Death, Profit, and Grinnell

William Rebelsky is a third year Mathematics, Chemistry, and Economics major at Grinnell College. After Grinnell, he plans to attend graduate school in a mathematically oriented field.

Death, Profit, and Grinnell. What do these three things have in common? Influenza pandemics. Over the last century there have been numerous Influenza A pandemics that have killed millions of people and generated profit for pharmaceutical companies. At least one has also been helped along by an unassuming community in the middle of Iowa. We will look at three main pandemics to illustrate each of these points: the Spanish Flu, the Swine Flu, and the Asian Flu respectively. Although people believe that the Swine Flu pandemic was overblown and that the World Health Organization gave in to pressure by pharmaceutical lobbyists, a proper understanding of influenza pandemics in the United States demonstrates that the precautions were both logical and saved lives.

In order to understand how each of these pandemics occurred and spread, we need to have a proper understanding of what it means to be a pandemic. To this end we will look at the classification scales published by both the World Health Organization (WHO) and the Department of Health and Human Services (HHS). Once we understand pandemics more generally, we will briefly study the 1918 Spanish Flu pandemic as an example of the inherent dangers in the flu. From there we will jump back to the present to review the protocols set by the Department of Health and Human Services and see how effective they were at reducing the impact of the Swine Flu in 2009. Finally, we will compare the “excess death rate” of Swine Flu with the 1957 Asian Flu that was similarly dangerous, but was not properly contained.

Before we can discuss these pandemics, we need to understand what the term “pandemic” actually means. The World Health Organization publishes a pandemic phase table that contains a description of each phase as well as the proper treatment for that phase [1]. The European Center for Disease Control has modified the table to a simpler form that I reformatted for Table 1 [2].

Table 1. Modified WHO Influenza Pandemic Phase Table. This table lists the phases and descriptions. Descriptions modified from the ECDC . The full table is available at . This link does not always work, so table 3 from the NCBI can be used instead.
Table 1. Modified WHO Influenza Pandemic Phase Table. This table lists the phases and descriptions. Descriptions modified from the ECDC. The full table is available from the WHO, however this link does not always work, so table 3 from the NCBI can also be looked at.

Although many people think of pandemics in terms of how deadly they are, it is important to note that this table classifies pandemics based only on how contagious the disease is and how many countries it has infected. This apparent lack of concern for mortality led the United States’ Department of Health and Human Services (HHS) to create their own pandemic categories that rely on the Case Fatality Ratio (CFR) or the percentage of people who are infected with the disease that die [3]. The Pandemic Categories are summarized in Table 2.

Table 2. Modified HHS Pandemic Categories. Scores and examples were taken from the Center for Infectious Disease Research and Policy at the University of Minnesota.
Table 2. Modified HHS Pandemic Categories. Scores and examples were taken from the Center for Infectious Disease Research and Policy at the University of Minnesota.

As this table suggests, the worst Pandemic that we have seen in recent memory is the 1918 Spanish Flu. The Spanish Flu was one of the most dangerous pandemics in history; it killed more than 50 million people [4] and infected more than 20% of the world [5]. Like most pandemics, the Spanish flu infected young people at a much higher rate than older people, in direct contrast to the seasonal flu where old people are more likely to get sick and die. The Spanish flu was also extraordinarily deadly. Unlike more traditional strains of the flu that have a mortality rate of under 0.1%, the Spanish flu killed more than 2.5% of those infected [6]. The Spanish Flu was the first H1N1 strain that humans had seen in a long time, and it is interesting to note that “All influenza A pandemics since that time, and indeed almost all cases of influenza A worldwide… have been caused by descendants of the 1918 virus” [7]. The Spanish flu was so serious that it continues to influence modern approaches to pandemic control.

In order to prevent future pandemics of the scale of the Spanish Flu, many governmental and international organizations have created plans to contain potential pandemic outbreaks. Let us consider the US Health and Human Services “HHS Pandemic Influenza Plan” [8], which Robert Roos and Lisa Schnirring summarize into four main measures: Isolation and Treatment, Voluntary Quarantine, Social Distancing of young people, and Social Distancing of adults [9]. The first two categories are self explanatory, if people are sick, they should be isolated and treated, and should voluntarily stay home until they are better. In order to distance young people, schools and extracurricular activities can be canceled. To distance adults, work schedules may need to be rearranged as well as having large gatherings cancelled. If a pandemic reaches Category 4, “the CDC recommends that all four interventions be used and that school classes be suspended for up to 12 weeks.”[10]

Since these recommendations came out by 2007, we can use the Swine flu Pandemic from 2009 to see how effective they were. In order to see their use, we will compare the Swine flu from 2009 to the Asian Flu of 1957. Both of these flu pandemics were influenza A viruses and descendants of the Spanish Flu. In addition, both of them had similar death rates. Although technology has progressed since 1957, the time taken to produce a vaccine was similar: the first vaccines for the 1957 pandemic came out within 4 months of the first reported case in the United States, which compares favorably with the time frame for the Swine flu. Since these two pandemics are so similar, we can consider the main difference in their outcomes to be due to how effectively they were contained.

Many of us remember the timeline of Swine Flu. The first recorded instance in the United States was in March 2009 [11]. Because the WHO had already declared that the flu could become a pandemic, the United States was prepared for its arrival. Precautions were made including extra antiviral medications being produced and stockpiled across the country. People were warned about the potential problems. Everyone knew that the “Swine Flu” was dangerous so people effectively self quarantined themselves. Luckily, due to the fast responses by the world governments, fewer people died than was expected when the term “pandemic” was used.

As we discussed earlier, the term pandemic refers only to a disease’s infectivity and not to its mortality rate. This difference in understanding led to many criticisms of the CDC and the WHO [12]. Since so few people died, some people, such as the Council of Europe, have argued that the WHO only pushed for vaccines because they were heavily influenced by the pharmaceutical industry who stood to make a lot of money off of people getting vaccines [13]. In addition, because the WHO did not address this disconnect in definitions, people believe that the WHO was being deliberately misleading. This mistrust culminated in an inquiries and criticisms by both the BMJ, formerly British Medical Journal, and the Parliamentary Assembly of the Council of Europe [14]. However, “nobody can predict the ways in which a new influenza virus will mutate, or how virulent it may become.” [15] With modern genome sequencing, they knew that the Swine Flu was a descendant of the 1918 flu, so it was better to be overprepared rather than underprepared. In addition, they knew that “between 2.0 and 7.4 million could die, assuming the pandemic was relatively mild.” [16]

This figure is likely based on the 1957 pandemic which was also a comparatively mild strain of the flu, being only slightly worse than the seasonal flu. This pandemic killed two million people worldwide [17]. The first recorded case of the Asian Flu was in Hong Kong in April of 1957, but by June it had been found in the United States [18]. Other than a few cases, it was relatively contained at this point. However that changed quickly. Grinnell College hosted a conference that was attended by more than 1600 people including someone from Davis, California where the flu had already spread [19]. The first case in Iowa was on June 26, and although the individual was quickly quarantined, by July 1st, more than 200 individuals had gotten sick so the conference ended early and everyone was sent home [20]. This action effectively seeded the country, spreading the flu everywhere. Luckily, since the flu does not spread well in summer, there were not large outbreaks until fall. However, this dispersion of attendees spread the Asian Flu far enough that no effective quarantine was possible.

When we compare the Swine Flu with the Asian Flu, we see that Swine Flu was contained more effectively, which is likely the main reason that the Asian Flu did more damage in the United States. Swine Flu is estimated to have caused 2,438 “excess deaths” over those that we would expect to see during the normal flu season [21]. 2,500 deaths is significantly fewer than the 60,000 excess deaths attributed to the Asian Flu pandemic [22]. When we account for the different population sizes, the Asian Flu would have more than 100,000 excess deaths attributed to it. Although many people believe that excessive caution was taken with the Swine Flu pandemic, it does seem to have decreased the excess death rate by more than a factor of fifty.

Although pharmaceutical profit may have been involved in the classification of Swine Flu, there was also potential for many deaths. Ultimately the relatively small number of deaths due to Swine flu should be taken as a sign that the World Health Organization did their job in properly preventing the worst case scenario rather than as a sign that the pandemic was overblown. On a more personal level, the next time Grinnell students get sick, we should probably quarantine the campus rather than sending them back across the nation and world.

 

Notes:
[1] World Health Organization,. WHO Pandemic Phase Descriptions And Main Actions By Phase. http://www.who.int/influenza/resources/documents/pandemic_phase_descriptions_and_actions.pdf
[2] European Center for Disease Prevention and Control,. 2009. WHO Pandemic Phases. http://ecdc.europa.eu/en/healthtopics/pandemic_preparedness/basic_facts/pages/who_pandemic_phases.aspx
[3] Roos, Robert and Lisa Schnirring. 2007. “HHS Ties Pandemic Mitigation Advice To Severity”. CIDRAP. http://www.cidrap.umn.edu/news-perspective/2007/02/hhs-ties-pandemic-mitigation-advice-severity.
[4] Vergano, Dan. “1918 Flu Pandemic That Killed 50 Million Originated in China, Historians Say.” National Geographic, January 24, 2014. Accessed March 17, 2016. http://news.nationalgeographic.com/news/2014/01/140123-spanish-flu-1918-china-origins-pandemic-science-health/.
[5] Billings, Molly. “The 1918 Influenza Pandemic.” The 1918 Influenza Pandemic. June 1997. Accessed March 17, 2016. https://virus.stanford.edu/uda/
[6] Frost WH. Statistics of influenza morbidity. Public Health Rep. 1920;35:584–97. http://www.jstor.org/stable/4575511?seq=14#page_scan_tab_contents
[7] Taubenberger, Jeffery K., and David M. Morens. “1918 Influenza: The Mother of All Pandemics.” Emerg. Infect. Dis. Emerging Infectious Diseases 12, no. 1 (January 2006): 15-22. Accessed March 17, 2016. http://wwwnc.cdc.gov/eid/article/12/1/pdfs/05-0979.pdf.
[8] Department of Health and Human Services,. 2005. HHS Pandemic Influenza Plan. HHS. http://www.flu.gov/planning-preparedness/federal/hhspandemicinfluenzaplan.pdf
[9] Roos, Robert and Lisa Schnirring. “HHS Ties Pandemic Mitigation Advice To Severity”.
[10] Ibid.
[11] Timeline: Swine Flu”. 2009. Nature. doi:10.1038/news.2009.416. http://www.nature.com/news/2009/090429/full/news.2009.416.html
[12] “Reconstruction Of A Mass Hysteria: The Swine Flu Panic Of 2009 – SPIEGEL ONLINE”. 2010. SPIEGEL ONLINE. http://www.spiegel.de/international/world/reconstruction-of-a-mass-hysteria-the-swine-flu-panic-of-2009-a-682613.html.
[13] Enserink, Martin. “Facing Inquiry, WHO Strikes Back at “Fake Pandemic” Swine Flu Criticism.” Science. January 14, 2010. Accessed May 19, 2016. http://www.sciencemag.org/news/2010/01/facing-inquiry-who-strikes-back-fake-pandemic-swine-flu-criticism.
[14] “The International Response to the Influenza Pandemic: WHO Responds to the Critics.” World Health Organization. Accessed May 19, 2016. http://www.who.int/csr/disease/swineflu/notes/briefing_20100610/en/.
[15] Specter, Michael. 2009. “The Fear Factor – The New Yorker”. The New Yorker. http://www.newyorker.com/magazine/2009/10/12/the-fear-factor.
[16] “Reconstruction Of A Mass Hysteria”.
[17] Specter, Michael. 2009. “The Fear Factor – The New Yorker”. The New Yorker. http://www.newyorker.com/magazine/2009/10/12/the-fear-factor.
[18] Brown, David. 2009. “Lessons To Be Learned From 1957 Pandemic”. The Seattle Times. http://www.seattletimes.com/seattle-news/health/lessons-to-be-learned-from-1957-pandemic/.
[19] Currier, Russell W. “People and Pigs: Iowa’s Role in 20th-Century Influenza History.” Iowa Heritage Illustrated 86, No. 2 (Summer 2005). Iowa City: State Historical Society of Iowa. 81-85.
[20] Brown, David.  “Lessons To Be Learned From 1957 Pandemic”.
[21] Nguyen, Ann M. and Andrew Noymer. 2013. “Influenza Mortality In The United States, 2009 Pandemic: Burden, Timing And Age Distribution”. Plos ONE 8 (5). doi:10.1371/journal.pone.0064198. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064198#s3
[22] Brown, David. “Lessons To Be Learned From 1957 Pandemic”.

Further Reading:
Bristow, Nancy K. American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic. Oxford: Oxford University Press, 2012.
Crosby, Alfred W. America’s Forgotten Pandemic: The Influenza of 1918. Cambridge: Cambridge University Press, 2003.
Dehner, George. Influenza: A Century of Science and Public Health Response. Pittsburgh, PA: University of Pittsburgh Press, 2012.