H1N1 and Big Pharma

Anyone still interested in the H1N1 shamdemic, and the role of Big Pharma should this expose from Der Spiegel. It is by far the most comprehensive chronicle of the events which enveloped us last year.

I just quote a couple of excerpts from the report below, but you should read the whole thing and form your own opinions.

"According to the regulations, phase 6 becomes effective when a new virus is spreading uncontrollably in several regions of the world. The regulations say nothing about the severity of the disease.

In fact, the vast majority of experts on epidemics automatically associate the term "pandemic" with truly aggressive viruses. On the WHO Web site, the answer to the question "What is a pandemic?" included mention of "an enormous number of deaths and cases of the disease" -- until May 4, 2009. That was when a CNN reporter pointed out the discrepancy between this description and the generally mild course of the swine flu. The language was promptly removed.

Apparently German infectious disease experts also misunderstood the official WHO definition of phase 6. An influenza epidemic, according to Germany's national pandemic plan -- updated in 2007 -- is "a long-lasting, international situation involving substantial loss…and causing such lasting damage as to jeopardize or destroy the livelihood of large numbers of people."

The situation on June 11, 2009 did not correspond with these descriptions. Critics were already asking derisively whether the WHO had any plans to declare the latest outbreak of the common cold a pandemic. "Sometimes some of us think that WHO stands for World Hysteria Organization," says Richard Schabas, the former chief medical officer for Canada's Ontario Province."


""The pharmaceutical industry did not influence any of our decisions," says Fukuda. But in mid-May, about three weeks before the swine flu was declared a pandemic, 30 senior representatives of pharmaceutical companies met with WHO Director-General Chan and United Nations Secretary General Ban Ki Moon at WHO headquarters. The official reason for the meeting was to discuss ways to ensure that developing countries would be provided with pandemic vaccine. But at this point in time the vaccine industry was mainly interested in one question: the decision to declare phase 6.

Everything hung on this decision. At stake was nothing less than a move to supply large segments of the world's population with flu vaccine. Phase 6 acted as a switch that would allow bells on the industry's cash registers to ring, risk-free. That's because many pandemic vaccine contracts had already been signed. Germany, for example, signed an agreement with the British firm GlaxoSmithKline (GSK) in 2007 to buy its pandemic vaccine -- as soon as phase 6 was declared. This agreement could explain why Professor Roy Anderson, one key scientific advisor to the British government, declared the swine flu a pandemic on May 1. What he neglected to say was that GSK was paying him an annual salary of more than €130,000 ($177,000)."

"What was this pandemic? Was it all just "good practice for an emergency," as WHO advisor and industry lobbyist Osterhaus puts it? Did the authorities do everything right, as Australian epidemiologist John Mackenzie insists?

Certainly not. No one at the WHO, RKI or PEI should feel proud of themselves. These organizations have gambled away precious confidence. When the next pandemic arrives, who will believe their assessments?"

What has the 3rd medical school got to do with GSK and the H1N1 pandemic?

A strange nexus seems to have developed between the much anticipated 3rd medical school and happenings with respect to GSK and the H1N1 story.

As we all have been told the planned for 3rd medical school was supposed to be a tie up between Tan Tock Seng Hospital, NTU and Imperial College. One of the champions of the proposed tie up was apparently the past rector of the Imperial College, Professor Sir Roy Anderson. Sir Roy is a pretty influential person and has been listed as a VIP on the Board of GSK. But he apparently has a bit of checquered past. In July last year he was in the middle of a controversy about his role in the British SAGE (Strategic Scientific Advisory Group for Emergencies), a 20-strong task force drawing up the action plan for the H1N1 virus, while holding a highly paid position with the drug and vaccine manufacturer, GSK. Earlier he had been in another series of controversies which led to his resigning from Oxford University. You can read the details here.

In November last year, he abruptly stepped down as Rector for Imperial College. The reasons for his departure is unclear and there have been a number of speculations. His departure has however created a bit of a hiatus in leadership for Imperial College. Sir Keith O’Nions, the Director of Imperial’s Institute for Security Science and Technology, took over as Acting Rector. It is also not clear if the new leadership is as enamoured with the tie up with NTU/TTSH for the 3rd medical school. I hear in the grapevine that the vibes are not that positive. Which means the 3rd medical school is now left in a bit of a lurch and scrambling to find a suitor.

So ....a right royal mess......

H1N1 scandal

As the world sits on massive stockpiles of unused and unwanted H1N1 vaccines, the WHO comes under investigation by PACE (Parliamentary Assembly of the Council of Europe) for its (mis)handling of the 2009 'pandemic'. Earlier, Dr Wolfgang Wodarg, Head of Health at the Council of Europe, accused the makers of flu drugs and vaccines of influencing the World Health Organisation's decision to declare a pandemic.

Among the accusations was the way WHO had modified the definition of a pandemic to make it easier for a pandemic to be declared. Previously (2005) the definition of a pandemic required there to be an enormous loss of lives, but with the new definition, it was only required for there to be 'worldwide epidemic'.

An influenza pandemic occurs when a new influenza virus appears against which the human population has no immunity, resulting in several, simultaneous epidemics worldwide with enormous numbers of deaths and illness. (WHO, 2005)

A disease epidemic occurs when there are more cases of that disease than normal. A pandemic is a worldwide epidemic of a disease. An influenza pandemic may occur when a new influenza virus appears against which the human population has no immunity. (WHO, 2009)

Now, Professor Ulrich Keil, director of the WHO’s Collaborating Centre for Epidemiology, gave evidence before the inquiry, that the 'the swine flu pandemic was part of an overblown “angst campaign”, devised in conjunction with major drug companies to boost profits for vaccine manufacturers.'

Not looking very good for WHO.... but pandemic communications expert Peter Sandman has another view of the proceedings. He reportedly told CIDRAP News that 'critics at today's hearing seemed unable to distinguish between what they called a "fake pandemic" and one that has so far turned out less severe than it might have been.'

'.... WHO may have set itself up for unfair criticism by making the same mistake the Intergovernmental Panel on Climate Change made, which led to successful attacks on its credibility: failing to acknowledge the small piece of the truth their critics are getting right.

The critics' strongest arguments are: first, that the WHO should have more quickly admitted that the pandemic was milder than initial evidence suggested; and second, that the WHO routinely included severity among factors to be considered before raising pandemic phases, until its most recent pandemic guidance revision, published in April 2009......

"By failing to concede these two points, WHO gives unjustified credibility to the critics' other, much less valid claims," he said. "Good guys have a harder time than bad guys understanding the need to concede the validity of valid criticisms, even when they're packaged with invalid ones."'

H1N1 pandemic? Now we know what a sham it had been

I had never been convinced of the H1N1 pandemic. All the time there had been this dichotomy between the alarmist messages being spread and reality that nothing much was happening on the ground. People weren't really falling over and dying as much as the the alarmists were saying they were. Tamiflu was never as effective as they made it out to be. I think many people were also not convinced, but there was little bases to counter the pandemic signals being rung at every street corner.

Now that the pandemic that never was is pretty much over, we are beginning to hear of another reality.

Dr Wolfgang Wodarg, Head of Health at the Council of Europe has come out to criticize the actions of the WHO, saying that "the swine flu scare was a 'false pandemic' led by drugs companies that stood to make billions from vaccines", and that "major firms organised a 'campaign of panic' to put pressure on the World Health Organisation to declare a pandemic."

Calling for a major inquiry, he called it "one of the greatest medicine scandals of the century".

More of Dr Wodart's comments in his blog, here.

View Al Jazeera report here: http://www.youtube.com/watch?v=hoQN1to3C2U

Countries are now stuck with massive stockpiles of vaccines that their citizenry were too smart to want to be exposed to. Some are still trying to persuade people to go for the vaccination even though the anticipated threats had had passed. Germany and Spain have cut back on their orders for the vaccine, and Canada is either trying to sell off, or 'lend' their stocks to other countries such as Mexico.

Meanwhile the WHO is undergoing a review of how it handled thre so-called pandemic, amidst accusations of big pharma complicity. The Council of Europe's Health Commission has voted to investigate.

And some people are laughing all the way to the bank!

Sigh....... who can you believe nowadays?

H1N1 mortality risks

So we get closer and closer to reality as the CDC revises its figures which suggest that the mortality for the dreaded H1N1 infection is somewhat less than the seasonal flu. Based on their figures we would be looking at a mortality rate of anywhere between 0.007-0.045% (average about 0.017%).

A recent report from the La Jolla Institute for Allergy and Immunology: "...the conservation of a large fraction of T-cell epitopes suggests that the severity of an S-OIV infection, as far as it is determined by susceptibility of the virus to immune attack, would not differ much from that of seasonal flu. These results are consistent with reports about disease incidence, severity, and mortality rates associated with human S-OIV (swine-origin H1N1 influenza virus)" further confirms its lack of threat.

How did we all get it so wrong? And what are we going to do with all those vaccines that nobody needs?

H1N1 vaccination, anyone?

So Singapore gets her H1N1 vaccine fix in a couple of week's time. I think the MOH had spent about S$10-20 million to the one million shots for us so we should grateful for the preparedness. Word out is that most of these are the Australian CSL Panvax vaccines, and about a third might be the GSK version, Pandemrix. But no idea how these gets distributed so you might want to ask when you do go for your shots. Pandemrix is the one with the AS03 adjuvant.

A couple of things bother me though. There's been a lot of talk about a second wave emerging. The reason for the vaccinations are to mitigate against this second wave. But I never quite bought into this second wave thing for Singapore. If indeed there is a second wave, given there will be more herd immunity, it would be a lesser wave than the first, would it not? Unless of course, the virus mutates. But it hasn't as yet, and it looks like we are dealing with the same, not so virulent, not so lethal , not so pandemic virus.

Also seasonal flu? That applies to temperate countries with summer/winter type seasons. Since the only winter we have in Singapore is the styrofoam/soap variety in Orchard Road, there isn't going to be much in terms of seasonal change in flu transmission. In fact, a scan of the MOH epidemiological stats over 2004-2008 confirm that the incidence of acute respiratory infections were pretty flat throughout each year. The only interruption to this flatness was the rather short-lived H1N1 pandemic earlier this year. So the only seasonal change we may expect in H1N1 would be due to increased seeding by travelers from temperate zones who carry the virus to us. And given the increased herd immunity, such seeds may not transmit that well.

Actually, I wonder why the MOH does not survey the level of herd immunity in our population beefore embarking on any immunization programmes? This developing herd immunity would certainly be one of the reasons why the earlier first wave pandemic fizzled out. After representing more than 60% of samples at the peak fo the pandemic, it is now hovering at about 24% of cases surveyed.

So is there a rush to get vaccination? Apparently not if the health care workers are polled. But these are still early days.

The Great Diarrhoea Mystery (continued)

One can't help but get the impression that the Ministry of Health was hoping the diarrhoea mystery would just fade quietly. But like that bit of floatie, it just doesn't want to go away. So here we are 6 weeks into a national diarrhoea epidemic. And strangely the MOH remains eerily silent.

Methinks this is not a food borne disease. Because if it were, the clusters would have been obvious by now, and the AVA would be running all over the place making a great show of catching rats. But everything's quiet at the moment. So to my reckoning this must a diarrhoeal disease caused by some other pathogen....an airborne virus perhaps?

Once we start thinking along those lines, one of the likely candidates, especially of recent importance, is the H1N1 virus. The novel H1N1 virus has been reported to be capable, more so than seasonal flu, of causing diarrhoea, and I can't help wondering if perhaps this 'epidemic' of diarrhoea is somehow related to the H1N1 virus. Perhaps it has somehow attentuated to just produce gastrointestinal symptoms.

Just some speculations, but I think, may be worth considering. I wonder if anyone has bothered to assay the virus in these doarrhoea cases.

One dose H1N1 vaccine - No need for adjuvants

So an Australian study has demonstrated that with the new crop of H1N1 vaccines, a singlae dose is all that's required. No adjuvants are required. This data confirms what the China vaccine had earlier showed.

The importance in these findings is that firstly, it means the amount of vaccines available can reach twice as many people; and secondly, more importantly, we do not need to use any fancy adjuvants.

One of the major concerns of vaccine technology is the need for adjuvants. Adjuvants are often used to heighten the body's antibody response. This is often needed as the antigen is used in low quantity or does not by itself elicit a strong immune response. The problem with adjuvants is that the hyper-stimulation of the body's immune response (theoretically at least) may induce an unwanted immune response to the body's own proteins. The Guillain - Barre syndrome emerged as one of the problems associated with the US mass vaccination in 1976-77.

Of recent concern has been the use of squalene in commercial adjuvants such as the AS03 (GSK) and MF59 (Novartis). These adjuvants have not been approved for use in the US.

The one dose vaccines (sans adjuvants) should ameliorate these concerns.

H1N1 - second wave?

I found the recent report in the Straits Times that the hospitals were gearing up for a second wave, somewhat intriguing

The report had cited an estimate that about 700,000 had already been exposed to H1N1 and was likely to have immunity. This estimate was based on a back calculation from WHO's estimate of case-fatalities, which was in all likelihood an overestimate, which means the 700,000 is probably an underestimate. But let's say that that represents a decent estimate.... the extrapolation would mean that based on a total population of 4.8 million, there remains another 4.1 million residents and non-residents without immunity.

So a second wave is not an unlikely event.

But as I pondered this with my mathematically challenged mind,.... I couldn't help wondering if the second wave may be reasonably expected to be greater or lesser than the first wave. It just seemed to me that all things being equal (i.e. that the virus hasn't changed) that a wave resulting form exposure to 4.1 million individuals with no immunity might be expected to be lesser than that arising from exposure to 4.8 million naive individuals. And if we had underestimated the numbers who have been exposed to the first wave, the numbers who remained vulnerable would be less ..... and the size of the expected second wave would be correspondingly muted.

So is a panic warranted? I hardly think so, especially since the first wave wasn't even quite the tsunami predicted.

Why the difference between HIV and H1N1? Exceptionalism?

The coincidence of the reports on our first H1N1 related death and the guy who came out with respect to his HIV, gave me cause to think about how the world treats these two pandemics.

It is becoming increasingly clear that the mortality related to H1N1 is nowhere as high as was initially estimated. A recent article in Eurosurveillance by two New Zealand public heath experts reviewed the methods for estimating the case fatality ratios (CFRs) for the H1N1 flu and concluded that the current methods overestimated the CFRs. They present possible alternative methods, which despite their limitations, all produce much lower CFRs (0.06% - 0.0004%) compared to the original estimates of 0.4%.

By contrast also, the HIV CFR has an almost surreal air to it. Nobody talks about HIV related deaths in the same way as for H1N1. For example, a heart attack patient with positive H1N1 would be an H1N1 related death, but an HIV patient dying of a heart attack would not be a HIV related death. Even so, the very crude estimates of HIV CFR is in a totally different ball park from H1N1. In 2007 WHO reported a global incidence of 33 million cases of HIV. Over the same period 2 million AIDS deaths were reported. This allows us to make a very rough estimate that HIV related deaths could be at least 6%, 10 x the worst estimated CFR for H1N1.

Yet we run around panic stricken, whacking at the H1N1 flu with fancy words like containment, mitigation - quarantines, contact tracing etc etc.....while treating HIV almost with kid gloves.

The word that epidemiologists use for this is - 'exceptionalism'.

HIV is probably one of the most destructive pandemics in human history. Since 1981 when it was first discovered it has been estimated to have killed 25 million world wide. Yet we are afraid to manage it in the same scientifically rational way we manage all other epidemics. Activists and lobbyists have managed to persuade the global community that to do otherwise is a human rights offense.

So we have been powerless to deal with this pandemic in the correct way.

But things seem to be swinging away from that falsehood as people come to terms with the destructive nature of the pandemic. In 2007, the US CDC and and WHO/UNAIDS finally got the courage to recommend that testing for HIV be part of routine clinical testing. This is 26 years too late if you ask me.....but at least it is now being done.

Singapore followed suit with Changi General Hospital taking the lead. Senior Minister of State Ministry of Foreign Affairs, Dr Balaji, reported (Nov 2008), "... Changi General Hospital was the first hospital in Singapore to pilot voluntary opt-out HIV screening for inpatients just under a year ago. They have shown that it can be done. More than 3,000 of their patients have been screened so far, and around 50 have been found to be HIV-positive. The Ministry of Health has asked other acute hospitals to implement a similar opt-out HIV screening programme for their adult inpatients, and it should be in place in all public sector hospitals by the end of the year. Private hospitals should also study how they can implement opt out testing as this becomes the standard of care."

Let's do away with exceptionalism once and for all, and deal with a pandemic the way pandemics ought to be dealt with. Scientifically, rationally and truthfully.

Read "Changing the Paradigm for HIV Testing — The End of Exceptionalism" in the New England Journal of Medicine.

Managing and Reducing Uncertainty in an Emerging Influenza Pandemic

Interesting comments from the recent copy of the New England Journal of Medicine.

I excerpt some paras for your reading. Can go to the original by Marc Lipsitch from Harvard School of Public Health above if you want to read full article.

"Crudely speaking, the (H1N1) case fatality ratio thus appeared to be 0.2%, near the upper end of the range for seasonal influenza, and superficially, this statistically uncertain estimate seems remarkably accurate given the data available on May 27, by which point there were 11 deaths and 7927 confirmed cases (a case fatality ratio of 0.14%)."

"Public communication of risk and uncertainty will be critical. It has been suggested that the existing criteria for moving to World Health Organization pandemic phase 6 (sustained transmission in multiple geographic regions) should be modified to incorporate a judgment that the world's population is at increased risk. We would argue against conflating assessments of transmissibility and severity in this subjective way, which risks adding to the confusion faced by decision makers and the public. Rather, the global extent of a pandemic should be described objectively and should be just one factor in decisions about how to respond."

"As we adjust our mitigation policies, there will be a continuing need to make decisions without definitive estimates of severity. For example, the decision to move from production of vaccine for seasonal influenza to that for pandemic influenza will need to be made in the next month or two. Similarly, the United States will need to decide soon whether to use adjuvanted vaccines to protect more people with a given amount of antigen, although such vaccines are not currently licensed in the United States. As always, however, the main losers from delays in such decisions are likely to be developing countries, which will have less access to vaccine while probably suffering the greatest clinical impact from this new pandemic virus."

H1N1 (aka American flu) - dying embers of a spurious fire

So Minister Khaw reckons the battle for H1N1 is almost over.

I think everyone is just kinda hoping that everything will blow over quite quietly with as little egg on people's faces as possible.

I do agree though, it's true that we should be looking to learn whatever lessons we can from this global event. And I really hope they will do it honestly and not sweep stuff under the carpet, in the interest of looking good.

Some lessons worth learning, I think:

a] How did the world get it so wrong?

Quite clearly the virus is nowhere is virulent as was initially made out to be. No, Minister Khaw.... the virus isn't getting weaker. It wasn't that 'strong' in the first place. Somehow data collected in those early days just massively inflated fatality risks of the novel flu.

We need to seriously look at how global flu data is collected, and have a better idea of credibility of data when they do appear.

b] How do we manage public health information in the context of a pandemic?

I don't agree with Minister that the whole thing was managed well and that the public has done well in managing the pandemic. I think the public did try their best in dealing with the very confused signals appearing. But the whole thing could have been managed much better. All those messages about how serious this whole thing was, just wasn't very convincing to much of the public, and very early became viewed as a massive nuisance that people had to bear when few were at all convinced it was a serious flu pandemic. Now that it is blowing over without much of a fanfare, is just confirming in everyone's minds, that this has been a complete overreaction.

I know that this is being said with the wisdom of hindsight, but I think the uneventful outcome wouldn't have been very different even if nothing much had been done in the first place. So I don't think there is any credit due anyone, that not much damage had been done by the novel virus.

I am not making these comments flippantly, because I think it is very important to be honest about these deficiencies because the next pandemic might well be a real one....and a bad one at that. We need to have more confidence in the data collected, and have a proper and accurate diagnosis of risks as early as possible. And we need real decisive leadership to know when to turn off the alarm, when we recognize that it is false. It goes without saying that in the management of a real pandemic, a very strong and clear buy in by the public is critical in order to make pandemic management effective. This did not happen.

c] Resourcing for the pandemic management was woefully inadequate.

Surprising especially as we had struggled so much through the SARS experience. So it is strike two, ...but we are not quite up to scratch.

Vaccine safety - preparing for the eventuality

I have posted on the topic of vaccines and vaccine safety before.

Here I want to highlight 2 recent scientific reviews on this topic which I think are important for us to consider as we hurtle down this road towards H1N1 mass vaccination programmes.

The first is a review in 2008, by Dr Fineberg in the Journal of Infectious Diseases (if you want the pdf of the original paper, just email me). This review was done when avian flu was a hot topic, and it draws upon lesson from the 1976 US mass vaccination programme for swine flu which resulted in a national fiasco where 25% of the poulation was vaccinated and no evidence of any pandemic. In the review, Dr Fineberg recalls the 7 features of the swine flu :

1. Overconfidence in theory spun from meager evidence.
2. Conviction fueled by preexisting agendas.
3. Zeal by health professionals to make lay superiors “do the right thing.”
4. Premature commitment.
5. Failure to address uncertainties.
6. Insufficient questioning of implementation prospects.
7. Insensitivity to media relations and to long-term credibility.


....and identifies 7 lessons today that we can learn from that fiasco:

1. Beware of overconfidence in models drawn from meager evidence.
2. Invest in a balanced portfolio of research and contemporary preparedness.
3. Clarify operational responsibilities in the federal government.
4. Refrain from overstatement of objectives and misrepresentation of risk.
5. Strengthen local capacity for implementation.
6. Communicate strategically.
7. Lay the basis for program review.


The second review is just hot off the press in the same august journal, entitled ""Prepandemic" Immunization for Novel Influenza Viruses, "Swine Flu" Vaccine, Guillain-Barré Syndrome, and the Detection of Rare Severe Adverse Events", by Dr Evans and his co-workers. (conclusions abstracted below)

"In summary, the risk of SAEs (serious adverse events) will remain important considerations in developing immunization policies for interpandemic use of novel influenza vaccines and implementing mass immunization programs. These issues are particularly challenging when the risks of severe illness or of a future pandemic are uncertain and, therefore, safety concerns more acute, as is the case in interpandemic vaccination. However, even if an association between SAEs and interpandemic vaccination could be discounted with confidence, the reality is that public perception of a link has the potential to undermine amass vaccination strategy over and above the scientific evidence, as clearly evidenced in the 1976 experience."


I will leave it to you to form your own impressions about our current approaches towards the H1N1 vis a vis the comments contained in these reviews. I would certainly recommend these as compulsory reading for those interested in vaccine safety, and also for our decision makers in MOH who may be contemplating a mass vaccination strategy.

H1N1 (aka American flu) - Making it clear

The MOH has made a significant attempt in clarifying the situation with regards this 'pandemic'. So thank you, MOH.

For those who are still confused, I have tried to summarize the current understanding and to give a simplified common sense layman approach if you get any 'flu-like symptoms' below:

a] This is a new strain of an old 'flu' virus. It spreads pretty easily but at the moment does not seem to be 'dangerous' other than to some 'high risk people. These high risk people are:
- pregnant women
- patients who have immunological deficiences such as on steroids, on cancer treatments etc
- patients on dialysis
- very young children less than 1 year old

b] If you have runny nose, sore throat and even a cough, but no fever, just stay away from people and wear a mask. Take the usual cough/cold medications. If you need and MC, go see any GP.

c] If you have runny nose, sore throat, cough plus fever and or body aches etc, these would be considered a flu-like disease (what the MOH calls 'influenza like illness') and you are not in the high risk groups of people, this would probably not progress more than the usual seasonal flu. Stay away from people wear a mask, go to your GP and get an MC until you are better (probably 5-7 days).

d] If you have flu-like disease(as in [c]) and are very sick, as in weak, breathlessless etc... best you call 993 or just go to one of those PPC (Pandemic Preparedness Clinics). They have Tamiflu to issue, and if you need to be hospitalized, they will know what to do.

e] If you or your relatives are in the high risk group and who have flu-like disease, it is best you go to one of the PPCs where the doctor there can assess if treatment with Tamiflu is required. You can call 993, if you are very ill.

H1N1 (aka American flu) - time to end the confusion, MOH

I have been trying to give the MOH the benefit of the doubt with regards to the H1N1 thingy because it's just been such a difficult position for the Ministry to be in. But day by day, its indecisiveness is getting more and more disappointing and frustrating. And the growing public confusion is worrying.

Where are we now, and what is the real strategy with regards this infection? Do we take this seriously not not?

The MOH website doesn't contain much more than the latest stats, and an uninformative statement - "Though the number of infected cases has increased, the severity of the disease remains relatively mild. .... Singaporeans should carry on with their usual activities whilst observing good personal hygiene at all times. If unwell, they should see a doctor, stay away from work, school or crowded places, and rest at home."

Ummm...so helpful lor. If it's 'relatively mild' why this concern about staying away etc etc...?

The Straits Times today quotes an unidentified spokesman as saying "We are now preparing to manage the disease in a more targeted and risk-stratified manner".

Ummmm....that's even less helpful I am afraid.

And neither is the ST report from that interview, that Singapore is preparing to switch to the mitigation phase of dealing with the H1N1. Whatever that means. I mean, we are either containing or mitigating... being told that we are preparing to move to mitigation is like saying we want to be there, we should be there and we are going to be there. But where are we exactly?

Clearly the public is confused. And I really don't blame them.

Do we need to still control movement / contact and do voluntary home quarantine? Are all these temperature monitoring really necessary? There is just such a confusing array of containment strategies out in the schools and workplaces, that even more puzzling when you consider we are actually moving (preparing to switch?) to mitigation.

If we are not going to treat all H1N1 cases, and we are not going to swab all flu cases, why do we need, as the spokesman said, to "call 993 for an ambulance" if travelers get flu-like symptoms within a week of return from affected countries?

If the MOH wants the public to be participatory and to be engaged in the management of epidemics/pandemics such as this, information and instructions must be clear and unambiguous. Why do we keep fueling this paranoia if we are really not going to do anything substantive about it?

And we are really not having that clarity of mission at the moment.

Anthropomorphising the virus - Prof Tambyah's view

NUS' Prof Paul Ananth Tambyah's opinion piece in the Sunday Times today, about H1N1, entitled 'Understanding the 'mind' of a virus' provided an interesting and useful insight into evolutionary virology. He makes some interesting points - such as that among other things, if you want to be a successful virus you should try and avoid the host immune system, and not do silly things like killing off your food supply. By his reasoning through this anthropomorphising of the virus, he reckons this virus will not turn lethal.

It is an interesting model. But he is wrong.

This novel H1N1 should not be considered an separate entity from the other H1N1 viruses,or indeed the othe Influenza A viruses. It is more correct to view the entire family of like viruses as an entity - much like the cybernetic borgs in Star Trek. These viruses seek to propagate themselves, find a utilizable biological niche to occupy and as Prof Paul Ananth points, need to stay ahead of host immune systems by a constant changing of their disguise. If they remain genetically static,develop either useless non-infective characteristics, or virulent ones which may overdo their virulence and kill off the host. These are random events. There is a balance that a successful virus strain strikes, but it cannot keep that position indefinitely because the host immune system will eventually hunt it down, and destroy it.

The common cold and Infuenza A have been extremely successful in this constant change and adaptation and engaging us poor humans in this biological cat and mouse game. And they will remain very successful. Influenza A will from time to time produce a virulent and lethal strain. Statistics don't lie. It's only a matter of time. This strain may arise in the most unexpected of places; as this one did. And as we will not have the immunity for it, many will die. But the survivors of the the onslaught will live to fight another day. And they will be stronger. Until the next real pandemic arrives. And so on.

But such is life. Que sera sera?

H1N1 (aka American flu) - 1 million in the US alone?

So here's a new slant on the H1N1. Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention has been quoted as saying: "We are estimating about a million people in the U.S. or more have gotten this virus... ,"

The laboratory confirmed positives are only 27,717, meaning the pick up rate is only 2.7%. I wonder what this means with regards to the alarmist estimates of fatality rates around 0.37% that we have been fed with? With an estimated denominator of ~1 million, the death rates would actually only be ~1/10,000, i.e. 0.01% in the US - far less than the fatality rates of previous pandemics and even seasonal flu.

I think health officials need to be a bit more realistic in their communications, and help us understand this better.

H1N1 (aka American flu) - mortality rates, real or not?

Minister of Health Khaw yesterday at his press conference quoted a mortality estimates of H1N1 of 0.37%. This is already a much lower estimated than was initially computed. And even less than what I had earlier roughly estimated (~0.55%) from the Wikipedia data.

But are the numbers a good reflection of the real risk of H1N1?

We won't really know because everyone has a different way of computing these numbers depending on whether they want them up or down. The crude estimates would be to take the total reported deaths divided by the total reported cases. If you take the current CDC figures for US it is 87/21449 = 0.4%, not far from Minister Khaw's figures.

Are these figures believable? Well they are pretty much what we have at the moment. It is probably quite an overestimate I believe. Why do I say this? Well.... reported case numbers do tend to be an underestimate, because many who develop flu symptoms may not be tested for H1N1 at all. On the other hand the deaths numbers are probably an overestimate because many H1N1 cases who die have many other concurrent problems and their deaths though associated with H1N1 may not be directly attributed to H1N1. So in all likelihood the numerator is an overestimate while the denominator is an underestimate, making it very likely the actual risk of dying is much less than the ~0.37% quoted by Minister Khaw.

Also the numbers have been inflated because the early death rates in Mexico and even the US were very high.... This has come down substantially. If you look at data from UK, Australia and Canada,...those with health care standards on par with the US and were involved later, the death rates are much lower - UK (1/2773 = 0.036%), Australia (1/2733 = 0.036%) and Canada (16/6457 = 0.25%).

Peter Doshi published a paper in the American Journal of Public Health last year criticizing the ways that scientists have traditionally computed fatality risks of pandemics. He is of the opinion the the risks have generally been inflated, for various reasons.

I quote from his paper:

"The notion that pandemic influenza’s fundamental property is excess mortality is difficult to reconcile with the recorded influenza death data over the past century. There are many possible explanations, one of which may be the tendency to generalize the exception—the 1918—1919 pandemic. In 1918, doctors lacked intensive care units, respirators,respirators, antiviral agents, and antibiotics, an important fact in light of historical evidence of interactions between influenza and secondary bacterial respiratory pathogens (e.g., Haemophilus influenzae) as a significant cause of death during the pandemic.

It is also important to recognize that commercial interests may be inflating the perceived impact of influenza and other infectious “pandemics.” There is a clear need for more evidence-based accounts of influenza in the context of historical epidemiology and current social and medical advances."

He concludes (2008):
"Whatever the reasons for the misconceptions, should the trends observed over the 20th century continue to hold in the 21st, the next influenza pandemic may be far from a catastrophic event."

Indeed.

H1N1 (aka American flu) - naming...not shaming

The Sunday Times carried an article about naming those who have been infected. This was in the context of the German researcher from the Biopolis who had gone socializing and carried on normal activities even though he was not well.

Doctors have come out to defend the need for patient confidentiality. And they are right. It is wrong to name patients publicly because they are entitled to a certain level of confidentiality about their condition. I say a certain level, because this entitlement is not absolute.

The American Medical Association in their Code of Medical Ethics say:

"that the information disclosed to a physician during the course of the patient-physician relationship is confidential to the utmost degree. As explained by the AMA's Council on Ethical and Judicial Affairs, the purpose of a physician's ethical duty to maintain patient confidentiality is to allow the patient to feel free to make a full and frank disclosure of information to the physician with the knowledge that the physician will protect the confidential nature of the information disclosed. Full disclosure enables the physician to diagnose conditions properly and to treat the patient appropriately. In return for the patient's honesty, the physician generally should not reveal confidential communications or information without the patient's express consent unless required to disclose the information by law. There are exceptions to the rule, such as where a patient threatens bodily harm to himself or herself or to another person"

The Singapore Medical Council Ethical Code and Ethical Guidelines states:

" A doctor shall respect the principle of medical confidentiality and not disclose without a patient’s consent, information obtained in confidence or in the course of attending to the patient. However, confidentiality is not absolute. It may be over-ridden by legislation, court orders or when the public interest demands disclosure of such information. An example is national disease registries which operate under a strict framework which safeguards medical confidentiality.

There may be other circumstances in which a doctor decides to disclose confidential information without a patient’s consent. When he does this, he must be prepared to explain and justify his decision if asked to do so."

So there are exceptions to the code.

The question here is whether the conditions here qualify to be exempted. In this case, the condition is not really life threatening, and although it was rather socially stupid and irresponsible to expose others to the risk if you think you are infected, this doesn't really go beyond being stupid and socially irresponsible. Naming is little more than a vindictive,punitive act.

On the other hand, it this were a really serious epidemic and a real risk of fatal consequences, then it might qualify for naming - not as a punitive act but for epidemic control.

For example, under current conditions, there is a real gap between exposure and effective contact tracing and quarantine/treatment. This gap can be in terms of days before the contact team can track down named contacts. This delay can be shortened if case contacts can self identify and come forward for advice/quarantine/treatment. But self identification requires that people know who the cases are and if they have had exposure to the case. In the case of the German researcher, I can only know if I have been exposed if I knew who he was and where he worked.

In the case of NUS' Prof Lee (reported in TODAY yesterday), he was only able to self identify because he could identify Case 73 by flight and seat details, and because of this, he was able to inform MOH and self impose home quarantine. If he had waited for MOH contact tracing team and track him down and serve the quarantine orders, there could well have been up to 2-3 days delay and otherwise preventable exposure to colleagues and family members.

We need to be mindful of the negative consequences of naming. Above all we should never do it out of vindictiveness. But we need to keep in mind the possibility that at some point in time (with some other epidemic) appropriate naming may actually save lives.

H1N1 (aka American flu) - puhleeez MOH, containment or mitigation??

So we are now confirmed to have breached the century mark. WHO had long before (seems like history now, doesn't it?) declared the pandemic. Yet MOH persists with a defunct containment strategy.

Could it be that MOH is testing the limits of it's capabilities to cope in a 'real' serious pandemic? If so, well, let me inform the MOH that we have already exceeded our capacity to cope. Alarming isn't it? We can't even cope with 103 cases.

• Quarantine facilities are bursting at the seems. Only for foreigners, I am told. I think Aloha Loyang will soon resemble a refugee camp.
  
• Local contacts serve the quarantine at home, - I suppose so that they can continue to infect their family members.
  
• Meanwhile their family members continue to move freely and therefore are free to infect the world at large.
  
• Even when quarantined at home, the Home Quarantine Orders are served so late as to be meaningless.
  
• CDC sends home infected patients, only to readmit them again. Read about Filipino worker, unlinked case.
• Contact tracings are delayed.
  
• and six hundred 993 calls per day??

I think it's quite clear that the system is not coping and that inadequate provisions had been made, despite all the claims of our readiness. I guess it should be time to go back to the drawing board, MOH.

Containment or mitigation, MOH? Maybe it's time to go to mitigation. Unless of course, the real reason for delaying is that we are still trying to get our mitigation resources up to scratch.