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By now, alert reader, you know the details. The entire world is engulfed with swine flu.  Even though the WHO dragged its feet in the final days before the Phase 6 declaration, we all knew this virus had achieved pandemic status.

But in this nation, the press, with the exception of the New York Times and local newspapers, has for the most part ignored the story since early June's pandemic declaration. So let's catch up on recent events:

• More people died in this country last week from swine flu than died in all of April and May combined.
• Same thing happened last week.
• Deaths in this country are doubling every week.
• It is spreading deeper into corners and pockets of America where it was not before.
• The Muscular Dystrophy Association has cancelled every single one of its MDA kids' summer camps, coast-to-coast. Other organizations are following suit.
• The average age of a dead American from swine influenza is 37.
• The CDC is telling us this virus is moving faster than the 1957 or 1968 pandemics did. Understandable, with quick, easy air travel and interstate highways. But so far, it is not moving with the ease of seasonal flu. So far.

What is difficult to gauge is just how we should categorize this pandemic from a "Saffir-Simpson" standpoint.  Drs. Fukuda and Chan of the WHO says this is a "moderate" pandemic. That would place it in the range of 1957's H2N2 pandemic, which killed 70,000 Americans and around 2 million worldwide. (If the 1957 pandemic hit today, it would kill 122,000 Americans).

A moderate pandemic would also nest 2009's swine H1 pandemic into high Category 1 or low Category 2 status on the US charts.   As you have seen from the charts I have published before, the case fatality rate from a Category 1 pandemic is up to 90,000 deaths. A Category 2 pandemic is anywhere from 90,000 to 450,000 deaths.

The case fatality rate from swine H1 is currently .0045, or .45%. That means that for every 2000 people who get sick from swine H1, 9 will die. Extrapolating this rate out over the probable three pandemic waves, we could see as many as 400,000 Americans die from swine H1.

There, first time in print. Unchecked, and at the current rate of fatality, some 400,000 US residents could die. And most of them would be under age 50.

Can you imagine what devastation that would cause to young families? To the economy? To the economic future of the Republic?  Is it any wonder, then, that the US government has arranged for some 600 million doses of swine flu vaccine, to be administered in two shots for each American at three week intervals?

Well, two shots spaced three weeks apart for anyone under age 50.  For those of us carrying AARP cards, we get one shot -- one shot, Vasily -- and one shot only.  At least that's the current thinking.  Nice to know that neither 1946 nor 1951, when subtracted from 2009, equals 50.  As you know, those were the last two aberrant outbreaks of H1N1 that caused either a partial pandemic or increased fatalities.  So the CDC should limit jabs to one for anyone ages 64 and older. that covers anyone who went through both 1946 and 1951.

Now the public health people would quickly say, "Wait! We think a million Americans have been exposed to swine flu! And only 127 have died, based on positive test results. Your projections are WAY out of line! And you're inciting panic!"

Am I?

First, let's take that "one million Americans" stat. I absolutely agree that at least one million Americans have been exposed to the virus. But in what quantity (titer) of virus? How many particles?

We know that a normal flu season will only infect up to a fifth of Americans. Why only a fifth is a matter of continual speculation. It is probably a combination of vaccination successes, cleanliness, partial immunity, and damn good genes. There is a growing community in the scientific and public health fields that believes some people are genetically doomed to always catch the flu, while others are genetically predisposed to never catch it. Most of the rest of us are constantly in the middle.

Pandemic calculations are different. The US government's own pandemic projections indicate 90 million infected, 45 million presenting serious illness, and then factor in the appropriate Case Fatality Rate (CFR). This is opposed to the 5% to 20% who gets seasonal flu every year, according to the CDC. Roughly 36,000 to 40,000 people annually die from seasonal flu. A CFR of .001.

But last year, the CDC only tested less than a quarter of a million people for flu, even though some 60 million may have been infected.From the CDC Website:

During September 30, 2007 – May 17, 2008, World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories in the United States tested 225,329 specimens for influenza viruses.

And another statistic:  In the 2007-08 flu season, only 83 deaths were reported of children ages 18 and under from influenza.  Eighty-three hardcore, confirmed pediatric deaths out of 36,000 estimated seasonal deaths from flu.

So the figure of 36,000 people annually dying from flu is an old stat that has pretty much entered the lexicon as fact. But certainly not every single one of those 36,000 people were tested for flu! Else the CFR for seasonal flu would be around 16%.  So the experts at CDC have algorithms to determine such things.

OK so far?  Let's continue.

The estimate of 36,000 deaths annually from seasonal flu is based on extrapolating the numbers of infected and looking at the CFR of those who tested positive and died, and then reapplying that CFR to the overall guesstimate of infected. And you really never know how it all turned out until it all turns out.

The calculations are really no different with pandemic flu. We've earlier mentioned the equations.  Let's do the calculations together:

• According to the CDC, one million Americans have been infected with swine H1.
• That means 330,000 Americans (nearly one-third) have become ill, even mildly so.
• That means 165,000 people have been seriously ill enough to (hopefully) stay home.
• That means an estimated 1,485 Americans have potentially died from swine flu or its complications to date.

How many Americans have died from pneumonia, or from other life-threatening complications, and were never diagnosed with swine H1? What are the chances that, from late March until today, that over a thousand Americans have died from swine H1 and those deaths have gone undetected and unrecorded?

I'd say, pretty damn good. Look at the massive, gaping holes in surveillance. Look at the people who have not been swabbed. Look at the immuno-compromised in this nation.

I would speculate that a significant number of deaths from pneumonia since March 2009, and many MRSA-related deaths, and significant numbers of death from "respiratory complications" since mid-March could, in actuality, have been swine flu-related.  As of last week, we have 127 documented deaths from some 27,717 confirmed or probable cases.  We know that 99% of all influenza A being typed in America today -- right this minute -- is testing positive for the pandemic strain. From the CDC:

During week 24 (June 14-20, 2009), influenza activity decreased in the United States, however, there were still higher levels of influenza-like illness than is normal for this time of year.

• Three thousand two hundred eighty-six (41.9%) specimenstested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories and reported to CDC/Influenza Division were positive for influenza.
• Over 99% of all subtyped influenza A viruses being reported to CDC were pandemic influenza A (H1N1) viruses. (bold mine)

OK, so we have 127 confirmed swine H1 deaths. Subtract 127 from 1,484 and we have 1,357 deaths. We have, according to the Census Bureau via Wikipedia:

The U.S. Census Bureau lists 3,140 counties or county-equivalent administrative units in total. There are on average 62 counties per state.

It would take less than one death in half the counties in America to reach that number. What are the odds that one pneumonia-related death, or one MRSA-related death, has occurred in each county in the United States since the inception of this swine H1 outbreak/epidemic/pandemic?

Pretty daggum good, I would say.

At the 2000 U.S. Census, only 16.7% of U.S. counties had more than 100,000 inhabitants. That would make 525 counties (let's round up in case some county had 90,000 people). What are the chances that each of these 525 counties had, say, three people die of pneumonia since late March that went untyped? And even if they only had one apiece in the past three months, that would leave the remaining thousand cases to be spread over some 2,600 counties, parishes, etc.

Not to mention the possibility that many swine H1 deaths may have been mistakenly attributed to seasonal flu.  I have great difficulty in believing that only 2 persons have died in Florida from swine influenza. Not when you look at the figures coming out of Latin America and you realize Miami is the gateway to Latin America -- not to mention Orlando's Disney World. 

Miami-Dade County has over two million residents.  It has reported, to date, 305 positive swine flu cases.  Yet only one death-- a 9-year old child -- has been reported?  Ridiculous.  Florida has recorded 941 cases, yet it has documented only two deaths from swine H1.  Using the nationwide CFR, Florida should have experienced 4 deaths.  Using New York's CFR, it should have 10 deaths.  Do the numbers yourself.  Check the CDC H1N1 Website and see your state's results.

This is probably as much a function of the diligence of state and local health departments to test suspected influenza cases as anything else.  New York has a higher CFR because they have been looking for the virus and they had a good health commissioner.  So good, he now runs the CDC, promoted by Obama in the middle of New York's problems. 

I think you can see where I am taking you.  We are missing many deaths.  You cannot speculate that we have a million swine flu cases without a concurrent speculation that we are missing many, many deaths.  And as I have just proven, it takes less than one death per county over two months to fill in those gaps in surveillance.  This is the danger in trying to look so closely at the actual number of positive swabs that you miss the Big Picture. 

That Big Picture includes monitoring large employers for signs of absenteeism.  It includes enlisting Chambers of Commerce and the US Department of Labor to check employee absenteeism.  It means coordinating with governments at the local and state level as well as the Federal government to monitor absenteeism on a daily basis.

Keep swabbing and keep testing, absolutely.  But do not solely rely upon swabs to tell you who is sick.  And do not tell me, or anyone else, that we only have 127 dead from swine H1 so far in this nation. 

Effect Measure has a sensational piece regarding the current state of the flu pandemic. It includes references to risk communication expert Dr. Peter Sandman, who was very kind in his praise of one of my recent blogs.  It concludes this way:

Public health authorities up north are counting on having some advance warning on how bad things can get by seeing what is going on in the southern hemisphere. But the virus may not give anyone that luxury. Countries like Australia, Argentina and Chile are already getting hammered and the virus seems to be increasing in places in the north at the same time. In other words, we have yet to take the measure of this virus.

Whatever that measure turns out to be, I feel pretty confident that "mild" won't be a word to describe it.

My good friend Mike Coston has also weighed in on the topic.  Both Revere at Effect Measure and Mike reference the piece by Helen Branswell of the Canadian Press.  Helen's work is always superior, and her article is spot-on perfect. Read her piece (you just passed the link).

Get set to get absolutely hammered this fall.   

The World Health Organization has moved the planet to full pandemic status. Just moments ago, Dr. margaret Chan declared a flu pandemic.

Won't change things much, save for vaccine preps and some other housekeeping items. But it does restore this virus to the forefront of public thought, which is a good thing.

One thing you need to be aware of: Do NOT place your faith in vaccines anytime soon. The earliest anyone will see a swine H1 vaccine is October, and those batches will be reserved (under pandemic Phase Six protocols) for first responders, the military, and decision-makers. This includes police, fire, and EMS personnel, trauma center and emergency room personnel, and the like.

So the chances of you getting a swine flu shot within that first batch are very low. But do not fret. The virus in all likelihood will come back to us well in advance of the vaccine, meaning it will only be helpful to the rank and file toward the end of the second wave, or possibly prior to the third wave of the pandemic.

A lot of false hope is placed on vaccines. More emphasis needs to be placed on the things Momma taught us:

1. Wash your hands vigorously.

2. Cover your cough and smeeze with your sleeve or tissue.

3. Keep a respectable distance from strangers.

These things, and not a vaccine, not Tamiflu and not any other pill, shot or med, will help us through any pandemic of any lethality.

Scan these blogs, and also if you are a businessperson, you may want to jump over to my other blogsite,http://blogs.computerworld.com/were_in_a_pandemic_but_theres_still_time_to_plan for additional analysis.

A report in today's New York Times says that as many as a half-million Big Apple residents may be displaying symptoms consistent with swine H1N1 influenza.

The city has twelve reported deaths that cre confirmed swine H1 cases. Three new fatalities -- a person under 40, a person under 60, and a person over 65, brought the city's total into the double digits.

It is absolutely clear that the virus has not abated, has not gotten weaker, and if anything may be headed in a different direction. From Manitoba, Canada, and as reported by veteran flu blogger Crof (of British Columbia) on his site H5N1:

Manitoba adopts pandemic response

Via the Globe and Mail, a remarkable report:Manitoba adopts pandemic response. Excerpt:

As the World Health Organization vacillated over whether to call the flu outbreak a full-blown pandemic yesterday, Manitoba shifted to a disaster footing, warning people away from hospitals, closing some northern schools and placing more flu victims in intensive care.

The Winnipeg Regional Health Authority posted flyers throughout city hospitals asking the public to limit hospital visits and urging people with flu symptoms to stay away altogether.

Nurses and physicians within those hospitals are straining to contain a surge in severe cases of the flu that appears to be unique in the country.

Yesterday, two more flu sufferers were placed in intensive care, bringing to 27 the total number of people on respirators due to flu symptoms.

More on this in the Winnipeg Free Press. Manitoba seems to be taking H1N1 a lot more seriously than the rest of Canada is.

Manitoba is seeing something in its "surge" sufficient enough to cause the province to move quickly and forcefully.  Twenty-seven people on respirators is clearly not a good thing.  The conventional wisdom is that when a flu sufferer goes on a ventilator, recovery is far from assured. 

It is time to stop counting positive test swabs and it is time to start counting employee absenteeism and school absenteeism.  Of course, schools are closing for the summer, so we are losing one of our most critically important "sentinels."  Still, we have summer school in places where it is still funded, and colleges still have summer semesters.  This, along with workplace absenteeism, is where we will get our data on the spread of the virus and its severity.

Also, Indonesia is reporting its first round of confirmed swine flu cases, and Egypt is trying to desperately contain what it believes to be its first cases -- at the American University in Cairo.  Recall that both of these nations lead the world in human H5N1 infections, and getting reliable information out of Jakarta on flu infections is like asking North Korea for nuclear advise. 

WHO set to declare Phase Six at emergency meeting in Geneva.

Finally.  Tomorrow, Thursday, June 11, 2009, the World Health Organization is expected to relent and finally declare what the world already knows; namely, that we are in the beginning of the first honest-to-God flu pandemic since the 1968 Hong Kong H3N2 influenza pandemic.

Dr. Margaret Chan, the head of the WHO, has been working with nations to make sure a move to Phase Six does not create some sort of bureaucratic nightmare.  Also, there has been concern that a move to officially declare a pandemic would provoke some sort of panic.

I think the WHO is seriously underestimating the ability of the world's population to filter that news and absorb it quietly, without panic and without fanfare.  The world already suspects that we are in panflu status; telling them they are correct will do far more to reassure people there is no coverup going on than to maintain a Phase Five status that is clearly obsolete.

There have been numerous articles regarding the collective inability of the world's animal health and public health professionals to look for the obvious (hogs) when doing their disease surveillance, and instead become preoccupied with avian flu that is still a threat, just not THE threat right now.

And that is very much a mystery, as we all go back to our Powerpoints and update them feverishly for swine flu.  While updating one of my roughly one thousand Powerpoints on the topic, I couldn't help but notice that one slide showed a hog as plain as day, sitting in some Oriental mud puddle, with a chart explaining how pigs are the proverbial "mixing vessel" for flus. 

If we always mention the pig, then why were we not looking at them more closely?  because we were spending more time swabbing dusk and tern behinds in the Alaskan tundra than we were swabbing hog nostrils in Wisconsin and Mexico.

I mention Wisconsin because that state has been a veritable incubator of swine flu.  At last count, some 2,200 cases of human swine H1 infection were reported to the CDC.  This outpaces California, Texas, Illinois, New York and Florida.

What is fascinating is when you look back at the dispersion of the 1946-49 maybe-pandemic of H1N1.  the first big area to be impacted by that epidemic was:  The western and central Great Lakes states.  That would include Wisconsin and Illinois.  If you add up their swine H1 exposure, those two states account for nearly one-third of all US confirmed swine H1 cases.  One-third.  And the last time I looked, neither state borders Mexico, previously considered to be Ground Zero in all this.

I say "previously considered" because someone needs to formulate a theory as to why Wisconsin is the nation's swine flu capital, while not producing a single human death (so far) from the virus.  Why is 2009's flu pattern mimicking that of 1946-48's?  Somebody get a study going on that one, pronto.

I'll have more on that later.  For now, rest assured that by evening drive tomorrow, and thus on the network news shows, we will be at Phase Six.  And Americans, at least, will go on about their business.

A blind man could see it in a minute: the World Health Organization, after a series of good moves and sound decisions, has blown the non-call on its reluctance to move the world to Phase 6 swine flu H1 status.

Why not Phase Six?  A technicality:  According to Helen Branswell of the Canadian press, Chile is in the WHO's North American reporting region.  Now, that is like saying Japan is in the European region.  But apparently the WHO is not too keen on Southern Hempsihere geography, else they would have a separate reporting schema for South America.  factor in Chile, and presto!  You have a Phase Six tripwire.  According to Branswell, however, if Britain or Australia show community spread (and they will, no doubt about that), the WHO has no choice.

Therefore, functionall there can be no doubt -- no doubt at all -- that the world is in the beginning (yes, the beginning) of a real, honest-to-God influenza pandemic. Yet for the WHO and for so many nations whose preparations wholly centered around a killer avian flu with a severe death rate, they failed to take into account one small detail.

What if the pandemic isn't all that lethal?

First answer: Excellent! We'll take a 1957 or 1968-type pandemic over 1918. Or 1830. Or even 1946's near-miss.

Second question: Why couldn't these best and brightest conjure up a scenario that would involve just what we are facing right now?

Second answer: Because public health professionals are not distinguishing themselves well as emergency managers or homeland security planners. It is amazing to see the number of nations who never planned for a minor pandemic, and now are crying to the WHO to loosen the protocols.  Heck, even the WHO itself has flirted with a rewrite of the protocols, although they just announced this week they will not do so.  Good call, Dr. Chan.

For a moment, I want to give some props to the Bush Administration.  The Obama Administration has admitted it is using the Bush playbook for this swine pandemic, and even President Obama has thanked the former president for his leadership in providing a roadmap to management of this crisis. And yes, it is a crisis.  ANY flu pandemic is a crisis-in-the-making.  We won't know just how bad of a crisis it is until many days from now.

Part of that playbook includes the ingenious move by HHS/DHS to classify pandemics according to a kind of Saffir-Simpson intensity scale.  As fans of the Weather Channel and residents of any state within 250 miles of a coastline know, the Saffir-Simpson Scale measures hurricane intensity.  What HHS/DHS did was take that metaphor and apply it to pandemics.

HHS/DHS have been using that Saffir-Simpson scale to measure response and move resources since Day One of this crisis.  It is so simple and easy to understand, more mainstream media attention should be placed upon it.  And I dare say if the other nations of the world had also applied it, or something similar to it, there would not be so much angst and political pressure applied to stifle a Phase Six declaration.

Look at the charts below to understand the United States' approach to this problem.

I frequently refer to this master chart as the "Saffir-Simpson" scale for pandemic lethality.  For those nations lobbying to slam the door on the WHO's desire to declare a pandemic, let me ask: has your planning taken the following items into account? See below.

The way I read it, we are currently somewhere between Category One and Category Two pandemic status in this country.  However, and despite the mainstream media's decision to ignore what is happening all around them, this virus is killing far more Americans now than it did thirty days ago.  It is being reported in the surviving hometown daily newspapers in each edition.  This means the virus is circulating freely in our communities and continues to attack and, sometimes, kill.  It is not going quietly away; it is continuing to spread, which of course is also what we are seeing across the globe.  At last count, some 64 nations had the virus, and no nation is declaring itself virus-free.  Except maybe North Korea, and that nation has collectively lost its mind anyway.

It is almost worthless at this point to try and track numbers of infections strictly by swabbing throats and noses.  We now have to assume, as the New York health officials have assumed, that any case of influenza is now swine flu.  Any case of summer flu (which is unheard of in seasonal flu, by the way) should, by definition, be considered the pandemic strain by default.

My Blackberry is going off multiple times a day with reports of confirmed H1N1 swine flu deaths across America.  Chicago: A 20-year-old pregnant woman dies after giving birth.  Deaths now reported in many states.

People say:  No biggie, it's not a killer, so what's the big deal? 

In Egypt, recent news reports talk of a village with a confirmed H5N1 human case ( a 4-year-old) and some 39 suspected follow-on infections.  A person is testing positive for H5N1 in Egypt at the rate of one every three days.  And we don't have any idea of the number of human H5N1 infections in Indonesia; the Health Ministry adopted a policy of only releasing human H5N1 cases every few months.  the only inklings of what is occurring in Indonesia come from news accounts, many of which are quickly denied by the government.

As swine H1 takes its victory lap around the planet, it will invariably create local versions of itself.  And it will (if it has not done so already) eventually and inevitably be introduced to H5N1 avian flu, either in the respiratory tract of a pig or a human.  How those viruses behave together, only God can predict. 

So let's go to Phase Six, remind nations of the excellent chart and methodology of HHS/DHS, and begin planning for an unpleasant autumn flu season.