Effect Measure

Effect Measure has moved!

2006-06-09T13:39:00.001-04:00

We have moved the blog, at the invitation of the folks at ScienceBlogs, publishers of Seed Magazine. ScienceBlogs.com is fast becoming the premier venue for science-oriented blogs and we couldn't pass up the opportunity to join some wonderful bloggers already there and new ones in our cohort. At Sb you'll find Pharyngula and Aetiology, already ensconced, and Coturnix's new blog and Mad Mike the Biologist arriving with us. Plus many more. Quite a varied selection and all of high quality. Several have already established themselves as A-list sites among the science blog community. We were pleased to be asked.

To our regular readers (now numbering in the thousands) the only things that will change are the address (new URL: http://www.scienceblogs.com/effectmeasure/ and the appearance. We will be on a MovableType platform instead of Blogger, which will give us the ability to have categories and subcategories. Commenting will now have a "Preview" function, so you won't have to post again to correct a typo. There are probably a bunch of other things that will be enhancements we haven't figured out yet, too. So it's a big plus as far as we are concerned, and we hope you will think so, too.

There are still some 1200 posts on this site, which will remain here. It isn't feasible at the moment to move all the posts and archives over to the new site. Unfortunately there is no way to categorize them here. You can still find things by using the Google Bar in the upper left of this site or Googling the subject with the words Effect Measure (e.g., Googling, biodefense Effect Measure, will get you to our post on biodefense, way back when).

If things get a little glitchy in the transition, we'll use this as a fallback site until things are straightened out, so if you have trouble you might check back here to see if it is a migration problem. We're not expecting it, except that we expect it. That's the nature of the world, especially the computing world.

We enjoyed our time here on Blogger (well, mostly; there were a lot of pesky outages but hey, it's free hosting). If you want to start your own blog, it's incredibly easy. It can also be dangerous if you have a tendency to obsessive compulsive disorder, so be warned. Just go over to Blogger.com and click the button that says "Create a Blog." We did it on Thanksgiving Day of 2004, just to see what it was like. We're still here.

We're already at the new address and that's where Effect Measure will be from now on. Our first post introduces ourselves to the new neighbors. So bookmark the

URL: http://www.scienceblogs.com/effectmeasure/

and come on over.

Update, 2:23 pm EDT: heh, heh. Oh, well. First glitch. Entry text is up on the first post (Housewarming) but no extended entry (Read More). Have a query in to the Sb tech folks to fix. Moving is always a pain.

Update, 2:31 pm EDT: Temporary fix. No extended entry, just the whole post on the page, like you are used to here.

Reader beware

2006-06-09T08:54:00.000-04:00

When you read news reports, you have to be circumspect. There are some excellent reporters on flu but most don't know much about it and have a tendency to transcribe whatever some official spokesperson says. Even large news organizations depend on local stringers who send in bits and pieces they think might be of interest.

A good example comes this morning in the form of two short filler pieces, one from Associated Press (AP) and one from Bloomberg News Service. Both report the failure of a WHO reference lab (neither tells us which one) to confirm H5N1 in a seven year old girl who died June 1 near Jakarta. Her ten year old brother had died three days earlier with similar symptoms but no specimens were obtained. Contact with sick poultry was alleged. "Local tests" of the little girl were positive for H5N1. Who does the local tests is not stated, but it is my impression the US Naval Lab NAMRU2 is involved and they are technically expert and all previous local tests have been confirmed for H5N1 by WHO reference laboratories. Apparently that isn't the case this time.

Here is the AP version, run under the headline,"Indonesian girl's flu death questioned," (RSS headline, "WHO lab indicates Indonesian girl did not die of bird flu"). The piece cited the Indonesian Ministry of Public Health:

A lab approved by the World Health Organization said a seven-year-old Indonesian girl who tested positive locally for bird flu did not have the virus, a senior Health Ministry official said Friday.

[snip]

"This is the first time local tests came back positive and Hong Kong laboratory tests negative," said Kandun, adding WHO needs to carry out new tests to reconfirm its findings. (AP via CANOE Network, Canada)

Believing the Indonesian Ministry of Health on bird flu these days is like believing Donald Rumsfeld on torture.

Here is the Bloomberg version, run under the headline "Bird flu tests are inconclusive on Indonesian girl: WHO":

Confirmatory tests for bird flu on a 7-year-old girl in Indonesia were inconclusive and more specimens will need to be tested, a World Health Organization spokeswoman said Friday.

"Test results are pending further analysis, and more samples are to be collected" for testing by a laboratory in Hong Kong, said Sari Setiogi, a spokeswoman with the WHO in Jakarta. (Bloomberg via Jakarta Post)

In this case it is pretty clear which is the more accurate report. But if you'd only seen the AP report and didn't read it carefully (it is only a small filler piece) you could easily have gotten the impression that WHO had determined the Jakarta case was not bird flu. So far, that hasn't happened (although it may). There are many reasons why a truly positive test may be inconclusive.

The internet brings us information of epidemiologic interest at unprecedented speed nowadays. But the usual cautions apply: caveat lector.

Banned in China

2006-06-09T08:30:00.000-04:00

Indonesia is a known problem spot for bird flu. An impotent central government, infected poultry everywhere, a huge but far flung population on thousands of small islands, and a poor and primitive health care system. Not a pretty picture.

But China may be as bad as Indonesia. A long story in Asia Times online is well worth reading. I'm surprised the reporter isn't in jail for revealing "state secrets" (infection with H5N1).

Having learned a bitter lesson from covering up the severe acute respiratory syndrome (SARS) epidemic in early 2003, the central government of China now is said to be taking a more positive, responsible attitude in dealing with avian influenza, or bird flu. But that hasn't filtered down to the provinces.

As the market economy has taken root in China, the country has become increasingly decentralized. Because of this, Beijing's tough orders regarding the prevention of a bird-flu outbreak may not necessarily be carried out at all levels. Overwhelmingly concerned with economic growth, some local officials still tend to cover up any outbreak of bird flu, defying Beijing's order to report new cases immediately.

Beijing has punished some local officials for their incompetence in dealing with bird-flu outbreaks. For instance, in May it was announced that five officials in Dazhu county in Sichuan province had been sacked for of dereliction of duty because they did not report and contain the local outbreak in time.

But during an investigative reporting trip to three locations in China, Asia Times Online found that in rural areas, local officials and residents really don't like any action that might expose a possible bird-flu outbreak, fearing the damage it would do to the economy. Because of this, they hate individuals who dare to inform authorities of any bird-flu case. (Asia Times online)

There follows chilling examples of cover-ups, retributions and missed diagnoses, not specifically at the hands of the Chinese government, but of the people in the rural countryside. It isn't just ignorance. It is deliberate cover-up. We posted in December about one of these instances, retribution against a local farmer who notified authorities there was infected poultry in his village. The Asia Times story has a follow-up and additional details. They aren't pretty, either. The reasons the whistleblower, Mr. Qiao, has become a pariah aren't hard to find:

Owing to wide coverage of Qiao, the poultry market in Gaoyou has slumped. "The price of eggs has dropped from 3 yuan [37 US cents] to 1 or 2 yuan per 500 grams, chicken prices are also down from 5 yuan to 2 yuan for half a kilo, even below the raising cost," Chen noted. "So no one wants to raise chickens now, even though chicks are free."

[snip]

More than half a year has passed since the bird-flu epidemic in Tianchang city, Anhui province, was exposed to the outside world. A recent visit by ATol found residents there still eager to see their hated local informer turned into a criminal defendant, while little attention has been paid to prevention of a possible return of the epidemic.

Ducklings and goslings roamed all over Liangying village, showing that no one was paying attention to the Animal Epidemic Prevention Law. Among other things, the law stipulates a six-month ban on breeding poultry after an outbreak, and the current ban only expired on May 24. "We started raising poultry after the Chinese New Year, and village leaders never stop us," a local farmer said.

The poultry population of Liangying village and the surrounding area is growing again, and some households even raise birds, dogs and lambs together, despite warnings to separate them to prevent cross-breeding of diseases between various kinds of livestock. "We're poor, and raising poultry is the only way to enrich our tables and honor guests," an elderly farmer said, herding a gaggle in the fields.

All these words and scenes reveal a complete and willful ignorance of basic precautions against a possible revival of bird flu, as well as a deadly apathetic attitude toward epidemic prevention that is shared by the local authorities and residents alike.

To the local farmers in Tianchang, Qiao was just a "bad guy". Because of his tip-off, the government decided to destroy all reared poultry in the neighborhood, but the state compensation did not suffice to cover the colossal loss. This seething resentment against Qiao even extends to his his fellows from Gaoyou. "Gaoyou guys dare not come here to trade anymore. They are afraid we will beat them up," grinned a local Tianchang farmer.

The reporter goes on to tell the story of Li Juhua and her 6 year old son Ouyang, so far China's youngest bird flu case. Ouyang was diagnosed with bird flu, received treatment, and recovered. His mother was never diagnosed, although her symptoms were similar. She took sick first and died. The onset of symptoms was several days apart, suggesting possible human to human transmission in this small two person family cluster. The family details are revealing:

Last December 21, the family had dinner to celebrate the winter solstice. They were not rich enough to kill a live bird and could afford only dead chickens dumped by owners, which the poor collect and preserve for festivals.

The wife, Li Juhua, soon felt sick and was taken to the county hospital on December 23. At that moment, a grisly thought occurred to Ouyang that his wife might have been infected with bird flu, as he had watched news of the epidemic on television. Yet none of the doctors heeded his fears. Li died the next day, to which the hospital only gave a single-sentence explanation citing some rare dermatological disease.

A few days later, the son developed the same symptoms as his deceased mother. At the county hospital, the diagnosis given was tuberculosis. Ouyang dared not take a chance with the county hospital again and took the little boy to a hospital in Chenzhou, where the medical staff were concerned and referred the child to Changsha. There his affliction was finally diagnosed as bird flu infection.

The mother's quick death induced the father, now a widower with two young children, to get his son to the better equipped hospital in Chenzhou. Otherwise Ouyang would be another undiagnosed, faceless death instead of the China's youngest case. To date the mother's case has not been discussed or reported by authorities.

The local attitude is clearly a difficult problem for Chinese authorities. But the central authority's claim to openness on bird flu has more problems than this. The Health Ministry and the Agriculture Ministry are not always on the same page regarding transparency. And information is still carefully managed in China.

If you live in China you are not likely to read that information is managed, however. Not even on Effect Measure. We are banned in China.

Transgenic chicken paradox

2006-06-08T07:57:00.000-04:00

Maybe if I didn't spend a lot of time thinking about bird flu and chickens I wouldn't have noticed this. But I did, so I bring it to you.

Origen Therapeutics announced today that it has succeeded in developing a robust and versatile technology for genetically modifying chickens that, for the first time, puts avian transgenics on a par with transgenic mice. The company made the announcement in conjunction with the publication of an article this week by Origen scientists and a collaborator from the University of California, Davis on its transgenic technology in the journal Nature. Using the new technology, Origen can, in principle, make any genetic modification desired to the chicken genome, including the insertion of genetic elements for the production of human therapeutics and the modification of the chicken immune system to produce novel human sequence polyclonal antibodies. Moreover, the new technology opens up the possibility of producing chickens with enhanced agronomic traits, including resistance to avian flu. (Press release via rxpgnews)

The technology uses, interestingly enough, chicken embryonic stem cells. President Bush has yet to outlaw chicken stem cell research, so this is legal (so far; but you never know). The idea is to modify the chicken genome to produce drugs and biologicals.

"We believe a transgenic chicken system offers a number of advantages over either plant or other transgenic animal systems for protein production. Besides the ability to produce antibodies with enhanced cell killing properties, the time from antibody identification to production in eggs is a matter of months, the purification of proteins from eggs is relatively simple, and good manufacturing practices have long been established for vaccine production in chicken eggs. Moreover, the overall cost of facility and operations is a fraction of that associated with fermentation methods of manufacture. The ability to readily create transgenic chickens through this technology, and then to scale up production through conventional breeding further adds to the practicality of this technology for large-scale production of therapeutic proteins," [said Robert Kay, Ph.D., Origen Therapeutics president and chief executive officer].

[snip]

"This work addresses a major biomedical issue -- how to produce antibody-based medicines in an easy, cost-effective way," said Matthew E. Portnoy, Ph.D., of the National Institute of General Medical Sciences, which partially funded the research.

The irony of this "breakthrough" is just too delicious. Consider. We are already terrified of one biological agent produced in chickens, H5N1 viral protein and its genetic material (in the form of a virus). We cannot rely on egg-based technology to make another badly needed biological, a vaccine against the first chicken-produced biological, so we are desperately trying to move to cell-culture techniques where the vaccine will be produced in large fermenters because it will be quicker and cheaper. Now we have the proposal to use transgenic chickens to make still other biologicals with an egg-based technology because using fermenters is too costly and not fast enough.

Go figure.

In defense of Juan Cole (as if he needs it)

2006-06-08T07:52:00.000-04:00

I'm an academic and a blogger. So I feel compelled to come to the defense of another academic and blogger, the estimable Juan Cole of Informed Comment. Cole's blog on contemporary Middle Eastern affairs is one of the most highly regarded on the net. Unlike many of the pundits and experts confidently holding forth about the Middle East, Cole actually reads and speaks the languages of the area and is an acknowledged scholar of the subject. By all reports he is scrupulous in his scholarship (which is very specialized) and respectful and fair with his students at the University of Michigan. His classroom is a safe place for expressing ideas.

But he is no shrinking violet. Cole's blog is accurate in its facts, well documented and brutally honest. It is a very political blog, but that is the nature of blogs (including this one). He has been straightforward in criticizing the monumental incompetence that has gotten the US into a catastrophic war in Iraq and fearless in calling Israel to account for its often brutal occupation of the Palestinian state. These two things have earned him the hatred of the neocons, who brought us the Iraq mistake, and the Israel lobby, for whom no criticism of Israel is ever allowed.

Earlier this year Cole was recommended for a tenured position to teach modern Middle East affairs at Yale. The Yale Sociology and History Departments separately approved the offer. This would usually be the end of the matter. But last week, in what was described by some Yale faculty members as a highly unusual move, the University's tenure committee turned the appointment down. The central issue, according to the newspaper The Jewish Week (who described Cole as one of the country's top Middle East scholars), was the political commentary on his blog.

Cole, while refusing to comment on the tenure committee’s vote, told The Jewish Week he believes that “the concerted press campaign by neoconservatives against me, which was a form of lobbying the higher administration, was inappropriate and a threat to academic integrity.

“The articles published in the Yale Standard, the New York Sun, the Wall Street Journal, Slate, and the Washington Times, as part of what was clearly an orchestrated campaign, contained made-up quotes, inaccuracies, and false charges,” he said. “The idea that I am any sort of anti-Jewish racist because I think Israel would be better off without the occupied territories is bizarre, but I fear that a falsehood repeated often enough and in high enough places may begin to lose its air of absurdity.” (The Jewish Week)

The orchestrated attack, involving op ed pieces and letters to large donors to Yale who are Jewish, had the desired effect. Now an embarrassed Yale is trying to rewrite the history of the episode. First, anonymous sources are maintaining that Cole's scholarly work is too specialized to be of general interest. But here's what the Search Committee said:

Political science professor Frances Rosenbluth, who was part of the search committee, said that Cole emerged as a clear choice.

“The committee read his work very thoroughly, in conjunction with the work of other scholars,” Rosenbluth told The Jewish Week. “We interviewed other people, we sent out letters to the field of contemporary Middle Eastern studies, and [Cole] is very highly regarded as a scholar. That’s why the committee made its recommendation.” (The Jewish Week)

They are also floating the absurd idea it wasn't Cole's blog politics but his collegiality that was at issue:

Second, the source continued, Cole appears to lack in collegiality, as his penchant for combative blog entries and personal spats with detractors might make him an unnerving fixture on Yale.

That really made me laugh. I've seen Cole many times on PBS's Newshour and he is invariably low key, respectful and non confrontational when presenting his views. Moreover if a penchant for combative blog entries were a criterion for employability, the Reveres and most of the commenters who make this such an interesting place would be unemployed.

Not one of Yale's better moments, although I am sure alum George W. Bush approves.

Chrome plated fraud

2006-06-07T08:12:00.000-04:00

In December we posted on a Wall Street Journal article about how a high priced corporate consultant (I hesitate to say, scientist) essentially ghost wrote an article which he signed for a now deceased Chinese doctor, apparently retracting earlier work the doctor had done showing exposure to chromium-VI was a risk factor for cancer. The orignal paper was some of the work relied on in the famous Erin Brockovich case featured in the movie starring Julia Roberts.

The Environmental Working Group, one of the environmental movement's more effective watchdog groups was all over the case and their efforts are bearing spectacular results.

In a real-life epilogue to "Erin Brockovich," a respected medical journal will retract a fraudulent article written and placed by a science-for-hire consulting firm whose CEO sits on a key federal toxics panel. The retraction follows a six- month internal review by the journal, prompted by an Environmental Working Group (EWG) investigation.

The July issue of the peer-reviewed Journal of Occupational and Environmental Medicine (JOEM), the official publication of the American College of Occupational and Environmental Medicine, will carry a retraction of a 1997 article published under the byline of two Chinese scientists, JianDong Zhang and ShuKun Li.

The article appeared to be a reversal of an earlier study by Zhang that found a significant association between chromium pollution of drinking water and higher rates of stomach cancer in villages in rural northeast China. Since its publication, the fraudulent article has influenced a number of state and federal regulatory decisions on chromium.

"It has been brought to our attention that an article published in JOEM in the April 1997 issue by Zhang and Li failed to meet the journal's published editorial policy in effect at that time," says the retraction, signed by JOEM Editor Dr. Paul Brandt-Rauf and obtained by EWG. "Specifically, financial and intellectual input to the paper by outside parties was not disclosed."

[snip]

Under the state Public Records Act, EWG obtained and posted online documents from California regulators and court records that showed the article was actually the work of ChemRisk, a San Francisco-based consulting firm whose clients include corporations responsible for chromium pollution. The documents and the story they outline are at http://www.ewg.org.

[snip]

ChemRisk's founder and CEO, Dennis Paustenbach, is a Bush Administration appointee to a U.S. Centers for Disease Control advisory panel on toxic chemicals and environmental health. His firm holds a lucrative contract with the CDC and the Energy Department to investigate radioactive and toxic releases from Los Alamos National Laboratory in New Mexico.

In this case, ChemRisk was working for Pacific Gas & Electric (PG&E), a San Francisco-based utility whose dumping of the industrial chemical chromium-6 had contaminated the drinking water of the small town of Hinkley, Calif. Hinkley residents' lawsuit against the company, which PG&E eventually paid $333 million to settle, was the basis for the film "Erin Brockovich," starring Julia Roberts as the legal investigator who uncovered the dumping.

PG&E hired ChemRisk to conduct a study to counter Hinkley residents' claims of cancer and other illnesses from chromium-6 in their water. ChemRisk tracked down Zhang, a retired Chinese government health officer, and paid him about $2,000 for his original data. ChemRisk distorted the data to hide the chromium-cancer link, then wrote, prepared and submitted their "clarification'" to JOEM under Zhang and Li's byline, and over Zhang's written objection. (Environmental Working Group)

This affair is not a tempest in a teapot. It has had real life implications for all of us. California regulators used the fraudulent paper to revise chromium-VI standards for drinking water, on recommendations from a panel upon which Paustenbach sat. And the EPA also used it to allow continued use of chromium as a wood preservative. CDC is refusing to remove Paustenbach as a member of the toxics advisory board or ChemRisk as a contractor.

EWG's coup comes on top of its recent victory to force DuPont to disclose drinking water tests on the teflon ingredient perfluorooctanoic acid (PFOA; posts here, here and here) and an earlier unmasking of ABC hack reporter John Stossel, whose use of fraudulent (non-existent) test results in one of his hatchet jobs (on organic food) forced him to make an on-air retraction and apology.

Kudos (once again) to EWG. I'm glad these guys are on our side.

WHO, part V: end of the beginning

2006-06-07T08:06:00.000-04:00

[This is the last post in the series about WHO (part I, part II, part III, part IV). We try to sum up where the story has (unexpectedly) brought us.]

For everyone reading this series of posts wondering where we were going, we were wondering, too. The Reveres started blogging because for us, "writing is thinking," and we believed strongly then and continue to believe now that the progressive public health movement did too little thinking and too much sloganeering. We started writing as a way of trying to think things through, doing it publicly because we beleived there was much raw brain power "out there" to help us move things forward. We haven't been disappointed, despite the occasional aggravation that goes with asking people what they think and giving them an opportunity to answer.

The WHO series originated because of our distress over criticisms leveled at WHO regarding their transparency, their honesty and their motives, especially the issue of sequence release and their incomplete recording of case data. If you read the comments here you will find us defending WHO and flu scientists and trying to parry accusations we felt were unfair and misdirected. It was our thought that one way to have a more persuasive response was to explain where WHO fit into the whole scheme of things. Hence this series.

But a funny thing happened on the way to the last installment. Our original ideas began to evolve, and we must acknowledge that some of our readers' criticisms of WHO had more force than we gave them credit for, and some of the optimism we had about WHO's own recognition of the problems has been tempered. We still have respect for the many highly competent professionals in WHO, some of whom risk their lives in the cause of public health. We still have sympathy for the extremely difficult position WHO finds itself in as an intergovernmental agency trying to work with governments whose highest priority is not the health of the world's people, or even, in some cases, the health of their own people. We still think the imputation of base motives to many in WHO is misguided, misdirected and unfair. And along with our wiki colleague anon_22, we still think we are better off having WHO than not having WHO -- by a long way. But we no longer see WHO as the principal engine safeguarding global public health.

One of the fundamental problems is that WHO, however global its vision, can act only through the same sovereign states that constitute its membership and are the instrumentalities through which any actions are taken. WHO's success in the SARS outbreak rested on its authority as a source of global alert, best clinical practice, and most dramatically, geographically-specific travel advisories. These products all depended on WHO's ability to provide information. But as the H5N1 threat has evolved in relative slow motion, old Westphalian habits hve reasserted themselves, as WHO scrambles to manage information and reveal it simultaneously. Cumulative missteps -- contradictory stories, clear spinning towards less threatening outcomes, unfounded claims of certainty and authority when uncertainty and powerlessness were the reality, lack of transparency about sequence information and case data, overstatement and understatement -- have seriously weakened the only real source of WHO power, its credibility and authority.

Three years ago WHO would have been able to weather these self-inflicted wounds. Now WHO must compete with an abundant free flow of information on the internet, information which is sometimes correct, sometimes not, but often as accurate or more accurate than WHO's. It comes from the same raw sources as WHO's but its interpretation is not bound by WHO's rules, traditions or constraints. If those rules and constraints were the source of discipline to make WHO's version superior, it would be one thing. But they aren't. They are another source of distortion. Thus one of the sources of WHO's enhanced powers after the revision of the IHR, the management of the flow of epidemiological information and surveillance, has been overtaken and perhaps made irrelevant by the advance of technology and the new social structures it fostered.

WHO's complementary role in coordinating global resources for control of local and regional disease outbreaks remains an important one, but it is moot for a pandemic which happens everywhere. There is not much ability to focus and coordinate resources that are needed everywhere. The "national system" upon which WHO depends is also clearly incompatible with the demands of reacting to infectious diseases that care nothing for national borders. For an evolving pandemic where managing the consequences is paramount, the main tool is information.

In that sphere, WHO and its sovereign member nations must not only share the stage with many non-state actors, but it must share them with actors that can rise to the demands of a pandemic better than WHO itself. WHO's epidemiological intelligence function has been superseded by a global internet that ferrets out, assembles and interprets information faster than WHO and often arrives at plausible interpretations at odds with the ones advanced by WHO.

Where does this leave us? We wish we knew the answer, but the H5N1 pandemic threat has left WHO and the world suspended in a kind of global public health limbo, recreating the anarchy of Westphalian public health but enlarging it to include all the other actors as well: states, intergovernmental agencies, NGOs, multinational corporations, public-private partnerships, and the increasingly influential world of information fed internet subcultures. Like the nations of the world, we need to find a way to work together. Information has become the currency in this world. We all want more of it and we want real gold, not fool's gold.

Information is a type of product that isn't depleted with use. It is not a counter in a zero sum game, with your gain my loss. Just the reverse. When it is distributed and redistributed, everyone gains. The lesson is that we all need to treat that resource with the greatest respect and the utmost of generosity. If WHO wants to regain some credibility and effectiveness, the single most important thing is to open the spigots of information full bore. We know it hasn't done so yet.

The same is true of my scientific colleagues. If you work on infectious diseases of pandemic importance, you will have to change your customary way of doing things. For some this is hard but it is necessary. For students and their mentors who fear this will put them at a competitive disadvantage in the academic world, that's going to be the price you will have to pay to be in this field. There are a lot of other subjects you can pursue if this is unacceptable to you. To health agencies like CDC, you will also have to provide the same kind of information, without regard for political, career or commercial considerations. It's not a choice. Do it or lose your authority and credibility. This is a constraint the outside world is placing on you.

For us, the distributed and global world of obsessed information harvesters, purveyors of hopes and fears, cassandras and hucksters, prophets and ordinary folks, there are also responsibilities. We need to practice fairness, consideration, empathy, constructiveness, and the desire to help each other and others engaged to the same ends, including WHO and CDC, in this increasingly turbulent drama against a virus that doesn't think, doesn't care and isn't even alive.

Maintaining that balance and openness ourselves may be the toughest job of all, as we struggle to push others to do their jobs, too.

Next question

2006-06-06T06:33:00.000-04:00

This is what WHO is up against in Indonesia. The largest bird flu cluster to date occurred in North Sumatra, Medan, Karo regency in Kubu Simbelang village. On May 30 and June 4 emergency shipments of protective equipment with spraying tools, boots, masks and medicines arrived in Medan's Polonia Airport. There were four packages, weighing 265 kilograms.

According to WHO's liaison officer in Medan, Elia Ginting, the four packages are labeled 'protective equipment bio packaging' and were sent via Singapore.

“The equipment was sent after the WHO's laboratory recommendation about bird flu transmission in Karo was issued. It was sent in special stages for bird flu eradication personnel in Karo,” she said.

However, she acknowledged that the import documentation for the packages was not yet completed by WHO at the time of shipment from Singapore.

Meanwhile, according to Jontara Siburian, Head of the Customs Section of the Customs and Excise office at Polonia Airport, told Tempo that Customs and Excise was not going to release all of WHO's goods because it has not received the import documents until now.

“Although they are for emergency purposes, Customs will not release the equipment yet,” he said. (Tempo Interactive)

Yes, get the paperwork done, by all means. But the real truth is the Indonesians don't want to cull birds. We posted on this last September and nothing has changed. A mass killing of birds there is as likely as a mass killing of cats and dogs in the US.

It is easy to wag our fingers at the Indonesians because they won't put their own house in order and they are endangering us. Probably the Columbians feel the same way about the US because we won't stop the drug demand that is fueling the culture of vicious violence in their home country.

The Indonesians are at fault, here. No question.

So are we regarding substance abuse. Next question.

WHO, part IV: one door closes, another door opens

2006-06-06T06:31:00.000-04:00

[This is the fourth of several posts (part I, part II, part III, part V) giving some background to the place of WHO in the international system. I am trying to explain some things about WHO behavior and positions I think might be useful to interpreting their actions and statements. It is not meant as a defense of either.]

Westphalian public health, as embodied in the International Health Regulations, was obviously a failure, and revision of the IHR was in order. The revision process began quietly in 1995. Early on it was realized that just adding to the list of notifiable diseases (including HIV/AIDS, for example) was not going to solve the serious structural problems caused by reliance on states as the only legitimate actors and sources of information. The member states were often blatantly disregarding their obligations to notify WHO, and through WHO, other member states. Adding to the list of diseases wasn't going to help much. The goal of the revision remained the same, however: to prevent the cross-border spread of infectious disease while interfering a little as possible with trade and travel (see also, the excellent monograph by David Fidler, SARS, Governance and the Globalization of Disease). The key move was to include information of non-state origin as legitimate sources of epidemiological information. This was a conscious break with Westphalian principles because it shared governance with non-state actors.

It was also a formal recognition of a fact. On the one hand, depending on states to divulge information that might damage them was unrealistic and obviously a failure. On the other hand, WHO and global health experts were already using to good effect non-state sources of information: newspapers, websites, chatrooms and email lists -- all the capabilities of the exploding new information technologies we know as the internet. In the mid nineties the Program for monitoring emerging Diseases (ProMED) was formed to harness the internet for a rapid dissemination of diverse sources of information. Today ProMED has tens of thousands of subscribers in more than 150 countries. Many of us receive it by broadcast email and its website is open to the world. It is currently sponsored by the International Society for Infectious Diseases, an NGO.

This kind of information was not just harvested, but also used by WHO in a new Global Outbreak Alert and Response Network (GOARN), which started operation in 1998. On paper GOARN was impressive:

This overarching network interlinks, in real time, 110 existing networks which toegether possess much of the data, expertise, and skills needed to keep the international community alert to outbreaks and ready to respond . . . .[o]ne of the most powerful new tools for gathering epidemiological intelligence is a customized search engine that continuously scans world Internet communications for rumors and reports of suspicious disease events. (WHO, as quoted in Fidler, p.. 66 - 67).

WHO claimed to have used GOARN to identify and investigate 538 outbreaks of international concern in 132 countries between 1998 and 2002. I have no way to verify this. But Karl Greenfeld, in his new book on SARS (The China Syndrome), points out that at the time of the SARS crisis, GOARN was in reality just three full-time medical professionals operating out of two offices on the first floor of the WHO annex building in Geneva. GOARN got its information from the same sources we do at Effect Measure: ProMED, media reports, websites, local correspondents and rumors.

On February 11, 2003 GOARN detected a developing respiratory disease outbreak in southern China, about a month after the Chinese government sent a team of doctors to Heyuan Number One Hospital to see the first cases of what later came to be know as SARS that came to its attention (they did nothing about it). Initially, the WHO suspected this was the start of an H5N1 outbreak and they alerted their laboratory network immediately, although public notification didn't come until weeks later. One might say that GOARN had "worked" much better than leaving it to China to report, but there was still a sufficiently long lag time that hads it been the start of a flu pandemic it would have cost many lives.

The SARS outbreak was resolved with the help of hard work on the part of many people, including heroic doctors in Hong Kong and WHO epidemiologists, one of whom died identifying the disease. Had this truly been H5N1, however, we would almost certainly have had a pandemic. This, despite even more dramatic departures from WHO's Westphalian heritage. In trying to stop the global spread of SARS, WHO issued travel advisories against the wishes of powerful member states and suffered a backlash from Canada as a result. And while WHO had made progress, SARS showed its capabilities were probably inadequate to stop a pandemic from the influenza virus.

In 2005 the IHR were officially de-Westphalianized, the culmination both of their failure in an age of global pandemics or threatened pandemics (HIV/AIDS, SARS, now avian influenza) and the "facts on the ground" regarding new actors on the global public health stage (discussed in Part III). The revised IHR don't seem up to the task, however, despite their departure from their Westphalian roots. In particular, there are many loopholes, long timelines, gaps and vague clauses, problems that to any lawyer's eyes, would vitiate the force of the new regulations.

Given the nature of this intergovernmental agency it may be as good as it can do. We don't have a world government and the US have done all in its power to circumscribe and weaken the UN, the world's only and already weak supranational force. And the revisions may prove very useful for other, regional or more localized outbreaks of disease. But it is hard to see how they will change much in WHO's ability to affect the evolution of an evolving pandemic threat from avian influenza. (You can read the IHR here and some thoughtful and heated commentary on it on The Flu Wiki in this Forum Thread. The Forum is the freewheeling discussion section of the Wiki and is separate from the "informational" side. In particular you will find useful annotations of the IHR by anon_22 at 10:35.)

If the revised IHR have any significance it lies elsewhere. In the final post, we broaden the question of where WHO fits in, not with respect to the international system, but with respect to the new global health system that includes WHO, NGOs, multinational and national businesses -- and the new communities growing up around the internet. In other words, us. This is a critical discussion we need to shape our response to the other actors who share the global public health stage with us: our own countries, NGOs, intergovernmental organizations like WHO, FAO, OIE and the World Bank, and the various internet communities that rub shoulders, sometimes cooperatively and sometimes in opposition.

Public-private default

2006-06-05T06:40:00.000-04:00

In today's post about WHO we mention public-private partnerships, one of the ways WHO was accommodating to a world stage that had more than national states participating in international health activities. One of the more pertinent examples is in the news today, the alleged effort of countries, NGOs and intergovernmental organizations to battle bird flu using $1.9 billion pledged by the parties in January. That was then. This is now.

Just $286 million has been spent to fight bird flu out of nearly $1.9 billion pledged last January by nations and organizations that said they wanted to make a "massive effort" against the virus, according to a World Bank report.

Only Japan, Switzerland and the Czech Republic have fully spent the money promised at a meeting of big donors in Beijing last January, according to the report, a copy of which was obtained by Reuters.
Africa in particular needs more money, the report said.

"Japan has fully committed its pledge in Beijing of $158 million to a range of countries and organizations at the regional and global level," the report reads. Switzerland pledged and has spent $4.7 million while the Czech Republic promised and has spent $200,000.

The report, prepared for a meeting of senior officials in Vienna on June 7, also singles out the United States, which pledged and committed $334 million, but which has spent $70.95 million. Of $500 million in loans promised by the World Bank, just $113 million has been committed and only $1.97 million sent out. (Leslie Wroughton and Maggie Fox, Reuters)

The money was meant to improve animal health systems and surveillance, poultry vaccination and rapid response measures, all critical to slowing the spread of avian influenza. The money is slated for projects in Vietnam, Indonesia, Nigeria, Turkey and Cambodia, all bird flu hot spots.

So it's just Japan, Switzerland, the Czech Republic (and an AP story adds Finland to the list) that have met their obligations. The European Community has disbursed nothing and the US only a small fraction of its pledge.

Pretty pathetic.

WHO, part III: the world changes

2006-06-05T06:36:00.000-04:00

[This is the third of several posts (part I, part II) giving some background to the place of WHO in the international system. I am trying to explain some things about WHO behavior and positions I think might be useful to interpreting their actions and statements. It is not meant as a defense of either.]

The idea that states were the only legitimate actors was the essence of the system WHO was born into, guiding and constraining its activities for the first 50 years or so. It derived from the Peace of Westphalia, 1648 (seep part I):

The Westphalian moment in the seventeenth century represented the effective abandonment of the legitimacy of transnational, non-state actors, such as the Catholic Church, that had played governance roles in earlier times. The Peace of Westphalia stripped governance of international relaitons bare of such actors and grounded governance in the interactions of sovereign states. (David Fidler, SARS, Governance and the Globalization of Disease, p. 50)

In part II we saw how this was reflected in the International Health Regulations that governed WHO's activities in infectious disease, establishing the state as the only legitimate source of epidemiological information and the only actor that could authorize its dissemination. The idea of the IHR was to reduce the possibility that one state would needlessly harm another by the unilateral application of quarantine or product boycott for reasons of infectious disease. The IHR were international health treaty counterparts to the kind of standardization that was done in many places in the twentieth century to standardize regulations, screw sizes and many other things to lubricate the wheels of commerce, travel and trade.

Despite the state-centered basis, non-state actors like multinational corporations (MNCs) and non-governmental organizations (NGOs) were not absent from the WHO world. WHO had both formal and informal systems of relationships with them to allow cooperation and consultation in matters of health. The difference was that the MNCs and NGOs were not part of the WHO governance scheme. Only states were.

But NGOs and MNCs were neither inert nor passive and their power and influence grew in the last third of the twentieth century. An international campaign against infant formula in the developing world had significant success in altering marketing practices of MNCs and national maternal and child health agencies. The field of actors was being enlarged beyond the states, affecting intergovernmental agencies like WHO indirectly through effects on MNCs and governments. MNCs in turn also were players with national governments and sometimes NGOs. The stage was becoming more crowded.

At the same time a new kind of actor was coming into being, the "public-private partnership." A recent example is the Bill and Melinda Gates Foundation's Global Alliance for Vaccines and Immunization, directed at working with WHO and other intergovernmental agencies like the World Bank, governments, NGOs and pharmaceutical companies to provide vaccines for the world's children. This is about as un-Westphalian an endeavor as one can imagine. These partnerships are not treaty agreements between sovereign states but agreements between a wide range of actors that include WHO, sovereign states, NGOs, MNCs and others. Nor is it the only such example. There are many others, including the ambitious voluntary bird flu fund established in January.

Thus while the IHR remained stuck in a Westphalian world, the international system had changed radically. On paper, international health might be populated solely by state actors, in reality that world was gone. Whether it was NGOs, corporations, public-private partnerships or the new sub-cultures growing up through the internet, the prohibitions and constraints that kept WHO confined to horizontal relationships between state actors had broken down and numerous new actors were busily engaged in influencing, intervening, opposing or supporting what was going on inside state borders.

There is more to it. A fundamental change was occurring in how we looked at the world, perhaps best symbolized by the iconic blue marble view of the earth from space. The right to participate in international health governance was no longer seen as the sole right of nation states, whose existence is not visible in this view. Nor is it presumed that the Great Powers should be either the sole producers or sole consumers of products meant to enhance the health of the globe. The Westphalian standard of "the national interest" was no longer the obvious touchstone of all global health decisions.

Fidler discusses how the new view influenced such establishment sources as the 2001 action agenda of the Commission on Macroeconomics and Health on a matter which concerns us here, so I'll end this post with it:

The Commission's action agenda included the recommendation that the supply of global public goods, such as international disease surveillance, be bolstered through additional financing of relevant international organizations, including WHO. The Commission captured why [the idea of global public health good] differs from the policy objectives targeted in Westphalian governance when it observed that global public goods "are public goods that are underprovided by local and national governments, since the benefits accrue beyond a country's borders." (Fidler, p. 60).

In part IV, we'll discuss how WHO responded -- and failed to respond -- to the new reality and the growing threat of emerging and re-emerging infectious diseases.

WHO, part II: Westphalian public health

2006-06-04T09:53:00.000-04:00

[This is the second of several posts (Part I here) giving some background to the place of WHO in the international system. I am trying to explain some things about WHO behavior and positions I think might be useful to interpreting their actions and statements. It is not meant as a defense of either.]

In Part I we gave a brief background to the international system to which WHO is tied, the Westphalian system. When WHO was created it was the only game in town. Throughout its history, WHO has struggled to overcome the incompatibility between the legacy of a political and diplomatic world where actors are nation states and the real public health world where these actors are irrelevant.

The problem of the irrelevance of political borders (and state sovereignty) to a microbe was understood even before the germ theory. Quarantine goes back at least to the fourteenth century, and as time went on the practice and others like requiring a "bill of health" from the port of origin became an increasing source of interference to free trade and trravel between nation states. In principle one country couldn't intervene in the affairs of another to stop an epidemic, but it could prevent its ships from its shores or incarcerate its crews aand impound once landed.

As trade increased so did the costs in spoiled cargos and lost cartage times. By the middle of the nineteenth century the community of large trading nations was exploring ways to reduce the frictional loss caused by sovereignty, of each nation acting on its own. Westphalianism allowed supranational controls as long as all parties agreed. Thus began a series of international sanitary conventions from 1851 onward. They were voluntary but binding agreements negotiated by sovereign states on how to minimize interference with international trade and travel while maximizing protection from specified infectious diseases. In other words, they were rules that managed state interactions while leaving the core of sovereignty alone. The sanitary conventions didn't interfere with what went on inside borders. They covered quarantine and requirements for certain facilities at international ports and airports, the gateways for cross-border disease spread.

The classical example of a Westphalian structure in international health are the International Health Regulations (IHR), adopted by WHO in 1951 from the international sanitary conventions in force at that time. They are discussed in David Fidler's monograph, SARS, Governance and the Globalization of Disease. As he observes (p. 33), the objectives of the IHR are pure Westphalian doctrine: to ensure the maximum security against the international spread of disease with minimal interference with world traffic. At the heart of the IHR is a surveillance activity that requires notification of the international community through WHO. The IHR only covered diseases of interest to the great powers, cholera, plague and yellow fever ("Asiatic diseases"). The original IHR/1969, in force until next June when they will be succeeded by the revised IHR/2005, are Westphalian through and through:

The IHR seek to achieve minimum interference with world traffic by regulating the trade and travel restrictions WHO member states can take against countries suffering outbreaks subject to the Regulations. The IHR provide that the trade and travel measures prescribed for each disease subject to the Regulations are the most restrictive measures that WHO member states may take (IHR, 1969, Article 23). The IHR contain the maximum measures that a WHO member state may apply to address potential cross-border transmissions of cholera, plague, or yellow fever . . . . The IHR have provisions that prevent the departure of infected persons by means of transportation and that limit actions taken against ships and aircraft en route between ports of departure and arrival, against persons and means of transport upon arrival, and against cargo, goods, baggage, and mail moving in international transport . . .(Fidler, p. 34).

This is not all. The flow of epidemiologic information has also been regulated by Westphalian principles:

The [IHR] also reflect the state-centric framework, especially with regard to the flow of epidemiological information to and from WHO. Under the IHR, surveillance information that WHO can disseminate to its member states can only come from governments (IHR, 1969, Article 11). As WHO observed [cite omitted], '[t]he IHR wholly depend on the affected country to make an official notification to WHO once cases are diagnosed." WHO has no legal authority under the IHR to disclose disease outbreak information it receives from reliable non-governmental sources. (Fidler, p. 51).

This explains a great deal of WHO's seemingly irresponsible behavior regarding release of case and sequence information. It did not have the legal authority, under international law, to release information without the consent of the member state. We at Effect Measure or Henry Niman at Recombinomics might rail that WHO "must" release the Turkish sequence information, but WHO could not do so without the permission of the Turkish government. We could bemoan this restriction (as WHO did for many years) and demand WHO violate international law. But such an act could have serious consequences for WHO's position in the international system. It would be like asking the police to violate the law for a higher good. It might be justified in some circumstances, but they would have to be extraordinary and the undertaking would be fraught with difficulty and hazard. They also would not have many chances to do it again if it turned out to be unjustified.

It is clear the Westphalian IHR were inadequate to the task of safeguarding the world from pandemic disease, not only in the bird flu case but in many others where state actors have violated their obligations to notify WHO because they would suffer economic harm. WHO understood that the core principles for the Westphalian IHR were inadequate as well and by the mid nineties was undertaking to revise them. At the same time, changes were taking place in global public health, like a chrysalis developing within the Westphalian cocoon. In Part III we will take a look at them.

Correction, 6/4/06, 12:50 EDT: Inserted the word "not" to make the second sentence in the penultimate paragraph read correctly, viz., "…but WHO could not do so without the permission of the Turkish government." Sorry for any confusion. Thanks to the reader who pointed it out.

Freethinker Sunday Sermonette: post deathbed conversion

2006-06-04T09:37:00.000-04:00

Chicago Democratic ward healers used to confer voting rights on the deceased, and lately Republicans have revived the practice (although not the voters). But when it comes to proselytizing, nobody beats the Mormons.

From The Jerusalem Post:

Jewish leaders in a dispute with the Church of Jesus Christ of Latter-Day Saints over the practice of posthumous baptisms say there is new evidence that names of Jewish Holocaust victims continue to show up in the church's vast genealogical database.

[snip]

Posthumous baptism is a sacred rite practiced in Mormon temples for the purpose of offering membership in the church to the deceased. Church members are encouraged to conduct family genealogy research and forward their ancestors' names for proxy baptism.

Church president Gordon B. Hinckley has said the baptismal rite is only an offer of membership that can be rejected in the afterlife by individuals. "So, there's no injury done to anybody," Hinckley said last November. (Jerusalem Post)

This is hilarious. No one's feelings should be hurt because the dead person can always refuse to be baptized?

What a timesaver. I don't even have to lampoon this, it's so daft.

Vaccine vaporware?

2006-06-03T08:17:00.000-04:00

There is no effective vaccine for H5N1 at the moment but there is a lot of activity. Whoever makes a vaccine will have a ready market if there is an outbreak and in a threatened pandemic, with production capacity inadequate to meet global demand, there will be room for more than one producer.

One of the first to announce it was well on the way to a practical vaccine was Hungary, whose partnership with a small vaccine developer, Omniverst, was touted as one of the first out of the gate late last year. Both the health minister and Prime Minister Ferenc Gyurcsany publicly took the vaccine and predicted Hungary would be able to protect its citizens against any pandemic. That was then.

Little has been heard since, according to a Bloomberg story reported in the Hungarian press. There have been no scientific publications and no one has ordered the vaccine from Omniverst. A large European pharmaceutical company looked at the technology and decided to proceed on its own. No regulatory approval has been applled for.

When contacted by Nepszabadsag, one of Omninvest's leaders, Tamas Laczko said that the Hungarian authorities had registered the vaccine and the company was in the process preparing the documentation necessary for European regulatory approval. The vaccine will only be deployed by the health authorities if there is an epidemic, he said. Therefore there is no urgency to get the European registration, which is costly for a small company like Omninvest, he added. (MTI)

No urgency. Of course not.

WHO, part I: 300 years old at birth

2006-06-03T07:55:00.000-04:00

[This is the first of several posts giving some background to the place of WHO in the international system. I am trying to explain some things about WHO behavior and positions I think might be useful to interpreting their actions and statements. It is not meant as a defense of either.]

The World Health Organization (WHO) came into this world with a congenital deformity. Since then it has struggled, against the odds, to walk normally and do things that might seem difficult or impossible, given its disabilities. It hasn't stayed static, however, but is trying to perform reconstructive surgery on itself. To understand what is wrong and appreciate its achievements given the circumstances, we need to consult some textbook history.

WHO was established as the health agency in the United Nations system by an international charter in 1948. This is exactly 300 years from the year the modern system of international relations was crystalized in the Peace of Westphalia, ending the disastrous conflicts known as The Thirty Years War. This may seem a strange place to start an explanation of WHO's predicament, but we will try to show why it is important.

The Thirty Years War was a complex, chaotic and catastrophic convulsion that devastated continental Europe between 1618 and 1648. The causes were on many levels: Princes versus The Holy Roman Emperor; Protestants versus The Church in Rome; and internecine warfare between states and princes and everyone else. It was a War of All Against All and it decimated the continent and killed almost half the population of Europe, a three decade pandemic of violence more deadly than 1918 flu. The Peace of Westphalia, the Treaty that ended it (at least most of it), was known to contemporaries as The Peace of Exhaustion.

The Peace of Westphalia also gave rise to what political scientists call the Westphalian System of international relations, identified with the idea of sovereign national states subject to no higher authority. Each state actor could determine whith what other states and under what conditions they would have legal relations. The Westphalian system is "anarchic" in the sense there is no authority above a nationally sovereign state -- except such authority as the state agrees to in advance. Power is divided, and no "world government" is possible except to the extent a state agrees to be subject to some extra-national conditions.

Anarchy in this case doesn't mean confusion and disorder. On the contrary. There is a definite structure to Westphalian relations and its core is sovereignty -- states have sole power within their borders -- and its corollary is non-intervention: states do not interfere in the internal affairs of other states (I have used international legal scholar David Fidler's monograph SARS, Governance and the Globalization of Disease as a source for some of this exposition).

These principles are enunciated in the UN Charter (art. 2.7) which states that

"[n]othiing contained in the present Charter shall authorize the United Nations to intervene in matters which are essentially within the domestic jurisdiction of any State or shall require the Members to submit such matters to settlement under the present Charter." (quoted in Fidler).

This idea, the sovereignty and equality of nations, is the linchpin of the international system within which the UN, and hence WHO, operate. Again, from Fidler:

The Declaration on Principles of International Law Concerning Friendly Relations and cooperation Among States (1970, p. 42) states, for example, that "[e]very state has an inalienable right to choose its political, economic, social, and cultural systems, without interference in any form by another State." The principle of non-intervention excludes a great deal of sovereign behavior from being the subject matter of state interaction. (Fidler, p. 23)

Westphalian relations have a politics as well as a structure, however, and the politics are largely (but not exclusively) the politics of the Big Powers. Individual state actors are the units, but with no power acting over them, material resources, military power and strategic alliances affect how states relate to each other, just as they do in a democracy where the individual is the theoretical unit but some individuals are more equal than others.

In Part II we will examine how WHO's birth as a Westphalian institution has affected its functioning in public health, with particular emphasis on infectious diseases. Sovereign states are demarcated by borders, but viruses don't recognize those borders. The Westphalian System recognized this early on and developed ways to handle it. It is those ways WHO inherited at its birth in 1948.

Behind the Indonesian curtain

2006-06-02T08:12:00.000-04:00

The curtain is being pulled back on the Indonesian bird flu control program and it reveals there is nothing there. In the last few days several major stories have highlighted the open secret that Indonesia is a No-Man's-Land of bird flu, a free for all with no one in control. This comes at the end of May, a month which saw 15 bird flu deaths in Indonesia and reports of several small clusters and one alarmingly large one. WHO is saying there is so far no evidence of spread beyond the family, information consistent with what we have heard through independent sources. But the ability of WHO and the Indonesian authorities to perform thorough contact tracing is limited.

Exasperation with the Indonesians is clearly evident. Even WHO epidemiologist Steve Bjorge, by all accounts a diplomatic and generous person, seems to be running out of patience:

"The situation is that there is a leak in the roof, and the Ministry of Health is just mopping up the floor every day," epidemiologist Steve Bjorge said.

Indonesia has the world's second- highest number of confirmed human bird flu deaths after Vietnam with 36 - and the most deaths this year.

Bjorge said Indonesia had to start mass culls of infected birds and more intensive testing of fowl suspected of carrying the H5N1 virus if it wanted to stem the spreading of the virus, which he said was "pandemic in poultry."

In Papua's Manokwari district, he said, "they have had three outbreaks in the last nine months, and each time they've culled and they've stopped it. That to me means, even in Indonesia, it is possible to do it."

But the sprawling country's hugely decentralized government - spread over 17,000 islands - means that preventing the spread of the virus among birds is a very complicated task, Bjorge said, adding there is no central authority that can order culling "on a minute's notice." (Marianne Kearney, AFP via The Standard, Hong Kong)

This is not just one person in WHO expressing a personal opinion. Almost exactly the same language was used by WHO spokesperson Dick Thompson, not previously known for the boldness of his pronouncements:

"We're tying to fix this leak in the roof, and there's a storm," World Health Organization spokesman Dick Thompson said. "The storm is that the virus is in animals almost everywhere and the lack of effective attention that's being addressed to the problem."

Indonesia, an archipelago of 17,000 islands with a population of 220 million people, has a patchwork of local, regional and national bureaucracies that often send mixed messages. The impression, health officials said, is often that no one is truly at the helm.

"I don't think anyone can understand it unless you come here and see it for yourself," said Steven Bjorge, a WHO epidemiologist in Jakarta. "The amount of decentralization here is breathtaking."

He said Health Ministry officials often meet with outside experts to formulate plans to fight bird flu, but they are rarely implemented.

"Their power only extends to the walls of their office," Bjorge said, adding that the advice must reach nearly 450 districts, where local officials then decide whether to take action.

[snip]

But public awareness and bio-security standards remain low in the densely populated countryside, home to hundreds of millions of backyard chickens.

"It's not quite so easy here, where you have to have the local authorities and provincial authorities and national all on board," said Jeff Mariner, an animal health expert from Tufts University working with the FAO in Jakarta.

"We find outbreaks every week scattered throughout Java. It's a diffusely endemic disease. In most districts, you can find it at any time," he said. "It's a staggering undertaking in a decentralized country." (AP)

Two things strike me about this. The Indonesian situation is probably mirrored in numerous countries in Africa. Who knows what's going on there? Second, WHO appears to be flexing its newly authorized muscles. We don't yet know if this is a sign of a sea change, and if it is, what its origin is. The agency is operating under the direction of an interim Director-General who may be taking advantage of international concern to do things differently, as WHO did during the SARS episode. Or maybe the newly revised International Health Regulations are starting to bite. Or maybe its a combination of factors.

Whatever it is, we can hope.

Indonesia "releases" the sequence data (sort of)

2006-06-02T08:06:00.000-04:00

In a curious statement, Indonesia's director-general of disease control and environment at the Indonesian Ministry of Health, I. Nyoman Kandun, said his government may share the genetic sequences of the Medan cluster if it helps researchers and isn't an "opportunity for them to make money." (Bloomberg).

"We have not received any request to share it with GenBank,'' Kandun said yesterday in an interview from Jakarta. "If there was a request, and it's clear that it is in the public interest to do so, why not? I would surely recommend it to the health minister.''

WHO spokesperson Maria Cheng responded from Geneva:

"We think it's important to share this information so that everyone can have a better understanding of what's going on.''

So it's settled. Or should be.

WHO should take this as consent to deposit the sequences immediately in GenBank. Cheng is still saying WHO "can't compel countries to do things they don't want to do." But this is not the issue here. Under the revised International Health Regulations(2005), whose bird flu provisions went into effect last week (a year early), Indonesia is required to provide the information and has tacitly released it via their statement. WHO has the information. The sequencing was done by Dr. Malik Pereis in Hong Kong, at Indonesian government and WHO request.

The Indonesian Ministry of Health has a record of saying one thing and doing another (or more frequently saying one thing and doing nothing). In this case it doesn't matter. They've essentially released the sequences, subject to conditions met by Cheng's response.

Time for WHO to tell Dr. Peiris to deposit them in GenBank.

Now.

New rules in a dangerous game

2006-06-01T07:57:00.000-04:00

Declan Butler, senior correspondent for the scientific journal Nature, also has a blog and he used it to amplify on his piece in the journal today about the situation in Indonesia. In particular he quotes from correspondence we both have had with Dr. Andrew Jeremijenko, formerly with the influenza surveillance unit of the US Naval Medical Research Unit 2 in Jakarta (NAMRU-2).

Andrew is an astute observer of the scene there, and his correspondence is filled with worry about the inability of the Indonesian central government to cope with the endemic poultry infection throughout this vast country and the continual sporadic appearance of human cases, culminating two weeks ago in the large family cluster in Sumatra which infected all eight members of an extended family and killed seven of them. There was unmistakable evidence of human to human transmission, probably extending to three generations of cases (human to human to human). The actual response was such as to suggest the futility of the kind of almost instant response WHO says will be needed if there is any hope of smothering a pandemic at the source.

Declan gives us the bottom line:

Working at NAMRU-2, Andrew witnessed the enormous gap between the official rhetoric and the reality on the ground. Take the recent declaration by Michael Leavitt, US Secretary of Health and Human Services’ statement to the World Health Assembly: “In closing, I ask this Assembly today to pledge with me to abide by four principles of pandemic preparedness:
Transparency,
Rapid reporting,
Data sharing and,
Scientific cooperation.
In reality of course, for many political and cultural reasons — including those of the scientific community itself — although some progress is being made, lip service is often paid to these on the ground, and that includes the US’s own CDC. (Declan Butler's blog)

Declan goes on to reiterate what we have been saying here. WHO has had no inherent police authority over its member states. Under the international system WHO is bound by the principle of state sovereignty and its corollary, non-intervention in the internal affairs of a state. Under the International Health Regulations in effect until last week, WHO may only release information about infectious disease within a member state with the permission of that state. On one occasion only (cholera in Guinea, 1970), a strong and decisive Director-General (Marcolino Candau) ignored the IHR restrictions, but that was the only instance before the SARS outbreak of 2003 that WHO issued any epidemiological information or advice without the assent of a member state. SARS was the signal event that pushed WHO to a more drastic revision of the IHR, going into effect in 2007. WHO's governing body last week authorized it to ask for voluntary compliance for bird flu, one year ahead of time.

The newly revised IHR will require states to respond actively and provide immediate information. WHO hopes this will extend to the vexing problem of release of sequence information, bottled up in the no-man's land of fragmented authority and personal agendas. WHO works with scientists, laboratories and governments around the world and is privy to most of the sequence information. So far it has not gone outside the legal constraints on unilateral release of country information, but that doesn't mean it is powerless. It should be using whatever influence it has -- including withholding isolates from scientists who won't deposit sequence information immediately. Now that the WHA has authorized the early application of the revised IHR to bird flu, WHO should also begin pressuring recalcitrant states using the new authority. Indonesia is a prime candidate for this because it essentially has no central government at all. Instead it continually "yeses" international agencies, so WHO could take those empty assents as a signal the Indonesian sequences are released under the new IHR.

But it's not just state actors that are the problem. Prominent members of the community of flu scientists are also wearing out the world's patience. CDC, St. Jude's, Weybridge, Mt. Sinai and others have unreleased sequence data for H5N1. It is time to deposit them immediately in GenBank or risk losing the respect of colleagues and the public. WHO has no legal obligation to keep sequences that are not from a member state private and they shouldn't. As a data gathering scientist myself I have an appreciation for what this means to the scientists involved. But these aren't ordinary times and the failure of CDC and prominent flu scientists to release all their sequences is reckless, irresponsible and dismaying. Why should China, Turkey and Indonesia do it when the most famous flu scientists in the world won't? Currently they are setting an example of the worst kind. They should set a good one.

There's enough blame to go around here, but it should be placed where it belongs most, with the countries and the scientists. It is time for WHO to start exercising more muscle now that the WHA has authorized it for bird flu.

And there's a lot WHO can do besides issue unrealistic fireblanket scenarios few think will work. They can use the bully pulpit and their own new authority to push countries (including the UK labs and US CDC) to open up the spigot of epidemiological and genetic sequence information. This is an unaccustomed role, but they need to learn to use it quickly.

The revised IHR are new rules in a new game. And the game is dangerous.

Another thought on the sequences

2006-06-01T07:37:00.000-04:00

Andrew Jeremijenko, the physician formerly in the influenza surveillance branch of NAMRU2 in Jakarta, has raised an interesting question about release of the sequences. The isolates come from patients and are sequenced elsewhere, often CDC or another WHO reference lab. One piece of information of interest to the treating doctors is whether the isolated strains have the genetic markers for adamantane-class and/or Tamiflu resistance. The adamantanes (amantidine, rimantadine) are older antivirals that are relatively inexpensive but little used in Indonesia, according to Jeremijenko. If the H5N1 strains there are sensitive to the adamantanes as some are elsewhere (although independent information suggests the ones in the Medan cluster were resistant), then this is important information for the treating physicians. There is an absolute moral obligation of the sequencing labs to provide the sequence information for use by treating physicians.

I don't know what, if anything, the Indonesian doctors have been told about the efficacy of amantadine. Jeremijenko suggests they have been told nothing. But this is just another case for releasing the sequences -- an urgent one. At the moment, post docs and young faculty (and their mentors) are aware that if they are sequencing H5N1 today they run the risk of having their work used by others who mine GenBank sequences for their own purposes. That's going to be a risk they must run if they want to work in this area. Meanwhile the profession should think of mechanisms to protect the sources of the sequences. GenBank might consider devising a policy requiring acknowledgment and credit (possibly co-authorship) for those using deposited sequence information so the careers of those providing the information will not be harmed.

But first things first. Scientists should not be the roadblock for H5N1 sequence release, despite the risk their work will be scooped by others. That's a hard case to make to someone who is trying to establish themselves in a competitive field. It should be one of the costs of entry, however. There are a lot of other scientific areas to work in, if that's unacceptable.

The sequence problem needs to be solved, and solved quickly. Time to cut the Gordian knot and for scientists to deposit them in GenBank on their own initiative and because its the right thing to do, career or no career. Maybe that will also shake some of the state actors loose.

Australia's best laid plans

2006-05-31T06:57:00.000-04:00

Australia had a great pandemic flu plan. On paper. Now paper is confronting reality and reality is winning.

Like a number of other places, it seemed only common sense that the priority for Tamiflu would be essential workers. Back in October the Australian government said it had enough Tamiflu for 1,000,000:

The Federal Health Minister, Tony Abbott, has been very frank about the inadequacy of Australian stockpiles:

"Certainly, we don’t have anything like enough antivirals to protect the entire population. At present, we have enough antivirals to protect one million essential service workers for about six weeks."

He has also been very candid about supply constraints being a clear reason for the limited stockpiles:

"[A]t the moment there are no additional antivirals anywhere in the world . . . If there were more antivirals to be had, by all means [we would expand stockpiles]. But on the best evidence we have, there aren’t."

Providing such protection will be essential in order to ensure that workers such as police, doctors, nurses, water and electricity staff and airport employees turn up for work and maintain essential infrastructure. When supplies run out after 6 weeks or so, Australia will then be competing to obtain preferential treatment for a scarce resource from Roche. (Medical Journal of Australia)

It turns out even this bit of pessimism was too optimistic. Australia has reversed direction and now will give Tamiflu only to the sick and those directly exposed to the sick:

"We came to the conclusion in consultation with the states that the attempt to keep prophylaxis going for the up to 1 million people who would normally be deemed essential was simply not going to work, there would never be enough anti-virals to do so," he said. (Australian Broadcasting Corporation)

Either a lot of Tamiflu disappeared since October, or the amount of Tamiflu was overestimated, or . . . they were just blowing smoke?

Score: Reality 1, Paper Plan 0.

Message to WHO: there is no barn door to close

2006-05-31T06:55:00.000-04:00

I try hard to be fair to WHO. They've got an exceedingly tough job and not much to work with. Every time I write an opinion or criticize them I am conscious I could be very wrong.

But this fireblanket business just exasperates me. Let's get real.

The World Health Organization (WHO) issued a step-by-step plan on Tuesday, including the rapid mass use of the antiviral Tamiflu, for containing a bird flu outbreak if the virus starts to spread rapidly among humans.

The "rapid response and containment strategy" has a chance of quashing the deadly H5N1 virus only if people in the zone at risk receive massive doses of the drug within three weeks of a confirmed outbreak, it said.

"The success of a strategy for containing an emerging pandemic virus is strictly time dependent," the WHO said in its latest containment report, based on recommendations by 70 international experts who held closed-door talks in March.

"Mathematical models have indicated that a containment strategy, based on the mass administration of antiviral drugs, has a chance of success only when drugs are administered within 21 days following the timely detection of the first case representing improved human-to-human transmission of the virus."

Under the detailed timeline laid down, a country should notify WHO of a cluster of suspicious cases suggesting sustained human-to-human spread of the virus within 24 hours of detection.

A WHO-approved laboratory has another 24 hours to confirm that the H5N1 bird flu virus has changed, either through mutation or through reassortment with human influenza.

The strategy relies on WHO's global stockpile for rapid containment, three million treatment courses of Tamiflu, donated by Swiss drugmaker Roche. Quarantine, infection control measures and contact tracing must also be carried out.

Once the WHO officially asks Roche for Tamiflu doses to be sent, they should arrive at the international airport nearest the outbreak within 24 hours, the Geneva-based agency said. (Boston Globe)

On Saturday (May 27), The Globe goes on to report, WHO asked Roche to ready the stockpile for shipment to Sumatra in Indonesia after becoming aware of the bird flu large cluster that wiped out an entire extended family and bore unmistakable marks of human to human transmission. They did this after disease transmission had already been underway for at least four weeks and three of the patients had been released from the hospital to the general community before returning to the hospital to die. If ever there was a graphic demonstation of the futility of the fireblanket approach, this was it. It's not going to work.

This doesn't necessarily mean they shouldn't try. Maybe they'll succeed in getting a couple of days grace, although it's unlikely. What worries me more is the real possibility of self-delusion. Let me say it again, as clearly as I can: It's not going to work.

I don't know if this virus will evolve into a pandemic strain or not, and if it does, where and when it will happen (although Indonesia still tops my list of likely places). But if the biology and circumstances allow it, there is nothing we can do to prevent it. The best we can do is get ready to manage the consequences.

And there's plenty we can do along those lines, things that are more likely to save lives than elaborate and futile plans to close the barn door after the horse has bolted. Because there's no barn door to close for influenza.

What to expect next in Indonesia

2006-05-30T07:52:00.000-04:00

What I think we can expect from Indonesia over the coming weeks is a fair amount of confusion. Sporadic cases of bird flu continue to be reported. WHO's latest update adds six to bring the Indonesian total to 48, of which 36 have been fatal. The wide publicity given the large cluster in Sumatra is likely to increase the index of suspicion that new cases of pneumonia, if there is a history of exposure to poultry -- common in Indonesia -- will be admitted to a bird flu isolation ward as a precautionary measure.

As we noted in an earlier post, there are a huge number of pneumonias every year in Indonesia -- 186,000 cases in the under five age group in West Java alone in 2005 -- many with exposure to poultry. If even a fraction of these is pegged a "suspect" case, the wards will fill up quickly with suspect bird flu cases. The result will be detection of some more genuine cases and more reports of crowded wards full of suspect cases, all possibly without any real change in the incidence of disease.

Add to this the chaos of a devastating earthquake, a government unable to cope at any level and a world peering in with trepidation and you have a recipe for -- a fair amount of confusion.

Unfortunately, expecting to be confused does not lessen confusion.

Revere's prep

2006-05-30T07:48:00.000-04:00

If the SHTF, I am ready to go on blogging, thanks to this 1935 beauty from modern mechanix (h/t Boingboing):

Orent gets it (mostly) right

2006-05-29T07:46:00.000-04:00

I've been tough on journalist Wendy Orent here because I thought her widely read op-ed pieces on bird flu were wrong-headed, inaccurate and unhelpful in getting people ready for a possible pandemic. Yesterday she had another op-ed in the LA Times and I'm glad to say it's on the right track. Not that I agree with everything she says, but it's informative and helpful to readers who want to understand some of the controversies. Here's the lede:

There's a lot of bird flu virus out there. Despite encouraging news from Vietnam and Thailand, neither of which has reported any bird or human cases of the lethal H5N1 strain this year, the situation in Indonesia continues to worsen. Eight members of a family contracted the disease, and seven of them died this month. The timing suggests person-to-person transmission. Although not the first instance of such transmission, it's the single largest cluster that has been seen, according to virologist Earl Brown of the University of Ottawa. Indonesia appears to lack the resources to combat the disease.

The virus is also active in Egypt and has spread to Israel, Jordan and the territories where Palestinians live. Africa has a wide belt of infection. With the disease spread over so much of the world, more people in contact with sick birds means more opportunities for humans to catch the virus. This appears how human influenza pandemics have begun — through human contact with sick birds.

But the factors that set off a pandemic remain unknown. No one has ever tracked the evolution of a new pandemic. All we have seen — in 1918, 1957 and 1968 — is the aftermath of that evolution. Still, we are told that all it would take for H5N1 to become a pandemic would be for the virus to mutate so it could spread in a sustained way from person to person. (LA Times)

The rest is a discussion of what she and others think this talk of mutation means. I might disagree in details, but essentially I agree we don't know much about what it would take. Most scientists don't believe a chicken virus turns into an easily transmissible human virus in one step (although it's possible). But Orent goes further. Her view is that natural selection is the key to the virus's evolution and it can't happen suddenly, requiring instead a period of adaption in mammalian and probably human hosts.

This isn't an unreasonable point of view, and this adaptation might be occurring now in Indonesia and elsewhere. But I think it's wrong to believe it is the only point of view. Here are a couple of other possibilities.

Whatever genetic changes are needed for transmissibility in humans may be traveling along with some that are useful for the virus in birds. Selection pressure doesn't explain everything, as we see in the sudden emergence of amantadine resistance in virtually all flu virus in the US. Amantadine is not used much in the US, so this isn't selection. Most likely it is a "hitchiker" effect with the amino acid change conferring amantadine resistance linked with another genetic feature that conveys some selective advantage (a point made by bioinformatician EC Holmes). Here's another possibility. It takes multiple genetic switches to be flipped to produce enhanced transmissibility in humans (let's say ten) but eight or nine are already flipped, leaving only one or two to go. Since we are largely ignorant of what it takes, we are also ignorant about how many switches are flipped already. Here's yet another point. Genetic changes that enhance transmissibility don't have to confer selective advantages or be linked to them. Without such an advantage the virus will eventually be replaced by another, more fit one, but the transient period could be very nasty. None of this is not a repudiation of Darwinism. It is consistent with the current neo-Darwinian synthesis ushered in by Sewall Wright, Ernst Mayr and others in the 1930s and 1040s.

So it's good to see Ms. Orent on board. A flu-denier has now become a useful source of information. I hope she's right about her viral evolution scenario. But the distinct possibility she isn't is good enough reason to prepare.

On Memorial Day

2006-05-29T07:33:00.000-04:00

Memorial Day and the usual talk of the bravery and sacrifice of soldiers. Soldiers are mostly ordinary people who do what they have to do in the most terrible of circumstances. In every war they have mirror images on the other side. It seems fitting, therefore, to present a memorial to all soldiers, via the lyrics of a wonderful song penned by John McCutcheon in 1984 to commemorate the Christmas Truce of 1914.

On Christmas Day, 1914, only 5 months into World War I, German, British, and French soldiers, already sick and tired of the senseless killing, disobeyed their superiors and fraternized with "the enemy" along two-thirds of the Western Front (in times of war, a crime punishable by death). German troops held Christmas trees up out of the trenches with signs, "Merry Christmas." "You no shoot, we no shoot." Thousands of troops streamed across a no-man's land strewn with rotting corpses. They sang Christmas carols, exchanged photographs of loved ones back home, shared rations, played football, even roasted some pigs. Soldiers embraced men they had been trying to kill a few short hours before. They agreed to warn each other if the top brass forced them to fire their weapons, and to aim high.

A shudder ran through the high command on either side. Here was disaster in the making: soldiers declaring their brotherhood with each other and refusing to fight. Generals on both sides declared this spontaneous peacemaking to be treasonous and subject to court martial. By March, 1915 the fraternization movement had been eradicated and the killing machine put back in full operation. By the time of the armistice in 1918, fifteen million would be slaughtered. (from Chestnut Hill Meeting House [Philly])

Christmas in the Trenches
©John McCutcheon, from his CD, Winter Solstice

My name is Francis Toliver, I come from Liverpool.
Two years ago the war was waiting for me after school.
To Belgium and to Flanders, to Germany to here
I fought for King and country I love dear.

'Twas Christmas in the trenches, where the frost so bitter hung
The frozen fields of France were still, no Christmas song was sung.
Our families back in England were toasting us that day
Their brave and glorious lads so far away.

I was lying with my messmate on the cold an rocky ground
When across the lines of battle came a most peculiar sound.
Says I, "Now listen up, me boys!" each soldier strained to hear
As one young German voice sang out so clear.

"He's singing bloody well, you know!" my partner says to me.
Soon, one by one, each German voice joined in harmony.
The cannons rested silent, the gas clouds rolled no more
As Christmas brought us respite from the war.

As soon as they were finished and a reverent pause was spent
"God Rest Ye Merry, Gentlemen" struck up some lads from Kent.
The next they sang was "Stille Nacht," "'Tis 'Silent Night,'" says I
And in two tongues one song filled up that sky.

"There's someone coming towards us!" the front line sentry cried.
All sights were fixed on one lone figure trudging from their side.
His truce flag, like a Christmas star, shone on that plain so bright
As he, bravely, strode unarmed into the night.

Soon one by one on either side walked into No Man's Land
With neither gun nor bayonet we met there hand to hand.
We shared some secret brandy and wished each other well
And in a flare lit soccer game we gave 'em hell.

We traded chocolates, cigarettes, and photographs from home.
These sons and fathers far away from families of their own.
Young Sanders played his squeezebox and they had a violin
This curious and unlikely band of men.

Soon daylight stole upon us and France was France once more
With sad farewells we each prepared to settle back to war
But the question haunted every heart that lived that wondrous night
"Whose family have I fixed within my sights?"

'Twas Christmas in the trenches where the frost, so bitter hung.
The frozen fields of France were warmed as songs of peace were sung.
For the walls they'd kept between us to exact the work of war
Had been crumbled and were gone forevermore.

My name is Francis Toliver, in Liverpool I dwell,
Each Christmas come since World War I, I've learned its lessons well,
That the ones who call the shots won't be among the dead and lame
And on each end of the rifle we're the same.

The last lines bear repeating:

That the ones who call the shots won't be among the dead and lame
And on each end of the rifle we're the same.

The Reveres, Memorial Day, 2006

Pandemic alert: phase shift?

2006-05-28T21:38:00.000-04:00

I don't want to get in the business of defending WHO, especially as I have much to criticize about how they have done some things. But it is important to explain and clarify what they are doing or trying to do. If that sounds like a defense, you'll have to deal with it.

Helen Branswell of Canadian Press has just put out an important story saying that WHO isn't going to change the pandemic alert from Phase 3 to Phase 4, despite the fact that Phase 4 now sounds like the most appropriate description. Instead, they are going to rewrite the description to better express what they think about the threat. Some will immediately interpret this as moving the goal line when the game is going badly. Still, the explanation merits serious consideration. The phasing rewrite is in progress so I can't report what it will look like, but from Branswell's story I can at least tell you the rationale.

The worrisome Indonesian cluster -- the largest to date and the first time person-to-person-to-person spread of the virus is believed to have taken place -- has provoked calls from some quarters to change the global pandemic alert level to Phase 4 from the current Phase 3.

Before it could consider making that change, the WHO would have to convene a panel of experts -- the task force Fukuda mentioned -- to comb through the accumulated scientific data looking for evidence H5N1 viruses are becoming more transmissible to and among people and therefore pose a greater pandemic risk.

The task force would advise the WHO. But the final decision rests with the Geneva-based global health agency.

The current pandemic phasing document is a six-step ladder going from no known pandemic threat (Phase 1) to a full-blown pandemic (Phase 6). Many experts admit it's hard to see the difference between Phase 3 (no human-to-human spread or rare instances where a person has had close contact with an infected person), Phase 4 (small clusters of limited and localized person-to-person spread) and Phase 5 (larger but still localized clusters of human-to-human spread). (Helen Branswell, Canadian Press)

With experience the defects in the original formulation of the guidelines are becoming apparent. The issue, as Fukuda points out, is whether there is new evidence of altered transmissibility of the virus, not how many clusters or even their size. Much hinges on the ability to detect this kind of change, which is certainly not an easy call given our current knowledge. On the other hand, it is not especially useful to be tied to a grading system that doesn't express the risk, especially as a change in the Phasing will have immediate consequences regarding public perception, staffing, international trade, travel and commerce and much else. It's not something you want to get wrong in either direction. WHO is between the proverbial rock and a hard place.

The significance of all this may not be apparent to those unfamiliar with WHO's role in the international system and the legal and political limitations it implies. I am hoping to write some kind of explanation of this confusing issue in the near future, but for now, let's just observe that like any entity bound by rules of conduct, WHO cannot blithely toss them aside when it suits them unless the urgency is so great there is no choice. Making that call is difficult and they only get one chance. If they guess wrong, the next time they may find they have used up all their capital.

My appreciation for the difficult position WHO finds itself in won't stop me from offering advice. They need all the advice they can get.

Let me start here: release the sequences under your control.

Indonesia: coffee's on

2006-05-28T08:53:00.000-04:00

Tamiflu is being flown to Asia by the US, although there remains much confusion about the number of tablets, their source and who controls the tablets and where they will be located. An AP story says there are 9500 treatment courses (presumably 95,000 tablets) from a WHO stockpile, but Secretary Leavitt said it was from a stockpile controlled by the US, not WHO. AP also says the drug along with protective gear was flown into Indonesia on Friday, although rumor had it on its way to Singapore or to Clark AFB in the Philippines. WHO spokesperson Maria Chang said it was likely control would be handed over to the Indonesian government, contradicting Leavitt's claim. Since the Indonesian government is widely considered both corrupt and incompetent, this seems a questionable move. However, it is a wise rule of thumb not to believe everything being said at this point, especially if it comes from or is meant to mollify the Indonesian Ministry of Health.

Not that WHO pronouncements seem very plausible, either. WHO has alerted Tamiflu's maker, Roche, that some of a 3 million treatment course set Roche set aside for use by WHO may be called upon for use in Indonesia. Don't worry. Just routine:

No further action on the emergency supply was expected for now, according to the U.N. health agency, which called the alert part of its standard operating procedure when a case arises like that in Indonesia.

"We have no intention of shipping that stockpile," WHO spokesman Dick Thompson cautioned. "We see this as a practice run." (AP)

Standard Operating Procedure? Well they've never done it before, so I guess they are setting the standard now for the operating procedure. But what exactly is the standard (not to mention the operating procedure)?

The seven person cluster of one extended family, spread out over at least three incubation periods (all have now died), began at the end of April, with cases dying through the first three weeks in May. WHO in Jakarta was only officially notified on May 22. CDC had people in-country but they were not invited to consult until mid-May. From what I hear third hand, NAMRU2 is not invited to be part of investigations, although this may have changed. The locals are hostile to the government. Indonesia has an active volcano and just suffered a catastrophic earthquake on its main island. The government is ineffective, slow, inefficient and passive aggressive toward international scientists.

Oh, and this:

Meanwhile, Nyoman Kandun, a senior official at Indonesia's health ministry, said a WHO laboratory in Hong Kong had confirmed five more cases of human bird flu, three of which were fatal. All five had earlier tested positive for the virus in a local laboratory.

The latest confirmed deaths were a 39-year-old man from Jakarta, a 10-year-old girl from West Java and a 32-year-old man, who on Monday became the last to die in the Kubu Simbelang cluster. (AP)

WHO so far has decided not to raise the Pandemic Threat Level from 3 to 4. But the facts speak for themselves.

Wake up and smell the Indonesian coffee!

Freethinker Sunday Sermonette: feat of Clay

2006-05-28T08:42:00.000-04:00

I can get exercised over religion with the best of them, but even I can't out do Pat Robertson. By now you probably all know of his phenomenal feat of strength -- leg pressing 2000 pounds. Here's the official announcement, via the Christian Broadcasting Network website:

Did you know that Pat Robertson, through rigorous training, leg-pressed 2,000 pounds! How did he do it?

Where does Pat find the time and energy to host a daily, national TV show, head a world-wide ministry, develop visionary scholars, while traveling the globe as a statesman?

One of Pat's secrets to keeping his energy high and his vitality soaring is his age-defying protein shake. Pat developed a delicious, refreshing shake, filled with energy-producing nutrients.

Discover what kinds of natural ingredients make up Pat's protein shake by registering for your FREE booklet today!

That must be some protein shake. As SportsLine's Clay Travis notes:

That would mean a 76-year-old man broke the all-time Florida State University leg press record by 665 pounds over Dan Kendra. 665 pounds. Further, when [Kendra] set the record, they had to modify the leg press machine to fit 1,335 pounds of weight. Plus, Kendra's capillaries in his eyes burst. Burst. Where in the world did Robertson even find a machine that could hold 2,000 pounds at one time? And how does he still have vision? (ClayNation)

Clay, duly impressed, asked to see a work-out and interview The Big Guy (not the one with the long beard in the sky; the one with the condos and limos here on earth):

After about 20 minutes on Robertson's Web site, I managed to find a way to send an e-mail without having to give my credit card information. Here was the text:

"I would like to interview Pat Robertson about his leg-press workout and protein shake. If possible, I would like to accompany Pat on his workout where I could help him stack on the 44 different 45-pound plates he would need to attach to leg press 2,000 pounds. By my calculations, his leg press of 2,000 pounds requires 22 forty-fives and one ten-pounder on each side.

I look forward to hearing back from you,

Clay Travis"

Like Travis, I am in awe of this achievement. In fact, it is so miraculous, if True, I will become a Believer. No more atheism. Just a deeply felt belief in the CBN Protein Shake and its representative here on earth, Dr. Pat Robertson.

A world-class dreck fresser ("leg presser" in Yiddish).

I need to get this off my chest

2006-05-27T08:50:00.000-04:00

The cost of one month of the war in Iraq, $9 billion, is approximately the same as six years of the total operating budget of the World Health Organization ($3.3 billion for the next two years). You can take this any way you want. For now, let's just say that WHO's total budget to save lives over the next year, $1.6 billion, is less than a week's worth of the US expenditure to take lives. This is a double commentary: one on the vast expenditures for killing, by a single country, deployed in a single country; the other, the pitiful expenditure to save lives in the entire globe.

Total US CDC budget for last year was $8.8 billion, $1.6 billion for infectious disease alone, the same as WHO's entire budget for everything, for the entire world.

And "everything" covers a lot. You may be unusually preoccupied with bird flu, but people are dying mostly from other things. When we criticize WHO for its performance in the bird flu , remember this is an agency that has little to work with and much to spend it on. Bird flu is just a piece of a vast and depressing picture that includes malaria, HIV/AIDS, vectorborne disease control, maternal and child health, clean food and water and much more. Without WHO we wouldn't even have known about SARS until it was on top of us. Without WHO we'd still have smallpox in the world. Without WHO tens of millions of women and their children would be dead. Without WHO you wouldn't get a properly matched flu shot every year. And they are asked to do all this on a pittance.

I'm not trying to excuse WHO for inexcusable lapses. But the demonizing of WHO going on here and elsewhere I find troubling and lacking in perspective. It is important to know who your friends are, who your enemies are, who your friends aren't and who your enemies aren't. WHO is not the enemy, no matter how you look at it. You may feel they are misguided, have made mistakes, lack transparency or honesty and many other things I think they could fairly be charged with respect regarding their performance in the rapidly evolving bird flu situation. But they are trying to cope while still carrying an extremely heavy burden through a landscape littered with political hazards, political hazards that affect many of the other things they must do to save lives. And with the most paltry of resources.

Don't worry about "getting your money's worth" from WHO, because frankly, you're not spending much on them.

I don't mind criticizing them here if I think criticism can move things in a better direction. But while I have a great deal of respect (and affection) for the little community that has grown up around Effect Measure (and I welcome the many others arriving daily), I don't mind criticizing some of you, my friends and comrades in this difficult fight, if I think it can move things in a better direction. Some of the talk about WHO here I think is poorly informed, unhelpful and really off the wall.

OK. Rant over. I feel better. And I still like you.

Nice place for a virus

2006-05-27T08:43:00.000-04:00

CA Nidom, the Indonesian researcher who a year ago found evidence of H5N1 infection in pigs living near infected poultry on the island of Java, is now saying (h/t crofsblog) what almost everyone else is saying, that the large cluster of cases in Sumatra is human to human transmission.

I say "almost" everyone because the Indonesian Health Minister, Siti Faila Supari, is still holding out:

"The cluster bird flu case in Tana Karo cannot yet be said a human-to-human bird flu case because proof on the mutation of virus DNA [sic] which is identical with the H5N1 strain of virus that infected the nine victims has not yet been found. And there is no proof of epidemiological human-to-human infection," the minister said. (Xinhuanet)

No change in the virus is necessary because there has probably been human to human transmission going on in Indonesia since the very first cluster of three cases appeared in Tangerang in July 2005. In fact this may also have been H2H2H, with the chain starting with one of the children (no source known) going to a sibling and then to the father. Contrary to the statement, the epidemiological evidence strongly favors human to human transmission there and in Sumatra.

The statement shows graphically what has been obvioius for a long time. The Indonesian Ministry of Health is incompetent to cope with the bird flu situation and nothing they say can be relied on. An Indonesian friend said to me yeseterday that since the fall of Suharto (no pearl of great value, to be sure), there has been no functioning government in the country. It is a free for all with the spoils going to the most corrupt.

Now they have an erupting volacano and an earthquake disaster. A great place -- if you are an influenza virus.

Imploding CDC

2006-05-26T07:52:00.000-04:00

The Atlanta Journal Constitution has another in a series of stories about poor morale at CDC. Finally the problems have attracted the attention of a congressional committee, the same one (the Senate Finance Committee) already looking into whether state bioterrorism funding has received adequate CDC oversight:

The U.S. Senate Finance Committee is investigating whether turmoil within the Atlanta-based CDC caused by a massive reorganization is "resulting in the loss of distinguished medical experts whose participation will be greatly needed in the event of future catastrophic health emergencies," committee spokeswoman Jill Kozeny said Tuesday night. (Atlanta Journal Constitution)

For some time complaints have been anonymously posted on an outside website, cdcchatter.net:

Some of the complainants are career CDC employees, many with distinguished scientific records, but they have unanimously refused to be identified, saying they fear reprisals on the job. The employees contend the reorganization has created new bureaucracies that hamper their work and that key scientists have been marginalized.

[snip]

"Current and former employees are reporting that morale problems caused by failure of current agency management to adequately involve employees in the ongoing reorganization are resulting in the loss of distinguished medical experts whose participation will be greatly needed in the event of future catastrophic health emergencies," Kozeny said in a written statement.

The morale problems at CDC have been an open secret for more than a year. I personally know very senior scientists who are retiring because they are fed up with a bureaucracy that makes it difficult or impossible for them to do their jobs. The AIDS group is imploding. The flu group has been reorganized and is in limbo. Professional scientists are disgusted. The place is a mess.

It's a good thing we aren't facing any serious infectious disease threats. Heck of a job, Julie.

Considering Bandung

2006-05-26T07:51:00.000-04:00

It appears the West Java provincial capital of Bandung may be the site of another (so far) small familial cluster, two young siblings. West Java has a population of almost 40 million, the most populous province of Indonesia and the second most densely populated. Xinhua is reporting the deaths of a brother and a sister earlier this week. Local tests indicated H5N1 infection. The younger sister was reported to be 10 years old, her brother 18 years old (Adnkron). Dead chickens were seen in the environment.

If this is indeed another familial cluster, does this signal a new phase in the human bird flu story? Possibly, but probably not. The official WHO and CDC line is that there have been other familial clusters with evidence of human to human transmission and the big one in Sumatra is just another example, although unusually large. In that context, Bandung, too, would be an example. I've also heard rumors of a couple of more small clusters. Is it plausible these are just more in an ongoing story of sporadic clusters?

Plausible, yes. The problem is not that WHO and CDC are concocting an implausible explanation for the Sumatra cluster but that they had previously downplayed the existence of even limited human to human spread in clusters, preferring instead to emphasize the poultry origin of virtually all cases, a position we find misleading, probably deliberately so. WHO has a mixed record on transparency, but habit of "happy talk" hs severely dmagaed their credibility. WHO will have to work hard to recoup and for some it won't be possible. But they should try. Straightforward reporting of facts would be a good start.

Back to the clusters. If we accept the virus has not changed genetically (and we are no longer willing to do so just because they say it, unfortunately), then we must also infer that there have likely been many other clusters, probably undetected. To return to Bandung, West Java had 186,000 cases of childhood pneumonia in 2005, about 6000 of them severe. This is the haystack a bird flu needle would hide in. Plausibly clusters and sporadic cases would be missed. Now that the index of suspicion is increased with the publicity from the Sumatran cluster, we may start seeing other reports of clusters here and there.

But why such a big cluster in Sumatra? Several possibilities. The index case could have been a super spreader (as was found in some cases of SARS) or it might just have been the upper tail of a distribution of cluster sizes. We'll probably never know, as investigators got there too late. Getting into the actual village at all proved difficult because of hostility toward the central government. The Indonesian government has now asked 33 villagers to self-quarantine at home. They are being followed for any signs of illness. So far, either publicly or via several of my own sources in-country, none has appeared outside this extended family.

If there continues to be no spread beyond the extended family, this is probably what WHO and CDC are saying it is, "another cluster," larger but not different in kind. The fact that there is third generation spread, however, sets it apart from other known clusters, so while my guess is there is nothing more to it, I wouldn't bet the farm on it. WHO is trying hard to do contact follow-up.

Too bad we are losing confidence they are telling us everything.

Clusters, sequences, trust

2006-05-25T07:32:00.000-04:00

If there is more upset than WHO feels appropriate about the large cluster of cases in Indonesia with apparent human to human spread within an extended family, they have no one to blame but themselves. With financial markets spooked and currencies in Asia falling, WHO is saying this may not be as unusual an event as appeared at first:

But Firdosi Mehta, acting representative of the WHO in Indonesia, urged against any over-reaction, saying this was not the first cluster that the world has known.

Limited transmissions between people are caused by close and prolonged contact when the sick person is coughing and probably infectious. (Reuters)

It is certainly true this appears more serious. One reason for this is WHO's habit of reassuring the world that whatever is happening at the moment is no big deal but what could happen in the future is a big deal. Whenever their prognostications elicit too much concern they ratchet them back. There has been evidence of human to human transmission right along -- sporadic but fairly clear -- but WHO has chosen to ignore it in their public pronouncements, instead electing to emphasize (falsely) that all the evidence to date has been it required close contact with sick or dead birds to put a person at risk. It has been clear to WHO and many others that close contact with sick and dead poultry is neither a sufficient nor necessary condition for contracting the illness. Had WHO been more accurate about this, the reaction to the Indonesian cluster might not be so great.

Lack of clarity from WHO remains troublesome, particularly regarding the viral sequences from this cluster and more generally. They have the sequence information in hand. They can deposit it immediately in GenBank so others can look at it and decide whether their claims of "no change" are correct. This needs to be done with the other Indonesian isolates as well, not just human isolates but those from birds and any other animals. Here is the WHO statement from yesterday concerning the sequencing:

Full genetic sequencing of two viruses isolated from cases in this cluster has been completed by WHO H5 reference laboratories in Hong Kong and the USA. Sequencing of all eight gene segments found no evidence of genetic reassortment with human or pig influenza viruses and no evidence of significant mutations. The viruses showed no mutations associated with resistance to the neuraminidase inhibitors, including oseltamivir (Tamiflu).

The human viruses from this cluster are genetically similar to viruses isolated from poultry in North Sumatra during a previous outbreak. (WHO)

WHO spokesperson Peter Cordingley said yesterday, "There is no change in the virus whatsoever. This virus has not developed the ability to jump more easily from chickens to humans, nor spread among humans more easily." (CNN)

We assume Cordingley isn't speaking literally ("no change whatsoever") since this is improbable and different than the WHO statement there was no "significant" mutation. A quibble, perhaps, but it raises the question what WHO considers a "significant" mutation. Does the statement the virus is "genetically similar" to poultry viruses imply the cleavage site is the same as the avian one and not the one seen in humans in Indonesia? Would WHO consider an anomalous cleavage site be considered "significant" because it wouldn't be expected to affect transmissibility? What is the WHO criterion for a "significant" mutation, anyway?

Even the statement there is no reassortment with human or pig viruses is ambiguous. Was it meant to leave open the possibility there was reassortment with other bird viruses? For example, if you were to draw phylogenetic trees for each of the eight segments, would you find there has been a swapping of some of the internal gene segments from one avian clade to another in the new isolates (i.e., the isolates are a new avian genotype)? This has been advanced as an explanation for the switch from one predominant strain to another in seasonal flu, but is visible only when you consider the whole viral genome, not just the HA and NA genes. Since no one else has the sequences for the many other Indonesian viruses, no one else can draw these trees. Have they done so?

The certainty with which WHO says there is no significant change in the genetics of the virus gives the false impression they will know such a change when they see it. We have an inkling of some things that might worry us, and presumably the statement means they haven't seen any of these. But our area of ignorance is much larger than our area of knowledge, so reassurances about the lack of change of the virus are premature. It is a melancholy truth that we will know a pandemic is coming our way when we see cases piling up somewhere, not before.

WHO has brought these suspicions on themselves. Let us be as clear as we can. Unlike some others, we don't view WHO as the enemy. Without it the world would be much worse off. WHO is not a monolith or a single person. There are many hard working and dedicated people giving their "all" at WHO and we would be ungrateful not to acknowledge this. If you want to battle an emerging pandemic, this is where the action is and it is going to attract the best, the bravest and the most dedicated. But WHO is also a lot of other people working in a complicated bureaucracy that has become ever more politicized since the days Director General Marcolino Candau ruled so effectively with an iron fist (and wasn't renewed for his trouble). Many countries, including the US, mess around politically with WHO, to everyone's detriment.

With bird flu, WHO's lack of transparency, titrating public reaction and attempts to avoid offending any of its member states have resulted in a serious loss of trust. We shouldn't have to raise any questions about the genetics of the isolates. WHO should release the new sequences (and many others). And so should CDC, St. Jude's, Weybridge and the other stellar flu scientists around the world who are sitting on sequences. If isolates come to a scientist with strings attached, they should tell the source they will not be party to suppressing scientific information. They run a risk that somone else will get the isolate or that no one will. But it is the right thing to do and will change behavior of sources if legitimate scientists cooperate. Scientists who don't should be held up to censure and their papers refused publication just as with any other ethical lapse.

We wish we could take WHO's statements about the genetics of the virus at face value. It is a sad commentary that we and many others no longer do this.

When in Romania

2006-05-25T07:09:00.000-04:00

A couple of days ago we reported on mass quarantines of an urban area in Romania's capital of Bucharest. The measure, affecting some 60,000 people all-told in the city and another town in central Romania, was so severe we asked if something extraordinary was occurring there. It turns out there was.

Extraordinary stupidity.

Officials from the World Health Organization said they believed it to be the first time that the movements of so many people were restricted because of bird flu. The Romanian authorities said the tough measures were necessary when the virus threatened an urban area, an assertion WHO disputes.

[snip]

A town in central Romania, Codlea, and its 23,000 residents, were also put under quarantine. All this happened after a dead chicken was discovered to have been infected with the H5N1 virus that health officials fear might mutate into a human epidemic.

[snip]

But by Tuesday afternoon, the authorities said the danger of contamination had been reduced.

The government relaxed measures in the capital and in Codlea.

International health experts questioned the necessity of placing humans under quarantine, and critics suggested the heavy-handed response was a way of covering up the government's inability to stop the virus in the first place.

"Generally we do not recommend that the movement of people is restricted to contain an animal outbreak," said Maria Cheng, spokeswoman for the World Health Organization in Geneva. (International Herald Tribune)

Not surprisingly people in the affected areas are pissed.

On Monday, Romanian television broadcast scenes of angry residents demanding that they be allowed to go to work. Several said they had to pay for food the government provided.

A combination of authoritarianism and incompetence that is the stuff of nightmares.

Heck of a job.

Indonesia: probably H2H2H

2006-05-24T07:55:00.000-04:00

WHO is now saying what could be inferred from their update yesterday: it is likely that for the first time H5N1 has spread from human to human to human -- three generations of cases, possibly four. This does not mean that a pandemic strain has started but it is another warning signal.

If we take the statement that there has been no change in the virus (let's see the sequences!), then there is another inference we might make. This is just the first time WHO has acknowledged this, not the first time it has happened. Since many cases in Vietnam, China and elsewhere lack solid evidence of close contact with poultry this may have happened many times over (see our post here). The index case here was a vegetable seller in a market where there were live animals, so she wasn't in contact with poultry as an occupation. She might well have contracted the disease from sick poultry at the market but she might also have contracted it from someone else at the market (or elsewhere).

As a result of this cogent evidence in Indonesia, WHO may convene a standing committee of experts to decide if the pandemic alert level should move from the current Phase 3 to a new Phase 4. Here is a description of Phase 3, Phase 4 and Phase 5 (see Flu Wiki for more details):

Phase 3: Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact.

Phase 4: Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.

Phase 5: 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).

Note: The distinction between phase 3, phase 4 and phase 5 is based on an assessment of the risk of a pandemic. Various factors and their relative importance according to current scientific knowledge may be considered. Factors may include rate of transmission, geographical location and spread, severity of illness, presence of genes from human strains (if derived from an animal strain), and/or other scientific parameters.

Many (including us) believe we have been in Phase 4 for some time, but WHO has been reluctant to make the call. It appears now they may do so. We shall see. WHO may still decide there is as yet no sufficient evidence the virus has changed and keep the level at 3. In an interview with Helen Branswell of Canadian Press, WHO spokesperson Maria Cheng said this:

"This is the first time we have seen cases that have gone beyond one generation of human-to-human spread,'' Cheng told The Canadian Press.

"It is an evolving situation and it is possible we would convene the task force if we saw evidence the virus was changing.''

[snip]

Cheng noted the pattern of infections in this cluster seems to point away from a substantial change in the transmissibility of the virus. So do the genetic sequences of two viruses retrieved from this group of people. A statement from the WHO said analysis of those viruses showed "no evidence of significant mutations.'' (Helen Branswell, Canadian Press)

Branswell also interviewed U.S. infectious disease expert D. A. Henderson who was not so sanguine. He points out that the disease spread beyond immediate caregivers to an 18 month old and a 10 year old.

"They all had contact, but it was not the kind of contact we've had described before, where the caregiver would be really heavily exposed,'' he noted.

"And from that standpoint, I find this worrisome. And I think there is an awful lot of information we need about those cases and the circumstances.''

"An awful lot of information" is not what we are getting, however. We do get much handwringing about the difficulty of getting cooperation from fearful and suspicious villagers whose relationship with the central government in Indonesia has been distant and hostile.

"We are still not getting the level of co-operation we would consider optimal,'' Cheng admitted.

Additional WHO personnel are being sent to the village. Included in the group is an expert on social mobilization -- the art of gaining local trust and co-operation in the high tension setting of an infectious disease outbreak.

While you're at it send some of those experts on social mobilization (and social responsibility) to Geneva, Atlanta, Weybridge, Hong Kong, Nashville, Los Alamos, New York. It is not just villagers that aren't cooperating. The genetic sequences need to be released, not just from this cluster but from many others WHO, CDC and individual researchers have not deposited in GenBank (discussion at Flu Wiki here). The lack of cooperation from knowledgeable international and national health officials and eminent scientists has been worse than that of the frightened villagers. It is inexcusable and irresponsible.

To my public health colleagues: Get your own house in order before blaming desperate villagers. Release the sequences and write your papers afterwards. These are not ordinary times. Your resumés are long enough.

Benzene and soda preliminary results

2006-05-24T07:52:00.000-04:00

The US FDA has just released preliminary data on their on-going investigation of benzene in soft drinks (see previous posts here, here and here). Using a convenience sample of 100 soft drinks from retail stores in Maryland, Virginia and Michigan, they found four different drinks (eight samples items) with benzene levels above the 5 ppb drinking water standard. Crystal Light Sunrise Classic Orange led the pack with two lots with 70 - 80 ppb of benzene. Interestingly, a lot of the same drink reformulated to have less benzene came in at less than 1 ppb.

The benzene comes from a reaction between a preservative, benzoate salt (sodium or potassium) and vitamin C (ascorbic acid). Other factos such as heat and light affect benzene formation from these ingredients so it is possible to reformulate drinks to suppress benzene exposure. There was no pretense that the sampling reported yesterday was at all representative of the retail inventory or consumer choices. The results of this relatively small sample suggest that a much larger sampling effort will be needed to estimate accurately consumer exposures to benzene, a known human carcinogen. FDA goes to some lengths to say that even those products and lots found to contain high benzene do not have uniformly high levels:

These data should not be understood to be a reflection of the distribution of benzene in beverages in the US food supply. The data cover a limited number of products, a limited number of brands, and a limited geographic region. The data do not fully address the variation from one production lot of a product to another lot. For example, when additional lots of some beverage samples initially found to contain benzene levels greater than 5 ppb were analyzed, the results indicate that benzene levels can be highly variable from lot to lot. Even products from the same lot collected at different locations may have different benzene levels depending on many factors such as time at elevated temperatures and amount of light exposure during shipping, handling, and storage. (FDA)

Fair enough. Of course this also means those products and lots found to contain little benzene in this survey may turn out to have very high levels in another sample. These results were also done in the cool weather of winter and since heat and light affect benzene formation it is likely that a study done in the summer will come up with higher levels.

Benzene is found in the environment from other sources, and some like power plants or gasoline fumes cause much higher exposures. But from the public health perspective, even small exposures with small risks are significant when billions of drinks are consumer around the world (see previous posts here and subsequent linked posts; and here). Lottery tickets have a small risk of winning, too, but if enough tickets are sold, "winners" appear. And this is a lottery no one wants to win. We shouldn't be giving cancer lottery tickets with a can or bottle of soft drink.

Additional info available at the Environmental Working Group site.

WHO update on Indonesia cluster: not comforting

2006-05-23T16:03:00.000-04:00

WHO has issued a new update on the Indonesian cluster and it wasn't very comforting. The 32 year old man who died yesterday was the father of a youngster (10 years old) who took ill on 5/3 and died on 5/13. The father took ill on 5/17. He had spent a great deal of time with his sick son and WHO suggests this was the source of his infection:

The case is part of a family cluster in the Kubu Sembelang village, Karo District, of North Sumatra. The man is the seventh member of an extended family to become infected with the H5N1 virus and the sixth to die. An additional person, who was the first member of the family to fall ill, died of respiratory disease on 4 May. No specimens were taken prior to her burial and the cause of her death cannot be determined. However, as her clinical course was compatible with H5N1 infection, epidemiologists at the outbreak site include this woman as the initial case in the cluster.

The newly confirmed case is a brother of the initial case. Specimens were taken on 21 May and flown the same day to Jakarta. Tests run overnight confirmed his infection. His 10-year-old son died of H5N1 infection on 13 May. The father was closely involved in caring for his son, and this contact is considered a possible source of infection.

Although the investigation is continuing, preliminary findings indicate that three of the confirmed cases spent the night of 29 April in a small room together with the initial case at a time when she was symptomatic and coughing frequently. These cases include the woman’s two sons and a second brother, aged 25 years, who is the sole surviving case among infected members of this family. Other infected family members lived in adjacent homes.

All confirmed cases in the cluster can be directly linked to close and prolonged exposure to a patient during a phase of severe illness. Although human-to-human transmission cannot be ruled out, the search for a possible alternative source of exposure is continuing. (WHO)

This last sentence is of some significance. If the 10 year old contracted it from one of the two sons or uncle who were infected by the index case (the mother who took ill on 4/27), then the father is either a tertiary or fourth generation case. This would be the first known case that has gone beyond one generation of infected human to human cases. The statement, "Although human-to-human transmission cannot be ruled out, the search for a possible alternative source of exposure is continuing" seems bizarre in this context. One would think it is the other way around: "Although human-to-human transmission seems the best current explanation, other sources of exposure cannot be ruled out."

An additional note gives some scanty information on sequencing of two viruses isolated from this cluster (presumably isolated and confirmed by NAMRU2 in Jakarta):

Full genetic sequencing of two viruses isolated from cases in this cluster has been completed by WHO H5 reference laboratories in Hong Kong and the USA. Sequencing of all eight gene segments found no evidence of genetic reassortment with human or pig influenza viruses and no evidence of significant mutations. The viruses showed no mutations associated with resistance to the neuraminidase inhibitors, including oseltamivir (Tamiflu).

The human viruses from this cluster are genetically similar to viruses isolated from poultry in North Sumatra during a previous outbreak.

If the sequencing is completed, why is it not being deposited immediately in GenBank (or is it)? It is not immediately obvious that the reassortments with pig and human viruses concern only HA and NA or also include all other segments. We are learning that there is a great deal of reassortment occurring among influenza viruses within subtypes. When the same HA and NA are present against new genetic backgrounds of internal genes, outbreaks can occur. There is some thought this is what is happening when one strain of the same subtype replaces another in seasonal influenza (e.g., replacement of A/Fujian(H3N2) with A/California(H3N2)). The statement that there are no significant mutations suggests non-significant ones have taken place. Does this mean the unique cleavage site mutation seen in the human but not avian viruses in Indonesia is not there?

Let's see the sequences. Now. With holding them from the world scientific community is unconscionable.

Stockpile information underload

2006-05-23T07:17:00.000-04:00

Yesterday Department of Health and Human Services Michael Leavitt told the World Health Assembly, WHO's governing body, that the US was sending some of a Tamiflu stockpile to an undisclosed Asian nation. The lack of specificity has created an information vacuum that is being rapidly filled by speculation, much of it well-informed, but still by necessity, speculation.

We are left wondering whether this is WHO stockpile stored in the US or US stockpile, how much was sent, where it went and why it is being sent now. Indonesia was the first thought of many because that country presents, on its face, one of the most threatening places for a potential development of a pandemic strain. It is populous and has endemic H5N1 infection in poultry throughout the country. Human cases continue to appear, including the largest cluster to date bearing all the marks of human to human transmission. The country has very substantial numbers of pneumonia cases at any one time so that avian flu could easily be missed in the noise of background disease. A colleague made the important additional observation that cases have mainly been reported around large cities like Jakarta (and now Surabaya) where there is medical expertise. Thus there might be a major reporting bias underestimating the true number of cases and distorting their distribution.

On the other hand, two in-country informed sources told me that so far they know of no triggering event for suddenly sending Tamiflu to Indonesia. The Tamiflu could be going to more routine WHO staging locations like Bangkok or Singapore or elsewhere. Why can't we know this? Why should anyone be guessing about it?

Transparency, credibility and trust are becoming collateral damage in the bird flu battle. WHO has squandered much of their credibility and CDC is following suit. In particular, failure to release sequence information to the scientific community is not just a scandal, it's a disgrace.

Leavitt's uniformative announcement about Tamiflu was a major blunder. We are not seeing competence at a time when we need it most.

Bioterrorism whistleblower at CDC

2006-05-23T07:15:00.000-04:00

The Atlanta Journal Constitution has an extremely interesting article (brought to my attention by a reader: thanks) about congressional investigators looking at CDC's bioterrorism division as a result of a CDC whistle-blower's complaint they were wasting taxpayer money. The investigators are with Senator Charles Grassley's (R-Iowa) Finance Committee. Grassley, a conservative who is a demon on government waste, is a strong supporter of the Federal False Claims Act which gives whistleblowers a piece of recovered funds. (There is a great book about FFCA, complete with lots of dirt about the Frist family: Giant Killers by Henry Scammell.)

The committee's inquiry involves whether the CDC is able to show that taxpayers have gotten their money's worth from the billions of dollars in grants they awarded to local health officials to protect citizens from a bioterrorism attack, according to interviews with CDC officials. (Atlanta Journal Constitution, link hat tip Robert)

Both the director of the bioterrorism division and CDC Director Julie Gerberding are said to have met with Grassley last week in Washington. CDC has dumped about $3.6 billion on states since 2002, but most public health professionals don't think we are much better off. The use of the money to strengthen state and local public health infrastructure has been hampered by restrictions on what the use of the funds, resulting in often silly purchases of equipment that couldn't be used and technologies and consultant services that provide little value to public health. The complaint that some of this money is used to plug holes in local and state public health caused by budget cuts is misplaced. That's not a waste of money, that's a necessity if we want to prevent even further deterioration of our public health infrastructure.

There is a widespread perception in public health itself, however, that huge amounts of this money have been wasted and many of us would like to see where it really went. If this is just an inquiry into whether the money went to buy hazmat suits or maternal and child health services, that would be a shame. If it is a legitimate look at how the millions of dollars sloshing around made its way to questionable state vendors and lobby-promoted biotech scam artists, that's something else. Given the corruption of this Administration, it is a real question. Grassley is usually more interested in fraud and corruption rather than misplaced priorities, but we shall see. The nature and scope of his inquiry are not known yet.

Meanwhile the CDC employee who raised the issue of poor CDC oversight has been granted official whistleblower status, affording her some degree of protection against retaliation. In Gerberding's CDC this is a necessity, as the Director is known as someone who takes criticism poorly.

We'll keep our eye on this one.

Quarantine in Bucharest: why?

2006-05-22T15:01:00.000-04:00

Agence France Presse is reporting that Romanian military and police have sealed off 13,000 people in a quarter of Bucharest where H5N1 infected chickens have been found. Forty streets in Luica quarter have been blocked off, with the quarantine estimated to last a week to three weeks. All institutions and businesses in the area were ordered closed. An immediate slaughtering of birds in the quarter was underway.

This is an unusually vigorous response to just another poultry outbreak in Romania and immediately raises the question of what is going on or suspected of going on.

Addendum: From MediaFax:

The presence of the bird flu virus was confirmed Monday for Bucharest’s district 4, and some 13,000 people are now in first-degree quarantine, Mayor of district 4 Adrian Inimaroiu told MediaFax.

Bucharest’s general mayor Adriean Videanu also confirmed for MediaFax that the virus has been found in district 4.

The planned quarantine in district 4 includes 40 streets, with 20 apartment blocks and tens of households, as well as factories, stores and a kindergarten which will suspend their activity for at least one week, which could be extended up to 21 days.

Available media reporting suggests this remains a poultry problem. Still…

Poultry and human bird flu

2006-05-22T08:24:00.000-04:00

One of the most repeated "facts" about the human cases of bird flu is that virtually all cases to date come from intimate contact with sick poultry. But the evidence does not show this.

One third of the Vietnamese cases are said to be without an adequate history of poultry contact, at least a third (if not more) of the Indonesian cases, and many of the Chinese cases. WHO continually repeats the necessity of the poultry connection but knows better. The Vietnamese figure is from WHO epidemiologist Peter Horby (personal communication reported in EFSA Monograph; see earlier post here). WHO is quite familiar and distressed about the situation in Indonesia. And in an article today, Helen Branswell writes:

The WHO has been extremely concerned that none of China's 18 confirmed human cases to date have occurred in areas where outbreaks in poultry were previously reported. In most of the cases thorough investigations after the fact have pointed to some possible exposure to poultry. But the lack of obvious links disturbs international public health authorities. (Helen Branswell, Canadian Press; my emphasis)

Yet WHO continues to say publicly all evidence so far shows the principal connection is from close contact with sick or dead birds.

WHO should not say the evidence shows "close contact" with sick or dead birds is required. We don't know that and it probably isn't true. If it were it wouldn't be so hard to elicit histories of poultry exposure in so many cases. The other possibilities are less close contact through poultry dust, feces, feathers, etc. If WHO wants to call this "close contact with sick or dead poultry" they are free to do so but they are using a private language. And it is largely an inference based on the fixed idea that almost all human cases can be traced back more or less directly to birds.

Given the evidence, we should keep our minds open to other possibilities, namely, contaminated food or water, an as yet unidentified animal reservoir or vector, and of course person to person transmission. At this point I believe WHO is probably right in substance: most cases probably are of proximate bird origin. But they don't have the evidence that they claim and I find that bothersome.

This is the way obvious facts are missed: we don't see what is staring us in the face until hindsight dramatically improves our vision.

Until the Fat Lady sings

2006-05-22T08:19:00.000-04:00

On a recent trip to a scientific meeting about something quite different than bird flu, several of my colleagues knowing of my interest in the disease wanted to know if this thing was finally over and the threat receding. This followed several optimistic news reports that Thailand and Vietnam have had few or no new cases this year and that their aggressive programs of combating the disease showed a pandemic could be avoided. Vietnam has used poultry vaccination, while Thailand has used area culling. WHO's flu czar Dr. David Nabarro has praised both countries and made cautiously optimistic sounds.

At the same time the largest cluster yet has occurred in Indonesia and the disease continues to spread uncontrolled in Africa. The latest case in that cluster is almost certainly an another example of person to person transmission. In Indonesia there is no aggressive program of any kind and two of the patients in the cluster were actually released from the hospital into the community and then readmitted to die. So much for the "fireblanket" and the computer models that suggested it was a possible strategy (also see our posts here, here, here and here):

As such, the Indonesian outbreak should serve as a stark reminder to all involved of the difficulties inherent in trying to translate the models' findings into reality, said infectious diseases expert Dr. Michael Osterholm.

"Our experiences with the virus during the last six months in Turkey, Iraq and now in Indonesia should give even the most ardent supporters of containment cause to realize why, while such an approach is an ideal, it also is a fantasy."

Osterholm has been skeptical since the modelling studies were published last summer that the optimistic outcome predicted by the work could be achieved outside of the hard drives of the computers on which they were devised.

"This was never about wanting to contain the virus. It's about the reality of what happens in everyday life," Osterholm said Saturday from Minneapolis, where he is director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

"One of the problems models can't address is the impact of politics, fear, panic and lack of compliance on written guidelines for public health actions."

The models, by two international teams of scientists, suggested the WHO could contain an emerging pandemic if it discovered the virus was spreading among people within the first 20 human cases or within seven to 21 days of the start of transmission. (Helen Branswell, Canadian Press)

Last week Maryn McKenna, the Atlanta Journal Constitution's expert flu reporter, had an excellent story about the difficulties of predicting what flu is going to do. The whole things is worth a read, but here is the pertinent point:

After the Asian strain of bird flu attacked humans for the first time in Hong Kong in 1997 --- sickening 18 people and killing six of them --- it disappeared for several years. It surfaced briefly in Hong Kong in 2003, infecting two people and killing one, and then vanished again for almost a year before resurfacing in Thailand and Vietnam.

Similarly, though the virus at first spread rapidly --- causing 22 cases and 15 deaths in Vietnam by the end of February 2004, and 12 cases and eight deaths in Thailand by the end of March --- it subsequently went underground again. Five months passed before Vietnam saw another human case; in Thailand, the gap was six months.

Those gaps, like the current one, occurred as the weather warmed. Influenza is seasonal: It flourishes during winter months --- or in the rainy season in tropical countries that have no clearly-defined winter --- and disappears in the summer, said Dr. Bruce Ribner, associate professor of infectious diseases at Emory University School of Medicine.

[snip]

Dr. D.A. Henderson of the University of Pittsburgh Medical Center's Center for Biosecurity, former leader of the international campaign to eradicate smallpox, warns that too little is known about the Asian avian flu.

"I don't think we can feel at all confident that because flu appears to be at a lower level in some countries it is not still spreading, at least in birds," said Henderson, who worked early in his career on the 1957 influenza pandemic that killed 70,000 Americans and about 2 million people around the world.

Behind health authorities' questioning of the Southeast Asian case numbers lies a fear that success will lead countries to drop their aggressive efforts against the virus --- a concern reinforced by memories of Thailand and Vietnam declaring premature victory against the virus in March 2004.

"We have to walk a fine line between continuing to aggressively prepare for a flu pandemic, and at the same time recognizing that people's attention span will wane if the H5N1 situation looks less threatening," [CDC Director Dr. Julie] Gerberding said. (Maryn McKenna, Atlanta Journal Constitution)

As if to underline the concern, China's vice Premier Hui Liangyu said Saturday he remained concerned about the bird flu situation in China and elsewhere:

“Summing up and analyzing the epidemic’s current development both inside and outside the country, the . . . situation is not optimistic,” Hui said at a national meeting on the prevention and control of avian flu.

His warning came as the agriculture ministry reported Saturday that a total of 308 wild migratory birds have died since a bird-flu case was reported in the northwest province of Qinghai on April 23.

As of Friday, 300 bar-headed geese and eight birds of other species had been found dead in the remote province, a statement on the ministry’s website said. (AFP via Manila Times)

Yogi Berra, relying on his deep knowledge of the opera once said, "It ain't over till the fat lady sings." Of course what happens after the fat lady sings is "curtains." (NB: This is not a prediction! It's just a way to finish off this post. You'll still have time to buy your personal 5000 gallons of bottled water later. Meanwhile contact your water utility and ask them if they have made any plans in case there's a pandemic.)

Is the virus becoming more deadly?

2006-05-21T08:42:00.000-04:00

The recent cases of bird flu in Indonesia have had an unusually high fatality. In the Sumatran cluster six of seven family members succumbed. Overall the case fatality in Indonesia is 78%. This has prompted a number of news sources to conclude the virus is becoming deadlier:

The bird flu is becoming more deadly, now boasting a 64 percent fatality rate.

According to the World Health Organization (WHO) 47 victims have died out of 73 cases in 2006. In 2004, however, 41 patients died out of 95 cases, which is only 43 percent.

The WHO believes that since 2003, 123 people have died from the virus, from the 217 documented cases. (All Headline News)

Maybe this is a good time for a quick review of Case Fatality Rate (CFR).

The first thing is that technically CFR isn't what epidemiologists today call a rate. Rates are the number of disease events per person per time unit or sometimes number of disease onsets in a time span. Thus a mortality rate for cancer might be 1 per 10,000 population per year. A CFR, by contrast, is a proportion. In technical terms it is an incidence proportion, a measure of average risk, in this case the average risk of dying of the disease given that you contracted it. It therefore varies between zero and 1.0 (rates vary from zero to an undetermined upper number that can be much greater than 1.0).

The CFR has a numerator (deaths from bird flu) and a denominator (all diagnosed cases of bird flu). What the number expresses is the risk of dying of bird flu once you get bird flu. From this viewpoint, that risk seems to be increasing (43% in 2004 to 64% today, overall, and 78% in Indonesia).

However there are complications. The numerator (deaths in bird flu diagnosed cases) may be accurate (death is a definite endpoint), but the CFR measures the risk of dying once counted in the denominator and that risk is subject to other factors than the deadliness of the virus--in particular care seeking behavior, timely access to medical care, the skill and resources of the care itself, and the general state of health of the patient. Thus the numerator may differ from place to place even though the virus remains exactly the same.

The denominator (diagnosed bird flu cases) is less firm than the numerator. WHO has a very strict standard for defining a case (requiring laboratory confirmation by one of its reference laboratories), so it is possible many truly existing cases are not being counted because they are not being diagnosed by anyone or are mild and do not seek medical care. This would artificially inflate the CFR by having a denominator smaller than it should be and many people thought this was a likely reason for the abnormally high CFR in this disease. Unfortunately there is no confirming evidence that many cases are being missed. While data from seroprevalence surveys is sparse (these are blood studies of the general population or contacts of confirmed cases to see if they have evidence of mild infection), so far they show stunningly little evidence of undiagnosed infection. Maybe the CFR slightly overestimates the true value, but there is as yet no convincing evidence it overestimates it by much.

Because the accuracy of both the numerator and denominator of the CFR might vary from country to country and within a country, comparing CFRs over a time period in cases from ten very different countries does not clearly measure a change in the deadliness of the virus. While it is quite possible the virus is becoming more virulent, we don't have a good way to determine that at the moment.

Treat the news headlines with the appropriate caution.

Freethinker Sunday Sermonette: the "religious left"

2006-05-21T08:33:00.000-04:00

Firedog Lake is one of the better blogs in the left blogosphere and this weekend there was a long post by Christy Hardin Smith on the "religious left." One of the great things about lefty blogging is it doesn't all march to the same drummer. We debate, we disagree, we argue -- and in the end we work together to try to make this a better world. This is by way of preamble to disagreeing with Christy's post. Since my disagreement doesn't prevent me from winding up in the same place she does I don't know whether to call it a strong disagreement, but I think it is a fundamental one.

What did she say? She begins by registering (appropriate) discomfort with the politicization of religion on the left, noting that for most of us religious faith of whatever stripe is a private matter, not to be forced on others and to be lived out in our lives. Some of us have no religious beliefs, however, and I believe she not only mischaracterizes us but commits the same error against us she accuses "ivory-tower liberals" of: condescension. She also reinforces a right wing meme that liberals are secular boors without respect for people of faith,. This is a failure to distinguish our views of "faith" and "religion" from our views of the persons who practice them.

She begins with a long excerpt from a 2005 essay by Van Jones, an African American who writes feelingly about the importance of religion in his life growing up in the days of American apartheid. Here is some of it:

I literally have had liberals laugh in my face when I told them I was a Christian. For awhile, I felt self-conscious about telling other activists that I preferred not to meet on Sunday mornings, because I wanted to go to church.

It is still commonplace to hear so-called radicals stereotyping all religious people as stupid dupes — and spitting out the word "Christian" as if it were an insult or the name of a disease. I thought progressives were supposed to be the standard-bearers of tolerance and inclusion. (Alternet)

I rather doubt this. It is reminiscent of the stories of anti-war protesters spitting at returning Vietnam Vets. I won't say that never, ever happened but if it did, no one has been able to find an example of this urban myth and if it ever happened it hardly ever happened. I'm guessing the same is true of "literally laughing in his face" upon declaring he was a Christian. This is hyperbole. All I can say about anyone -- left, right or center -- who literally laughed in the face of another person who said they were a Christian is that they are monumental boors whose rudeness knows no political stripe. This is a red herring and an extremely harmful way to depict the left. The same for the claim that "so-called radicals" stereotype religious people as stupid dupes. People say many things about those that disagree with them (consider what we say about the right wing), but there is no special singling out religious people as stupid dupes. Stupid dupes exist and some of them are religious and some of them are Democratic candidates duped by their consultants. So what?

The Jones piece goes on to give a moving rendition of the importance of the Black church in the civil rights movement. No argument there, of course, but the context is significant. The Black church was one of the few social institutions capable of organizing the black community. It is worth noting that outside of the Black clergy the churches and synagogues of America were silent, or worse -- actively racist -- in the civil rights years, (with some notable but rare exceptions).

Jones goes on to draw the inevitable conclusion:

The implications are clear for those who seek today to rescue and redeem U.S. society. The facts are simple and profound: The last time U.S progressives captured the national debate and transformed politics, people of faith were at the center of the movement, not stuck in its closet.

This zeroes out the subsequent anti-war movement, the woman's movement, the gay and lesbian movement, the environmental movement, etc., etc. It is an understandable conceit, but a conceit nonetheless. Again, with a few notable exceptions, churches played a minor role in those movements and when they were important it wasn't because of doctrine but because they transcended doctrine.

As a progressive, what should my attitude to religion be? To the extent it is someone's private affair, it doesn't matter. It is none of my business. But to the extent it is advanced as a political principle that we should embrace "good" religious arguments and support them, I reject it. As a public health professional I believe washing your hands is good hygiene. This doesn't mean I must approve of and support the arguments of a handwashing obsessive. I don't say, yes, there are germs everywhere. I am glad you are washing your hands every five minutes because I think hand hygiene is good. Or if someone tells me they will vote for someone because they are of the same religion, I am not required to say, good, that's a sufficient reason. Whether it makes sense to try to convince someone pathogens aren't everywhere, or that voting for Joe Lieberman isn't good just because he's a Jew is a tactical question. I might just keep silent. But agreeing with either is wrong. One shouldn't violate the truth for political expediency and that's just what an embrace of the "religious left" qua religious (or spirituality or whatever else you want to call it) would be.

Unfortunately Christy goes further and reinforces right wing canards about the secular left.

Yet liberals, trapped in a long-standing disdain for religion and tone-deaf to the spiritual needs that underlie the move to the Right, have been unable to engage these voters in a serious dialogue. Rightly angry at the way that some religious communities have been mired in authoritarianism, racism, sexism and homophobia, the liberal world has developed such a knee-jerk hostility to religion that it has both marginalized those many people on the Left who actually do have spiritual yearnings and simultaneously refused to acknowledge that many who move to the Right have legitimate complaints about the ethos of selfishness in American life.

Disdain for religion? Yes. What do you want me to say. I think it's good? Because I don't. Engage them in what kind of serious dialog? Certainly the dialog cannot be in the arena of a faith in a God I don't believe in or in the virtues of religious institutions that have been overwhelmingly vicious, hateful and reactionary. This is what this strategy leads to:

[Michael] Lerner, the California-based rabbi who founded the [Network of Spiritual Progressives], said the conference is partly aimed at countering an aversion to religion among secular liberals and "the liberal culture" of the Democratic Party. "I can guarantee you that every Democrat running for office in 2006 and 2008 will be quoting the Bible and talking about their most recent experience in church," he said.

The Democratic Faith Working Group, made up of 30 members of the House and scores of aides, has begun meeting monthly on Capitol Hill to discuss faith and politics, opening each session with a prayer. Its purpose is to "work with our fellow Democrats and get them comfortable with faith issues," said its chairman, Rep. James E. Clyburn (D-S.C.), a preacher's son who was raised in the fundamentalist Church of God. (WaPo)

Is this what the country needs? I don't think so.

Christy uses Ned Lamont as an example of someone who launched a successful political challenge on the grounds of values. Fine. But where was religion in this campaign? Nowhere. The business of equating "religion" with essentially secular values runs throughout Christy's post. It is wrongheaded.

Yes, let's embrace the secular values she enumerates. If some people want to consider them spiritual or religious values that's their business. I don't have to agree nor should I be asked to any more than I would agree with the premises of a handwashing obsessive. Nor should we suggest we should in the interests of "dialog."

Because none of the values she promotes depend in any way on religion, she finishes up just where I would:

What we need is language that speaks to the hearts of these voters — to the things they hold dear, which, coincidentally, are also the things we hold dear: family, children, safety, pride, our own lives and pursuit of happiness and respect and decency.

[snip]

What I do see, however, is an oppotunity for the Democratic party to speak to the values that people of faith have always held to be important and sacred duties: peace, respect for all of humankind, lifting up those who need a helping hand, nurturing those who have little or nothing, giving hope where there is currently none, shining a light in the dark places.

This was the Democratic party in which I was raised — perhaps it was a naive view of the world, but it was a wonderful lesson in the might of our souls and the ability to triumph over the darkness of selfishness and meanness.

[snip]

Let us work together — instead of picking each other apart — and wherever that well of faith comes from that propels you forward, let’s harness that strength instead of squabbling amongst ourselves and trying to marginalize one faction or another. In order to right this severely listing ship of state, we have to all pull on the oars together — one nation, one people, one faith in our ability to do better and to do right by all.

If that's what she means by faith, even I can say "Amen."

Cats, pigeons, Indonesia

2006-05-20T08:58:00.000-04:00

There has been much talk about the possibility of domestic cats being infected with H5N1 and some cases have been described (see posts here, here and here). Cats eating infected birds is suspected as the source of infection in some of these cases.

Cats, both feral and domestic, are common inhabitants of urban environments. So are pigeons. We've been told we don't have to worry about pigeons and bird flu. But this paper (which got by me when it appeared in Emerging Infectious Diseases in April) tells a somewhat different story.

In early February 2004, during the outbreak of HPAI (H5N1) in Thailand, a carcass of a 2-year-old male cat (Felis catus) was taken in an icebox 6 hours postmortem to the Faculty of Veterinary Medicine at Kasetsart University, Nakornpathom, Thailand. The cat's owner volunteered the information that the cat had eaten a pigeon (Columba levia) carcass 5 days before illness onset. The owner reported that the cat had a temperature of 41°C, was panting, and appeared to be depressed. Furthermore, the cat had convulsions and ataxia and died 2 days after onset of illness. The cat was given a single dose of 75 mg aspirin 1 day before it died; however, its body temperature remained elevated. Many dead pigeons were found in the area where the cat lived.

H5N1 was isolated from the cat and from dead pigeons in the area. The genetic sequences of the viruses matched closely and resembled the sequences of the H5N1 circulating simultaneously in poultry and large zoo cats (tigers, leopards) in early 2004 in southeast Asia. Horizontal transmission ("cat to cat") has been described elsewhere but so far no one has shown any cases of cat to human. In April Dr. Peter Roeder, a Food and Agriculture Organization scientist working with Indonesian colleagues, was reported setting up a study to see if cats were playing a role in the Indonesian outbreak but we don't know if that study is happening or not. The Indonesians have a history of foot dragging. Earlier, the former NAMRU2 epidemiologist Dr. Andrew Jeremijenko had swabbed a kitten in Indonesia and isolated an H5N1 that was a close match for a virus isolated from a human.

It seems not a day goes by that this virus doesn't confront us with something new and unsettling.

Addendum: Several commenters have questioned the use of aspirin for the cat in this report, believing that aspirin is deadly for cats. Cats lack the enzyme glucuronyl transferase which is involved in the metabolism of aspirin but they tolerate appropriate doses of aspirin well and it is used routinely in veterinary medicine for arthritis or as a blood thinner. A common dose is a quarter of a buffered adult aspirin once every three days for arthritis. The literature says that 10 mg to 25 mg per kilogram every two or three days is safe.

Note that acetaminophen (Tylenol) and ibuprofen (Advil, Motrin) are extremely toxic to cats and will kill them. This may be the source of the idea that aspirin, too, is deadly. The dosage of 75 mg in this report seems excessive and may have contributed to the cat's demise, but the animal was also infected with H5N1 which was the main issue. [NB: Disregard this last comment. 75 mg would be about right for a 3 kg cat and it is about 1/4 of an adult aspirin tab. Thus the cat's relatives shouldn't sue the owner for malpractice.]

The problem of Indonesia

2006-05-19T07:48:00.000-04:00

What to do about Indonesia? The fourth most populous country in the world, where 26 of 33 of the provinces have reported poultry outbreaks with H5N1, swine may be infected asymptomatically and 40 confirmed cases with 31 deaths, all make Indonesia the current epicenter of bird flu. Its government is struggling and is so far incapable of doing the investigations needed to keep a close eye on the evolution of this fast mutating virus. A well-equipped and technically sophisticated US Navy laboratory (NAMRU2) is operating in country, but a diplomatic spat complicated by the muslim world's backlash against Bush's Iraq war debacle have made it difficult for scientists there to lend a needed hand. The Indonesian government can't get its story straight, is issuing conflicting reports and seems to be intent on muddling through, meaning getting to the next day without everything blowing up in their face. At the same time they are effectively barring international scientists from rolling up their sleeves and finding out what's going on there.

Dr. Andrew Jeremijenko, an epidemiologist formerly with NAMRU2's influenza surveillance unit in Indonesia, remains concerned about the Indonesian government's inability to conduct needed investigations. He points out that the Indonesians have not been able to match an H5N1 virus in animals with the virus in the patients in any case to date. Thus the source of all the cases remains unknown. Moreover, in the latest cluster in north Sumatra two of the patients were allowed out of the hospital into the general population until they were too sick and readmitted. As an example of vigorous containment this is obviously defective.

Jeremijenko wants animal viruses as well as human viruses sent to CDC and WHO for sequencing, but so far the Indonesians have not allowed this. He observes the rather sparse offering of bird and other animal viruses available from Indonesia are not from the same geographic areas as the human cases. It is also important the sequencing of the human viruses be done promptly and the sequences released (WHO and CDC take note!).

NAMRU2 remains active in isolating, identifying and sending the human viruses to CDC. They are the only functioning influenza surveillance program in the country, but are not invited on field investigations. All international scientists in Indonesia are "walking on eggshells" lest the Indonesian government further obstruct their activities. While WHO and CDC epidemiologists are now there and reportedly engaged in investigating the large family cluster in north Sumatra island, my other in-country sources say they are not being allowed into the village.

So what to do about Indonesia? It appears the Indonesian government has to be handled with kid gloves. Whatever it takes. An international spotlight on them wouldn't hurt, however. While we don't want them digging in their heels because of high handed demands by outsiders, we do want them to feel the pressure of the international community.

Two things are now quite clear. (1) The bird flu situation in Indonesia is serious and better scientific information is urgently needed but it collection is being obstructed by the Indonesian government. (2) The Indonesian authorities are not competent to handle this.

This is no longer a matter that can be made subordinate to national pride, diplomatic pique or a habit of passive aggression by bureaucrats. The Indonesians need to feel the heat of the international community because their behavior is a danger to their own people and to everyone else. Many countries have been overwhelmed by the bird flu crisis and have thrown their doors open to international experts. Time for Indonesia to do likewise and act as a responsible and civilized member of the community of nations.

While the bird flu pot bubbles and threatens to boil over in Indonesia, there is no one in the kitchen.

Update, 5/19/06, 9:30 am EDST: A news conference called by Indonesian authorities to discuss the pig serology has just been canceled. Rumor on the ground is that the results showing antibodies in pigs are incorrect, or at least in serious question.

Rocket science

2006-05-19T07:44:00.000-04:00

Bush Administration rocket science:

A robotic NASA spacecraft designed to rendezvous with an orbiting satellite instead crashed into its target, according to a summary of the investigation released Monday.

Investigators blamed the collision on faulty navigational data that caused the DART spacecraft to believe that it was backing away from its target when it was actually bearing down on it.

"The inaccurate perception of its distance and speed ... prevented DART from taking effective action to avoid a collision," the summary said. (ABC News)

Absolutely emblematic of the Bush Administration. They thought they were going backward but they were going forward -- into a crash. They couldn't figure out their direction or speed, so they had a collision. They thought their technology would rendezvous with a Pentagon satellite and instead they smashed it. Oh, did I say it it ran out of gasoline?

DART successfully located the target satellite orbiting 472 miles above Earth and moved within 300 feet of it. But problems arose when DART tried to circle the satellite.

Investigators concluded that DART spent too much fuel steering itself toward the satellite. The excessive firings of its engines were caused by inaccurate navigational data from its on-board computer.

Determining that it wouldn't have enough reserve fuel to complete the mission, DART began shutting down about 11 hours into the mission, but not before crashing into the satellite.

Of course an investigation into the DART fiasco uncovered the usual managerial incompetence and failure to listen to professional scientists that has become the hallmark of the Bush Administration:

Investigators also raised issues with the mission's management style, saying that lack of training and experience caused the DART design team to shun expert advice. They also found that internal checks and balances were inadequate in uncovering the mission's shortcomings.

That's just the stuff we know about.

The 10-page document summarizing DART's failure comes a year after the spacecraft was launched from Vandenberg Air Force Base in California.

Last month, NASA said it won't release the investigative board's full 70-page report, citing sensitive information protected by International Traffic in Arms Regulations.

International Traffic in Arms Regulations? So I guess this wasn't exactly the peaceful uses of outer space and the thrill of exploring the cosmos.

The Bush Administration. Not satisfied to be the laughingstock of the world, they're shooting for being the laughingstock of the entire solar system.

Fixing the public health roof

2006-05-18T15:46:00.000-04:00

My Flu Wiki partner DemFromCT has a characteristically well-informed and sensible post up over at his blog, The Next Hurrah. It summarizes the Indonesian cluster at this point. The situation there remains unclear, with conflicting news reports saying either that human to human spread has been ruled out, that it remains under suspicion or that this seems to be another example of a familial cluster with human to human spread but no further spread. Indonesian authorities are also issuing mixed messages. On the one hand, they say there is no proof of human to human spread and that infected poultry or livestock are being investigated as the source. On the other hand, they admit there is no proof of an animal source and that human to human spread has not been eliminated.

Available information suggests that the originally reported timeline showing a gap of more than a week between the index case (who was buried prior to laboratory confirmation could be obtained) and subsequent cases is too long to make a common source a reasonable explanation. The possibilities then are multiple animal to human transmission or human to human. Henry Niman has repeatedly argued that limited human to human transmission has been occurring for some time in Indonesia and elsewhere, and I think the evidence suggests he is correct. This still leaves several questions, such as why there is not more secondary spread or more transmission to unrelated caregivers like health care workers., but not having an answer to those questions doesn't mean the proposition is wrong. I think the weight of the evidence is on Niman's side.

Henry and I have sparred here on occasion, but I have always been more than willing to give credit where credit is due and this is another such case. There remains a significant difference in style between us that is partly traceable to our different professional disciplines but also matters of individual temperament. Henry has been right, often (at least I think so) but not right, often, as well. That's not a fatal flaw. I am reminded that Babe Ruth hit more home runs than anyone else but he also struck out more often. There is a great deal of judgment involved in interpreting fragmentary and disparate data and Henry has systematic (but usually defensible) proclivities to move in one direction rather than another. He is in many ways the antipode of another figure with whom I have engaged in much more contentious battle here, Marc Siegel. I have sometimes thought we might solve the world's energy problem by putting Niman and Siegel together in one room and using their temperature difference as an energy source (or maybe like having a proton encountering an anti-proton, each annihilating the other with a burst of gamma rays).

For most of us, if and when this virus evolves into a pandemic strain (and it might never do this), we will have time. Maybe not a lot of time, but it won't be in our midst instantaneously. That is important to remember because even though every day we don't strengthen our public health and social services infrastructures to manage the consequences of a pandemic is a precious day lost, the appearance of the real thing will still have the wonderful ability to concentrate the mind -- if we can keep our minds clear and not clouded by an irrational panic.

Panic can be rational, but only when we are faced by a mortal threat for which there is no other response. Currently the threat may be a mortal one, but there are many ways to respond. If people can fill sandbags in the face of an impending flood, they can most certainly find numerous public health and social service sandbags to fill. The Indonesian cluster is a reminder we need to stay concerned and focused.

Here's another metaphor. It's like fixing the roof of your house. You want it to be intact at any time, not just when you think a storm is coming. Time to fix the roof, storm or no storm.

The airport

2006-05-18T07:59:00.000-04:00

Sitting in an airport (for a change) but one without wireless internet. Unfortunate downtime. After two lng days at a meeting without a regular connection I am suffering withdrawal. Not that I have an addiction. I'm connected almost continuously every day and have been for years and still don't have the habit. Meanwhile (another) weather delay. I am anxious to get home.

But I can still sit here and blog about bird flu and airplanes. What if bird flu had gone human to human in Indonesia and we were waiting here for the other shoe to drop? Let's say a plane is coming in from Europe with connecting passengers and someone aboard is sick with flu-like symptoms: headache, fever, cough. He feels really lousy. When the plane lands at this international airport the passengers are met by health officials and the other passengers separated and their temperatures taken and contact information collected. The sick passenger is segregated in a small room at the airport where he is examined. If there is a reasonable index of suspicion of avian influenza, he will be isolated in a hospital, forcibly if necessary. If tests confirm he is infected with H5N1 the other passengers will be contacted and follow-up started for secondary cases.

That's the theoretical scenario. If successful it might retard the start of a wave of influenza cases by a couple of days. If successful. Lots of luck. Consider the elements here. Someone on the plane would have to notice the person was sick and notify the flight attendant (who is busy servicing a full plane by not giving out meals). The attendant is not a medical professional but has to make a decision whether to notify the captain, who in turn will notify the destination airport. At the airport there has to be a "quarantine station," which despite its name is usually no more than a designated medical officer (most often not an MD) and a room with a cot and some rudimentary medical supplies. The personnel there will have to recognize a potential flu case (as opposed to a migraine or some other common medical problem) and the other passengers will have to be properly vetted and adequate contact information obtained. Since H5N1 has a variable incubation period infected passengers might not show symptoms for up to a week or more, by which time they may have infected others.

That's if all goes according to plan (if you call this a plan). At O'Hare International in Chicago almost 16,000 international passengers arrive daily. It has to go according to plan for all of them. And that's just O'Hare.

"The notion that we can detect people with (avian flu) with any kind of assurance and then contain the people that may have been exposed, and then think it will have anything but a trivial impact seems unlikely," says William Schaffner, an infectious disease specialist and chair of Vanderbilt University's Department of Preventative Medicine.

Indeed, there are concerns about whether flight attendants will be observant enough to notice someone's symptoms.

"We are talking about people who are not trained as medical professionals and have other challenging duties," said Katherine Andrus, assistant general counsel for the Air Transport Association, which represents major U.S. airlines.

Airlines are required to train flight crews to recognize illnesses at the basic stages. Currently, that consists of training videos or pamphlets. With a pandemic flu outbreak, the government would likely increase that education, adding particular symptoms for the disease. (by-line Joseph Ryan, The Daily Herald [suburban Chicago])

So the benefit will be marginal and it's not likely to work. The airlines are not happy either. They understand a flu pandemic will be a catastrophic economic blow.

The airlines have disputed some of the CDC's pandemic flu plans, fearing the agency could unnecessarily scare passengers - and money - away from the industry if a deadly flu breaks out in a foreign country. The airlines' lobbyists are currently fighting for clearer language in the plan that would limit when passenger screening would be implemented.

"There is always a concern that implementing measures either prematurely or more extreme than called for will send a signal to the public that the threat is greater than it might be," Andrus said. "If people start to see a health screening they will assume there is some threat to their health."

The bird flu surveillance plan. Now the bird flu airport security plan. Both looking more and more like a PR mirage.

Like the 6000 National Guardsmen at the US -Mexico border.

Data mining for flu

2006-05-17T05:59:00.000-04:00

Data mining is in the news these days with stories the Bush administration has been using automated computer techniques to sift through the phone records of tens of millions of US citizens looking for -- who knows what. One imagines the secret government eavesdropping agency, the NSA, to be using the latest in data mining technology, but more likely they are using some older technique because that's the kind of incompetency we've come to expect from this administration. Fortunately, in this case.

But the use of algorithms to find patterns in large piles of data is an important area of applied and theoretical computer science and is being used in many areas. The Department of Homeland Security just announced it would let contracts this summer to move forward on the National Biosurveillance Integration System.

The biosurveillance system will aggregate and integrate information from food, agricultural, public health and environmental monitoring and the intelligence community from federal and state agencies and private sources to provide an early warning system for an outbreak or possible bioterrorism attack.

“By integrating and fusing this large amount of available information, we can begin to develop a baseline or background against which we can recognize anomalies and changes of significance indicating potential biological events,” he told the House Homeland Security Committee’s prevention of nuclear and biological attack subcommittee yesterday.

DHS will combine the biosurveillance patterns and trends with threat information and include the completed product in its Common Operating Picture, which DHS distributes through the Homeland Security Information Network. The biosurveillance system will also send back to its system partner agencies completed situational awareness in real-time streams. (Government Computer Network)

The system, designed to detect bioterrorism events (for which it will be totally useless), is also being touted as a possible early warning system for a bird flu outbreak in the US (for which it might work but be superfluous in the setting of outbreaks elsewhere). Whether it would work or not once up and running, critics are saying the timelines announced in the flu plan are grossly unrealistic:

Dr. Rex Archer, health director of Kansas City, Mo., and president of the National Association of County and City Health Officials, said NBIS would need a level of funding and national commitment comparable to the 1960s’ space race to deliver what the plan calls for within a year. (Government HealthIT)

The flu plan also envisions an expansion of CDC's BioSense project, an ambitious system for streaming real-time data from hospital emergency rooms to CDC. CDC intended for BioSense to gather data from hospitals in 31 cities by the end of 2006. The pandemic plan calls for CDC to collect data from 350 hospitals in 42 cities within 12 months. Many are skeptical BioSense will work at all, but the forced expansion in a system already stressed, underfunded and reeling under budget cuts is not just premature but probably sure to fail.

Bottom line: the surveillance component of the flu plan sounds good, but it's bogus. Like a lot of what this administration does.

Message for Professor Bernstein

2006-05-17T05:53:00.000-04:00

There is a debate in Thailand about chrysotile asbestos. Asbestos is the general name for a group of fibrous minerals made of long fibrils of magnesium, calcium and silicates. Commercial asbestos is found in two mineral forms, the serpentines (chrysotile or white asbestos) and the amphiboles (crocidolite and amosite, brown and blue asbestos).

Asbestos is useful because it resists heat and chemicals and has high tensile strength. It is used as a reinforcing material in insulation and construction materials like vinyl tiles and cement. All three forms of asbestos cause a serious and potentially fatal scarring of the lungs called asbestosis and a variety of cancers, primarily lung cancer and a deadly cancer of the lining of the lungs and abdomen, mesothelioma. All are equally potent as causes of asbestosis and lung cancer while some evidence suggests chrysotile is somewhat less potent as a cause of mesothelioma, although it is still capable of causing the disease. In any event, when asbestosis and lung cancer are included, there is nothing "safe" about chrysotile asbestos.

You might not know this if you listened to some people, however. The promotion of chrysotile as the "safe asbestos" has been going on for decades but it is discouraging to keep seeing it. The latest version comes from aProfessor David Bernstein, billed as a "Swiss consultant on toxicology":

"We can use chrysotile safely if it is cleverly used," he said.

Bernstein, who is also a member of expert panels for the US Environmental Protection Agency and the World Health Organisation, said chrysotile was less dangerous than blue or brown asbestos due to its greater fragility and solubility.

"This helps it get out of the human lung easily before causing trouble in the body," he said. (The Nation [Thailand])

To which the only thing I can say is, "complete and total bullshit." Unfortunately there is a market for bullshit in Thailand:

Srichant Uthayopas, director of the Industrial Works Department's Hazardous Substance Control Bureau, said Thailand imported about 200,000 tonnes of asbestos a year, mostly for various kinds of cement products used in construction.

Some is used for auto parts like brakes and clutches, as well as insulators and textiles.

Asbestos made of crocidolite and amosite minerals has been outlawed here since July 2003, but chrysotile is still allowed into the country on prior approval.

"We now import only chrysotile, because our industry needs it for its strength and flexibility, which are required for construction projects," she said.

"A substitute for chrysotile would be costly, and I see no reason to pay more for one. Safety and environmental protection are important, but economics is more so," Srichant said, adding that Malaysia, the Philippines and China also still used chrysotile.

So that's it. Srichant sees no reason to pay more. Safety and environmental protection are important, but economics is more so. You can't get much plainer than that. Or more callous. Maybe the health and safety official in Thailand has never seen someone die of an asbestos related disease. I have, and I have talked to their widows and children.

So I guess there is one more thing I'd like to say to Professor Bernstein and Dr. Srichant: fuck you.

Indonesian cluster: What, me worry?

2006-05-16T05:55:00.000-04:00

The cluster of eight in Indonesia and the commenting on it here and elsewhere deserves a meta-comment.

In the early days of the H5N1 epizootic those of us paying attention seized on many signs that the character of disease transmission had changed. There have been other clusters and even more unconfirmed reports of hundreds of people falling ill in China and elsewhere. Each, taken separately, had some plausibility. Taken together, however, they tell a more cautionary tale.

This thing may go human to human at any time. Some believe it has already done so. And it may never do so. All of these are plausible and defensible positions. I am agnostic on the subject, although I think it is prudent to act as though it may go human to human at any time and that is the policy I've urged. Act as if it will and be glad if it doesn't.

One thing I've learned in many years as an epidemiologist is that disease outbreaks are rarely what they appear to be at first. Sometimes they are worse and sometimes they are better, but mostly they are different. I've spent a lot of years dealing with cancer clusters and I am a strong believer these clusters are real. But there is a school of thought that says they aren't and there is a strong argument to make there. I disagree with them, for technical reasons. The one thing I know about clusters, though, is that it is important to verify all the initial information. A large proportion of the time the cancers in a cancer cluster aren't even cancer, or they are a different kind of cancer than initially reported. Numerous other facts usually turn out to be different than originally thought .

So in the Indonesian cluster, as with other reports about bird flu that come to us from far away, filtered through media reports and machine translations, I now prefer to wait a bit and see how it shakes out. I didn't do that in the early days of the bird flu problem but I should have. I've checked the diagnoses with a source in-country and I'm satisfied it is H5N1. But the other information, like dates of onset, are always problematic, so I'm waiting to see what develops.

My personal opinion is that the Indonesian cluster looks like it is a possible instance of either increased bird to human transmission or an instance of human to human. These cases have occurred before, but the size of this cluster makes one ask if something has changed. Henry Niman derides the idea it is enhanced bird to human transmission on the grounds that bird flu is very hard to catch from a bird. True. There are millions of bird human exposures and very few human cases. On the other hand it is hard to catch from other people, too. So I'm not sure I understand Henry's point (although I am quite sure he'll tell me, in his usual gracious way).

So I'll continue to hold back a bit. A day or two here or there to get better information seems a reasonable investment that repays in sanity and a clearer head. Maybe this will turn out to be the start of human to human transmission. Maybe not. Or maybe it is but won't go any farther, as in other instances.

Watchful waiting seems indicated for those of us half a world away. In the meantime we can continue to try toget our communities ready in case H5, or H9, or something entirely different should appear. There's lots of things to do, but jumping on a horse and riding madly off in all directions doesn't seem like it should be one of them.

Keeping the world safe from DVDs

2006-05-16T05:43:00.000-04:00

Lucky and Flo are two dogs starting a career in law enforcement. Not K9 police dogs. Not bomb or drug sniffing dogs. Something else.

Here is a report of their first day on the job at the FedEx hub at Stansted Airport, UK:

"FedEx was glad to assist in Lucky and Flo's first live test in a working situation. They were amazingly successful at identifying packages containing DVDs, which were opened and checked by HM Customs' representatives. While all were legitimate shipments on the day, our message to anyone thinking about shipping counterfeit DVDs through the FedEx network is simple: you're going to get caught." (Spacegrinder via Boingboing)

OMG. Here's the MPAA Press release, courtesy Spacegrinder:

"United Kingdom, Los Angeles - - The Federation Against Copyright Theft (FACT), express delivery company FedEx and HM Revenue & Customs, has joined forces to launch an exciting new initiative to help combat DVD piracy.

As part of a project promoted by the Motion Picture Association of America, Inc. (MPAA), FACT instigated the training of two black Labradors named Lucky and Flo by one of the world's leading experts in the field whose other clients include police, fire and rescue service. The dogs were trained over an eight month period to identify DVDs that may be located in boxes, envelopes or other packaging, as well as discs concealed amongst other goods which could be sold illegally in the UK. These DVDs are often smuggled by criminal networks involved in large scale piracy operations from around the world."

Hmm-mm. Maybe I'll start hiding my Fahrenheit 911 DVDs by embedding them in a block of hash.

Clusters and Indonesia

2006-05-15T13:50:00.000-04:00

Clusters of bird flu cases are always worrisome. There is no strict definition of a "cluster." Essentially it is a group of cases closer together in space or in time than one would expect to see "by chance." Usually "cluster" is further taken to mean a space-time cluster, i.e., cases grouped together that occur in a specific span of time, the span usually scaled to take account of the serial time of the disease, the time from one case to another when disease transmission is efficient.

But clustering in space and time doesn't necessarily mean the disease is being transmitted person to person. Epidemiologists most often use case clusters to indicate some common source for the disease, such as chemicals in the air or water or a food poisoning outbreak. When considering cancer clusters, the statistical problem of detecting a genuine cluster is not at all straightforward. Imagine for a moment throwing darts at a dart board. Some of the darts will be closer together than others but be a "cluster" only by chance. In addition, disease cases can only occur where there are people. This seemingly obvious and innocent observation makes interpreting disease clusters devilishly difficult. Cancer cases plotted on a map are always clustered, for example, because where people live is clustered. Thus we have to disentangle the clustering of the underlying population from any additional clustering.

Even the more straightforward problem of infectious disease clusters requires interpretation. The relatively large cluster of bird flu cases in Indonesia at the moment is worrisome but not necessarily indicative of a change in the virus. The cluster comprises eight members of one family, six of whom have died. The index case had onset on April 27, a 40 year old woman. The cause of her death has not been confirmed. Five of the other seven cases had dates of onset on May 3 and 4. Date of onset of the other two were not available to us at this time. A nurse with flu like symptoms has also been reported but the diagnosis was not confirmed and indications are she is negative for H5N1. (Some Indonesian MetroTV news links here, here and here for those able to read the language.)

Given these minimal facts, there remain several possibilities. The mother (index case) could have passed on the disease to her seven relatives in an instance of human to human transmission. This is the big worry. Or they could all have been infected by a common source. Sick poultry is mentioned in several news reports (Wall Street Journal, subscription required, alas). The gap between the index case and the other cases might be a difference in timing of two separate exposures or an abnormally short incubation period for the mother (who might have been more heavily exposed) and the rest of the family, or both. Or the dates of onset might be incorrect.

If this is bird to human (or possibly pig to human; there are pigs in this region of Indonesia, which has more Christians than other parts), a cluster this size (the largest recorded to date) could signal more efficient bird to human transmission or an unusual susceptibility of these individuals said to be related by blood. A change in the virus to more efficient bird to human transmission might be signaled by the appearance of more clusters. More efficient human to human transmission might be signaled by the appearance of larger clusters with secondary cases, i.e., cases that seem to come from a connection with a cluster or by disease appearing among health care workers. We'll have to wait and see and hope the Indonesian authorities are paying sufficient attention to this case and have obtained help from international experts.

There is a curious lack of attention in the English language newspapers in Indonesia (e.g., The Jakarta Post). Whether this is attention to the volcano crisis, bird flu fatigue or a combination, I don't know. This is a situation to keep our eyes on.

Update, 5/16/06, 6 am EDST: Dr. Andrew Jeremijenko, an epidemiologist currently in Indonesia, has provided additional information and a translation of some current Indonesian language news articles in the comments. He notes that at least two of the cases in this cluster were hospitalized and then went home. Indonesia continues to have difficulty coping with their bird flu situation and the optimism of Nabarro over the actions of Vietnam and Thailand doesn't seem to apply there.

Organic foods advisory board

2006-05-15T08:07:00.000-04:00

You may never have heard of the National Organic Standards Board, but it was formed in 1990 as part of the 1990 Farm Bill's Organic Foods Production Act. Its 15 members are meant to assist the Secretary of Agriculture, Mike Johanns in developing organic food standards. Members have five year terms. According to the Department of Agriculture, "The current board is comprised of four farmers/growers, two handlers/processors, one retailer, one scientist, three consumer/public interest advocates, three environmentalists, and one certifying agent who sit on various committees." Except if you look at the current roster, you'll find a vacancy. It's in the Consumer/Public Interest slot.

That slot was left vacant in February when its occupant resigned. Losing one of three "Consumer" members isn't such a good thing, perhaps, but this particular individual was also a food industry lobbyist, Katrina Heinze, manager of global regulatory affairs for General Mills. Her appointment was protested by Consumers Union (CU) and the Organic Consumers Association (OCA) when she was appointed in December. So that left, two. But one of the two is occupied by Daniel Giacomini, a consultant to the organic dairy industry. He's still there.

Bad enough. But now we learn the vacant Consumer slot will remain vacant for the rest of the year.

When asked why the consumer position would remain vacant for the remainder of the year, Valerie Francis, staff officer for the NOSB remarked, "It was the Secretary's decision to pick [Ms. Heinze] and he didn't want to pick anyone else." (Integrity in Science Watch alert, May 1, 2006)

That says it all.

R0 of the bird meme

2006-05-15T00:08:00.000-04:00

Lindsay over at one of my favorite blogs, Majikthise, has tagged me with the ten bird meme. Given that bird flu is the major topic here these days you can take this as some kind of sick joke, but I never refuse a meme tag, especially if the tagger is Lindsay. Meme tags are tasks one blogger sets another; you can think of them as some kind of chain letter or, more appropriately, a contagious task that spreads through the blogosphere. Sometimes you have to tag two or three other bloggers. Since Lindsay only tagged me, I am assuming the basic reproductive number, R₀, is slightly less than one.

You can read more about R₀ at my entry over at The Flu Wiki, but briefly, R₀ is the average number of new cases of infection for each infective case introduced into a susceptile population with random contact. In this case, R₀ is slightly less than one for two reasons. It would be exactly one if there weren't some small chance that I would try to tag another blogger who has already been tagged, or, more likely, that eventually the tagged one will not know they have been tagged or just decide not to do it.

The importance of R₀ in infectious disease epidemiology is that if it is above one, the number of infected people grows and if it is below one it doesn't. So epidemics are characterized by R₀'s above one. For influenza R₀ has been estimated to be somewhere between 1.3 and 3.5 (even those boundaries are approximate), which is much less than some diseases, like mumps or measles where R₀ might be above 10. But because the serial interval (the time from one infection to another) is short, flu can spread quickly.

Where was I? Oh, yes, the bird meme. The task set for me by Lindsay was to pick my ten favorite birds. This is a tough job for people who know a lot about birds, and some fifty or more bloggers have already done this. Lindsay got tagged by the inimitable Coturnix, whose Science & Politics blog is one of the best science blogs around. Coturnix (aka Bora) had actual reasons and pictures of the birds he likes. Lindsay had pictures. I am clearly the most efficient because I have neither. In fact, this was a really tough meme for me because I had trouble even naming ten birds. I'm a city boy. I can only stand up on asphalt.

So here are my ten choices, culled (excuse the phrase) from my impoverished urban idea of the bird world:

crow, pigeon, sparrow, starling, robin, chicken, turkey, goose, chickenhawk (you know who you are) and the generic "bird" (used by Boston motorists to greet each other).

I tag Melanie of Just a Bump in the Beltway, my Flu Wiki partner, who says she knows something about birds. We'll see.

Trust him, he's an expert

2006-05-14T08:41:00.000-04:00

Vancouver's medical health officer, with the Dickensian name of Dr. John Blatherwick, is on a tear. Too much money and resources are being devoted to pandemic planning even though the real threat is low.

Speaking at a disaster forum in Banff, Alta., Dr. John Blatherwick said the $400 million set aside in last week's federal budget for pandemic planning would be better spent on more immediate health issues like cancer.

Blatherwick noted that there's been no continual pattern of bird flu jumping from animals to humans. And he said there has never been a case of avian flu being transmitted from human to human. (CBC)

I'm glad to hear that Vancouver's public health infrastructure is just fine, although I'm not sure exactly what Dr. Blatherwick wants to do about cancer as a public health problem. Preventing exposures to occupational and environmental carcinogens would certainly be cost effective, but somehow I don't think that's what he has in mind. But I'll let him clarify that.

The statement that there is no continual pattern of bird flu jumping from animals to humans, though, does need a wee bit of a correction. There most certainly is a continual pattern -- continual, as in the usual meaning of the word: continuing to happen with regularity. The jump isn't frequent given the number of bird - human encounters and we don't know what determines it, but one thing you can say with certainty is that it has been continual since the resurgence of the H5N1 epizootic in 2003. Of course the second statement that there never has been a human to human case is just plain false and shows the good Dr. Blatherwick doesn't read the medical literature.

The Blatherwick prescription?

Garry Mauch, the director of disaster services for Medicine Hat, Alta., thinks Blatherwick makes sense. He said he likes the idea of letting experts do the groundwork.

"If it falls on the shoulders of local planners, well, of course, then you're going to react to some information that may not be factual. . . . "

Leave it to the experts. Note that a pre-requisite is that they acquire some expertise.

Freethinker Sunday Sermonette: the suicidal Pope

2006-05-14T08:37:00.000-04:00

Sunday and Pope Benedict is working. He is quite tireless, really. Always working.

Like yesterday. Another defense of "traditional marriage" -- that is, another attack on gay marriage. From the Pope. Who has taken a vow of celibacy. That's a role model for traditional marriage?

Pope Benedict renewed his attack on gay marriage on Saturday, saying Christians must defend traditional heterosexual marriage as a "pillar of humanity" benefiting Christians and non-Christians.

Addressing the ponitifical council for the family, Benedict called on the faithful to stand up for traditional notions of marriage and procreation in the face of moves to recognise gay marriage.

Benedict said: "Such a witness can only stimulate politicians and legislators to safeguard the rights of the family.

"It's well known that legal solutions like so-called 'civil unions' are gaining ever greater acceptance, while they exclude the responsibilities of marriage, they claim the same rights.

"Sometimes, there is the wish even to change the definition of marriage to legalise homosexual unions, granting them the right to adopt children."(News24 [South Africa])

The saving grace is that this kind of hypocrisy will hasten the death of the Church. Suicide may be a mortal sin, but this is suicidal behavior and I can't say I'm sorry. I hope they drag some others down with them.

Indonesian cluster update

2006-05-13T09:18:00.000-04:00

The Indonesian cluster we reported yesterday continues to concern. Reuters has reported that four of the eight cases have now been confirmed locally (presumably by RT-PCR) and these are being sent to a WHO reference lab in Hong Kong. There has been no mention in available news reports of the role, if any, of the US Navy NAMRU2 lab in Indonesia. NAMRU2 still operates but its relationship with the Indonesian government is now murky (see here and here).

All eight in this cluster of cases from north Sumatra island (Tanah Kano district) are members of the same family and live close to each other. Four of the eight have died. WHO personnel are said to be on the scene and have not yet ruled out human to human spread, although the main suspicion, as always, falls on a common source of infected chickens. About two thirds of Indonesia's provinces have infected poultry.

Indonesia remains the most worrisome of the countries with widespread poultry infection. It is the fourth most populous nation in the world and already has the second highest count of confirmed cases (33) after Vietnam. Its ability to cope with the situation is far worse than Vietnam's.

A situation to watch.

Iraq and Afghanistan veterans: file and forget

2006-05-13T09:09:00.000-04:00

Everybody has their own notion of what it means to "Support our Troops." For us, it means packing them up and bringing them home ASAP. For the Pentagon, it apparently means, "File and forget."

I'm not an authority on Post Traumatic Stress Disorder (PTSD) but I've seen plenty of combat veterans who were exposed to horrendous experiences in combat and suffered serious mental health consequences. As the Defense Department said in response to a General Accountability Office report that took them to task for failing to refer veterans of the Iraq and Afghanistan campaigns for mental health evaluation:

. . . a negative reaction to the stress and trauma of combat is "just a part of human nature." (Reutershealth)

Well, yes. Agreed. And so is bleeding when shot or unconsciousness when concussed. The symptoms of a PTSD response don't just affect the patient (although that would be bad enough). They affect their families, co-workers and the general public:

Experts say the disorder's symptoms include irritability or outbursts of anger, sleep difficulties, trouble concentrating, extreme vigilance and an exaggerated startle response. A person may initially respond to the trauma with horror or helplessness, then may persistently relive the event.

The Pentagon medical brass have their own rationale for a policy that refers less than one in four veterans with PTSD symptoms for mental health evaluation: they don't want to medicalize "normal" reactions.

"If these normal reactions to an abnormal situation are immediately medicalized, the individual takes on a patient role and the symptoms that may dissipate with rest and restoration tend to persist," the Pentagon stated.

There is some superficial sense to this glibness. But failing to evaluate veterans with histories of extremely traumatic experiences who are having nightmares, feelings of detachment and emotional numbness and report they are trying not to think about what happened, are hypervigilant and jumpy seems not only like malpractice but cruel and callous.

The cogs in the military machine are human. They bleed and suffer and feel pain. But the military machine is just a machine and its levers are pulled by Rumsfeld types who take the lives of its human cogs for granted. All militaries are killing machines. Once the cogs have served their purpose they are of no more interest.

When will we ever learn?

Djibouti and Indonesia

2006-05-12T08:19:00.000-04:00

East Africa has gotten its first human bird flu cases in tiny Djibouti on the Horn of Africa. The two year old girl's diagnosis was made by the US Naval Lab in Cairo (NAMRU3) and confirmed by WHO. Djibouti's Health Minister announced on state TV that three chickens were also shown to have H5N1 infection on April 27. The patient is still alive. Her siblings are reported to be showing symptoms and are being tested.

This is the first human case on the African continent detected outside of Egypt (13 cases), although there is suspicion others cases might have occurred. Introduction of the virus into Africa is a source of unease in the medical community because of the many new environmental and ecological niches the virus might exploit, including many species of animals and a large population of HIV positive people.

But for many, China and Indonesia remain the places of most concern. In Indonesia, where H5N1 is endemic in poultry and there have been 33 officially recorded cases with 25 deaths, comes word of a possible large cluster, with three deaths in one family and five other relatives being treated:

Another bird flu suspect has died in Tanah Karo Regency, North Sumatra making it the third possible bird-flu death in the regency within a week.

The latest victim has been identified as Ana Br Ginting, 29, a resident of Jl. Veteran in Tanah Karos capital Kabanjahe. The victim died on Wednesday at 5 AM after being treated at Adam Malik General Hospital in Medan, North Sumatra. The family took her body back to Kabanjahe this morning, said a hospital official.

Previously two other bird flu suspects, Roy Karo-Karo, 19, and his mother, Puji Br Ginting, died on May 9 and May 4 respectively. Five other of their close relatives are also being treated at Adam Malik for bird-flu symptoms, while another eight-year-old boy from the family has been moved to the Elisabeth Hospital, also in Medan, due to medical reasons.

The family are residents of Kubu Simbelang village, Tiga Panah District, Tanah Karo. All suffer from high fever and respiratory problems. Reports indicate that the family fell ill after consuming chopped chicken meat bought at a traditional market in Kabanjahe. The houses of the family are surrounded by chicken and pig farms. (detik.com)

And this from MetroTV:

A 19-year old bird flu suspect has died in North Sumatra while five members of his family have been hospitalized with symptoms of the deadly disease.

Roy Karokaro died at Adam Malik General Hospital in Medan, North Sumatra on Tuesday at 11 AM after he was transferred to the hospital from Kabanhaje General Hospital in Tanah Karo Regency, also in North Sumatra, after the victim showed symptoms of bird flu.

Five of the victim's close relatives, including an eight-year-old boy and a one-and-a-half-year-old infant are currently being treated in the hospital's intensive care unit with the same symptoms, high fever, coughing and liquid on their lungs, said the hospital public relations officer, Sinar Ginting. All victims lived in neighboring houses. The victims mother recently suddenly died due to similar symptoms, the official said. (MetroTV News)

(Sorry, no links at this time for either of these Indonesian reports; will supply if and when I get them).

Despite occasional news articles that the bird flu situation is calming down in Europe, things are not much changed elsewhere and human cases are appearing in new locations. The Indonesian cluster bears watching, but at this point we don't have confirmation of the diagnoses. There is no mention in these reports of international scientists involved in the investigations. We would hope the Indonesian authorities have enough sense to ask for help when they need it.

Because they need it.

Publish and perish

2006-05-12T08:15:00.000-04:00

Two of my least favorite CongressThings, ~~Republican~~Democrat Joe Lieberman (CT) and Republican John Cronyn (TX), have introduced legislation I like very much indeed. It mandates that research funded by some eleven different government agencies, including NIH and NSF, be made freely available within six months of publication. Quite right. Taxpayers have already paid for it once. Why should we pay for it again via rapacious journal subscriptions whose price has far outpaced inflation at the same time production and distribution costs have plummeted?

Not surprisingly, the for-profit publishers are up in arms:

"Mandating that journal articles be made freely available on government Web sites so soon after their publication will be a powerful disincentive for publishers to continue these substantial investments," Brian Crawford, chairman of the professional publishers' trade group, said on Tuesday.

About 70 percent of a typical article's usage value occurs after six months, Crawford said, citing independent librarian research and publishers' own accounts.

He said that publishers are already taking voluntary steps to make more research available and that they firmly oppose the legislation. They are calling instead for an independent study to scrutinize the potential effect the proposal might have on research quality and taxpayer costs. Individual publishers deferred comment to Crawford's group, the Professional Scholarly Publishing Division of the Association of American Publishers (AAP). (Reuters Health)

Let's look at this for a moment. Even assuming the truth of the 70% number, a journal article that is 6 months old is not an incentive to subscribe to a journal. You either have to buy the paper separately from the publisher or hope your library has a subscription, preferably an electronic one. The idea that journals are the engines of research and their investment is essential is vastly overdrawn, if not false. Prior to the electronic age, the main value added of a publisher was in printing and distribution. Neither function is needed anymore.

This is not to say that commercial publishers add no value. Many major journals like Science and Nature have journalists who provide important news stories and craft interpretive pieces important to a well informed profession. Even Open Access publishers like BioMed Central or the Public Library of Science charge production fees that cover the costs of developing, deploying and maintaining websites, software tools and formatting systems that make web-based publishing possible (disclosure: one of the Reveres is Editor-in-Chief of an Open Access peer-reviewed scientific journal). But many of these tools may be widely available in free or in Open Source form in the near future, allowing scientific journals to be as easily published as blogs and wikis are today.

In the meantime, I wouldn't invest in a commercial scientific publishing house, even though they are now extremely profitable ventures. Their time has come, whether or not this bill passes. The request for an independent study might buy them time but it won't solve their basic problem, which is that we don't need them anymore.

Good riddance.

Mixed news on vaccine front

2006-05-11T07:58:00.000-04:00

Mixed news from vaccine land. A new vaccine trial reported in today's Lancet produced potential protection in 66% of a small number of subjects using two doses of 30 mg each, 21 days apart. The lowest dose of 7.5 mg still produced what might be an adequate response in 40%. These results are not terrific, but much better than the previous vaccine trials where much higher doses were needed for comparable responses.

The Sanofi-Pasteur trial in France used an alum adjuvant and whole virus, although the alum was only effective at the higher doses. This was a Phase I clinical trial designed to test the safety of the vaccine. More trials with it are needed to evaluate its effectiveness. These are preliminary data in that regard. If H5N1 develops into a pandemic strain, the amount of protection from this particular non-pandemic strain is unknown. Recent computer models suggest that protection below 50% still might have significant effects on rate of disease spread, so stockpiling even a mismatched H5N1 vaccine is under consideration.

On the bad news side, Helen Branswell of Canadian Press (whose sources are the best) is reporting vaccine makers are worried that making an H5N1 vaccine is a more difficult job than they thought, and it was already a formidable job. Early trials required far more of the hemagglutinin protein than seasonal flu vaccines to achieve protection. To compound the difficulty, vaccine makers are finding the amount of hemagglutinin produced by the vaccine seed strains of H5N1 is half or less that produced by usual flu strains. Branswell quotes retired vaccine executive David Fedson to the effect that at current world capacity we could vaccinate only 75 to 100 million people in six months. Ramping up productive capacity is a separate problem from having an effective vaccine. Currently the world has only a fraction of what it would need.

Vaccine makers are not sure why viral antigen yields are so low. Word is that the low yield affects all the current candidate seed strains both in egg-based production and cell culture. These strains have been engineered to grow in eggs or mammalian cells and something about this process seems to have decreased the amount of hemagglutinin they produce. The original ("wildtype") virus makes abundant hemagglutinin, so it isn't a characteristic of the subtype. But the wildtype can't be grown in eggs and growing them in cell culture under ordinary production conditions is too dangerous.

So the news is of two kinds: not horrible and not good.

$1000 find for violating quarantine?

2006-05-11T07:56:00.000-04:00

The ABC made-for-TV bird flu featured neighborhoods being penned up with barbed wire fences but this isn't likely to be a feature of even the worst pandemic scenarios because the disease will be raging outside the fence as well as within it. But the lure of quarantine calls those who think of disease as striking someone else, the "other."

In South Carolina, Representative Walton McLeod has co-sponsored a bill to increase the fines for violating state quarantine laws to $1000. It's not barbed wire but it's a pretty stiff fine for something that's not likely to be much good except as a psychological crutch for mentally hobbling legislators.

"Our intention was not to do something fresh or novel or revolutionary," McLeod said. "Rather, it was to improve the stationary authority DHEC has had since the late 1800s."

The bill, which has been referred to the Senate Medical Affairs Committee, attempts to bring up to date the state's power to combat communicable disease, he said. It adds a $1,000 fine or 30 days imprisonment to those who violate quarantine orders by leaving isolation or entering restricted premises.

While not originally directed at the bird flu, the proposed legislation will put in place some protections, he said.

"The avian flu is something we are really not yet able to fully anticipate and predict," McLeod said.

[snip]

Rep. Shirley Hinson, R-Goose Creek, said the stricter fines could help the public take quarantine laws more seriously, especially in regards to the bird flu.

"It seems to be a very serious disease we are looking at," she said. "It's death. If that's what it takes to get people's attention, I support it.

"Often we say that happens elsewhere. I don't think we should turn our heads and say that's not something we should deal with."

Rep. Wallace Scarborough, R-Charleston, said the proposed legislation needs to be seriously considered from a homeland security standpoint as well.

"We need to take a very close look at everything coming in and protecting our resources," he said. "It is important. If you are going to get anybody's attention, you have to raise the fines." (Post and Courier [SC])

The problem isn't legitimate concern over a genuine public health threat. The problem is finding intelligent ways to meet that threat. South Carolina has a decent Department of Public Health, but like all state and local health departments it needs substantive help to strengthen its entire infrastructure: maternal and child health, substance abuse, immunization, epidemiology, food safety, vital records, surveillance, smoking programs and all the rest.

It doesn't need a heavy fine for meaningless legal authority.

Transmission through the gut?

2006-05-10T08:07:00.000-04:00

It is usual to think of influenza as a respiratory disease because that's how it appears in humans. But in birds it is a disease of the intestinal tract, and the current H5N1 subtype as well as the 1918 variety invaded organ systems outside the lung, most obviously the nervous system. The notion that the disease couldn't be transmitted via food is based partially on the respiratory notion and partially on the mistaken impression that the acid environment of the stomach would kill any virus. We discussed this in an earlier post and warned that there was still much to learn about other routes of transmission. Now, Menno de Jong, head of the virology department at the Oxford University Clinical Research Unit in Ho Chi Minh City is cautioning that the intestinal tract may indeed be a portal of infectious entry.

Bird flu may be capable of invading people through the gut, not just the respiratory system, and diarrhea is sometimes the first symptom, said virologist Menno de Jong, whose team observed 18 cases in Vietnam.

Particles of the lethal H5N1 virus contained in the meat and blood of infected poultry may have been ingested by some patients, possibly causing their infection, said De Jong . . . .

"In a number of patients the only exposure risk has been drinking raw duck blood,'' De Jong said in a phone interview yesterday. "That could imply that the gastrointestinal tract is also a route of transmission or a route of first infection, and there are experiments in animals'' that suggest this. (Bloomberg)

We will say again what we have said repeatedly. This virus has the ability to surprise. It is now not beyond imagining it capable of either foodborne or waterborne spread, although neither has been demonstrated in human influenza transmission to date. Waterborne spread is a known route of transmission in wild birds, however, so the virus is able to remain replicable in these media. The frequency of diarrhea as a presenting symptom of H5N1 infection is a red flag. The fact that one can isolate virus from rectal swabs in some human cases is a red flag. The fact that the virus can invade other organ systems besides the lung is a red flag. Lots of red flags.

But not the time for a white flag. Much can be done and there is much to do. Calmly, patiently and with eyes open to all possibilities.

Staying on message

2006-05-10T08:03:00.000-04:00

One of the explanations we've given for CDC's long silence about bird flu until recently is that Director Gerberding, ever the pliant Bushie, refused to go "off message." The message was bioterrorism, not pandemic disease of natural origin. Hence no signal to state and local health departments that getting ready was a priority, no demand that vaccine makers start exploring new technologies, no imploring Congress to shore up public health infrastructure instead of pushing Big Pharma giveaways for phantom bioterrorist threats.

Now post-Katrina, bird flu is on the agenda, but the message machine keeps grinding on. The following has been widely reported elsewhere, but we just can't help doing so, too. It's just too typical of this administration.

Career appointees at the Department of Agriculture were stunned last week to receive e-mailed instructions that include Bush administration "talking points" -- saying things such as "President Bush has a clear strategy for victory in Iraq" -- in every speech they give for the department.

"The President has requested that all members of his cabinet and sub-cabinet incorporate message points on the Global War on Terror into speeches, including specific examples of what each agency is doing to aid the reconstruction of Iraq," the May 2 e-mail from USDA speechwriter Heather Vaughn began. (Al Kamen, WaPo)

Here are some talking points, taken from the actual administration memo, which you can see here (.pdf):

Introduction
Several topics I'd like to talk about today -- Farm Bill, trade with Japan, WTO, avian flu, animal ID -- but before I do, let me touch on a subject people always ask about . . . progress in Iraq.
[snip]

The President's Strategy
But revitalization is underway. President Bush has a clear strategy for victory in Iraq structured along three tracks -- political, economic and security -- to assist Iraqis in establishing a government that provides for and is accountable to its people.

As he said, this strategy "incorporates every aspect of American power, with assistance from agencies across the federal government."

USDA is one of those agencies -- we've had a continuous presence in Iraq since the first USDA advisor to the Ministry of Agriculture arrived in Baghdad in 2003.

Etc., etc., complete with three examples of how to make the transition from what your audience thought you were going to talk about to what the Bushies want you to talk about: how the obvious Iraq screw-up is really a Grand Plan.

Forget about the " Farm Bill, trade with Japan, WTO, avian flu, animal ID." In other words, "Enough about you. Let's talk about me."

Frist responder

2006-05-09T08:07:00.000-04:00

The most damning thing about the disclosure that the vaccine industry essentially wrote the lawsuit shield provision that "Doctor" Frist slipped into bird flu funding legislation in the wee hours before the Christmas recess (after House and Senate negotiators had agreed to dump it) is that no one is surprised. Least of all us, since we've been saying it since the event (see here, here and here). The provisions give Big Pharma virtual immunity, even when gross negligence is involved. Doctor Bill worked with his pal, House Speaker, Dennis Hastert and the lobbying team of three former Frist staffers and Hastert's son, Joshua Hastert. All in the Family.

Some of the sordid details are laid out in an article in yesterday's Tennessean, based on a Report from Public Citizen (.pdf). Included are emails between Frist and an industry trade group who worked with vaccine makers.

The group, called the Biotechnology Industry Organization [BIO], wanted such language in the bill, the e-mails reflect.

"At Senator Frist's staff's request, this morning, BIO (Tom and I) participated in a meeting with three other industry representatives (Sanofi and an outside counsel who works for both Pfizer and Roche, I believe), administration staff (HHS, DoJ and WH Leg Affairs), and Liz Hall to further discuss liability," BIO official Dave Boyer wrote in a November e-mail obtained by Public Citizen.

[snip]

Frist and the White House reached out to the industry, according to the communications cited by Public Citizen, and Boyer, chief lobbyist for the industry group, was asked to provide an analysis of draft legislation.

The group asked that the legislation make clear that a vaccine maker could only be successfully sued if "willful misconduct" on its part were proved. The law includes that standard and says a company is protected from claims of negligence or recklessness.

The analysis, which Public Citizen quoted from, included BIO's concerns that the draft bill would have still allowed people hurt by vaccines to get jury trials.

"The lack of any restriction on jury trial is problematic," the analysis said. "Where injured parties have no other avenue for relief, juries are likely to find ways to award damages."

In another e-mail, Boyer described a meeting in which a deputy of Bush strategist Karl Rove said it was "important to the President that a bill move this year," and said "they had invited industry to discuss what they understood to be a few key remaining points" of contention. (The Tennessean)

Here's our small contribution to the story. The FDA Commissioner recently named David Boyer as his new Assistant Commissioner for Legislation. Boyer is the former Director of Federal Government Relations at BIO named in the article.

No thanks, I read the book

2006-05-09T08:01:00.000-04:00

Tonight those of you either overcome by some horrible fascination with what the media can do to a serious issue or who accidentally tune in to the ABC crapfest, "Fatal Contact: Bird Flu in America," will see what sounds like real fearmongering in action. I'm taking a pass. We've inveighed here enough about fearmongering about fearmongering. Our position is that if the truth is unsettling, it is at least the truth.

But this movie isn't the truth, it's fiction. And the fiction isn't meant to provide awareness and understanding, unlike the faux blog that appeared in the scientific journal Nature by science journalist Declan Butler. It is designed purely to make money for ABC during "sweeps week," where ratings determine advertising rates.

The ABC news division, like other big media news outlets, has made a credible effort to provide factual summaries of the evolving bird flu problem at their website, Bird Flu: Fears, Facts and Fiction. But the news division is separate from the entertainment division (at least in theory, although the nightly news and 20/20 seem to breach the separation distressingly often). In this case, anyway, the news division seems to be distancing itself from the network's disaster movie:

A few weeks ago, we began hearing about ABC Entertainment's plan to broadcast "Fatal Contact: Bird Flu in America," a made-for-TV movie depicting a massive avian flu outbreak in the United States. Over the course of the past week, we began to see promotional trailers for the ABC movie, which featured what appeared to be a "worst case" outbreak scenario. The promos reminded some of us of movies like Michael Crichton's "The Andromeda Strain," a 1971 science fiction classic about a lethal virus epidemic, and 1995's "Outbreak," directed by Wolfgang Petersen.

After watching the movie promos, a discussion developed among ABCNews.com writers, producers and editors focusing on how we can best share the depth of our website's avian flu coverage with an online audience which may flock to our website after viewing the ABC-TV movie on May 9.

Our ongoing news broadcast and web coverage of the H5N1 virus has been cautious, measured and responsible. Our coverage provides our readers a dependable and up-to-date resource on global developments relating to the spread of avian flu, gathered from diverse scientific, governmental and medical resources.

None of us in the newsroom have had a chance to view the "Fatal Contact" movie in advance of its May 9 debut. We do hope, however, that those visitors who do come to our Avian Flu page following the movie's broadcast on Tuesday will find a comprehensive and useful resource on a developing and unpredictable story.

By all means go to the ABC bird flu site if you wish. Our own choice, of course, is our sister project, The Flu Wiki, which has several thousand pages of content and links to many other sources of information. Unlike ABC's disaster movie, it is meant to empower people, not paralyze them with fear for ratings sake.

But then we don't make any money here or at the Flu Wiki. We have no advertisers and we charge no admission. Maybe we're doing something wrong.

Genetic susceptibility to bird flu?

2006-05-08T07:06:00.000-04:00

Dr. Robert Webster, one of the most eminent and experienced influenza virologists has been quoted as saying there might be a genetic component in susceptibility to bird flu. His views were echoed by another long time virologist, Hiroshi Kida.

"There has not been a single case of infection involving husband and wife," Kida said told Reuters. Kida is with the department of disease control at Hokkaido University in Japan.

Kida explained that people infected with H5N1 have a carbohydrate receptor on cells lining their throats. The receptor -- called alpha 2,3 -- is predominantly found in birds. Avian influenza viruses like to bind to this class of receptors to replicate and cause disease.

Human influenza viruses, however, prefer to bind to another receptor called alpha 2,6, which is dominant in humans.

"I think people who are infected with avian strains are special. They must have alpha 2,3 receptors," Kida said. (Reuters)

Infectious disease is a product of three interacting components, the host (here, people), the agent (the H5N1 influenza virus) and the environment (conditions of exposure, temperature, etc.). All three take part for influenza, as they do for almost every human disease, including those often thought of as "purely genetic." For example, harm from the inborn error of metabolism, phenylketonuria (PKU) requires a diet containing the amino acid phenylalanine (an "environmental" variable). For this reason, it is wise to be careful when interpreting claims of a genetic component to disease. The environment and how it modifies host defenses are also relevant in most every instance, as are host factors that are not strictly genetic, like occupational history, age and nutritional status.

The appeal of genetics as an explanation in bird flu stems largely from the fact that only a few of those heavily exposed to infected poultry have thus far become infected, giving rise to the question of what is "different" about them. Resort to some inborn defect or susceptibility seems so natural that we often don't think beyond it. If one person smokes half a pack a day and contracts lung cancer while another smokes three packs a day and dies in their nineties of "old age," we naturally think it's "in the genes." Possibly.

But consider this. If I flip a coin and it comes up tails and you flip the same coin, under identical conditions and it comes up heads, we don't say that I have the "tails" gene and you have the "heads" gene. Or if you see a movie and like it and I see the same movie and hate it, we don't say you have the movie-loving gene and I have the movie-hating gene.

Genetic factors are probably at work in virtually every human disease. We are an outbred species and hence vary from each other genetically in ways that might be important for one disease or another. But the situation is almost certainly far more complex. Hunting for a bird flu susceptibility gene isn't likely to get us very far, especially as the virus rapidly changes itself, changing the equation with it.

Kida's claim that no co-habiting unrelated cases have been described shouldn't be taken at face value, either. I don't know if it is true or not, since it is often difficult to be sure of case identities and their circumstances. This has been a disease of young people, so most cases in household clusters have been sibs or related cousins. If true, it as an interesting observation that might provide some ideas for new research. But it shouldn't be seized on as the key factor, any more than the very preliminary data the virus can only find cells to infect deep in the lung is the answer to why the virus so far has had low transmissibility. It might (or might not) be a factor, but we are far from being sure.

We want science to move fast and in the case of flu science it is moving with uncommon rapidity. But it is still a relatively slow process, as much as we wish instant answers.

Cowardice at CDC

2006-05-08T06:55:00.000-04:00

Another story about missing CDC backbone. This one about a panel presentation, "Public Health Strategies of Abstinence Programs for Youth," slated for the National STD (Sexually Transmitted Diseases] Prevention Conference in Jacksonville, Fla. Title before Congressman Mark Souder, R-Ind. intervened at DHHS? "Are Abstinence-Only Until Marriage Programs a Threat to Public Health?"

Just a title change, right? A title change plus two panelists whose presentations went through scientific peer review kicked off and two new panelists whose presentations weren't reviewed, substituted. The former presenters, Penn State student Maryjo Oster (whose paper was on how abstinence programs were tied to rising STD rates) and William Smith, director for public policy for the Sexuality Information and Education Council of the United States were appearing at their own expense. The travel of the new panelists, Patricia Sulak, the obstetrician and gynecologist Director of the Worth the Wait abstinence advocacy group and Eric Walsh, a California physician, are getting their way paid by HHS. Is this because CDC thinks students are richer than doctors?

The gross political involvement by a right wingnut CongressThing and by CDC was portrayed as a matter of "balance." (Balance as in, "And now, for another view of lynching . . . ") The excuse is the panel didn't have anything good to say about the public health aspects of abstinence programs. Maybe because there isn't anything good to say?

Sex education has been a hot-button topic between public-health officials and politicians for years. The president's 2007 budget request increases abstinence-program funding to $204 million, up $22 million from 2006, according to Bruce Trigg, who heads an STD program in New Mexico and is one of the panel members.

In most of these programs, Trigg said, it is mandated that when condoms are discussed, it is only to point out failure rates and how they are not 100 percent effective.

Condom use does prevent pregnancy and STDs, health officials say, and if people aren't encouraged to use them, they will be at risk for both.

Abstinence-only proponents say it is hard to measure their programs because often other sex education is involved. But [Jonathan Zenilman, president of the American Sexually Transmitted Diseases Association and conference organizer] said the conference panel focused on the problems with abstinence programs because there are no credible data -- and no credible applicants offering otherwise.

"We've spent $1.2 billion over a 25-year period on abstinence-only programs. Shouldn't we have one study that shows that they work?" asked William Smith, director for public policy for the Sexuality Information and Education Council of the United States. He is no longer on the panel. (Philadelphia Inquirer)

CongressThing Souder emailed HHS, asking if CDC was required to notify HHS about meetings and topics. HHS then contacted CDC. Magically the panel was changed and two non-scientist advocates substituted at HHS expense.

CDC is an agency already staggering under the twin blows of managerial incompetence and infiltration by political aparatchiks. The issue may this time may be abstinence, but once again we all got screwed.

Another example of cowardice at the leadership level at CDC. Nauseating.

The best policy (honesty)

2006-05-07T08:59:00.000-04:00

I am mystified by WHO's regional director for the Western Pacific, Dr. Shigeru Omi, continuing to suggest we have the ability to snuff out the start of a pandemic by rushing help and supplies to an affected area:

Omi said that -- if the deadly H5N1 virus mutates to spread easily among people, threatening a global outbreak -- the first sign would likely be a cluster of flu infections within a family or neighbourhood.

The WHO would rush a team to the site, confirm the start of a pandemic, and quickly administer the anti-viral drug Tamiflu to the local population.

"Certainly we would have to ask the area concerned to implement containment, restrictions of movement and social distancing," he said, referring to measures such as school and workplace closures.

"The whole process has to be done within two or three weeks," he said. (AP)

I'm sorry, but this just isn't going to happen in Thailand or Vietnam, not to mention the worse off China or Indonesia. As Omi pointed out, only about half of the notifications of human cases are now arriving at WHO within two weeks of occurrence, making it almost impossible to move quickly enough to apply the fireblanket approach of containing and saturating the population with antiviral treatment. All I can think of is he believes this is an incentive for better surveillance and reporting, which will be beneficial in giving everyone an earlier warning.

But wouldn't it be better to be truthful and say that speedy notification is essential to give everyone, including the country of origin, as much warning as possible to mitigate the effects of a gathering pandemic?

I know it's old fashioned to say that honesty is the best policy. Call me old fashioned.

Freethinker Sunday Sermonette: don't pray for this man

2006-05-07T08:52:00.000-04:00

Now we know what the problem is.

In a Sunday Sermonette a month ago we took notice of a study in The American Heart Journal on the efficacy of "intercessory prayer" by strangers. Patients undergoing by-pass surgery were randomly assigned to "not prayed for by strangers" and "prayed for by strangers" groups, the latter divided between those who knew they were being prayed for and those who only knew they might be prayed for. Neither of the "prayed for" groups did better than the "not prayed for" group, but the group who knew they were being prayed for by others did significantly worse.

Maybe this explains why George Bush is doing so badly:

Bowing his head many times as Christian and Jewish leaders offered prayers, the president thanked those who pray for him, calling it the greatest gift a citizen can offer him.

"In my travels across the great land, a comment that I hear often from our fellow citizens is, `Mr. President, I pray for you and your family.' It's amazing how many times a total stranger walks up and says that to me," Bush said. "You'd think they'd say, `How about the bridge?' Or, `How about filling the potholes?' No, they say, `I've come to tell you I pray for you, Mr. President'." (AP)

This admission of an incompetency risk factor was made at a meeting Thursday celebrating National Day of Prayer (I missed it, unfortunately; too busy blaspheming here on the blog).

The Prayed-For-in-Chief also expelled this thought: America's history is inexorably tied to prayer:

"America is a nation of prayer. It's impossible to tell the story of our nation without telling the story of people who pray," Bush said during a White House celebration of the National Day of Prayer. "At decisive moments in our history and in quiet times around family tables, we are a people humbled and strengthened and blessed by prayer."

This doesn't even make any sense. To say it's impossible to tell the nation's story without telling the story of people who pray means about as much as saying you can't tell the nation's story without telling the story of people who pee or who cheat or who do evil things or go to movies. It is true that people will sometimes turn to prayer in times of stress (how often we don't know). They also turn to violence or alcohol or drugs. People cope in different ways.

Anyway, stop praying for this man. The country can't afford for him to do even worse.

Vaccine initiative: good "in principle"

2006-05-06T08:55:00.000-04:00

Five pharmaceutical companies just got big contracts to work on cell culture based vaccine technology. Big, as in one billion dollars among them, big. These are said to be 5 year contracts, so this isn't the quick fix we might need if a pandemic strain develops in the next couple of years. But in principle, it is the right thing to do. Let me start with the "in principle" part.

Egg-based vaccine production is not going to be able to respond quickly or with enough vaccine to protect the world's population from a pandemic virus, whether H5N1, another influenza A subtype or some different microbe altogether. For viruses, where antibiotics don't work, immunization is the surest form of protection. CIDRAP has a good summary of the advantages of cell-based vaccines:

It takes about 6 months to grow seasonal flu vaccines in eggs, and the eggs must be ordered well in advance. Growing vaccines in laboratory cell cultures promises to be a somewhat faster and much more flexible approach. The method is already used for a number of other vaccines, such as polio, hepatitis A, and chickenpox.

[snip]

With cell-based production, companies can skip the step of adapting the virus strains to grow in eggs, the HHS statement said. In addition, the method will make it possible to meet increased needs in case of a shortage or pandemic, since cells can be frozen in advance and large volumes can be grown quickly, officials said.

Cell-based methods also sidestep the risk of loss of egg supplies because of various poultry diseases. Such methods also eliminate the drawback that people who are allergic to eggs can't receive vaccines grown in eggs. (CIDRAP)

This is still undeveloped technology for producing influenza vaccine because it never received the proper attention from government and the pharmaceutical industry had more profitable targets like Viagra or anticholesterol drug look-alikes. Why bother with vaccines? While not surprising, it tends to put a bit of the lie to Big Pharma's claims of public spiritedness and commitment to public welfare. Not that anyone believes that anyway, unless they are brain dead or CongressThings taking the sweet medicine of campaign handouts and other perks. In any event, investing in vaccine technology is a good idea, even if it is woefully late in the game to wake up. A good idea. In principle.

The catch here is that the administration suggesting this is also one of the most monumentally incompetent bunch of Keystone Kops the nation has seen in a very, very long time -- maybe EVER. Can we trust them to do ANYTHING right? Will the $1 billion even be spent properly and will the companies involved be held accountable? No one else in this administration is held accountable. Why will this be different?

It's not the amount of money I worry about. It's the bigger picture. While $1 billion is a lot of money, it pales in comparison to what we spend on other astounding screw-ups. Money for this initiative is contained in a supplemental emergency spending bill for the next credit card installment for the wars in Iraq and Afghanistan -- $92.5 billion. Bush said he'll veto the bill if it contains additional monies stuck on by CongressThings for pet projects, but everyone knows is a charade because the money will be eliminated in a House - Senate Conference Committee. This just gives Bush a chance to grandstand as a fiscal conservative:

"Congress has got to be wise about how they spend the people's money," Bush said at Frager's Hardware on Capitol Hill. "They've got to make sure the supplemental comes to me at a rate that I'll accept." (AP)

Wise about spending other people's money? The $1 billion for five years of vaccine development being given to the most profligate and greedy industry in the world -- $0.2 billion a year -- is less than one day's worth of war money going up in smoke and cascading down as blood. More than $ 0.2 billion a day, day after day, week after week, month after month, year after year. Has it made us safer than starting three years ago on cell-based vaccine work? Has it made us safer than investing $ 0.2 billion a day on making our health departments and social service systems work -- not work better, but work at all? Has it made us safer than giving every child in the world immunizations for the next 90 plus years (because it's that much money), thereby dramatically reducing infectious epidemic disease for us and doing the right thing as well?

These questions aren't rhetorical. They are real questions. But they also answer themselves. These people are privileged, inveterate liars, corrupt profiteers, and world class incompetents* who as a matter of course and a "God given right" take the lives of others for granted. Nothing could be more obvious to anyone whose eyes aren't closed.

*Partial list of decomplishments: war on Afghanistan, war on Iraq, corrupt failure of the "rebuilding" of Afghanistan and Iraq, spectacularly failed Katrina response, Medicare Part D, destruction of CDC, destruction of CIA, turning US military into Paper Tiger, making US international moral pariah, destruction of US moral authority in the world, made US laughingstock of world of science with support for Intelligent Design, opposition to evidence for anthropogenic climate change and blatant intrusion of politics into science policy, erasure of separation of church and State, sell out to big business and the Christian Right minority, quotas and affirmative action for Christian Conservatives in government, unprecedented lobbying scandal, . . .

No surprise unfunded pandemic response

2006-05-05T08:48:00.000-04:00

David over at Greenhammer has collected commentary links for the new US Flu Plan. Yesterday I said I liked the tone of the document and I think the assessment of what the feds are capable of substantively is realistic and sober (as well as sobering for those not paying attention). Their role in a pandemic would be far different than a localized natural disaster.

However as more people are examining the document two critiques are emerging. One is the leadership issue. How will Department of Homeland Security be able to manage anything, much less a public health emergency. I weighed in on that myself. The other is the burden being placed on states and local authorities. You can find links to these comments in the excellent Greenhammer post.

However I have somewhat mixed emotions about these latter complaints. It isn't that I don't think they have validity. It's one thing to say the burden will fall on local communities, yet another for the Bush administration and the Republican congress to have done so little to help them. But in addition the states have done little to help themselves. Along with cutting taxes and starving public services at the national level has come an orgy of the same at the state level, resulting in an enfeebled and anemic local public health infrastructure.

Democrats have gone along with this Republican initiative out of weakness or cowardice or stupidity or lack of principle. I simply won't give them a free pass on this. I hope now some true Opposition Party backbone is developing and that's to the good. But in addition there has been too little leadership and push back from the medical and public health communities. Indeed the latter stupidly embraced the promise of bioterrorism monies as a way to beef up public health infrastructure. Not only didn't that happen, but the bioterrorism follies hollowed out public health like a cancer, diverting personnel, energies and commitments. So now a real public health threat comes along and suddenly we discover we aren't prepared.

Surprise.

It's in the blood

2006-05-05T08:41:00.000-04:00

The least surprising thing about H5N1 is that it continues to surprise. The latest is in a Letter in the journal Emerging Infectious Diseases showing the presence of H5N1 virus in the blood stream of a 5 year old Thai boy from last December that ended fatally. Influenza virus has been detected in blood only rarely. On the other hand H5N1 has also attacked multiple organ systems, so it was getting around the body somehow. The EID communication suggests bloodborne spread is on the list of possibilities. Since viral presence in the blood is not routinely examined, this may be more common than previously assumed.

An article by the excellent flu reporter Helen Branswell discusses whether this has implications for the safety and integrity of the blood supply in the setting of a pandemic, or even a more limited outbreak.

Canadian Blood Services and the American Red Cross have been studying the issue, but currently it is believed that the risk is more theoretical than real, because influenza's incubation period is so short. Once people develop symptoms they would be unlikely to want to give blood and would probably be turned away if they showed up to a blood-donor clinic.

"From the blood-donor and blood-supply point of view, the issue would be whether there's virus in the blood before the patient becomes ill,” said Dr. Jeffrey McCullough, who holds an American Red Cross professorship in transfusion medicine at the University of Minnesota.

“Once you've got somebody that's sick, of course, they wouldn't be acceptable as a blood donor,” he said. (Branswell, Canadian Press)

To these ears there is an element of "whistling past the graveyard" in this response. And what about people who are asymptomatically infected?

The Letter writers also raise the question of precautions in the hospital or elsewhere.

Because probable H5N1 avian influenza transmission among humans has been reported, this case should be a reminder of the necessity to carefully handle and transport serum or plasma samples suspected to be infected with H5N1 avian influenza. Because viable virus has been detected in blood samples, handling, transportation, and testing of blood samples should be performed in a biosafety (category III) containment laboratory to prevent the spread of the virus to healthcare and laboratory workers. (EID, cites omitted)

Probably it makes sense for all bodily secretions to be treated as infectious in these settings.

What a difficult and dangerous virus this is.

Pandemics: who's in charge?

2006-05-04T07:52:00.000-04:00

The National Strategy for Pandemic Influenza, Part II, has arrived. It is up on the White House site (.pdf).

I've been paging through the hundreds of pages and find a lot to like, at least in tone and language. And some things that bother me. Like the not-so-minor matter of "Who's in charge?" Just days ago, based on earlier drafts of the plan it was reported the Department of Health and Human Services (DHHS) would be in overall charge. This seemed to resolve a dispute as to whether responsibility for the coordinated response would rest with DHHS or the Department of Homeland Security (DHS), the dysfunctional agency that so distinguished itself (in a negative sense) during Hurricane Katrina. (See here and here for previous posts on this.) But yesterday I heard Richard Knox, now NPR's senior health correspondent, say the plan as issued is not entirely clear on this issue, so I took a look. I think it is quite clear. Homeland Security is in charge:

It is important that the Federal Government have a defined mechanism for coordination of its response. The National Response Plan (NRP) is the primary mechanism for coordination of the Federal Government’s response to Incidents of National Significance, and will guide the Federal pandemic response. It defines Federal departmental responsibilities for sector-specific responses, and provides the structure and mechanisms for effective coordination among Federal, State, local, and tribal authorities, the private sector, and non-governmental organizations (NGOs). Pursuant to the NRP and Homeland Security Presidential Directive 5 (HSPD-5), the Secretary of Homeland Security is responsible for coordination of Federal operations and resources, establishment of reporting requirements, and conduct of ongoing communications with Federal, State, local, and tribal governments, the private sector, and NGOs. (Implementation Plan, page 3)

This says The Decider has already decided: under the National Response Plan, that in Incidents of National Significance (these are incidents that are capitalized, apparently), DHS is in charge. If the incident is a medical or public health emergency, Health and Human Services will provide the support function and be the government's spokesperson for public health issues, coordinating with DHS, who will in turn coordinate everyone else:

Pursuant to the NRP, as the primary agency and coordinator for Emergency Support Function #8 (Public Health and Medical Services), the Secretary of Health and Human Services will lead Federal health and medical response efforts and will be the principal Federal spokesperson for public health issues, coordinating closely with DHS on public messaging pertaining to the pandemic. Pursuant to HSPD-5, as the principal Federal official for domestic incident management, the Secretary of Homeland Security will provide coordination for Federal operations and resources, establish reporting requirements, and conduct ongoing communications with Federal, State, local, and tribal governments, the private sector, and NGOs. In the context of response to a pandemic, the Secretary of Homeland Security will coordinate overall non-medical support and response actions, and ensure necessary support to the Secretary of Health and Human Services’ coordination of public health and medical emergency response efforts. (Implementation Plan, page 3)

This "coordinating" stuff is really a lot of handwaving. The real action will unfold as these agencies interact, and when that happens this will be a true Federal Disaster Area:

A pandemic will present unique challenges to the coordination of the Federal response. First and foremost, the types of support that the Federal Government will provide to the Nation are of a different kind and character than those it traditionally provides to communities damaged by natural disasters. Second, although it may occur in discrete waves in any one locale, the national impact of a pandemic could last for many months. Finally, a pandemic is a sustained public health and medical emergency that will have sustained and profound consequences for the operation of critical infrastructure, the mobility of people and freight, and the global economy. Health and medical considerations will affect foreign policy, international trade and travel, domestic disease containment efforts, continuity of operations within the Federal Government, and many other aspects of the Federal response. (Implementation Plan, page 3)

"Unique challenges" is bureaucratese for "we have no idea how we are going to pull this off." Commonsense says that if you put the whole shebang in the hands of a screwed up agency (DHS) with a notorious penchant for throwing its weight around you are asking for trouble. Since its inception DHS has dominated any dispute between agencies. In this case this is also in line with the Bush administration's basic view that DHHS is a pile of bleeding hearts engaged in the illegitimate administration of entitlement programs.

The bottom line is that an agency with no expertise in medical and public health matters will be calling the shots regarding quarantine, transportation, resource allocation, use of federal resources and much else. If DHHS disagrees about something, that will be just too bad for DHHS. So DHS won the battle and the rest of us lost.

I'm sure they'll do a heck of a job.

In a pandemic information is good

2006-05-03T08:49:00.000-04:00

With the feds releasing their continuity of operations plans for pandemic flu today (it has been leaked so copiously there is nothing new to report) let's look at another other kind of planning that may or may not be going on. A recent pow-wow at the Clarion Hotel in Millbrae, California (~~Alameda County~~San Mateo County) featured a panel of "experts" opining on how the whole thing might come down.

There was the now familiar scenario and it was scary, all right. Not because of the scenario itself, but the lessons some of the panelist drew from it.

"The fragile hope is we can pounce on this early and contain it," said Dr. Anthony Iton, public health officer for Alameda County, who served on a panel at the event. "If we miss that opportunity, all bets are off."

By the fifth day of a hypothetical outbreak of a pandemic-caliber flu virus — one that spreads easily and is far deadlier than usual — public health departments might declare a state of emergency, Iton said. The leading candidate for causing such an outbreak is a now-famous flu virus called H5N1, which is carried primarily by certain bird populations.

Companies with affected employees would temporarily shut down, schools might close their doors, and federal health officials would jet into town to help control the outbreak and screen foreign travelers. Hospitals could face a run on their services and supplies, and public health workers would be working themselves to exhaustion. Patients would be kept in isolation, and all those potentially exposed kept under quarantine.

All this by Day 5. (Oroville Mercury-Register)

Um, excuse me. Will somebody tell them what the word "pandemic" means? It means disease that is sweeping the globe, not just Alameda Country in California. Do they think they are going to stop it there? Since they're in California, maybe they think they can get Dustin Hoffman to reprise his role in Outbreak. In truth they must be living in some kind of Parallel Universe. There is worse:

By the fifth day, eight other employees working at the hypothetical firm, called Manufacturer, Inc., develop respiratory illnesses. Between the fifth and the sixth day, four of the sick employees are hospitalized. Two employees die that day, as does a janitor at the company hospitalized with a severe respiratory ailment.

A laboratory confirms four of the fictional cases are H5N1. Local health departments and Manufacturer Inc. begin receiving calls from the media worldwide, and it temporarily closes its doors. Word spreads of the disease, and workers at other companies start staying home to avoid the virus. An employee at the stricken firm also starts a blog, chronicling the illnesses.

To confine the outbreak to just these unfortunate few, health officials would have to move swiftly, invoking laws rarely used since polio and smallpox outbreaks in the first half of the 20th century.

"These legal tools haven't been dusted off in 50, 60 years," said Iton, who also has a law degree.

"We're also in an era of civil liberties," Iton added. "The balance of power has shifted much, much further away from government power and much more toward individual liberties, which is not a bad thing."

No, civil liberties are not a bad thing. I hope they remember that when they are dusting off the old tools.

And while they are dusting off the old tools, I hope they also remember information isn't a bad thing either.

Communication, Iton emphasized, is also crucial during an outbreak. A priority is communicating with politicians early, he said, to prevent them from inflaming the situation with misstatements.

"We don't want them saying stupid things," Iton said, as the participants laughed.

Echoes of the worst impulses of health officials. Don't release information for fear of "inflaming the situation." Of course, if the entire global epidemic is starting in Alameda County, that's different.

Significantly one of the non-public health panelists "got it."

Key in controlling an epidemic is media outreach, another panelist added.

"The blog doesn't bother me," said Jeffery Tanenbaum, a partner with the law firm Nixon Peabody LLP, referring to the hypothetical employee blog. "I'm operating on the principle that information is good."

Yes, the blog. Information is good.

Eggs no longer welcome in Omaha schools

2006-05-03T08:39:00.000-04:00

Here's a curious little story from Omaha, Nebraska. Students in public schools there will no longer see chicks hatch as part of a science unit. Reason: bird flu.

Now this sounds fairly bizarre until you hear the reasoning:

O-P-S [Omaha Public Schools] official Janelle Mullen says every egg supplier the district talked to required a responsibility release.

She says, quote, "And that got our attention." (KOTA-TV)

Whether it makes sense or not, it does get your attention.

Iraqi clinic boondoggle

2006-05-02T06:43:00.000-04:00

When last we saw the Clinic Boondoggle, a month ago, the plan to provide Iraq with a modicum of medical care which the war destroyed was about to receive Last Rites. Now a federal report presents the autopsy results:

A $243 million program led by the United States Army Corps of Engineers to build 150 health care clinics in Iraq has in some cases produced little more than empty shells of crumbling concrete and shattered bricks cemented together into uneven walls, two reports by a federal oversight office have found.

The reports, released yesterday, detail a close inspection of five of the clinics in the northern city of Kirkuk as well as a sweeping audit of the entire program, which began in March 2004 as a heavily promoted effort to improve health care for ordinary Iraqis. The reports say that none of the five clinics in Kirkuk and only 20 of the original 150 across the country will be completed without new financing.

[snip]

Interior photographs of the structures show bare walls made of brick fragments through which sunlight streamed and stairs made of concrete already crumbling into dust.

And when inspectors compared what they saw to progress reports, some of the numbers seemed suspiciously high. One structure, essentially a rickety shell of uneven bricks, had been declared 56 percent complete. The second floor of another shell held up by little more than wooden sticks — a standard method of bracing unfinished floors in Iraq — had been declared half complete. (New York Times)

Poor cost accounting, incompetence and lax oversight by the Corps are blamed, although the stench of corruption hangs over it, as with everything this Administration touches. Yes, it's a tough environment. Yes, the Corps made laughably incompetent management decisions.

And yes, $243 million is a shithouse full of money.

Turning point in Iraq

2006-05-02T06:40:00.000-04:00

Yesterday President Bush announced we were at a "turning point" in the war in Iraq, the seventh such turning point in two years (h/t Think Progress):

President Bush today called the formation of a new Iraqi government "a turning point," after hearing from Secretary of State Condoleezza Rice and Secretary of Defense Donald H. Rumsfeld about their weekend meeting with that country's prime minister designate. (5/1/06)

BUSH: There’s still a lot of difficult work to be done in Iraq, but thanks to the courage of the Iraqi people, the year 2005 will be recorded as a turning point in the history of Iraq, the history of the Middle East, and the history of freedom. [12/12/05]

CHENEY: I think about when we look back and get some historical perspective on this period, I’ll believe that the period we were in through 2005 was, in fact, a turning point; that putting in place a democratic government in Iraq was the - sort of the cornerstone, if you will, of victory against the insurgents. [2/7/06]

CHENEY: The basic point, and one I’ve made already that I believe that the elections were the turning point. And we had that election in January — first free election in Iraq in decades. [12/18/05]

MCCLELLAN: The election is a victory for the Iraqi people. It’s a significant step forward for freedom and it is a defeat for the terrorists and their ideology. It marks a turning point in Iraq’s history and a great advance toward a brighter future for all Iraqis, one that stands in stark contrast to the brutality and oppression of the past. [1/31/05]

BUSH: Tomorrow the world will witness a turning point in the history of Iraq, a milestone in the advance of freedom, and a crucial advance in the war on terror. The Iraqi people will make their way to polling centers across their nation. [1/29/05]

BUSH: A turning point will come in less than two weeks. On June the 30th, full sovereignty will be transferred to the interim government. The Coalition Provisional Authority will cease to exist, an American embassy will open in the capital of a free Iraq. [6/18/04]

Obviously progress is being made at a dizzying pace.

"Benign" bird flu in the UK

2006-05-01T07:53:00.000-04:00

Three poultry farms in eastern England (Norfolk county) have been afflicted with avian influenza, subtype H7N3. Since this is not the H5N1 subtype now rampant in birds in some 40 countries and over 200 cases and 100+ deaths in people, it is being described as "less dangerous to humans." Possibly. The fact is that H7 subtypes H7N7, H7N2 and (as here) H7N3 have infected human beings in the past and there is currently one confirmed infection in this outbreak. Three workers suspected of being infected are reported to have tested negative, but the three cases all had conjunctivitis ("pink eye"), a known presentation of H7 infection in humans, strongly suggesting the "negatives" are false negatives.

Since the consequences of infection are mainly benign, self-limiting cases of red eyes, tearing and itching one would think there is nothing much to worry about in any case. But there is more to it. In the largest outbreak to date, the H7N7 episode among poultry cullers in The Netherlands in 2003, the virus showed itself readily transmissible from person to person and fatal in one case, a 57 year old veterinarian who succumbed to the kind of viral pneumonia typically associated with H5N1. While the predominant symptoms in the 89 symptomatic Dutch worker cases was conjunctivitis, there were also seven cases of influenza-like-illness (ILI), defined as sudden onset of fever, muscle aches and pains and cough, runny nose or sore throat (see paper by Fouchier et al. here). Mask and goggle use by cullers seemed to have no effect, but Tamiflu did. Using antibody evidence of infection, moreover, an estimated 1000 people were infected and those infected passed on the infection to 59% of household contacts (Science 306:590, 2004).

The Dutch H7N7 was genetically similar to a low pathogenic H7N3 and H10N7 in Dutch ducks but had an HA cleavage site characteristic of high pathogenic strains. The suspicion was that the virus might have come from wild birds and mutated to a high path form in chickens. The virus from the fatal case was isolated as well and showed 14 separate amino acid changes in various genes when comparing it to the virus isolated from the chickens. This included the E627K mutation in PB2, characteristic of many H5N1 strains, as well as four other PB2 changes (see Table 1 in Foucier paper). By contrast, the virus isolated from the conjunctivitis cases has only one amino acid change (in the NS gene). Thus the H7N7 mutated significantly even during this outbreak but dead-ended in the fatal case.

An interesting paper by Olafsson et al. in 2005 (abstract) speculates that the conjunctivitis in the reported outbreaks of H7N7 and H7N3 might be related to the fact that the tissues covering the eyeball (the conjunctivae) have &alpha;2, 3 linked sialic acid receptors on them (the kind that bird viruses latch on to), but the tears and fluids bathing the eye have α2, 6 receptors, thus protecting the eye from human but not bird viruses. The situation in the human upper respiratory tract is just the reverse. The cells have α2, 6 receptors but are covered with a protective mucin layer with α2, 3 linked sialic acids. Olafsson et al. also wonder if the eye might not be an efficient way for bird viruses to make their way to the nose and throat through the nasolacrimal duct (tear duct), possibly allowing either adaptation or reassortment there with co-infecting human influenza viruses. Thus I don't feel especially comforted by the Dutch and UK examples of a supposedly benign bird flu virus. The H7 subtype seems readily transmissible and also has the potential to change to a highly virulent form in humans, although it didn't have both characteristics at once.

The UK cases also carry another warning. Because of the recent H5N1 cases in a Scottish swan UK poultry farms are on high alert and presumably practicing good biosecurity. Despite this, avian influenza struck one poultry farm and spread to two neighboring farms. The mode of spread is currently under investigation, but claims by the US poultry industry that they are unlikely to be affected even if H5N1 arrives here on wild birds because of their biosecurity measures sound rather less reassuring.

Influenza finds its natural host in birds. We are now seeing it spread from birds to humans and other species, where it is changing character. The reasons for this are not known, but suspicion must certainly fall on the huge factory poultry farms that jam birds together under unhygienic conditions made to order for epidemic disease in birds.

And from them to us.

A billion here, a billion there . . .

2006-05-01T07:39:00.000-04:00

As Everett Dirksen once said about the Defense budget, a billion year, a billion there, pretty soon you're talking about real money.

Yesterday it was scandal at the FDA. Today let's do the Veteran's Administration.

A subcommittee of the House Veterans Affairs Committee has opened a preliminary inquiry into a veterans administration contract with QTC Management Inc., a firm headed by former Veterans Secretary Anthony J. Principi.

Brooke Adams, a spokeswoman for the committee, said Friday that members agreed to the bipartisan inquiry after a report in The [Los Angeles] Times on QTC's multimillion-dollar contract to conduct medical examinations of veterans applying for disability assistance.

[snip]

Principi has stated that he recused himself from all matters relating to QTC during his four-year tenure as VA secretary ending in early 2005. QTC and department officials have also stated that the contracts were awarded in full accordance with federal bidding requirements.

Principi was the president of QTC in late 2000 when he was nominated by President Bush for the top veterans post. He returned to the firm, based in Diamond Bar, as chairman of the board in December 2005.

The Times reported Sunday that payments to QTC during Principi's tenure totaled $246 million. The Congressional Budget Office projected fees to QTC of $1.2 billion if its contract with Veterans Affairs was fully funded through 2008.

The original contract was awarded to the firm in 1998 and it won a second contract in 2003. Though the agency advertised for bids in 2002, no other firm submitted a proposal.

The contracts were awarded under a pilot program at 10 locations across the country. Under a series of amendments to those contracts, some approved during Principi's VA tenure, QTC also was authorized to conduct physicals on members of the military prior to their discharge.

The physicals to meet both Department of Defense and VA requirements were billed as cost-saving moves and recommended earlier by a congressional commission headed by Principi, before he joined QTC. (LA Times)

$1.2 billion. Is there no limit to the corruption of this Administration?

Scandal now reaches the FDA

2006-04-30T09:06:00.000-04:00

It just goes on and on. There are so many Republican scandals going on in parallel it is hard to keep track of them. Since this is a public health blog, let's just do the latest, involving the former head of the US Food and Drug Administration Lester Crawford. He resigned in September, just three months after being confirmed by the Republican Senate. Reason? It was time for someone else to lead the agency. Three months. That's time. He is now (what else?) a lobbyist in Washington.

Commissioner Crawford, you may remember was involved in nixing over the counter (OTC) sales of Plan B, the emergency contraceptive otherwise known as the "morning after" pill (see here and here). Despite recommendations from FDA and independent scientists that the drug was appropriate for ale OTC, the FDA declined to approve it. Virtually everyone involved knew this was a political pay-off to Bush's right wing conservative base. So the FDA is being sued by the Center for Reproductive Rights (CRR). As part of this suit, the CRR's lawyers have been taking depositions (questioning under oath) of FDA officials. On Thursday it was to be Crawford's turn.

[But on] Wednesday Ms. [Barbara] Van Gelder, who is his personal lawyer, asked for a delay, saying she would instruct him to invoke his Fifth Amendment rights. Dr. Crawford previously declined to answer questions from the Government Accountability Office about Plan B.

Ms. Van Gelder told Magistrate Judge Viktor V. Pohorelsky of the District Court for the Eastern District of New York on Thursday that Dr. Crawford had been represented by Justice Department lawyers in the reproductive rights center's suit.

According to the transcript, she said that Dr. Crawford was under criminal investigation and that the issue of his financial disclosures "is within the grand jury." (New York Times via Atrios)

Whoa. What's this all about? It seems financial disclosure forms showed that in 2004, when he was deputy FDA Commissioner and then Acting Commissioner, either Crawford or his wife sold shares in companies also regulated by the FDA (not that Crawford would ever let outside considerations affect his judgment).

Criminal investigation. I guess this is a bit of a fly in the ointment of Crawford's cushy retirement life as a Washington lobbyist. I wonder if he has a Plan B?

Freethinker Sunday Sermonette: Oh, Canada

2006-04-30T08:59:00.000-04:00

Sunday. Reading the news.

Polling in the US and Canada in the last year or two provides a snapshot of attitudes of the electorates in each country regarding religion and politics. Since the questions were different in the Canadian and American polls it is hard to compare them directly, but it is interesting to see the effect on Canadians of American views on the subject.

Earlier this month, Kevin Phillips summarized in The Nation results of several national polls in the US. More than 60% of "conservatives" and "republicans" (two separate -- but equal? -- categories) believe that a political leader should rely on religion when making policy decisions (Source: ABC/Washington Post poll, April 2005), with the figure for "democrats" and "liberals" in the low to mid twenties.

Canada just elected an evangelical Christian, Stephen Harper to lead their government, so it's interesting to look at their attitudes. According to a poll by CanWest News Service this month, 63% of respondents said they'd vote for an evangelical Christian "even [sic] if they liked the party and its views." (down from 80% ten years ago) but 68% said they'd vote for a Muslim or atheist candidate as well (down from 74% and 72% ten years ago). These are clearly different questions than posed to Americans, but comparing responses to the same questions within Canada shows slippage for identifying religion and politics. Canadian analysts suspect the US scene has something to do with it:

Mr. [Andrew Grenville, a senior vice-president of the polling firm Ipsos Reid] speculated that nervousness about American politics -- more so than the "Harper factor" -- is responsible for Canadians shying away from politics with religious overtones.

"One part of it is probably the Stephen Harper factor, but I don't think he has been really wearing his religion on his sleeve, nor really embraced strong moral stances that can be traced back to religious belief," Mr. Grenville said. "It's the U.S. example that has really turned people off."

The religious right in the United States is considered to be largely responsible for sending President George W. Bush back to the White House in 2004.

Moreover, the invasion of Iraq, which Canada did not support, was widely regarded to be infused with religious overtones.

"I wonder if we're being reactionary when we hear George Bush spouting off Bible verses along with rhetoric around his war?" said Richard Ascough, a religious scholar at Queen's University in Kingston.

[snip]

In Canada, there was also a slip in the belief Christians should get into politics to protect their values, with only 39 per cent agreeing with the idea, compared with 46 per cent a decade ago.

There was also a five per cent drop -- to 40 per cent from 45 per cent -- in the number who believe it's essential for Christian values to play a major role.

Mr. Grenville said he believes there's been a bit of a backlash against the divisive political debate in the last couple of years over same-sex marriage.

"To me it suggests a growing divide in Canadian culture where religion can become that wedge that pushes people apart," he said. (Ottawa Citizen)

So the news from Canada isn't all bad, despite electing a religious rightwinger to lead them. And the same Canadian article suggests the backlash is happening in the US as well:

Americans who were surveyed also appear to be less inclined than they were a decade ago to vote for a leader who is an evangelical Christian, even if they liked the party and its views.

Only 64 per cent would do so, compared with 78 per cent 10 years ago. The results also suggest Americans would be more likely to vote for atheists or Muslims as leaders than they would have been in 1996.

Someday future generations will look back on this era as some kind of weird Dark Age that gripped the country before the sun shone again. I hope it doesn't come complete with a modern version of The Plague.

Shorter road to Tamiflu synthesis

2006-04-29T08:20:00.000-04:00

Kudos to the Elias J. Corey laboratory at Harvard University for a chemistry tour de force and for their position on intellectual property rights. Both are important. First, the chemistry.

A serious obstacle to ramping up oseltamivir (Tamiflu) production in anticipation of a possible pandemic of influenza/A has been its long production cycle. Pharma giant Roche initially claimed the drug could not be made in less than 12 months and required more than a dozen steps, some of them involving very hazardous materials. It also required the use of expensive and scarce ingredients, (-)-shikimic or (-)-quinic acids. Shikimic acid is derived from fermentation of Chinese star anise fruit, in limited supply.

Now Corey has devised a way to make oseltamivir without these complex starting materials and without hazardous intermediates. A second alternative route by Japanese researcher, Masakatsu Shibasaki, is also said to have inexpensive starting materials and no hazardous steps, but smaller yield:

"Our synthetic pathway has several advantages over the current Roche production method," Corey says. "It is shorter, doesn't involve any hazardous substances, begins with very cheap starting materials that are pennies per pound, and has excellent overall yield." Corey's overall yield is about 30%—about twice that of the commercial route and significantly higher than the approximately 1% that can be calculated for Shibasaki's.

[snip]

Although Roche researchers declined to comment on the new synthetic routes, a spokeswoman says the company is in contact with the authors of both papers. Both the technical potential and regulatory impact of any new route still have to be explored, she comments. In his group's paper, Corey, who serves as an adviser to Palo Alto-based Roche Biosciences, thanks Roche researchers in Switzerland for their encouragement. (Chemical and Engineering News)

There is some way to go before either method is in production, but the more important part of the announcement is that Corey has placed his method in the public domain. Shibasaki, by contrast, has applied for a patent, although this wouldn't prevent him from allowing no cost licensing if he wished. However, given the situation, Corey's move is highly significant and should be considered a model for others.

"I hope the work will stimulate others to work on different ways of synthesizing Tamiflu," Corey says. "Although our route is already very efficient, it's conceivable that when you put new developments together, you'll have an even better and cheaper process. I think the Tamiflu supply problem is solved."

Solved, that is, if someone will make the drug with this process. Roche has invested much in production facilities using a process for which they have the license. On the other hand, many independent companies may now use this new process, with or without Roche's permission (Roche still has the license for the drug itself).

In 1990 Corey won the Nobel Prize in Chemistry for his achievements in chemical synthesis. He hasn't lost the touch.

Nor the commitment to the common good.

The doctor will see you now

2006-04-28T06:29:00.000-04:00

There's no flu emergency now. No heat wave. Just normal times. What's "normal" in the Emergency Department?

CDC has just reported that 10% of emergent cases (patients who should be seen in less than 15 minutes after arrival in the Emergency Department) and 20% of urgent cases (should be seen in under an hour) had waiting times of more than an hour to see a doctor. These two categories constitute half of all ED visits.

And if you are black or Hispanic you were even more likely to wait:

If this is "normal," what do you think a flu pandemic will be like at your friendly neighborhood Emergency Department?

The mask problem

2006-04-28T06:26:00.000-04:00

As noted previously, the "mask question" was kicked over to the Institute of Medicine (part of the National Academies of Science). The report came out yesterday.

If a worldwide flu epidemic strikes, face masks should be considered a defense of last resort since there's little evidence about whether the masks available to the average person or most health care workers can prevent influenza infection, the Institute of Medicine said Thursday.

[snip]

Health workers use masks — simple surgical masks or better-filtering ones called N95 respirators — mostly to keep from breathing their own germs into open wounds or onto otherwise vulnerable patients. But certain filtering masks also can protect wearers from specific respiratory diseases, such as tuberculosis.

The masks are supposed to be used once and discarded. Anticipating a staggering demand if the bird flu or some other super-strain of influenza sparks the next pandemic, federal health officials asked the IOM to determine whether there are masks that could be reused safely, to conserve supplies. (Lauran Neergaard, AP)

Do masks work for influenza? No one knows:

The first question is whether different masks really block influenza, noted the IOM panel — a question the government didn't ask, but that the scientific advisers said should be studied, urgently.

"Just to double-emphasize: We don't have good data to make a decision about how effective they are or are not," said panel co-chair Dr. Donald Burke of Johns Hopkins University.

It would seem a no-brainer that using a mask is better than not using one. But that depends on whether the mask affects your behavior, for example, encouraging you to do things you wouldn't do without it, like go into crowds. As we have noted here a number of times, we don't understand completely how flu gets around, specifically the relative importance of object to hand to mouth/eye versus large (quickly settling) droplets from coughs or sneezes versus tiny droplets that remains suspended for hours or days.

Filtering masks also have to be professionally fitted to the user's face (forget it if you have a beard). Assuming the mask works for flu (an open question), its outside remains contaminated, so it has to be handled and disposed of carefully. The IOM panel was reluctant to discourage people from wearing a mask because it honestly didn't know their value.

Masks thus join Tamiflu and the current experimental vaccines as methods absorbing a lot of resources but of unproven effectiveness. Better to invest in the harder but proven methods of strengthening the public health system and its social service counterparts. Those work, pandemic or no pandemic.

Better to bite the bullet than to wait for a magic one.

So you want to be a model

2006-04-27T07:18:00.000-04:00

[NB: corrected the date]

The results from yet another computer model of pandemic influenza spread have just been published in the journal Nature. They are being variously interpreted and reported by news sources. CBC News says they show there is no magic bullet to control flu, but HealthDay says fast treatment and isolation of the sick and their households is "key to effective control of any flu outbreak." On the glass-is-half-empty side we have an AP story:

If pandemic influenza hits in the next year or so, the few weapons the United States has to keep it from spreading will do little, a new computer model shows.

A pandemic flu is likely to strike one in three people if nothing is done, according to the results of computer simulation published in Thursday's journal Nature. If the government acts fast enough and has enough antiviral medicine to use as preventive dosings — which the United States does not — that could drop to about 28 percent of the population getting sick, the study found. (Seth Bornstein, AP)

What are we to make of these results, especially compared to a slightly different set announced two weeks ago from another group at Los Alamos National Laboratory? Let's talk about models.

It is a truism among modelers that all models are wrong, but some models are useful. The art of mathematical modeling consists in stripping down to its bare logical skeleton the part of the real world you are interested in. If you have included enough of what is important and discarded enough of what isn't you may be able to see things that are useful when you turn the mathematical crank. (I'm simplifying, but then that's what modelers do. Call this meta-modeling.)

One of the oldest and simplest mathematical models of infectious disease dynamics is called an SIR model: S stands for susceptibles, I stands for infectives, R stands for recovered or removed (possibly by death or immunity). The game consists in modeling what happens when you introduce a certain number of infectives into a susceptible population. If you assume that every susceptible has the same chance of coming in contact with an infective that a certain fixed proportion of those contacts result in new infections in each time interval, that the disease lasts a certain length of time with a fixed proportion of those infected recovering and another fixed proportion dying, then you can make some statements about what will happen given various starting points of initial infectives and susceptibles, and contact, transmission, recovery and mortality rates.

I teach students to do this using the techniques of ordinary differential equations but it can also be done by simulating the whole thing with a computer. You start out with the infectives. On day one they come in contact with the designated number of infectives, a proportion of those cause disease, etc. That gives you the number of new infectives and susceptibles at the end of day one. The computer moves on to day two. And so on.

This is a pretty simple model and some of the assumptions are highly questionable. Mixing isn't random in the population, not everyone is alike in his or her susceptibility or ability to transmit, infection and mortality rates differ with age, etc. With some ingenuity and a couple of supercomputers working in parallel you can incorporate a lot of complexity and do it for very large populations, whole nation-sized populations even.

A lot of the hard work consists in trying to figure out the parameters of the model. The parameters are the numbers like contact rates in different age groups and subpopulations, transmission rates, etc. Inevitably important elements aren't included. In the recent Nature paper, no account was taken of any resistance developing to the drug Tamiflu. You hope that the omitted factors are only important on the margin, not centrally. Anyway, you'll get a grant to stick them in the model next go around.

The Los Alamos modelers and the modelers who just published in Nature know what they are doing. They are among the best infectious disease modelers we have and these papers as well as those from some other groups are tours de force. But of course they are wrong. All models are wrong. The question is whether they are useful. This question needs to be made a bit sharper: useful for what?

If you know a lot about the mechanism and are sure of the parameters, mathematical models can be highly accurate and predictive. We use them to put spacecraft into orbit or figure out the efficiency of engines. That's because we have Newton's mechanics and thermodynamics to help us. We aren't so lucky in modeling infectious disease dynamics. But even if there is a lot of uncertainty about mechanisms and parameters the models can still be useful for some things.

We might be able to get some qualitative idea of disease dynamics, say, without being able to make exact quantitative predictions. For example, does the disease spread, involving more and more of the population with time until all are infected? Or does the number of diseased bounce around, going up and down, perhaps chaotically or regularly? Or does the disease sputter and peter out? Often this kind of qualitative description is extremely useful because the same general behavior occurs over large ranges of parameter values, for example, uncontrolled spread occurs over large ranges of transmission rates, contact rates and initial numbers of infectives. This means you don't have to get all these factors exactly right, but it might also mean that there are some things, like rate or pattern of spread you can't predict. As you make your models more and more "realistic" (meaning you think you have included more and more important things that will allow you to come up with more specified predictions), your model can also become more sensitive to the actual choices of parameters. You may test how sensitive your model is to the guesses so that you can get an idea of how far off it might be.

Back to the influenza models. You will find that they differ in how parameters are estimated, which elements of the real world are included (and how finely), how transmission and contact rate are modeled -- and in lots of other ways as well. All the choices are quite defensible and you hope the ones that were made don't screw things up by leaving out something important or including something unimportant that obscures what you want to see. Modeling is a process of successive approximations. You hope you are getting closer and closer to the real world. Unfortunately, most of the time we can't test them. There is a heavy dose of faith needed (this is not a religious statement!).

So here's where I am with the models. I think they are valuable for suggesting in broad outline general behaviors, such as closing borders doesn't seem to affect spread and peak case loads much. That's not conclusive that closing borders won't work, but it lends weight to what many experts believe on the basis of inference from experience and there is always something about saying it came from a computer that is persuasive to policy makers.

But we still have to use these models carefully. Take the quote from the AP article. Use of antivirals and isolation might reduce peak rates from 33% to 28% according to the model. What this really says is that even unrealistically widespread use of antiviral therapy and isolation doesn't do much. The "not much" of 5% suggested by the model shouldn't be taken too seriously because relatively small alteration in model assumptions could change the numbers somewhat even though the "not much" would still be true. On the other hand, there are cases where abrupt changes in qualitative outcome (for example uncontrolled spread versus containment) are very close to practically attainable parameter values (such as 50% effective antiviral use). We shouldn't believe that 50% works but 45% doesn't, even if the model says so. The models are being made to bear more weight than they can handle in that case.

To sum up: All models are wrong, but some models are useful. And many models are used wrongly. They are valuable if used wisely and understood properly but can be misleading if used blindly.

Not that that would ever happen.

Greenhammer does King County

2006-04-26T06:56:00.000-04:00

Another flu blog. They seem to be replicating. Many are really excellent, although I can't say I keep up with most of them. Too busy with this one.

However I did get notice of a fledgling I'll keep my eye on, the blog Greenhammer. It interests me because it is dedicated to news of pandemic preparedness in King County, Washington (Seattle and environs). The King County Health Department is one of the most forward looking in the nation on preparedness issues and I am looking forward to hearing more about what is going on there. I hope the new blogger, David Baum, will tell us, and do it in detail.

We need to learn from each other and there is much we can all learn from King County.

Welcome to the blogosphere, Greenhammer.

Your travel plans are not just your business

2006-04-26T06:54:00.000-04:00

If you mess around with people's privacy, the result is that there is resistance to every new measure that involves wholesale collection of personal information. CDC wants to collect personal information on all domestic and international travelers, they say to help track an epidemic.

"What we're asking for is the authority to collect the information in the context of modern travel on airlines," Dr. Marty Cetron, the Center for Disease Control and Prevention's director of global migration and quarantine, said Tuesday in a telephone interview with The Associated Press.

"There's just a number of conditions where acting quickly with electronic access to passenger information is going to make a lot of difference," Cetron said.

The CDC wants to be able to easily find, notify and recommend treatment to airline passengers who have been exposed to bird flu as well as such diseases as plague, dengue fever or SARS -- even if the travelers' symptoms don't appear while they're traveling. (Boston Globe)

The financially fragile airlines industry hates the idea, saying it will cost billions of dollars to get full name and address, emergency contact numbers and detailed flight information on every passenger and keep it for 60 days in a form ready for instant retrieval should CDC ask for it. One impulse for the measure is the difficulty public health authorities had tracking down SARS cases in the 2003 outbreak. CDC got information from paper customs declarations but much was inaccurate or useless.

But this isn't the only effort to get personal information of travelers. The Transportation Security Agency (TSA) has been trying to get airlines to share their electronic domestic manifests so names can be checked against the notoriously inaccurate terror suspect watch lists. International flights already give names to the Department of Homeland Security who has agreed to give them to CDC, in violation of an agreement with the European Union that such information can't be shared. Clearly this Administration doesn't care about international agreements and probably wouldn't care about any agreements they made about CDC data.

And therein lies the problem. This wouldn't stop a bird flu epidemic, although it is conceivable it could be useful in some cases, like SARS. But no one trusts the Bush Administration to use private information solely to protect public health. The Bushies are notorious violators of civil liberties, not to mention international law, which they flagrantly ignore, making this a rogue nation in every way but name.

Here is the expected (and rational) reaction to these proposals:

Infectious disease experts and the American Civil Liberties Union raised concerns on Friday [April 22, 2006] about an agreement that would allow U.S. Centers for Disease Control and Prevention and customs agents to detain anyone who looked sick with bird flu.

The memorandum of understanding, a copy of which was provided to Reuters, also provides for Customs and Border Protection agents to give personal details of airline passengers to the CDC.

It was signed in October by Health and Human Services Secretary Michael Leavitt and Homeland Security Secretary Michael Chertoff. HHS spokeswoman Christina Pearson denied it was secret or sinister.

[snip]

"CDC is authorized to isolate and/or quarantine arriving persons reasonably believed to be infected with or exposed to specified quarantinable diseases and to detain carriers and cargo infected with a communicable disease," it reads.

It also provides for Customs or Border Patrol agents to forcibly detain, if necessary, anyone coming in who appears to be sick while the CDC is contacted. (Maggie Fox, Reuters)

Not surprisingly, the threat of a bird flu pandemic is being used as a lever to get this unpalatable measure accepted, although the idea it would stop flu is just plain stupid, or, as Dr. D.A. Henderson said more kindly, "silly."

But Dr. Donald Henderson, an expert on influenza, smallpox and other infectious diseases who has advised the administration of President George W. Bush on such issues, calls it "silly."

"I was absolutely astonished when I saw that proposed federal regulation," Henderson said in an interview.

"It's so silly," added Henderson, who now works at the Baltimore-based Center for Biosecurity at the University of Pittsburgh Medical Center.

Henderson noted that people can be infectious with influenza and other diseases long before they begin to feel sick or show any symptoms.

"You are spending huge amounts of money and have we got any evidence that this is going to do anything? Is it worth all the energy we are going to be putting into it?" he said. (Reuters)

This comes as many suspect the core of the Bush administration's "plan" for doing something about bird flu is forced quarantine:

The ACLU [American Civil Liberties Union] believes that protecting the public is not the motivation.

"The tracking of data on airline passengers, which can amount to building lifetime dossiers on Americans, has been a hotly debated issue for many years -- and now we find out that two government agencies may have agreed, behind the public's back, to share data," said Barry Steinhardt, director of the ACLU's Technology and Liberty Project.

ACLU legislative counsel Tim Sparapani said: "Once again, we are seeing that DHS cannot be trusted to exhibit restraint in the handling of personal information.

"They collect information, say they'll use it for one purpose, and then they turn around and use it for another."

The Center for Biosecurity's Penny Hitchcock, a former National Institutes of Health infectious disease specialist, said the CDC risks losing the public's trust.

"The information that will be collected by CDC/HHS is part of this quarantine effort -- sharing information collected for disease prevention could be harmful," she said.

"The harm being that it will create suspicion and encourage people to regard the public health service as 'disease cops.' Why would people want to cooperate under those circumstances?" (Reuters)

Fear of disease brings every crooked quack out of the shadows to prey on people. It also gives license to crooked governments to do things they couldn't do otherwise. So it's not enough to "just" worry about a truly worrying disease, avian influenza. We also have to watch our backs for a truly worrying government, the dishonest and malevolent Bush administration.

Maybe on balance it doesn't bother you that much. If you trust them, then I've got a used car you might be interested in. You can drive it across the bridge in Brooklyn I'll give you a 99 year lease on as you head for the beachfront lot I'll sell you in the Everglades.

That's where the WMDs are.

Timing is everything

2006-04-25T08:05:00.000-04:00

Who needs OSHA, anyway? We know the Bush administration and its patrons don't. We know the right wing nutcases at Cato Insititute and the Heritage Foundation don't. We know the Republican congress doesn't. Who does?

This via (Koufax Award winning blog) Confined Space:

Medina Township - Building inspectors say they got there just in time.

They had just shut down construction of a new building for the Goddard School for Early Childhood Development, moving the work crews out from under the newly raised roof.
No more than 10 minutes later, the roof fell in and part of the walls collapsed. An OSHA investigator was on the scene, as were county inspectors. OSHA is investigating.

County Building Inspector Art Verdoorn said local contractors had their eyes on the Georgia company that was erecting the preschool on Normandy Park Road because the trusses for the roof were bowing.

Someone made an anonymous call to the Occupational Safety & Health Administration office in Cleveland and someone called Verdoorn. By coincidence, both agencies made a surprise visit to the work site a week ago Monday, just in time to issue a stop-work order before the collapse.

Verdoorn said the exterior walls were up and half the roof was on but the structure wasn't braced correctly. Verdoorn estimated a crew of six was pulled off the structure, some on the high beams and some inside, minutes before the collapse.

Standard Building Co. of Atlanta requested the building permit, Verdoorn said. OSHA records list it as a non-union company.

An OSHA spokesman in Washington said three complaints have been filed against Standard Building, two in 2005 and one in March on a job in Elyria.

The company was fined $1,200 for failing to provide a safe work environment for employees after a worker was struck by a forklift on a Georgia job. The two other complaints were unfounded, an OSHA spokesman said. (Cleveland Plain Dealer)

This "just in time" is great but doesn't quite balance out all the other "not in times." Like this one (regular type, Jordan at Confined Space, small type news clips. See link for sources.):

Jose Rodriguez Garcia of Mission, Texas, was killed yesterday when a 10-foot deep trench collapsed on top of him. But hey, what are you going to do? Accidents happen.

Santa Cruz Irrigation District Manager Roy Garza described Rodriguez as “a good worker. A very good worker; dedicated to his job; always on time. Just a good darn worker.”

Garza says his workers always practice safety. “They're careful. They don't horse around. They don't play around during the job. It just happened we had an accident,” he said.

The reporter, in this case, thought to ask a few more questions:

But some rescue workers say the accident could have been prevented. Edinburg firefighter Ubaldo Perez said, “If there would've been safety measures before it occurred. Prevention would've been the best scenario.”

Firefighters say a 10-foot trench requires safety measures. They believe there should have been reinforcements so the dirt would not cave in.
But that would have been hard work, according to Garza.

Garza tells us why reinforcements weren’t used. “Okay, it is hard to provide in this particular job. You have telephone lines. They go this way. You have to get a back hoe. This job would've taken an hour to do and maybe they didn't put the right protection they needed,” he said. When asked if they should have, he replied, “I believe so.”

Yeah, didn't want to spend another hour. Oh well, maybe next time. (Confined Space)

Mid-term elections, November 2006. As they say, timing is everything.

Playing chicken with imports

2006-04-25T08:01:00.000-04:00

In a month (starting May 24) processed poultry from China can be imported to the US despite widespread outbreaks of avian influenza there. This isn't Chinese poultry, according to authorities. It is US poultry (or poultry from countries the US accepts for import), sent to China for processing. Live poultry from China cannot be imported. The request to allow this came from China. One wonders what the quid pro quo was. According to the US government, here's what it wasn't:

Chinese President Hu Jintao visited President George W. Bush on Thursday at the White House. In advance of his visit, China made several commitments, including an agreement to drop a mad cow disease-related ban on imports of U.S. beef. Raymond said the deal is unrelated to poultry imports and has been in the works since 2004. (Canadian Press)

The US Department of Agriculture (USDA) says not to fear. The meat will be "fully cooked and perfectly safe."

"It will have been processed," said Richard Raymond, the department's undersecretary for food safety.
"Cooking will kill the virus, if there is any virus, in poultry meat."

That's a relief. I'm sure the processing facilities in China are regulated with the utmost strictness. Just like in the US. So we don't have to worry about cross contamination of the same machinery used for batches of Chinese poultry. They'll clean it throughly for the small batches of US chicken. Won't they?

Still, I wonder. In 2005 the journal Virology reported on H5N1 contaminated processed duck meat imported from China to Japan:

This duck meat isolate was highly pathogenic to chickens upon intravenous or intranasal inoculation, replicated well in the lungs of mice and spread to the brain, but was not as pathogenic in mice as H5N1 human isolates (with a dose lethal to 50% of mice (MLD50)=5x10(6) 50% egg infectious doses [EID50]). However, viruses isolated from the brain of mice previously infected with the virus were substantially more pathogenic (MLD50=approximately 10(2) EID50) and possessed some amino acid substitutions relative to the original virus. These results show that poultry products contaminated with influenza viruses of high pathogenic potential to mammals are a threat to public health even in countries where the virus is not enzootic and represent a possible source of influenza outbreaks in poultry. (Mase et al., Virology. 2005 Aug 15;339(1):101-9)

But don't worry. USDA and the Bush administration have this all figured out so that there's a net benefit.

For someone.

Et tu, pigeons?

2006-04-24T08:29:00.001-04:00

Don't worry about pigeons and bird flu, we're told. Well I wasn't, since there is so much else to worry about, but now that they've brought it up, let's take a look.

In an AP story that is all over the bird flu news today, we find the following:

City folks, don't worry. Nobody expects pigeons, more common than manhole covers, will bring the deadly bird flu virus.

Pigeons are not immune from the virus. But tests indicate the birds pick it up only when they are exposed to very high doses, do not always become infected under those conditions and are carriers only briefly.

"Pigeons aren't a big worry," said Rex Sohn, a wildlife disease specialist at the U.S. Geological Survey's National Wildlife Health Center in Madison, Wis. "But to make absolute predictions that pigeons won't be susceptible to this virus, in whatever form it arises in North America, is not something you want to say." (AP)

I guess you don't want to say them because we know some pigeons are susceptible to the virus, as the very same story lays out in detail. The Agriculture Department's Southeast Poultry Research Laboratory in Athens, Ga. has been studying it since 1997 or so and the results were said to have produced more questions than answers. Hmmm.

Using the virus that surfaced in Hong Kong (the story doesn't say from a bird or a human), USDA researchers couldn't infect pigeons, even with direct instillation into their mouths with doses orders of magnitude higher than would be encountered in the wild (they say; I'm not sure what this is based on). But in 2004, using high doses of isolates from a pigeon and a crow in Thailand, seven out of 12 pigeons were infected, with one death. This year, a 14 year old Iraqi pigeon seller contracted bird flu and died. So pigeons can be infected, although at this point they are not as susceptible as chickens or ducks, and while they carry the virus for more than a week, they are said not to be infective for more than a day or two. Maybe. The virus is changing and finding new hosts. Why not pigeons?

We can agree with the bottom line, summed up in the AP story:

"The experimental data is not very strong that pigeons are going to be spreading this virus around," [Southeast Poultry Research Laboratory Director David] Swayne said. "At this point they have not been implicated in spreading it to humans and to farms."

So it's true that pigeons aren't a big worry now. "At this point."

The wise man of Jamaica

2006-04-24T08:27:00.000-04:00

The Jamaica Observer has a terrific columnist by the name of John Maxwell. His most recent column dealt with a variety of issues, including bird flu. It is so good I am having a hard time selecting just pieces of it. Here is an extended excerpt:

Egypt is in the throes of a bird flu epidemic. Apparently, the Egyptian poultry industry has been destroyed but backyard rearing of chickens is making the pandemic impossible to control. Galal Nassar, writing in Al Ahram, says an unpublished study suggests that "the avian flu virus is now endemic in Egypt and will remain so for years because of the bungling of health authorities at every step of the way".

It is suspected that the virus entered Egypt by the illegal importation of infected birds, which implies, according to Nassar "on top of gross negligence, gross corruption motivated by a greed so voracious that it had no compunction at letting the interest of immediate gain override the dangers to which it was exposing society".

Nassar points out that the Egyptian pandemic has occurred despite sensible precautions taken early on; a state of emergency had been declared, there was wholesale slaughter of industrial poultry, but little attention was paid to backyard poultry rearing or to the possibility that unscrupulous people might import infected poultry into the country. So, despite enormous early sacrifice, Egypt is again threatened by a pandemic to which the government's response is to blame the backyard chicken rearers.

[snip]

In Jamaica, we need to realise that if bird flu becomes endemic here, as it has in Egypt, despite the fact that only a few people have died, it will mean the end of the tourism industry and wholesale unemployment. At that point we will have not only a public health emergency but a public security emergency. Before we are very much older we need to begin, and urgently, to devise a food security programme, diverting some of the millions we are spending on highways to nowhere to importing and planting food.

We really need to begin turning some of our sugar land over to peas and beans, to begin programmes to promote backyard gardening and to develop new strategies to guarantee reliable supplies of protein foods for the population. I believe it would make sense for us to begin to convert some of the enormous craters left by bauxite mining into fish ponds. It may make sense right now to forbid bauxite companies to mine out all the bauxite and instead to leave a lining of bauxite clay in the ground so that we can seal the ponds without too much expense.

It may also make sense to begin developing cottage industries around these ponds for the salting/pickling of freshwater fish, because if the pandemic really gets a grip even our electricity supplies will be in danger. We may not be able to import the oil to drive the generators to provide power for refrigerators and freezers. We need to begin a completely new look at our survival techniques and a completely new understanding of what it means to be civilised.

We can be certain of only one thing: we have no idea how desperate our situation may become.

But even if it does not become desperate we need to begin to understand the meaning of sustainable development and to prepare for future threats.

Wow. This guy is good.

Flu Wiki gets on its feet again

2006-04-23T08:13:00.000-04:00

Flu Wiki2 is now open for business. Pogge, Dem and Melanie (with the Reveres gesticulating offstage) have gotten the Forum back up on a new server. It still runs on the PmWikie platform, which is a problem for the discussion format, so in the near to mid term we will be moving to a different platform that can handle that kind of traffic. We are hoping that by splitting the Wiki side proper from the Forum we will buy time and get back decent responsiveness on both parts, now running on different servers.

The new arrangement should be relatively transparent to the user since the Main Page remains the same on each and there are direct links to the respective servers from there. The original Wiki URL remains the same and the Forum is now on Flu Wiki2. If you use the Forum primarily or the Wiki side primarily you can set your bookmarks appropriately, or just go to the other server from the sidebar.

The Forum is no longer Read Only and is wide open. We're hoping by the time it gets bogged down with files again (since each thread is a separate file on PmWiki) we'll be on a more appropriate platform.

Thanks to my Wiki partners for the gargantuan effort, and to you, our community for your patience, good humor and participation. We're still pursuing the plan we announced over at the Wiki last week, and this is the first installment, as promised and on schedule.

Business -- as usual

2006-04-23T08:12:00.000-04:00

The guy who won his spurs by designing the EPA's policy allowing power plants to keep emitting mercury will soon be out of that position, at least if the Bush Administration has anything to say about it. That's because they want to promote him to be Assistant Administrator for EPA's Office of Air & Radiation. That doesn't sit so well with more than a dozen public health groups, including Physicians for Social Responsibility (PSR). Here's what they said in a letter to Senate Environment and Public Works (EPW) Committee who is set to vote shortly on the appointment:

Mr. Wehrum was an architect of EPAís approach allowing power plants to continue emitting toxic mercury emissions at excessively harmful levels for nearly two decades longer than the Clean Air Act allows. Last year, EPA revoked its prior determination that it was necessary and appropriate to regulate power plant mercury emissions as a hazardous air pollutant. This step purported to eliminate the agencyís legal obligation to adopt plant-specific pollution controls requiring deep reductions in mercury and other hazardous pollutants by 2008. Instead, EPA adopted a weaker and delayed cap-and-trade approach that dispenses with plant-specific control obligations and fails to require mercury-specific reductions until 2018. In fact, EPAís own analysis projects that the utility industry will not achieve the agency's required reduction level until sometime after 2025. This approach also abandons regulation of other hazardous air pollutants from power plants altogether. On September 13, 2005, 47 senators voted in favor of a Congressional resolution disapproving this regulation.

EPAs Inspector General found that the mercury rulemaking process was compromised, in large measure because EPA senior management told agency staff what result they wanted (34 tons annual mercury emissions) and directed staff to work backwards to achieve the combination of standards for different types of power plants that would yield this pre-determined result. Even when staff analysis projected achievable emission levels lower than senior managements chosen outcome, EPA failed to make this analysis public until the Inspector Generals highly critical report disclosed it. EPA also refused to conduct analysis of more protective mercury control levels requested by the Federal Advisory Committee that EPA created to receive advice on the mercury rule. According to the Los Angeles Times, at a meeting when EPA staff expected to be discussing how to conduct the comparative studies requested by the advisory committee,

William Wehrum, a senior advisor to [then Assistant Administrator] Holmstead who also represented industry clients before joining the Bush administration, told the dozen or so staffers that comparative studies would be postponed indefinitely. The agency never conducted the studies. (full .pdf of PSR letter to EPW here)

That's just for starters. It takes PSR three pages of densely packed particulars just to hit the highlights. PSR wants Senators to vote against Wehrum, but this is a Republican dream appointment, so it's not likely. He's proved his worth to the power industry so that's all the qualifications he needs in this Administration.

There are some really stinker faux Democrats out there (Joe Lieberman in the Senate and Jane Harmon in the House come to mind), but come 2006 if the Republicans lose one or both houses, we are much less likely to see this kind of thing : just Business -- as usual.

Freethinker Sunday Sermonette: the road to Hell

2006-04-23T08:10:00.000-04:00

It's a pity there's no Heaven and no Hell. Heaven, because it sounds like a nice place to hang out in, although maybe a little boring. At my age, boring doesn't sound that bad, although I remember the physicist Richard Feynman was alleged to have said on his deathbed as he was lapsing into a coma, "I'm glad I only have to die once. It's so boring."

But Hell, now that's something to really regret doesn't exist. Just think of the bastards who aren't going to have to go roast in agony there, like Kissinger, Cheney, Rumsfeld and Bush.

And this guy.

An American evangelical franchise is plastering posters around the poorest areas of Lesotho, promising "miraculous" cures for AIDS. Headed by Ohio-based preacher Ernest Angley, the flyers effectively equate "salvation" with medical treatment, which is much harder to come by for Africa's poor. (Boingboing)

The cornu copia of AIDS misinformation spews forth from the Reverend Ernest Angley of Ohio. If you go to his site, contribute some money, because he has a lot of expenses:

Angley owns a huge complex in his home base of Cuyahoga Falls, Ohio, a complex formerly owned by another television evangelist, Rex Humbard, and formerly known as the Cathedral of Tomorrow.

This complex now includes the Grace Cathedral, the Cathedral Buffet restaurant, WBNX as well as other companies which lease space.

Outside of Angley's evening talk show, WBNX operates as a secular TV station, and is currently affiliated with The WB Network. It is consistently one of the top 15 WB affiliates in the country. It will be affiliated with the CW Network in the fall of 2006. (Wikipedia entry)

So what's the good Rev like? Here is a personal account from someone who survived one of his marathon revival meetings in 1991. From the blog, Truly Bad Films:

I went to see the televangelist Ernest Angley at the Convention Center Auditorium in Greensboro. The man fascinated me. His fake-sounding name, his god-awful toupee, and his faith healings combined to promise a show I could not miss. And it was free!

Many people seriously claim that they have been healed at Reverend Angley's Crusades, and I'm not in a position to dispute or confirm that. I was attracted to the event as pure theater, so I looked over the audience when I got there. Elderly folks in wheelchairs were on the front row. The rest seemed to be a generous cross-section of young, old, black and white. I saw a few bad perms and I spotted one woman with her head covered in Muslim fashion. That surprised me.

[snip]

The first 15 minutes was a pitch for the new book on Lucifer. "Lots of people paid $20 for it," he assured us. "Some paid $15. But today I'm gonna give it to you for a real bargain. I'll let you have it for $5.00. Get 2 copies. One for your married children."

Ernest led a sing-along during which his Lucifer book was sold around the auditorium. He sang, "I'll Fly Away," and "At the Cross," in an odd falsetto that hit every note on the scale before it found the right ones. He checked his watch during the sing-along.

"Kuwait was the last big war before Armageddon," he told us, because "Gorbachev brought the peace of the anti-christ to earth. In seven years the Rapture will take place. The anti-christ was born about 1967 or 1968. Our nation changed then. Did you know that?" Lots of uh-huhs and yes, lords were offered up from the crowd.

"If it hadn't been for God intervening, Saddam would have gotten Israel. God intervened for Israel's sake. And we lost Vietnam because we forgot God. I've been smuggling my literature into Saudi Arabia for years. You know it's a miserable situation over there!"

Then he led the room in chanting, "One flight out!" I had no idea what that meant, and I'm sure no one else did either, but they chanted it vigorously.

[snip]

Then Ernest began asking for donations to his television tower fund. He had lots of stories to tell to encourage generous offerings. He started with asking for $1000.00 donations and about 50 people went up to pledge that amount. Then the donation requests worked down until he was asking the people who would give $5.00 to come forward.

He prepared to do his healings. Three ushers stood by to catch each person who passed out from the healing bolt. As he paused before each person, he motioned for them to raise their arms, he performed the healing and then blessed them with a palm to the forehead. The blessing is what caused them to fall backwards, as it concluded with a short shove backwards.

He prepared to heal a deaf man, whose arms were lifted. Ernest put a finger into each of the man's ears and vibrated his hands, saying "Thou foul deaf spirits, COME OUT!" Ernest yanked his hands away from the man's head. Then he placed his right palm on the man's forehead and gave him the blessing blast that knocked him backwards. He was caught by the ushers and lowered to the floor. Like him, many others had to be gently lowered to the floor, where they rested for awhile after their healings. Eventually they would be helped up and they returned to their seats.

One woman in a wheelchair could not stand up after her healing. Ernest advised her to, "sit and let the power work." After healing a busload of deaf people from Danville, Ernest encouraged some of them to demonstrate their healing.

"Ah!" Ernest led off.

"Ah!" said the newly healed man.

"Men!" said Ernest.

"Baby!" said the man.

"Ah!" Ernest tried again.

"Ah!" said the newly healed man.

"Men!" said Ernest.

"Buh!" said the man.

"Baby!" Ernest tried.

"Kubep!" said the newly healed.

"Ah!" said Ernest.

"Ah!" said the healed.

"Men!"

"Kubep!"

This went on for a long time.

At last Ernest said he saw 117 people in the audience who had a blood condition. He wanted them to stand to receive healing. Then he spied 56 who suffered from stomach aliment. They were to stand for a healing. Apparently 17 people were suffering from a "head condition." Ten people had a severe throat condition and 3 of those had cancer, Ernest said.

The he had all 27 people who were deaf in one ear, who had not yet come forward, hold up a finger. Ernest was going to empower the finger by God. He blessed the fingers and had them all insert the fingers into their ears. "Evil spirits of the ear, COME OUT!" he bellowed. I wish you could have been there to see 27 people yanking their fingers out of their own ears.

At this point, Ernest had been talking non-stop for 3 hours. He looked like he could go another three, but I was exhausted.

The good Reverend also predicted The Rapture would be about seven years from that date (somewhere in 1998 or 1999). He's still around, if you consider conning poor people in Lesotho as being around. So he didn't go to Heaven on schedule, although I'm sure he cheered George W. Bush's attempt to hasten The Day.

But then he didn't go to Hell either. As far as I'm concerned, he can.

Flu denier two-fer

2006-04-22T08:47:00.000-04:00

A new AP-Ipsos poll says half of Americans aren't too confident that its government can handle the situation if bird flu gets into birds in North America.

In the poll, 52% said they were not confident the government would handle an outbreak properly; 48% were confident. Almost two-thirds expect U.S. birds to become infected.

Fear is likely to spread if the virus is detected in the United States: Half of the people questioned said they thought the bird flu would kill them if they got it.

The survey found strong majorities in favor of these steps to contain any outbreak among humans: quarantining those who have been exposed to the bird flu, closing the borders to visitors from countries that have experienced the flu, closing schools, offering experimental vaccines or drugs, and encouraging people to work from home.

The poll of 1,001 adults was conducted Tuesday to Thursday with a margin of sampling error of plus or minus three percentage points. (USA Today)

The public has no particular reason to believe in the competence of the government, since all it has seen from this Administration is a surfeit of incompetence. I won't bother with the whole list (Katrina, Iraq, etc.) It's too long.

But does it mean the public health system can't handle bird flu? Unfortunately, it probably does. Because one aspect of the incompetence has been to starve public services that would be needed in the event of a pandemic, including health care and public health but also the social services what we would all depend on.

To make matters worse, everyone, ourselves included, are learning on the job about this virus. There are confusing and mixed messages coming from Washington, from academia, from state officials, from the private sector, because we are all more than a little confused by this virus and there are more than the usual mixed opinions. This bug is presenting surprise after surprise. But it is an unusually nasty virus, of a type that periodically sweeps the globe in pandemic form. What most people agree on is there is serious public health potential here and recognizing this and preparing for it quickly would be, to understate the case, prudent.

Most people.

There are still a few contrarians who are making a living (literally) by muddying the waters further. The two most prominent flu deniers are Wendy Orent and Marc Siegel. Despite errors in fact and atrocious judgment they continue to peddle their shoddy wares wherever and whenever they can get a hearing. Since the press loves man-bites-dog stories, they are often successful. Here's a sample:

But a small group of skeptics say the bird flu hype is overblown and ultimately harmful to the public’s health.

There’s no guarantee bird flu will become a pandemic, and if it does there’s no guarantee it will kill millions of people. The real trouble, these skeptics say, is that bird flu hysteria is sapping money and attention away from more important health threats.

“I have a bunch of patients coming in here who are more worried about bird flu than they are about heart disease,” said Dr. Marc Siegel, an internist and associate professor of medicine at the New York University School of Medicine. “The fear is out of proportion to the current risk.”

[snip]

“Ridiculous,” scoffed Wendy Orent, an anthropologist and author of "Plague: The Mysterious Past and Terrifying Future of the World's Most Dangerous Disease." [NB: her own fear-mongering book about the Black Death]

She said public health officials have vastly exaggerated the potential danger of bird flu.

Several factors make it unlikely that bird flu will become a dangerous pandemic, Orent said: the virus, H5N1, is still several mutations away from being able to spread easily between people; and the virus generally attaches to the deepest part of the lungs, making it harder to transmit by coughing or breathing.

“We don’t have anything that makes us think this bug will go pandemic,” Orent said. “Yes, it’s virtually certain in human history there will be another pandemic strain … but there’s no reason for it to happen now, or 10 years from now or 20 years from now.”

[snip]

But skeptics like Siegel and Orent say you’re better off guarding against more realistic dangers — heart attacks, for example, or even gum disease.

“I’d worry more about flossing my teeth than I’d worry about avian flu,” Orent said. “I want people to see what the real dangers are.” (MSNBC)

Orent is an anthropologist who sets herself up as an expert in epidemic infectious disease and the pandemic potential of a virus neither she nor real virologists understand well enough to be able to say what will happen, although they understand all too well what might happen. Siegel is a primary care doctor who writes books about how other people are scaring us. He is a fear-monger of fear. He is also careless about his science and when it is pointed out to him he doesn't care enough to correct his errors (Example: "This bird flu appears to be better absorbed by the deep pockets of bird lungs, whereas human flu is absorbed by the cells of our upper airways." This is an intestinal disease of birds. The paper he refers to was about human lungs, not bird lungs).

Orent and Siegel know perfectly well that the public health and health care systems aren't up to coping with an epidemic of infectious disease that affects a sizable proportion of the population. It doesn't matter if it's an H5 or H9 influenza subtype or some other virus altogether. Proper preparation for an H5N1 pandemic is an investment for all sorts of other problems, extraordinary and ordinary, against which our long-term disinvestments have rendered us defenseless. The claim that a "laser-like" focus on H5N1 must impede more general preparations is a straw man. Bush has been glad to shovel money to Big Pharma for antivirals, which are mainly aimed at influenza. That's short-sighted, I agree, but I don't hear Orent or Siegel criticizing it. Instead they attack others trying to defend public health. They misleadingly assert the conservative line that public health is a zero sum game. It isn't, at least not in the sense they are implying. When Bush wanted to wage war in Afghanistan and Iraq (to the current tune of $10 billion a month), he just allocated money. He also simultaneously shrunk the size of the pie by cutting taxes.

Those were social decisions "The Decider" made. If we had another Decider we would have other decisions.

Let's hear more about this from Orent and Siegel, not the kind of know-nothing scepticism that does little to advance public understanding and makes the work of those worried about people as much as birds less difficult.

Cambodian village seroprevalence study

2006-04-21T08:07:00.000-04:00

A paper now being reviewed at The Lancet is reporting that the prevalence of antibodies against H5N1 is zero in 351 villagers in a Cambodian town that suffered a bird flu death in March of last year. This is surprising on several levels. First, the assumption many had (including us) that there was likely quite a lot of mild inapparent and undetected infection with this virus, thus artificially inflating the case fatality rate (CFR, which is technically not a rate but a proportion). The good side of this is that it implies the virus has very little transmissibility, either from bird to humans or human to human. The bad side is that it implies this is one of the most dangerous viruses known, with a CFR exceeding 50%.

The second surprise is that there seemed to be nothing unusual about the exposure of the 28 year old farmer who did become infected and died.

Dead birds were reported in the village in Cambodia’s southern Kampot province and the H5N1 virus was detected in poultry there. Many villagers surveyed said they had very close, daily contact with the birds – collecting dead or sick poultry, feeding them, cleaning up faeces, plucking and eating them.

“That supports data from all over the region suggesting that it’s actually very inefficient to transfer from birds to humans,” said Benjamin Coghlan, a WHO epidemiologist from Australia who participated in the study.

“So, what does (the transfer) require? Well, we’re not sure,” he said. “Certainly, this case in the village wasn’t doing anything unusual that everyone else in the village wasn’t doing.” (Ireland Online)

Host factors we don't understand are involved. It is not just the virus. We know that age is a significant host factor, because the virus seems to prefer the younger age group (see the age distribution of reported cases here and here). In addition we know that the environment is a factor, since there is a marked (but unexplained) seasonality to influenza, including H5N1.

This is a reminder of an important point. An infectious disease is a function of the host, the agent and the environment acting together in a particular combination. Virulence is not a property of a virus but of the combination of the virus and the host, modulated by the environment. So the talk of "mutation to a virulent" form is really a shorthand for a more complicated idea. It is also important to remember that transmissibility (the ability to pass on infection), and virulence (the ability of infection to cause serious disease), are separate things. At this point we have little or no idea of the genetic, host or environmental factors affecting either in human beings.

So far these data have not been published but only presented at a conference. We look forward to seeing the published paper with the supporting tables and description of methods. Since the prevalence was zero, this isn't a statistical issue, because while the results don't rule out a small probability of infection that couldn't be detected because of sample size, that in itself is a statement about transmissibility. More importantly, it doesn't rule out some kind of bias, for example a problem with the measurement or selection of subjects. Therefore it is important to see the published paper.

We can't assume too much about this virus. There is always the hope that the transition to transmissibility is more difficult for the virus than is a reversion to less virulence. This virus is continually changing and the result could go in either direction. We don't know the biology well enough to hazard a guess which. It is currently a very dangerous bug that is constantly evolving. It continually uses hosts to make copies of itself and if chance happens on a good recipe for a human host cases will come faster and more abundantly.

If that happens it won't matter whether you believe in evolution or not, nor does that kind of virus believe in abstinence.

Prostitutes, drug pushers and Congress

2006-04-21T07:58:00.000-04:00

Lots of bad news these days, but some people are pretty happy.

After years of pumping millions of dollars into election campaigns, the pharmaceutical industry is reaping the benefits of a vastly improved political climate on Capitol Hill.

The increases in donations have moderated since the last decade as the industry has won passage of long-cherished legislative objectives or fended off challenges that it deemed a threat to its way of doing business.

In the last year, drug companies have won protection from lawsuits involving production of a pandemic flu vaccine. They have been invited to join President Bush in mapping a government strategy to fight a pandemic and have been sought out to assist in producing vaccines against flu and bioterrorism.

At the same time, legislative measures aimed at the industry - notably, bills that would permit importing cheaper prescription drugs from abroad - appear stalled, with little likelihood they will come up soon. (Philadelphia Inquirer)

So bird flu has ben a mixed blessing. A deadly threat to most of us, responsible for much wheel spinning "preparation" on the part of the feds, but a boon to Big Pharma. I'm so glad someone gets something out of it. And now that they've gotten it, they aren't spending as much dough in the Congressional Whorehouse. The reasoning, as given by former Republican CongressThing Billy Tauzin, is breathtakingly blatant:

Billy Tauzin, president of the Pharmaceutical Research and Manufacturers of America, the drugmakers' lobbying arm, said one reason for the decline [in contributions] was passage of the Medicare prescription-drug plan in 2003, an important legislative hurdle.

The measure was a major victory for the industry, not only because it committed the government to spending an average of $67 billion a year over 10 years on their products but also because proposals requiring the government to negotiate for the lowest price were defeated. Drugmakers feared that provision would have cut deeply into profits and opened the door to price controls on other drug spending.

Tauzin helped write the prescription drug plan and then left Congress to become Big Pharma's chief pimp.

But don't despair if you are one of the Congressional prostitutes. If the Democrats win one of the houses of Congress in 2006 the money spigot for Republicans (and some Democrats like Joe Lieberman -- should be win his primary) will open again as the atmosphere becomes less congenial to the drug pushers.

Prostitution never goes out of business as long as there are addicted johns who live to screw somebody.