U.S Pandemic Update December 15, 2009

On December 10, 2009 the CDC published  CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April – November 14, 2009.  I won’t reprint it here (you can follow the link for more), but I’ll take just a few moments to point out some things that I noticed, along with a little “back of an envelope” calculating.

According to the CDC, the number of deaths each year directly related to influenza or secondary bacterial pneumonia is about 9,000.  Over 94%  of seasonal flu deaths are in people over 65 years old.

CDC estimates that so far H1N1 has killed 9,820 people, but the age distribution is quite different.

	Seasonal Influenza	H1N1
Age Group
65+	8,460	1.280
18-64	485	7,450
0-17	65	1,090
TOTAL	9,000	9,820

Even though these are estimates, this is the closest I’ve been able to come to comparing apples to apples.  The difference between seasonal flu and ‘09 H1N1 is striking.  While the actual numbers will differ from these, I believe the proportions are pretty close.  In the 18-64 group, deaths are 15 times more than seasonal flu, and in the 0-17 age group deaths are almost 17 times more.

2009 H1N1 Case Estimates April-November 14, 2009

Age Groups	Estimated Cases
0-17	16 million
18-64 years	27 million
65+ years	4 million
Total	47 million

 This table illustrates the CDC’s estimates of the number of cases for these three age groups.  Looking at both of these charts, we can see that the 18-64 age group has less than double the number of infections that the 0-17 age group, but has nearly 7 times the number of deaths.  Based upon these estimates, the Case Fatality Rate/Ratio (CFR) for the 18-64 age group is 4 times higher than that for the 0-17 age group.

Using age distribution data from the year 2000 census and the above CDC numbers, I estimate that only 18% of the 0-17 group have been infected and only 15% of the 18-64 age group.  This virus doesn’t need to change to kill a lot of people, it just needs to continue spreading.

Oh, by the way, flu season lasts until May.

Signs and Portents

(Updated)

Last week, gene sequences from the Ukraine influenza breakout were released by the WHO.  Four of the ten sequences (all four were deaths) contained a change at position 225 of the HA segment (D225G).  This change will apparently allow H1N1 to bind more easily to human cell receptors deep in the lungs, causing more severe disease.  This change has been seen already in other parts of the world (Brazil, Mexico, China and others) and has been associated with more severe disease and death.  It was also found in the 1918 H1N1 Spanish Influenza.

Within a day or so of the Ukraine sequence announcement, Norway revealed that the same change had been found there, also associated with severe disease and death.  The WHO, while acknowledging the that this change occurred, took pains to try to reassure that not every instance where D225G has been found resulted in death, that they couldn’t say that it was spreading, and that D225G H1N1 was not Tamiflu-resistant nor vaccine-resistant.

While all this was happening, Tamiflu-resistant clusters of H1N1 were announced to have been found in Wales and North Carolina.  Again, efforts were made to reassure the public that this change wasn’t spreading, in spite of the fact that clusters of the same virus are prima facie evidence of spread.

Today, Dr. Henry Niman, a virologist that predicted, weeks before they were released, that D225G would show up in the Ukraine sequences, published this commentary about additional information now available about those sequences.

WHO Silence on D225G Immune Escape Raises Concerns

Recombinomics Commentary 13:18
November 27, 2009

The recent upgrade of the characterization sheet for A/Lviv/N6/2009 to “low reactor” status has created significant pandemic concern. The change affects receptor binding specificity and allows the virus to bind alpha 2,3 targets which are on the lung, and also affects the antigenic site. However, early data on the development of the attenuated vaccine target indicated that there was no difference between the response to wild type and D225G. These differences have not been explained, although the testing of the candidate vaccine target would be on the cold adapted background, while the testing that produced the “low reactor” designation would be on the D225G on its natural swine H1N1 background. Initial investigations were carried out by Mill Hill, but then the CDC in Atlanta was also involved, possibly to confirm the “low reactor” results.

However, WHO has not issued any updates on this development. They have said that the D225G change in Ukraine was “not significant” even though it was in four of four fatal cases and now has been designated a low reactor. The only indication is at the GISAID database, which is public, but requires membership and is password protected. This designation has serious implications because there is direct and circumstantial evidence that D225G is circulating as a mixture, and immune responses that fail to target D226G can shift the ratio in favor of D225G, which could lead to a significant rise in severe and fatal cases.

It was the rise in severe and fatal cases that led Norway to closely examine cases there, and D225G was found in three cases (2 fatal and 1 severe). However, release of sequences from Norway identified a fourth case, where D225G was identified as a mixture with wild type. Moreover this mixture was the earliest sub-clade in Norway that matched the sub-clade in Ukraine. This sub-clade was isolated prior to the first reported fatal cases in Norway, which was also the same sub-clade, although D225G was not present in the sequence from a throat swab from that patient.

The failure of the WHO or CDC to comment on the low reactor status of the Ukraine sequences from fatal patients is also cause for concern. More detail on this designation, and vaccine plans to address this issue, would be useful.

A “low reactor” in this instances implies resistance to natural immunity and vaccine.  This would mean that if this particular sequence type spreads, prior infection with a different version of H1N1 and or vaccine would be little defense against this more severe version.  Potentially really, really bad news.

Right on the heels of that pile of bad news comes this:

Two die in France after mutated H1N1 flu infection

28 November 2009

Two patients who were infected by a H1N1 flu mutation that was also recently detected in Norway have died in France, health officials here said Friday.

“This mutation could increase the ability of the virus to affect the respiratory tracts and, in particular, the lung tissue,” said a statement from the government’s Health Surveillance Institute (InVS).

“For one of these patients, this mutation was accompanied by another mutation known to confer resistance to oseltamivir,” it added, referring to the main drug being used to treat H1N1 flu, under the brand name Tamiflu.

Now Dr. Niman’s comments:

D225G and H274Y in Fatal Infection in France

Recombinomics Commentary 17:30
November 27, 2009

In a statement, the Institute suggests “Reference of mutations in the genome of influenza virus A-H1N1″ from these two people who had no relationship and were hospitalized in two different cities. InVS was that for one of these patients, in addition to this mutation, another known mutation that is resistant to Tamiflu, the drug used to treat people infected with the virus.

The above translation describes two fatal cases in France with D225G. Moreover, one of the two cases also had Tamiflu resistance, presumably H274Y.

The presence of D225G in unrelated patients at distinct locations mirrors the results in southern California in April, when swine H1N1 was initially reported in the United States. The same strain in two patients who had no link to swine or each other signaled efficient transmission. The same is true for D225G. It is in multiple patients in multiple countries and appearing at increasing frequencies at the same time.

The finding of Tamiflu resistance in one of the fatal infections raises additional concerns. The circumstances surround the resistance would be useful. The number of reports of H274Y have spiked in the past week, suggesting it too is efficiently spreading at a detectable level.

So, a quick summary:

1.  D225G, a change associated with increased severity and death, is becoming more widespread.  The WHO has danced around the issue of actual spreading of this change and would seem to want to give the impression to the public that D225G is not spreading.  The actual evidence indicates otherwise, but we’ll see.

2.  Same situation with Tamiflu resistance.  Clusters of Tamiflu resistance, a very good indicator of spread, are appearing, but both CDC and WHO downplay the significance.  Again, we’ll see.

3.  A sequence from Ukraine, from a death and containing D225G has been designated a “low reactor,” indicating vaccine resistance.  No comment yet from WHO. (see UPDATE below)

4.  Two people in France have died and have been positive for D225G.  One of the victims may also have had a Tamiflu-resistant version of H1N1.

What does it all mean?  I wish I knew.  I can say this, though:

It ain’t over ’til it’s over and it ain’t over yet.

Stay tuned.

 

UPDATE:

The WHO is continuing to dance.  This article will be in Saturday’s New York Times.

Experts Say Swine Flu Mutations Do Not Warrant New Alarm

By DONALD G. McNEIL Jr.
Published: November 27, 2009

The World Health Organization tried this week to dampen fears about mutations seen in the swine flu virus in several countries, noting that both mutations had been found in very few people.

<snip>

Dr. Fukuda also said W.H.O. scientists were “not sure” of the level of threat posed by a separate mutation that helps the virus reach the lungs. It has been found in Norway, Ukraine, Brazil, China, Japan, Mexico and the United States, in both serious and mild cases.

Experts still need to see whether the mutation — whose shorthand name in virology is D222G or D225G — is becoming more common, and how often it leads to severe disease, he said.

One isolate from Ukraine with the mutation had changed so that swine flu vaccine probably would not protect against it well, Britain’s national medical laboratory reported Friday.

Flus mutate so fast, Dr. Fukuda cautioned, that announcing each change is “like reporting changes in the weather.”

<snip>

And so it goes…

Pediatric Deaths Continue

The CDC announced that they have confirmed 35 more pediatric deaths this week.  Over the last 5 years, the average number of pediatric deaths during week 46 from influenza is ZERO.

The cumulative 2009 total is 301.  The highest annual total over the last 5 years is 2008 with 90.  Of that 90, around 20 resulted from swine flu.  As you can see from the chart below, we have already surpassed the total annual pediatric deaths from seasonal flu since 2005 (and every other non-pandemic year on record) and it’s still November.  Move the 20 or so 2008 swine flu deaths to 2009 and we have confirmed at least 321 so far this year.

Obviously, I think this a big deal.  It’s an even bigger deal if one of the 321 is your child, and he or she attends a school where the administration decided that keeping the school open was the number one priority.

Let the Swine Flu Party Rock On!

Sometimes you have to laugh through the tears. 

Yesterday, two physicians spoke out, advising against parents participating in so-called “swine flu parties.”

…But health experts are universal in their condemnation of the practice of swine flu parties.

“Any time you willingly subject your children to an infectious disease, you run the risk of all sorts of complications,” said Dr. Tamara Kuittinen, an emergency medicine physician at Lenox Hill Hospital in New York City. “There’s always a risk of giving them more than you bargained for. It may be dangerous.”

Added Dr. Robert Frenck, a professor of pediatrics at Cincinnati Children’s Hospital: “It’s not anything I would advocate for swine flu or any flu. Most of the time the flu is a mild illness, but it can be severe. People die from H1N1 and from the regular flu.”

Since I assume that the CDC has at least a few physicians on the payroll, I wondered why the advice from these two physicians was in direct contradiction to what the CDC has been encouraging for months.  After all, what is school this fall but a big swine flu party?

Then it hit me.  Swine flu parties aren’t the problem; non-government approved swine flu parties are the problem.  In this brave new world where our benevolent Big Brother is offering to take care of us from our first whack on the rear end to that final boot-shove into the grave, it makes perfect sense.  Parents simply can’t be trusted to get this right.  Their pitiful attempts to gather a few kids together for an hour or two to get them all infected pale in comparison to the 8-hour-a-day, 5-day-a-week swine flu festival the government can provide.

Think about it.  Daily, millions of kids in classrooms, hallways, lunchrooms, gymnasiums, locker rooms, restrooms, and school busses, mixing and mingling for hours at a time.  What a cornucopia of infection opportunities!

It must be working, too.  Yesterday, the CDC announced that, using their cutting-edge, exclusive telephone survey methodology (see special offer at the end of this post), they have determined that 20% of all school kids had been infected by swine flu in October.  Shazaam!  That means the party’s just gettin’ started!  With 80% of our kids still to go and vaccine at a trickle, this celebration is gonna rock on for quite awhile.  And golly, since pediatric deaths from swine flu are already numbering at least 3 times what we’d see in a normal year, who knows what heights we could reach!

Now that boards of education across the country are sagely committing to keep the schools open as long as someone can stagger in and turn on the lights, parents can sleep soundly at night knowing their little ones are partying the days away.

Boy, I’m sure glad I’ve got the wizard-like geniuses at CDC to take care of the all the planning for this gargantuan viral bash.  I sure couldn’t come up with this myself.  Thanks guys!

Party on, Wayne!

Party on, Garth!

 

 

 

 

 

 

 

 

 

 

 

Special Offer:  Are you a government bureaucrat in a jam?  Do you have the tough task of making people believe something that isn’t true?  Like, maybe that the unemployment rate is actually low, in spite of the fact that seven people on your block have lost their jobs?  Well, chin up, Chuck!  You can put the public communication and statistical skill and experience of the CDC to work for you.

You, too, can receive the benefits of their proprietary process for creating credibility for your message, regardless of the facts!  If this sounds like “just what the doctor ordered,” call now.  Talk with Dr. Tom at the CDC for all the details.

 

By the way, my family and I will send our regrets in response to the party invitation.

Hundreds of regrets.

Searching for the Truth

My kids hate math. Well, at least they tell me they do. With the exception of my seven-year-old (who seems to love math but hasn’t had algebra yet), they insist that they don’t need to know all this “algebra stuff.”

Okay, there is also my four-year-old. She has a firm grasp of the “greater-than/less-than” concept. As long as her stack is greater than your stack, she’s fine.

“C’mon, Dad,” they say, “as long as I can count my money, I don’t need to know any more math.”

Yeah, right. Let’s check back in about twenty years and see how that’s working.

I tease them, “That’s why you’ve got parents; you don’t have sense enough to know what you’ll need beyond dinner.”

The response I usually get is that longsuffering, condescending look that teenagers have that means they’re thinking “Ugh! I can’t wait till I’m eighteen and outta here! I’m gonna change my name and no one will be able to find me.”

I am sympathetic, though. I was young once, long ago, though I probably wasn’t as cool as I remember myself being. I remember that I pretty much hated doing math, too. It always seemed so boring and tedious. I didn’t enjoy the work, and like my kids, I couldn’t see any use for it.

It wasn’t until later in life that I began to appreciate the beauty of mathematics. I started to see that numbers are the building blocks of the universe. Everything physical comes down to numbers.

I’m not going spend much time illustrating this, but an inability to understand numbers hobbles us in life. If we can’t do simple percentages, how do we keep from being overcharged at a 15% off sale? How do we understand an investment prospectus? How do we have even a snowball’s chance of understanding a bill before Congress that will cost tens of billions of dollars and will make sweeping changes in our lives? How can we make the proper choices to keep our loved ones safe in the face of an influenza pandemic?

We can’t.

If we can’t understand and decide these issues for ourselves, someone else will. Eagerly. And without being too concerned about our best interests.

Most of my posts have been, and will continue to be, about the numbers of this pandemic. I am not a mathematician, statistician, or any other “ician.” I do, however, have some experience at working with information like this, and I hope I can communicate well enough to keep your eyes from glazing over. I’ll also give my opinion about this stuff, but don’t just take my word for it and move on. I’ll try to provide enough links to sources so that you can investigate this yourself. There are too many people out there stating conclusions without any supporting evidence, and they expect you to just believe and follow. I don’t want to be like that.

Unfortunately, hard data is difficult to find, and I believe some key information is not being made available to the public. It’s as if someone holding this important data is playing a shell game, constantly moving the shell holding the pea, keeping it mixed up with other shells so we can’t find the right one.

One important piece of this puzzle is the number of infected people. This is key to determining how bad this pandemic may get. I discussed this in The Fog of War, a few weeks ago, and while the public still has not been allowed to see any of the studies that have been done on this, we do have some interesting hints.

Early in the pandemic, the CDC tried to float the idea that somewhere around a million Americans had been infected by swine flu. During this time, the U.S. had been having outbreaks around the country, in many locations. Also during this time, New York City was dealing with an outbreak of its own, and they were dealing with the highly publicized death of an assistant principal of a New York City public school due to H1N1.

So, at the same time that the CDC was trying to claim that a million people in the U.S. had been infected, NYC public health tried to claim half of that total for themselves. That’s right, they claimed that 500,000 New Yorkers had been infected by swine flu.

Both of them couldn’t be right, and in my opinion, they were both wrong.

The CDC later backed away from the one million number, with Dr. Anne Schuchat, CDC spokesperson saying that it was an “estimate” from some statistical models and that the number may be an “overstatement.” NYC public health stood by their 500,000 person estimate. It turns out that they had done some sophisticated telephone work and had called New Yorkers and asked them if they had any flu-like symptoms. Oh, boy.

Later in the summer, Dr. Thomas Freiden, the CDC chief, promised to release studies that had been done to determine the number of infected throughout the country. I’ve not seen any yet.

Oh, by the way, Dr. Freiden began the pandemic heading up New York public health and was later named to run the CDC. Was Dr. Frieden part of that laudable telephone survey? Did he bring that enviable level of strategic thinking to the CDC?

For more discussion of that strategic thinking, see my post We’re Off To See The Wizard.

Today, in large part due to the CDC bungling its mission to reliably inform us about this pandemic, one-half, or more, of Americans say they do not intend to be vaccinated against H1N1. Now, while I think vaccination is a really good idea, I can’t really blame people for thinking that the risk of vaccination is higher than the risk of swine flu. The CDC and almost every other public health department have been playing down the seriousness of this disease for months.

In my opinion, they have been doing this in the hopes that the vaccine will halt the pandemic, like a hero riding in on white horse to save the pretty lady tied to the railroad tracks. Well, much to their dismay, they convinced the lady that the train isn’t coming. To make matters worse, she also thinks the hero looks rather seedy and wants nothing to do with him.

Now, in an effort to get people to be vaccinated, Drs. Frieden and Schuchat and the elite CDC public relations/risk communications team are attempting to convince Americans that this pandemic isn’t mild. It’s like watching Mo, Larry and Curley.

Mo: “Who said it was mild? I never said it was mild.”

Larry: “You said it was serious, then, right?”

Mo: “Who said it was serious? I never said it was serious.”

Curley: “What did you say?”

Mo: “Larry did the talkin’.”

Larry: “I’m not sayin’ nuttin.”

Curley: “So it’s not serious?”

Mo: “It’s less serious than serious.”

Larry: “And more mild than mild.”

While he was NYC Health Commissioner, Dr. Frieden downplayed the virus.

 the virus isn’t more virulent than seasonal flu but appeared to be spreading more rapidly than other flu strains. He said the “large clusters” in the schools was “a little surprising.”

Soon thereafter he was moved to the CDC.  The Feds know a good one when they see one.

As late as September, Dr. Frieden was saying

“The good news is that so far, everything that we’ve seen, both in this country and abroad, shows that the virus has not changed to become more deadly.  That means that although it may affect lots of people, most people will not be severely ill.” 

He said this even though dozens of children had already died from swine flu.  In fact, by that time we had seen nearly a year’s worth of pediatric flu deaths in a few weeks.

Now, in the face of vaccine resistance, the tune has changed.

On October 6, 2009, Dr. Frieden had this to say about swine flu: 

 “…despite the clear message from all of us in public health… The first concern that we hear is, oh, flu is just a mild illness.  Actually, on average, flu is not a mild illness.  It can make you pretty sick, knock you out for a day or two or three.  Make you miss school and work.  And far too many people end up sending them to the hospital, to the intensive care unit and tragically some people may die from it.  In fact, this year already, we have seen quite a few children who have died from flu.  So, although it is not a disease that will send lots of people who get it to the hospital, it can be very serious and even for those for whom it’s an average case, it’s no picnic.”

During that same press conference, Dr. Frieden said this in regard to the number infected: 

“Even in places where flu has been widespread.  It’s affected 5% to 10%.  That leads [to] 90% to 95% of the population that’s still susceptible.”

On October 9, 2009, Dr. Schuchat said this in regard to the spring outbreak: 

“Even in places that were hard hit with the H1N1 virus last spring, at most, 5% to 10% of people were ill with disease even if many people were infected without having any symptoms.  We think the vast majority of people in a given community are vulnerable or susceptible to this virus.”

They have made quite a change in their message.  I’m still not sure where the CDC gets their 5-10% infected.  Seroprevalence studies?  I’ve not seen them.  More telephone surveys?  Did they just pick a number that fits their message?

Wherever they got it, I have some reason to think that they may, finally, be telling something closer to the truth.

The Alabama Department of Public Health has been publishing, sort of regularly, the results of influenza testing done at the state laboratory.  The lab receives samples from various physicians and hospitals from around the state.  These specimens are taken from patients that have an Influenza-Like-Illness (ILI).  For the week ending September 26, only 56% of the samples sent to the lab were positive for influenza, though only one of the positives wasn’t swine flu.  For the next week, 76% were positive for influenza, and all positives were swine flu. 

Apparently, a great deal of ILI in Alabama is being caused by something other than flu.

But, there is a lot of ILI activity in the state.  The activity reported for last week shows the percentage of visits attributed to ILI continues to be elevated in Alabama (8.1%).  The baseline set by CDC defines “significant activity” in Alabama as 2.5%.  Based upon this, if we were to take away the proportion of ILI activity associated with positive flu tests, Alabama would still be well above the baseline for significant ILI.  A lot of what people think is the flu, isn’t.

See ADPH

One study that I mentioned in The Fog of War seems to support the notion that a significant portion of ILI is not caused by flu.  In that study, only 5% of the ILI was caused by influenza.

Another interesting look at this can be found in a guest editorial at Clinical Evidence.  The author makes what appears to me to be a good case that influenza causes less than 10% of all ILI and typically infects a very small percentage of the population in given season, perhaps as low as 1%.

So, what does all this mean?  Most of us in flublogia have been trying to get a handle on how many people have been infected by the swine flu virus.  That number is the first step toward an accurate determination of just how bad this thing is.  The CDC, in my opinion, has made no effort to assist the public in finding this out.  They have, however, published inaccurate and inflated numbers that would appear to make the swine flu fatality rate less, and therefore diminish the perceived severity of the pandemic.

If, in fact, (1) they are now telling more truth than fantasy, and a lot less people have been infected than earlier estimates, and (2) much of the ILI being reported is not swine flu, and (3) the pressure put on our ICU/ventilator resources in a typical flu season is caused by flu infecting less than 5% of our population, then if we see true attack rate of 20% or more we are in for a really, really bad time.

I invite any discussion or criticism of my reasoning.  I would love for someone to convince me that I’m way off base.  Feel to comment or to email me at deanb2001@gmail.com.

I’m Glad It Still Hurts

Take a load off Fanny,

Take a load for free

Take a load off Fanny,

And put the load right on me.

“The Weight”                                                                                           The Band, Music From The Big Pink 

 

 

Even though I’ve been away from this blog for awhile, the pandemic marches on. 

In the last month, over 50 children have died as a result of swine flu. and increasing numbers of pregnant women are dying.

I’ve listed some headlines and links to several news articles about some recent swine flu victims.  Many articles have pictures and some have video; they are all heartbreaking.  Please read them anyway.  I know it’s hard to see these precious faces and know that they have been taken away from their families.  I know that hearing parents describe their little ones is really painful.  Read them anyway; I’ll tell you why later.

 

Nathan’s dad, brother beat the flu; he couldn’t:  Six-year-old boy becomes Minnesota’s latest H1N1 fatality

 

 

Swine Flu Kills Cabell Midland High School Student 

 

 

Family: Second Swine Flu Victim was ‘Sister, Daughter, Nurse, Bride-to-Be’

 

 

Dallas mother dies from swine flu

 

 

Girl who died of H1N1 remembered

 

The older I get, the more firmly convinced I am that the greatest gift we’ve been given is love.  When I consider my entire life’s experience, nothing else comes close.  When I look at my wife, or hold my children, I realize that no sensation, no emotion, no thrill can hold a candle to the overwhelming joy I feel in those moments.  Out of all the times of my life that I treasure, and there are many, I hold those moments as the most precious.  I could lose all that I’ve ever had or all that I’ve ever been, but if I could hold on to the love I’ve felt, it would be worthwhile.

Over the years I’ve known people that are in nearly constant pain, usually physical, because of injury or illness.  What if I could take it on me, even if only for a little while?  I want to be able to tell them that for the next minute, or hour, their pain will be lifted away and I’ll carry it for them.  Can you imagine what that would be like?  To be able to give that gift?  The real gift, of course, would not be to the one having the pain lifted, but to the one lifting it.  That’s love.

Reading about the loss of these children is hard for me because I can’t do anything.  When I hear the despair and the heartbreak of the families, it hurts.  It is with tears in my eyes that I read what a father or mother says about the loss of their child.  I realize that whatever vicarious sting I may feel is pale in comparison to what they feel, and it does nothing to lessen their burden. I keep reading because, even if I can’t carry it for them, I have the notion that somehow I honor their pain by feeling some myself.  Odd, perhaps, but there it is.

If you’ve skipped over the above accounts, please go back.  Take a little bit of your time to honor their grief.

Strangely, there is also joy with the pain.  This may be a little harder to explain, but the tears mean that I am not yet numb or indifferent.  They mean that I have not reached the point where I’ve seen so much that I won’t allow myself to feel anymore.  The fact that I can still shed a tear because of the death of a  little girl in Texas means that things are not yet as bad as they can be.  I hope and pray that they never are, that this pandemic never gets as bad as it can be.

So, for now, I’m glad it still hurts.

The Fog of War

“The great uncertainty of all data in war is a peculiar difficulty, because all action must, to a certain extent, be planned in a mere twilight, which in addition not infrequently — like the effect of a fog or moonshine — gives to things exaggerated dimensions and unnatural appearance.”

Carl von Clausewitz

 

How bad is swine flu? That’s all we want to know, right? It seems like it should be an easy thing to figure out. The Case Fatality Ratio (CFR) ought to particularly simple since all that you need is the number of people who have been infected (let’s call that x) and the number of infected people that have died (let’s call that y). Just divide the first group into the second group, and, voila! We now have the CFR, don’t we?

^y/_x = CFR

 

Well, we might be able to calculate CFR if we knew what x and y actually are, but we don’t. We have many estimates of x and y, and because some estimates are better than others, we have widely divergent estimates of CFR. Some have estimated that swine flu’s CFR is much less than seasonal flu’s, while others have estimated it to be considerably more. So what’s the holdup? Why can’t we get an answer to this basic, and really important, question?

 

What is x?

How many people have been infected? Well, it kind of depends on who’s counting. The problem is no one is counting. That’s right, no one. Very early on, the CDC asked hospital and physicians to limit the number of tests being sent to certified laboratories because the labs couldn’t keep up. In spite of years of talking and planning, meeting and greeting, our folks just weren’t prepared. They didn’t have enough test kits or people and machines to process them.

Now, the CDC has moved to tracking Influenza-Like-Illness (ILI) as they do with seasonal flu. The ILI case definition used by the CDC is a fever of 100 degrees or more and cough and/or sore throat. If the physician does not diagnose a cause other than influenza, it gets counted as ILI. Of course, lots of things can cause an ILI other than influenza and it’s sometimes expensive or other inexpedient to test for them, so it’s well known that the total ILI overstates the actual number of influenza cases. So the next question is how much does counting ILIs overstate the actual amount of influenza? One recent study sheds a little bit of light on that.

The scientists tested 80 people that had symptoms consistent with ILI. Only 4 actually had H1N1, and 3 had type B influenza. As far as I can tell, the study was well done and the results are accurate. How much that tells us about the CDC’s ILI Surveillance program is up for debate, but we would be very safe to say that it overstates the amount of influenza by a considerable amount.

If ILI surveillance can overstate influenza activity, it may also miss cases in which people are sick, but not sick enough to seek medical care. It may also miss cases that don’t meet the case definition of an ILI. Since the swine flu virus can cause illness, even severe illness, without causing fever, people that seek medical attention but don’t have a fever are not likely to be counted by ILI surveillance.

So, when it comes to ILI surveillance, one hand giveth and another taketh away. ILI counting is not a good way to determine y.

The CDC could use a much better method for determining y than ILI surveillance. They could do seroprevalence studies, for instance. This would be done by testing a sample group of people for H1N1 antibodies. Constructed properly, this type of study can give very accurate results and it doesn’t require cutting edge science. A seroprevalence study is such an expected procedure in a disease outbreak that it’s difficult to imagine the CDC not doing it. If they haven’t, why not? If they have, why have we not seen the results?

 

What about y?

How many people have died? Determining this number should be much easier than finding x. For one thing, the number of deaths ought to be a lot smaller then the number of infections. Additionally, most deaths take place while under some sort of medical care, so mechanisms are already in place to capture these cases.

Unfortunately, some of the same issues present with determining y arise also in determining x. Testing of hospitalized cases is much more prevalent, but is not universal. If the patient presents without fever and has other complicating factors, H1N1 may not even be considered. To further complicate matters, the recording and publication of H1N1 death information has been left to local authorities, and local procedures vary widely across the country. This lack of centralized record-keeping means that the number of actual deaths will always be understated.

 

Lag Time

Even if we could somehow find an accurate y and x, they both must correspond with respect to the time period they represent. For example, let’s say we have an infectious disease that kills 10% of those infected, it kills during the second week of infection and that the number of infected doubles every week. If 100 people are infected the first week, the disease progression would look something like this:

 

 

	Week 1	Week 2	Week 3
Total Infected	100	300	700
Total Deaths	0	10	30
Calculated CFR	0%	3.3%	4.3%

 

 

As you can see, if we simply use the current cumulative numbers, the CFR is understated by a considerable amount. The one-week lag time between infection and death will cause the calculated CFR to skew downward. As the weeks progress in our example, the gap between calculated CFR and actual CFR will close somewhat. In order to be accurate, the number of deaths must be calculated with the number of people infected at that same time.

If the lag time increases, or becomes variable, calculating CFR becomes very difficult.

All of the above is why you should take any estimate of CFR as just that, an estimate. Some estimates will be better than others so, before you rely on any one of them, examine it closely.  Also consider the possibility that the fog surrounding swine flu is intentional.

We are in a war with swine flu right now and certainly don’t need anyone working against us. We have already experienced a number of casualties, many of them heartbreakingly young, and I’m afraid we’ll see many more.

We’re off to see the Wizard

“Pay no attention to that man behind the curtain.”

The Wizard of Oz

 

 

Even as cynical as I often am, I have always wanted to believe that our leaders, whether in our local communities or business or state and local government, are a cut above the rest. I really want to believe that these folks are up to the task of understanding and dealing with the many difficult challenges that face us. I want to believe that they have the knowledge, the wisdom and the character to properly carry out the responsibilities they have agreed to shoulder.

Dorothy, in The Wizard of Oz, wanted to believe, too. You know the story. She struggled through many trials and tribulations along with her friends, all in her attempt to find the Wizard who she believed could save her and get her home. But when she reached the Emerald City, she found not a Wizard, but a charlatan, a snake oil salesman that couldn’t even save himself.

I have always believed that our CDC was the best of the best. They had the best scientists, the best facilities, and the right mission. When they did science, it must be the best science. I believed that they set the standard for the rest of the world. Untouched by politics, they would give the straight scoop, whether it was good news or bad. If the CDC said it, you could take it to the bank and that check wouldn’t bounce.

Well, here we are in the first pandemic in 40 years and my belief is sorely shaken.

Vaccine Issues

By early July, the CDC began claiming that a vaccine would be available in the fall. They made little to no effort to make sure that we understood that supplies would be extremely limited and that whatever vaccine that was available would be allocated to certain priority groups. HHS and CDC spokespeople continued the “available in the fall” mantra until August 14, well after most schools in the South had already begun classes. On that day, news reports stated the CDC’s predicted amount of vaccine available was three times the actual amount, and that instead of 120 million doses available there would be only 45 million doses. Since we have over 300 million people in the U.S., most people won’t see a vaccine until well after the predicted mid-October date. Why were we not told this sooner?

Swine Flu Called “Mild”

The CDC has continually characterized swine flu as a “mild” disease. However, their definition of mild and the average person’s definition are not the same. Most people do not understand that “mild” in this context means no hospitalization. I have seen rooms full of surprised people when they found this out. For a short description of a “mild case” of the swine flu, read Laurie Garret’s article here.

Seasonal flu itself doesn’t meet the “mild” definition popularly held. My informal polls of the groups I speak to about influenza pandemics have shown me that less than 20% of adults have even had the flu, and much less than that get infected in any given year. Most have had an Influenza-Like-Illness (ILI), that caused a day or two of discomfort that they thought might have been the flu. There are lots of little fellows that cause these, typically the rhinovirus, otherwise known as the common cold. A recent study ( here ) found that 95% of ILI’s tested were not influenza.

It’s fun to bring this up to groups, because the few who have had the flu nod knowingly to each other and tell the rest “If you’ve had it, you’d know it.” (This low number of true flu victims is quite significant when you consider the effect of a pandemic attack rate of 30% or more. More on this later.)

It doesn’t take long to figure out that telling the public that swine flu is “mild” is a miscommunication, at best. These folks either know, or should know, that our understanding of the message being delivered is quite a bit different from the reality supposedly being described. Yet we keep hearing that swine flu is “mild” or “mild for most people.” Why?

Swine Flu Characterized as Similar to “Seasonal Flu”

This is also a favorite of CDC and other public health spokespeople.  Since many people confuse the common cold with the flu, they are being ill-served by this comparison before even considering any specific factors of swine flu itself.

Swine flu is not like seasonal flu.  Here are some differences:

• It attacks and kills young people in much greater proportion than seasonal flu. So far, less than 3% of swine flu deaths have been people older than 65.
• It causes severe disease in a higher proportion of hospitalized patients. These severe cases require extraordinary, specialized and complicated care in intensive care units well above anything found in seasonal flu. Half of these people die even with this extreme level of care.
• A disturbing number of rapid onset cases are popping up. These people die within 2 – 3 days of showing symptoms. See Triage by Mirage for some examples.
• Unless the virus changes, it will infect one-third to one-half of the U.S., an immense amount more than seasonal flu. This will strain many hospital ICU’s past the breaking point.

Why are we told that swine flu is like seasonal flu?

Tamiflu Guidance

As I pointed out in Triage by Mirage, the CDC guidelines for Tamiflu administration exclude most people from Tamiflu treatment until it may be too late to do any good. Why restrict Tamiflu use when it clearly can save lives that are being lost?

Hand Washing Prevents Flu From Spreading

No scientific evidence exists to support this guidance. (See Newsweek article  ) When asked why they continue tell the public that hand washing will prevent the flu, the CDC responded that handwashing helps with other respiratory illnesses. Just think about that. Schools were told over and over that they could stay open becuase hand washing could protect our kids from swine flu, not “other respiratory illnesse.”  The CDC knew the claim was baseless, yet they made it anyway.  Why would they do this?

By the way, how has that hand washing thing been working anyway?  You and both know the answer to that one.

Swine Flu and Fever

Especially in our schools, CDC guidance relies heavily on the presence of fever an indicator of swine flu infection. In fact, the guidance uses the absence of fever for 24 hours as an indication that a child can return to school. However, a large number of swine flu victims don’t have fever, even serious cases. (See article here.)  Since these cases are infectious in spite of the lack of fever, focusing on fever as the dispositive factor guarantees that swine flu will continue to spread in our schools. Why has the CDC failed to inform us that many cases of swine flu do not have fever?

School Closings Won’t Stop the Flu

How many times have we heard this? While it may be technically true, the statement leaves out some very important facts. Study after study has shown that school closings and keeping children home will delay the spread of pandemic influenza substantially. This may not be significant for a flu victim that needs no hospitalization, but it could be a life or death difference for someone who needs an ICU bed or a ventilator. Instead of throwing massive amounts of severely ill patients at our hospitals over a short period of time, slowing the spread could mean that extremely limited ICU space and ventilators would be available due to a lower patient load at a given time. Why would the CDC ignore this obvious threat to the lives of severely ill patients?

 

I feel a lot like Dorothy. When Dorothy accused the so-called Wizard of being a bad man, he responded “Oh no, my dear, I’m a very good man; I’m just a very bad Wizard.”

Are we dealing with good people but bad wizards?  I have lots of questions but no good answers.  Have they decided that keeping us calm is more important than telling us the truth?  Do they believe that we can’t handle the truth?  Do they think that they are the parents and we are the children so therefore they can decide what’s best for us?

Well-intentioned or not , the CDC’s refusal to inform the public of all the facts has prevented us from making free and informed decisions about how to protect ourselves and our loved ones.  We have been treated as if we are too stupid to make decisions for ourselves.  I am not interested in a government that believes it’s my parent.  I didn’t elect them to be my parent or to appoint someone else to be.  I don’t expect infallibility, but I do expect honesty.  I want to trust these folks, but they’ve squandered their credibility.

I hate to say it, but whenever I hear “CDC”, or “CDC guidance” or some variation, I’ll be singing to myself “We’re off to see the Wizard, the wonderful Wizard of Oz.”

Coming Soon, To A Hospital Near You

As I have stated in other posts, there are two factors that I believe are of paramount importance at this time.  One is the Case Attack Rate (CAR).  The CAR, as I use it, is essentially the percentage of people that will be infected by swine flu.  We don’t know what that number will be, but credible estimates have ranged from 25% to 50% of the population.  The other factor is the age distribution of swine flu deaths.  So far, over 90% of swine flu deaths have been people between the ages of 5 and 55, with one-third to one-half being otherwise healthy individuals.

As I and many others have been saying for some time now, the combination of these two factors, without any change in the swine flu virus making it more severe, could likely cause a surge of seriously ill patients to slam into our hospitals like a runaway train smashing into the station.

In late June of this year, President Obama commissioned a report on H1N1 from the President’s Council of Advisors on Science and Technology (PCAST).  PCAST members are a veritable Who’s Who of Nobel Prize laureates, top scientists and researchers that are not government employees or political patronage appointees.  Their report to the President was officially dated August 7, 2009.  It was not released to the public, however, until August 24, 2009, nearly two weeks later.  In an uncharacteristic move for this administration, the report was simply made public with no fanfare, no press conference with solemn and dignified officials crowded around the podium with the President.  Why the stealth approach?  Let’s look at some of the report.

 

 

The Current Situation and a Plausible Scenario

Indeed, the 2009-H1N1 influenza is already responsible for significant morbidity and mortality world-wide — from its appearance in the spring, its continued circulation in the U.S. this summer, and its spread through many countries in the Southern Hemisphere during their winter season. While the precise impact of the fall resurgence of 2009-H1N1 influenza is impossible to predict, a plausible scenario is that the epidemic could:

••produce infection of 30–50% of the U.S. population this fall and winter, with symptoms in approximately 20–40% of the population (60–120 million people), more than half of whom would seek medical attention.

••lead to as many as 1.8 million U.S. hospital admissions during the epidemic, with up to 300,000 patients requiring care in intensive care units (ICUs). Importantly, these very ill patients could occupy 50–100 percent of all ICU beds in affected regions of the country at the peak of the epidemic and could place enormous stress on ICU units, which normally operate close to capacity.

••cause between 30,000 and 90,000 deaths in the United States, concentrated among chil­dren and young adults. In contrast, the 30,000–40,000 annual deaths typically associated with seasonal flu in the United States occur mainly among people over 65. As a result, 2009-H1N1 would lead to many more years of life lost.

••pose especially high risks for individuals with certain pre-existing conditions, including pregnant women and patients with neurological disorders or respiratory impairment, diabetes, or severe obesity and possibly for certain populations, such as Native Americans.

 

Neither the Whitehouse, nor the CDC made any effort to publicize this important information.  In fact, almost immediately, government employees began to distance themselves from the report.  At a press conference that same day, HHS Secretary Sebelius didn’t even acknowledge the report.  CDC spokespeople stated that the scenario was unlikely, improbable and overblown.  The media jumped in as well by diminishing the report’s importance and even referring to one of the co-authors, a Nobel prizewinner, as some “New York doctor.”

I’ll spend some time analyzing the numbers from the report in a few days.  For the moment, let’s look at what happening at some hospitals already, in early September.

Le Bonheur erects tent to handle swine flu

Hospital swarmed by non emergency patients.

By Tom Charlier • THE COMMERCIAL APPEAL • September 12, 2009

MEMPHIS — Although Le Bonheur Children’s Medical Center is completing a dazzling new $235 million steel-and-glass tower, the most urgent construction project at the hospital Friday night involved erecting a tent straight out of the TV show M*A*S*H.

Le Bonheur set up the 2,400-square-foot tent to handle a growing influx of patients stricken with H1N1 swine-flu virus.  The local influenza outbreak, part of a global pandemic, has more than doubled the patient load at the hospital’s emergency room in recent days — even though most of the children don’t need to see a physician, health officials say.

“These are people who are coming to our emergency room without emergency conditions,” said Dr. William May, chief medical officer at Le Bonheur, adding that only a few youngsters daily have been admitted to the hospital. “It has put a stress on our space.”

Don’t miss the fact that a few youngsters have been admitted to the hospital daily.

Huntsville Hospital Sets Up Overflow Flu ER

Posted: Sep 10, 2009 06:56 PM CDT

One area hospital isn’t wasting any time preparing for flu season.

Outside the pediatric ER at Huntsville Hospital, workers have been setting up blue tents all day long.

 

Swine flu makes its mark on Atlanta

Children hit hardest. Emergency rooms innovate to meet demands

By Christine Foster and Stephanie Ramage

<snip>

Arthur Kellermann and his fellow Emory University emergency doctor, Alex Isakov, have been working on a similar online diagnostic tool to help people determine whether they might have H1N1 and whether a particular case merits a trip to one of the metro area’s already-slammed emergency departments. The idea is to alleviate patient load and lessen the likelihood of spreading the flu by exposing more people to it in the ER.

<snip>

Emory’s Kellermann, however, warns that the biggest problem for hospitals and patients alike is metro emergency departments’ lack of capacity to handle the surge in patients that he believes H1N1 will cause over the next few weeks.

How bad it will get, and what that will mean to Atlantans, remain to be seen, but there are three things to keep in mind, says Kellermann.

First, younger patients have no pre-existing immunity to the newly recombined virus, so they are most at risk.

“Second, it is very contagious and in most cases it’s mild, but it makes some people sick as hell, and those cases scare the hell out of people,” he says. “Third, our health care system has little or no surge capacity.”

 

Modesto hospital sets up triage tent

Saturday, Sep. 05, 2009

By Garth Stapley
gstapley@modbee.com

An emergency room overflow tent went up this week outside Memorial Medical Center in Modesto for the first time since H1N1, or swine flu, appeared in California, but a spokeswoman said the tent is not purely a reaction to the pandemic.

“It’s a combination, a mixture of people coming in for different reasons,” said Catherine Larsen, regional marketing director for the hospital’s parent company, Sutter Health.

Memorial first put up the tent in late April when H1N1 was detected in the valley and used it for a few days as a waiting and triage area, where patients are screened for severity of illness or injury.

Dean’s comment:  That’s right, move along folks, nothing to see here.  We would’ve set that tent up anyway for the fall picnic.

 

Health officials scramble to cope with added demand

By ROB STEIN, The Washington Post
Published: Saturday, September 12, 2009 at 1:00 a.m.
Last Modified: Friday, September 11, 2009 at 9:22 p.m.

BALTIMORE – It was a slow day for Maryland’s hospitals. But one Baltimore emergency room and an intensive care unit were already maxed out. And the computer monitor tracking the ER and ICU at a medical center in nearby Washington was flashing yellow and red — signaling that they, too, had run out room. The next car crash victim would have to go elsewhere; the next heart attack patient risked losing precious minutes before getting life-saving treatment.

 

Patients with flu-like symptoms overwhelm ERs

Local ERs see increased patients with flu-like symptoms

September 16, 2009

Nashville, Tenn. – The number of patients going to emergency rooms with flu-like symptoms is skyrocketing in Nashville and surrounding communities.

At Nashville’s Vanderbilt University Medical Center, doctors report a 50% to 75% increase in the number of patients over the normal average.

The problem, according to Dr. Thomas Abramo, chief of the Division of Pediatric Emergency Medicine, more and more people, scared about the H1N1 flu virus, are heading straight to the ER before consulting their primary caregiver first.

<snip>

Dr. Abramo says whether it’s seasonal flu or H1N1, its keeping healthcare workers busy.

“Your resources are spread through more needs and assessments that have to be done so efficiency can be somewhat taxed,” he said.

Angie Atema, child life specialist at Vanderbilt told News 2 they’re running low on supplies and snacks for patients staying at the hospital and just trying to keep up with demand.

More donations are needed and with the flu season just beginning, experts predict it will get worse before it gets better.

 

A common theme here is that ER departments are dealing with a lot of people that have non-emergency illness. But remember, that’s always the case. Most ER visits in any season are for non-emergency reasons. The fact that they would be overwhelmed during a pandemic is no surprise.

Besides, this virus kills. It is not like seasonal flu. Seasonal flu pediatric deaths usually number around one hundred per year, more or less. This flu has killed over 100 kids since May, 43 just in the last 30 days. (see Spreadsheet here – thanks howmanydays and all your helpers!) In my last post I highlighted three children that died within 3 days of their first symptoms, and these little guys had none of the stated risk factors.

Of course non-emergency patients are flooding the hospitals. By the time you know that it’s an emergency it just might be too late.

Triage by Mirage

First, the mirage.  This excerpt is from our CDC.

 

Updated Interim Recommendations for the Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season

September 8, 2009 2:00 PM ET

Objective

To provide updated guidance on the use of antiviral agents for treatment and chemoprophylaxis of influenza including 2009 H1N1 influenza infection and seasonal influenza, and assist clinicians in prioritizing use of antiviral medications for treatment or chemoprophylaxis for patients at higher risk for influenza-related complications. Additional revisions to these recommendations should be expected as the epidemiology and clinical presentation of 2009 H1N1 influenza is better understood. This guidance can be adapted according to local epidemiologic data, antiviral susceptibility patterns, and antiviral supply considerations. Clinical judgment is always an important part of treatment decisions.

 

I’ll paraphrase the summary.

• Treatment with Tamiflu or Relenza is recommended for all persons with suspected or confirmed influenza requiring hospitalization.
• Or for persons with suspected or confirmed  influenza who are at higher risk for complications (children younger than 5 years old, adults 65 years and older, pregnant women, persons with certain chronic medical or immunosuppressive conditions, and persons younger than 19 years of age who are receiving long-term aspirin therapy.
• Other people do not require antiviral medications for treatment or prophylaxis, unless they are short of breath or have rapid shallow breaths or have other signs of lower respiratory tract illness.
• Treatment should be initiated as early as possible because studies show that treatment initiated early (i.e., within 48 hours of illness onset) is more likely to provide benefit.
• Treatment should not wait for laboratory confirmation of influenza because laboratory testing can delay treatment and because a negative rapid test for influenza does not rule out influenza. The sensitivity of rapid tests can range from 10 % to 70%.
• Groups at higher risk for 2009 H1N1 influenza complications are similar to those at higher risk for seasonal influenza complications.

 

One would gather, from the above, that only certain people, in predictable groups, need worry themselves about swine flu.

 

Now the triage.  Apply the CDC guidance to the following cases.

 

Garland swine flu victim ‘did not have underlying health problems’

Monday. September 14, 2009

By JANET ST. JAMES / WFAA-TV

GARLAND — Dallas health officials say the first child in North Texas to die of swine flu did not have underlying medical conditions

<snip>

School officials say Cynthia went home sick from school with a fever Thursday. She saw a doctor that day and then went home.

The popular student was taken to the hospital Saturday in respiratory distress. Her mother, Maria Bidillo, said Cynthia’s symptoms appeared very much like ordinary flu until that day.

“She was really weak,” Bidillo said. “In the evening, [she told me] ‘I don’t feel good, I need to go to the doctor.’”

Cynthia died later that same day.

 

 

State suspects swine flu in death of Scottboro boy

Posted by David Brewer August 31, 2009 5:57 PM
SCOTTSBORO, AL – State health officials said an 11-year-old Scottsboro boy who died Monday morning was apparently the state’s third fatality from swine flu.

<snip>

Jackson County Coroner John David Jordan declined to name the child, but said the boy was taken to a local doctor’s office Sunday and again Monday. He said the child was transferred to Highlands Medical Center in Scottsboro after he collapsed at the doctor’s office.

Later reports stated that this little guy felt symptoms on Friday night and felt well enough to play soccer on Saturday.

 

Davidson County Child Dies From H1N1 Influenza (Tennessee)

September 2, 2009

ASHVILLE, Tenn. – A 5-year-old boy has died from H1N1 influenza in Davidson County.

Officials with the Metro Public Health Department said the boy became ill Friday night and died Monday night at an area hospital.

 

None of these cases qualified for Tamiflu treatment under the CDC’s guidelines, though the 5 yr. old arguably might have.  Consider now that from one-third to one-half of all deaths would not fit the guidelines for Tamiflu treatment and that the CDC itself acknowledges that Tamiflu treatment should be given within 48 hours of symptom onset.

What’s going on here?  The CDC knows that these cases have occurred and will continue to occur; this guidance was issued after the deaths of two of these three.   Unfortunately, the three children that I’ve referred to here are not the only people to have this rapid onset of serious and fatal illness.

Well then, what about people that don’t have rapid onset?  The next excerpt is a bit long, I know, but please read it all, or, even better, follow the link to the entire story.  All text emphasis is mine.

 

Widow urges others to take swine flu seriously

By CARRI GEER THEVENOT
LAS VEGAS REVIEW-JOURNAL

Sep. 12, 2009
Copyright © Las Vegas Review-Journal

Richard and Elizabeth MacDowell didn’t live under a rock.

They had heard news reports about the swine flu pandemic. They had even discussed the topic.

“It was one of those nebulous things that happened to someone else,” Elizabeth MacDowell said Friday. “Maybe that’s why I’m so determined to come public with it.”

On Aug. 31, the swine flu claimed her husband’s life and changed hers forever. She is telling their story because she wants others to take the disease seriously.

<snip>

At 51, Richard MacDowell didn’t fall into a high-risk group. When the health district reported his death, along with the death of a 41-year-woman, a spokeswoman did not identify them by name but said both had underlying medical conditions.

Elizabeth MacDowell insists that her husband of 10 years suffered from nothing more serious than arthritis before he began feeling sick on Aug. 14. That day, a Friday, Richard MacDowell said he felt a little tired and had a sore throat.

“Nothing alarming,” Elizabeth MacDowell said.

He felt a little worse on Saturday but went to work on Sunday. His job as a shuttle bus driver involved transporting tourists between McCarran International Airport and the hotels.

After work that day, he went to an urgent care center and received a prescription for an antibiotic. “He told me it was pneumonia,” Elizabeth MacDowell said.

By Thursday, he was feeling worse. He returned to the urgent care center and was sent home with a prescription for cough syrup.

“His cough at this point was outrageous,” Elizabeth MacDowell said.

The coughing kept both of the MacDowells awake at night. On Saturday, Aug. 22, Richard MacDowell returned to the urgent care center with a 102-degree fever.

This time, he was sent home with oxygen tanks and a prescription for a different antibiotic.

Richard MacDowell still couldn’t sleep, and he made his fourth trip to the urgent care center the following morning. He still had a 102-degree fever.

“He’s walking like a little old man,” Elizabeth MacDowell recalled. “He could barely move.”

This time he returned home with a nebulizer, a device used in treating respiratory diseases.

“By Monday night, he was gasping for air and choking,” Elizabeth MacDowell said.

That’s when she decided to take her husband to Valley Hospital Medical Center.

At the hospital, Richard MacDowell told his wife to go home and get some rest. He knew he had kept her awake the previous four nights.

Elizabeth MacDowell remembers how her husband’s skin felt — sweaty and clammy — as she kissed him on the forehead before leaving. When she returned the next morning, she found him attached to a ventilator.

“I never spoke to him again after Monday night,” she said.

A doctor told Elizabeth MacDowell that her husband might not recover. He also told her a swine flu test had come back negative. A few days later, she learned that a different type of swine flu test had a positive result.

Elizabeth MacDowell’s phone rang early on the morning of Aug. 31. Medical professionals were trying to resuscitate her husband. She made it to the hospital within 10 minutes, but Richard MacDowell was already dead.

“It just wore him out,” his widow said.

 

Some folks in Texas have caught on.  Again, emphasis is mine.

 

Many Who Get Flu Won’t Get Prescribed Antivirals

Daniel Novick-KFOX News Weekend Anchor/Reporter
Posted: 6:16 pm MDT September 12, 2009
Updated: 9:07 pm MDT September 12, 2009 

EL PASO, Texas — As fall and winter is just around the corner, doctors are gearing up for a long year dealing with the flu — particularly the swine flu. And in their preparations, doctors are getting guidance from the federal government to not prescribe antiviral medication like Tamiflu and Relenza to patients who are not considered high-risk.

Are you angry?  You ought to be.  Young, otherwise healthy people, going to the doctor without initially showing any signs of serious illness, make up a substantial portion of the deaths from swine flu, and are excluded by the CDC guidance from receiving Tamiflu until it’s too late to do them any good.  That could be me, or you, or our kids.

Who is getting triaged here?  And why?