Tuesday, March 18, 2008

March 17 Flu Update

An 11 year old boy has died of bird flu in Vietnam.

Bird flu hits an 11th region in Vietnam.

A new region of India is having a bird flu scare.

ProMed on outbreaks in Vietnam and China (this one was reported yesterday).

Bird flu is also back in Borno, Nigeria.

Article on "caution" in Hong Kong

CIDRAP on the CDC pandemic exercise....the whole article is must read....but this excerpt rings pretty true, in my opinion.

The question of school closings and related "community mitigation" (CM) measures (also known as nonpharmaceutical interventions, or NPIs) arose early and often. At the first morning press briefing, Gerberding said, "As of this morning we're not recommending widespread school closures or other measures to reduce spread in crowds, but those measures are likely." She added that actual closings would be local decisions.

When she was asked what should trigger CM measures, Gerberding said, "When a community begins to see acceleration in the number of cases that suggests that transmission is really taking off, that's when closing schools and avoiding crowds can help. It's important to do it early, because if you wait till you have 1,000 or 10,000 cases, it's too late."

Hesitation and concerns about CM measures emerged in an hour-long Tuesday afternoon teleconference between senior CDC staffers and health officials from states affected by the pandemic. (The state officials were mostly played by CDC staffers in the Exercise Control Group, but three people from state health departments had joined the group for the exercise, according to Jerry Jones, director of the group.)

The Michigan official wanted to know if the CDC could recommend any particular NPIs as better than others. He said the state had a case-fatality rate of 7% in its 100 cases, signaling a severe pandemic under the CDC's community mitigation plan, so the state needed to launch mitigation steps. "But the local health departments are telling us they don't want to do all that work," he said. "So if there's one thing working better than others, we'd like to recommend it."

Revere blogs this as well, and note links to the FluWiki, where DemfromCt wrote extensively on this as an observer. Revere notes that exercises are one thing---but properly supported public health agencies are another.

Is it too risky to have backyard poultry?


At 6:11 PM, Blogger Wulfgang said...


Very nice selection of articles today. It is very evident after reading the Hong Kong “school closing” article, the excellent CIDRAP account of the CDC pandemic tabletop exercise, and Revere’s commentary – that there are some obvious glowing weaknesses in the US CDC’s approach to pandemic crisis management.

The first major weakness which is apparent, is there are no published federal guidelines, rules or procedures that the state authorities can adhere to for school closures and related NPI’s. According to Dr. Stephen Redd, the CDC’s influenza team leader, “there will not be any federal decision on school closures”. In my view, leaving both critical interventions unconditionally “up to local decisions” (presumably that is the states responsibility according to Ms. Gerberding), is unrealistic. It will only invite delays in implementing necessary emergency procedures, and lead to tense situations, maybe even potential disaster and chaos. Without stringent federal rules or guidelines to follow, the states and local authorities will devise their own rulebooks. Expectations and basic actions must be carefully identified and well thought out in advance for all known emergency contingency situations – to think they can be improvised “real-time” is foolhardy.

The second major weakness I see involves the Strategic National Stockpile of Oseltamivir and when supplies are to be released: there is clearly a lack of defined antiviral policy by the CDC for pre-deployment of antiviral, when distribution to regions and states will occur, and its intended use. It should be automatic. At the very first sign of a contagious influenza pandemic, supplies of Tamiflu should be distributed to the states immediately according to predetermined rules. There should also be a published set of recommendations for use of Tamiflu the states can adhere to, which prescribe its use, and the conditions for initial containment, prophylaxis, or for only treatment of the confirmed sick. At present, there seems to be total confusion on this subject which is unnecessary, because it is so ill defined.

The obvious third major weakness is (once again) the CDC’s lack of published guidelines and instructions in regards to “screening travelers”. Presumably this means incoming people at airports and other land points of entry, but the CDC doesn’t even have a clue what this really means or entails, or the resources required, and neither do the states.

I am continually astounded (but not surprised) at the naivety of the CDC, and their lack of leadership, when it comes to conducting pandemic tabletop exercises and lack of national coordination, with the vast resources available to them in the federal government. There were approximately 1.7 million federal employees employed across 95 federal government agencies in 2007. Many of these agencies have extremely valuable assets, lots of available manpower, facilities and expertise to offer (even in the areas of medicine, epidemiology, virology, world wide communications, facilities). Many of these federal employees are extremely talented and experienced in science and social areas – and HHS, DHS, FEMA and the CDC should leverage off of these resources. I would be willing to bet that not one of these four entities have one cooperative written pandemic agreement with any of the other 90-plus federal agencies. In fact, oddly enough, many of these 90-plus other federal agencies have been interfacing, planning and coordinating with state and local emergency operations officials, but have never been contacted or approached by the CDC, HHS, FEMA or DHS for pandemic national emergency assistance. Seems all very odd to me with such a vast federal (and state) workforce, somebody can’t take the lead.

According to Dr. Gerberding, the 10% case-fatality rate assumed in the CDC table top scenario was worse than in the 1918 pandemic (2-3%) and was “out of bounds of our planning scenarios”. Somebody at the top of the CDC really needs to get with the program or get out of the way: the average ACTUAL CFR for SARS victims was between 10-12% and the outbreak in Canada was exactly five years ago from today (March 2003). One would think the CDC would really plan for a worst case situation.

We will never-ever be fully prepared for a pandemic at this snails pace. It will take much more aggressive leadership, leveraging and cooperative agreements with other federal and state agencies, clear policies and guidelines, and more thinking “outside the box” than what I am seeing.



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