Step and repeat: the fast and easy way to use our noggins on flu fears

Sadly, judging by the news and internet buzz, a lot of innocent people are frightened all over again each and every time the same scare makes the news. But the lessons learned the first time you hear a scare can be applied the next time you hear it. Let’s look at three helpful adages:

1. Diagnosis ≠ incidence
More people diagnosed with a disease does not equal more cases of a disease. The corollary to this is more people seeking to be examined or tested for a disease does not equal more cases of a disease. This is sometimes referred to as the “seek and ye shall find” fallacy.

2. Bigger numbers ≠ better evidence
If claims of ten cases of some new disease are based on flawed science, the science doesn’t become more credible by claiming 100-fold more people are diseased. This is also sometimes referred to as “bigger numbers = bigger lies.” Don’t be scared by numbers.

3. “What-if” speculations ≠ science
Speculative scenarios and predictions with no credible evidence to back them up, or even their plausibility, are nothing more than scare marketing (aka scare mongering). Credible scientists and medical professionals don’t use scares to sell you on something, they objectively report the sound facts and body of evidence, along with risks and benefits, so that people and patients can make informed decisions for themselves. Try hard to look for the facts, then check them, and distinguish them from the “what-ifs.”

Let’s take a critical look at some of the latest scary news and myths about swine flu that give us an opportunity to apply these adages.

Media releases and news reports don’t always — okay, almost never — give us the complete story or leave us with accurate impressions. The subjectivity and play on our emotions, however, isn’t always apparent. A Reuters article titled “US Health officials troubled by a new flu pattern,” on May 18^th was typical of those we’ve been reading.

Reuters reported that, according to health officials, the new influenza strain spreading across the country is “putting a worrying number of young adults and children into the hospital and hitting more schools than usual.” The story went on to report that the virus had killed a school principal. Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention [Interim Deputy Director for the Science and Public Health Program] was quoted saying that it’s “very unusual to have so many people under 20 to require hospitalization and some of them in (intensive care units).”

According to the news article, there’s more influenza this year overall. “We are seeing more reports of influenza-like illness from outpatient visits that we monitor than is typical for this time of year,” Dr. Schuchat said. Dr. Thomas Frieden, identified as the New York City Health Commissioner,* agreed, saying: “We’re seeing increasing numbers of people going to emergency departments saying they have fever and flu, particularly young people.”

● Gulp. Did the words “troubled,” “worrying” and “killed” leave you feeling anxious? As we know, any time health reporting leaves us feeling worried or anxious, that’s our baloney alert that our emotions are being played and what we’re hearing is more marketing rather than an objective presentation of the medical research and scientific evidence.

● Did you catch the most glaring fallacies in the claims? After incessant media hype about an impending swine flu pandemic, consumers have been scared and are running to the doctor for every sniffle and cold symptom, fearing they’re going to die of swine flu unless they seek immediate treatment. Reports of more flu-like symptoms being seen at clinics and emergency rooms is an indication of swine flu panic, not actual disease.

In fact, the problem of people flooding emergency rooms, fearing they are infected, became so extreme that on April 30^th, the nation’s two largest organizations of emergency medical professionals — the American College of Emergency Physicians and the Emergency Nurses Association — issued a joint statement urging consumers to apply the “prudent layperson standard” when considering going to the emergency room: “If the average prudent person would think you have the symptoms of a medical emergency, then you need to seek emergency care,” they said. If you don’t have emergent symptoms, don’t go to the ER.

Emergency medical professionals across the country have been inundated by people “seeking reassurance that they are not ill,” which both organizations said was “understandable, given the widespread news coverage.” They reminded the public, however, that while news reports about the swine flu may have raised alarm, the actual number of cases are very small. Their joint statement emphasized:

“If you have symptoms that would not ordinarily take you to the emergency department but are considering going because you are afraid you have swine flu, you probably do not need to go,” said Bill Briggs, RN, president of ENA.

Plenty of healthcare professionals probably wished they could just get away with this other approach in providing the answer to people wondering if they have the swine flu.

● Did anyone read the transcripts of the CDC’s briefing or look at the CDC flu reports to fact check? None of those scare words were used in the briefing. Reporters could easily have checked the facts, but almost no one did. [Click on any graphic to view enlarged.]

According to the CDC surveillance data, the numbers of children being hospitalized this 2008-9 influenza season [the dotted red line] are not greater than in other recent flu seasons:

Nor are the number of pediatric deaths associated with influenza this season any higher than recent years. In fact, they’re significantly lower. For example, there were 78 pediatric deaths associated with influenza in 2006-7, 88 deaths in 2007-8, and by May 30^th this season’s total number of pediatric deaths was 67.

There are also not inordinately more cases of influenza overall this season, even including this novel strain. With the heightened testing, more cases being identified of all influenzas would not have been unexpected. Yet, seasonal flu cases have not even been near epidemic thresholds. In fact, CDC surveillance data reveals that this year’s total influenza cases [the last red bump on the right] have generally been below seasonal baseline. In contrast to all of the flu panic, this year has been a mild year for influenzas of all types:

The CDC surveillance data also shows that, in contrast to this year, most years over the past decade have exceeded “epidemic thresholds,” especially years where H3N2 type A influenza is the predominant strain.

Testing. If you’re confused by these facts that conflict with what you’ve come to believe about an impending flu pandemic, you may have missed the earlier coverage, where we learned that the CDC had cautioned that this strain of swine flu (H1N1) could not credibly be said to be new. The reason is because they had never tested for it before and between the new test, along with the new mandatory reporting and increased testing, they could be identifying a strain of H1N1 that has always been part of regular seasonal influenza. More cases identified by a new test and increased surveillance does not necessarily mean there actually are more cases.

As Dr. Schuchat explained to the media on May 18^th:

Our CDC efforts [to test for this strain] continue fairly aggressively. We still have more than 80 people deployed in the field, and we have continued to support the laboratories and states here in the U.S., as well as in countries shipping our diagnostic kits to 95 labs in 50 states, and to 237 labs in 107 countries. At this point, 40 of the states here in the U.S. have got validated testing going on.

Prudence is also warranted when interpreting results of a new lab test. There are reports of contradictory results, depending on the lab and the test, and a lot of people heard they could have swine flu based on rapid tests which later proved to have been negative. The CDC’s recommended test for this novel H1N1 strain is the real-time reverse-transcription polymerase chain reaction (RT-PCR) test, or a viral culture. “Currently, novel influenza A (H1N1) virus will test positive for influenza A and negative for H1 and H3 by real-time RT-PCR, their guidance states. “If reactivity of real-time RT-PCR for influenza A is strong (e.g. Ct <30) it is more suggestive of a novel influenza A (H1N1) virus.”

The CDC also cautioned medical professionals that the sensitivity and specificity of various rapid tests is not known and that it has received reports of false positives and false negatives. The reliability of the new rapid tests of this strain of swine flu, the CDC said, “depends largely on the conditions under which they are used and are entirely based on the experience with seasonal influenza”:

For detection of seasonal influenza virus infection, sensitivities of rapid diagnostic tests are approximately 50-70% when compared with viral culture or RT-PCR, and specificities of rapid diagnostic tests for influenza are approximately 90-95%. Sensitivity and specificity of these tests for detection of the novel H1N1 flu virus are unknown. False-positive (and true-negative) results are more likely to occur when influenza is uncommon in the community…

Mutant virus.During the May 18^th CDC media briefing, Dr. Schuchat also said that “from the stains we’re testing there is no evidence right now of any mutation toward a more virulent strain.” We learned that genotyping of the virus by scientists showed that it never was a new mutant swine virus with unique dangers compared to ordinary seasonal flu and that there’s no evidence that it’s more likely to become deadly than any other swine flu virus has ever been.

Seasonal flu and H1N1. Let’s read the transcripts of a later CDC media briefing on May 28^th and look at a few supported facts that we haven’t been hearing, and try to keep them separate from the speculations and claims. Dr. Schuchat said they’re not seeing dramatic large increases in H1N1 cases. In fact, beginning next week, she said, the CDC is going to be issuing updates less frequently.

She went on to explain that H1N1 strains have always been part of seasonal flu and that this newly identified strain is behaving much like typical seasonal H1N1 influenza strains, and that seeing the virus in younger people is common for H1N1 strains (nothing ominous about this season's H1N1):

Next I want to talk a little about what we've learned about the virus so far. There are some respects in which this virus is behaving like the seasonal H1N1 influenza viruses. Remember that for seasonal influenza, we usually see H1N1, H3N2 and B strains of influenza. And when we look at this novel H1N1, there's some similarities between this and the seasonal H1N1. Seasonal H1N1 often causes more disease in younger people compared with the other strains that can be more common in older people. The seasonal H1N1 typically doesn't cause as many deaths as the H3N2 seasonal viruses do. In years when H3N2 predominates, we have a higher death toll than in years when the H1N1 predominates. So during the annual flu seasons, we've often found that H3N2 influenza viruses are most strongly associated with severe illness and more deaths. Back to the novel H1N1 virus, currently the attack rates that we're seeing, that's the percentage of contacts of an infected person who becomes ill, are fairly consistent with what we see with seasonal flu. In a typical influenza season, about 7% to 10% of the people in a community may become infected with an influenza virus.

Virulence. She also reported that they have information on 11 of the 12 deaths reported as being associated with the virus. Ten of those deaths, she said, occurred in people with serious underlying health conditions that put them at risk for severe complications — in other words, opportunistic infections such as the flu.

But this virus hasn’t proven to be anywhere near as virulent as the 1918 pandemic, she said, which had a mortality rate in the 2 percent range. Deaths from this strain of H1N1 are so low, she said, “it’s hard to be very precise in these ranges that we’re seeing right now of 0.15% or 0.2% of all cases resulting in death.”

As of Friday, WHO reports that the total number of deaths worldwide that have been linked to swine flu (H1N1) this year are 125. According to the CDC, between 250,000 and 500,000 people die worldwide each year from the seasonal flu. In comparison, about 1.2 million people die from walking, cycling or riding on roadways, the highest deaths are among children walking along a road.

As Dr. Peter Collignon, a microbiologist with Australian National University, said, “the virus is no worse than annual influenza strains.” “I don’t actually think this particular strain appears from the data... to be worse than what we do predictably see every year,” he said. “My major concern about what’s happening is the fear is out of proportion to what the data shows.”

The "fear factor" within the community, he said, needs to change. Yes, you can let yourself be scared senseless about all sorts of “what-ifs” but why would you want to?

Should swine flu be declared a pandemic?

How many times have we heard that when or if the World Health Organization calls swine flu a pandemic, then it’s time to feel really scared because that means a deadly virus is spreading around the world? Before we run for the hills or invest in a biohazard suit, we know that the very first question we should ask ourselves about any health statistic is the definition. The WHO definition of pandemic is based on “how widespread a disease has become, without regard to its severity.”

“People don't understand what 4, 5 or 6 means,” said Jose Angel Cordova, Mexico’s Health Minister. “They think that when you go to a higher level [of alert] things are worse.”

Much of the recent fears are based on beliefs that a new flu strain means we’re doomed to die because we have no immunities to it. But, as we’ve seen for nearly a century with every outbreak of influenza, just because we haven’t developed resistance to specific strains doesn’t make them any more deadly. While the word “pandemic” sounds scary to laypeople, every influenza pandemic we’ve had since 1918 has been no more deadly than a typical flu season.

How many times have we heard the dire warning that it’s only a matter of time before the next influenza pandemic strikes? “But the truth is that the threat is being hyped,” explained Philip Alcabes, Ph.D., MPH, professor of urban public health at Hunter College of the City University of New York. It’s a myth that we need to brace ourselves for another pandemic like the Spanish flu, he wrote in the Washington Post.

“Fortunately, we’ll never see another flu outbreak of that sort,” he said. The Spanish flu hit at a time when the population’s immune systems were severely weakened by widespread food shortages, displaced refugees and health consequences of World War I. Most flu deaths also weren’t from the flu itself, but from the bacterial infections that attacked weakened respiratory systems. People in developed countries are not only healthier today, antibiotics and modern medical care mean a repeat of a pandemic of that magnitude is simply improbable.

As we’ve seen with other purported epidemics (obesity, diabetes, metabolic syndrome, autism or toe fungus), even calling something an epidemic or pandemic brings vast financial, political and ideological interests — on even how we should eat and live — to bear. The same is true with influenza.

● For example, warnings of a global pandemic of bird flu several years ago — which the soundest scientific and medical evidence indicated were similarly improbable, and with equally implausible predictions of deaths — were used to put Homeland Security in charge of a national pandemic response plan, increase federal funding for this new agency, buy 2.7 million doses of vaccines and antivirals, and introduce a massive data collection and public health reporting system. Those opposed to commercial food production, meat consumption and globalization used it to heighten scares and denigrate the poultry industry and imports from China.

● This April, the Administration was already calling for $1.5 billion more in funds to address swine flu which, according to Congress Daily, was on top of $1.4 million additional spending for pandemic flu over last year and $6.1 billion for pandemic preparedness the HHS had been given in other spending bills. Three pharmaceutical giants Sanofi-Aventis, GlaxoSmithKline and Novartis were given $191 million, $181 million and $289 million, respectively, to rush a vaccine into development.

● This week, the White House asked for an additional $2 billion to prepare for a swine flu pandemic and the power to use another $3 billion from the discretionary stimulus funds.

● The same groups opposed to commercial food production, meat consumption and globalization have been directing scares to pigs and commercial pig farmers. That’s probably why we aren’t likely to see an epidemic declared, linking impending doom to cute little bunnies. Not many people eat bunnies and there’s not much of a movement against factory bunny farms. :)

But don’t blame the pig, said virus expert Dr. Robert Webster of St. Jude Children’s Research Hospital in Memphis, Tennessee. “It’s a human virus.” Those pointing the blame for creating new viruses at modern pig farming, with claims of crowded unnatural environments, can cite no science to support the claims, the Los Angeles Times reported. As it explained:

Animal scientists say that [the factory farming connection] is not so. The biologically secure facilities, they say, protect pigs from germs like flu. The air is filtered, and bacteria-rich animal waste is kept out of pens. There is virtually no exposure to wild birds or other animals.

The number of humans who come into contact with the animals is far lower than on traditional farms, reducing risk of infection either way. People entering the facilities must shower and change into special clothes. “You don't even wear your own underwear in these facilities,” said Dr. Liz Wagstrom, a veterinarian and officer of the National Pork Board…

Animal breeder Ronald Bates of Michigan State University said that should be a warning: "If you have flu-like symptoms, don't go near pigs."

When so many interests stand to gain from creating panic over epidemics and pandemics, it means we have to be especially diligent to look for factual information in order to not let ourselves get caught up in the fear marketing. Sadly, when fears get the better of people, they can even be led to welcome the label of an epidemic or pandemic to validate that their fears are real, even when they’re not.

But what does WHO raising the level of alert from 5 to 6 and declaring a pandemic really get you?

Declaring a pandemic has more to do with politics than with medicine or helping you to stay safer. In fact, responses to fears about a pandemic are far more frightening and dangerous than the flu itself.

The belief that “we can’t be too prepared” isn’t true. “Actually, we run the risk of doing more harm than good by overreacting to the threat of a pandemic,” said professor Alcabes. Remember the 1976 swine flu outbreak at Fort Dix, New Jersey? It also resulted in medical experts warning of a pandemic and led the president to call for a mass inoculation program of the population with a new swine flu vaccine that contributed to about 500 cases of Guillain-Barré syndrome and 32 deaths before it was shut down. “But there was no swine flu epidemic, just a handful of cases,” professor Alcabes reminded us.

A pandemic announcement itself comes with considerable risks to people’s lives, health and safety, while offering little benefit. As was reported from WHO’s annual meeting last month, declaring a pandemic has severe economic consequences for nations, triggering expensive trade and travel restrictions such as border closures, airport screenings and quarantines. Mexico is still reeling from the economic hit it took when it literally shut down its economy for nearly two weeks trying to protect others from the spread of the infection because of fears of a pandemic. Its tourism and restaurant businesses were hit especially hard, with about 25,000 workers losing their jobs in Mexico City alone after more than 2,500 restaurants closed.

In declaring a pandemic, “governments may also fear outbreaks of mass panic, social disruption and increased pressures on their health systems,” WHO reported. “Under public pressure, extraordinary measures such as large-scale pig slaughters like the recent one in Egypt could be taken, whether or not they are scientifically justified.”

Fear and a sense of crisis causes extraordinary levels of stress and anxiety among people that can linger long after the crisis is over. In Japan, school children who’d come down with the flu have suffered an onslaught of hostility, threats and discrimination from frightened members of the community, blaming them for the spread of the infection.

People who are worried and anxious also seek more medical care. Needless scares have very real consequences by putting more strain on overworked doctors, on limited healthcare resources, and on cash-strapped consumers, themselves.

“Today, about 85 percent of the burden of chronic diseases is concentrated in low and middle income countries,” said Margaret Chan, Director-General of WHO. “The implications are obvious,” she said. “The developing world has, by far, the largest pool of people at risk for severe and fatal H1N1 infections.” A pandemic declaration will most harm underdeveloped countries whose health systems are already unable to take care of the deadliest health problems, such as diarrheal diseases that kill about 600,000 children under five every year in India or malaria that kills more than 3,000 children a day in Africa. Countries should not let fears over a possible flu pandemic overshadow or interrupt other vital health programs, she cautioned.

The bottom line, the term “pandemic” can itself be deadly. Fear can lead people to respond emotionally and in ways that aren’t very sound or based on reasoned evaluations of the benefits and risks. For every country and every person of the world, diverting precious healthcare resources away from caring for actual deadly diseases to put towards poorly thought out public health measures, means more people will die.

© 2009 Sandy Szwarc

* Dr. Frieden had actually resigned the prior week when President Obama appointed him the new Director of the CDC.

Readers may recall Dr. Frieden when he lead the recent initiative to put the entire population on a low salt diet. Many of the other accomplishments Dr. Frieden cited in his media release about his resignation may also be familiar:

New York City now has the nation's largest community-based electronic health record project — one designed specifically to make prevention central to health care. More than 1,200 local health care providers — many of them practicing in the city's poorest and sickest neighborhoods — have joined the city's Primary Care Information Project.

New York City led the nation in eliminating artificial trans fat, a known cause of heart disease, from restaurant foods. [Dr. Friedman had equated the invisible dangers of trans fats to lead paint.]

By mandating the posting of calorie information in chain restaurants, the city's Board of Health empowered consumers to make healthier food choices at the point of purchase and encouraged restaurants to offer healthier options.

New York City created the country's first A1C registry to monitor blood sugar levels among people with diabetes. [Reviewed here and here.]

He also noted: “Since 2004, the Health Department has spearheaded Take Care New York, the City’s first comprehensive health policy, targeting ten leading causes of preventable illness and death for coordinated public and individual action.” We may all soon be familiar with this program. The Keep Your Heart Healthy: Take Care New York, says that being overweight or obese causes a wide range of health problems and that you can cut risk by just losing a few pounds, eating right and exercising, including cut your risk of diabetes in half; it tells everyone they must “know your numbers” to prevent disease; eat at least five servings of produce every day, eliminate any sugary sodas, and it offers a variety of tips for sustained weight loss.