Swine flu: thoughts for the day

The White House briefing today had Obama written all over it. It's themes were Obama, it's tone of quiet, serious confidence were Obama. The sense of total command of the situation was Obama. There was the Obama-ese call for "personal responsibility." Government can't do everything. There are things we each have to take personal responsibility for.

Fine. I don't disagree. But I think there are some things missing from this frame. One is that it isn't a binary choice, government or the individual. We all live in a set of overlapping communities: work, home, neighborhood, civic organizations, churches, professional groups, etc. Our success as communities will depend crucially on whether neighbors help each other. Calls for individual responsibility can too easily slip into a brutal survivalist mentality that prepares for the infrastructure collapse apolcalypse. In that scenario it's everyone for him/herself. But independently of government there is the fundamental question about what community members will choose to do for each other.

That's not inconsistent with Obama's vision, but I'd like to see more talk about it instead of the alleged pole opposites of government and individual. Even those things that would seem to be the domain of the individual -- personal hygiene (hand washing), proper cough and sneeze etiquette, not traveling or working if you're sick, all things stressed at the White House briefing and the CDC briefings -- may depend on others. If you work, you need to have hand hygiene available, either with purse or pocket gels or sinks. Employers could provide that for workers and materially increase compliance. More importantly, keeping kids out of school or staying home if you aren't well can be infeasible without adequate sick leave or child care policies. It's fine to talk about staying home when sick as an individual responsibility, and in some sense it is. But what about the responsibility of the employer? If they don't want workers to work sick (and frankly, many employers don't care), they could and should -- as a matter of their responsibility -- make it possible or easier or more secure for workers to stay home.

We are interdependent to an extraordinary degree, which is one reason swine flu is able to spread. We aren't isolated from each other. That's a weakness from the infectious disease perspective, but it is a tremendous strength from the public health perspective. If we don't recognize this up front, it's going to be a much rougher ride.

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Obama-esque? How about if President Obama show up for the damn thing? Announcing a Public Health Emergency is pretty serious business. Besser was clueless and poor Napolitano kept looking, worriedly, at Besser whenever there was a sciency question.

Reports say President Obama decided to go golfing for 5 hours instead of addressing the nation on what is likely to be the most serious event in his Presidency. WTF?!!! That's the most un-Obama thing I've ever heard of.

He had better talk directly to the American people soon or certain "fringe" sites are going to start speculating about whether he has the damn virus himself. ;-)

This is one of the clearest and most succinct evaluations of what is needed in modern society at all times. It's interesting that the potential of disease, the great leveler, really reveals the common needs of all people to be responsible and to support each other. I am going to send this post out to lots of my friends, not because it gently criticizes the president, but because of the clarity expressed. Thank you!

By Speechless (not verified) on 26 Apr 2009 #permalink

Off the tip of my tongue and just connecting some dots.... Mexico decreased and/or shut off freshwater supplies to Mexico City and surrounding areas? about 3 to 4 weeks ago? resulting in a competitive situation between big factory farming and basic human necessities.
Is that the real crux of the matter?

For what it's worth, I suspect Obama would agree with you. Service to the community and reciprocal support are themes of his.

The trope, government can help but it can't do everything, is just a political calculation, aimed at defusing conservative rhetoric. It's a harmless way of reintroducing America to the notion that that government which governs the least isn't always the best, something that got lost from view even in the Clinton years.

Sorry to bring this discussion back to its rudiments, but has there been any more credible news on the developments in Mexico? Have the deaths been associated with the primary infection or with a secondary bacterial pneumonia? Has oseltamivir been proven effective, or is this just rumor? If it has, in what dosage?

You'll pardon me if these questions have been asked and answered or are otherwise off base. I'm not a practitioner and am new to this forum.

There goes the ball game folks. The antiviral blanket is coming out... And the warehouses here are starting to flow outbound with lotsa aircraft charters and trucks. Been a busy day for Randolphus. New York, Boston, San Antonio and Los Angeles bound. If you live in or near those then you can expect problems in the very near future. Other supply centers will also be sending so if someone hears of destinations... do tell.

Its also being thrown by Janet N. rather than Health and thats bothersome. She can still remove my misgivings and come up with a plan rather than waiting another week to do something. Revere is right, this is out and running but why would we allow the uninfected areas to be infected? Why have we waited so long. Doesnt fly that they dont know how its vectored. We know one for sure now and thats the airplanes from MEX to JFK. Start there Janet. Dont let it get on another airplane. When the first noise came out on Tuesday I gave a list of identifier codes to some friends. Three of them hit out of 8. If you cant stop it then slow it down. You wont do that on a golf course with a vision.

Wonder what that big vision is past that? I personally dont see Obama anywhere but away from this. Making a speech (again) yesterday doesnt quite get it. Minimizing the risk is about the worst thing that could be done. Panic? Oh yeah they can say that too I guess but she is already damaged goods so if it comes apart like a two dollar watch they can throw her under the bus like so many others. But, lets face it there are probably better people out there to handle it.

WTF is Gen. Honore doing these days?

Mono-Dont threaten us with Joe Biden......I hope Obama is alive and well in six months.

By M. Randolph Kruger (not verified) on 26 Apr 2009 #permalink

Re bacterial superinfection, are antibacterials any good re mortality?

By Eric J. Johnson (not verified) on 26 Apr 2009 #permalink

Oh and real quick Revere. OSHA specifically and by law requires that an employer provide equipment and training in that equipment to work in either a chemical or bio-hazardous area. I.e. that was found to include known pathogenic areas such as meeting the public, or if there was a declaration of a bio emergency.

Its probably too late for quite a few with the outcomes in question even though they are mild in the US now. Mexico isnt and that sounds like a killing field to me reading the news via the text interpreter.

Tomorrow is going to probably be the most important day after 9/11 in this century if not the most important.

Revere is right about one thing... Get into that fight and fight to win. Its a pandemic without a declaration. Throwing the blanket IS the 4th-5th level.

Politics.Its on day 5 of the geographic expansion and anyone who thinks its not is not following the protocols set forth years ago. cs.

I can hardly wait for the first one to stand up a year from now saying that they were the sole voice of reason during this darkest of hours.

By M. Randolph Kruger (not verified) on 26 Apr 2009 #permalink

Does anyone have a link to the video? I missed seeing the press conference.

By Lisa the GP (not verified) on 26 Apr 2009 #permalink

Obama has total command of all situations, you say? Ooohhkkaayy.......

In the event that a pandemic is announced, how would the use of antivirals be implemented? Would they only give it to those testing positive for the virus, to people known to be in contact with an infected person, to all healthcare workers? Is a US strategy devised or does each state / county implement their own strategy? They don't have enough stockpiled for everyone, and it does not make sense to give an antiviral until a person has been exposed.


what does the following from one of your recent posts mean?

"When the first noise came out on Tuesday I gave a list of identifier codes to some friends. Three of them hit out of 8."

I'm particularly baffled by "identifier codes."


By suzanne bunton (not verified) on 26 Apr 2009 #permalink

Carolyn, I don't *know*, but the logical thing to do since this bug might not be too severe, is to distribute it to various public health offices with guidelines for picking which patients are sick enough (or in the right demographic) to get the drug.
So, if it turns out to really whack 20-somethings, then the guideline would spell out that age as one of the factors in ranking which patients get it.
Reacting purely on a gut level, I think that the US version of the virus has already been circulating here for at least a week or two unnoticed, because it just doesn't make people that sick. If it proves to be a different, yet related strain to the Mexican one, it might even wind up acting as a sort of naturally occuring vaccine against its evil cousin.

By Lisa the GP (not verified) on 26 Apr 2009 #permalink

I'm not an expert on any of this, but it doesn't feel to me that the govt is moving too slowly, at the moment. In fact, I thought that today's activities were right on the money. The only thing I think they might have considered adding were travel restrictions to the affected areas.

There's just no reason to go nuts over this, yet. There's just not enough information to create even vague conclusions or patterns of virus transmission and behavior.

By the way, approval of the nomination for HHS secretary is stalled in the Senate, at the moment. Napolitano was sort-of a stand-in. Confirmation is expected to occur sometime this coming week, maybe more rapidly now.

By MildSkeptic (not verified) on 26 Apr 2009 #permalink

Reacting purely on a gut level, I think that the US version of the virus has already been circulating here for at least a week or two unnoticed, because it just doesn't make people that sick. If it proves to be a different, yet related strain to the Mexican one, it might even wind up acting as a sort of naturally occuring vaccine against its evil cousin.

As I said on another thread, my wife and I both got an odd flulike illness a couple weeks ago, right in the middle of a widely attended conference...an odd combination of upper respiratory symptoms, fever, and fairly intense nausea. Didn't think much of it at the time, but in retrospect, I can't help wondering if it was connected in any way.

If nothing else, it seems like there's a ton of background noise out there.

"In the event that a pandemic is announced, how would the use of antivirals be implemented?"

Shhh. It's a secret. Seriously, they don't want thefts and violence. Obviously first responders, health-care, and higher levels of government get 1st dibs. Last I read there was a debate whether to rush supplies to most at immediate infection risk or to hold off and do something else.

"If it proves to be a different, yet related strain to the Mexican one,"

The labs think the strains are identical. They *think* the tiny differences they've seen after sequencing Mexican and USA samples are minor enough not to be responsible for apparent higher Mexican death toll. If they were clearly two different strains you probably quarantine Mexico and prepare for 1919.

By Phillip Huggan (not verified) on 26 Apr 2009 #permalink

They may not have checked the entire genome. By 'identical' they may be referring to the antigenic determinants--the H and N parts--not to all the internal workings which have less interaction with the immune system.

The current thought is that the NS1 gene in H5N1 may be the one responsible for its lethality. I wonder if the NS1 gene in the US and Mexican viruses is identical (to each other, not to the one in H5N1) or not? Sometimes a single amino acid change can make a huge difference in a proteins activity.

By Lisa the GP (not verified) on 26 Apr 2009 #permalink


Re: "Obviously first responders, health-care, and higher levels of government get 1st dibs"...

As a healthcare worker I take this as a slight. Perhaps you'd prefer Glenn Beck to respond to a 911 call? Or come to your rescue in the ER? Perhaps rush to your house should it catch on fire?

Suzanne B.-Airport three letter identifiers. Such as MEX for Mexico City, JFK for obviously Kennedy in New York. etc.

A whole lotta Vaccinia for H1N1 went out of here in the last four days Lisa. I dont know what the process is to sensitize it but as I understand it you can get a lot of other things from the stuff other than protection. Tamiflu and Relenza has been fast tracked in all of the cargo haulers around the US. The number of cases is being grossly under reported in Mexico along with the numbers of deaths... Its shades of Supari, they ran out of testing materials a long time ago and remember, the ONLY cases that are accepted as cases and deaths are those that are generated by WHO certified labs.

So its "suspected" cases and "suspected" deaths. You can go in and put in "Mexican news papers" in a search and then use a translator program. There are a lot more cases than they are calling on.

If there is a mean bugger in the Mex version rather than the US version, then its only a matter of days before we see that showing up in all sorts of places other than Mexico.

Phillip, the use of the antivirals for HCW's, fire, police, and administrative essential personnel is contained in the National Pandemic Response Plan. Thats okay, Senators and Congressmen also get first dibs on vaccines along with their families too. They might also all of them be the first to find out that there is a defect in the vaccine as well because there aint gonna be no time to test it. In the field and without liability.

I have a rather lengthy list to ensure that they get their vaccines and antivirals...... Senators and Congressmen that is. We need the other guys. The others we wouldnt notice they were gone for about six months.

But as Grace says, the military and everyone else are going to take the shot in the face on this one. If there is no vax and they send those people in and its high path...They are going to die. Very simple and to the point. But they will go doing their jobs. As long as there is a fire to be put out, a crim stealing a TV instead of food in NOLA, a sick kid who's parents just bought it from H1N1 in the next room, we are going to need them. Not to have them in there will cause a system shutdown like we are seeing in Mexico City.

For my thinking, Grace is going to have her happy little self with a dilemma. She probably has a family, if she goes then she cant come back for about 21 days after the last case..If she comes back at all. Thats a Gordian Knot and only her and others action will cut it. At what point do you say that you arent going?

Attagirl to Lisa and Grace.

By M. Randolph Kruger (not verified) on 26 Apr 2009 #permalink

@M. Randolph Kruger:
I speak spanish and the only stories I'm seeing in any Mexican newspaper are showing a death toll of 103, with 1603 infected. Are these local papers you refer to? I'm checking the nationals.

As Swine Flu is spread by human to human contact, and children are the # 1 spreaders of germs, it becomes imperative to educate children on how germs are spread.
Young children don't spread germs because they want to, they don't know how NOT to.
Germy Wormy Germ Smart for Kids educates and entertains kids while teaching them how to NOT spread germs.
Please pass along to anyone who has young children and is concerned about the spread of the Swine Flu

Lots of people comment spamming their own websites to get traffic here. Go away, traffic ghouls.

Re. Chris, cases & fatalities: that works out to a CFR of 6.4%, which is a decline from an early and very rough estimate of 8% at the beginning of this.

Re. lower mortality in the USA: very subtle differences in the virus, or something else, for example exposure level and viral load. People closer to ground zero would have been more highly exposed than people in the second and third rings.

Re. water shortages in Mexico City area: this is convergent with my hypothesis about the origin of this thing. You have extensive backyard keeping of pigs & chickens in the area: the poultry/pig combination. Start with a new virus that originates in the wild bird population, pass it via droppings into the densely-populated suburbs' pig/chicken agriculture. Cut back water so people can't hose down the surfaces where pigs & chickens are kept: there's your transmission path from wild bird droppings to chickens & pigs. The pigs would also have been carrying human flu viruses from the regular flu season. Mix well, pass back to humans, and here we go.

Re. "the catastrophe of the century" and "Monday is the biggest thing since 9/11" and all that: Puh-leeeeeze let's cut the hyperbole! That kind of language does us no good whatsoever. What we have here is a Phase 4 event with a virus that appears to have become less lethal as it spread further from ground zero. We need to deal with this "as if" it's a Big One, but we do NOT need to go into panic mode.

Re. Obama: I'm not worried when he lets his people do their jobs. He did just that with the Navy's response to the pirate / hostage event, and never once claimed credit for any of it. His entire style is low-key, and it is starting to become apparent that a major part of that is to reduce emotionalism and sensationalism. Yet as Randy said, medications are on their way to potential hot spots, and that is an indication that the wheels are turning where they need to turn. I have my criticisms of Obama in other areas (Geithner & Summers, the bailout, inadequate support for nuclear power in the energy policy), but he seems to be doing a good job with this so far.

Now the Senate needs to confirm his HHS nominee, pronto. BTW, the issue there is that the nominee apparently is pro-choice, and the anti-abortion zealots are holding up the works. Disgraceful. Next time one of them has a house fire they ought to accept only "pro-life" firefighters.

Re: the differences between the "Mexican strain" and others

Has anyone considered the genetic differences in the population as a basis for the greater lethality of the disease in Mexico? There is a large indigenous population in Mexico, which has interbred with the European population to a much greater degree than in the rest of North America.

Given that the indigenous populations here were isolated for the first 10,000 years of human history, and did not live in close proximity to farm animals as the Eurasian populations did, they may not have developed the same level of genetic immunity through repeated exposures to pandemics over thousands of years.

Perhaps that explains the differences in outcomes.

By Lisa in Ontari… (not verified) on 27 Apr 2009 #permalink

Being new to this site, I am glad to see those with a medical background talking normally, to those of us without such specialized training in THAT field (as long as those same medical professionals would merely acknowledge that they are not omniscient in OTHER fields, I'd be less snide....).

But, you touch on issues and matters of civility in your post, and the need for 'right' choice. Sorry, but your description of apocalyptic scenarios (and a certain sense of panic I may be reading into it you have in describing such) are out there, precisely because the paradigms of 'civility' can only come, or long endure, in an explicitly religious framework.

And, as everyone should or is already aware, those of us who count religious fidelity of dogmas and thoughts two thousand years old or more, consider THAT more important than mere rhetoric of 'change' -no matter which Obamessiah is crowned king.

You cannot have neighborliness, when you have no 'neighbors' like you, to relate to. You cannot have heartfelt love and affection when your 'neighbor' is of a different race, religion, and language. In short, because of the heresy of multiculturalism, and the religion of 'diversity,' we are reaping what we have sown. You bring in illegals, you bring in EVERYTHING they offer-swine flu, chagas, sexual disease, etc. You bring in foreign religions, and you have internecine warfare transplanted to the Midwest, or Maine, or whereever Somali Muslims are 'placed.' You cannot expect to eradicate infectious diseases, if you will not ostracize those population groups/races/peoples that do not have an European/Caucasian/Christendom worldview- especially when Government sources KNOW they are allowing this in, as they allow the ubiquitous 'undocumented workers' to defecate and urinate on our spinach, our lettuce, our produce, etc.

No, you want to prevent disease? First, deport foreigners, and screen all those doing business in lands like that. As the old adage says, 'Fences do good neighbors make'- that truism is even more apt, when the 'neighbor' isn't even of your race/creed/nationality.

singin' "do wacka do wacka do wacka do wacka...."

By Lisa the GP (not verified) on 27 Apr 2009 #permalink

Going to go on record as saying that hate is not an effective anti-viral agent.

Fr.John, white people are foreigners. Go back to Europe and ask your god why he plagues mankind.

By Phillip Huggan (not verified) on 27 Apr 2009 #permalink

Fr. John, you ain't no father. Save your diatribes; there's work to be done here.

By Marie Josette (not verified) on 27 Apr 2009 #permalink

John the Rabbi.... Listen I get called a racist all the time because I am far from politically correct. To not follow the Obama line is to be attacked. Your stuff though pretty well is racist. I say deport them not because they are infection possiblities, hell I am a possibility if thats the case but because the bastards are breaking the law.

Breaking the law is just fine if you are Obama and well its not breaking it unless its enforced and I wouldnt say that a lot of Bush/Cheney was either. I think they followed the letter of the law but in a lot of cases certainly not the earlier intent.

But John.. I dont hate the illegals and foreigners. I say get a work visa and a passport and welcome. Else we should enforce the law based only on that.

On the other hand if you are a priest I think you need to ask for a prayer retreat from the bishop.

G336-Do you see anyone panic ridden? Its been called the herald wave and if thats right we have months likely before the 800 pound gorilla enters the room. How this administration responds today is going to reach all the way into the 09 flu season. Its mild, but will it remain so? Not likely by their own admission. 7.5% in Mexico City of the 1300 or so cases...give or take but no one is really being tested.

7.5% of 315 million Americans is what?

Do the math and then tell me what you think about the numbers and whether say very concerned is a better term than panic. Thats what I would call it.

By M. Randolph Kruger (not verified) on 27 Apr 2009 #permalink

Chris...-Its about the testing of course but ....

"In Mexico, the number of people who have died from swine flu may be as many a 149, a government official said. The country said it would close schools until May 6 as a precaution.

Mexico Health Secretary Jose Angel Cordova said only 20 of the deaths have been confirmed to be from swine flu and the government was awaiting tests results on the rest.

He said 1,995 people have been hospitalized with serious cases of pneumonia since the first case of swine flu was reported on April 13. The government does not yet know how many were swine flu.

Of those hospitalized, 1,070 have been released.

Outside of the U.S. and Mexico, there has been one confirmed case in Spain and two in Scotland."

One paper and I think its an off the wall one said that 200 had died according to Cordova. Might be a hype too, but that 149 I would buy. It seems the killer cases are limited to Mexico. I am looking at the "W" waves from past pandemics on graphs... Seems the start point for waves has a lot to do with the end points. E.g. in 2 weeks (really 3) we have nearly 2000 cases and popups around the world. Numbers, numbers, numbers. Thats not highly pathogenic I think from looking at the waves from the past. Even 1957 flu which was nasty was more than this ...so far. I wouldnt discount it though. We might have some limited immunity (vax, previous infections of near types) to keep us from getting clipped here.

Wake up call. Military bio books would call it mild too with a possibility of ugly later...so far.

By M. Randolph Kruger (not verified) on 27 Apr 2009 #permalink

Back to communication with Americans. We are short many people in the crisis. The CDC chair is just "acting" and we don't have a Surgeon General, although she/he is usually not a Public Health specialist anyhow which always puzzles me. Of course, Obama's nominees had tax problems and now the Republicans keep stopping the Cabinet position for Health nominee from coming to the floor in their wisdom so that position isn't filled either. These folks need to get their act together today!

So, we are not in a good place because we don't have a Public Health educated professional as a consistent spokesperson in charge of talking straight to the American people. What we have are a bunch of changing politicos or temporary job holders being thrown at us. We need a representative of the medical, public health community whom we can trust be the face of this, a huge potential crisis who is available to us and help keep the public doing the correct things if this goes to hell.

I have a Masters in Public Health nursing so I'm not just talkin'

By Barbara Mathew… (not verified) on 27 Apr 2009 #permalink

Randy, not to pick on you (we can have our political debates on their own terms, not by proxy:-) but "Tomorrow is going to probably be the most important day after 9/11 in this century if not the most important." Someone else made a similar comment but I found yours more easily with a simple text search.

The criticism I have of those kinds of statements is a) they associate the pandemic discussion with something that was a known cause of traumatic stress for the entire country, thereby engendering unnecessary fear; and b) they tend to focus on Big Dramatic Events rather than on the more drawn-out process that is more likely to occur.

The CFR in Mexico is still high, and we still have a way to go before we start getting usable numbers on a global basis. It appears that the fatalities are only occurring in Mexico.

One hypothesis I ran into for that (don't recall the source) is that there may be human genetic factors at work: most of the Mexican population is a Euro/Native mix, and the Native genetics may be more vulnerable.

One of my hypotheses is that this is a dose/response situation: heavier viral load in the first circle of cases, lower in the concentric rings of contact outward from that point. That would indicate that this virus is not terribly efficient at being transmitted, or that it is not highly virulent to begin with, or that its impact on humans ramps up more slowly than the immune response so a lower initial dose of virus is easier for the immune system to kill off.


Fr. John: that kind of bigotry is beneath contempt and is unAmerican as well as unChristian. Shame on you; go away.


California now has 11 cases, none in the San Francisco Bay Area yet but no doubt we'll have some soon.


Precautions department: when grocery shopping, and you get into the checkout line: Pull your shopping cart in behind you which will keep the person behind you 4' away from you, in case they're the kind of impatient person who likes to push the line so they can sneeze all over the next person. Leave 4' between you and the person ahead of you even if they have pushed their shopping cart ahead of them. If someone tries to cut the line into that gap, tell them politely where the line ends, and remind them to leave 4' of space between themselves and others to minimize contagion risk.

Re bacterial superinfection, are antibacterials any good re mortality? Yes.

By Tsu Dho Nimh (not verified) on 27 Apr 2009 #permalink

From Arizona: Current Arizona Department of Health Services advises clinics and physician offices against influenzae screening tests unless the office is equipped with BSL level 2 hoods. Here in Arizona physicians are to collect two swabs and send them to the state lab. Thence to CDC if specimen is Type A and cannot be subtyped. I think that is why no cases have been reported in Arizona--it just takes too doggone long. But locally we have had several extremely suspicious cases and I expect at least a handful in the next day or two.

Barbara, I think the validity of your post speaks for itself. It doesn't need more weight.

Waving credentials around here is a bit off-putting. The 'GP' in my monniker is to indicate that I'm not board certified (humility) rather than that I'm an MD (boast).

I'm of the opinion that honest communication is enhanced when people don't start worrying about 'rank'. All the regulars here have pretty decent brains, regardless of what body of knowledge they've chosen to study; all can process the information and have the potential to come up with good ideas. I think the ability of the group to come up with good or new ideas is enhanced by the fact that we're not all trained in the same way of thinking.

Regarding your post, I agree with you partly--I think that the healthcare experts making appearances need to be more consistent in their message, not that they can't customize it, but a set of stock phrases and buzzwords could help the inattentive retain the information better.

But I think to rely on a single spokesperson would wear that person out, and give the impression that some monolithic agency somewhere is going to 'make it all better'. By having multiple spokespeople it illustrates that many people/everyone is involved. Everyone is going to have to make some effort and some changes (even if it is just using hand sanitizer) if we're going to try to minimize outbreaks.

By Lisa the GP (not verified) on 27 Apr 2009 #permalink

I'm a student at Salisbury University. With the abundance of people I see using the restroom without washing their hands and then touching door knobs/handles, using computer systems, etc, I'd imagine if a case broke out at my University, it would spread like mad.
Lisa the GP, I agree. Everyone is going to make an effort to contain the virus. I was pleasantly surprised to see the University had supplied a boat load of hand sanitizer in every classroom. My hands have never stayed so clean :) While the government continues to do their job, we can do our part: Stop the flu from spreading and WASH YOUR HANDS!!