A Journey Through The World of Pandemic Influenza

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.