Friday, September 30, 2005

County Supervisor gets it

Appleton, Wisconsin is over a 1000 miles and a world apart from Washington, DC. About 30 miles south of Green Bay it is a town of about 80,000 people, at least one of which, Outagamie County Supervisor Mark McAndrews, has more brains than all the bureaucrats in the nation's capital. Or so it seems. This week he asked the County Board to watch an excerpt from a September 15 broadcast of ABC's "Primetime" news magazine in which Health and Human Services Secretary Mike Leavitt made the grudging admission the country wasn't prepared for an influenza pandemic. McAndrews therefore wants the county to start getting ready on its own:
“Because of the federal government’s poor planning, you and I and the people we represent might die this winter, next spring or next summer,” McAndrews told the County Board, which did not discuss the issue and took no action on it. (Appleton Post-Crescent)
He has this one right. Too bad it sounds like he is a voice in the wilderness.

Braindead take notice

My Flu Wiki partner-in-crime DemFromCT (The Next Hurrah) has an excellent rundown at DailyKos of the belated signs of life among our braindead politicans who are dimly seeing that maybe bird flu is the next Katrina. Their vestigial ganglions firing a few neurons, both party leaders have issued reasonable statements and the Democrats offered an amendment to an unrelated Defense appropriations bill (more money for Iraq) to provide $3.08 billion to increase the vaccine and antiviral stockpiles (never mind there is no vaccine for bird flu yet or available antivirals for the stockpile), beef up global surveillance and provide assistance to the states for emergency preparedness (haven't I heard this before?). So a few of these airheads are onboard (typically too late), but all.

The bill's floor leader, Republican Senator Ted Stevens of Alaska (the state whose pork-barrel bridges to nowhere are the poster child for misspent money), is a real treat. Thursday he complained the Democratic proposal was a waste of money:
"To compare the money we have in this bill to fund them (U.S. troops in Iraq) with funding a proposal to deal with virus ... that has not yet become a threat to human beings I think is wrong," Stevens said.

"We ought to wait for the scientists to tell us what needs to be done," Stevens added. (Reuters)
Hello - oh - ho. The Bush Administration? Listen to the scientists?

Like the bioterrorist infusion for public health, this money will likely be wasted, and anyway, by the time it gets to the end of the pipeline (if it ever does) it may be too late. The Bush Administration can't even finalize a Draft Pandemic Plan that is months overdue, even by their own tardy timetable. And the neutered and compliant CDC isn't even in the room any more, much less at the table. Until federal health authorities signal, but clear and urgent public statements that it is time to start moving with utmost speed, state and local health departments hard pressed by Republican budget cuts (often with Democrat collusion) won't divert their scarce resources from daily unmet vital public health needs to prepare for a pandemic of uncertain timing and severity. Thus it is up to local communities to mobilize their considerable resources to prepare on their own.

I'm glad the Democrats are finally showing signs of life. But it is too late to address this by the kind of stale solutions that haven't worked before and are not likely to work now. As in any crisis, this one will come down to neighbor helping neighbor. In a bad pandemic many things will go wrong, systems will fail and we will need to improvise workarounds. It isn't the apocalypse, any more than Ktrina was the end of the world. If we think ahead we will do much better when the time comes. The Flu Wiki is an attempt to organize the vast reservoir of wisdom and experience we already have in ways helpful to local community leaders, activists and citizens.

DemFromCT reports the amendment passed the Senate by unanimous consent last night. But it is likely to face a difficult time in the House and Stevens is said to be gunning for it in Conference committee. These are incompetent, shortsighted and greedy people. Stevens and his ilk will undoubtedly get their Tamiflu because they are "essential" government officials. And the rest of us? I guess we'll just have to do as he says and listen to the scientists.

And what the scientists are saying is that Senator Stevens is full of shit and he has put the rest of us in it.

Thursday, September 29, 2005

Bird flu and statins

In an extremely interesting article in the Clinicians Biosecurity Network Weekly Bulletin (issue of 9/27/05) Borio and Bartlett review a suggestion of David Fedson, an expert on vaccines (and former Director of Medical Affairs at Aventis Pasteur), that statins (tradenames Zocor or Lipitor) might be helpful in preventing serious complications of influenza, perhaps by dampening the cytokine response.

The statins are widely used and available drugs used to lower cholesterol. They also have anti-inflammatory activities, perhaps by preventing activation of the transcription factor NF-kappaB. One mechanism thought to underlie the virulence of the H5N1 virus is production of a "cytokine storm," an unregulated systemic inflammatory response that results in a rapidly developing generalized clotting disorder, hemorrhage, kidney failure and fluid-filled lungs. The phenomenon is similar to or the same as what is called gram-negative sepsis or septic shock, a serious complication of bacterial infections that claims 400,000 to 500,000 lives each year in the US and has 50% to 70% mortality. Treatment for sepsis is a high priority independently of any role for the same or similar mechanism in influenza.

The idea that statins might be helpful for sepsis or influenza is based on more than speculation about mechanism. In 2004 Almog et al. (Circulation, Aug 17 2004;110(7):880-885) reported that patients admitted to the hospital with acute bacterial infections and who were on statins for more than a month for other reasons had a dramatically reduced incidence of severe sepsis (19% versus 2.2%) and reduced admission to the Intensive Care Unit (12.2% vs. 3.7%). An interesting point is that patients on statins might be expected to be at greater risk because they are taking a medication for a pre-existing medical condition.

Another study (.pdf available free on line here) looked back at the experience of over 700 patients that were admitted to a hospital for pneumonia. About 100 of them were also taking statins. Using 30-day mortality as a measure of outcome, the statin group had about two thirds fewer deaths than the non-statin group (odds ratio .36, 95% confidence interval .14 - .92).

Borio and Bartlett also report on an article from The Netherlands by Enserink to appear shortly in Science (hence not available to me other than through their summary). Enserink examined influenza seasons between 1996 to 2003, and using a database of 60,000 primary care patients compared those with at least two statin prescriptions in the previous year to those without. There was a 26% lower risk of pneumonia in the statin group. Because of the imprecision of the measure of statin use, I would expect the statin effect to be even greater than reported here.

Borio and Bartlett conclude:
These studies suggest that statin therapy may ameliorate the course and/or prevent complications of influenza. In these studies, it appears that all of the people were already receiving statins when they got infected. Whether statins would be beneficial after the onset of symptoms is still unknown. However, further investigation is merited. This is particularly important given the likelihood that vaccines and antiviral agents will be in short supply during an influenza pandemic, and statins are widely available and may be produced relatively inexpensively.
This is extremely interesting work. It is too early to say that prophylactic statin use in a pandemic is a reasonable strategy, but it is worth considering.

Playing soon in a community near you?

Two more suspect bird flu deaths are being reported in Indonesia while a health ministry official in Jakarta is saying, on condition of anonymity, that there are now 63 confirmed or suspected cases under treatment or observation. This is higher than yesterday's report of 55 (or 53 or 57, depending on source and time of report). Thus the situation continues to evolve. Six of the cases have died, but the latest two would bring the total to eight, if confirmed. Meanwhile a second zoo in Semarang has been closed after tests on birds showed infection.

With events moving rapidly and the health ministry beleaguered it is difficult to get a clear picture of the true state of play. According to Agence France Presse (via ChannelNewsAsia), a usually reliable source:
Of the 63, six have died but further tests are still being carried out on the latest fatality to confirm that the victim died of the virus.

Some of those infected with the virus have not shown any symptoms and others have made a full recovery, officials said.

Bird flu has killed 43 in Vietnam, 12 in Thailand and four in Cambodia.

The health ministry official said that the 63 cases of bird flu could be broken down into three categories -- confirmed, probable and suspected cases.

A patient is suspected to have bird flu if the person showed clinical symptoms of the disease such as high fever, said Sardikin Giriputro, deputy director of Sulianti Saroso hospital, the main hospital treating bird flu patients.

Probable cases refer to those who have had initial tests that strengthened suspicion of infection, including X-rays showing that pneumonia had developed, he said.

Confirmed cases refer to cases which had been clinically and serologically tested positive, and had the results confirmed by the World Health Organisation through further tests in Hong Kong.

Only five of the 63 were confirmed bird flu cases, nine were probable cases, while the rest were suspected.
Meanwhile the Health Ministry struggles to cope with the growing sense of public unease and incipient panic. In such an atmosphere and with "flu-like symptoms" a vague category, it is likely there are many "worried well" consulting their doctors and visiting hospitals and clinics, as well as some who may be genuinely sick with bird flu. Unfortunately the desperate-appearing attempts to reassure will only promote further distrust of a government response that merits little trust:
The number of suspected bird flu cases in Indonesia rose to 48 today [sic] as the health minister appealed for people not to shun patients suffering from the virus, saying close contact with them was not dangerous.

Siti Fadili Supari was photographed in newspapers yesterday kissing a nine-year-old boy who had returned from a hospital where he was treated for bird flu after rumours spread in the neighbourhood that it was unsafe to get close to him.

Supari urged neighbours to go about their life as normal, saying that the virus could only be contracted from infected poultry, Kompas daily reported.

“This boy is proof that it is possible to fight bird flu,” Supari was quoted as saying. “He is a boy with muscles of steel and bones of iron.” (AP via Evening Standard
This AP report also gives another definition of "suspect" case, not present in the AFP report above:
Patients showing symptoms of the disease – including high fever, coughing and breathing difficulties – and who have been in recent contact with chickens are considered suspected cases in Indonesia.
If this is indeed the Health Ministry's suspect case definition (we cannot tell from this news report where it came from), the lack of evidence of person-to-person transmission may be a result of what epidemiologists call selection bias, in essence a self-fulfilling prophecy. The attempt by the Health Minister to prevent the shunning of those who are sick is admirable but hugging those who are ill is not. People need reasonable guidelines about how to care for those who are ill in ways that don't needlessly endanger the care-givers while still allowing the humane attendance that will promote survival and recovery. Masking the sick patient and the care-giver and reasonable hygiene (handwashing and not going out with clothing contaminated with blood, mucus or secretions from the sick) is minimally achievable advice that should be promoted, not embracing potentially infective individuals.

The Indonesian Health Ministry response is improvised, unthought-out and borne of confusion and panic. Unfortunately, they are not much worse off than many of their counterparts (including the US) because of a studious lack of preparation at the local level by the governments involved.

Take a good look at Indonesia because it will be a preview of what's to come wherever you are.

Addendum, WHO Case definition (.pdf) ; thanks to Declan Butler; elevated from Comments:
Possible influenza A/H5 case

i. Any individual presenting with fever (temperature >38°C) AND one or more of the following symptoms:

cough; sore throat; shortness of breath;


one or more of the following:

a. laboratory evidence for influenza A by a test that does not sub-type the virus;
b. having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious*;
c. having been in contact during the 7 days prior to the onset of symptoms with birds, including chickens, that have died of an illness;
d. having worked in a laboratory during the 7 days prior to the onset of symptoms where there is processing of samples from persons or animals that are suspected of having highly pathogenic avian influenza (HPAI) infection.


ii. Death from an unexplained acute respiratory illness


one or more of the following

a. residing in area where HPAI is suspected or confirmed;
b. having been in contact during the 7 days prior to the onset of symptoms with a confirmed case of Influenza A/H5 while this case was infectious*.

Probable influenza A/H5 case

Any individual presenting with fever (temperature >38°C)


one or more of the following symptoms:

cough; sore throat; shortness of breath;


limited laboratory evidence for Influenza A/H5 (H5 specific antibodies detected in a single serum specimen).

Confirmed influenza A/H5 case

An individual for whom laboratory testing demonstrates one or more of the following

a. positive viral culture for Influenza A/H5;
b. positive PCR for Influenza A/H5;
c. immunofluorescence antibody (IFA) test positive using Influenza A/H5 monoclonal antibodies;
d. 4-fold rise in Influenza A/H5 specific antibody titre in paired serum samples.

One with no heart, one with no spine

The 89-member Republican Study Committee has a plan to pay the bill for the Republican Administration's bungled response to Hurricane Katrina: make the old and sick pay for it. Last week they announced their plan for increases in Medicare beneficiary premiums and a one-year delay in the program's prescription drug benefits as a way to prevent the reconstruction costs to "become a catastrophe of debt for our children and grandchildren," as Indiana Rep. Mike Pence, put it.

As an extra little bonus, the Republican plan would also fight Big Government in a meaningful way: a $25 billion cut in CDC's budget over the next decade. Democratic Rep. Lois Capps of California had an appropriate response:
"This would be, if it happens, irresponsible, incompetent, and immoral.
CDC Director Julie Gerberding had an inappropriate response:
Gerberding declined to comment directly on how the proposed budget cuts would affect her agency's ability to respond to disasters. "It's a sobering proposal," she said.
This makes me want to scream. What Rep. Capps said is correct, if too mild and more polite than deserved. But it is easy to discount it as more carping from the political opposition (what there is of it). Those words should have been uttered by the CDC Director herself.

CDC (once the jewel in the crown of American public health), the public health profession, the citizens of this country, and indeed the world, deserve a CDC Director who will fight for public health, not an incompetent manager without the guts and spine to say what everyone knows needs to be said.

Once again, I am disgusted.

Wednesday, September 28, 2005

Challenged by challenged books

I got tagged with a "book meme" by Lindsay at Majikthise, and while ordinarily I don't mind, this one is really, really embarrassing. Here's the challenge:

How many of the American Library Association's top 100 most frequently challenged books have you read? The list of 100 comes from the 6,364 challenges reported to the ALA Office for Intellectual Freedom in the years 1990 - 2000. Kevin Drum (Washington Monthly) read 14. Lindsay read 29. Before I tell you how many few I've read, let me defend myself against the charge that either I don't read or I read only tame books.

I am currently reading Spin Resonance Analysis, so I do read. I think the book is challenging, but I haven't notified the ALA to that effect. I have too much respect for intellectual freedom and nuclear magnetic resonance. Moreover, a lot of the books on this list are children's books and in the 1990s my kids were grown up already (although two of the books I did read to them in the 70s). I'm not sure I've even heard of most of the books on the list. Goes to show you how effective the right wing repression has been. I now have two grandchildren and when they are old enough I am planning to read them Volume 1 of Das Kapital. It's not on the list.

So there. (Unfortunately many of the books are also what are sometimes referred to as "classics" and I haven't read them. Sigh.)

Here's my total: 4.

They are:
The Catcher in the Rye by J.D. Salinger
In the Night Kitchen by Maurice Sendak
The Stupids (Series) by Harry Allard
Brave New World by Aldous Huxley
So here's a new challenge: I challenge anyone to do worse than I did. I dare you Melanie Mattson of Just a Bump in the Beltway (payback time for the last meme), DemFromCT of The Next Hurrah (to pry him away from the Flu Wiki for a few minutes) and Cervantes of Stayin' Alive (because I always seem to be imposing on him, so what's one more).

On being foolish

Cases and suspected cases of avian (bird) flu are continuing to appear in Indonesia, with reports now coming in from outside the capital of Jakarta where most of the cases so far have been reported. Agence France Presse (AFP) now says 57 people are being treated for suspected bird flu, 20 at Jakarta's Sulianti Saroso hospital for infectious diseases. In addition, The Jakarta Post reports four people from outside the capital in Java hospitalized, some as much as a week ago (see also here).

Many of these cases also report contact with or simultaneous illness of poultry, usually chickens. Since contact with or living in the vicinity of poultry is extremely common in Indonesia, this cannot be taken as proof the person contracted the virus from the birds. Even if they did, the number of cases now piling up and the evidence from the zoo that even casual contact with infected birds is sufficient signals a change in the transmission efficiency of the virus.

It is difficult to get accurate information from a region where the situation is changing rapidly, communication is poor, and there are many social and political factors distorting an accurate message. But it would be foolish to do anything but assume the evolving Indonesian story is anything but extremely serious and bird flu is possibly epidemic in the country.

Unfortunately, foolish attitudes are quite common these days.

Thoughtful or provoking?

An editorial in Thailand's Bangkok Post has characterized as "thoughtful" in the flu blogging world. Perhaps. But there is much in it that requires additional editorial comment.

First, there are several assumptions that should be questioned, among them that there is evidence the virus has not mutated into a form that is easily transmitted. Given the poor surveillance and lack of seroprevalence studies, itself a scandal, we simply don't know this to be true. Niman at Recombinomics has repeatedly called attention to fallacies in the assumption that lack of evidence of reassortment is sufficient to conclude the necessary step to pandemic ability hasn't occurred. Clearly the biology tells us differently.

Second, the editorial praises Bush's "initiative" announced at the UN for "a new international partnership" to fight bird flu. It is doubtful Bush's do-nothing administration had much to do with it (except to take credit), and even worse, the stated goal of the 16 nation partnership is to ensure adequate sharing of information. The Bangkok Post editorial takes China and Vietnam to task for their failure to share information, but says nothing about the Bush administration's own lack of openness, as revealed in the Nature magazine article of last week (see our earlier post).

Third, The Bangkok Post again raises the hoary specter of avian flu being used as a bioweapon, citing an unpublished and highly censored Canadian military report. It is impossible to comment on leaked intimations of dire threats from sources with questionable motives, but suffice it to say use of avian influenza as a bioweapon makes very little sense, at least one designed against humans. Unless one assumes the object is just to kill as many people as possible (nationality, ethnicity and religion irrelevant), H5N1 would be an abysmal weapon. In the case of nutcase apocalyptic "End of Days" thinking, it is implausible they would have the technical expertise to figure out how to do something even today's best virologists can't do: determine what makes the virus efficiently transmitted. If the object is political, it is hard to see how its use could have any political use. Since an outbreak would appear to be natural (unless a group or country took credit for it, which seems like it wouldn't be such a popular thing to do as it would be killing its own people), no political purpose could be served, any more than a group that took credit for Hurricane Katrina would be likely to profit (or be believed). Talk of avian flu as a bioweapon merely diverts attention from the main focus: responding to the primary public health challgenge of managing a naturally occurring epidemic infectious disease in a highly connected global population.

So the editorial is thoughtful, yes. But some of the thinking is flawed.

Tuesday, September 27, 2005

Indonesia's birds in the hand

As a follow-up (and perhaps a needed clarification) of the last post, we find an interesting BBC story this a.m. about "Indonesia's bird flu dilemma."

In the earlier post we noted the government's reluctance to enforce a mass cull (in other words, mass industrial-strength killing) of birds in Indonesia. Such measures have been strongly advocated by WHO and FAO (the UN Food and Agriculture Organization) and have been undertaken in Thailand, Vietnam and Hongkong, among other places. Some authorities, although not all, believe they are effective. The point of the last post was not, however, that Indonesian authorities were refusing to initiate a policy proven effective, as much as their reluctance to undertake a policy major international agencies strongly advised. The BBC article gives some good indications of the source of this hesitancy.
As human deaths from bird flu begin to mount in Indonesia, the dilemma for the Indonesian authorities is as much how to save the birds as how to save the people.

To say that Indonesians love their caged birds is a serious understatement. Almost every house has at least one cage, and often a row of them, hanging from the eaves.

Every major town has a crowded bird market lined with hundreds of cages, where a top-quality singing dove can sell for the same price as a house.

As in several other Muslims countries, doves occupy a special place of honour in the culture, with streets, companies and even a domestic airline - Merpati - named after them.

The doves are not merely kept for decoration - they are taken out and handled, treated as much-loved pets and taken to vets when they fall ill.

Tapes of champion singing doves are available in cassette shops, and are played at home to birds in the hope that they will learn to emulate the champions, and become champions themselves.

In Javanese folklore, a man is only considered to be fully a man if he has a house, a wife, a horse, a keris (traditional dagger) and a singing dove in a cage.
Against this background, the BBC report draws the analogy between a mass killing of birds in Indonesia and a mass killing of cats and dogs in the UK (or for that matter, in the US). In the recent Hurricanes in the US we saw that people routinely put their own lives in danger by refusing to evacuate without household pets. In addition, eighty-percent of poultry in Indonesia is of the backyard household variety. Thus enforcing and carrying out mass kill policy would be a formidable political and logistic operation.

Thus, while mass killing may be possible in some places, it looks infeasible in Indonesia, an explanation for why the government keeps saying the are "about to do it" but never do.

In my own view, mass culling is unlikely to halt the spread of this disease in any event. It is too late for that, if it ever were possible.

Jakarta's bird flu levees

More fatalities on Monday but "Minister of Health Siti Fadilah Supari said that despite the growing toll, the situation appeared to be under control, and reiterated that there had been no confirmed case of human-to-human transmission" (The Jakarta Post). That's a relief. As long as you can't confirm something, it must not be happening. And maybe the mass killing of birds, urged on Indonesia for months but still not underway is good evidence that the jakarta Government is finally making some tough decisions:
The government said that it would commence a poultry cull in affected areas in the near future.
Near future. Hmmm. Judging from the plummeting sales of poultry and other evidence of public concern in infected areas, at last there is community mobilization to control the problem:
However, bird-flu free areas have not been so active in educating residents, particularly poultry keepers.
"We were only told by health officers to have ourselves checked if we came down with the flu," said Wiguno Adi, a resident of Jagakarsa, South Jakarta.

Community health workers in Cilandak and Pondok Labu, South Jakarta, said they had only been told to watch out for patients showing symptoms of bird flu.

"We are few in number. We can't go door-to-door instructing people to observe good hygiene," said a doctor at the center who refused to be identified.

City health agency spokesperson Zelvyno said the agency had told community health workers to meet with locals and reeducate them on good hygiene.

"It is up to the centers to allow time for the campaign, there is no special budget for it," she said. (The Jakarta Post)
No special budget? I thought "help was on the way" from wealthier donor nations, as the UN Food and Agriculture Organization called for last week :
FAO is concerned about the spread of avian influenza in Indonesia and has offered further assistance to control the virus in the country.

"Avian influenza has become endemic in Indonesia and it is continuing to spread," said FAO's Chief Veterinary Officer Joseph Domenech.

"In view of the worrying situation, it is necessary for the government to improve its virus control policies and strategies," Domenech said.

The fight against bird flu should become a national priority and veterinary and civil authorities should be provided with the full power to enforce disease control measures.

Local veterinary services should be strengthened to enable them to discover disease outbreaks at a very early stage and to immediately carry out control measures such as culling and targeted vaccination in high risk areas.

The national vaccination strategy should be reviewed to ensure that only quality vaccines are used, in accordance with the World Animal Health Organization (OIE) standards.

More financial resources should be made available for the control of bird flu in animals to prevent a human pandemic. Four people have died of bird flu in Indonesia and others are suspected of having the virus.

The involvement of the around 30 million backyard village households keeping around 200 million chickens would be a major challenge, FAO said. Major public awareness campaigns should be launched to inform farmers about risks and control strategies.
The global strategy for the control of avian influenza in animals remains largely under-funded despite important contributions pledged by some donors, FAO warned today.

"It makes sense to stockpile antiviral drugs to protect humans against a potential avian influenza pandemic, but at the same time we have to contain the virus at source, in animals, to reduce the risk to people," said FAO's Chief Veterinary Officer Joseph Domenech.

"Strong national veterinary services are essential to improve the early detection of avian influenza. The rapid exchange and analysis of virus samples require additional resources to immediately respond to avian influenza outbreaks," Domenech said.

The Global Strategy for the Progressive Control of Highly Pathogenic Avian Influenza launched by FAO, the World Animal Health Organization (OIE) and in collaboration with the World Health Organization (WHO) in May 2005, for control programmes in southeast Asian countries, has called for over $100 million for the next three years.

To date, donors such as Germany ($6 million), Switzerland ($4 million), the United States ($6 million) and Japan ($0.5 million) have pledged around $16.5 million. FAO will provide another $2 million from its own resources. The World Bank and the European Commission are also planning to heavily invest in controlling bird flu.

"This support is excellent, but it marks only a starting point and unless it translates into further financial funding to support affected countries, the cycle of bird flu infection that will occur in poultry this winter will not be stopped," Domenech said.

The circulation of so much influenza virus in animals in many countries in close proximity to humans remains a major risk factor that could trigger a pandemic, FAO warned.

There is still a small window of opportunity before winter to reduce the levels of infection through vaccination of poultry. In countries like Viet Nam it is the only way that the levels of infection can be dampened down in the short time available. It involves mass vaccination of poultry, especially in the smallholder sector where there is also close contact between poultry and humans.

"Countries in Asia are doing their best to control the virus but they cannot and should not be expected to do this job on their own," Domenech said.
Memo to George: Time to "pre-position" some bucks and technical aid to prevent the flu levees from being overtopped in Indonesia.

Monday, September 26, 2005

Flying to the US: me and what else?

Back in the United States after an eight hour plane ride against 150 km/hr headwinds from Milan's teeming Malpensa airport to a US Eastcoast International airport. In the ten or eleven hours I spent in travel, I came into physical proximity and contact with hundreds of people, including pass port control who took my passport and handed it back to me and then did the same thing for thousands of others from all over the world. I then got on a sealed flying tube, with a few hundred other people from disparate locations, breathed recirculated (but HEPA filtered) air, and was serenaded by the occasional coughs of fellow passengers. I repeated the airport process at in the states, then hopped into a taxicab that will in turn be used by hundreds of other city residents and visitors over the next few days. Viruses now travel at 700 km/hour, even against headwinds.

Our highly interconnected network is the skeleton on which contagious disease now travels. Short of a total shutdown in international travel, there seems little we can do about this. Since people are infective with influenza 12 to 24 hours before symptom onset, the measures used in the SARS outbreak of 2003 are of no avail. SARS is a disease most infective in the latter stages of the disease, when the patient is seriously ill. Hence most of the transmission was to health care workers. Even in the epidemiologically most favorable case of SARS, researchers from the UK's Health Protection Agency publishing in the British Medical Journal, conclude that identifying infected airline travelers is essentially fruitless.
This agency is charged with "investigating options for controlling infectious disease and protecting public health using mathematical simulations," lead investigator Dr. Richard J. Pitman told Reuters Health. "We looked to see if passengers developing a fever during flight would be effective way of preventing importation of SARS or influenza into a country."

Based on the incubation periods for influenza and SARS, the researchers estimated the proportion of individuals with latent disease who would develop symptoms during an international airline flight to the UK. They report their results in BMJ Online First.

"Our findings suggest that approximately 90 percent of cases would not develop symptoms en route and so would get straight through," Pitman said. "The 10 percent that would be picked up would be rapidly replaced by those that got through, so at best there would be only a small delay in onward transmission of the epidemic."

Even for passengers from the Far East or Australia, whose flight durations are the longest, the sensitivity would still be too low to be of benefit, the investigators report. (Reuters Health)
Politicians and health officials will undoubtedly try to restrict travel as a means to safeguard their populatin and appear to be doing something the public feels is "common sense." There is probably jno way to stop them. Just as there is no way to stop this virus once it attains the ability to move efficiently from person to person.

Predictable responses

Another Indonesian has died of bird flu and thirty four others are under observation (AP). Whether this is the sixth, as announced, or a higher number, we are seeing the beginnings of predictable cascading responses.

The island nation's traders in exotic birds have been hit hard.
"Many wealthy people are shying away from buying exotic birds. Most of our buyers now come from the lower income brackets, and they usually buy cheap pigeons for racing," said Hasyim, who said he was considering a change in profession.

The lack of business has not only affected the traders but also the parking attendants at the market. Maman, a parking attendant, said that during weekends and holidays he could earn as much as Rp 300,000 a day, but his earnings had fallen by about 75 percent since bird flu made the headlines.

Surabaya Zoo has also been hurting for business since the bird flu scare. When The Jakarta Post visited East Java's largest zoo on Saturday, there were very few visitors.

"Since the stories of bird flu killing birds at Ragunan Zoo in Jakarta a few days ago, few people have visited our zoo. But people should not worry because we check our birds every day," said zoo manager Liang Kaspe. (The Jakarta Post)
Indonesia's tourist industry is slowing and is bringing pressure on the government "to minimize the outbreak's effect on the industry." On its face the request is for a "transparent exchange of information" with other countries in the region, but a subtext is managing information and the message.

International trade is also being affected. Australia seized five metric tons of poultry meat from an unnamed Asian country or countries last week because of fears it might bring the virus. WHO lists 16 Asian countries as high-risk areas. These seizures have apparently been occurring periodically since July, when the first three cases appeared in Indonesia. But now a public announcement was made by Australia's justice minister, in a bid to reassure the public:
"We've seized several tonnes of poultry meat and associated goods and items, and I think the thing to remember is that in this case we shouldn't panic, we shouldn't cause undue public apprehension," he said.

"We're working closely with health and overseas organisations and we have our people posted overseas who are providing us with intelligence." (Radio Australia).
The first signal that panic is reasonable is frequently authorities telling people not to panic.

Australia is also taking blood samples from wild birds as the southern spring approaches (Reuters). The spread of Highly Pathogenic Avian Influenza to the poultry stocks of any nation would be a serious event. As the realization that poultry from many Asian countries is infected, we will see increasing pressure for restrictions in trade, commerce and possibly travel, with likely serious economic consequences, independent of any public health issues. The role of migratory birds in spreading the disease is a matter of controversy, with strong and sometimes vitriolic objections from the bird conservation community.

Wild and exotic birds,, zoos, parking attendants, the tourist and poultry industries, ordinary people. There will be many victims before this story is over.

Making a list, checking it twice

This is the sort of thing you can find over at the Flu Wiki, but I figured I'd post it front and center here because y'all can discuss it if you wish. It's the WHO checklist for influenza pandemic preparedness. It's 29 pages long so I'm not going to try to summarize the whole thing, but it's amazing how many of the specific points are exactly what we don't seem to have together here in the Greatest Country in the World, based on recent experience.


1.2 Command and control
In order to be able to make clear and timely decisions and to have a uniform policy that is endorsed by all officials, it is essential to know who is in charge of different activities within communicable disease control, and how that might change if a limited outbreak becomes a major emergency.
In addition, it is essential to know who is in charge of key elements in the response (e.g. travel or trade bans, enforcement of quarantine).

So who is it? CDC, DHS, local officials, the Army? It seems we're still trying to sort all that out. . .

Then there's public communication, which I posted about earlier:

1.4.1 Public communication

Develop a communication plan that addresses different target groups (e.g. press, general public, health-care workers, parliament, specific risk groups), key messages to be put across, possible materials that are needed (web sites, leaflets, information in different languages, etc.) and distribution mechanisms to reach the target groups.
As part of the plan, consider establishing an official national or regional influenza pandemic web site. Link this web site with similar ones developed by other countries, after evaluation of the quality and relevance of the information provided on these other sites.
Ensure a good relation with professional specialists able to help with development of accurate and timely messages, before and during a pandemic.
During the interpandemic period, develop fact sheets or other general information on pandemic preparedness for distribution to various target groups, including professional and community groups. Ensure national consistency of locally produced fact sheets.
Nominate pandemic spokespersons at the national and regional levels. These persons would be responsible for all media presentations to the broader community. Ensure adequate technical support at the national and regional levels for these spokespersons.

Then there's this one, that I also posted about earlier (unfortunately):

1.5.1 Legal issues
During a pandemic, it may be necessary to overrule existing legislation or (individual) human rights. Examples are the enforcement of quarantine (overruling individual freedom of movement), use of privately owned buildings for hospitals, off-license use of drugs, compulsory vaccination or implementation of emergency shifts in essential services. These decisions need a legal framework to ensure transparent assessment and justification of the measures that are being considered, and to ensure coherence with international legislation (International Health Regulations).

I'm sure that somewhere in the labyrinth of the bureaucracy, people are planning away at all this stuff. But there sure hasn't been much public discussion of it, and as far as I can tell from events surrounding a certain hurricane, we sure don't have answers. Maybe now that we have suddenly discovered that natural disasters do happen, even in the United States, we can at least get started.

Weird Science

I'm not sure where the Reveres are currently in relation to cyberspace, but in case they won't make it back today, here's something from me.

Apparently some people were disappointed with my sarcastic take on the new FDA Commissioner, and were hoping for something more substantive. Well, we don't have a nominee for the permanent job, but we do have a new Acting Commissioner, a urologic surgeon by training who is Director of the National Cancer Institute. According to the Associated Press:

FDA's new acting chief tells of a sea change in care
Predicts more tailored response to patients

By John J. Lumpkin, Associated Press | September 26, 2005

WASHINGTON -- The new acting chief of the Food and Drug Administration, Dr. Andrew C. von Eschenbach, said yesterday that he will be presiding over a transformation in medicine, as scientists understand diseases in a way that could improve doctors' ability to treat patients.

Von Eschenbach, tapped by President Bush as the temporary chief of the regulatory agency, said yesterday that discoveries about diseases at ''a molecular level" will lead to a new kind of healthcare.

Now, doctors treat illnesses based on how well other people have responded to a given treatment. Soon, they will develop a tailored response, built around specific understandings of the patient, the treatment and the disease, he said.

''We are discovering so much about diseases like cancer at the molecular level," said von Eschenbach, who is a urologic surgeon by training. ''Much of what we have done . . . has been based on a model of empiricism." Soon, doctors will be able to intervene with medical treatments more effectively matched to a specific patient's illness.

Preparing the FDA for such a transformation is among his goals, von Eschenbach said.

Hmm. In other news:
Targeted medicines are far off

September 26, 2005

Personalized medicines targeted according to a patient's genetic profile have been over-hyped and their widespread use is still 15 to 20 years away, leading scientists said last week.

The field, known as pharmacogenetics, has made strides in the battle against certain cancers and shows great promise in improving efficacy, reducing adverse reactions of drugs and limiting medical costs.

However, a report by the Royal Society, an independent academy of leading scientists, said more research into the genetics of complex diseases, DNA testing, international guidelines, and investment were needed before targeted therapies would be widely available.

''Personalized medicines show promise but they have undoubtedly been over-hyped," said David Weatherall, who chairs the working group that produced the report.

''This is a long-term goal and it will take many years to come to fruition."

The Royal Society goes on to say that the pharmaceutical companies won't invest sufficiently in this sort of technology, and it will require financial incentives, plus publicly funded testing of off-patent compounds. It seems to me the Commissioner of the FDA can worry about this Great Transformation later. Meanwhile, he needs to make the agency start working for us, not the drug companies.

Sunday, September 25, 2005

Sunday Sermonette: Jefferson

Sunday. Bird flu in Indonesia. Hurricanes in the Gulf. Poverty everywhere. And who runs the government?
"History, I believe, furnishes no example of a priest-ridden people maintaining a free civil government. This marks the lowest grade of ignorance of which their civil as well as religious leaders will always avail themselves for their own purposes"

Thomas Jefferson [Letter to von Humboldt, 1813].

Indonesia situation still evolving, WHO's isn't

Emerging from a connectionless two days, I was hoping to find the bird flu situation in Indonesia stabilizing, or even better, to be improving. Unfortunately, as far as I can tell that hasn't happened. Antara News (The Organization of Asian-Pacific News Services) reports that the number of suspected patients hospitalized in Jakarta's Sulianti Saroso hospital is now 21, an increase of at least four from last Friday. The three admitted on Saturday were all visitors to the (now closed) Ragunan Zoo, where dozens of birds were found infected with H5N1 last weekend.

WHO is also confirming that the 8 year old nephew of the woman who died of bird flu September 16 also is infected. In a sense this isn't news as it was obvious days ago this was a case. The virus from the Aunt and her nephew are undergoing sequencing. But as Niman (at Recombinomics, various posts voer the alst year) has repeatedly pointed out, the criterion WHO seems to be using for evidence of a genetic shift in the virus is the presence of human reassorted genes. If there is significant recombination occurring, this is sufficient to produce mutations that permit efficient human to human transmission. Thus WHO's statements about any lack of genetic change of the virus must now be discounted.

Given the number of people with casual contact at the zoo now infected, it should be obvious an important change in the virus has occurred to allow such efficient transmission from birds. The evidence of human-to-human transmission here is also strong. On the one hand WHO is sounding urgent warnings a pandemic is imminent and inevitable while on the other it dismisses evidence this is in the process of happening right now, probably because of the consequences this will have for Indonesia and international trade and tourism in Asia.

WHO's deference to its member nations is an established practice, based in international law. It was only during the 2003 SARS outbreak WHO they began to depart from it, announcing travel warnings against the wishes of some member nations. It is past time for WHO to have the guts to act independently again and to sort out the political repercussions later, when the dust settles.

Meanwhile, I'm not going to bother listening to what they say.

Saturday, September 24, 2005

I hope you don't mind . . .

If I change the subject. I'm afraid I can't give you another flu thread because I just came down from the mountain and I don't have any news, but the previous one seems to be doing just fine, so stay with it if you want. Come to think of it I will have a flu bit at the end, so hang in there.

The people are asking me to "do" the prospects for a new FDA Commissioner now that Lester Crawford has retired. Crawford served with about average distinction by Bush administration standards. I'm sorry for the gross insult, but at least I only used one profanity, specifically the "B" word.

So, possible replacements. Brownie is out of work, and he even has relevant qualifications, having investigated the alleged liposuctioning of a horse's ass.* However, in the present climate, the fraternity president probably can't get away with just pulling another brother away from the washtub full of KoolAid and grain alcohol and giving him a fancy job title. He'll probably have to nominate somebody who looks like he knows what he's doing.

Fortunately for the administration, it would be difficult to find a prominent physician/scientist in the field of drug development who doesn't work for the drug companies, even while being on a university faculty. They can easily come up with a candidate who will please the major corporate campaign contributors and who will also have impressive credentials and sail through confirmation. (David Graham and Marcia Angell are probably not waiting by the phone.)

The problem is not who is sitting in the corner office at the FDA. The problem is the fundamental structure of the pharmaceutical research enterprise. As long as the bulk of the money for developing new drugs comes from profit-making corporations, we're going to keep getting new drugs for common, incurable conditions, drugs that aren't necessarily any better than the old ones but at least have some marginal difference that can be sold as an improvement. Heartburn and GRD, allergy, high LDL cholesterol, high blood pressure, depression, schizophrenia, arthritis, that's where the long green is. These are all real problems, and all about as well treatable by off-patent drugs that we've been using for years and know how to use safely, as they are by more recently developed drugs that are still on patent, that cost 10 times as much, and that are heavily marketed, whose potential dangers we don't fully understand. Sometimes those heavily marketed drugs are actually much worse, and even kill people, and sometimes the drug companies even know it.

Since the medical profession seems unable to resist the siren song of a free post-it pad, a free triangular pen, and a free weekend in Aruba, the only protection we have is from those evil, greedy trial lawyers. Let's hear it for them.

Here's the flu bit. One consequence of this system is that vaccine development and manufacturing is a very low priority. Drug companies want people to get sick and stay sick. There's no incentive to give them a shot or two that will keep them healthy, when you could be selling them a pill every day for the rest of their lives. And of course once a vaccine is available, the political pressure to make it available cheaply to all those non-paying poor people is going to be very hard to resist. It wouldn't be a major technical challenge to develop a production facility for influenza vaccine using genetically engineered bacteria, that could crank out orders of magnitude more doses than our present chicken egg method, and ramp up for new strains more quickly -- at least not compared to sending human to Mars. But Aventis sure as hell isn't gong to do it.

*True fact. But I'm not going to touch it.

Heading for the Hills

In plagues of yore, the privileged got out of town. Shakespeare is thought to have written his sonnets and other poetry while the London theater was closed due plague in 1592-94. The conceit of Bocaccio's Decameron, as is well known, is that some aristocrats are entertaining each other with stories while escapaing the Black Death in a rural villa. In Poe's Masque of the Red Death, aristocrats are taking refuge in a rural castle to escape a fictional plague -- as it turns out, they can run, but . . .

In the event of a new epidemic, it is certain that people will have the same impulse to flee. As the conversion of the highways around Houston to parking lots demonstrates, that may not be a very pretty picture.

In the event of an epidemic, I presume -- and others more expert may correct me -- that the authorities will want people to stay put, not to travel; to wash their hands frequently; to stay home if they feel any symptoms; and to go to the hospital (not by public transportation) if and only if the symptoms become severe. It is a certainty that people will not obey these instructions.

The precise dynamic of panic will depend on how the mass media present the case. Since they have noticed the threat of a flu pandemic in the past week or two, I would say that they have been reasonably responsible and restrained, but that is unlikely to continue if the real thing comes. Here in the Hub of the Universe, two cases of West Nile virus were enough to cause mass hysteria followed by aerial spraying of high school playing fields. The SARS scare, which was only that and never resulted in an actual epidemic in North America, turned Chinatown figuratively radioactive. There was nearly an epidemic of restaurant bankruptcies. A report of a kitchen worker with Hepatits A became the lead item on the TV news for two days and had people lining up for blocks to be vaccinated against a minor, transient illness -- most of whom had never eaten at the restaurant in question.

A report of bird flu anywhere on the eastern seabord will have Muffy and Thurston packing up the Escalade and heading to the Berkshires before you can say "Every yuppie for himself!" Unless of course Thurston sneezes, in which case they'll head straight for a Major Teaching Hospital of Harvard University. Less privileged people may have more difficulty finding a destination but this isn't the Middle Ages. More people have automobiles today than had mules back then. It wouldn't surprise me if a fair proportion of the population decides their chances will be better in the countryside. Meanwhile the hospitals will be overwhelmed, but not with people who are actually sick. Any attempt to restrict travel or quarantine an area is just going to have people doing everything in their power to get out of the hot zone.

Note that all this happens just because people think the epidemic may have arrived. It doesn't have to actually get here. So how can we manage the flow of public information to tell people what they have a right to know, honestly and ethically, while avoiding panic and counterproductive behavior? The flip side of this problem is getting information to people who are harder to reach -- those who don't speak English well, the socially marginalized, the alienated; and making it possible for people who do need to access health care to get it, even if they don't have transportation, or are afraid of being turned away for lack of health insurance, or are afraid of deportation.

Is my vision of the hypothetical accurate? What are some solutions to these problems? Are responsible people even working on them?

Note: This question has nothing to do with constitutional law.

Friday, September 23, 2005

Have no Fear . . .

At least have no fear of Effect Measure going to dead air, or dead fiber optics or whatever, I am here.

Thanks to Abby for this tip. (And she's off to DC this weekend, to her credit.)

Of course the Indonesian government has powerful economic incentives to downplay any risk of a dangerous epidemic for as long as it can.

JAKARTA (Dow Jones)--Indonesia is bracing for reduced tourism revenues in the short term due to public concern about the country's ongoing H5N1 avian influenza outbreak, Minister of Tourism Jero Wacik said.

"I think for the short term, it will disturb tourism because people will worry about (avian flu contagion), especially domestic tourists," Wacik told Dow Jones Newswires.

"But for foreign tourists, the impact isn't too big yet."

Wacik didn't provide specific details about the potential financial impact of H5N1 on tourism, which contributes around 5% of Indonesia's total annual gross domestic product.

But a rise in the H5N1-related human death toll in Indonesia would compound the tourism sector's financial misery as it continues to recover from a downturn prompted by a series of terrorist bombings since 2002, and the outbreak of severe acute respiratory syndrome in 2003.

We must also remember that the WHO is dependent on voluntary cooperation from member governments, which it is not going to get if it starts to give them publicity they do not want. So we have to expect that the news we get from WHO and the countries where there are developments of concern will be very restrained. Read between the lines, is my advice.

Possible brief connection eclipse

The bird flu Revere, the CDC/WHO reveres, the Lakoff Revere and the others are traveling together in the wilds of Europe (Tuscany and Lombardy), wending our way back to the US after the Bologna conference but with a day or two of no connection looming on the weekend. Cervantes is also constrained but will do his best to cover for us.

So if there is a brief pause, rest assured we will be back full time on broadband by Monday. Meantime, keep checking as we believe there will be posts.

. . . and still no plan

Reports on the evolving H5N1 story out of Indonesia are confused and colored by a combination of wishful thinking and deliberate obfuscation by Indonesian authorities and WHO, whose main objectives seem to be preventing the spread of public concern. Unfortunately the virus doesn't care much whether the public is concerned or not. But attempts to calm people by downplaying the seriousness of the situation dampens enthusiasm for what needs to be done, some of it expensive and unpalatable.

Indonesia's health ministry is reporting either 16 or 17 people under observation with possible bird flu. They are also saying the 5 year old girl who died last week didn't have bird flu on the basis of tests they did, but they have elected not to send blood samples to the WHO reference lab in Hong Kong. Whether this is a true negative or a false negative we will probably never know. Niman at Recombinomics has discussed the false negative problem in this case and in the many others from Vietnam. In the Vietnamese cases, so-called negative tests later turned out to be positive when adequate procedures were used.

The UN continues to say there is no evidence that the virus is spreading person to person, on the one hand, but admits there is good evidence of transmission within families when contact is close. Unless these families are duck or chicken families, it is hard to see how this isn't evidence of person-to-person transmission. If they are talking about some measure of ease or efficiency, they should say so.

Speaking of ease of transmission, visitors to the zoo closed on Sunday after almost two dozen exotic birds were found to be infected continue to come under scrutiny. Nine of the 17 that Reuters reports to be under observation in a government hospital in Jakarta designated to receive suspect bird flu cases are zoo visitors. Three other zoo-exposed cases were earlier identified, all with non-occupational exposures to the birds. Hence the virus seems to be passing from birds to humans with greater ease than previously, although neither WHO nor the Indonesian authorities have observed this publicly.

Nor is it clear how vigorously the Indonesian government is moving to kill infected birds:
Joko Dwihartato, a driver who rears chickens in his backyard in Indonesia's capital, Jakarta, won't let the government cull his flock of seven birds without paying sufficient compensation as avian flu spreads in the nation.

"If they give me enough money, I don't mind,'' said Dwihartato, 40, who sells eggs to supplement his income. "Otherwise, why should I kill the chickens? They are perfectly healthy.''

President Susilo Bambang Yudhoyono's government, which is struggling to find ways to close a $2.5 billion budget deficit, isn't paying enough to compensate poultry owners for culling fowl infected with avian influenza, or spending the money to stem the spread of the virus in villages, UN agencies and health experts said. Culls are needed to curb a growing outbreak of a disease that's killed at least 59 people in Asia since 2003.

If the compensation "is perceived as not just by farmers,'' culling won't happen, said Juan Lubroth, senior officer at the animal health division at the Food & Agriculture Organization in Rome. ``I don't think the veterinary services have enough support to be able to do what I think the national strategy should be doing at the commune level.''


There are about 30 million village households in Indonesia that have about 200 million chickens in their backyards, the FAO said in a statement yesterday.

"The problem is with funding and not having enough resources,'' said Marthen Malole, former head of virology at Indonesia's Bogor Institute of Agriculture, who in January 2004 said the government was covering up the spread of the virus.

"The government needs to deploy officials, vaccinate, and then monitor the result of the vaccines,'' he said. "The inability to do this has helped the virus become endemic.'' (Bloomberg)
Not so, good, huh? But you wouldn't know it if you just listened to either the Indonesian government or the US government, whose ambassador, Lynn Pascoe had arranged a meeting with a "fact-finding" mission of US and Japanese scientists and experts from CDC and Japan on Friday. Pascoe reportedly praised the Indonesian efforts "to move very quickly" stood out (AFP via ChannelNewsAsia). Since the Indonesian's have been widely criticized for their slow response, it seems like this is just a case of liars covering for each other.

Meanwhile the New Zealanders are now talking openly about closing their borders:
New Zealand may lock down all air and sea ports if a lethal bird flu epidemic takes hold internationally, potentially turning planes around and putting all arrivals into quarantine.


In late October, New Zealand border agencies would look at the logistics of stopping all people and imports, such as food and medicine, from entering the country in the event of a pandemic, Customs business development unit manager John Ladd said yesterday.

Enormous problems would accompany such a move, he said.

"What do you do when you have got a whole lot of people in quarantine? Are there legislative processes available to stop New Zealanders coming into the country?"

The agencies would have to consider whether it was reasonable to direct planes in mid-air not to land in New Zealand.

People may need to be quarantined for as long as eight days if New Zealand hoped to stop the outbreak spreading while keeping its borders open, Ladd said. "How do we feed all these people?"


Customs officials will visit Christchurch next Wednesday to discuss a plan of action with airport staff.


"To do that, all those people overseas on holiday would not be allowed in either. It sounds a good idea, but I would find it interesting to see whether it could ever be done," he said.
Probably it couldn't be done, and even if it could it wouldn't keep the virus out. But this kind of talk is just a taste of what's to come if this beast really is loose. The effect on trade and travel will have enormous economic and material consequences, even for those who stay put. The lack of planning for this foreseeable eventuality on the part of national authorities, especially the United States, is nothing short of stunning.

Like generals fighting the last battle, they are currently engaged in getting hurricane preparation right. The global hurricane is brewing and still no plan.

Where is Tom Ridge now that we need him?

From Reuters Alertnet:
Despite the spread of the disease and developments in Indonesia, the avian flu outbreak was still at a level three alert on a scale of six, said [Dr Margaret Chan, the WHO's global special representative on avian flu].

"Until we see further evidence we are still at phase three of the pandemic alert," said Chan . . .


Under the alert system: level one is no outbreak, level two poultry outbreaks, level 3 poultry and human cases, level four small clusters of human transmission, level five large, localised clusters of human transmission and level six a pandemic with large scale human transmissions in several countries.
Time to change the Alert System (hat tip, Wayne at PSoTD)

Thursday, September 22, 2005

Ostrich industry thriving

The headline--from South African Broadcasting Corporation--sounds like satire from The Onion:

But it isn't about CDC or WHO. It's really about South Africa's ostrich industry which lost half its breeding stock and 30,000 birds to last year's bird (only) flu epidemic.

As if to reinforce the point, we see an epidemic of ostrich behavior among national and international health officials. Let's not leave out the chickens and the turkeys.

I'm disgusted.

The World Reassurance Organization (aka WHO)

The latest from WHO (via Reuters) tries one's patience:
The growing number of people with bird flu-like symptoms in Indonesia does not mean the outbreak is becoming worse, and there is no sign the virus can be passed easily among people, top U.N. health experts said on Thursday.

Alarm has spread in populous Indonesia after four people died and with now 10 are under observation in the capital.

But there is no evidence the H5N1 virus has mutated into a form that could trigger a pandemic, said Georg Petersen, the World Health Organisation's Indonesia representative.
Nevertheless, he pointed to the possibility of transmission through very close contact with an infected person.

"I think very close contact with a sick person might infect that caretaker. That is why in hospitals we need to take all precautions ... That would be in a way a human-to-human transmission, but that demands close, close contact," he said.

"Anytime someone coughs and you get it ... that would be much more what we would call transmission from human to human."
One wonders what it would take for these guys to say, "Holy Shit, we're fucked unless we get busy and prepare to manage the consequences."

But the World Reassurance Organization doggedly refuses to say out loud what everyone else can see. This virus has gone human to human and is spreading in Indonesia. The fact that it may (or may not) be as efficiently transmitted as current endemic strains of human influenza doesn't mean things have not changed. They obviously have, and to say there is no evidence the virus has mutated because they haven't sequenced it completely, just a lie. As is this:
Dr Margaret Chan, the WHO's global special representative on avian flu, also said on Thursday there was no sign the virus had mutated into a form that could easily spread among people.

"So far there is no evidence for increased chance of human-to-human transmission," Chan told Reuters by telephone from Sydney after attending a WHO conference in Noumea, capital of New Caledonia in the South Pacific.

The rise in the number of suspected cases did not point to an epidemic, she said.

"With increased surveillance it's not unusual that you would pick up more cases," Chan said. (AFP via Khaleej Times; my emphasis)
This may be true as a general proposition, but in this specific instance it isn't (and WHO knows it). AFP reports (via Khaleej Times) that a five year old boy and a five year old girl died on Wednesday from a bird flu like disease (confirmatory tests pending) and 13 people with symptoms of bird flu were being treated at a Jakarta hospital on Thursday. This is an increase of nine from the day before. There is also good evidence of transmission from only casual contact with infected birds, as with the cases of visitors and non animal care workers at the zoo, and within-in family transmissions.

All this (and more) does point toward an epidemic. "Pointing toward" doesn't mean we are there yet. But anyone with even a few neurons firing and not using one to breathe and another to drink coffee with must see this as an imminent threat. Imminent, as in "just around the corner." This could still turn out to be just more "simmering" of this very malignant virus. But no one should bet on it and WHO should be acting as if the genie were already out of the bottle.

Time to end your coffee break at WHO and get to work. If that means scaring the crap out of everybody (because sometimes being scared is warranted), so be it. If it's OK to scare people with vague terrorist threats, how much more appropriate is it when the threat is real and imminent.

Wednesday, September 21, 2005

No transparency at CDC on flu data

Nature magazine, one of the world's premier scientific journals, just blew CDC and the Bush Administration out of the water. Specifically, in a detailed story by Declan Butler we learn of CDC's abysmal record of data sharing with the world scientific community. Despite Bush’s call at the UN last week that the international community share sequences, samples and information about influenza, CDC has not done so, even with the US’s top scientists.
“Many in the influenza field are displeased with the CDC’s practice of refusing to deposit sequences of most of the strains that they sequence,” says Michael Deem, a physicist at Rice University in Houston, who works on predicting flu vaccine efficiency. Policy decisions, such as which vaccine to produce ahead of each flu season, are being made without the full data being available to the scientific community, he says. “The quality of their decisions, which can affect millions of people, cannot be checked.” (Nature, online now, print issue of 9/22/05)
Apparently flu researchers don't know what sequences and samples CDC has or even how many. While thought to be in the thousands, less than 10% of sequences deposited in national and international databases come from the agency, according to a Nature search. An NIH consortium has deposited almost 2800 this year alone.
“No other US laboratory receives thousands of influenza samples and sequences from around the globe,” points out one [scientist]. “They say it’s in [their weekly report],” says another. “Give me a break. I want the database.”
CDC's response?
“The advancement of public health and science is generally best served when data are shared in an open, timely and appropriate manner, and the CDC Influenza Branch is committed to accomplishing this objective,” says James LeDuc, director of the CDC’s division of viral and rickettsial diseases. But he adds: “This must be balanced against the needs for maintaining high standards for data quality and for protecting sensitive information when the situation warrants.”
Do they know how to spell Bullshit? Because it's a much shorter way of saying the same thing.
“Open data are better,” [says] William Glezen, a virologist at Baylor College of Medicine in Houston. “There is a lot that we have to learn about influenza.” A key issue, he says, is to match changes in the flu genome with the epidemiology of infections. He acknowledges that CDC staff are busy with programmes such as the annual vaccine selection, and lack time and resources to share data better. “That’s why other investigators need to look at the other parts,” says Glezen.
Obviously. Obviously. So while we complain about the lack of transparency of the Thais and Vietnamese and Indonesian, let's save a little time to put CDC in the same bucket.

Given the imminent peril of an influenza pandemic, this is simply inexcusable. Inexcusable. And shameful.

This Administration and its top water carriers at CDC are not just incompetent. They are a danger to the world and everyone in it. We all live in New Orleans now.

Indonesia: simmering or boiling?

With the deaths of two young girls (ages 2 and 5), the Indonesian alarm bells are ringing more loudly. WaPo reports ten more hospitalized with high fever, bird flu suspected (numbers of hospitalized patients differ in various news reports). TimesOnline says some of the hospitalized cases come from rural areas where poultry farming is prevalent. But they report also a 9 year old girl who died after visiting the zoo. Her death seems not included in the other reports, so it is unclear what the current toll is. If zoo visitor case is accurate, combined with the reports of infections in a zoo guide and food vendor, it suggests transmission from birds has suddenly become much more efficient.

The Indonesian reluctance to start mass killing of infected chicken flocks has allegedly been reversed:
"If we declare one area highly infected, we are going to do a mass slaughter," the Minister of Agriculture, Anton Apriyantono, said.

"We haven’t identified the high-intensive areas but once it is done then there will be [a mass cull]. According to the President, funds will not be a problem - if it needs to be done then we will do it with all our resources." (Times Online)
So it seems they haven't started yet and won't until they identify a "high-intensive" area. In other words, hurry up, slowly.

And find someone to blame. There has already been a bureaucratic sacrificial lamb (undoubtedly not an innocent one). The ministry's Director of Animal Health has been dismissed for failing to control the outbreak. (AP) Indonesia's lack of vigor is most certainly the fault of its top leaders and the Director of Animal Health is taking the fall. But swine are also infected in Indonesia and possibly many other species. It is unlikely there was ever any hope of containing this outbreak.

The public state of denial of the health ministry may have contributed to delayed recognition of what appears to be a developing epidemic. The viral pot is not just simmering. It is giving the appearance of boiling over.

Indonesia: international experts converge

The Indonesian health authorities seem scared and close to panic, even as they reassure everyone not to panic. Health Minister Siti Fadila Supari is now retracting an earlier statement that the country was experiencing an epidemic, saying only that "if things worsen it could become an epidemic" (BBC quoting an AP report). Earlier she had said, "This could be called... an epidemic. It will likely claim more victims because the source is not clear." Sounds like the higher-ups are reigning her in. Wouldn't want people to be unduly alarmed. Or even appropriately alarmed.

One of the probable bird flu cases (of six reported so far) has now died, a five year old girl who reportedly had been in contact with dead chickens. Sales of poultry in the country have plummeted. Indonesia has been reluctant to carry out the kind of mass culling of their infected poultry stocks recommended by WHO, primarily because of lack of funds. They now say they will carry out culls, regardless of cost. We'll see. Much of the poultry population is in small, backyard units, making control more difficult, but not impossible. The Health Ministry, using extraordinary powers declared earlier this week, has the authority to forcibly hospitalize suspected bird flu cases, using one of 44 state hospitals designated for the purpose.

Reading between the lines, it is clear that there is deep concern at WHO and even at CDC.
"It's obvious that a pandemic will occur, all the conditions are in place," WHO director general Lee Jong-Wook said on Monday. "The problem now is time." (AFP)
CDC sent a five-person team that arrived on Sunday on a "fact finding mission" and Reuters reports that other international experts are converging on Jakarta.
"Definitely the whole international community is very much present," [WHO representative George] Petersen told Reuters in a telephone interview.

The WHO was also working with the government to source new stocks of the anti-viral drug Tamiflu from India to bolster local stocks, he said.

"It's not very much, it's rather puny. They definitely need some more," Petersen said, adding that stocks being rushed from India were less than 1,000 doses.


Supari said Indonesia had 10,000 Tamiflu tablets. (Reuters)
Maybe the most ominous sign here in Europe is that even CNN International devoted a full 10 seconds to the Indonesian situation before returning to the more important business of supermodel Kate Moss's alleged cocaine use.

Tuesday, September 20, 2005

Bird flu conventional wisdom?

As a wise person once said, "It's not what I don't know that scares me. It's what I think I know and I'm wrong about." The current H5N1 outbreak in Indonesia requires we look at our conventional wisdom about transmission and presentation of this disease. In an electronic version of the Clinicians Biosecurity Network Weekly Bulletin yesterday (9/19/05), Borio and Bartlett reviewed a recent article in the Journal of Infectious Diseases (J Infect Dis. 2005 Oct 15;192(8):1311-4) by Frederick Hayden and Alice Croisier. Several points are made.

Conventional wisdom is that transmission of influenza is primarily human-to-human via respiratory droplets, with possibly some transmission via hands (handshakes, etc.) or inanimate objects with viable virus on them. But with many reports of viral particles in bird feces and in one case at least in human feces, the possibility of the fecal - oral route must be considered. This means the gastrointestinal tract is a route of exposure, consistent with reports of infection by consumption of undercooked poultry.If the virus can infect the human intestine (as it does the intestines of birds), then the persistent reports of diarrhea being a common presenting symptom must be clearly recognized, not as a rare presentation but a relatively common one.

The JID article also reports that a WHO study done this year shows that 30% of the Vietnamese cases do not give a history of contact with infected poultry. This suggests, once again, that there might already be much undetected human-to-human transmission of relatively mild disease in southeast asia. We have already made this point a number of times. The absence of any systematic seroprevalence surveys in the area is to be deplored. We should know the answer to this question by now.

In past pandemics there have usually been several waves, the first of which is often milder, with the second the most severe. If it is true that we may have already experienced a mild wave in southeast asia last spring, this bodes ill for the coming months. While it is quite possible that the Indonesian episode is a false alarm, alarm is now appropriate, false or otherwise. Time is getting short for individual communities to mobilize and organize themselves to minimize the consequences of what potentially is a much more serious threat than Hurricane Katrina. This is a warning of a global hurricane. And we are no more prepared than were the authorities in New Orleans.

Indonesia, more

The news from Indonesia continues to be worrisome. Recombinomics has a summary of the three or four children reported hospitalized with probable bird flu, including a nephew of last week's confirmed bird flu death. Today Indonesian health authorities announced "extraordinary" measures in the face of what might be a widening circle of infection:
JAKARTA: Suspected bird flu patients can be forced into hospital under "extraordinary" measures welcomed by the World Health Organization to counter a widening outbreak of the virus in Indonesia, officials said.

A day after declaring the country faces an "extraordinary incident" because of bird flu, Health Minister Siti Fadilah Supari said the number of cases has continued to rise in the country where four have died from bird flu over the past two months.

She said six patients are now being treated at a hospital for respiratory ailments.

"Two are almost certain to be bird flu cases. Four others are still under observation but judging from the symptoms, they are similar to those of bird flu although there is yet no laboratory evidence that they are positive," the minister said after the opening of a regional health ministers' meeting. (AFP via ChannelNewsAsia)
Two of the cases are reported to be in employees of Jakarta's popular zoo, which discovered over the weekend 19 infected birds of various species. One was a 28 year old tour guide and the other a 39 year old vendor. Thus neither were in continual and habitual occupational contact with the birds. Both have been hospitalized with symptoms of bird flu (CBS News).

It should be obvious that this represents an extremely serious situation. We should know within the next few days if we have entered WHO's pandemic phase five (Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk)) or even phase 6, the start of a pandemic (Pandemic: increased and sustained transmission in general population).

A good source of information on local,national and international pandemic preparedness plans and much other information is the Flu Wiki. Read it, use it, build it.

Monday, September 19, 2005

Bird flu: H2H in Indonesia?

Because of my intermittent connections while traveling I have been unable to get all the details of latest developments in Indonesia, but the reports I see this morning are unusually ominous. Three children have been hospitalized with symptoms of bird flu, while at least 19 birds of various species have been infected in Jakarta's Ragunan Zoo, which is being closed for 3 weeks (Yahoo News). The children are reported to be between the ages of three and nine. Two have been in intensive care for 6 days. The third was admitted to the hospital yesterday. All have high fever. and respiratory problems (Xinhua). BBC reports that one of the children is the relative of the 37 year old woman who died of bird flu last month.

Indonesian authorities have been reluctant to take strong measures (such as mass culling) against bird flu, believing they could contain it. As many have suggested, this is a ridiculous misjudgment. Even WHO believes this is a vain hope. Regarding the zoo closure:
"It confirms what we have thought for a while, that the H5N1 virus is widely spread in Indonesia," Georg Petersen, the World Health Organisation's (WHO) representative in Indonesia said when asked to comment on the latest developments. (, Australia)
Along with southeast asia, this huge island nation is now a gigantic incubator for H5N1. In July a government auditor, with no detectable history of exposure to infected birds, died of bird flu as did his two daughters. Most observers believed this was a cluster of human to human (H2H) transmission. With the three children, one at least a contact with another case, the possibility becomes a probability. One can expect human to human transmission to become still more efficient.

Meanwhile, the US still has no final pandemic influenza plan. Like the generals, this government is still fighting the last battle, not preparing for the next one. Expect the pandemic flu plan, when it finally appears, to contain massive monies for Halliburton to rebuild the bird flu levees in Republican states.

Update (9/19/05, 10 am EDST): The Indonesian government is urging all tourists and zoo visitors to be alert for symptoms of influenza. Blood testing of zoo employees is being done. In addition, ChannelNews Asia reports:
Zelfino, Indonesia Health Ministry, said: "From our tests, there are two workers who appear infected with flu. They will be referred to Sulianti Hospital - one of the hospitals designated to treat the bird flu victims."


Besides closing the zoo and carrying out blood tests on all its animals and staff, authorities are also reaching out to thousands of residents living in the zoo vicinity.

They are encouraged to seek immediate treatment should they developed the flu symptoms in the past few days.

Anton Apriantono, Agriculture Minister, said: "We are urging those who recently visited the zoo to go to the hospital immediately if they display symptoms of avian flu, and all expenses will be covered by the local administration."

Sunday, September 18, 2005

Talk is cheap

Back when conservatism was still "compassionate," the Resident appointed his so-called New Freedom Commission on Mental Health, which called for a "fundamental transformation of the mental health care delivery system in the United States -- from one dictated by outmoded bureaucratic and financial incentives to one driven by consumer and family needs . . . "

Now the Resident has unveiled the exciting Action Agenda to achieve just that! Let's see, what actions are we going to take?

It turns out we're going to have federal leadership, and shared responsibility, and strategic alliances, and prototypes, and plans . . . I'm not sure what we're actually going to do.

Here are some typical Action Agenda Action Items:

  1. Initiate a national public education campaign. (Don't we already have those? "You may have pharmaceutical gullibility disorder. Take this pill!")
  2. Launch the National Action Alliance for Suicide Prevention. That's a public-private partnership that will oversee a strategy supported by a broad base of stakeholders. No more suicide!
  3. Educate the public about men and depression.
  4. Develop prototype individualized plans of care. (Every mental health provider in the world already develops individualized plans of care, but thank God, now we'll have a prototype!)
  5. Promote quality services in the workforce development system. Yup, they're gonna promote 'em. And they're going to develop an employer initiative. And they're gonna facilitate linkages. And they're gonna disseminate information through existing existing grant programs.
  6. Initiate a national effort focused on meeting the mental health needs of children. That turns out to be another public education campaign. They're also going to propose a comprehensive approach.
  7. Launch a web site.
  8. Protect and enhance the rights of people with mental illnesses -- by continuing current voluntary compliance initiatives.
  9. Launch the Federal Executive Steering Committee on Mental Health
  10. Include eliminating disparities in mental health services in the HHS "close the gap" initiative (which consists of a list of goals).

And so on. They're going to develop plans, promote strategies, facilitate linkages, expand agendas, and relabel some existing grant programs. SAMHSA says that $24 billion annually will be "made available" for the reforms, but that the cash is not all new money. I have looked through the plan and I'm not sure I can find any new money at all. But maybe I just haven't seen enough new money lately to remember what it looks like.

Critics of the New Freedom Commission view with alarm something called the Texas Medication Algorithm Project, which was funded by drug companies and touted in the Commission's original report. It's a "decision tree" that by an amazing coincidence, leads to drugs manufactured by the project's sponsors -- and it was based on the expert opinions of drug company consulants, not evidence. (See also here for a perspective from a chapter of the National Alliance for the Mentally Ill, with some additional links.) Since the New Freedom Commission also called for universal screening of children for mental illness, critics are viewing the whole thing as a conspiracy to drug half the population and send the profits to Pfizer.

To be honest with you, I've looked at the action agenda pretty closely and it doesn't specifically mention the TMAP or actually implementing universal screening. Nevertheless, presumably the critics see the plan as a first step toward those sinister ends. I would be worried about that if I took the "Action Agenda" seriously, but my expectation right now is that not very much will come of all this, except for massive digestion of forests into wood pulp and emission of enough hot air to exacerbate global warming.

We inappropriately medicalize many problems, but there really are people with mental illnesses. They don't need plans, strategic alliances, partnerships, campaigns, facilitation, task forces, or promotions. They don't need universal screening (although early detection of prodromal psychosis is good) and they certainly don't need more drugs. (Less drugs, please.) They do need stuff that costs money that doesn't go into the pockets of major political contributors. These include coordination of care among psychotherapists and counselors, psychiatrists, medical doctors, and social services. They need adequate insurance coverage for counseling, therapy and case management, and continuity of care, not just pills. They need access to supported housing and day treatment, or occasional home based services if appropriate. They need occupational rehabilitation, job training, and supported employment, or reasonable workplace accomodations, non-discrimination, dignity and respect. That'll be the day.