Radio interview with Bobby DeMuro of Radio Exiles on the novel Mailaise

Swine Flu update

The CDC has learned of two cases of swine origin influenza A of the H3N2 strain in Minnesota and West Virginia. The WV case appears to have occurred in a young child and local health officials, in conjunction with the CDC, are investigating and testing other ill children. Those kids could have routine seasonal viruses, like RSV, another flu strain or the newest swine-origin flu to cross over to humans. Disease with this strain continues to be mild.

In NYC there isn't much flu around to speak of and all surveillance systems are at or below baseline. Stay tuned.

http://www.cdc.gov/flu/weekly/

http://www.cdc.gov/media/haveyouheard/stories/novel_influenza.html

http://www.dhhr.wv.gov/oeps/disease/flu/Pages/fluSurveillance.aspx

Another Swine Flu variant crosses over

It was reported last week that three children in Iowa contracted a swine-origin triple reassortment influenza A (H3N2). You may recall the H1N1 pandemic in 2009 started in the US in a similar fashion with cases in children in California and Texas before the HS outbreak in New York City. None of children were hospitalized and all recovered. Person-to-person transmission is suspected and these cases bring the total of swine-origin H3N2 infections in humans to 18. Because very few people with influenza actually get tested and diagnosed there likely have been more of these cases. What does it mean? Will there be another pandemic? As far as public health officials in Iowa can tell sustained transmission is not happening, so a pandemic seems unlikely. At least for now. Meanwhile, in NYC, the flu season hasn't yet arrived.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6047a3.htm?s_cid=mm6047a3_w

Two with Haff Disease equals a hole in our understanding

Last week a woman bought fish from a Brooklyn market and prepared it for herself and her mother.  The next day the younger woman, who ate more of the fish, vomited and experienced muscle pain severe enough that she made a visit to a nearby hospital. Laboratory tests showed muscle enzyme levels 300 times normal, evidence of rhabdomyolysis, the release of the muscle protein myoglobin into the bloodstream. She had none of the usual risk factors for rhabdomyolysis such as extreme muscle overuse, trauma, muscle compression or drugs. Within a few hours her mother presented to the same hospital with similar, but less severe symptoms. Both women were treated and are expected to make full recoveries. No additional cases have occurred.

First reported in 1924, Haff disease gets its name from the Koenigsberg Haff, a brackish inlet of the Baltic Sea where the syndrome was first described. The syndrome is characterized by the sudden onset of severe rhabdomyolysis with nausea, vomiting, chest pain, shortness of breath, and pain with light touch. In Europe Haff disease has been associated with consumption of burbot, eel, and pike. In the United States 23 cases have been reported since 1984 and have followed the consumption of Buffalo fish, crayfish, and salmon. Like paralytic shellfish and ciguatera poisoning, a heat-stabile toxin is suspected but has yet to be identified.

The Buffalo Fish (Ictiobus cyprinellus) is a fresh-water fish and was reported to have been eaten by the two NYC Haff disease cases. Samples of fish from the market have been sent for testing and a temporary embargo has been placed while a trace-back to the source is underway.

Crack the case- Salmonella Heidelberg and chicken livers

Last week the news covered a story of chicken livers contaminated with Salmonella Heidelberg. They were labeled as “ready-to-eat” but the livers had been braised such that from the outside they looked cooked but the insides were coolly raw. The outbreak had been going on in New York and New Jersey for two months and we were approaching fifty cases without a solid lead when two public health students, working as interns in our office, cracked the case. Interviewing cases is not a glamorous task, in fact it is downright monotonous. We employ a 17-page shotgun questionnaire to the approximate 1000 annual cases of Salmonella that occur in NYC annually in order to elicit suspect food items. To accomplish this task we have a team of MPH students dial the cases and beg their indulgence as we plunge into the twenty-minute interview. The students make the calls one aisle over from my cubicle, so I overhear them as they repeat the same questions to every case. Questions like “have you any eaten any stuffed, frozen chicken products, such as chicken Kiev or chicken Cordon Bleu?” So when two students, classmates and friends, shared the uncommon mention of chicken liver we had a new lead. Chicken and eggs are of course standard questions but we don’t usually ask about individual chicken parts, such as hearts and livers. The next day a third person mentioned chopped liver. We dispatched a food inspector to the store to retrieve the chicken livers. At the city’s Public Health Lab they were able to grow the same Salmonella species (serotype Heidelberg) from the cooked chicken livers. A week later the molecular results came back, a perfect match to the strain causing the outbreak. The chicken livers were recalled and outbreak was stopped.  Two new disease detectives earned their badges.

For more information:

http://www.nyc.gov/html/doh/html/pr2011/pr028-11.shtml

http://www.foodsafetynews.com/2011/11/cdc-157-salmonella-chicken-liver-cases-in-ny-nj/

http://www.cdc.gov/salmonella/heidelberg-chickenlivers/111011/index.html

OWS-using a hammer to put out a fire

This is a infectious disease blog, but I can't pass up an observation on current events.

The occupation of Wall Street got our attention, but now they are just pissing people off. They may have a few thousand protesters but there are 8.3 million people in NYC, and OWS is rapidly losing public support. When did this become a freedom of speech issue? A battle against the police? Every hour of police overtime is another city worker who will get laid off.  Is this the goal? To increase unemployment?  I thought greed was the enemy? Law enforcement should be an ally not an adversary. Does anyone believe that Bernie Madoff was the only crook on Wall Street? Don’t we want them investigating crooks instead of cleaning up the mess?

OWS get your heads out of the sixties. Regroup. Find a charismatic, well spoken, respected leader. Develop an agenda. Make a list of action items. Having people pull their money out of big banks in favor of credit unions was a good one. How about organizing a no stock trade week? Use the Internet, social media. Be creative. That will get Wall Street’s attention. They make money on every trade whether we do or not. Right now they are sitting up in their towers laughing at your foolishness. Hit them where it hurts, in their fat wallets. March to Washington to change legislation, but stay off the Brooklyn Bridge. Don’t litter.  Right now we the general public view OWS like a toddler throwing a tantrum. We hear you crying and see you misbehaving but we don’t know what you want. Use your big boy voice.

Inhalation Anthrax in NYC-Fall 2001 (Part 5 of 5)

Relieved, as we were, that no anthrax spores had been found in the NYC subways and that in the several weeks that had passed no new anthrax cases arose, it wasn’t the end to the spore story. The fifth and final death, the last of the 2001 mail murders, was perhaps the most perplexing. It occurred in a most unlikely setting: Oxford, a small rural town in southwestern Connecticut. With a population of just under 10,000 Oxford is far from major highways and cities. It boasts two banks, a beautiful public golf course and an annual crime rate of zero.

Retired legal secretary Ms. Ottilie Lundgren was a homebody. At 94-years old her mind was still sharp but she preferred the comforts and familiarity of her routine.  She didn’t drive or prepare her own meals and other than her family and a few trick or treaters her only visitor in the preceding months was her local pastor. On November 14^th she began to feel ill with fever and fatigue. When shortness of breath began two days later she was taken to a local area hospital and admitted. She had been a smoker and was known to have lung disease as a result. Pneumonia in nonagenarians is not uncommon. The next day four samples of her blood were growing bacteria, the gram-positive rod variety, and after only 14 hours. Bacillus anthracis was confirmed and a match to the other 21 cases. She died on November 21^st.

State and local health department staff along with CDC, EPA and law enforcement descended on the small town. They interviewed family, neighbors, postal workers and too samples. As we had done for Kathy Nguyen, they reconstructed her movements in the last two months. They turned out to be few. She went to church weekly, occasionally to a local favorite restaurant, a hair salon and doctor visits. Tests for anthrax spores at her home were negative, just like Kathy Nguyen. We met with Jim Hadler and his team to compare notes: both women lived alone and wore hats, other than this we could find no similarity other than their choice of perfume. The bottle tested negative.

We had checked USPS records to see if any letters that had passed though the contaminated postal sorting were routed to Kathy Nguyen. None were and her local Bronx post office tested negative for spores. Public health officials in Connecticut did the same, and likewise found nothing. They tested 29 pieces of mail found in her home, again nothing. They again tried testing the postal distribution center in Wallingford, again negative.

Four miles away, in the neighboring town of Seymour, Connecticut, a family was following the story with much trepidation. Then came a knock at their door. The visitors were from the State Health Department, CDC and the FBI.  A letter, sorted in Trenton on October 9^th just fifteen seconds after the contaminated letter to Senator Leahy and on the same machine had been sent to their address. The epidemiologist asked if by chance did they still had the letter and envelope? They did. The outside surface turned out to be positive for anthrax spores while the inside was not. With this information epidemiologists returned twice more to the Wallingford Postal Center and swabbed and vacuumed again.  This time four of the sorting machines returned hot with spores.

Mrs. Lundgren opened her own mail. Junk mail she tore in half before tossing into the trash.  CDC postulated that letters that had passed through the contaminated postal sorting machines in Trenton after the Leahy and Daschle letters had subsequently contaminated other sorting machines in other towns, including Wallingford. A letter, perhaps a bill or greeting card, passing though a secondarily contaminated sorting machine had picked up enough spores to infect Mrs. Lundgren. So, what did this mean about the minimal dose of spores necessary to cause infection previously believed to be in the thousands? The range of incubation period for inhalation anthrax was believed to be as long as sixty days, but if only a few spores were necessary could this be even longer? Were there still others incubating a deadly disease? How could we identify people at risk? Anyone over sixty-one? Was the mail safe? Only time would tell.

Inhalation Anthrax in NYC-Fall 2001 (Part 4)

No one wanted to say it out loud. The implications were too frightening. We were pretty confident that there wasn’t a release of anthrax spores other than when media staff opened the envelopes, but that alone wasn’t going to dissolve the city’s anxiety. As the November days passed and we had no explanation for the Kathy Nguyen inhalation case we faced the inevitable. We had to eliminate one very public place as the source, we had to test the NYC subway system.

None of us believed that the NYC subway was presenting a risk to anyone. If there had been a release underground we would’ve been dealing with many inhalation cases, not one. We had a pretty good idea though that spores could be tracked from their original location and the technology to find them was sophisticated. Staff from ABC, NBC, CBS or the NY Post could’ve tracked spores on the soles of their shoes anywhere. Despite our confidence that there weren’t legions of straphangers out there incubating inhalation anthrax we worried about positive results, even a single spore. We certainly couldn’t close the subways but it would be tough public message to craft. There are anthrax spores in the NYC Subway system, but it is safe to ride. I envisioned a TV crew taping Dan Rather and the Mayor sharing a pole on a downtown 6 train to make the point.

NYPD did the sampling with CDC and us directing them. Six train lines were tested at ten stations, over 200 samples. None were positive. While we breathed a collective sigh of relief, one final, tragic case was incubating the disease. A case as mysterious as Kathy Nguyen’s but one that would finally yield some answers.

Inhalation Anthrax in NYC-Fall 2001 (Part 3)

If you pay for a monthly Metrocard with a debit or credit card it creates a record of the location of each swipe. Along with interviews of Ms. Nguyen’s close associates, her phone records, and credit cards bills we were able to reconstruct the last two weeks of her life to try and discern how she became exposed to anthrax spores. Our concern was palpable; were other New Yorkers incubating the disease or being exposed?

Her favorite stores and the businesses along her commute route for which a charge or receipt was found were visited.  Armed with a photo epidemiologists questioned merchants. Few recognized her and no illnesses consistent with anthrax were uncovered. Ms. Nguyen was a religious woman and her co-workers had provided a list of churches she might have visited.  The pastors were cordial, however, nothing turned up.

Everywhere we knew a letter had landed we found spores. Aside from Ms. Nguyen we could place each case in the vicinity of spores.  It was some relief that in the week after her death no new cases had arisen, but what was different about Ms. Nguyen? The strain of anthrax was the same. Her work place, home and mail were all clean. So, what was the exposure? There was one place left in NYC we hadn’t yet looked.

Inhalation Anthrax in NYC-Fall 2001 (Part 2)

Within hours of dropping the slant off at the lab we had positive preliminary results for anthrax.  Sadly the patient never regained consciousness and died on Halloween. We knew from her doctors and co-workers that Ms. Nguyen worked as a stockroom clerk, lived alone and kept mostly to herself, but we’d never be able to interview her. The mailroom was next to the stockroom, so we told ourselves her case was not unexpected and fit with the other cases where contaminated mail was the route of exposure. 

The hospital voluntarily closed and a team of epidemiologists from NYC and CDC plus detectives and agents of the JTTF (Joint Terrorism Task Force comprised of NYPD, State Police and the FBI) descended on the building before dawn. I got there just as the TV crews were setting up and they mistook me for a patient and let me pass unmolested.  We were operating on the premise that anthrax spores, once settled, didn’t re-aerosolize.  The FBI and NYPD didn’t share our view and while they debated the risks of entering the building without moon suits we brazenly, and perhaps foolishly, began the investigation.

One team swabbed the basement for spores while others interviewed her boss and co-workers.  We were looking for anyone who was ill or had information on Ms. Nguyen's activities. Her locker contents and her clothes were swabbed. Anyone who worked near the stock or mail rooms got their noses swabbed and a vial of antibiotics. Patients who had been in the building that week were contacted and their health evaluated. No suspect cases were identified. Two curious leads emerged from the interviews.  Ms. Nguyen had a past relationship with a person described as an “agent” and two days before her illness she got dust in her eyes that irritated them enough that she asked a nurse to irrigate them.   We didn't find a single spore anywhere in the hospital or her home.  We had to reevaluate our hypothesis.

Historic thread-October 29, 2001 (Part 1)

We were stationed at the lab to help with the deluge of specimens to be tested for the presence of anthrax spores. It was hectic. New Yorkers had white powder fever in the fall of 2001 and were seeing danger in ordinary items they had previously taken for granted. Mail was carefully inspected and thrown away unless it contained a check or bill. The sugary remains at the bottom of a package of Little Debbie snack cakes or flour spilled innocently on the floor became suspected conveyances of anthrax. All of these specimens were being brought to the city's lab by cops only too happy to drop their packages and run away.

Denis built a database and we spent our days logging in samples and reporting the results to the Health Commissioner, Mayor, NYPD, FBI and an assortment of politicians and dignitaries. We had not heard of a new case of skin anthrax in nearly a week and were looking forward to getting back to our regular jobs and lives outside of work.  Sixteen hour days were getting old. On Sunday a doctor from an uptown hospital called, he had a worrisome case. The 61-year-woman didn't work with the mail, but appeared to be in the throes of a serious infectious pneumonia. By late Monday afternoon the hospital lab had isolated a large bacillus in the woman's blood. It was growing in long filamentous threads. Our hopes of returning to normalcy dashed, Denis and I hopped the uptown subway and met the lab director in the empty lab. Excitedly he ushered us over to a microscope. I peered down the barrel, adjusted the focus remembering my days in the emergency department looking at gram stains of cerebral spinal fluid searching for bacteria and white blood cells. Oil immersion, 100x. The lab director had taking a drop of the blood culture media and prepared a gram stain. Unlike my sparse csf gram stains, this one was a chaotic mix of red and blue. It took me several moments to orient myself, but I began to see the white blood cells in a matrix of what looked like blue thread. As I looked closer I could see that the threads were composed of long, brick-like cells. I had seen this before, not under a microscope but in a book. It was anthrax. He handed us a slant: a screw-top test tube filled with media and inoculated with a sample of the growing bacteria. I slid it into the steel canister we brought with us and placed it into my jacket pocket. Only specialized labs could make the definitive diagnosis of anthrax and we had to get it back to the city lab to know for sure.

Before we left we met the head of infection control who took us to the patient's bedside. Beneath the wires, tubes and tape lay an unconscious woman. Sedated, on special drugs to maintain her blood pressure and high powered antibiotics to beat back the infection, she was waging a war we couldn't see, except on the X-ray, which showed her chest and lungs filled with blood and fluid. On the subway ride downtown Denis and I tried not to speak and act non-chalant, but there were too many questions. 

"Do you think it is?" he asked. 

"I don't know," I replied. "It fits clinically, and the gram stain is suspicious." I didn't want to say what I felt. Denis wasn't a physician and although he had been an EIS officer I couldn't be sure how he'd react and after all we were straphanging in a rush hour subway car. He smiled, the nervous smile that sometimes creeps across the faces of people facing really bad news. 

"Where would she have gotten it?"he asked.

I looked around, maybe it was my baseline paranoia but some riders seemed to be listening to our conversation with interest. Others were lost in the complications of their lives. 

"I don't want to think about it," I replied. I knew the only persons to contract the inhalation form of anthrax during the outbreak had either been postal workers or at the AMI building in Florida. None in NYC. Terrorists had long eyed the NYC subway as a target. I re-examined our fellow riders. This changed everything. Our lives wouldn't be returning to normal, in fact, craziness was about to be cubed...

Down under

Two weeks ago a Queens construction crew broke more than ground. The story appeared as a short blurb in the NYT and was less than inaccurate:

http://cityroom.blogs.nytimes.com/2011/10/06/for-female-found-by-police-being-unresponsive-is-least-of-it/?scp=5&sq=body%20found%20in%20Queens&st=cse

The land was formerly a cemetery and the crew accidentally broke an iron coffin.  The coffin dated from around 1850 and iron was used instead of wood to prevent the transmission of communicable diseases.  Although the corpse was well preserved, no one mistook her for the recently alive and she was taken to the OCME for an "academic" evaluation. Tests did not find any evidence of infectious organisms. After 160 years the proteins of life had all disintegrated.

The Prisoner of Malta

It was a hot August night in the ED. The air conditioning pumped out tepid air and one could build a sweat just washing your hands. The asthma room was quiet, a welcomed relief from the usual standing room only crowd. I was near the end of my shift and looking forward to a shower and some homemade grub when Jenny, a third-year resident poked her head from behind a cubicle curtain.

“Dr. D, can I show you something?” I hopped off the stool that barely had time to make a dent in my derriere. Sitting anxiously on the stretcher was Maria, an 8-year-old girl. She held a bottle of soda in her mouth. Her mother stood by her side, also anxious.

“She can’t get it off,” Jenny said.

I looked closer. It was a bottle of Malta, a malt-flavored soda popular in the Spanish community. The bottle was short and stocky, with a wide mouth. Stuffed into that wide mouth was Maria’s tongue.            “She sucked the air out of the bottle and now it’s stuck,” explained her mother.

The girl watched me like a cornered squirrel. Her tongue was beefy red and swollen, but it was hard to tell much else through the brown glass. The weight of the bottle pulling down on her tongue was painful, so she was raising it up into her mouth. She was a mouth breather so positioning the bottle was tricky; not too far into her mouth so she couldn’t breathe but enough to take the weight off her tongue.  When one arm got tired she switched to holding the bottle with the other.

I delicately took a hold of the bottle and applied minimal downward traction. It didn’t budge but Maria’s eyes did, they bugged out. She looked weary and what concerned me was that her breathing was somewhat labored.

Several residents stopped by to see what was going on, sharing suggestions such as breaking the bottle with a reflex hammer or heating until it expanded and dropped off. The tongue is perhaps the most sensitive and vascular organ in the body.  We rejected both those ideas.  Instead we retrieved from the supply cabinet an infant feeding tube. About the size of a cocktail straw and made out of soft plastic, we used feeding tubes in the ED as urine catheters. The intended use was to supply nutrition for premature infants who had not the strength to suck. Jenny applied sterile lubricant to the tube, and gently attempted to insert the tube between the glass rim of the bottle and Maria’s tongue. It was a little like trying to push a lace that has lost its plastic tip through a sneaker eyelet.  It took several attempts and we had to steady Maria so she wouldn’t jump off the stretcher or pull the tube out once we had it in. Eventually Jenny got the tube in place. Nothing happened. The tube should’ve released the vacuum but it was pinched closed by Maria’s tongue against the glass. We went to plan B. Jenny reached for a 3cc syringe.

“You are going to need a bigger one,” I advised her.

“She started to unwrap a 10cc syringe.

“Bigger still,” I said.

 Jenny settled on a 20 cc syringe and attached it to the end of the feeding tube. Maria watched with trepidation. Jenny slowly pumped air into the bottle like a flat tire. After the second 20 cc the bottle slid a little and Maria jumped.  After 20cc more of air the bottle shot off into Maria’s lap with a pop and a puff of malty smoke. We examined her tongue, soaked it some cool water and after an hour or so Maria and her mom were sent on their way, with a promise to lay off the Malta or use a glass. 

Seasonal Illness-early fall

Infectious diseases are seasonal. Flu being the most obvious example. The "flu season," the time of peak activity, is usually a 12-week period that varies from late December to March. Lately in NYC it has been in February.

In September West Nile Virus is waning as mosquitoes populations decline in the cooler weather. Emergency department asthma visits are up. These are likely due to infectious and non-infectious triggers, such as changes in the weather, particulate matter in the air and kids returning to school where they can transmit respiratory viruses to each other. Its a good time to check in with your physician, refill your meds and monitor your peak flows if you are an asthmatic.

Shades of Typhoid Mary-Part Two

The thing about Typhoid fever, the singular feature that has allowed the organism to survive the sanitary movement of the 19th century and the modern antibiotic era, is its ability to induce a carrier state. Most people infected with Typhoid fever recover, but is some, as much as 5%, continue to intermittently shed the bacteria in their stool without any symptoms. Most people have heard of Mary Mallon, aka Typhoid Mary. She was cook for wealthy NYC families in the early 20th century and is perhaps the best know Typhoid carrier. The risk carriers pose is mostly from preparing food, though being a healthcare worker is another risky occupation for a carrier.

Leela sent the microbiology samples to the lab for DNA analysis. Pulse Field Gel Electrophoresis (PFGE) is a method used to determine if two or more strains share common genetic fragments suggesting a common origin. Not quite fingerprints, but close. The PFGE patterns of the seven patients was the same. Leela tallied the answers to the questionnaires finding a latin food restaurant in common for all but one case. We next headed out to the community to pay a visit to the restaurant.