Bubonic Plague in China

The pandemic du jour, now that H1N1 has lost its ability to scare the pants off us, is bubonic plague, which has recently cropped up in a very small way in China. To read some news reports, you'd think it was the first case of bubonic plague since 1350.

Actually, it's not that uncommon. For example, bubonic plague is endemic in the Usambara Mountains (Lushoto District) of Tanzania. I have visited the area... there were no travel advisories against doing so, at least in the mid 90s. A recent study of the sparsely populated area found that in the period 1986-2002, "there were 6249 cases of plague of which 5302 (84.8%) were bubonic, 391 (6.3%) septicaemic, and 438 (7.0%) pneumonic forms." Plague has been there for decades and illness from it is a seasonal phenomenon, like flu (although it's more deadly).

I mention this only because media seems to get stuck on a topic and ends up distorting reality - like making it seem that crime is rising, when it's actually falling; or clobbering us with every instance of abductions of pretty white girls, which are actually pretty rare.

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Planning for Flu Season

In past posts I have made light of the swine flu (H1N1) pandemic, arguing that it's unlikely to be the magnitude of the 1918 or even 1968 outbreaks. I have changed my mind about the seriousness of the situation, because:

1) Lack of immunity to this new strain of flu means that we are facing a problem this fall and winter, even if H1N1 doesn't mutate to a more virulent form. We are facing a much worse flu season than usual, at the very least.
2) When one child died of swine flu in New York City this spring, numerous schools were closed. The same thing happened in Texas, even though the child who died was a pre-schooler visiting from Mexico. We in Toronto should remember the enormous impact of SARS. The reaction to swine flu (whether we agree with it or not) will cause severe disruption.
3) Our precarious global economic condition means that we are more vulnerable as a society: less able to cope, and more prone to negative economic/social impact. This added shock will tip more companies over the edge into bankruptcy. All levels of government will be less able to summon resources. At this point, a bad flu season could send us into inflation, stagflation, and even a depression.

In light of this, it seems vital that we all plan for the coming flu season (December through April). With luck, enough of us will get the flu shot that this year's flu season won't be a disaster. But there's enough of a chance of serious problems that we should all be thinking ahead and making plans.

I remember the 1968 flu season, when I was 10. Kids in upper grades had to help run the classrooms of kids in lower grades because so many teachers were ill. At my school there seemed to be no plan at all for how to cope - and that might have been because the principal was out sick. Planning requires committees and written strategies that don't rely on the health of any individuals.

Companies should be gearing up right now to prepare for a prolonged period when many employees can't get into work. (Employees might be ill, but also their kids might be ill or their schools might be closed; transit could be affected by transit employee absenteeism; the public might be warned against taking public transit due to disease transmission; who knows.) IT departments should be busily setting up VPN so that employees can work from home computers. Some employees should be issued laptops. Everyone should be signing up for Skype. There should be identification of people who must be in the office and they should be planned for: where will they park if transit is down and parking is congested; etc.

HR should be creating guidelines for dealing with new issues that will arise: How to encourage people to come to work? How to make employees take hygiene seriously in the office? How to handle prolonged staff absenteeism, sometimes when not directly ill? There may be opportunities: for example, employees with medical conditions may be higher on the list for the vaccine.

Plans should be made for reducing vulnerabilities: what will you do if your suppliers are unable to provide you with inputs? (Alternative suppliers should be geographically distant in case an area is shut down.) How will you cope if your courier company has no working employees, or your employees and customers can't travel?

Organizations can also take steps to reduce illness. A humidifier in the office might reduce transmission. Plans should be made for getting flu vaccine for your staff (keeping in mind that there's not going to be enough for everyone). Anti-virals (Tamiflu, Relenza) may also help for staff who have to work with the public (although anti-virals may not be the silver bullet we hope, in part because the timing of delivery is crucial and because the virus could mutate to be resistant).

In a bad pandemic, the public may be warned against handling cash, cheques or post because of their ability to transfer disease. If this might affect a business, what can be done?

Companies who foresee problems and plan for them may have a competitive advantage over companies that do not.

Here are some useful checklists.

On a personal level, the main way to avoid getting infected is to practice social distancing: keep more than a meter away from other people. We all need to educate ourselves about how to reduce the severity of the flu. During an outbreak we should stop shaking hands. Cash and mail have been serious problems in previous flu outbreaks. Face masks can be effective but only if handled properly. When sick, you need to stay home, take care of yourself and avoid exposure to other disease. If you must go out while sick, you must wear a mask.

People with kids need to plan for what they'll do if schools close. Adults with some teaching ability might consider applying to be a supply teacher to help schools stay open.

If the flu incidence is high, pharmacies and even grocery stores might operate at reduced hours. There might be days when transit isn't running, or we might be warned against taking it. It is recommended that we all have food, water and medicine to last us at least two weeks.

People on contract don't get paid when they don't work, so contractors should be prepared for some non-paid time. In addition, vulnerable companies might not make it: there are going to be more lay-offs.

Here is a personal checklist.

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Pigs and Pandemics and Zombies (Oh my)

From time to time I write fake news articles for a web site called Zombie World News. The premise is that the zombie virus has spread around the world, resulting in marauding monsters causing murderous mayhem. Zombie world news is lots of laughs, but media coverage of the recent fears of a swine flu pandemic is not so ha, ha, ha.

I came to the conclusion some time ago that a flu pandemic is unlikely (I describe why here). Nonetheless, I'm in New York this week, hanging out in crowded public places, and the reports of swine flu pandemic were initially so disturbing that I thought I should keep an eye on the situation in both NYC and Canada. The Globe & Mail and New York Times home pages seem to be updated hourly with new causes of concern. At least the headlines cause concern; all the details seem pretty reassuring: outside of Mexico, everyone who has had this strain of swine flu has been only mildly ill; and the strain is not resistant to Tamiflu (which everyone stockpiled after the bird flu scare two years ago).

We in Canada have been through SARS so know how important it is to handle flu outbreaks carefully. But Jeeze Louise, this swine flu coverage is just fear mongering.

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Pandemics?

This just posted on Al Jazeera (though I imagine it will soon be flying through the news world): Bird flu kills woman in Egypt.

What are we to make of this bird flu thing? It appears that there is no cure for bird flu - at least not yet. The Egyptian woman was given Tamiflu but still died two days after her symptoms appeared, and not long after she reported having infected chickens.

My grandmother in Chicago once told me that a third of her family died in the 1918 flu epidemic. Worldwide, it killed tens of millions. The Center for Disease Control in Atlanta says that another global flu pandemic is inevitable.

In Plague Time : The New Germ Theory of Disease, Paul Ewald argues the theory of evolutionary epidemiology, in which disease is seen as an adapting force following Darwinian laws. Whether it's a parasite, cancer or virus, the goal of a disease organism is to survive and produce more offspring than competing organisms. In many cases these organisms reproduce rapidly, and so the evolution is very rapid. We can predict, and potentially control, the progress of the organism by understanding the conditions in which it develops.

For example, Ewald has discovered that when cholera exists in an environment where it is not widely spread, it becomes more benign. This makes sense because it must keep its host alive in order to spread. When it is in a place where there is unclean water and it can spread rapidly, the virus is much more virulent because it can kill the host and still be transmitted.

Ewald says that the 1919 flu virus became as virulent as it did only because it grew in the trenches of the Western front during WWI and then was carried home by soldiers as they were demobbed. He says, "Such conditions must have favored the predator-like variants of the influenza virus; these variants would have a competitive edge because they could ruthlessly exploit a person for their own replication and still get transmitted to large numbers of susceptible individuals. These conditions have not recurred in human populations since then and, accordingly, we have never had any outbreaks of influenza viruses that have been anywhere near as harmful as those that emerged at the Western Front. So long as we do not allow such conditions to occur again we have little to fear from a reevolution of such a predatory virus."

Ewald believes that bird flu will not result in the deadly pandemic that the CDC is predicting. That's good news. My one concern with his analysis is whether there is no place in our diverse world that might provide the right conditions to develop a killer virus, but of course there would also have to be a rapid mode of transmission akin to WWI demobbing that could spread the disease before it mutates into a less harmful form. If Ewald is right, the bad news is that we're squandering resources on false threats like bird flu when we could be using them to fight diseases that are currently wrecking millions of lives.

Ewald believes that evolutionary epidemology will lead to the eradication of many of the health problems of our time, possibly including cancer, AIDS, malaria, and diabetes, at very little cost. His caution is that there is going to be big time push-back from the pharmaceutical industry, biomedical researchers, and even health professionals, all of whom may become much less necessary in society. Ewald warns that his approach "does not mesh nicely with the profit motive of the free market." Therefore, government priorities and funding are going to have to change if this new approach to disease is going to be successful.

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