Scott McPherson's Web Presence

OR:  It's time to rediscover the theories of R. Edgar Hope-Simpson.

One of the most intriguing questions regarding seasonal influenza is just that:  Why is influenza seasonal?  Why is it that the virus only seems to move in the winter and spring seasons?  Why doesn't it move year-round?  It certainly isn't for a lack of hosts and victims. 

This phenomenon is so prevalent that people have simply taken to shrug their shoulders and take the information as immutable fact and have ceased to question it.

All, save for some intrepid researchers at Penn State University (Go Nittany Lions!), plus some researchers at NIAID and NIH.  http://pathogens.plosjournals.org/archive/1553-7374/3/9/pdf/10.1371_journal.ppat.0030131-L.pdf

They are (perhaps unknowingly, perhaps knowingly) continuing the work started three decades ago by the late R. Edgar Hope-Simpson, a British doctor.  Dr. Hope-Simpson challenged the Conventional Wisdom of influenza researchers by claiming the existing theories about the spread of influenza were flawed in many places.  He speculated (bear with me: I am only reading his book "The Transmission of Epidemic Influenza" just now, after eighteen months' worth of scouring the Internet for an affordable used copy) that influenza moves between humans all the time, but there is some significant event surrounding the autumnal equinox that seems to activate the virus and may also account for antigenic drift and shift.

Do not make the mistake of dismissing Dr. Hope-Simpson's work summarily.  He was the first individual to postulate that shingles was caused by the chicken pox virus.  Years later, someone else won a Nobel Prize off his research.  A simple country doctor from Gloucestershire, he became one of Britain's most respected physician-researchers.  I quote directly from his obituary in the prestigious British Medical Journal:  http://www.bmj.com/cgi/content/full/327/7423/1111?ck=nck

What a selfless visionary!  Self-taught, and free to make observations without the impediment of rigid scientific poo-pooing and inability to challenge the CW.  And a man who would clearly be uncomfortable with the accolades afforded him in this blog.

Hope-Simpson's work has been latched onto by a posse that I call the "Vitamin D Gang," a group of doctors and researchers who believe strongly that Hope-Simpson's missing catalyst is none other than The Sun Vitamin.  And there is some evidence to support that claim, but the jury is still out on the role Vitamin D plays in arresting influenza in the offseason.

Now back to the study, published in the Public Library of Science.  The theory is that seasonal influenza heads for a vacation in the tropics, where it does all the things you would expect randy influenzas to do while on vacation:  To frolic with other influenzas and engage in a shameless display of reassortment, over and over again. Then, when the vacation's up, these influenzas pack up and board the plane for each hemisphere until the Autumnal Equinox strikes and the viruses let go of their payloads.

Here are some key passages from the study:

Similarly, the seasonal importation of multiple global isolates appears to be a greater contributor to the genetic diversity of the influenza virus population in New York state from 1997 to 2005 than local in situ evolution [7]. While our findings confirm that human population movements play a role in introducing new viral variants at the start of an epidemic, some aspect of climate is clearly of importance in triggering epidemics. Additional research is required to define how human susceptibility to infection and viral transmissibility fluctuate under varying climate conditions and why influenza virus is absent in summer in temperate climates but exists year-round in tropical zones.

The traditional focus on epidemic influenza may detract from the equally important epidemiological question of why influenza A virus does not circulate in humans for so many months of the year in temperate areas, especially given its apparent ability to infect humans in tropical areas year-round. Attempts to predict, model, or contain the spread of the influenza virus require a unified understanding of how the virus's spatial-temporal dynamics, antigenic evolution, and seasonal emergence interrelate [27].  (Bold type all mine).

OK, pretty fascinating stuff.  Short form:  Influenza takes a holiday in the tropics.  The virus reassorts and then heads to the Four Corners, where some trigger changes either the virus, or changes us, and we become susceptible.  But why people can get the flu in the tropics year-round, and others only get it in the fall and winter, is still unknown.  The study, as one would imagine, calls for (among other things) a strenuous tropical surveillance effort.

Dr. Hope-Simpson died in November, 2003.  Let's hope others keep his legacy and his spirit alive.

Zoe Young has updated her diary.  The intrepid MSF (that's Doctors Without Borders to you and me) health care worker has her feet in the proverbial Boots On The Ground at what could be the worst outbreak of Ebola in recorded history.

For the record:  The worst known Ebola outbreak was in Uganda in 2000 and 2001.  It infected 425 and killed just over half of its victims (224), for a 53% case fatality rate.  The link to the official death tolls, locations of previous Ebola outbreaks and subtype of Ebola virus can be found at the CDC Website at: http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/ebola/ebolatable.htm  

So far, this new outbreak in the Congo has infected some 375 people and killed 168, according to the Washington Post in an article that ran Wednesday, September 19th.  The Free Press of Namibia (http://www.namibian.com.na/2007/September/world/07BA07B404.html) is reporting a death toll of 172 out of 381 cases, as of Friday, September 21st.

Zoe Young's amended diary can be found at: http://www.msf.org/msfinternational/invoke.cfm?objectid=1DAA2EDF-15C5-F00A-252C43D5B5FB4969&component=toolkit.article&method=full_html

I think you get the point.  The cases and deaths are still increasing. Angolan officials are also ramping up for what they fear could be an extension of the outbreak into their nation. Please take the time to read the Washington Post article, found below.

Congo's Ebola Outbreak Could Be Worst in Years

By Craig Timberg
Washington Post Foreign Service
Wednesday, September 19, 2007; A19

JOHANNESBURG, Sept. 18 -- International medical personnel and supplies are being airlifted to a remote region of central Congo to combat what threatens to become the world's most serious outbreak of the deadly Ebola virus in years.

Only nine cases of the disease have been confirmed by laboratory tests. But medical authorities suspect the virus has killed 168 people and sickened 375 others across a heavily forested region where villages are linked only by deeply rutted dirt roads. Health officials said it is possible that new cases will continue to emerge over the coming months.

"It's a serious outbreak," said Peter H. Kilmarx, an official with the U.S. Centers for Disease Control and Prevention who toured the area last weekend. "Every day there is a new town with a reported suspect case."

The outbreak's epicenter, which is serviced by a dirt-and-grass airstrip, consists of three towns in Congo's Kasai Occidental province, but the affected area appears to stretch for more than 100 miles.

Kilmarx, speaking from the Congolese capital of Kinshasa, said that one village market he visited had been abandoned and that many Congolese in the area appeared reluctant to shake hands for fear of contracting the highly contagious disease.

Efforts to control Ebola depend on identifying and isolating those who are infected. There is no cure, and many who contract the virus die, typically from acute flu-like symptoms such as high fever, headaches and diarrhea. Hemorrhaging also is common, and bodily fluids containing the virus are the main source of transmission. In previous outbreaks, caretakers and those involved in burying victims were particularly susceptible.

"The only thing you can do is isolate the patient and avoid other infections," said Josep Prior, the top official with Doctors Without Borders in Congo, speaking from Kinshasa. "It's quite shocking. It's not easy to endure such a thing."

The international medical aid group has taken the lead in a global response that also includes the World Health Organization and the CDC team. These groups are assisting Congolese medical authorities in tracking the disease, alerting the public and caring for the ill.

Doctors Without Borders has converted a mud-walled building with a tin roof into a 15-bed isolation ward. To prevent infection, members of medical teams wear protective suits along with surgical masks, gloves and boots. Orange plastic fencing, stretched between tree branches pounded into the ground, keeps potential onlookers away.

As doctors across the region report suspected new cases, medical teams are preparing to visit villages by truck and motorbike in search of people with symptoms. That process may yield many more cases, and two mobile laboratories being flown to the area will speed the process of confirming cases.

Anyone who had contact with an infected person is supposed to be identified, but the logistics are daunting in an area where roadways are so damaged by war and neglect that a trip of only several miles can take an hour.

Doctors Without Borders also is assisting Congolese authorities in attempting to keep medical facilities open. Without proper training and protective clothing, some medical personnel are reluctant to treat patients with Ebola.

Gregory Hartl, a spokesman for the World Health Organization, said other diseases, including typhoid, malaria and shigellosis, may be responsible for some of the deaths now attributed to Ebola. Reports of suspicious deaths date to April. WHO also has called for international help to control the outbreak.

Cases of Ebola have been reported over the past decade in Congo, Sudan, Uganda, Gabon and South Africa. An outbreak in Congo in 2003 killed 128 people; an outbreak there in 1995 killed 250.

If we read the Post article carefully, we see confirmation of Zoe's statement in her diary that three epidemics are raging in the south of Congo:  Ebola, Shigella, and Typhoid.  Confirmation of Ebola infection can only be accomplished by a fluid/blood sample; at least, until the person begins to ooze blood from every orifice of his/her body.  If proper decontamination procedures have not been followed from the initial contact with the infected, however, the consequences -- for the medical worker, the gravedigger, not to mention the entire village population -- are lethal.  Since Ebola starts as an abdominal pain and diarrhea, it is easy for people to mistake Ebola as just another illness.

Authorities are also looking with apprehension at the 100-mile long corridor of gristly death that reaches across the jungle.  Based on what they are finding -- abandoned village markets, very scared people, and a serious lack of trained medical personnel -- the chances for additional infections, be they individual Africans or entire villages, is strong.

The Washington Post story can be found at: http://www.washingtonpost.com/wp-dyn/content/article/2007/09/18/AR2007091801047.html

A Reuters headline of September 20th talks about "Congolese no longer kiss as Ebola seems to spread."  The story lists 174 deaths out of 385 cases. It is at: http://www.alertnet.org/thenews/newsdesk/L20801216.htm .

Last week, a 30-year old woman lost her life, probably to H5N1.  Her unborn baby also died as a result of the infection. She was from Indramayu region, Cilandak village, and was transported to a hospital in Bandung, West Java. Almost immediately, she was placed in isolation and what we would consider intensive care.  There is some speculation as to whether or not her husband is a health care worker, which would signal that she received much more rapid medical care than one would normally expect in a rural setting.  There is also speculation that the husband may also have exhibited symptoms but was not ill enough to be hospitalized.  The caption accompanying the photo (credit *RIRIN N.F./"PR") reads:

GAMBAR monitor di Ruang Flamboyan RS Hasan Sadikin Bandung memperlihatkan kondisi pasien ”suspect” flu burung, IK (30), Rabu (19/9). Sejak masuk RSHS, Selasa (18/9), kondisi IK masih kritis dan tak sadarkan diri.

Also, in Riau Province, Sumatra, Indonesia, two young children have been hospitalized with bird flu symptoms.  their young lungs are filling with fluid and  their condition is deteriorating. Also from Dutchy of FT:

http://news.xinhuanet.com/english/2007-09/24/content_6784596.htm

The following is a translation from "Dutchy" of Flutrackers, examining an earlier post from FT member "Commonground":

Watch out for bird flu in this rainy season

Bird flu in Riau is a horrible disease at the moment. Right now there were 23 bird flu cases (grand total, starting from 2005) 3 of them died. In the rainy season we have at the moment, the bird flu virus will circulate for three more months. The health service asked the whole society to watch out and be very carefull, especially the bird breeders.

Then the "sub head" of the health service and a someone from the Riau Food Authority say this: " There were extremely many bird flu cases in Riau, not only the 23. We will not know how much, because the cases were in the interior, dying from high fever is regarded as normal by the public".

" We reported 23 cases, our take is there could be as many identical cases in the disctricts that were not reported". "Because of this we ask the whole community to watch out for this virus".

Then the report goes on: people should go to a clinic or to the Health Service if they display symptoms especially sudden high fever, and get medication. The dedicated bird flu hospitals are: RSUD Arafin Ahmad, RSUD Dumai and RSUD Tembilahan.

They express their concern, because they expect the virus to circulate for the next 3 months.

Note: this story is adapted from a press release.

http://www.riautoday.com/new/index.php?option=com_content&task=view&id=2358&Itemid=1

So something is going on in Riau, where four confirmed cases of H5N1 have occurred, with three deaths, and five times that many suspected cases have been reported and treated as the Real Thing.  Not a good sign.

A little over a year ago, The Centers for Disease Control and Prevention (CDC) reported with breathless excitement the results of an experiment.  The CDC used ferrets to try and produce a reassortant H5N1 virus.  Under controlled conditions, and using multiple ferret subjects, the CDC was unable to kick-start a reassortant H5N1/H3N2 virus.  Thus, the CDC concluded, it was difficult to imagine such a reassortant occurring naturally.  I cannot tell you why they did not try an H7 or H1 virus.  You'll have to ask them.  The point was, under controlled conditions using the best genetic engineering techniques, they could not produce a reassortant in ferrets.

As one can imagine, the Mainstream Media (MSM) seized upon this as some sort of de facto proof a pandemic could not occur.  It was also seized upon by such people as H5N1 debunker and Amazing Randi wannabe Michael Fumento.  Fumento, who excels at recycling the same anti-bird flu message over and over again, cites this study as a major reason why he thinks H5N1 is much ado about nothing.

In May of this year, BioCryst Pharmaceuticals of Birmingham, Alabama, ballyhooed a breakthrough with its injectible antiviral Peramivir. The study was conducted under the auspices of St. Jude Childrens Research Hospital,  The press release (http://www.medicalnewstoday.com/articles/69680.php)  trumpeted:

A survival rate of 40% to 60% was observed in mice treated with one or two injections of peramivir; however, 100% survival of mice was achieved by two injections of peramivir on the first day followed by once-daily administration for 7 days. The longer duration of peramivir treatment also prevented viral replication in the tissues of the lungs, brain and spleen of the mice at the 3, 6, and 9 day post-inoculation time points.

Another St. Jude study, conducted by Dr. Richard Webby, showed a potential life-saving advantage of today's existing trivalent vaccine in an "N1" pandemic.  Webby's study theorized that the neuraminidase in H5N1 may not have drifted very far from today's H1N1 vaccine, and therefore a modicum of life-saving immunity may be found in people who either had experienced an H1N1 infection, or who had faithfully received a seasonal annual flu shot.  The tests were successful.

Successful, with one important distinction.  Webby remarked to me last year, qualifying the results of his study, "There's the whole mice to men thing," meaning that he personally understood that tests on mice are simply a stepping stone on the road to tests on humans, but they are far from being anything more than promising.

I mention this because BioCryst was the deliverer of bad news Wednesday.  Phase II human trials of its Peramivir injectible neuraminidase antiviral were not statistically any better in human tests than the placebo.  BioCryst postulates that such issues as the subjects' BMI (body mass index) and needle length were factors, but the press is reporting nonetheless that the tests did not go well at all. headlines such as "Flu Drug Misses Goal in Mid-Stage Study" (http://www.clinicaspace.com/news_story.aspx?NewsEntityId=70432) abound.  It is difficult to imagine using calipers to measure body fat and requiring inch-and-a-half needles for injections during a pandemic, but you see where this is going.  It's back to the drawing board for BioCryst.

Trying to create a bioengineered pandemic virus using ferrets has, mercifully, failed.  Big deal: This should show that terrorists cannot just set out and create a pandemic influenza virus.  Tinkering with this stuff in a lab gives me the willies, anyway.  Nor can tests on rodents show anything more than a road map toward further research and experimentation involving humans.  Influenza continues to confound even those who have dedicated their entire lives toward solving its riddles.  And for every innovation or breakthrough, there are several thousand new questions that must be answered and several steps carefully taken backward.

The simple fact is, we know as much about influenza as we did ten to twenty years ago.  "Influenza smoulders" is the best description I have ever heard of the virus' behavior.  Another way to put it is to repeat the words of Dr. Henry Niman:  "H5N1 doesn't read press releases." 

I spend a considerable amount of my "free time" lecturing on avian flu and pandemic preparedness, especially when it comes to information technology.  Those are my twin specialties:  I am a Chief Information (technology) Officer by profession, and I also have considerable experience in developing massive disaster recovery and business continuity plans (many of you know I developed and ran the largest State government Y2K project in the nation, Gov. Jeb Bush's statewide Y2K preparedness and awareness effort).

So this morning, as I scanned Crawford Kilian's Blogsite http://crofsblogs.typepad.com/h5n1/ , I was directed to an IT story that, quite frankly, doesn't surprise me at all.  Today's Computerworld blog title pretty much sums it up:

Pandemic disaster planning: We give ourselves a grade of C-minus, and that's generous.

The blog can be found at http://www.computerworld.com/blogs/node/6214 , and it should concern everyone who reads it.  Disaster recovery firm Sungard underwrote the cost of the survey of IT leaders, which was conducted by IDG Research and is published by CIO and CSO (that's Chief Security Officer) magazines.  Sungard is taking a strong interest in pandemic planning, if for no other reason than they understand that data centers may fail for lack of trained personnel, and frustrated executives may reluctantly order the implementation of an organization's IT disaster recovery plan just to keep the ol' mainframes and server clusters hummin'.  I recently sat through such a Sungard presentation and it was quite refreshing to hear someone other than me talk about IT failures during pandemics.

OK, the short form is that most business and government CIOs are aware of the threat of avian flu, but their own pandemic planning efforts  -- and those of their bosses -- are woefully lacking.  Nothing new there:  We all know pandemic planning lags far behind other disasters. 

My latest Powerpoint presentation (which can be found and downloaded at http://bpr.state.fl.us/pandemic/ is titled The First Pandemic of the Information Age deliberately, and with good reason.  We have never had a pandemic in the 21st Century, and we dodged a huge bullet with SARS (and its extremely scary 10% Case Fatality Rate).  We have no idea how IT will operate in the wake of 20%+ absenteeism and in the era of the Just-in-time economy.  But we all know that no entity can operate without IT.  It might as well try to conduct its operations by gaslight.  IT is the fuel that drives the modern economy, the modern government, the modern everything.  That is one major reason I strongly advocate government data center people being classified as "second responders" for purposes of antivirals.  Without IT, governments will lose their ability to effectively serve their citizens within 24 hours.  That is because in a pandemic, after medical help, citizens will demand sustenance.  The assistance will come in the form of checks, drafts, and warrants, usually via direct deposit.  The era of people with green eyeshades, writing checks manually, does not exist anymore.  And to move that money requires data centers, with mainframes and server clusters working overtime to produce the ones and zeros necessary to convert digital cash into real cash. Try to do THAT in the midst of a major pandemic.

Katrina showed us what happens when government cannot complete its most essential tasks in the most urgent time frame.  Imagine what will happen if/when governments fail to take care of their citizens' most basic needs.  Those needs include unemployment compensation; aid to families with dependant children; emergency food stamps (although whether or not there will be food to buy in a JIT-failed supply chain is debatable); and housing subsistence.  Without those direct deposits/swipe cards/ checks, people will invariably resort to other, more drastic measures to survive.

Which brings us to the source of the title of today's blog.  According to Computerworld and IDG,

Among those respondents with plans in place, most organizations plan to allow employees to work from home (76%) and/or will use their current business continuity/disaster recovery plans (72%), while 38% will geographically disperse their operation and personnel and 13% will outsource operations.

Has anyone bothered to ask Sungard or any of the Alphabet Soup Gang (IBM, KPMG, et al) if they have bought Tamiflu for their data center and network employees?  What is their strategy for a pandemic?  Just because they are selling pandemic services does not mean that they, too, will be ready.  So ask them! 

Here in sunny Florida, we constantly hear about taking an "All Hazards Approach" to disaster recovery planning.  It is preached to us day in and day out.  But until I am convinced otherwise, neither Florida, nor any other state with a similar mantra, is prepared for a pandemic.  The reason is simple: taking an "all hazards approach" should mean planning for a pandemic as the human equivalent of a 9.0 earthquake or a major terrorist attack or an ice storm of long duration or a Category 5 hurricane.  And unless the planning bookends a pandemic as the twin of the "other" Worst Case Scenario, the planning is fatally flawed.  Thinking you can manage a pandemic the same way you can manage a hurricane's aftermath is both arrogant and wrong. Pandemic planning and earthquake/hurricane/tornado/terrorist planning should be the twin bookends of disaster and business contunuity planning.  Pandemics should not be something you throw into the mix the same way you throw that extra piece of laundry into the washer. 

Yet that is exactly what people are doing when they say they will manage a pandemic using their existing DR plans.  Because they never planned for a pandemic in the first place, they think they can somehow try to look up "Supply chain failures" on Tab Three of their DR plan and have a solution.  Sadly mistaken, they will realize that plan called for massive reinforcements of goods and services from areas outside the affected zones.  There will be no mutual aid, no assistance pouring in from the outside world.  Government cannot stockpile what it needs, let alone what the population will need. 

Also, current disaster recovery and business continuity plans have an event horizon of a few days to a few weeks.  There is a conclusion to all these plans.  But with a pandemic, the event horizon will stretch for three months.  The event will not have a tidy conclusion; it will consist of sporadic, then massive influenza cases, coupled with equivalent sporadic-then-widespread supply chain failures, topped by failures in government's ability to cut checks and serve its people, capped with severe shortages of food and water. 

Gradually, as the first wave passes over the nation, people recover and go back to work, and slowly life returns to normal.  But unless all disaster recovery and business continuity plans embrace pandemic as the bookend of human suffering and hurricanes and earthquakes as the other bookend, the management of the event will fail.  The trucks full of ice will stop.  The trucks full of food and medical supplies will run out.  And patience with government as a relevant entity will also have run its final course. 

The appropriate question to ask governments and businesses is this:  "Have you embraced pandemic planning as the human equivalent of your hurricane, ice storm, terrorist and earthquake planning, with the same zeal and gusto and with the same allocation of resources, training and practice?"

If the answer is "No," or worse yet if you get no answer, then their plans will fail miserably. I guarantee it, sadly.