Thursday, July 31, 2008

A Tale Of Two Scenarios

# 2194

Earlier this week I highlighted a video of an ethics seminar held by by the Minnesota Department of Health and the University of Minnesota Center for Public Health Preparedness.

Here is a link to that presentation.

Ethics in the Worst of Times: Rationing to Protect the Public's Health during a Severe Influenza Pandemic

This event took place on June 5, 2008.

Contained in the first video was a slide graphically illustrating each state's planning assumptions about the type of pandemic they are preparing for.

As you will see, there is a wide divergence of opinion.

Roughly 20% of our states are preparing for a severe 1918-style pandemic, while 20% are preparing for a moderate (some might even say `mild') event.

For the remaining 60% of our states, the severity level they are preparing for is ambiguous.

States in White are planning for a moderate pandemic, orange colored states are planning for a severe pandemic, and the plans for gold colored states are ambiguous on this point.

This graphic also appears in the powerpoint presentation by Dorothy Vawter, PhD. entitled Age-Based Rationing in a severe Pandemic. This chart is current as of Sept.2007.

I'm aware that Michigan has recently released an addendum to their pandemic plan, and that may move them into the ambiguous column.

While no one can know what the next pandemic will bring, the U.S. federal government has adopted the attitude that it is prudent to prepare for a severe 1918-style pandemic.

The HHS defines a severe pandemic as:

    • An attack rate of 30% (90 million Americans sickened)
    • 50% (45 million) requiring outpatient medical care
    • 11% (9.9 million) requiring hospitalization
    • 745,000 requiring mechanical ventilation
    • 1.9 million deaths (2.1% fatality ratio)

A moderate (1958/68-like) pandemic is described as follows:

    • An attack rate of 30% (90 million Americans sickened)
    • 50% (45 million) requiring outpatient medical care
    • .9% (865,000) requiring hospitalization
    • 64,875 requiring mechanical ventilation
    • 209,200 deaths (.23% fatality ratio)

In other words, while the number of people affected doesn't change, a severe pandemic is envisioned to be about 10 times worse than a moderate one.

A quick check of some of these state's pandemic plans reveals that the definition of a `moderate pandemic' varies greatly. We'll look at two states (Georgia & South Carolina), and compare their assumptions with the Federal guidance for a pandemic event.

Georgia, with a population of roughly 9.3 million people, assumes the following:

Most noticeable here is the estimated attack rate of less than 15% (half of the Federal estimate for a moderate pandemic).

Since the rest of their numbers are based on a percentage of the number made ill by a pandemic virus, those numbers are proportionately lower as well.

South Carolina, with 4.3 million residents, acknowledges an attack rate of up to 35%, but their case fatality ratio is a little more than 1/3rd of 1%.

The upshot of all of this is that if we see a severe pandemic, tens of millions of Americans will reside in states that only prepared for a moderate event.

South Carolina, which is only expecting a maximum of 16,800 flu-related hospitalizations could, under the federal scenario, find that 150,000 of their residents could need hospital care. And instead of 5,000 deaths, they could be looking at 28,000 flu-related fatalities.

Similarly, Georgia could find that instead of 1.14 million people clinically ill, that they must deal with nearly 3 million. Instead of 22,000 requiring hospitalization, they may find the demand is closer to 300,000. And the number of deaths could exceed 58,000 - not the 6200 assumed in their plans.

The Federal assumptions are guidelines, and states are free to use their own judgement in deciding what kind of crisis to prepare for. If we see a mild pandemic, then I suppose those states that prepared for a moderate event will feel pretty good about themselves.

But if the next pandemic is like 1918, or worse . . . then states that prepared for a moderate pandemic are likely to find their plans inadequate for the task at hand.

And if that happens, then there are going to be a lot of state and local officials with some explaining to do.

Wednesday, July 30, 2008

Thailand : 4 Bird Flu Suspect Cases Test Negative


# 2193






Via  The Nation, we get word that the 4 suspect bird flu patients we learned about this morning  have tested negative for the H5N1 virus, according to the Thai Public Health Ministry. 





Four test negative for bird flu

By The Nation
Published on July 31, 2008

Four people in Phichit province who were suspected of having contracted the birdflu virus have tested negative for the disease, the Public Health Ministry said yesterday.


Deputy permanent secretary Dr Paijit Warachit said he ordered the mobile rapid diseaseinvestigation unit to collect blood samples from the four for testing against the H5N1 strain of the virus at Nakhon Sawan's provincial Science Centre.


The laboratory results found that none of the four had the H5N1 virus, which can be lethal to humans. Three of them are suffering from seasonal influenza, while the fourth has no flu whatsoever.


The four people tested were Krisada Tiangtham, six years old, Nadda Tiangyoo, 10, Tabtim Promsri, 62, and Wanna Toramram, 70. They all remain under observation in Phichit's Sam Ngam Hospital. Krisada does not have the flu.


The four reported they had come into contact with dead chickens in their village before falling ill. Three days later, they had a high fever, and it was feared they had been infected with the H5N1 strain of the birdflu virus.


Paijit has asked healthcare volunteers in Sam Ngam district to monitor the symptoms of the relatives of the three patients with seasonal flu for the next 12 days. If any suspicious symptoms are found, they will also be sent to hospital immediately.


He also urged villagers to avoid cooking food using chickens or ducks that have died suspiciously. Villagers should incinerate any such poultry in order to minimise the risk of the H5N1 virus spreading to other areas, he said.

Japan's Pandemic Assumptions Released



# 2192



While Japan's government has been fairly proactive in their pandemic preparations, including the acquisition of  20 million doses of pre-pandemic vaccine, little progress has been made in their private sector.   


Earlier this month we saw a survey that showed a surprising lack of pandemic preparation in that nation's business sector.



Thursday, July 10, 2008

Many public firms not ready for flu pandemic

Kyodo News

A majority of listed companies surveyed have devised no countermeasures for a new type of influenza that some fear may develop, a think tank survey showed Wednesday.


According to the InterRisk Research Institute & Consulting Inc. survey, 52 percent of 448 firms surveyed said they have no plans to work out measures against a possible new influenza pandemic for which people have little immunity.




In a move that hopefully will spur the private sector into action, the Japanese government has now released their own pandemic assumptions, along with a call for businesses to prepare.


The pandemic scenario envisioned by the Japanese government closely matches the United States, and some European nation's, pandemic assumptions.


Roughly 40% absenteeism, an attack rate of 25%, and a CFR (case fatality ratio) of 2%.


Of course U.S. officials are quick to point out that while this would be a severe scenario, comparable to the 1918 Spanish Flu, it isn't the worst-case scenario.  



This from the Yomiuri Shimbun.  (Highlighting is mine)



40% of workers might have to stay home in flu pandemic


The Yomiuri Shimbun


The Health, Labor and Welfare Ministry estimates that up to about 40 percent of the workforce would be forced to stay home in the event of an influenza pandemic.



The ministry estimates that the pandemic also could cause social and economic problems, such as medicine shortages and power outages.



For the first time, the ministry released estimates of problems that could be caused by a flu pandemic, hoping companies and other organizations would draw up preparatory measures.



The ministry also released a revised outline of suggested actions for companies in case of an outbreak.



Estimates were based on the human suffering figures in government's pandemic relief action plan--revised in October. The plan estimates 25 percent of people would suffer from a new influenza pandemic, with a fatality rate of 2 percent.



The ministry used figures mentioned in preparedness plans by countries in Europe and North America to estimate the absentee rate of employees.



According to the ministry's estimates, it would take about two to four weeks before a new strain of influenza virus reached Japan from abroad.



Up to 40 percent of company employees would not be able to come to work for about 10 days because of sickness or caring for sick family members, the ministry estimates.


As a result, business activities would be seriously affected. Power, gasoline and supplies of other necessities would be temporarily stopped, and imports would also be halted. Companies would have difficulty raising funds and settling accounts.


The ministry estimates that there are five stages in the development of the pandemic: a pandemic outbreak in foreign countries; the arrival of the virus in Japan; a large outbreak in the country; a pandemic outbreak; and the aftermath of the pandemic.



The ministry categorizes likely ill effects from a pandemic into 11 social fields, such as public transportation and medical services.



In the event of a pandemic influenza outbreak, the ministry would call on companies to temporarily scale down nonessential business activities to prevent the spread of infection.

(Jul. 31, 2008)



Dead Birds Raise Flu Fears In West Bengal



# 2191





And from  Crof over at Crofsblog, we get this story from West Bengal, where hundreds of dead chickens were found dumped by the side of a road.  



No samples were taken for testing, as the police just ordered the villagers to bury the evidence.



Cooch Behar is located in the northern part of West Bengal, and was the site of culling during India's massive bird flu outbreak earlier this year.







Flu fear after dead birds surface







The dead chickens beside NH31. (Main Uddin Chisti)


Cooch Behar, July 29: More than 300 dead chickens in a highly decomposed state were found lying beside NH31 this morning, triggering a bird flu scare in the area.



The administration is still in the dark about how such a large number of dead broiler chickens were thrown beside the highway, about 10km from here. Three dogs died after eating the birds, sources in the administration said.



Earlier this year, birds had been culled in Cooch Behar district, when chickens in a poultry in Dinhata’s Gitaldaha were detected with the bird flu virus.



Today, the local people set up a roadblock in the area, about 50km from Gitaldaha, from 7am to 10.30am to protest against the stink that had been emanating from the place.



The block officer of the animal resources development department, Swapan Das, said: “We are not yet sure where from the dead birds came. Collecting samples from them will be futile because they have all rotted.”


(Continue . . .)

CIDRAP NEWS: GAO Report On State Pandemic Preparedness



# 2190



From Lisa Schnirring of CIDRAP (Center for Infectious Disease Research & Policy) News we get an excellent overview of the recent GAO report on how well states are preparing for a pandemic, and their need for more guidance from the Federal government.


Here are just the leading paragraphs to this story, follow the link to read the entire article.








GAO: States want more pandemic planning guidance


Lisa Schnirring * Staff Writer

Jul 29, 2008 (CIDRAP News) – Despite a wide range of pandemic planning guidance documents from federal and private groups, states say they still need more information from federal officials, particularly on community mitigation measures, fatality management, and supporting medical surge efforts, the Government Accountability Office (GAO) reported recently.



The GAO released its findings on Jul 19 in a 52-page report posted on its Web site. Members of Congress had asked the GAO to describe how states and localities were preparing for a pandemic, along with how they handled their pandemic exercises, what they learned from them, and how the federal government can better assist state and local officials with pandemic planning.



The GAO based its findings on visits to the five most populous states, California, Florida, Illinois, New York, and Texas, and ten localities within them. The localities included five urban areas—Los Angeles County, Miami, Chicago, New York City, and Dallas—and five rural counties: Stanislaus County, California; Taylor County, Florida; Peoria County, Illinois; Washington County, New York; and Angelina County, Texas. Taken together, the areas include a third of the US population and account for a third of federal funds for pandemic planning exercises, and they also are border areas or international travel hubs. All 15 of the sites had developed pandemic plans.

(Continue reading . . . )

Report Out Of Thailand


# 2189


















There is nothing confirmed here, but this story has appeared in at least 2 major newspapers (Thaindian News, The Nation) overnight.  Reports state that either 4 or 5 people are in isolation with `bird flu-like symptoms' in Phichit.



It should also be noted that just a few days ago Phichit Medical authorities reported the heaviest Dengue outbreak in six years, and the Governor has declared 12 districts a disaster area.


Thailand has not reported a confirmed human infection from the H5N1 virus since the summer of 2006.



A Hat tip to Treyfish on Flutrackers for this story, and Carol@SC of the Wiki for the Dengue update.



Whether H5N1, or Dengue, or something else entirely - we probably won't know what these 5 people are suffering from before the end of the week.



Local authorities appear to be taking this seriously, so this is certainly something to watch.





5 in birdflu scare

By The Nation
Published on July 30, 2008


Five people admitted to Sam Ngam Hospital in Phichit with bird flulike symptoms have all had mysterious deaths of poultry near their homes.


Provincial health chief Prajak Wattanakul and a disease conrol team went to the hospital yesterday afternoon to visit the five, who were kept in isolation.


   They were Krisada Thiangyu, six, Nadda Thiangyu, 10, and Taptim Phromsri, 62, from Tambon Noen Por; Wanna Tolamlam, 70, from Tambon Nong Son, and an unnamed fiveyearold boy.


   The five reportedly touched dead fowl with their bare hands and a few days later developed fevers, coughing, exhaustion and breathing problems. Lab tests on blood samples should yield results in one or two days.


   Officials were dispatched to watch out for the disease.

Tuesday, July 29, 2008

Video: Ethically Rationing Scarce Resources In A Pandemic



# 2188




Via CIDRAP (Center For Infectious Disease Research & Policy) we get this link to two seminar videos from the University of Minnesota's  School of Public Health website on a seminar on the ethics of rationing scarce resources during a pandemic. 


This seminar was sponsored by the Minnesota Department of Health and the University of Minnesota Center for Public Health Preparedness, and was held on June 5th, 2008.



Specifically, addressing the difficulties of  rationing:


  • Antivirals (Prevention/Treatment)
  • N95's (PPE)
  • Masks (PPE)
  • Vaccine (Prevention)
  • Ventilators (Treatment)


The recommendations in the video are advisory, and are not mandates.   They are also provisional, as they intend to get public input before putting a final version out.



The two videos run about 2 hours total, and require Real Player.





Ethics in the Worst of Times: Rationing to Protect the Public's Health during a Severe Influenza Pandemic

This event took place on June 5, 2008.


Who should be first to receive scarce health-related resources in a severe pandemic? How should scarce resources like antivirals, masks, vaccines, and ventilators be rationed? How will you communicate a public health perspective to your community, supporting rationing strategies to further our common good? How will you educate them and enlist their support of a state-wide plan to ration these resources in ways intended to save the most lives, preserve public safety and order, and be fair?


Ethicists in Minnesota have worked with state and local public health agencies and a diverse community panel to develop an ethical framework to guide the Minnesota Department of Health's decisions in the midst of a severe pandemic, for the statewide rationing of a range of critical health-related resources for prevention, treatment and personal protection.


In this session, they will present their ethical framework, consisting of principles, goals, and strategies. They will engage you in the vexing ethical issues associated with deciding which groups should be prioritized to receive these vital resources when everyone is, in varying ways and to varying extents, at risk.


To watch the streaming video, your computer needs:

  • Internet connection with a 56K modem or faster.
  • Sound card with speakers so you can hear the audio portion of the course.
  • Real Player Software - if it isn't installed on your computer, download it for free at

Click below for videos from June 5, 2008




Debra A. DeBruin, PhD, is Director of Education in the Center for Bioethics, University of Minnesota.

J. Eline (Ellie) Garrett, JD, is the Assistant Director for Health Policy and Public Health for the Minnesota Center for Health Care Ethics in Minneapolis.

Angela Witt Prehn, PhD, is a Center Associate for the Minnesota Center for Health Care Ethics and an adjunct professor, University of Minnesota.

Mary Faith Marshall, PhD, is Associate Dean for Social Medicine and Medical Humanities and Professor of Family Medicine and Community Health, University of Minnesota Medical School.

Web Conference On Health Bloggers Today


# 2187




A reminder that HHS Secretary Leavitt will be delivering the Keynote Address to this conference, which may be viewed online today.






The Health Blogoshpere: What It Means for Policy Debates and Journalism


LIVE on Tuesday, July 29 at 1 p.m. ET: View a webcast of a discussion sponsored by the Kaiser Family Foundation on the growing influence of blogs on health news and policy debates. Submit questions before or during the event to



Rakesh Singh
(202) 654-1313
Tiffany Ford
(202) 347-5270

On Tuesday, July 29, the Kaiser Family Foundation is sponsoring a discussion about the growing influence of blogs on health news and policy debates. Only in the past few years has the blogosphere become mainstream. In the health policy arena, we now see policymakers, journalists, researchers and interest groups utilizing this new media tool to deliver information to their audiences.


The briefing will highlight how the traditional health policy world has embraced blogging and will feature a keynote address by U.S. Department of Health and Human Services Secretary Michael Leavitt, the first cabinet officer to author an official blog, followed by a moderated discussion with a variety of health policy bloggers and a media analyst.


Questions to be explored with the panelists include: Why do individuals and organizations blog? How does blogging impact the broader work of an organization? Are there different standards used when blogging versus other writing? Have blogs impacted the news business significantly? What kind of influence are blogs having on political and policy debates?


Welcome and Introduction


Drew Altman, President and Chief Executive Officer,
Kaiser Family Foundation

Keynote Address


The Honorable Michael O. Leavitt
Secretary, U.S. Department of Health and Human Services

Panel Discussion


Vicky Rideout (moderator)
Vice President, Kaiser Family Foundation and
Director, Kaiser Forum on Health Journalism and the News Business

Jacob Goldstein, Wall Street Journal

Michael Cannon, Cato Institute

Ezra Klein, American Prospect Magazine

John McDonough, Office of Senator Edward Kennedy and formerly of Health Care for All in Massachusetts


Tom Rosenstiel, Center for Excellence in Journalism

WHEN: Tuesday, July 29, lunch served at 12:30 p.m. and program begins at 1:00 p.m.


WHERE: Barabara Jordan Conference Center , 1330 G Street, NW , Washington , DC . For those who cannot attend, the event will be webcast live.


RSVP: If you plan to attend the event, please send your name and affiliation to

BlogEx: Final Day


# 2186










Today is the last official day of the Southeastern District Health Department's BlogEx pandemic exercise.    There is much to see and think about on this website. 


My congratulations to Darin Letzring, the All Hazards Planner with the Southeastern District Health Department in Pocatello, and everyone else connected with this project.    Hopefully this will inspire others to follow suit, or to come up with some other innovative way to use the Internet to spread pandemic awareness.








July 29: Scenario Update

July 29, 2008

This is an exercise. It is not real.

Good morning.  Today is the last day of the blogex. Yesterday’s mock news cast created the situation that pandemic has peaked here in Southeast Idaho. Tomorrow begins the Emergency Operations Center and Alternate Care Site portions of the exercise.


Now ask yourself: What am I doing? What am I eating? What am I drinking?  Where are my family and friends? What about my workplace?  Consider two, four, six weeks down the road with continued sickness, absenteeism at work, supply chain problems, and deaths.  The way to prepare for it is to visualize your daily life amongst all the problems. Some of the simplest things like having enough drinking water could become very difficult.


We’ll have a short wrap-up post in a day or two.

Apparently They Didn't Get The Memo



# 2185



Today we are seeing what appears to be damage control coming out of South Korea regarding the H5N1 infected cat announced yesterday.  I use the term `damage control' because it is a euphemism that almost everyone understands.


The assertions in the article below are so blatantly misleading, so contrary to the facts, that one must wonder who is at fault here.  The Korean spokesperson, or the reporter. 



I've highlighted the most egregious statements in red.





SKorea cat had bird flu: officials 


SEOUL (AFP) — A cat found dead in a South Korean city was infected with a virulent strain of bird flu, the first mammal in the country known to have had the H5N1 virus, health officials said on Tuesday.


They said it was the first report of a cat having had the virus since a case in Thailand in 1996, but that there was little risk to humans as there has never been a known transmission of the virus from a cat to other mammals.


"It is quite rare for a cat to be infected by the avian flu virus," said Cho Hyun-Ho, a deputy director of the National Veterinary Research and Quarantine Service.


Cats and dogs are usually not susceptible to the virus, so quarantine officials only normally check animals that have regular contact with birds.







First known cat infection in 12 years.   Very rare occurrence.   Dogs and cats are not generally susceptible . . .


Very comforting.   



Nothing to see here folks.  Move along.  You can go back to sleep.  Sorry to have bothered you.




Since I don't know the motivation behind these misstatements (although I can certainly guess), I'll skip over my righteous indignation (for now) and simply provide some `conflicting' data. 


Notice that none of these examples go back to 1996.  Where they got that date, I can't even begin to imagine.



(The bolding and highlighting of passages in the following articles is mine) 



First there's this, from the WHO (World Health Organization).



H5N1 avian influenza in domestic cats

28 February 2006


Authorities in Germany have today announced detection of H5N1 avian influenza in a domestic cat. The cat was found dead over the weekend on the northern island of Ruegen. Since mid-February, more than 100 wild birds have died on the island, and tests have confirmed H5N1 infection in several.




Experimental studies, published in September 2004, demonstrated that the H5N1 virus can infect domestic cats, and that cats can transmit the virus to other cats. In these experiments, the cats developed disease following direct inoculation of virus isolated from a fatal human case, and following the feeding of infected raw chicken.




Several published studies have demonstrated H5N1 infection in large cats kept in captivity. In December 2003, two tigers and two leopards, fed on fresh chicken carcasses, died unexpectedly at a zoo in Thailand. Subsequent investigation identified H5N1 in tissue samples.


In February 2004, the virus was detected in a clouded leopard that died at a zoo near Bangkok. A white tiger died from infection with the virus at the same zoo in March 2004.


In October 2004, captive tigers fed on fresh chicken carcasses began dying in large numbers at a zoo in Thailand. Altogether 147 tigers out of 441 died of infection or were euthanized. Subsequent investigation determined that at least some tiger-to-tiger transmission of the virus occurred.




And of course, we have this article from the New Straits Times from the summer of 2006.  Notice that the statement comes from a WHO medical officer.




Indonesian cat found infected with bird flu virus

19 Jun 2006
Amy Chew in Jakarta

A CAT has been found infected with the deadly H5N1 virus in Indonesia, in the first such case in the country.

Steven Bjorge, Medical Officer for Communicable Disease of the World Health Organisation said the cat was infected after having eaten contaminated birds.

“We have evidence from one cat in Indonesia that has already been infected by this virus,” he told Jakarta’s Foreign Correspondents’ Club.

Yesterday’s disclosure came just days after Indonesia confirmed its 38th death from avian influenza caused by the H5N1 virus, placing the country in second place behind Vietnam’s 42 deaths.

(link no longer active)



And then there's this from the Veterinary Sciences Tomorrow journal.



24 March 2006

Infection of cats with H5N1 Avian Influenza Virus

Compiled by Etienne Thiry (Liege/B), with the assistance of Diane Addie (Glasgow/UK), Herman Egberink (Utrecht/NL), Katrin Hartmann (Munich/D), Hans Lutz (Zurich/CH) and Hervé Poulet (Lyon/F).


The H5N1 subtype of Avian Influenza Virus type A, a member of the Orthomyxoviridae family, occurs primarily in birds. Transmission to mammals happens sporadically, and the infection then may cause disease with a high morbidity and a high number of deaths among ill animals. Humans, primates, rodents, lagomorphs, mustelids and felids, including the domestic cat may be infected and may succumb to the disease. A listing of susceptible species is given HERE .


Infection of cats

Felids can be naturally and experimentally infected with H5N1 virus.


In February 2004, infection of household cats was reported from Thailand (WHO, 2004); also from that country, two outbreaks of fatal disease in tigers and leopards have been published (Keawcharoen et al., 2004; Thanawongnuwech et al., 2005). 


In February/March 2006, three cats were found dead on the island of Rügen, Germany and infection with H5N1 virus was established by laboratory tests.


Also in March 2006, three cats were found infected but alive in an animal shelter in Graz, Austria. - First experimental evidence for the pathogenicity of H5N1 avian influenza virus for the domestic cat was obtained by Kuiken et al. (2004).



And then there is this from the FAO (UN's Food & Agriculture Agency).


Avian influenza in cats should be closely monitored

So far no sustained virus transmission in cats or from cats to humans


8 February 2007, Rome - Cats can become infected with the highly lethal H5N1 avian influenza virus, but at present there is no scientific evidence to suggest that there has been sustained transmission of the virus in cats or from cats to humans, FAO said in a statement today.


As a precautionary measure, FAO recommended that in areas where the H5N1 virus has been found in poultry or wild birds, cats should be separated from infected birds until the danger has passed. On commercial poultry premises cats should even be kept indoors.


The agency advised against killing cats as a virus control option because there is nothing to suggest that cats are transmitting the virus in a sustained way. Removing cats could lead to a surge in rodents such as rats, which are an agricultural pest and often transmit diseases to humans.


Unconfirmed reports that H5N1 infection has been detected in a high prevalence in cats in Indonesia has caused some alarm. The scavenging cats were sampled in the vicinity of poultry markets in Java and Sumatra where outbreaks of H5N1 avian influenza had recently occurred.



This is not the first time that cats have been infected as previous incidents in Thailand, Iraq, the Russian Federation, the European Union and Turkey show. Cats can become infected by feeding on sick domestic or wild birds; they can develop severe to fatal disease and excrete the virus from the respiratory and digestive tracts.



There are more examples I could cite - including the work of Dr. C.A. Nidom in Indonesia.   Or the reports of H5N1 infection in dogs in the CDC's  Journal of Emerging Infectious Diseases



But I think I've made my point.



Why any of this information should be (pick one) ignored, glossed over, or suppressed is beyond me.       



Cats and dogs, along with other mammals, are susceptible to the H5N1 virus.    We honestly don't know how often infection occurs.   But it probably happens more often than we are aware of. 


Thus far, we've seen no indication of cat-to-human infection.    More research is needed so that we can fully understand the role that mammals may play in the spread of the H5N1 virus.



Is this information so scary that it can't be readily admitted?   Is the public so immature, so easily frightened, that it can't handle the truth?  


Obviously some people think so.

Monday, July 28, 2008

Korea: Cat Death Attributed To Bird Flu


# 2184





Not unexpectedly, the South Korean government has confirmed that a cat suspected of dying from the bird flu virus last April, was infected with the H5N1 virus.   I first reported on this story here.


Cats, of course, have been known to contract the virus.  In tests conducted by Dr. C.A. Nidom among feral cats in Indonesia, 20% (100 out of 500) tested showed antibodies to the H5N1 virus.  


How many cats died from the virus is unknown.


All of this calls attention to the need for more rigorous seroprevalence studies of humans, and other mammals, in areas where the H5N1 virus is endemic.


Here is the confirmation from the Korean Times.




07-28-2008 22:01

Cat Infected With Bird Flu Virus


A cat found dead in April had been infected with the virulent strain of the bird flu influenza, the government confirmed Monday.

The National Veterinary Research and Quarantine Service (NVRQS) said tests conducted by Chungnam National University showed the cat, found in Gimje located 262 kilometers south of Seoul, died of the H5N1 virus that swept through the country from early April to mid-May.


Gimje, North Jeolla Province, was one of the first regions hit by this year's avian influenza that resulted in a record 8.46 million birds being culled at the cost of 264.1 billion won ($262 million).


``Since the cat died of the bird flu, it probably had eaten a sick bird or came in very close contact with chickens or ducks,'' a quarantine inspector was quoted as saying by Yonhap News. He added that because there has been no reported case of a cat spreading the bird flu, there was no risk to human health.


Cats and dogs are usually not susceptible to the avian influenza, so quarantine officials only check animals that have regular contact with birds.


In contrast, pigs are checked thoroughly because they are more likely to contract the disease. Under existing operating procedures, the movement of pigs is banned during an outbreak.


The NVRQS, which is under the Agriculture Ministry, said earlier in the month that samples from the latest outbreak sent to the U.S. Center for Disease Control and Prevention were confirmed to be from the virulent strain of bird flu. However, it said the particular sub-strain has no prior history of actually causing people to get sick.


South Korea has been hit three times with the bird flu, but humans have not caught the disease.

Idaho BlogEx : July 28th

# 2183


With just two more days to run, Idaho's BlogEx pandemic exercise begins its 3rd week with a new video (courtesy of the CDC), and updated fatality figures.

This exercise is being conducted by the Southeastern District Health Department of Idaho. There are dozens of blog entries, a number of videos, and well over a hundred comments to view.

The blog portion of this exercise will end tomorrow, but local agencies will continue to review their participation in this drill, and an after-action conference is planned for late August.

July 28: First Wave of Pandemic Flu peaking in Southeast Idaho

July 28, 2008


The pandemic flu has hit hard in Southeastern Idaho. Attack rates and death rates are close to expected, with an attack rate of 30%, meaning 30% of people get sick, and a death rate of 2%, meaning 2% of people who get sick die. Vaccinations are not available because of the long lead time required to identify the strain and create vaccines from eggs; research and development on faster production of vaccines was not completed in time, although it began in 2006. This year’s annual flu vaccine may provide some help by minimizing the affects of the pandemic flu strain, but it will not provide immunity. Local hospitals are providing drugs to people who are already sick, but these pills are not available to the public as a method to prevent the flu.

(Continue. . . )

Bird Flu Detected In Nigerian Poultry


# 2183



Today we are hearing a little more about the outbreak of H5N1 reported in Nigerian poultry late last week.    


This first report is from Reuters, and it identifies the two cities where the virus was detected. 




Fresh bird flu outbreak in Nigerian poultry

Mon 28 Jul 2008, 12:06 GMT


ABUJA (Reuters) - An outbreak of the H5N1 bird flu virus has been found in two Nigerian poultry markets, the first discovery in almost 10 months in Africa's most populous nation, the agriculture ministry said on Monday.


Junaidu Maina, agriculture director for the livestock department, said the infected chickens and ducks were located last week in the northern cities of Kano and Katsina.


"Immediate actions have already been taken to control the outbreak. The affected farms are being depopulated and disinfected," he said.




Three days ago CIDRAP had some early details, gleaned from an OIE incident report.     Lisa Schnirring also updates us on Hong Kong and South Korea in this report, and as always, it is worth reading in its entirety.




Nigeria finds H5N1 in bird markets

Lisa Schnirring * Staff Writer

Jul 25, 2008 (CIDRAP News) – Animal health officials in Nigeria today reported finding the H5N1 avian influenza virus at two live bird markets, as officials in Hong Kong announced they would go ahead with a buyout of poultry farmers and merchants to reduce the risk of H5N1 outbreaks in the city.


The H5N1 findings in Nigeria came during routine surveillance, according to an epidemiology report submitted by Nigeria today to the World Organization for Animal Health (OIE).


On Jun 27, veterinary officials detected the virus in a chicken at a live bird market in Kebbi state, in northwestern Nigeria. On Jul 19, animal health workers found the virus in a duck at a live bird market in Gombe state in the east-central part of the country. The reports did not say if bird deaths were reported in the area or if the birds that were sampled appeared sick.

(Continue . . .)



The actual extent of the H5N1 virus in Sub-Saharan Africa is largely unknown.   We've seen isolated reports of outbreaks in poultry, and a handful of human cases, but surveillance is almost non-existent in many areas. 


Frankly we've no idea how wide, or deep, the problem is in Africa.

Online Pandemic Conference


# 2182



On Thursday, September 4th, there will be an online pandemic conference entitled   The Pandemic Threat: Preparing an Organizational Response.


The keynote speaker will be Dr. Julie Gerberding, Director of the CDC, and other speakers include Governor Tommy Thompson (former Secretary of HHS),  and Dr. William Winkenwerder, Former Secretary of Defense for Health Affairs.



The conference will run from 10:00am to 3:00pm CST, and will be held in LaCrosse, Wisconsin.    It will also be broadcast live on the Internet. 


This conference is free to attend or to view online.   You do have to register in advance, however.




My thanks to Darin, over at the Idaho BlogEx website, for posting this information.

ProMed RFI On China


# 2181


Last night ProMED Mail, the global electronic reporting system for outbreaks of emerging infectious diseases and toxins, carried an RFI (Request For Information) on the report out of China of the mysterious disease outbreak that I mentioned in yesterday's blog.


Here is a snippet from the RFI.  Follow this LINK to read the entire post.  There is considerable discussion in this ProMed Post.





A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases


Date: 27 Jul 2008
From: Stephen O. Cunnion


I received the following email from Chuck Dolejs of the International Association of Emergency Managers regarding a Sound of Hope web page (<>) updated [26 Jul 2008]. Has this outbreak been verified by authorities?


"China reported that approximately 20 days ago, a man suddenly died from an unidentified disease in Wanjiakou Village, Xiaoguan Town, Wendeng City, Shandong Province. His entire body turned dark purple, and he bled from his mouth, nostrils, ears, and eyes just as he died.

Shortly after the man died, 2 other men who been in contact with him, died showing the same symptoms. Villagers who had left the village to work said "3 people died 10 days ago. 6 or 7 more are being treated in the Wendeng Central Hospital. People have been to the area to investigate, but they are unable to classify the disease."

Most people outside of the village do not know about the illness. Their families do not want people who have left the village to return.



Stephen O. Cunnion, MD, PhD, MPH
Medical Director, National Security Health Policy Center
The Potomac Institute for Policy Studies
901 N. Stuart Street, Suite 200
Arlington, VA 22203


[ProMED-mail would like to thank Dr. Stephen Cunnion for sending on this information. As a reminder, it was he who sent ProMED-mail the 1st report on an outbreak of "atypical pneumonia" in Guangdong, China, on 10 Feb 2003 that we posted and was the 1st public notification of the early outbreaks of what was later named Severe Acute Respiratory Sydrome (SARS) (see ProMED-mail posting Pneumonia - China (Guangdong): RFI 20030210.0357 for this report). 


(Continue reading . . . )







Please note that this email and RFI doesn't confirm this story, it simply references a report posted on a website, and asks if it has been verified.




Also, at this time, there is no compelling reason to suspect that this outbreak (if it truly exists) has anything to do with pandemic influenza.  



We really don't know anymore today than we did yesterday.  Except that now there are more eyes watching the situation.  



And that's always a good thing






ProMED-mail is a service of the International Society of Infectious Diseases (ISID), and you can either visit their webpage or subscribe to their email updates.    ProMED-Nail describes their service this way:


ProMED-mail is open to all sources and free of political constraints. Sources of information include media reports, official reports, online summaries, local observers, and others. Reports are often contributed by ProMED-mail subscribers. A team of expert human, plant, and animal disease moderators screen, review, and investigate reports before posting to the network. Reports are distributed by email to direct subscribers and posted immediately on the ProMED-mail web site. ProMED-mail currently reaches over 40,000 subscribers in at least 165 countries.


While I wouldn't recommend this service to hypochondriacs, those interested in keeping up with disease outbreaks around the world should consider joining, and financially supporting, ProMED-mail.

Sunday, July 27, 2008

In The Land Of The News Blackout The Internet Rumor Is King


# 2180



This past week has seen a resurgence of vague, disturbing stories of disease outbreaks in China, and tales of news censorship.    Whether there is any truth to these stories, or what that truth might be, is impossible to tell.


There are, after all, multiple political agendas at work here.


The Chinese government obviously wants the Olympics to go off without a hitch, and for nothing to sully China's image during the intensive press coverage that is building.


Even without the Olympics, China consistently ranks near the bottom of countries ranked by the freedom of their press by Reporters Without Borders.   Here are the bottom 10 countries on this year's list.



158 Iran
159 Saudi Arabia
160 Nepal
161 Vietnam
162 China
163  Eritrea
164 Turkmenistan
165 Burma
166 Cuba
167 North Korea


After the debacle of SARS coverup in 2003, very few observers are comfortable with the level of transparency exhibited by the Chinese government when it come to admitting they have a problem.   

So when articles begin to appear in the press suggesting there is a new disease outbreak somewhere in China, and the Chinese government either denies this, or simply refuses to comment, Internet speculation takes off.


This week, there have been multiple reports of some sort of hemorrhagic illness in a village in China.   The reports in Chinese are both difficult to translate and interpret.   


While the details vary, many are similar to this short report from 


(Hat Tip Pugmom on the Wiki)


July 27 - Tang Xingwen County in Shandong 10,000 Hau Tsuen recently, a man suffering from unknown disease, high fever for several days not to not long after the death, before his death vomit blood.


Contact with him many people are infected, of which his father had died and Gufu (man vomited up blood splashed on them). On the other infected people has been to follow the current missing.


The matter has been reported to authorities in Beijing, back on sampling. 10,000 Hau Tsuen has been closed, while contacts with the outside world, villagers were threatened not to leak information.



There have been other stories, in other newspapers, that talk of a `meningitis' outbreak in Qingdao with hemorrhagic symptoms. 


The various flu forums, and their newshounds, have been working overtime trying to figure out what, if anything, these reports represent.    It's hard, and frustrating work. 


We know, of course, that there are dissident groups who would like very much to disrupt China's Olympics.  Propaganda isn't just a tool of the government in power.   


So we can't automatically assume that these stories are true.


But we can't assume they are false, either.




               *           *          *          *           *      



Last month we heard similar stories out of North Korea;  mysterious deaths and illnesses possibly connected to `bird flu'.    Sitting at the very bottom of the Freedom of the Press list, denials issued by their government inspire little confidence.


Here is an AP report from June 19th.



North Korea denies bird flu

SEOUL (AP) — North Korea strongly denied Thursday that bird flu had recently broken out in the country, contradicting a report from an outside aid group.


The Seoul-based Good Friends organization said last week that the disease had been discovered in the communist nation's northeast on June 3, when several birds were found dead near a military base.


The group also said dozens of magpies were found dead inside a camp for political prisoners in an adjacent province, and a child of one prison official subsequently suffered a high fever and died, although the cause of the deaths was unclear.


If there was anything to this report (and I have my doubts), then the North Korean government has managed to suppress it.




               *           *          *          *           *      


Indonesia, which ranks 117th down the Press Freedom list, has recently stopped reporting bird flu cases or fatalities in `real time'.    What little information they are releasing, is provided on their own timetable. 


What they are withholding, if anything, is unknown.


What we do know is that over the past month news stories about bird flu (Flu Burung) have all but disappeared from the English language papers in that nation.    


Even the local, Bahasan language media, has little to say about bird flu anymore.  Occasional reports of poultry deaths, and that's about it.


While there are still some reporters valiantly trying to cover the story in Indonesia, the government is doing what they can to thwart their efforts. 


And of course, other nations are watching.   Taking note.  And considering their options.  


If Indonesia can get away with this . . .



               *           *          *          *           *      



The Internet abhors a news vacuum. 


Countries that believe they can suppress the news may find it possible for a while - even desirable - but eventually someone with a cell phone camera and an Internet connection will get the story out.   Or it will be smuggled out on a disk or memory stick.


Until real news emerges we are often left with little more than rumor and innuendo.    And frankly, these rumors are often far more damaging than the truth. 


While I believe that nations are shooting themselves in the foot by suppressing the news,  that isn't my real concern.


Someday, another disease like SARS will emerge from a country like China that has a history of controlling their press.   It could be a pandemic influenza, or it could be something else entirely.  But whatever it is, it wont just be a problem for the originating country.


It will be a problem for the world.   


And the longer the world is kept in the dark, the better foothold it will have.  And the more people it will affect.


Avian flu news this summer has been slow.  Almost non-existent.   Maybe that's a good sign.   Or maybe we just aren't  hearing from hotzone countries anymore.


That's the problem with the suppression of the news.  


You can't even take it as a good sign when the news is slow. 

Upcoming Conference On The Health Blogosphere

# 2179




The Kaiser Family Foundation will host a conference on the Health Blogosphere this coming Tuesday, with Secretary Michael Leavitt of the HHS (Health & Human Services) giving the keynote address, followed by a panel discussion on health related blogging.



Here is how the Kaiser Website describes the meeting. 




The Health Blogoshpere: What It Means for Policy Debates and Journalism


LIVE on Tuesday, July 29 at 1 p.m. ET: View a webcast of a discussion sponsored by the Kaiser Family Foundation on the growing influence of blogs on health news and policy debates. Submit questions before or during the event to





Rakesh Singh
(202) 654-1313
Tiffany Ford
(202) 347-5270



On Tuesday, July 29, the Kaiser Family Foundation is sponsoring a discussion about the growing influence of blogs on health news and policy debates. Only in the past few years has the blogosphere become mainstream. In the health policy arena, we now see policymakers, journalists, researchers and interest groups utilizing this new media tool to deliver information to their audiences.


The briefing will highlight how the traditional health policy world has embraced blogging and will feature a keynote address by U.S. Department of Health and Human Services Secretary Michael Leavitt, the first cabinet officer to author an official blog, followed by a moderated discussion with a variety of health policy bloggers and a media analyst.


Questions to be explored with the panelists include: Why do individuals and organizations blog? How does blogging impact the broader work of an organization? Are there different standards used when blogging versus other writing? Have blogs impacted the news business significantly? What kind of influence are blogs having on political and policy debates?


Welcome and Introduction

Drew Altman, President and Chief Executive Officer,
Kaiser Family Foundation

Keynote Address

The Honorable Michael O. Leavitt
Secretary, U.S. Department of Health and Human Services

Panel Discussion

Vicky Rideout (moderator)
Vice President, Kaiser Family Foundation and
Director, Kaiser Forum on Health Journalism and the News Business
Jacob Goldstein, Wall Street Journal
Michael Cannon, Cato Institute
Ezra Klein, American Prospect Magazine
John McDonough, Office of Senator Edward Kennedy and formerly of Health Care for All in Massachusetts

Tom Rosenstiel, Center for Excellence in Journalism


WHEN: Tuesday, July 29, lunch served at 12:30 p.m. and program begins at 1:00 p.m.

WHERE: Barabara Jordan Conference Center , 1330 G Street, NW , Washington , DC . For those who cannot attend, the event will be webcast live.

RSVP: If you plan to attend the event, please send your name and affiliation to




A little over a year ago, the HHS set up a 5-week Pandemic Leadership Blog, and invited roughly a dozen bloggers from around the country to participate.  This blog site, and the hundreds of comments it inspired, is archived online and may still be viewed.


Secretary Leavitt, as you probably know, is the first cabinet level official to blog on a regular basis.   His blog is both interesting and entertaining, and is well worth your time to visit.   He is currently in the middle of a multi-part series on the safety of global imports called Safety At The Speed Of Life. 


Here are links to the first 5 parts:


  • Safety at the Speed of Life- Blog 5
  • Safety at the Speed of Life- Blog 4
  • Safety at the Speed of Life- Blog 3
  • Safety at the Speed of Life- Blog 2
  • Safety at the Speed of Life- Blog 1


  • Earlier this year, the HHS held a pandemic communications tabletop exercise, and once again they invited the blogosphere to participate.  Sitting at the table with Maggie Fox of Reuters and Lisa Stark of ABC news were Internet bloggers  like Dr. Greg Dworkin of the Flu Wiki, Sharon Sanders of Flutrackers, and myself.


    We've obviously come a long way.   Bloggers are now considered to be part of the `new media'.   Earlier this month I explored this concept in Feedback on Flublogia.  


    According to Technorati, there are more than 112 million bloggers.  That's a lot of content.  Increasingly people are turning to bloggers to get news, information, and opinion.


    As always, whether it is mainstream news or Internet blogs, Caveat Lector.


    It will be interesting to see how these panel members view this `new media' of ours.    I know I'll be watching.

    Saturday, July 26, 2008

    The Long And Whining Road




    # 2178




    Today we get a pretty good article out of Canada about the need for the general public to get, and remain, prepared for emergencies.  


    Sadly,  it also points out how few people actually do it.



    I'll post a link, and a snippet here, but there is a section about half way down I want to focus on today.





    Be prepared. Be very, very prepared

    Flooding, hydro explosions, flu pandemics. It could - it does - happen here. The city and its hospitals are girding for the worst



    Special to The Globe and Mail

    July 26, 2008


    When west Toronto homeowner Dave Mckellar found a flyer tucked in with his hydro bill warning him to keep 72 hours worth of food and water on hand in case of emergency, he wasn't alarmed. "It sounds reasonable, but who's going to do that?" he says. "It's a little bit hard to imagine, really, having no supplies whatsoever for three days ... I think I would just go to the store."


    The notion of a Toronto so paralyzed by disaster that you couldn't go out for a falafel if the need arose does seem far-fetched. But ominous ads that have cropped up on waste bins around the city suggest otherwise. The ads feature a message straight out of Cormac McCarthy's post-apocalyptic novel, The Road: "Dad I'm hungry. Dad I'm hungry. Dad I'm hungry. Dad I'm thirsty." They're sponsored by Toronto's Office of Emergency Management (OEM); the fine print urges citizens to stock up on three days worth of provisions in case of disaster.


    So, should we be worried? Is there some new threat that we should know about?


    Not according to Warren Leonard, who heads up the OEM. "There's no change in the profile of the risks in this city ... the ads are just a new mechanism to reach out to the public."


    (Continue reading . . .)




    Halfway through the article, we get this assessment as to why people don't prepare: (reparagraphing & Highlighting mine)




    That's why his office is urging people to prepare generic emergency kits: backpacks stocked with basic survival goods, including food and water, flashlights, a radio and medical supplies.


    But a poll quoted on the Ontario government's website says that only 12 per cent of Canadians have made any such preparations at all.


    Some of this reluctance may be because the very generic nature of the preparations strikes people as futile. "I think that you wouldn't have the right stuff," Mr. Mckellar says. "Imagine if you stocked up on batteries for your flashlight and all that, and then it turned out that what you really needed was an N95 face mask."




    Being prepared isn't something you can buy off the rack with one easy payment.  


    It is a mindset. A lifestyle.  A commitment.


    Apparently most people would rather find reasons not to prepare.   They will also be the ones who will whine the loudest when help doesn't arrive during a crisis.



    Notice, the poll doesn't say that 12% have prepared 72-hour emergency kits.  It says that 12% have made some sort of preparation.  Maybe they have a battery operated radio, or maybe they have a first aid kit.   But they don't have to have both in order to answer `yes' to this poll.


    I doubt, except for places like earthquake prone California and perhaps the barrier islands and coastal cities of Florida, that U.S. citizens would be any better prepared.


    I confess, I'm bewildered by this failure to prepare.  This willingness to place their lives, and the lives of their loved ones, in the hands of a government that is loudly saying they can't come to everyone's rescue during a crisis.


    At least, not right away.



    What part of, "You need to be prepared to fend for yourself' do people not get? 




                   *           *          *          *           *      



    When I was 17, and still in High School, I took a 3-night American Red Cross first aid course.   At the time, I had no idea that a year later I'd be working on an ambulance.  


    It just seemed like a good idea.


    Since I was approaching my 18th birthday, and would soon be out on my own, it seemed like the responsible thing to do.   No one told me I should, my parents certainly didn't suggest it.   I just decided that there was useful knowledge there that I should know.


    So I went. 


    I spent 3 nights listening to the local fire chief teach us about first aid.  I watched the films  (most from the 1950's, btw), practiced bandaging the guy next to me,  and I made my own first aid kit.  


    Since that day, I've never been without a serious first aid kit.  In my car, and in my home.


                   *           *          *          *           *      



    Two weeks after I graduated from High School, during the summer of 1972,  Hurricane Agnes clipped the west coast of Florida.  It wasn't much as hurricanes go, but it sent tropical storm force winds, torrential rain, and some small tornadoes through our area.  



    Hurricane Agnes

    Category 1 hurricane (SSHS)

    Hurricane Agnes approaching Florida

    Hurricane Agnes approaching Florida



    My brother and I both ended up as part of the rescue effort that night, pulling the trapped and injured from collapsed trailers, and setting up an ad hoc emergency first aid center in an old post office.  


    We used the supplies from the first-aid kits we kept in the trunks of our cars to care for the injured.  


    For several hours, we were the only aid available to a half-dozen injured people.   For a kid fresh out of highschool, it was a long night. It also spurred me on to a career in emergency medicine.


                   *           *          *          *           *      



    Why anyone would abdicate their personal responsibility to care for themselves, and their loved ones, is a mystery to me.  


    Sure, if there's an ambulance handy, use it.   


    But what if there isn't?   



                   *           *          *          *           *      



    In the mid-1970's I became a CPR instructor.   I taught CPR to hundreds of high school students every year.    I was also working as a paramedic for the county EMS.


    One day we were called for a cardiac arrest.  We found a teenager doing effective CPR on an elderly man.  My partner and I were able to cardiovert him; get his heart started, and him breathing again.  


    Honestly, even with the cardiac drugs and defibrillator we carried- that doesn't happen often.


    The kid had done a good job.  He'd saved his grandfather's life.


    As we were loading the patient into the back of my rig, I asked him where he learned CPR?


    He beamed proudly and said, "Don't you remember?  You taught me!".    


    It was one of the proudest days of his life. 


    And mine. 


                   *           *          *          *           *      



    Hundreds of thousands of years of human evolution has been dependant upon our ability, as a species, to survive.  


    A hundred and fifty years ago, just about everyone was a `survivalist'.   As were all the generations that had come before.   You either knew how to survive . . .or you didn't survive.


    Somehow, just over the last generation or two, most of us in `civilized and enlightened nations' have forgotten the skills needed survive.   We have become a race of specialists, when in order to survive in a crisis, you need to be a generalist. 


    Ironic, isn't it, that the more advanced our society becomes, the less capable individuals seem to be. 




                   *           *          *          *           *      



    Our government, and the government of Canada, have asked that people be prepared.   In Canada, they are asking for people to put together 72-hour kits.  Here in the US, the Federal Government is asking people to stockpile for 2-weeks. 


    Being prepared is all about social responsibility.   By relying, at least a little, on ourselves we remove a burden from society to rush to our aid in a crisis.  


    Being prepared should be taught as being part of our civic duty.  Part of being a responsible member of society.


    I know we expect the government (ambulance, police, fire, etc.) to respond immediately when we need them.   The truth is, they often arrive too late.   And during a crisis, they may not be able to respond to everyone right away.  


    That's why people need to be prepared for emergencies.  They need to have that fire extinguisher in the kitchen, or workshop. They need to have the radios, and lanterns, and food in the pantry.  They need to have that first aid kit in the trunk of the car. 


    And they need to know how to use them.


    Someday, a disaster will strike your community.  It may be a hurricane, or a tornado, or an earthquake or a flood.   It might even be a pandemic.


    For those who aren't prepared,  I suppose they can console themselves  by writing a nasty letter of complaint to the editor of their  local paper.   


    They can whine, and complain bitterly about the system that they depended on.    The one that wasn't able to respond when they needed it.


    Assuming they survived, of course.