Sunday, July 31, 2005

Bird flu: next stop Europe?

Interfax News Agency reports that a 20 year old male has been hospitalized in Kazakhstan's Pavlodar region with symptoms of bird flu and "double pneumonia" and is in intensive care. Kazakhstan borders the Xinjiang Uyghur Autonomous Region in China where a die off of birds from influenza H5N1 was reported several weeks ago. The man is a poultry worker in the village of Golubovka, where Interfax also reports 600 domestic geese died between July 20 and July 30.
The first deaths of birds in Golubovka were registered a week ago, Yersain Aitzhanov, chief of the Irtysh district's emergency situations department, told Interfax. A quarantine order has been imposed in the village. "All necessary measures are being taken: the territory is being ploughed, additional fences have been built around the farm and a ban has been introduced on the delivery of poultry products and eggs from the village," Aitzhanov said.
Kazakhstan, while still in Asia, is on the doorstep of Europe. It has borders with Russia and many other Central Asian countries and borders the Caspian Sea. Infected birds are already reported in Novosibirsk in Russia. This is a reminder, if one were needed, that human risk travels with infected birds and infected birds are on the wing all over Asia and headed outward.

Next top Europe?

Bird flu mixed messages and nixed messages

Here's a case study on how not to do it. According to the Indonesian government people shouldn't panic about bird flu. That goes for everyone. No exceptions. None. Except maybe government ministers (The Jakarta Post):
Wearing a special white outfit complete with gloves and mask, Minister of Agriculture Anton Apriyantono was shouting stressfully to staff from the Tangerang animal husbandry office asking them if it was safe to open his mask to give an interview to the media.

Many reporters, waiting in front of the minister with no protective gloves or masks during a cull ceremony on a pig farm in Legok, Tangerang, Banten province last Sunday, were astonished to see how frightened he was.

For several minutes, no one seemed to listen to the minister's query as the ministry and regency staffers, reporters and hundreds of local people wore no protective gear -- the exceptions were Anton, the Coordinating Minister for People's Welfare Alwi Shihab and two or three ministerial aides.

"Don't blame me if you get bird flu because you don't wear a mask. This is very dangerous, you know, as the virus can be transmitted through the air," he warned reporters through his mask.
No, don't blame him. There they are, all standing around at a typical photo-op, the "culling" (that is killing) of 31 pigs and 40 ducks said to be infected. The object was to show everyone that the government had the situation under control. But despite the warning, the minister's staff had only a few masks for high-ranking officials. No protection for reporters or local citizens or curious members of the public attending what the Jakarta Post said many suspected was just "a public relations stunt," given the half-assed efforts at protection.

One of the skeptics was the Regent of Tangerang, Ismet Iskandar. He didn't even bother to attend, and those of his staff present seemed unconcerned, as did the hundreds of unprotected local residents who watched the slaughter of the infected animals at close quarters.

But the Regent did become quite concerned shortly afterward when the government declared his district a Red Zone for bird flu.
The regent later denied that there were any bird flu cases in Tangerang and asked the central government to revoke the red zone status. He insisted that the central government had no reason at all to declare his regency prone to the virus because the local animal husbandry office had not found any evidence of avian influenza there.
He also complained that the red zone status was having a negative impact on poultry breeders and market vendors, with their sales slashed by around 50 percent virtually over night.

The regent is putting his chicken where his mouth is, along with several of his colleagues. It was announced Saturday that several ministers, including the head of the animal husbandry and agriculture service of Tangerang, Didi Aswadi (whose staff didn't hand out masks at the culling event), will be having a public chicken-eating affair today (Sunday, 7/31/05):
Aswadi said the event was to be held to help chicken farmers in the region who had suffered great losses after chicken sales dropped following the spread of the disease.

Among the ministers scheduled to attend the event are Coordinating Minister for People`s Welfare Alwi Shihab, State Minister for Information and Communication Sofyan Djalil, Health Minister Siti Fadilah Supari, Agriculture Minister Anton Apriyanto and Trade Minister Maria Elka Pangestu.
Also to attend the occasion are Banten Governor Djoko Munandar and Deputy Governor Mrs Ratu Atut Chosiyah and Tangerang District Head Ismet Iskandar. (Antara News Service)
On the one hand, citizens are panicked about chicken and don't believe the government that everything is under control. On the other hand, local interests don't believe the government because they send mixed messages and don't seem to know what they're doing. The real problem, of course, is that the government isn't believable, so people keep on believing what makes sense to them. In such a setting it might be difficult to get cooperation of local jurisdictions in taking measures the government says are necessary (and may very well be).

Meanwhile in the US, our own government health agencies try to keep their credibility by saying nothing. That's not a mixed message. That's a nixed message.

Sunday Sermonette: Diderot reads the entrails of our civilization

On Sundays we pause for reflection on the Eternal Verities. Hence time for another Freethinker. This time we hear Denis Diderot, the famous French founder of the Encyclopedie, the world's first. Here is why they call his period The Age of Enlightenment:
Mankind shall not be free until the last king is strangled with the entrails of the last priest.

-- Denis Diderot (1713 - 1784), Dithyrambe Sur La Fête Des Rois (via Positive Atheism)

Saturday, July 30, 2005

West Nile: another disease from birds

With West Nile season is on us again, we are reminded that bird flu is not the only disease we blame birds for. West Nile virus also likes to hang out in birds, but its mode of transmission to humans is via mosquitoes that feed on infected birds and then bite humans. There is a rather puzzling story today on the CNN website bringing the "surprising" news that it might be the American robin, not the crow, that is responsible for harboring the disease. It also reports some unnamed "experts" as being skeptical of the new report, just published in the journal Emerging Infectious Diseases.

What is really surprising about this story is that I know hardly any real experts in West Nile who think crows are important in propagating the disease. The only thing unusual about crows is that they get sick and die from West Nile. The virus has been found in over a hundred other species of birds and last time I checked the reservoir hadn't been pinpointed with any specificity but the leading candidate was the common house sparrow. If the robin is also implicated as another reservoir that would not be at all surprising. Crows are important in West Nile surveillance precisely because they are large, obvious birds whose carcasses are easy to spot. They are "dead end hosts" (like humans), meaning that they are not the actual reservoir of the disease in nature but incidental victims, like people. The birds that are the real reservoir don't get sick. There is a lot yet to learn about West Nile epidemiology, such as exactly which species of bird is the most important reservoir and in which regions (it probably differs in different parts of the country); whether there are non-bird reservoirs (this virus is able to infect many species, including mammals); which species of mosquito is responsible for transmission from bird to bird and which ones from bird to humans (the so-called "bridge vectors"); etc.

The way to avoid contracting the disease, which is usually mild or inapparent but in a small percentage of cases can produce a disabling or fatal meningoencephalitis, is to avoid being bitten by mosquitoes. The best way to do that is to have as little exposed skin as possible when in an area cohabited by mosquitoes (a windy beach, for example, usually isn't mosquito infested but just inland from the beach there may be many breeding grounds so when you leave the beach you can cover up), and to use insect repellent. Until recently the only proven effective repellent was DEET (found in many preparations, such as Off!), but recently CDC has approved two more, Picaridin (KBR 3023), known as “Bayrepel” outside the US; and the active ingredient in oil of lemon eucalyptus, p-menthane 3,8-diol (PMD). CDC has a good webpage on insect repellent use and safety.

The most contentious issue in the management of West Nile disease in any locality relates to killing adult mosquitoes with broadcast applications of insecticides (usually pyrethroid agents with additional ingredients to enhance their effectiveness). We addressed this issue herea while back. It is not at all obvious there is any benefit to this and some evidence it might cause additional harm. It is difficult to get public officials, including public health authorities, to acknowledge this, however. They want to be able to show they are "doing something" and many believe what they are doing works. The most effective means of mosquito control is a systematic program to kill them in the spring in the larval stage. By the time West Nile season rolls around, that period is over.

So while you are fretting about bird flu, this is another thing to keep in mind. We inhabit this planet with many other species and when we screw up the balance of things we have to expect things to happen we don't expect and don't like. But the real issue, as President Bush reminds us so cogently and so often, isn't pandemic influenza or West Nile disease. It is Freedom for the Iraqi People by bombing the living shit out of them. Have to keep things in perspective, after all.

Friday, July 29, 2005

Vietnam, Indonesia, Russia, China

Four geographic areas seem to be "cause for concern" on the bird flu front, (as Henry Niman would say). They are Vietnam, Indonesia, Russia and China.

Vietnam (Thanhnien News): This is the easiest, although not necessarily the least concerning (I'm having trouble ranking different kinds of concerns, so I won't try). It's easiest because it represents "more of the same," where the "same" is not good. Two more H5N1 deaths have been reported, a 24 year old man from Tra Vinh (Mekong region, in the south) and a 26 year old woman from Ho Chi Minh City (also in the south). Both are confirmed bird flu cases, the first in the south for some time. The southern cases continue to be more serious than those from the north. Both cases were said to have eaten chicken before they became ill. So this disease, possibly in several different forms (north and south) continues to incubate and simmer in Vietnam, with endemic infection of poultry and sporadic but fairly steady human cases. Such smoldering is typical of pre-pandemic phases which then break out explosively. But of course, sometimes this doesn't happen. I'm not a betting person, so I prefer to purchase insurance for uncertain events in the form of adequate preparation. Are you listening CDC?

Indonesia: The reference laboratory in Hong Kong has confirmed what everyone knew anyway, that the index case in the family cluster of three fatal cases in a Jakarta suburb, the eight year old daughter, indeed died of H5N1. Tests results on her 1-year old sister are awaited but we know the answer already. Meanwhile, epidemiologic investigations seem to be coming up empty. How did this civil servant and his two children in a middle class suburb contract this fatal disease? We are learning some more details about the basis for the claim by the Indonesian Health Minister that they were infected by contaminated bird feces (the Chickenshit Theory). The Minister of Agriculture reported that feces from a caged bird on the side of the road opposite the family's house were "positive for H5N1" but the bird in the cage showed no sign of the virus and other environmental sampling, including caged birds in neighbor's houses. So much for the Chickenshit Theory.

The three family members fell ill on July 24, July 29 and July 2, so this doesn't sound like a common source outbreak but more like person to person (perhaps index case to other two family members). Indonesian authorities are following up some 300 contacts of the family, but have so far reported no additional illnesses. Forty-four referral hospitals have been alerted and prepared for possible new cases. So at the moment there is no identified source for the three fatal cases and the evidence of human to human transmission is strong.

Russia: The bird flu outbreaks in Russia have been widely reported to be with H5N2 and therefore no risk to humans. Aside from the fact that it doesn't necessarily follow that H5N2 infections of birds are no risk to humans, the point is now moot, as fresh outbreaks are being identified as H5N1. Today the Russian Agriculture Ministry announced that the hundreds of chicken, geese, ducks and turkeys that died in Siberia last week died of H5N1 infection. This virus is on the wing, literally and figuratively, and it can't be stopped. It seems it will inevitably spread to bird populations outside of Asia, with the next stop likely the Indian sub-continent and Europe. The longer it circulates in birds and perhaps other species, the more likely it will be to adapt to humans, the most widely dispersed species on earth.

China: Finally, the spreading outbreak in Sichuan, China. The Chinese have steadfastly maintained that this is just a huge outbreak from the bacterium Streptococcus suis, Type 2, a known pig pathogen that occasionally infects humans, causing meningitis. While it is capable of causing the type of sepsis presenting in these cases, the large number and continued spread together with the hemorrhagic presentation seems quite atypical for S. suis and more like a viral etiology. There are now over 150 infections with new ones occurring daily. The death toll stands at 51 as of Thursday afternoon. While bird flu remains a possibility (we are continually reminded that a significant proportion of cases in 1918 presented like this) there is no mention of respiratory symptoms which should still predominate. This one remains a puzzle, and while the pig bacteria may turn out to be the cause, it sounds at this point like something else is going on (although my intuiution tells me it isn't bird flu, but of course I may be wrong).

But with so much else going on elsewhere, "something else going on in China" is the last thing I want to hear.

Gerberding loses popularity contest at CDC

The votes are in . . . and the Loser is . . . CDC Director Dr. Julie Gerberding. In an "informal survey" of CDC employees, two thirds opposed Dr. Julie's Disorganization Plan, the so-called Futures Initiative. The Gerberding Disorg Plan consolidated 12 major subdivisions into four "coordinating centers." The result was not only a great deal of shuffling of assignments and responsibilities but extreme agency demoralization. When I asked a senior manager how Director Gerberding sold her new scheme to agency professionals, this person gave a four word summary: "Just deal with it." The anonymous on-line survey comprised about 37% of CDC's 8500 employees and one might anticipate a significant bias, with those most unhappy more likely to respond. Even so, 65% of them (and thus 25% of all CDC employees) didn't believe there was a bright future in the Futures Initiative (via Medical News Today).

In her Draconian "reorganization" Gerberding consulted with few old hands at the once proud and competent health agency. Word was she brooked no opposition and surrounded herself with "yes men." That's the story we hear, anyway. I know one of the inner circle quite well and he is not a "yes man" but an extremely competent and dedicated public health professional who can be counted on for good advice. But the other part of the story is that Gerberding doesn't listen, so good advice isn't much use. And contrary opinions, forcefully expressed, stronlgy discouraged.

According to the Atlanta Journal-Constitution, the paper that obtained the results of the survey, "respondents cited several main complaints: an 'inappropriate' business focus to the public health mission of CDC, low employee morale, increased bureaucracy, loss of trust, loss of important staff members and damage to the reputation of the agency." This is consistent with what we have been hearing on the outside and also explains the rush to the exits among the senior staff, who have practically trampled each other trying to get out the door once they have their 20 years in. The result is a catastrophic loss of institutional memory and experience that will inflict damage on the agency for years, if not decades, to come.

This resentment of the top professional staff with CDC "leadership" couldn't come at a worse time. Senior staff of the influenza branch are already gone with others rumored to have one foot out the door, this when an influenza pandemic, the biggest public health threat we have faced in decades, is threatened. Gerberding herself is said to be on the way out, awaiting only a suitably cushy place to come to rest. When that will happen is a matter of much speculation. Some rumors say ti will be within 3 months, and that there's even a short list, with a top candidate for her replacement coming from the state of . . . you guess.

Yes, that's right. The rumor mill has coughed up the name of Dr. Edouardo Sanchez, currently Commissioner in Texas. His bio is respectable but other than what's written there we know nothing about him. Anyone out there want to enlighten the rest of us?

Of course, this is all rumor. Maybe Gerberding is staying, to preside further over the disarticulation of the skeleton that was once CDC. Or maybe she will be replaced by someone else, say another Texan involved in public health. Tom Delay? He used to work as an exterminator. He can finish the job Gerberding started.

Thursday, July 28, 2005

Finger in food: Groundhog Day

It's happened again: someone finds part of a finger in his food. We've done this post before. This time it was a 3/4-inch fingertip in the vegetarian meal of a California prison inmate. Obviously this isn't fraud because the lucky guy who was given the finger was in isolation and he was served the "foreign object" in a frozen entree brought to his cell. Moreover, the food vendor to the prison, G.A. Food Services, has admitted one of its employees sliced off his right middle finger when cleaning a filling machine on the assembly line in July 2004:
At the time of the accident at the Florida plant, a department manager mistakenly thought all flesh had been flushed from the machine, the letter said. When workers couldn't find the fingertip, they assumed it had been washed down the drain.

In the March 29 letter, included in the lawsuit, quality assurance director Frank Curto apologized for the "foreign object that was found in one of our frozen entrees" and "any inconveniences that were incurred as a result of this incident."

The apology apparently wasn't good enough for Rocha, 29, of Los Angeles, incarcerated at the maximum security prison on drug, weapon and assault charges. Merin filed the suit Wednesday in federal court in San Francisco. (Suzanne Herel, San Francisco Chronicle)
It turns out the inmate doesn't sound like a sweetheart. He was serving 15 years for assault with a firearm and given an additional eight years for assault while in prison, hence the isolation cell. In this country no one feels any sympathy for prison inmates anyway (guilty or innocent), although we lock people up at a prodigious rate. But that's not the point here. It doesn't have to do with the person who got the finger, but the person who gave it to him, a worker in a non-union shop in a "right-to-work" state. A "right-to-work" state is a state where employers and unions are forbidden to enter into agreements requiring union membership of employees. This allows non-dues paying employees to benefit from the collective bargaining agreements of the union. These laws are widely regarded by the labor movement as blatantly anti-union because they make it difficult for unions to stay financially viable.

One important function of a union is to bargain for safe working conditions for its members. The food manufacturing industry continues to be one of the most dangerous. Here's the description by the US Bureau of Labor Statistics of working conditions in this industry:
Many production jobs in food manufacturing involve repetitive, physically demanding work. Food manufacturing workers are highly susceptible to repetitive strain injuries to hands, wrists, and elbows. This type of injury is especially common in meat-processing and poultry-processing plants. Production workers often stand for long periods and may be required to lift heavy objects or use cutting, slicing, grinding, and other potentially dangerous tools and machines.

In 2002, there were 9.3 cases of work-related injury or illness per 100 full-time food manufacturing workers, much higher than the rate of 5.3 cases for the private sector as a whole. Injury rates vary significantly among specific food manufacturing industries, ranging from a low of 3.8 per 100 workers in flavoring extracts and syrups plants to 14.9 per 100 in meat packing plants, the highest rate in food manufacturing.


Because of the considerable mechanization in the industry, most food manufacturing plants are noisy, with limited opportunities for interaction among workers. In some highly automated plants, “hands-on” manual work has been replaced by computers and factory automation, resulting in less waste and higher productivity. While much of the basic production—such as trimming, chopping, and sorting—will remain labor intensive for many years to come, automation is increasingly being applied to various functions, including inventory control, product movement, packing, and inspection.

Working conditions also depend on the type of food being processed. For example, some bakery employees work at night or on weekends and spend much of their shift near ovens that can be uncomfortably hot. In contrast, workers in dairies and meat-processing plants work typical daylight hours and may experience cold and damp conditions. Some plants, such as those producing processed fruits and vegetables, operate on a seasonal basis, so workers are not guaranteed steady, year-round employment and occasionally travel from region to region seeking work.
So no surprise it's happened again. And again. And again. Bon apetit.

We're having a heat wave

The headline in the Philadelphia Enquirer says, "It's not the heat . . . actually, yes, it is." But actually, "No, it Isn't." The old adage, "it's not the heat, it's the humidity" is much more correct.

Heat and temperature are not the same thing. Without getting into thermodynamics, temperature measures the intensity of thermal energy while heat measures its quantity. You can think of the heat content of your body as being like a bathtub. The bath water is at body temperature (98.6 degrees F.), while the surrounding environment is usually cooler. If more heat enters the tub than leaves it, the temperature will rise. Thus even on a day when the outside temperature is in the low nineties, your body naturally loses heat. The problem is, it also gains heat. Besides contact with other objects, another source source of thermal energy is from other objects that radiate heat (like the sun or a furnace or just the surrounding environment). Since a body radiates heat in amounts proportional to its temperature, you usually lose heat to the environment by radiation faster than you gain it by that means, but extra hot objects (like the sun) can actually produce a radiant heat load that heats you up (hence you feel cooler in the shade). You also produce heat by metabolism and muscular actions, enough heat in fact, that you can maintain body temperature despite the fact that your surrounds are almost always cooler.

But what happens if the surrounding environment is actually warmer than body temperature? You can't lose heat by contact with a warmer environment or by radiating your own heat to it (because it is radiating even more heat back to you). A fan won't work because it is just blowing warmer air past you and helping you gain heat faster. Fortunately, there is one remaining way to lose heat, and that's by turning body water into water vapor. This makes use of the "latent heat of vaporization," which takes 540 calories to turn a gram of water into water vapor. This is pure heat loss. Hence sweating, even when it is "insensible" (doesn't wet the skin), is an efficient way to lose heat and one of several reasons to stay hydrated in hot weather. The problem comes when the air cannot hold any more water vapor (100% relative humidity or close to it) and this last way to lose heat is shut down. To return to the bath tub analogy, the faucet is still open (heat is coming into the body via metabolism, a warm environment and radiant heat load) but the drain is now closed. Hence the tub begins to fill with heat. If your body core temperature rises too high (say above 106 degrees), it is a medical emergency and high mortality is the rule.

So heat obviously plays a part. But it is the humidity that does the real job on most people. Air conditioning, interestingly, derives most of its effectiveness, not by dropping the temperature, but by drying out the air, allowing increased evaporative heat loss.

So now you know the real problem. No sweat.

Wednesday, July 27, 2005

Indonesian chickenshit, bullshit style

The source of the virus that infected and killed three members of the same household remains a mystery. Direct contact with infected poultry, the preferred explanation of those hesitant to admit the likelihood of human-to-human transmission has apparently fallen to last on the list. But WHO and Indonesian authorities have a new theory, which might be called the Chickenshit Theory (CST). Thus Georg Petersen, WHO's representative in Indonesia has raised the possibility that transmission took place from environmental contamination, specifically from poultry feces.
[Petersen] said that the transmission of Avian Influenza virus in Tangerang, which claimed three lives, might have taken place through environmental contamination.

For example, the transmission could have been through chicken dung, Petersen told Tempo by phone on Sunday (23/07). However, he declined to speculate on the sources of the virus and the transmission process. (Tempo Interactive)
Excuse me? He declined to speculate? It sure sounded like he was speculating there. No reticence for Indonesia's Queen of Speculation, Health Minister Siti Fadilah Supari.
Minister of Health Siti Fadilah Supari said the latest field tests performed by her office had found bird feces containing the deadly H5N1 strain of avian influenza. She said it was possible Iwan Siswara and his two daughters contracted the disease from the feces of infected poultry.

"We can only say that we discovered bird feces that tested positive for the virus, but it remains unknown where Iwan contracted the disease," Siti said.

She said it was unlikely Iwan and his daughters contracted the virus by eating chicken or through human-to-human transmission.

Minister of Agriculture Anton Apriyantono confirmed the discovery of feces containing the avian influenza virus around Iwan's neighborhood.

"We have found feces that contained the bird flu virus. But we cannot determine if the feces was the source of the virus that killed Iwan and his two daughters," Anton said during a press conference after meeting with President Susilo Bambang Yudhoyono.

Iwan lived in Legok, Tangerang, Banten, where the government culled dozens of pigs and ducks on Sunday that had tested positive for the virus.

There has also been speculation that Iwan and his daughters contracted the virus from infected pigs.

Avian influenza can be transmitted to humans through an intermediate host such as a pig.
Siti said Iwan and his daughters were the only known human cases of bird flu in the country. She was commenting on three people, including a Malaysian national, who displayed symptoms of avian influenza infection
Ah, yes. Those "other three." But no need to worry:
Two Indonesians, AS and AB, are being treated at Sulianti Saroso Hospital in North Jakarta after displaying symptoms similar to those associated with bird flu. Their blood samples have been sent to the WHO laboratory in Hong Kong for testing. It normally takes the laboratory at least one week to complete the tests.

The Malaysian national died last week and has been cremated.

"After going over the medical records of the Malaysian man, I am convinced that his death was not caused by the avian influenza virus. He had a high fever for about two weeks, which is more similar to typhoid," Siti said.

People who contract the bird flu virus usually only survive for three or four days if they suffer from a high fever. (Jakarta Post)
She has apparently received training at the Dr. Frist School of Long Distance Diagnosis. Well, at least the source of the infected feces will be taken care of with plans for extensive culling of chickens and pigs, widely reported in the media last week.
In a response to Indonesia's first three fatal human cases of avian influenza, officials killed some infected pigs and poultry yesterday, but not as many as they had planned to, according to news services.
Plans had called for culling about 200 pigs in a village near the Jakarta suburb of Tangerang, the home of a man and two daughters who died of avian flu this month. But officials instead killed only 18 pigs, along with "dozens" of chickens and ducks, according to a Reuters report yesterday.

The agriculture minister, Anton Apriyantono, told a radio station that the original plan would have hurt the local economy, the story said. But his spokesman, Hari Priyono, said the plan was to kill only the pigs that tested positive for avian flu.

He said only 18 pigs tested "truly positive" for the virus, and those 18 were slaughtered, according to the story. "In days to come, whenever we find a positive one here, we will slaughter it straight away," he was quoted as saying. (CIDRAP)
Maybe they're spinning it a bit, but at least health authorities have a reserve of credibility for their otherwise sterling performance in truth-telling:
Fish vendors at Pasar Anyar and Cikokol markets are also enjoying booming sales. In contrast, chicken sellers have seen their sales drop drastically.

"I feel so lucky because I am selling more fish than usual. On the other hand, it is difficult to enjoy because my friends who sell chickens are staring at piles of unsold chicken," said Amawi, 46, a fish vendor at the municipality's downtown market.

Falling chicken sales have been cited as a motive in the suicide of a 22-year-old poultry farm owner from Cisauk district, Tangerang regency. (Jakarta Post)
Apparently this trusting nature is not confined to the poorer segments of Indonesian society, either:
When a government auditor and his 2 young daughters died suddenly this month, there was panic in their middle-class suburb along with reports that they were Indonesia's 1st casualties of avian influenza. Neighbors anxiously traded rumors across the metal fences surrounding their neatly landscaped yards. Mothers kept their children from playing on the palm-lined streets. Some families in this quiet California-style subdivision of bankers, businessmen and doctors considered packing up their belongings in their SUVs and abandoning their homes.

Most residents of the Villa Melati Mas [commuter] community on the western outskirts of Jakarta had paid little [attention] to reports of avian influenza, which has devastated poultry flocks across Indonesia during the last 2 years and killed dozens of people in other Southeast Asian countries.


"I'm wondering why this happened. I'm confused. Can we get this? We're trying to be calm," a doctor's wife said anxiously as she stocked up on broccoli and cauliflower from a vegetable peddler plying the subdivision's cobblestone streets. She has forbidden her children to eat outside the home in case the virus can spread through food. "We've stopped going to Kentucky Fried Chicken," she said.

Stoking the neighborhood's fear is uncertainty about the outbreak's cause. Unlike the rural villages of Vietnam, Thailand and Cambodia, where other avian influenza deaths have occurred, there are no farmers or live chickens in Villa Melati Mas. (Alan Sipress in WaPo)
Well, maybe they think they have a nice, clean neighborhood, but Indonesian health authorities know it is really littered with poultry feces.

Or maybe it's bullshit.

Tuesday, July 26, 2005

Why doesn't this give me confidence?

First this:
JAKARTA (Antara): Minister of Health Siti Fadilah Supari insisted on Monday that the government had not found any new victims of the deadly avian influenza in the country.

"So far, there are no new victims of the bird flu virus," Siti told reporters at the presidential palace on Monday.

She said that two patients who were admitted to a Jakarta hospital and a Malaysian citizen who died last week did not die of the avian influenza virus.

"According to the preliminary observation and routine laboratory tests, it's unlikely they were infected with the bird flu virus," Siti stated.

The two people -- Ari Basuki, a photographer with Tempo newspaper and Ari Sudarman (27) a security guard from Tangerang, Banten -- were admitted to Jakarta's Sulianti Sarono Infectious Disease Hospital on Friday.

Siti said that two were in good condition and had been "suffering from an ordinary flu."

"We came to the conclusion that they had not been infected with bird flu," Siti reiterated. (Jakarta Post)
Then this:
AKARTA (Reuters) - Blood samples from two Indonesians hospitalized in Jakarta will be tested for the bird flu virus even though initial results showed both have typhoid, health officials said on Monday.

The two men, including a news photographer who had recently photographed chicken farms, are under close observation following the recent deaths of three members of a family from the virus, officials said. The samples would be sent to Hong Kong, they said.

Both men have been treated at a hospital in North Jakarta and are suffering from high fever and flu symptoms.

"The temporary diagnosis is typhoid. We have sent specimens to the WHO this morning for further tests," said Evi Zelvino, a spokeswoman at the Jakarta health agency, referring to the World Health Organization.

The WHO's spokeswoman in Indonesia, Sari Setiogi, said they planned to send the samples to a laboratory in Hong Kong for testing and results should be known in 7-10 days. (Reuters)
So they are suffering from typhoid, but it's ordinary flu, the highly specialized test results for which will be available in 7 - 10 days.

What so proudly we're blind to . .

Everywhere except the US, it seems, the threat of epidemic disease is seen for what it truly is: a bigger threat than terrorism. Even in terror-stricken London, via its emergency Cobra Committee, they understand the toll from an influenza pandemic would dwarf almost any conceivable terrorist event, even one with a so-called Weapon of Mass Destruction. The UK government has announced it will tender orders for a vaccine stockpile. Unfortunately, while they "get it," they "got it" too late:
Despite this, the Government and other industrialised nations' handling of the situation has been criticised: some experts doubt that relying on a vaccine would have any short-term effects as the exact strain of virus would not be known until the pandemic struck.

Dr Douglas Fleming, the Royal College of General Practitioners' 'flu spokesman, is among those who have given a cautious welcome.

The vaccine tender was an important step, he said, particularly with the hope that a vaccine from an H5 virus could offer some protection from a range of H5 virus variants.

But he added: "Whilst we should regard that as prudent, we nevertheless should recognise that it is highly speculative. We know antiviral drugs have been ordered as a stockpile but manufacturing capacity is such that these cannot be delivered very quickly.

"I do not know what the delivery conditions attached to this vaccine order are. The human cases of bird flu have been serious and I think we should support this action even though its value is speculative."

But he added: "Whilst we should regard that as prudent, we nevertheless should recognise that it is highly speculative. We know antiviral drugs have been ordered as a stockpile but manufacturing capacity is such that these cannot be delivered very quickly.

"I do not know what the delivery conditions attached to this vaccine order are. The human cases of bird flu have been serious and I think we should support this action even though its value is speculative." (The Daily Mail)
Oh, well. Nevermind.

In Asia, too, the light has gone on:
An Asia expert says disease and natural disasters may pose a greater security threat to the region than conventional political conflicts.

The Asia Pacific Security Outlook is an annual survey of all security concerns facing Asia, from North Korea's nuclear weapons programs to Chinese relations with the United States and Taiwan.

Speaking in Hong Kong Friday, the report's editor, Richard Morrison, said the primary regional threat for the second half of the year is non-military and non-traditional.
Mr. Morrison, president of the Honolulu-based East-West Center, says disease and natural disasters threaten the entire Asia Pacific region, with potentially catastrophic results. (Asia Bulletin)
So where don't they get it yet?

"Oh-h say, can't you see . . . By the dawn's early light"?

Monday, July 25, 2005

Company privacy and bird flu antivirals

One reason it is hard to know how available the antiviral drug Tamiflu will be if there is an influenza pandemic is that its sole maker, Roche Pharmceuticals, won't reveal its own manufacturing capacity (news details from American Society of Health Pharmacists News). In an investor's conference call on 22 July, Chief Executive Officer William M. Burns said:
"We've never actually released what our capacity is, nor do we intend to," Burns said from London. "The question we ask governments is, 'What do you want?' And if you give us orders, we will ensure that we put in place the supply chain to meet that" demand.
The US currently has a pathetic 2.3 million treatment courses in its "Strategic" National Stockpile (the SNS). Maybe we need another strategy just new stragetists). Roche revealed that in May DHHS signed a "nonbinding letter of intent" to buy another (pathetic) 3 million treatment courses:
This amount is far below the 133 million treatment courses that the National Vaccine Advisory Committee and the Advisory Committee on Immunization Practices agreed on Tuesday is the optimal amount to stockpile for pandemic preparedness.

Andrew Pavia, chair of the Infectious Diseases Society of America's Task Force on Pandemic Influenza, told the committees that the minimum amount of oseltamivir needed for "a robust public health response" is about 40 million treatment courses, an estimate that is far above the amount currently being publicly discussed for the stockpile.


Some countries, according to Roche, have contracted for enough oseltamivir to treat 20–40 percent of their populations during a pandemic.
Let's see. At some point in the mid future, the US will have 5.3 million courses of treatment. There are about 300 million people in the US, so that's enough for--maybe 2% of the population? I guess US planners dropped a decimal point somewhere. Too bad we don't have a No Health Planner Left Behind Act.

Roche can still do the numbers:
"My dream scenario is that a government orders 5 percent of the population per annum over a five-year period and builds up to the 25 percent" of the population, Burns said. Because the drug has a five-year shelf life, he added, a country ideally would make a purchase for year six and "write off" the year-one purchase, treating it "like an insurance policy."


Burns said that Roche reported $450 million in oseltamivir sales for the first half of this year, about half in seasonal product sales and half for pandemic stockpiling. The company expects to record a further $235–275 million in pandemic sales for the remainder of the year.
But the skies are not cloudless for Roche. For one thing, there is another competitor antiviral that works by the same mechanism, although it has to be administered in a dry powder inhaler, considered a significant disadvantage by some. That drug is Relenza (generic name, zanamivir). It is marketed by pharmaceutical giant GlaxoSmithKline.

Big Pharma would have us believe they need their obscene profits to finance research and development costs for drugs such as these, but both Tamiflu and Relenza were developed by other, smaller companies and licensed to Roche and GSK. In both instances, the smaller companies are unhappy at the lack of zeal in marketing them until the pandemic threat boosted sales. In the case of Roche, the developer Gilead Sciences is seeking to terminate their exclusive license agreement. In the case of GSK, the developer is an Australian firm, Biota Holdings Ltd., who is suing them for alleged dilatory marketing practices. It seems both developers have awakened to the pandemic Golden Goose and want better deals.

These four companies deserve each other. But do we deserve them? GSK has not produced much Relenza either, admitting that currently it had no more than a million doses.
"Our global capacity could increase to about 41 million doses by 2008," [GSK's Andrew] MacKnight said. He added that the company "is interested in talking with the U.S. government and other governments about their requirements for the product for stockpiling."
2008. I'm sure we can wait until then. Someone please notify the influenza virus to stop mutating while GSK, Roche, Gilead and Biota sort out the legal niceties and can get the cash register working again.

Not that we will know anything about those legal niceties:
During an investors' conference call on Tuesday, Gilead Chief Financial Officer John Milligan declined to comment on the licensing issue. He explained that the dispute must, under the licensing agreement, be conducted in strict confidentiality.

"Consequently," he said, "we will not be providing status updates concerning the issues between Gilead and Roche until these issues are resolved."
Maybe someone should invoke the USA Patriot Act and take away their privacy, for a change. Then it might really be enhancing our security.

News flash: prayer ineffective

News Bulletin: prayer is not medically effective. Duh.

From Medscape Medical News:
July 18, 2005 — Distant prayer does not improve outcome of elective percutaneous coronary interventions (PCIs), according to the results of a randomized study published in the July 16 issue of The Lancet.


The main outcome measure was combined in-hospital major adverse cardiovascular events and six-month readmission or death; secondary outcomes were six-month major adverse cardiovascular events, death or readmission by six months, and six-month mortality. For the primary composite endpoint, there was no significant difference for any treatment comparison.
Not surprising, I'd say. You get a bunch of people who don't know you praying at different locations and the result is . . . nothing. But then there is also this:
"Although the primary endpoints in this study showed no definitive treatment effects, secondary analyses can be useful for hypothesis generation to guide future trials," Dr. Krucoff [the study leader] said.

Issues unresolved by this study include potentially differential effects of the timing and duration of prayer, the number of intercessors praying, prayers from individuals vs those from congregations, and prayers from different religions.
Well, this had an effect. It made me want to scream. It says the investigators hold open the possibility that no effect was evident because they chose the wrong religion, didn't have a big enough praying team, or they didn't pray long enough. And they want to do more studies to explore these variables?

Aargh! Excuse me while a lay in a supply of Tamiflu.

Sunday, July 24, 2005

Sunday Sermonette: Jefferson Day Dinner

Sunday Dinner with Thomas Jefferson. How Sweet the Sound:
"But a short time elapsed after the death of the great reformer of the Jewish religion, before his principles were departed from by those who professed to be his special servants, and perverted into an engine for enslaving mankind, and aggrandizing their oppressors in Church and State."
Thomas Jefferson (in a letter to S. Kercheval, 1810)

"Nevermind what we said": the UK's best laid plans go astray

First we heard plans about what governments were going to do in the event of a flu pandemic. Now that we are looking the pandemic in the eye, we are getting the Truth: lots of those things aren't really going to happen. Consider the plans to give essential workers in the UK the antiviral oseltamivir (Tamiflu). There are about 3 million key workers like health care workers, police and fire but currently only about 100,000 courses of the drug. So the alleged 12 million dose stockpile announced earlier was just "on order" and the manufacturer, Roche Pharmaceuticals, is overwhelmed with global demand. Thus the UK health authorities have decided they will only use it to treat those seriously ill with the disease, since using it prophylactially or as "post exposure prophylaxis" (giving it to the key workers and to associates and close family members exposed to infected cases) would quickly exhaust the supply.
At a conference in London last week, Dr Jane Leese the senior government medical officer in charge of pandemic plans, said they were working on the basis that the drug could not be given prophylactically - in other words as a preventative measure.

She said: 'Although it can be taken over time to prevent you getting flu, that would consume a huge amount of the drug, for a very inefficient use for the savings, so this is a strategy for treating ill patients.'

This decision was backed by a Department of Health spokesman. 'Under our current plans, we would be unlikely to use the drug for post-exposure prophylaxis for healthcare workers or for close family members of cases. As the drug takes seven to 10 days to develop an immune response [sic], we don't believe it would be the most effective use of the stockpile.' (The Observer)
Disregarding the incorrect notion that Tamiflu produces "an immune response," the big problem with this is that the drug is ineffective for those seriously ill with the disease. For some already sick it may work to improve their prognosis if treated within the first 48 ours of symptom onset (and preferably within the first 30 hours), but most people will not be treated within that narrow time window, and of those that are, the drug will only be partially effective. Moreover, recent studies suggest the currently stipulated dose may be too low for the H5N1 serotype (bird flu) and higher doses needed.

We are not the only ones surprised by this new policy:
The government's decision to ignore this latter use has surprised health professionals. Professor John Oxford, head of virology at Barts and the London Hospital, said : 'If you gave this to everyone as soon as the virus arrived on our shores it would obviously go very quickly, but if you give it to people once they have been exposed, that would be a sensible halfway house measure. Personally, that's what I would want for myself, knowing that you get 90 per cent protection from the virus if you use it prophylactically.'
Here's something else that allegedly won't happen (but in reality probably will):
It has also emerged that the government will not automatically start to ban flights from Asia once the disease becomes a fully human form of flu.

Studies show that banning international travel would not prevent it from entering the UK as there are so many potential points of entry and it would only have the effect of delaying the disease.
It's true that travel restrictions probably are fruitless to stop this disease, but you can be fairly sure that if there is an explosive outbreak in Vietnam or Indonesia there will be immediate restrictions, whatever the authorities say.

The UK has more advanced planning than the US, but this illustrates how far behind the curve even the UK is. It will all come down to timing. If we have a year, we will be in better shape (if we use the extra time wisely). If it is 6 months, the failure to prepare for what was foreseeable will have deadly consequences.

And I am betting that no one will be held accountable.

Saturday, July 23, 2005

Three? Orange? Give it up

Maybe that WHO is unwilling to raise its "risk level" from Three to higher is now pretty irrelevant, because whatever the "number" is they are making pretty clear they are scared shitless. (for an explanation see The Flu Wiki)
GENEVA (Reuters) - Indonesia's first human bird flu case, coupled with more birds dying elsewhere including Russia, are signs a long-dreaded global influenza pandemic may be approaching, the World Health Organization (WHO) said on Friday.

Health officials fear the virus will mutate and mix with human influenza, creating a deadly pandemic strain that becomes easily transmissible and could kill millions of people.

Margaret Chan, WHO's new director for pandemic influenza preparedness, said there had been no known sustained human to human transmission of the deadly virus, but called for stepping up disease surveillance among poultry and humans worldwide.


"This is perhaps the only time since 1968, which was the last pandemic, that we are getting signs, symptoms and warnings from nature … More and more birds are dying in different parts of the world — this is the kind of signals, and early warnings that we are referring to."

Russia this week said it had discovered a disease in poultry in a remote village in Siberia, its first suspected case of bird flu. Around 300 birds died and specimens are being analyzed.
This numbering system is now about as relevant as the US Department of Homeland Security's infamous color coding for a terrorist threat. WHO's words speak louder than any "risk number."

And actions will speak louder than words. And the best way to get action at the local level (the only place where it will count) is for national authorities to sound a General Alarm, loudly and clearly. They are traditionally reluctant to do this because of a fear that a pandemic this doesn't materialize (and nobody knows for sure), they will lose credibility.

Two things to say about that: when you don't do something you need to do out of fear, you are gutless. The other is this: these guys don't have much credibility left to lose.

How not to support the troops

When Napolean Bonaparte introduced conscription in the wake of the French Revolution he changed the nature of warfare. With the average civilian as cannon fodder at his disposal he could wage war in ways undreamed of in modern times. The human cogs in this machine, however, were still just machine components for military strategists, as they have been ever since--in wars that are just or unjust, good or bad, successful or disastrous. To the extent soldiers are treated with respect by military strategists, it is to the extent they need to be treated that way to retain their services and loyalties. Once they have served their purpose, Sayonara.

Here is a case in point, sent via the Comments of an earlier post on the difficulty of getting military and civilian personnel to submit themselves to the anthrax vaccine (which, make no mistake, is not for the benefit of the soldier but for the supposed benefit of the military and its mission). While rare, I saw a case of myelofibrosis in my training many decades ago, and it is indeed a terrible disease.

[NB: Lightly edited from a Comment by Mike Carlin]:
I know a Marine Chaplain, Lt. Richard P. Bradley, who has been diagnosed at Walter-Reed and Bethesda with a terrible disease, Idiopathic Myelofibrosis, the doctors tell him was brought on by his required anthrax vaccinations. He was diagnosed with Idiopathic Myelofibrosis around Jan. 2004. Since that time he has undergone 4 surgeries, 2 bone marrow biopsies, and many, many tests. Odds of getting Idiopathic Myelofibrosis are about 2 out of 1,000,000 but 80% of those who do get it don’t live more than 5 years. There is no known cure. He has to take Percocet, Morphine, and 800 mg. Motrin to control his pain.

Chaplain Bradley’s condition stems from a reaction to the anthrax shots he received in the fall of 1999 while onboard the USS Frank Cable AS 40.

In this condition he obviously must leave the service and in trying to get continued medical coverage his case has been reviewed by a military PEB (Physical Evaluation Board). They have determined he's only 10% disabled, which they say is from Chronic Fatigue Syndrome, [not] acknowledging the myelofibrosis. He needs to be rated at 30% to get medical treatment from the military Tricare system. His current out-of-pocket medical bill, oncology alone, is $1,136 weekly!

June 14th 2005 the PEB rejected his “Reconsideration Package”. The next step is a Formal Hearing, which has been scheduled for August 18th. Once the Formal Hearing has begun he should know within another 2 to 3 months regarding their final ruling. Here is a man, fighting for his life and having to deal with an uncaring, immovable bureaucracy.

To just about top it off he was just recently informed, by his command, that he will not be getting an End of Tour FITREP (evaluation, in civilian terms). After 13 years of honorable service he will not be getting an EOT award either.

. . . . While, it sounds like the military is trying to avoid some liability, which perhaps is understandable, it certainly shouldn’t be turning it’s back on their responsibility to this soldier. Chaplain Bradley is only seeking fair medical coverage and nothing more.

[Major Bradley is] fighting for his life right now and needs someone or some group to come forward and get this settled for him quickly so he can devote his energies to wellness. He's stationed on Parris Island.

Friday, July 22, 2005

Rationing: flu leadership in short supply

The CDC and the National Immunization Program are getting serious about what to do in the event of a pandemic. It is neither too little, nor too late but could easily have been earlier and certainly could be better. What we have at the moment is just a part of a plan scheduled for release early next month. Announced this week were the proposed "priorities" (read, rationing) of any existing and effective influenza vaccine.

This last part is important, as at the moment there are no existing vaccines shown effective in protecting the population against a pandemic strain of influenza A/H5N1 ("bird flu"). Some vaccines are in the clinical testing stages in the US, Canada and Japan but their efficacy and doses are still being evaluated. Should a pandemic strain emerge there is no guarantee these experimental vaccines will be effective against them and the current production cycle is at least 6 months, and probably closer to a year for sufficient quantities.

In the interim the only therapeutic means would be antiviral agents like Tamiflu, Relenza, both neuraminidase inhibitors, or one of the older M2 blockers like amantadine or rimantadine. Some H5N1 strains are resistant to the latter drugs, although the extent of this resistance in any emergent strain is unclear and it is possible they might have some role to play in an outbreak situation. There is only enough Tamiflu currently in the US to protect or treat about 1% of the population. Good planning, huh?

In any event, the DHHS plan, allegedly in the works since 1993 and in draft form for a year, isn't very different than past parctice or at all innovative. It targets health care workers, some government officials and high risk groups first, followed by others, as supplies permit. And since H5N1 is a new serotype for human populations, it will likely require a booster shot, thus cutting any effective supply in half. Here is the scheme, as reported in USNews:
Group 1. The highest-priority group includes 9 million healthcare workers involved in direct patient care; 40,000 people who are making the vaccine and antiflu medicines; and some 37 million people who are at greatest risk if they get the flu, namely those over age 64 with a medical illness, younger people with two serious underlying medical conditions, pregnant women, and all household contacts of children under 6 months of age. Also in this top group are key government officials and specialized pandemic flu responders. [my emphasis]

Group 2. In the next tier are healthy seniors; younger people with one risky health condition; young children between 6 to 23 months old (the vaccine is not recommended for infants under 6 months); and workers in critical fields like public safety, utilities, emergency response, transportation, and telecommunication. This group is 68 million strong.

Group 3. The third priority is 500,000 people, including key government healthcare decision makers and those working in mortuary services.

Group 4. At the bottom are the remaining 179 million healthy people, 2 to 64 years old, not included in any other category.
The working group did not include nursing home residents, who typically get annual flu shots, among the highest-priority group. Instead, they advise vaccination of the nursing home healthcare workers and the prophylactic use of the antiviral drug oseltamavir (Tamiflu) in the advent of an outbreak.
The Federal Advisory Group making the recommendation also suggests only government financing would make this feasible and allow the control required to adhere to the rationing scheme. How likely the Bush administration and its friends in Big Pharma will go for this is questionable. We'll see. If the drug manufacturers see little likelihood they will be able to exploit the situation, they may be willing to let Bush do it, although whether he has the intelligence and the guts to do it is questionable (this would not be a conservative-base friendly approach).

Aside from these mundane questions, there are others. The low-profile CDC and the administration have taken on bird flu means the ethical and public health issues have not been publicly debated. While it is alleged that ethicists were involved, the public certainly has not been made aware of the issues. From the public health side, too, questions remain. Since the first in the population to sicken are usually school children, the strategy of immunizing them first has been suggested as an alternative. While school age children usually suffer least from flu, they may be the main vectors to the rest of the population. The discussions about the conventional strategy were not done in a public way (although perhaps technically the meetings were open and announced ahead of time), so I don't know to what extent these or other options were considered and debated.

The entire avian pandemic threat was foreseeable more than a year ago. Its relegation to the back burner is inexcusable. Now that it appears it may be right on top of us we are handed decisions that have already been made and which may, in the event, be moot anyway because the vaccine will be ineffective.

The failure of imagination, political will and leadership by public health authorities and the public health community, generally (of which I am part), is stunning.

Indonesia starts to get ready

For a country that two weeks ago was set to declare itself "bird flu free," Indonesia certainly went quickly 180 degrees in the other direction. One of the world's most populous nations (220 million people) now also has human bird flu fatalities and has admitted infection in poultry in 21 of its 30 provinces resulting in almost 10 million chicken deaths. Four of the remaining nine provinces have shown preliminary evidence of infection. Just goes to show you what you might find once you actually look for it.

In a break from past practice, Indonesia will also cull (kill) the chickens on the infected farms. Prior to this they have relied on vaccination. There is considerable controversy about which is the best strategy, with WHO opposed to vaccination but the UN's Food and Agriculture Organization favoring it. The Indonesian government chose it because it didn't wish to compensate farmers for culling but has now reversed its position and has approved a little over $13 million for the purpose. This may slow the spread and gain time, but the H5N1 influenza serotype is obviously spreading globally and there is no way to stop it.

Health officials continue to try to balance caution and optimism, repeating that so far there is no evidence of human-to-human transmission outside of intimate family contact. I guess they need to be hit over the head with a two by four. But reading between the lines isn't difficult:
"Basically, the anxiety is person-to-person transfer," Sian Griffiths, director of the School of Public Health at the Chinese University in Hong Kong, told Reuters.

"And how do you stop any potential spread before it gets into the population and becomes an epidemic."
The disease already had jumped the species barrier from birds to pigs on populous Java Island and at least one asymptomatic poultry worker had been found prior to the three fatalities of last week (which were initially denied to be from bird flu). The pig connection is especially worrisome as it has classically been the "mixing vessel" whereby bird viruses combine with human viruses to produce new pandemic strains. So Indonesia is putting its rickety public health machine into what passes for high gear by "preparing" 44 hospitals around the country for the treatment and detection of bird flu (no details given as to the nature of these preparations).
Speaking at the same news conference [as the Indonesian Health Minister], World Health Organization (WHO) representative Georg Petersen said:
"It is an alarming situation. It shows us that most countries can get this infection and we need all to be alert and prepared." (Reuters)
Well, maybe. Not everyone is so alarmed. In Australia (Bush Lite in the southern hemisphere) the Health Minister says the Indonesian situation is no big deal.
There has been no change in Australia's bird flu risk level, despite Indonesia confirming three deaths from the deadly virus.

Australia's chief medical officer says the deaths are concerning but he does not think Australia's risk level from bird flu will rise.

Professor John Horvath says it makes no difference if the deaths occur in Thailand, Vietnam or Indonesia because air travel makes everything close.

"The figures people have been talking about are that, there is a small but realistic chance sometime in the next year or two that we could have an epidemic or pandemic," he said.

"The figures that have been bandied around are 10 per cent." (OptusNet)
Oh, ten percent. No problem (except that he pulled the number out of his ass, which is apparently where his head is also located). I'll grant the dumb shit this much: not much is changed by the Indonesian discovery (which was no a surprise). But it does make a difference whether a nation's health authority gives notice and license to the medical community, the business community, the public sector and everyone else, that this is a freight train coming down the tracks.

I expect that Dr. Horvath knows this, and like the US's CDC, is scared to death of the potential. But like CDC, if he doesn't start to say it, we won't get any substantive attention or action out of local and state health departments and officials who have so many other competing needs. Unless responsible officials make the decision to ramp up the priority of a pandemic threat, we will lose further precious time to prepare.

Thursday, July 21, 2005

The Sheriff comes to town

In May we posted about the Pentagon's new class of "non-lethal" weapons, among which was the Active Denial System, a 95 gigahertz microwave beam meant to cause intolerable pain in less than five seconds. It is meant to "break up a crowd" of rioters.

Yes, I'd say such a weapon would do that. And probably more. Reuters (via MSNBC and quoting New Scientist magazine) reports that in tests against faux rioters at Kirtland Air Force Base in New Mexico, subjects were first warned to remove contact lenses and glasses and metal objects like coins or buttons to prevent "local hots spots":
“What happens if someone in a crowd is unable for whatever reason to move away from the beam,” asked Neil Davison, coordinator of the non-lethal weapons research project at Britain’s Bradford University. “How do you ensure that the dose doesn’t cross the threshold for permanent damage? Does the weapon cut out to prevent overexposure?”
The magazine said a vehicle-mounted version of the weapon named Sheriff was scheduled for service in Iraq in 2006, and that U.S. Marines and police were both working on portable versions.
The Sheriff is said to have a range of 550 yards (five and a half football fields) and has so far cost US taxpayers 51 million dollars, shoveled into the hungry maw of the sweethearts at Raytheon Corporation, makers of the Patriot Missile (the one that doesn't work).

It sounds to me like this is a weapon both likely to kill people and to cause intolerable pain first. Proud to be an American?

Neurological discoveries I have made

As an epidemiologist I am interested in patterns of disease in populations. So imagine my excitement when I discovered, courtesy the site Brain, Mind and Language (via Boingboing) descriptions of obscure neurological syndromes immediately recognizable as afflictions of well known population groups, to wit:

Kluver-Bucy Syndrome: Described as temporal lobe and amygdala damage, sufferers try to put any accessible object into their mouths and also try to have sexual intercourse with inappropriate objects.
Effectively, it is the "what" pathway that is damaged with regards to foodstuff and sexual partner. As Ramachandran puts it, "they are not hypersexual, just indiscriminate. They [monkeys with surgically modified temporal lobes] have great difficulty in knowing what prey is, what a mate is, what food is and in general what the significance of any object might be."
My discovery: Unusual variant in the Bush administration where they try to put anything they want in the mouths of the Washington Press Corps and then try to screw them.

Capgras' Syndrome: Often mistaken for a mental illness, Capgras' Syndrome is described as damage to the kinesthetic component of facial recognition. Patients believe people close to them are imposters,
identical in every possible way, but identical replicas. Classically, the patient will accept living with these imposters but will secretly "know" that they are not the people they claim to be.
My discovery: I am suffering from this syndrome, although my symptoms are limited to delusions about the Washington Press Corps. I find this variant also prevalent in the left hemi-blogosphere.

Cotard's syndrome:
Named after a French psychiatrist Jules Cotard, this syndrome is characterized by the patient believing that he is dead, a walking corpse.
My discovery: Diagnosis of Democratic Congressthings.

Fregoli syndome:
This is an extraordinary experience where the person misidentifies another person as someone who clearly he is not.
My discovery: This is the most stunning discovery of all. This neurological disease afflicts over half the voting population of the United States.

Wednesday, July 20, 2005

"Dutch Farmer" responds

Last week we put up a post, "Killing your chickens far from home." It was about the difficulty--logistical and otherwise--of mass poultry culling and highlighted the new career of Harm Kiezebrink, who has invented and is selling a machine to perform this unpleasant task, after losing his father to what he believes was a disease contracted from infected poultry. The post elicited several comments from different points of view (although mainly from farmers faced with the same problem). They are worth reading and follow the post, linked above. But one in particular I felt it fair to post up front, because it is from the subject of the post, Mr. Kiezebrink himself. Here it is, in its entirety:
If bird flu is a subject that you read about in the newspaper or see on the television, it is like an abstract subject. Just a news item that pops up every now and then. If it comes as an unexpected and unwanted guest within your family, killing your father, than you suddenly realize that it can hit you. If you start to explore what can be done about it, you find that the spreading of the disease is unstoppable as long as you don't have techniques available. After the first outbreak of bird flu, the infection coefficient is 8. That means that one farm infects 8 other farms within 48 hours; they all infect again 8 farms within the next 48 hours, and so on, and so forth. The only thing you can do to stop this process is culling the infected birds within the first 24 hours. No matter how many birds are infected. How do you want to do that when there is no technique available? by hand? or like they do it in Asia, by putting them in bags, hit them with sticks and than inflame them?

Just try to imagine how you should do it. Than the risk for the people, the farmers and veterinarians involved. They expose themselves to a deadly virus, in case of an outbreak. I was responsible for more than 1,600 people trying to stop the outbreak in Europe in 2003. 40 of them got infected and those infected people infected more than 4,500 relatives, friends and others. We had to deal with the H7N7 virus. In case this was the H5N1 that is currently active in Asia, this would have been the start of a pandemic outbreak with devastating consequences.

I don't like to cull. It has nothing to do with animal welfare. you end the live of diseased animals. Not for fun, but to stop the further spreading of the virus. To animals and to humans. In Asia, people and animals live close together. 13,4 billion chickens and 3,4 billion ducks in China alone. Last month there was a major outbreak in a nature breeding resort for migrating birds. These birds will start to cross the world in August/ September. To Asia, to the US, to Europe, to Australia. Ask yourself what you should do if these birds would infect birds and people in your direct neighbourhood. Like it unluckily hit my father. You would probably choose a different option, but I decided to do something about it. Knowing that it would not be understood by many people, especially people who are concerned about animal welfare and the position of animals in our society. I respect these people and share their concerns. Nevertheless, what I do is inevitable to stop the spreading of the virus. And if you have to do this, you have to choose the best possible option. Using gas to cull the animals before they die. To use electrocution, to kill them in a fraction of a second. Efficient and quick with as less people involved as possible to minimize the risk of human infection.

I don't want anybody to agree with the option I had, after my father died. I hope you will undertand my choice why I decided to do something to stop further spreading of this deadly virus.

Harm Kiezebrink

Scientific evidence in court: publication event

Today the American Journal of Public Health published a Special Supplement on Scientific Evidence and Public Policy. [Full disclosure: one of the Reveres was closely connected with the Coronado Conference where most of the papers were presented.]

This is the first full scale attempt by scientists and science scholars to come to terms with the new rules on scientific evidence spawned by the 1993 Daubert decision which requires federal trial courts to make a preliminary determination whether evidence presented by scientists is "relevant and reliable." In making the trial judge the "gatekeeper," Daubert places a burden on the judiciary to make judgments about science they may or not be better equipped to make than a jury. In two subsequent Supreme Court decisions the trial court's judgment has been made difficult or impossible to reverse on appeal and the procedure extended to include testimony by all manner of experts, not just scientists.

While the principle of assuring only relevant and reliable scientific testimony is presented to a lay jury sounds commonsense and uncontroversial, in practice it has turned out to be anything but. Like many things that "sounded like a good idea at the time," this one has bowed to the inexorable Law of Unintended Consequences, among them a dramatic reversal of the burdens on scientific evidence required for criminal versus civil actions (it is now much easier to get questionable science into a criminal prosecution than to get clearly valid evidence into a civil case about money damages), a disincentive for scientists to get involved as helpers to the court and the jury, the exclusion of clearly relevant and reliable scientific evidence by skillful lawyering designed to cast doubt in the judge's mind about facts accepted by most scientists (think of climate change in the political setting), etc. The Daubert tangle has turned into just that: an intellectual tangle.

Thus this AJPH Supplement is a welcome and unique addition to a literature that has been mostly authored by and from the perspective of lawyers. Legal scholars and judges are represented, but they are in the minority. The tone is set by scientists and science scholars. Among the distinguished cast of characters: epidemiologist David Michaels (former Assistant Secretary at the Department of Energy), epidemiologist Kenneth Rothman and biostatistician Sander Greenland (co-authors of an authoritative textbook on epidemiology), epidemiologists Richard Clapp and David Ozonoff (Boston University School of Public Health), toxicologist Ron Melnick (National Institute of Environmental Health Sciences), science scholars Sheila Jasanoff (Harvard's Kennedy School of Government), Sheldon Krimsky (Tufts University) and Carl Cranor (UC-Riverside), philosopher of science Susan Haack (University of Miami), cognitive scientist George Lakoff, psychologist Neil Vidmar (Duke University), and also legal scholars Peter Neufeld (The Innocence Project) and Joe Cecil (Federal Judicial Center) and constitutional scholar Margaret Berger (Brooklyn Law School). Additional contributions were solicited by the Journal and deal with tobacco legislation, the Data Quality Act and other topics of interest to practicing scientists and public health practitioners. The Introductory Note was written by Federal Judge Barbara Rothstein, currently Director of the Federal Judicial Center in Washington, DC.

These papers are critical and analytical. The Coronado Conference organizers hoped it would be a significant contribution to an important public policy issue and further the public debate. You can decide for yourself. Most of the papers were supported by the Project on Scientific Knowledge and Public Policy (SKAPP) and all of them can be downloaded as .pdf files for free at the SKAPP website.

Tuesday, July 19, 2005

Indonesia: interim update

Antara, the Indonesian News Agency, says health authorities there are still investigating the three deaths last week, presumed due to bird flu. While urging calm, Health Minister Siti Fadilah Supari also urged caution and alertness:
"People should not be afraid but stay alert and pay greater attention to their surroundings, whether there are sick or dead poultry," Siti said after a meeting with President Susilo Bambang Yudhoyono.

The minister said people should also constantly watch out for people in their immediate neighborhoods who had a cold accompanied by high fever.
Significantly, Siti advised Indonesians not to eat chickens or eggs for the time being. Samples of blood and feces were sent to a reference laboratory in Hong Kong to confirm the infection was from influenza A/H5N1 (bird flu).

The Health Ministry is now trying to find the source of the infection and interest centers on an "animal husbandry" area in Tangerang, Banten, where the victims lived.
Agriculture Minister Anton Apriyanto on Monday inspected the animal husbandry area in Tangerang in question, during which he stated that the government was planning to stamp out all poultry and pigs within a radius of three kilometers from where the suspected bird flu outbreak was identified.

According to Apriyanto, the measure would be taken to prevent the possible bird flu virus from spreading further, especially to poultry in other places.

President Susilo Bambang Yudhoyono on Sunday asked the relevant agencies not to cover up the cause of death of the three people in Tangerang who were suspected to have died of bird flu.

"The causes of their death must be made clear and explained to the public. It should not be covered up," the President said. (Antara News Agency)
Thus, while there is no confirmation from Hong Kong as yet (test results expected 7/20 or 7/21), the government is assuming the answer will come back H5N1. But there is still much to be ascertained and made public, including any exposure histories and the timing of the onset of illness in the three cases. We need more than "not covering up." We also need information to be revealed.

Update, 7/20/05, 7:40 am EDST: The Indonesian Health Minister (Siti Supari) has confirmed that tests on blood samples from the father, one of three family members to die of acute pneumonia last week, have come back confirming bird flu (H5N1) as the cause of the infection. Results on the two deceased daughters were not yet available.
Asked if the three died from bird flu, Supari said: "Yes."

"It is not yet known how they got infected, but we continue to conduct an investigation on the ground," she said.

"The results show (the virus is) a conventional one, and not a new virus. Therefore, there is no need to worry about human-to-human transmission."

Authorities have taken samples of more than 300 people who had contact with the family on the outskirts of Jakarta.

They also plan to carry out extensive tests on animals within a 20-km (12-mile) radius of the family's house and slaughter those infected.

World Health Organization representative Georg Petersen told British Broadcasting Corporation that an in-depth investigation was needed, adding that in other countries the source of infection was often not known straight away. (Reuters, via Boston Globe)
If they don't known how this family was infected (there is no history of contact with poultry), it is hard to understand how they also know there is no worry about human-to-human transmission. This statement of the Health Minister can best be characterized as a lie. Indeed, a WHO representative confirmed that the question of human transmission was still under investigation:
The World Health Organization laboratory in Hong Kong confirmed the victims had contracted the H5N1 bird flu virus, she said. Authorities have kept 300 people who came in contact with the three victims under observation, Georg Petersen, the WHO's representative in Indonesia said in an interview. None have developed symptoms.

"More information is needed,'' to confirm if the virus spread from human contact, Peterson said. (Bloomberg)
It is worth noting that Indonesia has favored vaccinating poultry rather than culling them. The worry about this strategy is that it could produce infected but asymptomatic domestic poultry that were still infective.

Leadership on flu in Seattle, but where else?

The west coast is arguably the first place bird flu might arrive via an infected passenger, being closest to asia, although the difference in probability with any other place in the world may not be great. Even so, it seems King County, Washington (Seattle) is always a bit ahead of the curve. They get it.

Unlike most other localities they are not just putting plans on paper or restricting activities to the health department but actively involving both the medical and the business communities (story in Puget Sound Business Journal). The latter include some industry giants, such as The Boeing Company and Microsoft. The Seattle and King County health department is inquiring of these and smaller businesses what they are doing (if anything) to plan should a pandemic materialize with the thought this could be shared with other businesses.
By fall, the department hopes to have a core group of business leaders that will work with the agency on a response in the event of a major influenza epidemic.

"These things happen two or three times a century," said Dorothy Teeter, interim director of the Health Department. "If I were a business owner, I'd be very concerned about the potential impacts on my bottom line."
It is likely these companies are doing nothing, but just the inquiry might kick start some action. The health department is taking a proactive stance, since to date no business leaders have contacted them about the problem and seem unconcerned. But reasonable estimates indicate 1.2 million people (two-thirds) of the county could become infected in the first 6 weeks. The worst case would be 250,000 to 600,000 seriously ill, 5000 hospitalized and 500 to 1800 dead. The impact could be severe, with possible mandatory closing of shops, restaurants and other nonessential businesses. Even without mandatory closing, absenteeism could reach 30%.
At the same time, employers can be important sources of information for workers, and workers' families, about preparing for the flu and responding to an outbreak.

"The business community needs to play a key role, in understanding what might happen and making sure we have clear lines of communication," Teeter said.
The medical community also needs tending. While there is some awareness, the degree of ignorance among doctors is shocking. Thus the King County initiative with respect to the doctors and hospitals is also timely. Since there are only a little over 5000 hospital beds in the county, 5000 new hospitalizations would be unmanageable without extensive prior planning. Without planning, the hospitals would be in chaos.

What is unfortunate about this story is how unusual it is. Everything makes sense. By implication, the lack of comparable planning elsewhere doesn't make sense. This example of public health leadership is matched by the lack of leadership at state and national levels.

Given that leadership vacuum, individuals are trying to fill the gap. An interesting example can be found on the Flu Wiki where a physician has drafted generic letters to local businesses and City Councils to stimulate them to think about the potential consequences of a pandemic to their firms and their communities. As in King County, the discouraging thing is that it had to be done by an enterprising individual rather than local, state and national health authorities.

What's that huge sucking sound? Public health leadership vacuum.

Pining for the sixties--not

For those who missed the 60s or now pine for it (forgetting much of what it was like), take heart. Some of it is coming back. In the 60s it was commonplace for the FBI to surveil, investigate and keep dossiers on "groups" the government didn't like.

The AP has another such story, about thousands of pages of FBI records about civil rights, environmental and civil liberties groups--being kept in 2005. Two of the groups (the ACLU and Greenpeace) have taken legal action to force release of the reported 4000 pages related to the two organizations. The FBI wants until February 2006 to "process" the requests and until June 2006 to review them before responding and will not reveal the nature of the contents of the dossiers until then, if ever.
The ACLU's executive director, Anthony Romero, said the disclosure indicates that the FBI is monitoring organizations that are engaging in lawful conduct.

"I know for an absolute fact that we have not been involved in anything related to promoting terrorism, and yet the government has collected almost 1,200 pages on our activities," Romero said. "Why is the ACLU now the subject of scrutiny from the FBI?"

John Passacantando, Greenpeace's U.S. executive director, said his group is a forceful but peaceful critic of the Bush administration's war and environmental policies.

"This administration has a history of using its powers against its peaceful critics," Passacantando said. "If, in fact, the FBI has been deployed to help in that effort, that would be quite shocking."
The FBI isn't commenting on this, citing "the ongoing case." Sounds like they need help from professional liar Scotty McClellan, the White House Presshole.

Monday, July 18, 2005

Small arms hugging big profits

We hear a lot about the threat WMDs and their proliferation (which the US does little to stop), but from the public health point of view (population burden) the real weapons of mass destruction are small arms: handguns, rifles, grenades, "small" bombs. These are the weapons of choice of terrorists, whether state or non-state sponsored. This weekend The Toronto Star (via Common Dreams) had an important article about the UN Program of Action on Small Arms, which is strongly supported by Canada. Guess who the big problem is?
More than 20 governments have now signed up to a proposed legally binding Arms Trade Treaty, which would ban arms transfers likely to fuel conflicts and human rights violations, or undermine development — an event that has given campaigners new hope that the deadly trade can be reduced if not eliminated.
But, says Amnesty International's Ottawa campaigner Hilary Homes, "the issue still isn't getting the attention it deserves. Whether in Iraq, Afghanistan or Ivory Coast, it's not weapons of mass destruction that are the problem. It's small, conventional weapons."

One of the major stumbling blocks to controlling the small arms trade is America's strong attachment to guns, and suspicion of attempts to control them, experts say.

Statistics show that the United States has 220 million guns, or almost one for every man, woman and child in the country. With less than 5 per cent of the world's population, America harbors one-third of the world's 640 million small arms.
The Canadians have a right to complain because half of all handguns used in crimes in that country come from the US. In Mexico it's worse: 80%. The Canadians also chafe at the handwringing about terrorists coming to the US across their border (passing the guns going in the opposite direction?):
Ironically, Cukier says, Canada has been at the sharp end of complaints that dangerous terrorists can slip across its border to attack Americans. But although Ottawa has tightened security to meet Washington's demands, there has been scant interest in improving American control over smuggled weapons heading north to Canada.

"The fact is, many more American guns have killed Canadians than Canadian-based terrorists have killed Americans," she said.
Even the half of small arms homicides not involved in armed conflicts (125,000 out of 250,000 worldwide) are related to the profitable trade that finances terrorism and ironically, the US "war on terrorism":
"It's become a political policy for leaders to talk about the chemical or atomic threat of terrorism," says Loretta Napoleoni, a London-based economist and expert in the financing of international terrorism. "The truth is that small arms are what terrorists use."

She notes the invasion of Iraq provided a huge arsenal of new weapons flowing through the Middle East.

"Saddam Hussein had a very large supply of weapons, and they were looted during the war."


"It's caused a big collapse in prices, and made weapons even more available. They include (shoulder-fired) missiles like Stingers, which used to cost around $200,000 and can now be bought for $5,000."

For rogue states, warlords, traffickers and international criminals, finding and acquiring small arms holds little challenge. According to international arms trade analysts, several hundred arms dealers are able to supply weapons whenever and wherever needed. Recycled arms are not the only problem. Dozens of countries continue to produce small arms for export, with the biggest sales made by the United States, Italy, Brazil, Germany and Belgium, according to the Small Arms Survey's 2005 report. By 2001, it says, more than 600 companies in 95 countries were involved in some aspect of the small arms trade.

As a result, about 8 million new weapons a year are circulated internationally. Although many are officially destined for "legitimate" countries, they frequently turn up in the hands of abusive security forces and militias.

The most tragic result, human rights groups say, is the recruitment of child soldiers, 300,000 of whom are estimated to be fighting in conflicts in more than 30 countries.

"The weight and size of small arms makes them easy for children to use and encourages the use of children as combatants," says the International Action Network on Small Arms. "A child as young as eight can easily be taught to fire an assault rifle."

As in Afghanistan — armed by numerous countries — weak states of Africa have been further undermined by the infiltration of weapons. Once in control of a large supply, warlords can continue to defy efforts to make peace, and multiply human suffering.
The Star article ends on a hopeful note regarding the UN effort. The Bush administration, however, is unlikely to push for controls on the international arms bazaar.

Another crime History will lay at America's feet.