Scott McPherson's Web Presence

There was good news contained within the bad news coming from Indonesia this week.  The good news was that Indonesia will, indeed, continue to report bird flu deaths within some sort of usable timeframe.  As you recall, the Health Ministry had decided not to publish bird flu deaths within helpful timeframes but, instead, to roll up the death tolls and announce them on some sort of months-long schedule.

While I am not ready to call this week's announcements a reversal, it is welcome news and hopefully will eventually be proven to be a reversal of a disastrous policy.

The bad news, of course, was the announced new death toll, and in particular the deaths of two women.  The Health Ministry confirmed what we already suspected was an H5N1-related death -- a 16-year-old girl from South Jakarta  -- who was confirmed dead of H5N1 on May 14.  the second death was a 34-year-old woman from Banten province, who was pronounced dead on June 3.

The virus continues to strike lethally at younger persons, and women continue to be especially hard-hit.

The next story also confirms our deepening concern about the status of things in the archipelago nation of 18,000 islands.  A Reuters story of today validates/vindicates our belief that H5N1 is frequently and dangerously diagnosed as something other than flu.  Thus, we can assume rationally that the actual infection rates from H5N1 are many times higher than what has been reported.  Here's the story:

Bird flu mistaken as dengue and typhoid in Indonesia

Fri Jun 20, 2008 2:11pm IST

By Tan Ee Lyn

KUALA LUMPUR (Reuters) - Some cases of human bird flu in Indonesia have been variously misdiagnosed as dengue fever and typhoid, resulting in the late administration of drugs, a leading doctor in the country said on Friday.

Indonesia has had the highest number of human H5N1 cases in the world and while mortality rates are around 60 percent in other places, the figure is highest, or at 81 percent, in Indonesia.

Sardikin Giriputro, director of the Sulianti Saroso Infectious Disease Hospital in Indonesia, told an infectious disease conference in Kuala Lumpur that misdiagnoses and the late administration of drugs were partially responsible for the high mortality rates.

"It (H5N1) is misdiagnosed initially as dengue, bacterial pneumonia, typhoid and upper respiratory tract infection because of similar clinical features (symptoms)," Giriputro said.

Indonesia has had 135 confirmed human H5N1 cases from late 2003 to May 2008 and 110 resulted in deaths. The country reported two more confirmed cases this week, but these were not reflected in Giriputro's figures.

Oseltamivir, otherwise known by its brand Tamiflu, is considered the drug of choice against bird flu and Giriputro said fatalities mounted the later the drug was administered.

The survival rate was very high when Tamiflu was given less than 2 days after the onset of symptoms, but that plunged the later the drug was given.

"It's best if given less than 24 or 36 hours after the onset of symptoms," he told Reuters later.

While rapid test kits are now used to diagnose the disease in animals, Giriputro said these tools were much less reliable in people.

"It depends on the viral load (in samples taken from patients)," he said, adding that test results could turn out negative even if the person was infected with H5N1, simply because there was not enough virus in samples taken. (bold mine)

In a bid to reduce the death rate, the Indonesian government has begun distributing Tamiflu to health centers in areas where H5N1 cases have occurred.

"When doctors see influenza-like illnesses and where there is evidence of contact with sick poultry, then they give Tamiflu (without waiting for laboratory results)," Giriputro said.

© Thomson Reuters 2008. All rights reserved. Users may download and print extracts of content from this website for their own personal and non-commercial use only.

http://in.reuters.com/article/health/idINKLR31511520080620?pageNumber=2&virtualBrandChannel=0

Dr. Henry Niman and others have warned for years that the hasty administration of Tamiflu without first taking necessary samples causes false negatives and hinders accurate reporting of human H5N1 cases.  This new report from the Boots On The Ground confirms this in a decisive and final way.  It lessens the viral load and allows H5N1 to "fall under the radar" of reporting.  Likewise, Dr. Giriputro has also declared -- on and for the record -- that quick test kits are unreliable for use as the "last word" on whether or not H5N1 is present in someone.

So what can we deduce from all this? 

First, there are many, many, many more unreported cases of human H5N1 than we see in the press.  This may be a "DUH" to us, but it is important to see this in the global media.  And it is equally important that we are vindicated in that venue as well.

Second, we are unable to get some important viral changes mapped, because these people are getting Tamiflu and testing negative.  that may be good in terms of living, which is always nice, but it does mean that any genetic changes in the virus from these people are going undetected. 

Third, Indonesia is a human incubator of H5N1, and we must continue to monitor the situation there 24/7/365, preferably with the full assistance of the Indonesian government.

Screw it.

I am going to tell it like it is, and never look back.

The Indonesian government's self-inflicted death wish has reached intolerable proportions.  The most recent disclosure from Indonesian Health Minister and Court Jester, Siti Fadillah Supari, means Indonesia has reached the Tipping Point between political recklessness and geopolitical suicide.  Or maybe future homicide.

For those unfamiliar with recent developments:  Indonesia has announced it will no longer report bird flu deaths as they happen.  Instead, they will roll up the data and grace the rest of the world with reports every six months or so, or whenever the muse strikes them, or when a goat is slaughtered and the entrails are spread over the government's fax machines and computers.

This means Iran -- Iran! -- is more transparent than Indonesia.  It means China is more transparent.  It means Hell has frozen over.  It also means that for the rest of us, we will not know that an epidemic has started there until it is probably too late to do anything except batten down the hatches and pray.

It has gotten to the point that an ad hoc union of flu bloggers is trying to take more decisive action to bring someone -- anyone -- in the Indonesian government to his or her senses and stop this Supari woman before she dooms not just her nation, but the entire world, to disease and death.  Supari couldn't be jeopardizing the world's health any worse than if she bottled up a few sick people from Tangerang and flew them to Los Angeles.

So here are a few random ideas.  I appeal to my colleagues to use their resources to see if we can accomplish a few things and to add to this list within their own blogsites. 

1. First, let's have somebody ask John McCain and Barack Obama to sign a joint letter to the Indonesian president, expressing their regret and indignation at the government's policies.  If Indonesia knows that both presidential candidates will not stand for this Tomfoolery, and it is a bipartisan effort, it has to count for something. 
2. Second, let's start having some serious travel advisories about any travel to Indonesia.  The US, Britain, Australia (especially Australia, since Bali is to Australia what Disney World is to America) and other nations can all issue joint travel warnings, discouraging people from any travel to Indonesia.
3. Third, let's contact our local Congressman or -woman and Senator, asking them to write the White House and hammer for decisive action.  It is surprising just how few letters it takes to activate a slumbering Congressperson.
4. Fourth, and also within those letters, let's press for UN action against Indonesia.  A nicely-worded UN resolution should do the trick. 
5. Fifth, pull NAMRU the Hell out of Jakarta and put it where it is wanted.  Someplace like Vietnam or Thailand or South Korea would be just great.
6. Sixth, pressure American-led corporations to cancel all Indonesian conferences, including Bali.  Ask everyone to refuse to attend any multinational or multigovernmental conference that is booked in Bali or Jakarta.
7. Seventh, ask the WHO to begin applying the pandemic threat level to individual nations.  I have frequently called upon the WHO to raise the pandemic threat level from Phase Three to Phase Four.  Let's rethink this and take a Homeland Security approach to things.  As DHS applies the terrorism threat level to sectors such as the aviation sector, let's apply a Phase Four warning to Indonesia.
8. Eighth, let's do everything possible to empower doctors, scientists, researchers, reporters and bloggers to get the real story out of there.  Maybe we need a Bloggers Corps to go into Indonesia and teach bloggers how to post their stories and blogs anonymously and without detection by government censors.
9. Ninth, let's hope we have Boots on the Ground, James Bonds armed with Q-Tips and vials, ready to covertly swab the epithelial cells of suspected bird flu patients, and spirit the samples out of Indonesia via submarine.
10. Tenth, pull all US-bought antivirals out of the country.  Today. Save the Tamiflu for our own people.  After all, if the Indonesian government is willing to play Russian Roulette with a loaded gun regarding the health of the entire world's population, they obviously don't care one whit for the safety of their own people.

I am out of ideas.  Let's hear from you!

A story in today's Washington Post brings the "bandwidth crunch" issue to light, and shows what Internet Service Providers (ISPs) are doing to try and regulate the flow of ones and zeroes.

First, here are some quick excerpts and a link to the whole story.

Heavy Internet Users Targeted
Providers to Test Charges, Delays

By Cecilia Kang
Washington Post Staff Writer
Wednesday, June 4, 2008; D01

 

Cable service operators Comcast and Time Warner Cable said yesterday that they would begin testing new approaches that would slow Internet access for heavy users and charge more to those who want additional speed.

The tests come as the Federal Communications Commission wraps up an investigation on complaints that Comcast blocked certain users from sharing video, music and other files. The complaints fueled a larger debate, with hearings in Congress and by the FCC, on how much control Internet service providers should have over the flow of data.

"The cable companies see a hammer hovering above their heads and are scrambling to find ways to reduce the appearance of wrongdoing," said Ben Scott, head of policy for the public interest group Free Press, which advocates for better oversight of cable operators. He called the plans "Band-Aids" on the bigger problem of network capacity, which he said can be solved only by larger investments in the cable companies' networks.

Comcast said that on Friday it would begin tests in Chambersburg, Pa., and Warrenton, Va., that would delay traffic for the heaviest users of Internet data without targeting specific software applications. Public interest groups complained in November that Comcast targeted users of BitTorrent, a file-sharing application, by blocking or delaying video and other files exchanged with the technology. Free Press said the practice discriminated against certain content and impeded users from having full access to the Web.

Analysts said the test would not differ significantly from Comcast's current network-management practices. The new approach would, however, target a broader range of heavy bandwidth users instead of delaying all traffic using BitTorrent. Roger Entner, a senior vice president at Nielsen IAG, said about 5 to 10 percent of peer-to-peer users -- those who directly exchange files with other users -- gobble up about 50 percent of all Internet bandwidth. (bold mine)

"This is the politically correct version of doing what Comcast had been doing before, though it takes the occasional [peer-to-peer] user off the hook," Entner said.

Time Warner Cable is trying a different approach with a test that will charge customers more for larger volumes of data and faster Internet access. The metered-billing test, which the company compared to cellphone billing structures that charge extra for those who go over their minutes, will begin tomorrow with new customers in Beaumont, Tex. The company said its approach allows customers to choose plans that fit their needs.

"Instead of raising prices across the board, consumers who are excessive users would pay," said Alex Dudley, a spokesman for Time Warner Cable. "It is clearly the fairest way to fund the investment that is going to be required to support that use."

http://www.washingtonpost.com/wp-dyn/content/article/2008/06/03/AR2008060303248_pf.html

Note that five to ten percent of all Internet users consume fifty percent of all Internet bandwidth.  And much of that is peer downloading of crap, usually in the form of illegally pirated music and movies.  That makes it very difficult for the other ninety to ninety-five percent of the rest of us, who only occasionally download crap.

The ISPs all want to move to a "metered" system, similar to how you pay for electricity today.  You pay for what you use.  Personally, I think this is a wonderful idea, and I will expand on this idea over at my blogsite on Computerworld.com.  Paying for what you use could be exported as a fee to university students, where a good deal of this illegal file sharing and downloading goes on.

It is not the only answer, however.  Internet providers must continue to invest in bigger pipes and newer solutions. 

What does this all have to do with a pandemic?  As I have mentioned many times, "telework" or "work at home plans" will not be successful in a severe pandemic.  Why?  think about the bandwidth that will be consumed at home, while Jimmy plays XBox Live and his mom and dad are frantically trying to log into the corporate mainframe and email systems at their jobs.

Cable Internet connectivity is a communal experience.  that means a neighborhood is sharing a single point of access back to the home office.  They may tell you that a five jigabit connection is coming to your home, but it is divided by the number of packets of ones and zeroes that is simultaneously being transmitted and received by every other Internet connection in your community.

DSL claims that it is a "home run" cable pull all the way back to the Central Office of your Telco, but I seriously doubt that.  That is because DSL connectivity is horrifyingly unreliable.  I speak from experience: In my day job, I have over 120 "edge routers" connecting back to my network, and about 73% of those connections are DSL.  Failed DSL connections represent 93% of all my wide area network outages.  In any given week, up to 21% of all DSL connections can fail for extended periods of time.  I have the metrics to prove this.

So the chances are extremely good that if you are a cable subscriber, you will experience extremely slow activity at home during a pandemic.  And if you are a DSL subscriber, count on your DSL failing repeatedly  in a pandemic of any severity.

So your telework will be thrown out the window, along with your computer.  Businesses that depend on such telework will reluctantly call their employees back into work, because nothing will get done otherwise.  This is especially true for government employees, because government overall still moves on paper while business moves digitally.

Will those employees report for work?

Have their bosses bought them masks, gloves and hand sanitizer?  Have they trained their people to know what to do and what to expect in a pandemic?  Have they prepared them for the pain, the PTSD that will inevitably occur, while giving them the resources and the knowledge to think and act for themselves?

Employers, you can answer that question a lot better than I.  Perhaps it's better not to ask at this time.  Much better that your employees ask you these things now, rather than later.

Because the next pandemic might not be H5.  It could be H7.

Dear readers,

Soon, I will be resuming my blogs on pandemic readiness.  I have been recharging my batteries and doing some research.  Plus, things have been kinda quiet lately, and I am not one to write if I cannot offer meaningful dialogue (my colleagues all do that much better than do I).

So I will be posting entries again soon.

Scott

Bangladesh H5N1 human positive begs more questions

The recent disclosure from the Bangladesh government and the CDC that a toddler was positive for H5N1 when originally certified negative opens the door to a multitude of questions.  Read with me the capsule, as digested by Dr. Henry Niman:

The DGHS, as part of its routine surveillance, sent a swab with samples from naso-pharyngeal of the 16-month-old boy to the Centres for Disease Control and Prevention in Atlanta which confirmed the H5N1 infection Wednesday.

"When the child came to us it was diagnosed with strain A positive but the H5 was found negative. However, one and a half months later when we sent the sample to Atlanta, as part of our routine surveillance, it was confirmed after culturing the virus that it was H5 positive,"

The boy, who lives in Kamalapur in Dhaka, was cured without any medicine for Influenza. He was provided with medicines for respiratory infection for 14 days... (bold mine)

http://www.recombinomics.com/News/05220806/H5N1_Dhaka_Mild.html

This one small snippet of the news story is quite revealing.  First, why did it take six weeks to send the virus sample to the WHO and CDC?  Is this routine?  Second, why the false negative for H5?  What test was used that produced the false negative?  Thank the God of your faith that the Bangladesh government did its due diligence and sent a negative sample ahead to the WHO and CDC.

A significant case can be made for the global junking of the test that produced the false negative.  The unanswered question is, How many false negatives have been misdiagnosed across the globe using this and other tests since 2003?

The odds say that this 16-month old should not have survived.  By the way, I do like to play the odds, and got four horses right in the only two Preakness races I participated in last week.  Not bad. 

But I digress.  The odds say this toddler should have died.  Since the child is recovering without the aid of antivirals, this means that we are probably looking at a very mild Qinghai clade 2.2 H5N1.  This implies that if one toddler contracted high-path H5N1, then we need to assume others in the region bordering and including east India (a region the size and shape of the state of Maine) have also contracted H5N1.  Since we have not seen a massive die-off of humans in the region, my suspicion is this mild H5N1 is being misdiagnosed as seasonal flu.  If it is not tipping the scales on influenza tests, it is not evoking concern.  This hypothesis is bolstered by the false negative and subsequent discovery of H5N1 by the CDC six weeks later, in the culturing of the virus.

We have read about cases where Indian cullers have experienced flu-like symptoms.  I hope somebody is following up with those cullers to see if they exhibit antibodies to H5N1.  Certainly mass suggestion could also be a culprit, and I tip my cap to that theory as being entirely possible.  Just as possible now, however, with the Bangladesh disclosure, is the chance we are seeing mild human H5N1 (once again) go completely undiagnosed.  It is not an unfamiliar refrain.

I blogged not too long ago that perhaps Qinghai will not become the pandemic strain of H5N1.  I theorized that Fujian Clade 2.3 would be the trigger.  But I am also reminded of the words given to me by Dr. Richard Webby, protege of the Pope of Influenza, Dr. Robert Webster.  Dr. Webby said to me in 2006 that we would be surprised how little we really know about influenza.

Perhaps this is exactly how influenza becomes pandemic.  We see three or four substrains of a particular virus circumnavigate the globe.  We see the virus move from wild birds to poultry and back again; or we see the virus move from poultry to wild birds and back again.  The sequence really does not matter.  The "Three P's" (poultry, pigs, people) help move the viral goulash along in its evolution and help the virus substrains acquire -- slowly, maybe agonizingly so -- the necessary genetic elements for pandemic activity.

This evolution cannot be stopped, only slowed.  . 

Then, quite suddenly, these subtypes all recombine with each other.  A pandemic "Big Bang," if you will, ensues.  Since influenza A plays King of the Mountain, the strongest (most lethal?) substrain accepts other substrain's acquired genetic characteristics and takes its victory lap around the world a few times.

It is at that point that a pandemic occurs. This theory is not far removed from that of one of my heroes.  The late Dr. R. Edgar Hope-Simpson theorized that asymptomatic carriers of novel influenza were at least partly responsible for pandemics.  He also sprinkled in doses of sunspots and solar radiation -- kind of a Pandemic Theory of Everything. 

What if he was right?  Perhaps those "asymptomatic" carriers were not so asymptomatic, but were actually carrying a milder form of a novel strain that no one picked up on.  That 16-month old toddler could be one such asymptomatic carrier.  So could thousands of Indian, Chinese, Vietnamese, Russian, Thai, Pakistani and Turkish carriers.  This also would explain the sudden appearance of pandemic influenza all over the world simultaneously.  There are too many stories of historic pandemics where the virus' travel was much too quick for any of the conventional transportation mechanisms of the day.  Pandemic influenza outran sailing ships and other ocean-going vessels.  It outran horseback, wagon, carriage and train.  It did so because it was with us already for years, festering, smouldering, waiting for that simultaneous worldwide genetic addition that caused it to spark.

Only antibody testing of tens of thousands of people in bird flu hot spots all over the world will reveal any fact or truth to this hypothesis.  It certainly does underscore the prevailing belief that we won't know that we are in a pandemic until after it starts.  There are simply too many holes in surveillance to guarantee early warning.

But in one remote area of one struggling nation, we may have found a very important clue to solving this riddle.  And we found it courtesy of due diligence and surveillance.

If only other nations (are you listening, Indonesia?) would do as well.