From the monthly archives:

February 2008

Bird Flu Update - Pandemic Influenza Still a Threat

by Brian Carty, MD, MSPH
02-22-2008

A city is swept by an epidemic. Thousands are dead, the streets are silent, and all stores, schools, churches, and public places are closed. There are no pedestrians, no cars, no buses, and no trains. The supply of coffins is exhausted. So many have died that the dead must be buried in mass graves dug with steam shovels.

Science fiction? No. This scenario occurred in virtually every large American city during the 1918 influenza pandemic. It was the worst epidemic in human history and killed over 50 million people worldwide. Experts are certain that another influenza pandemic will occur, but when the pandemic will occur, how severe it will be, and what the responsible influenza virus strain will be are unknown.

Bird Flu:  Pandemic Influenza still a threat by Brian Carty, MD

Avian influenza virus (H5N1) is widespread in many wild and domestic bird populations

There is concern that an influenza virus now widespread in many wild and domestic bird populations, avian influenza virus (designated H5N1), sometimes called “bird flu,” may cause the next pandemic. Over three hundred people have been infected with this virus worldwide and over 50% of those infected died.

Avian influenza virus (H5N1) is widespread in many wild and domestic bird populations.

Influenza is a viral infection which involves the nasal passages, throat, airways, and sometimes lungs. Symptoms in uncomplicated cases include headache, fever, chills, muscle aches, cough, and sore throat. The virus is transmitted from person to person and can cause serious or even fatal infections, usually pneumonia, especially in the very young, the very old, and in people with underlying medical problems.

Epidemics and Pandemics

Influenza causes yearly epidemics. An epidemic is an outbreak limited to a particular city, area, or region. Flu epidemics occur between October and March in the Northern hemisphere, in the summer in the Southern hemisphere, and throughout the year in tropical areas. Currently, our yearly influenza epidemic is in full swing.

A worldwide epidemic or outbreak is called a pandemic. Influenza pandemics occur roughly every 10 to 15 years, and pandemic influenza is often severe with high death rates. In the 20th century, influenza pandemics have occurred in 1918, 1957, and 1968, although the 1957 and 1968 pandemics were not as severe as the 1918 pandemic. Pandemic influenza can start in the summer in the Northern Hemisphere.

Will H5N1 Cause The Next Pandemic?

Avian influenza (H5N1) is considered a candidate to become the next pandemic influenza strain. However, in order to cause a pandemic, a flu strain must be transmitted easily from person to person. H5N1 has been transmitted between humans only rarely. In a few clusters of human infection, the virus was first acquired from chickens by a human, and then transmitted to other humans. If the H5N1 virus changed so as to be readily transmissible between humans, that strain could cause a pandemic.

The Deadly 1918 Flu Virus Was a Type of “Bird Flu”

An interesting discovery came from research on the 1918 pandemic flu virus. Working with fragments of preserved lung tissue from patients who died in 1918 of influenza, scientists have recreated and analyzed the original deadly 1918 virus. The scientists found that the 1918 virus was, like H5N1, an avian virus which became adapted to humans. This discovery and occasional human to human transmission of H5N1 suggest that H5N1 may be the virus which causes the next influenza pandemic.

Preparations for Pandemic Influenza

Government and public health authorities are preparing now for the next flu pandemic, although no one can predict its timing and severity. Public emergency plans are being readied. Several H5N1 vaccines have been developed. Governments and even some individuals are stockpiling influenza drugs. Even so, in the event of a flu pandemic, there may be shortages of vaccines, drugs, and other resources. For example, if a flu pandemic were to occur now, the number of people with pneumonia and respiratory failure who require a ventilator for survival would exceed the number of available ventilators. This would require some difficult and unpleasant rationing decisions. Hopefully, research and adequate preparation will give us many advantages when we next confront one of mankind’s most dangerous natural enemies.

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Can Surgery Cure Diabetes?

by Brian Carty, MD, MSPH
02-14-2008

“A chance to cut is a chance to cure” is the surgeon’s motto. That bariatric (obesity) surgery for severe obesity often cures diabetes is not new information. What is new is research which shows that bariatric surgery can also cure diabetes in people with mild or moderate obesity. Even so, surgery is not usually considered a first line treatment for the severely obese diabetic, much less for the mildly or moderately obese diabetic. This attitude is likely to change.

Obesity and diabetes are common, serious, and interrelated problems. Obesity greatly increases the risk of developing type II diabetes. Type I diabetes is not usually associated with obesity, is not curable with surgery, and will not be discussed further here. While weight loss can improve or even cure type II diabetes, diet and lifestyle changes almost never result in significant, sustained weight loss. Furthermore, despite treatment with medications, diabetes usually causes progressive organ damage and sometimes blindness, kidney failure, amputation, or death.

The severity of obesity can be classified by the body mass index (BMI), which is the weight in kilograms divided by the height in meters squared. BMI can be obtained from this online calculator. Here are BMI ranges for normal weight, underweight, and different degrees of obesity:

BMI
Underweight <18.5
Normal 18.5-24.9
Overweight 25.0-29.9
Obesity 30.0-34.9
Severe Obesity 35.0-39.9
Morbid Obesity 40.0-49.9
Super-morbid obesity >50.0

 

Until recently, bariatric surgery was generally restricted to patients with a BMI of 40 or greater or a BMI of 35 or greater along with obesity related medical problems such as high blood pressure, diabetes, or sleep apnea. Government programs and insurance companies usually will not pay for the operation unless these criteria are met.

The number of bariatric operations done in the US has greatly increased in the past several years. You may know someone who has had such an operation. You may even know someone who has had to fight it out with an insurance company to get the operation approved.

The results of a recent study (Jan. 23 JAMA) challenge the practice of offering bariatric surgery only to patients who meet the standard criteria. In this study, bariatric surgery cured diabetes in over 70% of diabetics with mild or moderate obesity (BMI between 30 and 35). Thus, bariatric surgery should be considered for diabetics with mild or moderate obesity (BMI 30-35) as well as for diabetics with severe obesity (BMI over 35).

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Fearful of offending the gay community, the Canadian Red Cross refused to exclude male homosexuals, many infected with HIV, from blood donation in the 1980s.

Famous for their blended whiskeys, Canadians mixed politics, public health, and political correctness in the 1980s with deadly results, namely infections transmitted by contaminated blood and blood products. So far, the accused have escaped jail terms. On October 1, 2007, a Toronto court acquitted four doctors and an American drug company of charges of knowingly distributing HIV and hepatitis C contaminated blood products in the 1980s.

One of the defendants acquitted on Oct. 1, Dr. Roger Perrault, former medical director of the Canadian Red Cross, then faced additional criminal charges in a trial set to begin in Hamilton, Ontario. However, the prosecutor dropped these charges on Friday, January 18, 2008, stating that there was not a reasonable chance of a conviction. Victims of the tainted blood disaster were furious.

Blood system screw-ups infect thousands.

Bad Blood in Canada - Cartoon by Nacho Garcia, 2008

click image to enlarge
art by Nacho Garcia

The recent trial involved contaminated blood clotting products given to a group of patients with hemophilia in 1986 and 1987, but there were many other errors in the Canadian blood system in the 1980s. Together, these errors caused thousands of hepatitis C and HIV infections. Many victims who are still alive are terminally ill.

Hepatitis C is a virus which causes chronic inflammation of the liver and sometimes fatal end stage liver disease. The HIV virus causes AIDS.

American media and medical publications give Canadian blood fiasco the silent treatment.

Curiously, the affair has received no coverage in the American medical literature and virtually none in the lay press, aside from brief accounts of the recent verdicts given with few details and no explanation of the causes of the disaster. In fact, in the US, little media attention is given to the defects of the Canadian health care system, often praised as a desirable alternative to our own.

Krever Commission appointed to determine why blood system failed.

The events of the Canadian tainted blood fiasco stretch back almost 30 years. The sequence of events is complicated, but full details are given in a 1138 page document called the Krever report. This document was issued in 1997 by a Canadian government commission set up to study the affair and headed by Justice Horace Krever.

There was one common thread in virtually all of the errors which led to the infections. Many Canadian physicians and officials in the 1980s failed to adopt precautions which were standard practice in the US and in most developed countries to prevent hepatitis C and HIV infections from blood transfusions.

Political correctness produces fatal results.

For example, fearful of offending the gay community, the Canadian Red Cross refused to exclude male homosexuals, many infected with HIV, from donating blood in the mid 1980s. The US began to exclude male homosexuals, Haitians, and other donors likely to be infected with HIV in March 1983. This was standard practice in virtually all developed countries at the time. Canadian blood banks, however, did not consistently exclude high risk donors until more than 2 years later. Many Canadian transfusion recipients were thus infected with HIV.

Senior Canadian Red Cross officials not only failed to take measures to exclude high risk donors; they actually ordered local Red Cross medical directors not to exclude such donors.

Even so, some blood system employees were unwilling to sacrifice the lives and health of transfusion recipients in order to avoid offending political interest groups. In 1983 the employees of the Calgary blood center began to mark blood donations with a black dot if the donor appeared unwell or belonged to a group at high risk of having HIV. The marked blood was not transfused or processed further. This practice was concealed from the national Red Cross.

Canadian Red Cross rejects test which would have prevented thousands of hepatitis C infections.

An accurate test to detect hepatitis C virus infection in donated blood was not available until 1990,. A partially effective test, surrogate testing, was available in the late 1980s. Surrogate testing was effective in stopping about 60% of transfusion-associated hepatitis C infections and was used in the US from January 1986 to July 1990. Failure of the Canadian Red Cross to adopt surrogate testing until the 1990s caused thousands of hepatitis C infections.

Many HIV infections in transfusion recipients could have been prevented.

In the early 1980s hemophiliacs began to acquire HIV infections from the blood clotting factors they were given to treat and prevent bleeding. Eventually, heat treatment of the clotting factors was found to inactivate the HIV virus and prevent HIV infection.

Consequently, in November 1984 the Canadian Bureau of Biologics directed the Canadian Red Cross to adopt heat-treated clotting products as soon as possible. The Canadian Red Cross could have adopted heat-treated clotting factors promptly. It failed to do so for another eight months, presumably to save money by using up inventories of non heat-treated, often HIV contaminated products. The Canadian Red Cross continued to distribute non heat-treated clotting factor products even after it had an adequate supply of the safer heat-treated products. HIV infections in hemophiliacs were the unfortunate result.

Although the US adopted a newly available test for detecting HIV contamination of donated blood in March 1985, the Canadian Red Cross did not do so until November 1985, eight months later. For eight months Canadian patients continued to receive HIV contaminated blood transfusions.

In another incident in the 1980s, the Armour Pharmaceutical Company sold concentrated factor eight, a clotting factor product for hemophiliacs which was heat-treated to presumably inactivate the HIV virus. Despite Armour’s own research which showed that its heat treatment process did not adequately inactivate HIV, the company concealed the research results from regulators and knowingly continued to sell the HIV contaminated factor eight. This act, combined with inadequate oversight by Canadian officials, caused HIV infections in many factor eight recipients.

Canadian blood system in the 1980s inferior to systems in the US and other developed countries.

Physicians and officials implicated in the tainted blood affair have maintained throughout that they made the best decisions at the time with the evidence available. However, the Krever Report and other sources present clear evidence that the decisions were not reasonable, when judged with respect to available knowledge and practices in other developed countries at the time.

Canada’s dysfunctional government health care system was part of the problem.

The structure of the bureaucracies which controlled the blood system played a role in the disaster. Authority and accountability for decisions were not clearly assigned. Furthermore, delays in the funding of infection control measures were an inevitable feature of Canadian socialized medicine. The tainted blood scandal thus has to be blamed, in part, on the nature of government medicine itself.

In fact, in Canada private medical practice is illegal. For example, when the Canadian government decided to continue to use non heat-treated clotting factor products which were often contaminated with HIV, it would have been illegal for individual patients, physicians, or hospitals to purchase safe, heat-treated products on their own.

The Krever Report notes that officials often seemed less interested in safety than in saving money. Observers have also wondered whether the top-down management of the Canadian health care system fosters the kind of remarkable passivity and lack of initiative displayed by many Canadian physicians and officials in the face of this public health emergency.

Government records destroyed to hide responsibility for blood system decisions.

It is interesting that no politicians were named in the Krever Report or indicted in criminal cases. Government officials, who control all health care funding in Canada, undoubtedly had direct input into many of the decisions made in the tainted blood affair. Politicians may have escaped blame because in 1989 the executive director of the Canadian Blood Committee, Dr. Jo Hauser, ordered all records of Blood Committee meetings from 1982 to 1989 destroyed. This committee controlled funding of the blood system at the time. The records contained potentially incriminating details of decisions by federal and provincial deputy health ministers, acting on authority of their superiors. The records were destroyed 15 days after an access-to-information request had been filed.

Victims infuriated after acquittal.

One of the victims, James Kreppner, gaunt, emaciated, infected with both hepatitis C and HIV, was bitter about the October 1 acquittals: “It makes me feel that we have a real problem with the court system in Canada. You have a dream team of defense lawyers and they did a good job and somehow they managed to persuade this judge, but it wasn’t the conclusion that we would come to from the evidence that we’ve seen, which was very clear cut. We didn’t think this would be much of a case.”

Let’s see. Shredding of potentially incriminating documents.. A “dream team” of defense lawyers. Acquittal in the face of overwhelming evidence of guilt. Sound familiar? Our neighbors to the north seem to be catching on to American style justice.

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Medical Image of the Month February 2008

by Brian Carty, MD, MSPH
02-01-2008

Policemen in Seattle wear masks during the 1918 influenza pandemic

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