Update: about the swine flu epidemic

Part 2 in a series about the swine flu pandemic, and the evidence that governments have used this as an excuse to claim wide and disturbing new powers.  Other chapters:

(1)  What about all the hype, the extreme warnings, about swine flu?, 3 September 2009.
(3)  Is the Swine Flu pandemic being used to an excuse to expand government powers (UK edition)?, 14 October 2009
(4)  Who to blame for the delay in producing the swine flu vaccine?, 4 November 2009
(5)  More about the swine flu pandemic: about Cassandras, 26 November 2009 


  1. Stratfor’s summary
  2. Recent articles about Swine Flu
  3. Sources of information about Swine Flu
  4. Afterword

(1)  Stratfor:  A(H1N1): Just Another Flu, 14 September 2009 — As always, Stratfor provides an excellent summary.  Excerpt:

It has been five months since the A(H1N1) influenza virus — aka the swine flu — climbed to the top of the global media heap, and with the start of the Northern Hemisphere’s annual flu season just around the corner, the topic is worth revisiting.

If you take only one fact away from this analysis, take this: The U.S. Centers for Disease Control and Prevention (CDC) believes that hospitalization rates and mortality rates for A(H1N1) are similar to or lower than they are for more traditional influenza strains. And if you take two facts away, consider this as well: Influenza data are incomplete at best and rarely cross-comparable, so any assertions of the likelihood of mass deaths are little more than scaremongering bereft of any real analysis or, more important, any actual evidence.

Now to the details. …

So, while the flu will pose a significant logistical and public relations challenge to governments seeking to prevent outbreaks and control the virus’ spread, there is no indication that A(H1N1) will cause even a shadow of the disruption that the hysteria of months past suggested.

… More infections and deaths are sure to follow — as winter sets in, the rate will increase. And there is always the chance that A(H1N1) will mutate into a more deadly strain — in fact, this is precisely what occurred with the 1918 Spanish influenza virus. But, at present, neither the WHO nor the CDC appears to suspect that A(H1N1) is any more deadly than any other seasonal flu.

The critical factor to bear in mind is that all strains of influenza claim thousands of lives every year. In the United States, on average, some 36,000 people die of flu every year – 1,100 in New York alone. Globally, deaths related to influenza are estimated to range from 250,000 to 500,000 people per year. So far this year, only about 3,000 people have died worldwide in relation to the A(H1N1) outbreak, and most of those deaths occurred during the flu season in the Southern Hemisphere. From a statistical perspective, at present, A(H1N1) nearly falls into the range of background noise.

(2)  Recent articles about swine flu

(3)  Sources of information about the Swine flu

(a)  From the Centers for Disease Control

(b)  From the World Health Organization information about Pandemic (H1N1) 2009

 (c)  The US government’s site:  FLU.gov.

(4)  Afterword

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14 thoughts on “Update: about the swine flu epidemic”

  1. FM, I would recommend two pieces to you from the Public Health blog Effect Measure:

    * Making Sense of the “Flu Season”, by “Revere”, 27 September 2009.
    * More Crappy Journalism, by “Revere”, 26 September 2009.

    The first is a link to short post explaining how one should and should not interpret flue data sets. It is quite accessible to anyone who knows the definition of “standard deviation”, and should be required reading for those wishing to sound intelligent in discussions on the subject.

    The second post is a response to an article written by a Mr. Holland for Alternet. One of the criticisms Revere holds up against Holland is quite applicable to the Stratfor analysts as well:

    The trouble is, Holland doesn’t understand that influenza — not this influenza particularly, but all influenza — is a serious public health problem. And he doesn’t understand that this is a pandemic strain and isn’t the same as seasonal influenza. That’s not because of the “statistics” he cites about how many people have died of it; or how it compares to lightning strike risks (a fatuous technique beloved of wingnuts trying to trivialize whatever their paymasters find inconvenient); or that more people die of seasonal influenza (we don’t even know how many people that is, but if this isn’t any different than seasonal influenza and it’s the only flu A strain out there, then presumably hardly anyone will die of flu this year according to Holland’s “statistical context”); or that more people die of malaria (so we shouldn’t worry about the ones that get polio?).

    The problem is not the virulence of this virus (all influenza viruses are potentially virulent for certain people) but its epidemiology. It’s a pandemic strain, which means it is infecting a much different population (the very young, and adults through middle age), making more of them sicker, continuing to circulate at unprecedentedly high levels during times of year when flu is almost absent, and confronting an extremely brittle and unprepared medical care system especially vulnerable to just this kind of virus.

    Fabius Maximus replies: Thank you for posting these. I know little of these things, and don’t see how Revere’s critique applies to the Stratfor analysis. Stratfor does not deny that influenza is a “serious health problem”, merely that this strain does not appear to be substantially more serious — given all the factors Revere notes in the last paragraph.

  2. Burke G Sheppard

    Correct me if I’m wrong, but I seem to recall another swine flu scare many years ago, and everyone was urged to get vaccinated because this was going to be a horrible epidemic. In the end, the whole thing petty much fizzled out, except that a number of people died from the vaccine.

  3. The global and national reaction to the H1N1 swine flu is both overbown and justified, for these reasons:

    NIAID (National Institutes of Allergy and Infectious Disease) director and renowned medical researcher Anthony Fauci, M.D., calls the 1918 influenza pandemic which gave rise to the H1N1 family of influenzas, a “viral dynasty.” That is, the current virus is directly related to and derived from the 1918 agent, which is estimated to have killed 50-100 million people worldwide (precise totals are not known) over approximately two years. Given this link, a certain degree of fear is understandable, perhaps even logical. Moreover, the H1N1 virus type is not merely any virus, but a sort of super virus, whose evolved characterisitics suit it ideally to trasmission and reproduction in the modern technological world.

    The molecules that mark the surface of a virus, that allow it to engage and infect host cells, are antigens. These molecules, usually proteins or glycoproteins, are also what the human immune system uses to recognize an invader, produce specific antibodies to it, and destroy or neutralize it. The degree to which these antigens change is described by virologists/molecular biologists as “antigenic drift” or “antigenic shift,” the former a slower rate of change, the latter a radical and rapid shift. Something like the measles virus is antigenically stable; its surface markers change slowly. Once the immune system has “seen it” via an episode of illness (naturally acquired immunity) or vaccination (artifically acquired immunity), antibodies to subsequent exposures remain effective in warding off the virus. H1N1, on the other hand, is highly unstable antigenically, constantly mutating into new strains, making development of an effective vaccine problematical. Since antibodies to viruses are very specific, a new variant most likely cannot be fought effectively by pre-existing antibodies. The immune system has to gear up for and make ABs specific to the new viral structure, which is time-consuming, and may not occur quickly enough to save the patient from a fast-moving infection or secondary illness such as bacterial pneumonia. H1N1 is also transmissible by aerosol or droplet, and can be spread via coughing, sneezing, or fomite/inanimate object (i.e., on a doorknob after someone has wiped their nose with their hand). The influenza virus that killed millions struck not only the very young and old, but those in the prime of life. This is atypical, because those with healthy immune systems usually ward off infection better. However, H1N1 kills in part by provoking a strong immune and infammatory response; the victim dies not only due to the infection itself, but to the body’s reaction to it. The more robust the immune system (as in a young and healthy person), the more pronounced this reaction, which today might be called ARDS – acute respiratory distress syndrome. Today, supportive care would include corticosteroids to reduce inflammation, a treatment which was unavailable in 1918, and much else. These and other characteristics make the H1N1 virus especially difficult to beat, and the best minds in medicine and science have not yet unlocked the puzzle of how to comprehensively defeat the influenza virus.

    For these reasons, H1N1 is not to be taken lightly. However, there is good news: Viruses are parasites, and a too-successful parasite that kills off too many hosts, ceases to exist itself. Thus, successful viruses often start off as lethal, spreading very rapidly and killing many hosts in a population whose immune systems are naive to it, but then becoming less deadly over time and subsequent epidemics. Some become chronic illnesses, which rarely kill. Will influenza A follow this pattern? The evidence is still out, but some researchers believe it is doing so. The 1976 outbreak at Ft. Dix, N.J., to name one example, was not nearly as lethal as the 1918 variant. Finally, we have some effective/partly effective anti-viral agents available now, that did not exist in the early 20th century, i.e. oseltamivir (Tamiflu) or zanamivir (Relenza).

    The media, as usual, are providing more heat than light on this issue, fanning people’s worst fears to sell a story. The potential of swine flu to kill is there, but so far the current outbreak is many orders of magnitude less deadly than the 1918 variant. Recall also that public health authorities are far better equipped to handle a crisis, should one occur, than their counterparts in 1918. And even in 1918, surprisingly advanced measures were taken. Interested readers may wish to get John Barry’s “The Great Influenza,” a very well-done history of the 1918-1919 pandemic, for more details of how an earlier generation responded to the virus.
    Fabius Maximus replies: Thank you for this detailed analysis!

  4. On the Naked Scientist BBC Uk radio program last week , spoke a research doc who had read up on the 1918 flu outbreak .
    She reckoned many of the deaths were ascribed to ” pneumonia , fluid on the lungs “.
    At the time , aspirin was quite a new drug and proving useful and versatile .Many docs started using aspirin as a treatment for flu .Presumably then as now , young people would be enthusiastic about new things and older people more sceptical . Working on the assumption that if a little does you good , a lot does you a lot more good , docs prescribed huge doses of aspirin .
    One result of aspirin poisoning , can be fluid on the lungs .

  5. FM – I apologize. It was not my intent to come across as patronizing or condescending. I am nor more an expert on epidemiology than you are — which is why I find these resources so valuable.

    How should Revere’s criticism be applied to Stratfor’s analysis? Stratfor focuses on the virus’ virulence. What matters is the virus’ epidemiology.

    What do I mean by this? Consider a few known aspects of H1N1. Approx. 9% of all Americans who enter a hospital with H1N1 leave through the morgue. H1N1 targets a demographic younger than is seen by most traditional flu strains. Like all influenza, the swine flu’s geographic distribution is erratic, hitting some regions very hard while not touching other at all. Finally, the proportion of H1N1 carriers who are sent to Intensive Care Units (ICUs) upon reaching the hospital is much larger that the same proportion of those with traditional flu.

    Taken together, these aspects of the H1N1 strain point to many a city’s health infrastructure being overwhelmed by swine flu. Most hospital’s ICUs are overcrowded as it is; a large influx from a demographic group that has been herewith too healthy to make much use of intensive care would place hospitals on the breaking point. Influenza’s tendency to swamp a region for a season would only make this problem worse.

    So are we facing the next black plague? Of course not. This is not even a new 1918. Something on the scale 1957 is most likely — no end of the world, no massive pandemic, but a large disruption in the regions hardest hit by the flu.

    The scale of these disruptions is not clear yet. Data coming out from New Zealand seems to suggest that the uptick in critical care cases was manageable and small. In contrast, data coming from New Catalonia and Mauritius seems to suggest the opposite. More time will be needed to sort these contradictions in the data out. (By the time that has happened, I imagine we will be in the flu season full swing here, and this discussion will be largely academic.)
    Fabius Maximus replies: Again, thank you for these comments. Both provide precise and useful information. I do not consider them in any way patronizing or condescending (which would, even if true, not bother me). These are important issues, ones with which most of us (including me) have little knowledge.

  6. Quick update for those following this issue: I wrote “The influenza virus that killed millions struck not only the very young and old, but those in the prime of life.” Today, the Chicago Tribune reported the death yesterday of a 14-year old teenaged girl from H1N1, in west suburban Chicago.
    Fabius Maximus replies: Correct, but this is a widely known and undisputed factoid. Stratfor said it, the various global and national health agencies said it, etc.

  7. Update: I strongly recommend reading this article about the swine flu vaccine!

    Does the Vaccine Matter?“, Shannon Brownlee and Jeanne Lenzer, The Atlantic, November 2009 — Summary:

    Whether this season’s swine flu turns out to be deadly or mild, most experts agree that it’s only a matter of time before we’re hit by a truly devastating flu pandemic — one that might kill more people worldwide than have died of the plague and aids combined. In the U.S., the main lines of defense are pharmaceutical — vaccines and antiviral drugs to limit the spread of flu and prevent people from dying from it. Yet now some flu experts are challenging the medical orthodoxy and arguing that for those most in need of protection, flu shots and antiviral drugs may provide little to none. So where does that leave us if a bad pandemic strikes?

  8. I have a more optimistic view about this … and is that a first for me? It was a good trial run, it woke people up, systems were tested (and many failed around the World), changes (hopefully) have been or are being put in place.

    Because it is inevitable that we will one day be hit by something pretty or even (with a lower probability) very bad. To beat it will require individual countries acting quickly and effectively and lots of international cooperation.

    Can we handle something really bad (such as a 1919/20 swine flu) with minimum deaths and minimum disruption to our economies, etc? Potentialy yes.

    If this outbreak moved us a bit further down that route then I’m glad it happened. The last thing we need right now is a mass panic and total disruption of life, a calm, cool but coordinated and very quick response is the key.

    Because it is just a matter of time before something like that happens (hopefully a very, very long time in the future).
    Fabius Maximus replies: That’s a great point! But only if Brownless’s article in the Atlantic is incorrect. If she’s correct, then we’ll have learned the wrong lessons. I strongly recommend reading it.

  9. Update:US, Other Nations Stop Counting Pandemic Flu Cases“, AP, 9 October 2009 — Excerpt:

    U.S. health officials have lost track of how many illnesses and deaths have been caused by the first global flu epidemic in 40 years. And they did it on purpose.

    Government doctors stopped counting swine flu cases in July, when they estimated more than 1 million were infected in this country. The number of deaths has been sitting at more than 600 since early September. Health officials had previously counted lab-confirmed cases, though the tally was skewed because many people who got sick never were tested.

    Other nations have stopped relying on lab-confirmed cases, too, and health officials say the current monitoring system is adequate. But not having specific, accurate counts of swine flu means the government doesn’t have a clear picture of how hard the infection is hitting some groups of people, said Andrew Pekosz, a flu expert at Johns Hopkins University.

  10. Update: let the hysteria begin!

    (1) “CDC shocker: Swine Flu killing young people at surprising rate“, Charles Simmins, Examiner.com, 20 October 2009 — Hat tip to the Instapundit. Opening:

    The Centers for Disease Control (CDC) have confirmed what public health officials have been saying for some time. The Swine Flu, pandemic H1N1, is unusually deadly for young people in the United States.

    How can it be a “surprising rate” if it is what “public health officials have been saying for some time? The author links to 2 reports, neither of which seems shocking.

    (2) “Weekly 2009 H1N1 Flu Media Briefing“, CDC, 20 October 2009 — Excerpt:

    So what I want to talk about today is the age of people who are hospitalized or dying from the 2009 H1N1 virus this fall from September 1st through October 10th. We have data now from 27 states that are reporting hospitalization information on lab-confirmed cases. This is a set of about 4,958 hospitalizations that we’ve seen in those states just since September 1st. More than half of the hospitalizations are owe occurring in young people under the age of 25. We are seeing 53% in people under 25 years of age. 39% of hospitalizations are in people 25 to 64 years of age. And only 7% of hospitalizations are occurring in the elderly. This is really, really different from what we see with seasonal flu.


    The 2009-2010 influenza season officially started on October 4, 2009. Table 3 below represents H1N1 cases that have been confirmed in MA since October 4, 2009; the final column of this table is the number of cases of seasonal and influenza of unknown type, also since October 4. Table 4 shows the cumulative H1N1 cases that have been confirmed in MA since April 26, 2009. Both tables are updated weekly. It is important to note that the vast majority of persons with influenza-like illness are not tested. Of those that are tested, only a small percentage of tests are subtyped to determine whether they have H1N1 or another type of seasonal influenza. At this point in the season, most of the cases in the “seasonal and unsubtyped” column are likely H1N1.

    The Centers for Disease Control and Prevention (CDC) is no longer reporting the national total of confirmed cases of H1N1 and is instead focusing on hospitalized cases and deaths. Nationally, influenza-like illness (ILI) continues to increase with widespread activity reported by states in all regions. Please visit the CDC’s website for up-to-date information (www.cdc.gov/h1n1).

  11. MediaCurves.com conducted a study among 572 physicians regarding their concerns about the H1N1 swine flu. Results found physicians’ level of concern regarding a potential H1N1 flu pandemic is the highest since initial reports of the virus in April. With regard to the government preparedness in responding to a potential H1N1 epidemic, physicians rated preparedness the lowest since initial reports of the H1N1 virus in April. More in depth results can be seen at: “Docs’ Level Concern over Potential H1N1 Flu Pandemic Reaches New High“, Mediacurves, 25 October 2009.
    FM Note: Thanks for posting this! While accurate, the headline is a bit misleading. The question was:

    Please indicate your level of concern regarding the degree of the impact that the H1N1 swine flu epidemic will have on you and your family. Use a scale from 1 to 7, where 1 indicates “Not At All Concerned” and 7 indicates “Extremely Concerned.”

    The score was 4.4 in week one (Aprl 27) of the survey, declining to 3.5 in June 10, then rising to the current 4.5. How significant is this near-zero change over 11 weeks? To what degree does it reflect media frenzy rather than actual medical facts?

  12. Lessons we should learn from the swine flu pandemic, update

    We don’t learn because the initial misinformation is news, but the latter corrections are not news. We don’t wait for the detailed analysis, then do a lessons learned. This might be a fatal flaw in the 21st century.

    Here is an excellent analysis, well worth reading: “Flu Warning: Beware the Drug Companies!“, Helen Epstein, blog of the New York Review of Books, 12 May 2011

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