Experimental project may not be accurate but tries for real-time picture of flu’s spread
By Sharon Gaudin, April 30, 2009 (Computerworld) — Google Inc. is running an experiment of sorts to follow the swine flu’s path through Mexico.
The company is trying to compile information from swine flu-related Google searches in Mexico to map out how the disease is spreading through the country.
The Mexican effort is based on Google Flu Trends, which the company launched last November in the U.S. At the time, Google officials said that they had found a connection between people searching for flu information and the number of people who actually have the flu in any given area. “Google Flu Trends may be able to detect influenza outbreaks earlier than other systems because it estimates flu activity in near real time,” said Jeremy Ginsberg, one of the engineers on the Google Flu Trends project, during a press conference today.
Ginsberg acknowledged that the new effort, dubbed “Experimental Flu Trends for Mexico,” may produce somewhat faulty data because of the lack of available current information from the Mexican government.
“While we would prefer to validate this data and improve its accuracy, we decided to release an early version today so that it might help public health officials and concerned individuals get an up-to-date picture of the ongoing swine flu outbreak,” said Ginsberg in a blog post that also went up today. “Our current estimates of flu activity in the U.S. are still generally low as would be expected given the relatively low confirmed swine flu case count. However, we’ll be keeping an eye on the data to look for any spike in activity.”
The swine flu has been spreading — and spreading fear — across the world in recent days.
Today, the World Health Organization (WHO) raised its pandemic alert from 4 to 5, the second-highest level. CNN.com reported that Dr. Margaret Chan, the U.N. agency’s director general, said the decision means that all countries should “immediately” activate pandemic preparedness plans.
Swine flu, a highly contagious respiratory disease, has a mortality rate of between 1% and 4%, according to the WHO. While initially spread into humans by contact with pigs, the virus then mutates and spreads from human to human.
As of 5 p.m. Eastern Time on Wednesday, The Washington Post was reporting that the U.S. had 91 confirmed cases of swine flu, and there have been 367 confirmed cases in Mexico and nearly 500 across the world.
How does Google Tracking Flu Work?
We’ve found that certain search terms are good indicators of flu activity in the United States. Google Flu Trends uses aggregated Google search data to estimate possible flu activity at a state level in near real-time.
In response to inquiries from public health officials regarding the current swine flu outbreak, we built an experimental model for Mexico. You’ll see our unverified estimates on the Experimental Flu Trends for Mexico page. We hope this may shed additional light on possible flu activity in states in Mexico.
Unlike Google Flu Trends for U.S., Experimental Flu Trends for Mexico was not built using historical data on flu symptoms. This means the models have not been checked against actual historic flu data from Mexico and thus the estimates you see for Mexico are unverified. The models for Mexico are based on aggregated search queries likely to be associated with influenza-like illness (ILI).
Each week, millions of users around the world search for online health information. As you might expect, there are more flu-related searches during flu season, more allergy-related searches during allergy season, and more sunburn-related searches during the summer. You can explore all of these phenomena using Google Insights for Search. But can search query trends provide the basis for an accurate, reliable model of real-world phenomena?
In the United States we have found a close relationship between how many people search for flu-related topics and how many people actually have flu symptoms. Of course, not every person who searches for “flu” is actually sick, but a pattern emerges when selected flu-related search queries from each state and region are added together. For the United States, we compared our query counts with data from a surveillance system managed by the U.S. Centers for Disease Control and Prevention (CDC) and found that some search queries tend to be popular exactly when flu season is happening. By counting how often we see these search queries, we can estimate how much flu is circulating in various regions of the United States. Our results have been published in Nature.
During the 2007-2008 flu season, an early version of Google Flu Trends was used to share results each week with the Epidemiology and Prevention Branch of the Influenza Division at US CDC. Across each of the nine surveillance regions of the United States, we were able to accurately estimate current flu levels one to two weeks faster than published CDC reports.
This graph shows five years of query-based flu estimates for the Mid-Atlantic region of the United States, compared against influenza surveillance data provided by CDC’s U.S. Influenza Sentinel Provider Surveillance Network. As you can see, estimates based on Google search queries about flu are very closely matched to a flu activity indicator used by U.S. CDC. Of course, past performance is no guarantee of future results, but we have seen similar correlations this season for the U.S. We have not confirmed our Experimental Flu Trends Mexico model against historic influenza-like-illness data, but we believe that our model for Mexico reflects actual increases in flu activity. Our system is still experimental, but in the interest of providing additional information on the evolving swine flu outbreak, and after conferring with US and Mexican health officials, we decided to share our initial results.
CDC uses a variety of methods to track influenza across the United States each year. One method relies on a network of more than 1500 doctors who see 16 million patients each year. The doctors keep track of the percentage of their patients who have an influenza-like illness, also known as an “ILI percentage.” CDC and state health departments collect and aggregate this data each week, providing a good indicator of overall flu activity across the United States.
So why bother with estimates from aggregated search queries? It turns out that traditional flu surveillance systems can take time to collect and release surveillance data, but Google search queries can be automatically counted very quickly. By making our flu estimates available each day, Google Flu Trends may provide an early-warning system for outbreaks of influenza.
For epidemiologists, this is an exciting development, because early detection of a disease outbreak can reduce the number of people affected. If a new strain of influenza virus emerges under certain conditions, a pandemic could emerge and cause millions of deaths (as happened, for example, in 1918). Our up-to-date influenza estimates may enable public health officials and health professionals to better respond to seasonal epidemics and pandemics.
To learn more about the research behind Google Flu Trends, please read Detecting influenza epidemics using search engine query data, published by Nature. To further explore the data behind Google Flu Trends you can download CSV spreadsheets containing Google Flu Trends estimates going back to 2003 for the United States and recent estimates for Mexico.
Protecting User Privacy
At Google, we are keenly aware of the trust our users place in us, and of our responsibility to protect their privacy. Google Flu Trends can never be used to identify individual users because we rely on anonymized, aggregated counts of how often certain search queries occur each week. We rely on millions of search queries issued to Google over time, and the patterns we observe in the data are only meaningful across large populations of Google search users. You can learn more about how this data is used and how Google protects users’ privacy at our Privacy Center.
Medscape.com, April 30, 2009, by Robert Lowes – The nation’s top medical sleuth offered a handful of theories in a press conference today about why the swine influenza outbreak has produced fatalities in Mexico, but not so far in the United States or elsewhere.
“Why are some people getting sicker?” said Richard Besser, MD, acting director of the US Centers for Disease Control and Prevention (CDC). “We’re looking at their immune status, their age, their gender, and treatment practices. How did they self-treat themselves? How long did they take to seek [outside] care? What was their initial treatment? Were they quickly given an antiviral medicine?”
Dr. Besser said that milder cases of swine flu A (N1HI) virus in the United States and other countries besides Mexico may also result from a gradual weakening of the virus as it travels from person to person. “That would be a very comforting thing if we found that,” he said, adding that it’s early too early to reach that conclusion.
Amid all of this epidemiologic uncertainty, Dr. Besser described a swift federal response to the swine flu outbreak. “With a new infectious agent, you don’t sit back and wait and hope for the best,” he said.
The CDC, for example, is busy developing the seed stock for a vaccine to counter swine flu, and the agency is on course to produce it. “It will be a matter of us deciding not to make a vaccine rather than to move forward,” said Dr. Besser.
It is possible that health authorities could develop the new vaccine as a standalone as opposed to incorporating it into the vaccine for seasonal influenza now being prepared for the next flu season. “Production [of the seasonal vaccine] is moving forward, and we don’t want to delay it,” Dr. Besser explained.
With the blessing of the US Food and Drug Administration, the CDC is also distributing new diagnostic test kits to state public health agencies that will allow them to confirm cases of swine flu themselves, Dr. Besser said. And distribution of the antiviral medicines zanamivir (Relenza) and oseltamivir (Tamiflu) from the federal emergency stockpile is proceeding, with every state requesting its share. A dispatch issued today by the CDC’s Morbidity and Mortality Weekly Report underscores the new flu strain’s susceptibility to the 2 medications.
Dr. Besser reiterated an earlier prediction of his that cases of swine flu here will become more severe. “I expect that as we move forward, we will see deaths from this infection,” he said.
Events on Tuesday seemed to bear out Dr. Besser’s concern. The number of confirmed cases in the United States rose to 66 – 45 of them in New York – while the number of hospitalizations increased to 5. Meanwhile, New York City health officials were investigating possible outbreaks at 2 more schools, while their counterparts in Los Angeles were studying 2 deaths that may have resulted from the virus, according to news reports. In addition, the number of countries where confirmed cases have emerged increased to 7.
Dr. Besser revealed that the CDC may stop referring to the current virus as swine influenza, because that term has misled some to believe that they can catch the virus by eating pork, which he said is incorrect. “It’s not helpful to pork producers, or people who eat pork,” he said. “So we’re discussing whether there’s a better way to describe this.”
Medscape.com, 1 May 2009 — The situation continues to evolve rapidly. As of 17:00 GMT, 30 April 2009, 11 countries have officially reported 257 cases of influenza A (H1N1) infection.
The United States Government has reported 109 laboratory confirmed human cases, including one death. Mexico has reported 97 confirmed human cases of infection, including seven deaths.
The following countries have reported laboratory confirmed cases with no deaths – Austria (1), Canada (19), Germany (3), Israel (2), Netherlands (1), New Zealand (3), Spain (13), Switzerland (1) and the United Kingdom (8).
Further information on the situation will be available on the WHO website on a regular basis.
WHO advises no restriction of regular travel or closure of borders. It is considered prudent for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention, in line with guidance from national authorities.
There is also no risk of infection from this virus from consumption of well-cooked pork and pork products. Individuals are advised to wash hands thoroughly with soap and water on a regular basis and should seek medical attention if they develop any symptoms of influenza-like illness.
A pandemic is a global disease outbreak. An influenza pandemic occurs when a new influenza virus emerges for which there is little or no immunity in the human population; begins to cause serious illness; and then spreads easily person-to-person worldwide. A worldwide influenza pandemic could have a major effect on the global economy, including travel, trade, tourism, food, consumption and eventually, investment and financial markets. Planning for pandemic influenza by business and industry is essential to minimize a pandemic’s impact.
It is difficult to predict when the next influenza pandemic will occur or how severe it will be. Wherever and whenever a pandemic starts, everyone around the world is at risk. Countries might, through measures such as border closures and travel restrictions, delay arrival of the virus, but cannot stop it.
During a pandemic, transmission can be anticipated in the workplace, not only from patient to workers in health care settings, but also among co-workers in general work settings. A pandemic would cause high levels of illness, death, social disruption, and economic loss. Everyday life would be disrupted because so many people in so many places become seriously ill at the same time. Impacts could range from school and business closings to the interruption of basic services such as public transportation and food delivery.
Education and outreach are critical to preparing for a pandemic. Understanding what a pandemic is, what needs to be done at all levels to prepare for pandemic influenza, and what could happen during a pandemic helps us make informed decisions both as individuals and as a nation. Should a pandemic occur the public must be able to depend on its government to provide scientifically sound public health information quickly, openly and dependably.
Medscape.com, May 1, 2009, Laurie Barclay MD – Editor’s note: The outbreak of swine influenza A (H1N1) viral disease is continuing to grow in the United States and globally, with 91 laboratory-confirmed US cases and 1 death, according to US Centers for Disease Control (CDC) information updated April 29 at 11 am EST. The World Health Organization (WHO) has issued a phase 5 pandemic alert, and the CDC has implemented its emergency response and warned that the more recent illnesses suggest a pattern of more severe disease associated with this virus in the United States. Because most people are not immune to this new viral strain, the CDC expects more confirmed cases, more hospitalizations, and more deaths in the near future.
To learn more about the potential impact of H1N1 viral disease on public health, as well as treatment and prevention strategies, Medscape Infectious Diseases interviewed Neal A. Halsey, MD, professor in the Department of International Health, Bloomberg School of Public Health, Johns Hopkins University in Baltimore, Maryland. Dr. Halsey’s primary research and teaching effort is directed toward the prevention of infectious diseases with the safest vaccines possible. He has conducted or participated in epidemiologic studies of vaccine-preventable diseases and phase 1, 2, and 3 vaccine trials for influenza, hepatitis B, hepatitis A, inactivated polio virus, pertussis, Haemophilus influenzae type B, tetanus, Lyme disease, rotavirus, and Argentina hemorrhagic fever viruses
Medscape: How serious is the swine flu situation?
Dr. Halsey: The swine flu changes things and will change priorities for many people. The evidence that we have so far is that this does represent a potential threat to global public health, and a lot of resources are going to have to go into trying to prepare as best we can to minimize the impact.
That will include development, as rapidly as possible, of vaccines against this new strain and making those vaccines rapidly available. If we see more widespread transmission, especially this year, then drug therapy will be an important part, especially here in the developed world.
We need low-cost drugs against influenza in the developing countries as well, because we won’t have enough vaccines to protect the population against this new virus. We don’t have sufficient vaccine production capacity in the world to make enough vaccine for everybody.
The biggest concern I have is that this will distract us from use of other vaccines that also can protect against disease, like the new pneumococcal vaccine, and even the push to continue to introduce the Hib vaccine. But this new influenza is a serious threat.
Medscape: Are existing influenza vaccines effective against the new strain?
Dr. Halsey: No.
Medscape: How long would it take for a new vaccine to be developed and produced against this virus?
Dr. Halsey: That’s what the manufacturers are going to be asked this week, and the answer, with the traditional method, is that we usually give manufacturers 4 to 6 months. They find out about the virus that’s going to go in at the end of January, beginning of February, each year, and they make the vaccine, and make it available beginning as early as the end of September, beginning of October.
They’ve already been making the vaccine they thought was going to be in widespread use, and the key question is whether they should stop what they’re doing and put the effort into producing vaccine against this new strain, and that will have to be answered.
There are some new technologies that are being used that may be more rapid in terms of making new vaccine, but they have not yet been widely used. All vaccines currently approved for use require eggs for production, and the supply of eggs is likely to be limited and the manufacturers do not have the capacity to produce enough vaccine for everyone, so there will be shortages.
A number of the manufacturers are experimenting with making cell-based vaccines that don’t require eggs; that also could speed up the process, but so far, none of those vaccines that I know of has been approved for use. If we had the production capacity using these cell-based vaccines, it could be more rapid.
I’m sure that both the CDC and WHO are meeting with manufacturers of flu vaccines, and they’re all looking at this, trying to determine what their capability will be, but we don’t have any answers yet.
Medscape: Are antiviral drugs such as Tamiflu effective against this strain?
Dr. Halsey: Oseltamivir, or Tamiflu, and zanamivir (Relenza) are effective against this strain, but amantadine and the older drugs are not. They’ve tested the virus and it is susceptible to oseltamivir and zanamivir, which is the only good news out of what we’ve heard so far.
Medscape: Are there any concerns, with this new strain being a mixture of swine and avian and human strains, that this was in any way genetically engineered or terrorist-related?
Dr. Halsey: No, it doesn’t look that way to me. We have been anticipating a potential pandemic from a virus that would come through that same kind of mixing. We know that especially pigs, or swine, are a great mixing bowl, because they are susceptible not only to the swine flu, but also influenza from birds and influenza from humans. So the same pig can have in its body simultaneously several different infections with several different viruses and allow for that mixing. This happens naturally, and that’s part of why, especially in Asia, we’ve been seeing some problems with transmission. You don’t need to invoke any concern about bioterrorism to explain how this may have happened.
Medscape: What do you see as the overall potential impact of this swine flu?
Dr. Halsey: The swine flu epidemic, or if it turns out to be a pandemic, which is what we’re all concerned about, may turn out not only to have a significant effect on public health and potential mortality, but it could also potentially impair everything else we’re trying to do with regard to immunization, in terms of using everybody available to deal with this problem.
It also could have a significant exacerbating effect on the global economy. They’ve already shut the schools in Mexico; they didn’t have audiences for the soccer matches. You can imagine the impact it will have with regard to travel. Some individual countries in the European Union have issued some statements, or cautionary advisories, with regard to travel.
Imagine what the economic impact of loss of tourism in Mexico is going to be, and potentially the United States. So I see this as rapidly having an exacerbating effect on the current recession. This is not a small issue.
Dr. Halsey reports receiving research grant support from Wyeth for studies of pneumococcal disease in Guatemala and from Berna for studies of combination vaccines in Guatemala. He also serves on data and safety monitoring boards for Novartis and Merck.
SECRETARY KATHLEEN SEBELIUS
“It is an honor to lead the Department of Health and Human Services. I look forward to working with the dedicated staff at HHS as we work to protect the American people during this flu crisis and in the months ahead as we work toward reforming our health care system.”
Kathleen Sebelius Confirmed as Secretary of the Department of Health and Human Services
Kathleen Sebelius was sworn in as the 21st Secretary of the Department of Health and Human Services (HHS) on Tuesday, April 29, 2009. The Secretary governs one of the largest civilian departments in the federal government with more than 67,000 employees. HHS is the principal agency for protecting the health of all Americans by providing effective health and human services, especially for those who are least able to help themselves.
Secretary Sebelius has over 20 years of experience in state government, and has been a leader on health care issues for over a decade. She was first elected governor of Kansas in 2003 and was reelected in 2006. Throughout her tenure, Sebelius was lauded for her record of bipartisan accomplishment. She worked tirelessly to grow the state’s economy and to create jobs, to ensure that every Kansas child received a quality education, and to improve access to quality and affordable health care. As Governor, Sebelius expanded Kansas’ newborn screenings, put a renewed emphasis on childhood immunization and increased eligibility for children’s health coverage. More than 59,000 additional children were enrolled in health coverage during her time in office. Sebelius also worked closely with Kansas first responders and law enforcement to prepare for natural disasters and other emergencies. In 2005, Time magazine named her one of the nation’s top five governors.
Prior to her tenure as Governor, Secretary Sebelius spent 8 years serving as the Kansas State Insurance Commissioner. In that capacity, Sebelius turned her department into a steadfast advocate for Kansas consumers, and helped senior citizens save more than $7 million on prescription drugs. She also won praise for blocking the sale of Kansas Blue Cross/Blue Shield by an out-of-state, for-profit health care conglomerate, and for her role in drafting a proposed national bill of rights for patients. Previously, she was a member of the Kansas House of Representatives from 1986-1994.
Married to husband, Gary, a federal magistrate judge, for 34 years, they have two sons: Ned and John.
Thursday, April 30th, 2009
As a PSA, here are the President’s remarks on the H1N1 flu virus during the opening of last night’s press conference:
Before we begin tonight, I just want to provide everyone with a few brief updates on some of the challenges we’re dealing with right now.
First, we are continuing to closely monitor the emergency cases of the H1N1 flu virus throughout the United States. As I said this morning, this is obviously a very serious situation, and every American should know that their entire government is taking the utmost precautions and preparations. Our public health officials have recommended that schools with confirmed or suspected cases of this flu strongly consider temporarily closing. And if more schools are forced to close, we’ve recommended that both parents and businesses think about contingency plans if their children do have to stay home.
I’ve requested an immediate $1.5 billion in emergency funding from Congress to support our ability to monitor and track this virus and to build our supply of antiviral drugs and other equipment, and we will also ensure that those materials get to where they need to be as quickly as possible.
And finally, I’ve asked every American to take the same steps you would take to prevent any other flu: Keep your hands washed; cover your mouth when you cough; stay home from work if you’re sick; and keep your children home from school if they’re sick.
We’ll continue to provide regular updates to the American people as we receive more information, and everyone should rest assured that this government is prepared to do whatever it takes to control the impact of this virus.
(President Barack Obama speaks at a press conference in the White House on April 29, 2009.
White House Photo/ Chuck Kennedy)
He was also asked about the government’s response during the question-and-answer portion:
Q Thank you, Mr. President. With the flu outbreak spreading and worsening, can you talk about whether you think it’s time to close the border with Mexico, and whether — under what conditions you might consider quarantining, when that might be appropriate?
THE PRESIDENT: Well, first of all, as I said, this is a cause for deep concern, but not panic. And I think that we have to make sure that we recognize that how we respond — intelligently, systematically, based on science and what public health officials have to say — will determine in large part what happens.
I’ve consulted with our public health officials extensively on a day-to-day basis, in some cases, an hour-to-hour basis. At this point they have not recommended a border closing. From their perspective it would be akin to closing the barn door after the horses are out, because we already have cases here in the United States. We have ramped up screening efforts, as well as made sure that additional supplies are there on the border so that we can prepare in the eventuality that we have to do more than we’re doing currently.
But the most important thing right now that public health officials have indicated is that we treat this the same way that we would treat other flu outbreaks, just understanding that because this is a new strain we don’t yet know how it will respond. So we have to take additional precautions — essentially, take out some additional insurance. That’s why I asked for an additional $1.5 million, so that we can make sure that everything is in place should a worst-case scenario play out.
I do want to compliment Democrats and Republicans who worked diligently back in 2005 when the bird flu came up. I was part of a group of legislators who worked with the Bush administration to make sure that we had beefed up our infrastructure and our stockpiles of antiviral drugs like Tamiflu. And I think the Bush administration did a good job of creating the infrastructure so that we can respond. For example, we’ve got 50 million courses of antiviral drugs in the event that they’re needed.
So the government is going to be doing everything that we can. We’re coordinating closely with state and local officials. Secretary Napolitano at the Department of Homeland Security, newly installed Secretary Sebelius of Health and Human Services, our Acting CDC Director — they are all on the phone on a daily basis with all public health officials across the states to coordinate and make sure that there’s timely reporting, that if as new cases come up that we are able to track them effectively, that we’re allocating resources so that they’re in place.
The key now I think is to make sure that we are maintaining great vigilance, that everybody responds appropriately when cases do come up. And individual families start taking very sensible precautions that can make a huge difference. So wash your hands when you shake hands. Cover your mouth when you cough. I know it sounds trivial, but it makes a huge difference. If you are sick, stay home. If your child is sick, keep them out of school. If you are feeling certain flu symptoms, don’t get on an airplane. Don’t get on any system of public transportation where you’re confined and you could potentially spread the virus.
So those are the steps that I think we need to take right now. But understand that because this is a new strain, we have to be cautious. If this was a strain that we were familiar with, then we might have to — then I think we wouldn’t see the kind of alert levels that we’re seeing, for example, with the World Health Organization.
Medscape.com, May 1, 2009, by Emma Hitt PhD – After increasing the pandemic level to 5 last night, the World Health Organization (WHO) says that it will keep the pandemic level at phase 5 for the time being. No comment was made about whether an increase to phase 6 was imminent or inevitable.
Keiji Fukuda, MD, MPH, assistant director-general ad. interim for health security and environment at the WHO, discussed the pandemic level during a WHO media briefing today.
The WHO’s phase 5 alert level is characterized by human-to-human spread of the virus into at least 2 countries in a single WHO region. The final phase, phase 6, indicates that a global pandemic is under way and is characterized by community-level outbreaks in at least 1 other country in a different WHO region in addition to the criteria defined in phase 5.
“We do not have any evidence to believe that the pandemic level should be raised to phase 6,” Dr. Fukuda said, although he added that “I think it’s fair to say that the situation continues to evolve.”
He emphasized that the phase levels used by WHO are not a measurement of the epidemiology of the disease. “They are really a warning to countries and the global population to make preparations to reduce the health impact of the virus,” he said.
According to Dr. Fukuda, the WHO Director General Dr. Margaret Chan raised the level from phase 4 to phase 5 last night due to spreading of the virus within affected communities. “In New York City, for example, we began to see the virus spreading out to the community and not just travel-related cases. It was on this basis that we made the judgment that this was now the time to increase the pandemic phase from 4 to 5.”
As of 8:50 am EDT, the number of lab-confirmed cases of the H1N1 influenza strain totaled 236 cases, up from 148 cases yesterday. The largest increase was in Mexico, from 26 to 97 cases, probably due to increased testing of a backlog of thousands of specimens, he said.
“Cases are increasing in some countries, but appear to be holding steady in others, such as the United States,” Dr. Fukuda said.
Roche, which manufactures oseltamivir (Tamiflu), in 2005 and 2006, donated 5 million treatment courses to WHO to support a rapid containment operation if WHO deemed that necessary. “At this point WHO has begun distributing Tamiflu to developing countries determined by WHO to be most in need of this kind of assistance, and Mexico has also received a portion of this stockpile,” he said.
According to Dr. Fukuda, Roche has indicated that it is scaling up production of the drug and is working out the logistics for providing additional supplies.
The WHO has issued no travel restrictions, “because we do not believe that will slow the transmission down,” Dr. Fukuda said. “If you are feeling ill, you should consider delaying travel and staying at home. If you are traveling and you become sick during that travel, it is important to seek medical attention while there,” he said.