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Medical Forum / General / General / March 2004

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influenza pandemic

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Sterten - 28 Mar 2004 19:31 GMT
there had been a recent warning by WHO that we are facing a probable
influenza pandemic in the next years e.g. at:
http://news.bbc.co.uk/2/hi/europe/3524824.stm

I have tried to find concrete estimates of the expected damage but didn't find
any.
All experts are hiding behind unclear formulations and noone gives numbers
for the expected number of deaths or economical damage.

If someone knows where to get some numbers, I'd appreciate a message.
I mean expectation value, not worst case scenario.

Guenter Stertenbrink
anon - 28 Mar 2004 20:04 GMT
> If someone knows where to get some numbers, I'd appreciate a message.
> I mean expectation value, not worst case scenario.

Then your expectation is unrealistic.
Otavio Viegas - 30 Mar 2004 00:12 GMT
Maybe you can find that data at the WHO website: www.who.int, there
you can find other links related to the influenza pandemic

> > If someone knows where to get some numbers, I'd appreciate a message.
> > I mean expectation value, not worst case scenario.
>
> Then your expectation is unrealistic.
Sterten - 30 Mar 2004 08:56 GMT
>Maybe you can find that data at the WHO website: www.who.int, there
>you can find other links related to the influenza pandemic
[quoted text clipped - 3 lines]
>>
>> Then your expectation is unrealistic.

I was there, searched their pages and submitted my question on the "suggestions
form". Now waiting for answer.
I also searched various other pages.  also sent emails to several experts, but
those who replied didn't answer the question on probability-estimation or
estimates for the expectation value of the number of influenza-pandemic-deaths
in the next 10 years.

Any idea, where or from whom I could get such numbers
is appreciated.
bae@cs.toronto.edu.no-uce.yyz - 30 Mar 2004 16:18 GMT
>>Maybe you can find that data at the WHO website: www.who.int, there
>>you can find other links related to the influenza pandemic
[quoted text clipped - 10 lines]
>estimates for the expectation value of the number of influenza-pandemic-deaths
>in the next 10 years.

Nobody can reliably predict how likely a serious pandemic strain of
influenza is to turn up within any given time period.  You may find the
efforts to prevent the current epizootic of highly virulent avian
influenza from crossing the species barrier, described on the WHO web
site, interesting.

>Any idea, where or from whom I could get such numbers
>is appreciated.

As anon says, it's unrealistic to expect predictable numbers for
something that has many variables the affect the results by several
orders of magnitude.

- how virulent is the strain?

- how contagious?

- how early is it identified as a potential pandemic?

- at what time of year is it identified?

- is there a vaccine?  how fast can it be developed? produced in large
amounts? distributed? induce resistance in the vaccinated?  how
effective is it?  No vaccine is 100% effective.

- how willing are governments to take disruptive measures to reduce
spread or prevent the strain from entering their area?  At what stage
of the epidemic?  How willing are people to cooperate with such measures
when they conflict with personal objectives, from convenience to
family obligations to livelihood (or even survival)?

- are most cases in poor countries without the facilities to quarantine
and/or provide good medical care to victims?  do victims have strong
motivation to avoid identification? (the latter was a serious problem
with SARS in China and Taiwan)

- does the pandemic occur at a time when there are a lot of mass
movements of people, e.g. war refugees?

- how healthy are the potential victims?  are they well-nourished?  do
they have a high rate of existing conditions such as malaria, TB,
AIDS?  Note that annual outbreaks of influenza kill about 50,000 people
annually in the US, mostly the elderly and chronically ill.  Western
populations have a high percentage of the elderly, compared to Third
World countries in which the median age is usually about 15 years old.

- what's the morbidity rate?  does it outstrip the ability of people to
care for one another?  when the water supply is hauled several miles on
foot, when fuel is gathered with considerable effort daily, when food
preparation requires a lot of daily labour and most people are too ill
and feverish to even walk to the door, it may not be possible for
people to provide the basic necessities of life for each other.  If too
many people are too sick to work their farms effectively, famine may
follow the pandemic.

In developed countries, hospitals may not be able to handle a greatly
increased load, especially if medical workers are ill or quarantined.
People will also die of other conditions if, for example, surgery has
to be postponed.

I hope you can see that the numbers you want can only be obtained after
the pandemic is in full swing, if then.  Epidemiologists can model, but
with all these factors that are so difficult to quantify, even an absolute
worst imaginable scenario isn't so easy to develop, much less one that
has any real predictive value.

If you study the material on the SARS epidemic, you'll see how single
acts by a single person can have far-reaching consequences.  A doctor
from Kwangtung went to Hong Kong to attend a relative's wedding.  He
infected a number of people in the elevator lobby of the floor of the
hotel he was staying at, perhaps with a single sneeze or cough, and
these people carried the virus to several countries of southeast Asia
and started epidemics there.  One hotel guest was an elderly woman who
returned home to Toronto.  When a 78-year-old diabetic woman with
chronic heart disease develops the symptoms of flu and pneumonia in
February, very few doctors will consider the possibility that she has
an unknown and dangerous epidemic disease.  She died two weeks before
SARS was recognized as a new disease, and she was the index case for
the epidemic in Toronto.  Most victims in Toronto, and almost all the
fatalities, were among elderly people sick enough to be hospitalized
for other conditions -- strict and very expensive quarantine measures
kept it out of the general population.  The same was true in Singapore
and to a lesser extent, Hong Kong.

The point is that a sneeze by one person in one elevator lobby caused a
world-wide epidemic, though very fortunately a very well contained one
that killed less than a thousand people.  Had it gotten into the
general population of areas like India or Africa, the death toll might
have been in the millions or tens of millions.  You can model this
scenario, but you can't forecast the future from it.

Note that SARS is a great deal less contagious than influenza.
Sterten - 30 Mar 2004 18:41 GMT
>Nobody can reliably predict how likely a serious pandemic strain of
>influenza is to turn up within any given time period.

everyone has a probability estimate for it, those of experts are
expected to be more reliable, yet they don't tell us.

>You may find the
>efforts to prevent the current epizootic of highly virulent avian
>influenza from crossing the species barrier, described on the WHO web
>site, interesting.

yes, but all these info are less useful when I have no idea how big
the expected damage and likelyhood of such events is.

>>Any idea, where or from whom I could get such numbers
>>is appreciated.
>
>As anon says, it's unrealistic to expect predictable numbers for
>something that has many variables the affect the results by several
>orders of magnitude.

that's what the WHO experts are paid for. They _have_ estimates and
even if theirs are not very reliable they are probably better than
mine and they should tell us.
If they can't or don't want to, then I begin to wonder what those
experts are needed for...

>- how virulent is the strain?
>
[quoted text clipped - 28 lines]
>populations have a high percentage of the elderly, compared to Third
>World countries in which the median age is usually about 15 years old.

in a pandemic,I read, it is possible that also many younger people are killed.
Most deaths in the 1918 pandemic were in the 30s.

>- what's the morbidity rate?  does it outstrip the ability of people to
>care for one another?  when the water supply is hauled several miles on
[quoted text clipped - 4 lines]
>many people are too sick to work their farms effectively, famine may
>follow the pandemic.

you enumerate a number of factors which can influence the estimate
and it's not clear to a layman how important any of these is.
Nor can we research this topic, it's too complex and takes too
long. One more reason that the experts do this _and_ tell us
about the result of their research by given us their numbers for the
expected probabilities or expectation values.
That would also enable us to compare the numbers given by several experts.
But maybe it's just this, which they don't want us to do ??

>In developed countries, hospitals may not be able to handle a greatly
>increased load, especially if medical workers are ill or quarantined.
[quoted text clipped - 6 lines]
>worst imaginable scenario isn't so easy to develop, much less one that
>has any real predictive value.

yes, it is not easy to predict, but that doesn't mean that we should
give up trying to do so. When (e.g.) WHO issues a pandemic warning, then they
_should_ have some estimate of it's likelyness and estimated damage.
If they have no such estimate, then the warning is just not serious.
If they have and don't tell us about it then they are hiding important
information.

>If you study the material on the SARS epidemic, you'll see how single
>acts by a single person can have far-reaching consequences.  A doctor
[quoted text clipped - 20 lines]
>have been in the millions or tens of millions.  You can model this
>scenario, but you can't forecast the future from it.

of course I can. It might make it less reliable but it's possible.
It's only a probability estimate and nobody would blame the experts
when e.g. they give a 60% probability and then the event doesn't happen.
If only their estimate was based on reasonable assumptions and research.

>Note that SARS is a great deal less contagious than influenza.

Thanks.I didn't know. Do you have a reference ?

What's your estimate of the number of expected worldwide influenza deaths
in the next 10 years ?

Aassuming, that 8million were normal, without pandemic , I guess that
including the pandemic risk it could be 16million or such ?
Or is it more in the range of 100million ?

Guenter.
Otavio Viegas - 30 Mar 2004 23:59 GMT
> >>Maybe you can find that data at the WHO website: www.who.int, there
> >>you can find other links related to the influenza pandemic
[quoted text clipped - 103 lines]
>
> Note that SARS is a great deal less contagious than influenza.

That was a good answer. Are you an epidemiologist?
bae@cs.toronto.edu.no-uce.yyz - 31 Mar 2004 13:05 GMT
>> >>Maybe you can find that data at the WHO website: www.who.int, there
>> >>you can find other links related to the influenza pandemic
[quoted text clipped - 10 lines]
>> something that has many variables that affect the results by several
>> orders of magnitude.

[lots of verbiage snipped]

>That was a good answer. Are you an epidemiologist?

No, I'm just a dilettante with some technical background.  Thanks for the
compliment!

I should have just let anon's comment stand instead of going to all
the effort of trying to explain to the original poster that even for
the experts, reliable predictions are not possible, and in epidemiology,
what actions are taken and when can mean the difference between a few
cases and millions.  The real world is a complicated, messy place, and
there often aren't straightforward answers to apparently simple questions.
Sterten - 31 Mar 2004 16:51 GMT
I found a pretty good article at :

http://www.cdc.gov/ncidod/eid/vol5no5/meltzer.htm

which is close to what I was looking for.
They even have a software to be adapted for
local parameters.
But I'm not yet sure, whether they also estimate the probability of the
szenarios which they examine. I will look at this more closely later.

Guenter.
anon - 31 Mar 2004 23:48 GMT
> The real world is a complicated, messy place, and
> there often aren't straightforward answers to apparently simple questions.

Most physicians "get" this; unfortunately, the lay public doesn't.
 
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