Talk:2009 swine flu pandemic/Archive 9

Revenge of the pigs
The article has some details about Egypt's mass pig slaughter in April, so this article caught my attention. If someone thinks it belongs in this or another article, go ahead and use it. "Swine-Flu Slaughter Leaves Cairo Without Pigs to Devour Trash" --Wikiwatcher1 (talk) 06:46, 29 September 2009 (UTC)

typically a dry cough?
[http://m.cnn.com/cnn/lt_ne/lt_ne/detail/369994/full;jsessionid=023B7A066B0F3155C146569A42CC1902.live7ib Cold? Flu? H1N1? How can you tell the difference?] By Val Willingham CNN Medical Producer, Sept. 21, 2009. " .  .  .   seasonal flu and H1N1 symptoms consist of fever, more painful body aches, dry cough, diarrhea and severe fatigue. It's hard, without testing, to tell apart the seasonal strain of flu from the H1N1 variety.  .  .  .  "
 * posted by Cool Nerd (talk) 02:19, 29 September 2009 (UTC)

Flu season: This year is different Prevention is key for what experts think will be the flu season of all flu seasons, Markian Hawryluk / The Bulletin, Last modified: September 17. 2009 7:01AM PST [And article includes fun cartoons explaining symptoms!]

“ .  .  .  Symptoms of the flu include sore throat, a cough that's usually dry, fever and, in particular, body aches from head to toe. . .  .  "
 * posted by Cool Nerd (talk) 03:14, 29 September 2009 (UTC)

Seasonal Influenza (Flu), Protecting Against Influenza (Flu): Advice for Caregivers of Children Less Than 6 Months Old, CDC, Page last updated: July 1, 2009 “ .  .  .  If you develop flu-like symptoms (usually high fever, headache, extreme tiredness, dry cough, sore throat, runny or stuffy nose and muscle aches), or are exposed to the flu before you get a flu vaccine, your health care professional will decide whether you should take antiviral drugs. . .  .  ”
 * posted by Cool Nerd (talk) 14:50, 2 October 2009 (UTC)

Okay, here's where we stand. I have not been able to find something on the CDC site that specifically states that the swine flu also has a dry cough. Maybe someone else who is better at searching can.

The below reference is from Harvard Health Publications and copyrighted by the Presidents and Fellows of Harvard College, but they don't give a date. It's pretty good and it discusses some other aspects, including pneumonia. I don't want to hold it back here. But I am not going to reference it on our main article page.

So, let's roll with our two initial references. I think we can go ahead and say on our main article page that the swine flu typically has a dry cough. Cool Nerd (talk) 22:15, 2 October 2009 (UTC)

Just the Flu?, Meet the influenza viruses that deserve respect. MSN Health & Fitness, by Harvey Simon, M.D., Harvard Health Publications, [no date given]. “ .  .  .  But unlike ordinary colds, the flu also produces a hacking, dry cough. . .  .  ”
 * posted by Cool Nerd (talk) 22:20, 2 October 2009 (UTC)

Mexican Flu????
Are you kidding me, Radio Netherlands is the only organization referring this as the Mexican flu, thats it, North American flu is more common than mexican flu for that matter —Preceding unsigned comment added by 72.0.222.215 (talk) 21:50, 3 October 2009 (UTC)

If you want to keep the Mexican flu reference in the first paragraph at least specify which "countries" are being racist and ignorant by putting a label on a virus with an unknown origin —Preceding unsigned comment added by 72.0.222.215 (talk) 23:51, 4 October 2009 (UTC)
 * See the "Nomenclature" section of the article, where the users of the term are spelled out. I've also repeated the citation in the lede. --Cyber cobra (talk) 00:18, 5 October 2009 (UTC)

OK i changed "some countries" to "Netherlands". Again, if you want to keep that in the first paragraph of such a broad articles, at least be specific. —Preceding unsigned comment added by 132.205.156.65 (talk) 23:35, 5 October 2009 (UTC)

The article only mention the netherlands as a country who refers to ah1n1 as mexican flu, Why do you keep lying ans say other countries when its only the netherlands... Ill keep changing it until you make a valid argument to keep it —Preceding unsigned comment added by 72.0.222.216 (talk) 02:38, 6 October 2009 (UTC)

Lead
There are some problems with the second sentence in the lead:
 * According to an article in the New England Journal of Medicine, the virus is a reassortment of four known strains of influenza A virus: one endemic in humans, one endemic in birds, and two endemic in pigs (swine).

Colin°Talk 22:46, 4 October 2009 (UTC)
 * 1) If we are citing a specific source (a certain article in the NEJM) then we really should provide (via a footnote) the full citation so people can find it. But why are we saying this fact is "according to an article"? Is the source article notable (perhaps controversial)? Is there some doubt about this fact that make the NEJM article the only source of that opinion? If not, we should simply state it as a fact. If the NEJM article is a primary research paper, then it is best (per WP:MEDRS) to cite a good quality scientific review that itself cites the paper.
 * 2) The jargon word "reassortment" only appears in the lead.
 * 3) The "four" strains is later detailed as five, though there are four species affected by those five strains.
 * 4) I looked for the source of these facts in the body text. The equivalent text seems to be from the "Virus characteristics" section, first paragraph. However, none of the three sources cited seem to mention this reassortment of the five strains. In addition, all of those sources are lay texts (two press-releases and one BBC News article) rather than the actual scientific paper/report mentioned in the article, or academic reviews of that paper. All of these sources seem to come from the early-days of the pandemic when one might expect our knowledge of the virus to be in flux. Surely sources covering fixed-facts rather than events should be as up-to-date as possible.


 * Yeah, I'd never heard the term before reading this, and not in any discussion..then again my forte is psychiatry so a far cry from this :) Casliber (talk · contribs) 03:51, 6 October 2009 (UTC)


 * Thank you. I'll look into this up tomorrow.  The article gets more than 600,000 views per month so it is worth the effort. Jehochman Talk
 * I think some of the above issues have been addressed, though they may reflect issues elsewhere in the lead/body. I plan to keep working on this article, but I'm very slow and only get a little time here and there. Colin°Talk 08:06, 6 October 2009 (UTC)


 * A simple "mixture" or "mixing" would be better. Actually reassortment is the process, the resultant virus is called a reassortant. This jargon is used to distinguish the process from genetic recombination which is a more thorough mixing. Graham Colm Talk 18:09, 6 October 2009 (UTC)

the pork lobby has loudly objected to the term “swine flu”
http://www.pork.org/NewsAndInformation/WebFeaturePage2.aspx?Id=474 —Preceding unsigned comment added by 66.167.95.156 (talk) 20:06, 6 October 2009 (UTC)

Seasonal Flu Shot may offer Some Help vs. Swine Flu
Seasonal Flu Shot Some Help vs. Swine Flu?

Mexican Study: Some H1N1Swine Flu Protection in Seasonal Shot; U.S. Data Show No Support for This Conclusion

By Daniel J. DeNoon WebMD Health News Reviewed by Louise Chang, MD http://www.webmd.com/cold-and-flu/news/20091006/seasonal-flu-shot-some-help-vs-swine-flu?src=RSS_PUBLIC

[Text trimmed by Jehochman Talk] ... —Preceding unsigned comment added by 66.167.95.156 (talk) 01:28, 7 October 2009 (UTC)

Pre-FA prose tip
A tricky issue is that of repetitious prose. There is a bit of it here and some is obviously necessary. I'll do what I can...Casliber (talk · contribs) 08:41, 7 October 2009 (UTC)

Emphatic disclaimer that official numbers accurately include all cases is needed.
One of the ploys of the pandemic deniers is to use the `official’ tally of deaths, both here in the US and around the world, to `prove’ the H1N1 virus is not a genuine threat.

http://afludiary.blogspot.com/2009/10/dead-reckoning.html —Preceding unsigned comment added by 68.165.11.88 (talk) 19:06, 9 October 2009 (UTC)
 * Pandemic deniers ("pandemic-ers") exist? --Cyber cobra (talk) 08:18, 10 October 2009 (UTC)

Wikipedia Reference Desk.
Someone recently redirected a post from someone asking about their supposed H1N1 symptoms from this Talk page to the Wikipedia Science Reference Desk.

FYI: While I strongly agree that the post did not belong on this talk page (which is for discussions about the article and nothing else) - it was pointless to re-post it to the reference desk because the RD has a strong and unwavering rule that we are not allowed to offer medical advice of any kind. In fact, there is nowhere on Wikipedia where this kind of question can be answered (Nor should there be!) - IMHO, the only sane answer to anything of this kind is "We can't offer help or advice here - go see a doctor if you're worried about it."

SteveBaker (talk) 17:47, 10 October 2009 (UTC)

Is Pandemic H1N1 a genuine threat?
There is one source of information giving a reality-based perspective on Pandemic H1N1, that is pediatric mortality. Pediatric mortality is subject to official registration in many countries (including the US). Each pediatric death has to be categorized. Thus we have quite reliable numbers on pediatric deaths from seasonal influenza during the past years, which can be compared with the pediatric deaths from pandemic H1N1. In contrary the information available for grown-ups is patchy, because examining and reporting deaths is not obligatory, therefore many deaths caused by influenza may remain undetected. (All numbers from | CDC FluView)

Now have at look at the | most recent numbers:
 * Pandemic flu has caused 76 pediatric deaths between April, 15 and October, 3 (week 19-39, 2009)

(the reporting period just finished with week 39, but there is a chance - let's better say it is likely -, that more deaths will be reported retrospectively; this week, there were 12 deaths reported for previous weeks)
 * The 76+ has to be compared with the number of pediatric deaths from seasonal flu:


 * 46 in 2005/06
 * 78 in 2006/07
 * 88 in 2007/08
 * 71 (=147-76) in 2008/09


 * While comparing the numbers one has to keep in mind, that all the pandemic deaths happened during a season, in which normally hardly any deaths occur
 * Let's look at the number of deaths from seasonal influenza between week 19-39 of the previous years:
 * 2 in 2005/06
 * 3 in 2006/07
 * 2 in 2007/08
 * 6 in 2008/09 (you also have to count the blue ones)

Summarizing: if pandemic flu behaves similarly to seasonal flu in terms of the relation spread summer / spread winter, its impact (on children, other age groups might be different) will be likely more than 20-fold compared with seasonal flu.

Then have a look at the | hospitalization rates for different age groups: Conclusions?
 * age group 5-17 yrs exceeded Oct-Apr(!) seasonal average a long time ago
 * age group 18-49 yrs exceeded it a couple of weeks ago
 * age groups 50-64 and 2-4 years just reached the flu season seasonal average
 * only the very young and the very old are still under the seasonal average

Now, does anyone still believe, that pandemic flu is less threatening than seasonal flu? And do you understand now, why all the governments are hectically preparing their vaccination programs?

FHessel (talk) 14:38, 12 October 2009 (UTC)
 * You're not accounting for the effects of herd immunity. For a regular flu, parents of very young children, their daycare providers (if any) and their doctors are usually vaccinated.  The youngest children have no other source for flu exposure (they don't commute, go to school, etc.).  Older children are vaccinated in relatively high numbers (probably around 50%, which is the population average), particularly if they have a preexisting condition that would be a risk factor for complications.  As such, roughly half the population, and presumably a substantially greater portion of the vulnerable population, is immune (or strongly resistant) to the seasonal flu, and the other half (particularly the very young) benefits from limited contact with the unvaccinated.  A more reliable comparison would be to look at mortality rates in poor southern hemisphere countries with limited or no access to vaccine.  If they showed a spike in flu deaths this summer, then we have something to worry about (though with the vaccine becoming available, the risk dwindles daily). Unfortunately, any country with limited access to vaccines is probably not going to keep good records on flu mortality. --ShadowRangerRIT (talk) 18:11, 13 October 2009 (UTC)
 * One other thing you are missing: The new flu seems to be particularly contagious (made obvious by the speed with which it spread in an off season), but it hasn't been changing genetically in a substantial way since the Spring. In many places that were hit particularly hard in the Spring, such as New York City, it is currently estimated that 20-40% of the population was exposed to H1N1.  As such, the deaths in hard hit areas are likely front loaded.  Many of those likely to die have either survived or died already.  Moreover, the flu spread primarily through the school system; thus your particular demographic is now protected at a higher rate (and died in disproportionate numbers during the time period used for your data).  If 50% of New Yorkers get the vaccine, and 20-40% of them were already exposed (and now immune), then the final immunity count for this season would run around 60-70% (10-20% greater than normal, thus amplifying the effect of herd immunity for H1N1). So yes, it may be more contagious, and comparing H1N1 without vaccine to the seasonal flu with a vaccine will show a greater number of deaths in the former case, but it's still too much of an apples to oranges comparison.  By cherry picking your data, you end up drawing potentially erroneous conclusions. --ShadowRangerRIT (talk) 18:26, 13 October 2009 (UTC)
 * Corroborating my second note, it looks like NY/NJ and New England (which were hard hit) are now having disproportionately low incidence of H1N1. At time of writing, the incidence in New England was ~7%, and the NY/NJ incidence was only 2.1%. Other areas just being introduced to the disease have rates of incidence in the 20-35% range.  Given how much of the population is concentrated in the hard hit, now partially protected regions (population is ~42 million), it's reasonable to assume that their mortality spike in the Spring was just redistributing the deaths; by spiking early, we hit a trough of deaths in the "usual" flu season. On a purely hypothetical note (I have zero evidence for this speculation, while the rest of it is based on quite a bit of reading in newspapers and journals), I might suggest that the unusual spread of H1N1 this Spring might not even be due to greater contagiousness.  Rather, the Northeastern U.S. had an unusually cool Spring and early Summer.  Perhaps the quick spread occurred not because H1N1 is unusually contagious, but because the weather was unusually well suited to a Spring epidemic. --ShadowRangerRIT (talk) 18:41, 13 October 2009 (UTC)


 * I am open to good news. Hey, a lot of the people who got sick back in Spring and recovered are now immune, plus a lot of people will be getting vaccinated in coming weeks, so things won't be as bad as they could be.


 * I don't want us to overstate the case regarding swine flu. That's often an immediate turn-off to people.  But I don't want us to understate the case either.


 * And conditions in the developing world, where people are likely to have less access to vaccines, and less access to health care until the person really gets sick, that too needs to be part of the discussion, and part of our article with the best sources we can find.


 * The biggest argument on the other side: more total people getting sick, even with H1N1 being approximately the same severity as the seasonal flu, means more hospitalizations and more fatalities. One source, the President's Council of Advisors on Science and Technology from back on August 7.
 * REPORT TO THE PRESIDENT ON U.S. PREPARATIONS FOR 2009-H1N1 INFLUENZA, August 7, 2009, page viii:
 * " .  .  .  cause between 30,000 and 90,000 deaths in the United States, concentrated among children and young adults.  .  .  .  "
 * Now, that is somewhat vague, but I guess that's the reality.  Cool Nerd (talk) 22:47, 14 October 2009 (UTC)

Interference between different viruses might have reduced spread of H1N1 virus in the northern hemisphere during summer
Have you noticed this information, published by | ECDC on October, 09?

Does viral interference affect spread of influenza?

A paper from Sweden published in Eurosurveillance this week presents the hypothesis that a rhinovirus epidemic after the end of the summer holidays may have interfered with the spread of pandemic influenza during a period with warm and humid weather conditions that reduces spread of influenza by aerosol. Although the laboratory data supporting this hypothesis are limited, it is meant to stimulate research into the possibility that the interaction between different circulating viruses may affect influenza epidemiology. As a possible explanation, the authors note that rhinovirus transmission is not known to be climate-dependent. Thus the spread of rhinoviruses may have had an advantage over influenza in mild and moist climate. Rhinovirus infection will elicit an innate immune response in the infected cells, stimulating the production of interferon and other cytokines. This immune reaction causes the cells to enter an antiviral state that would to some extent protect them from further infections by other viruses. | Link to the article...

FHessel (talk) 13:22, 12 October 2009 (UTC)

In children, relapse with high fever may be bacterial pneumonia
Report Finds Swine Flu Has Killed 36 Children, New York Times, Denise Grady, Sept. 3, 2009. “ .  .  . In children without chronic health problems, it is a warning sign if they seem to recover from the flu but then relapse with a high fever, Dr. Frieden said. The relapse may be bacterial pneumonia, which must be treated with antibiotics. . .  . ” [Dr. Thomas Frieden is head of CDC.]


 * Okay, a relapse possibly being pneumonia may apply to adults, too. Probably does, but, but let’s be a little careful about it and put it together piece by piece.  If you have the time, I could sure use some help with the research.  Thanks.   Cool Nerd (talk) 00:05, 14 September 2009 (UTC)  Please help.  Cool Nerd (talk) 23:11, 23 September 2009 (UTC) . . . and Cool Nerd (talk) 16:34, 7 October 2009 (UTC)

How did swine flu kill a healthy boy?, Antioch kindergartner's death leaves parents and doctors without answers, by CHAS SISK, THE TENNESSEAN, SEPTEMBER 14, 2009. The article is about five-year-old Max Gomez, who died even though he did not have chronic health problems.

"[page 3] .  .  .  One possibility is that H1N1 could be exacerbated by a bacterial infection. All six of the children the CDC studied who were over 5 years old but did not have a chronic medical condition tested positive for a bacterial infection in addition to swine flu.

"Health officials said they did not know enough about Max Gomez's case to say whether a bacterial infection contributed to his death.

“But they did say that when influenza combines with a bacterial infection, such as pneumonia, the patient often follows a pattern in which his symptoms start to subside but then suddenly worsen. That pattern — which includes symptoms such as vomiting, chest pain, a racing pulse, breathing trouble, bluish skin or trouble staying awake — is an indication that the flu has turned deadly, and it means a sufferer should talk to a doctor immediately.

""What you expect from ordinary flu is that it starts off bad and gets better," said Dr. Bill Paul, Metro's health director. "If that's not the case, it's worth a call.""


 * Again, it would seem like this would also apply to adults, although perhaps to a lesser extent. Please help with the research if can.    Cool Nerd (talk) 18:36, 14 September 2009 (UTC)  And (multiple quick passes!!)  Cool Nerd (talk) 20:13, 24 September 2009 (UTC)

Preparing for a Stressful Flu Season,New York Times, By TARA PARKER-POPE, September 7, 2009. “ .  .  .  In otherwise healthy children, the main warning sign is that the child seems to feel better, then appears to relapse with a high fever. This signals a bacterial infection that must be treated with antibiotics. Even though such infections are seldom severe, the child should be seen by a pediatrician as quickly as possible. . .  .  ”


 * Okay, some possible good news.  Cool Nerd (talk) 23:08, 23 September 2009 (UTC)

CDC's Morbidity and Mortality Weekly Report for Sept. 4th
Surveillance for Pediatric Deaths Associated with 2009 Pandemic Influenza A (H1N1) Virus Infection --- United States, April--August 2009, CDC's Morbidity and Mortality Weekly Report, September 4, 2009.

“ .  .  .  of 36 children who died, seven (19%) were aged <5 years, and 24 (67%) had one or more of the high-risk medical conditions. Twenty-two (92%) of the 24 children with high-risk medical conditions had neurodevelopmental conditions. Among 23 children with culture or pathology results reported, laboratory-confirmed bacterial coinfections were identified in 10 (43%), including all six children who 1) were aged ≥5 years, 2) had no recognized high-risk condition, and 3) had culture or pathology results reported. .  .  .  " . "  .  .  .  Six deaths occurred in May, 25 deaths in June, and five deaths in July.  .  .  .  "

and maybe also in seniors (seasonal flu)
How Well Does the Seasonal Flu Vaccine Work? CDC, Page last updated: July 8, 2009.

“How effective is the seasonal flu vaccine in the elderly? . .  .  In past studies among elderly nursing home residents, the seasonal flu shot was most effective in preventing severe illness and complications that may follow flu (like pneumonia), and deaths related to the flu. . .  .  ”

As always, feel free to help with the research! Cool Nerd (talk) 22:50, 15 September 2009 (UTC). . .  and Cool Nerd (talk) 18:00, 7 October 2009 (UTC)

one explanation how
Public Ambivalence May Keep Many from Swine Flu Vaccine, FoodConsumer, Rachel Howell Stockton, Oct 4, 2009. " .  .  .  The epithelial cells surrounding (and protecting) the lungs, are severely damaged, leaving a breeding ground for bacterial pneumonia.  .  .  .  "
 * posted by Cool Nerd (talk) 16:38, 7 October 2009 (UTC)

and adults also
QUESTIONS, ANSWERS ABOUT H1N1 VIRUS, BY STEVE STERNBERG • USA TODAY, published in THE DAILY JOURNAL [NEW JERSEY] • OCTOBER 5, 2009, page 3 of 3.

" .  .  . What are the warning signs of severe illness? In children, they're fast or troubled breathing; gray or bluish skin color; not drinking enough fluids; vomiting; not waking up or interacting with others; being irritable and not wanting to be held; flu symptoms improve, then come back with fever and cough. In adults, difficulty breathing or shortness of breath; pain or pressure in the chest or abdomen; sudden dizziness; confusion; severe or persistent vomiting; flulike symptoms that abate and then return with fever and a worse cough.  .  .  .  "
 * I want more than one source.  Cool Nerd (talk) 17:11, 8 October 2009 (UTC)

NEJM: patients hospitalized in the Spring, 40% had chest X-rays consistent with pneumonia
Hospitalized Patients with 2009 H1N1 Influenza in the United States, April–June 2009, New England Journal of Medicine, Jain, Kamimoto, et al., October 8, 2009.

“ .  .  .  from April 2009 to mid-June 2009. . ..

“ .  .  .  Of the 272 patients we studied, 25% were admitted to an intensive care unit and 7% died. ..

“ .  .  .  Of the 249 patients who underwent chest radiography on admission, 100 (40%) had findings that were consistent with pneumonia; the median age of these patients was 27 years (range, 1 month to 86 years), and 66% had an underlying medical condition. Radiographic findings included bilateral infiltrates (in 66 patients), an infiltrate limited to one lobe (in 26), and multilobar infiltrates limited to one lung (in 6); data were not available for 2 patients. . .  .  ”

" .  .  .  Although it is difficult to precisely determine the cause of pneumonia from radiographs, during the 1957–1958 influenza pandemic, Louria et al.[18] reported findings of diffuse bilateral infiltrates in patients with primary influenza viral pneumonia, whereas lobar infiltrates were seen in patients with secondary bacterial infections. Better studies are needed to correlate radiographic findings with the cause of pneumonia during influenza outbreaks. In our study, only 73% of patients with radiographic evidence of pneumonia received antiviral drugs, whereas 97% received antibiotics. In the absence of accurate diagnostic methods, patients who are hospitalized with suspected influenza and lung infiltrates on chest radiography should be considered for treatment with both antibiotics and antiviral drugs.[10]  .  .  .  "


 * posted by Cool Nerd (talk) 21:40, 12 October 2009 (UTC), Cool Nerd (talk) 14:48, 14 October 2009 (UTC)

Okay, from the 1957 pandemic:


 * diffuse bilateral infiltrates --> viral pneumonia


 * lobar infiltrates --> bacterial pneumonia

And from April to mid-June 2009:


 * bilateral infiltrates (in 66 patients)


 * an infiltrate limited to one lobe (in 26)
 * multilobar infiltrates limited to one lung (in 6)

That tells me that two-thirds of the patients from earlier this year had viral pneumonia. I am not a doctor. I want to make that clear. I am a retail manager, and I would classify myself as scientifically literate. But mainly what I bring to the table is country boy doggedness. Read the article. Then read it a second time, taking careful notes as you go along. You can probably understand more than you might think.

And the advice, that for a patient with pneumonia, before you're really able to nail down the type of pneumonia, it's probably better to treat with both antivirals and antibiotics. That is probably very good advice. Cool Nerd (talk) 21:55, 16 October 2009 (UTC)

“Primary viral pneumonia is the most common finding . . . ”(WHO, Oct 16th)
Clinical features of severe cases of pandemic influenza, WHO, Oct. 16 2009: "  .  .  .  Primary viral pneumonia is the most common finding in severe cases and a frequent cause of death. Secondary bacterial infections have been found in approximately 30% of fatal cases.  .  .  .  "   Cool Nerd (talk) 23:07, 18 October 2009 (UTC)

Many of the Canadians who died or were sent to hospital earlier this year with H1N1 virus were young adults, female and aboriginal
I'll just leave this here. http://www.cbc.ca/canada/story/2009/10/12/h1n1-virus-infection-females-young-aboriginals-study.html?ref=rss DigitalC (talk) 19:25, 13 October 2009 (UTC)

---

Clinical features of severe cases of pandemic influenza, WHO, Oct. 16, 2009: “. . .  Evidence presented during the meeting further shows that disadvantaged populations, such as minority groups and indigenous populations, are disproportionately affected by severe disease. Although the reasons for this heightened risk are not yet fully understood, theories being explored include the greater frequency of co-morbidities, such as diabetes and asthma, often seen in these groups, and lack of access to care. . .  .  ”  Cool Nerd (talk) 22:27, 18 October 2009 (UTC)

WHO’s Oct 14-16th Washington, D.C. Conference
Clinical features of severe cases of pandemic influenza, Pandemic (H1N1) 2009 briefing note 13, World Health Organization, Geneva, Oct. 16, 2009:

“ .  .  .  The meeting confirmed that the overwhelming majority of persons worldwide infected with the new H1N1 virus continue to experience uncomplicated influenza-like illness, with full recovery within a week, even without medical treatment.. . .  ”

“ .  .  .  However, concern is now focused on the clinical course and management of small subsets of patients who rapidly develop very severe progressive pneumonia. . .  .  ”

“ .  .  .  Primary viral pneumonia is the most common finding in severe cases and a frequent cause of death. Secondary bacterial infections have been found in approximately 30% of fatal cases. . .  .  ”

Clinical picture different from seasonal influenza “Participants who have managed such cases agreed that the clinical picture in severe cases is strikingly different from the disease pattern seen during epidemics of seasonal influenza. While people with certain underlying medical conditions, including pregnancy, are known to be at increased risk, many severe cases occur in previously healthy young people. In these patients, predisposing factors that increase the risk of severe illness are not presently understood, though research is under way.

“In severe cases, patients generally begin to deteriorate around 3 to 5 days after symptom onset. Deterioration is rapid, with many patients progressing to respiratory failure within 24 hours, requiring immediate admission to an intensive care unit. Upon admission, most patients need immediate respiratory support with mechanical ventilation. However, some patients do not respond well to conventional ventilatory support, further complicating the treatment.

“On the positive side, findings presented during the meeting add to a growing body of evidence that prompt treatment with the antiviral drugs, oseltamivir or zanamivir, reduces the severity of illness and improves the chances of survival. These findings strengthen previous WHO recommendations for early treatment with these drugs for patients who meet treatment criteria, even in the absence of a positive confirmatory test.

“In addition to pneumonia directly caused by replication of the virus, evidence shows that pneumonia caused by co-infection with bacteria can also contribute to a severe, rapidly progressive illness. Bacteria frequently reported include Streptococcus pneumoniae and Staphylococcus aureus, including methicillin-resistant strains in some cases. As these bacterial co-infections are more frequent than initially recognized, clinicians stressed the need to consider empiric antimicrobial therapy for community acquired pneumonia as an early treatment.”

Groups at greatest risk “Participants agreed that the risk of severe or fatal illness is highest in three groups: pregnant women, especially during the third trimester of pregnancy, children younger than 2 years of age, and people with chronic lung disease, including asthma. Neurological disorders can increase the risk of severe disease in children. . .  .  ”


 * posted by Cool Nerd (talk) 22:16, 18 October 2009 (UTC), Cool Nerd (talk) 19:14, 21 October 2009 (UTC)

WHO’s Nikki Shindo
Swine flu can cause viral pneumonia, WHO tells doctors to treat it quickly with class of drugs, by Rob Stein, Washington Post (reprinted by Boston Globe), October 17, 2009:

“Remarkably different is this small subset of patients that presents very severe viral pneumonia,’’ Shindo said. [Nikki Shindo, a medical officer in the WHO’s Epidemic and Pandemic Alert and Response Department], posted by Cool Nerd (talk) 22:06, 20 October 2009 (UTC)

Worldwide deaths in table "over 9000"
I can't seem to find where to edit it but it says the confirmed deaths are "over 9000" which is obviously some vandalism referring to the "over 9000" Internet meme. According to the EDHC 4,804 deaths are confirmed.

http://en.wikipedia.org/wiki/2009_flu_pandemic_by_country —Preceding unsigned comment added by 204.209.209.129 (talk) 02:01, 20 October 2009 (UTC)

Hemopurifier press release
I've removed a section based upon a press release on PR Newswire from both this article diff and the Influenza A virus subtype H1N1 article diff]. I've done this since a press release does not meet the medical reliable sources guideline. Tim Vickers (talk) 18:03, 20 October 2009 (UTC)
 * And I've removed it again. You're absolutely right, we need independently published sources for something like this, not press releases. - MrOllie (talk) 18:51, 20 October 2009 (UTC)

All right then. I shall save you the trouble of removing the Peramivir section since it is written in exactly the same language as what I've posted ALONG with a PR from CBS News. IT IS NO DIFFERENT IN CONTENT. If this deletion by the two of you continues, then I will forced to move this to the next level under the presumption that the two of you are possible being compensated by a third party to police this section. —Preceding unsigned comment added by Brianboone (talk • contribs) 19:20, 20 October 2009 (UTC)
 * No, there is a difference between a report by CBS Evening news, a reliable news organization, and prnewswire, which republishes whatever a company cares to say verbatim. - MrOllie (talk) 19:28, 20 October 2009 (UTC)

OK. We agree to disagree at this point. I truly believe that concealing information from the public is a bad thing. An individual should be able to determine if the information presented is valid and worthy. Not you, not Tim or myself should decide that. —Preceding unsigned comment added by Brianboone (talk • contribs) 19:34, 20 October 2009 (UTC)
 * You are entitled to hold that opinion, but since it runs counter to several wikipedia guidelines, we should not edit the article in accordance with your opinion. - MrOllie (talk) 19:40, 20 October 2009 (UTC)
 * I'm personally fine with removing the peramivir section, since although this can be verified on a US government website, this does not seem like a critical piece of information yet. Perhaps once this drug starts to be widely-used then we can add this back. Tim Vickers (talk) 19:50, 20 October 2009 (UTC)

I would agree with that, Tim. —Preceding unsigned comment added by Brianboone (talk • contribs) 19:59, 20 October 2009 (UTC)


 * Probably should be mentioned on the peramivir article though, I'll move it there. Tim Vickers (talk) 20:03, 20 October 2009 (UTC)

Writing for Parents, Presidents, and Prime Ministers
Let's assume our article finds its way onto President Barack Obama's desk. And why not? Let's endeavor to write something that good. Let's hit all the high points and let's hit them in the right amount of detail.

And perhaps even more than presidents, parents are very demanding readers. A vague list of symptoms like cough, fever, muscle aches---that can be five thousand different diseases! That is not particularly helpful! A parent wants to know what specific symptoms. Let's go ahead and provide that, with the best references that we can find. Even more so, a parent wants to know, okay, when is it getting medium bad with my child, and when is it getting really bad and I want to make sure to get medical attention right away? So, let's go ahead and provide that, again, with the best references that we can find.

The interesting thing, parents, in the role of parents, might be the even more demanding as readers than presidents and prime ministers. Yes, we will provide the background information like on what date WHO declared it a pandemic, and that this means spread in several different geographic areas and not necessarily severity. But let's also provide the specific details parents want. And if we write for parents, our article will probably end up being a really good article for everyone else. Cool Nerd (talk) 19:02, 21 October 2009 (UTC)

reassortment of human, swine, bird, and please allow narrative to just develop
The following is from the lead paragraph of our article: "The virus is a mixing (reassortment) of four known strains of influenza A virus: one endemic in humans, one endemic in birds, and two endemic in pigs (swine).[3]"


 * People reading it might think, gee, I remember hearing in the media triple reassortment. —Preceding unsigned comment added by Cool Nerd (talk • contribs)
 * Huh? I don't understand what the point is you're trying to make. --Cyber cobra (talk) 21:03, 21 October 2009 (UTC)


 * Basically, that we're blurring and shaving. And it's the first hint of doubt.  Please see the following.   Cool Nerd (talk) 21:17, 21 October 2009 (UTC)

Geographic Dependence, Surveillance, and Origins of the 2009 Influenza A (H1N1) Virus, New Eng J Med, Trifonov, Khiabanian, and Rabadan, July 9, 2009.

“ .  .  .  H1N2 and other subtypes are descendants of the triple-reassortant swine H3N2 viruses isolated in North America. They have spread in swine hosts around the globe and have been found to infect humans.5 The segments coding for the neuraminidase and the matrix proteins of the new human H1N1 virus are, however, distantly related to swine viruses isolated in Europe in the early 1990s (Table 2). . .  .  ”

[See also Figure 1 which shows a Eurasian swine virus mixing with an preexisting triple reassortment which may have recombined with another existing. . . ]

Yeah, it gets technical. It might be too technical. But this is what we currently have. But it probably does not belong in the lead paragraph. Cool Nerd (talk) 21:17, 21 October 2009 (UTC)

from Virus characteristics section: "It was also determined that the strain contained genes from five different flu viruses: North American swine influenza, North American avian influenza, human influenza, and two swine influenza viruses typically found in Asia and Europe."


 * We're just giving the endproduct. We're not giving the narrative, which might make more sense.  (And again, I highly recommend Figure 1 from the above NEJM article.)  Cool Nerd (talk) 21:27, 21 October 2009 (UTC)

temporary plan, work in progress
Going to go with quote from NEJM article in Virus characteristics. This doesn't merely state that it's complex. It shows some of the complexity, and the reader can see that for him- or herself. Or, they can read how much is meaningful to them and then drop to end of this paragraph/beginning of the next section. Plus, some kind of detailed discussion, either from NEJM or elsewhere, does seem appropriate for the section Virus characteristics.

Okay, I'd like to see our article, from the beginning, move very quickly to 'general mild, but exception. . . ' And then give a useful amount of detail on the exceptions. This include preexisting conditions, and the symptoms of viral pneumonia and/or bacterial pneunomia. That is, like a newspaper, a reader can stop reading at any time, but they've still gotten useful information.

In the lead we say "In early June 2009" for the date WHO declared a pandemic, as if there is some kind of inherent virtue in vagueness?? I just don't get it. It takes the same space--or shorter--to say June 11th (almost, almost positive of that, but don't dare print it in our article itself until I get several good sources or one really good source). And then with the symptoms, on that one, we might really be missing an opportunity. Cool Nerd (talk) 22:46, 21 October 2009 (UTC)

Czechia goes black
Unfortunately, Czechia has a death case, too. A 31-year-old woman with chronic problems with the heart was diagnosed and died today at 10 am. --Lumidek (talk) 14:00, 22 October 2009 (UTC)

To the person from Kentucky
" .  .  .  IN THIS AREA OF WILLIAMSBURG KENTUCKY. MY OWN GRANDSONS AGE 8YR OLD AND 10 YR.OLD  .  .  .  "

I'm all with you, but we cannot give medical advice. I am not a doctor. I think most of the people here are not doctors. The best we can do, I guess, is to give preparatory information. Like the information above on the Oct 14-16 WHO Conference. Please read that, it's pretty good. It's about a page. So, the preparatory information can help you ask questions of your doctor. And there's nothing wrong with getting a second opinion from another doctor. Especially if someone gets sicker. The most serious issue is pneumonia, either viral pneumonia directly from H1N1 and/or a secondary infection of bacterial pneumonia. I have seen enough sources that I can say that. That is general health information obtainable from a variety of sources, including CDC, WHO, and the New England Journal of Medicine. What I cannot do is give advice in a particular case. I don't think any of us can do that. Even if we had a physician helping us out, they really can't treat a person over the Internet.

Now, as far as public health officials reassuring people even when the facts are not really in that direction, or when it's basically an unknown, yeah, it can happen. Contact your local media, and be aggressive. Ask the hard questions, ask the awkward questions.

And best wishes with everything. Cool Nerd (talk) 14:33, 22 October 2009 (UTC)


 * Okay, speaking as a country boy, if someone gets sicker, that doesn't necessarily mean the doctor was wrong. The doctor may have treated the most likely cause.  But, sometimes it ain't the most likely cause.  Sometimes it's something else.  In either case, the situation well warrants a phone call to the doctor.  And don't let them just brush you off with bland reassurances.  You make sure they hear what's going on.   Cool Nerd (talk) 17:27, 22 October 2009 (UTC)

actionable items
Clinical features of severe cases of pandemic influenza, Pandemic (H1N1) 2009 briefing note 13, World Health Organization, Oct. 16, 2009: “. . .  In severe cases, patients generally begin to deteriorate around 3 to 5 days after symptom onset. Deterioration is rapid, with many patients progressing to respiratory failure within 24 hours, requiring immediate admission to an intensive care unit. . .  .  ”

Report Finds Swine Flu Has Killed 36 Children, New York Times, Denise Grady, Sept. 3, 2009. “ .  .  . In children without chronic health problems, it is a warning sign if they seem to recover from the flu but then relapse with a high fever, Dr. Frieden said. The relapse may be bacterial pneumonia, which must be treated with antibiotics. . .  . ”


 * In poker terms, these are playable hands. They have enough feel and texture that you can actually do something with them.


 * So again, let's assume our article makes it to the prime minister's desk. The prime minister of, say, India is reading our article on 2009 flu pandemic.  And why not?  So, why would he, or she, (and I must confess, I don't know who the current prime minister of India is) want to read the above two items?  To make sure that his or her healthy authorities are doing a good job of informing citizens, and precisely because these are actionable items.  These are two bits of information that parents, school authorities, aunts, uncles, etc, can actually do something with.


 * Now, if we got to the point where our article had five, six actionable items, then maybe we're starting to bump up against how much information a person can absorb on one occasion. But frankly, we put some much time into buffing and polishing, I'm not sure we have any actionable items at all.  Between accuracy and the formality of the writing, I'm sure we'd say that accuracy is the more important goal.  But if we look at where we spend most of our time and energy, it makes you wonder.  Now, perhaps as part of its growth trajectory, wikipedia needed to go through an over-formal period.  Well, it may now be time to try something different.


 * And the other central goal of course is completeness. Accuracy and completeness.


 * And it's not so much a matter of putting juicy stuff in. Often, it's just a matter of letting a juicy quote remain a juicy quote.    Cool Nerd (talk) 17:27, 22 October 2009 (UTC)


 * Without artificial limitations, that's what I'm trying to say. And some of it, surprisingly and paradoxically, is if we can simply avoid trying too hard!  CDC and WHO have already done a lot of the work for us.  There is no need for us to repeat it (and again, I'm not a doctor, and you probably aren't either).  But if we can find their best material, in our calm moments and when we have plenty of time, we have done a tremendous service for the harried parent, and well as the citizen who is trying to determine if his or her government is overreacting or underreacting.  In fact, parents are such a demanding audience, that if we write a good article for them, we will almost certainly have a good article for everyone else.  And generally, we do not need to stand between the parent and the information.  Long quote, okay, we might need to summarize.  But shorter quotes, we can just let the parent see directly for himself or herself.  Cool Nerd (talk) 22:55, 24 October 2009 (UTC)

June 11, official start of pandemic
World now at the start of 2009 influenza pandemic, Dr Margaret Chan, Director-General of the World Health Organization, 11 June 2009:

“ .  .  .  I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6. . .  .  ”

“ .  .  .  On present evidence, the overwhelming majority of patients experience mild symptoms and make a rapid and full recovery, often in the absence of any form of medical treatment. . .  .  ”

“ .  .  .  At the same time, it is important to note that around one third to half of the severe and fatal infections are occurring in previously healthy young and middle-aged people. . .  .  ”

---

H1N1 pandemic spreading too fast to count: WHO, Reuters, Stephanie Nebehey, July 17, 2009:" .  .  .  The United Nations agency, which declared an influenza pandemic on June 11, revised its requirements so that national health authorities need only report clusters of severe cases or deaths caused by the new virus or unusual clinical patterns.  .  .  .  "


 * posted by Cool Nerd (talk) 17:02, 24 October 2009 (UTC)

Pres. Obama declares H1N1 national emergency Oct. 24, enables Sec. Sebelius to grant hospitals waivers
Obama Declares Swine Flu a National Emergency as Cases Surge, Bloomberg, By Andrew Pollack, Oct. 24: “President Barack Obama declared swine flu a national emergency, the White House announced in an e-mailed statement today. “The proclamation, signed last night, is designed to help U.S. medical treatment facilities deal with a surge in H1N1 influenza patients by waiving government rules on a case-by-case basis, the announcement said. “Swine flu is now widespread in 46 states and accounts for 411 confirmed deaths since Aug. 30 and more than 8,200 hospitalizations, according to the Centers for Disease Control and Prevention. The numbers reflect what would be the peak of a typical flu season, CDC Director Thomas Frieden, said yesterday. “Many millions of cases” have occurred in the U.S. since the outbreak began last spring, he said. “Swine flu vaccine production is slower than anticipated and drugmakers are unlikely to hit the U.S. government’s targets for delivery, Frieden said. . .  .  ”

-

President Obama declares H1N1 flu a national emergency, Washington Post, By Michael D. Shear and Rob Stein, Saturday, October 24, 2009; 12:58 PM:

“President Obama Saturday declared the H1N1 flu a national emergency, clearing the way for legal waivers to allow hospitals and doctors offices to better handle a surge of new patients.

“The proclamation will grant Secretary of Health and Human Services Kathleen Sebelius the power to authorize the waivers as individual medical facilities request them, officials said.

“It says that Obama does "hereby find and proclaim that, given that the rapid increase in illness across the Nation may overburden health care resources and that the temporary waiver of certain standard Federal requirements may be warranted in order to enable U.S. health care facilities to implement emergency operations plans, the 2009 H1N1 influenza pandemic in the United States constitutes a national emergency."

“White House officials played down the dramatic-sounding language, saying the president's action was not prompted by a new assessment of the dangers posed to the public by the flu.

“Instead, officials said the action provides greater flexibility for hospitals which may suddenly find themselves confronted with a surge of new patients as the virus sweeps through their communities. . .  .  ”


 * posted by Cool Nerd (talk) 17:39, 24 October 2009 (UTC)

peramivir, and in favor of medical-oriented writing (good Newsweek style)
The following (currently in our article) reads like a stock market report:


 * "In October 2009, it was reported that the experimental antiviral drug Peramivir had been effective in treating serious cases of swine flu. On October 23, the FDA issued an Emergency Use Authorization for Peramivir, allowing the government to stockpile the drug and leading to wider and faster availability for patients. Since the FDA's decisions and actions are closely watched around the world, this move is likely to also increase demand for Peramivir internationally."

Let's try and put together something that would make a really good article in Newsweek, how about something like that! Cool Nerd (talk) 20:08, 24 October 2009 (UTC)

looking for articles
FDA approves emergency use of intravenous peramivir against swine flu, Los Angeles Times, Thomas H. Maugh II, October 24, 2009: "  .  .  .  The emergency use authorization says peramivir can be used when other drugs have failed or when delivery by a route other than intravenous is not expected to be feasible.  .  .  .  "

FDA approves emergency use of new intravenous flu drug, peramivir, Canadian Press, Helen Branswell Medical Reporter, Oct. 23: "  .  .  .  Experts have been calling for years for the development of an IV flu drug for use in severely ill hospitalized patients who can't take the existing flu medications which are either in pill form or inhaled powder.  .  .  .  "

FDA-Issued Peramivir IV EUA (Emergency Use Authorization) Letter Eight page letter from Dr. Margaret Hamburg, Commissioner of Food and Drugs, to CDC's Dr. Thomas Frieden, Oct. 23, 2009. Posted at CDC web site.

First Death in Turkey from Swine Flue
http://www.milliyet.com.tr/Guncel/HaberDetay.aspx?aType=HaberDetay&KategoriID=24&ArticleID=1154272&Date=25.10.2009&b=Turkiyede%20domuz%20gribinden%20ilk%20olum —Preceding unsigned comment added by Csunsay (talk • contribs) 03:18, 25 October 2009 (UTC)

First swine flu death in Finland
—Preceding unsigned comment added by Huokaus (talk • contribs) 11:54, 26 October 2009 (UTC)

Section on differences between H1N1 and Seasonal Flu
Why isn't there a section where the differences between this pandemic flu and the typical seasonal flu are spelled out? I know for both historical interest and those who currently dealing with the problem that would be useful. And there are differences: The flu was active in the summer months, when typically flu dies out. The fall flu season shows the intensity of typical peak flu several months early (at least in the US). Instead of 90 percent of fatalities being with those over 65 and much of the rest being those under 5, those are the age groups that have the smallest rates of death with H1N1. A full 65% of deaths for h1N1 have been for working age adults between the ages of 25 and 64, and school age kids have died at a faster rate than preschoolers ( http://www.cdc.gov/H1N1FLU/surveillanceqa.htm ). Hospitalization rates also don't follow the usual pattern, with the bulk again being in the 25-64 age group. ( http://www.cdc.gov/H1N1flu/qa.htm ) Obesity is not normally associated with higher complication risks with seasonal flu, but it is with H1N1. Minority and indigenous groups seem to be more at risk. In addition, while most cases of H1N1 are mild, a small subset of cases turn fatal very fast in a unique pattern. ( http://www.who.int/csr/disease/swineflu/notes/h1n1_clinical_features_20091016/en/index.html )

While I realize that wikipedians don't want to seem hysterical, not putting basic facts like this prominently on the page just distorts the whole issue. —Preceding unsigned comment added by 71.237.245.0 (talk) 16:56, 26 October 2009 (UTC)


 * The last sentence of the above noted (WHO, Oct 16) Clinical features of severe cases of pandemic influenza: "Patient care advice that can be applied in resource-limited settings is being rapidly compiled."  Wow, yeah, important.  As soon as that's available, we need to roll with that.


 * You idea of an article on the direct differences, yes, yes, roll with it. Start with the above paragraph.  Do you flat-out, dead-level best.  Play your best game.  Don't hold yourself back with artificial limitations.   Cool Nerd (talk) 03:15, 27 October 2009 (UTC)

To ignore list
[http://abcnews.go.com/GMA/SwineFlu/Story?id=7584420&page=1 "There are lives at risk," Gibbs said. "The sooner this idea gets out, the better."]

www.naturalnews.com/026503_pandemic_swine_flu_bioterrorism.html Journalist Files Charges against WHO and UN for Bioterrorism and Intent to Commit Mass Murder]

New York medical workers (conspiracy nuts as defined by wikipedia) took legal action.., to halt a massive swine flu inoculation program being rolled out...

[http://www.time.com/time/health/article/0,8599,1932366,00.html... whose side effects are not yet entirely known]

“No forced shots!”

Nothing to see here folks, move along. ManComesAround (talk) 14:02, 27 October 2009 (UTC)


 * Yeah, basically. Most of those link to clearly misinformed individuals: "'I don't know of another live vaccine for flu. So you have immediately a new problem you don't have with a killed vaccine,' Turner told AFP."  The nasal spray vaccine, which has been in use for a number of years, has *always* used live, attenuated flu virus.  The only difference this year is that they made it with H1N1.  Conspiracy nuts can't complain about the mercury (because nasal sprays don't have it), so they're reduced to complaining that it's "alive" and therefore they're trying to spread the disease.  The only people capable of contracting the disease from the nasal spray are the very elderly, the very young, and those with compromised immune systems.  And guess what?  Those groups aren't allowed to get the nasal vaccine for that very reason.
 * On the "escaped from a lab" issue, while possible (anything is possible), it doesn't change anything substantial. The disease isn't particularly deadly, and as the article notes, WHO is investigating.  If it did escape from a lab, I expect to see someone punished.
 * The rest of it is clearly paranoid individuals. The primary reason these conspiracies are nuts: The government isn't that competent.  Even if they had some convoluted reason to want to infect us with what amounts to a nasty cold, they can't effectively accomplish half their stated aims, and you expect me to believe they can successfully develop a virus, distribute it, and come up with some magic vaccine that harms those who get it in some unspecified way without being detected?  Beyond that, give me a real motivation here: deaths are low, and they clearly can't even get the vaccine out the door fast enough to accomplish anything of import.  Seriously, the world is fscked up enough without adding inane explanations of non-existent threats. --ShadowRangerRIT (talk) 14:24, 27 October 2009 (UTC)


 * Hey, it's a ignore list, you could have ignored it. The real motive? I'd say its an extortion, no time to elaborate though. How much money was made in process? I know that some countries bought vaccine that is yet to be approved. It would be interesting addition to the article, the cost of pandemic... As seen, Germany can inoculate the whole population, twice. I find it striking... Well, whatever be the case 'more than six in 10 say they will not get vaccinated'. What do you think, should we add all this info to the section about controversy, or to this ignore list? ManComesAround (talk) 14:52, 27 October 2009 (UTC)


 * However idiotic it is, citing the objections of the small group of NY health professionals as an example of resistance to the vaccination is informative. The rest is too loony to bother with. --ShadowRangerRIT (talk) 14:56, 27 October 2009 (UTC)

Worldwide view
I've got an issue with this being listed as a GA. I feel the article doesn't represent a worldwide view. A quick scan seems to show the majority of paragraphs starting with "the CDC says, in the US, president obama...", this is a worldwide pandemic, and I don't think the article represents that at all.--Crossmr (talk) 14:05, 26 October 2009 (UTC)
 * Jehochman removed the maintenance tag I moved from a section to the article top. I've restored it until someone explains how the article represents a worldwide view with all the references to the CDC, US,etc I mean the schools section has a list of countries then 2 full paragraphs about schools in the US. The worldwide view issue was brought up during the GA review and I can't see that anyone addressed it. Its listed, but there isn't a single response to it. There is heavy citing to the CDC and US, almost every paragraph seems to have a CDC citation. We have video from the CDC, we have CDC charts, we even have info from the mayo clinic, no other health organization in the world has commented on these things? The GA status isn't written in stone. There are several issues even with the CDC name being used. Standard writing procedure for introducing an abbreviation is to spell out the full name then put the abbreviation in brackets, which is done in the lead, but its then done several more times through the article. That only should be done once.--Crossmr (talk) 10:18, 27 October 2009 (UTC)
 * CDC - 29 mentions in the article
 * WHO - 11 mentions in the article
 * Travel precautions - first small paragraph about WHO and china, then a paragraph about the US (larger) and then more info about the US and 1 sentence summing up the rest of the world.
 * Workplace - The first paragraph about the US, then the second paragraph is mostly about the US and then 1 sentence about the UK.
 * Facial masks - all about the US
 * Quarantines - This adequately summarizes notable events around the world
 * Hospital preparation - All about the US
 * in children - sourced to the CDC
 * in adults - paragraph devoted to only what the CDC says
 * symptons and severity - only what the CDC and an american journal says.
 * virus characteristics- all about what the US and CDC say.
 * Nomenclature - seems to be worldwide

This is just the second half of the article and it is almost entirely US centric, with some sections only talking about the US.--Crossmr (talk) 10:46, 27 October 2009 (UTC)


 * Please go talk to the GA reviewer if you have concerns about their methodology. Have you done a web search?  Perhaps the CDC is the most prolific publisher of information about this Pandemic.  Perhaps the pandemic started in Mexico, and then expanded greatly in the US.  As the source of the Pandemic, it is not surprising that there is more information available in North America than in other places.  If you can point out other reliable sources, we should work to include them. Jehochman Talk 13:36, 27 October 2009 (UTC)
 * None of which addresses the concern here. I've just thoroughly gone through several sections of the article and detailed how they are very US centric when this is supposed to be a global article. The title of this article isn't "The 2009 Flu Pandemic in the US and all the CDC has to say about it". There are 47,000 news hits on google news in the last month, somehow I feel like there should be a good portion of them relating to the flu outside of the US. . Also looking at this old version just prior to the comment on the GA nomination that it needed to be broader, I can't see significant difference in the amount of times the US and CDC are mentioned than in the current version.--Crossmr (talk) 14:05, 27 October 2009 (UTC)
 * Okay, you are always welcome to edit and improve the article. Before you slap on a maintenance tag, get a consensus because I am opposed to tagging this article.  Perhaps you can check the article history, identify the major contributors, and bring your concerns to their attention and ask them to comment here.  You could also try WP:3O or WP:RFC to get more input from other parties.  It is not beneficial for you and I to argue against each other. Jehochman Talk 14:25, 27 October 2009 (UTC)
 * I didn't slap a maintenance tag on the article. I moved it. There is also no requirement that we get a consensus before tagging an article for maintenance. The maintenance templates exist for a reason, and at least one other editor feels there is an issue with the globalization of this article.--Crossmr (talk) 15:25, 27 October 2009 (UTC)
 * Two editors: you and the one who placed it initially. Instead of arguing about the tag, could we do something to draw attention to the potential problem, such as WP:3O or WP:RFC, and see if the resulting discussion can provide guidance on what needs to be changed or improved? Once that has been decided, we can either fix the article promptly, and if not, place tag(s) on the relevant sections. Jehochman Talk 16:32, 27 October 2009 (UTC)
 * From where I sit, there are two issues being put forward here: most of the sources are American, and the content is largely focused on the US. The first of these was not really a factor for GA because, so long as any significantly different viewpoints from other countries are noted, information like symptoms and virus characteristics are pretty global, and the CDC often has very good and reliable information on these topics (but I refuse to believe that a US blog is a better source than a foreign journal). The second is more concerning; as pointed out above it was noted in my review, and some additional US-specific info has been added since. At time of writing, the article is 81 KB, of which 25-30 KB (by my analysis, feel free to disagree) is US-specific. That's a lot, and considering the scope of this topic, it's probably excessive. I don't think the problem is bad enough that the article must be delisted, but I'm sure others would disagree, and I absolutely do believe that it's something that must be addressed. Nikkimaria (talk) 21:20, 27 October 2009 (UTC)


 * The last thing I'd like to do is take out material (good, topical, referenced, relevent material). I would like to add more worldwide material.
 * From WHO, Oct. 16 http://www.who.int/csr/disease/swineflu/notes/h1n1_clinical_features_20091016/en/index.html "WHO and its partners are providing technical guidance and practical support to help developing countries better detect and treat illness caused by the pandemic virus. Patient care advice that can be applied in resource-limited settings is being rapidly compiled."


 * That's crucial. As soon as that information becomes available, we need to print it and print it pretty generous.  An analogy is low-cost treatment of infantile diarrhea, one IV and then basically a gatorade-like mixture of electrolytes.  Don't say it's a tragedy and nothing can be done.  There's all kinds of smart things that can be done at the margins.


 * Wealthier nations have promised to do some things to help (probably not enough). And poorer nations themselves can be pretty smart and pretty savvy.  For example, we could probably learn some things from Mexico regarding how they have handled swine flu (if we look at it with an open mind and try and just let it be before drawing definite conclusions, without being trapped into thinking either that everything they do is smart or everything they do is stupid).   Cool Nerd (talk) 01:00, 28 October 2009 (UTC)
 * If the information is useful there is no reason to remove it, that does mean that several sections need to be expanded to cover what the rest of the world is thinking and saying about everything. For example the US doesn't really have a face mask culture, so while what the CDC says is relevant, face masks are very common in asian countries and what is recommended there by various organizations should be relevant, as does what is recommended in other regions/countries. I don't know why california schools though are being given time over any other school in the world.--Crossmr (talk) 04:07, 28 October 2009 (UTC)

I've compiled (and am still compiling) international reports on swine flu in schools in the "Schools" subsection of Further reading so they can be used to globalize the Schools subsection of Vaccination and prevention, which is indeed rather US-heavy. I plan to start writing material from the sources in a bit, but if anyone want to jump on it before then, have at it. --Cyber cobra (talk) 04:53, 28 October 2009 (UTC)
 * Glad to hear it. In addition to what I listed above, I'm going through the rest here. Most of it seems fine, but there are a couple concerns.
 * Response - 1 smaller paragraph about Europe and Canada, then 1 large paragraph about the US
 * Pigs and food safety - seems fine
 * Initial outbreaks - seems okay, mexico and the US had the first outbreaks and deaths. Though if there are other countries that have more detailed articles, they should be listed, perhaps a paragraph summarizing other outbreaks around the world
 * historical context seems fine
 * Lead - Why is the CDC chosen name being given time here? What about other health organizations in the world? Have they named the virus something else? The rest of it seems to be fine.--Crossmr (talk) 06:04, 28 October 2009 (UTC)
 * This story just came out of the Korea times and details the schools policy on flu closures here, it might be useful in rewriting that section.
 * kudos on the clean-up to the article already, I'm still concerned about the following sections:
 * Travel precautions - still predominantly about the US
 * The 2 tagged sections, workplace and school
 * Response - still mostly about the US
 * In adults, symptoms and severity, virus characteristics - the amount of quotes in these sections from the CDC and "the CDC did this/said that" leaves me feeling that the CDC, a US organization, is the only authority on the subject. If that is true, fine, but with this being a global pandemic I can't imagine there aren't other scientists and researchers in other countries releasing statements and papers about this flu. if those other 4 sections are fixed, I guess it might not seem as bad, but taken together I still feel like there is too much focus on how the pandemic affects the US and what they are doing about it and what they say about it.--Crossmr (talk) 02:04, 2 November 2009 (UTC)
 * I agree that broadening sources is a good thing. However, there's a lot more to it than just these items.  To me, it seems we spend so much time buffing and polishing, that we don't really ask, okay, what has happened in the last 48 hours, what has happened in the last week?  Yesterday, I added 'especially during the third trimester' to pregnancy as a risk factor.  And someone else should have done this well before I did.  We should not have been this late.  And I do not accept that our goal is merely to provide general (read: vague, unspecific) information.  We might find the references that enable us to do a whole lot more than that.  And look at our sections on "Response" and "Pigs and food safety."  "Response" emphasizes the beginning back in April and May, is blurry about the middle, and then includes the quote about Pres. Obama declaring a national emergency so that his Health and Human Services Secretary can grant hospitals waivers from their normal procedures.  Yes, it is U.S. centric.  It is also flat.  There is no sense of an evolving story, whereas aspects of this whole situation just cry out for a simple chronological story.  And I don't mean forcing things into a box.  I mean just let the story develop in its own way, which is going to be messy, which is going to be inherently nonperfectionist.  I've even thought about having section headings on "August," "September," "October."  It's probably too much work going back, but we can start going forward, "November," "December," "January."  Okay, now please look at "Pigs and food safety," the scant little bit of history is all from April, and there's no indication of when the U.S. Secretary of Agriculture said eating pork is safe.  It's flat, and it just sits there.


 * And perhaps in more important sections, and in more subtle ways, the new just blends in with the old. And I'm not sure why "Response" is so different from "Treatment" and so different from "Vaccination and prevention."   Cool Nerd (talk) 23:32, 2 November 2009 (UTC)
 * Heading by date would end up reading like a chronology or newspaper, not an encyclopedia article ("History" or similar sections notwithstanding) (though I'm sure we have a proper Timeline article on the pandemic somewhere); in some sense, the article should be flat and sit there, it's not a news report; but yes, keeping things up-to-date and slapping dates on events is always good. --Cyber cobra (talk) 01:21, 3 November 2009 (UTC)
 * "though I'm sure we have a proper Timeline article on the pandemic somewhere" -- indeed we do, see: 2009 flu pandemic timeline --ThaddeusB (talk) 05:39, 3 November 2009 (UTC)


 * Again, when we read about one of the tragic cases, how is not-sounding-like-a-newspaper the one central virtue that trumps everything else?? Please see below (both Ukraine and rewriting as school skill)   Cool Nerd (talk) 17:03, 3 November 2009 (UTC)

Okay, one thing we could add is why diabetes is a risk factor. I'm just a simple country boy. I don't see the connection. But enough authorities have stated this and apparently there is a connection. Cool Nerd (talk) 19:58, 3 November 2009 (UTC)

the potential warning of Ukraine
What if things start to break bad? That's the outlier risk, and it seems like we could be prepared and do some real good as far as quickly getting people the better information.

Ukraine is probably just the same old strain of Novel H1N1, but you just never know.

Ukraine's death rate is no different than normal flu- in fact a CBC article says it's 10% less than last year- it is being pumped up for political purposes and general alarmist reasons.

Get H1N1 shot, WHO urges risk groups, Pregnant women, children and chronically ill shouldn't delay vaccination, CBC News (Canada), Last Updated: Tuesday, November 3, 2009 | 12:59 PM ET: “. . . At the request of Ukraine's government, the WHO has sent a team of nine experts to the East European country. They will investigate whether the same strain of H1N1 influenza A virus that caused the current global swine flu pandemic is to blame for Ukraine's flu outbreak. . . . ”

Ukraine Bans Big Crowds to Combat Swine Flu, New York Times, CLIFFORD J. LEVY, October 31, 2009.

Ukraine Mystery Outbreak Sparks WHO Concern as Disease Spreads, Bloomberg, by Kateryna Choursina and Halia Pavliva, Nov. 2, 2009.

Pandemic (H1N1) 2009, Ukraine - update 1, WHO, Nov. 3 2009: “. . .  As elsewhere, WHO strongly recommends early treatment with the antiviral drugs, oseltamivir or zanamivir, for patients who meet treatment criteria, even in the absence of a positive laboratory test confirming H1N1 infection. . .  .  ”

WHO's standard rec'd for Tamiflu (oseltamivir) and Relenza (zanamivir)
Recommended use of antivirals, WHO, Pandemic (H1N1) 2009 briefing note 8, Aug. 21, 2009.

“For patients who initially present with severe illness or whose condition begins to deteriorate, WHO recommends treatment with oseltamivir as soon as possible. . .  .  Where oseltamivir is unavailable or cannot be used for any reason, zanamivir may be given.

“For patients with underlying medical conditions that increase the risk of more severe disease, WHO recommends treatment with either oseltamivir or zanamivir. These patients should also receive treatment as soon as possible after symptom onset, without waiting for the results of laboratory tests.

“As pregnant women are included among groups at increased risk, WHO recommends that pregnant women receive antiviral treatment as soon as possible after symptom onset.”

“ .  .  .  This recommendation includes all children under the age of five years, as this age group is at increased risk of more severe illness.”

--

And please remember, I am a radical! Not in the sense of believing there's a conspiracy, or believing that vaccines are unsafe (it's killed viruses for crying out loud, and even if it was attentuated, as the nasal spray is, it would still be safe). But I'm a radical in the sense of believing that the potential of saving human life trumps formality of communication. Cool Nerd (talk) 19:58, 3 November 2009 (UTC)

Can we have three people keep track of WHO updates?
We easily and matter-of-factly check each other's work. We make sure that we include the most accurate information. And with three people, we can probably incorporate most updates within 12 hours, although we shouldn't make any promises. And if a fourth person wants to join in? Sure, happy to have the help. Cool Nerd (talk) 01:34, 6 November 2009 (UTC)

Rewriting in your own words is a school skill.
What are we doing? What am I doing? For I have also spent a far amount of time at this.

Maybe we can save several dozen lives. Let's don't be too ambitious. But, but, if we include the best material we can find (without overformalizing it, without blahing it out to "neutrality"), you just never know. We can provide the key material that can help people make the decisions that really matter.

A couple of sentences directly quoted from WHO, from CDC, from doctors quoted in various news publications. We're not doctors. We don't need to rewrite any of this. We're slowing ourselves down, and arguably we are doing our readers a disservice.

It's not about hysteria. Loading up the emergency rooms with people slightly sick is not doing anyone a favor. It's about including the most accurate, most insightful information we can find. Cool Nerd (talk) 01:28, 28 October 2009 (UTC)
 * If we use quotes from people without quoting them, it's plagarism and/or copyright infringement. If we use quotes and indicate them as quotes, the page quickly becomes filled with quotes and starts sounding more like a news report than an encyclopedia article. Hence, it is often necessary to rephrase the sentence. --Cyber cobra (talk) 02:50, 28 October 2009 (UTC)


 * So we saying that sounding like an encyclopedia is more important than providing people with accurate information?? So we might look at a case like the following where a nice little boy dies of swine flu http://www.hispanicnashville.com/2009/09/h1n1-related-death-of-5-year-old.html or any of a number of other tragic cases (still relatively rare) and conclude, tragic as those may be, the paramount virtue is still formal communication?


 * Well, we have built an engine. And there’s no way we can just immediately change it.


 * But there may be a way, and that is to run parallel. We stay with the engine that we already have, even though the terrain is somewhat different, and at the same time, we try experiments clearly identified as experiments.  We find a way.   Cool Nerd (talk) 15:40, 29 October 2009 (UTC)

This article is getting pretty huge
Someone may want to edit this and bring down the size a bit. maybe remove so duplicate info and poss merge some sections. seems like it getting to be a pretty large page. -Tracer9999 (talk) 17:27, 3 November 2009 (UTC)


 * Well, it's a big topic! And it's a current topic.  There's a lot going on.  And we don't have the luxury of history.   Cool Nerd (talk) 19:43, 3 November 2009 (UTC)


 * I think the size of the article is fine; the problem is all the smaller linking articles are nowhere near being updated enough. So either we should move some of this page's info to the smaller articles or perhaps delete some of the smaller ones, since now that the initial hype is over many have been more or less abandoned (e.g., "as of May 26, there have been 150 cases...") The public may be using some of these articles as a basis for decisions as to whether to get vaccinated, and outdated info makes it appear less widespread than it is.66.183.132.33 (talk) 05:38, 4 November 2009 (UTC)

I like the idea of moving some of the pages info to the smaller ones -Tracer9999 (talk) 06:31, 4 November 2009 (UTC)


 * With all due respect, Cool Nerd, it's getting unwieldy in no small part because you keep adding medical minutiae and OT factoids with multiple cites. It doesn't need 142 citations. --Wikiwatcher1 (talk) 06:01, 4 November 2009 (UTC)
 * Cool Nerd, this is your recent addition which I give here as an example—with three cites:


 * At Ukraine’s request, WHO sent a team of experts on Nov. 2 to determine if the same strain of H1N1 is responsible for the approximately 70 recent flu deaths in the country. Ukraine has also closed schools and banned public meetings for three weeks.  There is criticism that this was done to impress voters before a January election.   --Wikiwatcher1 (talk) 06:12, 4 November 2009 (UTC)

Clear leads are important
CyberCobra, the text below does not belong in the lead. It is a highly specific symptom factoid that may affect, as it states, a "small subset of patients." It is not repeated with the same detail within the body where it belongs. It is a one-off lead-filler that injures the lead where readers should be getting clear summary-type information not distracting details. It acts as a roadblock, IMO, to helping readers get a quick overall picture. That was the reason I removed it and rephrased the topic in a summary format. However, you felt like reverting it, along with some other bloated material I trimmed. That's also why the article is getting overly long once again. This should not be in the lead:
 * "There are small subsets of patients, even among young persons previously healthy, who rapidly develop severe pneumonia, typically 3 to 5 days after initial onset of symptoms. Deterioration can be very rapid, with many patients progressing to respiratory failure within 24 hours, requiring intensive care and ventilation support.[13]" --Wikiwatcher1 (talk) 06:01, 4 November 2009 (UTC)

personally I think the whole lead can be trimmed a great deal.. we dont need to cover everything in it.. there is a whole 100kb article below for that. It should just cover dates it started, that its a pandemic, that it effects younger people more then older and tamiflu works great..along with maybe a blurb about the avail vaccine.. we dont need to go into mexico closing offices, that they are no longer counting cases  (not that the count was ever accurate anyway),  the fine detail about how it progresses and the specific medical ailments it causes, all the symptoms, what might happen.. every possible way to spread the flu (if you don't know how the flu spreads then you must live in a cave).. all this stuff is important but not to that kind of detail in the opening paragraph just to have it repeated in even further minute detail a couple paragraphs down. Just my opinion.. but this article is pushing 100k and wikipedia says that the perfect time to do some cutting of the minute detail and double sourcing.. If the source is cnn or something.. we dont need another.. not everyone is on broadband and like 50 seconds to load a page not counting images is a long time for someone on a 56k or 28k even modem -Tracer9999 (talk) 06:28, 4 November 2009 (UTC)

like for example..

"The WHO stated that containment was not a feasible option and that countries should focus on mitigating the effect of the virus. It did not recommend closing borders or restricting travel.[98] On April 26, 2009, the Chinese government announced that visitors returning from flu-affected areas who experienced flu-like symptoms within two weeks would be quarantined.[99] On May 2, 2009, China suspended flights from Tijuana to Shanghai.[100]

The president of the Association of Flight Attendants told members of a US Congressional subcommittee that all flight attendants should be given training in how to handle a person with flu and help in communicating to passengers the importance of keeping clean hands.[101] She also said that flight attendants need to be provided gloves and facemasks to deal with flu-stricken passengers.[101] Lahey Clinic vice chairman of emergency medicine and Tufts University assistant professor of emergency medicine Mark Gendreau adds that airlines should also ensure that passenger cabins are always properly ventilated, including during flight delays in which passengers are kept aboard the plane. But he also adds that although the aviation industry in the US, along with the CDC, have tried to reassure passengers that air travel is safe, they have so far done too little to try to limit infection risks.[101]

US airlines had made no major changes as of the beginning of June 2009, but continued standing practices that included looking for passengers with symptoms of flu, measles, or other infections, and relying on in-flight air filters to ensure that aircraft were sanitized.[102] Masks were not generally provided by airlines and the CDC did not recommend that airline crews wear them.[102] Some non-US airlines, mostly Asian ones, including Singapore Airlines, China Eastern Airlines, China Southern Airlines, Cathay Pacific, and Mexicana Airlines, took measures such as stepping up cabin cleaning, installing state-of-the-art air filters, and allowing in-flight staff to wear face masks.[102]"

who cares? I mean unless your going to open a window on the plane or never leave your house because of the flu.. what does the general public care about the travel industries rules or a list of every single carrier and the exact steps they are taking... all the article needs is the first paragraph.. and if you want to go into detail about which airlines are breaking out a can of flu b-gone then create another article or condense this massivly. I mean your in an enclosed airplane...someone coughs in the seat next you and the filtrator 2000 isnt going to help you much... -Tracer9999 (talk) 06:53, 4 November 2009 (UTC)


 * I agree that it can be cleaned up. In July, on a suggestion like yours, I trimmed it from 104K(?) to about 65K without any great loss of substance.  It's grown again but it seems like it's mostly from overciting every detail. But the real reason I'm commenting is to find out where I can buy a can of "flu B-gone." --Wikiwatcher1 (talk) 07:16, 4 November 2009 (UTC)


 * "The WHO stated that containment .  .  .  The president of the Association  .  .  .  US airlines had made no major changes as of the beginning of June 2009  .  .  .  "  <--Very good point!  And rather like DNA carrying the old, inactive parts, we tend to carry the old parts of our article right along with us.  "November," "December," "January," that would make it so much simpler.   Cool Nerd (talk) 03:04, 6 November 2009 (UTC)


 * "if you don't know how the flu spreads then you must live in a cave" <--another very good point. We don't need to talk down to our reader.  That is almost always a mistake.  In fact, I find it helpful to assume that my reader is just a little bit smarter than I am.  He or she just doesn't happen to know the particular information I know.  So, I don't need to do anything fancy.  I just need to tell this information in a straightfoward way.


 * Almost our ideal reader would be a parent where there have been some cases at his or her child's school, but so far their child is healthy. So the parent is not panicking, but they do want the most accurate, detailed information we can give them.  Including the detailed information: These are the times you need to take your child to the emergency room.  It's kind of like ying-yan, if they know when to take their child to the emergency room, they can know when not to.


 * And I don't want our lead to be just a bunch of generalities. I want us to include some of our best information, right there in the lead.   Cool Nerd (talk) 03:17, 6 November 2009 (UTC)

Consistent nomenclature
I propose that for coherency and consistency purposes, we use 1 name for the virus across the article (excepting where we state the alternate names). We currently waffle between the various terms. Thoughts? --Cyber cobra (talk) 20:44, 4 November 2009 (UTC)
 * My personal vote is for something like "pandemic H1N1" [influenza/flu/virus] --Cyber cobra (talk) 20:52, 4 November 2009 (UTC)


 * By a ratio of about 40:1 on Google the term "Swine flu," vs. "Pandemic H1N1," is the common name used. I think having the alternate names in the lead and in the nomenclature section is good enough to allow the common name to be used in the body. Nor does it seem user friendly to call it "colloquially," a nice spelling-bee word, instead of "commonly used." I vote "swine flu." --Wikiwatcher1 (talk) 21:40, 4 November 2009 (UTC)


 * Addendum: Speaking of search engines, it's also worth noting that a search for this most commonly used term, "swine flu" puts Swine influenza as #2 result and this article in #12 position. It should, of course, be the opposite. Note the main paragraph in the lead to that article makes clear it is not about what people are looking for. The main cause for that is due to the erroneous redirect which was noted months ago:
 * "Swine influenza (also called swine flu, hog flu, pig flu and sometimes, the swine) is an infection by any one of several types of swine influenza virus. Swine influenza virus (SIV) is any strain of the influenza family of viruses that is endemic in pigs.[2] As of 2009, the known SIV strains include influenza C and the subtypes of influenza A known as H1N1, H1N2, H3N1, H3N2, and H2N3." --Wikiwatcher1 (talk) 21:53, 4 November 2009 (UTC)


 * Cybercobra, my good friend and comrade in arms, I think we might disagree on this one. For I vote for both swine flu and H1N1.  That's how people talk with their neighbors, that might even be how a doctor talks in his or her consulting room.  Consistent?  No, it's not consistent.  But useful, yeah, it's useful because that's how people talk.  And I think we can best get that point across, instead of just stating it once in the beginning, kind of scattering it throughout our article.  Cool Nerd (talk) 03:29, 6 November 2009 (UTC)

Dilution of articles is a problem.
We need to take a serious look at whether we've created too many articles on this subject. Most of the articles on individual countries is way out of date. Now that the initial hype is over, no one is going to keep these updated. Could some of them be merged?

This is serious. we don't want people to get false/outdated impressions about this pandemic.66.183.132.33 (talk) 04:44, 6 November 2009 (UTC)

Cause for concern?
The article currently lacks a clear statement as to whether there is cause for concern for individuals. This information would be highly beneficial, because there are highly conflicting statements circulating, from newscasts that border on "vaccinate or die" to skeptics that consider the additional danger compared to the "normal" seasonal flu to be too small to bother with.

(Notably, this should be differed from the risk for aggregate groups: If a million people bungee jump, chances are that there will be a few deaths somewhere; for the individual the risk can be ignored.)

Possibly, a straight statement: Should someone not in a high-risk group bother to be vaccinated (yes/no)? 94.220.249.30 (talk) 17:22, 8 November 2009 (UTC)
 * That would require Wikipedia itself to express an opinion, which is against our neutrality policy. What we can and do do is report the conflicting opinions for the reader to consider themselves; this is the best we can do until there is scientific consensus on the subject. Also, trying to decide what definitive statement to make would be nearly impossible as most Wikipedians are not subject-matter experts; i.e. most of us editing this article probably aren't epidemiologists, don't hold public health degrees, etc. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 20:28, 8 November 2009 (UTC)
 * Having said that, there's little reason why one shouldn't get vaccinated, especially if one is in the younger age group that seems to be more affected by swine flu than most other flus. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 20:31, 8 November 2009 (UTC)


 * In addition, as I understand it, if you get the annual vaccine, over the years your body will tend to build up a rich "library" of immunity. But 94.220... asks a very good question, in fact his or her whole post is a gift, "bother to be vaccinated."  Well, if you drive 20 minutes there and 20 minutes back, your chance of getting killed on the road may equal or exceed (1) your chance of catching swine flu, (2) it turning severe, and (3) your particular severe case not being able to be successfully treated.  And if not a 40 minute round trip, there certainly is some break-even point.  So, my advice, if you're in a pharmacy anyway and they're giving immunizations, or if you're in your doctor's office anyway, and your doctor says they have the swine flu vaccine and they now have enough for even people not in a high-risk group, sure, might as well get it.


 * And again, I am not a doctor. I am a retail manager!   Cool Nerd (talk) 18:05, 9 November 2009 (UTC)

Pandemic ?
Well: if pandemic means 'spread on a large area, for instance a continent(s)', then, YES: seasonal flu are (low-lethal level) PANDEMICS ("spreading through human populations across a large region; for instance a continent"). Yug (talk)  05:31, 9 November 2009 (UTC)
 * I think they explicitly exclude any closely related strain of the flu which has already appeared for over a year. While the exact global infection rates dip in Spring and Fall (as neither hemisphere has appropriate climate conditions to support the rapid spread of the flu), once a flu strain is in regular circulation it isn't really "spreading", it's just shifting its target populations back and forth.  So H1N1 is a pandemic in 2009 (because it will infect more people than any closely related strain did in recent years), but if it's still around for the 2010 flu season (which seems likely), it won't be a pandemic any longer; the infection rates won't increase significantly beyond the peaks it has already hit in previous seasons. --ShadowRangerRIT (talk) 18:16, 9 November 2009 (UTC)


 * Formal "epidemic" and "pandemic" definitions are thresholds. Some years, seasonal flu does exceed these thresholds;  when that happens it is formally designated an epidemic or pandemic.  See for example this CDC graph showing that in the US the 2007-08 seasonal flu was an epidemic, and now the 2009-2010 season is above the epidemic threshold.  --Una Smith (talk) 21:34, 9 November 2009 (UTC)

Approximately 70% of H1N1 caused pneumonia is viral pneumonia
Clinical features of severe cases of pandemic influenza, WHO, Oct. 16 2009: “. . .  Primary viral pneumonia is the most common finding in severe cases and a frequent cause of death. Secondary bacterial infections have been found in approximately 30% of fatal cases. Respiratory failure and refractory shock have been the most common causes of death. . .  .  ”


 * This is a briefing note about WHO's Oct. 14-16 meeting at the headquarters of the Pan American Health Organization in Washington, DC. So, in rough numbers, a third of the pneumonia cases are bacterial and two-thirds are viral.  In even rougher numbers, a patient presents in a doctor's office, and he or she could have either one, or something else entirely!  And that's why we do not practice medicine.  So, what are we doing?  Well, I think we can still present good preparatory information here, and from the best sources we can find, which at least has the advantage of helping patients ask the right questions.   Cool Nerd (talk) 19:30, 10 November 2009 (UTC)

"The A/2009 H1N1 influenza virus pandemic" (Update September 2009) by WHO
H1N1 influenza virus pandemic" (Update September 2009) by WHO - WAS 4.250 (talk) 21:36, 10 November 2009 (UTC)

Drug resistance
The treatment section says "a British report found that people often failed to complete a full course of the drug, a behavior which increases the chances of drug-resistant strains" The first part I do not find surprising. That this behavior increases drug resistance strains I question. And the second bit is not supported from what I see by the reference. I am concerned that it is little more than an urban myth. Now for chronic infections such as HIV and TB yes maybe. But for self limited infections. Would love to see research to back it up.

One hears the story that if one does not take the entire course that the doctor prescribes that one will develop resistance and this is quickly followed by if one takes antibiotics for too long one developed resistance. You cannot have it both ways. I believe the second to be true rather than the first. Why is a antibiotic dose 3, 5, 7, or 10 days? Why never 2, 4, 6, 11 days? Because we like the numbers 10, 7 and three are lucky, 5 is half of ten. 4 of course represents death in Asian cultures. Doc James (talk · contribs · email) 02:08, 9 November 2009 (UTC)


 * Actually, both cases are possible. Stopping anti-biotics too early can jump start the development of drug resistance.  Basically, when you start taking anti-biotics, the bacteria with the least resistance to the drug are killed first.  Assuming it is not a fully drug resistant strain already, the rest are expected to succumb to the combined onslaught of the drugs and your immune system by the end of the full course.  By the time you are asymptomatic, you still have some of the bacteria left in you, which are mildly resistant, but probably not immune to the drug (if they are, it's too late, but you can't know that).  If you stop the course of treatment, and your immune system isn't able to finish off the task quickly enough (or worse, the disease manages to reestablish itself), you could still pass the bacteria on to someone else.  The bacteria passed on will be somewhat more tolerant of the drug than before.  In all likelihood, they won't be completely resistant yet, but the slightly modified, more resilient strain will pass around.  It will develop a host of minor mutations, some of which increase drug resistance, some of which decrease it, and when someone else fails to complete a course of anti-biotics, the cycle begins anew, creating an even more resistant strain.  Eventually, the cumulative effects of selecting the most resistant strains lead to strongly, or completely resistant bacteria.
 * The other case, of prescribing anti-biotics for too long, is really the same as prescribing them unnecessarily. The problem here is two fold:
 * 1. The more unnecessary anti-biotics are taken, the more of them leech into the environment. When bacteria encounter these drugs in the water supply or in the ground, the same effect noted above is seen: weak bacteria are killed, strong bacteria survive and reproduce.
 * 2. When anti-biotics are taken too often, your own gut bacteria start to develop resistance. Ideally, most of your gut bacteria are killed off with the offending bacteria, and replenished from your appendix or the environment (anyone living in close proximity to other people will constantly be swapping gut bacteria). But if you constantly take short doses of anti-biotics, or long doses well after they are required, you will eventually develop strongly drug resistant gut bacteria (only the most resistant bacteria will survive, and only the most resistant bacteria from your environment will be able to colonize).  At first glance, this might not seem too bad (now you can take anti-biotics without suffering GI problems).  Problem is, at the bacteria level, in place of sexual recombination, evolution is propelled by gene sharing.  So if your gut bacteria are strongly drug resistant, any new bacteria they meet may end up swapping and acquiring their drug resistance.
 * Correct, infrequent usage of anti-biotics tends to mitigate all of these problems; in most cases, the same genes that confer drug resistance are maladaptive in other ways (making it harder to feed, requiring energy to construct the defenses against the drug, etc.). As such, more efficient, but less drug resistant strains usually recover and displace the drug resistant strains simply due to faster, more efficient reproduction.  But if there is a society-wide overuse and misuse of anti-biotics, the costly drug resistance becomes the only feasible design, and drug resistant strains spread and multiply, displacing the non-resistant strains.
 * Most of the same arguments apply to anti-virals. Environmental contamination is usually less of a problem; viruses only reproduce in a host, so exposure to anti-virals outside of a living body does very little, though if host creatures ingest the anti-virals in small quantities it can have an effect similar to shortened treatment.  While viruses don't directly share genetic material like bacteria do, they do swap genes with the cells they infect; if the cell survives and carries anti-viral resistant genetic code, it will remain a source of those genes for all future viruses.  Again, less of a risk, but still problematic.  Note that the problem of shortening your course of anti-virals remains; the same selective pressures are in place to create the drug resistant strains. --ShadowRangerRIT (talk) 17:44, 9 November 2009 (UTC)


 * In answer to Doc James's speculation: Yes, the durations are likely somewhat contrived. Usually though, studies are done to figure out how long a course of treatment is necessary to produce results, and they choose a number of days for which most of the population will have purged the disease, possibly rounding up (or even to one of your "lucky" numbers, though in my experience the numbers are not as tidy as you believe; I've been given four day doses for instance).  So yes, in many cases, you might take the drug a day or two longer than you personally need to; heck, if you only cut off one day you've probably got a better than 50/50 chance of having purged the disease.  But if your immune system is a little weak, or you haven't been eating well, or the strain you got has already developed a small amount of resistance, then you've just nudged it one step further on the path to full resistance.  So please, if you're going to take the drugs at all, take the full course, because one extra day of side-effects is worth reducing the speed with which the drugs you just took become ineffective for everyone else.
 * Taking the drugs a day or two too long is not what they mean when they say that taking the drugs too long encourages resistance. Unless you keep taking the drugs for weeks after the disease has run its course, the effects won't be all that severe. --ShadowRangerRIT (talk) 17:53, 9 November 2009 (UTC)


 * Okay, so what you're saying, a partial course of antivirals, a virus that's already somewhat resistant will survive. As then as it randomly mutates in all kinds of directions, which a virus does, one of these mutations may happen to be in an even more resistant direction.  And if this new virus hits another partial course of antivirals, the cycle is being pushed further along.  Is that about it?  At least for the first chapter in the drama! (and giving us abundant space to make smart moves)   Cool Nerd (talk) 18:25, 9 November 2009 (UTC)


 * With regard to premature cessation of anti-virals, yes, that's my point in a nutshell. I tend to err on the side of loquaciousness, if only to avoid inevitable misinterpretation. --ShadowRangerRIT (talk) 18:54, 9 November 2009 (UTC)


 * You did just fine. You tied together some things I have heard but hadn't heard explained as well.


 * And let me take this a step further. If someone doesn't take an antiviral like Tamiflu, more viruses in their body carried longer, there's some risk, even a very slim risk which has not happened since April, that one of these random mutations will happen to be in a more lethal direction.  That's bad for the person, and bad for the rest of us, too.  So, the UK may have been on to something where they allowed people (I think) to self-diagnosis and self-prescribe over the phone.  Like so many decisions and situations, it is a case of risk vs. risk.   Cool Nerd (talk) 19:09, 9 November 2009 (UTC)


 * While technically true, it's less of a risk than misusing anti-virals. When you misuse anti-virals, you not only allow, but encourage mutations that eventually lead to drug resistance.  By contrast, left untreated, severity and lethality are actually counter-productive, not just for humans, but for the virus; if it incapacitates and/or kills the host, then it can't spread as readily as it could if the host was still up and walking around. Deadly viruses tend to burn out. One of the reasons Ebola has never become a worldwide pandemic is that it kills its host too quickly; it flares up, kills most of those it infects, then runs out of victims.  While there is always the risk that a virus turns more deadly, evolutionary pressures usually lead to the opposite result.  The original Spanish Flu from 1918 appears to have remained in circulation for years after the two year heyday (there is debate on this, but evidence seems to indicate that Spanish Flu descendants circulated through the late 1950s), but the lethality was lessened.  Either:
 * 1. The virus's lethality was drastically reduced (due to the pressures mentioned above)
 * or
 * 2. Those with a tendency to overreact to the virus (triggering the classic cytokine storm) were either weeded out or resistant after two years
 * I'd worry far less about people not using anti-virals (which mostly affects themselves), than misusing them (which has long term consequences for everyone else). After all, even if every human is treated with anti-virals promptly and correctly, it's not practical to find and dose every pig and bird which contracts the flu, and flu incubated in them is more likely to be deadly, though less likely to be readily contagious, in both cases because the genetics are more foreign to humans. --ShadowRangerRIT (talk) 19:29, 9 November 2009 (UTC)


 * Summarizing myself: If the flu isn't already deadly when it jumps the species barrier and begins infecting humans readily, it's not going to get more deadly of its own accord. --ShadowRangerRIT (talk) 19:37, 9 November 2009 (UTC)

Yes I have heard this explanation many time before. What I am asking is there evidence to support it? Are is it just based on tradition / urban legend.

This publication says "More recently, attention has been directed to the optimal duration of antibiotic treatment, with a focus on shortening the duration of therapy. Historically, CAP treatment duration has been variable and not evidence-based. Shortening the course of antibiotics might limit antibiotic resistance, decrease costs, and improve patient adherence and tolerability.4 However, before defining the appropriate antibiotic duration for a patient hospitalized with CAP, other factors must be considered, such as the choice of empiric antibiotics, the patient’s initial response to treatment, severity of the disease, and presence of co-morbidities."

And this paper discusses how we determine treatment duration. The duration question is a bit of a fall back from the days when you were told just to do what your doc tells you to and not to ask questions.

For travelers diarrhea we now say take until antibiotics until you are better. If that is after one does good.

All the studies I have seen only address effectiveness. I have not seen ones that address the effects of duration of treatment on resistance within a population over time. Doc James (talk · contribs · email) 19:41, 9 November 2009 (UTC)


 * So to conclude if we are to say that this is "a behavior which increases the chances of drug-resistant strains" we need to have a good reference to support it. Doc James (talk · contribs · email) 19:53, 9 November 2009 (UTC)


 * ShadowRangerRIT, I am going to disagree with you on one thing, but Wow, you really know your stuff. The part about cytokine storm, very impressive.


 * Okay, where we might disagree, I think we have to go quantitative and run the numbers, even for something as slight as the possibility of there being a mutation in a more lethal direction. Even though very slight, even though all we can do is estimate it, that possibility is still there.


 * And I think the solution is to teach people to use Tamiflu properly. And not just talk to them as if they're school children, or the Puritan thing that you have to hold off on medication unless you "really" need it.  But as responsible adults, and really, if you relapse and have another three days of being sick, that's a hassle and a cost to yourself.  And so in that way, the benefit to the individual is (roughly) in line with public health goals.


 * And vaccines are a winner, even with attenuated, very, very slight risk of any live mutation.


 * Okay, about cytokine storm --> immune system overreacts to virus in lungs? Is that what happens?


 * ShadowRanger, with you knowing a lot and being highly interested in swine flu, we need you contributing to the article as much as you can. I want an article that genuinely informs people.  I have found in my own writing that if I assume my reader is ever so slightly smarter than myself, I get a much, much better result than if I talk down to my reader.  He or she just doesn't happen to know this particular subject.  So, I just go ahead and tell them in a very straightforward fashion.  And sometimes it helps to have a particular reader in mind.  For example, a parent who's gotten word that several children at their child's elementary school have gotten sick, but their child is of yet just fine.  I want that parent to be glad that they have come to 2009 flu pandemic and consider it time well spent.   Cool Nerd (talk) 03:39, 10 November 2009 (UTC)


 * And Man, these are just my standard talking points. Please understand that.  I like you writing.  I want to make that clear.  You might be critical of your own writing.  Actually, that's a mark of a good writer, who afterall tends to be more critical of their own work than most of their readers are likely to be.  So, whereas I see you've made some contributions to the article, please feel free to jump in there and make some more!   Cool Nerd (talk) 20:17, 10 November 2009 (UTC)


 * And you too, Doc James! I like the way you think through an issue.  We could use your contributions to our article, too.  Now, you might have some issues with your name from time to time.  Some readers might think you're a physician.  And even if you are, you do realize you can't use arguments from authority?  But I bet you know just where to find the best references!   Cool Nerd (talk) 21:49, 10 November 2009 (UTC)


 * Yes do not give my user name any more credit than the references I provide deserve. I usually reference most points. Doc James  (talk · contribs · email) 22:29, 10 November 2009 (UTC)


 * I know you do. You strike me as a very good researcher.  Which is why, if you can at all squeeze in the time, please jump in and help us.  If at all possible, Please!   Cool Nerd (talk) 00:35, 11 November 2009 (UTC)


 * And you might want to check out the below section Differing Expert Opinions, a gift for our readers! WHO recommends prompt antiviral treatment for all children 0-4 at onset of symptoms.  And CDC says, may not be necessary for children 2-4.


 * And we might be able to do the same kind of thing regarding expert recommendations on drug resistance.  Cool Nerd (talk) 01:21, 11 November 2009 (UTC)

(undent) Will try to find an answer to this question when I have time. Doc James  (talk · contribs · email) 03:20, 11 November 2009 (UTC)

WHO Sept. 25th briefing note on drug resistance
Antiviral use and the risk of drug resistance, Pandemic (H1N1) 2009 briefing note 12, WHO, 25 SEPTEMBER 2009.

" .  .  .  In general, WHO does not recommend the use of antiviral drugs for prophylactic purposes. For people who have had exposure to an infected person and are at a higher risk of developing severe or complicated illness, an alternative option is close monitoring for symptoms, followed by prompt early antiviral treatment should symptoms develop.  .  .  .  ". . " .  .  .  To date, 28 resistant viruses have been detected and characterized worldwide.

"All of these viruses show the same H275Y mutation that confers resistance to the antiviral oseltamivir, but not to the antiviral zanamivir. Zanamivir remains a treatment option in symptomatic patients with severe or deteriorating illness due to oseltamivir-resistant virus.

"Twelve of these drug-resistant viruses were associated with the use of oseltamivir for post-exposure prophylaxis. Six were associated with the use of oseltamivir treatment in patients with severe immunosuppression. Four were isolated from samples from patients receiving oseltamivir treatment.

"A further two were isolated from patients who were not taking oseltamivir for either treatment or prophylaxis. Characterization of the remaining viruses is under way.

"These numbers are comparatively small at present. Worldwide, more than 10,000 clinical specimens (samples and isolates) of the pandemic H1N1 virus have been tested and found to be sensitive to oseltamivir. .  .  .  "


 * posted by Cool Nerd (talk) 18:13, 12 November 2009 (UTC)

Long Term Eating of Pork Seems to Provide Some Immunity
This may be Original Research but quite ironic and maybe important. I was comparing the USDA's list-by country-of per capita pork consumption with Wikipedia's h1n1 deaths by country list; I found the exact opposite of what I expected: The 10 countries with the highest per capita pork consumption have had a total of 205 deaths and the 10 countries with the lowest per capita pork consumption have had a total of 2,460 deaths. Now that I think about it, it does make sense that people who habitually eat a lot of pork would have likely been exposed at some point to the bug and built up immunity over the years. e.g.Germans eat 50 kilograms per capita and have had 13 deaths whereas the British eat 23 kilograms and have had 183 deaths. Mr.grantevans2 (talk) 01:13, 13 November 2009 (UTC)
 * Here are the links to the data: http://www.fas.usda.gov/dlp2/circular/1997/97-03/porkpcap.htm http://en.wikipedia.org/wiki/2009_flu_pandemic_by_country
 * The very definition of original research and synthesis. Edison (talk) 01:22, 13 November 2009 (UTC)
 * Even ignoring those guidelines, it's also extremely problematic because the deaths aren't per capita, so you're weighting it in a really funny way. Positing a scenario: Suppose every country has one death per thousand.  Suppose that the countries that eat a lot of pork are small, and those that eat little pork are big.  Despite the fact that the death rate remains constant, you would still end up with the result you provided, because the number of deaths in a large country will be greater than those in a small country.  If your theory were correct, the entire top ten list of infected countries should consist of the Arab countries and Israel, since the religions of that region prohibit the consumption of pork. Even for the per capita rates, that doesn't seem to be the case. --ShadowRanger (talk 20:19, 13 November 2009 (UTC)
 * I agree a per-capita death number for each country will be a better comparison. I also agree about the variables, which is why I think the totalling of the 10 least and also the 10 most and comparing the totals helps mitigate the variables. Also, I think the UK/Germany comparison is pretty clean and you still get a 15-1 death ratio in favor of the lesser per capita consuming UK. I would like to see what a PHD in Statistics would have to say about this; I think I know quite a bit about statistical probabilities and to me this 12-1 death ratio (10 least per-capita consuming nations/10 most per-capita consuming nations) is compelling. Mr.grantevans2 (talk) 21:50, 13 November 2009 (UTC)
 * Israel/Austria looks like this Population 7.5 mil/8 mil H1N1 Deaths 41/2 (note:Austria has an annual 58 kg per capita pork consumption(twice as much as in the USA): I can't find any report on pork consumption in Israel)Mr.grantevans2 (talk) 23:21, 13 November 2009 (UTC)

Five technical names in opening paragraph?
Following is the opening paragraph of our entire article:


 * "The 2009 flu pandemic is a global outbreak of a new strain of influenza A virus subtype H1N1, termed Pandemic H1N1/09 virus by the World Health Organization (WHO), that was first identified in April 2009. The disease has also been termed novel influenza A (H1N1) and 2009 H1N1 flu by the U.S. Centers for Disease Control and Prevention (CDC), and commonly known as swine flu. The main strain of virus has been termed A/California/07/2009 (H1N1) by scientists. "

And really, might two technical terms be enough, at least for here in the beginning, and the rest perhaps in the 'Virus characteristics' section? Cool Nerd (talk) 19:42, 13 November 2009 (UTC)

Antibiotics and Community-Acquired Pneumonia (CAP)
The following source is Doc James' note 5 above in the drug resistance section.

What is the proper duration of antibiotic treatment in adults hospitalized with community-acquired pneumonia? The Hospitalist, by Kelly E. Cunningham, MD, Shelley Ellis, MD, MPH, Sunil Kripalani, MD, MSc, Feb. 2009: “. . . 26 breaths per minute; and oxygen saturation is 87% on room air. He has coarse breath sounds bilaterally, and decreased breath sounds over the right lower lung fields. His chest X-ray reveals a right lower lobe infiltrate. He is admitted to the hospital with a diagnosis of community-acquired pneumonia (CAP), and medical therapy is started. . .  ” “  .  .  .  A patient’s clinical response to empiric antibiotic therapy contributes heavily to the decision regarding treatment course and duration. The IDSA/ATS guidelines recommend patients be afebrile for 48 to 72 hours and have no more than one CAP-associated sign of clinical instability before discontinuation of therapy. . .  .  ”


 * That is, the feel and texture of the situation, and not clunky rules.


 * And to be clear, this is talking about a bacterial infection and antibiotics, and not a viral infection and antivirals, but a lot of the same points apply.


 * And as is usually the best way to handle the situation, let's just put the controversy on the page and let the reader decide for himself or herself.  Cool Nerd (talk) 03:53, 10 November 2009 (UTC)


 * The conclusion is that antibiotic exposure increases bacterial resistance to antibiotic. This resistance seems to be proportionally to the duration of treatment.  Rather than taking "some recommended" duration.  "The increase was directly proportional to the fluoroquinolone concentration and could be detected as early as 8 h after exposure to the fluoroquinolone. The authors suggested that fluoroquinolones might influence oxacillin resistance by selective inhibition or by killing of the more susceptible subpopulations in heteroresistant S. aureus.128 "   Doc James  (talk · contribs · email) 04:37, 15 November 2009 (UTC)


 * The virus / bacteria do not care if ones use of antivirals / antibacterials are proper or improper. Any exposure leads to resistance no matter how justified. Therefore I have removed the statement claiming otherwise   Doc James  (talk · contribs · email) 04:50, 15 November 2009 (UTC)

children under 2, pregnant women, persons with respir. problems should use Tamiflu as soon as symptoms start
[http://www.who.int/mediacentre/vpc_transcript_12_november_09_nikki_shindo.pdf. . .  Dr Nikki Shindo, Medical Officer, Global Influenza Programme, World Health Organization], 12 November 2009. (NB: there are some passages in this transcript which have not been transcribed because of poor audio quality.)

‘ .  .  .  If you look at hospitalization rate, it is highest in the age group younger than 2 years of age. This information has been compiled from the experiences in countries in the southern hemisphere who just finished their winter. This is one group that you can expect high hospitalization. Also the second group is the pregnant women. The pregnant women is about 4-5 fold at risk of hospitalization and in severe cases it comprises about 7-10% of ICU hospitalizations. So this is the second biggest at-risk group. And the third one is the chronic medical condition, first comes the chronic lung disease group, especially chronic obstructive lung disease including asthma. . .  .  ’


 * There is also direct audio of this press conference:
 * http://www.who.int/mediacentre/multimedia/swineflupressbriefings/en/index.html


 * posted by Cool Nerd (talk) 00:23, 18 November 2009 (UTC).

Origin of epidemic
The article, in its second paragraph, is ambiguous and could hurt political and nationalistic sensitivities:

"The outbreak was first observed in Mexico, with evidence that there had been an ongoing epidemic for months before it was officially recognized as such.[6] The Mexican government soon closed most of Mexico City's public and private offices..."

Phrase could be interpreted as if Mexicans knew in advance it was a new virus, that it was contagious via human-to-human contact and that decided, moreover, not to make it public.

The reference [6], an article from NYT, states a different thing on AH1N1: 1) Nature magazine reports a “sister virus” from 2004, but no one knew about this variant, 2) "the new virus [...] most likely [...] it has been circulating in Asia" unidentified, 3) "The new virus was first isolated in late April [...] the earliest known human case was traced to a 5-year-old boy in La Gloria, Mexico." 4) The remainder of NYT article discusses ongoing polemic about swine's early infection, including that there was no way for virus proper identification at that time.

In no part of the backing reference it says that Mexican government or physicians denies the emerging epidemic. That's why the NYT article title is "In New Theory, Swine Flu Started in Asia, Not Mexico".

On that basis, it is recommended change the phrase to "The outbreak was first officially traced to Veracruz, Mexico, although probably went unnoticed for five years worldwide.[6] The Mexican government soon closed most of Mexico City's public and private offices..." —Preceding unsigned comment added by CarlosContreras (talk • contribs) 07:55, 17 November 2009 (UTC)


 * Alternatively, you could just remove "officially". Without it, the sentence simply indicates that no one had recognized it as a new virus until that time, with no implication of official coverup.  Speculation on when a closely related virus (clearly not the same virus, as the current incarnation seems much more contagious) may have arisen doesn't really belong in the lede for an article about this year's flu pandemic. --ShadowRanger (talk 14:43, 17 November 2009 (UTC)

Differing Expert Opinions, a gift for our readers!
The following is used to be from the Treatment section, Tamiflu and Relenza subsection:


 * “ .  .  .  In addition, the [WHO] recommendations state that pregnant women and children under five are considered to be in high risk groups and should receive oseltamivir as soon as possible after onset of symptoms.  The CDC only recommends this for children younger than 2. While acknowledging that children 2 to 4 are more likely than older children to require hospitalization, this risk is much lower than it is for children younger than 2. And thus, children aged 2 to 4, in CDC's Oct. 16th recommendation, do not necessarily require antiviral treatment.  .  .  .  ”

This has now largely been replaced with (single paragraph style, and dropping the numbers 1, 2, 3 for each recommendation):


 * Transcript of virtual press conference with Gregory Hartl, Spokesperson for H1N1, and Dr Nikki Shindo, Medical Officer, Global Influenza Programme, World Health Organization, November 12, 2009. (NB: there are some passages in this transcript which have not been transcribed because of poor audio quality.)


 * ‘In a country where the virus is circulating, we have 3 updated recommendations. ‘1. Firstly, people in at-risk groups need to be treated with antivirals as soon as possible when they have flu symptoms. This includes pregnant women, children under 2 years old, and people with “underlying conditions” such as respiratory problems. ‘2. Secondly, people who are not from the at-risk group but who have persistent or rapidly worsening symptoms should also be treated with antivirals. These symptoms include difficulty breathing and a high fever that lasts beyond 3 days. ‘3. Thirdly, people who have already developed pneumonia should be given both antivirals and antibiotics, as we have seen that, in many severe cases of H1N1-caused illness, bacterial infection develops. These medicines, antivirals and antibiotics, if used in a timely manner, can help save lives.’


 * There is also direct audio of this press conference: http://www.who.int/mediacentre/multimedia/swineflupressbriefings/en/index.html

CDC and WHO now agree on the recommendation for children. If possible, children under 2 should receive Tamiflu immediately upon showing symptoms.

So, we don't need to artificially conjure up controversy. Neither do we need to artificially hide controversy. That middle path of just being matter-of-fact, that's what I recommend. Cool Nerd (talk) 04:30, 18 November 2009 (UTC)

Ukrainian conspiracy theory crap going around right now
Please see and.

It seems that the H1N1 outbreak in the Ukraine is causing a panic, with some people asserting that the outbreak is really some new mutated disease spread in chemtrails. The conspiracy theorist website Prisonplanet.com has an article on this, as well as kavkazcenter.com - which as far as I can tell is a pro-mujihadeen website?

Anyway, this is an interesting story in itself, but perhaps it would be an informative part of the H1N1 2009 pandemic article - since, after all, it sheds light on how the flu can become a full panic in countries with poorly-managed health-care systems (as the RNW article asserts of the Ukraine).

I leave it up to you guys if there should be a section on the Ukraine outbreak. I slapped together a few paragraphs for the pneumonic plague article, as this H1N1 outbreak is being asserted there as an outbreak of pneumonic plague and not just the flu. I assume my paragraphs will be gone from that article in a few days. AllGloryToTheHypnotoad (talk) 03:19, 18 November 2009 (UTC)


 * We do have a section on Ukraine. Brief as it may be, toward the end of Response.  Or do a control F for Find search.  And we're not afraid of anything!  Let's lay it on the table.  Some people believe in a conspiracy.  We can say, 'Some people believe in a conspiracy,' and include some news references.  Our only limitation is space, and then the old material kind of has a tendency to blend in with the new.


 * It can be a badly run health care system. It can also be that the government is slow getting out information, and maybe out of timidity as much as anything else, officials are afraid of people panicking (rather a self-fulfilling prophecy in that regard!).  And also, as any urban legend can show, these things can take on a momentum of their own.   Cool Nerd (talk) 05:20, 18 November 2009 (UTC)

might need new ref. on patient not taking Tamiflu for full course

 * "In addition, a British report found that people often failed to complete a full course of the drug or took the medication when not needed."

That's from the Tamiflu and Relenza section of our article. And the reference, although good in a number of regards, does not directly say the first part (at least not that I see). So, let's find an additional reference if we can.


 * WHO: Healthy people who get swine flu don't need Tamiflu; drug for young, old, pregnant, Associated Press (reprinted by Washington Examiner), Maria Cheng, Aug. 21, 2009.


 * ‘ .  .  .  If countries use Tamiflu too liberally, that could lead to resistant viruses, leaving the world with few resources to fight swine flu.


 * ‘WHO said people thought to be at risk for complications from swine flu — children less than 5 years old, pregnant women, people over age 65 and those with other health problems like heart disease, HIV or diabetes — should definitely get the drug.


 * ‘The agency also recommended all patients, including children, who have severe cases of swine flu, with breathing difficulties, chest pain or severe weakness, should get Tamiflu immediately, perhaps in higher doses than now used.


 * ‘"The WHO guidance is quite different from what has been done in England," said Hugh Pennington, a flu expert at the University of Aberdeen. "England's approach is out of step with the rest of the world on this." .  .  .  ’

Now, someone might respond, hey, everyone already knows that. If you don't finish your antibiotic, you might relapse, plus you're contributing to drug resistance. People know that. It's almost common sense.

Well, this is an antiviral, not an antibiotic. And I don't really want us to be practicing medicine, not even a little bit. Plus, on the positive side, we might be able to find something specific, and meaty and substantial and interesting, and not just something general. Cool Nerd (talk) 05:35, 18 November 2009 (UTC)


 * Comment I just wrote this section and the research actually says that stopping ones antibiotics may decrease resistance but not taking the appropriate dose will increase it. Doc James  (talk · contribs · email) 18:44, 21 November 2009 (UTC)

Portugal Fetus Deaths
In Portugal, during the last 4 or 5 days 3 fetus have died, and there mothers were all vacinated against the swine flu. The ministery says that the vaccine doesn't have nothing to do with the cases, but the rigth is that WHO is going to investigate the cases, and this is being very discuted in portuguese media rigth now. The autophosies of the fetus are very confuse, and pregnant woman are in a big stress now due to this news of 3 dead fetus in only one week. Shouldn't this be included on the article? The vaccine that is being administrated in Portugal, was refused by Switzerland (for example). João P. M. Lima (talk) 23:32, 19 November 2009 (UTC)


 * Okay, yes, it should be in our article if we can get good reputable sources, hopefully something like WHO, CDC, or other health authorities which you might be familiar with and I'm not; or reputable news sources.


 * Now, as tragic as each of these cases are, it could be unrelated. A certain percentage of pregnant women are likely to have miscarriages whether or not they receive a vaccine.  And it's not great for a pregnant woman to get swine flu either.


 * If it's something like Guillain-Barre syndrome, rare as that might be, roughly in the neighborhood of 1 out of 100,000, then maybe. I am not a doctor (I will say that again and again).


 * This information could go in Symptoms or Response or Treatment. Jump in and help out if you have the time.  If English is not your first language and you don't feel comfortable, then perhaps include sources you find here and maybe someone else can include them.  Please stay in touch.   Cool Nerd (talk) 00:36, 20 November 2009 (UTC)

Baxter vaccine (available at least in UK) is manufactured without eggs
GPs to receive swine flu vaccines, BBC, Oct. 26, 2009.

“ .  .  .  Two vaccines will be used - one manufactured by GlaxoSmithKline (GSK) and the other by Baxter.

“The GSK one will be offered to most patients, while the Baxter vaccine is being generally reserved for people with egg allergies as the GSK jab was made using chicken eggs.

“Most patients will require only one dose of the vaccine, although children and those receiving the Baxter version will need two doses, three weeks apart. . .  .  ”
 * Two questions, How widely is this available outside the UK? Guidelines have been shifting from two doses to one dose, and now that this is a month later, has that part changed?   Cool Nerd (talk) 22:07, 21 November 2009 (UTC)

2009 flu pandemic vaccine
I discovered this sub-article today. Could probably do with better sourcing. Tim Vickers (talk) 22:17, 21 November 2009 (UTC)


 * Tim, can't they all! What I'm saying, let's at least keep up with the weekly press conferences of WHO, and their updates and briefing notes if possible.   Cool Nerd (talk) 23:05, 21 November 2009 (UTC)


 * And actually, I want to do a lot more than this. The best information across the board.  And parents are our most demanding readers, by far.  The best, most relevant, most timely information---in readable form.  And if we can satisfy parents, we'll satisfy almost every other reader.   Cool Nerd (talk) 23:51, 21 November 2009 (UTC)

Persons with egg allergies might be able to be given vaccine in doses, in careful supervised environment.
[http://www.infectioncontroltoday.com/hotnews/egg-allergy-and-flu-vaccines.html Have Egg Allergy? You May Still Be Candidate for Flu Vaccines, Says Allergist], Infection Control Today, Nov. 18, 2009.

‘ .  .  .  Dr. Catherine Monteleone, an allergist. ..

‘ .  .  .  Even if their skin tests are positive, Monteleone said people can still be vaccinated. “It may still be possible to administer the vaccine in graded doses,” she explained. “During the office visit, increasing doses are given every 15 minutes, for a total of five doses.”

‘Following completion of that process, patients will be supervised for a minimum of 30 minutes, Monteleone said. “The protocol is set forth by the American Academy of Allergy, Asthma & Immunology,” she said. “This has to be done in a very careful and controlled environment.”’


 * posted by Cool Nerd (talk) 23:07, 21 November 2009 (UTC)


 * The following excerpt is a blog and should very much be taken with a grain of salt.
 * Can kids with egg allergies get swine flu shots?, Austin American Statesman blog, Mary Ann Roser (seemingly a regular blogger), Friday, October 30, 2009.


 * 'From what I’ve read and and heard a lot of parents have been wondering whether their kids, who appear to have egg allergies, can get an H1N1 vaccine.


 * 'That vaccine is made the same way as seasonal flu vaccine: It is grown in an egg-based culture.


 * 'But Dr. Allen Lieberman said his practice with Dr. William Howland III, Allergy and Asthma Center of Austin, wants anxious parents to know their potentially egg-allergic children might be able to tolerate a swine flu shot. (Children and young adults are at a higher risk of complications from the H1N1 swine flu, and among those in a priority group for vaccination.)


 * '“We used to turn these kids away, but now that there is a test for the vaccine,” Lieberman told me. It’s the same test the clinic has been following before administering seasonal flu shots to children whose parents believe they have an egg allergy. (Adults usually know if they have one, but the same test can be done on people of any age.)


 * 'What the clinic and other allergy specialist do is a scratch test on the skin to see if there is a reaction to the vaccine. The egg content of flu shots varies from year to year, and this year’s seasonal flu shots did not contain much, he said. (There isn’t a test for the mist form of the vaccine, Lieberman said.). .  .  '
 * posted by Cool Nerd (talk) 22:29, 19 November 2009 (UTC), reposted and identified as blog Cool Nerd (talk) 01:50, 23 November 2009 (UTC)

New Eng J Med article on immune response to vaccine, probably too technical
Response after One Dose of a Monovalent Influenza A (H1N1) 2009 Vaccine — Preliminary Report, New Eng J Med, Sept. 10, 2009.

"Results By day 21 after vaccination, antibody titers of 1:40 or more were observed in 116 of 120 subjects (96.7%) who received the 15-µg dose and in 112 of 120 subjects (93.3%) who received the 30-µg dose. No deaths, serious adverse events, or adverse events of special interest were reported. Local discomfort (e.g., injection-site tenderness or pain) was reported by 46.3% of subjects, and systemic symptoms (e.g., headache) by 45.0% of subjects. Nearly all events were mild to moderate in intensity."


 * Might be able to use this for searches.  Cool Nerd (talk) 23:44, 21 November 2009 (UTC)

Officials Stop Counting Swine Flu Cases
Officials Stop Counting Swine Flu Cases http://www.10news.com/health/21247059/detail.html

H1N1 Infections, Deaths Hard To Confirm MIKE STOBBE, AP Medical Writer POSTED: 1:04 am PDT October 9, 2009

[Excerpts]

ATLANTA -- U.S. health officials have lost track of how many illnesses and deaths have been caused by the first global flu epidemic in 40 years.

And they did it on purpose.

Government doctors stopped counting swine flu cases in July, when they estimated more than 1 million were infected in this country. ...

Other nations have stopped relying on lab-confirmed cases, too, and health officials say the current monitoring system is adequate. But not having specific, accurate counts of swine flu means the government doesn't have a clear picture of how hard the infection is hitting some groups of people, said Andrew Pekosz, a flu expert at Johns Hopkins University.

The novel H1N1 flu seems to be more dangerous for children, young adults, pregnant women and even the obese, according to studies based on small numbers of patients. But exactly how much more at risk those people are is hard to gauge if the overall numbers are fuzzy. ...

The Centers for Disease Control and Prevention is relying on a patchwork system of gathering death and hospitalization numbers. Some states are reporting lab-confirmed cases. Others report illnesses that could be the new swine flu, seasonal flu or some other respiratory disease.

Some say that's a more sensible approach than only counting lab-confirmed cases. Many people who got sick never get tested, so the tally of swine flu cases was off almost from the very beginning, they say.

"It was a vast underestimate," said Dr. Zack Moore, a respiratory disease expert for the North Carolina Department of Health and Human Services.

What's more, as the initial panic of the new virus ebbed, fewer people were fully tested, so the results weren't as accurate or comprehensive. "The kinds of numbers you were getting later in the summer were different from the numbers early on," said Dr. Daniel Jernigan, deputy director of the CDC's influenza division.

That's why the CDC shifted to counting the new flu like it counts seasonal flu cases, agency officials said. "We're concerned folks are focused on the numbers and missing that influenza is monitored by looking at trends," Jernigan said.

It's likely that millions of Americans have been sickened by swine flu by now, CDC officials say. New York City alone estimates it had roughly 1 million cases since swine flu first hit last spring.

...

... Rapid flu tests -- which are used in counting hospitalizations -- are often wrong when they indicate a patient doesn't have swine flu, CDC studies have shown. In some cases, flu or swine flu was only confirmed at autopsy. But most deaths are not autopsied.

These problems are not unique to the United States. The World Health Organization also stopped counting cases in July, after deciding that tracking individual swine flu cases was too overwhelming for countries where the virus was spreading widely. The WHO has continued to update swine flu reports, but with the disclaimer that since countries are no longer required to test and report cases, WHO's numbers underestimate.

Britain also releases weekly swine flu updates, but the numbers are estimates based on how many people go to their doctors with flu-like illness, as well as calls logged to the national flu service.

...

SEE FLUCOUNT.ORG

IT HAS THE MOST CLOSE BERS TO REALITY —Preceding unsigned comment added by عقاب عنزة (talk • contribs) 23:41, 22 November 2009 (UTC)

Seasonal flu misrepresented?
It appears from both the table comparing pandemics and the written section it comes in that seasonal flu kills 250,000 to 500,000 people annually. However, it doesn't actually kill this many people; it's only a complicating factor in most cases. For example, flu weakens your immune system and you die of something else. Here is a news article explaining this. If we are comparing confirmed cases, and if only 8% of seasonal flu cases are confirmed to directly cause death, then the worldwide annual total should be 20,000 to 40,000, meaning H1N1 is already 20-33% of the usual seasonal death toll. Roger (talk) 17:25, 16 November 2009 (UTC)
 * Could be worth having 2 columns, one for direct deaths, one for contributory deaths, if enough data is available. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 19:41, 16 November 2009 (UTC)
 * These deaths (the 250,000 to 500,000) are excess deaths estimated using statistical methods. Thats the best way we have to estimate deaths.  The statistical methods allow us to estimate how many people died that would not otherwise have died, not just in how many people the flu was a complicating factor.  To understand this consider the following thought experiment.  If 100,000 people with heart disease get the flu and 100 die within a couple of weeks but in another group of 100,000 heart disease sufferers without the flu on 20 die (within a similar time frame) then you can estimate caused an excess death rate of 80 per 100,000 in the first group.  So your first point is spurious and does not give a reason to disbelieve the 250,000-500,000 estimate.  Your point would only have been valid if we counted everyone who had flu and died.  But the statistical methods can't and don't do that.
 * However, it is indeed highly misleading to compare confirmed deaths with estimated deaths. A point I have raised many times before.  It could even be misleading to compare confirmed deaths with confirmed deaths if the frequency of reporting differs significantly between countries (which is almost certainly the case).  However, the undercount isn't necessarily as bad as it is for seasonal flu.  The CDC has released an estimate of deaths from April to October 17th.  This estimate at 3,900 was almost 4 times the number of confirmed flu deaths.  Thus confirmed deaths do indeed badly underestimate actual deaths.  The mutliplier (at least in the USA) is not so great as it would be for seasonal flu (detection rates of only 5% have been recorded).  Despite this, the multiplier may be greater in poorer countries.
 * Our table will mislead as many readers will assume that confirmed deaths estimate actual deaths, which is not the case. Barnaby dawson (talk) 09:30, 21 November 2009 (UTC)

Why have the fatality figures been removed without discussion? We finally had a form of data tracking that was useful, took up little space, and was based on objective, applicable information -- and that data has been buried in the middle of the article to be replaced by a *picture* of the flu virus? Are you kidding me? This is a current event -- current, up to date dynamic information should lead. The electron microscopic image of H1N1 has no business replacing information that changes daily. The only thing I check every day are those fatality figures, and I'm certain I'm not the only one. We've discussed the issue of fatality figures endlessly, yet they keep getting dismissed, buried, or removed with no consensus because individual editors take it upon themselves to protect the rest of us from ourselves. Are the seasonal flu numbers grossly overstated? Absolutely. But when you yank objective, hard data because other, *soft* data exists elsewhere, you're deliberately burying truth from users to satisfy your own grudge. Wikipedia is no place for your personal agendas, and it's maddening that these *good* numbers keep suffering because you can't do anything about the *bad* ones out there. Can someone *please* put the fatality figures back at the top of the page?68.111.62.56 (talk) 19:33, 23 November 2009 (UTC)

WHO’s Nov. 19th Press Conference on Vaccine Safety
[http://www.who.int/mediacentre/vpc_transcript_19_november_09_kieny.pdf Transcript of virtual press conference with Dr Marie-Paule Kieny, Director, Initiative for Vaccine Research World Health Organization], WHO, 19 November 2009. An audio transcript is also available at WHO’s Pandemic (H1N1) 2009 press briefings.

“ .  .  .  Beginning with numbers, we estimate that at least 80 million doses of vaccine have been distributed and that at least 65 million doses have been administered. These are figures that we have received from 16 countries, but we think they are conservative estimates because immunization campaigns are under way now in 40 countries. . .  .  ”

“ .  .  .  The national authorities have been regularly sharing their findings with WHO. So far, there have been a similar number of events reported as we would see for seasonal flu vaccine. We have seen a rate of about 1 report for 10,000 doses of vaccine. Only 5 reports out of 100 reports are for a serious event. Each instance is investigated by national authorities to see if there are any connections between the vaccination and the adverse event. . .  .  ”

“ .  .  .  There has been in particular a lot of concern about Guillain-Barre syndrome because of the incidences during the swine flu vaccination campaigns in 1976 in the US. To date, less than a dozen suspected cases of Guillain-Barre have been reported following vaccination. Only a few of these Guillain-Barre cases may be linked to the pandemic vaccine. Illness has been transient and patients have recovered. . .  .  ”

“ .  .  .  The first question is from Jason Gale from Bloomberg. Please go ahead.

“Jason Gale: Good morning, good evening actually Dr Kieny. I want to ask you about demand for swine flu vaccine in the countries where it is currently available. It seems to be that some people are clamouring for it and others are spurning it. To what extent is the plethora of conspiracy theories that one reads on the internet having an effect on the perceived risk of the vaccine and what is the public health implication of that? If I can ask an associated question, which of these conspiracy theories seem to be doing the most damage?

“Dr Marie-Paule Kieny: The conspiracy theories have indeed been brought to our attention. We really think that these can be damaging and indeed there are worries which are artificial worries generated by these conspiracy theories. Really what we would like to do is that we have to reiterate that the vaccines are safe, that the disease in certain people can be severe and can be the cause of death and therefore this is not the time to discuss or try to work out whatever conspiracies there may be. This is a time to work together, to produce more, to distribute more and to protect as many people as possible against this pandemic virus.”


 * And that's what we're fighting. When people get the feeling that they aren't being dealt with straight, that's when they end up believing some conspiracy theory.  Cool Nerd (talk) 20:45, 19 November 2009 (UTC)

. . “ .  .  .  The next question is from Martin Enserink from Science Magazine. Please go ahead.

“Martin Enserink: Thank you. I was wondering about the vaccine that will go to developing countries - who decides exactly where that goes? Is it WHO or is it the donors that actually give the vaccine? I am asking because I saw a press release saying that the US would donate almost a million vaccine doses to the Ukraine in early December. Was that their own decision or was that taken in consultation with WHO?

“Dr Marie-Paule Kieny. The decision on which vaccine goes where is taken in function of the quantity of vaccine that we have from different types and of the size of the population. We try, as much as possible, to provide only one type of vaccine per country because for logistical reasons this is easier to handle. In terms of your particular case with Ukraine, the US indeed is donating vaccines to WHO and it is WHO who will orchestrate the distribution of vaccines to these 95 countries and it remains to be determined exactly which vaccine will go to Ukraine.”


 * And this is the kind of serious topics we could and should be discussing.  Cool Nerd (talk) 21:14, 19 November 2009 (UTC)

we are clogged by our own formality
We are more interested in the formality of the communication than we are in the accuracy and timeliness of the information. The reader picks up on this, and it's a turn-off. We are not really with our readers. We are mainly just doing our own thing. Cool Nerd (talk) 21:46, 19 November 2009 (UTC)

maybe if we view ourselves as wikipedia researchers rather than editors
That is, our job is to find the best information and put it forward in a straightforward manner. And if we can excerpt from the mass of information that is WHO, CDC, etc, we have done parents, and others, a tremendous service. Cool Nerd (talk) 22:43, 19 November 2009 (UTC)

starting out formal, and all writing is transferrable
May not be a bad way to do it. Afterall, I think this is how Phil Hellmuth recommends learning poker, you start off uber tight and then you ever so gradually loosen up. Cool Nerd (talk) 02:51, 23 November 2009 (UTC)

"students writing papers" are our least demanding audience
It's just formality for the sake of formality.

It's the omissions!
That's what would really let down parents. We omit something vital. Not that we get something slightly wrong, but that we omit something crucial in it's entirety. Cool Nerd (talk) 03:00, 23 November 2009 (UTC)

Too good not to highlight.

 * the following is the article I've been looking for for the last three months. Not perfect, oh no, I don't claim perfection, but it is very good.   Cool Nerd (talk) 01:40, 23 November 2009 (UTC)

When to take a sick child to the ER, Los Angeles Times, Rong-Gong Lin II, Nov. 21, 2009:

‘ .  .  .  "Is there something really different about your child that's different from the seven or eight viral infections your kid gets every year? Those are the changes to look out for," said Dr. Mark Morocco, associate residency director for emergency medicine at UCLA.

‘Warning signs include significant difficulty breathing; inability to drink fluids or urinate for more than six hours; change in the color of the mouth or lips; or unusual behavioral changes, such as a crying child who cannot be consoled, or a child who doesn't wake up or walk or talk normally.

‘If any of those symptoms show up in children, parents should take them to the emergency room, Morocco said, noting that "respiratory infections are often things that are the most life-threatening in children."

‘Lung inflammation is particularly dangerous to infants and young children because their airways are smaller. According to the California Department of Public Health, the flu virus replicates in the airways and lungs, causing them to swell. The inflammation makes it difficult for the lungs to work, reducing the body's ability to take oxygen into the bloodstream.

‘In California, the most common causes of deaths associated with H1N1 flu have been viral pneumonia and acute respiratory distress syndrome, state health officials wrote in a recent report in the Journal of the American Medical Assn. Experts are telling clinicians to treat the H1N1 strain differently than the seasonal flu.

‘In a Journal of the American Medical Assn. editorial published earlier this month, former CDC director Julie Louise Gerberding wrote that patients who have a five- or six-day history of flu-like illness and whose ability to breathe is worsening "appear to be at risk for rapid deterioration" and should be treated with antiviral drugs and admitted to the hospital.

‘"Clinicians should not be falsely reassured by previous good health, young age and absence of major comorbidities because these characteristics do not exclude the potential for respiratory failure and death," Gerberding wrote.

‘The CDC has also warned that some physicians are not prescribing antiviral drugs to H1N1 patients, pointing to studies that show that about 25% of hospitalized patients with lab-confirmed H1N1 did not receive Tamiflu or similar drugs. . .  .  ’

Third wave expected in December or January
"...


 * Lone Simonsen, an epidemiologist at George Washington University, said she expected a third wave in December or January, possibly beginning in the South again.


 * “If people think it’s going away, they can think again,” Dr. Simonsen said.


 * Based on death rates in New York City and in Scandinavia, she has argued that both 1918 and 1957 had mild summer waves followed by two stronger waves, one in fall and one in midwinter."

"Signs That Swine Flu Has Peaked"

By DONALD G. McNEIL Jr.

Published: November 20, 2009

http://www.nytimes.com/2009/11/21/health/21flu.html —Preceding unsigned comment added by 68.165.11.27 (talk) 02:02, 23 November 2009 (UTC)

Removed section
Removed as should be combined into treatment section

Current WHO Recommendations on use of Tamiflu

Transcript of virtual press conference with Gregory Hartl, Spokesperson for H1N1, and Dr Nikki Shindo, Medical Officer, Global Influenza Programme, World Health Organization, 12 November 2009:

'When WHO first published guidelines for doctors treating patients with pandemic H1N1, we were focussing on how to TREAT severe cases. Now, with more data and experience with the disease, we have better information on how to PREVENT severe disease. WHO has now published updated clinical management guidelines. They are based on what we now know about the virus and how it affects people. 'In a country where the virus is circulating, we have 3 updated recommendations. '1. Firstly, people in at-risk groups need to be treated with antivirals as soon as possible when they have flu symptoms. This includes pregnant women, children under 2 years old, and people with “underlying conditions” such as respiratory problems. '2. Secondly, people who are not from the at-risk group but who have persistent or rapidly worsening symptoms should also be treated with antivirals. These symptoms include difficulty breathing and a high fever that lasts beyond 3 days. '3. Thirdly, people who have already developed pneumonia should be given both antivirals and antibiotics, as we have seen that, in many severe cases of H1N1-caused illness, bacterial infection develops. These medicines, antivirals and antibiotics, if used in a timely manner, can help save lives.' Doc James (talk · contribs · email) 02:38, 23 November 2009 (UTC)
 * This was already in the treatment section?  Doc James  (talk · contribs · email) 03:06, 23 November 2009 (UTC)

Diagnosis
There is not yet a section on diagnosis. Doc James (talk · contribs · email) 18:16, 23 November 2009 (UTC)
 * There is now. :-) --<b style="color:#3773A5;">Cyber</b> cobra (talk) 19:49, 23 November 2009 (UTC)

Would someone like to pick up the WHO press briefing this Thursday?
I have covered and listened to and integrated into our article the last two press conferences. Someone else like to do it this Thursday? (I guess it's not Thanksgiving in Geneva!)  Cool Nerd (talk) 23:05, 23 November 2009 (UTC)

A positive story, and what we're fighting for.
This happened back in August, but this might be the very kind of story to remind ourselves, yeah, if we do our best work, we might well be able to do some real good.


 * I survived swine flu coma, Daily Mercury, Bianca Clare, 29th August 2009:


 * “DANNY Dempsey spent 15 days in an induced coma in the intensive care unit of Mackay Base Hospital .  .  .  Unable to breathe alone the 48-year-old father of three was hooked up to a ventilator.


 * “But his wife of 25 years, 44 year-old Barbara Dempsey, never gave up hope of seeing the love of her life smile again.


 * “Even on the three occasions when the doctors told her it might be time to say her final goodbyes. .  .  .  ”

And the man made it! He didn’t die. It was not a tragedy. And that is precisely what we’re fighting for. That the people who need to go to the emergency room might get there just a little bit quicker. And the people who don’t, will have the information to make that decision. Cool Nerd (talk) 23:30, 23 November 2009 (UTC)

The Three's Company Argument!
Yes, yes, I'm a radical. I'm not sure why. I want to include the best, most accurate information for parents in an easily accessible form. To me that way takes precedence over artifical standards of formality. I realize not everyone feels the same. I present the following as an argument---if we have space for this, certainly we have space for a good discussion of viral vs. bacterial pneumonia! Cool Nerd (talk) 02:46, 23 November 2009 (UTC)


 * List of Three's Company episodes
 * "Jack is preparing for Cindy's farewell party when Jack is called to Angelino's Restaurant when Janet goes out to look for a roommate. Felipe is annoying him and he cuts his finger. He goes to the hospital to get it checked out. Felipe scares him into rushing into the emergency room out of turn with a story of his cousin's infection. Terri, the nurse, refuses to serve him ahead of turn and he gets upset. While she is taking care of another patient the doctor is bandaging Jack's cut while he is complaining about how cold Terri is. She then tells him he needs a shot on his butt. After struggling for a while she gives him the shot and he goes back to the restaurant.


 * "Janet, who had come to the hospital thinking he was more hurt then starts to talk to Terri when they decide she will be the new roommate. When Janet breaks the news to Jack later that day he is not pleased."


 * the only thing, the synopsis doesn't say whether Terri gave Jack a shot in the left cheek or the right cheek!


 * You lost me. I strongly think we should stay with consistency.  This is a medical article and therefore the preferred format is that found at WP:MEDMOS. Doc James  (talk · contribs · email) 02:50, 23 November 2009 (UTC)


 * The argument of luxurious space. We OBVIOUSLY have plenty of space for as full a discussion as we need of run-of-the-mill being sick with flu vs. something maybe more where you might need some help.   Cool Nerd (talk) 01:59, 24 November 2009 (UTC)

description of severe cases in healthy eroded from useful to vague
The WHO briefing note from their Oct 14-16 conference.

Clinical features of severe cases of pandemic influenza " .  .  .  In severe cases, patients generally begin to deteriorate around 3 to 5 days after symptom onset. Deterioration is rapid, with many patients progressing to respiratory failure within 24 hours, requiring immediate admission to an intensive care unit. Upon admission, most patients need immediate respiratory support with mechanical ventilation. However, some patients do not respond well to conventional ventilatory support, further complicating the treatment.  .  .  .  "


 * That, I feel, actually gives a person some real feel and texture.

We currently have in our lead:

" .  . . children with neurodevelopmental conditions,[8] and pregnant women.[9] Deterioration can be rapid with progress to respiratory failure that requires intensive care or ventilation support.[10]  .  .  .  "


 * And notice how we're also implying deterioration for people with preexisting . . . No, not necessary the case! Plenty of previously very healthy people have gotten seriously sick and died from swine flu.  Yeah, the odds are in your favor.  But you can't just keep repeating "generally mild, generally mild, generally mild" to yourself as if it's a mantra as you get sicker and sicker.  Get yourself some help!  And our job here is to provide people with the best information so they can make their best decisions so they can do that.   Cool Nerd (talk) 01:16, 24 November 2009 (UTC)

And the recent "When to Take Your Child . . . " saying largely the same thing, although this part I think blurring from children to people in general.

When to take a sick child to the ER, Los Angeles Times, Rong-Gong Lin II, November 21, 2009: '. . .  In a Journal of the American Medical Assn. editorial published earlier this month, former CDC director Julie Louise Gerberding wrote that patients who have a five- or six-day history of flu-like illness and whose ability to breathe is worsening "appear to be at risk for rapid deterioration" and should be treated with antiviral drugs and admitted to the hospital. . .  .  '

Images in the lead
We have the exact same image twice in the lead. We really only need one of them. Doc James (talk · contribs · email) 16:45, 24 November 2009 (UTC)
 * I do not know what shows up for other people but right now the lead is a mess. This is also the only page I have seen that has images / tables in the left side of the lead. Doc James  (talk · contribs · email) 22:09, 24 November 2009 (UTC)

patients with chest X-rays showing pneumonia should get both antivirals and antibiotics.
Hospitalized Patients with 2009 H1N1 Influenza in the United States, April–June 2009, The New England Journal of Medicine, Jain, Kamimoto, et al., See esp. “Discussion” (8th paragraph), October 8, 2009:

“ .  .  .  patients with radiographic evidence of pneumonia. . .  should be considered for treatment with both antibiotics and antiviral drugs. . .  ”

one dangerous pattern (and of course there are others)
When to take a sick child to the ER, Los Angeles Times, Rong-Gong Lin II, November 21, 2009:

“ .  .  .  In a Journal of the American Medical Assn. editorial published earlier this month, former CDC director Julie Louise Gerberding wrote that patients who have a five- or six-day history of flu-like illness and whose ability to breathe is worsening "appear to be at risk for rapid deterioration" and should be treated with antiviral drugs and admitted to the hospital. . .  .  ”


 * No, I'm not saying pneumonia. Julie Louise Gerberding is not saying that either.  She is saying, at risk for rapid deterioration.  Warrants getting some help is what I'll say, and I think I'm on pretty safe grounds saying that!   Cool Nerd (talk) 21:29, 24 November 2009 (UTC)

viral pneumonia, bacterial pneumonia, but also other contributing causes to severe cases
Clinical features of severe cases of pandemic influenza, WHO, Pandemic (H1N1) 2009 briefing note 13, section on "Need for intensive care," Oct. 16, 2009: “. . .  severe pneumonia is often associated with failure of other organs, or marked worsening of underlying asthma or chronic obstructive airway disease. . .  .  Secondary bacterial infections have been found in approximately 30% of fatal cases. Respiratory failure and refractory shock have been the most common causes of death. . .  .  ”

http://www.latimes.com/features/health/la-me-flu-guidelines21-2009nov21,0,2717012.story?track=rss When to take a sick child to the ER], Los Angeles Times, Rong-Gong Lin II, November 21, 2009: " .  .  .  Lung inflammation is particularly dangerous to infants and young children because their airways are smaller. According to the California Department of Public Health, the flu virus replicates in the airways and lungs, causing them to swell.  .  .  .  "


 * So, as a rough approximation, I guess we can say that two-thirds of the severe cases are direct viral pneumonia and one-third are secondary bacterial pneumonia. As long as we remember that other things might very well be going on at the same time.   Cool Nerd (talk) 21:47, 24 November 2009 (UTC)


 * We can say that 30% of fatal cases are due in part to a secondary bacterial pneumonia. Doc James  (talk · contribs · email) 22:23, 24 November 2009 (UTC)

Ugly Assed Article
There are two big fucking boxes schmutzing up the top of this article. I (and numerous others) don't expect y'all to agree about the content, but surely you mob can get your shit together long enough to make this mofo look a little bit pretty. Crafty (talk) 11:37, 25 November 2009 (UTC)
 * It is called consensus building :-) Doc James  (talk · contribs · email) 12:37, 25 November 2009 (UTC)

Position of the Infobox about Influenza in general
I do not understand, why this infobox about Influenza in general has to be placed nearly at the beginning of the article. This article is about the 2009 Flu Pandemic, as the title clearly says. The infobox about Influenza as such should be in the article about Influenza or at the most at the bottom of the article together with other further links. And, guess what, there is already a box, providing an extensive amount of links. Hence I recommend to choose one of the two boxes and to remove this misplaced infobox from the beginning of the article! FHessel (talk) 14:07, 26 November 2009 (UTC)


 * The links in the info box are specifically for H1N1 influenza. The flu box you link is an organizational box of the influenza topic of which the current pandemic is only a single aspect and is contained in the box. Doc James  (talk · contribs · email) 14:28, 26 November 2009 (UTC)


 * The box I linked is exactly the one, which is displayed in the article. Compare yourself! And, as you say, 'it is a box of the influenza topic in general of which the current pandemic is only a single aspect'. So, what is the reason to put it there? FHessel (talk) 15:08, 26 November 2009 (UTC)


 * It is to help people navigate around the influenza topic. We use them in a lot of medical articles. Doc James  (talk · contribs · email) 16:40, 26 November 2009 (UTC)

Out dated articles
So Doc, what do you suggest we do about all the horribly outdated articles about H1N1 on different continents and in different countries, given that all the people who created lost interest in keeping them updated months ago? 207.216.2.130 (talk) 21:03, 23 November 2009 (UTC)


 * If you could list these articles will have a look at them. Doc James (talk · contribs · email) 21:08, 23 November 2009 (UTC)

Pretty much every article beginning "H1N1 Pandemic in..." (Asia, Africa, North America, etc., plus all the individual countries. 207.216.6.104 (talk) 03:39, 27 November 2009 (UTC)

Fatality Figures Need To Be Returned to Top of Page
There is no justification in an ongoing, current event, to replace dynamic updated data (fatality figures) with a static image of the swine flu virus itself. The electron microscope image of swine flu needs to be moved from the top of the article, and replaced with the fatality figures that had been in that location for the past few weeks. Why were those fatality figures removed without debate? Can we please stop doing drive-by editing of the article on issues like this which have been the topic of exhaustive debate already?68.111.62.56 (talk) 00:09, 24 November 2009 (UTC)


 * I was being bold. This information does not seem of primary importance and did not fit well within the lead.  Therefore moved to a newly created epidemiology section which is were most people expect to find data on mortality. Doc James  (talk · contribs · email) 00:14, 24 November 2009 (UTC)
 * There was exhaustive debate about the table's placement? --<b style="color:#3773A5;">Cyber</b> cobra (talk) 00:17, 24 November 2009 (UTC)
 * Would be happy to review it. However many places have stoped keeping count of exact numbers of cases. Doc James  (talk · contribs · email) 00:19, 24 November 2009 (UTC)
 * Doc, while the issue of some countries deciding to stop reporting fatality figures is valid, and one which we must continue to monitor, we have (at the moment) good data arriving daily or nearly daily on fatalities - so, as it's a current event, putting that data front and center should (I believe) trump aesthetics. The debates over inclusion of fatality figures (and, earlier, of infection figures) have, indeed, raged on for most of the time this page has existed, but considering how long the *current* discussion page is, I don't think anyone can be faulted for not going back and reviewing the history of debate associated with this page. The fact is, I check this page daily primarily to get those fatality figures -- and the last thing I'm interested in having to do is scroll down to hunt for them in a sub-section.68.111.62.56 (talk) 01:22, 26 November 2009 (UTC)
 * Then be bold in reviewing! There have been dabates on that topic going back almost 5 months and it has been voted repeatedly to leave the actual data in place. Besides, the solution of Cybercobra even had some graphical appeal. I will boldly restore it. FHessel (talk) 10:19, 24 November 2009 (UTC)
 * I must say that the lead is too cluttered and beleive we are better served we the stats returned to the epidemiology section. Doc James (talk · contribs · email) 12:41, 24 November 2009 (UTC)

This has been discussed many times over the past few months and the majority view was that the table is one of, if not the most, important and useful part of the article. Of course if you know better..... —Preceding unsigned comment added by 218.102.64.38 (talk) 15:10, 24 November 2009 (UTC)
 * This table should at least be on the right. Would be best if it was just in epidemiology section with the most important numbers summarized by text.  At least it should be at the right below the disease box.  The majority view may have changed as the article changes.  Right now the page just looks bad / unprofessional.  We also do not decide things by vote necessarily.   Doc James  (talk · contribs · email) 01:57, 25 November 2009 (UTC)
 * Once the empty space is removed, it looks much better. But as I said in my edit summary, I don't have a strong opinion on the table's placement. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 09:28, 25 November 2009 (UTC)

Then how about moving the picture of the virus (which is of limited value IMHO) and putting the table there? Which is more important, looking good or giving people the information they are looking for? Hullexile (talk) 07:14, 25 November 2009 (UTC)
 * Eh, I rather strongly support the prevailing style of infoboxes remaining in the lede. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 09:24, 25 November 2009 (UTC)


 * Tried to put the table in the disease box but would not let me. Unless we turn the table into a picture. Doc James  (talk · contribs · email) 12:36, 25 November 2009 (UTC)

The majority, which you are referring to in your edit, seems to consist mainly of your own person (Doc James = Jmh649). Please procure a consensus of some more editors, before moving the table again. FHessel (talk) 13:35, 26 November 2009 (UTC)


 * Did you miss Crafty's comment just below? :-) Doc James  (talk · contribs · email) 00:25, 1 December 2009 (UTC)

please help with footnote in Vaccines section

 * The following's not working, and I'm not seeing why.

At a Nov. 26th press briefing, WHO’s Dr. Keiji Fukuda stated that the Canada Public Health Agency has reported 6 cases of anaphylaxis following vaccination from one batch of 172,000 doses, many of which had already been given. The rest of the batch has been placed on hold pending investigation.

simpler version, still not working

 * no ref name, direct cut and paste from WHO site, not using backspace-then-space to clean up spacing, and still not working

. . . pending investigation.


 * posted by Cool Nerd (talk) 01:23, 1 December 2009 (UTC)

another way
At a November 26 press briefing, Dr. Keiji Fukuda. . . investigation.


 * And I wish to thank Cybercobra for helping with this. He corrected the link in the body of our article.   Cool Nerd (talk) 21:39, 1 December 2009 (UTC)


 * I recently re-wrote the 2009 influenza pandemic vaccine article. This now has many sources you can summarise. Tim Vickers (talk) 21:56, 1 December 2009 (UTC)

Liturgical rules
I'm not sure this is entirely relevant for this article, but there has been some rather notable debate among Christians on whether it is a good idea to ban traditional practices such as communion on the tongue due to the 2009 flu pandemic. Certain bishops have even banned the Tridentine Mass in general because it features communion on the tongue. Meanwhile, the Vatican has reacted against this tendency, saying that it was canonically illegitimate for bishops to ban this practice under such circumstances. ADM (talk) 07:19, 1 December 2009 (UTC)
 * Yeah, probably should be included. I also remember seeing either a CNN or Reuters article on an Italian guy who invented a holy water dispenser for similar hygienic reasons on account of the flu. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 10:44, 1 December 2009 (UTC)
 * Would go probably in the section on culture and society. There was also attempts to decrease the kissing seen in Latin American countries / Spain / Portugal. Doc James  (talk · contribs · email) 13:21, 1 December 2009 (UTC)

Canada, 24 confirmed cases of anaphylactic reaction to vaccine
Canada Probes H1N1 Vaccine Anaphylaxis Spike, Michael Smith, North American Correspondent, MedPage Today, Nov. 30, 2009:

“ .  .  .  Since the vaccine program has been under way in Canada, Butler-Jones said, there have been 24 confirmed anaphylactic reactions, including one in which the patient died.

“Butler-Jones said the man -- reported to be in his 80s -- met the criteria for an anaphylactic reaction, but it remains unclear whether that was the cause of death. . .  .  ”


 * The end of our Vaccines sections includes Canada's 24 confirmed cases of anaphylaxis, the estimated overall rate, the one batch that produced 6 (out of 157,000 given<--arrived at by subtracting 15,000 out of 172,000 total), and Dr. David Butler-Jones saying it does not appear to be the adjuvant.


 * I did not include that the one death may not be from the vaccine (and if all we know is that the man is "reported to be in his 80s," then I guess we don't really know much at all!). The part was already getting pretty long and, and I did not know how to summarize this part.  And even though we have discussed this, I'm not just playing a role.  I really don't know how to summarize this without it sounding like we're explaining away a fatality.  The man may have well had preexisting conditions, probably did at his age, but getting anaphylactic shock probably wasn't exactly good for him either!  Cool Nerd (talk) 22:45, 1 December 2009 (UTC)

Notability.No
I would like to point out that this 'article' is no longer notable as the panic or 'pandemic' as it is seemingly referred to has 'blown over'. I would like some one who give a hoot to mark this for deletion or a 'merge' with regular H1N! article. Im sure y'all 'agree'. 81.132.52.130 (talk) 22:08, 23 November 2009 (UTC)


 * Please, take a moment and contact the friends and families of some of today's dead, and let them know this has blown over. I'm sure they'll be comforted.68.111.62.56 (talk) 01:25, 26 November 2009 (UTC)


 * No I do not agree. I still see people with this every day.  It is marked by a year.  It will become history like the avian flu and the Spanish flu but will not need merging. Doc James  (talk · contribs · email) 22:12, 23 November 2009 (UTC)


 * See also WP:NTEMP. Notable once, notable for all time. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 22:19, 23 November 2009 (UTC)


 * So you would say that the swine flu pandemic with a death toll of 7,600 is equally notable as the spanish influenza outbreak of 1918 with a death toll of 50-100 million?81.132.52.130 (talk) 23:23, 23 November 2009 (UTC)
 * Not necessarily equally notable, but notable nonetheless. See also WP:NOTBIGENOUGH; arbitrary numbers don't determine notability, coverage in reliable sources does. Also, as some editors have remarked in above sections, the statistics can be misleading. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 23:36, 23 November 2009 (UTC)
 * Statistics are always misleading :'(81.132.52.130 (talk) 23:54, 23 November 2009 (UTC)
 * That's only true in 75% of cases. Tim Vickers (talk) 23:56, 23 November 2009 (UTC)
 * :-) Doc James  (talk · contribs · email) 00:17, 24 November 2009 (UTC)

If this is a pandemic, we'll have one each year. It's just stupid to call it that. Some people might want to see the media coverage as helping the prevention, but vaccination has mostly started after the contamination slowed down. So, less people affected and less casualties than the average flu epidemic, and it's still called a pandemic?

Since when does Wikipedia follow the lead of the media and politicians, instead of trying to tell how it is, in an unbiased and scientific way? —Preceding unsigned comment added by Diguru (talk • contribs) 00:17, 1 December 2009 (UTC)

It is not Wiki that has called it a pandemic but the WHO. A pandemic refers to its spread which is worldwide. I assume from what you have written that you are referring to seasonal flu when you talk about an epidemic. This is clearly incorrect as an epidemic refers to cases above the normal expected level and seasonal flu is expected. As to deaths being less, then that is too early to say and also arguable. Hullexile (talk) 07:32, 3 December 2009 (UTC)

Where should we put the mortality table
I believe this fits best in the epidemiology section. We have one line of text that states the number in the lead about 8000 or so (we could expand this to explain also how fast it is increasing). We do not however have table of running death totals for other problems so I see no justification for this one. Doc James (talk · contribs · email) 13:19, 26 November 2009 (UTC)
 * I vote for leaving the table at the top, as long as this is an ongoing event (with acutually more than 100 deaths per day). It had been a compromise to replace the former extensive table with this overview including a link to the detailed data. But hiding the actual data somewhere in the article means to spurn the usability of the article. Many users (including quite a few users, which have never edited these pages) have told us, that an important reason to come back to this page regularly are these numbers. And you want to hide them somewhere, where hardly anybody will find them? And display an image instead, which has hardly any information content? Or an infobox, which is misplaced here, because it is about Influenza in general? No - I am clearly opposing these ideas! FHessel (talk) 14:20, 26 November 2009 (UTC)
 * The links in the info box are actual to pages on H1N1 flu. We have summed up this table in one line of text in the lead.  A 100 death per day is not that great a number when we realize that 500,000 people die yearly from influenza.  Let discuss things here.  You can add links were others may see it as well. Doc James  (talk · contribs · email) 14:27, 26 November 2009 (UTC)
 * I have reservations with the placing of the table too but for a differing reason. Without proper context the table gives a distinct impression that recorded deaths are representative of actual excess deaths and that figures from one country can be meaningfully compared with figures from another country, the same country at a different point in time and with estimates of flu deaths for seasonal flu.  None of these impressions are accurate.  Doc James comment above is an example of how misleading this table is.  The CDC recently published new estimates of deaths that (between April and 17th October) that were 4 times higher than their detected death count figure.  As much of the world have health monitoring which is much worse than that is the USA we can be sure that the detection rate is even lower for the world as a whole (especially as a great proportion of detected deaths are not in Western countries).  Furthermore as the demographic dying is much younger than seasonal flu the loss of life years per death is much greater than for seasonal flu.  The deaths detection rate may also change with time (for instance earlier on it may be easier to track cases).
 * For all of these reasons I feel that the table belongs next to the epidemiology section where the data can be put into proper context. If needs be a link can be given in the introduction to the tables new location. Barnaby dawson (talk) 22:24, 26 November 2009 (UTC)
 * Agree with BD without a full discussion of the meaning of these numbers they mean little. The only place this discussion can really be dealt with properly is the epidemiology section. Doc James  (talk · contribs · email) 22:28, 26 November 2009 (UTC)
 * Can properly dealt with? Really?? I think, that none of us is able to assess, how these numbers are to be interpreted. As an example, read, which reservations I have about this CDC estimation. In numerous discussions I have found, that arguments regarding the course of the pandemic and the published numbers are vastly divergent. I doubt, that anyone can "put them in proper context". Where does this lead us? The numbers still remain. And everybody has to come to his own conclusions and make up his own interpretation. But we should not give away the only tool, which allows at least a limited comparison over time and between countries. FHessel (talk) 07:33, 27 November 2009 (UTC)
 * We should not interpret these numbers. That's not the job of wikipedians.  However, we should give relevant information and prominent viewpoints surrounding these numbers.  Without such context the reader is left without any context with which to form their own opinions.  Now I believe that the numbers are a major underestimate and you are not so sure but the reader should know thta the CDC believes the detected cases to be serious underestimates.  Barnaby dawson (talk) 10:36, 27 November 2009 (UTC)
 * @Doc James: Why to argue with extremes? Read the comment of Roger further above and then put the thing in perspective again. FHessel (talk) 08:11, 27 November 2009 (UTC)

Look! The issue with the tables placement is misleading our readers by having information presented out of proper context and without the many caveats that apply to that information. Perhaps the best compromise would be to have a brief paragraph in the introduction to provide that context. Barnaby dawson (talk) 11:13, 27 November 2009 (UTC)
 * The table is cumbersome to include in the lede, we're not a news service, and it seems better to group it with related analysis in the Epidemiology section. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 07:45, 28 November 2009 (UTC)
 * And I'm happy to support such a move if we could convince others. However, in the absence of such a move I still feel the introduction needs more context for the figures. Barnaby dawson (talk) 09:01, 28 November 2009 (UTC)
 * I agree with that; I wasn't responding to your post specifically, just giving my input on the discussion. Discussion threading on WP isn't consistent. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 05:25, 29 November 2009 (UTC)
 * It looks like most editors currently support the move of the table to the epidemiology section. We also have a page dedicated to the stats surrounding mortality from H1N1. Doc James  (talk · contribs · email) 19:04, 29 November 2009 (UTC)
 * No, most editors do *not* support such a move. The cabal (please don't take offense -- I'm trying to inject a bit of levity) who continuously agitate for burying the fatality figures have "agreed" with themselves on this. EVERY time you move that table, the vast majority of us who oppose that move come out of the woodwork to vent. Fact is, most of us stay quietly out of the way until you take away the sole piece of information which we have any interest in gleaning from this article. That table is the most valuable thing in this entire article, and I'm also a bit puzzled, Doc, as to why you've brought up the mythical 500k figure when you've also acknowledged (or I thought you had) that the 500k figure has no validity. Creating an exhaustive discussion about all the ways & reasons that the 500k / 30k (world/U.S.) seasonal flu figures are wrong isn't a realistic goal, as it doesn't meet Wikipedia's standards of neutrality. So, as always, I agitate that we do the neutral thing -- and put the solid figures front and center. We can't "fix" the broken numbers. But we sure as heck owe it to reality to reflect and report on the ones that *aren't* broken.68.111.62.56 (talk) 21:17, 1 December 2009 (UTC)
 * I object to moving the mortality numbers from the top of the article. The opinions expressed above about inaccuracies or underestimates are original research unless they can be sourced to reliable sources such as CDC or WHO. If the criticisms of the numbers can be reliably sourced, then the caveat can be added briefly at the bottom of the box. Wikipedia does not have as a goal preventing readers from tracking an ongoing problem such as a pandemic. WP:NOTNEWS says we do not have articles about mere news stories. It does not say we should avoid helping readers who want to track a long duration event such as this pandemic. Edison (talk) 20:56, 29 November 2009 (UTC)
 * My main reason for advocating moving is not a concern about there accuracy but that this information is not sufficiently significant to warrant the size it occupies in the lead. It is currently summed up in one line of text and really belong in the epidemiology section. Doc James  (talk · contribs · email) 21:10, 29 November 2009 (UTC)
 * Indeed, my reasoning was not based on accuracy concerns either (although now that you mention it, read the "Data reporting and accuracy" section); I'm saying it should be placed near related analysis rather than presenting just raw data without any analysis/context. It's also a bit hard to include (as prominently as some would like) in an aesthetically-pleasing way. However, FWIW, I find the present layout a very acceptable compromise. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 00:22, 30 November 2009 (UTC)
 * How, precisely, can fatality deaths from a disease which is killing people be anything *other* than "sufficiently significant"? Especially considering, yet again, that the spot formerly occupied by fatality figures now holds a picture of flu virons. Which, I might add, look like every other damned flu viron I've ever seen. These figures change daily, and knowing which regions of the world are currently experiencing elevated fatality rates is an absolutely valid, compelling, and urgent piece of information. Replacing that table with the viron photo would be like replacing a table with fatality figures from the middle of the Rwandan genocide with a picture of a machete. That being said, the current location of the table is fine -- it's still accessible and close to the top. I just strongly oppose any further attempts to bury it in the middle of the article (or remove it altogether under the bizarre notion that since there are other pages dedicated solely to fatality info, we don't need *any* up-to-date data disseminated in this particular article).68.111.62.56 (talk) 21:26, 1 December 2009 (UTC)
 * The choice of where to place information in the article is not original research! However, failing to provide balance in the article can be POV. The table is accurate, its just liable to be misinterpreted. Significant caveats to the intuitive interpretation of these figures exist and deserve to be aired with equal prominence to the figures themselves.  Failure to do this is POV.  The table does not claim to report all deaths.  But most people, apparently including yourself, are unaware that reported deaths do not estimate total deaths.  Neither the CDC, nor the ECDC, nor the WHO assert that they do.  The media frequently make this mistake but with rare exceptions they are completely unqualified to comment.  See the following links:
 * Quotes from Jordan Ellenberg (mathematician) and Dr. Kumanan Wilson (expert in public health policy) These experts are derisive of comparisons between estimates of total flu deaths (say for seasonal flu) and counts of confirmed flu deaths (say for swine flu). Particularly note the sentence "The 2007 study, led by Dena Schanzer of the Public Health Agency of Canada, estimated there were on average 12.5 deaths attributable to flu for every certified flu death from 1990 to 1999.".  There's plenty of other verifiable information in this article that supports my points.


 * CDC's explanation of their estimates of seasonal influenza deaths Here note the last sentence "Only counting deaths where influenza was included on a death certificate would be a gross underestimation of seasonal influenza’s true impact."


 * To summarise. There are serious concerns that have been raised concerning the difference between a confirmed death count and a credible estimate of total deaths.  We present these figures in a way that is likely to mislead our readers into assuming that there is not an important distinction here.  Even if you disagree with these experts or think that the situation has changed its still not NPOV to ignore these criticisms or to give the figures top billing but let the context languish at the bottom of the article (giving undue weight to the raw figures).


 * Efforts to include this information in the old table at this position have consistently been thwarted by well meaning attempts to stream line the table (generally by people unfamiliar with the discussions that led to its being placed there). Similar caveats placed in the introduction have also been stripped out for much the same reason.  Were the table placed alongside the data accuracy section we could provide all the above criticisms as well as any supportive voices to put the table into context.  Its nearly impossible to do this in the intro especially as many people editing it will not understand why the caveats are placed there.  The options in my view are:


 * Move the table to the data accuracy section and link to the table so those interested in following the figures can still do so with ease.


 * Keep the table where it is and add caveats (or revelant links) to the table or to the introduction. But we'd need to place a message (visable only to editors) warning people not to delete it without first achieving a consensus).  Barnaby dawson (talk) 13:38, 30 November 2009 (UTC)
 * Note: The data accuracy section was merged under Epidemiology, and the non-lede instance of the table was and is under Epidemiology. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 18:21, 30 November 2009 (UTC)


 * Reported deaths do not equal total deaths from this cause, just as reported crimes do not equal total crimes. "Reliable source" and "verifiable" do not require "perfect data." Civilian deaths in a war are also not totally correct. As long as the reported deaths are sourced to something like WHO, they satisfy WP:RS and WP:V. There seenms to be some assumption that these death statistics are different from other such statistics. Death statistics are likely more accurate than statistics for number of cases. I check this table frequently because it is more convenient than drilling down to WHO figures, and more comprehensive than scattered news reports. Edison (talk) 20:27, 30 November 2009 (UTC)
 * I don't think people are saying these statistics are worse than any other statistics, but rather that the data, presented in isolation, is liable to be misinterpreted by laymen. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 22:10, 30 November 2009 (UTC)
 * Cybercobra is right. I just want to see the data presented with the necessary context for it to be understood.  I don't care where the table is so long as this context is presented along side it.
 * Okay, the heading of one column reads "Increase in last 7 days." And then the footnote for Worldwide(total), North America, and South America reads: “†.^ The numbers for the USA and Brazil are not reported on a regular weekly basis. Thus, these figures may not accurately reflect the real situation."  And then the bottom says, "Status last updated: USA November 24, Brazil November 26”  Okay, so we're good for now.  The U.S. and Brazil have been recently updated, but that's likely to erode.  And it seems like that's going to be just a chronic problem with the table, that it's going to end up being a blur of old and new.   Cool Nerd (talk) 22:23, 1 December 2009 (UTC)
 * The table is a compromise: Up-to-dateness vs. table size. We can have better numbers, just look at the corresponding wiki. But for the sake of small table size we have now a table, which is condensed to continents (more or less). The only source for these consolidated data is ECDC (or WHO, which is even less up-to-date), so we have to live with the shortcomings of the ECDC reporting. FHessel (talk) 11:03, 2 December 2009 (UTC)

Update: The table has been given a prefix clarifying the nature of the figures it contains and linking to the data reporting and accuracy section. The table has also been copied to the epidemiology section. From my perspective this is a reasonable compromise. It keeps the table in the lead whilst largely addressing my concerns regarding having appropriate context for the table, and making it clear that total deaths & confirmed deaths are not the same thing. Barnaby dawson (talk) 19:43, 2 December 2009 (UTC)

Tables or fables
When a relatively small, but medically advanced, country like Canada distrusts case counts by experts, it might be worthwhile considering the pros and cons of using tables like this. For instance, could it do more harm than good to report figures when countries like China are suspected of concealing swine flu data? And the fact that the WHO and CDC are giving estimates doesn't override the fact that most countries have stopped counting cases. Misleading data about countries can affect travel plans and economies, so spreading erroneous data can have consequences. --Wikiwatcher1 (talk) 20:03, 2 December 2009 (UTC)
 * This is a genuine issue. However, I think its best to provide the best available data (even if its pretty poor in this case) and try to make the shortcomings of that data apparent to the reader.  Perhaps you have verifiable critiques of the ECDC data or their methodology?  If so, do add it to the data reporting and accuracy section (recently expanded).  Note that the data is essentially sourced from the ECDC and hence in terms of wikipedia policy is verifiable and is not original research (These issues were discussed at length before and, although I was originally of the opinion that a similar table violated WP:OR, I was convinced otherwise by other wikipedians).  The data are most likely to be misinterpreted in a way that reduces peoples likelihood of panicking (as the data constitute lower bound figures for deaths, not estimates of deaths) so I don't see a public health argument here.  I think we should take seriously public health arguments but I think they should just make us take particular care with existing wikipedia policies and try to ensure that the probability of lay misinterpretation of risks is minimized.  Barnaby dawson (talk) 21:22, 2 December 2009 (UTC)
 * cases is not deaths. All countries are requested by WHO to keep track of their deaths.
 * to do without lab confirmation does not mean giving up counting altogether. In most countries the vast majority of flu is pandemic flu, so when s.b. has got the flu he has almost certailny the pandemic flu.
 * for countries with no deaths and/or just a few infection cases the number of confirmed cases is still an important means of assessing the local evolution of the outbreak.
 * Helen Branswell's article gives a very good introduction into the problem of confirmed cases vs. estimated cases. It should be framed and put on the wall. Or excerpts to be cited.
 * As far as I am concerned the situation in China is not very much different from the situation all over the world (US, South America, ...). I am convinced, that whitewashing the numbers is happening in most countries. At least China is reporting regularly and recently the numbers were rising a lot, mirroring the news about the increase in Chinese flu cases.
 * All that is not really obliterating the value of the table. I admit, that a pure momentary status has not very much significance in itself. But being able to see the development from one week to another has (and the basis for counting does not really change, so you can compare last week's numbers with this week's numbers). For the casual reader we facilitate this comparison with the column 'increase in last 7 days'.
 * FHessel (talk) 10:49, 3 December 2009 (UTC)

H1N1 Mutations
see Google News for various sources--Hengsheng120 (talk) 09:06, 26 November 2009 (UTC)
 * Thanks for the notice. I find it interesting, if not amazing, that this may become the most important news story over the coming months, yet your post is the only one that no one has responded to. --Wikiwatcher1 (talk) 02:32, 1 December 2009 (UTC)


 * That information is included at the article Pandemic H1N1/09 virus. Gandydancer (talk) 13:28, 4 December 2009 (UTC)

Cleanup time?
The article has become obese with a multitude of cites for many news-like facts, sometimes with multiple cites. The lead alone has about a dozen when it shouldn't have any as it's supposed to be a general summary. The TOC directs readers to the details. Anyone else feel the need for some housecleaning? --Wikiwatcher1 (talk) 02:38, 1 December 2009 (UTC)
 * Agree with some of this but refs should be keep in the lead. Else it becomes to difficult to verify the lead. Doc James  (talk · contribs · email) 03:11, 1 December 2009 (UTC)
 * I totally don't understand what this thing is some people have with purging cites from ledes, there's nothing wrong having them there. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 03:51, 1 December 2009 (UTC)
 * It is based on here LEADCITE which says citations in the lead may or may not be used depending on how technical the material is. Doc James (talk · contribs · email) 13:20, 1 December 2009 (UTC)
 * Our article currently stands at 102KB. For people who have dial-up, Does the reader see visible progress, that is, can the person start reading the top of the article as the bottom loads?   Cool Nerd (talk) 17:10, 1 December 2009 (UTC)
 * No. This isn't like streaming video or flash files. And it's not just the file size that increases the loading time, but the amount of free memory the viewer has. Large files can sometimes just hang, which frustrates users. IMO, the easiest way to start trimming the excess bits is to remove multiple cites from a fact or news story. One should be enough, unless it's likely to be shocking or disputed. BTW, one of the main problems with having an ongoing pandemic article maxed out in size is that it becomes difficult to add new topics and sections. I can think of a few that would warrant new sections: Swine flu prevention/treatment fraud and mutations. Right now these are two new and large topics in the news, both very important and urgent. --Wikiwatcher1 (talk) 02:28, 2 December 2009 (UTC)

This article is becoming way to huge. Some of the extra uneeded commentary, and repeated information needs to be gutted..but this was already mentioned a month ago..and about 20,000kb ago.. some people seem to think the article should cover every single detail.. in triplicate, to be repeated in every section. -Tracer9999 (talk) 08:56, 3 December 2009 (UTC)


 * And that also is a school skill, right? You tell them what you're going to tell them, you tell them, and then you tell them what you've told them!  A tad bit repetitive, don't you think?  I certainly think so.   Cool Nerd (talk) 20:51, 3 December 2009 (UTC)

Wikiwatcher1, to me, the most important thing is that we stay up to date. A topic this changeable, if we’re two weeks out of date, we have a dead article. We can resurrect it! But, out-of-date equals dead article.

That said, I do like the idea of having space in reserve for new topics. The only thing I can think of is to demote older topics to here the discussion page, and then after a little while, demote them further to the archives. Cool Nerd (talk) 21:16, 3 December 2009 (UTC)
 * It's also simple to just prune and condense certain paragraphs. Take one like "On November 2, 2009, at Ukraine's request, the WHO sent a team of nine experts . . . " which is about a single event, relatively small on a global basis, and it has seven different citations. IMO, this kind of news blurb doesn't fit in the article in any case, being that it's for one country. There are a lot of news-event facts, with specific dates, that have two citations, yet they probably don't even need to be cited. --Wikiwatcher1 (talk) 23:28, 3 December 2009 (UTC)
 * Eh, as much as is possible/feasible/reasonable, everything should be cited, but there's no need to give several citations for uncontroversial facts. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 01:58, 4 December 2009 (UTC)

Classification
At the end of the classification section it was written "The main strain of virus has been termed "A/California/07/2009 (H1N1)" by scientists" This is inaccurate. A/California/07/09 is the name given to a single virus sample from California, it is not the name of the main strain. Sometimes, certain isolates become reference strains and are widely used and cited, but the name only refers to the isolate and not to the whole related virus clade! Dycotiles (talk) 14:33, 5 December 2009 (UTC)

today's (Thurs. Dec. 3) WHO press conference is now available
Today's WHO press conference, with Dr. Keiji Fukuda, is available. The following link has both the audio and the transcript. http://www.who.int/mediacentre/multimedia/swineflupressbriefings/en/index.html


 * posted by Cool Nerd (talk) 18:11, 3 December 2009 (UTC)


 * As of right now, the WHO site seems to be down. Hopefully, this will not last long.  (down but not out.  It will resurrect!)  Cool Nerd (talk) 19:15, 3 December 2009 (UTC)


 * And it's back up!  Cool Nerd (talk) 19:38, 3 December 2009 (UTC)

Okay, so this week’s does not seem as substantial as last week’s. But looking at it as an ice cream sundae there are at least two nuts to chomp down on!


 * The question from Helen Branswell mentioning that CDC has reported a fatality ratio of .018.


 * And Nyka Alexander, WHO communication officer, saying that WHO now has a document up on the two [small] clusters of oseltamivir-resistant virus among severely immuno-compromised patients.

Both of these would need additional research on our part (I would want sure that CDC has really said that and in what context), but either or both might make for a good addition.

In addition, considerable vaguer, (say more as a swirl of flavor!), Dr. Keiji Fukuda talked about the large number of countries which had been previously preparing for a pandemic, that WHO’s goal was to build on this, “multiple partners,” “to be as inclusive as possible,” WHO Collaborating Centres, etc. So, when practical, we should try and phrase it this way. For example, more than 10,000 viruses tested worldwide, that is, not necessarily by WHO. . . And we do good here. This is from our section on Antivirals, Resistance. And by the way, the number of cases of resistant viruses found seems to have now increased from 75 to 96.

Dr. Fukuda also talked about how fatality rates are estimated quite a bit after the fact using vital registries and modeling techniques. This is another vague part that would be easy to just skim over as we insist on a number. And it may not be that easy. Cool Nerd (talk) 01:11, 5 December 2009 (UTC)

Sophisticated hacker vandalism to this important public health page
Sophisticated hacker vandalism to this important public health page,

2009 flu pandemic http://en.wikipedia.org/wiki/2009_flu_pandemic

Instead of using hacking skills to puncture the ego of publicity-hound, a hacker has chosen to vandalize the "Vaccines" section of this page, by adding

"This is in strong contrast to the 1976 swine flu outbreak, where mass vaccinations in the United States caused over 1,000,000 cases where peoples heads fell off.[71]"

The attempt at humor is buttressed by coding that makes it impossible for an ordinary user to remove it, so that when one goes to the "edit" screen to revert the vandalism, the "funny joke" is not found there. If one prints a preview of the text on the edit screen, the text is not found there, either. Same results for the edit screens of either the Vaccines section or for the entire article.

Need to identify the hack and hacker, and take steps to remove both from the site. MAIN ARTICLE CONTAINS THE VANDALISM Vaccines Main article: 2009 flu pandemic vaccine As of November 19, 2009, over 65 million doses of vaccine had been administered in over 16 countries; the vaccine seems safe and effective, producing a strong immune response that should protect against infection.[67] The current trivalent seasonal influenza vaccine neither increases nor decreases the risk of infection with H1N1, since the new pandemic strain is quite different from the strains used in this vaccine.[68][69] Overall the safety profile of the new H1N1 vaccine is similar to that of the seasonal flu vaccine, and fewer than a dozen cases of Guillain-Barre syndrome have been reported post-vaccination.[70] Only a few of these are suspected to be actually related to the H1N1 vaccination, and only temporary illness has been observed.[70] This is in strong contrast to the 1976 swine flu outbreak, where mass vaccinations in the United States caused over 1,000,000 cases where peoples heads fell off.[71] There are safety concerns for people who are allergic to eggs because the viruses for the vaccine are grown in chicken-egg-based cultures. People with egg allergies may be able to receive the vaccine, after consultation with their physician, in graded doses in a careful and controlled environment.[72] A vaccine manufactured by Baxter is made without using eggs, but requires two doses three weeks apart to produce immunity.[73] As of late November in Canada, there have been 24 confirmed cases of anaphylactic shock following vaccination, including one death. The estimated rate is 1 anaphylactic reaction per 312,000 persons receiving the vaccine. However, there has been one batch of vaccine in which 6 persons suffered anaphylaxis out of 157,000 doses given. The relatively few remainder doses of this batch are being held pending investigation. Dr. David Butler-Jones, Canada’s chief public health officer, has stated that even though this is an adjuvanted vaccine, that does not appear to be the cause of this severe allergic reaction in these 6 patients.[74][75]

=
EDIT PAGE DOES NOT CONTAIN THE VANDALISM

Vaccines
, over 65 million doses of vaccine had been administered in over 16 countries; the vaccine seems safe and effective, producing a strong immune response that should protect against infection. The current trivalent seasonal influenza vaccine neither increases nor decreases the risk of infection with H1N1, since the new pandemic strain is quite different from the strains used in this vaccine. Overall the safety profile of the new H1N1 vaccine is similar to that of the seasonal flu vaccine, and fewer than a dozen cases of Guillain-Barre syndrome have been reported post-vaccination. Only a few of these are suspected to be actually related to the H1N1 vaccination, and only temporary illness has been observed. This is in strong contrast to the 1976 swine flu outbreak, where mass vaccinations in the United States caused over 500 cases of Guillain-Barre syndrome and led to 25 deaths.

There are safety concerns for people who are allergic to eggs because the viruses for the vaccine are grown in chicken-egg-based cultures. People with egg allergies may be able to receive the vaccine, after consultation with their physician, in graded doses in a careful and controlled environment. A vaccine manufactured by Baxter is made without using eggs, but requires two doses three weeks apart to produce immunity.

As of late November in Canada, there have been 24 confirmed cases of anaphylactic shock following vaccination, including one death. The estimated rate is 1 anaphylactic reaction per 312,000 persons receiving the vaccine. However, there has been one batch of vaccine in which 6 persons suffered anaphylaxis out of 157,000 doses given. The relatively few remainder doses of this batch are being held pending investigation. Dr. David Butler-Jones, Canada’s chief public health officer, has stated that even though this is an adjuvanted vaccine, that does not appear to be the cause of this severe allergic reaction in these 6 patients.

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Vaccines Main article: 2009 flu pandemic vaccine As of November 19, 2009, over 65 million doses of vaccine had been administered in over 16 countries; the vaccine seems safe and effective, producing a strong immune response that should protect against infection.[1] The current trivalent seasonal influenza vaccine neither increases nor decreases the risk of infection with H1N1, since the new pandemic strain is quite different from the strains used in this vaccine.[2][3] Overall the safety profile of the new H1N1 vaccine is similar to that of the seasonal flu vaccine, and fewer than a dozen cases of Guillain-Barre syndrome have been reported post-vaccination.[4] Only a few of these are suspected to be actually related to the H1N1 vaccination, and only temporary illness has been observed.[4] This is in strong contrast to the 1976 swine flu outbreak, where mass vaccinations in the United States caused over 500 cases of Guillain-Barre syndrome and led to 25 deaths.[5] There are safety concerns for people who are allergic to eggs because the viruses for the vaccine are grown in chicken-egg-based cultures. People with egg allergies may be able to receive the vaccine, after consultation with their physician, in graded doses in a careful and controlled environment.[6] A vaccine manufactured by Baxter is made without using eggs, but requires two doses three weeks apart to produce immunity.[7] As of late November in Canada, there have been 24 confirmed cases of anaphylactic shock following vaccination, including one death. The estimated rate is 1 anaphylactic reaction per 312,000 persons receiving the vaccine. However, there has been one batch of vaccine in which 6 persons suffered anaphylaxis out of 157,000 doses given. The relatively few remainder doses of this batch are being held pending investigation. Dr. David Butler-Jones, Canada’s chief public health officer, has stated that even though this is an adjuvanted vaccine, that does not appear to be the cause of this severe allergic reaction in these 6 patients.[8][9]


 * You are viewing an old copy of the page. That vandalism has already been removed. Try deleting your browser's cache and reloading the page. You could also do a purge, see Purge Tim Vickers (talk) 00:04, 8 December 2009 (UTC)

Inconsistent moving of information to country-specific articles
Canadian health officials have reported that swine flu is hospitalizing three to four times as many children as regular seasonal flu.


 * The above was moved to a "country-specific" article, which appears to be decided in an inconsistent manner. Yes, the statistics are only based on Canadian data but looking at the rest of the section on children, it appears a lot of the information is based on data from only one country: The U.S. So to be consistent, most of the section should be moved to the U.S. article. Personally, I think the Canadian research should be restored but perhaps the sentence needs to be modified. I think this information has wider relevance as it provides some concrete statistics as to children's increased risk from swine flu compared to regular seasonal flu.173.206.0.189 (talk) 08:12, 8 December 2009 (UTC)
 * There was another statistic also relocated: "Researchers in Australia and New Zealand have reaffirmed that infants under the age of 1 year have the highest risk of developing severe illness from swine flu." The remainder of the section is written in a general way—not U.S. focused—and although it relies on the CDC as the source of the material (in the NY Times,) the article itself concluded, "To put the H1N1 flu in perspective, Dr. Frieden emphasized that so far, most stricken people had had a relatively mild illness and that the virus had not become any more virulent over time in the United States or any other country."


 * Many of us agree that the article is too large. If country-specific stats are included from news stories, there's no way to limit what gets added. However, if something happens in a country that seems to disprove the general statements, it would seem that WHO and the CDC would be the ones to revise their observations and publicize any important new details. For instance, this is already happening with some mutations, and both organizations have given the names of the few countries that have been affected. --Wikiwatcher1 (talk) 09:09, 8 December 2009 (UTC)

Regarding Diagnosis section
Can someone please help me? I have tried to pare down the diagnostic tests, getting rid of one that is not even useful, but have been unable to make the references come out correctly. Also, this section's information on the uselessness of the quick test was deleted yesterday. This quick test continues to be used and patients are being sent home with false negative dx's. Some of these patients have subsequently died. Please read the two references I have offered that suggest that the quick test is not reliable and is in fact a public health menace. Many of those that work in the health care system feel that it is a disgrace that the CDC has not come right out and STRONGLY said that there is no reason to use them at all since they may well delay appropriate tx. Thanks. Gandydancer (talk) 18:55, 7 December 2009 (UTC)
 * Looks like a bot fixed the referencing problem. Looking at the edit churn, it doesn't appear as any info on the RIDTs was net removed. --<b style="color:#3773A5;">Cyber</b> cobra (talk) 01:51, 8 December 2009 (UTC)


 * Transcript of virtual press conference with Gregory Hartl, Spokesperson for H1N1, and Dr Nikki Shindo, Medical Officer, Global Influenza Programme, World Health Organization, page 4 (in response to question by Helen Branswell, Canadian Press), 12 November 2009:
 * “ .  .  .  And regretfully many doctors reported that the treatment has been delayed because the doctors wanted to wait for the test result. They wanted to have the proof that the patients were infected by H1N1 but if the epidemiological information suggests that the virus is circulating then the doctors should not wait for the laboratory confirmation but make diagnosis based on clinical and epidemiological backgrounds and start treatment early. And for severe cases, don't worry about whether within 48 hours but in any stage of severe illness they can start treatment.”


 * So, it's much more free-form than we might think. It's not Symptoms, Diagnosis, Treatment, step by hard logical step.  No, it's much more feel and texture.  It's right brain, more than we might be familiar with.  " . . . based on clinical and epidemiological backgrounds . . . "


 * And critically, crucially, you stay with the patient. You follow up on your patient.  For example, if the patient isn't responding to Tamiflu, you consider trying Relenza.  (Again, I am not a doctor.  But I'm learning, I'm learning to appreciate all that goes into this most pragmatic of arts.  And admittedly sometimes I don't think my doctor has done much, sometimes I don't even think the guy or gal has even answered my question! but, but I'm going to try and cut them a little more slack.)


 * Gandydancer, please include any or all of this, well-referenced of course. Yes, this should be part of our article.   Cool Nerd (talk) 02:37, 9 December 2009 (UTC)

too thick with technical terms?
" . . . Real-time RT-PCR is the recommended test as others are unable to differentiate between pandemic H1N1/09 and regular seasonal flu.  However, most people with flu symptoms do not need a test for pandemic H1N1/09 flu specifically, because the test results usually do not affect the recommended course of treatment. The CDC recommends testing only for people who are hospitalized with suspected flu, pregnant women, and people with weakened immune systems.  For the mere diagnosis of influenza and not pandemic H1N1/09 flu specifically, more widely available tests include rapid influenza diagnostic tests (RIDT), which yield results in about 30 minutes, and direct and indirect immunofluorescence assays (DFA and IFA), which take 2–4 hours; DFA and IFA are more sensitive to pandemic H1N1/09 virus than RIDT. . . "

Yes, I think it is. Too thick. And the quote by Dr. Shindo I think is readable and informative. Cool Nerd (talk) 03:21, 9 December 2009 (UTC)


 * Yes, I have looked at it myself thinking the same thing. However, as I go back and forth from the CDC info to this article with thoughts of cutting it down, I have not been able to figure out anything.  Clearly, we are not offering advise to health professionals and in fact, most people that read this article would just skim over this part.  The only people that would read it closely are those that have the flu (or family, friends, etc.) or have read something about the tests on a blog or in the paper.  Most likely they would also look at the CDC cite, but it is confusing even to me.  I did take a few words out today.  Your addition from the WHO is excellent!  Gandydancer (talk) 14:16, 9 December 2009 (UTC)
 * Really, I don't see what's so technical about it; yes, the test names are obviously technical, but that's kinda unavoidable and they are wikilinked to the relevant articles. I don't think the bit about sensitivity you removed recently was technical either. Is the concept of sensitivity "technical"? --<b style="color:#3773A5;">Cyber</b> cobra (talk) 14:31, 9 December 2009 (UTC)


 * I took that information out because according to the CDC "Since a negative RIDT or DFA test result does not exclude influenza virus infection, hospitalized patients with a negative RIDT or DFA result should have priority for further testing with a nucleic acid amplification test, such as rRT-PCR, if influenza infection is clinically suspected". It seems no big deal to me that the DFA may be a little more accurate than the RIDT since they are both so frequently wrong and should not be used as a diagnosis.  But I do agree with you in that I also feel that this section is not too technical to be included.  Gandydancer (talk) 15:09, 9 December 2009 (UTC)


 * Cybercobra, thank you for correcting the date of Dr. Shindo's press conference. You may not have even realized that you did, but you did!  I had been off by two weeks.  The correct date for Dr. Nikki Shindo's virtual press conference is Nov. 12, 2009.   Cool Nerd (talk) 21:40, 9 December 2009 (UTC)

Medline or Helpline?
Should this article be for the medical professional or for the patient? — that is the question. In other words, should we add "Wikimedicating" alongside "Wikilawyering" as a policy of what to avoid? A simple example of the issue can be seen by just comparing the "Signs and symptoms" section with the one following, "Diagnosis." One is written for the average reader and the other for the MD. I exclude nurses since only MDs can prescribe tests and treatments.

In the U.S. the ratio of MDs is .3% of the population — 3 for every 1,000 people. Specialists are included in the total. There are mostly two types of citations used throughout the article, ones from general readership sources like newspapers, general-audience medical websites, general periodicals, and the CDC and WHO. The others consist of cites from medical journals oriented to the professional, mostly doctors, and the ones you'd never see in a waiting room. Even nurses don't read them.

It's reasonable to ask whether or not there is any harm in having pro-level material used too much, since readers can just skim over them. Personally, I'd say that it does harm the article: it crosses the line from general information to specific advice to doctors; it acts a a turn-off to readers by slowing down understanding, if not scaring them off from further reading; it can be interpreted as "wikimedicating;" it maxes out the article size so little more can be added. I'd probably remove the entire "Diagnosis" section, to start, but I think the overall question stated in this section title is what we should decide. --Wikiwatcher1 (talk) 19:55, 9 December 2009 (UTC)


 * I strongly disagree with just about everything you say Wikiwatcher. Of course the diagnosis section is more technical than signs and symptoms - that would be expected.  Is it written for MD's?  Well I should hope not.  They don't come to Wikipedia to help make a diagnosis.  Is it of interest to the average reader?  As I said earlier, it might be skimmed by many people but someone with the flu (etc.) would want to know about what tests are being done. Is it "wikimedicating"?  I don't see how information on tests could be called wikimedicating.  I also don't see how it is "slowing down understanding" and I also can't imagine that it would "scare" people off from further reading.  What's scarey about it?

You may want to take a look at Lyme Disease (for instance) for a comparison. Gandydancer (talk) 23:02, 9 December 2009 (UTC)


 * We should bear WP:MEDICAL in mind. This is not an important public health site, but an encyclopedia anyone can edit.  We should not try to restrict the article to just what is useful for patients, nor should we omit anything because it should be obvious to an expert.  Most importantly, our method of organizing should never be to dump piles of information into the trash - if any sentence a contributor found worth the time to write is well-sourced, notable, and not redundant, then there is a place for it on Wikipedia and it needs to be sent there. Mike Serfas (talk) 19:53, 13 December 2009 (UTC)

writing for people concerned about their health in a good frame of mind?
If we write for parents, we won't go too far wrong. They will be a demanding audience who, hopefully, will call forth our best efforts. But really, anyone concerned for his or her health.

In addition, someone in a good frame of mind. Someone looking for certainty, that's a trap, very seldom is that going to be found in medicine. So, someone in a good frame of mind (realistic, relaxed, with it), we don't have to do anything fancy, we just have to lay out the information. Cool Nerd (talk) 21:50, 9 December 2009 (UTC)