OK, now the Indonesian press is reporting that Gozi Sultia Ningsih, the 10-year old girl from Riau who died over the weekend of suspected (and lab test-confirmed) H5N1, did not die of the virus. 

This report directly contradicts the statement from Indonesian Health Minister Siti Supari (left).  Supari was directly quoted in the world press as saying the young girl did, in fact, die of H5N1-related illness.

See the AFP story below, and thanks to Crawford Kilian (CROF) for the blog entry at his site, http://crofsblogs.typepad.com/h5n1/ . I cannot add any more to what Crawford says, except to agree completely. 

Indonesian girl did not die of bird flu: official

Authorities are returning to Riau, Indonesia, in the wake of another suspected family cluster (for reference, see my earlier post All Eyes on Riau, http://www.scottmcpherson.net/journal/2007/10/8/all-eyes-upon-riau-indonesia.html ). 

Over the weekend, 10 year old Gozi Sultia Ningsih died of a confirmed H5N1 infection.  Her 17-year old aunt, Riri Rianti, also died after being hospitalized on October 11, but, incredibly, no samples were taken for analysis.  Just how, in perhaps the most bird flu-ridden province in Indonesia, can no samples be taken of a young girl with suspected H5N1 symptoms?!  This is beyond the imagination of any competent medical professional or layperson. 

This fact is not lost on the central government in Jakarta, which is growing increasingly frustrated with the inability of local medical authorities to observe suspected human H5N1 protocols.  The exasperation is clearly noticeable in the quotes from Dr. H Djuharman Arifinof, chairman of the Dewan Perwakilan Rakyat Daerah (DPRD), or Regional Council of Representatives, representing the Riau district.  

The following is again from intrepid Flu Wiki/Flutrackers poster and nimble-fingered lay translator Commonground.  Don't try to read each word literally; scan the translation and then read between the lines.

Admittedly, this is a rerun of a July, 2007 blog I wrote.  But things are pretty slow right now on the avian flu front, and we need talking points to keep people focused on the Big Picture.  So I felt a rehash of this old blog would be appropriate.

Scott 

With apologies to David Letterman, here is a quick list that you can keep handy and use to win arguments on the likelihood of an influenza pandemic. Feel free to add to this list, but it is written to be easily and quickly understood.

Top 10 reasons why we have not seen a pandemic since 1968:

10. The H5N1 virus has not “made it” around the globe – at least we have not seen high-path H5N1 yet in North America (at least none that any authority is willing to admit).

9. Surveillance of poultry and wildfowl, including aquatic wildfowl, has improved exponentially since 1968.

8. Rapid typing of influenza genetics allows public health officials to quickly make good decisions and move decisively to contain virus.

7. Education campaigns help to better promote awareness, especially in nations where H5N1 is becoming endemic. So when people get sick, or poultry gets sick, people are now a little more likely to report it.

6. Mass culling of poultry has beaten back the virus many, many times around the world. One major influenza researcher even went so far as to state that a pandemic strain of H5N1 has probably already died with a mass cull somewhere in this world.

5. Financial compensation for culled poultry helps convince some farmers to report deaths of poultry to the authorities.

4. The neuraminidase inhibitor antivirals (Tamiflu in particular) have been repeatedly effective in reducing H5N1 symptoms and ultimately in saving patients, but only in cases where a) the virus may not be as lethal, and b) when administered within 24 – 48 hours after onset of symptoms.

3. The WHO and global health authorities are ready to fly in supplies and “stamp out” outbreaks quickly. The August, 2006 “Tamiflu blanket” of 2,000 Indonesian villagers in four separate hamlets serves as evidence of the ability of public health authorities to combine Reasons #9, #8 and #5 into a coordinated action plan.

2. The Hong Kong government’s 1997 action to cull every bird in the city as the first suspected human-to-human transmission of the “new” H5N1 virus probably saved the world from a pandemic. Saved, or at least delayed the pandemic.

1. Global seasonal flu vaccine programs -- and the WHO's trying to pick the "Super Bowl winner" of three viruses (two Influenza A's and one B for the trivalent formula) in the February before the upcoming flu season -- have proven pretty accurate.  They miss the B formulation more often than they miss the A, but still it has helped reduce the amount of seasonal flu, which helps reduce the potential for a pandemic.  After all, each of us is a potential "mixing vessel" for a reassortant pandemic strain..

co-#1: We are damned lucky.

Top 10 Reasons why, despite all these efforts, we will still have a pandemic one day and probably soon.

10. H5N1 is becoming endemic in many parts of the planet, especially where people live in close physical proximity to poultry.  It is a mutating fool and cleverly defies attempts to kill it.  It is a supremely adept player at "King of the Mountain," which is the game all influenza viruses play.

9. Financial compensation for culled poultry helps somewhat, but the amounts paid usually are far short of actual losses incurred. If farmers do not feel that reporting avian flu losses are worth it in financial terms, they may (and already do) decide not to report the infections – unless their own family members become infected.

8. Smuggling of poultry, exotic birds and fighting cocks continues to accelerate. While not likely to be a principal source of spread of the disease, smuggling can nonetheless cause new outbreaks (ask the Vietnamese about their own “Ho Chi Minh Trail” issues along their border with China).

7. Modern industrial farming practices may actually and inadvertently encourage the spread of virus. Even a tiny particle of virus, trampled underfoot and brought into a poultry shed by a worker or farm machine, can kill thousands of poultry. And if left unchecked, even a “low path” avian flu can incubate, recombine with itself and emerge as a lethal, highly pathogenic influenza virus.

6. Despite the best 21^st Century medicine and technology, avian flu of all types continues to spread and the frequency continues to accelerate. Witness the recent outbreaks of H7N2 in the Delmarva (Delaware, Virginia and Maryland) peninsula of the United States (2004), the H5N2 outbreak in West Virginia (2007), the outbreak of H7N7 in the Netherlands and other parts of Europe which killed a veterinarian and infected at least 89 people via human-to-human transmission and possibly hundreds more (2003), and the outbreak of H7N2 in Wales which also infected 17 humans (2007).

5. Globalization has also inadvertently encouraged the spread of virus. Witness the Bernard Matthews disaster of early 2007. Hungarian-raised poultry, shipped to England for processing, carried high-path H5N1 with it. This was introduced into one shed, and then workers carried the virus to three adjacent sheds. In the end, over 160,000 turkeys had to be killed and disposed of. The Hungarian poultry were contaminated, in all likelihood, by wildfowl droppings laden with H5N1 virus that were carried into turkey sheds.

4. Migratory wildfowl continue to transport the H5N1 virus, along with every other flu virus known to Humankind, in their bellies. Migratory wildfowl are the custodians and reservoir of avian influenza. As they shed virus, it either dies or is picked up by other creatures.

3. H5N1 has jumped the species barrier. In Indonesia, a study postulated that up to 20% of all stray cats in the archipelago nation showed antibodies to high-path H5N1. That means cats can be asymptomatic carriers of the most potentially lethal virus ever seen. The Indonesian television videos of Army regulars accompanying healthcare workers into residential neighborhoods to swab the mouths of housecats is chilling.

2. The only continents where H5N1 does not have a strong foothold are the Americas, Australia and Antarctica. H5N1 can be found from sub-Saharan Africa to the Middle East, most of Europe, Asia, and Indonesia. Only in Europe has human death not yet occurred from H5N1. Unfortunately, that statistic can be wiped out with a single transcontinental or transoceanic airplane flight.

1. History is against us. In the past 300 years, no fewer than ten influenza pandemics have ravaged the world. Some, such as 1918’s Spanish Flu and the pandemic from 1562–1568 were extremely lethal. The 1562 pandemic may have had a death rate higher than 1918’s, which is almost unthinkable. Others, such as 1889’s, had a less lethal but still severe effect on the planet.

Sports teams, schools, hospitals wrestle with global MRSA epidemic

MRSA has claimed yet another young life.  Seventeen year-old Ashton Bonds of Lynch Station, Virginia, died following a bout with the disease.  MRSA is the acronym for Methicillin-resistant Staphylococcus aureus, a particularly nasty bacteria that is showing up all over the nation.  In Mr. Bonds' case, MRSA had spread via his bloodstream, attacking his kidneys, liver, lungs and heart muscle.

MRSA apparently began its life in hospitals.  The probable cause grew from lax oversight of hospital infectious disease control protocols. 

From a Bloomberg news story of December 19, 2005:  http://www.bloomberg.com/apps/news?pid=10000103&sid=aQGnyaFWj2FA&refer=us :

Researchers are concerned especially about antibiotic resistant bacterial infections that arise in hospitals and spread to homes and crowded workplaces. The microbe, called methicillin-resistant staphylococcus aureus, or MRSA, is creating a health hazard in the U.S. dwarfing the threat posed by the H5N1 avian flu, said Steve Projan, vice president of protein technologies for Wyeth, the drugmaker that markets the Tygacil antibiotic.

``This is a hyper-virulent virulent bug,'' Projan said in a press conference at the Interscience Conference on Antimicrobial Therapy and Antibiotics on Friday. ``While we're very concerned about H5N1, we do have in front of us today this outbreak of community-acquired MRSA.''  (bold mine)

Increasingly, researchers are finding these drug-resistant infections outside the hospital, leading to concerns about widespread outbreaks of hard-to-treat microbes.

In some hospitals in San Francisco and Los Angeles, the new toxic strain is the leading cause of drug-resistant staph infections. More than half the MRSA's at the Harbor-UCLA Medical Center are the community-acquired strain, according to a study presented Dec. 17 by Cynthia Maree, an infectious disease specialist at the University of California, Los Angeles Geffen School of Medicine.

``That's more than twice the rate we had in 1999,'' she said in an interview at the conference. ``When patients make repeat trips to the hospital with the same strain, health workers will sometimes clean the patient's home,'' in an attempt to get rid of the source of infection, she said.

MRSA has become a major pain in the rear for school districts.  It has hit sports teams especially hard -- especially those sports with a great deal of abrasion on hard surfaces, where the bacteria can transfer from skin to skin.  As a result, athletic coaches and trainers are learning about MRSA in clinics and lectures at coaches conventions.  Today, for example, wrestling coaches in several states are required to disinfect all wrestling mats after practice and before and in some cases, even during wrestling matches.

But the disease is certainly not limited to high school athletics.  In 2003, the St. Louis Rams had to disinfect their playing surface and their practice fields, following the revelation that opposing teams were contracting MRSA after playing the Rams in their domed stadium.  In fact, the New England Journal of Medicine published a scientific paper on the outbreak, submitted by researchers from (among other entities) the National Center for Infectious Diseases and the Epidemic Intelligence Service, Division of Applied Public Health Training, Centers for Disease Control and Prevention.  The abstract is located at: http://content.nejm.org/cgi/content/abstract/352/5/468 . It says, in part:

We conducted a retrospective cohort study and nasal-swab survey of 84 St. Louis Rams football players and staff members. S. aureus recovered from wound, nasal, and environmental cultures was analyzed by means of pulsed-field gel electrophoresis (PFGE) and typing for resistance and toxin genes. MRSA from the team was compared with other community isolates and hospital isolates.

During the 2003 football season, eight MRSA infections occurred among 5 of the 58 Rams players (9 percent); all of the infections developed at turf-abrasion sites. MRSA infection was significantly associated with the lineman or linebacker position and a higher body-mass index. No MRSA was found in nasal or environmental samples; however, methicillin-susceptible S. aureus was recovered from whirlpools and taping gel and from 35 of the 84 nasal swabs from players and staff members (42 percent). MRSA from a competing football team and from other community clusters and sporadic cases had PFGE patterns that were indistinguishable from those of the Rams' MRSA; all carried the gene for Panton–Valentine leukocidin and the gene complex for staphylococcal-cassette-chromosome mec type IVa resistance (clone USA300-0114).  (bold mine)

From the Bloomberg story of 2005:

Episodes of drug-resistant infections have occurred in the past year on professional U.S. football teams, including the St. Louis Rams, Baltimore Ravens, and San Francisco 49ers, said Dan Jernigan, chief of CDC's epidemiology branch at the National Center for Infectious Diseases. Infections have been seen among newborns in nurseries, he said.

In an article in today's Washington Post, reporter Rob Stein gives some unbelievable new factoids.  http://www.washingtonpost.com/wp-dyn/content/article/2007/10/16/AR2007101601392.html?hpid=topnews

A dangerous germ that has been spreading around the country causes more life-threatening infections than public health authorities had thought and is killing more people in the United States each year than the AIDS virus, federal health officials reported yesterday.

The microbe, a strain of a once innocuous staph bacterium that has become invulnerable to first-line antibiotics, is responsible for more than 94,000 serious infections and nearly 19,000 deaths each year, the Centers for Disease Control and Prevention calculated.

MRSA is a strain of the ubiquitous bacterium that usually causes staph infections that are easily treated with common, or first-line, antibiotics in the penicillin family, such as methicillin and amoxicillin. Resistant strains of the organism, however, have been increasingly turning up in hospitals and in small outbreaks outside of heath-care settings, such as among athletes, prison inmates and children.

The CDC's Scott K. Fridkin discloses the results of a multi-state study of MRSA.  It yielded the following information:

In the new study, Fridkin and his colleagues analyzed data collected in California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon and Tennessee, identifying 5,287 cases of invasive MRSA infection and 988 deaths in 2005. The researchers calculated that MRSA was striking 31.8 out of every 100,000 Americans, which translates to 94,360 cases and 18,650 deaths nationwide. In comparison, complications from the AIDS virus killed about 12,500 Americans in 2005.

"This indicates these life-threatening MRSA infections are much more common than we had thought," Fridkin said.

In fact, the estimate makes MRSA much more common than flesh-eating strep infections, bacterial pneumonia and meningitis combined, Bancroft noted.

"These are some of the most dreaded invasive bacterial diseases out there," she said. "This is clearly a very big deal."

The infection is most common among African Americans and the elderly, but also commonly strikes very young children.

So there are more deaths from MRSA in the United States that there are from HIV/AIDS, a recognized pandemic.  And perhaps MRSA is a candidate for true pandemic status, based on this snippet, also from the Bloomberg article of 2005:

The Netherlands has taken a ``search and destroy'' approach to drug-resistant superbugs, said Vincent Jarlier, an infection control officer for the Assistance Publique hospital network in France. Dutch doctors and nurses who test positive for the superbugs must have six negative tests before they can return to work, he said. Hospitals are required to shut down wards where the superbugs are detected; one hospital shut down ten at one time.

But wait, there's more!  Vietnam has had its own MRSA epidemic. From the National Institute of Health, published just last month:  http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1950567

An Outbreak of Severe Infections with Community-Acquired MRSA Carrying the Panton-Valentine Leukocidin Following Vaccination

We carried out a field investigation after adverse events following immunization (AEFI) were reported. We reviewed the clinical data from all cases. S. aureus recovered from skin infections and from nasal and throat swabs were analyzed by pulse-field gel electrophoresis, multi locus sequence typing, PCR and microarray. In May 2006, nine children presented with AEFI, ranging from fatal toxic shock syndrome, necrotizing soft tissue infection, purulent abscesses, to fever with rash. All had received a vaccination injection in different health centres in one District of Ho Chi Minh City. Eight children had been vaccinated by the same health care worker (HCW). Deficiencies in vaccine quality, storage practices, or preparation and delivery were not found. Infection control practices were insufficient. CA-MRSA was cultured in four children and from nasal and throat swabs from the HCW. Strains from children and HCW were indistinguishable. All carried the Panton-Valentine leukocidine (PVL), the staphylococcal enterotoxin B gene, the gene complex for staphylococcal-cassette-chromosome mec type V, and were sequence type 59. Strain HCM3A is epidemiologically unrelated to a strain of ST59 prevalent in the USA, although they belong to the same lineage.

So while we all try to figure out what the heck H5N1 is doing, remember that the Devil you know -- MRSA -- is out there, multiplying, mutating and killing.  Sometimes we'd prefer the Devil you know over the Devil you don't know.

Thomas P.M. Barnett has written an excellent opinion piece for the Scripps-Howard News Service. Titled "In the future: health screening at airports," the piece clearly and plainly lays out the enormous difficulties nations and the aviation industry in general will face when the next pandemic arrives (via a scheduled passenger airline flight). The link is at: http://www.scrippsnews.com/node/27573

Barnett is no stranger to planning.  In fact, if you have not heard of him, let me condense his story.  Barnett was in the Pentagon in the late 1980s and started giving Powerpoint presentations regarding what he believed was the inevitable implosion of the Soviet Union.  He even went so far as to predict the American Navy, for example, would be called upon to help its Soviet counterparts. 

The assembled admirals and generals scoffed at this heresy.  More than once he was laughed out of the room.  But the ensigns, commanders and captains in the back rows -- the inheritors of the military after the current silver-hairs retired -- they listened with intense interest. 

And they believed.

When the Soviet Union did collapse, just as Barnett predicted and within the timeframes predicted, and the U.S. was asked to help its former enemies, those same youthful military leaders sought out the visionary Barnett.  "Where's that guy with the Powerpoint!" they would yell at their adjutants.  In response, Barnett's first book -- The Pentagon's New Map -- was a New York Times bestseller and the second-most popular book in the entire Pentagon, behind the Bible.  Barnett's follow-up work, A Blueprint for Action, also sold well and both books are in trade paperback today and available at fine bookstores across the United States.

He is also a buddy of mine, so I am happy to shill for him!  Barnett gives the most lucid explanation for the violence directed against the civilized world today via his "Core and Gap" message.  It is simple yet not simplistic.  It is simple genius and one only wishes someone at 1600 Pennsylvania Avenue would stand up and articulate it to the world.  He is frequently bookended in peoples' minds with fellow globalization maven Thomas Friedman.  To contrast: Friedman is the diplomat and Barnett is the enforcer (again, a reference to his desire to revamp the military into "The Leviathan" and "System Administrators" -- oh, just go buy the damn books!).  He is sometimes described as "Jack Ryan with a Powerpoint."  He is brilliant.

Barnett was heavily involved in the Pentagon's Y2K planning effort in the late 1990s, which is where I first heard of him.  As I was running Florida's statewide Y2K preparedness effort, I naturally took a deep interest in those in Washington who were also thinking way outside the box.

Anyway, I have taken some excerpts from his latest column, which I referenced way back in the beginning of this blog.  Here they are:

The White House recently released its new homeland security strategy and, unlike the initial 2002 version, this one focuses far more on natural disasters as opposed to terrorist strikes. That's a welcome change not simply because Hurricane Katrina was a humbling experience, but because globalization's growing connectivity means a naturally occurring pandemic is the most likely mega-disaster we'll face in the near term.

A bird flu-triggered pandemic could easily become the most deadly global outbreak since the 1918 Spanish Flu, which killed at least 20 million people worldwide. In the United States alone, over one-quarter of the population became sick, with approximately 600,000 people succumbing to the virus. Extrapolated to today's American population of 300 million, that yields a potential death count of 1.5 million to 2 million.

Flu strains enter the United States in the bodies of sick travelers, so the key here will be our efficient and effective screening of in-bound passengers at international airports. According to Oak Ridge National Laboratory scientists currently investigating pandemic response procedures for the Department of Homeland Security, for every flu carrier who --unwittingly or not-- eludes that envisioned net, as many as 10,000 Americans could suffer exposure within three weeks time.

Consider the sheer volume: over 25,000 passengers arrive through Los Angeles' international terminals on a daily basis. In August, when a software glitch struck U.S. Customs' computers there, 20,000 passengers were stranded for up to 18 hours.

Ideally, any systemic approach would include initial diagnostic screens conducted overseas at originating airports. Since virtually all international flights are lengthy, passive diagnostic screening at points of embarkation and debarkation would offer authorities the opportunity to compare and contrast readings over time. For example, additional measures would be warranted if a passenger's symptoms worsened during the flight or if those symptoms spread to other passengers.

In the summer of 2004 my wife and I got a preview of this sort of screening at Honk Kong's international airport during a localized outbreak of avian flu cases. As we walked through the terminal with our youngest child, just then adopted from China, I noticed a large computer screen along the wall where our ghostly images were being displayed in real time. It turned out that airport authorities were scanning our body temperatures passively as we passed through a chokepoint.

I walked over to the technicians and asked about the procedure, only to be told that if any of us had registered an above normal temperature, our entire family would have been required to spend at least 48 hours in Hong Kong -- at our own cost! -- before we could again attempt departure on an outbound flight. Fortunately for us, what turned out to be our infant daughter's impending ear infection didn't kick in fully until we were several hours into our cross-Pacific flight. Had we been again screened at our American port of entry, we would have been nabbed, preventing -- for all we knew at the time -- something far worse from unfolding. (bold mine)

Where do you draw the lines in all of this? I can't begin to say.

I just know it's important that our Department of Homeland Security think through all realistic scenarios and gear up for the real-world tests that inevitably lie ahead.

Thomas P.M. Barnett is a distinguished strategist at the Oak Ridge Center for Advanced Studies and senior managing director of Enterra Solutions LLC.

As fellow bloggers Crawford Kilian and Mike Coston have pointed out, it is refreshing to have someone actually use the correct numbers when predicting an influenza pandemic.  It is no surprise that Barnett would use the appropriate numbers when predicting the potential pandemic's impact on the U.S. population.

What is most important to all of us is this: Because of Barnett's extreme gravitas inside and outside of the Pentagon and the Washington media, government think tanks and policy wonks everywhere, his voice becomes a powerful force for pandemic preparedness.  I am hopeful that this is the first of many, many written and vocal forays into the world of pandemic preparedness.  His Website/blogsite, by the way, is www.thomaspmbarnett.com .