AFD - H1N1 Pandemic Analysis

[sharon sanders]

A Tale of Two Pandemics


# 3228



A popular sport in the media these days seems to be taking pot shots at the WHO and the CDC for raising the alarm over what has, so far anyway, not turned out to be a horrific pandemic threat.

While I believe the jury is still out on what this virus ends up doing, pundits who snort, and write about the H1N1 virus with derision and scorn, may actually have a point.

At least if you are relatively well off financially, live in a developed country with good medical care, are in relatively good health, and are older than the `target age? for this virus ? which seems to be from about 5 years ? to 24 years of age.
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If you meet these requirements (and shouldn?t everybody?), then this virus understandably scores pretty low on your daily threat assessment.

At least as long as hospital beds in your community remain available, and antivirals continue to be effective against this virus. Otherwise . . .
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Of course, if you have a pre-existing condition, or live someplace where medical care isn?t quite so readily available, then this virus might be a wee bit more of a concern.

The WHO is the `WORLD? Health Organization, not the `Middle-to-Upper Class American/European Health Organization?.

Sorry, I know for some people, that has to come as a bit of a shock.

Not only do the billions of people who live in developing countries outnumber the rest of us, their health and wellbeing actually count.

At least to some people.
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The WHO actually has to consider what the impact of a disease might be in Haiti, or Cameroon, or Vietnam. Or how it might spread in mega population centers like Lagos, Mumbai, or Sao Paulo, or how it will affect the millions with Tuberculosis, or HIV around the world.

And the CDC, which also supports health agencies in countries worldwide, has to concern itself with the health of millions of Americans who live without health insurance, and the burden that even a mild pandemic would put on our already over-stressed health care system.

For these agencies, a `mild pandemic? is still a big deal.

Even if it doesn?t meet some people?s expectations that a pandemic must mean we?ll see push cart operators roaming our city streets crying `Bring out your dead?, or a collapse of civilization as we know it.
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Consider for a moment that we may very likely see two very different pandemics from this virus.

A relatively `mild pandemic? for developed countries where antivirals and antibiotics are available, and a moderate or even severe one in developing countries where they are not.
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It?s true.

We may find that this novel H1N1 virus will prove no more troublesome to Americans and Europeans than did the 1968 pandemic, which was so mild that many failed to realize we were having a pandemic.
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I certainly hope so, although that outcome is far from assured.

But even if that happens, that doesn?t let the rest of the world ? or the WHO and the CDC - off the hook.

Public Health agencies, and NGO?s like CARE and Save The Children, are engaged in a daily battle against disease and poverty around the world.

The already have to contend with the death and suffering caused by poverty, cholera, malaria, TB, HIV, and scores of other diseases.

Adding an influenza pandemic into this mix, even a `mild? one, is not going to make matters any easier.

It will undoubtedly add to their workload, stretch their meager resources even thinner - and despite their best efforts ? claim hundreds of thousands of lives around the world.

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To get an idea of what some of these agencies are dealing with, I would invite you to visit some of their websites.

• CARE
• Humanitarian Pandemic Preparedness H2P
• Save The Children

Just because the worst may not happen in the better neighborhoods of Los Angeles, London, or Paris doesn?t make a pandemic any less real, or any less important to deal with.
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While some pundits may find it hard to believe, it can?t always just be about us.

* * * * * *

Now is a good time to remind my readers that agencies like the Red Cross, Red Crescent, CARE, Save The Children, UNICEF, and others are working around the world every day to combat poverty and disease, and are going to be on the front lines during any pandemic.

They could use your support.

These NGO?s do a great deal with very little, and even small donations can help make a difference.

 

[sharon sanders]

Re: AFD - H1N1 Pandemic Analysis

CDC Estimates 1 Million Americans With Swine Flu



# 3394

It?s a subject that has generated considerable speculation over the past month or so.

With the number of `confirmed cases? here in the United States running in the mid-twenty-thousands, and our inability to test everyone, how many people really have caught this virus?
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According to this report, carried by the AP, that number is estimated to be near 1 million.

US swine flu cases may have hit 1 million

<cite>By MIKE STOBBE, AP</cite>
<abbr></abbr>
ATLANTA ? Health officials estimate that as many as 1 million Americans now have the new swine flu. Lyn Finelli, a flu surveillance official with the Centers for Disease Control and Prevention, voiced the estimate at a vaccine advisory meeting Thursday in Atlanta.

The estimate is based on mathematical modeling. Nearly 28,000 U.S. cases have been reported to the CDC, accounting for roughly half the world's cases. The U.S. count includes 3,065 hospitalizations and 127 deaths.

An estimated 15 million to 60 million Americans catch seasonal flu each year.
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This is no doubt, a rough estimate. And of course, the number of deaths registered from this virus are likely badly under-counted as well.

Still, it?s nice to get some idea of the size of the ballpark we are playing in.

 

[sharon sanders]

Re: AFD - H1N1 Pandemic Analysis

Categorically Speaking



# 3391




A little over two years ago the HHS released a pandemic severity index system for the United States. It categorized pandemics into 5 levels, with Category 1 being the weakest and Category 5 being the strongest.

To put things in perspective, the CDC estimates that in a normal flu season, 36,000 Americans die (indirectly or directly) as a result of influenza.

While this number may be flawed (it is derived from mathematical modeling, not an actual count), it is the benchmark against which pandemics are judged.
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The assumption is that in a pandemic (any category), 30% of the population would fall ill.

That is an estimate, based on the data we have from the pandemics of the 20th century. In the UK, the government?s SAG (Science Advisory Group) has suggested that number could go as high as 50%.

The truth is, every pandemic is different, and no one really knows. But we need some numbers to plan from, and a 30% attack rate has been deemed reasonable by many planners.

This is roughly 3 times the number of people normally stricken in a year by influenza.

Which means that a virus with the same virulence as seasonal flu would have 3 times the impact, based simply on the increased number of people infected.
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Three times higher absenteeism, three times as many hospitalized, and likely, three times the number of deaths. And many of those deaths will involve children and young adults.

No . . . not a Stephen King apocalyptic pandemic scenario, perhaps, but quite nasty in any event.
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The greatest impact would probably be felt in the health care field, where a tripling of emergency room visits, hospital admissions, and the need for ventilators or ICU beds would constitute an enormous challenge.

During a normal `bad? flu season, which we see every few years, these facilities are badly taxed by far fewer patients. Some hospitals are forced to temporarily suspend elective surgeries, and some emergency rooms have to close to traffic, simply because they are overwhelmed with flu cases.

Added to that would be a likely tripling of employee absenteeism due to the flu.

At a time when demand for services would be at its highest, the ability of these facilities to provide it would be at its nadir.
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So while a Category 1 pandemic virus may prove no deadlier than seasonal flu, its impact can be significantly higher.

A Category 2 pandemic would have a considerably greater impact, even though the virus would still be considered `mild to moderate? in severity.

If seasonal flu kills 1 in 1,000 (the CDC?s estimate), then a Category 2 pandemic virus might kill anywhere between 1 and 4 in 1,000.

Statistically, the odds of dying in a Category 2 pandemic are still pretty low, but the impact on society grows significantly.
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Here in the United States, that could translate into anywhere between 90,000 and 450,000 deaths. Globally, a Category 2 pandemic could kill between 2 and 10 million people.

Two pandemics of the last century would probably have fallen into this category. The 1968 Hong Kong Flu was probably a weak Category 2 pandemic, while the 1957 Asian Flu was probably a moderate-to-strong Cat 2.

Just as with hurricanes (which use a similar scale), the higher the category, the more damage you can expect. The ultimate `viral storm? would be a Cat 5 pandemic, such as we saw in 1918.

Luckily, that level of virulence in an influenza pandemic virus appears pretty rare. Recent history (the past 120 years or so) indicates that the lower virulence pandemics are more common.

The question before us is, what Category pandemic is Swine Flu?

And the answer is; We don?t know yet.
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Having a scale is one thing, having the tools to measure the `viral storm? is quite another.

And right now, our tools are meager at best.

In many ways it reminiscent of the way things were with hurricane forecasting when I was a youth, growing up in Florida. For those under the age of 50, it is probably difficult to comprehend how things were before the advent of the weather satellite.

Up until the early to mid 1960?s, the only way we knew there was a hurricane out in the Atlantic was from ship, island, and aircraft reports. Storms would sometimes get `lost? for hours or even days, when they moved beyond land-based observations.


Instead of having 48 or even 72 hours warning of an approaching hurricane, it wasn?t uncommon to get only 12 to 24 hours warning. And as far as intensity was concerned, that was even less precise.
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Our ability to monitor the virulence and spread of the H1N1 virus is pretty much in the same league.

We have a great many `blind spots? in our global surveillance system, and so a certain amount of guesswork is required to figure out the strength of any pandemic virus.

Allowing that the H1N1 virus could change and become more (or less) severe, right now it appears that we can eliminate the higher pandemic categories from consideration.

If this virus had a 1% or 2% (or higher) fatality rate, even with the spotty surveillance available globally, we?d know it by now.
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And it appears unlikely that the virulence rises to the level of a CAT 3 pandemic, either. Which, for now at least, leaves the bottom 2 categories in play.

And while the relative impact of a CAT 1 vs. a CAT 2 pandemic can be great, the measuring stick - the fatality rate (CFR) of the virus ? need only change a little to move the pandemic from one category to the other.

At this point in time, we simply don?t have a global surveillance system in place that can tell us if this virus is killing 1 out of every 1,000 people it infects . . . or 2 or 3 out of 1,000.
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Complicating matters, the CFR is likely very different from one community to another. What may turn out to be a CAT 1 pandemic in Ottumwa, Iowacould well end up being a CAT 2 pandemic in Buenos Aires.

Of course, the fatality ratio isn?t the only measure of a pandemic. The attack rate, the percentage of people affected by the virus, can be every bit as important.

According to the Utah Health Department?s website, in their June 24th Situation Report, the CDC is working under the assumption that the H1N1 virus will spark a CAT 2 pandemic.
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This doesn?t appear to be a determination, only an estimate, and according to the press release, the CDC is watching events in the Southern Hemisphere closely for validation of that estimate.

This would be in line with what we?ve seen to date. Something on the order of the 1968 or 1957 pandemic.

Whether it will trend towards the weaker 1968 event, or ramp up this fall to a 1957 style pandemic is impossible to know right now.

And of course, some places may see a greater or lesser event.
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The Deseret News this morning has a statement from the Utah Health Department that sums up things pretty well. A hat tip to AlaskaDenise and Colormyquilt on Flutrackers for these links.

"The public remains our most important partner as we respond to this developing pandemic," said Dr. David Sundwall, health department executive director. "One thing we can be sure of is that this virus will continue to change over time and we want to make sure Utahns don't let their guard down in terms of protecting themselves and others."

Officials continue to monitor any changes in the severity of illness that those who contract the virus are experiencing. They are concerned that it may become more virulent in the fall and spread more widely as cold weather begins. If that happens, Utahns may be asked to take additional steps to limit its spread.

"Families should begin preparing for what they would need if they are asked to spend a week away from school, work or other activities. Now is the time to update, or create, your emergency stockpile. Items like food, water, tissue, sanitizers, over-the-counter medications and prescription medications are all useful items to have on hand in the event you become ill and are confined to your home," officials said in a press release.
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Good advice, and not just for the people of Utah.

 

[sharon sanders]

Re: AFD - H1N1 Pandemic Analysis

Johns Hopkins Summer Flu Report



# 3396


The Johns Hopkins Bloomberg School of Public Health has released a flu-centric summer edition of their magazine, with articles and audio files on the emerging H1N1 pandemic.

I?ve not had an opportunity to listen to all of the audio files, but I intend to later tonight. In the meantime, I wanted to pass on these links to my readers.

A hat tip to AIDigest for these links.

Start with 5 LESSONS about H1N1 and then move on to the audio files (see below).

Prelude to the Fall: Special Flu Report

Welcome to the summer of unease. The new H1N1 influenza virus that emerged in Mexico in April quickly ignited outbreaks as far away as the U.K. and Japan. As epidemiologists accumulated data and scientists probed the novel virus, they found H1N1 was neither as virulent nor as lethal as first suspected. But the quick-mutating influenza virus should never be underestimated. To learn what might happen?and what should happen?

Meet H1N1

In this interview, Pekosz provides a nuts-and-bolts introduction to the H1N1, what makes it and other influenza viruses so dangerous, and just what those H's and N?s are all about. Interview by Brian W. Simpson, editor of Johns Hopkins Public Health.
Listen Now

Influenza: Past, Present, and Future

What was the 1918 flu pandemic like? What would happen if it struck today? Take a tour of the 20th century?s great pandemics with Bloomberg School virologist Andrew Pekosz?and learn how the latest H1N1 compares with them. Interview by Johns Hopkins Public Health editor Brian W. Simpson.
Listen Now

Manufacturing H1N1 Flu Vaccine

Will there be enough vaccines to go around? Respiratory virus expert Ruth Karron gives us a quick lesson in how vaccines are made, the challenges to meeting the demand in a pandemic, and novel approaches that could step up the global supply. Interview by Johns Hopkins Public Health associateeditor Christine Grillo.
Listen Now

How Do H1 and H5 Compare?

The Bloomberg School?s respiratory virus expert, Ruth Karron, tells us how the two influenzas are exact opposites of each other?and what to watch for with both. Interview by Johns Hopkins Public Health associateeditor Christine Grillo.
Listen Now

Tracking the Pandemic

From the first reported cases in Mexico, the H1N1 influenza virus spread globally with frightening speed. This timeline, based on WHO statistics, shows how the virus leaps borders and continents, spreading from a handful of cases to tens of thousands in a matter of weeks.
Photo Gallery

 

[sharon sanders]

Re: AFD - H1N1 Pandemic Analysis

Some Thoughts 60 Days Into The Outbreak



# 3403


It?s now been just over two months since the H1N1 virus first leapt into the headlines, and nearly 380 blogs later, I?m the first to admit that I don?t know where this H1N1 pandemic is going to lead us.

So far, this virus seems to be relatively `mild? for the vast majority of people. But, for an unlucky small percentage of cases, it produces severe ? sometimes, even fatal ? illness.

Which is pretty much what you see with seasonal flu.

Except . . . with this flu, the age groups hardest hit are much younger than we normally see with influenza. A lot younger.
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For weeks people have been trying to figure out if this flu is more, or less deadly than seasonal flu. I?m not sure we know the answer to that question yet.

I know that if you take the estimated number of cases around the country ? or around the world ? and divide it by the known number of deaths, you come up with a `comfortingly? low CFR (Case Fatality Ratio).

And I am comforted by this number.

But I?m not convinced we have a good handle on either the number of infected or the number of deaths, and so I take these calculations with a very large grain of salt.

I think we would have noticed by now if this virus had a particularly high mortality rate, although there are some worrisome reports coming out of places like Manitoba and Argentina.

For now, it appears that that this virus has roughly the same virulence as seasonal flu, albeit with a disturbing predilection for younger victims.

That could change over time, of course, and may vary right now between different populations and societies.
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So . . .assuming that this virus isn?t any deadlier than seasonal flu, why do we care?

First, we care because this is a novel virus, one that most humans have no immunity to, and that means that over the next year or two, a lot of people are going to catch it.

During a pandemic, 2 to 3 times more people are infected each year than normal. And so, even with a low mortality rate, the number of people that could die can double or even triple over that of a normal flu season.

That would also mean double or triple the number of people needing hospital care, and much higher rates of absenteeism from work and school.
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With this virus hitting younger adults and children disproportionately hard, it will also have a greater psychological effect than we see with seasonal flu, which primarily kills the elderly.

All of these things can have a serious impact on our society, our economy, and our ability to deliver essential services. Particularly health care.



Since the last pandemic, 42 years ago, we?ve reduced the surge capacity of our hospital systems considerably, in order to streamline them and save money.

We?ve neither the beds, or the staff, to care for hundreds of thousands of additional flu patients each year.

To make matters worse, HCWs (Health Care Workers) are likely to suffer a high rate of infection and absenteeism, further degrading the system?s ability to cope with a surge of patients.

We may also find ourselves facing shortages of ventilators during the peak of the flu season, and having to make tough choices about who gets one, and who doesn?t.

And all that assumes this virus doesn?t pick up virulence.
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Which brings us to our second big concern.

Influenza viruses are inherently unstable. They change over time. Sometimes they become milder, sometimes they pick up virulence, or resistance to antivirals.

Which is why we need to reformulate our flu vaccines every year or so, because influenza is always a moving target.

Over the past year, the seasonal H1N1 virus (a distant cousin of the pandemic H1N1), has become almost 100% resistant to oseltamivir (Tamiflu). There are serious concerns that this pandemic virus could, over time, acquire the same resistance.

That would seriously compromise our ability to treat people with severe influenza symptoms, and would probably drive the fatality rate higher.
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And, as we saw in 1918, and to a lesser extent in other pandemics, the first wave can be deceptively mild. As this virus replicates in more and more hosts, the odds of producing a dangerous mutation (or a reassortment with another virus) goes up.

It is impossible to predict what `Swine Flu version 2.0? will look like, or when it might be released. It might actually be less virulent than what we see today.

But it could also be much worse.

Even if we ignore the possibility of something worse coming down the pike next month, or next fall, or in 2010 . . . the pandemic we have right now will no doubt serve up plenty of grief.

And so it is prudent that we take this pandemic seriously. That we take reasonable steps to prepare our families, our businesses, and our communities to deal with it.

Even if it appears `mild? or `moderate? right now.

To learn how, visit the HHS?s pandemic website www.pandemicflu.gov.

There has never been a better time to volunteer to help with the American Red Cross, The Medical Reserve Corps, CERT, or your Neighborhood watch.

And if your pocketbook can stand it, there are organizations like the Red Cross, Red Crescent, CARE, Save The Children, UNICEF, and others that could use your financial support as well.
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If, for most of us, this pandemic turns out to be a non-event, we can thank our lucky stars. But as we do, we need to remember that not everyone will be that fortunate.

There will be families all over the world impacted by this, with many enduring terrible losses. Regardless of the overall statistics, for them, this won?t be a `mild? pandemic.

There will likely be economic, political, and probably even international diplomatic fallout from this pandemic, as well.
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As I stated at the top of this essay, I don?t know where this pandemic will lead us.

But I do expect it to be a bumpy ride.