A Journey Through The World of Pandemic Influenza

Upcoming changes

 

I am in the process of building a new (and hopefully much improved) pandemic influenza blog using WordPress as the platform.  I'm spending most of all the spare time I don't have right now tweaking it up getting ready for the Great Switch.  But, I'm having fun and the end product will be a much better (hopefully) and more robust blog.

 

News is slow (where have you heard that before) and I figured now is the perfect time to take the hit on that Google page rank thingie that we bloggers have a small concern over.

 

I am finding that going from TypePad to WordPress is like going from a Volkswagen Beetle to a Mercedes CL 550, all sorts of nifty gizmos and gadgets to figure out as I slip into the adjustable ergonomic leather driver's seat.

 

Oh, and I simply must offer a bit of praise: My new blog is being hosted by HostICan and in less than 24 hours I had a representative call me and ask if I had any questions or needed any assistance.  The gentleman was engaging and clearly cared about what my experience(s) had thus far been [NO, I'm not signed up for any "affiliate" program, just truly and sincerely impressed].  In a competitive business environment that "personal touch" can make a business… or break it… and HostICan seems to be pleasantly (for me) aware of this.  The only thing I've ever managed to contact with TypePad is a computer listing of FAQs.

 

So, I'm excited about the Big Switch, and I'll keep everyone "posted"…..

 

SZ

Insuring the business of HC against Pandemic Influenza

 

Although it's true you can insure just about anything against just about anything, today's news item came as a bit of a surprise:

 

From Marketwatch.com

Lexington Insurance Company Introduces Pandemic Rx

Endorsement to Lexington's Commercial Property Insurance Covers Financial Risks Faced by Healthcare Providers in the Event of a Pandemic Flu

NEW YORK, Jul 31, 2008 (BUSINESS WIRE) -- Lexington Insurance Company, a unit of AIG Commercial Insurance, today announced Pandemic Rx, an endorsement to Lexington's commercial property policy for acute care medical facilities to cover business income loss and extra expenses incurred during a declared pandemic influenza public health emergency (as defined in the policy).

"Because of the complex nature of healthcare economics, a pandemic flu would put tremendous financial strain on healthcare providers. An increase in hospital admissions, expected during a pandemic flu event, could actually result in reduced revenues and business income loss," said Kevin Kelley, Chairman and CEO, Lexington Insurance Company. "In an environment of resource scarcity, elective procedures may be canceled which may then lead to a lower average reimbursement rate for care provided during the pandemic event."

Continues….

 

Back in December of 07 I did a post, Pandemic Accounting, and it addresses why this insurance was brought to market. It is still relevant to the issue and if you haven't read it I [modestly] suggest you do so.

 

I close out that previous post with these words:

 

Even though this article addresses the financial burdens a pandemic will place upon most hospitals the supporting underpinnings are some of the best I have seen outside of dense scientific papers. Admitting it's crass and insensitive to lean on financial concerns to support PanFlu concerns in general when I refer to what will be human lives and miseries, it's as the saying goes—money talks.

The question is—is anyone listening?

 

The insurance industry is listening.

 

SZ

Japan’s H5N1 PanFlu estimates

Many days I am reduced to the briefest peek in on the world of H5N1 and Fla_Medic, along with Crof, are where I usually peek for the news. One of FM's offerings today was a post on Japan's estimates of the possible effects on the business sector should a severe pandemic occur. I would not be exaggerating to say that I was momentarily stunned, in fact stunned incredulity about sums up my reaction.

From the Daily Yomiuri Online:

40% of workers might have to stay home in pandemic

[Excerpt]

Estimates were based on the human suffering figures in government's pandemic relief action plan--revised in October. The plan estimates 25 percent of people would suffer from a new influenza pandemic, with a fatality rate of 2 percent.

I was stunned because I have long admired Japan's approach to the seriousness of the threat posed by a pandemic from H5N1, treating it more as a threat to their nation than a public health issue. As such, they have spent a great deal of energy and funds preparing Japan for the potentials. A few examples are their purchases of Tamiflu, pre-pandemic vaccines, and plans for containment on a national level. Japan has backed up words on paper with concrete actions and embraced some rather radical measures as necessary to their survival.

Given their demonstrated willingness to accept the more severe, but [some would say] less likely, severity assumptions reading 25% ill with a 2% case fatality ratio was counter to everything I had read from their planning assumptions previously.

Several hours passed as I mentally chewed on what could be driving their numbers and then it hit me:

Instead of using ill-informed and wishful thinking figures [as 25% CAR /2% CFR suggest] they quite well may be correct for Japan experiencing a severe pandemic. Japan, having done much already, and plans in place to do much more proactively, will experience a mitigated pandemic while most of the rest of the world will suffer an unmitigated pandemic.

A graphic of a community disease profile between a mitigated vs. unmitigated pandemic [FluWiki]

That graphic, though unproved for a future severe pandemic, speaks volumes in support of Japan's estimates. Doing the "tough stuff" pays off in numbers, both in CAR and CFR.

Lest we forget, those numbers represent people – many in the prime of their lives – which is exactly why Japan takes the threat so seriously, and exactly why they may just hold their numbers down to these percentages that, on their face, seem so unrealistic [and uncharacteristic for Japan].

SZ

Bangkok editorial connects pandemic dots

 

 

From the Bangkok Post [editorial]:

Poor Planning for disaster

Two disturbing reports have just been released by different authorities in the United States and the United Kingdom. Their parallel release is a coincidence, but authorities in nations around the world should be both interested and concerned - and so should their citizens.

Although they approach the problem differently, senior experts in both countries warn that there will be a terrible disaster, count on it, and the US, Britain and the United Nations all are woefully short of being able to cope.

The UK report, written on the evidence of an investigation by the upper House of Lords, should give the most concern. It centred mainly on the likelihood of a worldwide pandemic of influenza or similar disease. The report says flatly there will be such an outbreak, although of course it cannot say when or what form the disease might take. It could kill 50 million and take a terrible toll on trade, travel and society which would last years if not much longer.

[snip]

The fear of influenza is based on the spread of avian flu through, especially, eastern Asia including Thailand. Some experts argue that the H5N1 virus is not likely to ever be especially dangerous to humans worldwide. But they miss the point that influenza in general is the most likely source of any global illness. It is prudent to prepare for a human outbreak of avian flu. It is absolutely vital to be better prepared for an influenza pandemic.

It should an eye-opener to most that Britain and the United States are undoubtedly among the world's best-prepared nations for natural or man-made disaster. If they are unready and unrehearsed, how about the rest of us?

That there will be a medical pandemic is probably beyond debate. That the nations of the world will again be found wanting in caring for the sick and halting the spread of the disease, is perturbing. That even the WHO is doubted in ability and authority is worrying.

More planning and preparations for disaster management is needed. The tsunami of 2004 proved that even a highly local disaster could quickly overwhelm local response. At one time, Thailand was seriously preparing for an influenza epidemic. The waning bird flu seemed to end such concern. The government has effectively downgraded disaster preparedness officials to almost a non-entity. That may prove a terrible error when - not if - illness spreads globally as during previous flu pandemics.

 

The author's frustration and dismay over Thailand's pandemic preparations is clearly communicated in this piece.

 

Connecting dots of concern expressed by two members of the G8 points out the rarely discussed. Countries that traditionally provide assistance when disaster strikes another will be mired in their own troubles with nothing left over to offer up, irrespective of humanitarian need or tragedy should a severe pandemic happen.

 

SZ

H5N1 and Nigeria

 

I've said before that H5N1 does not exist in a vacuum, separate from all the other troubling and worrisome things and that occasional large scale disaster.  H5N1 in Nigeria is yet another example.  A country that has more than its fair share of corruption and greed, it is also struggling with being rich in oil.

 

Nigeria Reports New Outbreaks of Bird Flu at Farms in North [excerpt]

By Dulue Mbachu

July 28 (Bloomberg) -- Nigeria, Africa's most-populous nation, reported new outbreaks of bird flu in two of its northern states, the World Organization for Animal Health said.

Both cases, confirmed to be the H5N1 strain of avian influenza, occurred in ``backyard poultry'' in Kano and Katsina states, the organization said a statement posted on its Web site on July 25. 

 

Elusive peace in Nigeria's oil Delta

By Andrew Walker
BBC News, Port Harcourt

An effort by the Nigerian government to bring peace to the oil-rich Niger Delta region hangs in the balance before it has even begun.

[snip]

Corrupt politicians and military officers use armed militants to steal oil and protect their lucrative positions in government.

"Most of what is going on here is sheer criminality," says Anyakwee Nsirimovu, a human rights activist based in Port Harcourt.

"Maybe one day there will be a line drawn between who is a real fighter for the Niger Delta cause and who is not, but what we see on a daily basis is people killing civilians and pocketing money."

Without things like reliable power supplies, transport infrastructure and employment, people will remain dependent on the patronage of corrupt leaders and will be unable to speak out against them, he says.

"Not many people can speak the way I do, because they are afraid. Plenty of people spoke out in the day and were killed at night."

He says the government's intention to get militants to put their arms out of use is "absolute nonsense".

 

An interesting post on the "Nigerian background noise" from Greg Laden's Blog

The shit is hitting the fan in Nigeria 

[Excerpt]

At this point, in Nigeria, we may be at a tipping point of sorts. With increased international attention focused on oil exploitation, and a long period of time over which the same disgustingly corrupt system has been in place, the Nigerian situation appears to be heating up.

Over the last few days, there have been a number of incidents (see below) indicating a notable escalation. Militant leaders are now vowing that a major action will take place soon, possibly this weekend. Security warnings are going out to ex-patriots in the region. Expect the ongoing, in the background events that never boil to the top of the US news ticker to emerge on the front page any time over the next few days.

 

Although H5N1 in domestic poultry is old news and news we tend to not treat as news any longer, when you tack it onto corruption and chaos it might just be newsworthy.  If not newsworthy, at least a brief pause for that "oh crap" moment, in homage to the potential danger from stuff we have become inured to reading.

 

SZ

Influenza, a promiscuous virus

 

Today we have a brief announcement that two dead birds were found in Hong Kong at the location of the upcoming Olympic equestrian events (Aug 9 – 21).

 

The Associated Press (via USAToday)

2 dead birds found at Hong Kong equestrian site

HONG KONG (AP) — Two dead birds were discovered at an Olympic equestrian venue in Hong Kong, and authorities were testing whether they were infected with the bird flu virus.

The birds were found last week, equestrian competition official Mark Pinkstone said Monday.

The H5N1 bird flu doesn't pose a threat to horses, but can be lethal to humans. Hong Kong has struggled with the bird flu for years and six people died during the biggest outbreak in 1997.

The Olympic equestrian events, to be held between Aug. 9 and 21, were moved from Beijing to the former British colony because of a rash of equine diseases and substandard quarantine procedures on the mainland.

 

Even though the piece is small, it contains a great deal of information. The item most noteworthy to me is the fact that the finding was announced. Without diving too deep into The Waters-of-Conspiracy, some in the cyber flu community believe that the upcoming Olympic Games are directly driving our dry spell of news. I, myself, ascribe a certain amount of the silence to this. Nevertheless, I also believe that if something is of genuine concern we will hear about it – one way or another.

 

The second thing that I found noteworthy was the blithe assurance that H5N1 doesn't pose a threat to horses, and by extension, to people in contact with horses. On the 12^th I referenced a study where bovine (cows) calves were deliberately infected with H5N1 to study if they would become ill and if they would/could transmit the virus to other calves [here].

 

We continually learn more about the wide range of species susceptible to H5N1 infection, sometimes by surprise as was the case with cats, and sometimes like the calf experiment, deliberately. Unless someone, somewhere has scientifically validated the assumption then it is only an assumption at this point. An assumption that seems to be rather flimsy – at best – since there are strains of influenza that horses are known to be susceptible to, H7N7, H3N8, and H3N2.

 

A horse "snuffling" around in grass that has been coated with bird droppings from an infected bird seems (to this layman at least) a possible route of infection. Infected birds excrete large amounts of virus and that virus can live for quite some time in the environment.

 

The final thing I found noteworthy also bears repeating:

The Olympic equestrian events, to be held between Aug. 9 and 21, were moved from Beijing to the former British colony because of a rash of equine diseases and substandard quarantine procedures on the mainland.

 

It seems even with Olympic-sized reasons to control endemic zoonoses China has difficulty doing so. With August 8^th only days away, and several "mystery diseases" rumored to be within the region. For a great rundown of the China rumors please see Fla_Medic's post, and his follow-up if you have not already read them.

 

Finally, it is important to keep things in perspective. Two dead birds, even if they died of HP H5N1, are not a grand threat to anything, but they could be a symptom of a larger problem and as such, it is important that we know one way or another – especially when we have the (perhaps) ill-informed issuing ill-informed statements meant to placate and pacify.

 

SZ

 

PanFlu Vaccine Allocation Prioritization

 

It is rare that I ever disagree with what one (or another) of the Reveres from EffectMeasure say when it comes to issues of avian influenza or a human pandemic of same. Today, however, I found myself not only disagreeing but also asking myself "are they serious?"

 

The post [here] calls into question why the US military gets a top slot for scarce pandemic influenza vaccine allocation.

Putting frontline health care workers at the top makes sense (NB: I am a health care worker but as a researcher-physician would not be considered "front line," so this isn't special pleading). But why is the military at the top along with them, ahead of many other "mission critical" workers like police, fire and communications? Reading the document provides no obvious answers. The document is replete with claims that the guidance was developed by an open and transparent process with ample opportunity for the public and other stakeholders to comment to the Working Group that drafted the document:

"This guidance is the result of a deliberative democratic process," HHS Secretary Mike Leavitt said in a statement. "This document represents the best of shared responsibility and decision-making." (Reuters)

 

The guidance document [PDF] identifies approximately 700,000 "deployed and mission critical" as a Tier 1 priority group. What is not readily apparent in the Revere post is that there are segments of the military included in Tiers 2 and 3 as well, so the 700,000 are a specific sub-set of the military in its entirety. The operative phrase in the guidance document is "deployed and mission critical".

 

Since this Revere (there is more than one) included a thoughtful, as well as sincere, N.B., I will be include my own: my one and only child is a patrol officer for a small-ish city PD, and under the age of thirty (by several years). I could easily choose to be indignant right alongside Revere, adding my small cyber voice to the public challenge, and the "mother" in me wants to – make no mistake on that. However, from a purely logical, (to say nothing of dispassionate), standpoint, the "deployed and mission critical" military personnel should come before nearly everyone else.

 

Here's the No BS, No Personal Agenda, No Political Axe, No Heart Strings, No Philosophically Enlightened Pacifist – reality: The men and women in the military do not have a choice about whether or not they are going to report to hazardous duty. That contrasts with our doctors, nurses, police, fire, and emergency medical services personnel, all of whom do have that choice.

 

Ethically we are obligated to give military personnel in harm's way (of the pandemic) whatever level of protection (meager or otherwise) we are capable of giving. We have, by way of our government, denied them "choice", and in so doing we assume that moral and ethical obligation. To stint on that obligation would be tantamount to spitting in their faces and then pissing on their graves.

 

No one said the choices that had to be made would be easy. No one said that those choices would be pleasant. The plain and simple fact is that in pandemics people die, many well before their naturally allotted time. Babies, toddlers, children, teenagers, young adults, adults in their prime, middle aged, older, and the elderly are going to die in a severe pandemic (should we experience one). Each one will be tragic and almost assuredly needless.

 

Many things could be done to mitigate the deaths that are likely. They could be done by the individuals themselves, their parents, their communities, their local and state governments. Many things could be done by our federal government as well. Few are doing all they could to mitigate the misery and death that may happen.

 

The federal government does not have the responsibility to protect my son; that rests on other shoulders. That responsibility starts as his own, then mine, then his department, then his city, then his state, then, and only then, in the most general fashion, equal with every other citizen and resident of this country, the federal government.

 

Those in the military, especially those deployed, have no rights of self-determination (their "shoulders" carry our "burdens" so there is no room for their own), they often have no family to render them care and protection, they have no local or state government, what they do have however is the federal government – First, Last, and In Between.

 

Morality can vary person-to-person and/or culture-to-culture; ethics, however, are more rigorously defined. Someone could be morally indignant over something that might only produce a bored yawn from me. So, acknowledging Revere's moral indignation over the decision to place the deployed and mission critical military at the top of the allocation recommendation (along with front line medical personnel), I wholeheartedly disagree with it, publicly stated with my own bit of moral indignation tossed in for good measure.

 

Our ethical obligations, on the other hand, are clear – of the Crystal Kind.

 

And, I haven't even touched on the functions those military personnel will be tasked to perform. I'll save that for yet another evening….

 

SZ <Mother of a cop who comes after FL Medical and D&MC Military personnel>

What will it be like?

 

 

What will it be like if/when we have our next influenza pandemic and the public at large discovers the limited initial supply of pre-pandemic vaccine and the first batches to roll off the production line are for specific segments of critical infrastructure? What will we, as individuals, be thinking knowing that the vast majority are not going to receive a vaccine in any timely fashion?

 

Will it come as a shock to most people that they will have to wait for several months – or more?

 

Today from Reuters:

US vaccination plan puts health care workers first

Wed Jul 23, 2008 1:17pm EDT

By Maggie Fox, Health and Science Editor

WASHINGTON, July 23 (Reuters) - Essential health care workers would be immunized first if a flu pandemic broke out in the United States, the government said on Wednesday.

The Department of Health and Human Services released long-awaited details on who would get vaccinated and when if a serious global influenza epidemic emerged.

The plan put a million health care workers, such as emergency room staff and nurses skilled in vaccinating others, at the top. Next were military and "mission critical" personnel, public health workers and hospital and nursing home staff.

All of these play a "critical role in providing care for the sickest persons; highest risk of exposure and occupational infection," the plan read.

[snip]

WAITING MONTHS

Since it would take many months to produce enough vaccine to protect everyone, experts agree a plan is needed to determine who gets the first doses.

The HHS plan designates 700,000 "deployed and mission critical personnel" to follow the key health care workers. After that, 300,000 public health workers, 3.2 million inpatient health care providers, 2.5 million outpatient doctors, nurses and other professionals, and 1.6 million long-term care workers would be next to get the vaccine.

[snip]

Emergency services, law enforcement, makers of pandemic vaccines and drugs, pregnant women and babies and toddlers are also in the first designated groups.

[snip]

Healthy adults not in any other priority group come last.

 

Most people will fall in the later tiered groups, and that is only fair. Those who risk the most, and provide the most benefit to the community as a whole, deserve to be afforded whatever level of protection we can offer them.

 

Human nature being what it is, many will not see the wisdom and fairness of this distribution but hey, sometimes life just isn't "fair". Or, I should say, our operative definition of "fair" given the specific time-place circumstances we are saying "Not Fair!" about. And if we are honest with ourselves we know this to be true.

 

Our officials should be doing themselves [and everyone else in the process] a favor by making every effort to educate the public on the scarcity of vaccine issue(s) before the time comes for the public's shocked and indignant awakening at the dawn of a pandemic.

 

A part of honest and open communication is that all-important COMMUNICATION component. Publishing plans on the internet followed by the odd newspaper article do not constitute "communication"; it constitutes CYA and doing just enough so as not to be guilty of hiding information. I don't believe that is what is consciously being done, but it's also a part of general human nature that in difficult or distasteful situations we tend to do no more than we are minimally required. It's just easier.

 

It's not that I think officials don't know this – quite the opposite in fact – they are well aware. That's what makes their communications failure all the more frustrating, they know what they should be doing, they know the how of it, and they even know the why of it, yet still they fail [see Community Reaction to Bioterrorism: Prospective Study of Simulated Outbreak, here, for just one example of all that in-place knowledge].

 

It's only fair to inform as clearly and as concisely as possible that should a pandemic happen before major innovations in vaccine manufacturing most people will have to manage without a vaccine. It's only fair, not because it will alleviate allegations of unfair practice(s) being leveled by the public, but simply because one should always attempt to be as fair as possible, regardless of our own human natures to want to take the easy way out.

 

Openly admitting, frequently, and via multiple venues, there are no easy fixes or handy stashes of vaccine will produce the greatest potential for educating the public that their wellbeing will be dependent upon their own actions. Focusing on all the wonderful advances on the vaccine front that may not be available in time gives a false impression of supply. Silence in the face of a potentially life endangering belief is akin to validating that dangerous belief.

 

The public must know before they can act, and they must act before there is a pandemic.

 

SZ

Vaccination and morality

 

Sometimes the truth just needs to be said, and sometimes it is said so well that nothing needs to be added.

 

From the blog Denialism:

Excerpt:

Vaccination and morality

Category: Anti-Vax Denialism
Posted on: July 21, 2008 11:08 AM, by PalMD

Who has the moral high ground in the vaccination wars?

My initial response is that I do, "I" meaning the medical and public health fields---those of us who prevent disease, disability, and death.

But it's much more complicated. Many anti-vaccine activists are "true believers". They really believe that vaccines do more harm than good. But, without getting all Godwin, being a true believer doesn't insulate one from moral responsibility.

Those of us who are professionals have made the evidence available. The science is clear---vaccination is a good thing, and more important, it is better than the alternative. True believers will never be convinced by something as simple as truth.

On the front lines, though, are individual parents. They make good or bad decisions based on available information, propaganda and otherwise. The anti-vaccination cults are very effective at communicating lies to these parents, interfering with their ability to make good decisions. It is the equivalent of telling people "water purification is bad. It interferes to our individual rights, and you shouldn't do it. I keeps us from being exposed to vital immune boosters." This leaves individuals wondering what to believe, and the often try to pick the "safest" choice.

In the case of vaccines, this often means that parents chose not to vaccinate. (I don't have statistics on this, but the resurgence of vaccine-preventable illnesses points in this direction.)

Continues…

IMF loans and tuberculosis

 

I admit I am no fan of the IMF, its programs, much less their ramifications.  That admitted, the Reuters piece and the scope of the negative impact surprised even me.

British study links IMF loans to tuberculosis

Mon Jul 21, 2008 7:01pm EDT

By Michael Kahn

LONDON, July 22 (Reuters) - Austerity measures attached to International Monetary Fund (IMF) loans may have contributed to a resurgence in tuberculosis in eastern Europe and the former Soviet Union, researchers said on Tuesday.

Governments may be reducing funding for health services such as hospitals and clinics to meet strict IMF economic targets, the British researchers said.

The study, published in the Public Library of Science journal PLoS Medicine, found that countries participating in IMF programmes had seen tuberculosis death rates increase by at least 17 percent between 1991 and 2000 -- equivalent to more than 100,000 additional deaths. About one million new cases were recorded during the same period.

Nations that received money from other institutions with less restrictive economic conditions attached had seen a nearly 8 percent drop in tuberculosis death rates, David Stuckler and colleagues at the University of Cambridge said.

"IMF lending did not appear to be a response to worsened health outcomes; rather, it appeared to be a precipitant of such outcomes," they wrote.

But an IMF spokesman questioned whether the study took into account the instability following the break-up of the Soviet Union, and said it takes time for the disease to develop so the mortality rates could be linked to something previously.

"If the IMF had not stepped in to help the post-communist countries, the declines in health spending would likely have been more pronounced and disease generally more severe," IMF spokesman William Murray said in an email.

[…]

The researchers used a statistical model to compare tuberculosis rates for 21 post-Communist countries along with the timing and length of IMF loans to other lending programmes.

Even when considering population changes, war, inflation and other factors that can lead to new cases, the researchers found that rising TB rates correlated closely to when IMF funding began.

The size of a loan and length of time a country participated were also important, according to the study that analysed IMF programmes in the region and TB rates between 1991 and 2000.

"We tested a lot of competing explanations and none could account for the patterns," Stuckler said in a telephone interview. "We are not saying the IMF loans are the only determinant but they help explain some of the patterns." (Reporting by Michael Kahn; Editing by Maggie Fox and Sami Aboudi)