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Worcester Medicine President's
Message: Disaster Planning
From the Associate Editor
Bio Terrorism: A
New Discipline in Public Health
Bio Terrorism:
Past, Present and Future
Massachusetts 2 One DMAT's
Story
Influenza Viruses, Birds
and Pandemics Legal Consult: Public
Health Emergencies and the Role of "Community Caretakers" Science Corner: Doctor,
why do I feel so sick with the flu? Off Call: A Year
in the Round
Massachusetts Medical Society 6th Annual Creative Writing Contest President's Message From the early 1970s to the early 1990s, disaster planning was a priority for a small number of public health officials, emergency preparedness personnel, and medical providers. I recall attending a meeting called by the National Academy of Sciences early in 1978 to evaluate our nation’s level of preparedness in the face of catastrophic events. At the time, one of the federal government’s major concerns was the ability to respond to a limited exchange of nuclear weapons with the Soviet Union. It seemed that states were expected to plan for response to natural disasters. The Federal Emergency Management Agency (FEMA) was formed around this time as the body that would coordinate the deployment of federal resources to states in need of assistance. During this period, terrorist acts were seldom discussed at national meetings of medical disaster responders. The first attack of the World Trade Center (WTC) in NYC instigated some conversation of the risk for major terrorist attacks, although most discussions instead addressed major naturally occurring disasters. The shocking events of September 11, 2001 at the WTC, the subsequent anthrax threat spread through the postal service, and an upsurge in kidnappings involving Americans around the globe suddenly jolted the United States out of complacency. Response to the threat of terrorism became a national priority for all Americans. The earthquakes and tidal waves in the Indian Ocean in December, 2004 and March, 2005, followed by a series of devastating hurricanes along the Gulf Coast of the United States this fall, have contributed to a heightened sense of vulnerability to natural disasters as well as terrorism. This issue of Worcester Medicine focuses on medical aspects of Disaster Preparedness. It is important that every physician appreciate the need to prepare for Disaster Threats of all kinds. Disasters should be considered along with the other public health issues such as drug abuse, morbid obesity, and the rising incidence of asthma among teens. While it is not necessary for every physician to be highly trained in disaster response, it is appropriate for all members of the medical community to know how to access information about likely threats to patients and to know who within the medical community has the expertise to coordinate the care of a large number of victims affected by a wide variety of disasters. One thing I have learned from my three decades of interest and experience in disaster medicine is that disasters do occur, often unexpectedly. I have also learned that the medical community tends to underestimate the impact of naturally occurring calamities. Finally, I have learned that preparation is the key to successful response.
From the
Associate Editor On a cloudy November morning in 1918, in a tenement house in Boston’s south end, 41 year-old Timothy O’Farrell awoke as usual at 6:45 am. He bathed and shaved, ate a bowl of cornflakes, downed a cup of coffee, kissed his wife and took the trolley to the post office to begin his day of carrying mail. As he walked up the steps to the building, he was vaguely aware of feeling fatigued. A mere 17 hours later he was dead. In that same city, 24 years later almost to the day, a patron at a rollicking nightclub smelled the faint scent of smoke. Thirty one fire engines and ladders answered the call and 492 people died within the next 24 hours. For one 75 minute period, Boston City Hospital received one burn patient every 11 seconds. All disasters, including the 1918 influenza pandemic and the Cocoanut Grove fire, are like Tolstoy’s unhappy families in the opening line of Anna Karenina; they are all different and each is tragic in its unique way. Emergency preparedness has always stood as one of the greatest challenges to medicine. We seek better ways to treat cancer, neurodegenerative diseases and other disorders, but disasters do not call for pharmaceutical breakthroughs, new discoveries in diagnostic imaging, etc. They call for hyper-rational ~ even paranoid ~ anticipation and readiness, unwavering chains of command, stockpiled resources that match the worst-case scenarios and, most of all, teams of dedicated professionals. But as we have so painfully realized in recent years, we are still on the learning curve. For example, in the response to Katrina it became clear that the efforts of various first responders to establish and maintain radio communication were no more effective than they had been at the time of 9/11. The editorial board of Worcester Medicine decided that an issue devoted to emergency preparedness would be valuable to its readers at this time. On the one hand, we felt a need to take stock of what is known; on the other, we encouraged our authors to address what is still to be learned. In this latter respect, we believe that our emergency preparedness colleagues and their collective experiences constitute an active discovery laboratory. We hope that our readers will find this issue informative and perhaps provocative. As always, Worcester Medicine welcomes comments, and we hope to hear from you.
Bio Terrorism: A
New Discipline in Public Health In 1996, the United States Department of Health and Human Services founded the Metropolitan Medical Response System (MMRS) in response to the increased threat of terrorism as evidenced by the sarin nerve gas attack in the Tokyo subway system (March 1995) and the bombing of the Alfred P. Murrah Building in Oklahoma City (April 1995). The MMRS program was designed to enhance and coordinate local and regional response capabilities for highly populated areas, potential targets of a terrorist attack. The MMRS concept, organizing principles, and resources are also applicable to the management of large-scale incidents such as hazardous materials (HazMat) accidents, epidemic disease outbreaks and natural disasters requiring specialized and carefully coordinated medical preparation and response. Since May, 2002, the City of Worcester’s Metropolitan Medical Response System (WMMRS) has acted as the catalyst for the enhancement of emergency service capabilities relating to the health and medical needs of victims in the event of a terrorist attack. This program is designed to strengthen existing emergency response plans and, when necessary, develop new ones to deal with previously unidentified threats. Worcester authorities recognize that the resources of the City and the Greater Worcester region would be overwhelmed by the reality of massive destruction, disruption, disability, and loss of life should a nuclear, chemical or biological attack occur. The City of Worcester MMRS program is administered through the City’s Division of Public Health within the Department of Health and Human Services. The WMMRS, in cooperation with Worcester Emergency Management and the Commonwealth of Massachusetts, continues to integrate and synchronize individual agency response plans. Recognizing the various federal initiatives available to combat terrorism and other large scale events, WMMRS has forged several partnerships with the Centers for Disease Control (CDC) and Health Resource Services Administration (HRSA). Partnerships such as these integrate MMRS, CDC and HRSA, targeting capabilities that create an increased level of awareness, unification and communication nationally among the major medical preparedness initiatives. The WMMRS has matured into a regional initiative encompassing all 74 communities in Central Massachusetts, including all eleven HRSA funded hospitals and three area health centers. Some of the initiatives underway are regional communication centers where hospitals and emergency medical services can gather to effectively manage the surge of patients should a Mass Casualty Incident (MCI) occur. Regional hospital planning allows for parallel training like that offered by a radiation patient management course held in February 2006. The WMMRS has partnered with the regional MCI committee to develop an ambulance task force plan in cooperation with the 52 emergency medical service providers from amongst the 74 communities. An MCI could quickly overwhelm a community, thus prompting the need for additional ambulances at the incident. The developing regional task force plan will address the basic need to receive assistance in a timely manner. The WMMRS is equipping all first responders with personal protective equipment and UMass-Memorial EMS recently received an MCI response trailer. For the past three years the CDC has funded local boards of health to support this critical need for public health preparedness. The funding is administered by the Massachusetts Department of Public Health. WMMRS, in many respects, has a similar mission but is funded through the federal Department of Homeland Security. In conjunction with the Massachusetts Department of Public Health, WMMRS is working to increase the state of preparedness for the regional public health coalition. A major focus for these health agencies was to develop a plan where, if necessary, every community would be able to deliver chemo-prophylaxis to their respective population within the 48 hours following a highly infectious disease outbreak. For example, in the City of Worcester nine emergency dispensing sites have been established to be used for vaccinating or administering protective drugs to its 170,000 residents. The WMMRS has continued to develop a cache of pharmaceuticals with antibiotics and chemical antidote kits already warehoused. WMMRS, realizes, as a result of the recent intense media attention given to a potential avian influenza pandemic, that local Boards of Health are being heavily relied upon to answer questions and develop plans in response to such emerging threats. WMMRS has increased the level of communication among first responders and has instituted new approaches and expanded upon well-established and time proven disciplines in response to emergencies. With the possible use of infectious agents as an arsenal of assault, the face of terrorism has brought the discipline of public health into a new arena of responsibility. The WMMRS continues to move forward in addressing the evolution of disaster preparedness depending heavily on effective communication, new technology and, above all, on the expertise of health professionals. Bio Terrorism: Past,
Present and Future Bioterrorism can be defined as the intentional release of biological agents or toxins specifically targeting humans, water or food supply with the intent to intimidate.1 The use of biological agents to intimidate others is not a new phenomenon. Evidence of the use of biological agents dates back to the 6th century B.C., when the Assyrians poisoned their enemies’ wells with rye ergot, to the more recent use of anthrax in letters to reporters and U.S. Senator Tom Daschle.2 The United States began developing biological weapons for offensive purposes in 1943, ceasing in 1972 when over 140 nations, including the United States and the former Soviet Union, signed the Biological Weapons Convention. This treaty prohibited the development, production and stockpiling of biological and toxin weapons. 2, 3 Although many agents were destroyed, a small amount of the smallpox virus was kept in two repositories for research purposes only. One sample was kept in Atlanta, Georgia at the CDC and the other at the Institute for Viral Precautions in Moscow.2 It is widely believed that many nations have violated this treaty. The former Soviet Union had a robust biological weapons program before its fall in 1991. Unfortunately, due to the lack of security during the fall, many of the agents developed by the Soviets are unaccounted for and are believed to be lost or stolen.3 The Soviets worked extensively on the smallpox virus as reported by Dr. Ken Alibek, former deputy director of a large biological warfare program.1 The intentional release of agents such as anthrax (Bacillus anthracis), plague (Yersina pestis) or smallpox virus would quickly overburden the healthcare infrastructure. These agents are all considered Category A by the CDC and are regarded as the greatest threat to the public’s health. They have a high mortality and morbidity rate and can easily be disseminated over large areas. These agents require a great deal of planning by public health officials.4 If any of the above agents were released, every emergency department in the city would quickly fill up with not only those presenting with symptoms but also the “worried well.” There would not be an adequate number of hospital beds or respirators to treat all those in need. Emergency preparedness is the ability to respond to a threat or situation and prevent injuries or the unnecessary loss of life.3 After the anthrax scare, it was clear that the United States was not prepared for a biological attack and changes needed to be made to enhance our ability to respond. Some changes have occurred but much still needs to be done. In 2003, the former National Pharmaceutical Stockpile was renamed the Strategic National Stockpile (SNS) when the Department of Homeland Security (DHS) and the US Department of Health and Human Services (HHS) assumed responsibility. The SNS is a stockpile of large quantities of antibiotics, vaccines, antidotes, and medical supplies to be used in the event of a public health emergency (bioterrorist attack, flu outbreak or a natural disaster). The purpose of the SNS is not to be a primary response to an event but rather to replenish any supplies that may be needed by the state. The federal government agrees to deliver these supplies to any state within 12 hours. The inventory in the stockpile is capable of treating the population in several large cities at one time. Once the supplies are delivered to the state in need, it is up to the state and local officials to determine the distribution.4 The City of Worcester is fortunate to have the Metropolitan Medical Response System (MMRS) that works closely with the City’s Department of Public Health and the Worcester Emergency Management team. This program has developed a strong emergency response plan. In 2004, President Bush signed into law Project BioShield. As described by Landesman, “This law established a mandatory and protected source of funds within the annual budget for countermeasures related to biological weapons and other weapons of mass destruction.” 3 In the fiscal year 2004, approximately $6 billion over 10 years had been allocated to the DHS and other agencies to develop new vaccines (safer anthrax and smallpox vaccines) and medications to treat and protect against biological, chemical, radiological and nuclear weapons.3 Developing safe and effective treatments is a mammoth task. Pharmaceutical companies are not eager to develop new vaccines due to inadequate funding and liability concerns. Despite these efforts, many issues remain. Healthcare professionals do not have the adequate resources or training needed to attend to a sudden surge in patients. Preparedness training and education should not be limited to “first-responders.” Preparedness requires the proper training of all healthcare professionals including medical students. In the event of a biological incident, many patients will be calling their family practitioners, so they, too, must be able to quickly recognize and respond to a biological incident. The CDC offers a registry for physicians interested in receiving response updates and training opportunities: www.bt.cdc.gov/clinregistry. An additional benefit of emergency preparedness is captured by a statement made by Dudley and McFee: “Enhanced preparedness for mass casualties not only provides protection against terrorist attacks, it also enables us to better protect our communities against a wide range of industrial accidents, natural disasters, and emerging infectious diseases.”3 The author gratefully acknowledges the advice on this article from Derek Brindisi, Coordinator, Metropolitan Medical Response System. References:
Massachusetts 2 One DMAT's
Story Formed more than 15 years ago by Dr. Richard Aghababian, our visionary Chairman of Emergency Medicine here at UMass Memorial, Massachusetts 2 has become one of the top level Disaster Medical Assistance Teams (DMATs) in the country. Responding to crises as disparate as ice storms in upstate New York and the World Trade Center after September 11, 2001 and with 4 deployments to the Gulf Coast this past Summer/Fall for hurricane relief, Massachusetts 2 has seen the worst, and ~ more importantly ~ the best our country can offer. What is a DMAT? Essentially it’s a medical team comprised of nurses, doctors, paramedics, EMTs, pharmacists and support personnel. Typically, but not always, sponsored by a hospital, this group of volunteers remains ready to respond to any disaster, natural or manmade, in the United States. We volunteer our time to train and prepare, buying our own uniforms and much of our personal equipment. The Federal Government supports the team with equipment for its medical mission. When the call comes, each team puts together a group of personnel, determined by the mission, drops their personal lives and responds to the need for help. Like the logo on our team patch of a Massachusetts Minuteman, each member is ready and willing to respond at a moment’s notice to that call. The support of our hospital system and our families is crucial to our success. So, what is a “typical” mission? To paraphrase a cartoon character, “There ain’t no such thing.” What has Massachusetts 2 done this year? First, in January, we deployed to the nation’s capital to provide a ready medical presence for the President’s State of the Union Address. Our mission there was to be ready for potential terrorist action and/or a Mass Casualty Incident with on-scene medical care capabilities. Fortunately, our team had a quiet deployment. However, we got a lot busier with the onset of hurricane season! In July, we headed to Florida in the wake of Hurricane Dennis. While there, we augmented a local Emergency Department that was overwhelmed because all the local physicians’ offices where out of service due to lack of infrastructure. September saw the team respond to New Orleans in the aftermath of Katrina. Working in very adverse conditions at the New Orleans airport, Massachusetts 2 assisted in the evaluation and evacuation of people from the storm-stricken city. This deployment was more rewarding and more emotionally taxing than almost any we’ve ever done. One month later, with Rita again threatening the Gulf Coast, Massachusetts 2 traveled to Texas. Once on the ground, we assisted in evacuating people from Beaumont, Texas prior to the hurricane and in its aftermath staffed the only functioning emergency department in the ravaged city. For ten days, we provided not only emergency care to the remaining citizens of Beaumont, but also administered vital primary care. Finally, with the medical infrastructure of New Orleans still reeling from Katrina, Massachusetts 2 recently re-deployed there, this time operating out of a state-of-the-art Mobile Medical Unit. From the Unit, we provided primary and emergency care to the people of Louisiana and to those south of New Orleans, individuals who had seen their medical infrastructure, as well as most of their lives’ handiwork, swept away in a wall of water and wind. DMATs provide medical care in areas of disaster out of tents, hospitals, schools and mobile Medical Units. We are housed in tents, hotels, hospitals and airports. We are self-sufficient for up to 3 days with our own supplies. We can have a team roster ready in under 4 hours and can be almost anywhere in the USA inside of 24 hours. We deliver babies (3 in Beaumont) and critical care/emergency care/primary care to cities/states where the usual structure of society has been ripped apart. Much has been made of how “inadequate” the response to Hurricane Katrina was in New Orleans. It probably could have been better managed at many levels. However, with today’s National Disaster Medical System (NDMS) and DMATs, there exists here in the United States a superb group of teams and individuals who are ready and willing to respond to disasters, natural or manmade. New Orleans, Louisiana, Texas and Florida can testify that help is on the way. Are we better prepared than we were 2, 3 or 5 years ago? Absolutely. Finally, how was Massachusetts 2 received in each of its deployments? With great thanks and support, that’s how. It was striking how in each of our missions people who had lost almost everything responded with incredible gratitude and assistance. America is filled with truly extraordinary people; helping them is truly a service. Influenza Viruses,
Birds and Pandemics Avian influenza is spreading across wide areas of the world. Human cases of influenza caused by the avian strain are being reported in multiple countries. The news is full of stories about both. Patients are asking questions, anxiously requesting prescriptions for Tamiflu, canceling trips to Asia, and seeking a vaccine…any vaccine. Avian and pandemic influenza ~ Are they the same? Different? Is one the inevitable harbinger of the other? What should those anxious patients be told? Here are the basics: Avian influenza is a disease of birds. It spreads to people only rarely and it does not spread efficiently between people. Isolated cases may be severe, but are manageable. Pandemic influenza is human disease. It occurs everywhere at virtually the same time. It presents challenges that are unmatched by any infectious disease we face as a modern society. It may not be manageable, but preparation could help mitigate its impact. An influenza pandemic happens when a new strain of influenza A emerges, a strain never before experienced by the world’s population. Over the past 200 years, there have been at least 6 pandemics of influenza A, including the three in the 20th century. They occur, on average, every 20-40 years. So a pandemic is due, if the historic pattern holds true. The 1918 influenza pandemic was an extraordinary experience in human history. It was devastating, with a 2-4% overall mortality rate leading to between 50 and 100 million deaths worldwide over a matter of months. It was also the only observed pandemic that resulted in substantial mortality in people between the ages of 15 and 45 years. The elderly were actually spared (perhaps due to exposure to a similar virus in the pre-1880 years). The 1968 pandemic seemed to be due to an “ordinary” influenza virus that the human immune system had not seen before. The distribution of case-fatality by age was similar to that seen with annual influenza epidemics. The 1957 pandemic was peculiar in having higher mortality in infants. In all pandemics of influenza, infection spread rapidly around the globe over several months. It is very difficult to make robust predictions about the extent and impact of a pandemic because they vary so much. Pandemic influenza may behave in different ways in terms of human pathogenicity, but it is always massively disruptive to society. In the early 21st century, we live in a global community that is very complex in interaction and technology with rapid travel, instantaneous 24/7 media coverage, and a just-in-time economy. While we may have a certain pride in scientific and technological advances, the current structure of society leaves us more, rather than less, vulnerable to the impact of pandemic influenza regardless of pathogenicity. Capacity to cope with pandemic influenza in the developing world is even more obviously limited. In the developed world, dependence on communications and transport for coordination and supply compounds limited surge capacity in many sectors, not least of all in healthcare delivery. Experiences with terrorism, West Nile virus emergence, anthrax and other acute and frightening threats have demonstrated the impact these forces have on behavior and have shown that the bigger challenge is often presented by the public response to the threat rather than by the threat agent itself. And all of this is further compounded by the public’s elevated mistrust of the government’s capacity to respond effectively, especially in the aftermath of hurricane Katrina. Planning for a pandemic must account for continuity of operations in the face of staff and supply shortages. Healthcare delivery systems will face a massive surge of ill patients just when staff are suffering the effects of influenza themselves or when their families and loved ones become stricken. Effective vaccines will have to be matched to the infecting strain and, because of this necessary matching and because the method of production requires using hen’s eggs, will not begin to become available until up to six months after the pandemic has started. Antivirals, and perhaps even antibiotics, will be in short supply. And the public will see this timetable play out 24/7 in the news media, contributing to fear and anxiety. The threat is real, the stakes are high, and the challenges are daunting. But where do these viruses come from and why do they act the way they do? There are three types of influenza virus infecting humans: A, B, and C. Influenza B viruses cause epidemic disease some years and C viruses cause common cold symptoms. Influenza A viruses cause epidemic disease most years and are the viruses of pandemic influenza. Only some varieties of the influenza A virus infect humans. Some infect other animals (pigs, horses, seals, etc.), but all influenza A viruses infect birds; so, in a sense, all influenza A, and therefore pandemic influenza, viruses are ultimately of avian origin. Influenza viruses use RNA as their genetic material and this RNA is subject to frequent mutation leading to “genetic drift.” This contributes to the need for a new formulation of influenza vaccine each year to match the continuous changes in the surface proteins of the viruses. Unlike most other RNA viruses, influenza viruses have a genome of eight segments which can re-assort under the right circumstances, adding to genetic variability. We now know that bird influenza A viruses have the capacity to jump directly from birds to humans, as might have happened in influenza pandemic of 1918 and as is being observed, to a limited extent, in Asia today. Critical to the capacity of influenza viruses to enter and infect cells is the recognition of the body’s cell surface receptor by the virus’s surface protein, hemagglutinin, or “H.” The body’s cell surface receptor contains sialic acid molecules. Bird cells have one type of sialic acid linkage and humans another. The presence of hemagglutinin on the virus and sialic acid receptors on the cell membrane results in the virus being attached to the cell. The virus also requires neuraminidase, or “N,” on its surface to break the bonds and allow release of the virus or it would remain attached to the cell surface and be unable to infect the next cell. There are 15 types of H and 9 types of N that can, in various combinations, be on the surface of influenza A viruses. Thus far, those adapted to infecting humans are H1N1, H2N2, and H3N2. Each pandemic of influenza is characterized by the appearance of a new HN type, one not experienced by most people alive at the time of emergence. In 1918, it was H1N1. In 1957, it was H2N2, and in 1968, H3N2. Between each pandemic, the emergent strain circulates, to be replaced by the next emergent strain at the next pandemic. Therefore, H3N2 has been circulating since 1968. H1N1 also made a comeback in 1977, without a real pandemic, and has been co-circulating with H3N2. Thus, each year our regular influenza vaccine contains the H3N2, H1N1 and an influenza B strain thought most likely to resemble the expected circulating strains in the influenza season. We are actually vaccinating against the hemagglutinin (H) to block attachment and the neuraminidase (N) to block detachment of the virus. When the prediction is not completely accurate (like in 2003 when the emergent Fujian strain of influenza A H3N2 replaced the expected Panama strain), the vaccine is less effective at providing protection. Over the past 20-30 years, veterinary science has acquired the ability to identify and distinguish influenza A viruses in birds. Avian influenza occurs along a spectrum of disease in domestic poultry ranging from “low pathogenicity” (LPAI, a one to two week limited illness) to high pathogenicity (HPAI, fatal disease). However, the viruses are primarily maintained through infection of wild birds and water and shore birds. In birds, the infection involves the gastrointestinal, not the respiratory, tract. The wild bird hosts of the viruses show essentially no evident illness and go about their lives, including migration, apparently unaffected and excreting copious amounts of virus in their droppings. In the droppings, the virus is protected and can remain infectious for days to weeks. Avian influenza is a disease of birds. Currently, there is an avian “panzootic” of influenza A H5N1. There cannot be an “avian” influenza pandemic in people because humans are only rarely and incidentally infected. Prior to 1997, these infections were described in isolated case reports and usually consisted of mild illness, characterized mostly by conjunctivitis. But then in Hong Kong in 1997, 18 people were recognized as having respiratory tract infection with an avian influenza, an H5N1 virus coincident with an outbreak of HPAI in domestic poultry in the region. Six of these people died. It was the first time highly pathogenic avian influenza was observed to cause such illness in humans. Although there was no human-to-human transmission in evidence and complete culling of all domestic poultry eradicated the avian outbreak, it was a warning about the capacity of avian influenza viruses to jump to humans. Since 1997, there have been other instances of highly pathogenic avian influenza in humans. In 2003, there was a large outbreak of avian influenza A H7N7 in The Netherlands with 89 clinical cases (mostly conjunctivitis), one death in a veterinarian with influenza pneumonia, and over 1000 people with serologic evidence of infection. At the end of 2003, a large outbreak of influenza A H5N1 in birds began in Asia and spread to an unprecedented extent. It has reached Europe along migratory bird flyways. This was a drifted strain of the 1997 virus. Since the vast outbreak in birds, there have been up to 150 cases identified in humans in Viet Nam, Thailand, Cambodia, Indonesia, China and Turkey. Initially, the case fatality rate was 70%, but it has gone down to the 50% range. There have been two cases of apparent person-to-person spread in individuals who had close, prolonged, unprotected exposure to a case of severe illness. There have been no health care worker cases and evidence of infection in those who handle and cull poultry with recommended precautions has been very limited. However, the situation is very worrisome, because it might be the harbinger of the next pandemic. This would depend on the virus gaining the capacity to pass efficiently from human to human. The influenza A H5N1 virus is changing. Genetic drift is occurring. The virus is already resistant to one of the two major classes of antivirals effective against influenza A (the adamantanes: amantidine and rimantidine) and decreased susceptibility to the neuraminidase inhibitor oseltamivir has been observed. H5N1 has been isolated from pigs, which have both avian and human receptors for influenza A viruses plus the capacity to give rise to totally new strains when they are infected by both avian and human influenza viruses at the same time. The virus has become adapted to cats, with the observation of cat-to-cat transmission. Domestic ducks are also becoming more tolerant of the H5N1 strains, meaning that instead of dying in short order they can continue to excrete large amounts of virus over a longer period of time. All of these developments are worrisome. Yet, they do not necessarily mean that there will be an H5N1 pandemic. The next pandemic could easily be H7N7 (the Netherlands strain, which already has substantial adaptation to human infection) or H2N2 (which has not circulated since 1968), or even a 1918-like H1N1 (as was feared to be happening with “swine flu” in 1976). A pandemic of influenza A will happen at some point. It may or may not arise directly from the avian influenza strain spreading from Asia into Europe. But it will happen, and it could be as devastatingly pathogenic as in 1918 or just an “ordinary” influenza as was the case in 1968. Whatever the behavior of the virus, our complex society will be disrupted everywhere at once, with massive absenteeism on top of widespread illness; the impact will be felt for weeks to months. Influenza A H5N1 is a wake-up call and adds a degree of urgency to the planning necessary to mitigate the impact of pandemic influenza. The plan for facing the influenza pandemic cannot be just a public health plan, it must be a societal plan, and the call must go out for widespread public involvement. Legal Consult: Public Health Emergencies
and the Role of "Community Caretakers" With daily news reports of the spread of the avian flu virus comes
increasing concern about lo Emergencies have the eff These “community Those new roles and rules may come into play before, during, and after a
public health emergency. For example, physicians are aware of their
responsibilities to report communi Outbreaks of communi Thus, in the Liability prot Another statute may offer broader prot It is possible that physicians cooperating with public health officials
during an emergency might be prot Fundamentally, of course, a physician’s pri In 2005, the AMA House of Delegates adopted an ethics policy requiring
physicians to “…seek an appropriate balance of public needs and individual
restraints so that quarantine and isolation use the least restrictive
measures available that will minimize negative eff These additional considerations about the appropriateness of emergency
responses applied generally, and about a given patient’s individual rights
and best interests in the context of such measures, further compli When stepping into various “community Science Corner: Doctor, why do I feel so
sick with the flu? Why do most respiratory viruses (rhinoviruses, coronaviruses, respiratory syncytial viruses) simply cause “cold-like” symptoms that we tolerate as part of everyday life as adults while influenza causes high fevers and myalgias and makes the victim feel death would be a desirable alternative? Why do some patients have a much worse course after infection with the same virus and why are some virus strains deadlier than others? New experiments in humans and animal models indicate that the answer to all these questions has to do with the host response. The concept of “flesh eating bacteria” or “killer flu” is all wrong. The microbe is “merely” an innocent bystander that initiates a cascade of host-derived responses that may lead to the death of the host. In other words, the host sees the virus and the host commits suicide. The fault is not with the virus, but with the host. What makes for the fever, myalgias, shivering, sleeplessness, and fatigue that are so characteristic of influenza? Recent studies have revealed that these responses are the result of the virus interacting with the “innate” immune system. The interaction between the cell and the virus leads to the production of cytokines. The cytokine responses to microbial pathogens are the result of components of the bacterial cell interacting with cell surface proteins called Toll-Like Receptors (TLRs). It is these TLRs that cause fever and hypotension in gram negative sepsis. In particular, it is TLR4 (one of twelve different TLRs found in humans) interacting with bacterial lipopolysaccharide (LPS) that causes the release of cytokines, which in turn results in sepsis. The same is true with viruses. Why some viruses (like influenza) are more associated with cytokine release than others is not clear, but the severity of the avian influenza strains that are causing mortalities approaching 50% in normal children is likely related to their ability to induce elevated cytokine levels. Recent studies have allowed for the identification of specific viral proteins and nucleic acid sequences that are important in initiating the host response. So, if the reason we feel so terrible with the flu is because of Toll-Like Receptors, why don’t we just turn them off? As a matter of fact, several companies are looking at TLR inhibitors (especially for use in bacterial sepsis). There is a major problem with long-term use of these inhibitors. As with use of any cytokine inhibitor, turning off this response will eventually turn off the T and B cell responses that are required to eliminate the pathogen. The Holy Grail of the use of immunomodulators as therapeutics is that we can turn off the bad inflammatory responses (the fever and the myalgias) and just keep the good ones (the ones that stimulate the T cells and B cells to make antibodies and kill viruses). Vioxx for the flu? Probably not this year. References:
Off Call: A Year in the Round “Whose house is burning?” we asked as we drove near the end of our private road that was lined with cars, black smoke billowing into the air above the tree tops beyond. Our neighbor, John, looked down at his shoes before he could answer. “Yours is,” he said. Our house and possessions destroyed, we frantically cast about for solutions to our immediate problems. For the first week, we lived with neighbors we’d barely known before the fire who have since become cherished friends. Another set of warm and generous friends invited us to live with them until we could establish temporary housing. After moving in, accompanied by our meager possessions, we took turns making meals and sharing household tasks and worried every time our cat disappeared for three days, wondering if she’d tried to make the trek from Princeton back home to Rutland. She’d re-appear intact, though, and we switched our attention to negotiation with the insurance company and to finding a builder who would demolish the charred wreck of our home and rebuild it on its foundations. All the while, both Jeff and I worked resolutely to keep our practices running smoothly, our patients well cared for, and our family and relationship intact through the upheaval of our loss. By the time September 11th rocked the country, we’d moved into a spanking new singlewide mobile home newly parked on our property. The cramped space couldn’t accommodate a television and, mercifully spared, we missed the footage of bodies hurling out windows onto the concrete below. In the midst of a building boom and housing shortage, a semi-permanent residence remained elusive. As nights become cool, we turned up the trailer’s electric heat only to find the all-plastic interior emitted so many vapors that we were had to disable all fire alarms to keep them from screeching every time the heat came on. About this time we found a solution to our housing problem ~ yurts. A yurt?” the insurance adjuster asked in confusion. I explained the concept, an 8” thick circular foam insulated floor, latticework walls and a central ceiling ring with rafters notched into it and with the rafters running down and secured to a cable woven through the top of the latticework. Sheathing, first of insulation and then of a canvas-like material and roll-up clear vinyl windows are all topped by a clear plastic bubble skylight which opened for ventilation. Silence. “Sounds like a glorified tent,” he said. “Where are you going to live in the winter?” We ordered four. The biggest measured 30 feet in diameter and created the central hub, complete with space for a kitchen, dining area, lounging area, and a coatroom/mudroom area. Another, at 27 feet in diameter, worked as the bedroom and study area for our two sons. A third, 21 feet in diameter, functioned as the “master yurt,” and a last structure, 18 feet in diameter, became our bathroom and laundry. The yurt company had never connected them before, but 30 friends, 2 instructors, and a weekend of blazing fall glory later we’d built a small yurt complex. Propane heaters went in, we connected to the sewer system of our demolished home, and soon added plumbing, electrical, and appliances. Curved plywood counters and shelving made up our kitchen. We hung wooden bars from the rafters and voilá, closets. We shopped for the few crucial pieces of replacement furniture and we had created a home. “Once you live in the round, I’m told you don’t like to go back,” my architect said to me. It seems that he’s right. We’ve lived in our rebuilt house for two years now, and there’s storage and a place for a guest to spend the night. But I miss the ever present natural light, the sound of the wind in the trees, the soft staccato of rain on the roof, and being able to tell when it’s time to arise in the morning by the position of the constellations through the skylight over our bed. And what did we get out of the whole house-burning incident? We allowed our neighbors and friends to be generous with us in our time of great need in ways that we can never hope to repay and that overwhelm us with gratitude to and love for them. Our son Michael knows that you can burn the house down and his family will love him. And we had a great opportunity to live in a way we’d never otherwise have experienced. We lived a year in the round.
Massachusetts Medical Society 6th Annual Creative Writing Contest (Re: “Professor of Anatomy”) When he “introduced” us to our cadavers in Anatomy Lab, he said that we might be surprised to learn that in life many of them were doctors and other professionals who had donated their bodies specifically to help medical students in their training. He said something to this effect: “As a matter of fact, when I die, I plan to teach for another year.” Strangely enough, a year or so later, during one of my first clinical rotations, I was assigned to a patient at a V.A. hospital who was dying of recurrent colon cancer. This patient was a retired dentist. He told me not to be sad. He’d first been diagnosed more than five years earlier and he felt that his doctors had been able to give him an extra five years he wouldn’t have had otherwise. He also told me that he planned to donate his body to a medical school for anatomy lab! Perhaps it sounds a bit morbid, but I was able to thank him on behalf of the future students who would benefit from his generosity. In the early weeks after my roller coaster accident, while I was still a bit scared about my prospects, I’d written to Dr. McNary. He wrote a very kind and encouraging letter in return. He died in 1991, three short years after I’d graduated. PROFESSOR OF ANATOMY Lost, my youth of bloom. Katherine L. Phaneuf, MD (Re: “Air Wallenberg”) FLYING (AIR WALLENBERG) Flying through the air on twisted rails Katherine L. Phaneuf, MD I enjoyed the March issue of Worcester Medicine ~ from its new size to new format to new cover to its excellent content and yes, even the new "pull out" advertisement portion! I was particularly proud of Dr. Maciej M. Mrugala's introductory comments in the Creative Writing section. Doctor Mrugala is on the Executive Board of the AHHC MIN of the MMS of which I am Chair along with Dr. Robert Sorrenti. "Creative Writing" was Maciej's idea. The first winning entry in that issue, Dr. Robin Schoenthaler’s "The Grace Walk," was particularly poignant for me since I lost my first wife of thirty-six years, Ellen, to ovarian cancer. She certainly was one who walked "the grace walk!” Having dealt with various forms of cancer in my surgical career, I must say that this piece has caused me to look differently at death caused by cancer. The "In Memoriam" pages were very well composed. Having known and considered Drs. Felix Cataldo and Ed Prunier personal friends for many years, I'm sure their respective columns were appreciated by family and friends alike. The single rose was a nice touch! Congratulations to all involved with this fine issue! Edward Amaral, MD |