Wednesday, November 25, 2015

Indonesia: `Mystery Illness’ Kills 56 Children In Papua


Papua (red) Indonesia



ProMed Mail has picked up a report (see 25 Nov 2015 Undiagnosed illness - Indonesia: (PA) fatal, children, RFI) in the Jakarta Post, dated yesterday, indicating there has been sudden and unexplained rash of child deaths in Indonesia’s easternmost province; Papua.  


As of yesterday’s report, 41 children had died, along with some number of local pigs and chickens. 


As we’ve discussed often in the past, `Mystery’ diseases usually turn out to be far less mysterious once medical teams arrive and can begin testing.  Additionally, child mortality remains very high in Papua (see media report Unicef: Child Mortality Papua Three Times Higher than Jakarta), from a variety of non-exotic causes.


But given the  sudden onset, the apparent high mortality among children under 7, and the (possibly coincidental) die off of livestock, this is certainly worth keeping an eye on.


Three reports.  First, this from the Jakarta Post via ReliefWeb.


41 kids die from mystery disease in Papua

from Jakarta Post

Published on 24 Nov 2015 — View Original

  •  Nethy Dharma Somba, The Jakarta Post, Jayapura | Headlines | Tue, November 24 2015, 6:27 PM

A large number of children, many below the age of seven, have died of an unexplained disease in Mbuwa district, Nduga regency, Papua, following the start of the rainy season in early November.

A medical team consisting of health workers from Nduga, Wamena and Jayawijaya regencies arrived at the location but have yet to ascertain the cause of the deaths.

“As many as 41 children have died, as of today. They present with a slight illness at first but die shortly after these initial signs. The medical team from Nduga Health Office, assisted by the Wamena Health Office may have returned home, but the cause of these deaths remains uncertain,” said Mbuwa district chief Erias Gwijangge, during a call to The Jakarta Post on Monday.

Erias said Nduga and surrounding areas had experienced drought and were exposed to haze from forest fires. Rain only fell in the past month. When the rain began, a number of livestock, such as pigs and poultry, also died abruptly.

(Continue . . . )


I find no mention of this outbreak on the Indonesian Ministry of Health websites, but the Indonesian press and twitter (Hashtag `Kematian anak papua’  or `Papua Child Deaths’) is driving a lot of traffic on the story. Symptoms appear to be primarily fever and respiratory distress.


Today, at least based on one local media report, the number of fatalities has grown to 56.  This from Berita


Rabu, 25 November 2015 | 12:07


Died children in Papua Increases So 56

Papua Provincial Health Director, Aloysius Giyai.

Papua Provincial Health Director, Aloysius Giyai. (SP / Robert Vanwi)

Jayapura - The number of children who died from a mysterious disease in the District Mbuwa, nduga regency, Papua Province, increasing from 41 to 56 people. It was announced by the Chief District Mbuwa, Erias Gwijangga, Wednesday (25/11).

"Children who die under the age of seven years. Drugs gone. Medics at Mbuwa today seven people from the Department of Health Nduga," he said.

In such cases, the Provincial Health Director Papua, Aloysius Giyai, said he only heard of the incident three days ago.

"There was no report at all, even regents Nduga confirmation that we are also claimed to have received the report. But from the reports we have, there are 31 children who died, "said Giyai after the opening of a working meeting regional health Papua Province and the launch of his book Against Storm Extinction breakthrough-breakthrough Papua Healthy Towards Papua Risen, Mandiri Sejahtera at the Auditorium of Cendrawasih University, city of Jayapura , Papua, on Tuesday (24/11) afternoon.

Papua Provincial Health Office, he added, has deployed a team to the area. The team led by Section Chief and Disaster Outbreak Papua Provincial Health Office, Yamamoto Sasarari, joint head of PMK, a doctor Wopari Berry, who assisted the general practitioner, a pediatrician, nurses, laboratory personnel, and personnel survailance.

"The team will find out what the causes of child mortality and also to find a solution. Therefore, we can not tell the cause of death of children. There must be a field, looking for the cause, "he said.

(Continue . . . )


And lastly this report from the Suara Pembaruan, which describes the lack of medical care available in the Papau, and also mentions the updated number of 56 deaths. 



There's No Drugs, No Health Officer, Children's Papua It Even Died Mysterious

Wednesday, November 25, 2015 | 7:48

Papuan children in Biak. [SP / Jeis Montesori Kafiar]

[JAYAPURA] Pathetic. A total of 41 children under the age of seven years meninnggal the mysterious world throughout November 2015 in the District Mbuwa, nduga regency, Papua.

No medical help to save their lives. The local Health Department reasoned geographical problems and understaffed making them difficult to reach Papuans who mostly live in the interior.

Ironically, Chief Medical Officer of the Province of Papua, Aloysius Giyai admitted three days ago received a report related to the incident.

"There was no report at all, even Regent Nduga confirmation that we are also claimed to have received the report. But from the reports we have, there are 31 children who died, "said Giyai after opening Working Meeting of the Regional Health Papua Province and the launch of his book titled" Against the Storm Extinction breakthrough-breakthrough Papua Healthy Towards Papua Risen, Mandiri Sejahtera "at the auditorium of the University of Cendrawasih, Jayapura, Papua, on Tuesday (24/11) afternoon.

(Continue . . .)

UK ONS: 2014-15 Excess Winter Mortality Highest Since 1999



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Tying in nicely to my last blog  CPR As A Basic Holiday Survival Skill (which I wrote before seeing this report), is a statistical bulletin released today from the UK’s Office of National Statistics called:.


Statistical bulletin: Excess Winter Mortality in England and Wales 2014/15 (Provisional) and 2013/14 (Final)

Download PDF

Main points

  • An estimated 43,900 excess winter deaths occurred in England and Wales in 2014/15; the highest number since 1999/00, with 27% more people dying in the winter months compared with the non-winter months.
  • The majority of deaths occurred among people aged 75 and over; there were an estimated 36,300 excess winter deaths in this age group in 2014/15, compared with 7,700 in people aged under 75.
  • There were more excess winter deaths in females than in males in 2014/15, as in previous years. Male excess winter deaths increased from 7,210 to 18,400, and female deaths from 10,250 to 25,500 between 2013/14 and 2014/15.
  • Respiratory diseases were the underlying cause of death in more than a third of all excess winter deaths in 2014/15.
  • The excess winter mortality index was highest in the South West in 2014/15 and joint lowest in Yorkshire and The Humber, and Wales.

Get all the tables for this publication in the data section of this publication .


The last time EWM (Excess Winter Mortality) rates were this high in the UK was in 1999, a year which saw an unusually severe flu season both in the UK and the United States.   The report blames a less-than-optimal flu vaccine match, and a severe H3N2 flu season (which hits older people harder than H1N1), for the spike. 

From the report:

Levels of influenza in 2014/15 were higher than recent years, as were peak intensive care numbers, but were lower than 2010/11 which saw very high levels of influenza (Public Health England, 2015). Despite this, EWM was higher in 2014/15 than in 2010/11. In 2010/11 the predominant influenza virus was A(H1N1), as in 2013/14. One reason for the reduced EWM in 2010/11 when compared with 2014/15, is because the predominant strain of influenza in 2014/15 was particularly virulent in older people, an already at-risk group, whilst in 2010/11 the predominant strain of influenza was a particular problem in younger people and had less impact on the elderly (Public Health England, 2014). In addition to this, the influenza vaccine in 2010/11 was around 50% effective (Public Health England, 2011), compared with the 34% effectiveness in 2014/15. Vaccine uptakes were similar in 2014/15 to previous years, though uptake was slightly lower than in previous years in those under 65 in a clinical risk group (Public Health England, 2015).


While some of the UK papers are going for hyperbolic headlines like:


Ineffective flu vaccine causes the number of excess winter deaths to TRIPLE in a year - to the highest level this century – Daily Mail.

Perhaps the bigger story is how many lives have been spared over the past 15 years when the flu vaccine was a reasonably good match . . . and how many more lives we could save if we had a more effective flu vaccine for the elderly, and a greater uptake among vulnerable populations.


While most of the `excess winter deaths’ are attributed on death certificates to other causes – pneumonia, heart attack, stroke, etc. – we know these rates go up and down with the severity of each year’s flu season, and with the effectiveness of the each year’s flu vaccine.

Hence the spate of recent studies showing that flu vaccination can reduce the rate of heart attacks, and other cardiovascular events, in the elderly (see UNSW: Flu Vaccine Provides Significant Protection Against Heart Attacks).

Unfortunately, the flu vaccine’s effectiveness tends to drop the older the recipient, sometimes due to a less robust immune system, and sometimes due to medications (see JID: Statins & Flu Vaccine Effectiveness), or other chronic health conditions.


For those over 65 there is a High-Dose flu vaccine option currently available  that contains 4 times the normal amount of antigen; 60 µg of each of the three recommended strains, instead of the normal  15 µg (see MMWR On High Dose Flu Vaccine For Seniors).


While ACIP and the CDC have not expressed a preference for using a high-dose vaccine in those > 65, in their Fluzone High-Dose Seasonal Influenza Vaccine Q&A they write;


Does the higher dose vaccine produce a better immune response in adults 65 years and older?

Data from clinical trials comparing Fluzone to Fluzone High-Dose among persons aged 65 years or older indicate that a stronger immune response (i.e., higher antibody levels) occurs after vaccination with Fluzone High-Dose. Whether or not the improved immune response leads to greater protection has been the topic on ongoing research. A study published in the New England Journal of Medicine indicated that the high-dose vaccine was 24.2% more effective in preventing flu in adults 65 years of age and older relative to a standard-dose vaccine. The confidence interval for this result was 9.7% to 36.5%).


But even at a reduced vaccine effectiveness, some protection beats no protection at all.  And there is some evidence that even when it doesn’t prevent infection, the flu vaccine may reduce the severity of illness (CDC: Flu Shots Reduce Hospitalizations In The Elderly).


As regular readers of this blog already know, I get one every year. And while I sometimes worry that the benefits (and effectiveness) of the flu vaccine are oversold, flu vaccines remain our best protection against a virus that is estimated to kill a half million people around the globe each year.   

CPR As A Basic Holiday Survival Skill



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While some may call it a `Christmas Coronary’ or a Hanukkah Heart Attack’ , the winter holiday season usually heralds a spike in myocardial infarctions, which may be brought on by a variety of factors.  Seventeen years ago, a study looked at the rate of heart attacks in the United States, and found that Acute Myocardial Infarctions (AMIs) run as much 53% higher during the winter months than than during the summer.


Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction.

Spencer FA, Goldberg RJ, Becker RC, Gore JM.


Although cold weather combined with strenuous physical activity (like clearing snow from sidewalks) has often been blamed for this increase, even in balmy Southern California, studies have shown a 33% increase in heart attacks over the holidays (see below).


When Throughout the Year Is Coronary Death Most Likely to Occur?

A 12-Year Population-Based Analysis of More Than 220 000 Cases

Robert A. Kloner, MD, PhD; W. Kenneth Poole, PhD; Rebecca L. Perritt, MS


Non-climate related factors – like over indulgence in food and alcohol, diminished activity levels, forgetting to take prescription medicines, and combined holiday stressors like shopping, running up debt, traveling, meal preparation, and the angst that comes from dysfunctional family gatherings are likely contributors to this yearly spike. 


But increasingly influenza and other respiratory infections have been linked to this seasonal increase in heart attacks as well.

Which helps to explain why we’ve seen a spate of studies – like last Augusts'  UNSW: Flu Vaccine Provides Significant Protection Against Heart Attacks – linking flu vaccination to a lower risk of sudden cardiac death.

Others include:

  • In 2010 we saw a study in the CMAJ: Flu Vaccinations Reduce Heart Attack Risk that found that those over the age of 40 who get a seasonal flu vaccine each year may reduce their risk of a heart attack by as much as 19%. Questions were raised over the way this study was conducted (see Vaccine/Heart Attack Study Questioned), and so the results are in dispute.
  • In August of 2013 (see Study: Flu Vaccine May Reduce Heart Attack Risk), we looked at study out of Australia – published in the BMJ Journal Heart, that found compelling – but not exactly conclusive – evidence that flu shots may reduce the risk of heart attacks as much as 45%.
  • In October of 2013 (see JAMA: Flu Vaccine and Cardiovascular Outcomes) we looked at a meta analysis that found among patients who had previously had a heart attack, the receipt of a flu vaccine was linked to a 55% reduction in having another major cardiac event in the next few months.


Although the reputation of the flu vaccine took a major hit last winter after the late arrival of a `mismatched’ H3N2 virus (see CDC: Updated Estimated Seasonal Flu Vaccine Effectiveness), this year appears to be a better match and should provide something on the order of 40%-60% Vaccine Effectiveness (VE).

While it takes a couple of weeks for the vaccine to reach maximum effectiveness, it is not too late to get this year’s flu vaccine, as flu season is just getting started.


Regardless of the effectiveness of this year’s flu vaccine, or the severity of this year’s flu season, even on an `average day’ roughly 1,000 people suffer a Sudden Cardiac Arrest (SCA) in the United States alone. While the rate is higher in the winter than in the summer, having basic CPR skills can be a lifesaver year round.


This from the Heart Rhythm Association:

  • Sudden Cardiac Arrest (SCA) is a leading cause of death in the United States, claiming more than 350,000 lives each year.
  • Approximately 92% of those who experience sudden cardiac arrest do not survive.
  • SCA kills more than 1,000 people a day, or one person every 90 seconds


What the people who witness these events do in the first few minutes can mean the difference between life and death for the stricken individual. Luckily, hands-only CPR (cardio-pulmonary resuscitation) is easier to do than ever before, and there are thousands of AEDs (automated external defibrillators) stationed in public venues across the nation.


With a little bit of training, you have the potential to save someone’s life.



While it won’t take the place of an actual class, you can watch how it is done on in this brief instructional video from the American Heart Association.  To learn how to use an AED, you can use this online training module  I wrote about in CPR Skills & AED Simulator.  A  CPR class only takes a few hours, can be fun, and is well worth the effort.  


To find a local CPR course contact your local chapter of the American Red Cross, the American Heart Association, or (usually) your local fire department or EMS can steer you to a class.

Of course, despite your best efforts, many SCA victims will not survive. It isn’t at all like on TV, where 75% of  recipients of CPR survive.  Even when cardiac arrests occur inside a hospital, the survival to discharge rate is less than 40%. Outside the hospital, the odds of seeing a good outcome are lower.


While there are no guarantee of success, early and coordinated action taken by bystanders (calling 911, starting CPR, using AED if available) can substantially improve the SCA’s chances of survival. 


For more on heart attacks, and CPR, you may wish to visit some of these earlier blogs.

Deadlier Than For The Male

Survivability Of Non-Shockable Rhythms With New CPR Guidelines

Fear Of Trying

NPM11: Early CPR Saves Lives

Korean Govt. Statement On Death Of Last MERS Patient


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Korea’s last remaining MERS patient – a 35 year old man with malignant lymphoma – who was initially released from the hospital in early October but was re-admitted and placed into isolation 10 days later when his symptoms (and viral shedding) returned, has died.

The outbreak, which began in mid-May, eventually affected 186 people. 


While the last transmission of the virus in Korea reportedly took place in early July,  the outbreak could not be officially declared ended as along as any patients remained positive for the virus.  While a technicality, presumably the 28 day countdown clock for declaring the end to the outbreak will now commence.



Homers 80th confirmed death party

Department of Health and Human Services Homers central management task force confirmed 80th party (male, 35 years) has elapsed treatment of the underlying disease, malignant lymphoma is rapidly deteriorating announced the death hayeoteum (11.25 days 3:00)

* 80 patients lapse: Confirmed patient contact (5.27) → Samsung Medical quarantine admission (6.6) → confirm (6.7) → Seoul National University Hospital supply (7.3) → The final sound judgment (10.1) → discharge (10.3) → Seoul National University Hospital readmissions (10.11)

80th confirmed he received a quarantine treatment in 116 days after the Seoul National University Hospital confirmed 6.7 days (10.3 days discharge), 10.11 days were re-treated with the isolated state is repeated positive and negative genetic test phase after hospitalization,

Medical treatment the patient was explained that "in the course of treating the underlying disease, malignant lymphoma patients with the disease progression, progression was rapidly deteriorating"

Department of Health and Human Services has this refrain about the souls of the deceased was best wishes table condolences.

France: HPAI H5N1 Reported In Backyard Flock


Dordogne, France


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It was not quite 10 years ago (Feb 2006) when H5N1 first arrived in France, presumably carried in on the wings of migratory birds, and during 2006-2007 it sparked several dozen relatively small outbreaks in poultry. As with the rest of Europe, H5N1 in France was relatively quickly contained, and their last reported outbreak was in August of 2007.


During H5N1’s great diaspora of 2005-2006   the virus quickly spread from a handful of Asian nations into more than 60 countries, including much of Europe and Western Africa.


After what seemed like an unstoppable advance we saw an unexplained retraction of the virus around the world, with H5N1 settling into a handful of `hotspot’ countries (Indonesia, Egypt, Bangladesh, India, etc.).  By 2012, the number of countries reporting H5N1 had dropped back down to 15. 


But over the past year we’ve seen a resurgence of H5N1 around world at the same time that H5N8, H5N2, and H5N6 have taken off.  Combined – and when you add in today’s report , these HPAI H5 viruses have struck 35 countries in 2015 – the largest number reported since 2007 (which also saw 35 countries hit).

After an absence of anywhere between 5 to 9 years, we’ve seen H5N1 return to West African and European countries like Nigeria, Ghana, Burkina Faso, Hungary, Bulgaria and and now France.


The following report of the detection of HPAI H5N1 in France was published by the French Ministry of Agriculture this morning.   While just a backyard flock, this should serve as fair warning to European poultry interests that H5N1 has returned for the winter.


A case of avian influenza detected in a backyard in Dordogne




A case of avian influenza has been confirmed in a backyard in Dordogne, following an abnormal mortality has immediately led to the taking of samples for analysis by the Departmental Directorate of protecting populations.

The confirmation of cases of avian influenza has been established on the evening of Tuesday, November 24 by the National Agency Risk Assessment (Anses) and strain of the virus was identified. This is a highly pathogenic H5N1 in poultry. The sequencing of the strain is underway but it seems to be of a strain already detected in Europe, which until then had an LPAI profile.

Stéphane LE FOLL, Minister of agriculture, food and forestry, Spokesperson of the Government, immediately instructed his services to enable the national health emergency response plan in accordance with European rules and International.

Thus, protection zones and surveillance of 3 km and 10 km respectively livestock are implemented. Monitoring will be strengthened not only in farming but also in wildlife.

The Minister in charge of agriculture, Stéphane LE FOLL, in conjunction with the Minister in charge of health, Marisol Touraine will also enter the ANSES, as a precaution, to assess the potential danger of the strain for 'man.

Finally, Stéphane Le Foll asked the Director General to convene an emergency supply National Guidance Committee of animal health policy Thursday, 26 November to mobilize all stakeholders and to ensure the application immediate measures of protection and management against avian influenza. The speed of the implementation of management measures is a prerequisite to limit the spread and consequences of disease, especially for export.

Furthermore, it should be recalled that avian influenza is not transmissible to humans through the consumption of meat, eggs, foie gras and more generally any food product

Stéphane Le Foll reaffirmed total mobilization of the state and its services alongside professionals.

A case of avian influenza detected in a backyard in Dordogne (PDF, 131.97 KB)

Tuesday, November 24, 2015

Thanksgiving Is National Family History Day


Note: This is an updated version of my yearly post on National Family History Day.


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Every year since 2004 the Surgeon General of the United States has declared Thanksgiving – a day when families traditionally gather together - as National Family History Day, since it provides an excellent opportunity to ask about and document the medical history of relatives.


The CDC and the HHS have a couple of web pages devoted to collecting your family history, including a web-based tool to help you collect, display, and print out your family’s health history.


Family History: Collect Information for Your Child's Health

Surgeon General's Family Health History Initiative


Using these online tools, you can create a basic family medical history with relative ease.  But before you can do this, you’ll need to discuss each family member’s medial history. The HHS has some advice on how to prepare for that talk:


Before You Start Your Family Health History

Americans know that family history is important to health. A recent survey found that 96 percent of Americans believe that knowing their family history is important. Yet, the same survey found that only one-third of Americans have ever tried to gather and write down their family's health history.

Here are some tips to help you being to gather information:


As a former paramedic, I am keenly aware of how important it is for everyone to know their personal and family medical history.  Every day emergency room doctors are faced with patients unable to remember or relay their health history, current medications, or even drug allergies during a medical crisis.


And that can delay both diagnosis and treatment.


Which is why I keep an EMERGENCY MEDICAL HISTORY CARD – filled out and frequently updated – in my wallet, and have urged (and have helped) my family members to do the same. I addressed this issue at some length in a blog called Those Who Forget Their History . . . .   A few excerpts (but follow the link to read the whole thing):


Since you can’t always know, in advance, when you might need medical care it is important to carry with you some kind of medical history at all times.  It can tell doctors important information about your history, medications, and allergies when you can’t.

Many hospitals and pharmacies provide – either free, or for a very nominal sum – folding wallet medical history forms with a plastic sleeve to protect them. Alternatively, there are templates available online.

I’ve scanned the one offered by one of our local hospitals below. It is rudimentary, but covers the basics.





I’ve highlighted several other methods of creating histories in the past, some of which you may prefer.  A few excerpts (and links) from these essays. First, I’ll show you how I create and maintain histories for my Dad (who passed away several years ago) and myself.  This was featured in an essay called A History Lesson.

Today I’m going to impart a little secret that will ingratiate yourself with your doctor and not only improve the care you receive, but also reduce the amount of time you spend in the exam room. When you go to your doctor, have a brief written history printed out for him or her.

I’ve created a sample based on the one I used for my Dad (the details have been changed).   It gets updated, and goes with him, for every doctor’s visit.

And his doctors love it.


While every history will be different, there are a few `rules’.

  • First, keep it to 1 page.     Even if the patient has an `extensive history’.   If your doctor can’t scan this history, and glean the highlights, in 60 seconds or less . . . it isn’t of much use.
  • Second, paint with broad strokes.   Don’t get bogged down in details.  Lab tests and such should already be in your chart.
  • Third, always fill in a reason for your visit.   Keep it short, your doctor will probably have 10 to 15 minutes to spend with you.   Have your questions and concerns down in writing before you get there.
  • Fourth, list all Meds  (Rx and otherwise) and indicate which ones you need a refill on.   If you have a question about a med, put a `?’ next to it.   And if you have any drug allergies, Highlight them.
  • Fifth,  Make two copies!   One for your doctor to keep, and one for you.  As you talk to your doctor, make notes on the bottom (bring a pen) of your copy.  

Once you create the basic template (using any word processor), it becomes a 5 minute job to update and print two copies out for a doctor’s visit.


The history above is great for scheduled doctor’s visits, but you also should still carry a readily available EMERGENCY Medical History Card in your wallet or purse..

And a couple of other items, while not exactly a medical history, may merit discussion in your family as it has recently in mine.

  • First, all adults should consider having a Living Will that specifies what types of medical treatment you desire should you become incapacitated.
  • You may also wish to consider assigning someone as your Health Care Proxy, who can make decisions regarding your treatment should you be unable to do so for yourself.
  • Elderly family members with chronic health problems, or those with terminal illnesses, may even desire a home DNR (Do Not Resuscitate) Order.

Verbal instructions by family members – even if the patient is in the last stages of an incurable illness – are likely to be ignored by emergency personnel.

In Florida, the form must be printed on yellow paper. Different states have different requirements.  You should check with your doctor, or the local department of health to determine what the law is in your location.


My father, who’s health declined greatly in his 86th year, requested a DNR in early 2011. That – along with securing home hospice care (see His Bags Are Packed, He’s Ready To Go) – allowed him to die peacefully at home in his own bed. 


Admittedly, not the cheeriest topic of conversation in the world, but for a lot of people, this is an important issue to address.


A few minutes spent during this Thanksgiving holiday putting together medical histories could spare you and your family a great deal of anguish down the road.