Healthy Skepticism Library item: 2740

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Publication type: news

Homeland Security in charge of pandemic?
Effect Measure 2005 Nov 5
http://effectmeasure.blogspot.com/

Keywords:
Avian flu

Notes:

Ralph Faggotter’s Comments:

Here is a great forum in which public health issues are debated in a comparatively intelligent manner.
This thread takes up the opposing sides of the argument about how much of an imminent threat Bird Flu is at present.

The scariest thing for Americans is that the Dept of Homeland Security says it will be in charge of dealing with any pandemic!

In the words of one correspondent at Effect Measure-

“Don’t you feel better, now? The folks who brought us color coding, Katrina, Michael Brown and so many other museum pieces of incompetence will be coordinating a public health emergency.”

Full text:

Effect Measure

Effect Measure is a forum for progressive public health discussion and argument as well as a source of public health information from around the web that interests the Editor(s)
Saturday, November 05, 2005
Homeland Security in charge of pandemic?

In an August post about an important story by Maryn McKenna and Jeff Nesmith of the Atlanta Journal Constitution, we pointed out it wasn’t exactly who was in charge if a pandemic were to strike. Not clear to us and not clear to the feds. Both Homeland Security and Health and Human Services claimed the mantle of leadership. A look at the National Response Plan reveals Homeland Security won, although it isn’t very obvious from the PlanFlu.

In section 9 on roles and responsibilities of the National Response Plan we find the following:

While the Federal government plays a critical role in elements of preparedness and response to a pandemic, the success of these measures is predicated on actions taken at the individual level and in states and communities. Federal responsibilities include the following: • Advancing international preparedness, surveillance, response and containment activities. • Supporting the establishment of countermeasure stockpiles and production capacity by: • Facilitating the development of sufficient domestic production capacity for vaccines, antivirals, diagnostics and personal protective equipment to support domestic needs, and encouraging the development of production capacity around the world; • Advancing the science necessary to produce effective vaccines, therapeutics and diagnostics; and • Stockpiling and coordinating the distribution of necessary countermeasures, in concert with states and other entities. • Ensuring that federal departments and agencies, including federal health care systems, have developed and exercised preparedness and response plans that take into account the potential impact of a pandemic on the federal workforce, and are configured to support state, local and private sector efforts as appropriate. • Facilitating state and local planning through funding and guidance. • Providing guidance to the private sector and public on preparedness and response planning, in conjunction with states and communities. Lead departments have been identified for the medical response (Department of Health and Human Services), veterinary response (Department of Agriculture), international activities (Department of State) and the overall domestic incident management and Federal coordination (Department of Homeland Security). Each department is responsible for coordination of all efforts within its authorized mission, and departments are responsible for developing plans to implement this Strategy.

Read that carefully. DHHS has lead on the medical response, Agriculture on the veterinary response, State on international activities, and the overall domestic incident management and Federal coordination goes to — drum roll — Homeland Security.

Don’t you feel better, now? The folks who brought us color coding, Katrina, Michael Brown and so many other museum pieces of incompetence will be coordinating a public health emergency.

posted by Revere at 2:03 AM Comments (23) | Trackback
Friday, November 04, 2005
Beyond the fringe

Those of you following the little nuclear exchange over at the Scientific American blog between its blogger, John Rennie, Wendy Orent, Paul Ewald and Revere may wish to check in on my rather acerbic response to Ewald there.

I appreciated the opportunity Rennie gave me to respond. I have a minor complaint at his calling “foul” over my characterization of Ewald as a fringe figure. I have emailed him a response on that point, and here it is:

Thank you for posting my reply to Paul Ewald. I would like to draw your attention to an exchange of letters in The New Republic between Marc Lipsitch/Carl Bergstrom and Wendy Orent on the same subject, Paul Ewald’s scientific theories. For the record, I am neither Marc nor his co-author Carl Bergstrom. I know Marc (but he doesn’t know me as Revere) since we both do mathematical modeling. I don’t know Carl. Lipsitch and Bergstrom refer to Ewald’s work as based on fringe scientific arguments, which I acknowledge does not make him a fringe figure. On the other hand, his claim that so many diseases are actually microbial in origin, does make him a fringe figure. Few accept this. It doesn’t make him wrong. It makes him a fringe figure, for which his own manner has much to blame. He makes sweeping, immodest claims which also accuse everyone else of being wrong.

Consider this blurb for Ewalds’s book, Plague Time:

So what will the decisive medical technologies of the future be, if it is indeed accepted that many chronic illnesses are caused by infection? The author believes that, “Vaccines, antimicrobials, and hygienic improvements may control most heart disease, infertility, mental illnesses, and cancers, especially if these solutions are used not just to decimate pathogens but also to direct the evolution of the causative microbes.”

I am an environmental epidemiologist, so I’m sympathetic to the general thesis that improvements in the environment are superior public health practice to individually directed medical care. I doubt, however, that the sweeping thesis that Ewald trumpets will be sustained, but even if it is at some time in the future, it certainly qualifies at this point to being on the fringe. The far fringe.

So let me cry “foul” back.

revere

Here is the exchange of letters in The New Republic:

First Lipsitch and Bergstrom: Wendy Orent suggests we needn’t worry about the next influenza pandemic, but her argument is no more than a dangerous case of hope mixed with ideology, masquerading as scientific fact (“Chicken Little,” September 12). Flu pandemics occur every few decades. It has been 37 years since the last pandemic, and the h5n1 bird flu virus has an unprecedented combination of traits that make it a prime candidate for causing the next one: It is broadly dispersed across Asia, it is highly pathogenic in humans and some birds, and it is highly prevalent in birds. No responsible scientist has predicted with certainty that the next pandemic will be as bad as 1918, when Philadelphia faced coffin shortages and San Francisco suspended garbage pickup because 80 percent of its sanitary workers failed to show up for work. But Orent is irresponsible to claim that the “new field called evolutionary epidemiology” is “proving” that another severe pandemic is impossible. This claim is based on a set of fringe scientific arguments that have been extensively tested—and largely refuted—over the past decade. [my emphasis] A recent scientific review of the relevant studies from Trends in Microbiology concluded that there is “little theoretical justification and no empirical evidence” for the ideas Orent and her source, Dr. Paul W. Ewald, use in attributing the severity of the 1918 pandemic to the trench-warfare conditions of the Western Front. The argument also goes against common sense. The SARS virus, which was more deadly to infected people than even the 1918 flu, emerged without trench warfare. Indeed, it appeared in conditions similar to those in which it is feared the next pandemic flu strain might arise. SARS in Toronto showed us how a new and feared disease can put a whole city into economic and social crisis for several months, even by striking only a few hundred people. Dramatic as its effects were, however, sars is easy to control, relative to pandemic flu. SARS patients can be diagnosed days before they are likely to infect others, making isolation and quarantine measures possible and ultimately successful. With flu, a person can infect others within a day of becoming infected, even before his own symptoms appear. Unlike sars, pandemic flu will spread uncontrolled unless we have vaccine supplies dramatically larger than what we have now or those our health officials are contemplating. Counting on the alleged certainties of one scientist’s unproven hypotheses to shield us from another severe flu pandemic is the height of faith-based policymaking. Hoping for the best, and planning accordingly, proved disastrous in New Orleans. We must do better in preparing for the next flu pandemic. Marc Lipsitch Carl T. Bergstrom The authors are, respectively, an associate professor of epidemiology at the Harvard School of Public Health and an assistant professor of biology at the University of Washington. Wendy Orent responds: Marc Lipsitch and Carl T. Bergstrom accuse me of peddling ideology in the guise of science. But there’s little accurate science in their letter. First, they assert that flu pandemics occur every few decades. This is meaningless. The only three pandemics we can identify for certain are those of the twentieth century: 1918, 1957, 1968—hardly “every few decades.” The idea of being overdue for a new pandemic led to the mass vaccination of over 40 million people during the swine flu scare of 1976. There was no pandemic, but at least 25 people died from the vaccine. Thirty-seven years after the pandemic of 1968, Dr. Edwin Kilbourne, who argued for periodicity and led the drive for swine flu vaccination, insists that the idea of periodicity is dead. There is now no logical reason to believe in it. Lipsitch and Bergstrom claim that “an unprecedented combination of traits” make h5n1 a “prime candidate” for the next pandemic. But, as usda poultry-flu expert David Swayne points out, no known pandemic has been caused by highly pathogenic avian flu. Over the past two years, h5n1 has spread in birds across Asia; why have only 62 people died of bird flu? Why haven’t there been, at most, more than a few instances of probable person-to-person transmission? Why is there such a low rate of subclinical infection among health workers caring for h5n1 patients—unlike sars, where most cases spread in hospitals? Lipsitch and Bergstrom do not say. The writers attack Ewald’s explanation for the exceptional virulence of the 1918 flu as a “fringe” argument. They cite a 2003 article that says there is “little theoretical justification and no empirical evidence” for Ewald’s argument. But its authors get that argument wrong. Ewald uses Darwinian logic to argue that the Western Front allowed the repeated infection of new hosts by people immobilized by illness. The precise conditions of the Front, the hospitals, trucks, trains, and trenches packed deathly ill soldiers shoulder to shoulder with the well. Normal flu depends on host mobility: It can’t knock its host down, or it won’t spread. But, in the trenches, those brakes to virulence were off, and lethal flu evolved. The study’s authors think Ewald is talking about ordinary crowding: They announce that Ewald is wrong and crowding won’t boost flu virulence. Of course it won’t. That was never Ewald’s argument—though Lipsitch and Bergstrom appear not to realize that.

posted by Revere at 5:10 PM Comments (14) | Trackback
Planflu, II: The Edward R. Murrow version

To understand a plan, knowing what is being planned for, helps. Planning for a pandemic isn’t easy since there are few data points and the data are uncertain and lack common features. Estimated deaths in the 1918 pandemic, the severest of the last century was 500,000. The mildest pandemic was in 1968, an estimated 34,000 deaths, about the same as a “normal” seasonal influenza today.

Differences have little to do with medical care, much to do with the virulence of the virus. The current H5N1 so far has been more like a 1918 bug in nastiness, not a 1968 virus. Differences aside, in all pandemics a significant proportion of the US population (30%) has become ill and half of those will seek medical care (usually outpatient). It is this burden on medical services and the effects of absenteeism on all aspects of civil society that will be the practical and expensive consequence of a pandemic, not the fatalities.

Here are the parameters CDC planners used in framing the current plan:

* Everyone will be susceptible to infection, as no immunity to H5N1 (or other subtype not circulating in human populations) exists. * CDC used an incubation period of 2 days. There is some evidence H5N1 might have a slightly longer incubation period (4 days), so CDC is using a conservative estimate. A longer incubation period would slow spread. Viral shedding would start half to one day before illness onset with highest risk of transmission greatest in the first two days, perhaps longer for children. Some people (e.g., the immunocompromised) and children will continue to shed virus for some time, although CDC did not take this into account. * CDC estimated a basic reproductive number R0 of 2 (an average of two new infectious cases per infectious case), perhaps slightly low. A recent estimate of R0 for the 1918 virus was between two and three. * Overall illness attack rate will be about 30% but vary by age—40% for school-aged children, 20% for working adults. Half of the ill will seek outpatient medical care (15% of the population, 10% of working adults). That amounts to 90 million people in the US, 45 million seeking medical care. * There will likely be at least two pandemic waves, each lasting 6 to 8 weeks. The virus will then continue to circulate in the population as a seasonal virus. Seasonal timing is unpredictable. * None of this takes into account the virulence of the virus. For moderately virulent viruses like those in the 1957/1968 pandemics, CDC estimates about 865,000 hospitalizations; for a virulent 1918-like virus, 9.9 million hospitalizations. The range for those needing ICU care is about 130,000 to 1.5 million. Need for mechanical ventilators, 65,000 to 740,000. Deaths: 200,000 to 1.9 million. The lower end of these estimates will overtop our current capacity. The upper end would be a catastrophe.

The Plan sums up the situation this way:

An annual influenza season in the U.S., on average, results in approximately 36,000 deaths, 226,000 hospitalizations, and between $1 billion and $3 billion in direct costs for medical care. This impact occurs because influenza infections result in secondary complications such as pneumonia, dehydration, and worsening of chronic lung and heart problems. Despite the severity of influenza epidemics, it is sobering to understand that the effects of seasonal influenza are moderated because most individuals have some underlying degree of immunity to recently circulating influenza viruses either from previous infections or from vaccination. It is clear that pandemic influenza has the potential to pose disease control challenges unmatched by any other natural or intentional infectious disease event. Pandemic influenza viruses have demonstrated their ability to spread worldwide within months, or weeks, and to cause infections in all age groups. While the ultimate number of infections, illnesses, and deaths is unpredictable, and could vary tremendously depending on multiple factors, it is nonetheless certain that without adequate planning and preparations, an influenza pandemic in the 21st century has the potential to cause enough illnesses to overwhelm current public health and medical care capacities at all levels, despite the vast improvements made in medical technology during the 20th century.

The Plan goes on to say that the high degree of interconnectedness and the swiftness of travel today almost assure that a pandemic would make its way around the globe quickly.

As was amply demonstrated by the SARS outbreak, modern travel patterns may significantly reduce the time needed for pandemic influenza viruses to spread globally to a few months or even weeks. The major implication of such rapid spread of an infectious disease is that many, if not most, countries will have minimal time to implement preparations and responses once pandemic viruses have begun to spread. While SARS infections spread quickly to multiple countries, the epidemiology and transmission modes of the SARS virus greatly helped to contain the spread of this infection in 2003, along with quarantine, isolation, and other control measures. Fortunately, no widespread community transmission took place. By contrast, because influenza spreads more rapidly between people and can be transmitted by those who are infected but do not yet have symptoms, the spread of pandemic influenza to multiple countries is expected to lead to the near simultaneous occurrence of multiple community outbreaks in an escalating fashion. No other infectious disease threat, whether natural or engineered, poses the same current threat for causing increases in infections, illnesses, and deaths so quickly in the U.S. and worldwide.

So that’s what the planners were planning for. Straightforward. Correct. None of it news. It says, in essence, what many have known for years. If a pandemic strikes, we’re screwed.

A 1918-like influenza pandemic would tax the resources of the best prepared nation. It is an overwhelming natural catastrophe. But like other natural catastrophes (e.g., hurricane Katrina), adequately preparation makes a world of difference in mitigating the consequences. And we are not a best-prepared nation. Our government hasn’t gotten us ready, and in fact, has pursued policies that severely weakened us. The Iraq mistake was an ideologically based experiment that failed in spectacular and tragic fashion, its failure affecting almost everything else. As we generate anti-American feeling abroad, we spend more at home to cope with the anticipated effects. This diverts existing resources to topics like “biodefense” which have severely distorted and weakened our public health system. The gigantic $200 billion war cost has run up an even larger deficit (caused by give-to-the-rich tax cuts) which in turn prompts budget cuts which further weaken public health.

We hear daily about “the war on terror,” a war we are losing and whose vague outlines are often contrived or worse. Until now we heard almost nothing from our “leaders” about the pandemic threat public health scientists knew was ever-present. Even our preparation for terrorism was a botched job, so with the expenditure of countless billions, we are left worse off than before.

Hence the stark reality of the Pandemic Flu Plan, which has no real plans in it except to say to the states and localities, “Watch Out. Here it comes. Good night and good luck.”

posted by Revere at 11:16 AM Comments (9) | Trackback