Yesterday, I had the grand opportunity to be interviewed by "learning guru" Elliott Masie on the topic of pandemic influenza preparedness and the role that the chief learning officers and chief training officers of business, industry, academia and government will be asked/forced to play in preparing for, and mitigating the effects of, pandemic influenza.  Heckuva sentence, huh?

I am unfamiliar with the "training and learning universe," so I did exactly what Elliott did to come up with my name:  I Googled him.  He is an extremely well-respected and admired advocate of innovation and reinventing the entire learning and training experience.  He is also a facilitator and incubator of ideas.  His organization, the MASIE Center (www.masieweb.com) is a major supporter of the Malaria No More project, at http://www.malarianomore.org/.  His conference, currently under way in Orlando, has more than 2,100 attendees from 29 countries.

Masie also "vetted" me through the Central Intelligence Agency beforehand, which has caused me to start speaking in a friendly tone of voice to the little fire sprinkler I have in the ceiling of my office.  Anyway, with that kind of gravitas, I could not possibly resist his request for me to come down and have a personal discussion on influenza in front of twenty-one hundred of his closest friends!

We covered 1918, H5N1 and world history.  We covered my favorite line, WWID, or What Would Ike Do, regarding panflu planning.  But I asked a question of the audience.  I said, How many of you are currently involved in pandemic preparedness within your organization?

A fair number of hands shot up.  But then Elliott turned the question inside out and asked, How many of them were not involved?

A sea of arms and hands shot up.  Our look of surprise had to be evident on the two hi-def screens on either side of the stage.  We were both amazed that such a key pandemic resource as learning and training was being overlooked by upper management.  That, I feel, is symptomatic of where we are as a nation today with pandemic preparedness.  Few corporate leaders are seriously engaged in out-of-the-box thinking on this topic. For every Michael Dell, who I can personally assure you is engaged on this topic, there are ten thousand flu-clueless captains of industry.  For every Michael Leavitt, there are ten thousand flu-clueless agency heads, elected officials and political leaders nationwide.

CTOs and CLOs are a growing and influential lot.  And they were told, by Elliott and by me, that they need to become pandemic subject matter experts and agents for change within their own organizations.  Trainers and learning professionals need to quickly ramp up their knowledge of influenza, and of H5N1 in particular, I told the assembly.  Read John Barry's The Great Influenza.  Learn how to overcome supply chain failures.  Subscribe to Google alerts.  Go to flu blog sites and other important flu sites. Learn as much as they can about the disease themselves.  Don't rely upon the American mainstream media for when to prepare.  Be prepared to teach employees how to prepare -- and care for -- their families. And know when the whole thing is about to go Pop! 

So you captains of industry and government, pull up an empty chair for the learning and training officers.  They are your best hope at imparting the necessary knowledge and skills necesary to weather this coming storm.

As if in response to my diatribe regarding Riau, Indonesia doctors' reluctance to test for H5N1 and my comparison to American medical attitude (and I mean attitude in the 'TUDE sense), comes this superb AP article, given prominent treatment by MSNBC. 

It involves the personal crusade of a MRSA victim and the subsequent eye-opener, revealed last week, that MRSA kills more Americans than AIDS.  Here is the link: http://www.msnbc.msn.com/id/21456183/ and here is the story.

By the way, the photo of the brown recluse spider has nothing to do with the story, but everything to do with the subject.  A growing feeling in this country is that so-called "brown recluse spider bites" were, in fact, MRSA infections.  The brown recluse is a veritable pussycat of a spider and only bites under extreme stress, such as getting tangled in human hair, clothing, or having to read the words of Dr. Don Goldmann (below).

Few hospitals screen for 'superbug'

CHICAGO - Testing all new hospital patients for a dangerous staph "superbug" could help wipe out a germ that likely kills more Americans than AIDS, consumer advocates say and early evidence suggests.

Yet few U.S. hospitals do it, and many fight efforts to require it. Why?

Jeanine Thomas, who nearly died from the drug-resistant staph bug, says the reason is simple: "Doctors don't want to be told what to do."

The Chicago suburbanite's personal crusade led Illinois this year to become the first state to order testing of all high-risk hospital patients and isolation of those who carry the staph germ called MRSA.

Powerful doctor groups fought against it. The testing and isolation of patients would be too costly, they said. Many other germs plague hospitals that also require attention. Experts said a more proven approach would focus on better hand washing by hospital staff — a simple measure tough to enforce.

Yet, Thomas prevailed. Similar measures passed this year in Pennsylvania and New Jersey. And Thomas' national crusade to make hospitals test for MRSA and report their infection rates gained steam last week after a Virginia teenager's death from the germ and a government report estimated it causes dangerous infections that sicken more than 90,000 Americans each year and kill nearly 19,000.

Suddenly the little-known germ with the cumbersome name, methicillin-resistant Staphylococcus aureus, is getting lots of attention.

People in health care settings, like hospitals and nursing homes, are most at risk for MRSA infections. Doctors and nurses who treat staph-infected patients and then don't carefully wash up can spread the germ to other patients. Germ-contaminated medical devices used on people having dialysis or medical procedures also can spread staph. Older patients and blacks are most at risk, according to the recent report by government researchers.

MRSA, pronounced Muhr-suh, has been around for decades and in recent years has spread to schools, prisons and crowded public housing projects. Even healthy people can carry it on their skin. It may look like a pimple or spider bite that doesn't heal, but it can turn deadly if it enters the bloodstream or morphs into a flesh-eating wound.

Many opposed to testing
Yet, many infection control experts oppose required testing for it in hospitals.

Many note that MRSA is just one of dozens of risky germs that often infect people in hospitals — particularly those with weakened immune systems or open wounds.

But Lisa McGiffert doesn't buy it. The director of the Consumers Union's campaign to stop hospital infections calls that "an argument of distraction."

"Certainly there are other superbugs and they should be tackling those, too," said McGiffert. "To eradicate hospital-acquired infections is going to take a comprehensive effort" that should include testing hospital patients, she said.

About 1.7 million Americans each year develop infections from various germs while hospitalized and almost 100,000 of them die, according to the U.S. Centers for Disease Control and Prevention. (bold mine)

MRSA accounts for only about 10 percent of these infections. Other worrisome bugs include C-difficile (an intestinal infection), vancomycin-resistant Enterococcus (linked with intestinal, skin and blood infections), and drug-resistant Acinetobacter (which can cause pneumonia, skin and blood infections); none of them accounts for more than 10 percent of hospital infections.

MRSA infections have hogged attention, partly because they're on the rise. And, acknowledges the CDC's Dr. John Jernigan, "MRSA likely accounts for a disproportionate amount of illness and death" because of its strength and resistance to mainline antibiotics.

CDC recommendations for fighting drug-resistant bugs list MRSA testing as an option. However, the agency says it's unclear whether that works better than other measures. Those include judicious use of antibiotics, hand washing, and wearing gloves, gowns and other protective gear.

"We don't think (testing is) a silver bullet to that problem," Jernigan said.

The Joint Commission, an independent, nonprofit group that sets standards for the nation's hospitals, doesn't have specific rules on how to prevent MRSA.

The commission's Dr. Robert Wise said the organization wants to see evidence that MRSA testing and other measures work. He said the commission hopes to have an answer early next year and then will then decide whether to adopt new standards.

VA testing at all 155 hospitals
Perhaps the commission will review an experiment done in Pittsburgh. There, the Veterans Affairs hospital tried MRSA testing, and annual infection rates fell from about 60 to 18 cases, said Dr. Rajiv Jain.

The staph bug used to cause "occasional" deaths, but no patient has died since 2005 when testing of all patients began, said Jain, who is with the VA's MRSA prevention program.

In May, the VA began putting a $28 million testing system in place for all 155 hospitals. But it costs about $32,000 to treat one hospitalized MRSA patient, so "if you reduce infections by 50 percent, you more than recuperate the cost," Jain said. (bold also mine)

Denmark, Iceland, Norway, and the Netherlands have reduced their MRSA rates and all test high-risk patients. In the Netherlands, that means testing foreign patients.

Opponents of mandatory testing point out that these small countries all had low rates of the germ to begin with. Hospitals in larger, more diverse nations like Britain, for example, have long had problems with MRSA.

And testing may not make sense for hospitals that treat few high-risk patients or where other bugs are more prevalent, opponents say.

"The best approach is not to have state legislators dictating how hospitals go about fighting infections, said Dr. Don Goldmann, of the Institute of Healthcare Improvement, a nonprofit advocacy group.

At the University of Chicago Medical Center, doctors have been focusing on C-difficile bacteria, which can cause severe intestinal illness.

With Illinois' new law requiring MRSA testing, "We're having to shift gears and haven't been able to devote what we'd hoped on these other pressing problems," said Dr. Stephen Weber, the hospital epidemiologist.

At Chicago's Rush University Medical Center, lab supplies alone for the testing will likely cost about $80,000, said Stacy Pur, Rush's chief nurse epidemiologist for infection control.

"It's very labor-intensive and we would really much rather focus our efforts on infection control" measures proven to work, including better hand washing by hospital staff, she said.

But Thomas, the MRSA patient-turned-advocate, argues: "You're never going to control this with hand hygiene, because you're never going to get 100 percent compliance."

Thomas had never heard of MRSA until she slipped on ice seven years ago and broke her left ankle. That landed her in a Chicago hospital, where she believes she got the infection.

Two days after being sent home, she developed throbbing pain in her left leg. She went to the emergency room, where doctors removed her splint and found the ankle hugely swollen, black and draining pus. She was admitted and given antibiotics, but within a week the infection spread inside her body; her lungs, kidneys and other vital organs shut down.

Hospitalized for three weeks and bedridden for six months, she recovered but her ankle joint was destroyed. She formed a support group and began lobbying for the new law.

Now Thomas is working with advocates in several other states.

"We have a wave happening," she said.

And if Illinois hospitals don't comply, she may push to enact testing of all — not just high-risk — hospital patients.

Infections dropped 60 percent
That has been done since 2005 at three Chicago area hospitals in the Evanston Northwestern Healthcare system. There, the MRSA infection rate has dropped 60 percent, said the system's Dr. Lance Peterson.

And at the VA hospital in Pittsburgh, Jain reported an added bonus. The rates for other hospital-acquired infections also fell after MRSA testing began.

Why? The testing may have caused hospital workers to pay more attention to hand washing and other prevention efforts, he said.

Doctors and hospitals frequently miss the point, especially Dr. Don Goldmann, referenced in the story by his quote (repeated here) that "The best approach is not to have state legislators dictating how hospitals go about fighting infections."

Well, Dr. Goldmann, who else should do it?  Clearly the profession is incapable of doing it on its own, or it wouldn't have the bloody problem!  The medical profession routinely snatches defeat from the jaws of victory with attitudes such as the one exhibited by Dr. Goldmann.  One could only conclude from his remarks that defending his profession is more important to him than seeking the truth or protecting his patients or the public at large.  Sweeping the problem under the contaminated rug is more like it.  And while he says what he says, people get sick -- and die -- and families suffer and the trial bar gets richer.  And hospitals continue to do nothing, because there is little incentive for them to do anything.  Shame on Dr. Goldmann for his shortsightedness. 

Dr. Goldmann misses the other point, which is cost avoidance.  Just ONE avoided wrongful death suit, or avoided malpractice suit, more than defrays the cost of the testing.  In the immortal words of Stan Lee: "'Nuff Said!" 

The second death of a Tangerang child in the past two weeks has raised concerns that something is emerging there.  Here is a map showing the location of Tangerang (red start) to the capital of Jakarta.

JAKARTA, Oct 23 (Reuters) - An Indonesian toddler from Tangerang, west of the capital Jakarta, has died of bird flu, bringing the country's death toll from the disease to 89, a health ministry official said on Tuesday.

The four-year-old girl died on Monday after being admitted to hospital two days earlier, health ministry spokeswoman Lili Sulistyowati said by telephone.

The girl, who had been suffering from fever, died after being transferred to Persahabatan hospital in Jakarta.

Officials were still investigating the case, but four chickens had previously died in the girl's neighbourhood, another official at the ministry's bird flu centre said.

Contact with sick fowl is the most common way for humans to contract the deadly H5N1 strain of the virus.

Bird flu is endemic in bird populations in most parts of Indonesia, where millions of backyard chickens live in close proximity with humans.

Indonesia, which has now had 110 confirmed cases of the disease in humans, has suffered more fatalities than any other country.

http://www.alertnet.org/thenews/newsdesk/L23739948.htm

This follows a death just last week.  The details are listed in an Antara news story.

Tangerang, Banten (ANTARA News) - A 12-year-old child at Ceger village in Tangerang district, Banten province, died of the H5N1 virus over the weekend, bringing to 88 the death toll in bird flu cases in Indonesia, a health official said.

The child, identified as Irfan, was brought to a local midwife on Oct. 3 after suffering from fever for three days, Head of Communicable Disease Control and Prevention Section at the Tangerang District Health Office dr Yuliah Iskandar said on Monday.

As his health condition deteriorated, Irfan was later transferred to Tangerang Regional Hospital where he underwent a medical test on Oct. 8, Yuliah said.

He was later moved to Persahabatan Hospital in Jakarta on Oct. 9 for further medical treatment as he had tested positive for bird flu based on the result of a laboratory test conducted by the Health Research and Development Agency and the Eijkmann Institute, she said.

To anticipate the possible spread of the H5N1 virus in the area, the district health office had sent officers to Ceger village to take samples of the blood of Irfan`s relatives and neighbors, she said.

Yuliah said Irfan did not have contact with dead chicken before being infected with the bird flu virus. Neither did his parents raise poultry in their backyard.

"But there is backyard poultry about 500 meters from the victim`s house," she said.

This marks the seventh human H5N1 case in Tangerang in the past twelve months, according to the U.S. Department of Defense Pandemic Influenza Watchboard, located at  http://fhp.osd.mil/aiWatchboard/index.jsp .  An archive of Indonesian cases can be found at  http://fhp.osd.mil/aiWatchboard/archivedcases.jsp#oct_12_2007 . Don't forget to add the 4-year old girl to the cases when adjusting your scorecard at home.  That includes six deaths -- an 85% Case Fatality Rate.

If you have not done so already, add Tangerang to Riau and Bali as potential incubators of the Next Pandemic.  By the way, all but two of the human Tangerang cases (and all but one of the area's fatalities) are girls or women, ranging from ages 4 to 38.

Tensions between Riau and Jakarta, news media turn nasty

The recent flap over whether ten-year old Gozi Sultia Ningsih actually died of H5N1 avian influenza or "regular" fever rages on, and will not be resolved until the WHO weighs in with the final word. However, that has not stopped officials from demanding that surveillance be stepped up in the region.

And it has, with the disclosure that no fewer than eleven (11) children from Gozi's immediate neighborhood (photo) have been taken in for testing and observation. The eleven began displaying flu-like symptoms. It started with seven childrem. 

From China's Xinhua news service:

The number of suspected cases in Riau just this year now numbers 29, with either 5 or 6 confirmed cases, and 4 or 5 deaths.  The exact number of dead may never truly be known, since the local officials apparently are not that keen on taking samples.  This trait is not limited to Indonesia:  How many Western doctors -- shoot, how many American doctors are, be it due to arrogance or a lack of motivation, reluctant to take requisite samples because they are so stubborn in their belief they know the cause of the malaise?  Why are so many seasonal flu samples taken in this country not strain-specific (they just say "Untyped")?

Then the Riau testing number suddenly turned to eleven.  From Riau Today, with translation provided by alert multiflusite poster Dutchy :

7 children Siak Evidently Negative Bird Flu

on Wednesday, on October 24 2007

From results of the beginning inspection in RSUD Siak, seven children from the Merempan Hulu Village, Kabupaten Siak that was stated suspect bird flu, results of bird flu of the negative.

They it was warned only were affected by the common fever.

In accordance with protap (protocol,ed) the handling of bird flu, the seven children were from this Merempan Village reconciled by the beginning inspection in RSUD Siak.

’ Examination early, seven children the Merempan Hulu Village mentioned the bird flu negative. Afterwards four other children who also took part in being checked by us, results of the negative. (underline mine)

In accordance with clinical (examination,ed), both from results of the inspection x-rayed and laboratory , was not found by the existence of the sign that headed in the attack of the bird flu virus.

The sign was sick the fever that was found by only common fevers ,’’ said the RSUD Siak Head Dr R Toni to Riau Pos, on Tuesday (23/10) in Siak.

According to Dr Toni, originally from results of the survey that we received had seven villagers Merempan that it was suspected was attacked by bird flu.

The seven villagers Merempan that suspected was attacked by this bird flu in general was supervised by the age 10 years with the condition experienced the fever.

To strengthen this assumption, in accordance with protap (protocol,ed) the handling of bird flu, the seven children were at once reconciled to RSUD to be carried out examinaton early.

From seven that was examined, afterwards had four other patients who also went along dipriksa because of taking part in being suspected of being attacked by bird flu.

And from results of the beginning inspection, the eleven patients who were examined by all of them were not found by the existence of the sign of the bird flu attack. Both from the inspection x-rayed and from results of the laboratory cheque.

http://www.riautoday.com/new/index.php?option=com_content&task=view&id=2917&Itemid=1

OK, so the Riau authorities are apparently sick and tired of being branded as hillbilly quacks by the Jakarta regime, which is playing host to Pelestinian Authority President Mahmoud Abbas.  Remember that the PA and the Israeli government speak at least once daily on the avian influenza situation, so I am sure Abbas has H5N1 on the agenda for discussion.  Perhaps the "nonaligned" PA is seeking prepandemic vaccine???  I would not be the least bit surprised. Here is the story, also translated by Dutchy, who also credits History Lover for the help:

Tuesday, October 23, 2007

Jakarta (Suara Karya): Health Minister Siti Fadilah Supari said that the resident of County Siak, Riau Province, initials GZ (10), that died at Siak, Provinsi Riau, RSUD Arifin Achmad, Pekanbaru Riau, Sunday (21/10), was positively infected with bird flu.

"Iya, positive. Continuing with the account, she said that the suspect died displaying previously with lungs and idea that pretty much the same and a large possibility as bird flu," said Menkes (Minister) following a national ceremony greeting President of Palestine Mahmoud Abbas, in Istana Merdeka, Jakarta, Monday.

Even so, Menkes (Minister) pushed Riau district as new bird flu cluster, because GZ's aunt have not taken blood sample.

"Not must, because her aunt have not taken blood sample. If it is positive with family relations, it should be a cluster," she said.

With the last sacrifice, Menkes (Minister) said that the total number of postive bird flu patients in Indonesia has reached 110 people and 89 positive for bird flu have died.

Gz died in the world in RSUD Arifin Achmad, Pekanbaru, after having been attended for a few hours in the medical center in isolation space. Captain of Bird Flu Handling Team at RSUD Arifin Achmad, Dr. Azizman Saad said that a new sacrifice was reconciled to the medical center with references to bird flu illness after it was known/detailed that she suffered from bird flu disease.

While the team from Riau Province Health Agency along with Siak County Health Agency did field investigations in the location where the presumed bird flu patient lived as died in world at RSUD Arifin Achmad Saturday (20/10).

"An investigation was done to determine the risk factors of the death of the avian influenza suspect patient," said Riau Kasubdis Health Diskes, Burhanudin Agung, to Between in Pekanbaru, Monday.

Burhanudin continued, the investigation needed to be done despite the fact that the suspect patient have not assigned as a positive bird flu patient.  http://www.suarakarya-online.com/news.html?category_name=Sehat

Incredible candor and a downright pre-WHO Margaret Chan-ish change of tune regarding the situation in Riau.  And now both the local government and the Riau authorities are falling back on a tried-and-true strategy:  When all else fails, blame the media!  From multiflusite poster Commonground's translation of a Riauinfo.com article,  http://www.riauinfo.com/main/news.php?c=6&id=2800 :

And now, today, in Riau, things are getting really, really testy.  Again, from Commonground:

Burhanuddin and Azizman confess/promise/claim to be more and more confused when news that same garnish/embellish screen of television in form of raining text amounting to television private. "A Cause/sign/commotion raining test aforementioned I more and more receive telephone all kinds side that wish to find out truth including from WHO," sigh Burhanuddin.  http://www.riauterkini.com/sosial.php?arr=16273 

The disclosure that seven (now eleven) children in the immediate neighborhood were tested for flu burung was picked up quickly by the local newspapers and television -- so quickly, in fact, that even the WHO got on the phone to know what in Sam Hill was going on down there!  This, in a way, partially assuages the concerns of Crawford Kilian (CROFS, H5N1) who recently and correctly lamented that there are no journalistic boots on the ground in Riau.  Apparently, the local media are picking up the gauntlet -- much to the consternation of the people trying to get work done down there.

As usual, stay tuned.

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