Those of us who have made pandemic preparedness part of our curriculum vitae could not have been more excited about the premiere of Steven Soderbergh’s latest film, ““Contagion”.”

 And we were not disappointed.  “Contagion” is a paragon of what an intelligent biological thriller should be:  hyper-accurate, absorbing, and, most of all, a film that reminds us of our own individual responsibilities within a civilized society.

 Not to say that there’s not a little bit of Hollywood in this film.  More on that later.  First, let’s take a look at how the movie was made, the etiology of the fictional virus, and what Hollywood got right.  And in many cases, they got it absolutely right.

What “Contagion” got right 

The MEV-1 virus in the movie is the brainchild of Dr. Ian Lipkin, of Columbia University.  Dr. Lipkin directs the Center for Infection and Immunity at the Mailman School of Public Health at Columbia.    He was contacted by Soderbergh and the film’s writer, Scott Z. Burns.  He agreed to come on board the production as a paid technical and science adviser.

Dr. Lipkin created a virus for the film that is patterned after an actual virus: The Nipah virus.  Nipah was first discovered in Malaysia in 1999.  The natural reservoir of Nipah is in the Malaysian fruit bat population.  The WHO reports that Nipah has also been found in bat urine and in partially-eaten fruit in the region.  Oh, by the way:  The real-life bats in question are migratory.  Toward that end, antibodies to a virus very similar to Nipah have been found in India, Indonesia and Timor.

There is a danger in making bats the heavy in the film.  Bats are essential in such areas as insect control.  And North American bats are dying by the millions, due to “white-nose syndrome,” a fungal infection that essentially suffocates bats during their annual hibernation. 

But bats are also vectors of some of the world’s most dangerous diseases, especially Ebola – and SARS. 

While the MEV-1 virus is patterned after Nipah, the pattern of infection is modeled after the SARS virus.  How quickly we forget how threatening SARS really was.  In bookstore remainder bins all over the continent, one can find Karl Greenfield’s seminal work on the SARS epidemic, titled, “ China Syndrome: The True Story of the 21st Century's First Great Epidemic.” I highly recommend his book.

While the original vector of SARS in 2002/03 was a “civet cat,” a peculiar-looking mammal, it may be that the civet cat in question was infected by a bat.  SARS virus has been found in Brazilian bats, so the danger is not localized to Southeast Asia by any means.

Had SARS been more like influenza and less like the common cold, we would have seen a pandemic that would have made 1918’s Spanish Flu look like the common cold.  In the US, the H1N1 Spanish Flu pandemic killed 2.5% of everyone it infected.  In contrast, SARS killed 10% of those it infected, worldwide.  But luckily for us (“us” being the world), SARS infected so quickly, public health professionals got in front of the disease and eventually beat it down.  It is counterintuitive to be sure, but a disease that infects quickly is easier to corral than one with a days-long incubation period, such as influenza.

To go into how SARS infected and killed would also produce those obligatory “SPOILER ALERT!!” warnings and disclosures, which I want to avoid (where possible) in this review.  So suffice it to say that “Contagion” is disturbingly accurate when it comes to how quickly it was able to infect on a global scale.

SARS was not the exclusive province of China, Toronto or Singapore.  Two prominent Tallahassee residents (who I obviously cannot identify for HIPAA reasons) were infected by SARS during a visit to China in 2003.    The CDC and WHO were actually monitoring their health following their return to Tallahassee. By proxy, they were monitoring Tallahassee for signs of SARS infection.

So what Soberbergh, Burns and Lipkin created were a perfect fit of an established disease and historic established routes of transmission.  In other words, extremely realistic.

Dr. Lipkin also taught the cast how to correctly don protective gear, and how to speak the language of disease.

In the movie, the Elliott Gould character, Dr. Ian Sussman (yes, a probable nod to Dr. Ian Lipkin) is able to finally grow a sample of MEV-1 to produce a vaccine candidate.  This storyline parallels the first attempts to grow H5N1 in chicken eggs to produce a vaccine.  Bird flu was killing the eggs.  That was eventually overcome.  Of course, H5N1 poultry vaccines have arguably done more harm than good, but that is a matter left to my previous blogs on the subject.

Elliott Gould’s Dr. Sussman is handling the virus in a Level 3 lab, and the CDC has already ordered all samples not contained in a Level 4 lab to be destroyed by fire.  Dr. Sussman’s on-screen disregard for CDC protocols is reminiscent of the spanking that real-life Dr. Yoshihiro Kawaoka of the University of Wisconsin received in 2007 for handling “copies” of the dreaded Ebola virus in a level-2 lab. 

Laurence Fishburne’s admonition that “We don’t want that virus leaving on the bottom of someone’s shoe” refers to a frequent and ongoing concern.  For more information, refer to my ongoing blog series, “When labs attack.”

What “Contagion” could have done better

Where the movie deviates from probability, in this reviewer’s opinion, is in its depiction of how society would react to the virus.  These deviations are all permitted, because they are clearly possible. It is just in the areas that were left out that very minor – and forgivable – faults can be found.

In less than a month, society pretty much goes over the cliff.  Garbage lies uncollected and strewn about neighborhoods.  Unions strike, rather than perform their duties.  Governors call out the National Guard and seal borders without apparently seeking consultation from Washington.  And while grocery stores are ransacked and food is extremely scarce, the lights and phones somehow stay on.

The Enemy of the People in any pandemic is the stability of the supply chain.  That just-in-time supply chain is the most fragile part of our economy.  The level of global apprehension, not to mention the Case Fatality Rate of the MEV-1 virus in the film, would have produced much more damage to the global supply chain. 

Those of us who are sought-out as experts in pandemic preparedness often point to unions as a cause for concern.  In fact, pandemic planners factor in possible union (in)actions in their calculations, but I believe that people are also capable of doing heroic things.  The public health experts in “Contagion” are justifiably viewed as heroic.  But as we saw on 9/11, and as we were reminded this past weekend, heroism is not limited to one exclusive group of people.

However, the images of public employees such as law enforcement officers abandoning their posts in New Orleans during Katrina – and even joining in the looting and pillaging, in a few cases – is also testament to our individual faults and failings.  That, too, can be seen in “Contagion,” even at the higher levels of the government.

The film did not damage the critical infrastructure enough.  In a prolonged, 1918-type pandemic, we believe ports will clog, phones will become unreliable, and power will come on and off – all because there will not be sufficient levels of people healthy enough to work to maintain them, nor will there be sufficient numbers of people to work, due to absenteeism to take care of loved ones.  And there are always those who will burn sick days just for a headache.  We have estimated that, at the height of a pandemic, as much as a third of the workforce might be absent on any given workday.

The movie attempts to display the deterioration of society in a few select scenes, but the film did not go far enough in its depiction of the degradation of the infrastructure.  It did show the requisite looting of grocery stores, and certain unsettling acts of violence, and it did an excellent job in its frequent shots of uncollected refuse.

In a real-life, lethal pandemic, the military would be called upon to perform these tasks.  That would include the National Guard, which I must believe would be Federalized early on, in order to prevent the types of actions that were undertaken by individual governors as the pandemic worsened.  Federalizing the Guard places those units under the direct control of the Pentagon.  Governors lose their Guard in that scenario.  I would have to believe that the president would exercise that authority very, very early on in this process.

Sealing the borders, for example, has been almost completely tossed as a realistic countermeasure.  The SARS epidemic and the H1N1v “swine flu” pandemic showed how border closures would be ineffective to restrain any virus. 

This point (along with the supply chain issue) was actually done very well in the TV-movie “Fatal Contact: Bird Flu in America”. In that film, the military is called home from Iraq and Afghanistan to help maintain law and order.  I would expect governors to call all their Guard units home, to assist in stabilizing the infrastructure of their states and to curtail inevitable violence.

 Other than the depiction of labor unions as petty and self-serving, “Contagion” also serves as a confirmation of the Second Amendment during a crisis.  Cops are not around when the shooting starts.  Self-defense is the order of the day.  Being armed equals being safe.  These are two curious messages to be dealt by a Hollywood director, and I found it to be refreshing.

SPOILER ALERTS COMING!

My family felt that it was a little preposterous that key public health people would not continuously wear their masks and gloves, especially in public.  We have had many discussions regarding the efficacy of wearing masks in public, however, and I defer to the writer and director on this topic. 

Another concern (the most deeply-rooted one) is in the film’s conflict between the CDC and the Minneapolis public health unit.  This is where the Hollywood formula kicks in, resembling a Criminal Minds episode where the local cops resent the FBI intrusion into their bidness.  The reality is that local public health units generally work very well with the CDC, and welcome their participation when things go bad.  In my experience, the CDC is a first-rate organization, led by top-flight people.  Local public health units do the best they can do, especially in this current economy, but “overwhelmed” would be an understatement on any given workday – let alone during a pandemic.

Dr. Michael Osterholm, head of the Center for Infectious Disease Research and Policy at the University of Minnesota (and who worked at the Minnesota Department of Health for a quarter-century), alluded to this during a recent “Contagion”-inspired interview.  In fact, the Minnesota Department of Health is one of the best-run departments of its kind in the country.

The other area that the movie (which runs a brisk 106 minutes) glosses over is within the subject  of vaccine production.  Public health experts such as Dr. Osterholm have stated that the movie’s scenario for vaccine production is too rosy (my words).  Vaccine production takes months, even in a “good” viral situation such as producing an influenza vaccine.  It took every bit of six months just to produce the swine flu vaccine. 

With a new and previously-unseen virus, especially considering the repeated failures of the prototypes, it would take considerably longer.  The wait for vaccine could take almost a year, causing further destruction of the global economy and the further erosion of the critical infrastructure.  And this does not even deal with the issue of who gets vaccine and who does not. 

In another “Contagion”-imitates-life example, a Chinese group has kidnapped a WHO official, and demands -- as ransom -- vaccine produced in the West.  This is a nod to the possibility of natively-produced substandard or even counterfeit vaccine.  It is nice to hear someone demanding America vaccine –anything – because it is the best in the world.  Note, at the end of the movie, the architecture of the open-air school housing the Chinese children. 

The vaccine issue is personalized within the village, but once again, the script alludes to larger global issues.  In this case, the rural, poor demand for vaccine speaks to the problems caused by Indonesia in the fight against bird flu.  Back in 2007, the Indonesian government refused to share  human bird flu samples – or even to quickly report human bird flu cases and deaths – simply because they felt their samples would make the global pharmaceutical companies billions of dollars, and, at the end of the day, leave Indonesia without any vaccine.  It took years for the West to negotiate an agreement with Indonesia to give them vaccine in exchange for human bird flu samples.

The movie did do a good job of showing the agony involved with waiting and waiting until their vaccine lottery number was called.  I found the prospect of a “vaccine lottery” to be a curious and interesting (and fair) way to resolve the issue of who got vaccine and when. The reality is, there is a schedule of who gets vaccine, at least within the first responder community, the military and the government.  The Strategic National Stockpile has the goods.  The Department of Homeland Security and state governments have the plans.  After that, I doubt if there is a plan, so the lottery idea seems as fair as any.

Finally, we need to address the issue of the blogger character played by Jude Law.  “Blogging is graffiti with punctuation,” Elliott Gould admonishes Law’s character.  Law’s Alan Krumwiede is the worst sort of blogger, one who is only interested in promoting his “brand” at the expense of the truth, not to mention people’s very lives, by promoting an unproven homeopathic “remedy.”  He is the 21^st Century snake oil salesman, shamelessly hawking an elixir that is eventually proven to be dangerously ineffective. 

Fortunately, I do not know any bloggers personally who would fit into those shoes.  My disease-blogger friends are all dedicated people who, in their minds and in mine, are performing a valuable service by alerting their readers to some very real threats and dangers.  Their surveillance uncovered the swine flu pandemic before the world’s press did, and their work on tracking H5N1 has proven to be extremely accurate.  I hope Law’s Krumwiede would not get the attention he gets in the movie.  However, having sat numerous times where Law’s character sat, in a quiet studio, in front of a television camera with an IFB in my ear, talking to a reporter or a network news anchor, I can understand how a marginal “playa” could become a fiend, mainstreamed by the press. It is up to the individual to censor him/herself and to produce accurate content.

Summation

““Contagion”” is an incredibly well-researched, disturbingly plausible, and extremely well-made film.  With the exceptions of the vaccine production timetable and the downplaying of the damage to the economy and the critical infrastructure, Soderbergh and Burns got it right.  Soderbergh is his own cinematographer as well (under a nom de plume), and his use of “available light” in place of standard movie lighting techniques makes the film feel much more realistic -- which means, of course, much more disturbing.  The cast, without exception, is fantastic.  Gwyneth Paltrow factors heavily throughout the film, so her apparent quick departure in the film’s first act is compensated for throughout the movie. 

And equally exceptional is the villain, the MEV-1 virus.  The fact that it is based on a real virus should wake us all up to the need to engage more strenuously in personal hygiene, and remember the things Momma taught us:

•       Wash your hands frequently.
•       Cover your cough, not with your hands, but with your sleeve, or a handkerchief or napkin.
•       Keep a respectable distance from strangers.

Now go put on your Level 4 gear and go see the movie!

Here are some other sites, in case you want more “Contagion” stuff:

Mike Coston’s superb Avian Flu Diary, and his entry on the movie.

http://afludiary.blogspot.com/2011/09/why-you-should-catch-”Contagion”.html

An interview with Dr. Mike Osterholm on the accuracy of “Contagion”:

http://www.startribune.com/lifestyle/wellness/129464038.html

And a dynamite Wired blog, written by the extremely talented Maryn McKenna, featuring an interview with Dr. Ian Lipkin.  Maryn has two books in print that hypochrondriacs should not read.  Her latest is on MRSA and it is called Superbug. Find it at your local bookstore, if one still exists, or order it from Amazon.

http://www.wired.com/wiredscience/2011/09/”Contagion”-questions-spoilers/all/1

Last, and least, an article on “Contagion” from a Palm Springs, California newspaper, with some quotes from yours truly.

http://www.mydesert.com/article/20110911/NEWS01/109110341/-”Contagion”-not-far-fetched

This week, an elderly Central Florida woman named Catherine "Cay" Thompson died of swine (H1N1/2009) influenza.

The news report, a capsule of which can be found here, says the Lake County (just north of Orlando) woman had recently traveled to California.  the new report also says local health officials are "shocked" that a flu case should come so early in the season.

A more detailed Orlando Sentinel account can be found here.

There are a few takeaways to these articles that just jump out at me.

First, are we surprised that a (previously) pandemic virus would still be circulating in the United States outside of flu season?  Pandemic viruses do not follow the seasonal pattern.  When do we determine that a pandemic virus loses its characteristic ability to infect people outside of "flu" season?  We all know the WHO said "stand down, please" to the H1N1/2009 pandemic, declaring it over well before now.  But when exactly does a virus lose its ability to infect outside of flu season?  I would imagine that occurs when the virus burns through the population enough to establish more of a seasonal-looking infection pattern.  I would also imagine that occurs due to natural mutations in the virus itself.  But since the WHO declared the 2010 vaccine formula would be used again in 2011, it would seem that any evolution in the virus, to this point, and based on surveillance, was very minor.

The Sentinel article states the woman and her church group traveled to California, and she fell ill while there.  She then returned early back to Florida.  It does not state how long she was in California before she fell ill, but we all know that influenza takes several days to manifest symptoms.  She died on August 25th, and I cannot find a church calendar that would shed light on when she might have first been exposed to the virus.

Even with these gaps in the travel calendar, I think we can draw up a theory.  The answer to how this unfortunate woman contracted influenza may be found, not from the visit to California, but much, much closer to home.  Orlando, as everyone knows, is a massive tourist destination.  South Americans love Disney just as much as the Brits and the Europeans and the Chinese and the Japanese.  And, indeed, India is struggling with swine flu right now.  But it is amazing how we fail to look south and, instead, default to looking to our left and right for answers.  It's flu season right now in the Southern Hemisphere.  And it is officially Hot as &@%%$ in Florida right now.  Well, actually, pretty much everywhere.  So the chances of a flu virus circulating in 90-degree-plus temperatures is remote.

In my opinion, it is far more likely that this woman actually contracted influenza at the Orlando International Airport, rather than being infected in California.  One sneeze from a Chilean or Argentine would have done the trick.

The other takeaway from this story is the woman's apparent lack of immunity to H1N1.  We all know that pandemic viruses disproportionately attack the young, sparing the elderly, who -- hypothetically -- have been previously exposed to a similar strain of the returning pandemic virus.

But this was not the case with Mrs. Thompson.  There are references in the stories to her immune system, and how the virus overtook it.  But Mrs. Thompson, being 80 years of age, would have had to have lived through the transformation of the Spanish Flu (1918 A/H1N1) and its many mutations.  She would have lived through the near-pandemic 1943, 1947 and 1951 attacks of H1N1.  She would have lived through the transition from H1N1 to H2N2 in 1957.  And she would have gone through two waves of the swine flu, which attacked Orlando pretty hard, precisely because of its status as a global vacation destination. She also appeared to be in relatively good health, based on her levels of activity within the church.

Where I am going with this blog entry is that we should take a closer look at the virus that felled Mrs. Thompson.  It would be wise for public health experts and scientists to tke a look at Mrs. Thompson's killer through an electron microscope, because the death of an otherwise-healthy 80-year old woman from swine H1N1 should not be simply relegated to statistic status.

It has been a long time since I blogged anything about the flu.  For starters, I am busier than ever at work, which cuts severely into my blogging time.  But also because I just have not felt the muse.  The swine flu pandemic was blessedly mild overall, although there are thousands of families still coping with the loss of a loved one due to H1N1/2009 who would harshly disagree with my assessment. But it wasn't 1918, so we breathed a sigh of relief.

There are many seemingly divergent storylines currently out there, which I will just list at random.  I am not so sure they are not somehow interconnected, however.

First has to be the continued number of human bird flu infections and deaths in Egypt.  Overlaying this ongoing problem is the sudden departure of Mubarak, the takeover by the Egyptian military, and what this portends for both transparency and NAMRU's operations within the nation. 

Second is the realization that this year's seasonal flu vaccine was way off the mark.  I began to notice last month that my employees were getting sick from flu, and I knew they had received their vaccinations in the late fall.  My deputy, in fact, was tested type A-positive last month.  That's pretty specific.  Here in Tallahassee, doc-in-the-box and emergency rooms were positively overrun with flu cases.  Things are looking better, but the WHUMP! of flu cases in January was much more severe than at the same time last year.  And last year was the dang pandemic!  Almost everyone who got flu this year who I am personally acquainted with, had, in fact, received the vaccine months prior.

Third is the ongoing Siege of Japan by H5N1 in poultry.  We all have read the articles about the culling of hundreds of thousands of birds in Japanese poultry farms.  this has spread to the mainland, especially South Korea.

What is clear to me is that the H1N1/2009 pandemic was not sufficient to push the other subtypes off the radar.  This runs contrary to previous pandemics where a dominant substrain was capable of, and able to, sufficiently supplant  the previous Big Dog of Flu.  H1N1 was replaced by H2N2, which was replaced by H3N2, and so on.  Swine flu was not able to eradicate H3N2, nor was it able to eradicate B.  for that matter, I do not know what research existed prior to the mid-1950s to actually track Influenza B.  for all I know, Influenza B has been around since the Chinese domesticated ducks some 4,000 years ago. 

Or, since B mutates more slowly than A, and is therefore not capable of producing pandemics (so says Wikipedia), it is not subject to the King of the Mountain game like Influenza A.

But someone apparently blew the call on the vaccine this season.  I get the feeling the only strain they got right was, in fact, the pandemic strain! 

The other strain that H1N1/2009 did not push off the radar is H5N1.  In fact, so far this year, bird flu activity seems to be much more intense than at the same time last year.  Human cases and deaths in Egypt seem to be at the same levels as last year, but H5N1's overrunning of the Japanese poultry industry is disconcerting.

Finally, there seems to be some concern that this year's flu outbreaks are more severe than last year's.  Again, this is not scientific, but my people got hit and hit hard by the virus.  Their symptoms were severe, with one person requiring hospitalization.  In one case Tamiflu did nothing, although there is a chance it was not administered in time.

H1N1 had a comeback in the late 1940s and early 1950s, with several epidemics (the Liverpool Flu of 1951, for instance) that were considered equal to, or more severe than, the 1918 pandemic, depending on location.  Shortly afterward, H2N2 (re)appeared, seemingly wiping H1N1 off the face of the Earth.

I openly wonder if the appearance of swine flu in 2009 was, in fact, the Beginning of the End of H1N1 as it was in the 1950s, and we are at the brink of the introduction of a different substrain of flu.

The world press is beginning to focus on the province of Bak Kan (or Bac Can), Vietnam.  Bak Kan is in the extreme north of Vietnam, near the Chinese border.  Last week, I blogged on the potential H5N1 bird flu cluster that was threatening to emerge within that province. Just scroll down to read my previous blog.

Following my blog, a second story appeared regarding a second human infection.  It was dated at 6:01 PM, 04/09/2010.  It appears below, and the link to the VOV story is in the headline:

Another A/H5N1 infection case reported in Bac Kan