Politics, Religion, Science, Culture and Humanities > Science, Culture, & Humanities

Epidemics: Bird Flu, TB, AIDs, Superbugs, Ebola, etc

(1/419) > >>

Crafty_Dog:
The dilemma of a deadly disease: patients may be forcibly detained
Doctors fear TB strain could cause a global pandemic if it is not controlled

Chris McGreal in Johannesburg and Sarah Boseley, health editor
Tuesday January 23, 2007

Guardian

South Africa is considering forcibly detaining people who carry a deadly
strain of tuberculosis that has already claimed hundreds of lives. The
strain threatens to cause a global pandemic, but the planned move pits
public protection against human rights.
The country's health department says it has discussed with the World Health
Organisation and South Africa's leading medical organisations the
possibility of placing carriers of extreme drug resistant TB or XDR-TB under
guard in isolation wards until they die, but has yet to reach a decision.

Pressure to take action has been growing since a woman diagnosed with the
disease discharged herself from a hospital last September and probably
spread the infection before she was finally coaxed back when she was
threatened with a court order.

More than 300 cases of the highly infectious disease, which is spread by
airborne droplets and kills 98% of those infected within about two weeks,
have been identified in South Africa.

But doctors believe there have been hundreds, possibly thousands, more and
the numbers are growing among the millions of people with HIV, who are
particularly vulnerable to the disease. Their fear is that patients with
XDR-TB, told that there is little that can be done for them, will leave the
isolation wards and go home to die. But while they are still walking around
they risk spreading the infection.

Now a group of doctors has warned in a medical journal that if enforced
isolation is not introduced XDR-TB could swamp South Africa and spread far
beyond its borders. Regular TB is already the single largest killer of
people with Aids in South Africa.

Pandemic

Jerome Amir Singh of the Centre for Aids Programme of Research in South
Africa and two colleagues wrote in the peer-reviewed journal Public Library
of Science Medicine that the government must overcome its understandable
qualms over human rights in the interests of the majority. Without
exceptional control measures, including enforced isolation, XDR-TB "could
become a lethal global pandemic", they say.

"The containment of infectious patients with XDR-TB may arguably take
precedence over any other patients not infected with highly infectious and
deadly airborne diseases, including those with full-blown Aids. This is an
issue requiring urgent attention from the global community," they wrote.

"The South African government's initial lethargic response to the crisis and
uncertainty amongst South African health professionals concerning the
ethical, social and human rights implications of effectively tackling this
outbreak highlight the urgent need to address these issues lest doubt and
inaction spawn a full-blown XDR-TB epidemic in South Africa and beyond."

Mary Edginton of the Witwatersrand university's medical school endorses
enforced quarantining.

"You can look at it from two points of view. From the patient's point of
view, you are expected to stay in some awful place, you can't work and you
can't see your family. You will probably die there. From the community's
point of view such a person is infectious. If they go to the shops or wander
around their friends they can spread it, potentially to a large group of
people," she said.

Karin Weyer of the Medical Research Council has called for enforced
hospitalisation of high-risk TB patients on the grounds that the risks to
society outweigh individual rights. But she opposes forcible treatment
because of the dangers associated with the drugs.

Professor Edginton said that medical authorities in the US and other
countries can obtain a court order to detain a person with infectious TB or
someone who is non-infectious but has failed to adhere to treatment. "The
Americans are much better at enforcing their laws on this," she said.

South African law also permits enforced isolation but some lawyers say it
comes into conflict with the constitutional guarantees on individual rights.
However, the constitution also guarantees communal rights, including
protection from infection and the right to a safe environment.

South Africa's health department yesterday said it has discussed the
possibility of enforced isolation with the country's Medical Research
Council and the World Health Organisation but has not reached a conclusion.

Poor housing

Ronnie Green-Thompson, a special adviser to the health department, said the
issue at stake is the human rights of the individual weighed against the
rights of the wider public. "The issue of holding the patient against their
will is not ideal but may have to be considered in the interest of the
public. Legal opinion and comment as well as sourcing the opinion of human
rights groups is important," he said.

"Also of importance is preventing those factors that lead to infectious TB
and these are poverty, poor housing, overcrowding and poor nutrition and any
other factors that weakens patients' resistance to acquiring infections."

Umesh Lalloo, of Durban's Nelson Mandela School of Medicine and head of the
research team into the first XDR-TB outbreak, said he is not persuaded that
detention is necessary.

"It's a very difficult call. Given our recent past with human rights
violations we need to be careful. I'm not dismissing such a move but it's a
very radical step. What we should be pushing for is a reinforcement of the
TB control programme which would contain the spread," he said. Professor
Lalloo said one consideration is that almost all infections appear to have
spread to patients in hospital.

The doctors and co-authors said that it is essential that patients were
detained in "humane and decent living conditions" and they urged the
government to change the rules so that those in hospital with TB continue to
receive welfare payments which are cut off if they are treated at the
state's expense.

Although cases of XDR-TB were discovered in South Africa a decade ago, the
disease started claiming dozens of lives at the small Tugela Ferry hospital
in rural KwaZulu-Natal two years ago. XDR-TB's origins are uncertain but the
WHO says the misuse of anti-tuberculosis drugs is the most likely cause.

Guardian Unlimited © Guardian News and Media Limited 2007

Crafty_Dog:

INDONESIA: Two pigs in Bali, Indonesia, have become infected with the bird flu virus, Chinese medical expert Zhong Nanshan said. The virus' detection in pigs raises concerns that the virus could be transmitted to people.

stratfor.com

Crafty_Dog:
Today's NY Times:

Virulent TB in South Africa May Imperil Millions
By MICHAEL WINES
Published: January 28, 2007
JOHANNESBURG, Jan. 27 — More than a year after a virulent strain of tuberculosis killed 52 of 53 infected patients in a rural South African hospital, experts here and abroad say the disease has most likely spread to neighboring countries, and some say urgent action is essential to halt its advance.

Several expressed concern at what they called South Africa’s sluggish response to a health emergency that, left unchecked, could prove hugely expensive to contain and could threaten millions across sub-Saharan Africa.

The director of the government’s tuberculosis programs called those concerns unfounded and said officials were doing everything reasonable to combat the outbreak.

The form of TB, known as XDR for extensively drug-resistant, cannot be effectively treated with most first- and second-line tuberculosis drugs, and some doctors consider it incurable.

Since it was first detected last year in KwaZulu-Natal Province, bordering the Indian Ocean, additional cases have been found at 39 hospitals in South Africa’s other eight provinces. In interviews on Friday, several epidemiologists and TB experts said the disease had probably moved into Lesotho, Swaziland and Mozambique — countries that share borders and migrant work forces with South Africa — and perhaps to Zimbabwe, which sends hundreds of thousands of destitute refugees to and from South Africa each year.

But no one can say with certainty, because none of those countries have the laboratories and clinical experts necessary to diagnose and track the disease. Ominously, none have the money and skills that would be needed to contain it should it begin to spread.

Even in South Africa, where nearly 330 cases have been officially documented, evidence of the disease’s spread is mostly anecdotal, and epidemiological work needed to trace its progress is only now beginning.

“We don’t understand the extent of it, and whether it’s more widespread than anyone thinks,” Mario C. Raviglione, the director of the Stop TB Department of the World Health Organization in Geneva, said in a telephone interview. “And if we don’t know what has caused it, then we don’t know how to stop it.”

Cases of XDR TB exist elsewhere, in countries like Russia and China where inadequate treatment programs have allowed drug-resistant strains of the disease to emerge. The South African outbreak is considered far more alarming than those elsewhere, however, because it is not only far larger, but has surfaced at the center of the world’s H.I.V. pandemic.

Although one third of the world’s people, by W.H.O. estimates, are infected with dormant tuberculosis germs, the disease thrives when immune systems are weakened by H.I.V. At least two in three South African TB sufferers are H.I.V. positive. Should XDR TB gain a foothold in the H.I.V.-positive population, it could wreak havoc not only among the five million South Africans who carry the virus, but the tens of millions more throughout sub-Saharan Africa.

People without H.I.V. have a far smaller chance of contracting tuberculosis, even if they are infected with the bacillus that causes TB. But because tuberculosis is spread through the air, anyone in close contact with an active TB sufferer is at some risk of falling ill.

Most if not all of the 52 people who died in the initial outbreak of XDR TB, at the Church of Scotland Hospital in a KwaZulu-Natal hamlet called Tugela Ferry in 2005 and early 2006, had AIDS. Most died within weeks of being tested for drug-resistant tuberculosis, a mortality rate scientists called unprecedented.

Since then, South African health officials say, they have confirmed a total of 328 cases of XDR TB, all but 43 in KwaZulu-Natal. Slightly more than half the patients have died.

Those numbers are deceptive, however. The Tugela Ferry outbreak was reported in part because the hospital there was part of a Yale University research project involving H.I.V.-positive patients with tuberculosis. Because South Africa’s treatment and reporting programs for tuberculosis are notoriously poor — barely half of TB patients are cured — virtually all experts contend the true rate of infection is greater.

“We’re really concerned that there may be similar outbreaks to the one in Tugela Ferry that are currently going undetected because the patients die very quickly,” said Dr. Karin Weyer, who directs tuberculosis programs for South Africa’s Medical Research Council, a semiofficial research arm of the government.

Some other researchers and experts say they share Dr. Weyer’s concern. They say South African health officials have lagged badly in assembling the epidemiological studies, treatment programs and skilled clinicians needed to combat the outbreak, and say the government has responded slowly to international offers of help.
=========
Virulent TB in South Africa May Imperil Millions
 

 
Published: January 28, 2007
(Page 2 of 2)



Dr. Weyer said the council “shares the concern that not enough is being done, quickly enough, to get on top of the problem.” In particular, she said, officials have yet to carry out epidemiological studies or address a “shocking” lack of infection controls in hospitals that could allow TB and other infections to spread freely among H.I.V.-positive patients

“It’s an emergency, and we’re not reacting as if it were an emergency,” said Dr. Nesri Padayatchi, an epidemiologist and expert on drug-resistant TB for Caprisa, a Durban-based consortium of South African and American AIDS researchers. “I think we have the financial resources to address the issue, and we’ve been told the Department of Health has allocated these resources.”

Although the government was first told of the outbreak 20 months ago, in May 2005, “to date, on the ground in clinics and hospitals, we are not seeing the effect,” she said.

In KwaZulu-Natal’s major city, Durban, the sole hospital capable of treating XDR TB patients has a waiting list of 70 such cases, she said.

Dr. Weyer said the waiting list indicates that “capacity is becoming a problem” in KwaZulu-Natal, the outbreak’s center. “I’m quite sure we may find a similar situation in other provinces,” she added.

A spokesman at the hospital said it could not easily determine how many patients were awaiting treatment.

But the manager of South Africa’s national tuberculosis program, Dr. Lindiwe Mvusi, said such complaints were misplaced. The Durban hospital in question, she said, is under renovation, and officials are “looking for accommodations in other hospitals” while construction proceeds.

Hospitals in other provinces have enough beds now for XDR TB patients, and some are expanding isolation wards to handle any spread of the disease, she said.

She said other responses to the outbreak were under way, including a rough assessment of TB cases in hospitals nationwide. A more comprehensive national survey of TB cases may be conducted late this year, she added, and health officials in KwaZulu-Natal have begun surveillance programs to detect new cases of drug-resistant TB in the province.

Dr. Mvusi also rejected the notion that the tuberculosis had moved beyond South Africa’s borders. But in interviews, a number of TB experts and epidemiologists raised that concern, including Mr. Raviglione at the world health organization, Dr. Padayatchi, Dr. Weyer and Dr. Gerald Friedland, director of the AIDS program at the Yale University School of Medicine.

Dr. Raviglione of W.H.O. said that South African health officials were cooperating on responses to the outbreak, and that an official of his organization would arrive in Pretoria within days to discuss placing a team of global TB experts in the country.

“W.H.O. is ready to come to South Africa and to help in any place, for anything, whether surveillance, or detection, or infection control,” he said. However, those arrangements have not been completed.

Dr. Mvusi, the government’s TB program head, said global health experts were welcome, but “in an advisory role, because we want the capacity locally.”

Crafty_Dog:
Closings and Cancellations Top Advice on Flu Outbreak

 
By DONALD G. McNEIL Jr.
Published: February 2, 2007
ATLANTA, Feb. 1 — In the event of a severe flu outbreak, schools should close for up to three months, ballgames and movies should be canceled, and working hours should be staggered so subways and buses are less crowded, the federal government said Thursday in issuing new pandemic flu guidelines to states and cities.

This Is Only a Drill Health officials acknowledged that such measures would greatly disrupt public life, but argued that they would provide the time needed to produce vaccines and would save lives because flu viruses attack in waves lasting about two months.

“We have to be prepared for a Category 5 pandemic,” said Dr. Martin S. Cetron, director of global migration and quarantine for the federal Centers for Disease Control and Prevention, in releasing the guidelines. “It’s not easy. The only thing that’s harder is facing the consequences. That will be intolerable.”

Officials are, for the first time, modeling the new guidelines on the five levels of hurricanes.

Category 1 assumes that 90,000 Americans would die, Glen J. Nowak, a spokesman for the disease centers, said. (About 36,000 Americans die of flu in an average year.) Category 5, which assumes 1.8 million dead, is the equivalent of the 1918 Spanish flu pandemic. That flu killed about 2 percent of those infected; the H5N1 flu now circulating in Asia has killed more than 50 percent of those infected but is not easily transmitted.

The new guidelines advocate having sick people and their families — even apparently healthy members — stay home for 7 to 10 days. They advise against closing state borders or airports because crucial deliveries, including food, would stop.

The report urges communities to think about ways to continue services like transportation and meal service to particularly vulnerable groups like the elderly and those who live alone.

The guidelines are only advisory, since the authority for measures like school closings rests with state and city officials, but many local officials have asked for guidance, Dr. Cetron said. The federal government has taken primary responsibility for developing and stockpiling vaccines and antiviral drugs, as well as masks and some other supplies.

The new guidelines are partly based on a recent study of how 44 cities fared in the 1918 epidemic conducted jointly by the disease centers and the University of Michigan’s medical school. Historians and epidemiologists pored over hospital records and newspaper clippings, trying to determine what factors contributed to the varying impact.

A few small towns escaped the epidemic entirely by cutting off all contact with the outside, but most cities took less drastic measures. Those included isolating the sick and quarantining homes and rooming houses; closing schools, churches, bars and other gathering places; canceling parades, ballgames and other public events; staggering factory hours; discouraging use of public transport; and encouraging use of face masks.

The most effective approach seemed to be moving early and quickly. “No matter how you set up the model,” Dr. Howard Markel, a leader of the study, said, “the cities that acted earlier and with more layered protective measures fared better.”

Any pandemic is expected to move faster than a new vaccine can be produced; current experimental H5N1 vaccines are in short supply and are based on strains isolated in 2004 or 2005. Although the government is creating a $4 billion stockpile of the vaccine Tamiflu, it is useful only when taken within the first 48 hours, and Tamiflu-resistant strains of the flu have already been found in Vietnam and in Egypt.

“No one’s arguing that by closing all the schools you’re going to prevent the spread,” Dr. Markel added. “But if you can cut cases by 10 or 20 or 30 percent and it’s your family that’s spared, that’s a big deal.”

School closings can be controversial, and picking the right moment is hard because it must be done before cases soar.

Several public health experts praised the guidelines, though there were objections to some aspects.

Dr. Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said he saw no point in worrying about exactly when to close schools, because his experience in meningitis outbreaks convinced him that anxious parents would keep children at home anyway.

“I don’t think we’ll have to pull that trigger,” Dr. Osterholm said. “The hard part is going to be unpulling it. How do the principals know when schools should open again?”

Other experts said that children out of school often behaved in ways that still put them at risk. Youngsters are sent to day care centers, and teenagers gather in malls or at one another’s houses.

“We’ll be facing the same problem, but without the teaching,” said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at the Mailman School of Public Health at Columbia University. “They might as well be in class.”

Dr. Cetron said that caring for children in groups of six or fewer would cut the risks of transmission. He also said that parents would keep many children from gathering.

“My kids aren’t going to be going to the mall,” he said.

The historian John M. Barry, author of “The Great Influenza” (Viking Adult, 2004), questioned an idea underpinning the study’s conclusions. There is evidence, Mr. Barry said, that some cities with low rates of sickness and death in 1918, including St. Louis and Cincinnati, were first hit by a milder spring wave of the virus. That would have, in effect, inoculated their citizens against the more severe fall wave, and might have been more important than their public health measures.

Crafty_Dog:
From Bird to Person
By PETER D. ZIMMERMAN
February 7, 2007; Page A15

LONDON -- The "deadly" H5N1 avian flu is back on the front pages of newspapers and TV news shows. The British environment minister has pledged quick action to "eradicate" the disease from the U.K., and over 150,000 turkeys on one farm have been culled. "This is," someone said on the BBC's "Breakfast" show Monday, "a disease of birds, not humans." And so it is.

The H5N1 virus has still not made the critical interspecies leap which would make it easy for an infected person to give the disease to another person. That may happen, or it may not; and nobody can predict the outcome or its timing with any degree of confidence. Meanwhile, as of the World Health Organization's compilation on Feb. 3, there had been a total of 271 laboratory-confirmed cases of the virus in humans, and of that number a staggering 165, or 61%, died, making it one of the most lethal pathogens in history, even if not one of the most infectious.

Still, just 18 months ago many experts were predicting a global pandemic in a matter of months, perhaps one that would kill millions. There is historical precedent: The 1918-1919 "Spanish Flu" swept around the world in a matter of weeks, and before the disease burned out, more than 50 million people had died. Today H5N1 is reminiscent only of the Asian "Swine flu," which threatened the U.S. in 1976 but never turned into a serious threat to human life (although the media hype surrounding it helped undermine Gerald Ford's presidency). In 2004, worried people rapidly bought up much of the world's supply of Tamiflu and Relenza, the only two drugs that seemed to have a chance of beating H5N1. Now most of us have forgotten the names of these drugs.

Influenza viruses have eight genes and these mutate rapidly. Two sites on the viral genome, called H and N, are well catalogued, and each of those genes can come in many forms. Those are the markers that trigger the human immune system. If your body has seen a whiff of a particular virus, it will produce large numbers of antibodies if you later become infected with a strain having the same markers. If you have never been exposed to a particular strain, there are no antibodies in your bloodstream, and your body will fight an uphill battle for survival. The more virulent the virus, the less chance you have.

So far as is known, no H5N1 virus has ever circulated on the planet. That means nobody has any natural immunity. Our good fortune last flu season was that the bird flu virus had not yet learned the trick of passing easily from human to human. The few confirmed victims were almost all people who'd worked very closely with infected fowl in extremely unsanitary conditions. One can suppose that they were massively exposed, allowing this "disease of birds, not humans" to develop in their bodies.

Almost all influenza viruses originate in migrating water fowl in South-East Asia, and by and large the birds don't get sick. However, those birds can pass their viruses to domesticated birds. In the great viral mixing pot of China, where people live in close contact with both their birds and their pigs, influenza viruses can readily pass from one species to another, and sometimes to an animal or person already infected with another flu bug.

In this environment, mutations are guaranteed to occur, and from time to time a new pathogen with the ability to pass between people develops. If it carries the same marker combination as one or another previous flu virus, much of the world's population will have a basic immunity. If it does not have familiar markers, much of humanity is at risk once that virus learns to jump from person to person. Each year a panel of experts tries to guess which strains of flu will pose the highest risk in the coming influenza season, and orders up vaccines to give the vulnerable some protection. H5N1 has not been selected, because it still hasn't become contagious in our species. But it could make the jump at any time.

The last year has brought the world a major advantage, should H5N1 become a "disease of humans." The pharmaceutical industry has learned the difficult trick of making and producing a vaccine against a hitherto unknown disease. GlaxoSmithKline recently claimed that it had succeeded in developing a "second generation" bird flu vaccine that could be given in advance, even before knowing the detailed gene structure that would allow this bird flu to infect people. The vaccine could be given before the bug even learns that deadly trick. Other companies have also developed vaccines which appear to produce broad-spectrum antibodies against many strains of the virus, and many governments have ordered large stocks from various producers.

It is probably worth stockpiling many millions of doses before H5N1 escapes into the human population. Because none of us has any useful immunity, the virus could migrate around the world with the speed of commercial air travel, not the steamships that powered the Spanish Flu. If H5N1 escapes, and if it becomes as virulent as the Spanish Flu (which killed 1% of those who developed the disease), the pessimistic predictions of millions of people dead within months could come true. Only if vaccine bottles were already on the shelf, ready for instant use, could the virus be contained.

However, deadly as it could be, and as harmless as it has so far been, the H5N1 avian flu will not be the last new influenza virus to develop. The process that produced H5N1 is at work every year, and the more intense the agribusiness of raising chickens in China becomes, the more rapidly new viruses can spread and mutate. Even if we may have dodged the H5N1 bullet, another pandemic like the Spanish Flu is inevitable and could break out into the human population so quickly that vaccines cannot be produced in time.

New types of influenza virus must be detected and combated while they are still diseases of birds, not humans. Detection of new viruses will happen where they originate. A global pathogen surveillance system -- as Sen. Joseph Biden suggested almost five years ago -- is necessary because the global first line of defense against influenza is not the U.S. Centers for Disease Control and Prevention, but the public health agencies of China, Vietnam and other nations in that region. Those agencies need multilateral support and encouragement, and the United States must take the lead. And countries where flu viruses originate need the courage to recognize that reporting a new disease does not reveal weakness, but rather demonstrates the strength of their health systems.

Mr. Zimmerman is professor of science and security at King's College London. He was chief scientist of the U.S. Senate Foreign Relations Committee staff and science adviser for arms control at the U.S. State Department.

Navigation

[0] Message Index

[#] Next page