Larry Wein --- Terrorism, Bird Flu, and N95 Masks

"DESPITE all the attention given to anthrax and smallpox and potential weapons of mass destruction, pandemic influenza is probably the world’s most serious near-term public health threat. "

This is the way that Larry began his NYTimes OpEd Piece on the Threat of H5N1 Influenza. Larry is famous for his work on terrorism, especially the economic balance of threat and defense. Larry brings energy, originality, and lots of common sense to important problems that are often left entirely in the hands of beltway bandits.

Please do read Larry's piece. I'll only slice out one fact --- specifically one that reverses what I had earlier assumed. It has to do with the effectiveness of N95 Masks versus hand hygiene. The bottom line in that for the highly pathogenic viruses like H5N1, the role of hand hygiene does not seem to be nearly as important in preventing infection as it is for the rhino virus of the common cold.

The good news is that the weight of evidence is that N95 masks are likely to substantially decrease an individual's probability of infection. This has a double benefit if masks are widely used since the epidemiological rates would also decrease.

Is Your "Canadian Internet Pharmacy" in Pakistan? Now You Can (Almost) Tell

It has often been acknowledged here that many people want to buy Tamiflu so that they will have it on hand in case of an H5N1 pandemic. US public health officials take the view that this is not in the public interest, and they have put impediments in the way of individuals who want to obtain Tamiflu for this purpose. These impediments drive buyers to less reliable sources, such as internet pharmacies.

High Density of Rotten Eggs

Internet pharmacies that will supply Tamiflu without a prescription must accept as part of their business plan that they will operate at the margin of the law. This does not necessarily mean that they provide bogus products, but it certainly does increase the odds.

In earlier posts on this blog, I have explored several devices for ferreting out some of the most dubious practices of internet pharmacies. Most of these hunts involved detective work around the pharmacy's telephone number.

New Tool --- Locate the Origin of a Website.

Digital Point provides a free, easy to use Geotargeting Tool. Just plop in a site URL, and out pops the location of the web host. This works like a charm for all of your familiar sites.

It seems like a great way to check out "Canadian" pharmacies, right?

So, What Happened? Where Are They Hosted?

I checked as many sites as my attention span would permit. Every "Canadian" pharmacy that I examined had taken great lengths to avoid geographical identification of the IP address. Repeatedly, the geotargeting software gave only humorous interpretations of "location not found."

Here is a typical example:

Location of http://www.cantrustrx.com
Country: Atlantic Ocean
Region: 20,000 Leagues Under The Sea
City: Lost City Of Atlantis


Bottom Line?

The firms engaged in the Tamiflu-with-no-Prescription business tend to take clever internet steps to cloak their country of origin --- even while they splash big ink claiming to be Canadian.

The internet is large, and there may be exceptions to what I have found. To discover the exceptions will call for lots of persistence --- and the kind of luck that turns up needles in haystacks.

Michael Trick's OR Blog and Logistical Planning for a Bird Flu Pandemic

I am off to Rio very shortly, and I will be away for two weeks.

While I am on the road, I will complete up some long incubating posts, but, before I go, I want to post up a quick link to Michael Trick's OR Blog.

In one of his recent posts, Michael mentions the dreadful state of US Emergency rooms, and --- in essence --- he puts out the call for logistical help from the OR community.

I'd like to echo the sentiment from the "bird flu planning community."

Logistical nightmares are at the heart of every H5N1 pandemic senario anyone has ever concocted, yet it is hard to tell if anyone in the OR community is currently looking hard at this.

Isn't it clear that pandemic logistics is a research area that deserves encouragement at every level?

Let's at least catalog what is being done --- or not being done!

Paris Hilton vs Bird Flu: How Do the Internet Mindshares Compare?

One of the most human of qualities is to wonder what other people are thinking.

It's a given that readers of this blog often consider the ways that an H5N1 pandemic are likely to impact society. We have taken the task as our own. Still, it's plain as day that not too many have a comparable level of concern.

So, How About the Average Joe?

In the past, it would have been very expensive to try to compare how much mindshare the world places on "Bird Flu" versus some other topic of pressing world concern --- say, for example, "Paris Hilton."

An honest survey would cost at least several grand. Moreover, even if one is willing to pay, it is not easy to line up a competent polling firm.

Now, amazingly enough, you can get a very useful indication for free.

What's the Trick?

The Digital Point Keyword Suggestion Tool will answer for you the question:

"Today, how many people did an internet search for 'name your phrase'."

For the moment, let's not second guess how Digital Point designed their box. This is intriguing technology, and it deserves a careful look. Still, let's first just see if this nifty tool tells us anything interesting about public concern about bird flu.

So, What Happened?

Pessimist though I am, I was still surprised by the results: (1) "Bird Flu" --- 5,900 searches per day and (2) "Paris Hilton" --- 110,000 searches per day.

Bottom Lines?

Many people who have concerns about the possibility of a bird flu pandemic will have asked themselves, "Am I the only one concerned about this?" Well, the first inference is "Yes, there are many concerned people, but almost 19 times as many are concerned about what's up for Paris Hilton."

In other words, bird flu still has quite a trivial public mindshare.

The second inference is that we now have a stunning new way to use internet search data to help us understand public opinion. For me, this second inference is HUGE.

Entire careers have been made out of less --- much less.

Hand Hygiene: The Boring Way to Save a Few Hundred Thousand Lives (or More)

Donald Goldman, M.D. began his article in the New England Journal of Medicine with the true story:

"A new mother sits by her tiny, premature baby in a neonatal intensive care unit. She watches as a physician touches the baby without first washing his hands or using the waterless, alcohol-based hand antiseptic just a couple of feet away. A few minutes later, a nurse and then another doctor also fail to perform these basic procedures. When her baby was admitted to the unit, the mother was told to remind caregivers to wash their hands, but only after witnessing repeated failures does she muster the courage to speak up about the practice she thought would be routine. By then, her baby has acquired methicillin-resistant Staphylococcus aureus (MRSA) probably transported on the hands of a caregiver who had been examining other babies who are colonized with MRSA. A few days later, MRSA invades the baby's bloodstream; it eventually proves fatal. Such preventable infections, caused by the failure to practice hand hygiene, are far from rare, and they occur in many of the finest neonatal intensive care units in the United States."

Beyond Neonatal Care

The challenge of this blog is not to improve neonatal care, but to think through the likelihoods, possible evolutions, and ultimate denouement of an H5N1 pandemic. Still, there are implications of Goldman's report that are directly relevant:

1. Even among experts and even in highly aware environments, there are repeated incidents of faulty hand hygiene that cost lives.
   
2. Given this and given a pandemic influenza, how many lives might be saved by improving the hand hygeine of the "average Joe"?
   

A Measure of the Benefits

There are only a few things that one can do to increase the probability of living to see the other side of a HPAI pandemic:

1. Social distancing --- the more the better. Self-quarantine is best.
   
2. Hand hygiene
3. Use of N95 (or better) masks when exposed to outsiders
4. Appropriate use of antiviral drugs, such as Tamiflu or Relenza

Each of these measures is capable of cutting your mortality risk by a substantial factor. Naturally, the sizes of these factors are subject to debate, and the realized values will depend on the features of the pandemic.

Anyone can place a bet. If I were to put my money on the values for the discount factors, I would suggest:

1. Social distancing is HUGE. It should at least buy you a factor of 3 and might buy you a factor of 10 depending on the nature of the pandemic and how well you can genuinely isolate yourself.
2. Hand hygiene is likely to buy you a factor of 3 to 5. If you cannot achieve serious social distancing, this is a very important factor.
   
3. Masks are useful, but even if appropriately used they may only buy you a factor of 2. Most likely, they will buy you less.
   
4. Finally, antivirals have been observed to cut serious side effects of 'regular' flu by a factor of 5 or so. Many people expect this ratio to hold up in the case of H5N1. Governments around the globe are making serious bets that this factor, or a larger one, will apply.

Bottom Line

People who can effectively execute all of these defenses will probably be able to cut their risk by a factor of 120 to 400. In the commonly assumed 'worse case' model with 2% US fatality rate, this would cut your probabilities to perhaps about one chance in 10,000.

This is a risk one can live with.

----------------------------
Many Thanks to Dean Foster who provided the reference that motivated this note.

Bird Flu Found in Philadelphia

A Philadelphia live fowl market was closed Wednesday after discovery of bird flu in the inventory.

The press release from a department of agriculture hit the web via brief report from CattleNetwork.com. I am sure this site has never had so many hits from Philadelphia.

To be sure, the flu in question was not H5N1.

What's the Subcontext?

It will be interesting to see what comes of this storm in a tea kettle. If we see more than the tiniest of ripples, then we get some sense of the gale force winds and waves that will come from serious news about H5N1 in an American city.

Paranoid Products: Are We There Yet?

Let me be the first to assert: I am not paranoid about bird flu --- just cautiously pessimistic.

Besides, why shouldn't one make regular use of products like alcohol-based hand cleaner? The new hand cleaners feel good, and they make good health sense even in a non-pandemic world.

Going a step further and acquiring N95 masks, Tamiflu, and a few months of emergency food supplies --- well, these are more substantial actions. Nevertheless, there is nothing in this list that has not been strongly advocated by one or another of the world's leading health experts.

A Product Too Far?

Still, there are products that do go too far, and I am not talking about HEPA air filtering systems for the home. HEPA systems are expensive and perhaps over-the-top, but one can still make a solid argument for them. At a minimum, seasonal allergy sufferers are likely to get valuable help.

No, to qualify as a paranoid product, it has to be truly goofy.

Yes, candidates are starting to appear. One of these was recently reported at Strange New Products, one of my favorite sites. Are you ready?

Sanitary Handles for Shopping Carts!

The product post for July 04, 2006 observes that the Healthy Handle helps you push around a shopping cart without having to worry about getting germs on your hands. It's your first line of defense against the dreadful shopping cart-borne diseases.

The product review notes that "the red plastic handle can be slipped over a shopping cart's handle. When not in use, it can shrink down by pushing the ends together, like a telescope."

You've got to check out the picture via SNP's Perma Link: Sanitary Handle.

Fun to laugh at; insane to buy.