A Journey Through The World of Pandemic Influenza

Viral Sovereignty

 

This morning we have an excellent offering from The Washington Post:

'Sovereignty' That Risks Global Health

By Richard Holbrooke and Laurie Garrett
Sunday, August 10, 2008; B07

Here's a concept you've probably never heard of: "viral sovereignty." This extremely dangerous idea comes to us courtesy of Indonesia's minister of health, Siti Fadilah Supari, who asserts that deadly viruses are the sovereign property of individual nations -- even though they cross borders and could pose a pandemic threat to all the peoples of the world. So far "viral sovereignty" has been noted almost exclusively by health experts. Political leaders around the world should take note -- and take very strong action.

The vast majority of repeated avian flu outbreaks the past four years, in both humans and poultry, have occurred in Indonesia. At least 53 types of H5N1 bird flu viruses have appeared in chickens and people there, the World Health Organization has reported.

Yet, since 2005, Indonesia has shared with the WHO samples from only two of the more than 135 people known to have been infected with H5N1 (110 of whom have died). Worse, Indonesia is no longer providing the WHO with timely notification of bird flu outbreaks or human cases. Since 2007, its government has openly defied International Health Regulations and a host of other WHO agreements to which Indonesia is a signatory.

[…]

A year ago, Supari's assertions about "viral sovereignty" seemed to be odd yet individual views. Disturbingly, however, the notion has morphed into a global movement, fueled by self-destructive, anti-Western sentiments. In May, Indian Health Minister A. Ramadoss endorsed the concept in a dispute with Bangladesh. The Non-Aligned Movement -- a 112-nation organization that is a survivor of the Cold War era -- has agreed to consider formally endorsing the concept of "viral sovereignty" at its November meeting.

 

I, along with my fellow PanFlu bloggers [see sidebar] have repeatedly commented on this issue, and I welcomed this piece by two rather "Big Hitters", Mr. Holbrooke and Ms. Garrett. My first post on "viral sovereignty", Viral Cold War, expresses my own, still operative, opinions on the issue.

 

Also from the WP article…

In this age of globalization, failure to make viral samples open-source risks allowing the emergence of a new strain of influenza that could go unnoticed until it is capable of exacting the sort of toll taken by the 1918 pandemic that killed tens of millions of people. As the world learned with the emergence of severe acute respiratory syndrome (SARS) -- which first appeared in China in 2002 but was not reported by Chinese officials until it spread to four other nations -- globally shared health risk demands absolute global transparency.

There is strong evidence from a variety of sources that forms of the bird flu virus circulating in Indonesia are more virulent than those elsewhere and in a few cases may have spread directly from one person to another. The WHO has tried for two years to accommodate Indonesia, without success. Under pressure from scientists worldwide, Indonesia agreed in June to share genetic data on some of its viral samples but not the actual microbes. Without access to the viruses, it is impossible to verify the accuracy of such genetic information or to make vaccines against the deadly microbes.

Outrageously, Supari has charged that the WHO would give any viruses -- not just H5N1 -- to drug companies, which in turn would make products designed to sicken poor people, in order "to prolong their profitable business by selling new vaccines" (a charge oddly reminiscent of the plot of John le Carré's novel "The Constant Gardener"). The WHO has elicited pledges from the world's major drug companies not to exploit international repositories of genetic data for commercial benefit, but this has not satisfied Indonesia.

[…]

The failure to share potentially pandemic viral strains with world health agencies is morally reprehensible. Allowing Indonesia and other countries to turn this issue into another rich-poor, Islamic-Western dispute would be tragic -- and could lead to a devastating health crisis anywhere, at any time.

 

Many of the consequences of the Cold War were morally reprehensible. That is not a "catch phrase" but the simple truth of the past follies of our governments.

 

Have we learned nothing?

 

Apparently not.

 

SZ

Indonesians test negative

 

The test results from the 13 Indonesians came back negative. This from Singapore's The Straights Times:

 

Indonesian villagers test negative for bird flu: health ministry

JAKARTA - THIRTEEN people in Indonesia suspected of having bird flu have tested negative for the feared disease, the country's health ministry said on Saturday.

Experts from the World Health Organisation (WHO) arrived Friday in the affected village in North Sumatra to help investigate a possible outbreak after three people died and the 13 were admitted to hospital.

'All specimens collected from suspect cases have given negative results'.

'They are all recovered', I Nyoman Kandun, director general of the ministry's communicable diseases department said on a text message.

Officials and residents in Asahan district in North Sumatra province said villagers began showing symptoms of avian flu after a large number of chickens died suddenly last week in Air Batu village.

The local husbandry office took preventive action this week by slaughtering and burning some 400 chickens and ducks.

The ministry, which has stopped giving regular bird flu updates, announced earlier this week that the human toll from avian influenza in Indonesia had risen to 112 following the recent death of a 19-year-old man.

 

 

I will not belabor the issues of accuracy of the tests. We all know they are fraught with false negatives. However, if all thirteen villagers have indeed already recovered then it is highly unlikely that they were suffering an H5N1 infection. Unlikely though it is, it is not guaranteed, however at this point in time, it's a good enough assumption.

 

It's "good enough" because the Indonesian government has proven to be less than fully transparent with the rest of the world, we have a test that is officially only presumptive at best, but mostly because there isn't a thing any of us can do about what is or isn't happening in the village of Air Batu and to its residents.

 

Can we take comfort in the fact that WHO arrived on the scene and if there were a genuine cause for greater concern we would be well served by their presence and actions? Maybe. Maybe not.

 

As I typed that sentence it came as something of a surprise to me that I actually do take comfort in the WHO's presence. Perhaps a sign I have not lost all of my naïveté, or perhaps my expectations have eroded so severely that the World Health Organization represents, at least to me, our Last Best Hope for anonymous Indonesian villagers and their 6.x billion neighbors.

 

Then again, perhaps it's a combination of being naïve with very low expectations. Hey, isn't there a term for that? Yeah, I think there is, and I think it's something along the lines of "clueless".

 

SZ

H5N1 assumptions, the good, the bad, and the who knows

 

Today Crof and Fla_Medic each covered an editorial from The Australian, Australia unprepared for epidemic, their excellent offerings notwithstanding, I would also like to comment.

 

[snip]

Given the magnitude of international air travel and the likely length of the asymptomatic incubation period of any new influenza virus, which would certainly exceed the time taken to fly between any two points on the earth's surface, it is highly likely that the entry of a new virus into Australia is almost unstoppable.

Professor Peter Curson of the Centre for International Security Studies at the University of Sydney has recently highlighted the difficulties facing traditional quarantine measures in an age of mass air travel.

If, however, the first case arriving in Australia is detected and isolated in time, there is still a chance that an epidemic on our continent can be prevented.

The current H5N1 virus has been known so far to have infected at least 385 people around the world, mostly in Asia, and the death rate — despite all modern available treatment, including all the currently available vaccines and antivirals — is approximately 63 per cent.

If and when a pandemic next occurs, if the new virus retains the same pathogenicity of the current avian influenza virus, we can expect about 4 billion people to die in the world over a six-month period. And that is how long it will take for a truly protective new vaccine to be developed and produced.

And the virus will be no respecter of wealth or class or education or intellect. In fact, if it behaves like past influenza viruses, it will not spare any age group. Even physical fitness will provide little or no protection.

 

I have frequently bemoaned the inability of many to understand and admit, or just to understand, that a pandemic from an genetically avian A/H5N1, but adapted to enable sustained human-to-human transmission, does not have to behave as 1918's H1N1 pandemic strain.  I have bemoaned it so often that recently I created a brand new category, [ Poverty of aspect], to tuck these frequent moans into.

 

They lay out some of why I believe Dr. John Graham, the Australian editorialist, might be closer to a correct assumption than those who believe 1918's pandemic is as bad as it could possibly ever be.  Please note: "Closer to correct" doesn't mean I'm saying he IS correct, only possibly closer to the measure.

 

Vindication-of sorts, and Vindication-of sorts II.

 

No one knows what the next pandemic will offer humanity, whether it will be a relatively "non-event" such as 1968's or whether it will be a beast beyond our current imagination, we just don't know.  Dr. Graham doesn't know, our officials don't know, our most renowned and well-respected virologists don't know, and I certainly don't know.

 

We can only attempt to understand the future by what we DO know, even though that is pitifully lacking.  And, what we DO know at this point in time, and A/H5N1's epidemiological profile, is that it is a DIFFERENT beast, the likes of which we have never seen before.

 

Interestingly, at least to me, is our collective willingness to believe, without question, assumptions based on a past event, an event that is for the most part only understood via assumptions and empirical data, over data coming out of our current labs underpinned with our greater scientific and continually evolving understanding.

 

If we heard about the full range of potentials for an H5N1 pandemic Dr. Graham's editorial wouldn't be so shocking to our sense of reality, instead, we could judge his words and opinions on what he bases them on, the science as we know it at this moment in time.  That "science" says it may, just may, be possible that billions would die.

 

SZ

It may or may not be H5N1

 

 

Wouldn't you know, I am swimming against the tide of "month end" and Indonesia becomes a news item.

 

Reuters UK is running the story of 13 people who have fallen ill and suspected as being infected with H5N1:

[Excerpt]

JAKARTA (Reuters) - Thirteen people from a village in Indonesia's North Sumatra province have been hospitalized after suffering symptoms of bird flu, a media report said on Wednesday.

Sinar Ginting, a spokesman for the Adam Malik hospital in North Sumatra's capital Medan, was quoted by Kompas.com as saying that two patients from the group had been transferred to the hospital early on Wednesday morning.

The other 11 from Air Batu village were being treated in a local hospital, he said.

"They have bird flu symptoms such as fever and breathing difficulties," Ginting was quoted as saying.

Not all the patients were believed to have had contact with fowl, which is the most common way of contracting the virus, but Ginting said some chickens in the area had died suddenly and were found to have had the deadly H5N1 virus.

Indonesian health ministry officials could not immediately be reached for comment.

 

 

This early in a situation half a world away it is impossible to know if this is something to be concerned about or just another "something" from a long list of potential "somethings" that are of no concern beyond those connected to the situation. I would be less than honest if I said that this story didn't cause me at least a modicum of concern. Three dead of an unidentified illness in a short span of time, along with somewhere around a dozen others ill would always cause me to watch a situation. But, this is after all, Indonesia, and we are painfully aware of some rather glaring shortcomings when it comes to efficient and proactive actions in the face of H5N1.

 

I would like to say this however, it is not at all likely that all of these cases are H5N1, even allowing that a few might be. For the answer to that we may have to wait weeks or months if this is an isolated outbreak that will settle right down as they have in the past. If, however, and is emphasis if, this is a significant cluster with human transmission involved, we will not have to wait very long at all. With that many cases of a transmissible virus and the cases begin to mount rather rapidly, even if only locally.

 

Finally, it has been my long held belief that it is not so much a single person infecting another person or two, or even three that we have to worry about, it is when we see transmission onto a third and fourth generation. And it is that that I, and others, will be watching for, the third and fourth generation in a connected chain of transmission.

 

Unfortunately, it is only a few watching. Indonesia's problems with H5N1 have become such a common story that it is no longer even much of a story. Tomorrow is the eve of the Olympics' opening ceremony and the world's attention will be riveted to the happenings in China, not unwarranted mind you, but the Olympics will drown out much of any other international news.

 

Added to the natural draw of the Olympics is the "side story" of the media and the Chinese government. Nothing captivates the media's attention more than stories about the media being victims of censorship or ill treatment. China appears to be willing to weather their wrath with all the contempt of outsider's opinions that China has shown historically. I suspect a few anonymous villagers ill and dying in Sumatra Indonesia cannot compete for journalistic attention when said journalists will be a "news item" themselves.

 

And so the "few" watch.

 

SZ

Australian GP’s and a severe pandemic

 

Today a story is circulating around the cyber flu community about another sector that will likely suffer a dangerous level of "job abandonment".

 

From News.com.au [excerpted]:

GPs refuse to treat bird flu patients

By Tory Shephard August 05, 2008 12:01am

BIRD flu will hit Australia but some GPs will refuse to treat patients - preferring to keep themselves and their families safe, research shows.

Others say they are unprepared to deal with the "horror" situation and hope it never happens, although experts say it is a matter of "when", not "if" disaster strikes.

Research in the latest Medical Journal of Australia shows only one of the 10 South Australian GPs surveyed felt prepared for a pandemic.

The report's authors said the doctors "felt their responsibility to themselves to stay healthy and to protect their families outweighed their responsibility to continue working".

Australian Medical Association state president Dr Peter Ford said most doctors had received no formal training in dealing with a flu pandemic.

 

I have touched on this issue several times (as have others around Flublogia).

Pandemic Dominoes: HCW's stand at the Apex

For the Greater Good

For the Greater Good II

 

I have also previously quoted this from the AMA:

AMA policy document "Physician Obligation in Disaster Preparedness and Response" adopted in June 2004:

National, regional, and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future. (AMA 2004)

 

The above bolded sentence cannot be any plainer.

 

The article Australian article further states:

The report's authors said the doctors "felt their responsibility to themselves to stay healthy and to protect their families outweighed their responsibility to continue working".

 

Everyone who provides a critical service to, and interacts with, the wider community, doctors, nurses, firefighters, EMT's, police, to name the most obvious, will have to make the choice about whether or not to work should we suffer a severe pandemic. Those that make the choice to work will no doubt make that choice each day the danger exists.

 

It will be a tough decision for most, but certainly not all.

 

It is important to realize that doctors and nurses did not "sign on" to risk their lives wantonly when they chose their professions. I would hazard the bet that most chose their professions out of a deep respect for health and life, even their own, most especially their own, if they are worth their parchment.

 

To expect someone, anyone, to step into harm's way we assume an obligation to make them as safe as we can while they do so. We do this with our first responders via training, equipment, and their fellows who valiantly stand at their sides (or backs) while danger presents.

 

During a severe pandemic (should we have one) who will equip our medical workers to stand in the face of infection? Who will "stand beside them"?

 

Until we can answer those questions, and provide the means and materials to those answers, we have no right to expect anyone to aid strangers at the risk of their own lives. Keep that in mind as you read the following, also from the Australian article:

 

Australian Medical Association state president Dr Peter Ford said most doctors had received no formal training in dealing with a flu pandemic.

[…]

Vaccine expert Professor Nikolai Petrovsky, Flinders Medical Centre's director of endocrinology, is working on vaccines to protect against bird flu. A lack of funding and of political will means the whole health system is unprepared for a pandemic that is already "overdue", he said.

"The reality is that we will be hit by an influenza pandemic at some point. But we don't know if it will be this year or in 50 years' time so governments are loathe to spend the money and the effort when they don't know," he said.

 

Those last two paragraphs could be applied to any number of countries, not just Australia. And, equally as damning, to most states, counties, municipalities, and districts (or a country's equivalents).

 

I wish I had an easy answer to offer up, unfortunately, I don't. There are no easy answers, and there certainly aren't many inexpensive ones either. We must have the wisdom and foresight to prepare those we will hope to see in our moments of greatest need by providing them the means to be there safely.

 

Even if it costs money.

*********

 

I've said it once or twice before, and I always suffer an internal cringe when I do:

 

As the mother of a police officer I have moments of very selfish "not my son" when I think about the possibility of his being hurt in the line of duty and not receiving medical care. When I am being brutally honest with myself – and with you – I admit that his life is far more valuable to me than yours.

 

My son "signed on" accepting the "normal" risks his profession carries, something his father and I are both appreciative of since we both wore the uniform ourselves. We, as his parents, understand that what can be done to guard and protect him is being done, or will be done, should the worst happen, and yes, we understand – and accept – that a positive outcome is not always guaranteed. However, things change when not everything that "could be done", is not.

******

 

Before we blissfully assume others have a self-sacrificing "obligation" to risk themselves we need to ask what we are "obligated" to do in return. If you're honest with yourself, as honest as I have been with you, you will know that we, the collective "we", have done pathetically little, nor have "we", the electorate, demanded anything from those in positions to effect what needs done.

 

"We" just blissfully assume all will be well and fine because someone else has an "obligation".

 

Please think about what I've said here.

 

Please consider adding your "voice" to the chorus against dangerous assumptions; ask that we adequately protect those we want to be there during our times of need.

 

Please.

 

SZ

 

Public threats in the Age of Ignorance

 

This Sunday morning I settled down to my first cup of coffee and began my jaunt around the 'net to confirm that the world was in roughly the same condition as five hours previous, fortunately, it was. I say "fortunately" because I was not searching to find stories of miraculous improvement to any of our pressing issues and conditions, I was searching for "bad news".

 

This story from SFGate caught my bleary eye:

Anthrax case raises issues about risk level

Biodefense spending gives more people access to deadly toxins for use in research

Eric Lipton,Scott Shane, New York Times

Sunday, August 3, 2008

[Excerpt]

Until the anthrax attacks of 2001, Bruce Ivins was one of just a few dozen American bioterrorism researchers working with the most lethal biological pathogens, almost all at high-security military laboratories.

Today, there are hundreds of such researchers in scores of laboratories at universities and other institutions around the United States, preparing for the next bioattack.

But the revelation that FBI investigators believe that the anthrax attacks were carried out by Ivins, an Army biodefense scientist who committed suicide last week after he learned he was about to be indicted for murder, has already reignited a debate: Has the unprecedented boom in biodefense research made the country less secure by multiplying the places and people with access to dangerous germs?

"We are putting America at more risk, not less risk," said Rep. Bart Stupak, D-Mich., chairman of a House panel that has investigated recent safety lapses at biolabs.

FBI investigators have long speculated that the motive for the attacks, if carried out by a biodefense insider like Ivins, might have been to draw public attention to a dire threat, attracting money and prestige to a once-obscure field.

If that was the motive, it succeeded. In the years since anthrax-laced letters were sent to members of Congress and news organizations in late 2001, almost $50 billion in federal money has been spent to build new laboratories, develop vaccines and stockpile drugs. For example, an experimental vaccine Ivins had spent years working on moved from the laboratory to a proposed billion-dollar federal contract after the attacks, which killed five people.

[snip]

Federal officials say they are convinced that the surge in biodefense spending has brought real gains.

"Across the spectrum of biothreats we have expanded our capacity significantly," said Craig Vanderwagen, an assistant secretary at the Department of Health and Human Services who oversees the biodefense effort. Systems to detect an attack, investigate it and respond with drugs, vaccines and cleanup are all hugely improved, Vanderwagen said. "We can get pills in the mouth."

But the proliferation of biodefense research laboratories presents real threats, too, congressional investigators recently warned.

[…]

Nationwide, there are an estimated 14,000 people working at about 400 laboratories who have permission to work with "select agents" - which could be used in a bioterror attack - although a much smaller amount of this research involves the most dangerous materials, like anthrax.

With so many people involved, there is insufficient federal oversight of biodefense facilities to make sure the laboratories follow security rules and report accidents that might threaten lab workers or, in an extreme case, lead to a release that might endanger the public, Rhodes testified.

[snip]

Apart from the threat from insiders, some public health experts believe money being used to study obscure pathogens that are not a major disease problem could be better directed to study known killers like influenza or AIDS.

 

I found myself agreeing and disagreeing in turns, and by my second cup of coffee I was comfortable with the fact that my ambivalence was not due to sleep and caffeine deprivation.

 

To be aware of potential threats, and what those potentials might bode, we do have to study pathogens, even those that are obscure [to someone other than those who concern themselves with such, for good or ill]. However, our reaction to a biological attack was excessive, as our reactions tend to be.

 

I have major "issues" with the "All Hazards" approach to threat preparedness. Conversely, I am appreciative of the counter productiveness of concentrating on a narrow threat with only a very small probability of actualization. Added to that bit of concept waffling is the distinction between a contagious and non-contagious infectious pathogen.

 

I could become infected with anthrax but I would be in no danger of passing that infection to another person [excluding passing along the stray environmentally acquired spores that I managed to come into contact with]. However, were I to become infected with pneumonic plague or smallpox I would pose an extreme threat to everyone who came into contact with me.

 

Non-contagious pathogens, even those deliberately released upon an unsuspecting public, do not pose the same threat as contagious pathogens. Yet, because we suffered an attack of anthrax those who control, or have influence over, the federal Bucket-O-Bucks [budget] it is anthrax that is viewed as a potential threat worthy of billions of dollars from that bucket. And, since that bucket is not exactly bottomless, the funds given to anthrax research and threat preparedness are funds that don't go to some other potential threat, pandemic influenza being my favorite "budgetarily deprived waif".

 

We need to bring informed rationality to our threat assessments, whether they are pathogens being studied in labs, those who study them, or the threat(s) those pathogens pose to the public, as distinct from the consequences of contagious infectious diseases in general. Which brings me to my point.

 

We are a nation populated by the profoundly ignorant.

 

From The Cutting Edge:

How Ignorant Are We? The Voters Choose… But On The Basis of What? [Excerpted]

Rick Shenkman

July 14th 2008

Cutting Edge Contributor

Excerpted from Just How Stupid Are We?, by Rick Shenkman, in arrangement with Basic Books.

"If a nation expects to be ignorant and free, in a state of civilization, it expects what never was and never will be." -- Thomas Jefferson

Just how stupid are we? Pretty stupid, it would seem, when we come across headlines like this from Associated Press March 01, 2006: "Homer Simpson, Yes -- 1st Amendment 'Doh,' Survey Finds"

"About 1 in 4 Americans can name more than one of the five freedoms guaranteed by the First Amendment (freedom of speech, religion, press, assembly and petition for redress of grievances.) But more than half of Americans can name at least two members of the fictional cartoon family, according to a survey.

"The study by the new McCormick Tribune Freedom Museum found that 22 percent of Americans could name all five Simpson family members, compared with just 1 in 1,000 people who could name all five First Amendment freedoms."

 

[snip]

Taking up the first of our definitions of stupidity, how ignorant are we? Ask the political scientists and you will be told that there is damning, hard evidence pointing incontrovertibly to the conclusion that millions are embarrassingly ill-informed and that they do not care that they are. There is enough evidence that one could almost conclude -- though admittedly this is a stretch -- that we are living in an Age of Ignorance.

Surprised? My guess is most people would be. The general impression seems to be that we are living in an age in which people are particularly knowledgeable. Many students tell me that they are the most well-informed generation in history.

Why are we so deluded? The error can be traced to our mistaking unprecedented access to information with the actual consumption of it. Our access is indeed phenomenal. […] It is little wonder then that students boast of their knowledge. Unlike their parents, who were forced to rely mainly on newspapers and the network news shows to find out what was happening in the world, they can flip on CNN and Fox or consult the Internet.

But in fact only a small percentage of people take advantage of the great new resources at hand. In 2005, the Pew Research Center surveyed the news habits of some 3,000 Americans age 18 and older. The researchers found that 59% on a regular basis get at least some news from local TV, 47% from national TV news shows, and just 23% from the Internet.

 

Read the Cutting Edge piece in its entirety, and be afraid – be very afraid. Informed rationality is rare, although admittedly not as rare as anthrax attacks.

 

We can no longer afford the Age of Ignorance. We cannot afford it monetarily, and we cannot afford it from a public health standpoint. Beneficial research must continue, even if the pathogens are dangerous. Genuine threats need to be prepared for, even if they are not a certain threat. Understanding the distinctions requires being informed.

 

A state of ignorance is remediable. We are already in possession of the "cure", now we just have to pinch our noses and swallow the medicine.

 

SZ

 

 

 

 

 

Watching Nepal

 

The following wouldn't be of much significance even for the "Flu Obsessed" except for the part that I bolded.

From The Himalayan Times [credit Crof @ H5N1]

Mystery Disease Afflicting 50 in bake  

THT Online Nepalgunj, August 3:

At least 50 people of Banaghusra in Basudevpur Village Development Committee of Banke district have been suffering from an unknown disease.

Headache, dizziness, fever, cough and diarrhoea are symptoms of this disease, Mansoor Khan, a local, said, adding that the disease has been afflicting senior citizens and children the most. Raju Sunar of Basudevpur 4 said, "Though we have informed the sub-health post based in the village about the disease, it has not sent health workers to diagnose the ailment and treat the patients."

Meanwhile, officer of the District Public Health Office, Om Upadhyaya, pledged to send a team of health workers to Banaghusra. Basudevpur VDC lies near the township of Nepalgunj.

 

The reason the bolded part holds significance for me is because most endemic diseases, of which there are many in this corner of the world, effect children the most, if not almost exclusively. The sentence reads "senior citizens and children the most", suggesting that those in between may be suffering sickness as well, albeit, at a lesser rate or severity.

 

A disease that affects more than one cohort is suggests a pathogen that the population has no preexisting immunity to, or a non-infectious pathogen acquired via the environment.

 

A story from Nepal Horizons from Friday:

Mysterious Disease Grips Entire Village

Nepal Horizons Reporter
Aug 2, 2008: An outbreak of an unidentified disease has affected 300 villagers in Basudevpur VDC of Banke district.

The sick people are showing symptoms such as headache, fever and diarrhea. A team of health workers led by Agat Shahi today treated the patients and distributed medicines free of cost. Shahi said that they have examined 215 patients and taken blood from three persons affected by Malaria for further test.

 

Neither story mentions any deaths, nor do they mention life-threatening illness, just illness of an unknown cause. It could be one of any number of illnesses, and H5N1 is not a likely candidate, but it is not completely out of the realm of possibility.

 

As I've noted before, at least we are getting word of an outbreak that might be something that would be concern to us in the "wider world". But even if this is of no concern to us (in the wider-world) we learn about issues and conditions faced by people in places we've likely never heard of, and perchance take that opportunity to realize that what effects a village in Nepal might, at some point, come tapping at our own door.

 

Villagers in Basudevpur are our "neighbors" in this interconnected world of ours, so we watch and hope for a quick resolution with a positive outcome. We hope for this for the villagers – and selfishly – for their "neighbors"

 

SZ

Good news for food safety

 

I've touched on my concerns over the safety of our foods a few times, mostly as it has affected my life and food choices.  Beyond personal "issues" food safety is a problem that we are coming face-to-face with more frequently.

 

Are there more problems out there or are we just hearing about them more frequently?  I don't know the answer to that question, and perhaps no one does with any certitude.  Regardless of whether there are more problems, or whether we are just being regaled with them more frequently, there are problems.

 

High-tech safeguards for food being developed [Excerpt]

By Lauran Neergaard
Associated Press
Saturday, August 2, 2008

WASHINGTON -- Could food producers literally squeeze the salmonella out of a jalapeño? Or zap the E. coli from lettuce without it going limp?

Headline-grabbing food poisonings from raw foods are prompting new interest in technology -- from super-high pressure to irradiation -- to get rid of some of the bugs. It won't be a panacea: Far better to prevent contamination on the farm than to try to get rid of it later.

"This is never an excuse for a dirty product," warns University of Minnesota infectious disease specialist Michael Osterholm.

But it's impossible to prevent all contamination in open fields. And increasingly popular ready-to-eat foods -- salads already washed and bagged, fruit peeled and sliced -- allow another processing step where a single slip-up can introduce pathogens.

Washing, even with chlorine or other chemicals, only gets rid of surface contaminants, not germs that sneak inside the fruit or vegetable. Enter high-tech options.

 

 

Even though I have concerns for the safety of my food and our food supply overall, I am not one to get "het-up" over issues such as irradiated or genetically modified foods.  In reality, I support both… <gasp>.

 

I find it an embarrassment that in the 21^st century we find people who think that rice meant to feed malnourished children that has an included gene to produce vitamin C is a BAD thing.  I find it angering in an age of food scarcity people shun and actively lobby against genetic modifications, which by the way have been going on for a very, very long time (Mendel in the kitchen, Fedoroff and Brown).  But I digress.

 

The safety of the foods I purchase in the store was something I took for granted only a short decade ago.  And two decades ago I would not have thought a thing about biting into an apple or grape without first washing it… <gasp>.  Yes, those attitudes were more driven by my own ignorance over food safety back then, but still and all, I don't feel as though I am being fastidious in my concern today, merely informed enough to realize the problems.

 

Because there are genuine problems, as opposed to media driven hype and hysteria we saw with the pesticide Alar and apples, (JunkScience.com), we need a combination of solutions and smart consumption.  I applaud the efforts and those working toward solutions. 

 

For all the Luddites out there – well – it is the 21^st century after all, and we have 6.5 billion people to feed.  If I promise not to take away your choice of organic heirlooms will you promise not to take away solutions for the hungry and malnourished?  Why do I have the feeling that's a stupid question.

 

SZ

Introducing my new Pandemic H5N1 blog

Today I introduce my new blogging home A Pandemic Chronicle .

For the month of August I plan to post my blogging efforts here at Journey as well as at my new site A Pandemic Chronicle, but after this month I will only be posting at APC and Journey will go dormant, though still accessible. I have imported all of Journey's posts into my new blog but I did not want to invalidate all of the old links and refs to Journey so I will maintain it as a historic repository.

I did not decide to make this move without consideration for the issues of discontinuity but what I – and my readers – will gain by moving to a WordPress platform should help offset the "costs" associated with such a move.

Although I have yet to figure out how to get a "Contact Me" function up and running I'm working on it (in my spare time of course).  In the meantime, if anyone has any feedback or suggestions (like how to do a Contact Me form) I can be reached at the following email address: sophiazoe AT me DOT com [replace AT with @, and DOT with . ]  It's easy to remember, even for me.

So, check it out already!  [ remember to update your bookmarks]  I hope you like what you find as far as presentation and functionality goes. 

SZ

Influenza, bacterial pneumonia, and our elders

 

Tonight I am going to post as a follow-on to one of FM's posts today [here].  Although he did an excellent job of bringing the issue before us, I have a bit more to say on the subject. Vaccines and vaccination are an integral part of pandemic considerations and plans so they are subjects that are somewhat “near and dear” to my heart. But first a bit of a digression.

 

 

I believe in vaccines in general, believing they are of immeasurable benefit to a population as a whole, and to the individuals who receive them. 

Are they effective for 100% of those who receive one? No. The immune response a vaccine produces can, and does, vary by individual, and cohort generalities exist. The article that inspired this post is about the weak immune response in frail elderly folk who receive a vaccination against influenza. The very young (who generally have not had influenza) also produce a weaker immune response, that is why their shot is delivered in two doses separated by a month. The first shot “primes” the immune system, the second produces antibodies at a presumptive level of protection.

Are they 100% safe and free of side effects for 100% of those who receive one? No. Nothing in this world is safe for every single person drawing breath. The level of risk – on average – for each individual receiving a vaccine is directly correlated with the length of time the vaccine has been given and the number of people who have received it. The ancillary: The longer a vaccine has been available and the greater number of people having received it might well find those 1-in-100 million who will have a meaningful adverse reaction.

Do they prevent the scourges of past generations? Yes. Have they enhanced quality of life and extended life expectancy? Yes – on both counts. Proof of these statements are the fact that I grew up without having to face the threat of polio or smallpox, and my son never had mumps or chickenpox.

 

 

Please feel free to skip the references, I've only included them in the interest of thoroughness.

 

On to today's news item…

Flu Vaccine Doesn't Protect Seniors From Pneumonia
Older, frail folks are more susceptible to flu and its complications, researchers say.

By Steven Reinberg
HealthDay Reporter

THURSDAY, July 31 (HealthDay News) -- Flu vaccine may not protect older people from pneumonia once they get the disease, researchers report.

Older, frail adults are more susceptible to getting the flu, even if they have been vaccinated, and once getting the flu, they are more susceptible to such complications as pneumonia. It had been thought that flu vaccine would prevent flu -- and pneumonia -- across all groups of seniors, but this benefit appears to be largely confined to younger, healthier seniors.

"In seniors, flu vaccine was not linked to a reduced risk of pneumonia," said lead researcher Michael L. Jackson, a postdoctoral fellow at the Group Health Center for Health Studies in Seattle.

Continues….

 

This article references a newly released finding published in the Lancet…

The Lancet 2008; 372:398-405

DOI:10.1016/S0140-6736(08)61160-5 

Articles

Influenza vaccination and risk of community-acquired pneumonia in immunocompetent elderly people: a population-based, nested case-control study

Dr Michael L JacksonPhD

[Excerpted]

Summary

Background

Pneumonia is a common complication of influenza infection in elderly individuals and could therefore potentially be prevented by influenza vaccination. In studies with data from administrative sources, vaccinated elderly people had a reduced risk of admission for pneumonia compared with unvaccinated seniors; however, these findings could have been biased by underlying differences in health between the groups. Furthermore, since most individuals with pneumonia are not treated in hospital, such studies should include both outpatient and inpatient events. We therefore assessed whether influenza vaccination is associated with a reduced risk of community-acquired pneumonia in immunocompetent elderly people after controlling for health status indicators.

Findings

1173 cases and 2346 controls were included in the study. After we adjusted for the presence and severity of comorbidities, as defined by chart review, influenza vaccination was not associated with a reduced risk of community-acquired pneumonia (odds ratio 0·92, 95% CI 0·77–1·10) during the influenza season.

 

 

The problem (as defined by me of course) with this finding and the resultant reportage is that in our "sound-bite" world the issue will not receive a critical and thorough airing.

 

My first (of several) problem with this paper is that there is no mention of the parties involved having been vaccinated against bacterial pneumonia.  If the main aim of an influenza vaccine is to prevent pneumonia wouldn't getting a pneumonia vaccine be of benefit as well?

 

Secondly, it is known that although an influenza vaccine will not always prevent infection, it will attenuate severity of illness.  This gets a bit "fuzzy" when we consider the differences between H1N1 and H3N2.  The former produces a (generally) milder illness, the latter, more (generally) severe.

The Journal of Infectious Diseases 2005;192:249–257

© 2005 by the Infectious Diseases Society of America. All rights reserved. 

0022-1899/2005/19202-0008

DOI: 10.1086/430954

Influenza Virus Neuraminidase Contributes to Secondary Bacterial Pneumonia

Ville T. Peltola, et al.

Influenza A virus causes epidemics annually and pandemics several times a century. Two subtypes of influenza A virus, H3N2 and H1N1, are presently circulating in the human population. Epidemics caused by H3N2 are associated with higher mortality in human populations than are epidemics caused by H1N1 or influenza B virus.

[snip]

The level of NA activity decreased in influenza viruses isolated from 1957 to 1968 and increased again in those isolated from 1968 to 1997. This trend in NA activity correlates with the observed historic mortality caused by H3N2 influenza viruses, which was highest in 1957, decreased during the next decade, but increased again during the 1990s (table 2). Low levels of NA activity in the influenza viruses circulating in 1968 is consistent with lower mortality from this pandemic, compared with that in the 1957 pandemic or during the epidemics caused by H3N2 influenza viruses during the 1990s. It has been suggested that conservation of the N2 NA in the influenza viruses circulating in 1968 resulted in relatively low mortality during this pandemic, but this does not explain why influenza viruses circulating later that had no antigenic shift in HA or NA caused higher mortality. The N2 NA in the influenza virus circulating in 1997 had the second highest level of NA activity, and this influenza virus caused the highest mortality during an epidemic since the 1957 pandemic.

 

The years encompassing the vaccine effectiveness analysis had a considerable amount of H3N2 circulating.

Another recent finding that sheds light on the effectiveness (or not) of vaccines:

The Journal of Immunology, 2006, 177: 7811-7819.
Copyright © 2006

Cyclooxygenase-2 Inhibition Attenuates Antibody Responses against Human Papillomavirus-Like Particles1

Elizabeth P. Ryan, et al.

Vaccination to generate protective humoral immunity against infectious disease is becoming increasingly important due to emerging strains of virus, poorly immunogenic vaccines, and the threat of bioterrorism. […]The widespread use of nonsteroidal anti-inflammatory drugs and Cox-2-selective inhibitory drugs may therefore reduce vaccine efficacy, especially when vaccines are poorly immunogenic or the target population is poorly responsive to immunization.

 

And this…

The Journal of Infectious Diseases 2002;186:341–350

© 2002 by the Infectious Diseases Society of America. All rights reserved.

0022-1899/2002/18603-0006$15.00

DOI: 10.1086/341462

Lethal Synergism between Influenza Virus and Streptococcus pneumoniae: Characterization of a Mouse Model and the Role of Platelet-Activating Factor Receptor

Jonathan A. McCullers and Jerold E. Rehg

A lethal synergism exists between influenza virus and pneumococcus, which likely accounts for excess mortality from secondary bacterial pneumonia during influenza epidemics. Characterization of a mouse model of synergy revealed that influenza infection preceding pneumococcal challenge primed for pneumonia and led to 100% mortality. This effect was specific for viral infection preceding bacterial infection, because reversal of the order of administration led to protection from influenza and improved survival. The hypothesis that influenza up-regulates the platelet-activating factor receptor (PAFr) and thereby potentiates pneumococcal adherence and invasion in the lung was examined in the model. […] The model of lethal synergism will be a useful tool for exploring this and other mechanisms underlying viral-bacterial interactions.

 

Attempting to pull it all together:

Elderly have a reduced antibody response to vaccinations.

Our circulating H3N2s have undergone a change for the worse when it comes to mortality. 

Our influenza vaccine is given intramuscularly and the antibodies produced are the ones that have a lesser effectiveness at warding off illness [humoral vs. mucosal], and you must add to that the fact that the longer the time frame between inoculation and infection, the less effective these lesser effective antibodies become.  The study offered no hints as to the lapse of time that may or may not have been at play.

The population analyzed tends to be on anti-inflammatory and/or COX-2 inhibitor medications, often at high levels.

Even a vaccine attenuated infection of H3N2 in a frail elderly person would seem to indicate a high level of risk of a secondary infection of pneumonia.

 

All-in-all, the issue is extremely complicated and our knowledge is evolving, as evidenced by the myriad refs I had to pull to make that point. 

 

The effectiveness (or not) of a vaccine should not be reduced to statistical analysis of cases that were not even lab confirmed to be influenza. 

Nor should effectiveness be written off when there are simple change-ups (no anti-inflammatory drugs for two weeks following immunization, intranasal vs. intramuscular inoculation) that might dramatically improve antibody response.

 

But none of that will even enter the picture as we all read the headlines Flu vaccine doesn't protect… and those that already don't believe in vaccine efficacy and overtly fear the miniscule risk(s) of receiving them will feel vindicated and supported in their (ill-informed) opinions and choice of abstention.  And that "personal" choice places us all – and our children – at greater risk.

 

SZ