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One of the things not generally talked about during pandemic discussions is the impact a severe flu pandemic will have on financial markets such as life insurance.  I mentioned this lack of discussion when I recently lectured to senior employees of the Florida Department of Financial Services, or DFS.  DFS is run by a very impressive woman, Alex Sink.  Ms. Sink has run a banking empire (Bank of America) and has also served on numerous private sector boards and commissions.  She is also the only elected statewide Democrat on Florida's elected Cabinet, so she is unique in her ability to get her message of fiscal discipline to voters of all persuasions.

Anyway, CFO Sink required all her senior staff to listen as I gave my then-new "First pandemic of the information age" presentation, giving new meaning to the axiom "Death by Powerpoint."   Her senior managers and policy experts came to terms with the sheer volume of human suffering and the resultant stress that a sudden spike in death claims would have upon the life insurance industry, not to mention a downturn in tax receipts.  The actuarials in the audience quickly performed their unique calculus and their faces went pale with concern about the solvency of some life insurance companies who would hypothetically be paying death claims on young lives whose premiums had not been given time to prosper within the Law of Large Numbers that is the industry's hallmark.

Add to that growing list of concerned organizations the venerable Lloyd's of London.  Lloyd's, whose very name is synonomous with global best practices in the insurance and reinsurance fields, recently conducted a seminar on pandemic planning. It is one thing to read bloggers' diatribes about pandemic preparedness, including my own.  It is another thing to hear our government's top leaders -- including the President himself -- speaking on the need for preparedness.  But for some, confirmation only comes whan a prestiege firm such as Lloyd's comes out and says, "Do this."

For those people, consider yourself warned.  Lloyd's is taking the approach that a pandemic is an event with a very close beginning date. An extract taken from the Lloyd's press release:

Prepared for a pandemic?

2 May 2008

A pandemic ‘flu that causes massive disruption to economies around the world is inevitable and all businesses must prepare for it now. That was the stark message to emerge from a recent high level seminar co-organised by Lloyd’s and XL.

In a series of sobering presentations, business continuity and risk management experts explained how insurers and their customers could be affected by a pandemic and what they can do to mitigate the fall-out from a nightmare scenario.

In risk management terms, a pandemic is unlike any other natural or manmade disaster that businesses routinely prepare for. A ‘flu pandemic is not a sudden, short lived event like a terrorist attack or industrial explosion that destroys infrastructure in a localised area. It could last for months.

“Nobody knows when this will happen, so it is a challenge to make it real to people,” Professor Lindsey Davies, national director of pandemic influenza preparedness at the Department of Health admitted. “But it will happen.”
When the UK’s Financial Services Authority simulated the effect of a pandemic ‘flu on the City it assumed an absence rate of 49%. Richard Maddison, deputy head of business continuity risks at the FSA, said that the exercise revealed that from the outset participants’ were not fully aware of the impact a pandemic would have on their suppliers and that there was uncertainty about how a pandemic will spread. “Plans and HR policies need amending,” he warned.

All the evidence points to a lack of preparedness among business. A YouGov survey last year found that over three quarters of companies have inadequate plans; around a third have no strategy at all.

Drawing a pandemic timeline, the FSA’s exercise showed how institutions will be challenged as a pandemic quickly develops momentum. Chillingly, by week five of the simulation, companies were extending HR policies to include emergency financial support, accommodation and death in service benefits to employees.

The insurance industry will potentially have to cope with an variety of claims , while it is still reeling from its own business continuity problems, Trevor Maynard, emerging risk manager at Lloyd’s, said. Life and health programmes will be directly impacted but less immediately obvious losses could pile up as businesses grind to a halt, from credit insurance to event cancellation.

When the UK’s Financial Services Authority simulated the effect of a pandemic ‘flu on the City it assumed an absence rate of 49%. Richard Maddison, deputy head of business continuity risks at the FSA, said that the exercise revealed that from the outset participants’ were not fully aware of the impact a pandemic would have on their suppliers and that there was uncertainty about how a pandemic will spread. “Plans and HR policies need amending,” he warned. All the evidence points to a lack of preparedness among business. A YouGov survey last year found that over three quarters of companies have inadequate plans; around a third have no strategy at all. Drawing a pandemic timeline, the FSA’s exercise showed how institutions will be challenged as a pandemic quickly develops momentum. Chillingly, by week five of the simulation, companies were extending HR policies to include emergency financial support, accommodation and death in service benefits to employees. The insurance industry will potentially have to cope with an variety of claims , while it is still reeling from its own business continuity problems, Trevor Maynard, emerging risk manager at Lloyd’s, said. Life and health programmes will be directly impacted but less immediately obvious losses could pile up as businesses grind to a halt, from credit insurance to event cancellation.

http://www.lloyds.com/News_Centre/Features_from_Lloyds/Prepared_for_a_pandemic_02052008.htm

There is more, but I will let you read the release.  I do want to post Lloyd's Top Ten things to remember in a pandemic:

Top 10 tips for businesses to cope with a pandemic

• Although the emergency services are taking pandemic preparedness very seriously continuity plans should consider the impact of a reduced level of service.

• Educate your staff in advance on the hygiene and quarantine procedures they may need to take.

• Identify who your key personnel are and explore cross training to help cope with absent staff.

• Check that your suppliers are as well prepared as you are for a pandemic.

• Decide on corporate priorities and the key services that must be maintained.

• Exercise contingency plans against the timeline of a pandemic.

• Fully understand how telecommuting can serve the business and where the weak points are.

• Evaluate your requirements for bandwidth at your gateway and consider buying extra now.

• Be prepared for subsequent waves and plan for the recovery phase.

• Expect a more fluid job market as employees react to how they were treated by employers during the pandemic.

This is among the best advice I have ever seen for pandemic preparedness.  Of course the Devil is always in the details, but these tips are simple, straightforward and can apply equally to the public and private sectors.  And note that final bullet:  If your business fails to properly consider the role that pandemic planning and response took in their own lives, do not expect to retain them.  If you care not a fig for your employees enough to prepare them for pandemic flu, they will repay your lack of care by leaving you.  Hey, that rhymes!

Hat-tip to Flutrackers poster Shiloh. 

Over the weekend, a news story broke that a federal task force had released recommendations for triage of victims of a future flu pandemic.  The task force comprised doctors and researchers from well-known universities, medical organizations, and government agencies including the Department of Homeland Security, the Centers for Disease Control and Prevention, and the Department of Health and Human Services.

The story was picked up by the Associated Press and other news organizations.  Here's the story:

Triage plan details whom to let die during a pandemic

Treatment blueprint gives severely hurt, elderly lower priority

Lindsey Tanner, Associated Press

Monday, May 5, 2008

Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding whom to let die.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention, and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux, a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.

Their recommendations appear in a report published today in the May edition of Chest, the medical journal of the American College of Chest Physicians.

"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing," the report states.

To prepare, hospitals should designate a triage team with the Godlike duty of deciding who will and who won't get lifesaving care, the task force wrote. Those out of luck are the people at high risk of death and a slim chance of long-term survival. But the recommendations get much more specific and include:

-- People older than 85.

-- Those with severe trauma, which could include critical injuries from car crashes and shootings.

-- Severely burned patients older than 60.

-- Those with severe mental impairment, which could include advanced Alzheimer's disease.

-- Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

Dr. Kevin Yeskey, director of the preparedness and emergency operations office at the Department of Health and Human Services, was on the task force. He said the report will be among many the agency reviews as part of preparedness efforts.

Public health law expert Lawrence Gostin of Georgetown University called the report an important initiative but also "a political minefield and a legal minefield." The recommendations would probably violate federal laws against age discrimination and disability discrimination, said Gostin, who was not on the task force.

If followed, such rules could exclude care for the poorest, most disadvantaged citizens who suffer disproportionately from chronic disease and disability, he said. While health care rationing will be necessary in a mass disaster, "there are some real ethical concerns here."

James Bentley, a senior vice president at American Hospital Association, said the report will give guidance to hospitals in shaping their own preparedness plans, even if they don't follow all the suggestions. He said the proposals resemble a battlefield approach in which limited health care resources are reserved for those most likely to survive.

While the notion of rationing health care is unpleasant, the report could help the public understand that it will be necessary, Bentley said.

Devereaux said compiling the list "was emotionally difficult for everyone." That's partly because members believe it's just a matter of time before such a health care disaster hits, she said.

"You never know," Devereaux said. "SARS took a lot of folks by surprise. We didn't even know it existed."

http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2008/05/05/MNM210GNVM.DTL

I have told the story before.  Back in late 2006, HHS floated a trial balloon:  Let the governors of the states decide how best to distribute vaccine and antivirals during a flu pandemic, once the first responders were taken care of.  I sent my friend, then-governor Jeb Bush, an email that included the balloon from HHS.  I concluded in the missive,

"Jeb, Who do you vaccinate in a pandemic?  Your future or your past?"  I also told Jeb that, blessedly, he would not have to make that decision -- but his successor very well might.

The answer to my rhetorical question is very, very clear to me:  It is whoever is at highest risk.  If it's 1918 all over again, I would not hesitate to treat and vaccinate the most vulnerable first, based on mortality:  Young adults 18 to 40.  That might rankle the ire of AARP, but that is just too bad.

Allow me to explain why.

Look at the results of the Spanish Flu pandemic of 1918-19.  Depending on whose book you read, the life expectancy of an American dropped by anywhere from ten to twelve years in the wake of that pandemic.  That is how many youthful Americans died, both from World War I and the Spanish Flu.  We know today that more American soldiers died from flu than from contact with the enemy. 

We know that the most likely person to die in 1918 in the United States was a pregnant woman aged 27.  Her chances of dying if she acquired the Spanish flu were 55 in 100. 

America was able to weather that pandemic storm and prosper because making babies and building families were still the preferred projects in the eyes of American youth.  Now let us look at the realities of today.  We cannot say that with any confidence whatsoever. Political leaders must look at a pandemic within that context, and not just within the context of administering care for people. 

Were it not for immigration (legal and otherwise), the United States would have lost population from 1990 to 2000.  That is because people are not having babies in sufficient quantities to replace the people who are dying.  This fact is borne out in every single projection regarding future imbalances in Social Security, Medicaid, Medicare and federal entitlements in general.  Medicare is already out of balance, according to a good friend of mine, a Federal economist with the Department of Labor.  That means recipients of Medicare are pulling money out of the system faster than wage-earners  are paying into it.  Soon, Social Security will be the same way.  And by 2042, according to the Comptroller of the Currency, 100% of the Federal budget will be taken up by these entitlements.  No defense.  No transportation.  All entitlements.  What a mess.

Again, this is because there are fewer people being born than there are people dying.  And if you think this is bad, you should look at the looming danger about to befall Europe.  At least we grew:  Europe did not, and as a result has to import its labor now, with consequences we can see on televisions nightly.  Of all the nations of the earth, only Australia grew the "old fashioned" way.

From the Website of the Population Reference Bureau:

The more developed countries in Europe and North America, as well as Japan, Australia, and New Zealand, are growing by less than 1 percent annually. Population growth rates are negative in many European countries, including Russia (-0.6%), Estonia (-0.5%), Hungary (-0.4%), and Ukraine (-0.4%). If the growth rates in these countries continue to fall below zero, population size would slowly decline. As the chart "World population growth, 1750–2150" shows, population increase in more developed countries is already low and is expected to stabilize.

http://www.prb.org/Educators/TeachersGuides/HumanPopulation/PopulationGrowth.aspx

Imagine a scenario that takes the 1918 pandemic and extrapolates that pandemic's societal impact across today's population and across today's social and economic realities.  Take the 675,000 who died in the US and assume half were 18 to 40, as we always say in our presentations.  Now imagine if we took the 2.5 million Americans who would die if 1918 broke out all over again.  Imagine if we took more than one million Americans between 18 and 40 and just erased them from the map.  We also erase their earnings potential across their lifetimes.  We erase their incomes, their contributions to society, their ability to buy homes, their ability to build businesses, their ability to help mold a new America.  And we erase their ability to pay the taxes that will be needed to keep the nation afloat. 

That is where pandemic flu also crosses the line into the illegal immigration debate.  It is simple economics.  If a million younger wage earners die, a million more must take their place.  The United States will have no choice.  It will have to import its labor from wherever it can take it, and it will reshape the nation's future permanently. 

Forget the IMF, World Bank, CBO and British government projections of a drop of nearly 6% in global GDP.  Imagine if that drop maintained itself for years, maybe even decades..

In short, were a flu pandemic to erupt today, and if we do not try to save our future wage earners, leaders and mothers and fathers, we will surely bankrupt the nation and plunge the world into economic depression.  Without a national pandemic triage strategy to debate in the sunshine, and without the proper national resolve, we may wind up dooming the United States to its darkest period since the Civil War.  And this is assuming only a 2.5% Case Fatality Rate.  What if it is worse?  Heck, the CFR from SARS was nearly 10%! 

If H5N1 "goes pandemic," we know the CFR -- and the death curve -- are potentially even more depressing.  Sure, elderly people die.  But 90% of the deaths due to H5N1 infection are people under 40, and younger children suffer disproportionately.  Elderly people do not die in the same percentages when infected by H5N1.

The United States, therefore, simply cannot afford to treat all its people equally in a pandemic.  It must have a national triage strategy, saying that based on the mortality of the disease, certain age groups must come first for Tamiflu, for ventilators, for vaccine.  It means others will have to take a back seat or, regrettably, not get a seat at all.  And I doubt if there will be any real legal consequences for these decisions, since any flu pandemic invoking this level of triage will certainly also invoke a national state of emergency, maybe even martial law.  Those declarations pretty much wipe out any legal standing for dying plaintiffs.

So in the next pandemic, who gets the ventilator?  The 29-year old woman, or the 69-year old man?  Who do you save, your future or your past?

Is it really that hard to decide? 

C.diff sickening half a million Americans a year.

Intrepid reader,

Florida's legislative session is winding down its final hours, and you will find me blogging again on a more regular basis. Until then, read this MSNBC article on C.diff, a bacteria that is quite nasty indeed.

A bad germ gets worse

‘C. diff’ rivals MRSA as the next deadly bacteria threat, experts say

By JoNel Aleccia

Health writer

MSNBC

updated 8:22 a.m. ET, Fri., May. 2, 2008

Amy Warren had never heard of the germ that made her so miserable.

In January 2005, weeks after giving birth to her daughter, the Ohio mother of two knew only that she was in pain, suffering cramping so severe she felt like she was still in labor. Then came the diarrhea, uncontrollable bouts up to 50 times a day, which left Warren weak and raw and stranded in her Maineville home.

"I was so sick; I thought I had colon cancer and was dying," Warren recalled.

Three tests failed to detect the source of her intestinal trouble. A fourth, however, confirmed Warren as part of a toxic trend: She was among growing numbers of people sickened by an especially virulent form of the bacterial infection Clostridium difficile, known as C. diff.

Doctors told Warren she’d contracted the NAP1 type of the bacteria, a mutated version that produces roughly 20 times the toxins responsible for illnesses ranging from simple diarrhea to blood poisoning — and death.

“It’s like a science fiction disease,” said Warren, who struggled for six months through three relapses before controlling the infection. “That’s what scared me. People die from this.”

C. diff has long been a common, usually benign bug associated with simple, easily treated diarrhea in older patients in hospitals and nursing homes. About 3 percent of healthy adults harbor the bacteria with no problem. But overuse of antibiotics has allowed the germ to develop resistance in recent years, doctors said, creating the toxic new type that stumps traditional treatment.

"This is the one we're scared of," said Dr. Brian Koll, chief of infection control at Beth Israel Medical Center in New York.

C. diff produces anaerobic spores transmitted through feces that are able to survive for months on most surfaces. People are infected when they ingest the bacteria, typically by touching contaminated surfaces and then touching their mouths, or by eating contaminated food.

Overall infections caused by C. diff more than doubled between 2000 and 2005, according to the latest government figures. In 2005, the year of Warren’s illness, 301,200 cases of C. difficile-associated disease (CDAD) were logged in discharge records kept by the nation’s hospitals. Some 28,600 people who had the infection died.

That's only hospitals, however. Counting nursing homes and other care centers, the number of cases nationally is likely closer to 500,000, experts estimate.

Contaminated health care settings remain the main source of C. diff infections, primarily because they treat so many people with serious diarrheal illness.  The NAP1 strain has been found in other sites and populations in recent years, infecting young adults and pregnant women with no history of antibiotic use, according to federal sources.

Despite the concern, scientists don't know how many people contract NAP1 infections, or how many die from them. C. diff infection is not a reportable condition in most states, although a rare pilot project that mandated reporting in Ohio in 2006 found more than 14,000 cases in hospitals and nursing homes that year, according to the state health department.

Mutant strain detected in 38 states
What is clear is that the most toxic strain is taking hold, according the federal Centers for Disease Control and Prevention.

In February 2007, 23 states told the CDC they'd seen cases of the NAP1 strain; by November, that number had grown to 38. Officials in the remaining states and territories contacted by msnbc.com said they hadn't detected the virulent bug, but most also said they don't look for it.

Better data about the scope of the C. diff problem may be available by this fall, when the Association for Professionals in Infection Control (APIC) presents the results of a prevalence study being conducted this month.

Last year, APIC was among the first agencies to note that rates of Methicillin-resistant Staphylococcus aureus, known as MRSA, were about 10 times previous estimates. The so-called superbug claimed headlines last year when researchers linked it to more than 94,000 infections and nearly 19,000 deaths in the U.S. in 2005.

Health officials now rank C. diff on par with MRSA as one of the top two infections acquired in hospitals.

“In light of how frequently it is already occurring as well as the trajectory of its recent increase, it is an infection that definitely deserves our respect and attention,” said Dr. L. Clifford McDonald, chief of prevention and response for a division of the CDC.

Attention must also be paid, scientists say, because the infection that mostly affects older, sicker people with long histories of antibiotic use now appears to be showing up in younger, healthier patients like Warren.

Warren’s not sure how she contracted the infection, which is caused when normal flora in the gut is disturbed, typically by antibiotics. About 90 percent of CDAD cases occur in patients who've used antibiotics recently, especially fluroquinolines such as the popular drug Cipro.

The resistance allows the C. diff bacteria to take over and flourish. Consequences can range from severe diarrhea to colitis and toxic megacolon, a condition that can lead to shock and death.

Warren, now 39, may have gotten the infection from her daughter, Celeste, who had a mild C. diff infection shortly after birth. Infants often harbor C. diff harmlessly in their intestines for about the first year of life, before more mature flora take over, experts said.

It's also possible Warren may have acquired the bacteria the previous fall, when she was briefly hospitalized and wound up sharing a room with a woman with severe diarrhea.

“I was sharing a bathroom with her,” Warren said.

‘Filthy’ hospitals perpetuate problem
There's no question that the rise of C. diff is tied to the cleanliness of the nation's hospitals, say researchers and health care advocates lobbying for better infection control.

"Outbreaks highlight the fact that standard infection control procedures in hospitals are not as good as they could be," said Dr. Curtis Donskey, director of infection control at the Louis Stokes Veterans Affairs Medical Center in Cleveland, Ohio.

Even after cleaning, studies show that C. diff spores linger on virtually every hospital surface, including bedrails, telephones, call buttons and toilets.

C. diff spores cling to patient skin, and not only in expected areas, such as the groin, according to a small-but-telling study published by Donskey and colleagues in the February issue of the journal Clinical Infectious Disease. Nearly 40 percent of patients diagnosed with CDAD infections tested positive for C. diff on their hands, and nearly 20 percent had the bacteria on their forearms, researchers found. About 60 percent had C. diff detected on their chest and abdomen.

 

Typical hospital germicides and alcohol hand sanitizers don’t kill C. diff, experts said. Instead, it takes bleach to eliminate it from surfaces and the friction of soap and water to remove it from hands.

But many hospitals have failed to make controlling C. diff a priority, critics contend.

“The biggest problem in our hospitals is that they are filthy dirty,” said Dr. Alfonso Torress-Cook, an epidemiologist who says he adopted practices that cut C. diff infections by 90 percent at his acute rehabilitation center in Orange County, Calif.

"If we start cleaning the environment, the infection will take care of itself," he added.

Interventions can range from ultra-violet light targeted to kill C. diff germs to silver-infused flooring and antimicrobial curtains aimed at resisting the bugs.

 

Making infection control a daily habit
The most important remedy is building infection control practices into the daily routine of organizations, said Koll, who is known for his work reducing potentially deadly central line-associated bloodstream infections.

Koll has spent the last two years improving prevention of C. diff in his hospitals, revamping protocols ranging from housekeeping techniques to quicker diagnosis.

"The minute somebody has diarrhea, you think 'C. diff'," he said.

Some changes have been obvious, Koll said. A switch from reusable rectal thermometers quickly contributed to C. diff rates that have fallen by 25 percent.

Key to a new collaboration with three dozen Northeast hospitals is a checklist of infection control steps and a “C. diff bundle,” a portable, prepacked kit of supplies that keeps health care workers from having to search for gowns, masks and necessary tools.

“People will do the right thing,” said Koll. “No one wants to give their patients an infection.” 

It's long past time hospitals began to pay attention to their infection control practices related to C. diff, MRSA and other organisms, said Lisa McGiffert, director of the Stop Hospital Infections project for Consumers Union, a patient advocacy group.

Hospital-associated infections affect nearly 2 million patients and are associated with nearly 100,000 deaths each year, according to the CDC.

“Here’s the problem with these bad bugs: They’re very hard to stop when they get inside the body,” McGiffert said. “The only defense we have is prevention.”

Medicare may not pay for C. diff infections
It may take proactive efforts like those proposed by Koll and others to implement hospital-wide control practices. Or it may take punitive efforts, such as the move by federal Medicare officials to cut payments to hospitals for certain avoidable conditions acquired after admission. Last month, Medicare proposed adding C. diff to the growing list of preventable problems after the agency recorded 96,000 cases of the infection in 2007 at an average cost of $59,000 apiece.

In the meantime, patients need to take care into their own hands, often literally, advocates said.

They need to become acutely aware of hand hygiene, making sure to wash their own hands frequently and remembering to ask visitors and health care workers to wash up as well, said Betsy McCaughey, who heads the advocacy group Committee to Reduce Infection Deaths, or RID.

“No matter how dirty the hospital is, if that spore does not go in your mouth, you won’t get C. diff,” she said.

 

Some patients and their family members have become even more vigilant, bringing their own bleach-infused hand wipes to wash down hospital door knobs and bed-rails, said McGiffert.

“People are cleaning the bathrooms themselves because they’re filthy,” she said. “People have lost faith that the hospitals are going to do those things. They’re taking it on themselves.”

Officials with the CDC and APIC decline to recommend such forceful interventions because clinical studies haven't proven their effectiveness.

But even Donskey, the Ohio scientist, said his research has given him personal pause.

"I might bring along a bottle of bleach to disinfect my room and ask every health care worker who examines me to wash their hands, but I don't think most patients are willing to do that," he said.

Anxiety lingers, three years later
Nearly three years after her last bout with C. diff, Amy Warren said she does everything she can to avoid sources of the infection, including hospitals and antibiotics. She’s acutely aware that it took three doses of vancomycin, the strongest antibiotic available, to get rid of the bacteria after six months.

“If I get sick, I get a panic attack,” she said. "What if the vancomycin doesn't work? I have no other medicine."

She tries to warn friends and family about the dangers of C. diff, urging them to limit their use of antibiotics and to be vigilant about hand hygiene. But, she said, it's clear they're not listening.

"They think, 'How can diarrhea be that bad?'" Warren said. "But this is more than diarrhea."

http://www.msnbc.msn.com/id/24407803/

A spore that can live and infect people for months!  A CFR of nearly ten percent!  Infections disgnosed and confirmed in 38 states (see map at left)!  The possibility that if you try to calculate the number of unreported or undiagnosed cases, the total number of infected could reach half a million!

I am reminded of a line from the recent and groundbreaking film "Cloverfield."  In the scene in question, youthful adults are fleeing from some incredible monster that is trashing Manhattan.  They run straight into an Army patrol in a department store that has been turned into a command post. 

One of the young adults blurts out, "What is that thing?"

The soldier replies, "Whatever it is, it's winning."

It should be apparent to anyone and everyone that in our war against bugs, the bugs are winning.  And our enemy, to paraphrase Pogo, is us.  It is lax hospital protocols that threaten nearly everyone who walks into one.  It is our inability to teach proper hygiene, even in our own homes.  It is ludicrous (not the rapper) decisions such as the one recently taken in Leon County, Florida (Tallahassee) schools, where alcoholic hand sanitizer was declared a fire hazard and ordered removed from classrooms. And it is not mandating the testing and reporting of these pathogens to local and state health authorities.

We don't need a bird flu pandemic to threaten our lives.  We are doing perfectly well threatening ourselves..

And we thought that bird flu news was slow recently.  Recently, genetic sequences from a 2004 human case of H7N2 avian flu infection were released.  The sequencing was dutifully covered by Dr. Henry Niman, among others.

Why it took a whopping four-plus years for the genetic sequences to be released is a matter of serious conjecture.  But what is clear is this:  the H7N2 was a reassortant virus that carried several human H3N2 pieces.  The reassortant H7N2 virus was a matter of grave concern to the doctors and researchers, who were at a loss to explain how a New York man with zero contact with poultry could have contracted an avian reassortant.

From the New York Times story of April 20, 2004 (almost exactly four years ago):

Dr. Joshua Lipsman, the Westchester County health commissioner, said, "While we can't rule out it being person-to-person transmission, the likelihood is still very small." He added that the patient "had some potential exposures that we're looking into," but declined to elaborate.
Officials said the man was infected with Type A influenza, Strain H7N2, the same one that hit chicken farms in New Jersey, Maryland and Delaware this year. The H7 viruses are thought to be less virulent in humans than the H5 strain that appeared in Southeast Asia in recent months. Other H7 strains were responsible for outbreaks in Canada this year, and in the Netherlands last year.
The Westchester patient, a Caribbean immigrant, lives in Yonkers with his wife and children, officials said. (Hospitals and health officials do not reveal the names of patients in cases involving public health issues.) He entered the hospital in November suffering from other serious ailments that weakened his immune system and that might have masked the symptoms of avian flu. One official said the patient had symptoms of a respiratory illness, including coughing and an abnormal chest X-ray. Doctors at first suspected tuberculosis.
"We knew it was something weird, but we didn't know what it was," said Claire Palermo Flower, spokeswoman for the hospital. "They did an elaborate culture and asked the lab to do more than the usual tests."
The county's laboratory tentatively identified the virus as a human flu strain, H1N1, and sent sputum samples to C.D.C. in Atlanta, said Ms. Flower and Dr. Cox. The specimen was set aside because few H1N1 cases were reported last winter, and the centers routinely concentrate on testing the most prevalent strains.
It was not until February that C.D.C. tested the sample, when scientists there found that the virus was not from the H1 group, Dr. Cox said. A subsequent test ruled out another family of flu viruses, Type B. Further testing showed that it was Type A, but not the H1, H3 or H5 subtypes.
Finally, on March 17, scientists using other tests identified the virus as H7N2. The next day, Dr. Cox said, C.D.C. notified health officials in New York that they had a suspect human case of avian flu. To be certain that the sample had not been contaminated in a laboratory, they did further tests.
Doctors asked the patient for another blood sample, to compare antibody levels in it with another sample kept from the initial phase of his illness. Last week, the tests confirmed a recent infection with H7N2, and the C.D.C. alerted state and local officials in a conference call on Friday.
Westchester officials and the state Department of Health have also tested the man's family, co-workers and close contacts - none of whom were sick - without finding evidence that any had also been infected.
C.D.C. officials said the federal agency did not believe that the case represented an imminent threat to public health.
Dr. Cox said C.D.C. reported the case Monday to the World Health Organization, which has repeatedly warned about the threat of avian flu. But a W.H.O. spokesman said that as of 5 p.m. in Geneva, where the agency is based, no such report had been received.

http://www.nytimes.com/2004/04/20/nyregion/20flu.html?ei=5070&en=2ae918bf11e66f81&ex=1209528000&pagewanted=print&position

As we see, misdiagnosis and a lack of comprehensive testing tools contributed to this situation.

All this goes to show that while we stalk H5N1, another influenza or another disease entirely could sneak up on us and bite us in the surveillance read end.  Just a few days ago, that concern was shared to me by Mike Coston (FLA_MEDIC).  And he is right.  H7, as we have seen repeatedly, is usually benign but is ridiculously easy for humans to catch.  And it is not always benign:  As we see in the 2003 Westchester case, the patient was quite ill.  And in 2003, a Netherlands vet was killed by H7N7 that went from an outbreak in poultry to an outbreak in people.

Now why did it take four years to get this data?

One would be hard-pressed to find anyone as tuned in to the avian influenza situation as Florida's Commissioner of Agriculture, Charles Bronson.  A former state senator from the Vero Beach area, Commissioner Bronson was appointed Commissioner of Agriculture and Consumer Services in 2001 after the departure of his immediate predecessor, Bob Crawford, to the Citrus Commission.  He has been re-elected twice by massive margins.

It is easy to understand why.  He absorbs information like a sponge, he makes excellent decisions, and he has not allowed the trappings of his office to change him as a person.  In fact, the last substantive conversation I had with him was in the ice cream aisle of an Albertson's grocery store close to our homes.

It was the next-to-last substantive conversation I had with him -- on the floor of the Florida House -- that really floored me.  It was late April, 2007, and I sat down next to him to talk him up on the topic of bird flu.

It was he who talked me up!  Among the things I learned:

• Bronson hired the top avian influenza vet in the FDA away from them, following that person's work on the Delmarva Peninsula AI outbreak of a few years ago. 
• Bronson told me he wanted the nation's best bird flu vet working for him, because Florida has a significant poultry industry and he did not want to see that industry wiped out by bird flu. 
• That showed great wisdom and a desire to obtain the best minds, regardless of cost.
• Likewise, he began explaining past AI and equine influenza and equine encephalitis problems.  He also spoke about detection efforts and problems with same.  He knows his stuff, this Commissioner.

I was comforted by Bronson's knowledge of the threat and impressed with his methods to move forward to combat it, if and when it comes.  I am truly proud of my friend.

At the left are two charts.  One is the HHS "Wildfowl Flyways of North America" that we are all familiar with. 

Now look at the second chart, "Commercial Poultry in Florida' and see the areas of commonality.  No wonder Bronson wanted the best person he could lure away from the FDA to help with current and future AI efforts in Florida.

Commissioner Bronson takes a down-to-earth approach to things, so it is no surprise his agency's Pandemic Influenza Agriculture Planning Toolkit reflects his approach.  Written in plain, everyday English, this 28-page guide is an easy read.  It also seeks to both educate and urge preparedness without sugar-coating the situation.  This is both welcome and refreshing.  It tells things like they are, or will be.  For example, in the subheading "Vaccines," it mentions flatly that there will either be no vaccine, or vaccine will be in exceedingly short supply.  Likewise, it makes short shrift of antivirals, barely mentioning them other than to say there will be a "limited amount".  Under "Risk Communications," the Toolkit says that "sustaining public confidence over many months will be based on consistency" of the message during a pandemic.  Finally, under "Federal Assistance," the toolkit says there won't be any. 

The guide mentions that essential goods such as food and water, and services such as electricity could be compromised for several days or weeks. It then inserts the HHS panflu checklist for individuals and families, which we all are familiar with.  The guide next gives the HHS business panflu planning checklist.  Note the order of the inserts.  Placing families first, ahead of business concerns, is key to successful management of a pandemic.  I cannot tell you how many panflu plans I have seen (or COOP/DR plans, regardless of event) that fail because they fail to take reality into account.  that reality is that people's concern moves away from the business or corporation or government, and moves correctly into concern for family and the safety of the family.  Once the family is secure and safe, then the consciousness moves back to the workplace. 

Any pandemic plan that fails to take this concern into account will fail miserably.  ExxonMobil knows this, for example.  the ExxonMobil plan is to move entire families to its refineries and give them food, shelter and health care.  This, they recognize, is the only way they can ensure the continued refining of gasoline and other products during a pandemic.  

So the Florida agriculture plan rightly presents the order of concern during a pandemic; families, then the business.

After a page of links to Florida and Federal resources for pandemic information (regrettably, they forgot the Florida CIO Council's superb panflu Website, at bpr.state.fl.us/pandemic), the Toolkit moves into the Things Momma Taught Us:  Proper personal hygiene, covering your cough or sneeze, and keeping a respectable distance from strangers.  The Toolkit uses Red Cross and Florida Department of Health information to offer much more detailed family healthcare tips. These tips include making an electrolyte drink to hydrate victims, and how to reduce fever.  While good for the workplace, they are especially important for caregivers at home.  So the message to take care of family is doubly reinforced.  Seasonal vaccine steps are also encouraged, always important for poultry workers.

Closing out the Toolkit are two poster templates, provided by the Florida Department of Health.  They are good for seasonal flu and should be up in bathrooms and near time clocks all year round.

Things not in the Toolkit, but are covered by other Department of Agriculture and Consumer Services programs, include surveillance and management of poultry.  Bronson is a huge proponent of surveillance and, being a hunter himself, he works with other State agencies to make sure hunters report any suspicious behavior or activity by wildfowl.

This simple, easy-to-understand Toolkit should be printed and kept in a three-ring binder in everyone's home -- in a prominent place, close to medicines and food.  Perhaps Florida will use this guide as its default personal and business guide to send to every family in the state, as other states have done.

You can't get much better than this Toolkit as a starting point for family and business preparedness.