A/H1N1 ("swine") flu outbreaks
 

[quote=ewmayer;171404][URL="http://www.telegraph.co.uk/health/healthnews/5228878/Estimates-of-economic-costs-of-a-flu-pandemic.html"]Estimates of economic costs of a flu pandemic[/URL]: [I]The World Bank estimated in 2008 that a flu pandemic could cost $3 trillion and result in a nearly 5pc drop in world gross domestic product.

< snip >

[/I] You had one top CDC official (Besser) saying "we see no reason to impose travel restrictions ... just monitor airports for people showing signs of possible infection, blah, blah." Hello? We know that the incubation time for this disease is 1-4 days. If a person is infectious during the incubation time (and that's what I wanted to hear something about, even if speculation based on other better-studied strains of flu), wouldn't that be a compelling argument for imposing travel restrictions to and from countries.areas which are hotspots of the outbreak, irrespective of whether a would-be traveler is showing signs of sickness?[/quote]Public health officials have to be cautious about not only the spread of disease, but also the disruption of economy. As soon as travel restrictions are imposed, there begins an accompanying hit on the economy of the restricted regions plus those trading with them. If they provoke a deep depression that otherwise would have been much shallower, that will cause a lot of deaths all by itself.

Also, they have to be very careful about being perceived as having cried "wolf". If there's a general public perception that officials imposed restrictions unnecessarily, then [I]the next time, when it really [U]is[/U] necessary, many of the general public will ignore them[/I]. That could lead to catastrophe.

If, in the current economic environment, the public develops a perception that health officials needlessly deepened a recession, or ensured a depression, that perception would come back to bite us, hard, at some future time when the consequence could be billions, rather than thousands, of deaths.

[quote]It seems that with modern air travel a several-day presymptomatic infectivity window is exactly the thing one needs to be the most concerned about, i.e. rapid spread of a pandemic agent occurring right under one's nose, so to speak. In that scenario, by the time one obviously-sick person gets stopped at an airline gate, hundreds or even thousands of asymptomatic carriers may have already dispersed all over the globe. Think of the movie "12 Monkeys".[/quote]Okay, tell us how [I]you[/I] would simultaneously minimize the "wolf" probability, minimize the chance of unnecessarily impacting the world economy, and maximize the chance of catching a potential pandemic before it's too late to prevent its full flowering.

[quote=ewmayer;171577]The worst-case airline-vectored scenario involves airborne transmission, so let's focus on that: One thing I have long advocated would be to equip all passenger planes operating in and out of the U.S. with a simple kind of air-sampling system, just a compact shoebox-sized sampler which would collect swatches of floating particulates down to virus size.[/quote]Fine. I thought you were advocating some change in WHO's decision process.

Then you'll may be interested in:

"How to Prevent a Pandemic"

[URL]http://www.nytimes.com/2009/04/30/opinion/30wolfe.html[/URL]

[quote=Nathan Wolfe]THE swine flu outbreak seems to have emerged without warning. Within a few days of being noticed, the flu had already spread to the point where containment was not possible. Yet the virus behind it had to have existed for some time before it was discovered. Couldn’t we have detected it and acted sooner, before it spread so widely? The answer is likely yes — if we had been paying closer attention to the human-animal interactions that enable new viruses to emerge.

While much remains unknown about how pandemics are born, we are familiar with the kinds of microbes — like SARS (severe acute respiratory syndrome), influenza and H.I.V. — that present a risk of widespread disease. We know that they usually emerge from animals and most often in specific locations around the world, places like the Congo Basin and Southeast Asia.

By monitoring people who are exposed to animals in such viral hotspots, we can capture viruses at the very moment they enter human populations, and thus develop the ability to predict and perhaps even prevent pandemics.

Over the past 10 years, my colleagues and I have demonstrated that such monitoring is possible. In Cameroon, we have studied hunters who are exposed to the blood and body fluids of monkeys, bats, wild pigs and other hunted animals. By collecting specimens from both the hunters and their prey, we have discovered previously unknown viruses and documented how they’ve jumped from animals to humans. We have seen, for example, a gorilla retrovirus, never before seen in humans, infect one of our study subjects.

Then, by monitoring infected people and those who are in contact with them, we observe what effects these novel viruses have on people, and how easily they can move from person to person.

We can also identify a virus’s genetic and immunological signatures and other biological information that is needed to create diagnostic tests, vaccines and treatments — so that when a disease appears, it is possible to respond as quickly as possible.

Had similar monitoring systems been in place at farms in Mexico, where the current swine flu outbreak is assumed to have emerged, perhaps we would have been able to identify the movement of the virus at or near the point where it entered humans. Such information could have significantly speeded up our response.

. . .[/quote]


[quote=ewmayer]You're right about not shutting down the economy to an inordinate degree, but that does need to be weighed against the spanish-flu type scenario, i.e. the very real probability of a pandemic which ends up killing on the order of 1% or more of the world's population? What's 100 million lives worth these days? But merely looking for "obviously ill" people at airports is idiotic, in my opinion. We need to be just a little smarter than that.

Compare sampling-based proposals such as the above one to the amount of money being spent on e.g. near-earth asteroid detection - not that I'm against the NEO search, I just want the $ spent on such catastrophe-prevention efforts to be roughly proportional to the potential lives saved.[/quote]Let's see if I have this straight ...

You're implying that the NEO search effort, which aims to prevent a catastrophe that could potentially kill [B]100%[/B] of the Earth's population, is somehow being lavishly funded in comparison with current efforts to monitor outbreaks of diseases which may, in the worst case you cite, kill less than [B]2%[/B]?

Sir, you have some sort of mistaken idea about NEO search funding and/or disease-monitoring funding.

Perhaps one difference between the two, namely that the NEO search can be conducted using specialized technology at only a few locations, while disease-monitoring is inherently widespread (though its information is collected centrally) through millions of doctors and health facilities around the world, has misled you in your estimation of funding. It's a lot easier to add up the short list of NEO funding figures than it is to tally the costs of the monitoring/reporting time spent by millions of health workers annually.

Do you think that worldwide annual NEO search costs averaged over several years (to spread the cost of equipment purchases equitably) exceed the annual CDC (which is only a small part of the world's health monitoring but also includes non-monitoring costs) budget? (I haven't looked up the figures before I post this.)

"Swine flu: why I'm not complaining" on the Effect Measure blog:

It's the comments that are interesting IMO. Link at end of each one.

[quote]2 I work in an already overtaxed emergency room in a major city. Yesterday we were "out of" masks and therefore the nurses in triage went without. It is concerning to me as a nurse that has first contact with those that are ill, that basic resources are not available. I love my job yet I love my family more. Creating a potential reservoir within myself for a virus with so many unkown variables is not an option. You are right in your critique of our health care system. Understaffed and unable to handle the noramal changes in pt census we are truely vulnerable to an exponential increase in patient loads.

Posted by: theloneyoni | [URL="http://scienceblogs.com/effectmeasure/2009/04/swine_flu_why_im_not_complaini.php?utm_source=nytwidget#comment-1601193"]April 30, 2009 10:05 AM[/URL]

3 While the CDC and WHO are sending the right messages, I think we are on the brink of the media backlash (it started in that LA Times reference in the comments of another blog entry) since the body count hasn't started piling up in the US. Note: we may have a very low body count thanks to the CDC and WHO informing the public and making people fearful enough that they are getting checked out. What can be done to fight a media backlash is the real question?

If the 1918 pattern occurs, I think CDC and WHO's public image will be undermined and people will ignore them in the fall. The general public doesn't know the 1918 story - it needs to get out there so people will understand that a summer lull may not mean anything.

Posted by: GeorgeT | [URL="http://scienceblogs.com/effectmeasure/2009/04/swine_flu_why_im_not_complaini.php?utm_source=nytwidget#comment-1601223"]April 30, 2009 10:16 AM[/URL]

. . .

9 My 2 cents again:

1. As an ER physician at a teaching hospital, I am constantly frustrated by the lack of attention the govt has given in regard to the fact that most EDs in the USA function above capacity and we have little to NO surge capacity. A white House report in March 2008 called 31 EDs throughout the USA at the same time during a Monday afternoon and asked how many people they could take (simulated a mass casualty event that had same number of victims as the Madrid train bombings several years back--i.e. 215 victims) and most could either take 1 or 2 or none. Yes I wrote those numbers correct. One hospital in Wash DC was functioning at 250% over capacity during that nice phone chat! We have neglected our public health infrastructure and now that we have as Obama said last night not 1 or 2 major problems but 8 or 9--we dont have the money to fix it like it should be. Thankfully this pandemic wanna be were enjoying appears to be a wimp. And now that I am going What in the hell was the WHO thinking in putting so much money and resources on the pipe dream of source containment? That policy was based upon 2 computational models that were flawed and had unmeetable requirements for such as policy to work. Spend the money on prevention stupid!

2. I wrote an (I know self promotion--but this is important) Op ED for CNN on travel and swine flu that folks on this site may find useful when they fly during an outbreak. Please check it out [URL]http://www.cnn.com/2009/HEALTH/04/30/gendreau.swine.flu/index.html[/URL]

Take care everyone and remember sanitize those hands.
Mark

Posted by: Mark Gendreau | [URL="http://scienceblogs.com/effectmeasure/2009/04/swine_flu_why_im_not_complaini.php?utm_source=nytwidget#comment-1601303"]April 30, 2009 10:46 AM[/URL]

. . .

19 The only problem I've had with the "panic mongering" is with CNN, MSNBC, and other major news outlets. They're taking soundbytes from WHO and the CDC and not really providing context. If this was three years ago, before I entered the sciences and started actually learning to read and think, I'd be terrified right about now. People who rely on the major news aren't being given the full picture or how to even view the full picture.

Posted by: e.d. | [URL="http://scienceblogs.com/effectmeasure/2009/04/swine_flu_why_im_not_complaini.php?utm_source=nytwidget#comment-1601795"]April 30, 2009 1:31 PM[/URL]

. . .

25 Revere, as always, thought provoking. Thank you.

Mark: where do you think all those masks and respirators are going to come from? In every country around the world, the same response is occurring. I wonder how many healthcare professionals there are in the world? And what about the millions of everyday workers who use them for protection at work? What will happen to those supplies? I am sure there is not a huge warehouse somewhere full. If manufacturers of these are like every other business hit by the GFC, then I am sure inventory and raw material supplies will be reduced.

Posted by: Pete | [URL="http://scienceblogs.com/effectmeasure/2009/04/swine_flu_why_im_not_complaini.php?utm_source=nytwidget#comment-1602135"]April 30, 2009 3:48 PM[/URL]
[/quote]Hmmm... [I]Are there[/I] large emergency stocks of masks, at least, somewhere?

If not, something to add to the national preparedness checklist.

Long-term deterioration of the rubber straps for holding them on could be a problem.

[quote=cheesehead;171744]Long-term deterioration of the rubber straps for holding them on could be a problem.[/quote]I should have looked at a real germ-screening mask like this:

[URL]http://www.amazon.com/gp/product/B0027ENFX6/ref=s9_topd_gw_tr11?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-8&pf_rd_r=0P0ESEP27WK1ADK9YGXX&pf_rd_t=101&pf_rd_p=475766091&pf_rd_i=507846[/URL]

instead of the little dust masks on my shelf. [I]Real[/I] germ masks have fabric earloops, no rubber.

[QUOTE=cheesehead;171760]I should have looked at a real germ-screening mask like this:

[URL]http://www.amazon.com/gp/product/B0027ENFX6/ref=s9_topd_gw_tr11?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-8&pf_rd_r=0P0ESEP27WK1ADK9YGXX&pf_rd_t=101&pf_rd_p=475766091&pf_rd_i=507846[/URL]

instead of the little dust masks on my shelf. [I]Real[/I] germ masks have fabric earloops, no rubber.[/QUOTE]
I don't think it's the earloop so much as the qusality of the facial fit that matters - in addition to the flitration fineness, obviously.

I ordered several dozen N95 Respirators from an outfit in Texas (TASCO) yesterday, just in case - been meaning to add some face masks to the home emergency kit for several years now anyway. They run about $2 each, but importantly (especially if there is an outbreak of something really nasty and you don't want to end up trying to buy enough for several-per-day for say a month) they are washable and reusable at least a few times that way. In a pinch I suppose one could always douse the fabric with rubbing alcohol, which will dry within minutes.

Gonna send at least one box to my Mom, who is flying out next weekend to visit me and my sister and sis's 2 one-month-old twin boys. Airplanes are basically flying petri dishes, that's one place where I'd definitely consider wearing a mask at this time.

[QUOTE=ewmayer;171815]Airplanes are basically flying petri dishes, that's one place where I'd definitely consider wearing a mask at this time.[/QUOTE]

Taking cues from Joe Biden???

[QUOTE=ewmayer;171815]
Gonna send at least one box to my Mom, who is flying out next weekend to visit me and my sister and sis's 2 one-month-old twin boys. Airplanes are basically flying petri dishes, that's one place where I'd definitely consider wearing a mask at this time.[/QUOTE]

[QUOTE=rogue;171820]Taking cues from Joe Biden???[/QUOTE]
Why not? In a full-blown epi/pan-demic, most precautions taken before the fact will seem timid although currently they seem extreme.

I'm more concerned about strip searching a young girl for possibly hiding an ibuprofen and diverting an airliner because it held a pacifistic musician that years ago adopted the Muslim religion.

Joe Biden's advice may be damaging on a macroeconomic and national policy level but is perfectly sensible on an individual and personal level of deciding what risks and preparations for unknown levels of risk we accept on a private decision bases day to day. Even two weeks ago though, wearing any mask on that airline was sure to bring the full force of DHS scrutiny upon the wearer, and maybe still does.

[QUOTE=ewmayer;171815]Gonna send at least one box to my Mom, who is flying out next weekend to visit me and my sister and sis's 2 one-month-old twin boys.[/QUOTE]A major consideration that is often overlooked is having a well stocked larder/cellar/pantry/fridge. If you have to hunker down for a week or 2, you will need to be able to feed yourself(& family). If you are sick, you need things like chicken soup (Jewish penicillian) and other sick friendly foods.

I'll just use my hepa/acid gas respirator. Magneta and yellow cartridges :smile:

[quote=cheesehead;171744]Hmmm... [I]Are there[/I] large emergency stocks of masks, at least, somewhere?
[/quote]... but today I'm seeing/hearing that masks aren't very important flu-spread-preventers all by themselves.

The main virtues for most folks is that they (a) help remind oneself not to touch ones nose or mouth with hands/fingers, and (b) serve as visual reminders to other folks to keep their distance from each other. In addition, those who are already sick should wear them to help prevent spreading disease to others, and health care workers who have to come in close contact with many sick people get some protection from contracting disease.

That is, the average person can get the same benefits as masks are commonly thought to have by (a) washing ones hands frequently, (b) refraining from touching mouth/nose/eyes with hands/fingers, and (c) keeping greater distance from others in social situations.

(* begin excursion *)

Notice that this is yet another case of the general principle (not just in health) that people would much rather use some artificial device or take some pill than change their own behavior, in order to achieve some health or safety benefit. Thus, the general preference for automobile airbags rather than seat/shoulder belts that have to be fastened. Thus, the longing for a fat-blocking pill one could take instead of changing ones dietary and movement habits. Or our resistance to undergoing change in general.

OTOH maybe this complaint simply overlooks the very real important of labor-saving or time-saving convenience. Weren't people generally more physically-fit when they had to chop/haul firewood for heating the home? Scrubbing clothes by hand allows better attention to treating particular stains than just dumping them in a washing machine. And I just love washing dishes by hand in a dishwasher-less apartment after living for ten years in a house with a dishwasher

... not.

(* end excursion *)

Mods, can y'all break out the swine flu to a different thread?????
Thanks.

A/H1N1 ("swine") flu outbreaks
 

Here's a thread for comments on current flu news.

[quote=Uncwilly;172326]Mods, can y'all break out the swine flu to a different thread?????
Thanks.[/quote]I've started a thread, [URL="http://mersenneforum.org/showthread.php?t=11830"]A/H1N1 ("swine") flu outbreaks[/URL], for just that purpose. Please move flu comments there.

[QUOTE=cheesehead;172330]Here's a thread for comments on current flu news.[/QUOTE]

[SIZE="7"]We are all going to die![/SIZE]

Okay, maybe not, but by following the media, it certainly seems likely to happen.

It's probably safe to say that the majority of us will die, just maybe not anytime soon, or particularly from one or more types of influenza.

[url]http://www.explosm.net/comics/913/[/url]

Alex

I have found the 2 most effective masks to prevent one from getting the H1N1 flu virus.

[URL="http://www.buycostumes.com/Hannibal-Lector-Half-Face-Mask/34071/ProductDetail.aspx"]Mask 1[/URL] [URL="http://www.maskarny.sk/item.php?lang=en&main=27&category=68&item=953&name=Jason%20hokey%20mask"]Mask 2[/URL]
I plan on using both of them (one at a time) and don't think I'll get the flu.


And a [URL="http://www.youtube.com/watch?v=ICPDeM14Oeg"]PSA[/URL]

How it all started....
 

beware....

[QUOTE=petrw1;172362]beware....[/QUOTE]

Apparently the kid survived...

...

...and is now feeling Perky.

(Re: How it all started)
 

[QUOTE=petrw1;172362]beware....[/QUOTE]Ob. USA election reference: Does that pig have lipstick on?

Swine Flu cause foot-in-mouth disease?
 

One of the students at a local high school which was closed last week due to several students testing positive for H1N1 decided to write the local newspaper to express his feelings, and is probably feeling a tad embarrassed as a result -

From the [url=http://www.mercurynews.com/opinion/ci_12275034]May 2nd reader`s letters section[/url] of the opinion page:
[quote]Subject: Swine flu is not only virus to worry about

The swine-flu "pandemic" is being blown out of proportion. The media and government are once again making money off this small virus. [u]Attention should be put toward others like influenza[/u], which claims an average of more than 30,000 per year. It seems that because the swine flu or A (H1N1) influenza virus is so new and it originated in Mexico, once again this gives people a new reason to dislike immigrants from Mexico. The swine flu has claimed one life in the United States, a 23-month-old baby in Texas who had a relatively new immune system. While the media and the public are focused on the swine flu, other viruses are feeling lonely and should have this kind of attention because they are the real threat to our nation.

Trevor Tuma
Student, Branham High School San Jose[/quote]

[QUOTE=ewmayer;172431]One of the students at a local high school which was closed last week due to several students testing positive for H1N1 decided to write the local newspaper to express his feelings, and is probably feeling a tad embarrassed as a result -

From the [url=http://www.mercurynews.com/opinion/ci_12275034]May 2nd reader`s letters section[/url] of the opinion page:[QUOTE]While the media and the public are focused on the swine flu, other viruses are feeling lonely and should have this kind of attention because they are the real threat to our nation.[/QUOTE][/QUOTE]The timing of this outbreak when the flu season was winding down and even the fact that it was detected as an outbreak at all will serve us in good stead. It let all the tools developed over bird flu and SARS be dragged out and utilized before they dissipated into complacent neglect. The public is better informed on mitigation and hygiene; this alone could save thousands of lives each year in the near future. Emergency plans and preparedness were given a good shake-off and examination and evaluation, as well as the full spectrum of immunization capabilities and production methods (modern antiviral drugs too).

Here's hoping it doesn't do much more before dropping off and also that it doesn't come back in some more virulent form in the fall; even if it does, all these steps taken now will serve us well.

[quote=only_human;172490]The timing of this outbreak when the flu season was winding down and even the fact that it was detected as an outbreak at all will serve us in good stead. It let all the tools developed over bird flu and SARS be dragged out and utilized before they dissipated into complacent neglect. < snip > Emergency plans and preparedness were given a good shake-off and examination and evaluation, as well as the full spectrum of immunization capabilities and production methods (modern antiviral drugs too).

< snip > all these steps taken now will serve us well.[/quote]Indeed. All your points are also made in more detail here:

"In swine flu, key moments and decisions lie ahead"

[URL]http://news.yahoo.com/s/ap/20090509/ap_on_he_me/med_swine_flu_pivotal_moments[/URL]

[quote]WASHINGTON – The most pivotal moments in the swine flu saga are yet to come.

Will it sweep through impoverished Southern Hemisphere countries in the next few months? Will it roar back in the rest of the world in the fall? And who will be vaccinated if it does?

In the weeks since swine flu grabbed international attention, and even years before that, some important actions have helped shape the course of this outbreak and the ways the world will handle future epidemics.

. . .

"We've been given an opportunity to take a look at this before it really got bad, and we need to," said Dr. Michael Osterholm of the University of Minnesota, a prominent pandemic flu specialist. "We better damn well do it now because one day we are going to really be in it for more than a week. If it's not this virus, there will still be another one."

For this virus, the coming months will bring a series of big decisions: Do manufacturers start brewing millions of swine flu vaccine doses? Will they be stockpiled unless the new flu returns or given along with or soon after regular flu shots? Will rich countries share enough with the developing world? Who gets in line first — the younger people that this strain so far seems to target or the elderly who usually are flu's most vulnerable?

"You may only have one chance to get out ahead of it," Dr. Richard Besser, acting chief of the Centers for Disease Control and Prevention, told The Associated Press. "It's important for people to understand that all of these decisions will need to be made with incomplete science."

___

THE FIRST TURNING POINT

A different virus was the world's wake-up call. SARS (severe acute respiratory syndrome) started in China, and once it broke out of the mainland in early 2003, it took just weeks to infect more than 8,000 people from 37 countries. The virus killed more than 770 people before it disappeared.

Governments started scrambling to put together plans to handle the next global disease threat. Soon after, bird flu hit Asia, reinforcing the need.

Had the new swine flu hit sooner, before all that pandemic planning, it almost certainly would have spread faster. Even if it proves no more dangerous than garden-variety flu, that's deadly enough; a pandemic is more about geography than super-lethality. ...

. . .

UNCOVERING THIS THREAT

As early as February, people in the Mexican hamlet of La Gloria were suffering unusually strong flu symptoms. When officials arrived to investigate in mid-March, nearly half the 3,000 villagers came out seeking medical help. About 450 were diagnosed with acute respiratory infections and given antibiotics. Mexico was investigating, but not until April 12 would the outside world — the CDC and Pan American Health Organization — start getting official word of the unexplained illness that eventually would be blamed for dozens of deaths throughout Mexico.

By then CDC already was on the trail of swine flu in California. The virus had spread before anyone knew it existed.

Preparation had paid off. In its pandemic planning, the U.S. starting in 2005 put money into researching better influenza detection. Studies of new methods found two unrelated children in San Diego with a strain of Type A influenza that turned out to be a never-before-seen type of swine flu. Puzzled, CDC announced the cases and started hunting more. On April 23, the agency confirmed five more illnesses in California and Texas and put all states on alert.

"At what point does unusual become concerning and at what point does concern lead to action?" Besser said. "We had to make that call."

That same day, CDC and a Canadian lab that Mexico had consulted delivered the bad news: The new flu was in Mexico, too.

Could Mexico have signaled a problem sooner? The Pan American Health Organization dismisses the question as one for historians.

"We would have done everything the same if we had it to do over again," said Hugo Lopez-Gatell Ramirez, deputy director of Mexico's Intelligence Unit for Health Emergencies.

___

AGGRESSIVE ACTION

. . .

Overall, "what happened was not overreaction. It was a prudent response," said Michael Leavitt, the Bush administration health secretary who led development of the U.S. pandemic flu plan and advised other governments on theirs. "If imminent information about terrorism is known to authorities, they need to react. A pandemic is sort of nature's terrorist."

Young children tend to be initial spreaders of regular winter flu, taking it home to family and friends, which is one reason that school closings are included in pandemic plans. But in this case, travelers were early spreaders.

"I'm not saying that was the right approach or the wrong approach, but what we've learned is we need to be proportionate in our response with what the risk is in our community," said flu specialist Osterholm.

___


PANDEMIC OR NOT

The World Health Organization, following its post-SARS guidelines, declared an international emergency the day after Mexico's outbreak made headlines, to spur countries to check where else the new flu had spread — eventually to two dozen countries and counting.

Days later, the WHO issued an unprecedented warning: The world was close to a full-fledged pandemic. Sustained spread in regions beyond North America, rather than smallish outbreaks, would tip the scale.

For years, the U.S. had run drills. What would it do if bird flu started rapidly spreading in Asia? Close the borders to buy a little time. Reality brought a surprise.

The new swine flu started in North America, too late to close any borders. While the U.S. joined other countries in discouraging travel to hardest-hit Mexico, and some nations discouraged travel to the U.S. and Canada, too, once flu starts spreading in numerous places, such actions have little effect.

. . .

STILL TO COME

What happens to all those antiflu medicines that were shipped to U.S. states but not used? They're waiting, under guard, in case they're needed come fall. Leavitt, the former health secretary, said that's the next weakness. Flying in drugs is easy; getting them to the sick is hard.

"The further into a pandemic you get, the more spontaneity that's required and the more lack of preparation reveals itself," he said.

Then there's the vaccine dilemma.

Makers could be told to start brewing doses in a few weeks. But that will take months and require testing, led by the U.S., of initial shots to see if they induce immunity, with one dose or two, and seem safe. The last mass vaccination against a different swine flu, in the U.S. in 1976, was marred by reports of a paralyzing side effect — and that time the flu didn't return.

"One of the lessons of the '76 experience is to take account of the uncertainty," said Institute of Medicine President Harvey Fineberg. "Be able to take account of new information to modify your course."

If vaccine is ordered, would developing countries get a fair share? The WHO is calling vaccine makers together in late May to push for fair access. Regardless, any shots will come too late for the Southern Hemisphere, where influenza season is about to start.

World authorities will closely track the new swine flu there, for help deciding whether to order vaccinations for the rest of the world starting in the fall. The big worry is that the virus will mutate, becoming more severe.

"The thing that's keeping me up at night right now is that feeling of dodging the bullet, in the sense that people are taking a sigh of relief too soon," the CDC's Besser told the AP.[/quote]