Wednesday, April 29, 2009

Swine Flu Update

Since I wrote the post on flu pathophysiology, there have been several developments in the 2009 swine flu story.  First of all, it is still likely that no one who caught this virus within the United States, has died.  The report about the 23 month old toddler concerns a young boy who came to a border town of Brownsville, Texas from Mexico City.  Several news stories describe him arriving on April 4th with health problems.  His symptoms became typical of flu by April 8th, and after being very ill for several weeks, he developed bacterial pneumonia.  In a very sad turn of events, he eventually died.  

The reason why I make a big deal about where this boy was exposed to this flu virus, is because it would be inaccurate to claim that this boy is representative of the people now being diagnosed with the swine flu virus within the United States.  There was recently a large number of children in Queens, NY who have also been diagnosed with this flu virus strain.  This occurred at a very large private school, which is attended by 2700 students.  Approximately 140 children became ill, but they have all experienced only mild symptoms. Some of these children were contacted, and viral cultures could be obtained from their nasal secretions.  Of those tested, nearly all turned out to be positive for the unusual swine flu strain - the same one that was earlier reported in Mexico.  If the other children were reachable and consequently testable, the number of confirmed cases in NYC would have been much larger.  One very important aspect of this outbreak that is worth restating, is that all these NYC children had only mild symptoms.   In Mexico, some people are claiming that this infection carries a 7% risk of being lethal, while among the American population thus far, the mortality is 0%.

As we are trying to obtain an accurate number of Americans who contracted this flu virus, there are strange guidelines now being advocated for testing patients.  These guidelines specify that only those who have severe respiratory symptoms or a very high fever, should undergo the collection of samples to be tested for viral typing.  What is so strange about such instructions, is that from the newspaper descriptions of the NYC swine flu sufferers,  none of the recently confirmed cases would have been approved for viral testing.  In other words, if these guidelines were followed, then there would likely be no confirmed cases in NYC.  There are several bogus reasons being given for instituting such policy, including the idea that the CDC office might get overwhelmed with samples.  It may actually be that there is some dumb bureaucrat trying to conserve the "valuable" supply of nasal swabs.  I find it very hard to believe that everyone associated with drafting policy is that lightheaded, so some must have other reasons.  Despite thoughtlessness, the only reason to promote such nonsense, while knowing it would miss most of the people coming down with this illness, is to pretend that this problem has not really affected New York City.  Why?  Because a large outbreak would cut down on travel and the flow of tourist money. This really reminds me of a scene from the movie Jaws.   Could a similar policy have affected the Mexican reporting of this outbreak?

Returning to Mexico, it would seem highly probable that the number of people sick with this flu has been grossly under-reported.  If the parents of the boy described above, fled to the US on April 4th, there must have been a significant outbreak there prior to that date.  I would guess that people have been becoming ill with this particular virus for at least several months. Considering the number of sick tourists returning from Mexico, I would also have to conclude that a significant portion of the Mexican population has been exposed to this flu strain.  Not just some 2000 people reported in newspapers, but likely hundreds of thousands, or more.  If that is the case, it would make a lot of sense to not bring your family to Mexico on vacation at this time.

Furthermore, If I am correct about a widespread epidemic with this flu virus occurring in Mexico, the relatively low number of deaths reported would correlate with the American experience.  Within the United States, the yearly flu affects approximately 10% of the population which translates to roughly 30 million sick Americans each year.  If 36,000 die of flu related causes each year in this country, it would suggest a mortality of 0.1%.  We shall soon see if this particular strain is any more deadly.  

Another explanation for the reported number of people affected by the swine flu and the strangely large number of corresponding deaths in Mexico, is that the virus affecting people in Mexico City may have been more lethal than the virus that was spread to tourists returning from Mexico.  The usual swine flu virus affects a small number of people in the US each year, and it is not easy for a human to become infected with it. Typically it only occurs in situations where someone has a significant exposure to swine, like working at a pig farm.   Those people who develop an infection, can have severe symptoms.  It is possible that this flu strain has affected a large number of swine in Mexico, and consequently spread to a limited number of people in that area.  Within the human host, the virus might have mutated and became more easily transmitted among humans.  This may have led to a slightly different virus that was transmitted to a student from the NYC school and then spread among others at that school.  This scenario could also account for the very different reported experience among Mexicans and Americans, who came down with the swine flu.  It should also be reassuring that if you developed flu symoptoms and have not recently travelled to Mexico or spent much time among pigs, you shouldn't expect more of a problem than you would get from any other flu.

At this time, all of the predictions for the impact of this swine flu outbreak are suspect, because we simply don't have an accurate assessment of the situation in Mexico.   They have not tested a a large enough sample of the population, for the presence of this virus.  I believe that political and economic considerations have skewed the data, and we simply don't know how many are sick and how many deaths are related to this swine flu strain.  Of those reported deaths, we don't really know what they died from.

In summary, there is still no real indication that this swine flu virus is any worse than the other flu virii we have encountered recently.  If you develop symptoms, you should drink plenty of fluids and rest.  Your co-workers would greatly appreciate not being coughed on, and you may not even need to present a doctor's note these days.  If you are very young, very old, or have significant other health issues, you should see your doctor and be evaluated for treatment with the available antiviral therapy.   If your symptoms improve and then suddenly worsen, you should definitely seek a doctor as you may need antibiotics.


Happy Independence Day, Israel!

Tuesday, April 28, 2009

Some recent experience with government health insurance.

Although, I doubt that the recent swine flu fears will amount to much of anything, I have been asked to write prescriptions for Tamiflu by many people in the last several days. Despite our conversation about how this flu only produced mild symptoms, some people remained very worried and would only feel satisfied if I wrote them a prescription. Those who had private insurance found pharmacies that had this drug in stock, and obtained it. Those who had government insurance required a doctor's authorization prior to approving the coverage of this drug. People could chose to pay full price and still obtain the drug, but few would ever do this. In practical terms, this meant that when someone couldn't get a commonly used anti-viral, I would have to call the insurance agency to argue the necessity of this prescription. By the time I was alerted of this problem, nearly all the pharmacies in NYC ran out of Tamiflu. I was told that even with authorization, the patient would simply not be able to obtain this drug. How is that for an effective government health policy? Welcome to rationing.

I also want to add that these prescriptions were for those individuals who were worried about being recently exposed to the flu and they were for preventive purposes. I have not yet seen widespread flu symptoms in the NYC area.

Again, I would still like to comfort those panicking that the swine flu in US has produced only mild symptoms and there is no need at this time to be any more concerned about this flu than you were about the flu last year. However, I also think that those on Medicaid and Medicare got a really crummy deal in NYC this week. For a detailed description of flu symptoms and pathophysiology, see my post below. Consider this story if you have high expectations regarding government assistance and government management in any field. Whether that field is medicine, banking, automotive, education, or housing.

Sunday, April 26, 2009

Of Swine, Birds, and Humans.

During the past two days, I have read many confused statements regarding the recent swine flu outbreak, and decided to write an educational post rather than my typical emotional rant. In this post, I will attempt to shed some clarity on the subject of influenza, from the perspective of a physician.

The swine flu is a respiratory infection in swine which can occasionally infect humans. Similarly, the bird flu is a respiratory infection commonly seen in birds, which can also occasionally infect other animals, including humans.

How can one catch the flu?

The flu is caused by a number of genetically related viruses, and they gain access to our bodies through special cells located in the back of the nose. These viruses have specific proteins on their surface that allow them to attach to these cells and once inside, they take over the cellular machinery to manufacture many more viruses. These proteins need to be specific enough to be able to attach to these cells, otherwise the attachment is not strong enough to allow entry, and consequently no infection can occur. You can think of these viral surface proteins as keys and these nasal cells have doorlocks that these keys can fit. This specificity explains why we are not susceptible to most viruses that infect other species. To reiterate, the only entrance for these flu viruses is through the cells located in the back of the nose. That means you can only catch the flu if someone coughs on you or if you touch a contaminated object, like a door knob or a hand, and then rub your nose. You cannot get swine flu from eating pork.

Flu symptoms.

Once your body's cells are infected, they start producing these offensive foreigners and spreading them throughout the rest of your body. These troublemaking cells will eventually become recognized by your immune system, and consequently destroyed by your own white blood cells. As this battle within your body rages, you develop inflammation at the affected site, and accumulate lots of fluid there. For this reason, the most common symptoms of the flu are a stuffy nose and a mucus discharge from the nose. The best place for this mucus to go, is to be expelled outside of your body. Otherwise, it can cause a lot more trouble as it reaches other body organs and systems.

Headache results from stuffed sinuses, but it can also be due to other effects of the flu virus on the body. Whenever there is significant inflammation or activation of the immune machinery, fever may occur and some develop a headache directly due to this fever. Rarely, influenza inspired immune response may result in inflammation of the brain meninges. These are covering tissues of our brain which lie near blood vessels and sensory nerves. Inflammation of these specific structures is known to cause severe headaches, and is given the diagnosis of meningitis.

Other common symptoms of the flu include cough, which usually results from this inflammatory mucus draining down the back of your throat. The contents of this mucus include viruses, inflammatory cells, and dead respiratory cell debris. This fluid irritates any tissue it comes in contact with, and consequently we cough and our throat feels sore. There are specialized cells in our respiratory passages that sweep such junk upwards and prevent all this nasty fluid from reaching our lungs. Cough aids this cleaning process and it is a normal mechanism of keeping our lungs free of unwanted fluid. The lungs are technically air passages that branch into smaller and smaller tubes, which eventually lead to small sacks where we exchange oxygen for carbon dioxide. It is very difficult to accomplish this task of gas exchange, in lungs filled with fluid. If this fluid is accumulating in your lungs, you might feel shortness of breath. People who have damaged lungs from many years of smoking, have a very difficult time with this aspect of flu and they may need to be hospitalized.

Our mouth and nasal passages meet posteriorly in the same cavity, in the back of our throat, called the pharynx. From there, two different pathways arise. One leads further into the respiratory system and the lungs. The other, leads into our digestive tract. As this inflammatory exudate, from infected nasal cells, enters our stomach and intestines, symptoms such as nausea, abdominal discomfort, and even diarrhea arise. Inability to keep your food and fluid down, causes dehydration and this is the most common reason for needing to be hospitalized.

As your body is battling the flu virus, you will often feel tired, and many people develop joint aches. The reason for joint aches has to do with your immunity system activity, but to explain that adequately would require a very long discussion.

This above scheme is somewhat simplified as these viruses can also infect cells in many other parts of the body, once they establish the beach-head in your nose. Respiratory cells may become infected, and some people even develop a viral pneumonia. Intestinal cells are also susceptible to penetration by these virii, which may explain why some have primarily gastrointestinal symptoms. Rarely the liver can become infected causing symptoms of hepatitis. However, for a general understanding of how the flu virus causes its damage and gives rise to common flu symptoms, the above system is very useful.

Swine flu outbreak.

Now back to the current swine flu outbreak. This virus does seem to have the ability to infect humans but it also seems to be better at infecting swine. That is likely because its attachment surface proteins are better fitted for swine nasal cells, than for human ones. Also, it may not be produced in large enough numbers within a human host, to successfully infect other humans. There will be rare exceptions as everyone has slightly different susceptibilities to these foreign invaders, and that may account for the few documented human infections. To appreciate this comparison, you need to contrast the 20 US documented cases of this swine flu, with a number that accounts for 5-15% of the US population. That is how many Americans become infected with a different, more human prone, flu virus each year. These other outbreaks infect millions, cause an estimated 200,000 hospitalizations, and 40,000 deaths each year within the US. That said, there is a very real fear that this swine flu virus may mutate its proteins enough to gain the ability of direct human-human transmission, and then we will see widespread human infection. So far the CDC has not indicated that this is actually taking place.

Is this swine flu more deadly that other seasonal flu viruses? Too little is known about this outbreak at this time, to make such an assessment. The archaeologist who was in contact with visiting Obama, is reported of dying from pneumonia complications. Although, it is not clear what exactly caused the recently reported deaths in Mexico, if they were flu-related, I suspect that a secondary bacterial pneumonia infection was the real culprit in most cases.

The 1918 Spanish Flu Pandemic.

Speaking of pneumonia, I want to reflect on the infamous 1918 Spanish Flu pandemic. This virus was also a swine flu type virus, and it led to widespread human-human transmission. It is estimated to have killed 20-100 million world-wide and 500-675 thousand in the US. It typically killed about 5% of those infected, while this current outbreak in Mexico may have a kill rate of 2.5%. Yearly flu epidemics in America might lead to death 0.1% of the time. So far, this flu outbreak within the US, has a kill rate of 0%.

Why was the Spanish flu of 1918 so deadly? One should consider that the world had just emerged from a world war, many were starving and in poor health even prior to contracting the flu. When pathologists examined lung samples of those 1918 flu victims, most deaths were attributed to secondary bacterial pneumonia. That particular flu strain might have been very effective at destroying the respiratory epithelium, and interfering with the self cleaning function of our airways I described above. This way, the flu victims became very susceptible to bacterial infections. Although such pneumonia is now easily treated with antibiotics, these drugs were not available at that time. Penicillin was only discovered in 1928.

Why is it so much milder in the US than in Mexico?

First of all, no one really knows what the Mexicans in news reports actually died from. There is a great deal of confusion regarding this data. If you assume that in Mexico people actually died from this swine flu, while in the US swine flu patients seem to have very mild symptoms, you should consider the difference in the standard of living and the medical care between these two countries. Yearly flu vaccines in the US, may be playing a role here. There are contradicting reports about whether this year's flu vaccinations offer any protection for this particular strain of swine flu, but these vaccinations may be partly responsible for this difference in symptom severity. Furthermore, experts report that even when you don't obtain a diligent yearly flu shot, you may still have some protection from the prior year's vaccination. Another possible explanation is that this flu virus may have developed an improved ability to cause human-human transmission. However, it had to mutate its genetic code to accomplish this transformation. Often when this change happens, the viral ability to cause severe symptoms diminishes. It is sort of like giving up strength in one area, to become stronger in another.


For those who are feeling tired, have a stuffed nose, headache, fever, and an upset stomach, there is still some comforting news. If you really believe that you contracted the dreaded swine flu, you can take an effective medicine. Tamiflu and Relenza should decrease the severity and duration of your symptoms, and the treatment course is only 5 days. If you live with someone who has a flu and you want to minimize your chances of catching it, these medications are also effective at prevention. Aside from taking drugs, you should also get plenty of rest and drink lots of liquids. Obviously if you are having trouble keeping down liquid or feel short of breath, see a doctor. Nevertheless, you have an excellent chance of recovery regardless of taking or not taking any drugs.

Concluding comments.

In summary, even if this flu does become an epidemic in this country, there is little indication that it will be any worse than the other flues that we have suffered this year. Don't despair, and don't forget to get your flu shot next year.

UPDATE (4/29/2009)
I initially miscalculated the mortality rate for the yearly flu, and have since corrected my numbers.  The method I used at arriving at the earlier erroneous numbers was by dividing the number of flu related deaths by the estimated number of people who developed flu symptoms.  I should have then multiplied that number by 100 to obtain the percent mortality. Sorry for the confusion.  Regarding the mortality of this swine flu among the people in Mexico, there is simply no way to accurately assess the situation.   Nevertheless, my earlier statement that there is no indication that this flu will be any worse than other recent flues remains true.  Please see my latest post for details.

Wednesday, April 22, 2009

Enough Time Wasted

My political growth and developing the ability to critically analyse news reports, I would largely credit to the LGF community. However, for months there have been nothing but dumb attacks on conservative writers, often resorting to childish name-calling. I have not read an intellectually stimulating, or even interesting post at LGF for a very long time. The latest waste of time, was a commercial for Amazon, masquerading as a post? I excused the prior ads for Apple products, because there were other important posts on his site. Now I've had enough. Good luck and goodbye.

Sunday, April 19, 2009

Interesting reports from over there, across the pond.

As posted on Gates of Vienna, there was a recent "illegal" demonstration in Luton. This appears to have taken place on April 13th; that is two days prior to the TEA demonstrations over here. Over there, violence erupted while over here things remained peaceful. The question in my mind is - why?

Were there major differences among the demonstrating crowds? From the watching the video, I would say no. Those people over there, have very similar concerns to their counterparts here. They worry about a government that does not protect its constituents. They are upset over an attempt to deny a people its cultural identity. And, they were demonstrating over their rights as citizens. From my perspective, the major difference accounting for the violence was the refusal of the city government to allow these people to assemble.

What would happen...what will happen here when the right to assemble is denied to us? What will happen when our our verbal protest is no longer an option? I say, we are just one short step from a violent protest in this country.

Do I want this? Absolutely not. Violent protests will turn this great nation into another 3rd world spectacle. Our economy will collapse, and the nasty pack of jackals that surround us will move in.

These are the same bunch that Obama has been paying homage to on his recent trips: Saudis, Iranians, North Koreans, Castro, and Chavez. Opposite to these outside hyenas, we have our own crazies: the neo-nazis, black supremacists, and eco-terrorists. Lets us also not forget that both the British and the Americans need to contend with Muslim fascists trying to incite violence among us.

As I posted in comments on other sites, we need some sane leadership both in our government and in the TEA movement. We need it immediately.

The MSM attempt to delegitimize these rallies will only add fuel. I am afraid that might be the desired result for some of these "reporters". Other talking heads on the network channels are just plain stupid.

In the next weeks and months, we need to take some clear headed steps in the right direction. We need to become organized, and we need to obtain some real results from our government. Some evidence demonstrating that our voice has not been uttered in vain. We need a policy that makes sense and that stabilizes our economy. We need to believe that our children's future is safe.

If our political class really believes that these rallies are anything less than a chance being given to our legislators, they might be in for one hell of a surprise. That is because the people across the pond, just like the people over here see their government as working for them, rather than presiding over them. And we are very close to firing the whole sorry lot.

Saturday, April 18, 2009

It ain't over!

I saw this new shirt design over at Simon Jester's outfit, and I think it captures the mood of the city well. I am certain that they won't mind the free advertising, and it is a site well worth visiting.

Friday, April 17, 2009

Passage of Time

Time passes, and what was once only a painful reminder of loss, now hints at an opportunity. A chance to remind the world of what the Sons of Liberty showed an oppressive regime, all those years ago. Freedom is is not something that can be denied to those who seek it. No propaganda from a government controlled media can extinguish this flame. The MSM may vilify us, try to deny our significance, and even our existence. They may slander us as extremists, but I say we are passionate. They may label us - a crazy fringe group, but I say we are determined. They claim that we are few, but there are millions of us and our ranks grow every minute. For the sake of our children, we are devoted to preserve what is the foundation of America: the freedom to speak our mind, the freedom to defend ourselves, and the freedom to chose our destiny. We will win, because their control over us is an illusion. It is a fragile glass house, built on lies. Ours is built on self-evident truth, and our rights are endowed to us by our creator.

Thursday, April 16, 2009

Reporter attacks a father and his infant.

The face of a government controlled media outlet. Reporter? More accurately a propagandist. Please see the video at the coffee shop. Also see Michelle Malkin's site for more detailed analysis. Disgusting.

Tea Party NYC

I arrived early and looked around for familiar faces. I saw several members of the Brooklyn Republicans passing out pamphlets. I took one, but felt that their activity was intrusive as this was not a Republican event. There were many excellent posters and flags, including the Gadsdens. I saw working people who appeared as if they had just came out of the office, teenagers, older Americans, and there were families with small children. People were polite to one another, and at the same time fired-up. I was hoping to meet some fellow bloggers, but the crowd was so huge that it would likely have been impossible to spot a familiar face. I tried to do a rough estimate and I am certain that there were over 5k people there; it was likely around 10k. Shortly after 7PM, the speakers introduced themselves to the crowd and the roar from around City Hall park became deafening. With one voice we shouted "We are America", "U.S.A.", and we were heard! I don't care if the MSM reports this event or not, we were heard! There is just no way to suppress this kind a gathering. Chuck Schumer, deservedly, received several chants such as "Schumer Must Go" and "Chuck is a Schmuck!"

One attendee that I wish to describe in detail was a kind faced woman who was probably somebody's grandmother standing next to me. I asked her if she did any writing, hoping to hear that she also writes a blog, but she said no. She does read from such sources and we briefly spoke of Charles Johnson's turncoat behaviour. She stood there holding up her sign until her strength faded and she asked people to allow her to sit down. After a brief rest, she again stood up and held up her sign, and this pattern repeated throughout the evening. On her sign she addressed her disgust at the DHS attempt to criminalize those of us who honor our Constitution and the Bill of Rights. Shame on you Napolitano, if this is who you consider a threat to the United States of America. A kind grandmother, who has difficulty walking and yet she forced herself to attend a rally to defend the Constitution and the rule of law in this land is a domestic terrorist suspect? A right wing extremist?

There were more than 700 such rallies April 15th, drawing a crowd likely totalling more than a million of concerned American citizens. As I looked around at the people present, I couldn't help but notice the similarities to another such crowd I encountered at this same location. On September 14-16th, 2001 I worked at a triage centre located near the pile of what was once the World Trade Centre. Good people came together to sift through this pile of rubble with the hope of finding survivors. Those patriotic Americans who couldn't get into the area also tried to help in any way they could. They lined up at blood banks, donated food and clothing, prepared meals and freely gave them to the volunteers walking towards the pile. Inside, there were fire-fighters, policemen and policewomen, doctors, nurses, and contractors all working together. All working to help their country at its hour of need. This crowd were no different. They came together to help their country. No babbling, infanticide promoting, imposter who bows down to foreign kings will change the spirit of these heroic citizens. No phoney news agencies will keep our voices from being heard. We will rescue our country and secure this nation for our children.

Wednesday, April 1, 2009

Return of Fascism.

In my last post, I pointed out certain similarities between Putin and Obama; specifically in how they exerted their control over private businesses. I used to think of Putin as a thief, because he used the power of the government to steal other's companies and consequently became Europe's richest man. I also see many of our congressmen and senators as thieves, because they use public office to line their pockets with our tax money. They award contracts to friends and they buy votes with taxpayers' money. Michelle Malkin astutely refers to the multi-staged bailout, as the generational theft act. Our government is stealing our children's future by leaving them responsible to pay off this wild spending spree.

Obama's prior behaviour with the Annenberg foundation where millions were funnelled God knows where, while Obama became richer, led me to believe that he is just another thief. That view was again confirmed when his multiple tax hikes were unveiled. At each new revelation, I thought that he simply wants to steal everything in my pocket. However, when he appropriated for himself the power to fire the CEO of General Motors, and appointed himself the de facto ruler of any corporation that partook in the bailout feeding frenzy, a very different line was crossed. That move left many speechless and wondering about what has happened to our country.

It was enlightening to read a quote attributed to Benito Mussolini, regarding the nature of fascism.

"Fascism should more properly be called corporatism because it is the merger of state and corporate power." - Mussolini's diary.

From Wikipedia we get more illuminating quotations:
"The Fascist State lays claim to rule in the economic field no less than in others; it makes its action felt throughout the length and breadth of the country by means of its corporate, social, and educational institutions, and all the political, economic, and spiritual forces of the nation, organised in their respective associations, circulate within the State. (p. 41)."
—Benito Mussolini, 1935, "The Doctrine of Fascism", Firenze: Vallecchi Editore.

Do you see what is happening in our classrooms? Do you recall Michelle Obama stating that her husband will save America's soul?

"State intervention in economic production arises only when private initiative is lacking or insufficient, or when the political interests of the State are involved. This intervention may take the form of control, assistance or direct management." (pp. 135-136)
—Benito Mussolini, 1935, "Fascism: Doctrine and Institutions", Rome: 'Ardita' Publishers.
Look around people. On March 29, 2009 the new fascist state has come into being on the North American continent. Who better to understand and to clearly characterize fascism than Il Duce himself? Welcome to our bewildering Brave New World, or if you like - welcome back to Europe, circa 1935. With the latest resurgence of anti-Semitism, we should see Kristrallnacht and other ugly faces of fascism soon enough.