to the sum total of my point of view.//
// of course not. You still gave no estimate about the threatening// H5N1-pandemic.// //
>anon_22 at 01:57 // >For everyone else, // >This conversation between clark and myself is NOT a vendetta // >or whatever. There are important issues being thrashed out, // >including science, communication, ethics, personal prejudeices,// >to name a few. // >If we have a pandemic, ALL of these and more will come up for// >resolution for a lot of people.//
// very good. Not so long ago you attacked me for repeatedly // asking these questions here.//
sorry for the formatting. I hope this is better:
>Martin Meltzer of the CDC and I have had several long discussions
>about the use of numbers.
looks like some philosophy of math,logics,set-theory…
>Even though he is an economist(think
>number cruncher) and policymakers hound him for numbers,
>his point of view, and I concur, is that straight numbers are
>meaningless and misleading
what are “straight” numbers ?
>without accompanying understanding
>of how one arrived at them,
that holds maybe for a teacher who has to decide whether the
student does understand the approach.
It doesn’t hold, when it’s clear that the approach is understood
and tested, e.g. an established computer program.
>what are the confidence limits,
>the context in which these data was collected, sensitivity
>analysis, and so on.
it’s up to the operator to decide this, and the other experts
to check it. But don’t bother the average reader with the details,
how the result was achieved.
>What you get depends as much on what questions you asked
>and how you asked them as the data that you collect.
sure. Proper interpretation is important.
>In other words, Garbage in, Garbage out.
Meltzer is one of those who even early in 2004 worked on
models to predict the likelyhood and impact of a pandemic.
But he did _not_ answer a clear formulated question about
his subjective probability estimate.
(what’s your subjective estimate of the probability that
there will be more than 1e8 panflu deaths in the next 10 years)
Now what he is trying here to explain to you looks just
like an excuse, why he does not _want_ to give his estimates.
Clear question in, void out.
You must question the whole sense of the analysis, when the
decisive conclusions are withhold.
>If I look at 1918 and ask those same questions, immediately
>what comes up for me is that the degree of accuracy varied
>widely all over the world. Where does one start? Sure, you
>can start with China or Gambon, but let us say I am kinda
>lazy (or my research grant is running out soon) and just want
>to start with what appears to be relatively accurate for a
>first assessment, I would start with data from US or British
>cities. It does not mean that I ignore Gambon, but I am
>hypothesizing that the accuracy for Gambon would be a lot
>less than US, and that gives me an index or reference point
>to work from.
so what ? Of course you should use the best data available
and make the estimate as good as you can.
Others will use the same data and give their own estimates,
based on their interpretation and experience.
Some other person might start with Gambon.
Some third person might read both approaches and find an even
better estimate etc.
>Let us say some of the mortality figures were taken from health
>department records because doctors were required by law to report
>flu cases. Since CFR = no of deaths/no of clinical cases, the
>accuracy or confidence with which you can declare your CFR
>accurate depends on many things. To name just a few:
>…
not necessary. However long that list is, it can be extended.
It’s not necessary for the reader to dig into the details.
The question is clearly formulated.
Let’s just compare the answers. You don’t want every reader to
elaborate on it, that’s what we have the experts for.
The differences in the answers depending on these “things”
is not very big anyway. It gives some uncertainety, but the
estimate is still useful.
>Garbage in, garbage out.
it’s not important what happens on “Garbage in”.
It’s important what happens when the input obeys to
the rules and can be processed. Some programs even then
produce garbage.
>anon_22 at 00:36
>Since there is little accuracy or hard science to fall back on,
>how you communicate becomes a matter of personal choice.
but some choice it better than the other
>And some people are more pragmatic than others.
>For me, I would try to assess whether someone:
>1 have close to zero idea of what a pandemic is and what is H5N1
>2 have little time, patience, tolerance for complexity
>3 have a vested interest or resistance to preparing
>4 demands a quick answer by way of probability or percentage
>5 requires those numbers to convince their boss, spouse,
> the finance department, their subordinates
>6 needs to be motivated by fear
>7 goes into denial or complete paralysis and unable to take
> action if there is too much fear
>8 is likely to shoot the messenger
>9 is likely to be shot by others for being the messenger
>and so on.
so, you assume being asked by someone. And then you select your
answer depending on the personality of the questioner rather than
the scientific truth ? The same question produces different answers
depending on _who_ asks ?
>and use whatever method that is going to get them to do
>the right thing. But then frequently because of limitation
>of resources the gap between current status and the right thing
>is so big, and the danger of yourself being discredited is so
>extremely high currently,
when there is chance of discredit, there is equal chance
of credit. Avoid speaking/writing altogether when you’re
afraid of discredit.
>that I choose to err on the conservative side in risk communication,
>knowing that even the conservative and expert estimate of 2 or 2.5%
>will require far more than any of these folks are likely or able
>to commit to doing.
>Rather than freak them out and have the door shut in your face.
>It is a personal choice.
we want scientific fact here, it is important.
Not just fine smalltalk and nice behavious.
>anon_22 at 00:47
>A thought occur to me: were doctors licensed in 1918?
>Does anyone know? It is in John Barrys book, I think.
sort of licence. But he complained about the standards.
And in the pandemic they took almost anyone.
>clark at 01:12
yes there are 2 papers about these estimates.
I found a reference in the CIDRAP-guide
>As Mark Twain said There are lies, damned lies and statistics.
is Mark Twain a scientist ?
>If you have to resort to statistics to support your point of view,
>well, IMO, you are on thin ice.
if you have no statistics to support your point of view,
well, IMO, you are on thin ice.
anon_22 at 01:53
>> The population of 1.8 billion in 1918 is an accurate number.
> Really? How did you arrive at that?
it is pretty exact. No one really doubts it. It could be 1.6 or 2.0,
but that is within the margins of the other uncertaineties.
>a pandemic with H5N1 likely to be devastating, the answer is Yes.
that is much more debatable
>(btw, Monotreme and I were the lone voice for a long time about
> a very high CFR.)
>If you are saying that suggestions that CFR must fall are not
>supported by hard science and CFR may not fall, or may not fall
>a lot, therefore let us not be complacent, then Yes.
it may fall. We must try to estimate how likely it is and how much
it might fall. Just saying : it need not fall is not enough.
>If you are saying that the CFR for H5N1 pandemic in 2006 has
>to be very high, I would disagree.
>If you ask me to give an educated guess, gut feeling, place
>a bet as if I am in a casino,
no need to go to a casino. We bet all the day intuitively on all
sorts of things. Guesses and gut fellings as you call it are
very common in science. Rarely (never) are you 100% certain.
>I would say it could be anything between 2 - 50%, with a median
>of approximately 30%, based on my limited understanding of virology
>and epidemiology, as of now. But that could change as information
>becomes available.
yes, thanks for the estimate of 30% . Don’t know what you mean with
median here. I think, it’s lower , say 10%. And I assume you agree,
that most expert’s anticipated estimates are closer to my 10% ?!
>If you are saying do I think the CFR for 1918 was 2.5% or was
>it higher, I would say, a rough overall guess is that it was higher.
yes.
>But there were local variations due to many factors, just as there
>will be if we have a pandemic in 2006, so one must be careful how
>you interprete such numbers.
of course. It’s the global CFR.
>If you ask me how much higher, I would ask you a question back
>and say for what purpose are you asking this question?
the true answer of that question cannot depend on the purpose.
It seems that you are trying to give deliberately a wrong answer
if it serves a certain purpose.
>If it was for intellectual curiosity, then good for you, please
>go and do more research and share the information, but remember
>to also share all the limitations of the data. Remembering that
>all data has limitations.
>BTW, notice I carefully choose not to condemn people who disagree,
>whereas you have no qualms in doing so persistently, as in
>As Mark Twain said: There are lies, damned lies and statistics
>If you want more exact estimates to prove a point, I would say
>what point? To prove people are liars? Then what?
>To prove you are right? Then what?
>If your point, which by now I am very sceptical about, is to
>facilitate pandemic preparedness in communities or governments,
>then I would say use whatever number works for you.
that is not what the government pays the scientists for.
>Just do not tell me that I lie because I use it differently.
he cannot know whether you lie. It is an estimate.
Just if you are permanently wrong with your estimates,
that reduces your credences of a good estimator and people
might start weighting your estimates lower and concentrate
more on other people’s estimates.
>And THAT is not even close to the sum total of my point of view.
of course not. You still gave no estimate about the threatening
H5N1-pandemic.
>anon_22 at 01:57
>For everyone else,
>This conversation between clark and myself is NOT a vendetta
>or whatever. There are important issues being thrashed out,
>including science, communication, ethics, personal prejudeices,
>to name a few.
>If we have a pandemic, ALL of these and more will come up for
>resolution for a lot of people.
very good. Not so long ago you attacked me for repeatedly
asking these questions here.
>><<
Corky52,
“You all dance around the real question, will the death toll be high enough to break down social cohesion and the working of society?”
I quote Guiliani, the then NY mayor, spoken on 9/11/2001. “The numbers will be more than any one of us can bear.”
anon_22, you are just thrashing around, muddying the waters. All I am talking about is the worldwide average CFR from 1918 and how that simple range of percentages (say 9% to 28%) could influence planners when they decide to stock up tamiflu for the guys and gals who put chlorine in the City water supply.- or who are going to decide whether to buy good masks for the police force. Or decide how much food to stockpile down at the phone exchange in case they all have to quarentine. Should we get a good stock of fuel for the power station. The potential lethality of the bug will help planners, plan. There seems to be a consensus that 1918 is the Worst Case Scenario. OK
You are taking this too personally. You are anonymous#22- no name, no body. None of what I am saying is about you personally.
Incidently, I am at a University and work with statisticians quite regularly. The Mark Twain quote is about the use of statistics. My statistician says it all the time.
anonymous,
(I and probably a lot of people reading this would prefer that you are not anonymous, but we respect your choice.)
Thanks for your long comments. I am going to be offline soon so I haven’t read all of it. I will give a brief big picture view.
I think it is healthy to have debate, we need it. Really I do, otherwise I would not have spent so much time doing this (and I have a flight to catch.)
It is also healthy to understand and respect that people have different learning styles, different communication styles, live in different communities/countries where conditions vary.
It’s called diversity.
I think it is also important to separate debate and accusations and innuendos and attacks on people’s integrity, without justification.
clark in his posts on this thread has twice stepped over that line, first by implying racist attitudes where none existed, and second, implying lying where none happened.
THAT is not acceptable.
If anyone else think my approach as described above 00:36 constitute lying, please re-read every word that I have written on this subject, and if you still think so please say it and explain.
I choose the way I think. I choose the way I approach life. I clearly and freely declare that this is my personal choice. You don’t have to agree.
I am clear on my own integrity.
I will not bow to half-truths and pseudo-logic.
anon_22,
What a cop out! 2 million deaths will mean one thing, 20 million another and 100 million yet another! Death will happen and we will have only two choices, bear it and go on or give up and die. Cold blooded and subhuman as I am, I’m far more interested in the possible outer limits of what I’ll have to cope with than political platitudes.
anon_22 at 02:43
>I quote Guiliani, the then NY mayor, spoken on 9/11/2001. >The numbers will be more than any one of us can bear.
Just rhetorics. For some (religious,ethical) reason US-people like to hear such things. He was clearly wrong with that.
>clark at 02:47 >anon_22, you are just thrashing around, muddying the waters. >All I am talking about is the worldwide average CFR from 1918 >and how that simple range of percentages (say 9% to 28%) could >influence planners when they decide to stock up tamiflu for >the guys and gals who put chlorine in the City water supply. >- or who are going to decide whether to buy good masks for >the police force. Or decide how much food to stockpile down >at the phone exchange in case they all have to quarentine. >Should we get a good stock of fuel for the power station. >The potential lethality of the bug will help planners, plan. >There seems to be a consensus that 1918 is the Worst Case >Scenario. OK
yes, but don’t you agree that this reliance on 1918-data is very unsatisfactory anyway , no matter what CFR you assume ? Take actual H5N1-expert-estimates instead. Average over all expert-estimates available. Hey, that’s their task to work out estimates where the communities should base their preparations upon !
>You are taking this too personally. You are anonymous#22- >no name, no body. None of what I am saying is about you personally. >Incidently, I am at a University and work with statisticians quite >regularly. The Mark Twain quote is about the use of statistics. >My statistician says it all the time.
sort of humor, I assume.
anon_22 at 03:03
>anonymous, >(I and probably a lot of people reading this would prefer that >you are not anonymous, but we respect your choice.)
you know who I am and most others too. I’m one of the few non-anonymous here with email, homepage, profile, 9 years of active internet posting history available at deja.com and as many posts here as you, #22.
>Thanks for your long comments. I am going to be offline soon >so I have not read all of it. I will give a brief big picture view.
OK.
>I think it is healthy to have debate, we need it. Really I do, >otherwise I would not have spent so much time doing this (and I >have a flight to catch.) >It is also healthy to understand and respect that people have >different learning styles, different communication styles, >live in different communities/countries where conditions vary. >It is called diversity. >I think it is also important to separate debate and accusations >and innuendos and attacks on peoples integrity, without justification. >clark in his posts on this thread has twice stepped over that line, >first by implying racist attitudes where none existed, and second, >implying lying where none happened. >THAT is not acceptable.
even if true, he clarified and I see not so much a problem here. There is no real disagreement about the 1918 figures or racism, right ?
>If anyone else think my approach as described above 00:36 >constitute lying, please re-read every word that I have >written on this subject, and if you still think so please >say it and explain. >I choose the way I think. I choose the way I approach life. >I clearly and freely declare that this is my personal choice. >You do not have to agree. >I am clear on my own integrity. >I will not bow to half-truths and pseudo-logic.
no problem with your integrity and personal choice. But this debate is about what estimates the panflu preparings should be based upon and the difference easily is worth thousands of lifes and billions of $. So it is not just a matter of personal choice or approaching life.
oops, sorry. Formatting again. You have to include double slash-backs
after each line. Let me try again:
anon_22 at 02:43
>I quote Guiliani, the then NY mayor, spoken on 9/11/2001.
>The numbers will be more than any one of us can bear.
Just rhetorics. For some (religious,ethical) reason US-people
like to hear such things.
He was clearly wrong with that.
>clark at 02:47
>anon_22, you are just thrashing around, muddying the waters.
>All I am talking about is the worldwide average CFR from 1918
>and how that simple range of percentages (say 9% to 28%) could
>influence planners when they decide to stock up tamiflu for
>the guys and gals who put chlorine in the City water supply.
>- or who are going to decide whether to buy good masks for
>the police force. Or decide how much food to stockpile down
>at the phone exchange in case they all have to quarentine.
>Should we get a good stock of fuel for the power station.
>The potential lethality of the bug will help planners, plan.
>There seems to be a consensus that 1918 is the Worst Case
>Scenario. OK
yes, but don’t you agree that this reliance on 1918-data
is very unsatisfactory anyway , no matter what CFR you assume ?
Take actual H5N1-expert-estimates instead.
Average over all expert-estimates available.
Hey, that’s their task to work out estimates where the
communities should base their preparations upon !
>You are taking this too personally. You are anonymous#22-
>no name, no body. None of what I am saying is about you personally.
>Incidently, I am at a University and work with statisticians quite
>regularly. The Mark Twain quote is about the use of statistics.
>My statistician says it all the time.
sort of humor, I assume.
anon_22 at 03:03
>anonymous,
>(I and probably a lot of people reading this would prefer that
>you are not anonymous, but we respect your choice.)
you know who I am and most others too. I’m one of the few non-anonymous
here with email, homepage, profile, 9 years of active internet
posting history available at deja.com and as many posts here as you, #22.
>Thanks for your long comments. I am going to be offline soon
>so I have not read all of it. I will give a brief big picture view.
OK.
>I think it is healthy to have debate, we need it. Really I do,
>otherwise I would not have spent so much time doing this (and I
>have a flight to catch.)
>It is also healthy to understand and respect that people have
>different learning styles, different communication styles,
>live in different communities/countries where conditions vary.
>It is called diversity.
>I think it is also important to separate debate and accusations
>and innuendos and attacks on peoples integrity, without justification.
>clark in his posts on this thread has twice stepped over that line,
>first by implying racist attitudes where none existed, and second,
>implying lying where none happened.
>THAT is not acceptable.
even if true, he clarified and I see not so much a problem here.
There is no real disagreement about the 1918 figures
or racism, right ?
>If anyone else think my approach as described above 00:36
>constitute lying, please re-read every word that I have
>written on this subject, and if you still think so please
>say it and explain.
>I choose the way I think. I choose the way I approach life.
>I clearly and freely declare that this is my personal choice.
>You do not have to agree.
>I am clear on my own integrity.
>I will not bow to half-truths and pseudo-logic.
no problem with your integrity and personal choice.
But this debate is about what estimates the panflu
preparings should be based upon and the difference
easily is worth thousands of lifes and billions of $.
So it is not just a matter of personal choice or
approaching life.
>><<
I understand people’s desire to get certainty by those numbers.
But consider this: At the current time, there is no community, hospital, country that is fully prepared for a pandemic even with a 0.5% CFR. What is the chance of them being prepared for a 2.5% CFR in the immediate future, say 6 months? With all the goodwill in the world (and you may not have that, especially if you get the door shut in your face for scaremongering), starting immediately today, most communities and governments will still not be able to achieve that.
Unless and until they have adequately prepared for a pandemic with a 2.5% CFR, for example, it may be counter-productive to push beyond that AT THE PRESENT TIME.
Recommendations based on (currently) unreachable goals have a high chance of being rejected, together with whatever wonderful ideas that you may have.
We can discuss 1918 or 2006 CFR here, that’s fine. We all have our opinions.
The problem is that there is only 24 hours a day, and so much to be done. We all have to choose how we spend our time.
I am interested in the easiest, shortest, path to achieving an important (albeit insufficient) goal: to get communities & countries prepared as best they can for a pandemic of 1968 severity first, then for 1918 type severity if resources allow, knowing that whatever they or I do, a lot of people will still die and there will still be a lot of heartache. Knowing full well that with all the goodwill in the world, there will be things that you cannot prepare for because they are unexpected, because the solution is beyond your/their capability, because your numbers were wrong, or simply because at a moment of weakness, you gave up.
But you still do it anyway.
At the end of the day, it may be more important to focus on what we can do than whether we are right.
anon_22.
I think that is what we are all passionate about here: to save lives.
there are important nuances of uncertainety, best expressed by numbers for probabilities. It’s not just hospitals. It’s quarantine, protect essential workers, coordination with other departments elections, treaties, war, civil war,etc. For privates it’s not just getting food, it’s moving, getting financial plans, jobs, preparing for school, studies, job-education… At some probability level your whole future planning might dramatically change.
Anything beyond 2.5, we’re screwed anyway.
You can only prepare up to a certain point, beyond that it is a case of diminishing returns.
I wonder what Sandman and Lanard have to say about all this.
My own (shaky as gelly) position, right after reviewing this thread:
Strange little cells, we are. I’m curious as to how we’ll help the body to prep.
yes, when death is certain you can do what you want. But even in the Webster-scenario 50% will survive. When we can make it 60%, that’s worth some billion $ !
“When we can make it 60%, that’s worth some billion $ !”
What is that supposed to mean?
10% more survivors , the effect of preparaction (measured in $) even increases when the expected number of deaths increases. 2% or 3% CFR is not so big a difference than 50% vs. 40%. Of course you can say 40% CFR is too bad to even think at - people won’t accept any preparation for that. For the hospitals it won’t matter. But maybe for quarantine, social order maintaining, organizing of infrastructure.
only if you think they can improve their non-existent preparations from 40% mortality to even better preparations for 50% mortality.
Think global act local is as poignant today as it was 20 years ago as a green slogan. Survival begins and ends at home
It’s a matter of politics. You would change laws. You would have martial law. I think, with 40% mortality any of the quarantines considered useless in the MIDAS studies are starting to make sense. These studies assume 2% CFR , and then a complete quarantine is considered too expensive. But I wonder what the calculations are with 40% CFR. You’d also buy better protective cloths for the workers with 40% CFR. You won’t treat normal cases in hospital then, maybe even close the whole hospital. There might be strict curfew and people will be forced to work. These things might be overreacted with 2% CFR but make sense with 40% CFR.
I wonder if TPTB have fallen victim to their own internal propaganda.
What if people at the very highest level of govt consider that the publication of the prospect of a CFR greater than 1918 is too hard for people to stomach and accept, and act on. Therefore they focus on what may be considered more acceptable i.e a 2.5% CFR as a worst case. This is then the formal pandemic ‘position’ at highish, medium and lower levels of govt; all departments, those in a positition to plan, act, etc take this literally. This then feeds back up to the decision making levels (via their plan conclusions etc) as the worst case scenario and decisions are made accordingly.
Thus planning becomes sub optimal.
It doesn’t matter what number gets pulled out of the hat, as a possible threat, if the seriousness does not get communicated to the population. How many people are going to know to read the government web site? The media covers a few headlines, “someone else died”, with a final closer of “experts fear the virus may mutate into…”. That’s as far as most people know about bird flu. Individual self sufficiency would have the biggest effect in preserving lives and social order. The Federal Government can not solve the problems without the people and communities totally preparing, for what a pandemic can do.
anonymous in the middle of your 4:25 post- “you know who I am and most others too. I’m one of the few non-anonymous here ..” I give up! Can anybody clue me in on who this is? You appear to be a new but knowledgeable poster, unfamiliar with the formatting surprises, and a distinctive style of slicing and dicing up other people’s posts. The last records I saw of this site show “anonymous” with 1447 posts. I believe you would not want to be credited with the quality of most of those posts. Can you distinquish yourself somehow by capitalizing all the letters? Any nickname will still be just as anonymous, and some people switch names for a new personna.
Put very simply, the CFR (case fatality rate), is your chance of dying if you get sick. It is a very very important number for people to come to grips with- because it is the single numbers (the odds) that you will use to make decisions. We know that cancer has a high CFR- so we give up smoking. We know that AIDS has a high CFR, so we don’t engage in dangerous practices. Chickenpox has a low CFR, so it doesn’t much affect our behavior. The CFR dramatically effects the way the community behaves.
In most peoples minds, the Flu has a low CFR, so in the case of a pandemic, they will wash their hands more often, take Vitamin C in the morning, send the kids off to school and head off to work. They are acting on the CFR data that is common knowledge about the annual flu.
If you thought your chance of dying if you got sick was one in a thousnad, or one in a hundred- you would modify your behavior. If you thought your chance of dying was one in ten or one in five or even one in 3 or 2- you would act differently again.
People have got to know the odds. Not to tell them is (“unethical” is not the word- I won’t even try and use a word for this-).
Anonymous at 9.09 is right on the button.
Clark,
In good conscience, we can’t tell them any CFR. We don’t know what it will be when it eventually becomes efficiently transmissible between people. Any number given would be nothing more than a guess.
I decided sometime back to base my decision to work/not on CFR. As I work in a hospital, that may not last long in any case. BUT, ther will still be places to go to get care; community centers, MASH units clinics. People will continue to crash cars, have heart attachs, ect. At what CFR will I just go home and stay for awhile? At this point I do not know.
clark – at 16:35 “People have got to know the odds. Not to tell them is (“unethical” is not the word- I won’t even try and use a word for this-).
I agree. But I am unsure just what most people will do with this information. I do not assume that they would use it as I do. Education, education. Most people are not concerned. I have come to believe, like some others here, that most will not pay attention until people they know start dieing. Kelly
clark at 16:35 - it sounds as though you think normal flu has a CFR of less than 1 in 1000. Not so. (0.35% is what’s usually quoted, I think, i.e. 3.5 per 1000).
We tend to underestimate many of the risks of everyday life. I was shocked to find that today, in developed countries, around 1% of babies die around the time of birth, for example. (And it makes sense: when I think about it, I know of two among the children of my friends, which is about right - but I thought I was unlucky to know that many, rather that about average.)
Melanie, don’t we have to give some sort of worse-CFR-than-you-expect-for-seasonal-influenza-and-your-demographic-group ?
- also because a new, pandemic, strain will have a relatively high attack rate, and even if you might not die if you were the only case in your hospital, you certainly might die from lack of proper care just because so many, including medical and support personal may be ill too, and supplies used up when no supply chain functioning.
The excuse for not telling the public I have heard is that, “they are foolish and don’t listen; see how many still smoke and still have unprotected sex?”
But, the public would listen, if they knew pandemic influenza, unlike cancer or HIV, could have them or their children dead in a week or two.
Things that affect their health years down the road should not be classed with their interest to take action against a deadly disease we have no protection or cure for currently. (Then, the public official line flops to “We can’t tell them that, or they’ll ‘Panic’ !”)
Certainly we have to say a pandemic could be worse than they expect, and, systems will surely collapse as soon as it starts if we don’t make better contigency plans and preparations now. We are all unused to emergencies that last months, or when we cannot rely on mutual aid/outside resources to come help. (Not to mention not used to having many young healthy people die from disease in the US.)
With people contagious before they feel sick, our hyper-travelling world, and, the fact the virus doesn’t have to drop the virulence segment to grab the very-contagious segment (unlike a toddler with a toy in each hand who is eyeing a cookie) I am afraid the mortality rate does not have to drop as low as we’d need it to to keep functioning the way some assumptions/current plans paint as possible.
Public education needs a fuller explanation, even 2.5 is a dangerous rate, but it means nothing without the public understanding it. The government doesn’t seem to want the public to be motivated to do much of any preparing. Why?..I do not see what harm could come,to calmly explain the need for storage of food,(more than a week),water, and alternatives to no power. Instead, the government, not the poultry industry, is paying for commercials, with our tax dollars, to encourage us to keep eating chickens!!- http://tinyurl.com/m3c8t
That makes me clucking mad!! They obviously have no intention to put anything into preparedness communication - one of their three big pillars.
Well, we know what a 3-legged stool with 2 legs does.
“He’s no fun; he fell right over!”
You’re right, NJPreppie; the public is not ready -even if 30% to 50% got ill and didn’t die, the supply chain, power grid, medical care, security, ect, would collapse, as things are right now.
crfullmoon. I have a bit of a problem with Governments and Regulators (WHO) from a philosophical, ethical and functional approach to the issue.
The way I see it, a pandemic is imminent, within twelve months from today, and very well could start in the fall of 2006.
Okay, we all agree that 2.5 % is unrealistic and the probable CFR is potentially much higher. This has also been confirmed by many experts in the field of animal-human virology.
So we have higher CFR’s (mortality)which do not include survivors with serious quality of life issues, which does not include deaths and injury from collateral damage, loss of infrastructure.
The point is…what is the point of avoiding the relative potentials now to deal with them for real in a very short period of time.
If it breaks in the fall, what exactly is their plan at that point.
The point is if you spin long enough…you start to smoke the very dope you’re supposed to be selling…I think they have forgotten the truth and are buying their own spin…This is the most dangerous situation a regulator can be in because they are in charge of preparing the Governments of the world (remember that 2–7 million worldwide estimate one year ago).
The way I see it, a pandemic is imminent, within twelve months from today
what do you base this upon ? Is it just only your (unsubstantiated ?)
prediction or are there also experts who give similar predictions ?
“People are, smart. Yhey can handle it” J
“A person is smart. People are stupid, panicky animals, and you know it” K
The process is slow but dropping “death odds” on people who are not somewhat knowledgable will probably not yield a good reaction.
The Innorant and Incorrect can be worked on. CFR as it relates to 2 million or 5 million doesn’t really change anything. A number we can confirm after the fact but useless to argue about now. How many dead? “Like the stars”
Too many is a good number for me.
rrteacher, now go to the local pandemic preparing officials
and tell them that.
What rational should they base their spendings on ?
They could as well prepare for earthquakes,meteorites,revolution,
measles,rain,smog,narrow streets, … anything.
They must somehow select priorities, so they need numbers.
How can you best invest the $xxx which you have to safe the
most expected lifes possible ?
rrteacher,
There are no data upon which to make any predictions. None.
anonymous,
chose a handle so we can get to know you.
People understand odds. They know that if they get drunk and drive, bad things can happen. They know about the odds with illegal drugs. They know about the odds with mountain climbing. We take risks all the time.
Telling people what the CFR was worked with AIDS and cigarette smoking (cancer). If someone continues to smoke and then gets lung cancer- we are sorry, but they were given fair warning. Not so in the 30s and 40s when people were told that smoking was good for their lungs!
People need to be told the truth about the 1918 world wide CFR figures (>10%) and the truth about what we know about H5N1 (>50%) so far. What people do with the information is their responsibility.
One of the anonymous’ made a great point. A CFR of 2% makes it too expensive to close boarders. A CFR of 15% (I am just making up numbers here) makes it too expensive to keep boarders open.
A 2% CFR pandemic- it makes sense to spend $10 billion on tamiflu, hospitals and gowns.
A 15% CFR pandemic, it makes more sense to spend the $10 billion on rice, milk powder and beans for the population sheltering at home-and on space suits, rations and positive pressure accomodation for water, electricity, refuse, police and mortuary workers. Forget about the hospitals
A very high CFR means that you do not want to get sick- the way you do not get sick is to not be exposed to the virus- everybody just quarentines. Those that do not, must face the consequences. (If you are afraid of getting sunburn- do not go sunbathing- it is simple)
My understanding is that simple quarentine is the single most effective way to deal with a high CFR infectious disease. The interesting thing is that is not that expensive- Money that was to be spent on a couple of courses of Tamiflu could buy alot of rice and beans.
The thing about quarentine to be effective- people have to be willing to give up their important lives for 3 months or whatever- BEFORE the pandemic takes hold. Once every family has at least one family member infected with the virus- whether from working at the hospital, or regular work or kids from school or their school friends- then we are in trouble - because it is then endemic. This is all conjecture- I am making this up.
We have to be willing to stop everything for awhile- if the shit hits the fan and we have a high CFR flu pandemic
I only have my small part to do. Working in healthcare, I have carried the message to a few and now to many. For us, it will be in the details. What do we do and how do we do it? Need more data? Yes. But we already know a lot. We are anticipating effects of the virus on people and on health care processes. We have enough experience and knowledge to predict what actions to take. We are addressing problems one at a time. It’s work in progress. I have sent this document to most of the 50 states and Canada, to RTs and disaster people. I have sent it to HHS leaders and academics working on Panflu. Its merit is not in the answers but in the questions is asks. I have only been around for abour 8 months on this problem, but in that time, I have seen a lot of people change. I just can’t think and scream at the same time.
Dem has been nice enough to post our early work here. Here is a link to our post. http://tinyurl.com/gznsl
Melanie, lots of data. Lots.
No handle, no cookie. Argue about the arguments themselves
without discrediting the arguer.
Clark, agreed. The thing about self-quarantine and how well it works
should be examined in a study. The MIDAS-computer simulations
seem to indicate that it won’t help a lot. But they might have made
unrealistic assumptions.
There is no official study how to make a lodgement panflu-isolation-proof.
Whether and how long people can isolate, how to handle and protect
essential workers etc. Probably because the models assume a small CFR and
strict isolation doesn’t make too much sense. But with high CFR
it makes a lot of sense. This has to be examined ! Only planning for
small CFR is insufficient.
anonymous at 3.33 is the anonymous I referenced at 3.07.
On strategic risk communication and the use of numbers:
If I want to get an interview with a senior official, for example, you think I can just turn up and talk to them? Everyday they have people knocking on their doors, people who are passionate about all sorts of pet causes, probably half of them nutcases giving some sort of doomsday warning if the government does not do X.
No, they have ‘gate-keepers’, mid-level Harvard/Oxford graduate types who will look at your brief and decide whether you should be one of the lucky few who will get through the door. So you give them your brief, what’s the first thing they ask? You bet it’s going to be something along the lines of “Where did you get the data?” or “Who says? What does (name of expert) say about this?” (BTW chances are they have done more calculus than you and have more names in their book to throw around than you.) If you keep in mind that their job is to NOT let you in, why should they go out of their way to help you unless what you are presenting is irrefutable, undeniable, water tight, AND the consequences of not letting you in is far worse?
Say I get through the door.
If I get a 30min interview, I want to spend 5 min explaining pandemic and CFR and 25 min on what to do about it. You think that will happen if I use figures that speak of apocalypse but are not solidly backed by heavyweight references or official agencies?
I give way on a minor point to gain a bigger point. It is about being UNDENIABLE.
So then, what do you think their reaction will be if you give them apocalyptic estimates?
They will either buy it or they won’t.
Those who don’t will kick you out.
Those who do, there is an additional danger: them freaking out so much that they decide to quit, either physically or mentally abandoning the responsibilities or their post.
I don’t want policymakers to get so freaked out that all they can think of is whether they or their family are going to die; they won’t hear anything else I have to say. Those who have their hands on the check books or who will sign the laws need to be steered towards playing win-win. They need to believe that their personal risk is moderate but the systemic risk is high, or that their family are more likely to die from consequences of systemic breakdown than from the virus. Otherwise they will either quit or there will be a big scramble to get their hands on whatever they think will save their lives. I don’t want public resources siphoned off to build bunkers for leaders and their families.
I want a number that will get me through the door and get something going. If you succeed in doing that, there will be time to explain the complexities and consequences and all the rest of it. And to recommend strategies for a higher CFR.
But you gotta get through the door first….
I agree with clark – at 03:07.
anon_22, I understand the problems in getting through to the bureuacracy, but why not start with the current fatality rate of H5N1? This is backed by the WHO. There are now numerous seroprevalence studies indicating that H5N1 truly is a highly lethal disease. I don’t think this is seriously disputed by any credible scientist. Let this be the default position. You can say that we hope that fatality rate will decline if a pandemic strain of H5N1 emmerges, but that this is a hope, not something we can count on. The burden of proof is on the people who claim that the CFR will decline.
As far as adjustment reactions go, it is difficult for me to judge. I went through mine a long time ago, so it’s hard for me to argue what’s the best approach. I accepted that a pandemic might have a very high CFR right from the beginning, but I realize that some people are slowly edging upwards in their estimation of the worst case scenario. It’s like getting into a cold lake. Do you just jump right in or slowly edge in?
Monotreme, Of course I start with the current CFR.
Here’s what I would say: There’s a chance that H5N1 is going to cause a pandemic (blah, blah, blah). We don’t know how many people are going to die. Currently the CFR (of course adapted to laymen terms etc and explained) is at >50%. If a pandemic happens, some scientists hope this number may go down, but there is no solid science to say that is a given. Just to give an idea of the impact of a CFR of say, 20% might mean, there were 3 pandemics in the 20th century, of which 1918 was the most severe. Estimates of worldwide mortality ranges from 20–50 million, but there are indications that it could have been more. The CFR for that is estimated by experts to be 2.5%. So if we have a pandemic with H5N1 as we currently know it, the CFR has an awful long way to drop before we even match 1918, and we know that today the world being so interconnected (etc etc) the chance not just of any individual dying but of catastrophic systemic breakdown is quite high.
anon_22, Your approach (at 09:34) seems reasonable. Do they let you through the door?
anonymous – at 01:40, there is by now, because of the spread across nationsand continents, no way to prevent all contact between humans and species infected with the current H5N1, nor is there any way to know about, test, treat isolate, monitor and report on each human case. Parts of African nations, and other places too, have zero health infrastructure, and people die and get buried every day who were never even known to their governments.
H5N1 has been “unprecedented” in many ways, and it now is so widespread and has access to so many species (list is in the Wiki somewhere) the virus is sort of rolling dice, and rolling dice, in thousands and millions of creatures. Lots of chances to interact with other influenza viruses in wild and domestic birds and mammals too. Humans do not have the money, scope, materials, nor science understanding and motivation among the populace nor the governments to drop everything and stop H5N1 from being a pandemic threat. Impossible.
So, for the first time we have forewarning of an influenza pandemic, but can only watch it happen. We have no way to stop it and no real way to even know if it has started; it may be out and about before it is noticed, verified, and who knows if governments will choose to announce it? Too many past officials in history chose “preventing panic” over telling the public what was known and what was unknown, and having a helpful, co-ordinated response was not possible then, and doesn’t seem very possible now.
H5N1 has only seemed to be going farther down the path to a pandemic; nothing in its behavior so far has made it look like it is stopping or moving away from the possibility of pandemic.
I have no credentials that could get me past gatekeepers. Maybe we have all been just lucky that it hasn’t started already. I haven’t learned anything reading the scientists discussing H5N1 and pandemic viruses that would say we couldn’t have more than one strain go pandemic, or more than one strain in a wave at a time.
Perhaps they should all just drop the numbers and say, anything that will impact our children and our vigorous and healthy reproductive and working-age population, like pandemic influenza (looking at 1918 and, H5N1,) is going to overhwelm the unprepared on all levels, and then, the unprepared also overwhelm the few currently preparing.
“Anything we say before a pandemic happens feels alarmist. Anything that we have done once a pandemic starts seems inadequate. We’re at a greater risk of a pandemic than at any time in decades. We are overdue. And we’re under prepared.” ~”Secretary of Health and Human Services Mike Leavitt, the man charged with preparing America for the next pandemic.
The ones who don’t want to do anything until they know with certainty that pandemic is occurring just haven’t grasped the concept. Preparations, building buildings stronger in better locations,contingency planning, education of the public can’t start when the mega-quake does, nor when a tsunami wave is actually sighted… Pandemic Influenza would be worse natural disaster;it lasts longer and everyone is affected. Wish the officials would see grassroots education as a good use of their time and money too.
>Here is what I would say: There is a chance that H5N1 is going
>to cause a pandemic (blah, blah, blah).
sure, but how big is the chance ?
>We do not know how many people are going to die.
sure, but what’s the best prediction ?
>Currently the CFR (of course adapted to laymen terms etc and explained) >is at >50%. If a pandemic happens, some scientists hope
only some ? We all _hope_ that. But how many scientist do predict it would go down and how much in average ?
>this number may go down, but there is no solid >science to say that is a given.
sure, (almost) nothing is a “given” in pandemics prognosis.
>Just to give an idea of the impact of a CFR of say, 20% might mean,
why ? They can do the calculation by themselves.
>there were 3 pandemics in the 20th century, of which 1918 was the >most severe. Estimates of worldwide mortality ranges from 20–50 million, >but there are indications that it could have been more.
best current estimate is 80million deaths (see Woodson in the other thread)
>The CFR for that is estimated by experts to be 2.5%.
>So if we have a pandemic with H5N1 as we
>currently know it, the CFR has an awful long way to drop before
>we even match 1918, and we know that today the world being so
>interconnected (etc etc) the chance not just of any individual
>dying but of catastrophic systemic breakdown is quite high.
“awful long”, “quite high” is not what they need. Give numbers. Unbiased averaged expert estimates.
Hi everyone Intersting discussion. The point I was trying to make was… if it is assumed that we will be in the middle of a pandemic in less than twelve months…what is the point of hiding things now when they are going to hit the listener on the head later…better to have a controlled panic now then a vindictive panic later.
Big enough chance we should prepare. Governments certainly prepare on national and local levels for much less likely events.
Since the US hospital/ER system, (and, most first responder departments) are stretched to the breaking point now, anything at all extra is going to be too much.
People like “gs” wanted accurate estimates and probabilities, but, humans are imperfect and limited in resources, and do not have the data to make accurate estimates. But we can see when things are spun way too low, for reassurance purposes.
And Leavitt saying, no vaccine ammounts for the public for 3 to 5 years from now, no pandemic vaccine until after the first wave and then not enough even for first responders,
and the US CBO expecting each wave to be in an area 3 to 5 months,
and, the federal and state governments telling communities Don’t Plan on us Being Able to Help You
should be enough, no matter what the CFR turns out to be, for communities to be having public meetings of all community “stakeholders”, and, households changing priorities enough to make preparations.
crfullmoon. If I haven’t said it before, you’ve made perfect sense in the past and I hope you continue to make perfect sense in the future.
Yeah, Tom_DVM at 10:45, and I don’t call shoppers emptying shelves now, when supply chains work, “panic” (unless anyone gets injured).
I don’t call people saying, “What do you mean we might die?!” “panic” even if public health and local government officials don’t want to hear public’s adjustment reactions,
nor all the “How will we pay our bills/taxes if we can’t work during a pandemic or the economy goes into a Depression?” questions that there are no good answers for.
Problem is, too many assume we can’t have a pandemic, or that the WHO says we’re only at Level 3 therefore, we must have long stages between all those numbers up to 6:Pandemic.
Or, it is too terrible to think about, so, they want to do nothing, and figure ‘no planning would have helped anyway if it will be that bad’, so, they plan to fail. They still expect the military to save them or something. I think there is much that can be done and should be done anyway, if only in the mass casualty management, (and that will be needed if they aren’t going to do anything else!).
Tom DVM – at 10:45
a “controlled panic now” has unwanted economic and political consequences.
People are moving, suspending/modifying their jobs, their treaties,
their future planing, their career-planing, their education.
Insurance policies were modified or cancelled,
people would stop saving for pensions, would stop taking care
for health etc. When you have a good chance to die and another
good chance for political or economical instability you will
concentrate on short-term planning rather than long-term (decades).
The government itself might be at risk - they were not elected
for pandemics, pandemics were no subject in the last election
campaign, so it could be argued that they have no legitimation
in a severe pandemic and new elections are required.
etc….
nobody ever said this was going to be easy.
Controlled panic is the lesser of many evils.
crfullmoon at 10:48, “accurate estimate” is a strange expression. An estimate needn’t be very accurate and when there are different estimates you typically take the average and you have a deviation, so this isn’t accurate. There is no point in refusing an estimate just by claiming it weren’t “accurate” and others might differ. But yes, most of the estimates I’ve seen do indeed indicate that current planning and preparing levels should be increased.
Tom DVM at 10:51, thanks, (and I hadn’t realised SARS was the coronavirus-equivalent of the Rock of Gibralter falling into the sea), and I sure wish you could come up and we’d both go around here, because, I don’t seem to be accomplishing much.)
Monotreme, I read your post again and think that maybe you didn’t realize what the big fight here was about. It was about whether it was appropriate for me to act as if the CFR for 1918 was 2.5% and not try to seek or present a higher number. Now do you get my point? That one doesn’t always have to harp on the most awful figures to present a good case.
crfullmoon. Mantra to live by…
….Stay calm…be brave…wait for the signs.
(Tom King: Canadian Native Author)
anon_22, I try not to get involved big fights ;-)
However, I basically agree with clark. I don’t think we should mention 2.5% for 1918. There is no scientific basis for this number. All we can say for sure is that alot of people died back then.
ahh, “ a lot” is very inexact. 10–15% worldwide or 2–3% for USA looks justified and is certainly more informative.
Please, anonymous, give us your own summarized estimate. What exactly would you say? Can you write the sentence without the numbers? What numbers would you provide? Would you provide the names of the scientists or just a number of scientists or what?
What you say may be felt as irritating by a number of people - I find it interesting, and I’m not sure about the value of it all. If your position really represents the position of many decision-makers, then we should adapt to that and see what we should do.
We might get scientific about it: try all aproaches and see which one works better? Of course we feel we don’t have time. Or we have lost lots of time already.
My take on this:
In short, we need both their adjustment reaction and their action. We want them to keep talking to us. We want them to talk to others.
We can make several assumptions, ranging from sooner to later, ranging from mild to worst. That “surface” has some areas - I have not looked deeply into this, just making it up as I type - and I’m sure all areas have something in common: resistance to action. If we have some available time, we’re going to have to use some of it upping their adjustment reaction.
Sincerely, I don’t know what’s the best course of action.
I think I’d rather tell the whole truth, ignorance included.
In short: we don’t really know what to do to get the world to prepare effectively and quickly.
This “what to do” plan should take into account several factors:
So far we have tried some strategies and we know their success or lack of it:
The anonymous person previously known as you-know-who suggests we should try harder to come up with a few numbers. Then what? We would have to tell something to agree publicly with them, in order to get the ball rolling.
Let’s treat this as an unsolved and important problem - which it is.
All suggestions from ‘The anonymous person previously known as you-know-who’ appear to never go far beyond trying to get more numbers…
:-)
jokes aside, lugon, I think we should try everything. Whatever works, whatever we think might work, whatever seems harmless though off-the-wall, whatever people are willing to engage in, etc…
And then those who have done something that works or seems to work please report here.
How about that?
Do you think that this whole discussion is itself part of a larger adjustment reaction? That is, one where you see one reality but everyone disagrees with you, and how do you get them to see what you see?
As for my own adjustment reactions, I’m starting to feel bad, maybe guilty for harping on the flu the way I have been to some people. I feel like I’m just focusing on the negative and who wants to be around someone like that. Moreover, focusing on the positive might actually make it happen.
Anyone else feel guilty telling people about the flu? Maybe it’s just the way I do it. Maybe I haven’t mastered “risk communication” properly yet. I think I have used mild-moderate scare tactics, stating the blunt facts and risks, rahter than this moderate/mediated/”make up your own mind” type tactic.
So I oscillate between needing to give more info as it unfolds (since no one here has done anything about it yet) vs. deciding OK, that’s it, I’m shutting up about it now….
I am reposting Dr Woodson’s post from the “CFR was 19% during 1918 flu epidemic” thread.
“The case fatality rate during the Spanish Flu is unknown. Neither this data nor the clinical attack rate for the pandemic was accurately recorded for the Great Influenza except in a few places like Boston, MA USA.
I have been working with a simple model that included variables for these data, the world population in 1918, and the most up-to-date estimate of the number of deaths during the Spanish Flu using modern epidemiological techniques. This range of deaths is between 60 million and 100 million people worldwide. The midpoint of this range is 80 million deaths. Accepting this figure as a reasonable estimate of the death number during the Great Influenza together with the known population size of 1.6 billion, various combinations of clinical attack rate and case fatality rate for the event can be projected.
Having run the numbers, the most likely combination of estimates consistent with the facts are a worldwide clinical attack rate of 40% and a case fatality rate of 12.5% during the 1918 pandemic. When these estimates are applied to a world population of 1.6 billion, the death number of 80 million is derived. While this projection is just a guess, I think these estimates contain some insight into the possible shape a severe Great Bird Flu Pandemic might take today.
The effect of a pandemic occurring now in the developed nations would probably be reduced somewhat by our healthcare resources. A reasonable adjustment would be a reduction in the case fatality rate by one third to 8% in the developed nations compared with a 12.5% rate in the third world. The US Dept of Health and Human Services has a more sanguine assessment of our fate during a 1918-like event. It projects a case fatality rate of no higher than 2%. Let us hope they are correct.”
Grattan Woodson, MD, FACP
Clark. As you know, I have equal respect for every one of our colleagues on flu wiki, and the family has just grown by one.
However, I respectfully disagree with one of Dr. Woodson’s statements.
“A reasonable adjustment would be a reduction in the case fatality rate by one third to 8% in the developed nations compared with a 12.5% rate in the third world”.
This may have been true in the 1960′s and 70′s but is not true today, in my opinion. There may be a good chance with our fragile infrastructure that our overall mortality rates, from all related causes, may be greater than the third world.
My worry is that planners are using “The impact on the economy” as the filter through which they run all of their figures and make all of their plans. As anon_22 has stated “Garbage in, garbage out”. In other words, if the numbers or estimates you start with to make your calculations are wrong, then the conclusions will be wrong. The conclusions can be catastrophically wrong- think of the space shuttle blowing up.
In our experience, the 1918 virus is the best metaphor we have for H5N1 virus. Nobody can argue a world wide CFR of 2.5% with the data (concensus estimates) that we have right now. I know that any figure is going to be an estimate. I am happy to go with Dr. Woodson’s estimate of 12.5%.
If planners, who are using the 1918 experience as their worst case scenario, use 12.5%CFR as the worst case scenario for a present day pandemic- or even as a likely CFR for a present day pandemic- Then I think we will see a completely different type of planning.
Our ancestors got through it and so will we. The economy will be the least of our worries- and planning should reflect that (if TSHTF).
Tom DVM – at 16:55 I agree. As a society, we are in the “I’ll Sue McDonalds if I scald my tongue” frame of mind. We are not mentally prepared for a pandemic. I am 55 years old, and really, my life has been a breeze- nothing but coffee and donuts -with a few scalded tongues now and then.
I really hope that I am up to the challenge if a pandemic shows up. My forebears were- God bless everyone one of them.
There are four types of economy (I once heard): the transfer of goods and services itself, the transfer of money that represents (or remembers) the transfer of goods and services, the Wall Street economy (which is related to rumors, expectations etc), and I don’t remember what else. So if Wall Street goes down, and if normal money is scarce, I still want to see food and water running around.
WHO summed it up well: “buy time, keep basic things running”.
I think we might give it a shot at thinking of 4 scenarios and giving our best advice for each: soon+mild, soon+bad, later+mild, later+bad. It looks like some countries are are planning for later+mild, and most are not planning at all.
Ok, maybe there’s no real “mild”, but rather a “mostly disruption” pandemic versus a “deaths and disruption” pandemic. And “soon” or “later” is whatever we want to call it.
So we’re seeing plans for “less than mild + very much later”, if we agree?
At what stage can we expect working vaccines to be available to fight this, and enough for a reasonable portion of the worlds population. Or put in another way, for how long must live on a prayer?
Use egg-based vaccine cultivation, it will take a year following the emergence of the pandemic strain before sufficient vaccine to be available to confer even a modicum of herd immunity. Cell culture technology is 8–10 years down the road.
But a year is not enough time to produce enough vaccine for the world, even if every single vaccine factory in the world produces the new vaccine (AFAIK). My question was really how many years do we have before we can feel “safe”?
This is a relevant question. If technology makes it so that, say 20 years later, there’s the capability to create all the needed doses in 2 weeks, then we would only have to worry for 20 years.
lugon at 15:01
IMHO, I think too many choices will make people scratch their heads and move on. However, I honestly do not know what format ie mild-moderate-severe context to pose the question to others.
At this time, I plan to:
1.) Remind people for the immediate and long-term screw-up that Katrina brought to the residents of the Gulf, with all levels of government seemingly unable to work together. Do you want yourself and your family to be in that situation?
2.) Show them, or tell them about the last paragraph on page 9 of the newly released National Strategy for Pandemic Influenza Stategy Plan under “Federal Government response to a Pandemic”.
snip
“The center of gravity of the pandemic response,however will be in communities..local community will have to address medical and nonmedical effects of the pandemic with available resources. This means it is essential for communities…to support the full spectrum of their needs over the course of weeks or months…”
For once, no double-speak. We are being told NOW, that each little hamlet in America is going to be on their own when TSHTF. To me, this means plan for yourself, try to get your neighborhood and community to plan, but count on no one except yourself.
Grace:
This is not happening in Europe. At all.
And our anonymous friend’s fixation on probabilities (if we could only have what he or she suggests) would make for a powerful way to convey your very message to many more people. 50% people prepping is better than .5% people prepping.
Regarding vaccine. DNA vaccine technology is here today. It is scalable. It could easily produce enough vaccine for the whole world in a few weeks. Only two problems. We don’t know if it’s safe. We don’t know if it’s effective. I really think we should make finding the answer to those two questions a priority.
Europepanflu, European,
Check out my new thread European Policy
Richard Adams, in his book, “On Watership Down”, told a story about a society of rabbits and other creatures. Social, but not terribly bright, rabbits could count up to four. Anything more was ‘thousands’.
It is probably important that we get close with an predicted CFR so we can better prepare all the logistical and resource needs. Food, fuel, medical supplies, body bags, etc. Like anon_22 says, the credibility is in the facts.
Most of the HCWs I have spoken with believe the CFR will be one, or not, at a time. Anything more is thousands. You don’t have to get the significant digits to get it. Someone said “more than we can bear”. Close enough.
rrteacher.
Would that be a philosopher in a scientist’s clothing…or a a scientist in a philopsopher’s clothing.
Either way, I like you approach to things.
“Vaffie” posted this over at CE yesterday. I think that it speaks directly to the subject of this very long thread.
http://www.curevents.com/vb/showthread.php?t=47519
“the population dynamic of the world is very different now than it was in 1918. For instance, the population of the US was about 106 million, and now it’s about 250 million. But not only that, but in 1920, there were 54 million urbanites in the US (or about 50%). Now there are about 188 million (75%). This is similar all over the world now. Thus, though the population has increased 135%, the urban population has increased 240%. It is this number that should be considered more important than just the population, because city-folk are far more susceptible to spreading an H2H infection rapidly, as was seen in 1918 too. But it doesn’t work linearly however. Mere common sense would tell you that if you triple the number of moving balls in a gymnasium suddenly, the chance that you are going to get hit in the next minute increases by much more than 3 times. In the same way, a dense population will propagate any virus far more than you would predict linearly, and so the percent affected may also be much higher. On a global level, the change has even been more dramatic, going from 14% in 1920 to >50% in 2005. This translates to an increase in the world’s urban population of 13–14 times—creating an unprecedented ability for an epidemic to affect almost everyone instantly.”
Ok, lets produce a newsletter with a summary on the subject of Bird Flu that we can have everyone e-mail to their address book. Let’s make it good enough and clear enough to really communicate. Remember our audience is at the average of the Bell shaped curve.
Clark @20:11 I did the math long ago on this forum in the thread, “H5N1 DEATHS IN THE UNITED STATES.” I extrapolated the data from 1918 and applied it to our current situation. One problem with thread formats is that we go over the same territory again. We need to summarize and synthesize and then design the communication tool for general consumption.
In my day we published our own newspaper and started our own news service to get our information out. Today, I would let the internet forward the information (short and to the point) from person to person. We could put it in a focused one topic newsletter format.
Yep- Dude - you are so right.
I sent Woodson’s Pandemic guide to everyone in my email mailing list. Most would have been binned- but some people saved and read. I would do that again-
If you send via your mailing list, it gets past alot of spam filters.
Tom DVM —
Someone else asked , and I too am curious…
Why/What makes you think this fall? …or within a year?? (gut feeling??)
tc in CT. Thanks for the question…yes, it is all intuition…and there are so many variables and factors in coming to a solid personal decision that I’m probably a little too tired at the moment to be able to describe them all.
In a communication to the Canadian Government in Jan. 2005, I predicted that the pandemic would start in the Fall of 2006. I didn’t know about flu wiki or crofsblog etc. The only reason my family had the internet was because I had a daughter in high school, she just finished second year university…I didn’t want the internet…but lately my family has been a little angry with me for the time I spend on it.
All of the information I have learned since Jan 2005 has re-inforced my opinion.
I collect patterns in nature not from the center of things where everyone concentrates their attention but on the periphery of things where nobody looks. Also, my patients can’t talk to me and Farm Veterinarians spend all their time preventing hopefully or treating localised epidemics on intuition alone…so I’ve had quite a bit of practise over the years.
All of my senses point to 2006 as the year…but I could be completely wrong and maybe I can give you a more complete description at a later date.
I am tired of scientists and politicians hedging all their statements. It does no one any good and everyone including many on flu wiki just end up being confused…so I decided to stop beating around the bush.
Tom DVM—
Thanks for the answer.
Every now and then I’ve read postings that make “just so much sense…” You mentioned that buying rice and beans for the multitudes makes better sense then on Tamiflu.
Like DUH!
MHO now… nobody knows if it’ll (Tamiflu) work (partly because you have to TIME it right), or for how long it’ll be useful before a resistant strain may emerge, so it just might be a total waste of precious funds…
Preparing so that there will be food on everyone’s table is IMO, brilliant…
anonymous – at 02:48 there is a common argument that the CFR (case fatality rate) will decrease in a pandemic. The virus can better spread when the host lives. This is a common observation with other viruses. It was clearly observed in the 1918 pandemics.
However, H5N1 could be different. We didn’t so far observe any decrease in CFR, neither in chickens nor in humans. We do have asymptomatic ducks, and less severe desease in some animals, though. But when H5N1 goes efficient h2h, can we assume that selection would favour less lethal strains and mutations ? Will people who recover spread more virus to others than people who die ?
lugon – at 04:26 This has been dealt with at Forum.MustAPanFluDecreaseInLethality.
Short answer: no, CFR doesn’t have to decrease. It might, and we all wish it would.
If selection does favour less lethal strains, then that’s one more reason to buy time and try to make it happen in slow motion - or at least in a slower motion - in order to let the not-so-evil strains advance faster than the really evil ones. If we can.
Please go to that other thread. Admins, could we close this one? Thanks!
anonymous – at 04:56 yes, it has been discussed before. But I am missing arguments why H5N1-survivors are more likely to spread virus to others than non-survivors. Are we more likely to isolate (handle,bury) non-survivors more carefully than survivors ? What’s the difference here between 1918 H1N1 and possible 2006 H5N1 ? Also, many experts still argue that H5N1 would go down in lethality when it goes pandemic. So this is controversy. You can’t just say : “short answer is:no , now close the thread”
anonymous – at 05:08 lugon, that thread is long and not very much on topic. I can’t follow monotreme’s argument in the first post. It seems valid for 1918 H1N1 too, yet the lethality did decrease. I’m not so much interested in whether it “must” decrease, (of course it needn’t) but how likely it will decrease. Yes, virus is shed before infection, but also later. How much more virus is shed by survivors ? That’s the critical question.
lugon – at 05:39 I was suggesting to close this thread, and only to avoid duplication. We can of course continue here, and close the other (or at least redirect new posters to this one).
There is controversy. But there wasn’t much of it before, at least not that I was aware of. In my opinion, before it was more or less blindly accepted that lethality must come down. Now we (or at least I) are not so sure. So yes, the possibility space has widened.
And the probability space is as muddled as it was before. My personal opinion is we must act on possibilities, and looking for probabilities takes away energy I need for other tasks.
The possibility space includes:
a hard pandemic soon a mild pandemic soon a hard pandemic later a mild pandemic later
I believe even “a mild pandemic later” (say lethality 0.3%) would be highly disruptive in a globalised world that depends on travel. I would be surprised, gladly surprised, if it were different. Call it a 95% or higher if you like.
I believe a highly lethal, highly disruptive, “sooner rather than later” pandemic is possible. I don’t know how likely. If it is 10% this year (and I don’t know) then that’s enough. 5% is still enough. 1% is still enough.
Give me a limit where it’s not enough. Then ask that question.
Sorry if I sound upset. I am, at times. I reply because I feel your arguments are valid, but I don’t see how we could move forward from this “probabilities? I don’t know! but how come? I don’t know” loop.
I feel we can make a strong case for preparation without probabilities. See this thread.
How much more virus is shed by survivors? I don’t know what will happen when there’s a pandemic. I would guess non-symptomatic carriers (before falling ill or those who don’t fall ill at all) shed less but for a longer time. I don’t know what the net (pun implied) effect would be. (Any expert in simulations here?) Social distance and so on do make sense in any case. To what degree? We’ll have to find out as we go along, if we can.
anonymous – at 06:03 you address the individual preparations done here, not the important decisions on government basis. When it comes to billions of $, you definitely want some numbers to justify your decisions.
To compare the R_0 of H5N1-survivors in a pandemic with that of H5N1-deaths, it’s easier to think about the differences from 1918. What’s the infection-time, the estimated number of people infected before onset of symptoms , defore death, after death, before recovery, after recovery. What can we do to improve these numbers ? (only ethical suggestions) Clearly, the more severe an illness is, the more we should avoid infection. Not only for our own immediate health but also for disruption of the spread of the dangerous strain. Should we go so far to “support” mild strains in a pandemic ?
lugon – at 06:37 I wrote: Give me a limit where it’s not enough. Then ask that question.
Anonymous wrote: you address the individual preparations done here, not the important decisions on government basis. When it comes to billions of $, you definitely want some numbers to justify your decisions.
Yes, some numbers: a 1% possibility of a civilization breaker. A 5% possibility of major disruption. A 20% possibility of major health-care disruption.
Do you really think they are not paying attention? It’s just that they don’t know what to do.
Or maybe numbers would bring people on board faster?
Please, do create a page on the wiki titled “the numbers game”, outline why this is so crucial, what you’ve understood about what others say about this, your summary of who has said what regarding numbers, and what we should be doing next.
It’s not that I dismiss your work in this area. It’s just that I find it terribly frustrating. I feel it doesn’t take us any further, at all! An important, yet impossible question.
I suggest you settle it as best you can. I’m moving on to other things. Thank you.
lugon – at 06:39 My numbers are not official: just a way to say “if it’s this or higher, then it’s worth the investment; and it is this or higher”.
Most of the investment would not be monetary, by the way: just plain old talking about it, organising around it, planing for it.
Nikolai---Sydney – at 06:42
And I, too, feel this has been fine-combed on the previously
cited thread. There is no question in anyone’s postings but
that this is a vital question, but there is question as to
whether we need or even wish to rehash it.
anonymous – at 07:36 the old thread is lengthy and the subject of the thread was missed in most of its posts. Alas, the same is happening here already. If lugon and nikolay-sidney don’t like the discussion, they can just skip it. No need to close the thread. Even if it were discussed before, which I can’t see, there are lots of examples in the archive where repitition was no reason to close a thread.
anon_22 – at 08:18 anon,
Go and post your questions on that thread. For the benefit of everyone, it is better for threads of EXACTLY the same question to stay in one place.
lugon – at 08:38 I repeat: I was suggesting to close this thread, and only to avoid duplication. We can of course continue here, and close the other (or at least redirect new posters to this one).
Anonymous - at 07:36 wrote: the subject of the thread was missed in most of its posts. Alas, the same is happening here already. So here’s the subject again: But when H5N1 goes efficient h2h, can we assume that selection would favour less lethal strains and mutations? Will people who recover spread more virus to others than people who die?
My answer to the three questions (well, actually, one assumtion and two questions):
We don’t know if H5N1 will go efficient h2h or not. We don’t know if it will happen, when, or how would the resulting pandemic virus (which H5N1 currently isn’t) behave. If someone asks about probabilities, I will skip it because I badly want to use my limitted time working on something which, in my mind, will be more useful. I think selection favours less lethal strains and mutations … in the long run. But that doesn’t necessarily happen short term. Sometimes it happens, sometimes it doesn’t. The deeper mechanisms escape me: I’d sincerely like to know more about how “selective pressure” works. But the practical conclusion, for me at this stage, is another “I don’t know”. Will people who recover spread more virus to others than people who die? Let me see …
Three groups of people here:
People who will die have a more severe form of the disease than those who will recover. More severe may or may not mean more virions inside the patient, and likewise for shedding. More severe may mean more contacts with care-givers, or less time to contact anyone, or contact with protected care-givers. People who will recover will have a less severe form. They may shed less virions, but for a longer time, and maybe to care-givers who are less protected. Some may even go to work even when ill, at least in the last days of disease when they are a bit better. People with little or no symptoms. They probably shed a small amount of virions, to anyone who is around.
I guess the factors are:
amount of shedding per time-unit number of time-units the patient is alive number of people who are around the case degree of protection by those who are around the case
What info do we have on each? What would happen in a pandemic?
How all of this adds up I don’t know.
THIS THREAD IS SO LONG IT SLOWS THE ENTIRE WIKI.
I RESPECTFULLY SUGGEST WE GO ON TO A NEW THREAD
Don’t know either; so many unknowns.
People who die may not have had a worse form of virus; they may have had no caregiver preventing dehydration, ect.
And, dead from many causes not the virus itself, will add to the “surge” of bodies to be buried. Don’t see places buying enough PPE now for surge mortuary needs (and I think places will need to bypass the funeral industry somehow, to get all the extra losses buried. But, live infected people spread virus more than dead ones, who may need contact precautions, (and I’m not sure about surface water contamination - get cemetery departments planning and stocking up at home now, so bodies are getting buried promptly -and with id/paperwork done- but aren’t getting buried where/how they shouldn’t be).
What is anyplace’s HIV rate? This is not even known for sure, because so many don’t get tested. But they and others with low immune systems, (probably can get numbers of transplant or cancer treatments) if they survive, may shed virus for longer, and be more likely to give time for more strain mutations?
Getting people prepared, and, officials able to tolerate erring on the side of caution; don’t tell people not to wear masks, don’t be in a hurry to tell them a wave is over and to stop taking distancing/infection control precautions, ect, might help, but, we need to educate and prepare now.
Having recovering/recovered people still try and take precautions, in case they do shed, is not unreasonable.
We (and tptb) can’t prove pandemic won’t happen, and we can’t prove it won’t drop in lethality, so, better to get preparing.
With being able to spread the virus before one feels ill, and airflight criss-crossing people ‘round the globe every hour of the day and night, a virus could do great damage even if its host dropped in its tracks, as long as it had a few days to spread without symptoms first; it wouldn’t burn itself out to fast not to give it a try. It doesn’t have to make sense long-term -its a virus, and evolution tries everything, for as long or short as possible.
closing this thread. Will open part 2.