July 3, 2009, marks the end of the tenth week of the so-called swine flu in the United States. Cases of novel H1N1 influenza in America have been tracked and publicly reported by the Centers for Disease Control and Prevention (the CDC) in Atlanta since April 23rd when five persons in California and two persons in Texas contracted the novel flu strain; the World Health Organization (the WHO) in Geneva, Switzerland, tracks the virus throughout the world. In the ten weeks the United States has hosted the virus—which first appeared in humans in Mexico in March and early April, 2009, shortly before moving northward—novel H1N1 has pretty much covered the globe with almost half (44%) of the worldwide cases occurring in the United States at last report (by comparison, the U.S. constitutes about 4.5% of the world's population).
Here's what's been happening with H1N1 in the United States during the past ten weeks and what the nation's disease prevention agency has been doing to keep us up-to-date about the spread of the virus. As you read this diary, please keep in mind that an influenza virus that has graduated to pandemic status—as this one has—is not necessarily cause for alarm and it's certainly no reason to believe whacked-out conspiracy theories, but it is cause for concern because history has shown us that:
The 1918 flu pandemic (commonly referred to as the Spanish flu) was an influenza pandemic that spread to nearly every part of the world. It was caused by an unusually virulent and deadly Influenza A virus strain of subtype H1N1....The global mortality rate from the 1918/1919 pandemic is not known, but it is estimated that 10% to 20% of those who were infected died. With about a third of the world population infected, this case-fatality ratio means that 3% to 6% of the entire global population died.
Additionally, the last influenza pandemic—the 1968 Hong Kong flu pandemic—killed about three-quarters of a million people to one million people which is two to four times the number of people that run-of-the-mill seasonal flu strains kill each year. Using 1968 population figures (3.556 billion people worldwide) and a mortality count of one million people, the percentage of the world's population killed by the 1968 Hong Kong flu during the 1968 pandemic was .0281%. That is, the 1968 pandemic was between 107 and 214 times less lethal than the 1918/1919 influenza pandemic. If the current pandemic turns out to be as widespread (but no more widespread) and as lethal (but no more lethal) as the 1968 pandemic, we can expect to see about 1.9 million deaths worldwide, including about 86,000 American deaths, other things being equal. To put this estimated American death toll in perspective, as of May 21, 2009, there have been 4,296 United States military personnel killed in the Iraq War. Eighty-six thousand American deaths are about the number of homicides in America in 2003, 2004, 2005, 2006, and 2007, combined.
But this is 2009, not 1968, and things aren't equal. For one, information about disease prevention is more readily available now than in 1968 thanks to the Internet. Also, advances in the availability of flu vaccines and advances in flu treatments have occurred since 1968. Four pharmaceutical companies are working on a two-shot vaccine that is scheduled to be made available to the American public this September. This is the good news. The bad news is that when using run-of-the-mill seasonal influenza figures provided by the CDC and current U.S. population figures, the annual estimated mortality rate (case-fatality ratio) due to influenza in the United States ranges from .2348% to .939%. These figures are in the ballpark with the current mortality rates of the H1N1 strain based on the WHO's report that there have so far been 89,921 cases of H1N1 influenza with 382 deaths worldwide as of July 3, 2009. That the current worldwide mortality rate of H1N1 (.4248%) is as lethal now as the good old strains seen annually suggests to me that we could be dealing with a more lethal strain of virus when H1N1 mutates than we were dealing with 41 years ago. Why? Because we are in the "first wave" of the pandemic, and "first waves" have historically been much less lethal than "second waves" (the "first waves" of the Spanish flu pandemic and the Hong Kong flu pandemic were both quite mild). This is due to more lethal mutations of the virus immediately prior to the "second waves." Logic dictates that when dealing with a pandemic flu virus, you want to have as low of a mortality rate as possible early on, that is, you want lower than average seasonal flu strain mortality rates during the "first wave", with the hope that when the strain mutates to something more deadly, it is not going to be something that is über-deadly like the 1918/1919 strain. But, H1N1 now does not appear to be less deadly than annual flu strains. This concerns me.
Yes, this is 2009, not 1968, and this pandemic has hit the United States particularly hard. If the current H1N1 pandemic is no more lethal and no more widespread than the 1968 pandemic, and if the U.S. continues to have 44% of the world's cases, then we are on course for having over 800,000 U.S. H1N1-caused deaths.
In May, as the WHO considered H1N1 to be growing closer to their definition of a pandemic and as the virus continued its spread throughout America, the CDC began to do something strange, something mystifying, something that is bad public health policy: the CDC slowly reduced the frequency with which it publicly disseminated reports of new cases of H1N1. Specifically, beginning May 15th, the CDC stopped its weekend reporting of new H1N1 cases; from April 23rd until May 14th the agency had reported new H1N1 cases daily, including on weekends, after receiving this information from state boards of health. Then, when the number of U.S. cases of the virus passed 6,500 (on May 22nd), the CDC stopped daily business-day reporting and began to report new cases of H1N1 only on Mondays, Wednesdays, and Fridays. Then, on June 8th, just three days before the WHO declared the H1N1 spread to meet its criteria for a pandemic (the first declared influenza pandemic in 41 years), the CDC reduced the frequency of its H1N1 tally again, this time to just one day per week (Fridays). This decrease in transparency, of course, makes no sense if the agency really does not want the public to panic. And panic has happened in at least one country. On June 11th msnbc.com reported a version of one Associated Press story that in part read:
In May, several countries urged WHO not to declare a pandemic, fearing it would spark mass panic.
Panic has already gripped Argentina, where so many people worried about swine flu flooded into hospitals this week that emergency health services have collapsed. Last month, a bus arriving in Argentina from Chile was stoned by people who thought a passenger on it had swine flu. Chile has the most swine flu cases in South America.
How quickly has H1N1 spread throughout the United States? How deadly has it been so far? Is it becoming more deadly? Less deadly? Is the novel virus slowing down in its rate of transmission, remaining steady, or increasing? In this diary, I try to answer these questions using the data that the CDC has made available to the public; but, with the CDC providing H1N1 data only on a weekly basis, it becomes more difficult for someone in the general public, like me, to attempt to answer some of these questions adequately. Significantly, some doctors have pointed out the importance that the general public—in particular the online public—can play in providing services that can help in times of a pandemic. Specifically, in the May 21, 2009 issue of the New England Journal of Medicine an article titled "Influenza A (H1N1) Virus, 2009—Online Monitoring" states:
The value of Web-based information for early disease detection, public health monitoring, and risk communication has never been as evident as it is today, given the emergence of the current influenza A (H1N1) virus. Many ongoing efforts have underscored the important roles that Internet and social-media tools are playing in the detection of and response to this outbreak.
If anyone reading this has any authority to reverse the CDC's reporting procedure, then for God's sakes do so, because we are in a pandemic and up-to-date data is useful for the public to have. Near-daily reporting of new H1N1 cases—not weekly reporting—is the responsible thing to do.
Using the available information from them, I've examined the CDC's H1N1 data (and I've put them in graphs for the visual learners among us), and while it seems clear to me that the virus has not mutated to be horrifically deadly, I don't like what I see. First, as shown in the pink and blue graph immediately below, the novel H1N1 virus has spread very quickly throughout the United States. In just two weeks it had hit over half the states. By Day 20 (May 12th) 44 states (plus Washington, DC) had reported cases. Having arrived in America on April 23rd, H1N1 spread to all 50 states, and DC, in just 40 days (that is, by June 1st); Puerto Rico logged its first H1N1 case on May 29th, and the Virgin Islands theirs by June 19th. Given that air travel during this timeframe had been lower than in previous years (due to the recession), in its "first wave" state, novel H1N1 proved to be a fast-mover.
Second, the "first wave" shows no sign of letting up even though the typical influenza season has ended by now. As shown in the two graphs below, not only do H1N1 cases continue to rise at a (pardon the pun) healthy rate (green and yellow graph), but a relative slow-down in new daily cases between Day 23 and Day 34 (from May 15th to May 26th) has reversed itself such that we are now seeing a marked acceleration of new cases (the "plateaus" and "valleys" in the bluish and yellow graph beginning around Day 44 [June 5th] are artifacts of the CDC’s now-weekly reporting). This acceleration is not due to the virus being present in states where it had not previously been present, because as earlier described, H1N1 was in nearly every state by May 12th. I'm not sure what to make of the steep up-tic in new cases around Day 35 (May 27th). Perhaps people are not taking precautions to prevent infection like they had at the initial outbreak of the virus (perhaps because the annual influenza season is typically over by now), or perhaps H1N1 has mutated to a more easily transmittable form. I don't think that the entire ongoing "first wave" has to do with the mild, wet spring in New England, although that may account for some of it. Whatever is happening, we know that infants, children and teens appear more susceptible to H1N1 than others, although persons throughout the lifespan have contracted the illness. Also, just because the school year is over for most kids, don’t conclude the risk for them has vanished. Instead, be especially mindful of your child's summer activities.
My biggest concern after ten weeks of H1N1 infecting the United States is this: it has been more lethal in the past five weeks than in the first five weeks of its outbreak (see graph below). And by more lethal I do not mean that there have been simply more deaths due to H1N1 which can solely be attributed to the fact that there are more cases of the strain now than at the beginning of its outbreak (as shown in the green and yellow graph above).
As of July 3rd, the United States mortality rate for H1N1 was .501%. However, for the first five-week timeframe the mortality rate was .1388% with six of 48 states having cases (8%) reporting a death, whereas for the most recent five-week timeframe the mortality rate has increased to .612% with 17 new states (33%) reporting a death (as shown in the table below). As with the steep up-tic of new H1N1 cases around Day 35, I'm not sure what to make of the consecutive five-week mortality rate differences.
The geographic spread of the United States' H1N1 deaths appears to have also increased dramatically beginning around Day 35 (May 27th) as shown in the green and gold graph below. Almost half (23) of all states now have recorded an H1N1 death; fifteen of these states have multiple H1N1-caused deaths.
I also have another concern. In doing research for this diary, I spoke with an infection control nurse in Massachusetts and I also spoke with two scientists who work for a large pharmaceutical company. These three professionals communicated that the number of H1N1 cases reported to the CDC not only has always been a low-ball figure (because not all symptomatic persons were tested for H1N1, and of course, because some symptomatic persons—unless they required hospitalization—didn’t seek medical care), but that beginning the week of June 15th state health departments throughout America were slashing the number of H1N1 tests done on symptomatic persons. The infection control nurse explained it this way: "Unless the person is so sick that they need to be hospitalized, they aren’t likely to be tested. It’s too costly and it’s clogging the [public health] system. The assumption now is that if the person has a cough and a fever, assume it’s H1N1 and don’t test." This means that CDC data for Week 9 and Week 10 of the U.S. outbreak of H1N1 is likely to be significantly lower than the low-ball figures for Week 1 through Week 8. If it’s true that higher percentages of the really sick started to get tested at higher rates during Week 9 and Week 10 than were H1N1-infected persons during the first eight weeks of the outbreak, then this could explain (at least partially) the more recent higher mortality figures I’ve presented. Of course, if it’s true what the health professionals said, H1N1 is much more widespread now than the numbers tell us. msnbc.com reported on June 19th that:
The United States has been hardest hit, with upward of 100,000 likely unconfirmed cases and probably far more.
But this July 3rd Reuters story puts the number much higher:
The U.S. Centers for Disease Control and Prevention says at least a million Americans are likely infected.
If it is also true that state departments of health have significantly reduced the number of allowable tests to be done on potentially infected persons because of economic reasons, then this, to me, shows us how fragile our health care system is right now. It makes me ask: why are we continuing with such a huge Iraq War budget, and not allotting money to state health departments to keep up with adequate H1N1 testing? Don't we want to know as precisely as possible how many persons have become infected? Don't we want to know exactly when we are seeing new strains of the virus? Ultimately, history will decide whether or not the federal government did enough to prepare the nation for the "second wave." I hope the pandemic does not become Barack Obama's hurricane Katrina, although I can imagine that some Republicans are salivating at that possibility.
I am also concerned that the poor economy may influence a significant number of Americans regarding their decision vis-à-vis getting an H1N1 vaccine when one is made available (and assuming it is a safe vaccine). According to one report, 17.4% of U.S. households are postponing or delaying healthcare, and preventative health care is the first to go by the boards in an economically strapped household. This could spell disaster if H1N1 mutates to something very virulent and lethal, and if local and state governments (themselves cash-strapped) don’t provide an H1N1 vaccine for free while also making efforts to inoculate as many people as possible. Using the concept of herd immunity, it is quite possible that the more people in a family who inoculate themselves against the H1N1 strain, the less likely the non-inoculated family members will contract it. Recent research by Jason M. Glanz, Ph.D., David L. McClure, Ph.D., and others at the Institute for Health Research (published in June, 2009, in Pediatrics) has shown that for one easily transmitted disease (whooping cough or pertussis) when parents refuse to get immunized, their children are at substantial risk for contracting the disease. However, viruses do what they can to survive, and this alarming report out of Denmark indicates that H1N1 has already found a way to render impotent one of the drugs used to fight it:
Scientists have established the first case of the new H1N1 influenza strain showing resistance to Tamiflu, the main antiviral flu drug, Danish officials and the manufacturer said on Monday [June 29, 2009].
Of course if the United States provided health care to all of its citizens, then there would be no financial barrier to vaccination. In times of pandemic illness a nationalized health care program saves lives not only in the obvious way (by providing free vaccines thereby reducing illness and thereby reducing death by illness), but also by having a healthier population. Already we can see the effects socialized medicine is having with respect to the H1N1 influenza pandemic. As shown in the gold and yellow graph below, seven countries with socialized medicine (Australia, Canada, Cuba, Finland, Israel, Russia, and the United Kingdom) have, as of July 3, 2009, a significantly lower H1N1 mortality rate (.179%) compared with the rest of the world (.498%), including the United States (.501%), using the latest figures from the WHO. Right now the H1N1 mortality rate in the United States is 2.8 times higher than in countries with socialized medicine.
Like all of us, I’m keeping my fingers crossed that H1N1 does not mutate into something really awful; and, when a vaccine for it is made available to me, I'm going to get it (in addition to my annual flu shot). For now, it doesn’t look like H1N1 has mutated into something extremely deadly especially taking into account the low-ball guesstimate of the number of confirmed cases of H1N1 in the United States. There have been 170 deaths in the United States due to H1N1 as of July 3, 2009 out of 33,902 total H1N1 cases. As I've said, this mortality rate of .501% makes H1N1 no more deadly now than regular seasonal influenza strains.
Critical as I have been in this diary about the CDC's H1N1 reporting changes during the first ten weeks of the outbreak I want stress now that the agency continues to provide at its website very, very valuable information about steps that you and I should take to help prevent us from contracting (or spreading) the flu, including these prevention and treatment recommendations:
What can I do to protect myself from getting sick?
There is no vaccine available right now to protect against novel H1N1 virus. There are everyday actions that can help prevent the spread of germs that cause respiratory illnesses like influenza.
Take these everyday steps to protect your health:
*Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
*Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
*Avoid touching your eyes, nose or mouth. Germs spread this way.
*Try to avoid close contact with sick people.
*Stay home if you are sick for 7 days after your symptoms begin or until you have been symptom-free for 24 hours, whichever is longer. This is to keep from infecting others and spreading the virus further.
Other important actions that you can take are:
*Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.
*Be prepared in case you get sick and need to stay home for a week or so; a supply of over-the-counter medicines, alcohol-based hand rubs, tissues and other related items might could be useful and help avoid the need to make trips out in public while you are sick and contagious.
What is the best way to keep from spreading the virus through coughing or sneezing?
If you are sick, limit your contact with other people as much as possible. If you are sick, stay home for 7 days after your symptoms begin or until you have been symptom-free for 24 hours, whichever is longer. Cover your mouth and nose with a tissue when coughing or sneezing. Put your used tissue in the waste basket. Then, clean your hands, and do so every time you cough or sneeze.
What is the best technique for washing my hands to avoid getting the flu?
Washing your hands often will help protect you from germs. Wash with soap and water or clean with alcohol-based hand cleaner. CDC recommends that when you wash your hands -- with soap and warm water -- that you wash for 15 to 20 seconds. When soap and water are not available, alcohol-based disposable hand wipes or gel sanitizers may be used. You can find them in most supermarkets and drugstores. If using gel, rub your hands until the gel is dry. The gel doesn't need water to work; the alcohol in it kills the germs on your hands.
What should I do if I get sick?
If you live in areas where people have been identified with novel H1N1 flu and become ill with influenza-like symptoms, including fever, body aches, runny or stuffy nose, sore throat, nausea, or vomiting or diarrhea, you should stay home and avoid contact with other people. Staying at home means that you should not leave your home except to seek medical care. This means avoiding normal activities, including work, school, travel, shopping, social events, and public gatherings
If you have severe illness or you are at high risk for flu complications, contact your health care provider or seek medical care. Your health care provider will determine whether flu testing or treatment is needed
If you become ill and experience any of the following warning signs, seek emergency medical care.
In children, emergency warning signs that need urgent medical attention include:
*Fast breathing or trouble breathing
*Bluish or gray skin color
*Not drinking enough fluids
*Severe or persistent vomiting
*Not waking up or not interacting
*Being so irritable that the child does not want to be held
*Flu-like symptoms improve but then return with fever and worse cough
In adults, emergency warning signs that need urgent medical attention include:
*Difficulty breathing or shortness of breath
*Pain or pressure in the chest or abdomen
*Sudden dizziness
*Confusion
*Severe or persistent vomiting
*Flu-like symptoms improve but then return with fever and worse cough
Are there medicines to treat novel H1N1 infection?
Yes. CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with novel H1N1 flu virus. Antiviral drugs are prescription medicines (pills, liquid or an inhaled powder) that fight against the flu by keeping flu viruses from reproducing in your body. If you get sick, antiviral drugs can make your illness milder and make you feel better faster. They may also prevent serious flu complications. During the current outbreak, the priority use for influenza antiviral drugs during is to treat severe influenza illness.
What is CDC’s recommendation regarding "swine flu parties"?
"Swine flu parties" are gatherings during which people have close contact with a person who has novel H1N1 flu in order to become infected with the virus. The intent of these parties is to become infected with what for many people has been a mild disease, in the hope of having natural immunity to the novel H1N1 flu virus that might circulate later and cause more severe disease.
CDC does not recommend "swine flu parties" as a way to protect against novel H1N1 flu in the future. While the disease seen in the current novel H1N1 flu outbreak has been mild for many people, it has been severe and even fatal for others. There is no way to predict with certainty what the outcome will be for an individual or, equally important, for others to whom the intentionally infected person may spread the virus.
CDC recommends that people with novel H1N1 flu avoid contact with others as much as possible. They should stay home from work or school for 7 days after the onset of illness or until at least 24 hours after symptoms have resolved, whichever is longer.