Scott McPherson's Web Presence

You know, we don't get to see many breaking television bird flu news stories outside of the US, but Indonesia's MetroTV seems to be doing a good job of broadcasting breaking bird flu news to their viewers.  Back in the 1980s, then-news director of Miami's Channel 7, Joel Cheatwood coined the expression "If it bleeds, it leads,"

The MetroTV mantra must be "If they sneeze, they lead."   Sorry.

Anyway, if you click on this link, you will see the news story of the family being transported to Jakarta via ambulance.  Again, a top of the cap to Commonground, veteran flusite poster.  Now I want you to put yourself in the position of any Indonesian resident who is watching this unfold on television.  How would you feel if this was broadcast in New York, or Peoria, or Billings, Vancouver, or Tampa?  Or Tallahassee?

As Count Floyd used to say:  Pretty scary, kids.

http://www.metrotvnews.com/berita.asp?id=50975

Doctors in Serang, Banten Province, West Java, Indonesia, have begun applying a Tamiflu blanket over the village of Desa Terumbu in Benten Province. This follows another potential family H5N1 cluster in the nation of 18,000 islands. The sick were initially taken to hospital in Serang, the capital of Banten Province, which is home to some 9 million Indonesians.

They now reside in Indonesia's special Avian-Flu (AI) center at the Jakarta-based Persahabatan Hospital, transported by four ambulances, earlier today.

Flu sites and bloggers (click links at left for FluTrackers, H5N1 and Avian Flu Diary) have been atomic today with growing news of the emergence of this potential cluster. The dead giveaway, according to Dr. Henry Niman (www.recombinomics.com), are the depressed leukocyte levels, accompanied by the usual symptoms of H5N1 infection.

Newspaper accounts are starting to coalesce around five siblings in the same immediate family being sick. The ages range from 8 to 30, also a cause for concern. Accounts are also starting to coalesce around two being the first ones ill, and then the other three got sick sometime later (the word "afterwards" shows up in machine translations). Whatever "afterwards" means, in flu symptom timelines, usually means after a period of days.

Two additional family members -- a 33-year old and a 65-year old -- are awaiting treatment at hospital. They were apparently triaged and the first five were the most seriously ill, so they were moved first, according to flusite poster Commonground's translation of a MetroTV repot (http://www.metrotvnews.com/berita.asp?id=50975).

Here's the rub: There were apparently two other infected students who bolted, cut and ran like the Indonesian wind when the words "Flu Burung" were mentioned. So they have to be located, tested and treated.

Jum'at, 21 Desember 2007 22:08 WIB
Five patients was suspected BIRD FLU was reconciled to RS PERSABAHATAN

Serang: Five the patient was expected by bird flu from the Terumbu Village, Kecamatan Kasemen, Kabupaten Serang, Banten, Jum'at (21/12), was brought to the Persahabatan Hospital, Jakarta.
When being brought by the condition for the five casualties was increasingly critical in a hot manner high that never will descend. They will undergo the inspection that was more intensive in the Persahabatan Hospital, Jakarta.
The patients were carried by the ambulance belonging to the Public Hospital of Daerah Serang and Regional Government Serang. According to the family, the casualties had the story was touching with the poultry in their house environment.
The five patients were expected by this bird flu each being Mukhlis, 27 years; Iklima, 17 years, Muhaimin, 15 years; Nujun, 10 years and Najad, 8 years.

All are awaiting test results.

The next story is from the Vietnam News Agency (!) below: http://www.vnanet.vn/Home/EN/tabid/119/itemid/228803/Default.aspx

21/12/2007 -- 9:09 PM

Jakarta (VNA) - Five members of a family in Indonesia's densely-populated West Java province are suspected to be infected with the deadly bird flu virus.
The suspects, aged between 8 and 30, suffered from high fevers, coughing and had difficulty breathing following an outbreak of the virus among local poultry. They were reportedly admitted to Serang hospital, about 80 kilometres west of Jakarta , earlier this week.
They were transferred on December 21 to Persahabatan hospital in Jakarta, which is designated to treat avian influenza patients, Serang district health office chief Encep Mukardi told Antara news agency.

Flusite poster Laidback Al's map of the Banten Province is above.

A local Indonesian report speaks of a boarding school where the headmaster and several students became ill after eating duck for dinner. The original Malay report link is below. I trust the machine translation from Flusiteposter Dutchy, and have kept her bolding for emphasis:

Students were affected by bird flu
Six students and a management of the Islamic Boarding School (ponpes) Riyadul Huda, in the Village/Desa Terumbu, Kecamatan Kasemen, Serang, Banten, was stated suspect bird flu by the team of the doctor RSUD Serang.
From the seven students and the management ponpes that terindikasi this bird flu, the team of the doctor could only diagnose 5 patients.
His article, two other students that terindikasi the same illness escaped. Suspected two patients that bolted, frightened when being checked.
Five patients have been done by the inspection and their results terindikasi bird flu, said Dr. Sulhi Azis, Kepala RSUD Serang to several reporters, in his office, on Friday (22/12).
The five casualties were affected by the illness attack from the animal, Muklas, 30, (the management ponpes), Mubin, 25, Imah, 20, Enjat, 15, and Nuzul, 9, the four of them were the student who came from the local village.
They have been reconciled by us to be treated in RS Persahabatan, Jakarta, explained Sulhi.
Sulhi added, the indication of the five students was infected by the bird flu illness, among them the level of leucocyte of bird flu casualties that less than the range of the normal figure.
Duck Carcass
leucocytes the five of them were based on results of the inspection of RSUD Serang was in the figure was supervised 5,000 cells/cubic mm.
"If the healthy person of the level of his leucocyte might not less than that."
Occupants ponpes was run off with to RSUD Serang on Wednesday (19/12) on local reconciliation of the community health centre doctor.
The five of them it was reported experienced the increase in the temperature of the high body, breathless as well as paralysed after beforehand consumed a duck that was shattered because of being sick. The other news mentioned, casualties beforehand also could hold the duck carcass.
The head of the Health Service of Serang, Dr. Encep Mukardi said, his side carried out prevention efforts by distributing Tamiflu to the occupants ponpes this and the resident of surrounding area.
The Ponpes Riyadul Huda management, Samsuri said, the environment ponpes that was taken care of by him was gotten by many of much poultry livestock breeding belonging to the resident. http://www.poskota.co.id/news_baca.asp?id=42797&ik=4

Apparently, "ponpes" is "school," I guess. But as Dutchy's translation attests, it is an Islamic church-connected school, which would explain the wide divergence in victim's ages (from 8 to 65). Islamic religious instruction (as in other religions) ideally stretches from cradle to grave. So we can reconcile the two stories with Dutchy's other translation, this time of a Kompas story, Lima Warga "Suspect" Flu Burung Jalani Isolasi :

Dr. Niman contributes this report, from Indonesia's English-language Antara News Service:

Five suspected bird flu patients moved to AI center
Serang, Banten (ANTARA News) - After three days of medical treatment at the Serang General Hospital, five suspected bird flu patients were moved to the special Avian-Flu (AI) center at the Jakarta-based Persahabatan Hospital by four ambulances on Friday.
The five, identified as Mubinul Hamidi (16), his younger brothers Nujulul Hak (10) and Najatul Hidayat (8), Muhlas (30) and his younger sister Iklimah (17) were rushed to the general hospital on Wednesday after being treated at a local health service post.
Fathurahman, the father of the first three patients, said his children were suffering from fever with respiratory difficulty and cough before being taken to the health service post.
He said a day before they fell ill, about 60 ducks and chickens owned by him and his neighbors had died suddenly.
"Local agriculture officers who checked the dead fowls said they tested positive for bird flu," he said.
Bird flu has so far claimed the lives of 93 people in Indonesia.
The last fatality was a 47-year-old man who died at Persahabatan Hospital, after falling ill from the H5N1 virus on December 2.

http://www.antara.co.id/en/arc/2007/12/21/five-suspected-bird-flu-patients-moved-to-ai-center/

So as we read in multiple accounts, poultry in the immediate area also tested positive for H5N1 just days before the first suspected human cases started rolling in.

OK, so here's my take: At least five, or possibly seven, members of a family were at a school, probably associated with and connected to a mosque, taking religious instruction, or maybe just studying or even celebrating. At least some of the family members apparently ate a duck that was possibly infected with H5N1, as reports summarize the duck didn't look so hot to begin with, and H5N1 is endemic in the immediate area. The local clinci quickly became overwhelmed, and the regional hospital sent them ahead to Jakarta, which is also not unusual. What is unusual is the application of a Tamiflu blanket on the attendees of the school, we presume the mosque, and residents of the surrounding community.

Or, more accurately put, a Tamiflu blanket used to be unusual, but is rapidly becoming routine in Indonesia. Maybe elsewhere too.

What we don't know is if the family is testing positive for H5N1. As we also know, Tamiflu has the demonstrated capacity to reduce virus to levels below positive in the usual tests. So we shall see.

Now where did those two students run off to?

An excellent article via Bloomberg.com is circulating today.  It describes the growing problem the state of Texas is having with MRSA, particularly in its prep football stadiums.

Texas loves its high school football arguably better than any other state in the Union.  Many high school stadiums are fancier, better-equipped and have a seating capacity larger than many Division 1 college counterparts.  It is not uncommon to see a Jumbotron in some stadiums, along with skyboxes and -- artificial turf.

In earlier blogs (search keyword MRSA), I have mentioned the problems indoor stadiums have containing this deadly bacteria.  Recall that the NFL's St. Louis Rams had to disinfect all their playing and solid surfaces awhile back, because they were a MRSA Petri dish and were also passing the pathogen to opposing players. 

But now the problem is moving outside. Some snippets from the Bloomberg story:

Texas has artificial turf at 18 percent of its high school football stadiums, according to Web site Texasbob.com. It also has an MRSA infection rate among players that is 16 times higher than the estimated national average, according to three studies by the Texas Department of State Health Services.

``This is a disease that can kill you,'' said Carolina Espinoza, a graduate epidemiology student at the University of Texas in Houston, who helped conduct one of the studies. ``If I were a football player, I would be alarmed.''

At least 276 football players were infected with MRSA from 2003 through 2005, a rate of 517 for each 100,000, according to the Texas studies. The U.S. Centers for Disease Control and Prevention in Atlanta reports a rate for the general population of 32 in 100,000.

Football players often become infected at the site of a turf burn and are misdiagnosed, said David Smith, co-author of a study showing that MRSA-related hospitalizations in the U.S. more than doubled from 1999 to 2005.

``The turf burns themselves are just the kind of minor skin injury that MRSA can exploit,'' said Elliot Pellman, medical liaison for the National Football League, which also has had infections among its players.

Football dominates high school sports in Texas, which has more participants than any other state. Seventy-four schools have stadiums seating more than 10,000. The sport provides 22,041 full-time jobs and generates $2.88 billion in annual spending, said Ray Perryman, president of Perryman Group, a Waco economic and financial analysis firm.

MRSA causes more deaths than any of the 51 infectious diseases tracked by the CDC, including AIDS, according to CDC data. The agency doesn't require medical professionals to report MRSA cases.

Texas plans a pilot program next year making MRSA a reportable illness in three regions, said Bryan Alsip, assistant health director for San Antonio.

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=alxhrJDn.cdc

As you know from reading my bio, I am heavily involved in high school football here in Florida and specifically at (Tallahassee) Lincoln High School, where NFL Pro Bowler Antonio Cromartie (yes, THAT Antonio Cromartie), Pat Watkins, Pro Bowler and Super Bowl ring-holder Kevin Carter, Craphonso Thorpe and other current or former NFL players and a massive list of college alumni played.   Or, more specifically, where all the local high schools play football.  the teams play on natural grass, which is not immune to MRSA either. 

Regrettably, in the third-largest state in the Union, Florida's governing high school sports organization is apparently either unaware of or is downplaying the nation's growing concern with MRSA.  The Florida High School Athletic Association's Website, www.fhsaa.org, only contains three references to MRSA, and two of them are within minutes of 2004 committee meetings.  A third reference is a link to a National Federation of High School Associations 4-page paper on MRSA.  None are on the main page, and are instead buried deep within the site.

Big deal.

Last year and with much fanfare, the State of Florida instituted mandatory steroids testing for its student-athletes.  That is symbolically important, and maybe they'll even catch an athlete or two.  But in an area that matters much more, and affects far, far, far more students in and out of athletics -- namely, the prevention and mitigation of a potentially deadly staph infection that footballers, wrestlers and weightlifters are especially susceptible to, but any student can catch -- the State's high school athletic association is absolutely mute.  

I am sure this is not limited to Florida; how does your state stack up on the issue? 

Ask your coach.  If s/he doesn't know the acronym "MRSA," you have your answer.

There are two apparently conflicting schools of thought, when it comes to predicting which strain of influenza will eventually "go pandemic."  The first school believes that a novel strain -- usually, as we all believe, H5N1 --  will be the one to eventually explode.

But the second school rarely gets attention.  That school believes that pandemic viruses recycle themselves and reappear every so often.  There is not a lot of information available Out There on that subject, but one of its strongest proponents was the late scientist, Dr. Maurice Hilleman.

Hilleman's name should be a household word by now, but the man was not into that sort of thing.  I offer you, verbatim, and from Amazon.com, the Booklist starred review of Dr. Paul Offit's superb work Vaccinated: One Man's Quest to Defeat the World's Deadliest Diseases.

From Booklist
*Starred Review* Maurice Hilleman's name isn't well known, and according to infectious disease expert Offit's riveting biography, that is both a shame and a blessing. It's a shame because the outspoken, brilliant, yet humble scientist from Montana invented vaccines that all but wiped out a number of infectious diseases. Thanks to his genius, such diseases as mumps, rubella, measles, and hepatitis A and B no longer claim millions of lives, mostly children's. He merits greater recognition. His obscurity is a blessing because it prevents more people from using his name in vain, for Hilleman's vaccines have recently become increasingly controversial and their efficacy clouded by questions about adverse side effects. Still, Offit pulls no punches in defending Hilleman against those who would crucify him for combining measles, mumps, and rubella vaccines into one shot and for the choice to add thimerosal to extend the shelf life of all vaccines. Despite the fact that Offit's bias on behalf of public health shows, the book is a powerful examination of the kind of single-minded determination it takes to tackle diseases that threaten the world's children. And to do so without bravado—no vaccine bears Hilleman's name, no awards his mantle—is to define what it is to be simply heroic. (Chavez, Donna)

Flu aficionados who are not aware of Hilleman need to look carefully at the work he did in 1957.  Offit makes a persuasive case that it was Hilleman who first uncovered the 1957 H2N2 flu pandemic and was the first to develop a vaccine -- in four months!  Admittedly, he did this without regard to the Feds, and he took risks.  But the results of his work are indisputable.  The mortality of 1957's H2N2 was ten percent of the 1918 pandemic.  And with astonishingly little available in the literature regarding the 1957 pandemic, any time anyone devotes multiple pages to that event, it is worthwhile reading.  And since the book opens with a look back at the 1997 emergence of H5N1, and closes with a prediction of H2N2 as the next Big One, it is also required reading -- if even using the index on a cold Sunday at Borders -- for all who are interested in influenza and infectious diseases.

Before his death, Hilleman said he did not think H5N1 would produce the Next Pandemic.  But he believed he had stumbled onto a pattern of viral behavior that may be hard to shake.  He believed that pandemic influenza viruses came in 68-year intervals.  using this technique, he believed that the 1889 pandemic was an H2 virus.  He supported this with testing which (at the time and using 1957 science) purported to show that elderly people who survived the 1889 pandemic possessed antibodies to the H2 substrain.  Influenza textbooks have also adopted this view; namely, that 1889 was an H2; 1900, an H3; and so on. 

This view is hotly debated in microbiological circles.  Some researchers, such as W.R. Dowdle of the Task Force for Child Survival and Development in Decatur, Georgia, believe that an H3, not an H2, was responsible for the 1889 pandemic.  Hilleman believed an H3 was responsible for the mini-pandemic of 1900; Dowdle also believes differently.

But not too differently:  I quote from the abstract of Dowdle's research paper, H2 variants should be included in pandemic planning for a number of reasons, but not because of evidence of recycling. It is not known when the next pandemic will occur or which of the 15 (or more) haemagglutinin subtypes will be involved. Effective global surveillance remains the key to influenza preparedness.

OK, now on to today's events.  A brand new research paper has uncovered a new reassortant hybrid swine/avian H2N3 virus, previously only detected in wild birds.  Dr. Richard Webby of legendary St. Jude Childrens Research Hospital in Memphis (home of Dr. Robert Webster), along with researchers at the University of Iowa (where swine influenza was first discovered) and the University of Minnesota (also no slouches at the flu) released a major work.  The short form:  Pigs can, indeed, be the "Mixing Vessel" to produce a potential pandemic strain.

The bigger news is that H2 is now officially back on the Short List for the Next Pandemic Strain.  No doubt this will be welcome news to those who are laboring fruitlessly to persuade/convince their superiors that a flu pandemic is around the corner, if not outright imminent.  Anyone under the age of 50 is not immune to H2.  Also, no one is immune to the neuraminidase N3.  And a swine/avian H2 reassortant may not afford complete immunity to those who lived through 1957, as I did.  I recall my fever:  I was 2 at the time, and I hallucinated that a train was running up the wall of my bedroom.  The memory of that hallucination stays with me today. And no, it was not provoked by the 60s!. Wise guys.

By the way, the H2N3 was not found in Guangdong Province, China.

It was found and typed in Missouri last year, which is ironic, since it is the Show Me state.

Now, do we go back, like the Indonesians and Pakistanis have done, and try to find untyped influenza infections in farms in Missouri that were passed off as seasonal flu, no biggie?

Hmmmmm.

A huge hat-tip to Crof and FLA_MEDIC for breaking this story on H5N1 and Avian Flu Diary.