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Mexican Swine Flu - Mild or Severe?

by: SusanC

Tue Apr 28, 2009 at 06:55:12 AM EDT


SusanC :: Mexican Swine Flu - Mild or Severe?
There's this ongoing 'mystery' as to how come the swine flu outbreak appears to be mild in the US and other countries, and severe in Mexico. I want to turn the question on its head and ask, do we really know that it is severe in Mexico?

Let's just take Mexico City.  It has a population of 20 million people.  In a full-blown pandemic, you would expect at least 50% AR if not more, in such a densely populated metropolis.  The outbreak has been raging for > 1 month.  Let's assume, say, that only 10% of inhabitants have been infected up to now.  That still gives you 2 million infections.

At a CFR of 0.1%, with 2 million infections, you would see 2,000 deaths.  In 1918, about half the deaths were aged 45 or under.  Let's assume that is again the case here, and that deaths in older people did not raise any suspicions.  That still leaves you with 1,000 deaths in the younger age groups that have been flagged as probably swine flu deaths.

A CFR of 0.1% is very severe for seasonal flu, but would be pretty mild for pandemic flu, don't you think?
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Mexican Swine Flu - Mild or Severe? | 104 comments
Maybe what we are seeing
is a consistently 'mild' first wave everywhere.  Doesn't mean that it won't turn nasty later on.  It may, it may not.  Too soon to tell.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
2M
2 million infected and they manage to keep it secret ?

ask experts for their subjective
panflu death expectation values
and report the replies
[ Parent ]
Flu-like symptoms n/t



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
mild v severe
I'll bet that there were thousands of mild cases that have occured since 3/22 and weren't picked up, and they are reporting (truthfully I hope)  severe cases because they are easier to identify than a 'bad summer cold'. If so, that would explain why so far the cases picked up outside Mexico have been mild SO FAR.

Mild, moderate or severe, personally I have made the assumption that it is a pandemic. What I want to know-how far down the chain of H-H-H-H.....can this thing go?

It is better to look ahead and prepare than to look back and regret.

With the H-H-H ..
is every contact becoming infected or 1 in 5 or 1 in 2?  What is the infection rate? And how many generations is it taking for mutations to occur - reducing the virulence or increasing it?

By the way, I read a "ridiculous" report yesterday saying this form could only be spread through skin contact ....  

Eat pudding first - who know's what might happen next! - Anon

[ Parent ]
it looks pretty sustained to me
and if you watch the WHO press conference, the way that Keiji Fukuda carefully worded their certainty about h2h, but relative lower degree of certainty on the 'sustained' part, you know that those experts all believe this is sustained h2h, just that they need the evidence, before they can officially pronounce this as a pandemic (which, basically, is what the issue is about, semantics!!)


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
"what the issue is about, semantics!!"
For sure!

Well, most likely!

Well, I'll need more evidence to determine this fact before making a definitive declaration.

[ Parent ]
LOL! Let us know what you are ready to make a definitive declaration! n/t



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
Thanks Susan
Kinda had the same feeling. I'm glad the US stated their approach to this will be to assume it's a full pandemic at this time.

Other than the CFR-which may time to determine-it's the sustainability that worried me the most. Also keeping me up at night, but I know there may well not be answers for a while:

Given the warm climate currently in Mexico, makes me wonder if: CAR/CFR will climb in the US as we progress into warmer weather?

Did we miss a prior wave of this flu, making this the second wave?

As The Doctor noted, what are the post-mortems in Mexico showing? (is it just me, or is there a really creepy similarity to 1918 flu here?)

What will ocur in the Southern Hemisphere as they enter their flu season?

What will happen when this hit areas endemic with H5N1?

It is better to look ahead and prepare than to look back and regret.

[ Parent ]
re:severe or mild
I've asked that question a few days ago.  The thing is that if a large percentage of the population gets a "mild case" resembling seasonal flu( which I understand can keep you home for week) it can still be a major disruption to to our communities.  People stay home because they are sick or taking care of someone sick.  I still don't want to be sick with a fever, respiratory, vomiting etc.  Doesn't sound good.  
oh, I'm not suggesting this is not a serious problem
see what I wrote a while ago, There is no such thing as a mild pandemic


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
sorry, posted before I finished!
I'm only making a scientific observation.  We cannot truly assess risks and impact unless we look analyze the situation dispassionately, IMHO.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
apologies for the typos. Argh! n/t



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
Do we really even know
that the samples that have been sent to the Canadian and U.S. CDC were from the fatalities?  

Are we even sure that what those who died had was swine H1N1 influenza?  Are we sure we got samples of whatever that was?  

Are we sure there is only one strain of one virus circulating in Mexico?  That seems a reasonable enough question to ask, considering the differing presentations of the virus.  

these are all good questions
I did hear Richard Besser say that 7 of the 14 samples tested positive.  I believe those were from the deceased cases although I can't find the source right now.

We need to keep looking for sure, but I am raising the simple mathematical argument, that even 1,000 deaths in a city with 20 million people may not indicate a 'severe' strain, by pandemic flu standards.  

And, as I said, it may very well turn severe later on.  A severe pandemic in a city of 20million will be truly catastrophic.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Given international travel
- which we are already seeing the impact for spreading if H1N1, what forms of influenza went into Mexico and mixed with this one before it made its way out?

Were other countries experiencing an "unusually harsh" (symptom-wise) form of flu prior to this?  

In New Zealand we have seen a "debilitating" form of the flu rage through the country in the past 2 months - Feb/March.  All of us who got a dose were astonished at how weak it left us and how long it lingered for.  It was not unusual for people to be re-infected within 3 weeks.  

That was "classic" flu with its multiple waves being clearly demonstrated.

Eat pudding first - who know's what might happen next! - Anon

Re-infected? Not immune from previous exposure?
Isn't that unusual?  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 
[ Parent ]
That's my question, can someone answer this, please?
Is it possible to be re-infected? If it's a 'mild' form now, wouldn't it be better to catch the virus now and get an immunity for when/if the virus goes more lethal? I thought one of the advantages of those who caught it early on could then assist others during the 2nd and 3rd waves and not worry about catching it again. Please clarify.
[ Parent ]
Big question, no clear answer.
You can catch future waves, should there be any, much as you can catch seasonal flu strains each year and need a regular vaccine to try and avoid catching it.

Will catching an early wave help mitigate the effects of a later wave? Probably but no one knows how much. ie it might still kill you. Don't assume you're safe.

Do the benefits of catching a 'mild' early wave balance the risks? Don't know, wish I did.

[ Parent ]
yes, it's possible to catch it twice
Even for seasonal flu, you can catch the same virus again next year just cos it's changed.  A newly emerging virus changes even faster, so it would in principle be possible to get repeat infections, although there may (again in principle) be some protection from prior infection.  How much protection there is, really is anybody's guess.

There is yet one more way of looking at this.  Suppose you are not exposed, and you get vaccinated.  How long did it take for the vaccine to be produced?  They usually say 4-6 months, but that's based on best-case scenario AND only for the first batch.  Suppose you don't get the vaccine till 8 months after they first isolated the vaccine virus.  Do you think a virus like that, would have changed a lot in 8 months?  8 months is enough to cover 2 pandemic waves at least.  Do you think something isolated at the beginning of the first wave, will be a good antigenic match towards the tail end of the second wave?

Sorry, I didn't mean to make people even more despondent, but it is the reality we are faced with.  


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
Lots of reports this morning that close relatives of those
who have died have NOT been interviewed by local health officials.  Wouldn't you talk with them first to see

1) if they are ill themselves
2) history of patients' illness
2) health histories of patients: did they have underlying medical conditions that might have contributed to their deaths?

to me this is vital in understanding how threatening this virus is.  

yep, that too
but I suppose the Mexican authorities are so overwhelmed this would go very low in their list of priorities.  But outside experts from the CDC and WHO can and probably will do that.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
High Ro Low CFR
I've taken the stance that this has so far presented itself as a High Ro, Low CFR, event, even taking into account the normal .gov misinformation / delay of results / general bureaucratic bumblings.

The reason I've taken this stance so far is from the fact that we are not seeing large number of deaths in Mexico.  A 6.5% CFR as some hysterical folks have "calculated" is absurd in the face of anecdotal reports in Mexico of the sick swamping hospitals.

I could believe an under-reporting of the sick by a factor of 10.  That would drop the CFR to .6 and a sick to date of 20K. It's even within realm of reason to believe under-reporting of sick by 100 for a CFR of .06

In reviewing the Pandemic Velocity Calculations we have discussed previously, combined with the ease of tourists getting sick, and their secondary contacts getting sick so easily and quickly as well, we are definitely dealing with an Ro that is very high, which is to be expected of a pandemic strain.

So we are faced with either of two incompatible assertions.

1.  The swine flu has a high R0 as proved by the ease of tourists getting sick and the quick worldwide spread.

2.  The swine flu has a high CFR as proved by the 6.5% calculation from the "reported" results from Mexico.

If 2 were true, then we would have seen a much higher number of dead to date. Why?  because the virus has proven to be easily spread in the US.  You can't ignore this fact without applying the logic to Mexico as well.

Therefore, 2 is wrong.

We are dealing with a Pandemic, for sure.  It's not clear to me we are dealing with a dangerous pandemic to date.

Of course, as we all know, even if the CFR of this strain remains at by hypothesised .06, the very, very real possibility of a re-assortment or recombination of a more lethal version is very very worrisome, and could justify the fear present and the .gov's response to date without having to resort to conspiracy theories that the .gov wants us all to die.



redacted in deference to the very real pain being suffered across America by families.

that is also my gut feeling
high R0, low CFR.  At least for now.  We know that flu viruses mutate pretty quickly.  It can very well become worse later.  No way to predict.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
Additional thoughts
I did have another thought concerning my analysis.

Okay, it's a logical thought bomb.

Let's take the official numbers:  2000 infected, 150 dead.
(or whatever the numbers are to get to 6.5 %

In order for my post to hold water, I have to assume that if the .gov is underreporting the number of infected, I must also assume the .gov is underreporting the number of dead.

So the ratio of underreporting error is important.  If it is underreported in the same degree, IE the error ratio is 1, then the CFR of 6.5% is okay.

So the trick, therefore is to figure out where the underreporting bias lies.

And down that path is where we've been for the past few days.

redacted in deference to the very real pain being suffered across America by families.

[ Parent ]
in general, it's much harder
to under-report deaths, particularly in young healthy people, than to under-report influenza-like illnesses.

Frankly, I suspect the Mexican government is so overwhelmed that numbers are no better than whatever happened to appear on a piece of paper!

Also, remember that during the SARS outbreak, with cases highly visible and with highly developed countries working on the problem, the CFR was unclear till almost the end of the outbreak.

As far as I'm concerned, right now and for the foreseeable future, all numbers are for reference and illustration only.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
There's also the fact that with the panicked people now "swamping the hospitals" as you say
the chances of missing those mild cases is far less. Yet by the latest count in Mexico the cfr - based solely on the confirmed or suspected cases of swine flu (not those thousands turned away with ordinary or imaginary ILI) vs death from suspected swine flu - has moved up a notch to 7.5%...absurd or hysterical as that may be. It's just math.

Always have a plan B.
[ Parent ]
The underreported high RO would be true during any epidemic or pandemic
 as you can never be sure how many mild or asymptomatic cases you have. Therefore calculating the cfr with the figures given of reported ill is the only way one can do it.

This comment of yours:

I've taken the stance that this has so far presented itself as a High Ro, Low CFR, event, even taking into account the normal .gov misinformation / delay of results / general bureaucratic bumblings.
The reason I've taken this stance so far is from the fact that we are not seeing large number of deaths in Mexico.  A 6.5% CFR as some hysterical folks have "calculated" is absurd in the face of anecdotal reports in Mexico of the sick swamping hospitals

particularly the part I bolded is arrogant and derogatory.

The 1918 pandemic cfr of 2.5 was calculated in rough figures by the very same criteria, number of sick vs number of dead. So were the pandemics since then, as well as various outbreaks of this or that disease all over the globe. If you want a more definite amount, which is what you're talking about, then go with mortality rate not cfr, and calculate deaths per 100,000 population. But then you're comparing applies and oranges when trying to determine how virulent or lethal this pandemic is relative to earlier ones.

Go see effect measure, he's got an article going on this very thing.

Always have a plan B.

[ Parent ]
ok, some deep breaths may be in order ;-)
for all of us, I mean.  This is real stressful times with a lot of uncertainties.  This is an interesting and important discussion, but I suspect it may be a long time before we find out which version is correct.    


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
I would like your input on this as the in house expert.
My reasoning is that we have always accepted - albeit reluctantly - the method in which the cfr for H5N1 is calculated, which is confirmed deaths from H5N1 divided by confirmed cases of H5N1. The vast majority of these cases were hospitalized and/or family or close neighbors of confirmed cases who were symptomatic usually.

Even though we have long felt that there were no doubt undercounts of both the sick and the dead from this virus, we accepted the cfr based on WHO confirmed cases, as above.

Now it seems that many people do not want to count the cfr of this new swine flu in the same way, saying that the 6.5% cfr is an "hfr" (hospital fatality ratio) even though it is the way H5N1 cfr was determined. This change of criteria makes it very hard to have any kind of valid comparison with past cfr counts. To me, changing the way in which we determine cfr then makes the comparison with past pandemics, with the H5N1 cfr etc a case of "apples with oranges" and leaves us no point of reference as to just how dangerous this new virus is.

Can you please address this in the wiki diary as an up to date entry and not just an answer to this email. Thank you.  

Always have a plan B.

[ Parent ]
things are happening so fast
that conclusions from one day becomes inapplicable the next day.  So rather than going back to what was said before, I'd like to say, 1 child died in Texas, where there are 16 confirmed cases.  That gives us a CFR of approximately 6%.  Of course these numbers are too small to be statistically significant, but with 2 other cases (one confirmed, one suspected) being in critical condition, I'm inclined to believe that at least in Texas it is behaving like a Cat 5 pandemic virus.  

Personally, I'm focused on mitigation, what we need to do next, asap, so all I need is just some ball park figure that tells us where we are.  Some of you may want more refinements and that's ok, but that's not my priority right now.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
We're not changing CFR criteria, we're waiting for "C" data
The numbers we have so far for Mexico do not provide "cases" as far as I can tell, only "hospitalized cases".  

So dividing the number of deaths by that number does not give you a case (infected) fatality rate, it gives you the fatality rate of those already sick enough to require hospitalization.  You can use that rate, but you can't compare it to 1918 or 1957/68 Case Fatality Rates.

MEXICO CITY (AP) - Mexico's government is ordering closed schools nationwide as the suspected death toll from swine flu climbed to 149.

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

He says 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.

http://www.google.com/hostedne...

You can divide 149 by 1995 and get 7.47%.  We cannot call that CFR based on the information we have in front of us.

I went into this is some depth here:

http://www.newfluwiki2.com/sho...

And if we want to use HFR (or whatever letters we want to signify fatalities among the universe of those hospitalized with Human Swine Flu) then we would need to use the same numbers from 1918 and 1957/68, which would be something closer to 20% for both.

And the only reason that H5N1 Case Fatality Rate was calculated any differently than 1918 and 1957 or 68 was that H5N1 was producing almost no cases other than those requiring hospitalization.  If they were identified, they were counted as cases.  

The criteria had not changed.  That H5N1 (bird flu) virus had changed the typical allocation from lots of people infected (but not badly enough to even see a Dr.) and lots of cases infected (but just badly enough to seek outpatient care) with from 1-10% seeking hospitalization.  

If H5N1 had been found to have produced a whole bunch of infections (cases) in the community that had not required any care or any hospitalization, those numbers would have been plugged into the formula.  They looked.  They could not find any.  

And as to your question posted elsewhere about whether those planning scenarios accurately reflected those pandemics, I don't know for a fact that the scenarios used for the pandemic planning assumptions and for the other work tools prepared by the federal agencies and experts were based on the previous known history of the pandemics experienced in this country - adjusted for any relevant changes.

I don't know that, but based on all the discussions that went on while they were being developed and then revised, I sure assume that's the case.

And while they included all the various levels, the historic CFR (Case Fatality Rates) were calculated based on the numbers of people who were infected not just those hospitalized.

My point is not to argue these assumption tables represent precise historical accuracy.  My point is that we don't know a couple of the critical numbers that we will need to calculate what the CFR really is and if we are going to use that term, especially if we are using it in a way that conveys the absolutely unsupported implication that today's rate is about 3 times as bad as 1918, I just think we had better be very sure of both our data and our math.

Before we all assume that Mexico's results show a more virulent strain, we will need their case #s and we'll need enough cases here in the US and elsewhere to form a statistical sample of adequate and equivalent size.  We have neither, though unfortunately it looks like the experts are predicting that we will.

*US Pandemic Planning Assumptions:
http://www.pandemicflu.gov/pla...

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

[ Parent ]
If you want to stick only with a tally of confirmed cases leading to death
then here it is:
It revised down its count of deaths confirmed from the virus to seven, and said 26 cases had been confirmed among 2,498 people treated for severe pneumonia since the outbreak began.

7 divided by 26 comes out to a cfr of 26.9%.

I'm in no way saying that's what it is, I'm just saying that's what it would look like using your criteria stated above.


Always have a plan B.

[ Parent ]
Sorry, you seem intent on misunderstanding what I say
Nowhere do I mention "confirmed cases".


ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 
[ Parent ]
Perhaps, but I would say you also seem intent to misunderstand what I say.
Here is a quote from your last communication to me, explaining your rationale:
The criteria had not changed.  That H5N1 (bird flu) virus had changed the typical allocation from lots of people infected (but not badly enough to even see a Dr.) and lots of cases infected (but just badly enough to seek outpatient care) with from 1-10% seeking hospitalization.  

If H5N1 had been found to have produced a whole bunch of infections (cases) in the community that had not required any care or any hospitalization, those numbers would have been plugged into the formula.  They looked.  They could not find any.  

I have highlighted the parts that I personally feel represent flawed reasoning.

If people are not sick enough to see a doctor, as you say, nor sick enough to receive " any care or any hospitalization" then my belief is that they would not be included in the cfr of any prior pandemic because no one would have ever known they were sick. This is particularly true of the 1918 pandemic, because we didn't even have PCR or antibody testing back then. Yet you intimate that somehow they would have been included in the cfr for any previous pandemics, despite the fact that they never saw a doctor, and thus were never tested let alone confirmed. That, to me, is illogical.

I realize some limited testing was done here and there for H5N1 antibodies in communities without finding any "subclinical cases" to "plug into the formula" but this was not and could not have been done in the 1918 pandemic, and I don't think we had really definitive genetic testing methods developed even by the 1968 one, when the study was still in its infancy. So again, I don't know on what you base your premise that these subclinical cases were found and included in the cfr.

That has been my argument from the first; that there will always be a certain percentage of flu victims that will not get sick enough to require care and will thus never be included in the cfr. And, as well, there will be those that get sick, but either die or recover without going to a doctor and thus are missed. (Especially in developing countries.) This is the big unknown factor that will in all likelihood remain unknown, especially during a very widespread outbreak like this. Thus if we continue to determine cfr using just the victims that do get sick enough to require care and be tested, you will have a valid basis of comparison with past pandemics when the same thing happened, even if overall both cfrs are too high.

Since we don't know what the proportion of under-the-radar infections would be in any of the outbreaks, it is virtually impossible to compare the unknowns with unknowns to get an accurate comparative cfr. But we can get a comparative cfr by comparing the known cases (sick enough to require care) with the known cases in each pandemic.

Always have a plan B.

[ Parent ]
1918 CFR?
Wasn't the 1918 cfr based on the numbers returned by the then advanced countries? Sure I read somewhere that a billion of the 1.8 billion on the planet were thought to have got it got it and 50 to 100 million of them died.
That sort of gives me a strike rate of around 60% and a cfr of 5-10%.

 Man occasionally stumbles over the truth.  Most of the time though, he manages to pick himself up and carry on as if nothing had happened.

Winston S Churchill


JK
[ Parent ]
..ya makin' me crazy..
I can't get into the numbers quite yet because: 1. we don't have enough info to be sure 2. a long, long time ago in a land far, far away [Turkey] I hit a PPF of 10. Not healthy to stay that stress out so I decided for sanity's sake to act as I knew Phase 6 was to be scheduled tomorrow. Know what-it worked. I was less stressed and kept prepping as if I were the only one on the planet with that info. So everything that happends-or not-has long been pre-programmed in my noodle.

It is better to look ahead and prepare than to look back and regret.
[ Parent ]
Phase 6 mindset is
Great for preparation, but a little more difficult when considering social isolation, pulling kids from school, etc.
[ Parent ]
it's ok for me
kids are grown and gone, I work in a hospital. Wearing a mask on the train now.

My kids had bad asthma when younger, so if this was going on back then, I'd pull them out of school in a heartbeat.

It is better to look ahead and prepare than to look back and regret.

[ Parent ]
Woa MaryinH
from the wiktionary - only one meaning of absurd is derogatory, the rest are more accurate of what I meant.

Any CFR is bad, can we agree on that?  Can we also agree that a CFR above, say, 2, as we have discussed for years is worse than a worse case scenario the .gov has ever planned and gamed for?

I too have been active for years in the flu community, but I differ as to some of the hysterical (see the wiktionary for the correct def here too) accusations and threads about nefarious .gov plots.  Conspiracy theories indeed!

The facts are plain.  We have a pandemic. It has a very high RO. It's CFR is, for all intent and purposes, looking to be quite low as well, given current information.  Show me pictures of bodies, and I will change my mind.  No .gov can hide a 6% CFR for long with a huge body disposal problem with the R0 numbers we have been seeing.  

For goodness sake, open up the spreadsheet and insert in some hypothtical R0s and start dates.  Then start applying the CFRs you propose to the modeled infected to date.  You will change your mind, if you apply so logic to the problem.

absurd (comparative absurder or more absurd, superlative absurdest or most absurd)

Positive
absurd
 Comparative
absurder or more absurd
 Superlative
absurdest or most absurd

Contrary to reason or propriety; obviously and flatly opposed to manifest truth; inconsistent with the plain dictates of common sense; logically contradictory; nonsensical; ridiculous.
This proffer is absurd and reasonless. - Shakespeare, Henry VI, Part I, V-iv
This phrase absurd to call a villain great. - w:Alexander Pope

[edit] Usage notesSaid of people, opinions, dreams, etc.
Among the synonyms:

Irrational is the weakest, denoting that which is plainly inconsistent with the dictates of sound reason; as, an irrational course of life.
Foolish rises higher, and implies either a perversion of that faculty, or an absolute weakness or fatuity of mind; as, foolish enterprises.
Absurd rises still higher, denoting that which is plainly opposed to received notions of propriety and truth; as, an absurd man, project, opinion, story, argument, etc.
Preposterous rises still higher, and supposes an absolute inversion in the order of things; or, in plain terms, a "putting of the cart before the horse;" as, a preposterous suggestion, preposterous conduct, a preposterous regulation or law.  

redacted in deference to the very real pain being suffered across America by families.

[ Parent ]
OJ simpson trial logic: "Show me the blood." Got him off, wasn't true. n/t


Always have a plan B.
[ Parent ]
Apples And Oranges?
We are trying to reach a conclusion without good information.

In my uneducated opinion, there is probably going to be a difference between the CFR of people with access to first class medical care, including a ventilator, and the CFR of someone with without access to that standard of life support.

So my first question is, exactly which socio economic groups have been treated in Hospital in Mexico? Are members of these groups the majority of fatalities that have been reported?

or, to put it another way, is there the possibility of undetected cases and undetected deaths in Mexico? If this is possible, then roughly what is the proportion compared to those we know about?

And of course then what is the CFR for the admittedly theoretical invisible group of cases?

[ Parent ]
Pablo escobar - clarification of decimal on #s?
I could believe an under-reporting of the sick by a factor of 10.  That would drop the CFR to .6 and a sick to date of 20K. It's even within realm of reason to believe under-reporting of sick by 100 for a CFR of .06

Just so someone does not take this statement without understanding the context of the rest of your post, the .6 above is 0.6 % (.006) and the .06 is 0.06 % (.0006), correct?

I don't want to invite the always heated discussion of "why aren't they using a worst case of 60% CFR".

Just want folks to be reading the numbers you meant them to read for your point, because it's a good point.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

[ Parent ]
yes
Yes, ITW, you are correct in the fine tuning.

6.5% vs a 10 fold reduction or a 100 fold reduction to .6% or .06%

As pointed out, it's too soon to tell, really.

Show me the bodies.


redacted in deference to the very real pain being suffered across America by families.

[ Parent ]
I think the stats don't give the whole picture.
I certainly think that there were more fatalities in other age groups than the 20-40.

Here's an example

"News sources in Mexico have reported that residents living near the Granjas Carroll farm at La Gloria were suffering from severe upper respiratory diseases, and a five-year-old girl in the village tested positive for swine flu. The bodies of two more children who died recently were being exhumed by Mexican health officials."

http://www.allgov.com/ViewNews...

I think it was the deaths of apparently fit adults that finally raised the alarm.

We also don't know that they were truly healthy. They may have had immunity ailments, heart problems, asthmatics, etc.

My theory, and it sounds plausible...

The idea is that mexico has thousands of infected. But its a country with a large poor population, and limited health care. When you are poor, you don´t go to the doc if you are not very very sick.. So all registered Mexican cases have unbalanced high numbers of very sick, and they are also very likely to die since they are reacting very negative to the virus,

In the US there is very few cases, 40 or more.. They are all aware of the danger during this period, they go to the doc. they get registered. Buts since you need a lot more than 40 to have any clue about the death-rate there is very unlikely that these few are the ones that will die... After all, even if its a bad bad pandemic, the overwhelming majority will only have "a flu"...
Give it one week and the numbers are in the hundred and thousands, all will seek medical help, get registered and we will know the outcome of this pandemic in numbers..


But, all will not necessarily seek help
It seems to me that there will be a big group without any insurance here in the US that can't pay that will try to tough it out, as they always do when it comes to the flu. They hope they will just survive, as they have in the past.

So far, most have been people that could travel, so are more likely to be able to pay or have insurance.

[ Parent ]
give it a week....
.."Give it one week and the numbers are in the hundred and thousands, all will seek medical help, get registered and we will know the outcome of this pandemic in numbers.. "

I hope you're not talking about the US. All may seek medical care, few will get it. There will armed guards at the doors of all hospitals and most doctors offices will be closed.



It is better to look ahead and prepare than to look back and regret.

Mild or Severe
I seem to remember reading somewhere that the 1918 Influenza began in some places in spring 1918 in a milder form. This article says pretty much the same thing...

From a pubmed article: 1: Gesnerus. 2008;65(1-2):30-41

Spanish influenza in the heart of Europe. A study of a significant sample of the Basque population.

"This article presents calculations and comparisons of mortality rates for influenza... between May 1918 and April 1919. The Spanish influenza pandemic affected this population sample to a varying extent... The first wave of the pandemic (spring 1918) was benign like a seasonal influenza. The second wave (autumn 1918) was extremely virulent owing to the mutation of the virus in Europe during the summer."

A JAMA article at this link seems to show that the 1918 influenza didn't begin to register significantly until September. http://jama.ama-assn.org/cgi/c... In other words, during the virilent wave.

So, I'm wondering if we are experiencing a mild wave as a precursor to a wave that will have us all shaking in our shoes.

yep, a mild spring wave in 1918
was clearly documented in various parts of Europe by different authors.  There is also at least one study, on NYC, strangely speaking, that is suggestive of the same.  

Epidemiological evidence of an early wave of the 1918 influenza pandemic in New York City.  The paper is free, and there's a most interesting chart showing the increased mortality in those aged 15-45, during the spring wave.  In other words, even though it was milder, the age distribution was still detectable.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
mild spring
That's really interesting.

As the article states : "... we show that an unmistakable shift in the age distribution of epidemic deaths occurred during the 1917/1918 influenza season in New York City".

So, I am thinking that if we could look at the numbers for this influenza season to see if there is any evidence of higher influenza mortality in Mexico in the 15-45 age group, we might possibly have a comparison to the events in the 1918 pandemic.

[ Parent ]
oops!
That the jama issue: Vol. 298 No. 6, August 8, 2007

http://jama.ama-assn.org/cgi/c...

DEREK VON STURMER: 'Bloody Mexican flu.'
Kiwi tells of battle to breathe
By TOM FITZSIMONS - The Dominion Post
Last updated 05:00 29/04/2009

http://tinyurl.com/djwk25

DEREK VON STURMER: 'Bloody Mexican flu.'

When swine flu struck Wellingtonian Derek von Sturmer in the middle of Mexico City, he was taken to hospital barely able to breathe.

The 26-year-old former real estate agent came down with the virus about a week ago, his mother, Frances, said from her home in Papakowhai last night.

After suffering normal flu symptoms for two or three days, his condition suddenly worsened and his Mexican girlfriend took him to hospital. "He could hardly breathe, he couldn't cough," Mrs von Sturmer said. "His partner took him into the hospital, where they had him on oxygen for a couple of hours and gave him some pretty strong antibiotics."

Mr von Sturmer has been in Mexico City since last July, coaching rugby.

His mother said her son's temperature had soared to about 40 degrees celsius and he lost about a kilogram a day for several days after becoming infected. "He said it was the worst thing that had happened to him in his life."

Mrs von Sturmer found out about his ordeal several days later, when he was well enough to post a message on Facebook that started: "Bloody Mexican flu."

She had been worried by his lack of contact before the message, but only realised how serious the situation was when media reported the swine flu outbreak.

By yesterday morning, when she had talked to him again over her computer, Mr von Sturmer had been in bed for a week but was on the road to recovery. "He's still coughing, but he's on the mend."

He told her Mexico City was "quite surreal, with nobody on the streets, no cars".

Smoking
Is smoking a factor in the increased incidence of severe flu in the 20-45 year olds?  I do not believe I have read anyone address this question.
Hope Not
I have been smoking up a storm since this whole thing started :(
[ Parent ]
<: ^ Q Drag. nt


ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 
[ Parent ]
1957 Pandemic
Wasn't the 1957 Pandemic reported to have a CFR of .1% (0.001)?? It was a pandemic, but as pandemic's go relatively mild (1968 was even milder as I recall).  In fact, most people I talk to, when I mention 1957 and 1968 being pandemic years, don't recall anything special happening during those years (those that lived through that time of course :-)
It's no longer mild
All in Texas http://www.khou.com/video/news...

  1. 22 month old confirmed, dead
  2. second 23 month old confirmed, critical
  3. a pregnant woman, suspected (non-subtypable influenza A) respiratory failure, on ventilator, critical.  Her baby was delivered by emergency Cesarian section but the mother remains critical.

3 severe cases, one death (so far) in the same state with only 14 confirmed cases.

This looks like a Cat 5 pandemic to me.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

sorry, 16 confirmed cases
for Texas http://www.cdc.gov/swineflu/

1 death in 16.  That's a 6% CFR.  Even though the numbers may not be high enough to be 'statistically significant', the fact that there are 2 additional severe cases supports the estimate.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
info?
I can't find any info on the severe cases in MSM.........

It is better to look ahead and prepare than to look back and regret.
[ Parent ]
I heard it on CNN live
the press conference at Dallas, but that was not archived on CNN.  I've been trying to find a link since.  However, I need to move on, there are many things to do, so if someone else can find a link that will be good.  

I too would like a link, cos I need it for what I'm writing next.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
see if you can find a transcript of that press conference
from Houston, not Dallas, sorry.  From some official website, maybe.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
got it!
http://www.cbc.ca/world/story/...

Scroll down:

With 16 confirmed cases in the state, Texas Gov. Rick Perry issued a disaster proclamation Wednesday.

State health officials also confirmed a second child in Texas, another 23-month-old, has swine flu and is in critical care.

A pregnant woman in the state also "likely" has swine flu, said Dr. David Lakey, the commissioner of the Texas Department of State Health Services. The woman had an emergency caesarean section and is in critical condition. The baby is fine, said Lakey.

So far the virus appears to behaving like many flu viruses, Persse said. "It appears to spread human-to-human and it appears to be spread just like the seasonal flu."

Washing hands, covering mouths during coughing and sneezing and avoiding public places if ill are the best methods to prevent the virus from spreading, he said.




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
Cat 5 Pandemic - How That's Determined, What it's used for
Category 5 Pandemic is a classification of the severity of a pandemic as measured by a PSI (Pandemic Severity Index)used by the US government in a number of its planning documents, especially relating to community-based mitigation strategies.

A Cat 5 Pandemic was defined as one with 2.0 CFR or greater and projected fatalities exceeding 1.8 Million in the US.  I highly recommend reading that document, or at least the Executive Summary of that document for both Figure A (which shows a graphic depicting the Severity Index) and Table A (which summarizes the graduated levels of interventions based on the projected severity of the pandemic.  It will be important for people to understand why they will be asked to stay home, close their schools, close their businesses, etc, etc..  

That discussion must start now.  

Back to Cat 5 and community interventions.  

The thought was at that time that the pandemic would start elsewhere and by the time it got here, we'd have plenty of data from which to calculate and project these things. We don't.  Gotta say I told you so.)

The previous Community Strategy for Pandemic Influenza Mitigation* used the PSI as a trigger to guide communities initiation and continued application of various non-pharmecutical responses (non-pharmecutical interventions or NPI) that communities could take to mitigate the impact of a pandemic.  

However, the CDC, in the recently published Interim CDC Guidance for Nonpharmaceutical Community Mitigation in Response to Human Infections with Swine Influenza (H1N1) Virus is basically throwing at least some of that escalating trigger mechanism out the door. At least for now.

The previously published United States government guidance on community mitigation relies on knowledge of the Pandemic Severity Index (PSI) to characterize the severity of a pandemic and identify the recommendations for specific interventions that communities may use for a given level of severity, and suggests when these measures should be started and how long they should be used.

The substantial difference in the severity of the illness associated with infections from the same virus, the relatively low number of cases detected in the United States, and insufficient epidemiologic and clinical data to ascribe a PSI, present a formidable challenge in terms of assessing the threat posed by this novel influenza A virus until additional epidemiologic and virologic information is learned.
...
It is prudent for communities to act in the absence of sufficient data to protect their citizens and take advantage of a narrow window of opportunity for intervention. CDC recommends that affected states with at least one laboratory-confirmed case of swine influenza A (H1N1) virus infection consider activating community mitigation interventions for affected communities.


That's from the recently published Interim CDC Guidance for Nonpharmaceutical Community Mitigation in Response to Human Infections with Swine Influenza (H1N1) Virus
http://www.cdc.gov/swineflu/mi...

Be aware that they use ILI (Influenza Like Illness) to describe the pandemic in that new document.  

If you compare the Table A from the older document showing graduated application of community intervention techniques according to PSI with the new recommendations of the CDC found in their new community mitigation guidance, their current recommendations include a blend of those that would be recommended under a Cat 2/3 and under a Cat 4/5 pandemic, with certain aspects (duration of school closures) left up in the air and other aspects (general social distancing of adults or children not related to closure of a facility due to suspected infection) not recommended at this time.  

New: http://www.cdc.gov/swineflu/mi...

Old:  http://www.pandemicflu.gov/pla...


ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

[ Parent ]
Spanish situation
Given the rapid increase in suspected cases in Spain (some of which are among people who didn't go to Mexico), I'm thinking this may meet WHO's "Phase 6" definition in the near future.
[ Parent ]
h2h in Spain will trigger phase 6
Given the way that the WHO has been making determinations (on phase change) based on evidence of h2h in countries, I think you're right.  


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
Makes sense.
Still reeling from going from Phase 3 to 4 to 5-maybe even 6 in such an extremely short period of time.

It is better to look ahead and prepare than to look back and regret.
[ Parent ]
we've known that for some time
and saying that to people, that phase 4, 5, and 6 can follow quite quickly.  WHO had said a long time ago, that they could skip phases.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
It will also clarify the message: 6 = Pandemic Has Begun
Though serious questions will remain, at least the confusion about epedemic (easy, sustained h2h of a new virus) in One country = 4; same in two countries = 5 (but not yet "pandemic") makes it sound a little like there is reasonable doubt about whether it will just fade away (otherwise they'd call it pandemic).

At this point Phase 6 is not a warning that something might happen but a measurement of how far (geographically speaking) it has already happened.  

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 

[ Parent ]
agree
Phase 6 is when, not if.

Even though I was mentally prepared to go rapidly from 3-4-5+, it still seems a little 'dream-like'.

It is better to look ahead and prepare than to look back and regret.

[ Parent ]
1 death, 2 critical in Texas
http://www.click2houston.com/n...

Child Dies From Swine Flu In Houston

The Texas Department of State Health Services said the nearly 2-year-old boy had underlying health problems when he arrived in Brownsville, Texas, on April 4 from Mexico City via Matamoros, Mexico. He developed a fever and other flu symptoms on April 8 and was admitted to a Brownsville hospital five days later, Cameron County Judge Carlos Cascos said.

[snip]

Dr. David Lakey, commissioner of the Texas Department of State Health services, said a 23-month old suspected to have swine flu in Texas is in critical condition. A woman who was pregnant is also suspected of having swine flu. Her baby was delivered by Caesarean section and is doing fine. The woman, however is in critical condition. Lakey did not say where in Texas those cases are.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

New York school with 'hundreds' infected
According to an article about the New York school outbreak(s)

Six children at a Catholic school in upper Manhattan have flu symptoms, which the city is also investigating. City Health Commissioner Thomas Frieden said the apparent outbreak at PS 177 could represent a second cluster associated with the outbreak at nearby St. Francis. Of PS 177's 380 students, 82 called in sick, city officials said. Frieden said one of the sick students has two siblings at St. Francis, and that "many hundreds of students were ill with symptoms, which look like they were swine flu."

If there were hundreds of students sick and just two hospitalized, and no deaths, that indicates a milder CFR, less than .003. It seems like a large enough sample to start feeling a little more certain about the severity.


Anti-virals
What happens when the Tamiflu and Relenza runs out?  Are you confident the number of severe cases will stay low?  We do not have an endless supply of anti-virals.  Sometime in the not too distant future the powers that be will begin rationing or reserving them for medical personnel and those involved in essential services.  We must keep electricity and water flowing.  I know this is looking somewhat into the future, but under the circumstances we better be doing so in a calculating dispassionate manner.  When the anti-virals run out, for a significant portion of the population time will stop.
[ Parent ]
if it acquires resistance, won't much matter.


It is better to look ahead and prepare than to look back and regret.
[ Parent ]
Kind of ominous
The Washington Post notes:

http://www.washingtonpost.com/...

U.S. public health authorities have been worried that the virus would start producing the severe pneumonia and deaths that so far have been limited to Mexico, where the epidemic began. "The clinical picture in the United States is looking a bit more like the Mexican situation," said Nancy Cox, a flu expert at the Centers for Disease Control and Prevention.  

(Nancy Cox is more than "a flu expert", she's the Director of CDC's Influenza Division)

that's almost inevitable
"The clinical picture in the United States is looking a bit more like the Mexican situation,"

There will be a wide range, from mild to severe to fatal.  The question is what would the proportion be, and in which age group?  That is what we are all waiting to find out.


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
The intersection of flying birds, flying people and stationary pigs
Swine Flu Threat Level Raised
http://www.dotmed.com/news/sto...

Mark Jerome Walters, D.V.M.,  author of "Six Modern Plagues and How We Are Causing Them" (Island Press, 2004).

"A spate of ominous mounting human cases has suddenly cast the threat of a pandemic into the headlines once again. If a severe pandemic does occur, nobody knows how many people will get sick or how many will die. The death toll could be in the millions," he cautioned.

Dr. Walters explained that nearly all infectious diseases are the result of the intersection of people and animals, with people disrupting natural processes and bringing on the trouble. He described the genesis of swine flu: "You have three different pools or families of influenza zooming around the globe," Dr. Walters told DOTmed News. "You have the birds migrating... carrying the virus from one pig farm to another. Then you have two billion people a year who fly. People migrate in their own way and so you now have these different pools colliding."

While people can contract a virus directly from livestock or birds, that is a contained or "dead end" jump because the virus spreads no further. This is what happened with the bird flu. The problem with today's swine flu is that it spreads directly from human to human.

"There have been a tremendous number of mild cases and one death in the U.S. and many more in Mexico but you cannot come up with a fatality rate. There are just not the numbers to do that. It may be extremely low. And it may stay that way. It may decrease or it could increase [in fatality]."

ECDC report with worldwide data
http://www.ecdc.europa.eu/en/f...

European Union and EEA/EFTA countries

Within the last 24 hours, 8 new confirmed cases were reported in the EU: 3 cases in Spain, 3 cases in the United
Kingdom, as well as the first cases in The Netherlands and in Switzerland. This brings the total to 27 confirmed
cases in the EU and EEA/EFTA countries.

As reported yesterday, all European confirmed cases have a history of
travel to Mexico [COS THAT'S WHERE THEY ARE LOOKING?], except for one case in Spain where transmission probably took place within the household, from
a person who had travelled to Mexico.

The first confirmed case in the EU was reported on 27 April, 2009. For the 13 cases for which the information is
currently available, age ranged between 3 and 41 years. Both males and females are equally affected.

As of 1 May, one probable case is reported from Ireland, 2 from France and 7 from the United Kingdom.

Outside of European Union and EEA/EFTA countries

Outside of the EU and EEA/EFTA countries, 454 confirmed cases of influenza A/H1N1 virus infections have been
reported from 5 countries (Table 2). This substantial change compared to yesterday's report is mainly due to a
new series of laboratory results becoming available from the Ministry of Health in Mexico, which now reports a
total of 312 confirmed cases and 12 deaths. The US CDC reports a total of 109 cases from 11 different States.

Cases reported yesterday from Costa Rica and Peru are removed from table 2 pending validation.

Canada reports a total of 28 confirmed cases, 9 more than reported yesterday. These further cases are linked to a
school outbreak, similar to the situation observed in New York, US.

So, what's the "perceived CFR" now?  Is it evolving, our perception I mean?

Is CFR all that matters for school closure?  I think not!  AV availability etc, matter too.  JMHO.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

not looking like a serious CFR
Call me jaded, but after years of imagining how terrible a H5 pandemic would be, I don't find this H1 scary. It could be a new reassortment virus like '57 or '68.   Considering our big increase in meat production, we are lucky to have escaped getting a new virus for 40 years.

My prediction is this is not going to be a 1918 type with a severe second wave. Even though this H1N1 has been in pigs for 90 years, I believe the majority of people's immune defense systems will recognize it as another H1N1, just a new version. The fact that a hundred high school students experienced it as a mild/normal flu tells me their immune systems recognized it. Otherwise they would have been walloped off their feet, and teetering on the brink of winning or losing the battle. There will be some whose systems don't respond right, and I would agree with the guestimates of under 1.% CFR such as .6%.

I read one expert saying that this swine H1 will not be recognized by people's immune systems, and I don't know how he can make that assumption based on the evidence. It sounds like misinformation to me. No one will have antibodies or immunity to this new version, but "not recognizing" the HI at all would be dramatic, similar to what happen to the native Americans when the Europeans arrived, - 90% of the native population died from the onslaught of common European diseases. Our immune sustems' macrophages not recognizing H5N1 and immediately designing antibodies, is what makes bird flu so dangerous. The unchecked cell death leads to the cytokine deregulation.

We had 19,000 deaths in one year from hospital acquired staph infections, and the news media didn't make much about that. Those were tragic deaths of people who may have survived their other health problems. I worry that the current over-reaction in the news to this pandemic will give people the wrong idea that pandemics are overhyped. The word pandemic is not synonymous with dangerous CFR, it just means a new epidemic which goes worldwide. I don't think people are being taught that a totally new virus, which isn't recognized by our immune systems, is a possible disaster that we need to prepare for personally.

In the same frame of mind.
Maybe the MSM spin is getting to me? Seriously, as this continues to play out, I actually feel my PPF lowering. I understand that the virus has the ability to change but I don't think this is the "Big One." I did restock some preps because I had let them run low and I am being more vigilant with the hand sanitizer but I pretty much am continuing on as normal. For me personally, I don't see the need to do anything more at this point.

One thing this is teaching me is to pay attention and be flexible. If things suddenly escalate, I am ready to act. But, at this time, I just don't think it is necessary to make any significant changes in my lifestyle. Everyone has to make their own decisions about what they feel comfortable with.

[ Parent ]
I won't call you jaded ;-)
Several thoughts come to mind:

1) This is a evolving situation and risk assessments change as new information becomes available.  I think we need to remain flexible in our assessments.

2) Whether a pandemic is severe depends on your (not you personally, but anyone) perspective.  From a personal POV, 1-2% CFR looks very mild, cos if infected, you have 98-99% of recovery.  But from a societal POV, a 1-2% CFR is very severe.  Read this description of what a 0.4% CFR pandemic will be like in London.  http://www.newfluwiki2.com/sho...  Substitute for any large city nearest to where you live.

3) There probably is some immunity to this new H1N1, since it looks like most cases are mild.  However, our immune response is mostly directed towards the surface proteins HA and NA, which determines whether one gets infected, and, to some extent, determines severity.  But the other parts of the virus, including especially the internal proteins making up the polymerase complex, do play a big role in severity as well.   When a flu virus first switches host, the polymerase is not well adapted, and may not cause severe disease.  As the virus circulates among humans for longer, it will adapt to human hosts, at which point the polymerase complex may become more 'efficient' or 'optimal' eg increased viral replication, which is when we may see more severe disease.  

Finally, my personal observation is that while people may abreact to perception of media over-hype, within policy circles, this outbreak is 'beneficial' in that more resources will be put into pandemic preparedness and research, as key policymakers now realize that it really could happen, and next time it may well be H5N1!!


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
All good points
I'm reading some fascinating research work being done on this virus at http://tree.bio.ed.ac.uk/group... .  The latest results are particularly interesting:

1) Analysis of the various gene sequences are at this point all independently pointing toward a most recent common ancestor (MRCA) for this virus sometime around September, 2008
2) The evolution of at least one of the genes (NA) has basically gone unobserved in the wild for upwards of 20 years (big surveillance gap)
3) Evolution of the new H1N1 virus, while it may be a bit faster than for normal H1N1 as it adapts to its new host, is not particularly accelerated at this point
4) Comparison of genes in the virus with those from H5N1 indicate the new H1N1 is lacking in several genes that have been identified in H5N1 in particular for enabling virulence in humans, but it has a majority

This is as much as I've been able to gather in my amateur capacity.

The fourth point (though the pdf reporting the results has formatting issues, so some of the info is sketchy: http://tree.bio.ed.ac.uk/group... ) is rather sobering, as it indicates (at least to me) that the new H1N1 likely doesn't have that far to go before it could mutate/reassort into a form that could cause some serious problems in those it infects.

[ Parent ]
thanks for the links, very interesting n/t



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
Mexico in South America
said the chief of RKI (the German CDC):
the reason why it's more severe in Mexico than in Germany
is because of the different flu-season in the
South-American country.
http://www.welt.de/wissenschaf...

ask experts for their subjective
panflu death expectation values
and report the replies
[ Parent ]
CFR

Thompson: h2h starting in Spain
Hacker: no indication for h2h yet
Stefan Kaufmann: 1% of infected in life-danger
Kekule : 2500suspects, dark digit typically 10fold , 25000 infections,7 deaths, --> CFR=1:3000
Nikolaus Müller-Lantzsch : no deathvirus
Sauerbrey: pandemic danger is given
Kekule : 1 death for 3000 infected in Mex.,
Stephan Pleschka: not very agressive virus, mild outside Mex.
Kekule earlier: one death per 1000 infected
------------------------------------
are they honest or have they order to avoid panicmaking ?
7 confirmed cases in Mex., but most are not tested, Kekule must know that
outside Mex. we have 175 cases now and one death for
a CFR of 0.6%. But these have good medical treatment, not what
is expected at the peak of a pandemic.
0.6%CFR would mean ~100000 deaths in Germany

reports from doctors from Mex. about >200 deaths, 3-4 dying
each day since 3 weeks. Mex. clearly tries to manipulate numbers,
maybe other countries too. Are deaths being reported ?
Expect some "Dunkelziffer"

------------------------------------------
A professor interviewed on Channel 4 news (female but did not catch her name) put a 1% CFR figure guestimate
____________
Mexico's airports handled approximately 69 million passengers in 2005, of which 59% were on scheduled domestic flights, 34% were on scheduled international flights, 5% were on charter flights
and 1% were on general aviation flights(private aviation)

that makes 65000 international passengers per day, 520000 since 24.Apr.
175 of these infected with swine flu =0.034% , Dunkelziffer = ?
Mexico population = 100M, 0.034% of this is ~30000
300 deaths (from pneumonia) would give a CFR of 1%, 156 deaths
from assumed swine flu gives 0.5% CFR

world:25(0),,38(0),73(7),104(7),148(9),257(11),331(11)
[cases(countries)]
usa:7(0),,20(0),40(0),64(0),91(1),109(1),109(1)
mex:18(0),,18(0),26(7),26(7),26(7),97(7),156(9)
[confirmed cases(deaths)] , 24.Apr - 01.May
_______________
------------------------------------------------------  
 

ask experts for their subjective
panflu death expectation values
and report the replies

[ Parent ]
yeah, all eyes on South America next n/t



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
it's not just the death rate-
It's the attack rate, too.

If we have enough people out sick for long enough and not able to do mission critical jobs, we're going to be in trouble. It does seem that this H1N1 variant is extremely infectious based upon anecdotal evidence of apparent ILI infections, and it also seems that this variant has a longer than average latency period.

Still, in my judgment it is too early to tell.  We will know much more by the end of next week, when the early infections will have progressed, and we can see what the population infection demographic looks like.

We can all amuse ourselves with speculation until we have more data, but it is well to remember that we have limited factual information.

If I had to guess, I'd guess at a CAR of roughly 50% for this wave; it seems infectious, but that's very rough guess.  I will not hazard a guess at CFR at this point.  Let's see what we see in a week, and perhaps I'll guess then.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
New Scientist report
Hello. This is my first post.

I just wanted to mention that New Scientist is reporting that, based on initial genetic analysis, it has been tentatively concluded that this H1N1 variant "spreads barely well enough to keep itself going": http://tinyurl.com/cdfkxb .

[ Parent ]
thanks, and for the science types
the collaborators are making their data available here http://tree.bio.ed.ac.uk/group...


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
R0 1.16 n/t



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
[ Parent ]
A question
Ro is calculated, in part, by the mean virus generation time.  In the work presented at the collaborators' web site, they assume a normal mean generation time of 3 days (typical of flu), which does indeed lead to an Ro of 1.17 (assuming the rate of exponential growth is also typical of flu).

Now, we've heard reports that the typical incubation period of this flu is 7-10 days, which is unusually long.  Does that correspond with the generation time?  Because if you set the mean generation time equal to 7 days while holding everything else steady, I get an Ro = 1.38 -- certainly not earth shattering, but also not "barely keeping going."

Thoughts?

[ Parent ]
Hmmm
Frankly, I'm having a terrible time tracking down authoritative incubation period figures.  The most commonly cited one is "1-7 days", which sounds like a typical number for influenza.
[ Parent ]
R0 musings
I will characterize these comments as 'musings', not as well-organized as 'thoughts'.  It is too early to be sure of much of anything at this point; we have very little data upon which many are constructing far too many unsupported theories.  With that said, here are my musings- they are worth the paper you see them printed upon.

R0 is a rather slippery concept.  So much depends upon so many variables;  transmission type, proximity, infectious bolus, environment, attacked host resistance, age and genetic factors in the infected host spreading the virus, and many others.  I'd be very careful using a monovariable model to simulate a highly dynamic multivariable process.

It does appear, however, that there are enough data to conclude that the epidemiological picture presents as a slower than 'normal' presentation.  Longer time pre-symptomatic and longer time to fully develop the infection.  If this indeed the case, then I agree with the trend of your conclusions regarding 'R0'; if one can use that concept effectively at all, one must conclude that R0 is much higher than 1.  

I especially would argue that one does not get thousands of hospitalizations in 6 weeks with a 'minimally replicating' virus, as has been demonstrated in Mexico.  Nor does the example currently evolving in New York City support that hypothesis; both of these situations support a virus that is slow to develop, but highly infectious.

KEEP THE GRID UP!
Prudent People Prepare Properly

"better to have it and not need it than need it and not have it!"

[ Parent ]
Thank you!
I'm pretty new to modern genomics and virology :)  My background is in electrical/electronics engineering and device physics.  So I'm giving myself a crash course in all of this.

Now I need to learn how to run "beast" and other software packages...

[ Parent ]
R0 is difficult to figure out
even with lots of data.  Frankly, I don't know how much importance to place on their calculations.  I posted it as a point of reference, that's all.

Among other things, do we have enough generations of cases to know?  Cos if the virus fizzles out, OR if we are unable to verify all cases (which is the case at the moment) you just don't have the data, to tell.  Any guess is a guess, I guess.  LOL!!


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
the most interesting info on that site
is this chart

source




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
not really exponential
world:25(0),,38(0),73(7),104(7),148(9),257(11),331(11),365(13)
[cases(countries)]
usa:7(0),,20(0),40(0),64(0),91(1),109(1),109(1),141(1)
mex:18(0),,18(0),26(7),26(7),26(7),97(7),156(9),156(9)
[cases(deaths)] , 24.Apr - 01.May  

ask experts for their subjective
panflu death expectation values
and report the replies
[ Parent ]
Not reflective
of actual cases, just those identified by labs so far. Labs can't keep up with samples.
[ Parent ]
some more information
from today's CDC press briefing, responding to a question about attack rate:

The proportion of family members that are infected is a good way to come up with an attack rate.  So we're looking at lots of families, and aggregating the information to estimate an attack rate.  At this point I would say that we're estimating an attack rate that's fairly high.  You know, in the 25% to 30% range.  But that's not a final attack rate.  And it's consistent with what we see with seasonal influenza.

http://www.cdc.gov/media/trans...

That is very high for a newly emerging virus.  


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

[ Parent ]
sea-level
could it be that swine flu is more virulent and/or more contagious
in regions high above sea level  like Mexico city ?

ask experts for their subjective
panflu death expectation values
and report the replies
[ Parent ]
I don't thin there's enough information collected to tell very much about this virus
You can't compare Mexico's experiences with those in (predominantly) western cases.

Cases resulting from tourists aren't being allowed to demonstrate natural expansion or destruction (thankfully). What the disease would do in those new countries without the controls that are currently being enacted is unknown. There will probably come a point where there are too many cases to manage successfully.

[ Parent ]
Look up...
information relating to flu and anti-cyclones and health effects of air pressure/disease.  I chased down a bit of info trying to get a handle on a possible link along these lines.  Early on (1920) there was some thought in the medical community along these lines, but I think it was influenced by the still common belief in bad air/miasma linkage with disease.  

It is interesting, but after a quick look I do not think there is a correlation.  I looked at the April/09 air pressure in Mexico City compared to New York City and there was not much difference.  I have a tendency to look outside of the box where other folks may not be looking, but I usually end up getting in over my head into an area of science different than I have education/experience.  Maybe there is some type of linkage, but probably not since I would think there would have been extensive research in this area if so.  

[ Parent ]
is the swine flu not as severe as expected?
http://www.newfluwiki2.com/sho...


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...
More information on ages in Mexico deaths
I wanted to mention this. As far as I know, this information hasn't really been available. I'm not sure of the reliability of the source.

From theledger.com (http://tinyurl.com/cvpefm):

"Kuri said three of the dead were children: a 9-year-old girl, a 12-year-old girl and a 13-year-old boy. Four were older than 60.

The other nine were between 21 and 39 - unusual ages for people to die of the flu because they tend to have stronger immune systems."

Mexican Swine Flu - Mild or Severe? | 104 comments
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