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Friday, October 07, 2005

YARGH - H5N1 (bird flu)

Yesterday I found YARGH (Yet Another Really Great Blog) and spent several hours reading it. It is great.

It's a group blog, and the subject matter is broad and the content is extremely good. For example, try this post on the levees in New Orleans.

One of the bloggers on YARGH is RogerA (he is in the public health field), who left the following comment on this post:
The issue in Toronto is a marker for how we will confront an H5N1 pandemic flu situation. Epidemic situations are like 9/11 except in slow motion. They unfold over days and weeks. Poliltical leaders thus do not always understand when the stuff has hit the fan. The result is the loss of precious response time.

There is no easy public health answer because public health follows a medical model of lab confirmation.

These are genuine national security risks, and IMHO, we are not adequately prepared to deal with them.
No, we aren't prepared to deal with this risk. One of the things that I do is disaster planning (a.k.a. business continuity) for banks. The reason I began to study up on bird flu is that I needed to see if banks should plan for it. I concluded they did. So then I started to try to establish the risk parameters, and (gasp) they were very high.

But I still needed something to establish the realworld parameters, and the events of the last three months in Indonesia and now this particular outbreak in Toronto gave them to me. So now I have enough data to write the business continuity (general segment) for a bank.

I will probably establish a new blog and publish the whole darn thing split into various topics. It will be huge. The long and the short of my research was disturbing. We are not prepared. The bulk of the hospitals are not prepared and the bulk of the EMT services are not prepared, and that leaves businesses such as banks, grocery stores and gas stations highly vulnerable. However, even the health services were prepared there is relatively little they can do, so our society would still be highly vulnerable to business disruption.

We cannot count on having effective medication, and we cannot count on having effective tests to quickly distinguish who might have a bad cold or another type of flu rather than a strain of H5N1 dangerous to humans. It is unlikely that we will have an effective vaccine, too. Nor are these really failures of preparation. They are structural problems that can only be marginally addressed. We don't have the drugs that would be effective against a pandemic, and we will not. We can't prepare a vaccine likely to be effective against the disease, and if we did, we are short the manufacturing capacity to produce it.

It's not that a new flu epidemic or pandemic has to be such a crisis as the doomsayers are now claiming. This virus could eventually make the leap as a relatively mild one. However, the probability is that it will not. So the measures that will work to mitigate the problem are very generic disease control measures, and they are ones with which our population is unfamiliar. Those strategies, I concluded, are what are necessary, and they will have to be implemented at the lowest levels of government and in individual businesses to make a difference. Basically we are talking about building the tactics and strategies that will form a floodwall to stop the virus from propagating as quickly within the population.

In other words, if you address the risk of the pandemic as a medical problem, looking for rapid diagnosis and treatment, we have little or nothing. But if you address the risk as a procedural problem, you can greatly mitigate it. So it is not a hopeless problem at all - but it is one that will require a concerted effort. The libertarians among you will be interested to learn that my calculations showed me that the greatest level of mitigation would be gained from non-governmental action, and much of it will not be extremely expensive. More perturbingly, my calculations showed me that unless there is a lot of activity on the part of individuals, businesses and counties, almost nothing that big government can do will mitigate the situation.

Yesterday the esteemed Dymphna asked for resources, and I told her I would post some today. However, I probably won't start until next week and then it will be on the new blog. I think the new blog will be the most effective way to deal with this, because I would like as much criticism and backtalk as I can get for each segment. Obviously it will be too late to test my assumptions when people start getting sick and I certainly did not do all of this for my own pleasure. I will link the new blog here as soon as I start setting it up.

The doomsayers are wrong. People are more than capable of acting effectively to deal with relatively severe problems. What people need is information so that they can do this, and the press is not going to give it to them.

A very ambitious undertaking about H5N1 MOM! There is some information starting to show up in blogs--Glenn links to one today. There are lots and lots of major issues that could arise since we really dont know the infection and mortality rates. The economic impact can be found in Martin Meltzer's on line article in the Journal of Emerging Infectious Diseases. It constructs what amounts to a cost benefit analysis around vaccination priorities (search the CDC website using Meltzer's name in the search engine)

There are other significant international issues: for example, does it make sense to wait until H5N1 arrives in the US to contain it; or does it make more sense to putting what resources we have (a potential vaccination and anti-viral treatment) to areas in SE Asia where human to human transmission is mosts likely to emerge.

Another BIG question concerns containment strategies in the United States; to quarantine or not quarantine. There are also major issues about treating people when there is clearly a national shortage of ICU beds and ventilators for the projected patient numbers. Who should vaccinations knowing as we do the supply of vaccine will be limited at least initially. Who should get antivirals (Tamiflu specifically). Should the public be advised to buy N95 masks which provide a great degree of personal protection; should the public be advised to buy Tamiflu? (its available)

At any rate, these are just some of the major questions involved.
Roger - I would vote for putting in the early effort abroad.

As it stands, if the virus is not contained the anti-viral drugs we have will probably be only marginally useful later. Buying time this way is likely to increase our knowledge base, and time is of the essence. The longer you can suppress this the more vaccine and treatment options will be available.

Purely on an ethical basis, there is no question that we should attempt to save lives in these countries.

So to me both the utilitarian and ethical arguments indicate that we should put forth an aggressive effort abroad.

As to the effort, it is unfortunately one that my job responsibilities require. The government and the health departments will have to work on their end. The businesses and individuals will have to work on their end. The second area is where my responsibilities lie.

As for the N95 masks, absolutely they public should buy them. It also makes sense for businesses to acquire them for their employees as well as gloves for certain jobs.
MOM: your point about public education is well taken--it is really imperative to start that campaign now--simple things like handwashing, masks if infected, avoid family gatherings and getting a regular influenza shot this season (to aid in diagnosis) and those kind of things--All the academic studies of these incidents suggest the public is really quite cooperative when they know what is going on and are given solutions.

You are absolutely correct that there really is not much the feds can do let alone the states--In my county we are planning to use churches as additional hospital beds because churches usually kitchens, bathrooms, and a congregation that is already closely knit.

Involving the other sectors is also important--particularly grocery stores and wal-marts. There really isnt too much outside the box thinking going on regretably because when you dont know what box you are in, its hard to think outside of it.
Roger - yes. Most of the truly effective planning will take place on the county level or lower.

One of the big variables is childcare.

The schools will probably be closed during a severe outbreak, which will put an additional strain on the workforce at exactly the wrong time.

One of the ways churches might help would be to arrange for alternate daycare in small groups.
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