Saturday, 2 January 2010

Lessons of the Swine Flu Pandemic in USA

Please note that the fatality rate in USA is twice that in UK because
USA didn't use Tamilflu quickly enough.
In fact, 30% doctors didn't prescribe Tamilflu to patients that had
been admitted to hospitals with flu symptoms.

Even UK hesitated on prescribing Tamilflu causing many unnecessary
deaths unlike Japan that had steadfastly prescribe Tamilflu even for
common flu that can also kill. The lowest fatality rate of Swine Flu
in Japan is testimony of the effectiveness of Tamilflu. I also
witnessed the effectiveness of Tamilflu when given quickly, i.e. less
than 48 hours. The later Tamilflu were given, the longer it takes for
the flu symptoms to disappear.

However, it is not over yet in USA. Vaccination rate in USA is less
than 50% unlike Canada and the peak flu season is not over yet, i.e.
late January. Let us see if those who are anti-vaccination can survive

U.S. Reaction to Swine Flu: Apt and Lucky

Published: January 1, 2010
Although it is too early to write the obituary for swine flu, medical
experts, already assessing how the first pandemic in 40 years has been
handled, have found that while luck played a part, a series of rapid
but conservative decisions by federal officials worked out better than
many had dared hope.

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John Amis/Associated Press
The supply of swine flu vaccine was far below expectations, but
experts say the pandemic was still generally well managed.
Signs Swine Flu Wave May Have Peaked in U.S. (November 21, 2009)
Times Topics: Swine Flu
Enlarge This Image

Brendan Smialowski for The New York Times
Public health officials have been credited with quickly debunking
misinformation that arose at the height of the pandemic.
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Béatrice de Géa for The New York Times
The decision to order vaccine made with a 50-year-old egg technology,
rather than experimental methods, was controversial.
The outbreak highlighted many national weaknesses: old, slow vaccine
technology; too much reliance on foreign vaccine factories; some major
hospitals pushed to their limits by a relatively mild epidemic.

But even given those drawbacks, "we did a lot of things right,"
concluded Dr. Andrew T. Pavia, chairman of the pandemic flu task force
of the Infectious Diseases Society of America.

Federal officials deserve "at least a B-plus," said Dr. William
Schaffner, chairman of preventive medicine at Vanderbilt University's
medical school.

Even Dr. Peter Palese, a leading virologist at Mount Sinai Medical
School, who can be a harsh critic of public policies he disagrees
with, called the government's overall response "excellent."

About 10,000 people had died by mid-November, the Centers for Disease
Control and Prevention estimated; the pandemic seems unlikely to reach
even the lower end of a forecast of 30,000 to 90,000 deaths made in
August by the President's Council of Advisers on Science and

The virus and the vaccine cooperated. While the former proved highly
transmissible in children, it was only rarely lethal, remained
susceptible to drugs and has not thus far mutated into an
unpredictable monster. Vaccine supply was a problem, but one small
dose was enough. (By contrast, an experimental avian flu vaccine
protected people only when it was six times as strong.)

For that reason, the relatively cautious decisions by the nation's
medical leadership contained the pandemic with minimal disruption to
the economy.

For example, in the early days, they ignored advice to close the
Mexican border and pre-emptively shut school systems. They released
part of the national Tamiflu stockpile, but did not give it to
millions of healthy people prophylactically, as Britain did. They
ordered vaccine made with a 50-year-old egg technology rather than
experimental methods. They bought adjuvants — chemical "boosters" —
that could have stretched the first 25 million vaccine doses into 100
million, but did not use them for fear of triggering a backlash among
Americans made nervous by the messages of the antivaccine movement.

To alert the public without alarming it, a stream of officials — from
doctors in the navy blue and scrambled-eggs gold of the Public Health
Service to a somber President Obama in the White House — offered
updates, at least twice a week for months.

It is now clear that this is the least lethal modern pandemic. The flu
appears to kill about one of every 2,000 people who get it, American
researchers say. (British researchers found half that death rate.) By
contrast, the Spanish flu of 1918 killed about 50 of every 2,000, and
the 1957 and 1968 pandemics killed about 4 of every 2,000.

The flu has reached more than 200 countries and is still peaking in
places like Eastern Europe and Russia. Even though there was no
vaccine yet, it killed fewer than expected during the Southern
Hemisphere's winter, June through August.

Officials in the United States conceded that some mistakes were made.

For example, they could have spotted the new virus earlier if there
had been better cooperation with Mexico. In late April, the United
States isolated it in samples from Texas and California just as
Canadian officials were testing Mexican ones. The outbreak probably
began in rural Mexico in January, but was spotted only when thousands
fell ill in late March or early April in Mexico City.

The C.D.C. tests viruses in Southeast Asia, where new flus are usually
born. "This time," said Dr. Thomas R. Frieden, the C.D.C. director,
"one happened to emerge in a place where we don't have a surveillance

Also, the government predicted in early summer that it would have 160
million vaccine doses by late October. It ended up with less than 30
million, leading to a public outcry and Congressional investigations.

"Imagine if they'd managed the expectations better," said Michael T.
Osterholm, director of the Center for Infectious Disease Research and
Policy at the University of Minnesota. "If they'd said, 'We won't have
any till December,' and had some in October, they would have looked
like heroes."

Robin Robinson, chief of vaccine purchasing for the Department of
Health and Human Services, was the most overly optimistic. In an
interview, Dr. Robinson said he had actually tried to be conservative,
assuming that manufacturers would get 1.4 doses per egg, when they
typically got two or more.

Until the eggs could be tested in August, "we didn't know that we had
one of the poorest-producing viruses in the last 50 years," he said.
Good batches had 0.6 doses per egg, he said, bad ones had 0.2.

If he had it to do over again, he said, "I'd factor in the worst-case
scenario — which was 2009."

Another controversial decision — sending a few early vaccine doses to
Wall Street firms like Goldman Sachs and Citibank — was more of a bad
public relations move than a bad public health one, experts said. That
choice was made by the New York City Health Department, "and we made
the decision not to second-guess local health authorities," Kathleen
Sebelius, secretary of health and human services, said in an

The government allotted vaccine to states based on population size.
Some local health officials had thousands line up in parking lots for
shots, some sent teams into schools and some relied on private

Distribution of the vaccine could have been focused more precisely,
experts said, directing it to hospitals first, or to doctors treating
children and pregnant women, or to cities with big outbreaks.

"I still think sending it out on a per capita basis was the fairest
and most equitable way," Ms. Sebelius said.

The early combination of fears about the vaccine and anger over
shortages, said Dr. Paul Offit, chief of infectious diseases at
Children Hospital of Philadelphia, reminded him of an old Borscht Belt
joke: "The food at this resort is so terrible," one patron complains.
"Yes," agrees her companion. "And such small portions!"

One real triumph, several experts said, was how little damage
misinformation did. In 1976, many people refused shots after three
elderly Pittsburgh residents died shortly after getting theirs; it
took the C.D.C. five days to explain that it was just a coincidence.

This time, many rumors arose but were quickly debunked: That thousands
had died in Mexico. That the virus had circulated in the Midwest for a
decade, undetected. That it had escaped from a laboratory. That
seasonal flu shots made catching swine flu more likely. That flu shots
did not work or caused autism. That the administration would make them
mandatory. That Tamiflu resistance was widespread in Northern
California. That a flu shot had disabled a Washington Redskins
cheerleader, or that she was cured by chelation therapy by a doctor
associated with the antivaccine movement. That mutant killer flu
strains were circulating in Argentina or Ukraine or North Carolina.

The debunking succeeded, Dr. Osterholm said, "despite the fact that
there are many fewer reporters who understand medical issues than
there used to be."

This time, both the C.D.C. and the World Health Organization responded
quickly to almost every rumor. At the epidemic's height, they held
several news conferences a week, taking questions by phone from all
over the world.

They also invited dozens of reporters to daylong seminars on influenza
at C.D.C. headquarters in Atlanta and to exercises around the country
led by the former anchorman Forrest Sawyer, at which they debated, for
example, whether a miscarriage by one woman after getting a flu shot
was a big scoop or a nonstory.

Remaining to be seen is what effect the pandemic has had on Americans'
feelings about vaccines.

Dr. Frieden said he thought a victory over the antivaccine movement
had been scored. Nearly 60 million people have been vaccinated,
including many pregnant women and children, with no surge in side

John P. Moore, an AIDS researcher at Weill Cornell Medical College,
was less sure. Dr. Moore, who spent years fighting AIDS denialism, has
called skepticism about flu vaccine "an unholy alliance of the left
and right" because it joined the liberal natural-medicine proponents
with anti-big-government conservatives.

"It's hard to say if it hurt or helped," Dr. Moore said, pointing out
that polls still show a large minority of Americans rejecting the
vaccine. "As with AIDS, people have to die before others understand
the consequences of ignoring science-based medicine."

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