UN health official: Flu could kill up to 100 million

Will avian flu become pandemic?
It's hard to say, but it very well might.
With vaccines not working, we now must fight
For quarantines and methods systemic.
But what we have learned from performance past
Is that funds don't appear 'til die are cast.
--Ross Silverman of The Public Health Press

The editor of Effect Measure offers some sobering commentary and a good roundup of flu-talk in the blogosphere.

The mainstream media don't seem to be taking the pandemic as seriously as one might hope, given that the potential death toll could exceed that of the holocaust. This story was relegated to somewhere in the middle of the NYT Health section.

As a rule, I pay close attention to stories that include the phrase "The W.H.O. does not want to scare the planet, but..."

U.N. Health Official Foresees Tens of Millions Dying in a Global Flu

November 29, 2004
By KEITH BRADSHER
and LAWRENCE K. ALTMAN
HONG KONG, Nov. 29 - A pandemic of human influenza could kill up to 100 million people around the world, a World Health Organization official said today, significantly raising the agency's earlier estimates of the number of deaths in such a catastrophe.

W.H.O., a United Nations agency based in Geneva, has been warning about the potential for the A(H5N1) strain of avian influenza virus (known popularly as bird flu), which has spread widely through Southeast Asia to mutate and cause the next pandemic.

Governments should be prepared to close schools, office buildings and factories to slow the rate of new infections if a pandemic strikes, and should work out emergency staffing arrangements to prevent a breakdown in basic public services like electricity and transportation, W.H.O.'s regional director for Asia and the Pacific, Dr. Shigeru Omi, said.

Such arrangements may be needed if the disease infects 25 to 30 percent of the world's population, Dr. Omi said in a speech and news conference. That is the W.H.O.'s current estimate for what could happen if the disease - currently found mainly in chickens, ducks and other birds - develops the ability to spread easily from person to person.

The death toll associated with the rapid spread of a new form of human influenza would be high, Dr. Omi said. While W.H.O. has previously said that the death toll would be 2 million to 7 million people, Dr. Omi said the toll "may be more - 20 million or 50 million, or in the worst case, 100" million.

And Dr. Omi said that in his opinion a global pandemic of influenza was "very, very likely" now.

And Dr. Omi said that in his opinion a global pandemic of influenza was "very, very likely" now.

Reached later, W.H.O. officials in Geneva said they had not received an advance copy of Dr. Omi's remarks and did not know the basis for his estimates and why he believed a pandemic was imminent.

W.H.O. has expressed concern that the avian strain has become a more dangerous threat as it has jumped species. But Dr. Omi's estimates are not based on any new scientific information about the virus's ability to cause human disease or ways to assess the odds that the virus will become readily transmissible among people.

In sounding the alarm about avian influenza, "W.H.O. is trying to raise concern because we're concerned, but W.H.O. is not trying to scare the planet," a spokesman for the agency, Dick Thompson, said in a telephone interview.

"No one knows how many are likely to die in the next human influenza pandemic", even when it will occur, Dr. Klaus Stöhr, W.H.O.'s top influenza expert, said. "The numbers are all over the place."

W.H.O. is using different historical, mathematical and demographic models to better estimate the number of people who might become ill and die in the next pandemic, Dr. Stöhr said. Such reports are expected to be available by next week.

Dr. Malik Peiris, a top influenza researcher at Hong Kong University, said that Dr. Omi's range of possible death tolls was realistic and consistent with current research into the A(H5N1) avian influenza virus. The biggest questions, Dr. Peiris said, are whether the disease will develop the ability to spread easily from person to person and, if it does so, whether it will retain its current deadliness.

"H5N1 in its present form has a pretty lethal effect on humans," he said.

A few analysts have suggested that the death toll could be considerably higher. Henry L. Niman, a medical researcher in Pittsburgh, who tends toward gloomy predictions and is a strong critic of W.H.O. for being too conservative, said that with more than 70 percent of the human victims of the disease dying so far, the death toll could in theory exceed a billion people if the disease were to spread rapidly among people with little if any reduction in current mortality rates.

"That estimate is unscientific unjustified, and an inaccurate extrapolation from the current situation," Dr. Stöhr, the W.H.O. expert, said.

W.H.O. has reported 44 confirmed human cases of A(H5N1), all in Thailand and Vietnam, and 32 of the patients, or 72.7 percent, have died. W.H.O. has identified only one case of probable human-to-human transmission, a Thai mother who cradled her dying daughter all night, while the rest of the cases appear to have been acquired directly from animals.

Dr. Stöhr, Dr. Omi and Dr. Peiris each said that the high death rate recorded for human A(H5N1) infection so far might be overstated, because people with less severe cases of the disease might not be diagnosed as having it at all.

Virologists have been struggling to determine how and whether the disease might develop the ability to spread easily from person to person through the air the same way human influenza viruses do. Dr. Omi said that for several reasons, it was becoming more and more likely that the virus would develop the ability to spread among people.

The virus has proved highly versatile in mixing genetic material with other viruses, he said. The disease has recently evolved the ability to survive in domesticated ducks and be excreted in large quantities without making the ducks sick, making it hard for farmers and veterinarians to know which birds to cull. And the world has gone an unusually long time since the last influenza pandemic, the relatively mild Hong Kong flu pandemic in 1968.

No significant quantities of vaccine for disease caused by A(H5N1) are likely to be available until five or six months after the virus becomes a pandemic, Dr. Omi said. The virus is constantly evolving, and vaccine manufacturers will not want to commit themselves to large-scale production now of a vaccine that may prove worthless if the virus evolves further before starting a pandemic, he said.

Even when a vaccine does go into mass production, pharmaceutical companies have the capacity to make enough vaccine only for a small percentage of the world's population. "Some people say if we develop a vaccine, that can avert a pandemic - that is not the case at all," Dr. Omi said.

"W.H.O. has never said that a vaccine would avert an influenza pandemic," Mr. Thompson said. But, he added, "it would be irresponsible not to try to develop a vaccine against a pandemic strain of human influenza virus" because such a vaccine would reduce the severity of illness and "hopefully save lives and perhaps slow any pandemic."

At W.H.O.'s urging, a small but growing number of governments are starting to make contingency plans for a pandemic. The United States unveiled its plan earlier this autumn, but that plan said that further study would be needed on how to address difficult questions like how to allocate scarce medical supplies during any crisis.

The secretary of health, welfare and food in Hong Kong, Dr. York Chow, said in a radio interview there this morning, before Dr. Omi spoke at lunchtime, that in December the Hong Kong government would announce its plans for preventing the spread of avian influenza in local poultry and to respond to any possible outbreak among people.

Comments

[Jay]

Not to sound complacent, but there's nothing in the article to suggest that the situation is more dire this year than next, and Lindsay, there is *always* a chance that a flu virus can mutate to something 1918-like.

I remember having a conversation with a public health official in 1995 about just this issue. I asked her why there hasn't been a pandemic like the 1918 one and she said: "luck." It was just a particularly deadly virus.

So, while concern is always warranted, and we've always got to do what we can, this is not exactly *news." I'd file the information just where the Times did: the red pending folder, but not on the front page.

BTW, a slight nit: comparing natural disasters with human-made ones ("the holocaust"--which one, by the way, there have been many...) doesn't sit well with me.

[Lindsay Beyerstein]

Why shouldn't we compare numbers of deaths from epidemics to numbers of human-caused deaths? It's a simple fact that a death toll of 100 million in a single flu season would be larger than the death toll of Hitler's genocide.

Let's think proportionately. It's just luck as to weather avian flu breaks out this year or next year, or the year after. But it is a statistical certainty that it will happen. Random mutations and human proximity to domestic foul are facts of life.

An unusually deadly strain has been identified this year, the H5N1, a strain which has already killed several dozen people who caught it from birds and at least one person who got it from prolonged personal contact with an infected human.

Add to that the fact that there's a lot we can do to reduce the death toll when the flu breaks out. The evidence suggests that the US is not mobilizing effectively to prepare itself, nor are most other countries.

The sooner the world gets its act together, the better off we'll be. Plans will be honed. Personnel will be trained. Vaccines will be developed and stockpiled. Even if the avian flu doesn't become pandemic for 5 years or 15 years, now is the best time to get serious about prevention.

It makes me angry that theoretical risks terrorism capture the public imagination, but people won't take the grim certainty of the flu equally seriously.

[Ray]

I almost agree with you on the Holocaust comparison, in that a deliberate avoidance of prevention can be an immoral act, especially if it's foreseen that certain populations will be (attractively) more vulnerable than others (by the way, how is that HIV/AIDS research/prevention coming?).

Still, with the kind of numbers we've seen, the Holocaust isn't enough, it isn't a large enough crime. How many people died directly or indirectly, because of the Second War? Probably fifty million. That's what we're talking about, isn't it? Not just its central evil, but the War itself? Especially because, not the deaths, but the dying of tens of millions people is what would confront us.

But, then, I doubt it'll happen, anyway.

[Lindsay Beyerstein]

I'm not saying that failure to minimize the impact of the flu is morally equivalent to genocide. I'm just trying to underscore the scale of preventable death we're talking about.

I read last week that there are 40 million HIV-positive people in the world today. The situation is rightly regarded as a global medical and moral emergency. I just wish the world would give similar consideration to the flu--given the number of lives at stake and the relatively low cost per life saved.

[quisp]

It's remarkable how one death does not always equal one death. People attach extra emotional significance to certain ones, and dismiss others utterly. The day the Challenger blew up, there was a car crash out here in CA where a whole family died. Reaction to Challenger: tragedy of historic proportions; reaction to family dying: whatever. Hey, hundreds of thousands of people die from smoking every year (we have a nice billboard in Santa Monica that keeps a running tally). These deaths are preventable. So what? It's not exciting. It doesn't tap the collective whatever like Nazis. People get upset like nobody's business when you compare something to the Holocaust, but Dafur? Nah, too busy. Starvation in Africa? ibid. Drunk driving? blah blah blah. People prefer to be upset about tragedies in the past about which they can do nothing, rather than apply themselves to averting potential future tragedies.

My favorite running example of the All Deaths Not Created Equal principle: any foriegn plane-crash or other natural disaster (or for that matter, tallies of Iraq war dead). "All 250 passengers on board are believed dead. [But, don't worry,] No Americans on board.[!]" That's a relief! No Americans! Nothing bad happened to people like me? Good. [wipe brow]

[Mary R]

One thing to keep in mind about the 1918 epidemic is that it hit during the final year of WWI. There were men in the trenchs, large numbers of factory workers living away from home in dormatories, masses of refugees. Civilian population largely malnourish with no sick time allowed workers during the war.

Excellent conditions for an epidemic, ones that are not matched now.

Not to belittle the current viruses, far from it, honesty demands that the 1918 situation be explained when talking about its death tolls. (And it's another good way of reminding people of the horrors of The Great War.)

[Ray]

Well; if some family should crash their car in Space, yeah, I'm sure it will make the news.

But pointing out that not all deaths are equal seems a particularly disingenous and sanctimonious exercise. What's the practical consequence here?

I went to calling hours last night for the father of an old friend. He died after a long illness. Neither you, nor the citizens of any foreign nation sent flowers. What are you telling me?

Yes; a beautiful young person who dies in a hail of gunfire fighting stormtroopers dies more interestingly than grandma does of an aneurysm. And Pakistan did not hold a day of mourning for those drowned Haitians. Is there really some dark essential Human Truth in that? Or, anyway, something we didn't already know?

Terrorism is just way cooler than the flu--there's no getting around it.

Plus, you're mixing inequivalencies: on the one hand, there's boring vs. interesting deaths (not going to change); on the other, a response to death proportionate to the importance to us of those who died (often reasonable).

You do have a point in saying that people don't pay attention to potential future tragedies (or certain current ones), but the kind of prevention that prevents smoking death and the kind that could prevent deaths from terrorism or the flu simply have nothing to do with each other.

Of course no one cares about smoking deaths (my friend's father was one); no one should: these days, there's nothing we don't know about cigarettes; it's personal responsibility, and that's it.

But personal choice doesn't play as much of a role in fluing one's way into the Great Beyond. The two kinds of death don't carry the same meaning, and we respond to them differently.

Does this mean that we'll move to prevent a pandemic of this asian flu? Of course not! But that's largely due to the fact that those most able to respond to such an impending crisis couldn't care less about those most vulnerable to it. In other words, mostly, third-worlders will die. The inequivalency, then, isn't in the deaths, not in the way people die, but in the injustice that these deaths have no importance for those who could help to prevent them.

[Lindsay Beyerstein]

One thing to keep in mind about the 1918 epidemic is that it hit during the final year of WWI. There were men in the trenchs, large numbers of factory workers living away from home in dormatories, masses of refugees. Civilian population largely malnourish with no sick time allowed workers during the war.

True. We're very fortunate in the developed world. But the world's population is larger and more urbanized today. I wouldn't be surprised if there turned out to be a greater absolute number of vulnerable people today than there were in 1918. Think what might happen if influenza ripped through Sudanese refugee camps, the slums of Calcutta, the shantytowns of Mexico city, etc.

[revere]

No one knows if "this will be the year of the dreaded pandemic" just as no one knows if this will be the year "of the Big One" in California. However in California they worry about it, adjust their building codes and plan ahead, because if it happens, it will be even worse than watching a Hollywood disaster epic (I said watching one, not recreating one). The main issue here is this: it is highly plausible, given everything we know about the epidemiology and molecular biology of influenza A viruses and the current incubator region of South Asia where many humans live in close proximity to fowl and pigs. thus it is foreseeable. Foreseeability of even a low probability high consequence event carries with it substantial responsibility (think nuclear power plant). Now ask yourself if our public health officials are meeting or able to meet that responsibility (where "able to meet" here is meant to encompass political issues). Consider that we just spent $877.5 million for a contract to produce 75 million doses of anthrax vaccine, a non-contagious disease. Meanwhile the 80 plus year old mother of my colleague in Florida can't get a flu shot.

[quisp]

"If some family should crash their car in Space, yeah, I'm sure it will make the news."

The issue is not whether or not the Challenger explosion is news. Certainly, it's a huge news story and it's very sad, not to mention infuriating once all of the ignored warnings are revealed (etc.). But I remember that day very clearly: people at work watching the TV and hugging each other, heaving sobs, etc.. And, p.s., the folks in the car accident the same day? Mexicans. It's neither disingenuous nor sanctimonious to point out the disparity. In fact, it's sanctimonious to pretend that the disparity has no practical consequence. For example, as a matter of practicality -- by which I mean in terms of the actual number of human lives you would save -- it would be better if people got genuinely worked up to the point of activism with regard to highway safety, rather than getting worked up over the interesting (in fact, spectacular) deaths of the Challenger crew.

"I went to calling hours last night for the father of an old friend. He died after a long illness. Neither you, nor the citizens of any foreign nation sent flowers. What are you telling me?"

I also didn't put an American Flag on my car after 9/11. As to your friend's father, what I am telling you is it would be nice if we responded to people's lives as if they deserved respect apart from their entertainment value, sensational accompanying video, etc..

"Is there really some dark essential Human Truth [at work]."

I don't think I'm pointing out anything "dark," although I don't think anything good (or as you might say, Good) can come from people responding to public events as though they were TV shows. The advantage of ostentatious public displays of grief over the Challenger explosion is, of course, catharsis. I cry, I wipe my eyes, I feel better, I have had to do nothing, and of course nothing has changed (c.f. if I were to focus my grief on something actionable, sooner or later I might be expected to do something about it).

"Terrorism is just way cooler than the flu--there's no getting around it."

We agree. And I would add that one of the reasons it's so much cooler is that the chance of you dying in a terrorist attack is about zero. Also, it usually involves explosions, which are very cool. In movies.

"Plus, you're mixing inequivalencies: on the one hand, there's boring vs. interesting deaths (not going to change)"

well, in fiction, I insist on interesting deaths; in real life, each person's death is of equal value. It is, in fact, the blurring of the lines between fiction and reality that is the heart of this matter for me. Some people (not all people; but maybe most people raised on television or by television) respond to the "news" as though it were a movie or TV show; in that light, the boring death is just a big fat dud.

" ...on the other, a response to death proportionate to the importance to us of those who died (often reasonable)."

I will reread what I posted, but I didn't think I made any reference to actually knowing any of these hypothetical dead people. No question we care more about the deaths of people we know or love. I was thinking only about our reactions to what happens "out there" in the world.

Re smoking deaths vs. flu deaths: you say "the two kinds of death don't carry the same meaning" because one is personal choice and the other is not. First of all, I more or less agree with you. Second of all, here's the more and the less: (1) I don't think the line is as clean as that. Smoking is not just personal choice; i'll leave aside for now the fact that it's an addiction and therefore arguably not a choice at all; it affects the family of the smoker; it affects the health care system, my premiums, etc.; and who do you think is going to be dying first from this flu? Also, there's a corporate interest in who smokes, just as there is in who gets flu vaccine.

(2) one of the prejudices we apply to news of death is, it's always better if they died because of something they did, as opposed to a random act of violence, say. "He smoked, so he got what he deserved. If I don't smoke I won't die that way. Cross it off the list." A version of the same process applies to the flu concerns, as you point out: "those most able to respond to such an impending crisis couldn't care less about those most vulnerable to it. In other words, mostly, third-worlders will die." Another version of this is the Pope's annual reminder that AIDS is spread by weak morals. All versions of "hey, it's not me, man."

Thirty years ago, Meathead (a liberal, for those of you under 30) complained to his father-in-law Archie Bunker about the number of people killed every day with handguns. Archie's response: "You'd be happier if they was pushed out of windows?"

[Ray]

"in real life, each person's death is of equal value"

No; clearly, the opposite is true. You think this is wrong and that things should be different. But it's still the case that, in real life, according to the way people actually respond to death, no, each person's death is not of equal value.

It would be a happy thing if this changed to some extent, though for this to happen we'd have to present a reasonable case.

When it comes to smoking and driving and their like, there's no argument: everybody understands that we willingly massacre ourselves with these practices and in an ordinary way. There's simply no contest between risking one's ass by taking a ride on a huge rocket and motoring down to the grocery store. Race has nothing to do with spaceships beating cars.

What you're saying about how people respond to various forms of biting it, based on whether they expect to participate in them is true--and it's perfectly unreasonable to expect that this can be any basis for ethical change in areas where we've already made our choices.

First, who can say to a smoker, 'hey dude, you're raising my health care premiums' and expect to be taken seriously?

Second, if our killing ourselves through smoking or driving has such terrible consequences for us all, why not outlaw them completely? Well, no, we'll have to find some happy medium between convenience and totally gross death.

Of course, that's what we've already done. Evidence: deaths by automobile accident and smoking don't mean that much to us. You'd like to lower our tolerance, I guess? Pull a cause out of a car wreck, along with the mangled flesh? Fine. But impugning indifference won't do it--not without a more general critique of the benefits that weigh against car wrecks.

Not the same case for the flu. 100 million deaths, mostly in the third world, would constitute a catastrophe--and one that we have not already agreed to.

But there are still a great number of resistances to acting now in order to prevent such a disaster: it seems irreal; it seems unlikely; it doesn't seem that it would greatly harm those who could mitigate it.

Give people evidence that it will happen and that it will devastate the first world--there's the way forward. A generalized lament about how people deal with death has no meaning.

[quisp]

>"No; clearly, the opposite is true...according to the way people actually respond to death, no, each person's death is not of equal value."

I guess I'm not making myself clear. Maybe I should have said, "I believe, in real life, one kind of death is not more valuable or important than another." Like the old joke, "which weighs more, 100 lbs of feathers or 100 lbs of lead?

>"When it comes to smoking and driving and their like, there's no argument: everybody understands that we willingly massacre ourselves with these practices and in an ordinary way."

You say there's no argument, but that doesn't make it so.

>"it's perfectly unreasonable to expect that this can be any basis for ethical change in areas where we've already made our choices."

Tautology.

>"First, who can say to a smoker, 'hey dude, you're raising my health care premiums' and expect to be taken seriously?"

Straw man who makes idiotic statements kinda sorta like what I said.

>"if our killing ourselves through smoking or driving has such terrible consequences for us all, why not outlaw them completely?"

See Baby/Bathwater Dichotomy.

>"Evidence: deaths by automobile accident and smoking don't mean that much to us. You'd like to lower our tolerance, I guess?"

See Daffy Duck, "pronoun trouble."

>"A generalized lament about how people deal with death has no meaning."

If my grandma had wheels she'd be a wagon. And there is a difference between meaning you don't like -- or meaning you can't be bothered to attend to -- and no meaning.

[Andrew Spark]

The limited access to medical facilities and reliance on the service of health planner are mainly responsible for this situation.

[Thomas]

The distinction between phase 1 and phase 2 is based on the risk of human infection or disease resulting from circulating strains in animals. The distinction is based on various factors and their relative importance according to current scientific knowledge. Factors may include pathogenicity in animals and humans, occurrence in domesticated animals and livestock or only in wildlife, whether the virus is enzootic or epizootic, geographically localized or widespread, and/or other scientific parameters.

The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include rate of transmission, geographical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain), and/or other scientific parameters.

The pandemic stage 6 may be marked by two or more waves. For example, the initial wave of the Spanish Influenza pandemic in the spring of 1918 was so mild in its effects that it received the dismissive nickname of the "three day flu." But when the second wave hit North America a few months later in the summer of 1918, it was lethal. Apparently in the interim the novel H1N1 pandemic strain had added the gene or genes that made the final wave a killer. Perhaps the effects of the lethal second wave would have been even more devastating if the innocuous first wave had not already passed through the population, leaving in its wake at least some immune response to the surface antigens presented by the H1N1 in both waves.

CIDRAP provides a thoroughgoing overview, which has its roots in materials from the U.S. HHS National Vaccine Program Office. CIDRAP's overview originally set forth a model listing five numbered stages for the pandemic itself, preceded by four additional pre-pandemic stages, each numbered as zero, that overlapped the WHO's first five stages of a pandemic. CIDRAP's overview has since adopted the WHO's 6-stage model.

[Matue]

Re smoking deaths vs. flu deaths: you say "the two kinds of death don't carry the same meaning" because one is personal choice and the other is not. First of all, I more or less agree with you. Second of all, here's the more and the less: (1) I don't think the line is as clean as that. Smoking is not just personal choice; i'll leave aside for now the fact that it's an addiction and therefore arguably not a choice at all; it affects the family of the smoker; it affects the health care system, my premiums, etc.; and who do you think is going to be dying first from this flu? Also, there's a corporate interest in who smokes, just as there is in who gets flu vaccine.