A Journey Through The World of Pandemic Influenza

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

Perceptions

 

I read an interesting (65% serious) piece on Wired this morning about eating pigeons. The two main points were that pigeons are edible and we should adjust our perceptions of them a tad bit.

Pigeons: The Next Step in Local Eating

Alexis Madrigal

Blogs: Wired.com Science

When you look at a pigeon, you might see a dirty, rat-like bird that fouls anything it touches with feathers or feces, but I see a waste-scavenging, protein-generating biomachine.

 

At a time when rising demand for meat across the globe endangers the food system, and local eating has gained millions of (T-shirt wearing) adherents, it's time to reconsider our assumptions about what protein sources are considered OK to eat.

 

You see, city pigeons are the feral descendants of birds that were domesticated by humans thousands of years ago so that we could eat them and use their guano as fertilizer, we read in Der Spiegel. They're still doing their part, i.e. eating and breeding, but we humans have stopped doing ours, i.e. eating them.

 

Numbering in the hundreds of millions, they could be a new source of guilt-free protein for locavores in urban centers. Instead, we're still trying to kill off our species' former pet birds, which (as any city-dweller can attest) doesn't work.

 

It's the "perception" bit that sparked my attention, although I will unequivocally say that refuse scavenging pigeons are (slightly) more conceptually palatable than tilapia raised in ponds "fed" chicken dung to boost plankton growth (which the fish then feed on). Chicken dung is also commonly fed to carp, but, hey, I've never eaten carp so I'm not willied-out about that practice.

This from The Independent (UK) 2005:

Chicken dung used to feed fish may help spread bird flu

By Michael McCarthy, Environment Editor
Wednesday, 28 December 2005

Bird flu may be spread by using chicken dung as food in fish farms, a practice now routine in Asia, according to the world's leading bird conservation organisation.

Fertilising fish ponds with poultry faeces, which can dramatically improve fish growth, may set up major new reservoirs of avian influenza infection if the chickens providing the manure are infected themselves, according to BirdLife International, the Cambridge-based umbrella body for bird protection groups in 100 countries.

The suggestion, which has echoes of the BSE outbreak in Britain - when cattle were infected by their food - puts a question mark over a technique firmly backed by the UN's Food and Agriculture Organisation (FAO) as a primary means of providing protein for mushrooming populations in developing countries.

Known as integrated livestock-fish farming, the technique involves transferring the wastes from raising pigs, ducks or chickens directly to fish farms. At the right dosage, the nutrients in the manure give an enormous boost to the growth of plankton in the ponds, which are the main food of fish such as carp and tilapia.

BirdLife International is now calling for an investigation into the possibility that thousands of manure-fed ponds across Asia may be the means by which the new potentially deadly strain of avian influenza, H5N1, is being spread. BirdLife points out that outbreaks of H5N1 have occurred this year at locations in China, Romania and Croatia where there are fish farms.

The Chinese outbreak of H5N1 in May, which mainly involved bar-headed geese, took place at Qinghai Lake, a location where the FAO helped establish an integrated livestock fish farm in the early 1990s, BirdLife said.

"This outbreak helped lead to the widespread media speculation about wild birds spreading H5N1," said Richard Thomas from BirdLife. "We pointed out that bar-headed geese migrate from India, where H5N1 has never occurred, and migrate early, so they must have contracted the disease locally, at Qinghai."

Although no mention has been made of the possible links between manure-fed ponds and influenza in the recent alarm over bird flu, the issue has been raised before, and the FAO, although actively promoting the technique, is well aware of the threat.

Continues….

 

 

 

I haven't eaten tilapia since I read The Independent article when it first hit the net in 2005. I am fortunate; I have the option of choice of food(s), would I be so finicky if I didn't? Probably not.

 

I naively thought that farm raised fish were more "environmentally responsible" so I supported the farm raised fish concept and when a choice between farm and wild was available I always chose "farm", believing (naively) that my support somehow directly lessened the over-fished burdens of our oceans. Now, left without the farm-raised option (personal choice) and guilt over the over-fishing issue, for the most part I don't eat fish any longer. OK, except my (greatly reduced) consumption of sushi, now down to roughly a "quarterly treat".

 

I rarely eat beef any longer, not from a "beef is bad for you" perspective, but because of the issues of how they are raised and slaughtered, pork has fallen prey to this as well. I try to restrict myself to two steaks a year, although I admit last night I splurged and had a glorious offering at a local restaurant I've been meaning to check out, newly opened a year ago. It was, perhaps and without exaggeration, the best steak I have ever had the culinary pleasure experiencing. Of course, I did experience a few moments of guilt when ordering, quickly forgotten with that first bite.

 

The restaurant, Harvest Moon, is three miles from my home, and although my husband had long been suggesting that we check it out, I always demurred on the grounds of "how good could a local restaurant be… really?" My assumption was if it rose to "diner" level it would probably be accomplishing all that could reasonably be expected.

 

My "perception" was one thing, reality turned out to be quite another. Harvest Moon Low Country Grille would, in fact, be quite at home in downtown Charleston competing with just about any (and all) of our well-known (and rated) continental fare establishments. Please forgive my brief digression, but if y'all out there are ever near Ravenel, SC you should do yourselves (and your taste buds) a favor and give them a try.

 

Oh, and there was no ice dilemma since I chose to pair my steak with a Yuengling lager.

 

There is one dish that I still eat at every opportunity, without regards to "where and how" it lived, died, and shipped, great (ok, even good) calamari. After all, life without certain things (calamari and that occasional steak) just doesn't seem to be within my capacity of self-denial.

 

Perhaps a bit of supreme irony, but I eat chicken, almost exclusively, as my meat protein. However, I do treat my uncooked chicken with all the respect and caution of a genuine bio-hazard. See here for my post on biohazard poultry and its proper handling.

 

My food choices, and at this point in my life they are still choices, are already highly driven by perception(s), irrespective of factuality, and being such they are subject to being influenced. Those influences come from my concerns about safety, social and ecological consciousness, being a good citizen of the world, respectfulness of the "web of life", and last – my taste buds.

 

I read the Wired piece thinking hummm… this makes sense on a number of levels, but – could I eat pigeon? Honestly, probably a choice just above eating rat, and it would likely take a lot of "influence" to change my perceptions. After all, my dietary choices seem to revolve around the elimination of foods not inclusion, but then, the main theme of the piece… inclusion… truly did set me to thinking.

 

Our food supply is not all that it should be from the standpoints of safety, ecology, responsible and humane stewardship, and last but not least, supply-and-demand. Perhaps it's way past time to rethink a number of things.

 

Perhaps perspicacity needs to replace perception.

 

Just don't suggest I start eating rat due to its ubiquitous plentitude.

 

SZ

OK You can call me a germaphobe

One of the drawbacks to studying influenza and H5N1 has been the development of an acute awareness of infectious diseases in general. I say "drawback" because with that awareness mysophobia (a fear of dirt or germs) has crept into my life. Slowly at first, and still not especially overtly noticeable, but my behavior(s) in public and around "strangers" has changed and become "uncomfortable".

 

Oh, I can still turn a door handle or shake someone's hand, but they, and many other "public interaction behaviors", produce jerking hesitations and pained internal groans, followed as soon as socially acceptable by a surreptitious deployment of my alcohol gel hand sanitizer, in a convenient travel size of course. I have become what I term "non-tactile" in public, or at least as non-tactile as I can manage and still be in public. It's not easy, as that hideous Lysol commercial with those disgusting animated green germs crawling all over hands graphically illustrates: Germs are everywhere, deposited and passed along to unsuspecting – and more normal folk.

 

I have greatly reduced the amount I eat out because of my infectious disease awareness. I used to eat out at every opportunity, because, honestly, I hate to cook. Now even my own cooking has taken on an entirely new dimension, as more and more e-coli and salmonella contaminated food products have been in the news. So, the "general germiness" of food is something that has developed into its own little offspring phobia. Then I read this…

 

Hold the Ice
Updated: Feb 15, 2008 06:08 AM

Bob Segall/13 Investigates [NBC affiliate WTHR]

Scientists say improper hand washing, food handling and equipment maintenance are to blame for high bacteria levels found in local restaurant ice.

What 13 Investigates discovered in the ice at many Indianapolis-area bars and restaurants is not supposed to be there. In fact, at one of every three restaurants checked, the ice contained more bacteria than toilet water, and health officials say it shows improper practices at local eateries that could make you sick.

This month, WTHR collected ice samples from 25 popular bars and restaurants and took it to a state-certified laboratory for analysis. The results showed at 13 of the 25 bars and restaurants tested, at least one ice sample tested positive for the presence of coliform bacteria.

Continues….

 

Not that I drink many iced beverages, except that is, when I do eat out. Since I'm only an occasional imbiber of adult beverages, generally my drinks are either ice water or tea, or diet Coke. Now, well, yet another behavior will be modified because those out and about can't be counted on to have actually washed their hands.

 

Such a simple thing hand washing is. Water, soap, lather, rinse, dry. Making sure top and bottom of hands and between fingers are soaped and lathered, the lather forming a foaming "glove". Even done properly it doesn't take long at all, hardly many more seconds than doing it improperly.

 

Should an influenza pandemic befall us we will have to be doing quite a lot of hand washing. It is the first and last line of defense against fomite transfer (the surface of an object that can harbor and transfer pathogens), a line of defense against others who don't wash their hands as well as those who cough and sneeze near the objects that we, in our turn, touch.

 

We may not be able to quantify with exactitude the role fomites play in disease transmissions but as the investigation of restaurant ice demonstrates, we know it's a problem. The fact that it's a problem that shouldn't be doesn't make it less of a problem.

 

In the name of thoroughness….

Proper hand washing with soap and water
Follow these instructions for washing with soap and water:

• Wet your hands with warm, running water and apply liquid soap or use clean bar soap. Lather well.
• Rub your hands vigorously together for at least 15 to 20 seconds.
• Scrub all surfaces, including the backs of your hands, wrists, between your fingers and under your fingernails.
• Rinse well.
• Dry your hands with a clean or disposable towel.
• Use a towel to turn off the faucet.

 

As they say: It ain't rocket science.

 

SZ

A Journey into the world’s slums

Several times over the life of this blog I have written or mentioned the world's mega-slums, vast slums attached to mega-cities (defined as having populations of at least 10 million). A phenomenon that has long held a certain fascination for me and I have undertaken a more disciplined study of them.

Slums and mega-slums are a natural adjunct to the subject of pandemics, if only from the sheer number of people who populate them. Although statistics are rather imprecise, given the nature of the "unofficial residents", they are precise enough to allow for generalized conceptualization of the issues.

According to the UN's Global Report on Human Settlements 2003: The Challenge of Slums approximately 1 billion people live in what they define as a slum community. Defined with the following indicators to arrive at the baseline global estimates:

• Inadequate access to safe water
• Inadequate access t sanitation and other infrastructure
• Poor structural quality of housing
• Overcrowding
• Insecure residential status

One billion is shocking enough but even more so when contrasted with the total urban population of three billion. That's one in every three urban residents (roughly half of all people live in an urban environment). By anyone's measure, that's a bunch of folk.

One billion people equate to almost the entire population of China or India (and many of the urban slum and mega-slum dwellers find themselves in those two countries). As I said: That's a bunch of folk.

The domiciles of these informal communities (a more neutral term) are generally small, cramped, rudimentary structures with no means in-home personal hygiene. These things alone mean the residents will suffer far greater morbidity with the accompanying mortality everyone else will face (whatever that ends up being) aggravated by (generally) barely subsistence levels of nutrition and high levels of other endemic diseases.

Diseases caused by contaminated drinking water or mosquitoes and often life limiting or threatening: hepatitis, dengue, malaria, encephalitis, typhoid fever and cholera to name a few of the more common. As if it's some sort of cosmic joke not only do these communities have a severe shortage of safe drinking water, most contend with terrain altered by their very habitation to such a degree that when it rains it floods, and fecal contaminated rainwater inundates everything, inside and out.

Generally, either occupations are low paying unskilled menial jobs, within the city proper, or they are entrepreneurial. The entrepreneurial nature of much of the income generation places it to one degree or another outside of the legal system, either criminal or civil. Unlicensed businesses rob the wider community of license fees and criminality ranges from petty crimes, to prostitution, to illegal drugs.

Given the informal and unofficial nature of these communities, most residents have a greater likelihood of being victimized by crime and thuggery than being the perpetrators of such. Life is generally tenuous and demanding but not bereft of dignity and cultural vibrancy. The one thing residents have in abundance is hope for a better future – if only they can manage to hang on one more day, one more week, one more year.

It is difficult to use generalities given the disparate countries and cities the informal communities spring from. Generalities are just that, generalities, and there is no attempt on my part to say that there are not exceptions. Not all residents of informal communities are poor, nor do all find their way out. Some are born into, and die, in "non-person" status. Some are cold blooded brutal parasites. And, some have lives so tragic as to wilt my soul. But, most are families, trying to survive, making the best of what little they have and hoping for that golden ring to appear before their eager grasps.

 

A billion people living on the margins.

A billion people at extraordinary risk (known euphemistically as At Risk Populations) during a time that may well end up defined as an extraordinary risk, a severe influenza pandemic.

How many will be lost?

We don't even know (with any authority) how many live, there is no expectation that their deaths will be any more accurately accounted for.

Informal lives – informal deaths – in informal communities.

Adenoviridae

Today's news has been heavy with the internet publication of information on yet another emerging human pathogen, a variant of Ad14.

Ad14 is an adenovirus, of which there are somewhere between 40 and 50 human serotypes, depending on which resource one reads. There are also adenoviruses that infect other mammals, birds, and even amphibians.

From today's CDC MMWR:

Acute Respiratory Disease Associated with Adenovirus Serotype 14 --- Four States, 2006--2007

Adenovirus serotype 14 (Ad14) is a rarely reported but emerging serotype of adenovirus that can cause severe and sometimes fatal respiratory illness in patients of all ages, including healthy young adults. In May 2006, an infant in New York aged 12 days died from respiratory illness caused by Ad14. During March--June 2007, a total of 140 additional cases of confirmed Ad14 respiratory illness were identified in clusters of patients in Oregon, Washington, and Texas. Fifty-three (38%) of these patients were hospitalized, including 24 (17%) who were admitted to intensive care units (ICUs); nine (5%) patients died. Ad14 isolates from all four states were identical by sequence data from the full hexon and fiber genes. However, the isolates were distinct from the Ad14 reference strain from 1955, suggesting the emergence and spread of a new Ad14 variant in the United States. No epidemiologic evidence of direct transmission linking the New York case or any of the clusters was identified. This report summarizes the investigation of these Ad14 cases by state and city health authorities, the U.S. Air Force, and CDC. State and local public health departments should be alert to the possibility of outbreaks caused by Ad14.

 

As with most infectious diseases, it is difficult to know the true extent and severity of a pathogen based solely on the cases that result in medical consultations and/or hospitalizations. There is no way of knowing how many cases occurred, and probably continue to occur, that were not severe enough to require medical treatment. Were we to have access to that data the alarming statistics in all likelihood wouldn't be so alarming, but without the full data set we are left with what we the data we do have. And that data is rather alarming.

This from MSNBC:

New cold bug kills 10, scores sickened

Scores sickened as mutated virus becoming more common, CDC says

The Associated Press

updated 1:55 p.m. ET, Thurs., Nov. 15, 2007

ATLANTA - A mutated version of a common cold virus has caused 10 deaths in the last 18 months, U.S. health officials said Thursday.

Adenoviruses usually cause respiratory infections that aren't considered lethal. But a new variant has caused at least 140 illnesses in New York, Oregon, Washington and Texas, according to a report issued Thursday by the U.S. Centers for Disease Control and Prevention.

That is incorrect based on the MMRW report:

[snip]

Cases reported postinvestigation. Since the investigation, new cases of febrile respiratory illness have continued to occur at LAFB, but the weekly incidence has declined from a peak of 74 cases with onset during the week of May 27--June 2, to 55 cases with onset during the week of September 23--29 (the most recent period for which data were available). In addition, during March--September 2007, three other military bases in Texas that received trainees from LAFB reported a total of 220 cases of Ad14 illness (Air Force Institute for Operational Health, personal communication, 2007). However, whether Ad14 spread from LAFB to these three bases has not been determined. Ad14 also was detected in April in an eye culture from an outpatient in the surrounding community who had respiratory symptoms and conjunctivitis. No link between this case and the LAFB cases was identified.

 

The Associated Press article from MSNBC closes with this paragraph:

More common
It's not clear how the changes made it more lethal, said Linda Gooding, an Emory University researcher who specializes in adenoviruses.

Earlier this year, hundreds of trainees at Lackland became ill with respiratory infections. Tests showed a variety of adenoviruses in the trainees, but at least 106 — and probably more — had the mutated form of Ad14, including five who ended up in an intensive care unit.

 

So while the reporting is alarming, the story that they attempt to report on is not clearly delineated, nor can it be; we just don't possess all of the facts on all of the (likely) cases.

We do, however, know that adenovirus is long-lived outside a host. Door handles/knobs, counter surfaces, toilet and bathroom sink handles, shopping cart handles, and the myriad other surfaces we touch on a regular basis throughout our normal day. Washing our hands regularly and keeping our hands away from our face will go a long way in helping to guard against infection. In today's "viral jungle" we must learn to adapt our behaviors as rapidly and efficiently as the pathogens we face.

 

 

Friday’s Miscellanea

One of the major areas that I have been concentrating some of my research on is the moral and ethical dilemmas a severe influenza pandemic might likely present us with. Medical ethicists have been tasked with defining treatment/triage criteria, rationing of scarce vaccine and antivirals, and even more scarce ventilators.

So when I ran across the following two articles this week I took note of the medical and social moral/ethical dilemmas they present us. They are actually what inspired the creation of a new post category for this blog, "It's a Brave New World".

Brain-boosting drugs spark ethical debate in UK 

08 Nov 2007 13:43:36 GMT

Source: Reuters

By Ben Hirschler

LONDON, Nov 8 (Reuters) - A rise in healthy people popping pills to boost performance in exams or work, raises long-term ethical and safety concerns about the effects of such treatments, British doctors said on Thursday.

The British Medical Association (BMA) wants a public debate about the risks and benefits of using drugs to improve memory and concentration, sometimes called "cognitive enhancement".

The ability of prescription drugs and medical procedures to improve intellectual performance is likely to increase significantly in the next 20 to 30 years as technology advances.

"We know that there is likely to be a demand by healthy individuals for this treatment," Dr Tony Calland, chairman of the BMA's Medical Ethics Committee said at the launch of a discussion paper on the issue.

"However, given that no drug or invasive medical procedure is risk free, is it ethical to make them available to people who are not ill?"

Surreptitious use of brain-boosting prescription drugs is particularly common in the United States and likely to increase in Britain, the BMA said

Continues…

And this from cnsnews.com:

Outsourcing Wombs in India 

By Deepak Mahaan
CNSNews.com Correspondent
November 08, 2007

New Delhi (CNSNews.com) - In a new twist to the outsourcing for which India has become renowned, poor Indian women are renting out their wombs to foreigners.

Surrogate motherhood -- carrying to term and giving birth to another woman's baby - once was limited in India to helping close relatives who couldn't complete a pregnancy due to medical difficulties.

But leading gynecologist Dr. Kamla Selvaraj says it's now becoming a regular "profession" in India, with more and more women willing to carry babies for others, for a fee.

India has for years been providing foreigners with in-vitro fertilization (IVF) treatment at a cheaper rate than the equivalent services in Western countries.

Surrogacy comes in when the biological mother is unable to carry the child. Alternatively, a surrogate also provide eggs when the woman wanting a child is unable to do so herself.

Apart from low-cost IVF treatment, India also is offering surrogate mothers at a considerably lower price than couples would pay in the U.S. or Europe.

Women's counselor Harleen Ahluwalia says surrogacy cases are estimated to have nearly doubled in the past three years.

"Foreigners find Indian legal procedures easy and less exploitative, unlike [in the] U.S., where any complication could cost a fortune," she said.

Continues…

Beyond the general interest these issues raised in me, and their (minor) connection to a PanFlu issue I am actively working on, I also have a personal connection to these issues. I went through fertility treatments to have a second child that ultimately were unsuccessful so I understand the women who avail themselves of an option, infertility can drive a couple to try nearly any option. As a Libertarian I feel that a woman has the right to direct her own body, and that inherently includes "renting" her womb. As a mother I find the idea of carrying a baby for nine months and then handing him/her over to "another" mother to be beyond my comprehension.

The mental enhancement issue has a different personal angle. Were it readily available to me I would be there in a heartbeat. Not to be flippant about the issue, but I would certainly take advantage were there meaningfully effective pharmaceuticals that I could get, even if I had to pay for them out of my own pocket. But that highlights the very thing this issue raises, there will be those who choose to do it, and who have the means, and then there will be those who won't or can't. Ah—but just because there will be those who won't or can't does that preclude me the option of this choice?

Interesting moral and ethical questions for a Friday evening.

SZ

Fear of Medical Treatment

I found the below article this morning as I was doing a quick 'net surf of the overnight doings, particularly poignant due to watching over (albeit from afar) the progress of a Fellow Flubie recovering from major surgery. To say nothing of my own experiences with my husband's recent health issues.

From Scotland's The Evening Times

Scots 'skip vital ops' in bug fears

SCOTS are avoiding treatment amid growing fears about catching hospital bugs, it was claimed today.

Former Strathkelvin and Bearsden MSP and health campaigner Dr Jean Turner says some patients are so worried about superbugs they are bringing their own cleaning materials into wards.

Dr Turner's comments come just days after orthopaedic operations at the Southern General were cancelled when six patients were hit by wound infections.

It is the latest infection crisis to grip the city hospital and came just weeks after an outbreak of superbug MRSA there.

Dr Turner said: "Hospitals are simply losing the cleanliness battle and patients are getting more and more worried about getting these superbugs."

One patient Dr Turner knew had three times refused to go for a hip replacement at Glasgow Royal Infirmary amid fears of contracting a superbug.

Calling for "drastic action" Dr Turner said health board chief executives should be "forced to resign" if wards are not cleaned up.

A study by Health Protection Scotland showed almost one in ten patients picks up infections in Scots' hospitals - the highest rate in the UK.

 

While I wholeheartedly sympathize with fear of going to a hospital due to infection fears I couldn't help but also worry about if/when PanFlu first hits if we will have issues of our first cases delaying medical attention (thus our attention) because of fear of infection from a clinical setting. I admit that when I injured my hand several months back and should have gotten it attended to by medical professionals I didn't because of my own fear of hospital infection. There is a term for a healthcare setting acquired infection: Nosocomial infections, problem that will likely be with us for the foreseeable future.