Beyond irony. Way-y-y beyond.

From Political Site of the Day (PSoTD):

Beyond. any. sense. of. irony.

President Discusses Schiavo

"In cases where there are serious doubts and questions, the presumption should be in the favor of life."

Among Bush's accomplishments

• Most Americans killed in war since the Presidency of Richard M. Nixon.
• Most noncombatants killed by American forces since at least Bush's Dad, if not before.
• Most death row inmates put to death under any Governor in the history of the United States.
• First war started by America under proven wrong reasons in which there were considerable doubts since the Spanish-American War.

Update, Suicide-by-Governor:

Governor Jeb Bush:

"I still firmly believe that human life is a gift and a mystery, and that its mystery is most evident at its beginning and ending. May all of us whose hearts were moved during the life of Terri Schiavo grow in wisdom at its ending," said Governor Bush in a statement sent to the Governor's e-mail list shortly after Schiavo passed away.

Floridians for Alternatives to the Death Penalty:

"I certainly hope Governor Bush has gained some wisdom about the value of life -- all life," said Abe Bonowitz, director of Floridians for Alternatives to the Death Penalty (FADP). "We hope and pray that he will now adopt a consistently pro-life policy."

[snip]

"Suicide-by-Governor is getting very popular in Florida," said FADP Director Abe Bonowitz, noting that five of the last eight Florida executions were of prisoners who waived their appeals and asked to be killed. So far Governor Bush has overseen the execution of 16 prisoners, seven of whom have been volunteers.

(via Common Dreams)

You bet your life

The epidemic of bird flu among poultry in North Korea is taking on a decidedly desperate cast. UN Food and Agriculture experts are flying there from Bangkok, China and Australia (Reuters).

The context is grim. A great deal of money, effort and hope was invested in poultry production by the North Korean government. Struggling to feed its undernourished population of 23 million, a special state agency was established for breeding chickens and ducks in December of 2001 (UPI via World Peace Herald). While poultry was one of the few growing sectors of the economy, the country produced only about 25 million birds in 2004, just over one per person/year, far short of Kim Jong Il's promised one kilogram of chicken meat and 60 eggs a month for every household in Pyongyang. The number of chickens estimated in North Korea is about 19 million. Now mass culling is reducing this already inadequate source of protein.

Pyongyang's public admission of the previously denied bird flu outbreak is seen by many as a sure sign the problem has spiraled out of control and foreign help is needed. The epidemic has probably already hit the poor rural area and is spreading. North Korea has mobilized its military to cull and disinfect poultry farms around Pyongyang, according to the South Korean Unification Ministry:

"Thousands of soldiers from the Pyongyang Defense Command and 3d Army Corps are involved in the slaughter and burial of diseased fowl," a Unification Ministry official told the Joong Ang Ilbo.

[ . . . ]

According to the Unification Ministry, the North's mobilization of the military is evidence of the seriousness of the situation. North Korean troops, after finishing winter drills this month, were scheduled to assist farmers during spring planting, the ministry said. The North shifted the assignment of the soldiers to cope with the spread of bird flu, officials said.

So while the Bush Administration and our European allies were dithering over North Korea's nuclear shenanigans, another kind of bomb was ticking in the Korean peninsula, where the current Asian bird flu outbreak began in 2003 in the South and spread to Cambodia, Thailand, Vietnam, China and Indonesia.

Reuters reports that the FAO experts are hoping to contain the virus before it mutates to a form easily transmissible between humans. This view is incomprehensible. The virus is already solidly entrenched in poultry in Asia, animals in close proximity to human beings. By common consent the virus cannot be eradicated at this point. If there is no intrinsic biological barrier to its making the feared genetic change, it will happen and containing the poultry epidemic (a worthwhile enterprise on its own) will not prevent it.

It is time to stop talking this way and plan seriously for a pandemic in the near future. With good luck it won't happen, although no one at the moment can give a convincing argument why it shouldn't and there are plenty of plausible arguments why it should. If I were a betting person, I wouldn't bet my money against a pandemic. Why should I bet my life on it?

CDC fallout cover-up

If you were a resident of southern Utah or nearby Nevada years ago in the nuclear testing era you are now safe. Safe, that is, from finding out if you aren't safe. After spending 8 million dollars to investigate any connections between thyroid disease and fallout, CDC is pulling the plug on an ongoing study that was designed to provide the answer (Joe Bauman, Deseret News [Utah]).

Reason given: CDC can't afford it (I guess the government needs the money for the $38 million additional they gave to the worthless "sexual abstinence program"; maybe if they practiced what they preached and stopped screwing people . . . )

It is highly unusual to stop funding in the middle of a study. Earlier work, done by principal investigator epidemiologist Joe Lyon of the University of Utah, showed an increased cancer risk in those downwind of the above ground nuclear tests at the Nevada Test Site. Additional work by Lyon in 1993 suggested a link to thyroid disease (nodules and some malignancies). He was in the midst of studying 4000 people identified in the St. George-eastern Nevada area who were 6th to 12th graders in 1965. Lyon has already examined 1300 and located most of the rest.

Lyon said he is loath to use the word cover-up, but it seems the federal government does not want to know about health effects of fallout on American citizens. Still, "That's the only interpretation I can place on it," he said.

I know Joe Lyon. Besides being a good epidemiologist he is a nice guy. So I'll say what he is too nice to say:

Cover-up.

Reading Secretary Leavitt's mail

A reader sent along the following letter that The Sexuality Information and Education Council of the United States (SIECUS) sent DHHS Secretary Leavitt regarding the Department's www.4parents.gov website. The letter is long, so if you don't have the patience (or the stomach) to read it, here is the short version: inaccurate, misleading, incomplete, unhelpful and with subtle anti-gay and anti-choice framing aimed at parents to use in educating their children. Paid for by the US taxpayer.

March 31, 2005

Secretary Michael O. Leavitt
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Dear Secretary Leavitt,

We the undersigned are writing to express our deep concern with the Department of Health and Human Services‚ recently launched website: www.4parents.gov. While all of us agree that parents should ideally be the primary sexuality educators of their children, it is incumbent upon all of us to make sure that parents receive the most accurate information and resources they need to achieve this difficult task. Unfortunately, 4parents.gov fails to meet these goals and instead, relies on fear to motivate and contains many errors and biases that undermine its intent of encouraging parent-child communication around sex and sexuality. 4parents.gov presents biased and inaccurate information as fact and does not address the needs of many youth, including sexually active youth, youth who have been or are being sexually abused, and lesbian, gay, bisexual, transgender and questioning (LGBTQ) youth.

Specifically, the website dictates values to parents rather then helping them to incorporate their own values into discussions regarding sex and sexuality. For example, while discussing what parents can do if their child has become sexually active, parents are told how to convince their teens to stop having sex by telling their children that they are "worth it." No resources or suggestions are given if a parent does not convince their teen to stop being sexually active, implying that these youth are not "worth it."

Additionally, the website contains inaccurate information regarding the effectiveness of condoms and the ability of youth to properly use condoms and other forms of contraception. While www.4parents.gov states that it is easier to prevent a teen's first sexual experience rather then to increase contraceptive use, research has shown that programs that include both messages actually effectively do both. According to the Youth Risk Behavior Surveillance System, condom usage among sexually active teens has gone up almost twenty percent in the past two decades (from 46 percent to 63 percent). Messages to teens should encourage them to delay sexual activity and, when sexually active, to use condoms and other forms of contraception.

4parents.gov also contains a distressing lack of information for parents of sexually abused and assaulted youth. While it is commendable that the website includes some of the signs of sexual abuse in youth, it lists only one resource for parents and this resource does not focus specifically on sexual abuse, but rather on all forms of child abuse.

The website also fails to address the unique needs of parents with LGBTQ children. Whenever 4parents.gov discusses LGBTQ youth, it uses outdated and alienating language and ideas. For example, in the section of the website where sexual orientation is mentioned, it repeatedly uses the terms "alternative lifestyle" and "homosexuality." This language assumes that being lesbian, gay, or bisexual (LGB) is a choice and also reduces LGB people to the mere equivalent of their sexual activity. The website also fails to include any information about transgender youth. Additionally, referrals for further information for LGBTQ youth and their parents is conspicuously absent.

The website also contains language that is clearly anti-choice in nature. For example, 4parents.gov states that "abortion complications" are one of the major reasons for infertility. In reality, less than 1 percent of woman receiving an abortion have a major complication and there is no evidence of infertility issues resulting from abortion among woman who have had the overwhelming majority of abortions. Further, the website omits the more likely causes of infertility, such as blocked fallopian tubes. In other examples:

• In its definition of menstruation, the website states that "If the egg is fertilized, this lining will nourish and protect the unborn child." "Unborn child" is not medically correct language; embryo or fetus would be accurate.
• The website defines abortion as "ending a pregnancy before a live birth occurs by removing the fetus or unborn baby from the uterus." Again, there is an agenda inherent in the language used.
• In its definition of uterus, the glossary section states "It is also called a womb. Womb has a religious, not medical, context.

Also troubling is that only one non-governmental organization is credited as having worked with HHS to create 4parents.gov: the National Physicians Center for Family Resources (NPC). The NPC represents views that are far outside the values of mainstream Americans and the public health community. NPC has ties to right wing religious organizations, like the California Family Council, Alabama Family Alliance, and Focus on the Family and boasts of alliances with fringe medical associations and doctors such as the Alabama Physician Resource Council, the Physicians Consortium and Dr. Laura Schlesinger. Additionally, the NPC has repeatedly asserted a specious connection between abortion and increased breast cancer and has advocated for non science based interventions like "abstinence only until marriage" programs. By creating the website with only one organization--and one organization that has questionable credentials in this area--HHS has dangerously narrowed the information included on 4parents.gov and in turn, shortchanged the very parents the site is meant to serve.

We respectfully request that the 4parents.gov website be immediately taken down and subject to a formal review of its content and techniques for communication and behavioral learning. This review should be done by a broadly accepted panel of experts in parent/child communication with well established credentials in this area.

We look forward to a response and to working with you further on creating a website that truly meets the needs of all parents and is based on the best available research.

Sincerely,

The Sexuality Information and Education Council of the United States (SIECUS)

Haiphong and North Korea

We have made a conscious decision not to chase every case report or bird flu event on this site but instead to summarize every few days, with any appropriate observations (other than "Holy Shit!"). We do this now with the Haiphong cases and the North Korean poultry outbreak.

Haiphong

Simultaneous infection with H5N1 influenza of five members of one family in northern Haiphong has now been confirmed by health officials there:

Initial tests showed the H5N1 virus was present in samples taken from a 35-year-old man, his 32-year-old wife and their three daughters, aged 10 years, 4 years, and 4 months, said Nguyen Van Vy, director of Haiphong Health Department.

The five family members were admitted to the hospital on March 22 (one week ago) with fever and shortness of breath. The family raised about 400 chickens. A month ago the birds began to die and the family ate some of them. Today XinhuaNet reported a 41 year old woman who lives "near" the family was admitted to the hospital with suspicion of H5N1 infection. Niman at Recombinomics reports two other "neighbors," a 41 year old male and a child (or perhaps a 35 year old woman, a 41 year old male and a child). There is no information if there was any actual contact in any of these instances.

Exactly how many people are involved in addition to the family, whether they all have H5N1, and their condition is unclear at this point, as is what all this means. Niman's interpreation is that it is evidence of suddenly increased transmission efficiency (from birds to humans). He may very well be right and this is an obvious interpretation. Others might be some unusual host factor among the family, an unusually heavy exposure of some sort, or (less likely) a common exposure other than the family's chickens. The significance of the "neighbors" is also unclear at this time.

What is clear is that H5N1 infection is entrenched in local poultry, has not been eliminated and continues to be transmitted to humans. Whether this witch's brew is simmering or starting to boil over is not obvious. One could defensibly see it either way. But it is indefensible to act as if it is not boiling over. The costs of an error are too great. But that is what we continue to do.

North Korea

As long as two weeks ago there were rumors that North Korea had an avian influenza outbreak (emphatically denied at the time), but not until Sunday did North Korea admit it had avian influenza virus at "two or three poultry farms" in Pyongyang and had destroyed hundreds of thousands of chickens. The nature and scope are still unclear, however. In particular, WHO's Delhi office still is unsure if this is an H5, H7 or H9 (or some other?) strain and how widespread the outbreak is. Scattered reports say the infection has spread to rural areas and poultry was not being sold in the markets, a blow to North Korea's poorly fed population. (AFP via Turkish Press and New Zealand TV)

We now learn that WHO was in touch with Pyongyang well before the rumors surfaced to offer assistance in preparing for human cases of avian flu. At this point, however, the lead UN agency is FAO. No human cases have been reported but no one trusts the North Koreans. An Editorial in South Korea's Joong Ang Daily believes the public admission is evidence that the damage "must be colossal." North Korea's lack of credibility and the perilous nutritional state of the population is spawning rumors that "North Korean citizens are digging up dead poultry and selling it on the market." These rumors have not been verified. However it has been known that the country has been trying to expand its poultry industry since 2001 in an effort to increase sources of protein to the population and this has resulted in "scores" of "poultry factories" in the country.

Now South Korean intelligence sources are being cited as believing that the cancellation of the regular session of the Supreme People's Assembly, that had been scheduled for March 9, was postponed because of fears of an avian flu epidemic (Joong Ang Daily):

"With more than 600 delegates from all over the country supposed to gather in Pyongyang for the legislative meeting, there was concern the disease would spread uncontrollably," the [South Korean] Unification Ministry source said. In connection with the Supreme People's Assembly session, North Korean officials usually tour poultry farms, other cooperatives and power plants in and around Pyongyang.

Even more interesting was the report in the same paper that South Korea was aware of the outbreak sometime before rumors surfaced and had imposed secret quarantine measures.

Following the indications that North Korea was facing a bird flu outbreak, Seoul quietly began quarantine measures. The 400,000 tons of chicken meat, scheduled to be imported from the North on March 11, was stopped, and incoming travelers from the Kaesong industrial complex and the Mount Kumgang resort were given thorough health checks at the border.

"Because the North would possibly get upset, we had to carry out the measures secretly," Rhee Bong-jo, vice minister of unification, said.

This is just one more example of the complex interaction between politics, social conditions and the natural environment. Fortunately most of the time the stars don't line up just right. But sometimes they do.

If a tree doesn't fall in the forest . . .

A new national opinion poll conducted in Canada estimates that 36% of Canadians feel authorities are exaggerating the risk from bird flu in order to encourage people to take precautions. Yes, really. Sixty percent are not very worried or aren't worried at all. But two thirds are aware of the issue.

"These numbers say that they're not sure yet what they should do or how worried they should be," [poller Bruce] Anderson said in an interview.

American risk communication expert Peter Sandman was surprised by the results.

"There are ways to prepare -- but so far I don't think the government has asked people to do anything at all," says Sandman, who consults with the WHO and other agencies.

"Far from exaggerating, I think the government is actually understating the risk--the worst cases the experts are considering are far worse than the public announcements tend to imply."

I don't find the results at all surprising, however. People have enough to do just getting by, in what has become a difficult world. There is only so much you can worry about, especially when worrying doesn't get you anywhere. The only reason why people should worry is if worrying is a spur to productive action. And that can't happen without leadership. And apparently, that can't happen at all.

In one respect Canadians are way ahead of Americans. Sandman nails the reason:

"At least most Canadians know that the Canadian authorities are worried about the pandemic possibility. Most of the U.S. public still thinks bird flu is a Southeast Asian problem. They haven't quite reached the stage of doubting their government's warnings; they're not yet hearing the warnings."

Here's a riddle: If a tree doesn't all in the forest but everyone is there to hear it, does it still make a sound?

"Terri's" budget cuts

The Bush budget proposal of last month continues to amaze. Little noticed in the pre-Schiavo circus days was the complete zeroeing out of the Health Resources and Services Administration (HRSA) Federal Traumatic Brain Injury (TBI) Program. It wasn't a lot of money ($9 million), not even a fourth of the $38 million additional (to $206 million) for the federal sexual abstinence program that demonstrably doesn't work (or even works in reverse). The HRSA TBI Program was chump change. But highly symbolic of priorities.

Doubly damning in that an unusually high proportion of injured Iraq war veterans have some kind of traumatic brain injury.

A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.

Known as traumatic brain injury, or TBI, the wound is of the sort that many soldiers in previous wars never lived long enough to suffer. The explosions often cause brain damage similar to "shaken-baby syndrome," says Warren Lux, a neurologist at Walter Reed Army Medical Center in Washington.

"You've got great body armor on, and you don't die," says Louis French, a neuropsychologist at Walter Reed. "But there's a whole other set of possible consequences. It's sort of like when they started putting airbags in cars and started seeing all these orthopedic injuries."

The injury is often hard to recognize — for doctors, for families and for the troops themselves. Months after being hurt, many soldiers may look fully recovered, but their brain functions remain labored. "They struggle much more than you think just from talking to them, so there is that sort of hidden quality to it," Lux says. (H. Darr Beiser, USA TODAY)

Physicians at Walter Reed Army Medical Center have surveyed all returning soldiers injured in explosions, vehicle accidents, falls and gunshot wound to the face, neck or head. They found evidence of TBI in 60%. In 2003 there were 437 cases of TBI, with slightly more than half showing permanent brain damage. Results at other military medical centers are similar. The HRSA money is directed to help cash-strapped states prevent traumatic brain injury, improve rehabilitation outcomes through research, strengthen and improve State systems to better serve individuals with traumatic brain injury and their families, and advocate for and protect the rights of individuals with traumatic brain injury and their families. In other words, the kind of programs that help discharged veterans with TBI. Like this person:

In severe cases, victims must relearn how to walk and talk. "It's like being born again, literally," says Sgt. Edward "Ted" Wade, 27, a soldier with the 82nd Airborne Division who lost his right arm and suffered TBI in an explosion last year near Fallujah. Today, he sometimes struggles to formulate a thought, and his eyes blink repeatedly as he concentrates.

They can't spend $9 million for this but they can spend $209 million for abstinence education that doesn't work.

That says it all. What a bunch of miserable hypocrites.

US News on bird flu

We have complained here about the relative lack of attention to the bird flu problem in the American MSM, but there have been some very good articles here and there. The problem is they get lost in the din created by media circuses like the Scott Peterson trial, the Schiavo affair and the Social Security non-crisis. There has been some good reporting but it is lost in the noise. And it will probably stay that way until the Four Horsemen are galloping across the Great Plains.

Anyway.

This week brings some good reporting by US News Senior Correspondent Nancy Shute. It covers the usual material (at least for readers of this site) and also brings to the front issues that need to be grappled with at the local level if a threatened pandemic were to materialize. Things like where will be find the hospital beds? what kinds of things will be closed (what businesse? what schools by whom)? who will deliver food to the supermarket, pump gas, bury the dead (where and in what)?

The doctors are alarmed not because of the number of people that "bird flu" has killed but because the H5N1 virus displays an ominous adaptability and persistence. About 70 percent of those infected so far have died. Since 1997, when the new virus first showed up in chickens and killed six people in Hong Kong, it has spread to birds in eight countries in the region despite repeated efforts to halt it by slaughtering millions of chickens. "The virus has gotten even more widespread," says Klaus Stohr, head of influenza for WHO.

Shute acknowledges that this is not 1918, a time when the cause of the disease that eventually killed an estimated 40 million people worldwide was not even known (it was only identified as a virus in the 1930s). But she correctly points out that despite our ability to make vaccines and antiviral agents, if a pandemic were to strike in the immediate future we would be unprepared. This is not news to readers of this site, but it is good to see an explicit and in-context statement in the MSM:

All this casts harsh light on long-standing weaknesses in the nation's medical defense system, which include an unreliable vaccine supply and insufficient hospital surge capacity. Many hospital emergency rooms are already hard pressed to treat the influx of patients from a normal flu season, let alone a contagion that could send as many as 10 million people to the hospital. And the country's vaccine production capability is woefully inadequate, with only two manufacturers in the market and little financial incentive for other companies to enter. When contamination shut down one company's plant last year, obliterating half the nation's flu vaccine supply, the United States' entire influenza immunization program was thrown into chaos.

This is exactly correct. It puts the lie to the public health establishment's delusion that the influx of biodefense money would somehow "save" public health and rejuvenate its infrastructure. Indeed, as Shute notes, the Bush administration has made things much worse:

Yet the call to arms comes at a time when perpetually lean local health departments have exhausted a few years' worth of federal bioterrorism funding that came their way after 9/11. State budgets are hurting, and the Bush administration proposes cutting funding for the CDC, which is leading much of the nation's antipandemic efforts, by $500 million.

Nor has the endless cycle of needs assessments, draft draft plans, draft plans and no implentation or leadership produced any outcome of use:

The Department of Health and Human Services unveiled a draft national pandemic plan last August; many reviewers said the feds need to be far more explicit, providing state and local governments with priority lists for vaccine distribution and other guidance. HHS is convening panels to revise the plan, with the aim of finishing sometime this summer. "This is one of those rare times when states are saying we really do need some direction and guidance from the feds," says George Hardy, executive director of the Association of State and Territorial Health Officials.

There is much else of interest in Shute's US News report (newstand issue of April 4, 2005). Here is one last sinippet:

Although the 2003 SARS outbreak is estimated to have cost the global economy at least $30 billion, most businesses have yet to consider the cost of a flu pandemic, both in terms of employee absenteeism and disruptions of the global economy. The CDC estimates the economic impact of a pandemic in the United States at between $71 billion and $167 billion, but those numbers don't include disruptions to commerce and society.

Given this scenario, it is amazing that knowledgeable people still don't get the big picture. In a short companion piece antivirals are briefly discussed:

So far, 17 countries are stockpiling Tamiflu, but lagging countries could end up with too little, too late. Hong Kong has only enough to cover 5 percent of its population. The United States has 293 million people--and 2.3 million treatment courses.

Why delay? "Choosing an arbitrary number is probably not the most efficient way to spend public-health dollars," says physician Ben Schwartz, a science adviser in the National Vaccine Program. Among his concerns is Tamiflu's five-year shelf life: "If we stockpile enormous amounts and the pandemic doesn't occur within that time the drug would be worthless."

If a pandemic were to arrive this year or next, relying on antivirals would be futile as the sole manufacturer does not have the capacity to supply the US, much less the global population. But let's examine the thinking here. The Infectious Disease Society of America called for antivirals to supply half the US population, roughly 150 million people, or sixty times the current stockpile for ten days or 240 times the current stockpile for 6 weeks, the recommended time for prophylaxis in the case of an outbreak. At approximately $300/six week course that's quite a lot of money: about $45 billion dollars to keep in reserve for five years. That's an insurance policy of $9 billion/year, or about 2 months costs of the Iraq debacle per year. And the costs of not having it?

"We've never suffered an event of such magnitude that it shuts down the global economy," says infectious-disease specialist [Michael] Osterholm [of CIDRAP]. "In 1918 we were much more self-sufficient."

We'll have to become self-sufficient again because there is no leadership at the national level. Time to roll up our sleeves at the local level, which is where the action will be anyway.

[NB: I have corrected an earlier arithmetic error that was posted briefly earlier this morning]

I want a Frist opinion

If you can't afford health insurance--or even it you can--there is now a new resource open to you. The Dr. Bill TeleDiagnosis Service, courtesy the US Senate. Senate Majority Leader Bill Frist launched the service this week, speaking from the Senate floor. Its first patient was Terri Schiavo, who, Dr. Bill opined ("more as a physician than as a US senator") had not been definitely diagnosed because there was "insufficient information to conclude that Terri Schiavo is in a persistent vegetative state." Dr. Bill used digital imaging--in this case a years old video of the patient--to reach his professional opinion.

Announcement of the new service came from Michael Bassik who is brokering the system at the technology oriented Personal Democracy Forum. Here are the details, as Bassik revealed them:

Take a digital picture or video of your medical problem – tennis elbow, acne, runny nose, hemorrhoids, or whatever ails you - and send it to the doctor in charge of the US Senate and your health care.

Everyone, take two minutes and upload your photos to Flickr.com [register first if you aren't a member; it's free]. "Tag" the photo "Frist." If we get critical mass, we'll send everyone's photos to Dean Rosen, the good doctor's Health Care policy director!

My hat's off to Dr. Bill. I've been a doctor for almost four decades but I can't make a diagnosis from a fuzzy video image. I guess I learned before we had that kind of fancy technology.

Quang Binh status still unclear

A story from Bloomberg News Service (reported by Jason Folkmanis in Ho Chi Minh City) provides the most detailed information to date on the situation in Quang Binh. The story broke Monday (March 21, although Bloomberg records it as March 23) when a local newspaper, Nguoi Lao Dong, reported 195 people in the province suffering flu-like symptoms. The story was picked up by Thanh Nien News and posted on the net (see our posts here and here). There had already been several cases of H5N1 in the province, so this report sounded alarm bells.

According to Bloomberg, the figure was based on a household survey asking for the number of people feeling ill, rather than on a medical assessment of each person. A follow-up investigation by "local health officials" brought the 195 number down to 24 with flu-like symptoms. The drop from 195 to 24 is substantial, but even if accurate, is rather a large number of simultaneous cases. The report now says the figure of 24 has been reduced to 7 people with temperatures above 38 degrees Celsius (100.4 degrees F.). This criterion neither rules in nor rules out influenza infection, but selects the more seriously ill for further investigation.

Characteristically, WHO is playing down the seriousness of the situation:

"The whole thing seems to be shrinking,'' said Hans Troedsson, WHO's chief representative in Vietnam, in a telephone interview yesterday. "But we still need to get this verified and confirmed officially. We are still waiting for the conclusions in the reports from the investigating teams.''

[snip]

"We don't have enough information to make any certain statements about whether there's anything significant happening in Quang Binh or not,'' said Peter Horby, an epidemiologist with WHO in Hanoi. "Our information is that the numbers reported in the local press are very exaggerated, but we don't know the number of people with significant symptoms.''

So they have no idea, but they are relying on reports from local health officials that it's not likely anything significant to reassure us. Unfortunately accurate information, one way or another, seems difficult to obtain from "local officials":

Meanwhile, a local health official said that there are about 200 people in the commune suffering from flu, 120 of them in the village.

Nguyen Tang Ba, an official of the Centre for Hygiene and Epidemic Prevention, said it’s difficult to contact the communal health centre because they lack money for telephone service. The centre sent seven workers to the commune, but they lack resources to stem an outbreak.

Ba said no one here wants to be moved to the district or provincial hospital because they will lose their livelihoods. However, Local residents are already having difficulty selling their agricultural products because buyers worry about catching the bird flu. (Vietnam News Agency)

Agence France Presse (via Vietnam Tribune) reported on Thursday that all test samples submitted so far are "negative," although other tests were being done, exact number and nature unclear. All this tells us is that whatever tests have been done on whatever kind of samples and of whatever number have so far not come up with anything.

There are clearly significant obstacles to getting information and incentives and disincentives to report. It doesn't sound as if we should place much confidence, one way or another, on the basis of what we know from this. Why WHO feels the constant need to minimize public concern when it has insufficient basis to do so is beyond me. Apparently they don't understand they are wasting one of their most precious resources: credibility.

Something they're going to need it when it counts.

Menu tip: meatpacking is dangerous work

This is the story of a diner in Santa Clara, California, who took a spoonful of chile at a Wendy's restaurant and found she was eating the tip of a human finger. She immediately spit it out, warned the other diners, and threw up. Santa Clara County Health officer Dr. Martin Fenstersheib sought to reassure her:

[Fenstersheib] said the finger had been cooked at a high enough temperature to kill any viruses, including hepatitis or HIV, and it was unlikely that she will suffer any health effects from her experience, aside from psychological trauma.

The finger was described by Santa Clara County Medical Examiner Dr. Joseph P. O'Hara as cooked but not decomposed. The finger was found in two pieces, a one and three-eighths inch long fingertip complete with the skin whorls used in fingerprinting, and a half-inch long piece of fingernail. The joint appeared to have been torn off, possibly by manufacturing machinery, rather than cleanly cut. Because of its slightly longer than average length and neat grooming, it may have belonged to a woman, O'Hara said. (SFGate)

Since all restaurant employees had a complete set of intact digits, the assumption was that the finger tip had entered the food chain during "the manufacturing process." Which is the point of this post.

If you read Upton Sinclair's The Jungle in highschool you have a pretty fair idea of the extremely dangerous workplaces slaughterhouse and meatpacking workers endured a hundred years ago. If you read Eric Schlosser's Fast Food Nation you also know things have changed little in today's industrial killing machine we call the meatpacking industry. Packing houses are still incredibly dangerous places to work.

And now you also know that somewhere there is a worker in one of these meatpacking houses missing the end of one of her fingers.

Bird flu recap

On Sunday Thanh Nien News reported 195 people had flu symptoms in the same commune in Quang Binh province where the care-giver aunt and 5 year old brother of a 13 year old girl who reportedly died of bird flu on March 9 were also reported ill. The brother had already been shown to have H5N1 infection. The aunt developed a fever after caring for the girl but now appears to be better. In addition, a 41 year old male was admitted to the Hue hospital on March 21 after suffering high fever during the previous week. However there are also reports that a 41 year old male from the same commune (Chau Hoa) walked out of the hospital and was being sought by authorities (Reuters). It is not clear if this is the same individual. Today Thanh Nien News reported a 16 month old from Quang Binh was admitted to Hue Central Hospital Tuesday. But the deputy director of the hospital is quoted as saying the toddler no longer has a fever and no symptoms of flu were evident (AFP). Finally, a woman from another commune was reported to have a light fever and breathing difficulty and was being monitored at home.

WHO and Vietnamese authorities despatched a team to Quang Binh to investigate. As yet we don't know the results. AFP reported today from Hanoi that

The first bird flu tests carried out on several inhabitants of a village where residents reported an epidemic were all negative, a doctor in central Vietnam said.

Chau Hoa commune in central Quang Binh province, 400 kilometres (248 miles) south of Hanoi, is under scrutiny after local people reported a flu epidemic. A five-year-old boy there tested positive for bird flu last week.

"All tests on samples sent from Quang Binh province are negative," said Bui Trong Chien, deputy director of Pasteur Institute in the coastal city of Nha Trang, 500 kilometres north of Ho Chi Minh City.

"We are still making other tests," he said Thursday. The exact number of tests was unclear but he said both sick patients and residents without symptoms were examined.

[snip]

[O]n Thursday Peter Horby, a WHO epidemiologist in the capital, Hanoi, said there was "no serious information so far to substantiate media reports."

On the other hand, The Sun (UK) reports that nine people in Quang Binh have reported symptoms and a total of 30 samples were taken from villagers in the province. Yet Reuters reports that

In hardest-hit Vietnam, where 34 Vietnamese have died, health inspectors found 37 people with fever in Chau Hoa commune in the central province of Quang Binh, where the 5-year-old boy tested positive for bird flu nearly 2 weeks ago.

"We don't see anyone in serious condition and nobody shows clinical symptoms that need medical intervention," said senior provincial health official Truong Dinh Dinh, disputing state media reports that up to 200 people had flu-like symptoms.

He said samples taken from residents, chickens, flies and the water supply would be tested for bird flu.

Finally, today Thanh Nien reports:

Currently, over 190 residents of the commune have a common flu. Bird flu outbreaks were spotted in the area in early February.

To deal with the situation, Vietnam has sent more health and veterinary officials to probe into suspected cases and work out concrete preventive measures. Over 1,000 fowls in the commune have been culled.

Thus the reporting is confusing, if not contradictory. It is becoming even more difficult to keep all the cases (confirmed and unconfirmed) straight.

Meanwhile, the death of a 28 year old Cambodian man is being widely reported (see, for example, AFP via ABC [Australia]). He came from the same area, bordering Vietnam, as Cambodia's first victim, a woman who crossed the border and died in a Vietnamese hospital last month. The victim was a business man who traveled frequently to Vietnam. Recently 400 to 500 chickens and ducks had died in his village, although it was unknown if he had any contact with poultry in Cambodia or Vietnam. Eight contacts of the victim had been "tested" for bird flu and "cleared."

Thus, Quang Binh is still under investigation and there are contradictory reports as to the number of people affected there. Additional cases in Quang Binh are suspected. A Cambodian man has become the second reported death from that country.

Again, the bottom line is there is nothing particularly reassuring in the news. On the contrary, to use one of Henry Niman's stock phrases over at Recombinomics, there is still "cause for concern."

The shoe is still on the other foot

Hong Kong certainly seems to be taking the situation in Vietnam seriously, and in particular the possibility of a flu outbreak in Quang Binh. Hong Kong authorities have set up a telephone hotline for travelers to Vietnam who feel unwell after visiting, have established a special liaison with WHO and the Vietnamese Consulate in Hong Kong to get the latest information and are setting up temperature screening at the airport with informational leaflets on all in-bound flights from Vietnam.

The Quang Binh story appears to have precipitated tougher measures (via The Standard [HK]):

"Up to [Wednesday] morning, the WHO tells us they are still investigating the reported outbreak,'' [Dr. Thomas] Tsang said. ``The situation in Vietnam is changing fast but if the WHO confirms that bird flu is being transmitted from humans to humans, we do not rule out endorsing further measures, including issuing a travel warning.''

Asked if people from Vietnam will be banned from entering Hong Kong, or have to go through compulsory health checks before being allowed to enter should there be a confirmed bird flu pandemic in the country, Tsang said the government "does not rule out taking further measures.''

Tsang is a consultant to the Centre for Health Protection. He noted Hong Kong is just entering peak flu season, and unlike last year when most strains were H3N2, this year they are seeing a mixture of H3N2, H1N1 and influenza B virus. Reports from public clinics of influenza-like illness were up 78% from the previous week. Tsang said Taiwan and Japan were also seeing a high number of flu cases.

Meanwhile, reports from Cambodia and Vietnam indicate that the H5N1 strain may be changing once again. We will follow up with a summary shortly. So while we wait for the other shoe to drop with bird flu, the "garden variety" viruses are still with us, causing serious illness and death in Asia, and co-circulating with H5N1, with the obvious increase in chances for reassortment and recombination.

Preparing for a pandemic: GMAFB

In a companion post (here) we drew up a quick "To Do" list for preparing for a pandemic on a local level (the only level that counts for preparation). It is interesting to compare this to the "immediate action" items proposed by the Infectious Diseases Society of America (IDSA) this week, as reported in Medical News Today:

Immediate action is needed to prepare the United States for a deadly pandemic of influenza, the Infectious Diseases Society of America (IDSA) is telling policymakers.

In meetings with congressional and administration leaders, IDSA has explained that the H5N1 “bird flu” spreading in Asia has the potential to develop into a pandemic like the one that claimed more than half a million American lives in 1918. Even if this strain does not emerge as a pandemic, infectious disease experts agree that another flu pandemic is just around the corner. The U.S. Centers for Disease Control and Prevention (CDC) predicts even a “mild” pandemic could kill at least 100,000 people if the nation is not prepared.

“This year's serious problems with flu vaccine supply showed us just how unprepared we are,” says Andrew T. Pavia, chair of IDSA's Pandemic Influenza Task Force. “If this had been a pandemic year, we would have been in serious trouble. Now is the time to fix these problems and develop the ability to respond, before the pandemic strikes.”

Good start. Let's look at IDSA's "seven steps to prepare for a flu pandemic" (my comments indented and small text):

1. Secure vaccine and antiviral supplies. Enough vaccine and antivirals need to be in place before a pandemic strikes, as well as a plan to distribute them. IDSA is calling for a stockpile of antiviral drugs that is adequate to treat at least 50 percent of the U.S. population.

This seems infeasible if you don't have a vaccine and won't have one until you know the nature of the pandemic strain. Nor is there the vaccine capacity in the US for this. The same goes for antivirals. This recommendation calls for 150 million courses. It is estimated that there are only 6 million courses in the US currently and we are competing with the rest of the world for the very limited production capacity of a single company (Roche in Switzerland). Unless there is an immediate move to make production license free and allow any company in the world to produce it, the cost is prohibitive at Roche's prices (~$75/10 day course of treatment or $300 for 6 week prophylaxis). Worse, if the US were to buy up the supply at that price there would be nothing left for the rest of the world. There is also no infrastructure for delivering them in the "pay for play" US health care system.

2. Strengthen liability protections during emergency outbreak response. In case of a declared influenza emergency, it will be vital to immunize and treat large numbers of people. Even rare adverse reactions associated with a therapy would become more common when millions are treated. Health care workers and medical facilities administering emergency therapeutics, as well as the companies that make them, should be protected from lawsuits stemming from these adverse events so long as they follow standard medical and manufacturing procedures. A fund should be established to cover the medical costs and lost earnings of anyone who develops complications due to vaccination or treatment.

Why do we always socialize the losses and keep the profits private? Let's socialize both the losses and the profits. I'm sick of hearing about "liability" barriers. How about "affordability barriers" for a change?

3. Require health care workers to be vaccinated. Unfortunately, health care workers caring for sick people often spread patients' infections. To prevent unnecessary deaths and disease, an annual flu vaccination should be mandatory for all health care workers who have contact with patients.

Vaccinated with what? There is no H5N1 vaccine at the moment. The question of priority for antivirals is important and is raised in my post.

4. Strengthen education. Health care workers and the public need to better understand the seriousness and potential impact of an influenza pandemic, as well as how to prevent and treat it.

You might start by educating our public health non-leaders. Education is always good. Yawn.

5. Create financial incentives. Most pharmaceutical companies have left the vaccine business because demand is extremely unpredictable. Even this season, after starting out with a shortage, millions of doses of flu vaccine will likely be thrown away. To secure vaccine supplies for the future, the government needs to guarantee it will buy a set amount of vaccine each season, and buy back a percentage of unsold vaccine at the end of the season.

Also, the United States does not have the manufacturing capacity to produce enough vaccine and antivirals to meet its needs in a pandemic. Tax credits should be offered to encourage companies to build new manufacturing facilities in this country so that the United States is not dependent on foreign suppliers. Tax incentives and patent extensions should be available for companies that research and develop new anti-flu therapies.

See number 2, above. If the pharmaceutical companies don't find this profitable, that's their choice. Let's produce this with public monies and public production facilities.

6. Strengthen federal agencies' responses. The Food and Drug Administration should “fast-track” vaccine and antiviral review, and streamline regulation of the manufacturing process. Congress should increase CDC's budget for global surveillance to detect influenza strains with pandemic potential. The U.S. Department of Agriculture should develop a plan for culling poultry or other livestock and compensating farmers in the event of a pandemic, if necessary.

How about strengthening the backbone of our public agencies?

7. Improve coordination, communication, and planning. The Department of Health and Human Services should develop a detailed plan to coordinate pandemic response at all levels, from local to national to international, including links between federal authorities and clinicians throughout the country.

Yawn. There have been many draft plans, needs assessments, efforts to improve communication, etc., etc. The sound of spinning wheels is deafening.

"IDSA is working with congressional leaders to integrate these recommendations into bio-preparedness legislation now being considered on Capitol Hill. The Society is working to achieve bipartisan support for this effort."

My (unprofessionally phrased) response? Give me a Fucking Break! (GMAFB)

Pandemic "To Do" list: some initial thoughts

If there isn't a pandemic this year, there will be one at some point. So I started to make a To Do list of things we need to think about in preparation. I don't mean a "Pandemic Influenza Plan." I mean a To Do list. Consider this "shark bait" to be torn to pieces by wiser minds.

I'll start it off. Feel free to add/correct/delete things that will need to be done. Then we can set about trying to get someone to start doing them in our local communties. For if there is a pandemic, it will be everywhere and have to be fought at the local level--everywhere. This is not a situation where "federal stockpiles" can be rushed to the scene of a disaster. "The scene of the disaster" will be everywhere.

1. The rationing problem

Whenever it happens, I will be very surprised if we have enough of most of the things we'll need. So we have to think of an ethical, humane and pragmatic plan to ration antivirals, vaccines (if they exist), etc.

Some questions: Who gets what first? Who gets what at all? Some possibilities:

• Essential services such as health care workers (which ones?), public safety, transportation, communications, ?
• Highest risk or those where intervention might stop the epidemic fastest (e.g., the elderly or healthy young adults/children).
• Lottery?
• Market forces (highest bidder)? (I should hope not, but you know this question will arise)
• Citizenship status? (I should hope not, but you know this question will arise)

And some way to assure the security of scarce supplies to prevent them from being looted or diverted into a black market.

Obviously we all have views about how to do some of this, but we need some kind of mechanism to think this through together and debate it in our local communities, assuming we have the luxury of a little time (of course, if the immediate threat recedes, we'll probably waste the time handed to us).

2. The care-giving problem

There aren't enough hospital beds for even a moderately bad epidemic. In many big cities emergency rooms are frequently on "diversion" (they send cases to other hospitals) already. In an epidemic we will have to make use of alternatives.

Some possibilities: hotel and motel beds (every room has a bathroom); increased use of Visiting Nurse assistance to keep very ill people at home.

The nursing problem will be particularly important. Hospitals beds that aren't staffed are essentially worthless. But if 25% of the workforce is sick there will be an acute shortage of nursing care. Some alternatives: organizing retired nurses, trained volunteers (requires a training program, of course), etc. This would require rosters, a way to contact people and some means to assure minimal skill level, perhaps on a tiered basis.

Mortuary space, enough caskets, burial arrangements, grief counseling. We need to organize the funeral homes.

3. Equipment

There are probably not enough respirators to handle the huge increase in adult cases that would need them, and certainly not enough pediatric respirators to handle a disease with a proclivity for the young. Do we even have an idea of how big the shortfall is? Do we have any inventories that would allow a local area to re-distribute them according to need?

What other critical equipment problems do people foresee?

This is just a start and meant only to get people thinking about what needs to be done and how it might be accomplished. All of these things can be done without huge resources and done locally. I'd love to hear about folks getting some of them started.

Obviously a strong and vigorous public health infrastructure would be the best solution, although a pandemic would stress even the strongest system. But we don't have a strong and vigorous infrastructure and neither this Administration nor our public health non-leadership is securing us one. Indeed, our public health infrastructure is going right down the toilet. Maybe addressing this important task can help jump start a re-invigoration of public health from the ground up. At the moment, that seems to be the only place it can come from.

Tangled Bank #24 is up

Tangled Bank #24 is up, hosted by Syafolee. For those not familiar with Tangled Bank, it is a weblog "Carnival" or compendium that selects submitted links from around the net, in the case of TB, the best articles in science and medicine, very broadly defined. Effect Measure is represented via its "How oseltamivir works" post, but there is much else of interest there, including a good primer on influenza virus and how vaccines are produced in eggs over at Living the Scientific Life. There are a couple of more flu posts on that site. There is also much else of interest up at TB for the scientific omnivore, so check it out.

Quang Binh: earning trust

According to Agence France Presse, WHO's Hans Troedsson has said "[t]he (200 people) figure [for people with symptoms of bird flu in Quang Binh] seems to be very exaggerated. We have discovered very few sick people so far after examining seven families."

This should remind us that responding to news of disease outbreaks or clusters is rarely straightforward. In my experience as an epidemiologist who has looked into many cancer clusters over decades, the first step when responding to a report of a cluster is the most important: first, verify the diagnosis. That works fine for chronic diseases like cancer. It is still important but tougher to implement for an infectious disease like influenza that evolves and may spread even as verification is taking place.

AFP reports that verification is underway:

World Health Organization representative Hans Troedsson said the cases "needed to be rapidly and thoroughly investigated."

"We have asked for an urgent meeting with the Ministry of Health," he said. "We could send a team from abroad at very short notice."

Pham Sinh Quyet, an official from the provincial health department, said a local team was sent to the commune on Saturday.

How soon can we expect some information? Past experience is not encouraging. WHO's record of keeping the world informed is spotty. The result is that unverified information rushes in to fill the information vacuum reticence produces.

One of the things we hear most often from public health authorities concerning bird flu is "there is no reason to panic." This reveals a mistaken attitude toward the general public. Yes, it is true many people keeping track of this situation are extremely anxious about it. But the source of their anxiety is not hard to find: good reasons to be anxious. But the readers of this site and the other sites aren't panicked any more than public health authorities, who are also anxious about bird flu, are panicked. Those who are paying attention want and need accurate and timely information. Panic comes from uncertainty. Uncertainty is fed when trust is lost in what public health authorities are saying.

I hope we will see the results of the Quang Binh investigation made public soon. Very soon.

Correction (3/22/05, 7 pm EST): Henry Niman (via Comments) points out an error in this post. The statement that the number of symptomatic individuals was "exaggerated" was not made by WHO's Hans Troedsson but by Pham Sinh Quyet, an official from the provincial health department. We apologize for the error and thank Dr. Niman for pointing it out.

Pulling the plug on Agent Orange

When Federal judge Jack B. Weinstein dismissed the lawsuit against the 37 chemical companies that supplied the US military with the dioxin contaminated herbicide Agent Orange, the news was little noticed in the US. In a day it was submerged under the outrage du jour. But in Vietnam it didn't just fade away. The Vietnam News agency describes how the news was received there:

A farmer whose village was fiercely destroyed by US troops dropped his fork over dinner and gaped at the television as the US court dismissed the lawsuit filed by Vietnamese victims of Agent Orange (AO/Dioxin).

Huynh Ky is a victim of AO/Dioxin and has fathered four disabled children in An Xuan Village of Tam Ky Commune in Quang Nam Province. Three of his four children were born with mental disabilities.

"The criminals have turned their back on my children," the farmer angrily argued, saying he often watched the lawsuit process on television and wanted the US chemical companies (administration) to take responsibility for his condition and that of his children and all of the Vietnamese suffering from the effects of AO/Dioxin.

[snip]

"It is an unjust verdict," said Vo Sy Kieu of HCM City. Kieu, 60, is a father of an 18-year-old boy who is paralysed and mentally disabled. Kieu was in the army and fought in the Quang Tri Battle of 1968, which was hit hard with AO/Dioxin.

"They reject their crimes and fail to claim responsibility in fear of scrutiny and condemnation of Americans and the international community," he said.

Weinstein ruled there was insufficient evidence that dioxin exposure was linked to the damages claimed by the Vietnamese, although he also cited broad legal grounds as a basis for his decision. The US government has never accepted the link, although they compensate US veterans for many of the same injuries.

Not surprisingly, the government seems uninterested in resolving the scientific issue. Last week they cancelled a major study of the health effects of Agent Orange in Vietnam (New Scientist):

Under a 2003 US-Vietnam agreement, the study would have looked at the health effects of the dioxin TCDD, with which Agent Orange was contaminated. But the US National Institute of Environmental Health Sciences cancelled the project on 25 February 2005 after "failing to receive the necessary cooperation from the Vietnamese government".

Project head David Carpenter, director of the Institute for Health and the Environment at the University of Albany in New York, US, adds that the research "could have been definitive" in a class action brought by Vietnamese plaintiffs against US manufacturers of Agent Orange, including Monsanto and Dow Chemicals. Carpenter says the ongoing legal action would have "increased the reluctance of the US government to fund this project".

The cynicism of this takes one's breath away.

More on Quang Binh

Thanh Nien News now says authorities in the central Vietnamese province of Quang Binh were unaware of an outbreak, possibly involving hundreds of residents in Chau Hoa commune, until the newspaper reported it. The nature of the outbreak is still unclear except to be characterized as "symptoms of bird flu." Two children from the commune were reported to have tested positive for H5N1, one of whom, a 13 year old girl has died at Dong Hoi Hospital on March 9. The newspaper says the hospital never reported the case to provincial leaders. Commune residents were also said to have continued "to eat dead chickens" (sic) throughout the Tet holidays in mid February while mass culling was going on in other parts of the country. It sounds like the finger pointing has started in earnest.

Vietnamese authorities have apparently recognized the potential seriousness of this situation:

An interagency task force has now arrived at the commune to take immediate necessary actions to stabilize the situation and fend off the spread of the epidemic, a Thanh Nien source said.

Tests are being carried out with all 195 suspected patients to determine whether they are infected with bird flu.

Meanwhile, patients with unusual symptoms have been transferred to a special hospital in the central city of Hue for quarantine treatment.

It seems strange that a small quasi-official newspaper should be the main source of information about this worrying situation.

Homeland Security: a political autoimmune disease

Wow, talk about nailing it. This from Sandia National Laboratories (via Science Bl0g):

Anticipating attacks from terrorists, and hardening potential targets against them, is a wearying and expensive business that could be made simpler through a broader view of the opponents' origins, fears, and ultimate objectives, according to studies by the Advanced Concepts Group (ACG) of Sandia National Laboratories. "Right now, there are way too many targets considered and way too many ways to attack them," says ACG's Curtis Johnson. "Any thinking person can spin up enemies, threats, and locations it takes billions [of dollars] to fix."

That U.S. response is actually part of the war plan of our opponents, points out ACG vice president and Sandia Principal Scientist Gerry Yonas. Yonas reports that an al Quaeda strategy document signed by Shiekh Naji, dated September 2004, reads: "Force the enemy to guard every building, train station, and street in order to plant fear in their hearts and convince Muslims to join and die as martyrs instead of dying as infidels."

Osama bin Laden put it in this way, according to Yonas: "We are continuing . . . to make America bleed profusely to the point of bankruptcy . . ."

There is also a lot of dangerous horse crap from the Sandia guys (" 'Suppose every PDA had a sensor on it,' suggests ACG researcher Laura McNamara. 'We would achieve decentralized surveillance.' These sensors could report by radio frequency to a central computer any signal from contraband biological, chemical, or nuclear material." Lovely.) But what do you expect from scientists called the Advanced Concepts Group ("a technical think tank that influences the direction of long-term research at Sandia, a National Nuclear Security Administration laboratory")? Let's stay with the obvious.

You can't harden every target or even any but a miniscule number of targets. Anybody with more than a neuron or two firing can think of ways to attack the soft targets all around us with easily obtainable materials or products (like assault rifles). Yet except for 9-11 the only such attacks so far are from "homegrown" terrorists like Timothy McVeigh, the Unabomber, anti-abortion assassins like Eric Rudolph or the as yet unknown anthrax attacker who almost certainly came from within the bioweapons establishment itself.

What that says is there aren't many, if there are any, al-Qaeda type terrorists in this country. And as the Sandia analysts point out, why should there be? They are getting everything they want without lifting a finger. And they aren't stupid enough to think they can actually attain the objective of bringing the society down from terror attacks.

Autoimmune disease occurs when the body's defense mechanisms turn against its own tissues, as in rheumatoid arthritis or lupus. Homeland Security is a political autoimmune disease.

Teflon and ACSH: truth-proof

Headline of a Medical World News story: "Teflon-Production Chemical Does Not Pose Health Risk to General Population, Science Panel Finds." Unfortunately the "science" panel involved are the hacks from the American Council on Science and Health and they bear as much relation to a real science panel as particle board does to wood. Cheap sawdust for principles held together with a noxious cement (money).

EPA's Science Advisory Board, a real science panel, recently reviewed the same subject. Their report has not been issued yet, but judging from comments made at the public hearing by panel members, it is unlikely to ratify the ACSH's judgment that the chemical at issue, perfluorooctanoic acid (PFOA), is absolutely harmless.

ACSH, a notorious industry whorehouse, regularly puts out "don't worry, be happy" stories for their corporate johns. They are the subject of an earlier post here that the real health hazard in New York City is bicyclists. Enough said.

For more (and more reliable) info on PFOA, visit the Environmental Working Group site.

Very worrying bird flu report

Henry Niman at Recombinomics saw it first and posted it this morning. I saw it shortly afterward on the Thanhnien news site. As far as I can make out, it was posted there about 8:30 am EST. So far there are no other reports or confirmation. Thanhnien News is a publication of the Vietnam National Youth Federation and has tended to minimize bird flu news (this is the source that earlier reported the second nurse from the Thai Binh cluster had "tested negative").

Thus the Thanhnien story this morning that a top provincial official has reported a commune in central Vietnam with 195 patients with symptoms and two confirmed H5N1 infections is extremely unsettling. As the story states, it is not clear if the symptoms are from bird flu, the "usual" human strains (H3N2, H1N1 or influenza B) or some other respiratory malady.

Here is the full report from Thanhnien:

Bird flu hits central province, 195 locals show symptoms

A commune in central Vietnam has been severely hit by the bird flu, with 195 patients showing symptoms and two children testing positive with the virus, reported a top provincial official.

Two siblings from the province’s Chau Hoa commune of Quang Binh province had tested positive for the H5N1 strain of bird flu, said Mai Xuan Thu, vice chairman of the provincial People’s Committee on March 20.

The older sister, Hoang Lan Huong, 13, died from the bird flu on March 9, while the brother, Hoang Trong Duong, 5, is in serious condition at the Hue Central Hospital.

Meanwhile, there are 195 other local residents who have shown symptoms of the flu, said Ms. Thu.

It is not yet clear whether these people, some of who had reportedly eaten sick chickens, have the symptoms of the deadly bird flu or the normal flu.

Of the 195 patients showing symptoms, 108 are from Kinh Chau village while the rest live in other villages in Chau Hoa commune.

The outbreak hit the province’s Kinh Chau village in Chau Hoa commune just ahead of the Lunar New Year holidays which started Feb. 9.

The province is currently trying to stop the spread of the influenza by culling all poultry in the commune.

More details as they become available. With any luck we will report this is a false alarm. However, this is one way we would expect the story to unfold if it were the real thing.

Abstinence education: tough love

While Bush's budget claims to cut "programs that don't work," it rewards at least one program that really doesn't work. Which one is that?

The one that peddles sexual abstinence to teenagers. The one that lies to them that condoms don't prevent sexually transmitted diseases or prevent pregnancy. The one that purveys false information on the risks of abortion and portrays blatant sexist stereotypes. The one that numerous studies has shown is ineffective and a waste of money (Reuters Health):

In one of the latest, conducted by researchers in Bush's home state of Texas and released last month, teenagers in 29 high schools became increasingly sexually active after taking such courses, mirroring overall state trends.

The one that eliminates accurate sex education about contraception and reproductive options:

[Michael McGee of Planned Parenthood] said the abstinence-only movement had had a chilling effect on U.S. classrooms, forcing teachers to stop mentioning contraception in health classes even when the curriculum requires them to do so.

The one that drops all pretense to provide a balance:

"Our program started 11 years ago out of grassroots concern that students were only hearing safe sex messages and didn't even realize that abstinence was an option," [Jimmy Hester, coordinator of True Love Waits, sponsored by Lifeway Christian Resources, a Nashville-based publishing group] said.

Including information about contraception and safe sex just "waters down the message," [Hester] said.

The one that gets an increase in funding from $39 million to $206 million in Bush's budget.

That one.

Rachel Corrie, 1979 - 2003: in memoriam

Rachel Corrie, 1979 - 2003
Originally uploaded by Revere.

From The Dominion blog of March 17:

Two years ago today, Rachel Corrie, a 23-year old American volunteer with the International Solidarity Movement, was crushed to death by an Israeli Defence Force bulldozer as she sought to prevent it from demolishing the home of a Palestinian doctor. Her family's efforts to find justice have so far been unsucessful, and her story now all but forgotten by the mainstream media.

To honour her memory, please take a moment to read the writings of, and about, this woman who died for her conviction that we all have a responsibility to stop preventable injustices, and who thought her body and her passport would be enough to stop a man in a bulldozer from going forward.

Rachel Corrie Memorial

Rachel's letters home (which were published in both the Guardian and the Globe and Mail):

The International Solidarity Movement

Background on Palestine, Israel and the Arab-Israeli Conflict

And from a letter to the International Herald Tribune on the first anniversary of Rachel Corrie's death from her cousin, Elizabeth Corrie:

Rachel was run over by a Caterpillar bulldozer, manufactured in the United States and sent to Israel as part of the regular U.S. aid package to Israel, which amounts to $3 billion to $4 billion annually, all of it from U.S. taxpayers. The use of Caterpillar bulldozers to destroy civilian homes, not to mention to run over unarmed human rights activists, violates U.S. law, including the U.S. Arms Export Control Act, which prohibits the use of military aid against civilians.

. . . residents and citizens of the United States should ask themselves how it is that an unarmed U.S. citizen can be killed with impunity by a soldier from an allied nation receiving massive U.S. aid, using a product manufactured in the United States by a U.S. corporation and paid for with U.S. tax dollars. When three Americans were killed, presumably by Palestinians, in an explosion on Oct. 15, 2003, as they traveled through Gaza, the FBI came within 24 hours to investigate the deaths. After one year, neither the FBI nor any other U.S.-led team has done anything to investigate the death of an American killed by an Israeli.

Congress responds to gun violence

Congress is responding to the news of the shooting of a judge, a court reporter and two others in Atlanta; the shooting of a judge's family in Chicago; and the shooting of seven people at a church gathering in Wisconsin. They are going to immunize gun makers from lawsuits. (Newsday)

The mastermind behind this is Sen. Larry Craig (R, Idaho):

Craig had the 60 votes last year to ensure the bill's passage, but Democrats succeeded in persuading a few Republicans to help them attach a renewal of the assault weapons ban onto the legislation. Republicans -- at the NRA's urging -- then killed the legislation.

The NRA's political action committee spent hundreds of thousands of dollars on ads, postcards and other publicity calling for the election of the new GOP senators or the defeat of their Democratic opponents.

For example, the NRA Political Victory Fund spent at least $526,911 in support of Florida's Mel Martinez. Other freshmen benefiting from the gun-rights group's independent spending were North Carolina Sen. Richard Burr, at least $468,376; South Dakota's John Thune, at least $349,120; Jim DeMint of South Carolina, at least $176,833; and Georgia's Johnny Isakson, at least $68,109.

According to Newsday, Craig will bring the legislation to the floor for approval right after Easter recess. Opponents will again try to tie to an assault weapons ban. The bill protects not only gun makers, but ammunition manufacturers, distributors, dealers and importers and bars local authorities or private individuals or groups from bringing cases.

Makes you glad to know congress can respond when the stakes are important. All it took to immunize the gun industry was money.

Maybe next they'll look into to immunizing the public against flu. All they want is a bribe.

Bird flu and labor organizing

A reader sent us this from the International Labor Commuications Association:

One of the largest concentrated groups of unorganized workers in the US is largely ignored by organized labor. This proposal is for a coordinated effort to organize in this key industry.

Organizing the poultry industry would have a significant and immediate impact on the future of the labor movement and would carry national resonance on debates over the rights of workers both to organize and have real enforcement protections from state and federal agencies. Labor can simultaneously increase our membership numbers, strengthen labor's image as the advocate for working people, and increase our relevancy within minority communities.

It should be an embarrassment for Labor that a human rights organization (Human Rights Watch 'Blood, Sweat, and Fear: Workers' Rights in U.S. Meat and Poultry Plants, January 25, 2005) and the GAO (Safety in the Meat and Poultry Industry, While Improving, Could Be Further Strengthened, January 27, 2005) are the only ones speaking out against the systemic abuses in poultry. Those abuses are legion and must be addressed by Labor.

The bird flu situation should remind us that there is an important occupational health and safety issue here for poultry workers. A major population of the poultry workers is in the south. Health and safety, especially if it potentially involves the families and children of workers, is a potent organizing issue, more so than wages. The ergonomic and injury issues of great concern to poultry workers can be strengthened by adding an infectious disease that can be brought home to the list of issues. Organized labor should be alerted to this problem and begin to organize poultry workers around it. (Hat tip: Debbie)

Skeptic's Circle #4

Fourth edition now up. Our Biodefense post is up along with lots of other great stuff from other blogs. Visit early and visit often at Two Percent Company.

Georgia on my mind

Most of you have likely never heard of the Daubert Decision, the 1993 Supreme Court case that instructed federal trial judges to examine scientific evidence for relevance and reliability before allowing it in court. Sounds pretty good, especially as it replaced what was clearly an unscientific criterion, the Frye Rule, requiring evidence to be "generally accepted by the scientific community." Science is not a "majority rules game" and the Frye Rule was out of step with scientific practice. Unfortunately, the way Daubert has been applied has worked out very badly for those who wish to get their Day in Court against powerful and moneyed interests. It has decimated the toxic tort landscape and is now threatening to worm its way into the regulatory arena as well. We have previously discussed this so I won't go into it further.

Instead I want to call attention to a recent Georgia law, billed as "tort reform," that makes Daubert the governing principle in the state's civil cases as well (hat tip to Daubert on the Web, an invaluable source of information on a matter that should be of concern to all scientists).

Among other measures, the legislation now places Georgia squarely in the ranks of the Daubert states, for civil cases. In civil cases, the bill emphasizes Georgia's insistence that its courts "not be viewed as open to expert evidence that would not be admissible in other states."

Criminal cases, however, are another matter. The bill provides: "In criminal cases, the opinions of experts on any question of science, skill, trade, or like questions shall always be admissible; and such opinions may be given on the facts as proved by other witnesses." (The emphasis is ours.)

There has long been a de facto dichotomy in federal court between Daubert's application in criminal cases (fairly licentious) and civil ones (more strict). Perhaps Georgia is to be applauded for its candor in making the difference in standards explicit and official, though some might feel that the distinction should operate in the opposite direction.

What is really unbelievable about this is it that it raises the bar for getting scientific evidence into court to force a defendant to pay money to a victim while at the same time preventing those stricter standards of scientific evidence from being used on behalf of a criminal defendant whose life and liberty are at stake. One would imagine that the burdens would be just the reverse, but not in Georgia. In Georgia a "scientist" can opine on how psychology shows that a person will commit a future violent act and should therefore face the death penalty, or how "fiber analysis" or "footprint" analysis "proves" that someone is guilty (despoite the fact that neither practice has been subjected to scientific scrutiny or test), but not be able to use epidemiology in a courtroom when a well-heeled civil defendant like a chemical company hires some hack to say it isn't good science.

In a related story, the Justice Department has finally decided to find some answers to the Big Cahuna of forensic science, fingerprinting (which of course could not be subject to challenge under Daubert in Georgia, no matter what DOJ research finds about its validity).

The research solicitation [by the National Institute of Justice, DOJ's research arm] seeks to "provide juries with increased information about the significance and weight of fingerprint evidence" and also to create tools "to improve the fingerprint examination process," said Catherine Sanders, spokeswoman for the Office of Justice Programs, which includes the institute.

The agency's decision is the latest example of an unmistakable shift in the previously defiant world of fingerprint experts. Until recently, they had pointed to nearly a century of convictions in U.S. courts to dismiss calls for a closer examination of their discipline.

[snip]

The broader reassessment of fingerprint comparison is largely being driven by a series of high-profile errors committed by examiners, including their role in the wrongful conviction of Stephan Cowans, a Boston man imprisoned for six years after a false match linked him to the shooting of a police sergeant.

A few months after Cowans' release last year, an even more embarrassing mistake occurred when the fingerprint world's elite--examiners at the FBI lab--falsely connected Brandon Mayfield, an Oregon lawyer, to the 2004 train bombings in Madrid through a print found near the scene. (superb reporting by Flynn McRoberts and Steve Mills in The Chicago Tribune)

The use of Daubert in a criminal proceeding in federal court burst on the scene several years ago when it was used to challenge fingerprint testimony in a Philadelphia court. The judge initially granted the Daubert motion. The FBI countered by sending the controverted prints to examiners across the country.

While most examiners agreed with the FBI's conclusion that the defendant's prints matched those found on the getaway car, 17 examiners in nine states were unable to make an identification, underscoring that the discipline is much more subjective than many fingerprint experts have acknowledged.

After receiving the conflicting responses, one of the FBI's top fingerprint experts asked the dissenting examiners to take another look, with the help of some FBI enlargements of the prints in question.

`Test your prior conclusions'

"These enlargements are contained within a clear plastic sleeve that is marked with red dots depicting specific fingerprint characteristics," wrote Stephen Meagher, chief of the FBI lab's latent print unit, in a June 1999 letter. "Please test your prior conclusions against these enlarged photographs with the marked characteristics."

Three months after Meagher's letter, the National Institute of Justice approved a call for research into fingerprinting, only to eventually let it die amid uproar from police and prosecutors.

Meanwhile, in Boston the police are rebuilding their fingerprint unit.

Six years after authorities used a fingerprint match to implicate him in the shooting of a Boston police sergeant, DNA tests excluding Cowans forced them to recheck the print. The re-examination last year revealed that his print wasn't even close to a match of the one found at the crime scene.

Six years into a 35- to 50-year prison sentence, Cowans was released from prison last winter.

Don't worry. This couldn't happen in Georgia.

Bird flu miscellany

This is a miscellany of bird flu items from the last day or two. Most people who read this site are aware of these things as they read other sites. Here is my take.

The Journal of Virology has just published a paper by Nguyen et al. ("Isolation and Characterization of Avian Influenza Viruses, Including Highly Pathogenic H5N1, from Poultry in Live Bird Markets in Hanoi, Vietnam, in 2001," J Virol. 2005 Apr ; 79(7): 4201-12) that examines the genomes of the highly pathogenic poultry viruses circulating in Vietnam in October, 2001. Strains included H5N1, H9N2, H4N6, H5N2 and H9N3, collected from 189 birds and 18 environmental samples in live bird markets in Hanoi. I have only been able to see the abstract so far. Examination of the HA protein on the H5N1 viruses showed them to be similar to H5N1s isolated elsewhere in Asia during this period, suggesting that the viruses came from a common original source. But they were also genetically distinct from H5N1 viruses isolated in early 2004 during the most recent outbreak. Thus either the more recent virus comes from a different source or represents a mutated 2001 virus. The abstract does not indicate the nature of the genetic differences or the authors' interpretation, if any, of this. Meanwhile there is continued fretting over the lack of timely information provided to WHO and the international community by the Vietnamese authorities. New reporting procedures are allegedly in place that will remedy this. We'll see.

The case of the female nurse from the Red River Delta province of Thai Binh, initially thought to have bird flu but then reported as "testing negative," has not been further clarified with any official reports. There is some skepticism about the negative test, as false negatives have been common in Vietnamese testing. This is a matter of considerable importance as it bears on whether the case clusters are increasing in size (the Thai Binh cluster is already four and with this nurse would be five, the largest cluster yet reported).

Thanh Tien News (Vietnam) is now reporting a 5 year old boy from the northern province of Quang Binh hospitalized with fever and pneumonia. His 13 year old sister died 10 days after eating "a dead chicken" (sic) 3 weeks ago. His illness, if of recent onset, is 10 days after that, so human transmission is a distinct possibility. And SABC News (South Africa) reports that a death over the weekend of a male, age not given, is being investigated by Vietnamese authorities as due to bird flu. The patient was from the southern province of Kien Giang, the first death in the south in many weeks. Tissue testing was not complete, so we await further details on this case.

The Vietnamese are also considering poultry vaccinations, something now only done officially by China and Indonesia, although the Thais are planning to do it. There is some controversy about this as vaccination prevents birds from getting sick and probably decreases viral shedding, but also allows infection without visible symptoms, increasing the likelihood that the birds can infect other birds, or possibly people, although the latter has not been shown. to date there is little experience with H5N1 vaccination. There are unconfirmed reports of fresh outbreaks of avian influenza in poultry in North Korea (News24, South Africa) and Indonesia (Irish Examiner). Now South Korea is postponing a planned import of chicken for later this month.

A ministry [of Agriculture and Forestry] official said Tuesday it was waiting for confirmation of rumors that a high-ranking North Korean official who defected to the South spoke of an outbreak of avian influenza in the reclusive country. It asked the Unification Ministry to confirm the validity of the rumours through communication with the North, and failing this, will take preventative measures against the deadly virus, he said.

Thus the disease is firmly entrenched in Asia, providing the ingredients for the kind of genetic shift that emerges periodically as pandemic influenza. The H5N1 strain has already mutated considerably, increased its host range to infect mammals including humans, and is remarkably virulent.

Bottom line: no good news to report.

Tamiflu: Dylan's retort, part III (conclusion)

This is the last installment of reader "Dylan's" commentary on the Tamiflu issue (previous posts here and here). For readability I am not "block-quoting" and reducing font size as I usually do for quotes. Instead Dylan's remarks are full width and full font size, mine in block quotes and reduced font. Dylan's intention is to provoke discussion. In that spirit I have engaged him in a dialog. Whatever you think of his arguments, which are substantive, he has done us a service. He has my thanks.

Dylan concludes:

Since the level of lethality of H5N1 first became established at around 70%, there has not been any demonstrated reduction of this figure to date (disregarding the latest cluster in Thai Binh, about which any conclusions would be premature). There could be several reasons that this state obtains, but nothing about it says anything about Tamiflu. In the pantropic and neurotropic strains of H5N1 the NA segment of the virus is encoded for the binding and sequestering of plasminogen, and this changes the nature of the hemaglutinin cleavage at receptor sites. Instead of being confined to the upper respiratory tract, the virus can now fuse with the cells in most of the major organs of the body (pantropic), or with the cells of the central nervous system, including the brain (neurotropic). With the first symptomatic expression of nonpneumotropic H5N1 a victim's condition would almost certainly be beyond the scope of any prophylactic protection that Tamiflu might confer upon him/her. Research could certainly be conducted regarding Tamiflu's express capacity to confer limited "immunity" to infection by a pathogen of this nature, but I don't think that any has been conducted at this point.

Several ideas are expressed here. Let me try to unpack them. First, whatever changes in virulence the virus is or is not exhibiting, it is separate from the efficacy of Tamiflu. I agree, but I don't see the relevance of this to the discussion. Second, Dylan hypothesizes that pantropic strains get that way via an enhanced ability to cleave HA into two pieces in many tissues, not just lung. This has been suggested in the literature, but that same literature makes clear that virulence is a complex, multigenic affair and likely involves a complicated interaction with other altered genes (like NS and PB1). To settle on changes in NA, which is involved in the mechanism of action of Tamiflu, as the major or only factor is almost certainly not the case. Moreover, the active site of NA seems well conserved, so changes in NA that enhance virulence would likely not affect the active site. The third idea expressed here is that Tamiflu only works for pneumotropic viruses. Your comment that Tamiflu would not be an effective prophylactic after the first symptoms is a contradiction and I assume an oversight. Obviously, if there are symptoms then the use of the drug is therapeutic, not prophylactic. However your argument seems to just boil down to the claim that we don't know for sure Tamiflu would work for a neurotropic strain. We have covered this already.

Number three: If you are using Tamiflu to ward off the effects of H5N1 during the course of known exposure to the pathogen, then the fact that you are not displaying any symptoms does not mean that you are not capable of infecting another person (were the two nurses in Vietnam taking Tamiflu; I would think they should have been). It follows from this that all immediate family members in contact with any health care worker, first-responder, etc., who is exposed regularly to H5N1 will also have to be provided with Tamiflu, as a practical and an ethical matter.

Your statement is correct, but does not take into account the substantially reduced viral shedding that accompanies use of the drug. The main point is to reduce the average number of secondary cases each case produces. This will shorten the epidemic. The drug would plausibly do this, even if it isn't given to all contacts.

Assume, for the sake of argument that 60,000,000 ten dose courses are available when the pandemic arrives (we're probably dreaming here, right). Then if used as a preventative measure, which would require each person to take one dose a day for six weeks, at least, roughly 14,300,000 people world wide could be protected for six weeks. Three-million-six-hundred-thousand of those could be health care workers and first-responders, etc. Assuming three family members for each of these people, all 60,000,000 ten dose courses have been used up. And that these people are protected in the first place assumes that Tamiflu works perfectly. We have problem here, as I see it. How many nations around the world are going to be relying very heavily on Tamiflu when the pandemic arrives? What happens if Tamiflu doesn't work almost flawlessly? Anybody care to answer?

I agree with this argument. Tamiflu cannot stop a pandemic nor will there be sufficient supplies to make much of a dent if the event occurs in the next two years, which seems likely. I am not sure what we are supposed to take away from this argument, however. It is not an argument against the drug.

Number four: All human isolates of pneumotropic H5N1 tend to produce high cytokine response. This involves elements of the immune system that are the body's first response to any flu infection. They include interlukin, interferon, macrophages, tumor necrosis factor-a, and several others. I've encountered research that demonstrates that a single passage of H5N1 through mouse (not the best model, or the one of choice where flu studies are concerned, as I understand it) lung tissue was sufficient to evoke high cytokine response. I don't want to get too far into this -- I'm sure revere can explain it better than I could -- because it's very complicated, and it isn't necessary to make the point. Something in the NS segment of the viral RNA apparently interferes with the regulation of the cytokine response. When the response fails to neutralize the virus -- which is essentially immune to it -- it simply continues to produce progressively greater, and more "toxic," amounts of pro-inflammatory cytokines. The result is that the lungs are overwhelmed with the fluids that are produced. Most of the people who are dying because of H5N1 infection are probably dying as a result of this being the way that their body is responding to the pathogen. Tamiflu would have to prevent this at a very early stage of infection, because once begun it is rarely, if ever, reversible.

As you indicate, this is a complicated argument and the subject of a great deal of ongoing research. The NS (non structural) protein at both its C-terminal and N-terminal ends is capable of dampening cytokine response in infected cells. It is not clear whether this leads to a positive feedback situation with a consequent "cytokine storm" that is part of the problem or whether something else or many something elses are occurring. The way Tamiflu works is to prevent the virus from massive replication by preventing the virus from budding off infected cells and going on to infect other cells. It is likely that there is a balance between the various response mechanisms at different times and scales that can be tipped one way or another and probably turns on particular host characteristics. Tamiflu may or may not affect this complex chain of events. What we know so far, however, is that the drug is quite effective against influenza A infection if given prophylactically or early in infection (first 2 days). So far that is the bottom line. Arguments that some strains will be unaffected are hypothetical at this point. However to say that we may discover instances where the drug will not work is not an argument to say we shouldn't use it or that if we do use it it will be useless.

I'm sure that I have made some mistakes here, but on the other hand, I think that I have also proposed some fairly important questions.

Dylan, you have done a remarkable job in synthesizing a vast amount of information. To the extent I or anyone disagree, we should be required to make a counter argument, which I have tried to do, however briefly. In any event, I hope our conversation is useful and even interesting to some of our readers.

Many thanks to you.

British Medical Journal publishes statement on Iraq casualty count

This week's British Medical Journal (no subscription required) has a statement from public health experts stating that the failure of US and UK governments to account for casualties in the Iraq war is irresponsible.

We the undersigned experts in public health call on the US and UK Governments to commission immediately a comprehensive, independent inquiry into Iraqi war-related casualties.

Monitoring casualties is a humanitarian imperative. Understanding the causes of death is a core public health responsibility, nationally and internationally. Yet neither the public, nor we as public health professionals, are able to obtain validated, reliable information about the extent of mortality and morbidity since the invasion of Iraq. We believe that the joint US/UK failure to make any effort to monitor Iraqi casualties is, from a public health perspective, wholly irresponsible. The UK policy of relying on extremely limited data available from the Iraqi Ministry of Health is unacceptable.

The experts also call of a scientifically independent study to resolve uncertainties. The issue was raised dramatically by a study in The Lancet in late October (see here and here) which estimated civilian deaths from the invasion to be around 100,000, although the authors believed the number was actually higher than that. The article was much discussed abroad but heavily "spun" in the US where administration and right wing "experts" immediately went about the business of casting doubt on the findings. Experts in epidemiology, however, have vouched for its rigor and the judgment it represents an underestimate, not an overestimate.

The writers of the statement note that if "democratic decision making" is one of the principles for which the war is being fought, failure to count the costs makes it impossible to render an informed decision. Obviously the US and UK would rather the war "ran unopposed" and are setting about assuring this is so. So much for Democracy.

Tamiflu: Dylan's retort, part II

Here is the second part of reader "Dylan's" comments on the Tamiflu post (part I, here). For readability I am not "block-quoting" reducing font size as I usually do for quotes. Instead his remarks are in plain font and full width, mine will be in block quotes and reduced font. Dylan's intention is to provoke discussion. In that spirit I have engaged him in a dialog. Whatever you think of his arguments, which are substantive, he has done us a service. He has my thanks.

Dylan continues:

Now for Tamiflu. I'd like to keep this short, but that's not possible. I have not read the research paper written by Ms. Ward and her associates of Roche, but even so I will state my objections to their findings which clearly strongly support the case for Tamiflu. Since Roche makes the drug, this should surprise no one.

Number one: Research conducted by "in-house" researchers is always suspect. That doesn't mean that the research in this case is in any way "tainted, or "fraudulent;" it simply means that all research is directed towards a particular end, and that end may exclude possible avenues that are not entirely consistent with the desired outcome of the research in question. Tobacco companies, for instance, conducted research for years that found no connection between cigarette smoking and lung cancer. Drug companies (all of them, I suspect) pushing antidepressants conducted many studies that failed to find a relationship between antidepressants and adolescent suicide rates (they finally got caught flat-out lying on this one). Ever hear of Agent Orange? I could go on with this line of reasoning, but I think this will suffice.

I think some comment is needed here. Clearly I agree with the thrust of your remarks regarding conflict of interest to the piont where I felt it necessary to call attention to it in my post because of the ethically challenged history of the drug companies. However there are two points I want to make. The first is that the drug companies are often the only source of information about these drugs, at least initially. That information has to be judiciously evaluated but we shouldn't throw it out because of the source. It is a lot like going to a new car dealer and getting information about the different models from the salesperson. They know about the cars and it is normal to ask them questions. It is also normal (and prudent) to think critically about what they say, compare it to other sources of information and try to "triangulate" to get a fix on the most accurate data. Data that is uncomfortable for the company is not usually falsified but rather suppressed or spun in a way that requires an informed reader to "read between the lines." I tried to do that with their paper, to the extent I was able. But as I said, caveats are in order.

The second point is perhaps more important. Conflicts of interest are not the only sources of incorrectly presented or perceived data. We all have a tendency to latch on to things that accord with our prior beliefs and to discount things that don't. This can easily lead us astray. There is also a reflex tendency to defend our own prior judgments or statements, as I did when reader Gaudia objected to my casual characterization of Roche's Tamiflu storage indications as "room temperature." Nothing much rested on this matter and I could easily have let it go. I didn't, instead dredging up a statement from The National Library of Medicine's Medline Plus database to show they also characterized Tamiflu storage as "room temperature." My point here is it isn't only economic incentives that can modify our perceptions, how we express things and how we react to others. The avian flu issue calls forth strong emotions for many reasons. In my case it relates less to my personal safety than what it says about the state of the profession in which I have spent my life. Others will have different reasons, but the emotions will be there need to be taken into account. Sermon over.

Number two: Research that is not thoroughly comprehensive -- especially when it could have been -- is necessarily inconclusive, premature, and completely suspect, at best.

I must respectfully disagree. No research is "thoroughly comprehensive," whatever that might mean. All research is in some sense inconclusive and premature. This does not imply it is "completely suspect." I'll take this as a momentary lapse into hyperbole on your part. It isn't needed for your argument.

Isolates of H5N1 that produce pantropic, and neurotropic infections that are atypical -- when compared with the symptoms produced by pneumotropic isolates that would been used in this research -- could not have been part of the research conducted in this study because knowledge of their existence was not available before this research was published. I'm sticking my neck way out here, but I'm almost certain that this is the case because the publication date of the research matches almost precisely the date that the existence of these particular isolates was first made public. Now, I don't want to be too harsh here, but if I had a piece of research that was nearly complete and that strongly supported my position, I might find it very awkward to have to reevaluate things by introducing variables that are very likely to skew the findings in a manner that does not support my position. I would get that paper right out the door, before this ever became an issue. And no one could really fault me for it.

As you point out, at the time the manuscript was written and submitted there was likely no concrete knowledge of neurotropic forms of H5N1. The context here was the usual influenza pandemic disease, which is devastating enough. But even if there were some suspicion or even some evidence, in my view delaying publication until such time as it could be incorporated into this paper (and even now there is not enough information to allow publication of that material) would have been very unfortunate and might even be considered irresponsible considering the wealth of information the authors already had. Whether they presented that information fully and fairly is another question which we will never know or know only at some future time. Withholding what they did know, however, would have opened them to justifiable criticism. Remember that H5N1 is not the only strain out there and we could easily have a pandemic with a pneumotropic strain. This was a review article to inform the scientific community. I believe it accomplished that.

In Vietnam right now there are strains of H5N1 that are pneumotropic but may segue into neurotropic expression as the disease progresses; and there are strains that express first in a neurotropic, or pantropic pattern (sometimes with complete absence of any upper respiratory involvement, where neurotropic strains are concerned). I have seen nothing anywhere that suggests that Tamiflu can have any effect whatsoever on an H5N1 infection of a pantropic or neurotropic nature. Dedicated pneumotropic strains would fit well with research constructed to test the efficacy of Tamiflu, with regard to them alone. The hemaglutinin in a strain of this sort would be constrained to interaction with receptors in the epithelial cells of the upper respiratory tract only. In the lab at least, neuraminidase inhibitors could prove to be very effective against a strain of this sort. I have reservations where Tamiflu's efficacy in the field is concerned, though. The record is not entirely clear, but it is in no way conclusively supportive of Tamiflu.

In my view this is unwarrantedly pessimistic. There are good reasons to think oseltamivir will work against any influenza virus that requires neuraminidase to release the budding virus from its receptor, i.e., all of them that we know of so far, including those with tropisms other than the lung. Moreover data shows that viral shedding is substantially reduced, which one might expect, given the mechanism. In short, I do not see the rationale for saying Tamiflu won't work on neurotropic or pantropic strains.This may or may not turn out to be true, but the same can be said for virtually any therapeutic modality. Indications so far suggest it will work with H5N1 strains. That's all we know at present. But if it isn't effective in some strains, the authors of this study can hardly be blamed for that.

Dylan continues the line of argument that Tamiflu might be of doubtful efficacy in an H5N1 pandemic. That will be in the next, and concluding, post.

Tamiflu: Dylan's retort, part I

Once again one of our readers, "Dylan," forces me to acknowledge the extraordinary raw talent in the mindhive that is the blogosphere. In a very extended comment to the Tamiflu-storage post he has raised a number of points that deserve wider readership and also some comment from me. The Haloscan Comment system, even with my ponying-up some extra dough, is limited to 3000 characters a Comment (for which I apologize). Dylan had to split his extensive remarks into four segments which I have pasted together, interspersed with some of my own remarks.

To avoid really long posts, I will divide his remarks into separate items over the next few days.

For readability I am not "block-quoting" his remarks in reduced font size as I usually do for quotes. Instead his remarks are full width and mine will be block-quoted with reduced font.

What follows is not intended to discourage anyone from purchasing or using Tamiflu. I, and my wife and daughter, will all be using it when the time comes, since it's the only thing available at this point. The purpose here, then, is to promote discussion.

I strongly encourage discussion, hence these posts. First, a personal comment of my own. I have not bought Tamiflu, partly as a matter of conscience. As Dylan notes, if a disaster strikes, this drug will be rationed and, I hope, apportioned on some ethical and rational basis of need. I would be short circuiting that by having the foresight to buy my own supply, so at this point I have not done so. I agree with Dylan that it is not even remotely the solution to dealing with a pandemic. It is only one tool and, given the numbers, probably would be effective only around the margins.

Okay, here's my two cents worth; well, maybe three-or-four cents before I'm finished. This has to do with Tamiflu, but I'm going to begin with H5N1 to limn the current state of events, and what all of this may imply (stockpiles of antivirals, mutations in H5N1, etc.). Vietnam is looking more and more like the launch-pad for the pandemic (doesn't mean that it has to be though; there is plenty going on in other places, too). The latest familial cluster in the Thai Binh Province area (assuming the female nurse proves positive for H5N1, and the isolate is identified as essentially identical to the others that comprise the cluster) is the latest example of the pathogen's rapidly advancing adaptability to human beings. Zero human flu genes are involved here, so it should now be assumed that this can no longer be considered as an absolutely necessary component of a potential pandemic flu strain, as had previously been thought to be the case.

This is probably correct, but I am not aware of any sequences of the latest round (late December 2004 onward and especially the northern Vietnam viruses). So some human, or least, non-avian genes might conceivably be involved.

It's doing things that we haven't figured out, yet. On the other hand, H5N1 is doing an enviable job of figuring us out, even though this may have required a (temporary?) suspension of its extremely high level of lethality (all four people in the largest cluster are still alive, but none of them are out of the hospital yet, either, so lethality here remains an open question).

Given the current case-fatality rate, this is certainly a remarkably lethal virus. However I am of the mind that there are many inapparent infections (and probably substantial human-to-human transmission to go with them) so that the true virulence is being overestimated by a Vietnamese government that has only counted the most serious cases, and probably not all of them. Having said that (and in agreement with Dylan), if the case-fatality rate even goes down to single digits (from the current 70%) we have a gigantic problem on our hands.

I mention "temporary" here because a signature of H5N1 in many early poultry infections was an initial low pathogenicity that spiraled into high pathogenicity that ultimately raged through a flock of birds like a firestorm, and resulted in lethality levels approaching 100%.

Here is my take on the incredible lethality for chickens. I think it is caused by high confinement poultry farming, which makes it possible for the virus to kill a chicken quickly and still be transmitted to another bird. Remember that for the virus the chicken is just another way of making another virus. "Backyard" chickens are not so densely congregated, nor are people. Thus for traditional farming and for humans one might expect a far less lethal virus. Let me try to differentiate this from unwarranted optimism. I don't know, nor does anyone else, what is going to happen. From the public health ("precautionary") perspective one needs to plan for the worst, and in this case the worst is unimaginably bad and quite plausible. What I am doing is giving my "best guess" as to what I think will happen, based on my view of the biology. I am sure there is much room for disagreement, and I welcome it (as long as it isn't also disagreeable, a line that no one on this site has yet to cross).

And this current intensified infectiousness of pure avian H5N1 doesn't in any way alter the fact that H5N1 could still mate up with something like H3N2/California, for instance, and undergo an antigenic shift; it just suggests that there are far more options on the table for H5N1 to pursue than could have been considered feasible even a few short months ago. We are orders of magnitude beyond where this thing was at the beginning of 2004, and light years beyond the state represented by the first expression of H5N1 in human beings in Hong Kong, in 1997. We have gone from a state where there was absolutely no evidence whatsoever of transmissibility between human beings, to a state where not only is that apparently a common component, but the evidence increasingly suggests that transmission through casual contact is now occurring.

I agree with this, but to be fair, there are others, who I consider knowledgeable, who do not.

The overall state of affairs being what it is right now, I find myself thoroughly ensconced in the camp of those who insist that we will be dealing with a full-fledged pandemic before the end of next winter. To qualify as alarmist these days, one would have to insist that the pandemic has already begun, and we're all just in a state of global denial. Alarms are sounding all over, and unfortunately our Government seems to be one of the few that is virtually deaf to all of them. Maybe the same in-house scientists who are advising the Administration on the causes of global warming are providing the advice on this issue, too?

I think this is a reasonable judgment, which I share.

Now for Tamiflu.

[To be continued in the next post].

One answer to a tough question: save UNICEF

After our post about the Bush administration and international treaties ("Tough questions"), we received the following letter:

Dear friends at Effect Measure,

You've got a great blog going, one of the few I receive as an RSS feed. I'm writing here to let you know about, and hope you will publicize, a

CAMPAIGN TO DEFEND UNICEF'S MISSION TO DEFEND CHILDREN!

In May 2005 Ms. Ann Veneman, former US Secretary of Agriculture, will take office as the Executive Director of UNICEF. Her nomination, negotiated secretly by the UN Secretary General with the US Government and rapidly approved by UNICEF's Executive Committee, has alarmed public health advocates around the world. Ms. Veneman has no background in public health, children's welfare, or the rights of disadvantaged people. Her history as an advocate for agribusiness, both as a private lawyer and in government, is characterized by privileging private profit above the public good. Applied at UNICEF, this will be a disaster for the world's children.

I don't know if Paul Revere can SIGN ON to the People's Health Movement's Letter of Concern detailing our reservations about the appointment of Ms. Veneman and the appointment process, but it would be great if you could let your readers know about it. To read the letter and sign on, go to www.saveunicef.org.

Thanks for your help and your work defending people's health.

Yours

Todd Jailer

Todd Jailer * People's Health Movement - USA * c/o Hesperian Foundation 1919 Addison St. #304 * Berkeley, CA 94704 USA

HEALTH FOR ALL, NOW!

The Reveres will be signing under their own names later (to preserve anonymity). We invite readers to join us in this important movement.

Tamiflu storage and adverse reactions

In response to my earlier post on the mechanism of action and brief comments on efficacy of the influenza A antiviral oseltamivir (Tamiflu), some readers had questions about storage. In addition, one reader (Gaudia) was kind enough to send links to scanned images of the drug as marketed in both the US and Canada. Those links (from the Comments) will be repeated at the end of this post.

With respect to storage, Gaudia sends this in: Tamiflu box says, STORE AT 25 DEGC (77 DEG F). EXCURSIONS PERMITTED TO 15 DEGTO 30 DEG C (59 DEG TO 86 DEG F). SEE USP CONTROLLED ROOM TEMPERATURE. This corresponds to information I obtained from the literature which says the 75 mg capsules can be stockpiled by civil authorities, no special conditions specified. Note that the conditions Gaudia cites are essentially ambient (room temperature) conditions.

Here is some additional information that may be of interest (source: Ward et al. "Oseltamivir (Tamiflu(R)) and its potential for use in the event of an influenza pandemic," Journal of Antimicrobial Chemotherapy (2005) 55, Suppl. S1l, i5 - i 21).

Side effects: This drug seems remarkably free of side effects, although, as with any drug, they do exist. Since its introduction in 1999, its manufacturer, Roche, estimates it has been given to about 20,000,000 people world-wide, although post-market surveillance is not well-developed. Roche claims that only one of every 10,000 patients has had one or more adverse reactions. During one review period, about 1000 of the 4000 adverse events were considered "serious." Most of the reports come from Japan. My interpretation: adverse reactions are very uncommon, but when they occur may be more serious than with other drugs.

Most adverse reactions were gastrointestinal (nausea, vomiting, diarrhea), dizziness and more rarely some allergic-type reactions (rash, hives, eczema, swelling of the face). On rare occasion the allergic reactions were serious (Stevens-Johnson Syndrome, erythema multiforme).

Use during pregnancy and while nursing: There is not enough information available to make a judgment of safety during pregnancy, so Roche's cautions that it be used only when potential benefits justifies potential risk to the fetus. They cite its use during pregnancy in 61 cases, among which there were 10 reports of abortion (of which 6 were therapeutic abortions, reason is not stated) and there was one each of trisomy 21 (Downs) and anencephaly. It is hard to know what to make of these data but I do not find them particularly reassuring, even though more than 80% of the pregnancies resulted in normal babies.

Based on animal studies the drug and its active metabolite would be expected to be excreted in milk during breast feeding. Therefore its use in lactating women is subject to the same strictures as for pregnancy: use only if the potential benefit for the lactating mother justifies the potential risk to the nursing infant.

Bottom line: this is a medicine, not a candy. Do not use without good reason. With that qualification, it is more than usually safe and should be used when indicated.

I have decided not to give dosages here at this time. This is a drug to be used on the advice and at the direction of a health care provider. In medicine we have an old saying, "If you treat yourself, you have a fool for a doctor and a fool for a patient."

Here are the image links from Gaudia (thanks!):

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Tough questions

Tough question. What is the one other country besides Somalia that has not ratified the Convention on the Rights of the Child? OK, that was too easy. How about the Kyoto Protocol, which has been ratified by 141 nations and every industrialized country except Australia and one other one. Well, how about this. What country has nullified her signature on the International Criminal Court? Or has announced it won't fulfill a prior commitment to ratify the landmine ban treaty by 2006? Still don't know? Ask Eduardo Bianco. He knows (LA Times):

When he helped pioneer an antismoking movement a decade ago, Eduardo Bianco looked to the United States for novel ways to keep young people in Uruguay from taking up cigarettes.

Today, the 49-year-old cardiologist no longer considers America a leader in the fight against smoking. That's because it is not among the 57 nations that ratified the first global tobacco control treaty, which took effect in recent weeks and imposes tough restrictions on tobacco advertising and packaging.

The Bush administration signed the treaty in May, but the president hasn't sent it to the Senate for ratification, saying it needs further study. Uruguay did ratify the treaty — and Bianco was among those who persuaded his government to do so.

[snip]

Under the World Health Organization's Framework Convention on Tobacco, countries are obligated to restrict tobacco advertising and sponsorship, increase the size of warning labels and limit the use of terms such as "light" and "low tar" that may convey a more healthful image.

How about the Law of the Sea Convention?

Bush's hesitancy to spend political capital on treaties may be a reason for delays in ratifying the Law of the Sea Convention, which was originally championed by the United States in the 1970s and has been in force since 1994. More than 100 nations have ratified the wide-ranging agreement governing such things as ocean navigation, fishing rights and seabed mining.

The treaty has garnered the support of Bush, the Navy and leaders in both parties. But conservatives argue the treaty would threaten U.S. sovereignty and endanger national security, forcing American fishing fleets and Navy ships to abide by the rules of a global body that could be hostile to U.S. interests.

Frank J. Gaffney Jr., president of the conservative Center for Security Policy in Washington, said he was confident the president wouldn't push for the treaty now because it would antagonize the "core constituency" he needed if he was to win congressional approval of changes in Social Security and the tax code.

Second term. Afraid things will get worse? Here's the answer in two words: John Bolton.

Those fears were heightened last week when the Bush administration appointed John R. Bolton, an outspoken critic of multilateral institutions, as the U.S. ambassador to the United Nations. Bolton pushed for U.S. withdrawal from the missile pact and opposed U.S. involvement in the International Criminal Court. The U.S. said Thursday that it was withdrawing from an accord that allowed the International Court of Justice to rule on U.S. treatment of foreigners in its jails.

Hmmm. Now why would they be concerned about someone else ruling on U.S. treatment of foreigners in its jails? That's another tough one.

Dow-Monsanto-Hercules war crimes case dismissed

The First Act in the Agent Orange/War Crimes trial is now over (William Glaberson, New York Times). The War Criminals won. Excuse me. They aren't war criminals. The first requirement for being a war criminal is whether your side lost and is subject to the power of the opposition. That's why Saddam is a War Criminal, but Henry Kissinger is a NewsHour guest.

Those minor issues aside, United States District Court Judge Jack B. Weinstein decided last week that supplying poison to the US military to defoliate vast swaths of jungle and contaminate the environment in the process wasn't a war crime.

"No treaty or agreement, express or implied, of the United States," Judge Weinstein wrote, "operated to make use of herbicides in Vietnam a violation of the laws of war or any other form of international law until at the earliest April of 1975."

Because of sovereign immunity, the United States government was not sued.

In 1975, President Gerald R. Ford adopted a national policy renouncing the first use of herbicides in warfare. Also in 1975, the Senate ratified an international Geneva accord dating from 1925, which outlawed the use of poisonous gases during war.

The suit claimed that because of the dioxin in Agent Orange, spraying it amounted to the use of poison during war.

But Judge Weinstein concluded in a 233-page decision that even if the United States had been a Geneva signatory during the Vietnam War, the accord would not have barred the use of Agent Orange.

"The prohibition extended only to gases deployed for their asphyxiating or toxic effects on man," said the decision, issued in response to a motion for dismissal by the defendants, "not to herbicides designed to affect plants that may have unintended harmful side-effects on people."

So if you despoil the environment with a poison that as "collateral damage" kills people and deforms their infants, that's OK, even if documents show you knew the toxic contaminant dioxin was in the herbicide and that it caused health effects. Thus the big chemical companies who did it (Dow, Monsanto, Hercules) don't have to pay a penny to any Vietnamese citizens, even though the same companies paid $180 million to American veterans in 1984.

Weinstein's decision seemed to rest heavily on the question of whether Agent Orange was a "poison gas" or not, a narrow technical interpretation irrelevant to the questions of simple justice involved here. But this is about what is right. The Judge could easily have gone the other way and done so within the Law. Indeed he ceded many crucial points to the plaintiffs:

Though he ruled against the Vietnamese plaintiffs, Judge Weinstein agreed with many arguments put forth by their lawyers. He rejected arguments of the Justice Department that the court had no place in reviewing military strategies adopted by President John F. Kennedy and his successors.

Saying "presidential powers are limited even in wartime," Judge Weinstein said American courts had the power to decide whether presidential decisions about the conduct of a war violated international law.

"In the Third Reich," the decision said, "all power of the state was centered in Hitler; yet his orders did not serve as a defense at Nuremberg," where war crimes trials were conducted after World War II.

Similarly, he rejected an argument from the chemical companies that they were shielded by rules that typically protect military contractors from suits for providing war materiel.

Clearly writing to influence courts in the future, Judge Weinstein used sweeping language and employed extensive citations to historical, military, scientific and legal writings.

If supplying contaminated herbicide had been a war crime, Judge Weinstein wrote, the chemical companies could have refused to supply it. "We are a nation of free men and women," he wrote, "habituated to standing up to government when it exceeds its authority."

So the Judge got to look high minded and sound off on "matters of principle" without having to take the heat for calling a spade a spade: the chemical companies aided and abetted war crimes.

Plaintiffs said the case will be appealed.

More Bankruptcy Bill "links of shame"

More on the Bankruptcy Deform bill fight that is roiling the blogosphere. This is from Josh Marshall's Talking Points Memo. It has a special "Bankruptcy Page" hosted by Harvard Law Professor Elizabeth Marshall and her law student teammates. Here is a brief excerpt, with the "links of shame":

Because of this fight, there will be no quiet, smooth passage for this bill. Instead, folks are now on record: 58 voted against giving just a little protection for military families set upon by predatory lenders. 74 voted against a 30% usury cap, saying the credit card companies are free to take whatever they can get. 58 voted against treating families beset by cancer and diabetes differently from those that run up bills on fancy vacations and over-priced nonsense.

Worrying new case of bird flu in Vietnam

In an alarming new development (AP via USA Today), a 42 year old nurse from Thai Binh province was hospitalized Thursday with symptoms of bird flu -- high fever, cough and evidence of pneumonia. The most worrisome element of this case is that she cared for the same 21 year old patient as another bird flu victim, a 26 year old male nurse. They are all part of a larger cluster which includes the younger (14 year old) sister of the patient and his grandfather (80 years old). The grandfather is apparently healthy, although infected, while the others are all hospitalized in serious condition. Two doctors and two nurses who also cared for the patient are now being monitored. All are reported as healthy at this point.

Earlier we noted that the first signs of a mutated virus that could move more easily from person to person might not be an increase in the numbers of cases or clusters, per se, but an increase in the size of clusters. If this case is confirmed (and it seems highly likely this is a true case), this is now a five person cluster, the largest so far reported.

This comes at a time when it is acknowledged the authorities in Vietnam have not been providing timely information to WHO about new cases in the country. The government in Vietnam has only just now notified WHO about 10 cases (already known and reported on here and elsewhere but not counted by WHO in its official tally) after a silent interval of five weeks. The newly notified cases, however, do not include cases that have arisen since mid-December 2004:

That has raised concerns that agency officials might learn of dangerous changes in the virus's transmission pattern - if such changes occur - too late to try to stop or slow the development of a flu pandemic that would be expected to kill millions around the globe.

[snip]

The latest report from Vietnam does not cover seven people who had fallen ill in January but who were initially ruled out as H5N1 cases. Retesting of samples from those people suggested they were infected by the virus.

"We're still looking to get more details about these cases. But we expect to get those shortly too," said Dick Thompson, director of communications for the WHO's communicable diseases branch.

While the WHO welcomed the new numbers, it is still waiting for crucial information about the cases from the Vietnamese Ministry of Health.

The agency needs to know what kind of field investigations are being done to determine the details surrounding each human case so that it can better assess what is going on with the virus and whether the risk of a pandemic arising has increased. Raw numbers aren't enough to go on, Stohr said.

"It's a question of seeing that the right things are being done," he explained.

"If a case is positive in a hospital, fine. That's not the piece of information which will allow you to decide whether rapid intervention is necessary now or not.

"The piece of information is: Has somebody gone to the village? Do you know whether the husband, the family members, the neighbour is still OK? Is there something cooking in the village?"

Vietnam has not yet provided that level of detail, but Stohr said the WHO will persist.

"We will keep on insisting that a full spectrum of information is being shared." (Helen Branswell via CNews [Canada])

Given these concerns, it is hard to understand why WHO continues to reassure the world, when in fact it is still in the dark about the situation.

Update, 3/13/05 3 pm EST: Bill (hat tip), in Comments, calls attention to a fresh story from Thanhnien News (Vietnam) reporting that the second nurse has tested negative for bird flu. This is reassuring but I think there are two reasons to be cautious. Thanhnien News is the official publication of the Vietnam National Youth Federation. Its editorial slant has tended to downplay bird flu concerns. Moreover, "negative" test results from Vietnamese laboratories have frequently become "positive" results on later retesting or by other laboratories. We will keep our eye on this.

Taser round-up

Now for this week's round-up of Taser news. Some of it is tragic. Some of it is almost comic. And at least one instance reminds us that there might be instances where the use of a Taser-like device is appropriate. We'll start there.

The Good

Police subdued a 6 foot, 350 pound woman, said to be schizophrenic who had gone off her medication. She was locked in an apartment and threatening a 5 year old, a 4 year old and her adult son with a knife. Once the door was unlocked they confronted the woman who waved the knife and a chair at police. Sgt. Karen Popp, who is 5 feet four and 150 pounds repeatedly asked the woman to drop the kniffe and chair, and when she refused, Popp shot her with the Taser.

The woman fell to the floor, and police restrained her, she said. She was then transported to St. Bernard Hospital, and has not been charged, Popp said.

Popp said she did not know the woman's condition, but said she was not seriously injured. (Chicago Tribune)

The Bad

In DeLand, FL, police were searching for a burglar when they spotted Willie Towns hiding behind a tree.

Police said they tried to talk to him but he darted off and climbed up on the roof of a nearby building. Towns started punching out windows with his bare hands, investigators said.

Police tried pepper spray, but then they used Taser guns to subdue him.

"He was extremely desperate. Just by the way that he was acting there, I don't think there was a way to calm him down," said Hollie Jirak, a waitress who was working nearby and saw the whole thing.

Towns stopped breathing on the way to the hospital and could not be revived. Before he died, police said he told them he had been using cocaine.

[snip]

Detectives now say he was not the man they were looking for in the burglary. (WESH via Officer.Com)

The combination of drug use, especially cocaine, and being shocked with a 50,000 volt Taser, seems a deadly combination. In such a circumstance the device is no longer a "non-lethal" weapon.

The Ugly

Meanwhile, in nearby Orlando, a suspect on a drug charge (cocaine) was taken to an emergency room where he refused to provide a urine specimen for a drug test. He was handcuffed and secured to a bed with leather straps to be forcibly catheterized.

Officer Peter Linnenkamp reported he jumped onto the bed with his knees on Wheeler's chest to restrain him. When Wheeler still refused to be catheterized, Linnenkamp said he twice used his Taser, which sends 50,000 volts into a target.

"After the second shock (Wheeler) stated he would urinate and calmed down enough to be given the portable urinal," Linnenkamp wrote.

The Florida Department of Law Enforcement is investigating; Linnenkamp has been relieved pending the investigation's outcome. (AP via CNN)

The Expected

CINCINNATI -- A Cincinnati Police officer accidentally stunned his partner with a Taser during a struggle with a suspect, police said. The incident began with a traffic stop in Over-the-Rhine Sunday night, WLWT-TV in Cincinnati reported. The driver tried to run and a female officer struggled with the driver.

The officer's partner Tased the suspect, but one of the darts struck the female officer. She was able to stay on the scene. (NewsNet5 via Officer.com)

Immorally bankrupt and dis-credited

We're primarily a public health blog, so Bankruptcy Deform might seem beyond our scope. Remember, however, that for average people the main cause of bankruptcy is overwhelming medical bills. And anyway, this legislation is a moral outrage. Indeed The Blogosphere is up in arms in an entirely non-partisan fashion over the abomination called Bankruptcy Reform, which just made its unimpeded way through the Senate. If you aren't following this story, here is the gist from New York Times columnist and economist, Paul Krugman:

The bankruptcy bill was written by and for credit card companies, and the industry's political muscle is the reason it seems unstoppable. But the bill also fits into the broader context of what Jacob Hacker, a political scientist at Yale, calls "risk privatization": a steady erosion of the protection the government provides against personal misfortune, even as ordinary families face ever-growing economic insecurity.

The bill would make it much harder for families in distress to write off their debts and make a fresh start. Instead, many debtors would find themselves on an endless treadmill of payments.

The credit card companies say this is needed because people have been abusing the bankruptcy law, borrowing irresponsibly and walking away from debts. The facts say otherwise.

A vast majority of personal bankruptcies in the United States are the result of severe misfortune. One recent study found that more than half of bankruptcies are the result of medical emergencies. The rest are overwhelmingly the result either of job loss or of divorce.

To the extent that there is significant abuse of the system, it's concentrated among the wealthy - including corporate executives found guilty of misleading investors - who can exploit loopholes in the law to protect their wealth, no matter how ill-gotten.

One increasingly popular loophole is the creation of an "asset protection trust," which is worth doing only for the wealthy. Senator Charles Schumer introduced an amendment that would have limited the exemption on such trusts, but apparently it's O.K. to game the system if you're rich: 54 Republicans and 2 Democrats voted against the Schumer amendment.

Other amendments were aimed at protecting families and individuals who have clearly been forced into bankruptcy by events, or who would face extreme hardship in repaying debts. Ted Kennedy introduced an exemption for cases of medical bankruptcy. Russ Feingold introduced an amendment protecting the homes of the elderly. Dick Durbin asked for protection for armed services members and veterans. All were rejected.

There's more in Krugman's column, which I urge you to read in full. But the real story here is the justified moral outrage on both the Blogosphere's right and left.

Bloggers of all stripes are outraged about the bankruptcy bill that passed the Senate earlier this evening. [Right-winger] Glenn [Reynolds, Instapundit] has a pretty broad round-up. There's a protest organizing online. And, the trend I like the most, bloggers are naming names to hold legislators accountable. Bills don't pass themselves. If you don't agree with the way the person representing you in Congress is voting, let them know. It'll be interesting to see if bloggers can influence politicians in the way they've influenced the media. (MSNBC)

If you click the "naming names" link above you'll come to a list of the ten Democratic Senators (all the Republicans were onboard, of course) who voted for cloture and let the bill come to the floor where it passed with no difficulty. Some of them, like faux-Democrat Joe Lieberman, tried to cover themselves by voting against it on the Senate floor, knowing full well that once it got there it was Game Over. Here are the rest of the names (I want you to see them in case you don't click the link).

The Democrats Hall of Shame (aka, Democratic Senators who will never be President):

Biden (D-DE), Byrd (D-WV), Carper (D-DE), Conrad (D-ND), Johnson (D-SD), Kohl (D-WI), Landrieu (D-LA), Lieberman (D-CT), Lincoln (D-AR), Nelson (D-FL), Nelson (D-NE), Pryor (D-AR), Salazar (D-CO), Stabenow (D-MI).

Via MyDD, the list of Democratic House Members who sold to the highest bidder:

Rep. Ellen O. Tauscher, Rep. Adam Smith, Rep. Ron Kind, Rep. Artur Davis, Rep. Carolyn McCarthy, Rep. John Larson, Rep. Stephanie Herseth, Rep. Dennis Moore, Rep. Mike McIntyre, Rep. Joe Crowley, Rep. Jay Israel, Rep. David Wu, Rep. Diane Hooley, Rep. Melissa Bean, Rep. Jim Davis, Rep. Harold E. Ford, Jr., Rep. Ed Case, Rep. Jay Inslee, Rep. Shelley Berkeley, Rep. Gregory W. Meeks

This will be really, really interesting. MyDD and InstaPundit both outraged and geared for action. We join them. If any of the above "represent" you, tell them what you think of them.

Update: Here is the explicit link to politilogy, home of the "united blogosphere" on this issue. It is in the post above, but may be hard to see. And here is the RSS feed so you can keep track of daily/weekly "Actions" to try to stop this beast.

WaPo is so sure about biodefense

Now The Washington Post editorial page is weighing in on the Biodefense Fiasco. Now, that is, that it has been brought to their attention by 758 microbiologists complaining in an open letter that the $1.7 billion earmarked for biodefense research is distorting the research agenda, wasting scarce resources, and subverting the scientific peer review process. Where was The Post before this letter hit them over the head with a two-by-four? Same place they are now. Clueless.

If [the open letter] were intended only to get the government to think harder about the best ways to define, fund and manage biodefense work, the open letter would serve a useful purpose. If the letter were intended to point out that some basic research in microbiology, immunology, genetics and other fields could prove, in the long term, more important to the nation's biodefense than specific work on anthrax or plague, we would also agree. That, certainly, is a message that Congress and the administration need to hear.

Where we lose sympathy for the authors is when they state that funds have been diverted from "projects of high public-health importance" to "projects of high biodefense but low public-health importance." This country has already experienced one anthrax attack. Security officials have stated repeatedly their belief that al Qaeda and others continue to search for more lethal bioweapons. Surely that makes biodefense projects of "high public-health importance."

Oh, yes. Surely. Yes. Surely. Surely.

Wait a minute. Didn't that anthrax attack come out of the biodefense research establishment itself, not from al Qaeda? "Surely" doesn't that make the biodefense agenda of matter of "public health importance" because for reasons we have already given, it is a threat to public health?

Wait another minute. The Washington Post. Aren't these the same folks that issued a mea culpa because they were too gullible about administration claims in the run up to the Iraq debacle? Or was that another Washington Post?

Related item from ABC News:

No 'True' Al Qaeda Sleeper Agents Have Been Found in U.S.

Mar. 9, 2005 - A secret FBI report obtained by ABC News concludes that while there is no doubt al Qaeda wants to hit the United States, its capability to do so is unclear.

"Al-Qa'ida leadership's intention to attack the United States is not in question," the report reads. (All spellings are as rendered in the original report.) "However, their capability to do so is unclear, particularly in regard to 'spectacular' operations. We believe al-Qa'ida's capability to launch attacks within the United States is dependent on its ability to infiltrate and maintain operatives in the United States."

And for all the worry about Osama bin Laden's sleeper cells or agents in the United States, a secret FBI assessment concludes it knows of none.

The 32-page assessment says flatly, "To date, we have not identified any true 'sleeper' agents in the US," seemingly contradicting the "sleeper cell" description prosecutors assigned to seven men in Lackawanna, N.Y., in 2002.

[snip]

Surely.

Blog rollin' Friday: BrooklynDodger

It's Friday again (what took it so long!) and time to highlight another blog. Community building, as our leader PSoTD reminds us. Instead of featuring our cats and dogs every Friday (not that there's anything wrong with that, as Seinfeld might say). Today, my public health colleague BrooklynDodger:

BrooklynDodger is a public health science person who wants to share random and contrarian observations on technical matters without involving the Dodger's public persona or institutional affiliation.

Yeah, right. Another anonymous blog. Except I think I know who this one is. But I'm not telling and I might be wrong. Whoever it is, this is a damn good public health blog, mainly concerning occupational health and safety. Along with Confined Space, the blogosphere has an embarrassment of riches in this area.

The Department of Public Reassurance

If you are confused about the significance of symptomless cases of H5N1 infection, this is not surprising given the variety of messages coming from Vietnam, WHO and flu experts. Here is Voice of America reporting on Hanoi-based WHO epidemiologist Peter Horby:

A researcher with the World Health Organization says people who test positive for bird flu but have no symptoms of the disease may be contagious, but probably pose a lower risk of transmission to others.

Peter Horby, an epidemiologist based in Hanoi, made the comments a day after the grandfather of two bird flu patients tested positive for the virus, despite never falling ill.

Here is an interview with Horby from Reuters:

"In most infections, or many infections, it is not unusual to get people who have either mild or asymptomatic infections," Hanoi-based WHO medical epidemiologist Peter Horby told Reuters.

"There is no evidence that asymptomatic infection like this poses any significant risk of onward transmission, so it is not alarming in that sense," he said.

This is reassuring. On the other hand, we read this from the AP (via CBC):

A string of bird flu infections in northern Vietnam involving several families has raised troubling questions over whether the deadly virus that has killed 46 people in Asia may be changing, health experts said Thursday.

Six of the last seven cases confirmed in the past couple weeks are from northern Thai Binh province and are connected to two families - with some relatives showing no symptoms of the disease. Health experts are unsure whether the new cases signal the possibility that the virus is slowly transforming to allow human-to-human transmission or just underscore more careful detection.

"Certainly, it calls for investigation. It's too early to say whether these cases are any different from previous cases or not," said Dr. Peter Horby, a Hanoi-based epidemiologist for the World Health Organization.

"The two people with atypical infections could be related to improved testing, or it could relate to some difference in the virus. We won't know till we isolate the virus. It's too early to be raising alarms," he said, referring to the two latest cases.

In those cases, an 80-year-old man, whose two grandchildren are hospitalized with the bird flu, and a 61-year-old woman, whose husband died from the disease, both tested positive for the H5N1 virus but showed no signs of illness.

The mild or even symptomless infections raise the possibility that the H5N1 virus is changing, and that there may be more undetected cases.

"Undoubtedly, there are more cases than those we detect . . . I'm sure there's cases we're missing," Horby said.

Hmm. What do other flu experts think (KeralaNext)?

The H5N1 bird flu virus might be acquiring a greater ability to spread from human to human, recent cases in Vietnam suggest. But as two elderly relatives of patients killed by the bird flu test positive for the virus and yet have no symptoms, there are also indications that it may not be as lethal as currently thought.

The 2004 outbreak of H5N1 in Vietnam stopped in spring after the country killed millions of infected and exposed poultry. But outbreaks resumed in December, probably because the virus persisted in ducks showing no symptoms, say flu experts. Since December, 22 people have tested positive for H5N1 in Vietnam, of whom 14 have died, including one woman from Cambodia.

Five of the cases occurred in clusters that suggest the virus passed from person to person. In the most recent, a 14-year-old girl fell ill on 14 February, her 21-year-old brother on 21 February, and a 26-year-old male nurse who cared for the brother, on 26 February.

Spread of the virus to health care workers would be worrying, says leading flu expert Robert Webster at the St. Jude Children's Research Hospital in Memphis, US. Attending a conference on microbial threats in Lyon, France, last week, he told New Scientist: "That's where we'd expect to see the first cluster if this virus starts spreading among humans."

So here is how I read it. Dr. Horby may express confidence asymptomatic cases represent no threat, but there are enough uncertainties here to suggest his expression of confidence may indicate he sees himself as working for the World Reassurance Organization, not the World Health Organization.

Not very reassuring.

How oseltamivir (Tamiflu) works (and does it?)

If avian influenza transforms to a form easily passed from person to person it cannot be stopped. The question then becomes what to do at that point. At the moment there is no vaccine and it is likely that an effective vaccine will take many months to produce and many more to distribute. Social measures to reduce contact between people like cancellation of public gatherings, quarantine or isolation might have some effect and will certainly be tried. But the only other preventative is the use of antiviral medications. There are four currently effective against influenza A, but it appears that the two oldest, of the adamantine class, are ineffective against H5N1. That leaves two neuraminidase inhibitors, oseltamivir (Tamiflu)_and zanamivir (Relenza). The latter cannot be taken orally so it must either be given i.v. or via inhalation. Only the inhaled product is currently available.

This is a brief primer on influenza A virus and oseltamivir (many details have been omitted).

Influenza A/H5N1 and antiviral drugs

Viruses exist on the border between living and non-living. They don't grow and they don't metabolize. They just reproduce. And while they possess all the genetic information needed to reproduce, they have none of the machinery to do so. They are like a blueprint and a mailing envelope but no factory to make new copies of themselves, depending on their host's biological mechanisms to reproduce. Sometimes commandeering host machinery can be done peacefully. Sometimes it kills the host cell in the process.

The genetic information in influenza virus is encoded in RNA (we encode our genetic information in DNA, and use RNA as part of our protein manufacturing process). However the replication process in this virus is especially error prone, with an error rate roughly 100,000 times that of DNA replication. Thus every round of virus replication produces a number of variant copies, most of which will be changes disadvantageous to the chances for viral survival, but some few of which might confer a competitive advantage. They are the ones that come to predominate over time. As conditions change, new ones arise. Influenza A is a prime example of evolution in action. (NB: Not believing in evolution will not protect you against influenza.)

These individual copying errors are not the only way genetic variation can arise in this virus. The genetic material is segmented into eight sections, each of which codes for a particular protein important for viral survival and replication. If two different strains of virus, say one from a bird and another from a human, coinfect the same cell, they can "mix and match" segments and produce entirely new combinations. In addition, some suspect that occasionally pieces of segments from different strains can become swapped (a process called recombination), although this has been the subject of scientific debate. Whatever the mechanisms, this is a quickly mutating virus.

The consequence of mutation from our point of view is that it may affect how virulent the virus is (i.e., how likely it is to kill its host cell), what host species it can infect, how contagious it is and how much natural or previous immunity we have. Little is known about the genetic determinants of most of these important characteristics, but we know something about the question of immunity.

Most of the foreign viral proteins are invisible to our immune systems, but two of them are "seen" by it. Physically the virus has genetic material surrounded by a protein and fat-containing capsule which has two kinds of "spikes" sticking off its surface, called hemagglutinin and neuraminadase, abbreviated H and N. In bird species, which are the natural home or reservoir of all influenza viruses, there are 16 different H types (H1 - H16) and 9 N types (N1 - N9). Human infections have so far been limited mainly to the H1N1, H2N2 and H3N2 strains. We know of no previous (before 1997) infections with H5N1, which means the human species is immunologically naive to this strain, one of the main concerns of public health authorities.

The virus begins its life cycle by attaching to the cell surface of its host via its H protein spike. To do this it needs an attachment spot marked by a particular kind of molecule, its "receptor." This is an important place where genetic information determines what kind of host the virus can infect, because different influenza strains recognize different receptors. If the host doesn't have that receptor the virus can't attach. Other factors specific to the host cell are also required for attachment and subsequent events. Acquiring the genetic information that allows attachment to a new host is one instance where mutation or reassortment can produce strains of virus with entirely new properties.

Following attachment the virus fuses with the host cell membrane and enters the cell (we omit here some imortant detail related to other antivirals). After the virus replicates its genetic material inside the host cell and produces new viral proteins the components assemble themselves in many copies at the cell membrane, budding outward and incorporating some parts of the host cell's membrane in the enclosing capsid. However the resulting viral progeny are still stuck to the membrane via the receptors. The function of the N (neuraminidase) spike is to break that attachment and allow the virus to float off and find a new host cell within which to make still more copies of itself. Without the action of neuraminiadase the virus will remain stuck on the cell surface and not be able to reproduce further. That is where oseltamivir and zanamivir come in. By inhibiting neuraminidase they prevent the virus from leaving the cell surface.

It appears that the mutations in the N spike needed to make the virus resistant to oseltamivir also compromise the function of the neuraminidase enzyme so it is much less effective in releasing the virus. Thus, at the moment it seems viral resistance to oseltamivir does not develop easily or effectively. This could change as the cat and mouse game of virus and defenses continues. We don't know at this point.

Does it work?

Apparently, yes. Experience in animal models and human outbreaks shows that oseltamivir is quite effective if given prophylactically or within the first 48 hours of onset of illness, where it can shorten the duration and decrease the severity of illness. Because this is a short period, because illness onset may be hard to recognize and because viral replication and shedding peaks early, prophylaxis will be more effective than attempted rapid treatment in an epidemic situation. For this, of course, adequate supplies and a distribution system is required, neither of which we have. So while oseltamivir works, it is unlikely to help much if a pandemic comes within the next year or two, as many expect. Given the lead time we have had, this is inexcusable. But even if adquate supplies were available (and they are not), its use might slow but wouldn't stop a pandemic. However the added time could save many lives as the world hurries its preparations.

Those interested in more of the underlying clinical data might consult a recent paper by Ward et al. "Oseltamivir (Tamiflu(AR)) and its potential for use in the event of an influenza pandemic," Journal of Antimicrobial Chemotherapy (2005) 55, Suppl. S1l, i5 - i 21. This paper was written by scientists at Roche, the makers of Tamiflu. Given the rather sorry ethical history of big pharma, you should make up your own minds as to whether this affects its very positive assessment of their product. My reading suggests the information is accurate and reliable, but I would be interested in informed views to the contrary.

Two ways to get it wrong but only one is right

It may be understandable, but it is also unacceptable. The "default assumption" is that a new case of bird flu was contracted from contact with sick poultry, to be ruled out only in the face of overwhelming evidence to the contrary. This is the reverse of the precautionary approach appropriate to such a grave public health threat.

Today Vietnam announced several more cases that were missed because they did not have the typical presentation of bird flu infection. It is significant that in both cases they are family members of confirmed cases, that is, part of familial clusters. One is an 80 year old grandfather of the two confirmed sibling cases (ages 21 and 14) from Thai Binh province reported earlier. AP (via ABC News) is also reporting that the 61 year old widow of a 69 year old man who died of bird flu on February 23 has also tested positive for the infection. Both of these new cases are reported to be in good health but have been isolated in their homes.

In each instance the reports start from the assumption that the disease cluster arose from a common source rather than person to person transmission.

Health authorities suspect that the three family members, from northern Thai Binh province, caught the virus after eating an infected goose slaughtered by the grandfather a month ago, and there was no immediate indication that they had infected one another.

Earlier this week, Vietnam reported that a 26-year-old male nurse who cared for the grandson had also been infected by bird flu but health officials said it was likely he contracted the disease outside the hospital.

Several cases in Vietnam and Thailand have involved family clusters, with several relatives were infected at the same time, though there has been no evidence that the virus has mutated into a form easily transmitted by people. Health officials warn that when that happens, the virus could spark a global pandemic that kills millions. (Irish Examiner)

Unfortunately, wishing won't make it so. The two possibilities here are that a family cluster arose from a common source, such as contact with infected poultry, or from person to person transmission. Contact with poultry in this part of the world is almost ubiquitous, so eliciting a history of such contact by no means rules out person to person transmission. The main indicator would be the timing of onset of the cases, and in each of these instances the assumed common source exposures (eating chicken, duck or goose) around the Tet holiday seems too remote to account for these cases.

Nor is it true there is "no evidence" of person to person transmission in these cases. As Henry Niman has emphasized repeatedly, the bimodal timing of onset and the period from the last known or assumed poultry contacts in a number of the familial clusters points in the opposite direction.

Underneath this is a widespread but unspoken fear among public health authorities that "raising the threat level" (to use contemporary terminology) will "unnecessarily" produce widespread fear and panic. If we are lucky enough for this to be a false alarm, the result would be a loss of credibility.

If you are looking for propositions for which there is "no evidence" I suggest you start right there. If the public trusts its health authorities (and that trust has to be earned by a history of honest communication) they will neither panic nor lose faith in them when a feared possibility doesn't materialize. I know of no evidence to show that sounding a justified alert will result in a damaging loss of needed credibility if the alert turns out to be a false alarm.

Admittedly this is a tough call for public health and there are two ways they can get it wrong: failure to warn when it turns out the warning was justified, or warning when it turns out otherwise. Using a public health precautionary approach it is clear we should be more inclined to accept the latter risk than the former, although national and international officials are tilting in the other direction. If you are going to get it wrong, it is better to err on the side of precaution than the reverse. In the US, the low key posture CDC is taking to bird flu is an unfortunate example of the wrong way to do it.

To use another well-worn cliché of the post 9/11 era, we are talking about a possible failure to "connect the dots." The dots can't get any bigger. The disconnect is at the level of responsible public health leadership.

Open questions remain open

It has been evident for some time that there are many missed cases of influenza A/H5N1 (bird flu) in southeast asia (newstory from AFP; for a good summary with some acerbic commentary, see Henry Niman's Recombinomics site). Most confirmed cases have come from Vietnam, which has the best developed public health and medical care infrastructure, but Thailand, Cambodia and Laos all have endemic poultry problems and very likely human cases as well. It is also likely that not all of the reporting failure relates to infrastructure. Civil authorities are often reluctant to admit the existence of cases for economic or political reasons.

The implications for public health of this missing information are hard to judge. On the one hand, it might mean that there is more widespread human infection and thus evidence that the disease is more easily transmissible between people than believed to this point. Evidence from last year's Japanese studies of bird cull workers and the experience of the H7N2 outbreak in The Netherlands certainly point in this direction. Thus we are missing early warnings of an impending pandemic. On the other hand, it might mean the disease is less virulent than the recognized cases suggest, which would be good news. At this point either or both could be true.

It is past time when the international community should insist upon and support intensive and urgent case finding and seroprevalence studies in the southeast Asian region and other areas where bird flu is a plausible explanation for unexplained illness. Henry Niman's suggestion that the Baguio, Philippines meningo-like disease should be ruled out as avian influenza is a case in point.

The uncertainty and confusion caused by the missed cases is now part of the public discourse. It is very hard to understand WHO's failure to make public statements about what they know or don't know about these questions, as we asked in our Open Letter of February 16. It would cost them nothing to respond. Failure to respond will only encourage further the speculation which always rushes in to fill information vacuums.

We repeat the summary questions from our Open Letter here:

i. What are the criteria by which statements regarding possible person-to-person transmission of H5N1 are made in the face of evidence that initial testing produces some false negatives? In particular, what does WHO know about the negative predictive value of the diagnostic tests now in use in Thailand and Vietnam where time-space clusters of cases have been reported?

ii. The Recombinomics website (http://www.recombinomics.com) raised the possibility that in a number of instances certain events could conceivably represent H5N1 infections. These include the meningo-like outbreak in the Philippines and reports of sudden bird deaths in North America. There was no claim these were H5N1 infections, only the reasonable question whether anyone had thought of the possibility and bothered to verify it or not. It was announced that WHO sent a team to the Philippines to investigate the outbreak there. Given the level of concern regarding an H5N1 event, a response from WHO would be useful.

iii. Recently there has been some discussion, both on the Recombinomics site and via email, about influenza A/H1N1/WSN/33 sequences in Korean swine influenza A/H9N2 reported to GenBank in October 2004. There are rumors that WHO has looked into this and resolved the issue. If this is true, a statement to that effect is necessary. Because of the gravity of the implications, we believe some public explanation is required.

We urge WHO to recognize the new setting regarding public health information generation and dissemination and act accordingly. Failure to do so will only create confusion where clarity is desperately needed.

The Editors (phrevere@gmail.com)
Effect Measure
http://effectmeasure.blogspot.com

CDC on the skids

The open secret that CDC was in disarray poked its head above water Saturday in a story in the Washington Post, "Internal Dissension Grows as CDC Faces Big Threats to Public Health." For months there has been a rush to the exits by some of the agency's most senior scientists, as Director Dr. Julie Gerberding "restructures" CDC out of existence and opens the door wider to political interference. Last week a National Academy panel criticized the agency for lack of leadership in implementing the ill-fated smallpox vaccination program of health care workers, a program that was flawed from the outset in purpose, public health rationale and buy-in from the nation's public health establishment.

Gerberding's restructuring has caused deep resentment at CDC and was reportedly done in a heavy handed style that brooked no discussion or explanation. As one senior CDC scientist told me, the only "rationale" given was "deal with it." Like other incompetent managers, Gerberding blames complaints on "resistance to change." Assuming the massive changes she is calling for make sense (something disputed by many), it is clear she has failed to prepare the ground.

"CDC folks are a very dedicated bunch . . ., [but] it's gone from dedication to make change to being aghast at the process and the changes being made," one senior official said. Among the 34 people interviewed for this article, this official and a number of other current and former CDC staff spoke on the condition they not be identified because of their intense loyalty to the agency and, in some cases, because they fear retribution.

[ . . . ]

Taken together, the turbulence at the agency has created a "crisis of confidence" and an atmosphere of fear in which employees feel "cowed into silence," wrote one top CDC official, Robert A. Keegan, in a widely circulated memo to Gerberding and other top leaders.

"I think there is a crisis," added Keegan, deputy director of the global immunization division, in a phone interview. "Clearly there is a real problem with morale. People are feeling tired and frustrated and don't know where we're headed."

With respect to the Bush administratioin, however, Gerberding has been unusually accommodating. Among other strong criticisms, the National Academy panel had this to say:

"The ability of the Centers for Disease Control and Prevention to speak authoritatively as the nation's public health leader, on the basis of the best available scientific reasoning, was severely constrained, presumably by the top levels of the executive branch," the panel wrote.

But her "make nice" strategy didn't protect CDC from deep cuts in the Bush budget request, cuts that come despite a potential public health catastrophe of an influenza pandemic. As a result the agency still has no final pandemic plan, has grossly insufficient stockpiles of antiviral agents and no firm plans to secure the needed amount and has failed to provide leadership to state and local public health on this and many other issues. CDC is now coasting on a reputation that it no longer deserves. Its decline into second class status started before Gerberding's tenure and is symbolic of the overall leadership crisis in public health in this country. But she has accelerated the fall at a time when we can least afford it.

I wonder how many people will die because of the Bush administration's lack of support for public health, their meddling in the judgments of competent scientists, and the lack of leadership at top levels? Gerberding and her agency have failed to provide independent leadership at a time when we need it most. When will she publicly fight for public health?

Nurse with bird flu in Vietnam: source uncertain

A 26 year old male nurse from Thai Binh province who cared for case number 18 (the 21 year old elder brother of case number 20) has been diagnosed with influenza H5N1 (bird flu) and is in stable condition at Bach Mai Hospital in Hanoi (via AFP, AP, Reuters, The Scotsman)

At this time health officials could not say if the patient had exposures other than to the other patient. Thai Binh province is the site of several other human cases and also poultry outbreaks. The Vietnamese health authorities speculated he might have been exposed to infected poultry when he visited his girlfriend in Thai Binh during the Tet holiday, but this remains speculation at this point (and perhaps wishful thinking).

Biodefense: a (very) bad idea whose time has come?

This week more than 750 microbiologists sent an open letter to NIH Director Elias Zerhouni warning that an overemphasis on "biodefense" was threatening to harm fundamental research in public health (.pdf here and supporting material here, also .pdf). Using publicly available data the scientists demonstrated the baneful effect the biofense agenda was having on support for important research into organisms of genuine public health concern, while simultaneously diverting vast sums into research of little public health significance, all on the grounds it involved potential biowarfare agents. This is an important development and a good start. But the argument they advance is too narrow. The problem goes far beyond effects on basic research in the physiology, pathophysiology, genetics and epidemiology of infectious disease agents.

Here are other important issues:

1. The wholesale distortion of priorities entailed by the biodefense agenda is not limited to infectious disease research. Virtually all of public health is affected. It is no secret that fiscal pressures on federal, state and local health authorities have produced cutbacks in routine public health services like substance abuse, maternal and child health, immunization programs, vital records and surveillance, sexually transmitted disease clinics and programs, and many others. Simultaneously, earmarked funds for biodefense have been flowing uncontrolled into the system. The result is that personnel are taken off routine public health activities that deal with problems that happen daily and put onto worthless biodefense "leaf-raking" exercises (like repeated needs assessments and contingency planning for events that will likely never happen). This produces major personnel reassignments and massive reordering of priorities.

2. Infiltration into the public health mentality of the military mindset is now taking place. The money comes from Department of Homeland Security and the DHS boys don't take you seriously unless you talk the Homeland Security talk. And that vocabulary is the vocabulary of terrorism and terrorists, al-Qaeda targets, strike opportunities, assets, threat assessments, vulnerabilities and on and on. It used to be if you went to an interagency meeting, the fire folks sent their chief, the police their commander, public works their director and public health sent a committee. Public health used to be horizontally organized: many programs working together across different populations but for a common purpose. Now public health is part of the "chain of command" and is organizing to respond via the "incident command system," becoming an arm of public safety (fire, police, EMS), not the care-givers and invisible supports of the community. There is an old saying, "When public health works, nothing happens." Now, public health doesn't work until something happens. And maybe not even then. Meanwhile we have named our own "commanders" to send to the meetings and everything travels up and down the "chain of command."

The Science Friday NPR show on 3/4/05 provides a poignant illustration (link to streaming audio here). In an otherwise sensible discussion of the total lack of "biosecurity infrastructure" in the US (by which the discussants meant basic public health infrastructure, but the change in terminology itself is telling), Jeffrey Romoff, president of the University of Pittsburgh Medical Center, strongly pushed the notion that the model to use is not a public health model but a defense model. He blatantly tried to hook the public health wagon to the biodefense star by saying the threat of an avian influenza pandemic was like a terrorist threat and should be approached and treated in the same way. It is obvious what he meant here and equally obvious what his strategy is. But the end result is that we play with their ball, on their field and by their rules. Bad idea. Here are some other reasons why.

3. The "biodefense" agenda is likely to make us less safe, not more safe, even from bioterror weapons. Terrorists aren't sitting around reading molecular biology journals and planning intricate experiments that are not likely to succeed, even after months or years of effort. These kinds of experiments require years of training and equipment not found in apartments in Hamburg or ranches in Montana. If they are so inclined they fill up a truck or a car with explosives or buy a dozen assault rifles and hit a "soft" target. The weapons are ready to hand. Novel pathogens are not . . . They aren't, that is, unless someone is obliging enough to make them for you, which is exactly what is happening under the guise of the biodefense research and development agenda. If you want to make a detector, a diagnostic reagent kit, a therapeutic drug, a vaccine--the first step is to make the organism. Now, something that never existed before is ready to hand. Forget about the high containment and high security laboratories are springing up to house this work. No matter what the containment, the weak link is always the human element. Even without considering the inevitable lab accidents (and they happen and even cause death to workers in the highest containment laboratories in the world), we shouldn't forget that the weaponized anthrax that brought American public health to its knees responding to "white powder events" in 2001 almost certainly came from one of these laboratories.

4. Some of the research will inevitably be secret or classified. No public health research that is classified can serve a public health purpose or even a legitimate scientific agenda. If the results of our research is not to be made available to the global public health community of scientists and public health workers, we are not serving public health, a global enterprise of shared knowledge and endeavor. Instead, we corrupt that enterprise, just as physics was corrrupted by the Cold War.

5. There is no effective civilian oversight for this research. This means we will have no way of knowing whether it violates the community standards of public health, or as a public health leader put it, no way of guarding against public health pornography, by which he meant research on ways to hurt people or make them sicker.

6. Parts of the biodefense agenda will plausibly stimulate a biological arms race. In Boston they are building a "biodefense" laboratory that, from the outside, has all the appearances of an offensive weapons laboratory (although I hasten to say I doubt it is). But appearances are crucial. The laboratory will have animal quarters, aerosol exposure chambers and high containment laboratories (BSL4) which could also be used to work on offensive biowarfare projects. Even for our allies, this is liable to give pause and suggest to them they might want to hedge their bets and start or augment their own programs.

Public health advocates initially welcomed biodefense money on the grounds it would have "dual use" effects. But it hasn't turned out that way. The infrastructure continues to decay, and deforms in the process. As one leader put it recently, public health is like the man who goes to the gym every day and exercises his right arm, which becomes hypertrophied, while the rest of his body atrophies. The same source compared trying to build public health with bioterrorism money with trying to invent Tang by building the space program.

Unfortunately, the Bush Administration seems to have gotten public health to drink the KoolAid, not the Tang.

Bush funds scientific pornography

When the Supreme Court first ruled on pornography, one Justice noted that while it was difficult to give hard and fast criteria for what was a violation of community standards, "he knew it when he saw it." From The New Scientist (via Common Dreams):

Maximum pain is aim of new US weapon
Exclusive from New Scientist Print Edition
David Hambling

The US military is funding development of a weapon that delivers a bout of excruciating pain from up to 2 kilometres away. Intended for use against rioters, it is meant to leave victims unharmed. But pain researchers are furious that work aimed at controlling pain has been used to develop a weapon. And they fear that the technology will be used for torture . . .

The "research," discovered by our friends at the Sunshine Project and going under the title "Sensory consequences of electromagnetic pulses emitted by laser induced plasmas," generates Pulsed Energy Projectiles (PEPs) from a laser, producing a burst of expanding plasma when it hits something solid (like a human being).

According to a 2003 review of non-lethal weapons by the US Naval Studies Board, which advises the navy and marine corps, PEPs produced "pain and temporary paralysis" in tests on animals. This appears to be the result of an electromagnetic pulse produced by the expanding plasma which triggers impulses in nerve cells.

The new study, which runs until July and will be carried out with researchers at the University of Central Florida in Orlando, aims to optimise this effect. The idea is to work out how to generate a pulse which triggers pain neurons without damaging tissue.

The contract, heavily censored before release, asks researchers to look for "optimal pulse parameters to evoke peak nociceptor activation" - in other words, cause the maximum pain possible. Studies on cells grown in the lab will identify how much pain can be inflicted on someone before causing injury or death. [my emphasis]

To say this is beyond the pale doesn't begin to describe it.

New Scientist contacted two researchers working on the project. Martin Richardson, a laser expert at the University of Central Florida, US, refused to comment. Brian Cooper, an expert in dental pain at the University of Florida, distanced himself from the work, saying "I don't have anything interesting to convey. I was just providing some background for the group." His name appears on a public list of the university's research projects next to the $500,000-plus grant.

I wonder who will play the "dental scientist" Mr. Cooper in the movie now that Laurence Olivier is dead.

If this isn't obscence science, I guess I don't know it when I see it.

Automation, chicken shit and sole food

If you are wondering what "industrial chicken farming" is like, go to this site and click on the video for the EZ Catch Chicken Harvester. Here's Boing Boing's teaser:

No science fiction movie has ever had a machine as creepy as the E-Z Catch Harvester, a machine that uses rapidly rotating brushes to catch chickens and convey them into pens. The video clip is a must see.

The link to the video is at the top of the page, under "Life just got Easier." Not for the chickens.

They may still have posthumous revenge. In the UK (not sure if this is true in the US or not; readers?) imports of poultry meat from bird flu infested areas are banned, but not imports of feathers. Professor Hugh Pennington told listeners on BBC Radio 4's Farming Today show that duck, chicken and turkey feathers were still being imported for pillows. He raised the possibility that virally contaminated fecal material might remain on the feathers, bringing bird flu to UK poultry.

Professor Pennington's chicken-shit objections aside, the US Department of Agriculture has issued a warning to eleven states that banned boneless chicken feet were illegally smuggled into the country from Asia (ApP via via MSNBC). Stores in Cleveland and Columbus, Ohio, have been de-feeted already by on the ball inspectors. Colorado, Georgia, Kentucky, Massachusetts, Michigan, Minnesota, Pennsylvania, Rhode Island, Tennessee and Wisconsin also got them from a Connecticut distributor, Food King.

Presumably because they weren't wearing shoes, they passed through US airport screening unmolested.

"This is Chuck E. Cheese, you know"

The call was a larceny in progress at Chuck E. Cheese. Aurora, Colorado police officers arrived to find 29 year old Danon Gale allegedly loading his plate at the salad bar but refusing to show the manager proof he had paid. He had two accomplices, ages 3 and 7. Asked to step outside "to discuss the incident," Gale refused. A police spokesperson said he then became argumentative and shoved one of the officers. While the spokesperson wasn't there to see what happened, another patron was:

"One of the officers kept poking the gentleman in the chest," Felicia Mayo told the Rocky Mountain News.

She was there with her 7-year-old son. She told the newspaper that Gale told the officer, "You don't have to do that." She said Gale never put his hands on the officer who was confronting him.

The argument escalated until Gale was shoved into the lap of Mayo's sister, who was sitting two booths away, holding a 10-month-old baby. That's when police pulled out a Taser stun gun to subdue him.

"They beat this man in front of all these kids then Tased him in my sister's lap," Mayo told the newspaper. "They had no regard for the effect this would have on the kids. This is Chuck E. Cheese, you know."

Gale's two children were "screaming and hollering and crying" as Gale was tasered two times with the stun gun.

Police arrested Gale as his children and other customers and their children watched. They took him outside, leaving his children inside the restaurant.(ABC Denver7 News)

He was booked for disorderly conduct, resisting arrest and trespass. Police determined that proper procedures were followed in the use of the Taser.

Yep. Sounds right to me. If you can't use a Taser to stop larceny at a Chuck E Cheese salad bar, when can you use it?

ChoicePoint: an undistinguished choice

Ever since first writing (here, here and here) about ChoicePoint as Taser, International's pick to do background checks when they sell their weapons to the public, I've been hearing from EMers with other ChoicePoint revelations. Here are a couple of things that have come up.

It is not too reassuring that ChoicePoint will be all that stands between me and a fellow citizen wielding a Taser since we know so far they have not been too astute in figuring out that they themselves were doing business with criminals. It turns out that the recent sale of 150,000 private records to identity thieves was not even the first time this has happened to ChoicePoint. Wired has a story that a brother and sister took them for a ride in 2002 by using false papers to obtain the accounts of 7000 people, which the pair then sold to Nigerian immigrants for $40 to $50 a pop. (AP via Wired)

There has also been a fair amount written about ChoicePoint's role in the 2000 Florida presidential election "process" as well. The dKosopedia has a good rundown. Here's a bit of it:

Journalist Greg Palast has argued that the firm cooperated with Florida Governor Jeb Bush, Florida Secretary of State Katherine Harris, and Florida Elections Unit Chief Clay Roberts, in a conspiracy of voter fraud, involving the central voter file, during the US Presidential Election of 2000. The allegations charge that 57,700 people (15% of the list), primarily Democrats of African-American and Hispanic descent, were incorrectly listed as felons and thus barred from voting. Palast estimates that 80% of these people would have voted, and that 90% of those who would have voted, would have voted for Al Gore. The official (and disputed) margin of victory, in the election, was 537 votes.

ChoicePoint Vice President Martin Fagan has admitted that at least 8,000 names were incorrectly listed in this fashion when the company passed on a list given by the state of Texas, these 8,000 names were removed prior to the election. Fagan has described the error as a "minor glitch". ChoicePoint, as a matter of policy, does not verify the accuracy of its data and argues that it is the user's responsibility to verify accuracy.

There's lots more stuff at dKosopedia and plenty of links.

So good choice, Taser, International. You've hired the best.

Student summit: "Carry It On"

When this blog was getting started I posted a call to action, "The Train is Leaving the Station: All Aboard." Here is part of it:

One of Revere's (not so modest) objectives is to jump-start the process of reconstructing and re-invigorating the progressive public health movement in this country and by speaking in a distinctive voice, to advance the conversation . . .

[ . . . ]

Since the social movements of the 1960s, in which Revere took part, a whole generation has matured, and yet another appeared. Within the ranks of public health are many young, savvy idealists. Revere believes they are ready to take the lead in a new public health movement. Climb aboard.

That was in early December, 2004. Well, the Train is starting to move and there are people aboard. Here is an Announcement I received via email:

Day-long PUBLIC HEALTH STUDENT SUMMIT
Defining the Future of Public Health
Saturday, April 9, 2005

Boston University School of Public Health and the Health Not War student caucus are hosting a full-day summit on the future of public health. While all are welcome, we are particularly interested in reaching out to students of public health (broadly defined) who are thinking about their future, and the future of global public health.

The day will include two plenary sessions with speakers, workshops, and an evening social event. Workshop topics will include the history and legacy of public health activism, global health implications of U.S. policy, the ethics of advocacy by public health scientists, and the consequences of the increasing bioterrorism focus of public health.

There is no registration fee, although we are still seeking contributions and co-sponsorships from other student groups, campus organizations and schools.

Please spread the word, visit our website, and register!

http://people.bu.edu/hnw/

If you have questions, suggestions, would like to participate in the planning, or are interested in co-sponsorship, e-mail hnw@bu.edu

I inquired about this event and this is what I found out. These public health students are exactly the kind of new activists I was hoping would materialize in my post of months back. Moreover, they are not alone, but are in contact with their many colleagues in the region. They have already received, through their website, dozens of advance registrations from around the New England region in just a few weeks. I guess the time has come. The Train really is leaving the station.

Expecting people via car, train, bus, subway, whatever, their sleeping bags and sandwiches for the journey in hand, they will broker "lodging" on the couches, floors and spare beds of the locals. Some contributions are in hand but more are hoped for. Sixties redux. Be still, my atherosclerotic heart!

As of my inquiry, the program was something like this. Early plenary keynote; two concurrent workshops in the morning (tentatively on the History of Public Health Activism opposite Global Public Health Issues and US Policy) and two others in the afternoon (tentatively, Public Health Advocacy opposite Implications of the "Biodefense" Agenda for US Public Health), separated by Lunch and at some point, either before or after the afternoon workshops, time set aside for Caucuses on specific issues (anti-War, reproductive health, GBLT, etc., depending upon the initiative/intresesets of participants). Final wrap-up plenary speaker, dinner and a "social event" (aka, party).

Not sure if other things will happen or not (My fantasy: drafting of a "Boston statement" for a new progressive public health movement). The Reveres will be there (under their real names).

I visited the Summit website and was pleased to find links to the progressive public health blogs Confined Space, Impact Analysis, Health Care Renewal and, of course, Effect Measure (of course!).

These folks have their act together. Saturday, April 9. Hope to see some of you there. Be another link in the chain.

Recent bird flu developments

Local newspapers in Vietnam are reporting three more suspected cases of bird flu in the northern part of the country (via Xinhuanet [PR China]). The previously confirmed cases of the 35 year old woman garbage collector and the brother and sister, from Thai Binh province near Hanoim are still being treated, although they appear to be doing better. One of the new patients was again from Thai Binh, the other two from Hai Duong and Nam Dinh provinces.

Meanwhile in Indonesia's West Java region, bird flu has reported again, killing over 12,000 chickens in the last two months and still spreading (reportedly H5N1 and H7N1). The Indonesian government is upbeat about containing the outbreak, but The Jakarta Post (via IndoExchange) has this caution:

The government only went public with last year's bird flu outbreak after remaining silent for five months.

Until it came out and publicly acknowledged the outbreak, the government was insisting the country was free of the disease, which was first spotted on Aug. 29, 2003, in Pekalongan, Central Java. The government had been blaming the deaths of thousands of chickens across East Java and Bali on Newcastle disease, which is caused by a virus that is harmless to humans.

Hardly reassuring.

Friday cat flogging: Taser, the cat

Friday is the day we obey the injunction of PSoTD to feature another blog rather than show pictures of our cats and dogs. I departed from this once before when I featured a bizarro religious rant on why Christians shouldn't have cats. I will violate the order of PSoTD again this Friday to bring you:

Police say using Taser on cat appropriate (Big News Network.com)

Police in Gillespie, Ill., say that after failing to catch an injured cat with a harness pole, they used a Taser gun on the animal.

Gillespie Police Chief Rick Hearn said his officers' response was appropriate given the circumstances, reported the River Bend (Ill.) Telegraph Monday.

Officers were called after it was reported two cats were fighting in a garage. One cat, which had lost an eye and was badly mangled, escaped to the garage's rafters and police called animal control officer Jessica Spangler.

The newspaper said the officers tried to net the cat, but when that failed they used Taser gun on the injured animal.

Once the cat was brought down, Spangler told the officers the cat was severely injured and ordered them to shoot it. They did . . .

So first they Tasered it, then they shot it. I get it.

"Chicken Flu" and the bioterrorism drumbeat

A reader has linked in Comments to a Commentary published February 28 in the LA Times by Wendy Orent, "'Chicken Flu' is no big peril" (hat tip, Akka). Orent's argument goes something like this.

Earlier this year we heard a lot about the possibility of a pandemic because of the explosive spread of H5N1 among poultry in southeast asia combined with the potential for mutation into a form that could pass easily from person to person. Then came the flu vaccine shortage. But the flu season has been milder than usual and there has been no pandemic yet. So Orent takes CDC Director Julie Gerberding to task for spreading the alarm despite the fact that there is no fire. This is the opposite position we have taken here, taking Gerberding to task for not spreading the alarm because there is smoke.

There is more to Orent's argument, of course. She notes that virologist Jeffrey Taubenberger, who has studied the genetic make-up of the 1918 pandemic virus, believes it did not acquire its HA gene directly from birds. She does not mention that he believes the 1918 was already "mammalian adapted" (see Taubenberger, J. Virology, August 2002). This is an important point because the H5N1 currently circulating in southeast asia has already adapted to an impressively wide range of mammalian hosts, including humans.

I don't disagree with her point that the high virulence for chickens is likely a by-product of large industrial farming practices, a point made here a number of times. So what? Orent's claim that the current H5N1 virus has "evolved to kill chickens" is incorrect. It has evolved to reproduce. Killing chickens is an irrelevant by-product. It does nothing to ducks. This is typical of most avian influenza viruses: they are of low pathogenicity. The fact that this one is highly pathogenic to poultry is unusual and likely a consequence of the crowded conditions she cites.

The only thing needed now for a pandemic is a change to allow efficient human-to-human transmission. If the virus does mutate in that fashion and retains only a small fraction of its current virulence for humans, we are in for a big problem. Note that it is already highly pathogenic to humans, with a high case fatality that is much different than the 1% she cites for the 1918 virus. And her argument has a flip side: consider the havoc wrought by a virus that only had a 1% mortality. Suppose this one has a case-fatality of only 5% or 10% instead of the current figure which is in excess of 70%?

Finally, her claim that it is "faulty logic" to expect that the absence of the heightened human crowding accompanying World War I troop movements would allow a pandemic virus to develop is itself an astounding case of defective logic. Looked at purely as a matter of logic, this amounts to the claim that crowding in humans is a necessary (not just a sufficient) condition for the mutation of a virus to virulent form. This is not a matter of logic but of what the facts might or might not be. Moreover she confuses transmissibility with virulence. This virus has already developed terrible virulence for chickens and humans. The only thing missing is easy transmissibility, for which crowding is not a selector.

But the most bizarre part of Orent's argument comes at the end. Don't worry about bird flu, she says. What we really should be worried about is a resurgence of pneumonic plague (The Black Death). She cites a reported outbreak in a mine in the Congo:

The logic is clear: It's human disease factories and not a virus mutating among chickens that should command our attention. We ought to be more worried about conditions such as the Congo mine, where sick people huddle with healthy people and deadly disease can evolve to terrifying effect, than about an avian flu threat that most likely will never come to pass.

But there is no logic here, much less clear logic. There is only a dubious claim. I agree we should be worried about human disease factories "where sick people huddle with healthy people and deadly disease can evolve to terrifying effect," but I strongly disagree with her illogical path to complacency about "an avian flu threat that most likely will never come to pass." Wishing won't make it so.

Orent has a history of beating the bioterrorism drum. This is another example of how that preoccupation is destroying genuine public health concerns.

Shoe leather epidemiology

Here's the way you hope it would work :

Last week, a British Midlands flight from London to Dublin was quarantined after eight passengers, who flew to London on a chartered flight from the Chinese capital, became severely ill.

Two of the passengers developed flu-like symptoms and began vomiting at London’s Heathrow airport and later boarded a flight to Dublin. The pilot, who knew 40 of his 188 passengers and eight crew had travelled together from Beijing, quarantined the plane and called ahead for medical assistance. He suspected they had contracted the deadly bird flu. (via Sunday Times Online (Dublin); hat tip, Pathogen Alert).

And here's how it actually did work:

However, when he landed in Dublin no public health experts were available because of a strike. The passengers were allowed to leave the plane after being diagnosed with food poisoning by an airport GP and were only checked by public health officials several days later, when they were given the all clear.

[snip]

“We could have found ourselves in the middle of a serious international outbreak,” said Catherine Hayes, a public health doctor and the chair of the public health committee of the Irish Medical Organisation.

“We could have been dealing with avian bird flu or Sars. We have now traced the victims, who suffered from a norovirus (gastroenteritis), but we were two days behind in our investigation. . . .”

We can take comfort in the fact that if folks come through a US airport we would check their shoes before they disperse around the country.

Keeping track and chasing the numbers

With Xinhuanet (PR China) reporting two additional suspect cases of bird flu in the north of Vietnam, it is perhaps time to step back and take stock. The confusion over whether the the 21 year old man from Thai Binh (case 18) is alive or dead (see update to post here) should remind us that in a rapidly developing situation with multiple sources of information it is hard to keep track of what is going on. That is why we can be grateful that the Center for Infectious Disease Research and Policy at the University of Minnesota (CIDRAP) is doing the heavy lifting for the rest of us. You can find their count here, including a useful comparison with the "official" WHO figures.

Since mid-December 2004, the combined WHO, press and governmental sources, as disambiguated by CIDRAP, show 22 cases and 14 deaths (case fatality of 63%), all (except one Cambodian case) in Vietnam. The "official" figures are 11 cases and 10 deaths (case fatality 91%), representing confirmed human cases according to WHO. Going back to the beginning of the current outbreak in southeast asia (January 2004), there are 65 cases and 46 deaths in the CIDRAP tabulation (case fatality 71%) and 55 cases with 42 deaths in the official account (case fatality 76%).

People will interpret the recent spate of cases differently. WHO is urging calm:

. . . WHO says the latest reports of bird flu in Vietnam are not necessarily alarming.

It's not an alarming situation, said Hans Troedsson, Vietnam's WHO representative. What we see is the end of this outbreak.

Three or four new cases don't mean something has dramatically changed, he said. We could see sporadic cases popping up irregularly. It is very difficult to predict. (AP/AFP via The Star Online [Malaysia])

Maybe. The question is what will signal a real change in the state of affairs. We suggested earlier that an increase in the size of clusters, not necessarily the number of clusters or cases, would be a red flag. If true, this makes it all the more important to conduct thorough investigations of the familial and other clusters that do appear.

Teflon chemical sticks to DuPont 107 million times

You may not have heard of perfluorooctanoic acid (PFOA) but it has heard of you. You are probably carrying around 5 parts per billion of it in your blood serum at this moment, give or take a few ppb, as judged by measurements on populations of blood donors around the country. PFOA is one of the feedstock chemicals for Teflon and other non-stick polymers, made by DuPont and 3M. How it finds its way into virtually everyone in the country is still unknown, but people who work with it or live around factories that use it have much higher levels, by perhaps ten to thirty times. PFOA is just one of the so-called C8 chemicals that also appear in blood and the environment, although it is usually PFOA that is measured.

Is this a problem? It was for DuPont. Monday a judge in Charleston, West Virginia approved a $107.6 million settlement of a class-action lawsuit seeking damages for contaminating the class's drinking water supplies (WaPo). Some members of the class who drank the water had PFOA blood levels comparable to occupational exposures. PFOA is very persistent, with a half-life in humans of about 4 years. Even though levels in the water were relatively small (around 1 ppb since the early 1980s), it built up to levels over 100 ppb in many people tested. No health damages are being alleged, but part of the settlement will support medical monitoring and other health outcome studies, finance treatment equipment at the six water utilities and pay the legal fees and expenses of the plaintiffs (20% of the settlement).

Naturally, DuPont denies any "wrongdoing" (isn't the preferred phrase these days, "evildoing"?). They don't want to go to the expense of litigating the matter. Yeah, right. Since when has this made a difference to a chemical giant like DuPont, especially when it sets a precedent?

There is still much to know about the health effects of C8 exposure. PFOA is a known carcinogen in rats and some evidence from epidemiological studies suggests the same might be true for humans. In addition, developmental, immunotoxic and cardiovascular effects have also been seen, sometimes in animal models or test tube experiments, and in the case of lipid (fat) metabolism, in humans.

Something else for all of us to worry about. If we could only get the neocons to be as interested in these threats as they are in the ones they make up out of whole cloth, just think . . .

what? huh? Mrs. R. just poked me. I guess I was dreaming.

Tamiflu: worth "considering"

The UK Department of health clearly gets it.

The chief medical officer, Sir Liam Donaldson, said: "We must assume we will be unable to prevent it reaching the UK. When it does, its impact will be severe in the number of illnesses and the disruption to everyday life."

So today the UK announced its bird flu action plan to reduce the spread of an influenza pandemic by closing public gatherings like movies, concerts, sporting events, schools and some public spaces (Guardian Unlimited). These kinds of "social interventions" are to be kept "in reserve," to be used only if necessary. There were no current plans for quarantine or curfew.

In addition the UK announced it will buy 14.6 million courses of oseltamivir (Tamiflu), which if given within two days of onset may reduce the severity of the disease, and could have some prophylactic value for essential populations like health care workers, police, transport workers and firefighters. The purchase will be made in two 7 million-course buys, this year and next year.

And what about the US? CDC and DHHS undoubtedly have a plan, just as the UK does (although the public version has been in "draft" form since August and hasn't been finalized). But what the public announcement in the UK does is alert everyone, from local health officials and politicans to the general public, that extraordinary action might be needed and allows them to start making their own preparations, in substance and psychologically. Right now too many politicians who control scarce resources are under the impression this is another "Chicken Little" episode. But those who know don't think so.

Professor John Oxford, of Barts and The London, Queen Mary's School of Medicine and Dentistry, London, said on Tuesday governments needed to do more to accelerate planning to combat the threat of a flu pandemic.

"Whilst experts agree that over one million people could lose their lives in the next influenza pandemic, only about a dozen countries have pandemic plans in place, and even fewer of these have stockpiles of antivirals assembled," he wrote in a paper in this month's Lancet Infectious Diseases journal.

Roche's pharmaceuticals head William Burns told reporters on Monday that the United States, which has so far ordered a stockpile of 2 million Tamiflu doses, was among countries considering buying extra supplies. (MSN)

Two million doses? If the estimated quarter of a population is infected, that's 75 million courses of medication for the US, not 2 million. But don't worry. They are "considering" buying some "extra supplies."

Dr Anarfi Asamoa-Baah, assistant director general for communicable diseases at the World Health Organization, said the plan showed that Britain was at the forefront of international pandemic preparations. "We hope that every country will develop their preparations to the same high degree." (Reuters)

Yeah. Well Hope Springs Eternal, I guess.

Update, 3/1/05: Anita Manning at USA Today reports this:

France has ordered 13 million five-day treatment courses of Tamiflu, enough to cover 20% of its population, and Canada has asked for 8.6 million treatments, which would cover 17% of its population, says Terry Hurley, spokesman for Tamiflu maker Roche.

In comparison, the USA ordered 2.3 million courses of treatment last year and none so far this year.

Julie Gerberding of the Centers for Disease Control and Prevention says the stockpile is being expanded, but Health and Human Services spokesman Bill Pierce won't say whether more Tamiflu is being ordered. "We're constantly evaluating the composition of the stockpile," Pierce says.

And then there's this postscript in Manning's article:

Tamiflu is produced in Basel, Switzerland, but Hurley says at HHS request, the company will start making it in the USA this fall.

Is that what this is all about? Made in America? Jeez.

The New Yorker article

The New Yorker is running a long article on bird flu by Michael Spector in the issue of 2005-02-28. In the last week the topic has also been featured in Time, NPR, the wireservices and numerous other Main Stream Media sources. The MSM is finally awakening. Maybe they will even turn the US government from their preoccupation with phantom risks to a recognition of a real and likely one. Probably the best we can hope for is the second part of that. If that.

Anyway, The New Yorker article. It is long, interesting and reasonably informative if you haven't been following the story, although readers of this blog probably won't learn that much. However there was one new, and slightly disconcerting, piece of information I didn't know concerning the Thai person-to-person case reported in The New England Journal last month. Spector went to Thailand and interviewed many of the people involved in that case. Here is his account:

Two weeks after the girl died in Kamphaeng Phet [this is the girl whose mother would contract the disease after caring for her], Thai epidemiologists were asked to visit a hospital near Bangkok, where a woman had symptoms that matched those caused by the virus. It turned out to be a false alarm, but while the investigators were there a nurse took one of the doctors aside and mentioned that another woman had just died of similar flu symptoms. The death hadn't been reported, but the victim's last name sounded familiar, and so did the name of her village.

"It was just a fluke," Scott Dowell told me not long ago over tea in his office, on the sprawling campus of the Thai Ministry of Public Health, in the suburbs north of Bangkok. "Sure enough, the woman was the mother of that eleven-year-old girl. We would never have known if that nurse didn't happen to mention it." Dowell is the director of the Thailand office of the International Emerging Infections Program, which was established by the Centers for Disease Control in 2001.

Spector describes a helter-skelter dash to the village in an effort to secure some tissue before the mother's body was cremated. Using a mobile phone to call ahead they were successful, but the story makes clear how close we came to not detecting the only documented case of person-to-person transmission to date. Without it, there would be those who would still say that such transmission has never happened and maybe that it couldn't happen.

If you want to read the whole article you'll have to buy the magazine (worth it even if you know the subject), but there is also a short Q&A with Spector online, here. Although much shorter than his print piece, it is also informative. Here are a few of the more interesting responses:

The way that animal and human populations coexist also seems to be a major factor. How can that be controlled? Do we have to rethink such things as large-scale poultry farming?

Well, I can’t imagine a better prescription for killing large numbers of animals with a single disease than packing tens of thousands of them into factory farms where they are lucky if they have fifteen inches of personal space. Still, the economic incentives toward factory production of food are huge—we want cheap meat. So it’s going to be very difficult to change.

[snip]

You spoke to dedicated health officials, but some of them told you that they were disappointed by the way in which some governments have responded to reports of disease. How much does politics affect the spread of a disease?

Well, if you are a government official in charge of exporting food, then it’s easy to say, “Gee, there are always viruses. If we say that this is a problem before we know whether or not it is serious we are going to lose market share. And our neighbor—who almost certainly has the same problem—doesn’t seem to be doing anything.” Still, in the case of Thailand, the government has now put a great deal of money and energy into stamping out the avian flu—or, at least, into controlling its spread. But it is never easy to do, because it scares your citizens, potential tourists, and trade partners.

Is anyone in charge of global health? Are there treaties, for instance, that can force a government to take action regarding the health of its citizens?

Nobody is in charge—and, in an age of global illness, we desperately need that to change. The World Health Organization is filled with dedicated officials and smart scientists. But they are not a police agency, and they have very few powers to enforce their edicts or to convince political leaders to follow their suggestions. As a result, politics often enters into decisions that should be based solely on trying to decide what is best for the public health.

The question I have is, who is in charge of US health? You could change "global health" to US public health and WHO to CDC in the last response above and not have to change anything else.

Sigh.

The Agent Orange - War Crimes lawsuit

Agent Orange is back in the news (NYT). This time a lawsuit filed on behalf of millions of Vietnamese for damages and the costs of environmental clean-up. The cost: potentially billions of dollars, or about two IWUs (an IWU is an Iraq War Unit, the cost of one week of the War in Iraq, roughly $1 billion).

Agent Orange was used in the Vietnam war to defoliate the jungle to get a better view of enemy troops. The claim in the civil suit is that American chemical companies committed war crimes by supplying the US military with this dioxin contaminated herbicide. The US government is weighing in on the side of the chemical companies, although the government is not being sued because the case has more than monetary implications.

Though the case drew little attention when it was first filed, it has become an important test of the reach of American courts, drawing worldwide interest and setting off a fierce debate among international-law experts.

"The implications of plaintiffs' claims are astounding," the government's filing said, "as they would (if accepted) open the courthouse doors of the American legal system for former enemy nationals and soldiers claiming to have been harmed by the United States Armed Forces" during war.

Not exactly. The government itself is not being sued and the issue here is not just harm, but criminal harm.

The Judge in charge of the case, Jack B. Weinstein of Federal District Court in Brooklyn, also handled a contentious 1984 class action lawsuit involving Agent Orange which was eventually settled for $180 million. Weinstein's view then that the causal relationship with cancer and birth defects was shaky was considered questionable by many and some felt he strongarmed a settlement for less than its actual value. The science since then, however, has tended to support the plaintiff's position, and in deciding to move forward this time around, Weinstein noted that it raised additional issues that might eventually have to be decided by the Supreme Court.

International Law experts representing the chemical companies defended their clients by claiming that during the Vietnam era the US didn't accept any treaty or principle that prohibited the US from using herbicides as a military instrument (but why would we expect the US government to accept such a principle during the war n Vietnam?).

Unfortunately for that position, there is precedent for a finding even in the absence of such an acceptance. Judge Weinstein himself raised it:

[Weinstein] asked from the bench whether precedents concerning the treatment of makers of Zyklon B, the hydrogen cyanide gas used in Nazi death camps, might be applicable to the claims against the companies that supplied Agent Orange to the military.

After World War II, two manufacturers of Zyklon B were convicted of war crimes and executed.

The chemical companies should be grateful this is only a civil case.