Tuesday, June 23, 2009

Swine Flu Economics

The World Health Organization (WHO) declared on June 11 that it has classified the rapidly spreading H1N1 swine flu virus as a pandemic event, the highest level of intensity on its six point scale of severity.

WHO applies that classification only when a dangerous pathogen appears on a significant scale in numerous countries and at least two major world regions. As of mid-June, almost 30,000 cases of H1N1 infections and 144 related deaths have been confirmed in 74 countries around the world.

The swine flu has had a significant effect on tourist-related industries in Mexico, where the H1N1 virus is believed to have originated. But its macroeconomic impacts in the U.S. and other countries have been relatively minor to date. This reflects the relatively mild impact of the H1N1 virus. Less then 10 percent of its victims require hospitalization, very few of them die, and most recover quickly.

In fact, according to the U.S. Center for Disease Control’s (CDC’s) Pandemic Severity Index, the current swine flu barely qualifies as a category one event, on the CDC’s rising scale of one to five. Its current case-mortality rate is low, and its illness rate as a percent of our population is very low.

The only generally recommended U.S. public health response to date is to call for voluntary isolation at home of those who are infected and for the general public to pay close attention to simple hygienic measures such as frequent hand-washing.

If and as the scope and/or the virulence of the swine flu escalates here, the CDC can be expected to step-up its alert levels and recommend progressively more intense and economically costly interventions. However, unless the virus mutates into a far more dangerous pathogen, it is unlikely to have global macroeconomic effects.

Unfortunately, world health experts believe that a deadly mutation of the H1N1 virus is possible. If that happens, and if its global incidence mounts dramatically when the normal flu season begins this fall in the northern hemisphere, the swine flu could then trigger a more serious global recession than the one we are currently experiencing.

That, in turn, would conjure up images of prior deadly global flu outbreaks, such as the Spanish flu of 1918, which created a major global recession in addition to infecting more than over one-fourth of the world’s population and killing more than 50 million people.

However, the likelihood of a truly catastrophic flu pandemic being driven by the H1N1 virus in its current form is, thankfully, quite small.

By way of comparison, the bird flu (H5N1) virus, to date has about a 60 percent mortality rate for the confirmed global cases.

Fortunately, that virus has not yet mutated into a strain that can be transmitted from person-to-person like the swine flu. If the bird flu were in play today globally, rather than the much less dangerous swine flu, the economic threat it poses would be dramatically greater.

Aside from killing relatively fewer infected people (in economic terms, workers and consumers), the H1N1 virus also is less harmful to the world economy because, as noted above, most infected people recover quickly.

Compared to the bird flu cases or the Spanish flu, this results in far fewer deaths and also fewer lost workdays. Most importantly, the currently milder nature of H1N1 puts less strain on the world’s limited supply of medical personnel and facilities which could be easily overwhelmed by the global spread of a more virulent virus.

But the relatively benign current outlook could change dramatically should the swine flu mutate into a more virulent virus. Whether that will happen remains to be seen.

Brachytherapy for Prostate Cancer

Maybe you saw the reported botched prostate cancer therapy report in the news this weekend. Prostate cancer kills 25,000 men each year. Twenty per cent of the male population develops the cancer over their lifespan. While very common, only 3% of those who get it actually die from the disease.

Brachytherapy is a new type of therapy in which radioactive implants are placed directly in the tumor field of the diseased prostate gland. The radiation kills the nearby cancer cells. It is generally very safe with few side effects. Usually, the risk of anesthesia is the riskiest part of therapy.

Apparently, a doctor and surgical team in the Philadelphia VA hospital did not place the implants correctly and caused some severe problems. Over six years, 92 of 116 procedures were incorrectly performed as reported by Walt Bogdanich in THE NEW YORK TIMES (June 21).

The radioactive seeds are placed n the gland with the use of an ultrasound images that are put together to produce a three dimensional representation of the gland by a computer. The surgeon then places a needle into the gland and manually inserts the radioactive seed into place. Hundreds of seeds can be used. You want the majority to be placed within the gland.

The computer displays placement of the seeds. If the surgeon decides they are in the right position, then the procedure is considered successfully completed. However, the seeds can be placed outside the gland near other tissue like the bladder or rectum.

This can cause radiation damage to the local tissue. One of the patients in the article suffered radiation injury to the anal canal. If not placed in the gland, the cancer is not treated properly and the procedure needs to be repeated.

It appears that peer review and other safety procedures failed in the hospital to detect these failed procedures. The radiation dosing machine that measures the adequacy of the radiation therapy was broken. Even so, the treatments were still done. There also was inadequate peer review of the procedure. The program opened in 2002 and was ended after these results become known.

The most frightening thing in this whole episode is that it may not have even been discovered if an order for seeds had not gone awry. A clerical error led to the problem’s discovery.

Lower dose seeds were incorrectly ordered and used for implantation. The nuclear commission noticed this and asked the hospital to investigate. What they found was that the seeds had been improperly placed in several cases. They looked at more cases and found more problems: 45 in all.

The program was stopped. The nuclear commission concluded that many case had undertreated the prostate as seed had been placed in the wrong areas or some other non-prostate tissues had been overdosed by radiation. None of this was reported to proper officials. The cases mismanaged mounted.

A major system failure occurred here. The nuclear commission did not feel they were responsible to report this as they did not regulate medicine. Peer review by doctors of the surgeon and his team also failed. There is no excuse for this. What do you think?