Day 109: You Can't Handle the Flu

The Spain issue arises again, as news outlets attempt to claim Brazil has reached third place in the coronavirus rankings. But for those who count all tested Spanish cases, not just PCR-tested ones, Spain is still at #3 with 278,000 cases compared to Brazil's 271,000. (Brazil should level up tomorrow at the rate they're going.) Russia remains at #2 with as close to 300,000 cases as makes no difference. The US retains the lead with 1.57 million cases.

While no nations have exceeded China lately, PlagueBlog notes that Massachusetts, at 87,000 cases, recently exceeded China's current count of 84,000 cases. (We exceeded China's death toll some time ago.) CNN notes that the Navajo nation has exceeded New York State's infection rate, with 2,304 cases per 100,000 (still using old census data) versus 1,806 cases.

On the somehow-not-the-flu front, a Washington Post article put forth the strange notion that we should suddenly, after thousands of years, start mourning victims of disease as though this were a new, surprising, and meaningful way to die instead of one of the most pedestrian causes of death known to man. PlagueBlog is tempted to remind WaPo of the 500,000 or so flu deaths worldwide that we brush off every year, but instead I'll let some "trusted sources" make the unspeakable comparison for me:

The New York Post reported on the summer of '69, when people cowered in their houses and wore masks crowded together barefaced in the mud at Woodstock, because the Hong Kong flu had been ravaging the land that winter and was looking to do it again the next winter. The article gets into the weeds after that, though it does let slip a couple of reasonably coherent theories about why people back then brushed off a flu pandemic on the scale of our coronavirus pandemic: one, men were real men a belief that challenges were good for your immune system, not something to run away and hide from, and two, an optimistic attitude about the potential of science to triumph over disease.

The New York Times has also taken on our international flu legacy, reflecting on the almost universal lack of memorials to the Spanish flu that killed upwards of a hundred million people worldwide. They do come to the conclusion that men were real men back then and they didn't want to think about embarrassing deaths from pneumonia in hospital, but noble deaths from mustard gas in the trenches. Or something like that.

Massachusetts is up 1% today, our first full day of Phase 1. Middlesex County is up only 0.8%, and Somerville, never a hotspot of the county, is at this very moment cancelling most of Phase 1 because the mayor and the health department in his head think it's too dangerous for someone from a young, healthy, and well-to-do community to get a haircut in the city rather than in one of the many saner cities conveniently located within walking distance.

Day 94: Still Not the Flu

Cases in Massachusetts are up only 1.5% today, though this may be lag from the weekend. Neither the state nor PlagueBlog is maintaining a 3-day running average of our numbers, but the New York Times has graphed our seven day average among plenty of other colorful stats.

For reasons that remain obscure to PlagueBlog, we are not supposed to compare COVID-19, a viral respiratory infection spread by droplets that tends to kill the elderly in large numbers mainly via the accompanying pneumonia, to the flu, a viral respiratory infection spread by droplets that tends to kill the elderly in large numbers mainly via the accompanying pneumonia. The Wall Street Journal didn't get the memo, and actually compared the two last month. Despite missing the memo, they managed to hit a bunch of the usual specious arguments without ever really answering the title question, Why Doesn’t Flu Tank Economy Like Covid-19?

PlagueBlog has a simple answer: because we're used to the flu. If you gave it a fake name and said it was going to kill 60,000 mostly old folks in the US this season, we might all freak out and shelter in place. But since it's been killing large quantities of people every year since before the Spanish flu, we give it a pass. This is not to say that we should tank the economy for the flu, too, or even that we shouldn't have done it for the coronavirus. PlagueBlog is just answering the WSJ's rhetorical question.

And, of course, PlagueBlog is willing to compare coronavirus to the flu. Some would say you cannot compare the two because we have a vaccine for the flu, but actually, the flu goes on killing the elderly in large numbers despite the vaccine, while, PlagueBlog hopes, COVID-19 will actually be stopped by a vaccine. (It seems one is not allowed to say the flu is worse than coronavirus, but one may say coronavirus is worse than the flu.)

Some would say you cannot compare COVID-19 to the flu because the death counts are vastly different. While it's true that the death counts are different, the difference is less than an order of magnitude. Coronavirus has already slightly exceeded a bad flu year in the US (69,000 vs. e.g., 61,100 in 2017–2018). The US is a heavily vaccinated country, but worldwide the flu is still well in the lead: recent estimates put the worldwide annual flu death toll at 291,000 to 646,000. The current coronavirus death toll is only 250,000, and while it seems likely to equal a mild flu year (especially considering undercounting of deaths), it's less likely to match the flu in a bad year.

Some have suggested that the number of low-grade and asymptomatic cases in the community matters somehow, especially (it seems) because we're having trouble detecting them for COVID-19. However, we have similar difficulties detecting low-grade and asymptomatic flu cases, which is why flu rates and deaths need to be modeled rather than simply counted outright. Due to the current intense interest, prospects are somewhat better for calculating IFR (infection fatality rate) for all conceivable cases of COVID-19, and this number will certainly be lower than the more useful CFR (case fatality rate), which at least tells you something about the chance a particular sick patient will survive the disease. However, PlagueBlog fails to see how this forthcoming low number will somehow lessen the impact of the actual deaths of the 250,000 dead victims of COVID-19.

Similarly, some claim that dying all together from COVID-19 in the first four months of the year is somehow different and worse than dying at a slower rate over the eight months of flu season. The one-time debut speed of COVID-19 does have some potential effect on the health care system and access for other patients. But, since we still don't have particularly good treatments for COVID-19 (that an infected patient might be missing out on due to rationing of health care), the speed of infection seems a minor issue compared to the absolute number of COVID deaths.

Some feel that the occasional deaths of young people from COVID-19 is somehow worse than the occasional deaths of young people from the flu. But the flu actually kills between ten thousand and a hundred thousand children under 5 each year, not to mention plenty of other young people at higher rates than COVID-19. PlagueBlog begs you to think of the children.

Double Dipping

Via ProMED-mail: the Charleston Daily Mail reports on a pediatrician who came down with swine flu twice.

Parsons says she's spoken with CDC representatives about the results, and they said the double infection isn't all that unbelievable.
"They said this happens every year with seasonal flu, so there's no reason to expect that it wouldn't happen with swine flu," Parsons said. "Every flu strain can change a little bit."
The pediatrician says there may have been a tiny change in the virus that stopped her immune system from recognizing it or her body never built up immunity to it.

Swine Flu Shots vs. Seasonal Flu Shots

Via ProMED-mail: temperatures are still high in Canada, where the Globe and Mail reports that two and a half provinces have rebelled against seasonal flu shots in reaction to as-yet-unpublished research showing that a seasonal flu shot makes people more susceptible to swine flu.

The hodge-podge of vaccination strategies comes after a controversial, unpublished study suggested that people under 50 are twice as likely to contract the H1N1 virus if they have received a seasonal flu shot compared to unvaccinated people.
With no data revealing the optimal way of rolling out vaccines against the looming double threat of seasonal flu and the pandemic swine flu virus, the abrupt changes by provinces and territories could create disarray in inoculation programs, with fewer people turning up for either shot, potentially resulting in more cases of severe illness.
New Brunswick's public health authorities, skeptical about the science behind the Canadian study, have moved up seasonal flu shots for all their residents to October before proceeding to the pandemic vaccine campaign. Meanwhile, Quebec and Nunavut are deferring their seasonal flu campaigns until after their H1N1 mass vaccination clinics.

The Pandemic in Boston

Declared a pandemic on Thursday, swine flu has already claimed its first casualty outside the Americas and its first death in Massachusetts.

On the bright side, at least we aren't warehousing the ill in a tent camp on Summit Hill...yet. (Massachusetts news via Universal Hub.)

Flu Mask

Via GeekPress: a mask spotted by Movin' Meat.

Swine Flu VII: Already a Pandemic

Via ProMED-mail: Bloomberg.com reports that novel influenza A (H1N1) has already met the WHO's vacillating standards for a flu pandemic, and has also been vastly underreported.

One in 20 cases is being officially reported in the U.S., meaning more than 100,000 people have probably been infected nationwide with the new H1N1 flu strain, according to the Centers for Disease Control and Prevention. In the U.K., the virus may be 300 times more widespread than health authorities have said, the Independent on Sunday reported yesterday.

Most disturbing are the prospects for ongoing summer transmission:

“While we are seeing activities decline in some areas, we should expect to see more cases, more hospitalizations and perhaps more deaths over the weeks ahead and possibly into the summer,” Anne Schuchat, CDC’s interim deputy director for science and public health program, told reporters on a May 22 conference call.

Swine Flu VI: A Vaccine

Via ProMED-mail: as this flu season draws to a messy end, Scientific American blogs about the prospects for a swine flu (Influenza A H1N1 etc.) vaccine for next season. Reuters reports that the WHO is optimistic about such a shift, although it is unclear what impact swine flu will have on regular seasonal flu vaccine production.

Marie-Paule Kieny, WHO director of the initiative for vaccine research, said the agency is discussing with drug companies whether and when to stop making seasonal flu vaccine production and shift to making one for the new H1N1 strain.

See my twitter updates for the latest swine flu news.

Swine Flu V: Sequence Analysis

Via ProMED-mail: sequence analysis indicates that swine flu may be entirely domestic and porcine, despite previous reports linking it to human and bird flus as well as Asian swine flu strains.

"...the NA and M genes are most closely related to corresponding genes from influenza viruses isolated in swine population in Eurasia."
However, the NA and M genes from 2 swine virus isolates from America are also closely related to the novel H1N1 virus (A/swine/Virginia/670/1987, A/swine/Virginia/67a/1987), if a reasonable nucleotide substitution rate is accepted. Thus, H1N1 from Mexico may be a swine flu virus strain of entirely American origin, possibly even of relatively ancient origin.

Swine Flu III: Mexico Timeline

Via Effect Measure by way of The Pump Handle: the blog Biosurveillance reports on Veratect's extensive timeline of swine flu in Mexico, starting with an incident in Canada on March 30th.

At Veratect, we operate two operations centers based in the United States (one in the Washington, DC area and one in Seattle, WA) that provide animal and human infectious disease event detection and tracking globally. Both operations centers are organizationally modeled after our National Weather Service using a distinct methodology inspired by the natural disaster and meteorology communities. Our analysts handle information in the native vernacular language and have been thoroughly trained in their discipline, which include cultural-specific interpretation of the information.
[...]
March 30
Veratect reported that a 47-year-old city attorney for Cornwall was hospitalized in a coma at Ottawa General Hospital following a recent trip to Mexico. Family members reported the individual voluntarily reported to the hospital after gradually feeling ill upon returning from his trip on 22 March.

Of special note are the pig farming connection on April 6th, the Semana Santa [Holy Week] connection under the heading "Large mass gatherings", and Veratect's new Twitter feed.

Swine Flu II

Although no pigs have become ill and no patients have reported contact with pigs, the new swine/avian/human influenza mix coming out of Mexico has been dubbed "swine flu." Since Mexican health officials first admitted the problem on Thursday, swine flu has been detected in California, Texas, Kansas, New York City, and Nova Scotia. Suspected cases are currently under investigation in British Columbia, France, Spain, Israel, and New Zealand, mainly in tourists returning from Mexico. No fatalities have been reported outside of Mexico (where the case count now stands at approximately 1500 with over 80 fatalities).

The Associated Press reports that the WHO has declared the outbreak in North America to be a "public health emergency" with "pandemic potential."

The CDC has a page up summarizing the current investigation.

A ProMED poster notes that like this one, the Spanish Flu first appeared at the end of the flu season, but came back with a vengeance for the next one:

The 1st cases of that agent showed up in May 1918 in an army base in Kansas -- it went quiet over the summer -- and started ravaging the globe in early fall that year.

Also, someone is maintaining a Google map of the outbreak.

Swine-Bird Flu

Via an unnamed source: The BBC reports on a rash of deaths in Mexico from a new strain of flu with both swine and bird elements.

Fifty-seven people had died in Mexico City from flu-like symptoms, [WHO spokeswoman Fadela Chaib] said, and another three in San Luis Potosi in central Mexico. There are around 800 suspected cases, she said.
Health Minister Jose Angel Cordova said the virus had "mutated from pigs and then at some point was transmitted to humans".
The strain of flu had been confirmed in at least 16 deaths, with 44 others being tested, the government said.
It urged people to take preventative measures such as not shaking hands or sharing crockery.
In the US, experts say the seven people who fell ill across two states were suffering from a new form of swine flu that combined pig, bird and human viruses.
"This is the first time that we've seen an avian strain, two swine strains and a human strain," Dave Daigle, a spokesman for the CDC, told AFP.
The CDC said none of the seven victims had been in contact with pigs, which is how people usually catch swine flu.

Google Flu

Via Google Web Clips: Elizabeth Landau at CNN.com/health reports on a new Google tool, Google Flu Trends.

Google's new public health initiative, Google Flu Trends, looks at the relative popularity of a slew of flu-related search terms to determine where in the U.S. flu outbreaks may be occurring.
"What's exciting about Flu Trends is that it lets anybody -- epidemiologists, health officials, moms with sick children -- learn about the current flu activity level in their own state based on data that's coming in this week," said Jeremy Ginsberg, the lead engineer who developed the site.

See also the Official Google Blog for details.

Bird Flu Hits 200

Via ProMED-mail: AFP reports Indonesia's 85th bird flu fatality, for a total of 200 bird flu deaths worldwide.

The plantation worker died at 2:00 pm (0700 GMT), the doctor treating him at the state general hospital in the city of Pekanbaru, Azizman Daad, told AFP.
A health ministry official earlier confirmed that the man was infected with the deadly H5N1 virus, after two tests came back positive.
H5N1 is endemic in birds across nearly all of Indonesia.
The archipelago nation has now reported 106 cases overall, including the 85 deaths.
Daad said it was not clear whether the man had come into contact with infected poultry, but he had bought two live chickens at a local market.

Indonesia Hits 100

Via ProMED-mail: the WHO reports that Indonesia has reported its 100th human case of bird flu and 80th bird flu fatality.

A 26-year-old male from Riau Province developed symptoms on 3 June, was hospitalized on 6 June and died in hospital on 12 June. Investigations into the source of his infection indicate exposure to sick and dead poultry.

Bird Flu Vaccine Approved

Via ProMED-mail: on Wednesday the FDA announced the approval of an H5N1 vaccine for humans:

The vaccine was obtained from a human strain and is intended for immunizing people 18 through 64 years of age who could be at increased risk of exposure to the H5N1 influenza virus contained in the vaccine. H5N1 influenza vaccine immunization consists of two intramuscular injections, given approximately one month apart. The manufacturer, sanofi pasteur Inc., will not sell the vaccine commercially. Instead, the vaccine has been purchased by the federal government for inclusion within the National Stockpile for distribution by public health officials if needed. The vaccine will be manufactured at sanofi pasteur's Swiftwater, Pa., facility.

A Plan to Trade in Death

Via an unnamed source: the AP reports on a new bird flu futures market:

Such markets have sometimes proved controversial. In 2003, the Pentagon dropped plans for a futures market that would have allowed traders to profit from accurate predictions on terrorism, assassinations and other events in the Middle East. Some lawmakers attacked the idea as immoral; U.S. Senator Tom Daschle of South Dakota described it as a "plan to trade in death."
Organizers predicted the bird flu market should prove less controversial, and the New Jersey-based Robert Wood Johnson Foundation cautiously agreed.
"It might be considered controversial if it's not well understood," said the philanthropy's Robert Hughes.
He noted that public health experts won't be gambling their own money, so opportunities for financial gain are extremely limited.
Also worth noting is the buy-in of ProMed, a respected disease-monitoring program of the International Society for Infectious Diseases. ProMed, with a staff of 30, collects disease updates and e-mails them to 40,000 international members, making it the largest such service in the world.

Bird Flu Kills At Least One Nigerian

Reuters reports on the first human death from bird flu in Nigeria:

The 22-year-old died after feathering and disembowelling an infected chicken. She was from Lagos, the commercial capital of Africa's most populous country, Information Minister Frank Nweke said.
Test [sic] on three other victims, one of them the woman's mother, were inconclusive.
Nigeria was the first African nation to detect the H5N1 virus in poultry last year and had conducted tests on 14 people suspected of having the virus.

The WHO is taking it in stride:

World Health Organisation spokesman Gregory Hartl said a human case of bird flu in Nigeria was to be expected because of the experience in other countries, such as Indonesia, with huge poultry populations where chickens and hens live in close proximity to humans.
"It does not change anything from a public health point of view," Hartl said. "It had to happen sooner or later."

Cat Flu

Via ProMED-mail: New Scientist reports on the implications of widespread H5N1 infection among Indonesia's cats.

Chairul Anwar Nidom of Airlangga University in Surabaya, Indonesia, told journalists last week that he had taken blood samples from 500 stray cats near poultry markets in four areas of Java, including the capital, Jakarta, and one area in Sumatra, all of which have recently had outbreaks of H5N1 in poultry and people.
Of these cats, 20 per cent carried antibodies to H5N1. This does not mean that they were still carrying the virus, only that they had been infected - probably through eating birds that had H5N1. Many other cats that were infected are likely to have died from the resulting illness, so many more than 20 per cent of the original cat populations may have acquired H5N1.
[...]
Osterhaus emphasises that the cat infections still pose a potential threat. "We know the 1918 pandemic was a bird flu virus that adapted to mammals in some intermediate mammalian host, possibly pigs," he says. "Maybe for H5N1 the intermediate host is cats." If similar percentages of cats are infected at every outbreak location, there must have been many thousands of cat infections since the virus emerged, compared to 267 confirmed cases in humans. Every sick cat is a chance for the virus to adapt, and with renewed outbreaks this year in birds, people or both in China, Indonesia, Japan, South Korea, Hong Kong, Vietnam, Thailand, Egypt and Nigeria, it is getting plenty of such chances.

Playing with the Spanish Flu

Nature has a Web focus on the 1918 flu virus. For a free account of the latest on Frankenstein's reconstituted flu virus, see this press release from the University of Wisconsin-Madison:

By infecting monkeys with the virus, the team was able to show that the 1918 virus prompted a deadly respiratory infection that echoed historical accounts of how the disease claimed its victims.

Shocking! But wait, there's more:

Importantly, the new work shows that infection with the virus prompted an immune response that seems to derail the body's typical reaction to viral infection and instead unleashes an attack by the immune system on the lungs. As immune cells attack the respiratory system, the lungs fill with fluid and victims, in essence, drown.

Somehow I doubt anyone spent the last 90 years believing that the victims were drowning in liquid flu virus. But on a more optimistic note,

The same excessive immune reaction is characteristic of the deadly complications of H5N1 avian influenza, the strain of bird flu present in Asia and which has claimed nearly 150 human lives, but has not yet shown a capacity to spread easily among people.
"What we see with the 1918 virus in infected monkeys is also what we see with H5N1 viruses," Kawaoka says, suggesting that the ability to modulate immune response may be a shared feature of the most virulent influenza viruses.

At least these guys are playing with Frankenstein's Flu at biosafety level 4 this time:

In the new study, conducted in a high-level biosafety laboratory (BSL 4) at the Public Health Agency of Canada's National Microbiology Laboratory, seven primates were infected with the reconstructed 1918 virus. Clinical signs of disease were apparent within 24 hours of infection, and within eight days, euthanization was necessary. The rapid course of the disease mirrors how quickly the disease ran its course in its human victims in 1918.