A Journey Through The World of Pandemic Influenza

Standing at the Gates of Hell

Yesterday I posted on the Ebola outbreak going on in Uganda with a large portion of the entry dedicated to discussing the fleeing of medical personal from the outbreak. Today, crfullmoon of PFI posted a link to Paradoxuganda written by Drs. Scott and Jennifer Myhre based in Bundibugyo, Uganda. Their recent blog entries have dealt with an on-the-ground-up-close-and-personal account of this team amidst the Ebola outbreak. They have not "fled", instead, they are "standing their ground".

 

There is a Tom Petty song that I am quite fond of:

I Won't Back Down

Well I wont back down, no I wont back down
You can stand me up at the gates of hell
But I wont back down

Gonna stand my ground, wont be turned around
And Ill keep this world from draggin me down
Gonna stand my ground and I wont back down

Hey baby, there aint no easy way out
Hey I will stand my ground
And I wont back down.

Well I know whats right, I got just one life
In a world that keeps on pushin me around
But Ill stand my ground and I wont back down

Hey baby there aint no easy way out
Hey I will stand my ground
And I wont back down
No, I wont back down

 

With those words in mind…

Thursday November 29, 2007:

 

The mysterious disease that has infected people in Bundibugyo was this morning revealed to be Ebola virus (verified by the CDC-Atlanta laboratories). 79 cases have been identified since August, with a 43% death rate. So far all cases have come from a village area called Kikyo, which is 25 km from our mission, or through direct prolonged contact with patients from that area. Ebola is a panic-inducing word. We are treating this news with sober respect,…

 

[a listing of facts on Ebola]

 

Please pray for our doctors and other health workers. Dr. Jonah is in Kampala now, but he saw quite a few cases before he left, as did Dr. Sessanga. Scott has attended to many of these patients already. Pray for us to wisely support the health system in our district, to graciously care for the ill, to be alert to any danger to our team and children, and to advocate for the best possible response that Bundibugyo can receive from international aid workers.

 

Friday November 30, 2007

 

[snip]

 

We're still waiting for the cavalry to arrive.  Meanwhile the MAF pilot has hung out at our house, and I've been at the Nyahuka Health Center.  We had one patient admitted to the isolation ward but she probably just has malaria.  I had an hour-long meeting with the staff, who are understandably nervous.

And with good reason.  I just got off the phone with Dr. Jonah.  He had gone to Kampala on personal business a few days ago.  Yesterday he had a headache, and today a bit of fever, so he admitted himself to Mulago Hospital's isolation ward.  We are hoping that his illness is not related, but I think he was wise to put himself there, so that he does not infect others.  PLEASE pray for him!!!

 

Later in that day…

 

[snip]

 

The WHO rep, a sharp, experienced, epidemiologist emphasized in the first meeting of the day with local govt leaders that this seems to be a new (fifth) strain of Ebola, atypical both clinically and genetically from previously identified strains. A more non-specific clinical syndrome (fewer specific hemorrhagic signs) will make the containment of this epidemic more challenging, he said. That first meeting also revealed a lack of consensus on what public health message should be disseminated to the pubic. Will schools, markets, basic health services be shut down or curtailed? Hand-shaking cease? There was no debate about the answers, only a request from the experts to wait for their final assessments.

 

The visit to the Ebola Isolation Units at Kikyo Health Unit and Bundibugyo Hospital consisted of physical assessment of terrain, potential tent and gate locations, patient traffic patterns, water and latrine availablity, and staffing evaluations. Surprisingly (to me), not one member of the International Team donned protective gear in order to lay eyes on any patient. Their mandate, they said, was logistical assessment not clinical management. At Kikyo Health Unit, the staff and community seem much less aware of the ramifications of the Ebola diagnosis. People milled around the grounds of the Health Unit gawking at the entourage with its six vehicles and foreign visitors.

At Bundibugyo Hospital a significant portion of the hospital staff have gone AWOL or called in sick. A few brave nurses volunteered to staff the Isolation Unit, previously built by MSF for Cholera Isolation. During our discussion of potential layouts of an expanded unit at Bundibugyo Hospital, I received the short message on my cell phone that Dr. Jonah admitted himself to the Mulago Hospital (Kampala) Isolation Unit with fever, headache, and vomiting (and a history of contact with Ebola cases). Up to that moment, we had all expected Jonah to return today to resume his active role in the assessment and management of this crisis. Not possible now.

 

[snip]

 

I realized this morning that there are, in reality, two related emergencies. The Ebola Epidemic trumps all as the primary crisis. However, there is a secondary Medical Staffing Emergency in this District. Our only two Ugandan Medical Officers lay ill, presumably from Ebola. The official Ministry of Health initial press release revealed 51 cases and 16 deaths. That's a 31% case-fatality rate. Nearly three-quarters of those afflicted may survive (according to the official numbers). So, our doctors may survive, but are likely to be out of commission for weeks.

 

[snip]

 

Bottom line....

We desperately need at least one more physician at Bundibugyo Hospital who can do emergency operative obstetrics. The District has failed miserably in recruiting doctors even before Ebola. The likelihood of a Ugandan Medical Officer volunteering to come to Bundibugyo now seems slim and none. I have appealed to MSF to recruit a doctor from their ranks to come and do non-Ebola hospital work (they are sending two already to manage the Ebola cases).

Please pray...

For Dr. Jonah, Dr. Sessanga, Joshua Kule (a senior Physician Assistant), and Fred (a nurse)--health workers who have all fallen sick with symptoms of Ebola this week.

For another doctor to come in and serve at Bundibugyo Hospital.

For Jennifer and I as we balance the responsibility of leading our team and being involved in District-level response and planning.

For Jennifer and I...for our health. We have personally examined patients (using some protective measures—but not the head-to-toe suits which are on the way), but I do not believe our exposure has been to the level of our Ugandan colleagues.

For Bundibugyo. It's another bad rap for a disdained district. We know, however, that God has a special concern for the poor, the lowly, the despised. He has not forgotten or forsaken us.

 

Sunday December 2, 2007

 

[snip]

 

Admitted at Bundibugyo:  15, including Dr. Sessanga whose sister just came to our house looking for Scott because he's no longer responsive; the matron (head nurse); the nurse who was working in the isolation unit Fred; a clinical officer named Joshua Kule; and an ophthalmic assistant.  Among the other patients are six direct contacts (mother, brother, wife, daughter and two friends) of Muhindo Jeremiah who died just over a week ago.

Admitted at Kikyo:  8 as of yesterday, haven't heard today.

Died:  official number is 18.  Likely higher, hard to say.

Calvary:  Still en route, but expected any minute.  They slept in Fort Portal last night.  There is a 17 person team from combined MSF branches (Belgium, France, Spain, etc.) including the doctor who was in charge of the recent outbreak in Congo.  They have two doctors, four nurses, and a wide variety of other staff who won't see patients but do logistics, education, investigation.  Even an anthropologist.  The CDC lab team arrives in the country Tuesday night.  They say they'll be up and running for labs in Entebbe (Uganda Viral Research Institute) by Thursday, possibly even Wednesday evening.

Jonah:  I just talked to his sister, she says there is definite improvement since yesterday.  We heard he had a positive malaria smear, so it is possibly not Ebola.  But then he developed more symptoms, so we are waiting for a confirmation.  His blood sample is with the CDC in Uganda, not yet reached America.

Team:  OK.  We had a prayer and discussion time this morning.  As team leaders we are leaning towards sending out non-medical staff and children, to be cautious.  Scott and Scott zipped up to Bundibugyo again mid-meeting to do an emergency C section, but by the time they got the mother into the OR the baby had died, and she then delivered the still-born vaginally.  So you could, in a public health sense, count that as another Ebola casualty.  As soon as they got out of that they were called to see a motorcycle accident victim, a lady with severe facial trauma and fractures they need to refer to Fort Portal, but probably can't because she's a family member contact of an Ebola survivor (one of the cases Scott has been following the last two weeks).  He was actually driving the motorcycle when it crashed.  It is incredibly complicated.

 

Still Sunday, different post…

 

I am making this two separate posts, to separate the facts from the emotions.  And since my mother and my son both read this from America I probably won't be fully honest.  But I will say that the emotional toll of the last 72 hours has been tremendous.  There is first of all the wrenching anxiety about the patients that we know.  Since about a third right now are hospital staff, they are not mere numbers in a list.  Jonah of course top of the list of people we love who are in danger.  A virus that selectively attacks the people who care for the sick seems positively diabolical.  Then second there is the small but real possibility that one of us, mostly Scott, would fall ill.  Since the only other two doctors who have seen these patients are down, we can not ignore that risk.  We have been careful and pray that we've been careful enough.  The full protective MSF biohazard garb is arriving today, before that we've worn masks and gloves only.  And related to that sobering hypothetical scenario is the responsibility we feel to protect and care for and make good decisions about our children and our team, a third area of gut-twisting thoughts.  It is unbelievably painful to consider that we (Scott, Scott Will, and me) might be dangerous to them.  So over the last day we've been growing in our conviction that we need to get the non-medical team members out of here, away from us.  It is an impossible dilemma, to look at my beautiful three children who are here with me, and think that for their own good I need to send them away from me.  To look at our bewildered team scrambling to make plans and feel that we can't go with them.  So far we are all well, but if our medical exposure stopped this minute it would still be at least two weeks, maybe three, until we were sure we were safe.  Over the last three days since we knew it was Ebola, I have only been with one patient who may have been a case (she died), while Scott has continued to care for the ill until MSF arrives (hopefully soon).  Clearly it would be good to keep one parent healthy, but where does that leave the support we need to give each other?  And if those three areas of stress are not enough, there is the parallel crisis of the collapsing medical system.  Scott has been gone all day again, third day in a row of juggling the medical and surgical emergencies that would have fallen to Dr. Sessanga and Jonah.  How do we weigh ethically protecting ourselves and our children and our responsibility to the community here where we've spent  a large portion of our lives, in their time of greatest need?  

 

I strongly encourage you to visit paradoxuganda to read the heart wrenching account of the Drs. Myhre in full, along with the few recent entries I did not "snip".

If you are a person of faith, your prayers have been asked for, I'm confident they aren't particular as to what faith.

 

Standing at the gates of hell. Afraid, but still standing.

I fervently hope that the Drs. Myhre do not mind me "snipping" such a large portion of their recent entries, I did not bother them with asking permission. I did so to honor their struggles, their fears, their prayers, their courage, their commitment, and above all… their humanity.

 

SZ

Norovirus Stressing Britain’s Hospitals

Norovirus is in the news a lot and not especially noteworthy here at BFJ but the fact that the DailyExpress is reporting a "Black Alert" at some hospitals and a general "stressing" of the system is noteworthy for me.

The disease is usually self-limiting, and characterized by nausea, vomiting, diarrhea, and abdominal pain. General lethargy, weakness, muscle aches, headache, and low-grade fever may occur. Symptoms may persist for several days and may become life-threatening in the young, the elderly, and the immune-compromised if dehydration is ignored or not treated.

 

CRISIS AS NEW BUG SWEEPS BRITAIN

Monday December 3,2007

Mark Reynolds

 

A VIOLENT stomach bug is sweeping the country and pushing hospitals to breaking point.

Some have already turned away patients because they have no beds available.

 

Last night health campaigners warned of a "meltdown" in hospitals and "unnecessary deaths" this Christmas.

 

In the past week, the bug has prompted several hospital trusts to issue Black Alerts – the highest state of emergency for the NHS.

 

The sudden outbreaks of the bug, norovirus, has seen stretched hospital staff forced to keep patients waiting in ambulances outside casualty departments while they try to find beds for them.

 

At other hospitals, wards have had to be closed to new admissions as the bug takes a hold on existing patients – further exacerbating the bed shortage.

 

The depth of the crisis, which began to worsen about 10 days ago, has been highlighted by a series of leaked memos from hospital managers.

 

Norovirus led to the closure of wards at 10 hospitals across the country last week, prompting a raft of Black Alerts, with trusts warning of worse to come as the winter months take hold.

 

Hospitals in Aberdeen, Bath, Bury St Edmunds, Bradford, Chichester and Worthing have already been forced to turn away patients because of the crisis. 

 

And half of Norfolk's entire ambulance fleet recently became stuck in a queue at a flagship hospital after it was found to be "full" and could not admit more patients.

Last night a spokesman for the national Save Our NHS campaign said: "We are getting reports of hospitals beginning to fill across the country.

 

"We know that some hospitals are managing the problem by turning away patients or making them wait in ambulances until they have a bed. 

 

"Cutbacks in beds have been causing problems and they are bound to be exacerbated by extra pressures in the winter."

 

On the front line, paramedic Tom Reynolds, based in east London, said: "The next few months are going to be a shambles. 

 

"People forget staff also suffer with sickness. Everyone is so exhausted. We can't keep up with what we are being asked to do."

 

Accident and Emergency registrar Dr Nick Edwards said: "The NHS is failing to cope with a predictable winter problem. Just imagine what would happen if we face an emergency like bird flu.

 

"We would need to invent a colour more serious than just black alert."

 

Geoff Martin, of the patient pressure group Health Emergency, warned that the crisis could lead to unnecessary deaths.

 

"We are staring down the barrel at the prospect of the worst NHS crisis for many years," he said.

 

"Our fears of a meltdown as the winter pressures build appear to be coming true as the norovirus gets a grip on our wards."

 

But last night the Government tried to play down the beds crisis. 

 

Health Minister Ben Bradshaw said: "Winter crises used to bedevil the NHS.

 

"Thanks to record investment under Labour and better organisation we've not had a major winter crisis for years.

 

"However, we are not complacent and constantly update contingency plans."

 

The piece from the DailyExpress has hints of "political" spinning however, I am well aware of the limitations our modern health care systems have been placed under irrespective of political party in power. It is that "limitation" that drives a great deal of the concerns the "Flu Obsessed" have when thinking about a sever pandemic.

 

Perhaps it is worth pausing a moment and considering what even a 30% clinical attack rate (CAR) during an influenza pandemic will do to our respective health care systems in light of this Norovirus outbreak.

 

SZ

Pets and Human Disease Risk

I have four Chesapeake Bay Retrievers that I love very much and occasionally as I buzz around the 'net looking for news on the PanFlu front I come across information about other zoonoses (any infectious disease that may be transmitted from other animals, both wild and domestic, to humans or from humans to animals (the latter is sometimes called reverse zoonosis). Today there were two such items.

Drug-resistant staph found in pets

The Associated Press
Oct. 28, 2007 03:45 PM

MELVILLE, N.Y. - Some veterinarians are documenting more and more cases of drug-resistant staph infections in dogs and cats, but say there is no reason for alarm among pet owners if they follow measures of simple hygiene.

Dr. Lewis Gelfand, a Long Beach, N.Y., veterinarian, said he's treating an increasing number of animals with skin eruptions infected with methicillin-resistant Staphylococcus aureus - MRSA. The cases seem to have increased, he said, in recent months.

"It's definitely a rapidly expanding problem," Gelfand said, adding that he has had 19 cases in dogs in the past year. "I believe it is a significantly underdiagnosed problem. We have been seeing dermatological cases as well as open sores.

Continues…

And:

From The Times

October 29, 2007

Exotic pets trade is 'raising risk of global pandemic'

Melanie Reid

The international trade in exotic pets such as monkeys, crocodiles and rats must be stopped if human beings are to be protected from global pandemics, a leading microbiologist has cautioned.

Dorothy Crawford, Professor of Medical Microbiology at the University of Edinburgh, said that the risk to people from zoonoses – animal-borne microbes – had never been greater, and that there was a need to reexamine our relationship with wild and domestic animals.

Professor Crawford also predicted that global travel would need to be restricted in the event of an avian flu pandemic.

Most emerging infections, including HIV, severe acute respiratory syndrome (Sars) and bird flu had been acquired from animals and no one could say how many other devastating diseases could yet mutate to human beings, Professor Crawford said. "Who knows what could be hiding around the corner? We really have to think about what we are doing," she said.

Professor Crawford highlighted the example of a consignment of giant Gambian rats, which were flown from Ghana into the US as exotic pets. The rats carried monkeypox virus, which transferred to prairie dogs that were sold in the same pet shop. The prairie dogs then passed the disease to their human buyers. The chain of infection was only terminated after the microbe had infected 71 people. In another instance, crocodiles being farmed in Papua New Guinea to provide luxury items for the West had been infected by a virus from wild pig meat, which crossed to their keeper.

Professor Crawford, whose new book Deadly Companions was published last week, said that it was "only a matter of time" before the growing tourist demand for bush meat in Africa led to a new epidemic from microbes jumping from their primate host. She said that common sense could be as helpful as scientific advancement in preventing pandemics. "Microbes are always going to be one step ahead of us. Their generation time is 24 hours, ours is 30 years. They mutate, they change, they will find a way. They are amazing opportunists," she said.

Continues…

I will probably always have dogs as the unconditional love and devotion that bestow so willingly and abundantly is something that my own heart seems to require. Coming home after a long day at work and looking into their big brown eyes just melts the weight of the day away. But having animals as members of our families requires us to be as diligent with their health and wellbeing as our own. It is also incumbent upon us to understand the issues that living with animals brings to ourselves and the humans we also love.

If we are not responsible pet owners I fear that we will start to suffer public backlash as more and more information on zoonosis becomes available and understood. If that day does come I hope I am long since so much scattered dust.

SZ