Comment on Post at Effect Measure
Interesting thoughts.... and even more interesting to those of us who live in smaller cities and towns and wonder about the prospect of people "invading" when fleeing from a potential danger in the metro areas.
Constitutionally I believe it is the responsibility of the local mayors to respond to any pandemic.
The federal role is limited to awarding fat contracts to bury the dead after the fact, and appoint the committee to determine why there was no warning.
The federal government's role in controlling the populace will be small because the federal government is just not that big.
The federal government can seem big in a local disaster. But that is only because local disasters are, well, local. Scale up to a national level and the National Guard of several states can't rush in to reinforce a single state. Besides, National Guard call-ups aren't going to work real well. Why go out there and risk getting exposed to badly behaving looters and such?
As for fleeing: Suburbanites do not need to flee. They can avoid breathing viruses if they just avoid other people in close quarters. Their odds of getting the virus if they just go into deep cocoon mode and stay in-doors for weeks at a time. This needs to be explained to the suburbanites so that they do not panic.
This is interesting for sure - especially after what we witnessed during the Katrina mess. Another thing that has me thinking is how the provision in the USA PATRIOT Act to quarantine people against their will play out. I can't imagine the quarantines the gov't sets up will be any better than what went on in the Superdome.
Ooopps, meant to close the italics tag after the word "local".
eRobin,
Where will the staff come from to grab people and transport them to quarantine facilities? They won't all go to quarantines voluntarily. I think the US, state, and local governments will be overstretched.
I wonder if we will see urban riots. I also wonder if the response to those riots will be extremely brutal. After all, police and soldiers will not want to get close to rioters and looters. They'll prefer to shoot from a distance. Plus, law enforcement will be very overstretched. So they will need very brutal methods to compensate for being short-staffed.
Randall:
>Where will the staff come from to grab people and transport them to quarantine facilities?
I've always thought that the first order out of the West Wing after the quarantine subject has been broached (not instituted, just brought up) would be to recall all troops from the Middle East.
Constitutionally, there's a problem with federal troops rounding up citizens, but a good portion of the troops that will be recalled are Guardsmen. Of course, they will stay federalized and under Army/Navy/AF control (to prevent desertion).
Of course, that's just been my thought. I have no proof or verification.
I believe panic will not occur until bird flu deaths are really happening
in the US. When they are really happening---it will not just be one city or one town----but many cities and towns simultaneously. Once a few well known celebrities die of bird flu---the major cities will start having the mad panic and exodus. This will only serve to spread the disease further and faster. Quarantine efforts in major cities will fail due to a lack of enforcement manpower and public knowledge.
Chaos will be the new world order.
I have been greatly discouraged by the failure of communications and false government statements during the Katrina tragedy.
Government is not to be relied on.
Hospitals will not be able to cope and will close. The poor will suffer disproportionately. No one will take responsibility for them.
I think that most people will realize that if the flu is (or could be) everywhere, then it doesn't make sense to flee. It's best to stay home.
This could change, in the short term, if there is a noticeable hotspot or internal quarantine. But really, I don't see the odds of internal quarantines being that great. Once it's in the country, it's in. I expect a few localized panics, perhaps recurring, but I don't think there's going to be mass migration. Nor do I think that there's going to be a huge breakdown of food distribution and so on; some people are going to get the flu, and of those probably 95% plus will survive, and the survivors will presumably have immunity and can distribute food for everyone else.
One thing is for sure: there will be no worthwhile Federal response. This is the Bush administration; no "responsible person" is working on anything.
It all depends on the death rate and whether basic services, especially food delivery, break down.
If the death rate is less than 1%, Rich Puchalsky is right. If the death rate is over 10%, Earl E. is right.
Most people will not quietly sit in their homes waiting to starve. No food = anarchy. Again, what's the plan for feeding New York?
Rich, you are making alot of assumptions, some of them contradictory. You assume a well-organized response to food delivery problems, yet correctly point out that there is no evidence of a plan from the current administration. They will have exactly 2 days to figure it out if food supplies are disrupted. People will not wait longer than that before they begin foraging.
Do you really believe that the current administration will figure out how to feed 8 million New Yorkers in 2 days?
I have always been under the impression that any quarantine order would be a 'shelter in place', not a 'gather together in a big crowd increasing your chances of exposure'. I have only passing familiarity with past pandemics via general reading, but it seems to me every historical account, be it fact or fiction, has had households quarantined in place.
If the government and media would start honest discussion of what could happen and give people the directive to stock up for more than 10 days as advised on ABC's Primetime last week, then I think that people would be able to respond to a quarantine order in a rational fashion.
There is also the issue of explaining the difference between quarantine and isolation--quarantine keeps well people from getting sick. Isolation keeps sick people from infecting the well.
Quarantine should be explained not as 'you're in a hot zone' but as 'traveling and contact with others is unsafe so stay home'. This is a message that needs to start reverberating around the 'flubie' community so that it can seep into the 'newbie flubies' as people become aware of this issue and come online to learn more.
Authorities also should determine what criteria will be used to lift quarantines. If, for example, we determine that the incubation period is by six sigma criteria always less than 10 days, then a quarantine of 11 days should cause all cases to become manifest--after that time, apparently well folk who are not in a household with a sick person could be de-quarantined and those houses with an infection could be labeled 'in isolation', with resources and food delivery provided for households in isolation status so that this is not a death sentance and purgatory but a way to contain the menace and target help specifically to the households that need it.
So far the mainstream media has focused on scaring the hell out of the public that this is dangerous and that they should pay attention. But they have done nothing to realistically convey what the public needs to do to take part in their own protection. I don't know how to get the media to do this. Any thoughts?
Lisa - I've just been trying to think about what you say, only you've come farther.
I think we need to place that information in the hands of Neighborhood Watch teams, so they may self-organise.
Food may be in my home or in a neighbour's home, if we play our cards well.
We need to empower the Block Champions.
Let's build us/them a HowTo document which we will then translate etc.
Yes!
Monotreme, I expect local organization to take over once it becomes apparent that the situation is really serious. New York in particular is likely to be well-organized; it is further advanced in pandemic planning than any other major American city that I know of and has enough management culture in place to handle the not very difficult problem of ensuring that enough truck drivers are well paid enough and Tamiflued enough to be willing to do the not inherently risky job of driving food stocks into distribution points within the city. There are probably enough existing food stocks in the country as a whole to feed everyone for the initial period, if they are distributed. And you don't have to get things in place from 2 days after the outbreak; people will have some existing food stocks.
Other places may not have their local organization come through. In many of those places, the local police response will be the same as that of the police in Greta after the New Orleans flood -- put up a roadblock on the highway into town. I don't doubt that some places are going to panic. But I do think that you may actually end up safer in a large city like New York than you would in many places that are smaller and have no ongoing need to organize anything but police response.
Rich,
I'm afraid I don't agree with you about NYCs preps. My understanding is that they've done a few tabletop exercises and that is it, publicity statements to the contrary. Where is the stockpile? Where is the plan?
Let NYC put their preps on the web so we can see them. I've heard the "Don't worry, we've got it covered" story before. I don't believe it.
Energy, especially in the northern states, will become a major problem. If people at generating plants get sick we could be in for a very bad winter. I thought about this after a heavy snow left us powerless for four days. If there is no power for an area in winter then there also is no electricity to run gasoline pumps even for those of us prepared with generators. In cities this could leave many trapped in high rise buildings with no heat or water. If you think of all the ramifications especially with complex nuclear energy stations and no one well enough to run them-- well it gives me the creeps. Four days without power, I wonder if any in our government have experienced anything like that- I think not.
Lisa (or anyone): Please consider calling the county office of your state's Cooperative Extension system.
The nationwide Extension network, the public outreach arm of the nation's land grant universities, could prove extremely useful in getting high-quality information to ordinary people, especially if you offered to provide briefings and in-service trainings to Extension leadership.
Cooperative Extension field staff in many states work in every county and most local communitiy in their state. Field professionals mostly have advanced degrees in sciences or social sciences, and they are motivated to serve the public weal. Typically, they also participate in numerous partner networks.
The organization has professionals (often supported by hordes of well-trained volunteers)in natural resources (agriculture/horticulture, forest resources, water resources), family (parenting, money management, health, nutrition), and youth development (4-H).
Also important: they have nationwide communications networks that could spread the information rapidly.
Approach Cooperative Extension leadership respectfully and professionally; summon well-known and respected political figures to support you if possible.
Big obstacles for Extension in situations where they need to move quickly: their close ties to govternmental funding sources (USDA)and their three-to-five year plans of work. Makes 'em risk-averse to an extreme. Pitch to their public spiritedness first, survival instinct close behind.
Here is a short symposium they did in New York yesterday---with a stellar group of experts. I wish I could have been there to ask questions, like "Which are you more concerned about? Economic losses or people losses?
http://www.upmc-biosecurity.org/...nflu/
index.html
http://www.upmc-biosecurity.org/
...onsors.html#cpe
I like the "neighbors, let's prepare" idea.
Now it could be planned on paper, but no one will go for it until the pandemic obviously starts.
I do hate to be so grim.
We have too many unknowns right now:
Everyone would like clear ANSWERS to the questions of:
When is the pandemic starting?---What will the fatality rate be?---What percentage of people will catch bird flu?-----How long will the pandemic last?------What drugs will definitely work?----Who will get priority for the vaccine after it takes 6 months to make?---How will you give it to people securely?----Who will take care of the poor?----Who is going to pay for all this?---Who will provide security?---Are food, masks, gloves, medical supplies being stockpiled?---Will the power stay on?---How will I pay bills if I cannot work?
There are no answers now. That is what is so frightening.
http://www.firemarshals.org/miss...HS5-
24FINAL.pdf
It's time to start warning people that those effective, convenient, alcohol-based hand cleaners will function as a small flamethrower squeeze-bottle.
When the power fails and the candles come out each one, and any stockpile of them, will be a source of rapid combustion if not carefully handled.
God forbid a terrorist gets control of one, of course.
Watch for them in the fire exits of a health care facility near you; they were approved for use there in May 2005 against strong objections about safety, among them the document linked above (multipage PDF)
QUOTE
Exit corridors are the primary means of escape during a fire ... as places building occupants can be protected, feel safe, and allow for an unimpeded escape. The introduction of flammable liquids to this “protected” environment in the quantities allowed ... appears to be contrary to everything fire safety officials know about protecting exit corridors. In health care facilities in particular, where many of the occupants are ill, immobile or otherwise impeded ... the protection of exit corridors must never be compromised.
.... does not address maintenance or the consequences of improper installation and use, or intentional acts. With limited staffing and higher patient-worker ratios these devices can, and will, become troublesome over time. This, coupled with the allowed storage and use quantities, represent the components for disaster....
ENDQUOTE
Monotreme, I'm not suggesting that somewhere there is a plan worked out. What I'm suggesting is that the technology of food distribution is old, early 20th century stuff. Mostly, it's just basic organization. It is not that hard to distribute food if you are motivated to do so and if there is no natural disaster physically blocking the roads.
So much of the pessimism here appears to be based on the idea that society now can not do what society used to be able to do more than 50 years ago. That's Republican and libertarian propaganda, not reality. That and a disturbing tendency to be attracted to Mad-Maxism.
11 dogs, I don't buy the "power plants going out" idea. If what's going around is flu, then even pessimistically 9 out of 10 people who get it are going to get over it and go back to work. If what's going around is hysteria, then critical workers are going to be rousted out and sent to work, whether with bribes (more money, protective gear), through a desire to be useful, or through police escort. The idea that everyone is going to sit around and do nothing isn't credible. I mean, you can come up with a scenario in which both the flu is maximally deadly and society at all levels is maximally incompetent. But it just isn't very likely.
Just so I don't sound totally hopeless, let me suggest that even in the big cities there are things people can do. The most important thing is to put their city officials feet to the fire. In New York, there is a campaign going on for Mayor. Before the democrats coronate Mayor Bloomberg, maybe someone should ask him to spell out his plan.
Ask Mike here:
http://www.mikebloomberg.com/ask...ike/
answers.cfm
Rich, if you have confidence in Mayor Bloomberg, please ask him how he will handle city services and food delivery during a pandemic and post his response here.
There's a rumor that there's a democrat running against Mayor Bloomberg. Is this true? If so, maybe this guy could actually try to win (shockingly bad form for a democrat, I know) by asking Mayor Bloomberg to spell out his pandemic plan during a debate, assuming there will be one.
I don't think that who the mayor is is really going to be that important specifically for this issue. What the mayor is going to do is turn to city staff and say "What do we do now?" And NYC has enough staff so that they'll come up with something, because the city is sufficently large and complex enough as it is so that they need to have people capable of large-scale organization.
Having a foresightful leader and a plan would help, yes. But no one really knows what's going to happen, so there is a good chance that any plan would be overtaken by events in any case. What's important to have are competent people. And a large city is to a certain extent forced to have them by the pressure of ordinary events, and has the resources to hire them. Since it will be quickly clear that the Feds aren't going to do anything, they won't be under New Orleans' double penalty of both waiting ineffectually for the Feds to step in and of having the most corrupt police force and so on in the country to start with.
Rich, I would like to clarify something just in case you are not up on the topic. You said "if what's going around is just the flu, then 9 out of 10 people will come back to work".
First of all thats a much higher rate of non-return to work than we've seen with any prior epidemic, including 1918.
Second, currently the only data we have on the new flu H5N1 is that it kills 50% of those infected. So the worst case scenario is half of those who go out sick don't return to work.
While some may argue that the 50% figure comes from third world nations, I would like to counter that with the argument that the small number of cases to date means that people who needed respirators got them. In a pandemic, that will not be the case, which I think offsets any increased mortality due to poverty/nutrition factors.
We don't know if that mortality rate will change or not when this mutates to a transmissible form. But it is starting from a worse mortality than has ever been seen with flu.
Lisa
Does Rich Puchalsky live in New York City?
Rachelle,
I'm afraid that Rich cannot possibly live in NYC. Either that, or he is a comedian.
Rich:
"What the mayor is going to do is turn to city staff and say 'What do we do now?'"
Yeah, that part I believe.
Rich:
"And NYC has enough staff so that they'll come up with something, because the city is sufficently large and complex enough as it is so that they need to have people capable of large-scale organization."
Ha, Ha, Ha. Funny Rich, that is hilarious. Anyone who lives in NYC or who works for the City want to tell Rich the sad truth.
Lisa, I really would expect better from you as a GP. The version of the flu that kills 50% (if it actually does, i.e. if the mild cases aren't going undetected) is not a version of the flu that is easily human-to-human transmissable. There has never been a flu pandemic, including the 1918 one, in which the flu was both easily transmissable and had such a high death rate. There is no reason to expect that there would be, and various good reasons to expect that such a flu would not be likely to be one that is highly transmissable. Of course, it is possible. Many things are possible. I don't think that we're well served, in a situation in which a flu that may kill 3% of those infected is quite possible, to spend time on truly improbable events.
As for the rate of 9 out of 10 returning being too high, I stated that I was being pessimistic.
Rachelle, what does it matter where I live? I'm the only one commenting here under my real name, and if you are one of those disagreable people who likes to poke into people's lives, you can quickly Google most things about me.
There has never been a flu pandemic, including the 1918 one, in which the flu was both easily transmissable and had such a high death rate.
But has there ever been any flu AT ALL with such a high death rate? If not, then you're drawing your conclusion (that flu viruses tend to decrease from very high to relatively low mortality when they become pandemic) based on zero relevant data points. (For that matter, how many pandemics do we have decent data for? Not many...)
(How does one of us comment on "constructiveness and respect" without being destructive or disrespectful?)
How My Friend Was Killed By A Fly
John and I are reporters for the New
York Times. We we sent to the Central
Java Province in Indonesia to observe the work of researchers from the local university.
They had recently discovered that some of the flies in Central Java are infected with bird flu.
After we arrived in Central Java, one day John and I were outside eating lunch. A fly landed on John's sandwich. He ignored the fly and continued to eat the sandwich.
Five days later John became sick
with bird flu, and after two weeks, he
died.
Juan, is that a real story or a made up one? Link?
A lot of the arguments against a highly lethal virus becoming easily transmissible rely on the assumption that a highly lethal bug makes its victim so sick so early that there is very little time for the host to encounter potential new hosts before they become incapacitated.
This is not the case with H5N1. Like other flu viruses, H5N1 has a few days of asymptomatic viral shedding before the patient becomes ill. For cases with known bird exposures in Vietnam, that latency period has been 2 to 4 days, with an average of 3. This is comparable to that for ordinary flu. Therefore this mechanism does not have any more selective pressure toward a 'milder' H5N1 than it does on ordinary seasonal flu; the virus still has ample opportunity to get out of its host and into a new one even though it is highly lethal.
Ordinary flu can be transmitted by contact, by droplet, and by fomite (contaminated surfaces). In the case of H5N1 there is also fecal contact transmission, as in both birds and humans H5N1 replicates in intestinal epithelial cells as well as lung cells (roughly 70% of human cases have diarrhea, which is unusual in other flus). All these modes of transmission have been seen with H5N1 in birds. All but fecal are seen in ordinary flu.
Comparing the situation of pandemic in birds to the situation of ordinary epidemics in people suggests that the viruses have a similar degree of hardyness on fomites in the environment.
If you think about the steps of transmission, you have to start with a host that is producing virus. We know H5N1 can do this in humans. Then that virus has to get into the environment where it can encounter other possible hosts. We know that H5N1's victims are walking around long enough before becoming ill that they might do this, but we don't know how easily H5N1 can get out of a human host. Then it has to survive in that environment. We know from the epidemic in poultry that H5N1 can do this. Then a new susceptible host must contact that virus in sufficient quantity for the virus to infect some cells. We don't know what quantity that is for humans and this may be what has saved us so far. Then the virus must replicate within those cells. We know H5N1 can do this in humans.
I submit to you that the limiting steps in this chain that have protected us so far are the virus getting into the environment from a human host, and the virus getting into the cells of a new human host.
Currently H5N1's RNA replication relies in part on a protein whose optimal operating temperature is that of a bird's lung. This is hotter than the lungs of humans, but similar to that of the human gut. The result is a virus that stays in the warmest parts of the lung, which quickly loose aeration due to damage and possibly 'cytokine storm'. The location of the infection and its poor aeration mean that less virus comes out when a person coughs than with other forms of flu that can replicate efficiently in cooler areas of the respiratory tract, closer to the exit, so to speak. This reduces the amount of virus that can get into the environment from a human host even if s/he's walking around for 2 or 3 days.
You can put birds in proximity to an H5N1 contaminated environment and they get sick, while their handlers do not pick up the virus. Is this because it requires a larger initial viral load to infect the humans, or because the chickens are breathing closer to the ground and flapping up dust of infected feces, thereby getting a higher viral dose? It is unclear what the infective dose of this virus is for humans; if elevated above the typical flu's '1000' or so viral particles, then this could also be protective and might explain why we don't see 100% infection in poultry workers.
Now, the unusual mortality of this virus is due to a 'cytokine storm' like that seen in the pandemic of 1918. TNF-alpha is invoked by the body in fighting normal flu; H5N1 causes a dysregulation of TNF-alpha production, resulting in a gross over-expression of TNF-alpha in the lungs. This causes a sort of 'cascade failure' of the immune system, causing excessive cytotoxic chemicals to be released in the lungs, destroying them. It is by this means that the H1N1 of 1918 is thought to have killed people in their 20's to 40's--those with the strongest immune systems--sometimes within a single day of onset of symptoms. I do not know if it is known which portion of the virus interacts with the TNF-alpha regulatory mechanism.
At this point there is no clear reason to suspect relationship between the ability to muck with TNF-alpha regulation and the ability to replicate RNA at a lower temperature or to gain entry to a human cell. Therefore I see no reason why mutations in these latter two areas, which would allow for efficient human-human transmission, would necessarily have any effect whatsoever upon the mortality rate of this virus, which is related to the former.
Because we have so little data we are left with these 'rationalist' conjectures as to what could happen. As of yet there is no known mechanistic reason why a change in transmissibility would have to be accompanied by a change in mortality rate.
Therefore, for planning purposes, I think it is appropriate to project the current mortality rate onto any scenario of increased transmissibility.
If you project morbidity and mortality to remain unchanged, and add only the minimal mutations to achieve transmissibility, then until a large portion of the population has survivor immunity, there is no evolutionary pressure on this virus to become less deadly, as in its current form it already has sufficient time to get into the environment, but lacks only the 'geography' to do so.
I'm writing this off the cuff and a bit 'hot' on the topic, so I hope that came out coherently.
Lisa - if that's the case, is there a point in planning at all? I guess yes, even more so, but I'd like to read your thoughts.
Excellent post, Lisa. You should save that one for future use.
I would add that there are even arguments for why lethality should INCREASE over time. In fact there must be, because the worst strains of h5n1 HAVE BEEN growing deadlier over the last several years (based on mouse studies). As long as there are new hosts around, and a sufficient delay between onset and death, a virus strain that replicates better within a host can have an evolutionary advantage -- and can also be deadlier. I'm not qualified to talk in detail about why that is, but it's clear that evolution allows for increasing mortality as well as decreasing. There's just way more randomness involved here than any of us would like.
Bystander
It is fictional. It is so well written that I plan to apply for some kind of fictional literary award.
Now for the realilty, which to me is very disturbing.
Please go to:
www.vnanet.vn which is a Vietnamese
Newslink.
"An Indonesian research agency has announced that flies can be infected with bird flu. Samples from flies living in central java, Sulawasi, and East Java provinces showed some had tested positive for the virus"
And here is another newsclip from another source:
"On Thursday the Indonesian government anounced virus surveillance beyond birds and pigs to other animals.
Mathur Riady said the surveillance would include domesticated animals such as cats. He said the virus may infect rodents, such as rats."
And here is another newsclip:
"Health Minister Siti Fadilah Supari has warned people there is evidence of
avian influenza (A1) infection through
rats and flies, as the research by the Dadjah Mada University showed that could become vectors for the deadly disease"
And another news clip says:
"Steve Borge, an epidemiologist for
who, (who is stationed in Jakarta) says the virus may be changing in birds into one that can more easily infect people, as may have been the case for the 1918 Spanish flu.
The 1918 virus was a bird virus--and the current thinking is that it did modify itself to be more easily transmitted to humans."
Borge says it is a pure bird virus with no combinations with any human virus, just as the Spanis flu virus was a pure bird virus.
I think Borge may be correct. Otherwise, how could 115 people who were recently at the zoo in Jakarta become so easily infected. I believe,
it is possible that only casual contact with birds, such as inhaling
the dust created from bird feces that
are disturbed, or some other such mechanism; expliains it. Otherwise,
how the hell could all those people
get sick by just being in a zoo?
I realize I have no scientific evidence for what I am saying in this last paragraph. Perhaps others may have a better explanation.
But if we now have vectors to bird flu through casual contact with birds,
by indirect contact with rats, and contact with your cat, or with flies,
we can all bend over and kiss our butts goodby, because the increased use of Tamiflu will produce drug resistance to bird flu, and Tamiflu
has never been tested outside the Lab.
You would have to take a higher dose than the recomemded, if you look at the recent research presented by Henry Niman, and it appears to me you would
still have a good chance of dying, even after taking Tamiflu, because it
probably will only protect your lungs,
but it is doubtful it will protect
you against an infection of the
central nervous systems, and may
bird flu patients have central nervous
system involvement.
I apologize for writing such a long post, but I just wanted to clarify my
ideas.
Lisa, I understand everything you've written. I'm not a doctor, but I disagree with several parts of it:
First, I don't think that we really know that the current death rate is 50%. Flu surveilance, while still better than for previous flus (bystander, that is why we would probably have missed 100 or so scattered deaths in Asia for previous flus) is still inadequate to detect whether there are in fact many current mild cases.
Second, you've given one of the reasons that I was thinking of when you mentioned the fact that the current flu appears to attack lower lung tissue. As you write, that's one of the reasons why it isn't as transmissable as a flu that attacks tissue higher in the respiratory tract. That's also one of the reasons why it is so deadly. If it mutates to attack tissue higher up preferentially rather than lung tissue, and therefore becomes more transmissable, it will probably thereby become less deadly.
Third, it depends on whether you think that flu mutates to become more human transmissable through recombination. If it does, then we're likely to be more immunologically familiar with whatever part of human flu it uses.
Finally, I don't how you know how long the viral shedding period is. There is a latency period, yes. How do you know how much virus is being shed during this period?
Juan, if you want to write such award-worthy fiction that's fine, but please make it clear when you post it that it's fiction. Otherwise it's the same as lying.
Lugon,
Based on looking at known transmissible flus, we could expect 30% of the population to catch this flu. If half of those die, that means 15% of the population dies.
It also means 85% survives the virus.
If I were in a situation to do a tabletop exercise, at the beginning I'd have everyone roll a die and get a number 1 through 6. Then when a model outbreak occured locally, for that 'turn' of the exercise, I'd roll the die, and declare anyone with the same number to be 'dead' and relegated to merely watching the remainder of the exercise for educational purposes, leaving the survivors to continue to deal with the problem as best they can with the random loss of expertise. Then I'd roll another number, and that would be the group 'out sick' for a specified number of turns.
This can be planned for, and must be planned for if those 5 out of 6 survivors are going to get life back to what we see as 'normal' in any reasonable timeframe. Without planning we'll have people starving in the cities, refugee gangs raiding in the country--total chaos, and additional deaths.
We can't do all that much about the virus itself but we can do a lot about everything else, and that is what we must plan for.
Would you bet on a dice game in Vegas where you win on 4 out of 6 rolls, lose on 1 out of 6 and draw on 1 out of 6? I think you would.
Good points, Rich.
FWIW, I agree that mass starvation isn't very likely, even in big cities. (I've been criticized at CurEvents for saying so.) But I'm trying to prepare for it anyway, becasue I do think it's possible. There are just so many uncertainties, no matter how much we try to think them away.
Oops, for recombination substitute reassortment above. Too much influence from reading the title of Niman's blog.
Great posts Lisa.
We can't predict or control the fatality rate, but we can affect the attack rate.
Closing schools and implementing strict shelter-in-place rules would help alot. People need to be told to stock up, now.
Personal protective equipment would help alot for the essential workers. No reason why this can't be stockpiled, now.
I'm not pessimistic because nothing could be done, I'm pessimistic because nothing is being done.
Rich--
It is true, surveillance in these countries is very poor.
On the other hand a pool of about 1000 outpatient flu cases in Vietnam was being used to test a new means of detecting H5N1. Many of these came back positive! But, on further testing with the 'gold standard' methods in Hong Kong, it was found that these were false positives; the new testing method had a low false negative rate and a high false positive one. But, looking at that information from another viewpoint, it means that out of 1000 community-acquired low-intensity flu cases, in an area where bird flu is endemic in birds, *none* of those cases were a 'missed' low-intensity bird flu.
I know of only 3 cases of H5N1 antibodies found in people who do not recall being ill--the poultry worker in indonesia and two elderly relatives of a bird-flu death in Vietnam.
You have a point that if greater transmissibility occurs farther up in the respiratory tree then the direct viral damage to the lungs may be reduced. However I'm not convinced that this will be enough to seriously blunt the effect of increased TNF-alpha systemically. It is as though the virus makes a poison, and that poison can circulate to areas where the virus doesn't actually live; cytokine storm also causes kidney and liver failure if the patient lives long enough with the lung damage. Your logic does offer a bit of hope though.
I think spontaneous mutation dominates as an evolutionary mechanism because it does not require additional viruses to be present, followed by reassortment, followed by recombination. Spontaneous mutation could result in something totally novel to the immune system, or could 're-invent the wheel' and result in something for which you have immunity or partial immunity (after all, the proteins have to perform their functions and that limits how much they can change). Reassortment with a human-capable virus would probably result a you said, with a virus to which many people already have partial immunity, because viral proteins would be wholescale copied from existing human capable viruses.
Recombination doesn't necessarily result in a familiar protein on the outgoing end. The immune system learns to grab only certain domains of a viral protein; if you happen to transfer the gene segment for a part of the protein which is not the 'handle' by which the immune system grabs it, or if you transfer only a portion of that region, then as far as the immune system is concerned, the bug is still a stranger and existing antibodies do not know how to grab the virus.
About viral shedding. We know the latency period as I said. Since this flu seemingly doesn't shed well from humans, it is very hard to say what this flu will do if it moves its geography.
In ordinary flu, people generally start to shed virus about 24 hours after exposure, and become ill 2 to 4 days after exposure. For ordinary flu this translates to a silently infective period of 1 to 3 days. No way to know if this will hold for H5N1; the fact the latency period is the same makes it seem likely to me but I can't really argue that strongly based on known facts.
BTW, Rich, I'm very impressed with your posts and questions. Prompts me to think more clearly--thanks!
Bystander, I think it's odd that you've been criticized for saying that mass starvation isn't likely. Clearly, if decision makers really thought ahead for a 3% fatality flu, they'd be doing all of the planning that we think they should do, and they aren't. So I don't see why a prediction of a 50% fatality flu, or a prediction of greater than ever seen levels of societal breakdown, would cause them to do more. Such predictions, however, do make people warning of flu look like alarmists and therefore discredit them, secondly they make people throw up their hands and say that the situation is so bad that they might as well do nothing.
Nor is there really anything that you'd do differently to prepare for a 3% flu with minimal societal breakdown than a worse one, since the whole idea of minimal societal breakdown is predicated on the idea that someone eventually gets their act together. I happen to think that people will do OK if forced to at the last minute, but clearly planning would be better.
BTW, bystander, I'm starting a garden to fend off starvation not only because of bird flu, but because we keep getting whacked in the oil rigs this year and I'm worried about *those* impacts.
Here in distant California there is suddenly a shortage of plastic milk-jugs; only cartons are available. Why? The resin used in the plastics (even those that are partly recycled) comes from oil that is processed in the hurricane areas.
I've decided a garden is easier to deal with than wondering whether all this crud is going to affect my grocery shoping.
Rich--
That 'alarmist' label is why when I'm approaching anyone about this issue I emphasize the 30% projected absenteeism lasting more than a month at a time, in waves over 1 to 3 years. Regardless of death rate, this is what will dominate any social disruption and it can be planned for without addressing death rate.
However the worst possible case must be discussed so that contingencies for body management and interment can be made, and so that people don't freak if in their particular area there *are* high fatalities. Seeing a backhoe digging a trench in the local cemetary would be a lot less disconcerting if people knew that was one possible (though maybe unlikely) impact of this flu.
Michael Osterholm speaks of the demoralization that occurred when refrigerated trucks had to be brought to the parking lot of the coroner's office to store bodies during the big Chicago heatwave a few years ago. If people had expected that was a possible thing, they wouldn't have been as upset by it.
Here in distant California there is suddenly a shortage of plastic milk-jugs; Why?
GuadiaRay?
:-)
Yeah, a garden sounds like a great idea, for multiple reasons as you say. I'd consider one myself, but I've been known to kill house plants from several towns away.
Gardens are good... and some flowers and weeds are good. .... Dandylions (flowers, stems, roots and leaves) are nice simply steamed.... They should not be from areas that have been sprayed, though. A good book on the edible vegetation in your area is a good tool, too.
Easy plants to grow: radishes, onions, garlic, carrots, tomatoes, bell peppers, sunflowers, chard and most things in the mustard family.
I'm glad that you find my questions useful, Lisa.
I don't think that planting a garden is going to do any good if social disruption really is that severe. You can't live off of a garden alone, and if there really is mass starvation, people will just show up and take the food. (If you have a gun, then you will shoot some of them, they will shoot you, and then they will take the food). If society really breaks down to that extent, individual survival is mainly going to be a matter of luck, perhaps modified by preexisting culture, i.e. how cooperative the people in your area are. If gardening helps you to relax, then it's worth it, but not as a survival measure. We already grow more food than the country can use, and this food is either going to be available, or your garden is going to be vulnerable to whatever form of societal failure takes out the farms in the Great Plains and/or the trucks that bring food from them.
And no amount of preparation is going to keep people from freaking if there are high fatalities. Nor, based on previous pandemics, do I think that there are going to be hot spots that are more than temporary; over the course of a year or so, the flu is going to be either everywhere or nowhere. People will panic, then they will get over it once they realize there is nowhere to go.
So I really don't see the downside in sticking to predictions based on previous pandemics, with 1918 at the low end.
Oh, and I forgot to mention, beans, peas, and peanuts....
You don't have to plant your garden in rows. Plant your food plants near marigolds, sages and Chrysanthemum cinerariaefolium (painted daisy) - botanical insecticides. Radishes can be planted everywhere in your garden or in a flower pot - and don't forget to let a few of them go to seed for your next crop.
LIke children, all disaters have their special qualities... and we should take away what ever we can learn from them all.
That was funny, Bystander (image of Gaudia, with several tucked under each arm...and a shopping cart too full to hold any more).
I think Monotreme talked about (a few comments sections down) small and large communities having different conditions which would predispose them to different 'infectiousness' (my term) and perhaps different problems (food, medical care, etc.). I think that certainly would be the case. Transportation of food in this country is at best fantastic in the west and mediocre in the midwest (I have lived in both places). And food like medicine are bound by our abilities to get them to the ones that need it.
In Cal., for example, there are large swaths of the land that is used specifically for growing grains which is shipped north to cattle country. Cattle is shipped south again for slaughter (and north, too - but for illustration...) and packaged a distance from , say,... the Los Angeles county line.
In Ohio, grains and pigs are in the same general outlying areas of the large cities, and so are the slaughter houses. The farms surround the cities. The other fruits and vegetables are shipped from across the county into the large Ohioan metropolitan areas.
Who are the people who farm the land in California? Family farms (some are big guys these days- not all) hire small farms for their land and then they bring in illegals...
In fact the Mexican farm worker is absolutely essential for California farm industry.
Now, the question as pertaining to the flu.... How will the flu effect the different economic and social strata in this nation... Many who truck our food across this nation are also in this segment of the population. Will the illegals seek medical attention in time? Will they get the proper information to protect and care for each other? How about the homeless?
Getting food to the various parts of the nation is only one issue that shapes the different communities. In Los Angeles many hospitals have been closed for one reason or another. That will be one of our many problems.
Slightly off the main topic, a comment on what Lisa the GP said:
"I do not know if it is known which portion of the virus interacts with the TNF-alpha regulatory mechanism."
Might this give a hint or have the answer:
http://www.ncbi.nlm.nih.gov/entr...807&
query_hl=18
"H5N1/97 strongly activates mitogen-activated protein kinase (MAPK), including p38 MAPK and extracellular signal-regulated kinases 1 and 2. Specific inhibitors of p38 MAPK significantly reduced the H5N1/97-induced TNF-alpha expression in macrophages. Taken together, our findings suggest that H5N1/97-mediated hyperinduction of cytokines involves the p38 MAPK signaling pathway"
Probably not...?
The abstract does not tell us which part of the virus interacts specifically with what, if you mean structural features/chemical features or whatever, and it is a test of 97/H5N1. But it gives us an idea of how TNF is up regulated, and as the abstract suggests, can be used to explore ways of helping to prevent any hypercytokineamia/"cytokine storm."
Also, if this is right, it still doesn't answer directly that this feature will be forced to disappear by selection.
I am still hopeful that the virus will be like others and infect more easily through a more "conventional" route, upper respiratory site and delivery.
On the topic of "we're all going to die/starve" etc, I have no real idea. Plan for the worst, hope for the best is good. Even if you end up eating dried noodles for years after a pandemic, whilst everyone chides you for going crazy and stocking for years.
Regarding the garden issue and people coming to 'take the food' in the event of a total collapse:
Here in the west all back yards in suburbs are fenced, usually with opaque 6 foot high fences.
No one will know that I even have a garden except my two direct neighbors on each side--those below are too low on the slope to see into the yard. Of the side neighbors, one set are good friends and the other house has a sociopath and his family, and I worry more about him with regard to my safety than I do about flu itself.
However Mr. Sociopath has a brother with a place in the country and I think (or at least hope) that he and his brood will bug out to the brother's if things start to look bad. By the time there's a food shortage there'll be a gas shortage too and I doubt he'd drive all the way back just to loot my place.
Otherwise, my town of 50,000 or so is surrounded by commercial farm fields, and beyond that is the uber-city of the SF area. These farms grow vast acreages of monoculture. So I'm hoping that the hoardes of urban hungries raid those fields and don't detour to notice my little backyard patch.
If I have a garden I won't have to be one of the raiders. I expect the farmers will shoot some of them.
To boot, there are limited accesses to my town and I think if there were maruading bands our surviving police would be able to checkpoint the roads and divert through travelers to the interstate.
Anyway, my point here is that if the flu-aware all grow gardens and convince neighbors to do so as well by any means available, then there won't be as much of a problem with hunger-driven refugees. Whether its 'grow a garden so you don't starve' or 'grow a garden because I bet you I can grow a bigger tomato than you can' doesn't matter so long as you encourage the practice locally.
Oh, the p38 MAPK abstract doesn't say what part of the virus causes the hyperexpression of TNF-alpha, it just says what pathway in the macrophage is activated.
Individual survivalism isn't realistically planning for the worst, enantidrone. If you ever really need more than a couple of weeks worth of dried noodles, then people aren't going to let you eat them. It just takes time, energy, and money away from more useful things. Having a stockpile is like having a pandemic plan; useful, but only in conjunction with organized people who can do something with it.
Lisa, I previously had a problem with your assertion that deadliness of the virus didn't matter with regard to how it spreads, because there was still a latency period, but passed it up because of other material. I think that I can express it more clearly now (it would be easy if I were an epidemiologist).
A flu virus normally spreads through both a day or so period before the person notices they are sick, during which they shed virus, *and* during and after the period in which they are sick -- typically about 5 days, if I remember rightly. The number of people that get the virus on average from each sick person depends on the average number of contacts during this time. With normal flu, people typically do sometimes pass it on after they have obvious symptoms -- they go to work anyway, go back to day care before the 5-day period is up, etc.
If the virus is deadly enough so that sufferers quickly stop contacting people once they get sick, then the virus can still spread, but its overall effectiveness at spreading will be far lower. That's one of the important reasons why viruses typically mutate from deadly to benign. It's not that the virus literally kills the host before the virus can be passed on; it lowers the overall rate at which it is passed on. If H5N1 did mutate to be easily transmissable by human-to-human contact without losing deadliness, it still wouldn't spread as quickly as an ordinary flu virus would, and there might be real chances of stopping it.
This is what he gets for not letting the spider swallow the fly.
About mortality rates:
1) Real mortality rate
We now have a solid sample for this question: wthe mortality rate of the 115 mild-symptom people who were turned away from the Jakarta hospital? This will give us a solid clue about the real mortality rate of this stuff. "If it bleeds, it leads": until now we may only have seen the visible cases - the folks who died.
2) Racially variable mortality rates
The fact that certain families got hit by a hammer is possibly due to genetic vulnerability. Inheritable resistance to diseases varies quite a bit among races I mean ethnic groups. (F.x. Southeast Asians have several genetic defenses against malaria but don't have sickle-cell anemia.) The vulnerability and mortality rates of various populations will vary. The solid evidence here is whether unrelated family members died. If they're unrelated, this gives a much more random sample of the genetic variance of vulnerability.
Anonymous--what you say is true, but the computer models published so far say that if each case infects only 2 other people, then the pandemic is beyond any form of control. Some of the models say that number is 1.7 people. I think most people encounter enough folk in a single day that they could possibly meet these levels of transmission if the virus is capable.
I think in the initial stages there will not be much pressure on this thing to chill out.
Rich, you seem to be advocating a fatalistic acceptance of our fate with this pandemic and an idea that if the worst case hits you won't be able to survive so don't bother trying. Or you don't believe it could actually happen and be that bad.
Metaphorically, levees do break, you know. It just doesn't happen very often. If you see it coming and can't evacuate it makes some sense to prepare, even if mauraders may make the situation worse or kill you trying to take what you've set aside. Some people survived the flood by doing just that, and banding together with neighbors to protect what is theirs from the looters.
Lance, we don't know how many of those 115 cases were 'worried well' or other illnesses--there is also a dengue outbreak in Jakarta and the symptoms are very similar initially.
"Effect Measure comments v.s. Flu Wiki: Smackdown!"
Now I'm confused. On FluWiki it is claimed that a "cytokine storm" (keen? kyn?) is at present a Yeti not ever witnessed, but only deduced by its tracks. Googling "hypercytokinemia" turns up zillions of refences to "known to occur", "seen", etc. So which is it? Bigfoot or known medical situation? Are these even the same phenomena?
And then to my idee fixe: can you drop the severity of the storm by pre-exposing the patient to the various H5 and N1 proteins involved?
Or with any lame-ass H5N1 vaccine lying about in the warehouse?
Lance--
About 3 weeks ago the National Academy of Sciences had an article by Webster of vaccine fame, where he looked at 7 different 'vaccines' based on the 2004 strain against 2005 isolates. Ferrets were the experimental system. All unvaccinated ferrets died. All vaccinated ferrets got sick. One vaccinated ferret died but this was attributed to a handling error that resulted in a neuro-influenza. While not the point of the study, it does suggest that exposure to even an imperfect vaccine is enough to prevent death. If you are a ferret, at least.
I think the Wiki asserts that the high death rate of pandemic flu 1918 was due to possibily, the cytokine storm cascade/hypercytokinemia.
People are guessing that it's likely H5N1 will be the same. I think there have been clinical cases of it, deaths from it and it's been induced in mice too.
So I think it is a legitimate concern.
In my completely layperson unprofessional opinion.
Of course, no-one knows for sure whether the young people in 1918 died due to cytokine storms. Its an hypothesis. The important thing to me is that lots of young people did die in 1918 and lots of young people are dying of H5N1 in 2005.
Does anyone know whether there is a table with the age distribution of deaths vs. survivors with H5N1? I think this would be very useful.
Putting together assertions from another 2 authoritative explanations: One from a Revere about bodily temperature control and how it is much more difficult to shed heat in humid weather, and Lisa-the-GP above about the unusual temperature needs of H5N1. Jakarta this week has daily highs of 90 deg. F and was 93% humidity overnight. It's always nice and dry here in California, and only hits 100 deg. F for at most a couple of months.
Putting the above two together, I the poultry industry apologist declare H5N1 to be just another Terrible Tropical Torment, and we can all put our hands in the air and go "La la-la la-la" until our mouths bleed.
P.s. I make a great pet and am banned in California, but I am not a ferret.
Monotreme: I believe that the frequently cited presence of "heliotrope cyanosis," during the pandemic of 1918, would indeed confirm that "cytokine storm" was the killer that it has been credited with being. It was probably the most common attribute of the 1918 pathogen. All of the medical reports that I have read suggest that the patients diagnosed in northern Vietnam died as a consequence of this phenomenon. Case histories often cited "viral pneumonia," but I think that the terms are largely interchangable, here. Heliotrope cyanosis may not present, if the patient is on a respirator -- but there were no respirators, in 1918. And they will be in short supply, when H5N1 becomes efficient, h-to-h.
Lance--
You are a gerbil.
Because I live just outside Chicago, gardening will have to wait until mid-May 2006. Havesting would begin in July. Is it the best guess of this group that H5N1 won't reach the States until, at least, my first harvest?
If that's the case, fine, I'll garden; if not, I'm all for canned foods.
Debra----
Go for the canned goods. Vegetable gardening is a lot harder than it looks---especially when you have voracious groundhogs,pesky rabbits, cabbage worms, flea beetles, and drought to contend with.
I don't know how our ancestors survived. I hope I still have their genes in good order somewhere.
Dylan,
I'm quibbling, but I don't think the data you mention "confirms" the cytokine storm hypothesis for 1918. Scientists would insist on data that simply cannot be obtained to be sure about what happened in 1918. That doesn't mean that it wasn't a cytokine storm that killed peole back then, only that we can't be 100% sure.
However, in 2005, we should be able to find out whether H5N1 is killing this way. At this point, I don't think the necessary data has been collected.
According to Yuen and Wong:
"The lethality of this disease may reflect systemic viral dissemination, cytokine storm, or alveolar flooding due to inhibition of cellular sodium channels."
http://www.ncbi.nlm.nih.gov/entr...1584&
query_hl=1
So it would appear there are other hypotheses that could explain H5N1's lethality.
The tools are available to determine exactly what does cause H5N1 lethality. Unfortunately, they aren't being used.
Survival Rates
Hope for the best, expect the worst
As Dylan points out, if this virus we're afraid of really gets going H2H, respirators will be in short supply. So, if the pandemic cranks up, it would seem you're on your own (or flat on your back at home, at least). Since the 50% survival rate is based on patients who received intensive care, it seems reasonable to assume a worst-case scenario of survival rates much less than 50%. So we better hope and pray for a milder bug, and/or vaccines or lots of antiviral drugs that significantly ameliorate our situation, successful isolation/quarantine measures, etc. or we are REALLY f*cked.
The Spanish Flu death rates may not be that relevant, certainly for the WW1 combat troops. The nutrition levels then were generally lower for the kids who went to war. After you've lived in a muddy trench for a year you won't have the strongest immune system. At one point France's entire available troops were in the trenches or in hospice. WW2 was the first war in history where the combat deaths outnumbered disease deaths. The "healthy at breakfast, blue by lunch, dead by dinner" syndrome will be rare.
Lisa wrote, "Based on looking at known transmissible flus, we could expect 30% of the population to catch this flu."
A few questions from a layman:
Does everyone here agree with that, or can the transmission capacity of a virus be just as variable as its lethality rate?
Did the 1957 and 1968 pandemics infect 30% of the population worldwide? I was 15 in '68 and don't remember hearing about it.
Aren't there some viruses that start showing some measure of efficient H2H transmission and then stop spreading (i.e. the bird flu virus that spread among people in the Netherlands a few years ago and killed a veterinarian)?
Thanks to everyone sharing their knowledge here.
Jon Schultz
Las Vegas
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